Dr. William Hueston’s editorial “Rekindling the Fire of Family Medicine” [January 2006] deserves some credit for successfully identifying the motivations that brought most doctors I know to the veil of tears that primary care has become. However, I don’t know what planet Dr. Hueston was on when managed care came knocking on his door, but it was not mine. I am incensed that the editorial implies I “jumped at the benefits of increased reimbursement without accounting for the emotional costs of discontinuing established relationships.” Let me cite my own experience, albeit it unpublished and therefore not worthy of a formal citation.
Some years ago, my practice was offered a managed care contract with a miserable reimbursement schedule that hit us right in the chops. Initially, we turned it down. Then we discovered that a number of existing patients (schoolteachers we had taken care of for a decade) were employed by a school district that had changed to this particular health plan. After much soul-searching, we bit the bullet and signed on with the stipulation that we would not, under any circumstances, take any new patients with this plan.
One afternoon, my medical assistant told me that an established patient was in the waiting room. The patient had changed her insurance to the new program and wanted to continue as my patient. The insurance company’s policy was rigid; she was a new patient to their rolls, not part of a general rollover and not considered an established patient. If I took her as a patient I had to open my practice to all new patients. Before my medical assistant could tell me who the patient was, I stopped her. “Don’t tell me!” I said. “I don’t want to know because it will eat me up. Explain the situation to her and tell her how sorry I am.”
Being a dutiful employee, my medical assistant rolled her eyes, scowled and left my office. Four hours later, my medical assistant appeared at my door looking slightly defiant. “Remember that patient you refuse to continue caring for? She’s still here,” she said. My medical assistant had a terrific way of punching my buttons.
I looked at my watch and said, “Well, I guess you’d better send her back.” The patient walked into my office with eyes red from crying. She apologized for bothering me. I felt absolutely terrible. “Doctor,” she said, “my husband has lost his job. We’ve lost our house. I’ve taken a job as a clerk at an elementary school. I took it primarily for the insurance. We knew you were on it. I’ve lost a lot. I don’t want to lose my doctor. Please, please take us as patients.”
I’d like to say I deliberated about my decision. That would at least imply I gave some consideration to my specialty’s responsibility to “regain our independence,” as suggested by Dr. Hueston. I did not. I nodded, and she started to cry. I was grateful she left quickly or I would have joined her.
I opened my practice to new patients so this one family could continue to see me. I never even had the courage to figure out how much it cost our practice as new patients flooded us with the lower-paying contract. Lucky for me, my three partners were altruistic enough to realize I really had no choice about accepting the family. When I agreed to take on new patients, I opened their practices as well. So there’s my unpublished account of how it really was. My guess is I’m less of an aberration than you might think.
My group of nine family physicians read “Rekindling the Fire of Family Medicine” with some dismay. Instead of writing negative articles about our specialty, we should put more effort into examining successful practices to determine what makes them work. Our group has a busy practice in Green Bay, Wis. We are employed by a hospital system that is extremely supportive of family medicine and primary care. Its medical director and chief medical officer are both family physicians. The system employs only primary care physicians, and there are about 80 of us.
We must spread the word about models of care that allow family physicians to compete and survive. We are doing it, and we know of other groups succeeding in a variety of situations. If first- and second-year medical students could read about practices like ours, perhaps the match rates wouldn’t be so low. Many of us still find careers as family physicians very satisfying.
I was disappointed that Dr. Hueston’s essay included the tired old myth that family doctors are somehow responsible for their current predicament. Like many others, I embraced family medicine back in the '70s. Those days were good; they were fulfilling. But let’s face the facts: Those days are gone. Practicing in a managed care environment, I now function as little more than a referralist. Am I to blame for this? No. The coming of managed care was a result of decisions made by politicians and businessmen. These decisions were driven by trends in society over which family doctors had no control. Opting out of managed care is not a feasible solution in my area.
The fact of the matter is that insurers decided to pay handsomely for procedures and poorly for cognitive services. I recently visited an ophthalmologist because of a blocked tear duct. Using a syringe with a special attachment, he lavaged it clear. This took less than a minute to perform. The charge for the procedure was $450. This was in addition to the $150 office visit. Almost all of this was quickly paid by my insurance carrier. Now, consider the care I provide an adult male patient who suffers from hypertension, diabetes, coronary artery disease and dyslipidemia. During the course of a year, I could see the patient four or five times for extended office visits, fill out endless forms for lab tests and referrals, check his prostate, spend time on the phone trying to get precertification for medications and radiological studies, check for neuropathy, discuss diet and lifestyle, provide round-the-clock call coverage and give him pneumonia and flu shots. This would bring in about $300 in capitation payments over the course of a year – about half what an ophthalmologist can make during a brief office visit. Medical students know this. That’s why fewer and fewer of them want to go into family medicine. Please don’t accuse them of avarice. It’s just common sense.
As for the rest of us, let’s not be bitter. Let’s not think of ourselves as victims. Let’s simply move on. In the near future our health care system will consist of two groups: physician extenders and physician specialists. The physician extenders will screen and refer patients to physician specialists who will perform procedures. We need to phase out the academic faculties of family medicine. Let individuals who are interested in performing what was the traditional work of family doctors become nurse practitioners or physician assistants. There is no need for physician extenders to go through the long, difficult training of medical school and residency.
I say let’s not rekindle the fire of family medicine. Let the embers die. Report the location to Smokey the Bear and give those ashes a good soaking. Let’s not sit on the front porch wheezing about the good old days – the days of wine and roses, grandma’s lemonade and long-term relationships with patients. Let’s pack up our little black bags and head for pastures that are both greener and more procedure-intensive. Our field has changed profoundly. We’re to blame only if we fail to adapt.