Timothy J. Hoff - Searching for the Family Doctor: Primary Care on the Brink

SEARCHING FOR THE FAMILY DOCTOR

Primary Care on the Brink

TIMOTHY J. HOFF

JOHNS HOPKINS UNIVERSITY PRESS | Baltimore

2022 Timothy J. Hoff

All rights reserved. Published 2022

Printed in the United States of America on acid-free paper

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Johns Hopkins University Press

2715 North Charles Street

Baltimore, Maryland 21218-4363

www.press.jhu.edu

Library of Congress Cataloging-in-Publication Data

Names: Hoff, Timothy, 1965 author.

Title: Searching for the family doctor : primary care on the brink /

Timothy J. Hoff.

Description: Baltimore : Johns Hopkins University Press, 2022. | Includes

bibliographical references and index.

Identifiers: LCCN 2021017978 | ISBN 9781421443003 (hardcover) |

ISBN 9781421443010 (ebook)

Subjects: LCSH: Primary care (Medicine)United States. | Family

medicineUnited States.

Classification: LCC RA427.9 .H642 2022 | DDC 362.10973dc23

LC record available at https://lccn.loc.gov/2021017978

A catalog record for this book is available from the British Library.

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To my wife Sharon, and son Kieran, who are everything to me

I am a Family Physician,

one of many across this country.

This is what I believe:

You, the patient, are my first professional responsibility whether man or woman or child, ill or well, seeking care, healing, or knowledge.

You and your family deserve high-quality, affordable health care including treatment, prevention, and health promotion.

I support access to health care for all.

The specialty of family practice trains me to care for the whole person physically and emotionally, throughout life, working with your medical history and family dynamics, coordinating your care with other physicians when necessary.

This is my promise to you.

The Family Physicians Creed

The Family Doctors Role in the Primary Care War

There is a fight going on for the soul of not only American health care but health care everywhere. Primary care is at the center of this struggle, the essence of which is the unresolved tension between two different goals. One goal is a fair, empathic, and highly relational care delivery system, built around primary care and trusting relationships between doctors and patients. Another goal is a more efficient, convenient, and highly transactional care delivery system, impersonal and built on algorithms, health care corporations, and technology. The former needs family doctors to succeed. The latter probably does not, relying instead on business thinking, scale, cheap labor, and technology.

Make no mistake, this is an escalating war with combatants joining both sides. The COVID-19 pandemic has accelerated it by providing further rationales for minimizing the imperfect equation of using humans in health care delivery and embracing the transition to technological solutions instead. This will be a war that is fought in health care over the next several decades, and there will be lots of casualties. One combatant fighting on the side of relational primary care and the role of doctors, particularly general doctors, is the specialty of family medicine. Born out of the chaos and opportunity of 1960s America, this specialty has tried to position itself at the center of primary care medicine in the United States. For over fifty years, it has been selling us the idea that a comprehensive physician who can manage care and who sees all patients as unique, whole individuals has immense value. This specialty has grown since the late 1960s, has had success, has been bogged down, has languished at times and briefly flourished again, and now exists in a precarious state. It has experienced an ongoing identity crisis related to what it wants to be and can be in our health care system. But it remains vulnerable to assaults from health care corporations and technology companies seeking health care as the next profit-making frontier.

There are approximately 223,000 primary care physicians in the United States, which is almost one-third of all physicians. Almost 90,000 of these primary care physicians are family doctors (Peterson et al. 2018). It sounds like a lot, but it is nowhere near enough to bring the vision of the generalist doctor and holistic care to everyone in America. These foot soldiers of the primary care army are turned out annually into a medical specialty that has tried in the past to pitch itself as counterculture, providing pushback against the overly procedural, highly specialized, and fragmented care delivery system which has been ascendant since the 1960s.

It does not seem like a fair fight in many ways for 90,000 family doctors scattered across the United States to take on even larger numbers of procedural specialists, the Amazons and Apples, and big health care organizations that tower like moated castle kingdoms over our countrys landscape. It is an army that cannot seem to grow any larger, whose core identity is suspect, whose ranks are balkanized, and whose resources and control on the ground weaken with each passing day. Especially over the past couple of decades, when the health care system in America continued to underpay for and underinvest in primary care, encouraged system fragmentation that makes the family doctors job harder, and became enamored with technology and retail thinking.

Why should we be interested in this war and who wins? Why should we care about the future of family doctors as a viable army to win the war for the side of physician-centric, primary care medicine? On a big-picture level, health care is another example in modern society of a service industry overrun by innovators thinking they can provide better care for patients than doctors. Doctors are under threat and increasingly marginalized through the Amazoning of health care, where the large corporation controls everything upstream and downstream in the production process. Family doctors are first in the crosshairs of that powerful idea because family doctors stand in the way of big organizations taking over health care. As these doctors go, so may go other types of doctorsalong with the notion of a health care delivery system with the physician-patient relationship and physician expertise at its core. The ideal of a comprehensive or generalist doctor who can manage our care and needs holistically could vanish.

These types of doctors, and the primary care medicine they practice, are eminently important for all of us to lead longer, happier, and healthier lives. The research shows that, as does common sense. The kind of medicine family doctors dispense is focused on preventing disease, keeping individuals healthy, improving the health of communities, and taking care of health problems before they spiral into bigger problems. The best family doctorpatient relationships have high degrees of interpersonal trust, empathy, mutual respect, and loyalty. These features have been shown over time to be vital to improving peoples health. It is not just the kind of medicine that counts. It is the human-to-human bonds that family doctors form with their patients which positively impact patient care. It is the notion of health care as a humane enterprise, typified not by decisions around what is most efficient and least costly but rather around what is most caring and conducive to patient needs. This is why the war is so important.