The end of the general practitioner

When pharmacists know so much, why do we need family docs?

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I get many questions about how to pick a primary care physician, or general practitioner. My answer is that maybe you don’t need to.

Over the holidays, my wife and I were en route to “getting away from it all.” On Highway 62, midway between Yucca Valley and Joshua Pines, Calif., at the crossroads of a one-intersection nameless junction, we ran across a large, freshly painted billboard with bigger-than-life pictures of Dr. X — “A Family Doctor Who Cares and Listens.” He looked like a middle-aged banker with jowls, Ben Franklin glasses and an unduly serious demeanor. Beneath, posted on the front door of the single-story wood-and-concrete clinic, was a small hand-printed sign: “Accepting new patients.”

Across the road in a small strip mall were a home-care and hospice service, an ambulance service, a storefront outpost for the Visiting Nurses’ Association, Rite-Aid drugs and Ruth’s Natural Foods and Herbs, with the carved wooden sign greeting: “FOR ALL YOUR HEALTH NEEDS.” We stopped for coffee at the end store — a cyber-cafe. Inside, two women were huddled over adjacent $5-an-hour terminals, comparing notes as they surfed the Web for treatments for hot flashes.

“What about asking Dr. X?” I asked.

“Dr. X’s a good listener,” one woman answered without looking up from the monitor, “but what does he really know?” The other added, “Yeah, we’re taking our printouts over to Ruth. She’s up on everything.”

I looked out the window at the two competing signs. Ruth’s, at eye level, was hip, cozy, comforting and evoked thoughts of chamomile tea, soft down quilts and feminine wisdom. The doctor’s overhead commercial was overly solicitous, maybe even a bit condescending. Perhaps it was the bleaching effect of the sun, but Dr. X appeared tired and embarrassed.

And perhaps he should be. The days of the family doctor are numbered. Dr. X is on the way out. If you have any doubt, let’s compare his services to those offered across the road from his office.

Take the most serious event of all — a cardiac arrest. Who would you choose to give you CPR — Dr. X, who probably hasn’t performed CPR more than a few times in his entire career, or the paramedic from the ambulance service? And if you had the sudden onset of chest pain would you trust Dr. X’s EKG interpretation, or would you prefer your EKG sent via telemetry (transmission of medical data directly over the phone) to a first-rate cardiologist (a service available at the ambulance dispatcher)?

Or, what if you have a fever and a sore throat and think you need an antibiotic. There are standard algorithms that a nurse practitioner can easily follow. But doesn’t Dr. X know more about potential side effects? He did take year-long courses in pharmacology and infectious disease (many years ago). He dutifully takes annual courses in continuing education, but privately confesses that it’s hard to keep up with the proliferation of new drugs and drug-drug interactions. His closest competitor, Rite-Aid, provides a printout of all possible complications, even a handy list of potentially serious symptoms that should trigger a call to your doctor. And the Rite-Aid’s computer is continuously updated with the most recent recommendations culled from the latest clinical trials.

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Quickly run through a list of the most common ailments about which we consult our family doc and the point becomes obvious. Lest we forget, the treatment of GI upsets and arthritis was once the mainstay of outpatient practice. Now you can get over-the-counter stomach acid blockers (Tagamet and Pepcid) and a bevy of non-steroidal anti-inflammatory meds (Motrin, Aleve, Nuprin). Dr. X can prescribe higher doses of ibuprofen than those available at the arthritis counter, but you do not have to be a rocket scientist to double the recommended dosage of Motrin. And if we want reassurance, we can watch Nolan Ryan or Jimmy Connors testimonials.

What about minor surgery? Forget it. Malpractice insurance for the smallest procedures is prohibitive. Besides, there’s a glut of well-trained, board-certified general surgeons. The same goes for delivering babies. Uncomplicated deliveries are easily handled by midwives; high-risk births require fancy monitors and specialists, including neonatologists and pediatric surgeons.

If you want advice on nutrition or alternative care, Ruth has row after row of untested remedies probably equal to whatever placebo effect Dr. X can drum up with his kindly, concerned bedside manner. Dr. X does have a corner on the psychiatric drugs, from Valium to Prozac, but St. John’s Wort is already making inroads.

