Why I Left Primary Care, Part 1: The Dream of Family Practice

I stopped seeing patients for primary care late in 2007, after having struggled to balance hospitalist, OB call and clinic responsibilities for almost three years.  Now I am a full-time hospitalist and I also contribute to the prenatal care and call-sharing for my clinic's perinatal program.  It's been about a year since I made the big change and I often find myself thinking about my past and future in primary care, so I've decided to discuss the topic in a short series of posts.  Today I want to talk about what I like to call the Dream of Family Practice, an ideal of clinical medicine which inspired me to enter family medicine oh so many years ago, and which served as a clinical framework for my entry into a primary care specialty.

So what is the Dream of Family Practice (DoFP)?  Some components:

• Community health anchored by the services of family doctors, rather than specialist and subspecialist care.
• "Womb to tomb" spectrum of care:  seeing everyone from newborns to nonegenarians in practice.
• Wide scope of service, or "doing it all":  Providing office-based and hospital care to the full spectrum of patients, including inpatient management, procedures, attending births, and surgical privileges depending on interest.
• Community service and leadership, such as volunteering to be high school sports team doctor, promoting local health care initiatives and access, and serving on hospital and community boards.

In the DoFP, family doctors represent the health of families and the community.  They are everywhere, not just hidden away in office complexes.  The also do everything, so many people may say of their doctor, "He delivered my daughter and was with my dad when he died."

I suppose at its heart, the DoFP presents a Rockwellian utopia of medicine, but I had contemporary examples of its existence too.  When I was a third-year medical student I accompanied a family doctor on his outreach rounds to one of the more remote Native American reservation communities near his office practice.  We met with him and a nutritionist representative of the Women, Infants and Children (WIC) program and piled into a van for a long, winding, hour-long drive up difficult mountain roads.  I remember almost getting carsick.  I also remember the profound, demoralizing poverty of that remote community, where obesity, poor nutritional quality, and alcoholism had taken deep root.  But the businesslike, practical approach of the doctor and the WIC counselor impressed me.  They bustled from house to house, checked blood pressures, reviewed diet quality and blood glucose logs, dispensed antihypertensives, listened to children's lungs and looked in their ears, and a hundred other things I'd only ever thought possible in an office setting.

At one house, we found a young mother who was worried about her 9 month-old who'd had a fever and not been eating well for several days.  The infant's temperature was 103 and she was breathing fast and audibly wheezing.  The doctor gave her an anti-pyretic and nebulized albuterol, but she still had significant chest wall retractions with each breath.  We made lightning rounds at the neighbors, piled baby and mother into the van and rushed back to town so the child could be seen in the ER and ultimately hospitalized for a pretty bad RSV bronchiolitis.  As we rocketed back down the winding mountain road, I remember thinking how gritty and exciting it all was to do work that was so fundamental to people's well-being, even if all a doctor could do was offer imperfect solutions to profound problems.  At least family doctors were out there trying, getting their hands dirty, bearing witness to what other professions only theorized about:  illness, poverty, human depravity, institutional neglect.

There were other instances of the DoFP in action: a family practice clinic located only steps away from a tiny rural hospital, so the doctors ran back and forth seeing patients in clinic and evaluating others in the Emergency Room; a family doctor in private practice who made rounds on his patients in the hospital, assisted a hysterectomy, and delivered babies; and the strangely awe-inspiring sight of the rural hospital at which I went on to do my residency, from whose parking lot I could see the itinerant farm workers, who would make up the majority of my patients, picking lettuce in the densely-planted fields of the Central Coast.  Each experience convinced me the DoFP was the only worthy goal for a doctor to pursue, and so I planned my path to become a rural family physician.  How the dream and reality measured up to one another will be the subject of a later post.

Comments

[sara]

Oooo please hurry so maybe I can see where I'm about to go wrong in making my choices based on the DOFP.

[James Hubbard, M.D., M.P.H.]

I practiced in my hometown for 10 years. It was fulfilling in a lot of ways. But very time-demanding. The only way I was not on call was to leave town.

[pat]

I'm a PA who started in 1978 in California....very familiar with your neck of the woods and did some of my early rotations at your local free clinic. Worked for a solo FP for 6 years who did it all. We had an incredibly satisfying practice and he was a really really good doctor (note past tense). Of course, he almost went bankrupt once, was sued multiple times, eventually bought out by MajorHealthCompany of NorCal (read your posts about "the other hospital"), went back and got his MBA and now runs an HMO. We both used to spend huge amounts of time with patients, occasional house calls, hospice care, all of that stuff. I started at $15/hour without benefits or vacation. Family docs were lucky to make 50K a year. I cried when I left.

Fast forward.........30 years. I work in an urgent care, average time per patient 6 -8 minutes, and at the end of a very busy day, I realized that I had become one of the people that most discouraged me about medicine 30 years ago, and definitely not the kind of provider that encourages new "recruits" to primary care. All of my old colleagues are now retired or doing derm or esthetics. But, we are much in demand and can make a healthy six figures. Go figure!

[Med Student Jared]

The post above kinda made me weep.

[Phledge]

Sara, word. All the PCPs I talk to say specialize, specialize, specialize...wonder why?