February 26th, 2019

My Primary Care Manifesto

Scott Hippe, MD

Scott Hippe, MD, is a Chief Resident at Family Residency of Idaho in Boise.

“She is meant for more than just primary care,” mused an attending on my internal medicine rotation in medical school. He was referring to a particularly adept resident with whom we were working. This resident was planning on practicing clinic-based general internal medicine. I wasn’t sure why this attending disclosed his thoughts regarding this resident to me, but the implication was clear: “primary care” — whatever is meant by the term — is an easy career path, meant for the mediocre clinician.

The comment left me scratching my head, because the general internist who said it worked in the outpatient setting almost exclusively. Something about the outpatient care he provided was apparently different than “primary care.”

A year later, I matched in a family medicine residency. I chose the field not because I had low test scores (I didn’t), but because I couldn’t find a single area of medicine that wasn’t interesting to me. I didn’t want to give anything up. I was attracted by the never-ending challenges afforded a generalist who is willing to push the boundaries of his or her knowledge. Asking “how much can I do [before reaching my limits] in the care of my patient?” is more compelling to me than saying “I know nothing about this particular organ system; this patient needs to go see another specialist.”

Medical education fails trainees interested in primary care

I did my medical training in the Northwest U.S., where the attitude towards primary care is generally favorable. My medical school actively encouraged students to consider primary care fields. But it isn’t that way everywhere. Trainees are frequently told explicitly or implicitly that primary care specialties are second-rate. Family medicine is seen as a convenient fall-back option for students who didn’t ace Step 1. General internal medicine and general pediatrics are the fields for residents who don’t match in their perfect fellowship.

A handful of medical schools even lack a department of family medicine. You might recognize just a few of them on the list mentioned in this article.

Rewriting a paradigm

The attending I mentioned in this post envisioned primary care as stuffy noses and pap smears. The way I see primary care is different. For the docs out there who look down on primary care fields and medical trainees who have received inadequate exposure to generalist medicine, I want to share this paradigm with you.

Primary care is the entirety of care that I provide for my patients as their first provider. This is far more than those stuffy noses and paps. My specialty’s broad scope of training incorporates services such as comprehensive obstetrics including cesarean section, reproductive health, addiction medicine, inpatient medicine, emergency medicine, screening colonoscopy, treadmill stress testing, treating hepatitis C, and end-of-life care. My domain encompasses the clinic, hospital, emergency room, delivery room, and nursing home. And I still visit patients in their homes.

To the undifferentiated medical trainee: staying general in medicine begets a land of huge opportunity and variety.

Generalists, and more of them, please

Image result for primary care physician graph

We’ve all heard about how the US has the highest health costs of any country in the world.

It takes a specially trained eye to focus on the big picture, to treat the whole person, and to be effective in varied care settings. There are 36 countries in the world that deliver better and cheaper healthcare than the U.S. What do they have in common? A strong base of generalists. I am grateful for the well-trained specialists who help me at the limits of my abilities. But the U.S. cannot specialize its way out of its poor-performing and exceedingly expensive health system.

Our hyper-specialized, fee-for-service health system deters many physicians from becoming generalists. Every medical trainee doesn’t need to choose a primary care specialty. But we need more than are

Although a bit out of date, this figure highlights the dearth of GPs in the US.

choosing primary specialties now. I advocate against the notion that generalist medicine is inferior to specialist medicine (partialist medicine? for some humor). Primary care is more stimulating and requires more clinical acumen than many realize. Until our medical community changes the way it thinks about generalists, I don’t see our health system improving — whatever political or policy “fixes” might be on the way.



NEJM Resident 360

16 Responses to “My Primary Care Manifesto”

  1. Nice says:

    Love this concept, but let’s let medical society actually back it up.

    Does the New England Journal even know what’s going on regarding mid-levels and the way they seem to think they can provide primary care at the same level of a physician while unsupervised?!

    Hospitals and health care entities think primary care can be handled by severely untrained and unsupervised “providers” — these “providers” often get away through practicing medicine by consulting and consulting and consulting.

    A good primary care physician is an amazing boon to both their patients and the healthcare system but ours won’t recognize that.

    Being able to grow old amidst 2000-3000 patients is a blessing as you take care of them and guide them through chronic illness.

    Also crucially when the inevitable end comes, nothing comes close to a primary care provider’s word that states when “enough is enough” — medicine can only do so much (specialists will offer and offer and offer it seems).

  2. Suman Pal says:

    As a resident in Internal Medicine, I whole heartedly agree with the premise of the article and it’s message. Recently, I decided to pursue hospitalist medicine as a career. Since I have made that decision public, I have faced a barrage of questions from incredulous enquirers as to why should I, an “ace resident”, chose to ‘settle’ with hospitalist medicine. While most of these statements were made with the best of intentions, they showed me the magnitude of prejudice that exists against general internal medicine as a career.
    With rising costs of healthcare, it is of paramount importance now more than ever to focus our energy into highlighting the beauty, diversity and intellectual challenge that general internal medicine provides those who choose to pursue it.

