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Making the case for 'big doctoring' in primary care

To strengthen their role in American medicine, generalists should take a broad view—and speak with one voice

From the December ACP Observer, copyright 2003 by the American College of Physicians.

By Deborah Gesensway

If primary care medicine in the United States is going to survive the subspecialization of American medicine, advocates of generalism need to make their case more forcefully and persuasively to both the public and the government. To help advance that cause, one of the nation's leading advocates of primary care professions has written a book that depicts the wide variety of careers that make up general medicine.

Primary care providers have had trouble advocating for themselves, explained Fitzhugh Mullan, MD, a Washington-based pediatrician and former director of the federal Bureau of Health Professions and National Health Service Corps. In part, he said, that's because primary care is such a fragmented field.

General internists, for instance, have not always seen eye-to-eye with family physicians or with nurse practitioners. Instead, these groups are often better known for fighting with one another over such issues as reimbursement and scope of practice than for presenting a united front to payers and regulators. But focusing on what primary care professionals have in common, according to Dr. Mullan, is a key first step in gaining more clout. "We often know about our own discipline, our own valley, so to speak," he said. "The book is an effort to let people know who lives in the next valleys."

What general internists, family physicians, pediatricians, nurse practitioners and physician assistants share—whether they work in small private practices or large integrated groups—is what Dr. Mullan calls "big doctoring," which he defines as "an approach to health care and healing, a skill set and a mind-set that is called primary care."

In "Big Doctoring in America: Profiles in Primary Care," published last year, Dr. Mullan argues that the future is going to need "big doctors," particularly those who can function as the "general contractors" of health care. These are the broadly trained experts who can help patients navigate a highly specialized system.

"The generalist," he wrote, "will be the human magnet who holds the increasingly centrifugal world of medicine together for the individual."

In an interview with ACP Observer, Dr. Mullan explained why the profiles he has collected give him reason to be optimistic about the future of primary care. After working for 20 years in government service, Dr. Mullan is now clinical professor of pediatrics and public health at George Washington University, contributing editor of the health policy journal Health Affairs and a pediatrician at the Upper Cardozo Health Center in Washington.

Q: You said you initially embarked on the research for this book to test your presumptions about generalism. What did you find?

A: I concluded two things. If the question is, "Is there a vibrancy to generalist practice?" the answer is yes. These individuals are living proof of that, and they aren't alone.

But I also found frustration and discouragement in the medical community, particularly in the generalist sector. Since the mid-20th century, generalism has been on the defensive. Young people in medicine know that this is important, valuable work, but we need policy and political organizing to make the generalist portion of health care in America stronger. It isn't going to happen by itself.

I was trying to raise consciousness that generalists have a great deal in common, more than we normally focus on, and that there is a great deal at stake in terms of organizing and speaking with a more unified voice. Fragmented voices are ultimately not going to be effective in advancing the generalist part of medical culture.

Q: What makes generalism relevant in a medical system that puts a higher premium on subspecialization?

A: There are people who argue it isn't relevant. There is the siren song of medical informaticians who say we aren't really going to need generalists. Their view is that a medical coach, maybe a nurse consultant, and the Internet will be all that is necessary to diagnose the pain in your left flank and send you on your way to the correct specialist.

In addition, breakthrough technologies with very pronounced commercial interests are promoting further subspecialization. For example, implanted defibrillators are an incredible scientific capability and undoubtedly will save a number of lives. But they have nothing to do with your diabetes or depression.

The problem is that the human being is more complicated than a series of specialties. Our end is more than the sum of our parts.

It is going to take public policy to say, "It's all well and good about technology, but we need to invest in training and support for the people who are going to provide a basic glue to hold the system together."

Right now in education and federal reimbursement, which is often mirrored by private reimbursement, we do quite the opposite. We spend more money on specialty training and care, while those who train and practice as generalists do not enjoy the kind of public support that they are going to need.

Q: How did you select the 15 clinicians you profiled?

A: I wanted to talk to generalists who had been around for a while, who had dirt on their shoes, who could tell a good story and were well-informed. I tended to get people who were upbeat.

From a scientific point of view, this is not a representative sample. But I think the interesting story is not that there are people who are frustrated—and there are plenty of them—but that there are people working in this area who see both the importance and joy of what they do.

Q: Are primary care physicians looking for examples of colleagues who aren't burned out?

A: I think so, and it's because the system is hard to work in now. We have abandoned the old solo practice model, but we didn't quite make it to a prepaid group practice team model a la Kaiser Permanente. These are very choppy waters, particularly with all the commercial winds blowing through medicine in terms of reimbursements and referrals.

With the profiles, I was trying to take this amorphous term "primary care" and give some historical and substantive understanding to it. When internists talk about primary care, they often are talking about fairly advanced primary care, including a fair amount of secondary and hospital care. When you have nurse practitioners talking about primary care, they are talking about a strong emphasis on health maintenance. While both are important aspects of primary care, these individuals can sound like they come from alien camps.

Primary care has many colors, which makes it rich, but it also makes it hard for the people working in it to see they are all on one team. It is hard for people to line up together professionally or politically to fight for change. The issues are there: better reimbursement for primary care providers, a standardized primary care curriculum for medical schools, a national institute for primary care research at the NIH, and better professional PR, to mention a few.

Q: In the book, you wrote that many generalists today fall into one of two camps: They work in primary care either because they believe it's a way to promote social justice, or because they see it as a platform for medical "industrial efficiency," such as quality improvement. To choose generalism today, do you have to fall into one of these camps?

A: No, you don't have to be one or the other, but I think those are two important themes. I chose to emphasize them because quality improvement and social justice are very important topics of our time for many people.

A favorite profile from one camp was William Kapla, MD. He's a gay family practitioner in San Francisco who was there when AIDS erupted. And I think that Linda Headrick, ACP Member, [now at the University of Missouri in Columbia involved with quality improvement] is the future in terms of systems improvement thinking.

But I also profiled the old-time general doctor. I think that concept is still relevant, even though I think the solo practitioner form of practice needs to fade out. The best way to provide medical care is probably not by one person working 24/7.

But the idea of big doctoring—the notion that you want to do corns and depression, babies and hearts—is still relevant. It's the desire to take on patients and deal with their problems as best you can and refer when necessary. I firmly believe that the concept of today's generalist needs to remain big.

Deborah Gesensway is a freelance health care writer living in Glenside, Pa.

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