Friday, December 12, 2014

The Lost Glory Days of General Practice, and a Vision of it's Resurrection

I'm on my family medicine rotation right now.  One of my preceptors is ~80 years old, and went through medical school in the 1960s.  He is still sharp as a tack, and quite possibly the most BAMF-ing family practitioner of all time.  He used to do c-sections, hernia repairs, appendectomies, fracture repairs, and get this- emergency burr holes for subdural hematomas (aka neurosurgery).  He stopped ~1997, mostly because he got tired of his morning cases getting bumped constantly for overnight emergencies and throwing off his schedule for the rest of the day when he had clinic in the afternoon.  He has since moved out to Palm Springs, where he still sees more patients than any of his fellow physicians in the group, still does all his own trigger finger release surgeries and SCC/BCC excisions, and still administers the group.  In addition to all this, he is one of the nicest people I've ever met, beloved by his patients.  He truly epitomizes the fading glory days of family medicine, the ideal of the General Practitioner who could truly do it all.



It's a pity that it is impossible for anyone now entering the field to practice like he did.  He could do it all because he learned to do it all during his residency.  And he learned to do it all during residency because he spent his MS3 year delivering 8 babies a shift for 6 weeks, and his MS4 year doing appendectomies and choles on his own.  Why could he do this?  Because his MS1 and MS2 years were spent being taught the use of forceps to deliver babies and how to do a c-section on a cadaver.  After all, what else was there to learn?  The Krebs cycle hadn't been discovered, nor lyme disease.  We had only discovered that smoking might actually be bad for you a few years earlier, and if you had a heart attack or stroke the best hospital would give you about the same improvement in chance of survival as the average hotel- which is to say, none.  Now we have thrombolytics to bust open clots- and to make us qualified to use those drugs, every medical student memorizes the coagulation cascade (only fully discovered in the 1960s) in the first two years of medical school.  This is but one example of the incredible amount of knowledge that we learn.  The vast expansion of medical knowledge has made it impossible for any family practitioner to match the scope of what an old-school physician could (and still can) do, and caused the removal of a lot of practical training from the 1st and 2nd years of medical school curriculum.  The basic science that has replaced it is necessary, but nevertheless it is true that the average medical student is significantly less capable in practical terms than one graduating 50 years ago.

This forms the basis of my proposition: that if we want family practice to TRULY be the general practitioners of old, capable of taking care of 80% of anything that walks in the door, we need to extend the minimum FM residency to 5-7 years in order to fully train all family doctors into competently performing tasks that are now overwhelmingly performed by specialists.  This is the only way of reducing the malpractice threat that forces FP docs to refer so much out that they could manage themselves.  ("Doctor, are you a specialist in the area of ____?  If not, what makes you think you are competent to diagnose and fix this problem instead of referring it out?")

Family Medicine has two pathways in the future.  The first is to stick with the current pathway consisting of 3 years of residency training.  (After perhaps only 3 years of medical school, since apparently the field of medicine that sees the greatest variety of things walking through the door needs 1 year less of medical school than everyone else.  And people wonder why family medicine has a prestige problem...)  This future will see family medicine increasingly take on care-coordination/management of NPs, PAs, and other mid-level providers, with limited direct patient contact.  Most patients will be referred for management of their disease, and most of their job will be spent in the background making phone calls and silently coordinating care between specialists without ever laying eyes on the patient.  After all, how many patients are there that are too complex for a PA but not complex enough that a Family Practitioner can manage it without referral?

The other future is a return to the General Practitioner model of old.  This future residency will be hard, it will involve as many sleepless nights as the busiest neurosurgery programs, and should take as long (7 years).  But at the end, it would produce doctors capable of surgically setting 80% of fractures, putting in burr holes for acute neurotrauma, managing heart failure up to stage IV as well as any cardiologist, doing screening colonoscopies as well as any GI scope-jockey, doing a c-section as well as any Ob/Gyn, and perhaps being able to excise skin lesions from anywhere in the body excluding the face.  The key to all this?  The internet.  The rapid, raging expansion of medical knowledge has increasingly been tamed by a tool capable of harnessing it: the computer, which can provide rapid information and decision support at the point of care: allowing these General Practitioners to provide care that is as high quality as any specialist for most problems.

Which vision will Family Practice choose?  We shall see what the future holds.  As for myself- while I've greatly enjoyed my time on the rotation, I have finished it less likely to go into the field than before I started; filled with melancholy at the reality that extinction will soon claim lions like Dr. George Wilson, MD.  Even should Family Medicine adapt my favored vision of the future, I will never have the option of entering it as my match is just 1 year away.  Here's hoping the glorious legacy of generalist family doctors does not die out in the era of care coordination and medical homes.