Primary care doctors are in retreat

Where have all the primary care doctors gone? And more importantly, how can we get more of them?

When I was growing up, a single doctor handled most of our family’s problems. Sure, he called in a surgeon for gallbladders and maybe a cardiologist for heart failure, but most people figured they’d rather have just one doctor, and they trusted him to know what they needed.

But as medical knowledge expanded, we doctors found that it was easier to restrict ourselves to just one part of it. Another two or three years after residency could turn you into a specialist, meaning that you knew more about some things than the rest of us and could do special stuff like surgery and heart catheterizations. It carried a lot of prestige, and the cars those specialists were driving made it clear that there were other benefits, too.

The American public bought into the specialist mystique, partly thanks to stories in the media about miracle cures that could only be provided by the right medical expert. Family doctors, general internists and pediatricians started to look a little inadequate.

Once trusted to diagnose and treat pretty much anything, they began to be seen as “entry-level” doctors: OK for routine checkups and minor stuff, but when you had a serious illness or injury they were only valuable for finding the right specialist.

Thanks to managed care they also got labeled as “HMO gatekeepers,” suspected of conspiring with insurance companies to deprive patients of the latest tests and treatments.

Preventive medicine isn’t very glamorous. It means spending time listening to people instead of doing things to them, explaining how to stay healthy or deal with illness, writing a lot of prescriptions and returning phone calls.

Adjusting blood pressure medicines or insulin doses isn’t nearly as camera-friendly as operating on a brain hemorrhage or bringing somebody out of septic shock, even if both of those could have been prevented by regular medical care. And if you think you know what’s wrong with you, why not just start with the specialist you think you need?

But specialists have a downside. They regularly miss or ignore problems outside their area of expertise.

“Your heart is just fine, don’t worry about a thing” sounds great unless your chest pain is caused by blood clots or acid reflux. If you’re taking your complaints to a series of different doctors, nobody is looking at the big picture.

Take your tremors to a neurologist, your excessive sweating to a dermatologist and your menstrual problems to a gynecologist, and none of them ever recognizes the thyroid problem that caused all of those.

Preventive screening? Good luck finding an ear-nose-and-throat doctor who will look at your family history and recommend early colonoscopy.

Primary care should be attracting the best and brightest medical students, those willing to learn about all the problems their patients may face.

But low pay and lower prestige has driven all but the most idealistic to practice where they can work shorter hours for more money and status.

Why put in the effort to prevent diabetic complications when you can be the eye doctor who saves patients’ eyesight or the surgeon who bypasses their clogged arteries? Why study rheumatoid arthritis or ulcerative colitis when the patient will insist on having a specialist treat those?

Dr. Atul Gawande’s May 2009 report in the New Yorker on McAllen, Texas, showed how much money can be spent on medical care without improving its quality. He pointed out that many of the doctors there prefer doing elective surgery to handling emergencies, and that treating sports injuries pays better than managing acute illnesses, particularly in uninsured patients.

Even when state-supported programs like Medicare and Medicaid pay for the care that could prevent expensive illnesses and injuries, the rates are too low to compete with private-practice medicine.

Before the idea of a personal physician dies out completely, let’s take a hard look at how society and third-party payers motivate doctors to take care of people. Offer them incentives to see the sickest patients first, cover hospitals and ERs nights and weekends, and to prevent some of those dramatic medical rescue stories from ever happening.

And if you know a good primary care doctor, maybe you could arrange for him to have his own TV show. Let’s hope that it’s not too late for him to inspire others to do what he does.

Dr. Stella Fitzgibbons is a hospitalist at a 400-bed hospital in Houston.