The Shrinking Role of Primary-Care Docs

November 11, 2014

Giving up important aspects of patient care has become the imperative for many physicians. But that doesn't make letting go any easier.

Over the last twelve years, my medical career has largely mirrored the plight of family medicine in the United States. I was trained well to do a lot of different things in both the outpatient and inpatient areas. Even though my training wasn't that long ago, things have changed significantly. When I was a resident, I was expected to do everything from a lumbar puncture to an arterial blood draw. We managed and evaluated patients from newborns to nonagenarians and admitted them all. I did my own OB ultrasounds and KOH preps. While I suspect there are many pockets across this country in which family physicians continue to provide that kind of patient care, I believe the numbers dwindle every year.

When I graduated residency and took my first job, I continued to do everything residency trained me to do. I did pediatric and adult hospital medicine, delivered babies, rounded at the nursing home, made home visits, did flex sigs and vasectomies and colposcopies in clinic, and saw outpatients. Since then, I have slowly peeled away parts of my practice until I am now what I thought I'd never become - primarily an outpatient doctor who takes telephone call. For some time, I thought this career path was a sell-out of sorts - giving up too much in the name of convenience, lifestyle, and comfort. If I'm honest, I'll admit some of those were the motivations for giving up aspects of full-spectrum family medicine, but in truth, it was more complicated than that.

The first thing I stopped doing was flex sigs. Truthfully, they were my least favorite procedures and I was happy to let them go. At the time I stopped, colonoscopies were becoming much more popular and quickly developed into the standard of care. I don't even know any family physicians who still do this procedure. Next was inpatient medicine and home visits. Inpatient medicine was something I felt I'd always do because there is something so crucial in the continuity of a family physician caring for patients in the hospital. However, when I changed jobs, the call schedule and practice I went into did not support it, so I turned my patients over to the hospitalists. While I still think continuity suffers when there is a different outpatient and inpatient doctor, I also recognize that a hospitalist can provide a superior level of coverage as they are at the hospital all the time, where I would have to balance rounds and nursing phone calls around a full clinic schedule.

Last year, I gave up OB - a difficult decision, but also one partially made for me by changes to the call schedule. Now the only time I go to the hospital is to round on (healthy) newborns. I've held on to a number of office-based procedures and still follow some nursing home patients. However, our health system is developing a nursing home service, so I suspect in the next few years, that part of my practice will also decrease and possibly disappear.

I can't pass judgment on doctors like me who give up aspects of care they've been trained to provide. Medicine is changing rapidly. I am trying to figure out how I will balance visits in the office with virtual visits, as I suspect this will become increasingly requested by patients. I continue to focus on chronic disease management and try to memorize the increasingly long list of preventive health screenings and the complex, and often controversial, data supporting their implementation (or not). I don't think my residency training saw the world in which I currently practice, so I feel the evolution of my own practice, much like the evolving practice of primary care is necessary.