Two physicians lamented the decline of primary care in Yale Medicine [“Taking the e-road,” Autumn 2007]. Having been a primary care doctor for over 30 years, I felt compelled to respond.
Robert P. Gerety, M.D. ’52, correctly pointed out that the practice model of primary care began its decline as long ago as 1968. Clearly, primary care never found a comfortable fit within the medical hierarchy despite the continuous public outcry for over 50 years for more general practitioners. American medicine is research-oriented; because primary care is practice-oriented, it has received second-class status and will remain there until the focus of American medicine changes.
But there are many other reasons why primary care is attracting fewer practitioners than ever. Over the past few decades health insurers have overburdened primary care doctors with administrative hassles that consume an inordinate amount of time. Unfortunately, the doctors are not paid for the extra time they put in on administrative work. Some studies estimate that administration consumes about 20 percent of their time. Being underpaid by insurers forces primary care doctors to see large numbers of patients in order to survive. The large number and broad spectrum of patients and diseases greatly increases the physicians’ risks of making errors and intensifies their exposure to malpractice suits.
Although Gerety believes that house calls disappeared because people stopped asking for them, I think that doctors stopped making them because they were overburdened in their offices and because the complexity of modern medicine made house calls a source of medical liability. Clearly, medicine had become too complex for the family doctor to “do it all.”
The answer? A new model of primary care is needed—one that takes into account the realities of modern medical practice. The scope of the family doctor has to be redefined. Also, the medical malpractice system needs reforming. It’s too adversarial. Finally, health insurers have to be regulated. Their philosophy of profits before patients has completely transformed medicine from a profession into a business; as a result demoralization among doctors is widespread.
Family doctors can make a comeback, but their return will take work on many fronts.
Edward J. Volpintesta, M.D.