What Matters in Medicine?

What Matters in Medicine?
Indian Health leaders must realize that

it is in our national interest to maintain a robust primary health care

system. Some see it as a solution to the unsustainable rise in health care

costs, which gathers steam like a runaway train as baby boomers board

for their golden years. Lawmakers, corporate executives, and health care

officials are paying close attention to studies that demonstrate higher

rates of preventive care, improved health outcomes, and lower overall

costs for health care delivery systems that integrate a strong primary care

Component.

I hope to flesh out the work of primary care,

but not from the perspective of an advertising agent, systems analyst,

policy maker, or corporate executive. My view comes from the clinic, and

from living among my patients for most of my professional career. I believe

that the delivery of timely, appropriate, effective, and personalized

care can be achieved, and at a substantial savings in cost. But to do so,

we all need to share in the inherent risks and responsibilities of “getting

better” and to reexamine our biases about health and disease
Decline of the GP

Until World War II, there was only one kind of physician, the generalist,

who was trained as both a general physician and a general surgeon. In

1940, more than three-fourths

of doctors in active practice called themselves

generalists.2 But World War II and its escalating need for tighter

governance and greater specialization altered the landscape of American

medicine.

Specialty boards had, in fact, emerged much earlier—slowly

at first

and then with gathering momentum. Ophthalmology broke the ice in

1916, followed by otolaryngology in 1924, obstetrics and gynecology in

1930, and dermatology and syphilology in 1932. Pediatrics, orthopedic

surgery, urology, radiology, and the combined disciplines of psychiatry

and neurology created specialty boards in 1935, and internal medicine,

pathology, and surgery followed suit in 1937.

During World War II, physicians were organized according to specialty

board, and board-certified

physicians commanded a higher rank

and pay scale. The Veterans Administration paid board-certified-physicians

25 percent more than non-board-certified-physicians,

argued

strenuously for the revival of the generalist physician. This ultimately

led, in 1969, to the approval of family medicine as the twentieth medical

specialty. But it did little to redress the growing imbalance—in

numbers,

prestige, or salary—between

specialists and generalists. By 2008, primary

care physicians (family physicians, general internists, and general pediatricians)

represented only a third of the total workforce actively involved

in patient care.4 The ratio of generalist to specialist physicians in training

fares worse: only a fifth are preparing for practice in primary care.

The causes of the current crisis are multiple and complex. Physicians

in training, under the tutelage of highly specialized clinicians and

surgeons, are given a clear (if implicit) message about the institutional

disregard for general practice. Many rural rotations expose the country

doctor as someone who is overworked and underappreciated. The practice

of primary care requires a temperament and skill set that admission

committees in medical schools typically undervalue: a mastery in

problem solving rather than memorization; an affinity for teamwork .
 It is not enough that researchers, social scientists, and health care
administrators appreciate the value of primary care. Medical schools
and training programs, as social servants of the constituencies that fund
them, are politically and morally obligated to redress the imbalance they
helped create. Patients themselves should act on their enormous stake
in the survival of primary care. They could exercise their considerable
political muscle