Dr. X has narcotics. Ruth and Rite-Aid sell magnets.

Most HMOs already use nurse practitioners for much of primary care, from triage screening and vaccinations to common ailments such as back sprains and even the management of diabetes. And in many instances, nurses have replaced G.P.s in making house calls. They are equipped for providing post-op rehabilitation and physical therapy, home IVs for antibiotics, parenteral nutrition, and, if all else fails, hospice care.

What additional magic can Dr. X pull out of his black leather bag? I still have mine on a shelf in my office, but patients look at it as a curiosity. Some inquire if I got it at an antique store.

The domain of the family doctor (general practitioner and internist) is inexorably shrinking, even vanishing. Whether this is good or bad or a mixed blessing for the patient is irrelevant. The comforting horse-and-buggy image of the family doc is ancient history.

But aren’t we overlooking the real primary purpose of the skilled G.P./internist: to distinguish between the minor ailments and the complaints of the worried well vs. the potentially serious and life-threatening conditions? Isn’t his clinical skill of value?

Evidence-based medicine (objective evaluation of results) hasn’t been particularly kind to the notion of gut-feeling or the experience-based hunch. In evaluating a child with acute abdominal pain, the skilled surgeon hasn’t been shown to be any better than a computer at predicting which patients will need an appendectomy. In a famous study of patients admitted to an E.R. with acute chest pain, a world-class cardiologist provided less accurate EKG-based prediction of a heart attack than a computer. And family docs can’t be expected to do as well as the surgeon or cardiologist.

Each new study comparing clinical skill to a prescribed algorithm leaves the doctor questioning his own abilities.

What about the early detection of cancer? Self-breast exams, properly done, are probably as good as the annual exam, and can be done in conjunction with mobile mammography. We can test our own stools for blood with kits from Rite-Aid. A nurse can do a pap smear.

Even the annual physical is coming under attack. Envision a Norman Rockwell G.P. with one hand on your shoulder while he listens to your chest with his stethoscope. “Breath in, breath out.” (Sounds a bit like yoga, and maybe has the same intended effect?) I asked a young Harvard cardiologist the value of a stethoscope in this day of echocardiograms and angiograms. He shrugged, thought a minute, and said asymptomatic heart murmurs could be detected, though the diagnosis needed to be confirmed by imaging studies. (I took a one-year course in physical diagnosis, but can’t remember the last time that my standard exam discovered anything of consequence.)

Sound extreme? Sure there are examples of a diligent exam being of value, of a shrewd physician picking up an unexpected finding. (Most M.D.s take great pride in just such rare occurrences — these are the exceptions that keep most of us going.) But, overall, the stethoscope is primarily for show, a tool of reassurance akin to a shaman’s rattle.

Med school plus postgraduate family practice/internal medicine training is, on average, seven to eight years. Who will be attracted to such a field? We talk glowingly of those doctors who love their patients, aren’t in it for the money, work pro bono in inner-city clinics. But do they have to be doctors? Couldn’t a nurse practitioner do as much, consulting when necessary with Internet specialists and the Rite-Aid pharmacy computer?

In the last 15 years, medical schools have gradually shifted from training specialists to training primary care physicians (because of a glut of specialists and a huge maldistribution of primary care providers). Yet isn’t the entire concept of a family doctor an anachronism?

Assuming that the field continues, who will be the primary care doctors of the future? My friends on medical school admissions committees tell me that the applicants are better than ever, that their MCAT scores are higher, their grades better. Maybe so, but I cannot imagine this trend continuing. Even if it does, the better students will veer off into research and specialization; it will be increasingly unlikely to find the best, the smartest, most curious students volunteering to be governed by algorithms, to defer to paramedics, pharmacy computers and health store clerks.

A final note: I love my family doc. He is clinically superb, comforting, readily available — everything you could ask for. If you are reading this, please accept my apologies. This is not personal.

Robert Burton, M.D., is the former chief of neurology at Mount Zion-UCSF Hospital and the author of "On Being Certain: Believing You Are Right Even When You're Not." His column, "Mind Reader," appears regularly in Salon.

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