We read with interest your editorial in the July 2005 edition of the Journal of Family Practice. We found the title provocative but disagree with your basic assumptions and conclusions.
First, our patients are not our “financial” customers. In the last 20 years in the US, the paying customers for healthcare have become governmental programs, insurance companies, and large corporations. The decision to base the US health system upon specialty care was made by our “real” financial customers, not by the patients we see in our clinics and offices. Many medical specialty associations understand this fact and spend considerable time lobbying to maintain high reimbursement procedures within the scope of practice of their specialty. On the other hand, many Family Medicine leaders spend time arguing that FPs should not be trained to do profitable procedures that are needed by their patients. This argument is bad for patients and bad for the specialty.
Second, for a third-party payor, utilizing an FP only to be an “expert in outpatient care” is a waste of money. Capitalism values rapid, predictable, effective, economic results on investment. A provider who can assess patient needs and then effectively and efficiently eliminate a medical problem is a provider that the payor will attempt to retain (some might call this the specialty model of medical care). Someone who merely specializes in the chronic, never-ending treatment of insoluble medical problems is essentially viewed as a “loss leader” by the payor (ie, always needing more resources, never “solving” the problem). If FPs are only “outpatient experts,” as you suggest, the people who pay for health care will always see us as a “losing” investment.
Many physicians will be upset by this analysis because they feel that it ignores the great value of preventative medicine. We agree with them that chronic care management is very important to the public health. However, a capitalist economy devalues long-term planning. If you doubt, explain why we have a multi-billion dollar automotive and petrochemical economy, when we know that fossil fuels are limited and exhaustible, vehicle accidents kill tens of thousands of people per year, and combustion engines cause pollution that may permanently poison our environment.
Although everyone realizes that many medical problems can’t be solved, no payor with an eye on the bottom line can afford to “maximize the use” of providers who can only deal with these chronic problems. If Family Medicine is to survive as a specialty we must prove ourselves in the marketplace by offering an efficient, effective service valued by a third-party payor, not by creating providers who never solve insoluble problems and cost huge amounts of money in the process. We should be much more than just “outpatient experts.”
Currently in the US there are not enough specialists to provide all of the care that patients need. For example, every gastroenterologist in the US could do colonoscopies all day long and still not accomplish all of the indicated screening procedures. If ERs required 100% board-certified ER physicians, most would close. There are nationwide shortages in obstetricians, general surgeons, general pediatricians, and many other specialties, especially in rural areas. The health system and the third-party payors cannot possibly afford the cost to train sufficient specialists to provide all of the common specialty care that is needed in this country. In fact, even if we could afford it, the system of care would be hampered by the fact that most specialists prefer not to focus their practices upon the most common medical issues seen in their field. Ob-Gyn doctors are giving up obstetrics and pregnancy termination care. Few surgeons make an entire practice treating hernias and surgical skin problems; instead, they tend to specialize. Many orthopedists are refusing to take emergency calls and prefer not to care for simple traumatic fractures. The list goes on and on.
FPs can provide these and many other common medical services in a safe and effective manner. Indeed, FPs can provide this care very cost-efficiently. Therefore, we should be talking about training our residents to do more, not less. We should train them, as one of our mentors used to say, “to do the common things, uncommonly well.” That means we must actively train residents to compete with specialists for common procedures (ie, hospital care, colonoscopies, obstetrics, HIV care, orthopedics, allergy care, ER care, low-tech surgery). We should consider expanding the curriculum to 4, perhaps 5 years. Require rigorous documentation of competency and quality outcomes. Hire the best, most experienced, most talented faculty available. Set high expectations and we will have high-quality graduate physicians. When the bar is set high, we will attract the best.