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Am Fam Physician. 1998;58(2):339-342

The fact that increasing numbers of family physicians are limiting themselves to an office practice is alarming. There always has been a small minority of family physicians who chose to practice in the “Doc in the Box” environment, but with the advent of the “hospitalist” concept, it is apparent that more and more family physicians who formerly had traditional practices now are opting out of caring for their patients when they require hospitalization.

Our specialty was built on the concept of a caring generalist physician who was knowledgeable about a breadth of medical problems, one who could handle the vast majority of a patient's needs and who always would advocate for the patient even when the patient's condition required the help of subspecialists. We touted ourselves as the “cradle to grave” physicians or even the “womb to tomb” physicians if we practiced obstetrics. In my years of private practice, before I started teaching at the residency program in which I had trained, I had a busy office practice, took care of my patients in the hospital, delivered babies, saw my patients in the emergency department or met them at the office when trouble befell them at night or on weekends, made house calls when needed, cared for patients in nursing homes—basically I committed to taking care of my patients, and the patients of the physicians with whom I shared calls, whenever and wherever they needed care.

That was the idea. That was what attracted many physicians such as myself to family practice in the first place—the challenge, the variety, the involvement in the lives of patients at every stage. I have maintained a limited practice of several hundred patients even while I have been a full-time teacher for the past 14 years, and I still give those patients that kind of care. It is what they expect from me.

As members of a specialty, family physicians have fought hard for the recognition and respect that we now enjoy. I hate to see that thrown away. Most family physicians do not practice obstetrics, and I can accept that. However, increasing numbers of family physicians will not admit patients to nursing homes. Many will not see Medicare patients (“It's not cost effective for what the government pays,” they might say), and they actually turn away patients whom they have treated for years once these patients turn 65. Rarely will family physicians now go to the emergency department when their patients are there. (“After all, we have full-time emergency physicians right there to see them,” is the thinking.) In addition, many family physicians now want hospitals to hire “inpatient managers” to care for their patients when they are admitted to the hospital. Again, they cite cost-effectiveness or the waning of their competency in procedural skills or some other rationalization for why it is better for the patients if they stay in their offices and leave the hospital care to the hospitalists. I am afraid the patients will not buy these excuses much longer. Do we really think patients are so naive that they cannot tell the difference between what is best for them and what is convenient for us?

Maybe the “leaders” of family medicine are at fault. Rather than being content with training generalists, they have promoted the oxymoronic concept of “specialization” within family practice by developing fellowships and other routes by which we could obtain “certificates of added qualification” in sports medicine and geriatrics. Maybe we are victims of our own financial success, now getting paid enough for office work that we do not have to go to emergency departments, nursing homes or hospitals to make a good living. Maybe it is the new system of health care delivery that distances family physicians from their patients. (A physician might think, “They're not really my patients, after all, they are patients of the ‘Really Big Health Plan,’ and I'm just one of the providers for that plan.”) Maybe it is just that too many of us have become lazy.

Whatever the reasons, it is worrisome to me that some family physicians are turning their backs on the tradition of continuity of care, the cornerstone on which our specialty was built just over a quarter of a century ago. Cradle to grave? Sure. As long as it happens from 9 a.m. to 5 p.m., and the patient can come to the office.

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