In a recent New Yorker article about him, Dr. Mehmet Oz was paraphrased as saying that “Marcus Welby — the kindly, accessible, but straight-talking television doctor — is dead.” If he believes that, Dr. Oz needs to get out of New York.
At 51-years-old, I’m a little too young to remember the television show Marcus Welby, M.D, that aired on ABC from 1969 to 1976. A colleague told me the show was pretty schmaltzy and that it implied Welby could make a living on long conversations with two patients per day, which has never been a reality in primary care, not even then.
Perhaps a better nostalgic model of family medicine is Dr. Ernest Ceriani, a rural Colorado general practitioner and the subject of an extensive photo essay in Life Magazine in 1948. In the essay, Ceriani delivers babies, makes house calls, reads x-rays, splints fractures, tends to elderly patients, flushes out waxy ears, cares for patients after a heart attack, amputates a gangrenous leg, and is called away from a Saturday morning at a trout stream to care for a little girl who has been kicked in the head by a horse. He repairs the facial laceration, but has to tell her parents to take their daughter to Denver for surgery to remove the eye that was damaged beyond repair.
The writer of the article concluded, “His income for covering a dozen [medical] fields is less than a city doctor makes by specializing in just one, but Ceriani is compensated by the affection of his patients and neighbors, by the high place he has earned in his community and by the fact that he is his own boss. For him, this is enough.” Clearly, fair pay for comprehensive primary care is not a new issue. We see this issue threaten our field with every medical school graduating class.
But the country doctor is still alive. Dr. Ceriani’s spirit lives on in my family medicine residency and others. I am on the faculty of the John Peter Smith (JPS) Family Medicine Residency in Fort Worth, TX. We are the largest family medicine program in the country, and in spite of our location in the fourth-largest metropolitan area in the country, we have trained more rural family physicians than any other program in America.
We were one of the participants in a program called Preparing the Personal Physician for Practice (P4), which was an experiment in family medicine residency curriculum that started in 2007. We were allowed to revamp our curriculum in the way we felt best prepared young family physicians for future practice. Our curricular innovation comes in two layers:
- We allow residents to stay for a fourth year of training to do just about anything they want (within reason).
- We take their vocational passion, delivering babies, for example, and try to make the training experience as longitudinal as possible. We increase the residents’ exposure to maternity care throughout all four years of training, not just in a fourth-year fellowship. By far, our most popular extra training request has been a combination of maternity care and rural or global rotations. Sports medicine and geriatrics are also commonly sought, and we’ve had a few residents create experiences in hospital care, general surgery, and emergency medicine.
The final data are just now being collected, but preliminary results show that of the people who chose the maternity care track, 80 percent deliver babies in practice, and of those, all do their own C-sections. They average 106 deliveries per year.
And they’re not just watered down obstetricians. They do so much more than maternity care. They address numerous needs in their communities. Ninety percent of them care for newborns and children in the hospital. All of them see elderly patients. Eighty percent feel comfortable providing end-of-life care. Eighty percent care for hospitalized adults. All of them place IUDs and perform endometrial biopsies. About a third do colonoscopies and EGDs.
Our graduates provide these services in a variety of underserved settings such as a remote jungle valley in Papua, New Guinea, the African savannah, and small towns across Texas and many other states. Because they provide comprehensive care to complex patients and they are able to provide a full basket of procedures, their local health care infrastructure is strengthened.
A great example of this phenomenon is Randy Lee, MD, a graduate from the pre-P4 days who has served his rural hometown of Hamilton, TX, for nearly 20 years. When he first arrived in Hamilton, the county hospital ER saw less than 100 patients per month, had an average daily inpatient census of less than five, and was about to close. Now Dr. Lee has seven family physician partners that have helped increase the hospital’s capacity. Besides ambulatory care, they provide hospital care, ER coverage, colonoscopies, EGDs, and other minor surgeries. The ER now sees 600 patients per month, and the daily inpatient census ranges from 15 to 30. The hospital operates in the black and community support is strong.
Although the CMS fee schedule allows Dr. Oz to make more in a two-hour surgery than family physicians make in an entire day, the spirit of altruism and service is still strong enough to carry many of our graduates to fulfilling careers in underserved populations. If primary care physicians are ever paid fairly for providing comprehensive care to complex patients, our ability at JPS to train even more young family physicians to serve vulnerable populations will grow, and so will family physicians’ visibility and accessibility.
And maybe then, enough Americans will have an accessible and trusted comprehensive generalist physician, so that the parochial opinions of Dr. Oz will forever fade from our collective memories.