The Future of Family Practice…If Any

By: Doug Pitman, MD from Whitefish, MT

If you have never heard of Marcus Welby M.D. stop reading and get back to work. Your patients are piling up in the waiting room. For those of you who have, please read on. You might find this interesting. In the pilot show of Marcus Welby M.D., “A Matter of Humanities,” which aired on March 26, 1969 four years after Medicare was signed into law, Dr. Welby predicted the end of the general practice of medicine. I suggest you watch Marcus’s monologue to the assembled house staff of his local hospital at 24:38 minutes into the episode as history is in the process of repeating itself.

Let me give you a fictitious, over-simplified 2-minute family history of Family Practice. In 1950, my grandfather was a GP. In 1980, my dad was a family doc. By 2010 I’m a primary care provider. Not a practitioner, not a doctor, a provider. The insurance companies call me a vendor; like I’m selling sunglasses at a mall.

In 1960 my grandfather was kicked off the staff of North Shore Hospital as specialists took over. By 1975 specialization lead to higher fees and the greedy doctors got sued by greedy attorneys. So then the specialists raised their fees even more to cover their costs and big businesses and insurance companies responded by forming HMOs to gain control over the specialists and rising costs. In 1985 my dad became an HMO gatekeeper to stem the flow of patients to the high-priced specialists; a nice title without any significant remuneration other than immoral financial incentives of NOT making referrals to higher priced doctors, whether needed or not.

Meanwhile, Medicare was ratcheting back payments to everyone but still rewarding the specialists with higher fees for cutting, freezing, injecting, and otherwise invading their patients’ bodies while the family docs got much less for trying to prevent disease. You can thank Dr. William Hsiao’s RBRVS system* for that.

By 1995 insurance companies had total control of primary care doctors through PPOs or managed care organization because we agreed like sheep to provide health care at reduced rates to the insurer’s clients like school systems and big business. By 2010 we had to see 25-30 patients a day spending an average of 8 minutes with each patient while keeping them waiting for an average of 30 minutes for appointments that took them 3 weeks to get to generate enough funds to pay for our billing department, which does nothing but battle with our patients’ insurance companies.

Is it any wonder that the current crop of medical school graduates are shunning family practice residencies in favor ER medicine by a ratio of 5:1 at some medical schools, which in the past have been bastions of family practice? Can you blame them? Who would want to be a family doctor in the next twenty years, as 100 million citizens (70 million baby boomers and 30 million Obamacare bloomers) enter the Medicare pool? You can hear the whistle very clearly; “Everyone out of the pool.” There’s no room for students entering family ran medical practices due to many American students currently enrolling in other medical school programs, such as a Med school in the Carribean or other locations.

The new healthcare paradigm will be a very small number of Family Doctors…if any and a very large number of Physician Assistants and Nurse Practitioners taking care of the frontline of Medicine, which is in the process of crumbling. My son is a compassionate and very smart PA and I have worked with several highly qualified Nurse practitioners. Once the dust has settled in ten years or so I suspect the frontline will stabilize as these talented primary care providers settle in; however, nothing will be the same. Medicine as we know it will be finished.

And what about the future of Family Practice…if any? What are the Marcus Welbys of the medical community (those physicians who believe in spending time with patients, forming relationships, and providing the best possible care based on wellness and prevention) supposed to do now? Strike? Not a bad idea but we’ve never been very good at such things as our individuality gets in the way. Quit? Some of us already have. Work for the CEO of a hospital? Maybe, but viability will be paid for in vulnerability. How about Change? The only real constant in the universe. Why not? We can change our mind set and consider a new model of medicine that will meet our patients’ needs and our needs; a model that will keep the family doctor alive and true to his calling. We need to consider the Concierge Model for our own survival and as a tribute to Marcus Welby M.D.

William C. Hsiao an American economist, is the K.T. Li Professor of Economics[1] at the Harvard School of Public Health in Boston, Massachusetts. Among his many contributions to the fields of health care economics, policy, and social insurance was a landmark study called the Resource-Based Relative Value Study or RBRVS which examined the United States system of reimbursing physicians for medical services. RBRVS led to a revolutionary reordering of physician reimbursement payments under Medicare Part B which was passed by Congress and signed into law in 1989.

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