The End of Old-School Family Practice

Via the Healthcare Entrepreneur, today I learned Dr. Steve Harrison is closing his practice in King City, CA. (Image credit.)

King City is a very small agricultural town in central California. I've never been there but the residents in my program used to take care of King City's patients when their own rural hospital, Mee Memorial, couldn't provide needed services. The people of King City and surrounding environs don't have many options for obtaining health care except for a publicly-funded FQHC and Dr. Harrison's private practice.

Dr. Harrison used to come to our resident's clinic and supervise the residents one or two days per month. I always looked forward to his being there, because he offered a no-nonsense, real-life approach to family doctoring. He didn't spend a lot of time agonizing over theory but got right down to what-if scenarios. "If it's five o'clock on a Friday afternoon, what do you want to do?" I can hear him asking.

Dr. Harrison always belonged to what I call the Old School of Family Practice. These days people have forgotten what the original general practitioners, or GPs, used to provide to small communities such as King City: comprehensive medical care across all age groups. GPs used to see adults for sore throats, kids for immunizations, deliver babies, and take care of old folks at the end of life.

When general practice was phased out in the 1970s, it was replaced with the specialty of family practice, which you might think of as general practice academicized. Instead of a year's internship, you now had to complete a three-year residency, in which you learned to do all the things the GPs used to do, but with a greater academic grounding.

I have always been inspired by the Old School family doctors who were my preceptors during residency, Dr. Harrison included. These family docs ran clinics, saw their patients in the hospital, delivered babies, did C-sections and critical care, ran codes and stabilized critically ill newborns for transport. Even in the era of specialization and subspecialization, there was a niche for an Old School family doctor, in remote Alaska or even nearby King City, where the drive to the next largest hospital was two hours.

Despite my original hopes, I am not going to be joining the Old School. I never developed a taste for being in the operating room, and abandoned the pursuit of C-section privileges without regret. I do enjoy providing critical care as a hospitalist, but maintaining and improving my skills in this area has only been possible after giving up primary care--the cornerstone of the Old School philosophy. Furthermore, I no longer take care of hospitalized children, because our hospitalist group consists of internists as well as family doctors, so we have given up pediatric inpatients to the overworked pediatricians in town.

I do not mourn my decision not to join the Old School, because this decision is based in my own preferences and practice style. I do mourn the departure of doctors like Steve Harrison, who is closing his practice due to business factors, including an abortive investment in EMR and a major financial loss after over-purchasing influenza vaccines last year. In other words, his practice failed because he tried to do the right things to keep it going. Now he is exploring other opportunities which may take him into academic family practice or urgent care, but the Old School has clearly lost another giant.

I believe we need to keep the Old School philosophy alive, if only to provide rural areas such as King City with comprehensive care doctors of the ultimate kind: those who are able to manage 90% of the medical problems they see, whether the patient is a newborn or a nongenarian. The alternative--to recruit pediatricians, internists and OB/GYNs enough to staff every rural community--has eluded the best efforts of small towns everywhere.

Comments

[ddx:dx]

People are people wherever you go.

I was a small town old school doc who thought that I could survive the rigors of old school accessibility demands by being in a group of like-minded docs. But we didn't do the work to keep our minds alike, and the pressures of "the system" came to bear. One cannot pencil out paying a family doc $160k if she sees 20 people a day, doesn't do hospital work or babies...So the old guys doing all the procedures don't want to share the cash/compensation flow and we end up getting New school docs and the practice loses OB, hospital work. And the new guys want an average FP income doing outpatient well care...On medicare and medicaid pts.
I still believe excellent care can be provided by old school docs. But they tend to be cowboys, not team builders. And a team approach is the only sustainable answer. I don't think I need to be the best at everything, but just have good judgment and a fund of knowledge. Both can be practiced and worked at. I guess the judgement is the tough one. And the willingness to work together.

But even small towns have bitter, angry people. Maybe even moreso. Last shift I did in this ER an ambulance rolls in at 11 pm on Sunday night with a 78 year old short of breath. He had just been discharged from a neighboring (16 miles away, another critical access 10 bed hospital in a town of 700..."Critical access" is keeping some small town hospitals alive, when maybe some should die...) hospital the day before after a post radiation pneumonia. Lung cancer diagnosed a month ago. The man lived in a tiny town 30 miles from our town and 45 miles from the other where he had been hospitalized. He'd gone home Saturday, now called the ambulance SUnday PM. He rolls in on the gurney, big guy, gasping, holding the O2 mask to his face, cussing.He's pale, gray, talking three words at a time, tachy. But he's glaring at me and angry that the ambulance had stopped here, not taken him on to "his" doctor. In the ensuing 90 minutes of him refusing treatment( a little lasix and he'd be alot more comfortable, 3+ pitting edema)I got the story why he hated this hospital and only wanted care from the one down the road....I sat and watched him pant, called the doc, arranged the ambulance, and listened to his anger.
I had never met this man before. I might never again. It's hard to say where this sort of wasteful, hurtful loathing comes from. I try not to be a part of it... But people are people.

[enrico]

So very sad. Too many people with far more experience and knowledge than I can and have written about this, but what I don't see mentioned enough is that with the death of "old school" medicine is also the death of the "old school" respect and gratitude from patients that such a doc would get as a matter of course. Rural patients have the same Google people in "the city" do, but I doubt they come in with the same haughty "I'm gonna quiz you to make sure you're competent" attitude because they KNOW what they're getting--personalized care on their terms, in their community.

The Dr. Harrisons are not "acceptable losses" to the actuarial tables of modern medicine. I never wanted to be a rural doctor, but spending my time in Mexico and having it be the norm instead of the exception I grew to respect it tremendously beyond the "out of date country doc" stereotype.

There is so much more I could say, but it's all a substitute for "I'm so sad." Dr. Harrison will be fine; the community, I'm afraid, will not.