For most of us the term “Family Doctor” brings up images of Dr. Marcus Welby, the quintessential family doctor. There are almost no Marcus Welbys left out there, but there are thousands of family doctors in small practices that still have personal relationships with their patients and their families. Most of these physicians chose medicine for all the right reasons and most are frustrated with a system that seems to perversely sabotage their desire to provide quality care to the families in their charge. These days we are witnessing what could be the beginnings of major healthcare reform in this country. Will this also inadvertently be the beginning of the Industrial Revolution for primary care? Are we looking at Institutions of Primary Care replacing the solo family practitioner? At first glance it seems that in the name of efficiency and cost cutting these institutions, or mega-clinics, make perfect sense. After all, no one can dispute the achievements of the Mayo Clinic. Similar consolidation occurred in almost every sector of the economy in one form or another. The corner bookstores are all but extinct and the same is true for mom-and-pop grocery stores and pharmacies. It usually starts in the city and then Wal-Mart completes the process in small-town America.
There is much talk these days about medical homes. At first I thought that Marcus Welby was the perfect medical home. He was accessible to his patients day and night. He was there when the babies came and when it was time to accept the inevitable end of life, providing hope and comfort and sound medical advice devoid of unnecessary expensive tests and heroic measures. His patients trusted him and they were very likely to accept his prescriptions for changes in lifestyle. He coordinated all their care with hospitals and specialists. Sounds like a medical home to me. However when you begin reading today’s definition of a medical home, you quickly realize that Dr. Welby would not qualify. He simply didn’t have enough staff. The solo doc in rural Nebraska of today will not qualify either. And then there’s the technology question. Dr. Welby’s definition of technology was a stethoscope. Today’s medical home requires technology beyond Dr. Welby’s wildest imagination. For over a decade, HIT vendors peddled EMRs at exorbitant prices and failed to convince doctors in small practices to purchase anything. Maybe because the value proposition to the physician was nonexistent. Today we are about to make these certified, overpriced and, by and large, unusable products mandatory for medical homes and the practice of medicine in general. The solo doc in Nebraska cannot afford these products even if the government is proposing to eventually bear some of the financial burden.Are we saying that a medical home should by definition be a mega-clinic with deep enough pockets to bear the costs of arbitrarily imposed staffing models and dubious software purchases? Shouldn’t the choice of tools, whether staffing or technology, be left to the physician? Is anybody consulting America’s practicing physicians on how best to practice medicine? Are we absolutely certain that large institutions will provide all around better quality of care? I fear that the independent family doctor is going to go the way the corner bookstore went, and be replaced by the cold, impersonal, shiny mega-clinic chain in the city. It won’t be long after that before Wal-Mart sets up the Wal-Health clinics in rural America. Any young kids out there planning on going to medical school and hoping for an illustrious career with Wal-Mart?
Margalit Gur-Arie is COO at GenesysMD (Purkinje), an HIT company focusing on web based EHR/PMS and billing services for physicians. Prior to GenesysMD, Margalit was Director of Product Management at Essence/Purkinje and HIT Consultant for SSM Healthcare, a large non-profit hospital organization.