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The end of the general practitioner | page 1, 2
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.
Ask Dr. Bob Dr. Robert Burton, who is a neurologist and novelist, answers health questions every Monday in Salon Health & Body. Please e-mail your queries to him at AskDrBob@ 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.
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