Family Medicine is Dying, can it be saved?

I hated my job. After nine years of school and three years of advanced specialty training I found myself waking each morning with a sense of dread that only increased as I drove to the office. My job as a Family Physician was nothing like what I had imagined. I had dreamed of making an impact in the lives of patients, counseling and serving others in times of illness and crisis. The clinic to which I was assigned had a different agenda. Relationships did not matter. What mattered was that patients had a doctor to see for their routine health care needs. Who the doctor was did not matter to the patients and who the patient was did not matter to the doctors. My colleagues were more concerned with their days off and going home on time than they were with the needs of the individuals under their care. The physicians in the medical group were all employees and they acted accordingly.

One of my greatest frustrations was my inability to take care of my patients when they were sick. Primary care doctors were not given room in their schedules for same day visits. Every sick patient was sent to an urgent care clinic. Appointments were booked only for routine care and follow up. These routine appointments were hard to get as most doctors were booked several weeks out.

I did not feel at home in such a world. I told others my feeling that if I was not available to patients in their time of need that I wasn’t their personal doctor, I was just a doctor. This was not what I thought being a Family Doctor was about. I took it upon myself to identify spots in my schedule where my sick patients could be squeezed in and I worked extra days to decrease my appointment backlog. My colleagues all took a day out of clinic after each night on call; I decided to forego those days off and work a full clinic day.

In some ways my efforts paid off. Within a few months I had openings in my schedule and patients could schedule a visit within two days. I was the only doctor who saw his sick patients in the office and was seeing 50% more patient visits that any other doctor. I was developing relationships with my patients. Patients loved it but my colleagues didn’t. I found myself ostracized and criticized and I began to look for a job in private practice.

It was my belief that a career in medicine was not meant to be an 8 to 5 job. Patient needs didn’t (and don’t) fit neatly into a schedule. I entered medicine to serve patients and knew that service would at times require putting the needs of others ahead of my own. I started to look for another job, hoping to find a place where my attitudes were valued. When I interviewed for positions in private medical groups I found that my beliefs were welcomed. I was told, “You belong in private practice.”

They were right. Working in private practice has been an incredible experience. The occasional long days, evening phone calls and weekend emergencies pale in comparison to the blessing of helping people in their time of need. The ability to adapt my schedule to the needs of patients, to squeeze people in or add them to the end of a day, has led to truly meaningful relationships. Because I own my practice I have had the opportunity to directly reap the rewards of my labors and also to charge nothing for patients enduring tough times. In my mind this is what being a family doctor is all about.

My mind is apparently out of date. While service may once have been the mark of the Family Physician, those days are disappearing. The new generation of Family Doctors is less interested in personal sacrifice. The goal is a consistent schedule that ends each day at 5 o’clock, a guaranteed salary and no after hours calls.

This change in physician attitudes was brought home recently in a conversation I had with the director of a Family Practice residency program. She bluntly told me that none of the doctors she is training has any interest in a job like mine. Current doctors are most interested in “work-life balance.” They want to help others, as long as they can do it between the hours of 9-5 Monday through Friday. After 5 PM, patients cease to be the responsibility of their primary care doctor and become the responsibility of the health care system, the hospital or medical group. They do not want to be bothered. The fact that patients in crisis will be under the care of complete strangers is perfectly acceptable to the vast majority of doctors and patients.

Therein lies the problem. We live in a world where service and sacrifice are no longer commonly held values. While the increasing complexity of medicine makes it difficult for Family Doctors to take good care of hospitalized patients (when your office is 20 minutes from the hospital you can't respond immediately), the only obstacle to going the extra mile in the office is personal preference. The new generation of physicians seems to prefer not being bothered. In the hierarchy of goals doing one’s best has been replaced by doing enough. For those who work for insurance companies, medical groups and hospitals, enough may be an acceptable goal. Those of us who work for our patients understand that only our best is enough.

If things are going to improve patients will need to become more engaged. One of the main reasons physicians are able to be less available and responsive is that patients accept it. Patients are people and people are creatures of habit, so many patients choose to accept poor service instead of dealing with the perceived hassle of changing physicians. If patient engagement increased, if patients used review sites such as Yelp! to praise excellence and critique poor service, if patients started to vote with their feet and moved to offices with better service, the rules of basic economics would force physicians and medical groups to improve. 

I am beginning to see this on a small scale in my office. Many patients have shown their appreciation on Yelp!, with prospective patients choosing my office as a result. (Hopefully this will continue, if you are a patient reading this, you can make this happen!).

Regardless of what patients accept, what insurance companies pay for or what others do, I am committed to doing my best to serve the patients God has entrusted to my care. To me, a changed life and a "Thank you, Doctor Barrett" are still the best reimbursement there is.

Finally, it seems appropriate to acknowledge that declining service and commitment are not limited to the medical profession. Personal service and caring are declining all around us. We can all complain about it but words are not enough, we need to do something about it. I encourage everyone to repeat the simple prayer I pray each day before as I drive to the office, "God, may I be your hands to today to touch the life of someone in need." And then look for opportunities to see the prayer answered.

- Bart

Thanks for reading and for sharing. Patients, Thanks in advance for the reviews you are about to leave on Yelp! and HealthGrades. :-)  I can be followed on twitter @bartbarrettmd, and can be contacted by clicking the contact button on the page for those who have questions or who are looking for someone to speak to their church or community group. Comments are welcomed.