It is almost impossible for me to believe that my views on primary care in the United States have changed so radically in fifty years. When I graduated from medical school in 1961, I was determined to become a primary care doctor. I completed residencies in both medicine and pediatrics to prepare for a career as a general physician in rural Vermont. That dream was put on hold by an unexpected opportunity to develop and lead a section of general internal medicine at a major medical school.
I believed then that the best way to deliver primary care for adults was through physicians thoroughly trained in internal medicine. As a result, we built and developed a Primary Care Center that housed required primary care clinics at the medical school and the local Veteran’s Administration Hospital, and was staffed by faculty, medical residents and medical students. We had high hopes of stimulating interest in primary care in the residents and students who participated. That did not happen.
As the years went by, I was disheartened to see so many internal medicine residents abandoning the idea of general medicine practice to pursue subspecialty training instead. Each year, fewer medical students chose residencies in internal medicine. General internal medicine, that once was the backbone of American medicine, had lost its appeal to many of our most able future physicians. Although many critics lay the blame on the low reimbursement and demanding work-loads of primary care; or on excessive educational debt; or on the lifestyle associated with primary care, I believe that there is another, possibly more important, force at work.
The world of medicine is a very different place today than it was when I chose primary care in 1961. Young doctors-to-be are captivated by the remarkable scientific and technical advances in science and medicine that have occurred in recent years. Many of these discoveries offer paths to early diagnosis, extension of life, or even to potential cures for patients. Unfortunately, despite its importance, primary care does not do well competing for trainees who increasingly prefer these exciting new opportunities in medicine and surgery. Sophisticated technologies such as joint replacement, organ transplantation, angiography, endoscopy, amazing new imaging modalities, robotic surgery, and designer drugs that target specific molecules are just a few of the many attractions that trump primary care for many young graduates.
During this same period, a growing army of very smart nurse practitioners, nurse midwives, and physician assistants has flooded the health care scene, many in primary care. For the past few years, I have had an opportunity to work beside some of these caregivers at a community health care facility in New Haven. I am greatly impressed with their knowledge, dedication, clinical skills, clinical judgment, and overall competence to manage the full range of primary care medicine. They are also interested and enthusiastic about disease prevention. They are happy and eager to work with physicians to care for patients who need more complex care. In marked contrast to my earlier opinion, I have now come to believe that, with adequate training and supervision, the future of primary care medicine is in their hands.
In the decades ahead, it is likely that the main role of the generalist physician will be to supervise those providing primary care and to personally care for patients with complex illnesses who are hospitalized, an idea already well established as the hospitalist movement. No physician today can master all medical and surgical subspecialties. The continued expansion of medical knowledge and technology will demand that even more specialists are trained to cope with them. These areas will continue to be a magnet for young graduates, pulling them away from primary care. The challenge will be to successfully integrate a new primary care system that relies more heavily on nurses and PAs with specialty-based medicine, hopefully through health care reform and the help of a universal electronic medical record.
Robert H. Gifford is Professor of Medicine (Emeritus) at Yale University School of Medicine. This article originally appeared in Primary Care Progress Notes.
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