Sunday, May 13, 2007

American family practice: Canada looking better?

I still believe my "generality" of Family Practice makes sense in settings that reflect real-world resource constraints, such as a "free market" libertarian system or a single buyer/payor model or the future mixture thereof. Alas, FP doesn't make sense in the unreal world of today's American health-care marketplace. FP is a weak and wounded beast, and the "minute clinics" are moving in for the kill.

So it's not surprising that this month's issue of FPM was suspiciously thin, and included some grim correspondence:
Letters - May 2007 - Family Practice Management

In response to Dr. James Glazer's editorial "Specialization in Family Medicine Education: Abandoning Our Generalist Roots" [February 2007], I have to ask why are we wasting our time saving generalism? The marketplace has deemed us valueless. Supply and demand has dictated that we are unnecessary. Insurance companies, the government and the public have said we have no worth... mostly I get up in the middle of the night to see patients with minor problems that should have been dealt with in the clinic during daylight hours. I applaud my colleagues who have limited their practices, and I plan to do the same in about five years.


... I don't mean the above to sound dark and angry. Part of the paradox of life in family medicine is that it would be hard for me to conceive of a more satisfying career. I would never trade my practice life for that of another specialty. Caring for patients with the spectrum of needs that mine have is immensely rewarding.

Still, I'm not sure that today's medical students are willing to meet the demands of family medicine. The financial rewards are likely to be greater in almost every other specialty, and many young physicians have difficulty seeing beyond that.


I am now retired, but having practiced for more than 30 years, developed a family medicine residency program, taught residents for many years and watched the ancillary services once preformed by family doctors disappear, I am disillusioned and afraid for the continued existence of family medicine...

The same issue features a somewhat discouraging look at an idealistic (but unpersuasive) attempt to "reengineer" family practice. Ahh, they'll miss us when we're gone. You have to love a group of people who, faced with immense economic pressures, decide to make their board certification five times harder. There's a definite impulse to self-punishment among family physicians ...

Primary care will return to America when we emerge from our delusional health-care mess; the names will change but no-one will really be fooled.

In the meantime, not coincidentally, my wife and I received a recruitment survey from the Canadian Medical Association. They've noticed an unprecedented reversal of the "southwards flow of physicians" in the past two years. It's probably too late for us (I left practice for research and development 10 years ago), but if I were still doing primary care I'd be looking north again ...

Update 5/14/07: I forgot to mention one of the more direct "killers" of family practice. Evaluation and Management coding. It diverted primary care from patient services to documentation services, and biased towards the delivery of suboptimal, but coded, services. Performance measures will have a similar effect, though for primary care that will be a "flogging a dead parrot".

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