  3. James Wilk, MD says:

    I graduated from medical school with honors, was AOA, had stellar reviews from my attendings during residency and excellent scores on my ABIM exam. I was offered letters of recommendation to fellowship programs.

    But I CHOSE primary care and I’m glad I did! I’ve been a general internist for nearly a quarter of a century and I find it intellectually challenging and emotionally satisfying work. I have patients I’ve known and cared for (and about) for 20+ years. There’s no feeling like that long-term doctor-patient relationship!

  4. Richard Levitt says:

    Thank you for stating the obvious. I used to feel that by the time I had to refer I had failed, but knowing your limits is critical. I just wish that the compensation was commensurate with the “specialists”. Also, the more experience you have the fewer tests you do, yet the “specialist” runs the test prior to seeing the patient, in many cases. Nothing beats a good history and physical exam .

  5. Having spent the past 25 years living the dream described by Dr Hippe with full scope comprehensive care, I still cannot imagine doing anything less. The insights gained, complex problems discovered and treated, along with the efficiencies created by caring for the whole person are professionally satisfying and have helped many patients after multiple subspecialty visits have failed them.

  6. Evan Ballard, MD says:

    Have you decided where you want to practice Family Medicine, as you describe it?
    Consider the Jonesville Family Medical Center in Jonesville, NC, part of Wake Forest Baptist Health system. I recently retired from that practice after 39 years at of comprehensive, rewarding primary care in this lovely community in the foothills of our state.
    Let me know if you might be interested.

  7. Robert Diederich, MDPhD says:

    I am a firm believer in primary care and chose that as a specialty. Unfortunately, it is the residency training programs in family medicine, in particular, that leave much to be desired. Often times the so-called “faculty” at these institutions are, in fact, the burn-outs in the profession. They no longer enjoy seeing patients and seek a residency faculty position as a way to coast until retirement while still making that six-figure income. They have too much time on their hands and attempt to justify their position by piling on needless make-work on residents. They don’t want smart residents, and the dirty little secret is that many applicants are poor quality and/or dropouts from other specialties, surgery being the one I’ve seen most often. In my view this environment is not limited to isolated programs.

  8. Craig says:

    I’m finishing medicine subspecialty training at a large academic medical center with a focus on a sub-area of that subspecialty for my ongoing practice after finishing. I generally believe that being a good generalist/primary care provider requires both greater general aptitude and greater curiosity as compared to sub specialists–in fact, I have witnessed several conversations regarding IM trainees where it was determined that they were more suited to further subspecialty training rather than generalist practice because they required “further supervision and training” and weren’t quite ready for independence after 3 years.

    Much respect for good family practice docs–I can’t imagine trying to practice adult, pediatric and OB/GYN medicine after 3-4 years!

  9. Todd Carlson, MD says:

    I’ve practiced family medicine in a small community in the Northwest for almost 20 years. I’m always surprised and somewhat frustrated when I hear of people’s perceptions that we see mostly simple problems. I see very few people with sore throats, coughs, etc. My few acute patients are often dizzy 90 year olds and other complicated problems.

    I feel that primary care is at least as intellectually demanding as the sub-specialities, and often more demanding, because of the breadth of problems that we address. It’s unfortunate that we are not appreciated or respected for what we do. Often patients come to me to have results explained for tests that were ordered by a sub-specialist but not adequately explained, or sometimes because they were never informed of the results. We also manage the bulk of industrial injuries and chronic pain, which are two of the most challenging things in outpatient medicine.

    I believe that much of the reason for inferior quality of care in this country is that the payment and delivery structure runs on a factory model, valuing production and efficiency over spending the quality time needed to provide the best care.

    I still have hope that the system will improve.

  10. Roy W. Harris, D.O. says:

    You are spot on and way ahead of your time. I to was at the top of my class and Chose Internal Medicine because I felt it was a more holistic approach and affordable approach to caring for patients. Which they are PATIENTS not clients.
    Internists are MULTI specialists and in rural areas they can be real life savers. In 1966 when Congress passed the authorization of Medicare the average number of physicians a patient was seeing routinely was 2 and mainly female patients, Now that number is 5 to 6 do you see a problem. Ihe commitment to keep your knowledged honed in such a vast array of health conditions is a daunting task and really only one attempted by individuals that have a passion for what they due. The general Internist are special breeds and a more affordable choice for healthcare in this country.

