What we value...or don't.

An anecdote from the front lines of primary care...

A woman calls our office asking "do you fill out these sports physical forms?" No established relationship with the practice - just a mom needing her daughter's "forms filled out" for a sport starting the next day at an expensive private school nearby. "We have a pediatrician...but they can't see us today? Can you?" Given my practice structure we're able to offer a sports physical later the same afternoon. "How much will it cost?" Eighty dollars is the answer...much less than we would collect from an insurance company if we billed them for such a visit. "Eighty dollars! Walgreens will do it for $60!"

Do they have doctors at Walgreens? Is there any value at all in having your daughter's heart listened to by someone who went to medical school? Is there any value at all for a practice's ability to see someone on short notice? Does quality primary care still matter...or should we just go the "forms department" at our local convenience store for our care? Over $20k per year being spent for this girl's high school education and I have to justify why the care I provide as an accessible, quality physician is worth $20 more than what is purchasable at Walgreens.

I wish stories like this were rare. The truth is that primary care has been so systematically devalued by the government, third-party payors, medical schools and even many physicians that this attitude is neither unique nor surprising. We need to do a much better job of explaining that health outcomes are significantly improved when primary care physicians are the first point of contact for patients. We need to do a much better job of explaining the various roles of physicians, nurse practitioners and physician assistants and when they are and are not interchangeable. We need to do a much better job of enlisting our specialty colleagues in the fight to save primary care in this country.

What's in a name?

What exactly is a family doctor? How about an internist - is that a person who specializes in an organ called the "intern"? If so, where is this mysterious organ located? What's the difference between a pediatrician and a family doctor who takes care of kids? Fundamentally, people need to know where to go first when they get sick or want a doctor to help them stay well. The divisions we physicians have created within primary care don't help patients answer this question.

The organizations who claim to represent these groups of doctors, namely the AAFP (American Academy of Family Physicians), the ACP (American College of Physicians) and the AAP (American Academy of Pediatrics) have failed to effectively coordinate their efforts to support primary care doctors. Too often, we've spent our energies promoting narrow agendas. Pediatrics claims the ethical ground as the ultimate advocates for kids. Internal medicine claims the "evidence" ground; they're rightly serious about the science of disease. Family practice claims the stump for the doctor-patient relationship and treating the "whole person."

All of this is noble and good-intentioned but fails to aim at the right target. Primary care is dying in this country. The average age of primary care doctors has increased significantly in the past 10 years and alarming percentages of those doctors want to retire early. Quality medical students are avoiding primary care to a degree never before seen. The vast majority of young doctors finishing their residencies are choosing to extend their training by a couple of years in order to specialize. It's an unsustainable situation largely ignored in the debate on healthcare. Until the primary care physician community that includes general internists, pediatricians and family physicians gets it's act together to advocate in a united way for our patients, the problem cannot be solved.

The size of our patients and whether we treat whole families or specific age ranges of patients may determine what tests we take when we become board-certified. It may have dictated which ICU we haunted during the endless nights of residency, but it does not define our responsibility to society. We hold a sacred trust to advocate for a system that supports accessible, comprehensive, personalized and coordinated primary care for patients. We need to get collectively focused on that. We need to stop angling for relative respect under the disrespected umbrella of primary care and start collectively leading healthcare transformation. Our patients deserve and want just that.