  11. robert neveln says:

    I, an IM “primary care” physician of the past 40 years dove into the specialty that pushed my boundaries every week. It gave me unparalleled access to the most challenging continual learning endeavor I could ever hope to have. That is only if the
    primary care specialist works to the max regarding thinking and learning, rather than becoming a “referral doc”. I also gave me the gift of truly knowing the health of my patients, rather than part of the health, which allows for better well informed decisions. I is a specialty that requires a greater tolerance for risk, and to me much greater rewards compared to any subspecialty. However, as stated, the “primary care” physician does have to guard against becoming that “referral doc”. We definitely need to find systems that rid us of the increasing and onerous documentation to allow us to be The Doctor.

  12. Sanford Kimmel says:

    I prepare to retire from a career spanning over 40 years in family medicine with a side interest in general pediatrics (Yes, I did two residencies in primary care specialties!), I can say that it has been varied and challenging. Primary care requires a breadth of knowledge far greater than many sub-specialists and the ability to recognize when something fits the pattern of a disease and when something does not. I have also enjoyed working with a number of nurse practitioners and physician assistants and think they do an admirable job of dealing with common ailments and well care. However, their training still lacks the depth of knowledge imbued by a medical school education and at least three years of residency training. On several occasions, I have made diagnoses that were not considered by ancillary primary care providers and even some specialist physicians. This is not meant to be hubris but to emphasize that if the pattern of the illness does not fit, then one should look elsewhere.

    I have enjoyed the continuity of care that enables one to get to know a patient and their families over the course of many years. I used to teach in a family medicine residency and one night a 1st year resident called about a patient who was short of breath, but had a (supposedly) negative chest x-ray and wanted to discharge the patient. I knew that the patient rarely complained of such things and instructed that a CT scan be obtained. This demonstrated a pneumothorax, that was not seen on the chest x-ray. I believe that Sir William Osler said something to the effect that ” It is more important to know what kind of patient has the disease than what kind of disease the patient has”. Please excuse me if I am paraphrasing this incorrectly. Unfortunately, continuity of care is not valued by the business side of medicine with its emphasis on ‘minute clinics’

    I understand that a recent study correlated a longer life-time survival in areas served by a greater number of primary care physicians. Not only is primary care cost-effective, it is also results in improved population health.

  13. Phillip Shepard says:

    Totally agree. I graduated from a “top ten” med school in 1968. I always tell people I went into Family Practice when it was unpopular. Only 21 FP Residencies in the US then, only 4 out of 190 in my class went to FP programs. I practiced in rural areas of the US. I provided long-term, longitudinal care. Specialists were only for referrals because they were too far away and expensive. At small rural hospitals the ER coverage was provided by the attending staff. Most FP’s did normal deliveries, C-sections and general surgery were provided by older GP’s and a general surgeon from a nearby county. I enjoyed the variety of patients and the longitudinal aspect of primary care. I saw patients as persons not as cases. I was a clinician not a technician. I spent the last 15 years overseas as a volunteer. I’m glad I’m retired and don’t have to deal with the performance requirements, EMR and other stuff being imposed on physicians by insurance companies, clinics and other agencies.

  14. Carl Knopke says:

    The thoughts you have expressed are nice and ones that I had and have as a Family Medicine Physician. The problem that you will have as a generalist is that though there is more satisfaction in taking care of the whole person, our reimbursement rates are quite a bit less. We are the first doctor to see a patient and often there can be more than one request from the patient. The combination of being able to manage these requests is hard. Despite what is arguably more difficult work, we are paid less per encounter (FFS visits), zero or a flat fee per encounter (capitated care), and we have more problems that we are responsible for. Modern coding guidelines set by the AMA still favor the specialist. Coding is heavily weighted in terms of how bad the problem is, not how many problems that the patient presents with. When you consider that specialty care is valued higher for each visit code, specialty care is self limited in the number of problems addressed, and the visits can often be done in less time, it starts to be easy to see why primary care is less valued. All doctors in private practice compete for the same spaces to rent, the same staffing resources and similar supplies. It gets more and more difficult for primary care to compete especially when we are valued so much less. Each of these things makes your aspirations for what you want to do as a primary care doctor that much more difficult. I applaud your viewpoint. The execution of what you want to do is yet to come.

  15. Dan Urbach says:

    I’ve been in primary care for 27 years now, and it’s become very clear to me that the bias you describe is an artifact of academia. It’s silly and arbitrary.

    Regarding reimbursement, the laws of economics are the key, as described in prior comments. If society wants more primary care, the pay disparities need to be fixed. That will only happen when the RBRVS update committee membership is corrected to proportionally represent primary care or the committee becomes redundant (the latter would be my preference). (See https://www.ama-assn.org/about/rvs-update-committee-ruc/composition-rvs-update-committee-ruc)

  16. Dean Phillips says:

    I thought it was interesting when you said that you chose family medicine because every aspect of medicine was interesting to you. My family and I just moved to a new town, and my son has been complaining about pain in his stomach. We should probably find a family medicine doctor who can help us figure out what is causing his pain.

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