The End of Dr. Marcus Welby

Marcus Welby hard at work 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.

Categories: Uncategorized

Tagged as: ,

14 replies »

  1. We have a choice as patients. We can see doctors who have the time to answer our questions. We can see doctors who use intuition with the facts to come up with a medical diagnosis’s. Fancy machines have their place but they tend to be the first option used by doctors. We can see doctors who treat us as human beings not as a number. Some have started the practice of having the nurse call you (to see the doctor) by number because of privacy concerns. We should be called by name not a number. We can see doctors who show empathy.
    I now see a Naturopathic Doctor and the contrast could not be more startling. She has time to answer my questions, to go over a test result with me, and show empathy. She will not see me for any time less than 30 minutes. This gives her and me enough time to have a productive satisfying appointment. It is a win-win for both of us. I prefer this and you should also. After all (and this is key) it is our health and our life we are talking about!
    And since we started this discussion by talking about Dr. Welby let us end this discussion by talking about him. According to an article in McCall magazine many years ago Robert Young (who played Dr. Marcus Welby) was at a convention of family physicians when a doctors came up to him and said, “You’re getting us all into hot water. Our patients tell us we’re not as nice to them as Doctor Welby is to his patients.” Young didn’t mince words. “Maybe you’re not,” he replied. I read another article where at a doctors convention after being told by doctors, “Patients tell us we are not like Dr. Welby.” To this Young replied, “You should be.”

  2. I’m glad the people are in morning for the by gone days of a family doctor who cares for you. That is all well and good if you have insurance that can pay for such care. Well I don’t have insurance and yes I work, but can not afford insurance at all. I wish life was perfect and we all had a “Marcus Welby”, at the other end of the phone, with his concerned looks. I just want be able to see a doctor, weather they care or not, to see me when I get sick. I am lucky right now, I am very healthy, but I wonder anytime I get sick.
    May be in this economy I am thinking like this because the only jobs I can get is contract jobs. But this has been going on for the last two years. I am starting to think America has changed and not for good. Why should I accept that you can get the care you want, but I can not. I do not think I can live with that. Want I can live with is, your care can be reduced so I can get care. I think I can live with that.

  3. Good questions, but I can’t answer them. I have minimal knowledge of the politics of the AAFP.
    I feel that the AAFP has done a increasingly poor job of representing the interests of practicing physicians. There seems to be real unwillingness to confront third-party payers and the AMA about the obvious factors that are killing primary care. Most physicians I know think that the “medical home” concept will be very harmful to all but the largest practices.
    I’m criticizing from the outside: I’m no longer a member of the AAFP, so everything I say needs to be taken with a grain of salt!

  4. Dr. Watkins, why is it that physician organizations like AAFP and many others, are not advocating for their constituency? Or are they?
    Is the leadership misguided, incompetent or just plain disconnected from its members? Are there personal gains involved?
    Is the leadership in these organizations elected by members? How are decisions made, like endorsing CCHIT, for example?

  5. Dr. Oates, the demise of the primary care physician has been well documented, and is the result of multiple factors: 1)shrinking reimbursement 2) medicare’s emphasis on paying for procedures rather than cognitive problem solving 3) unrealistic mandates such as the “medical home” which reduces primary care physicians to the role of supervisors of Nurse Practitioners and Physician Assistants 4) the emphasis on defensive medicine, such that most complicated patients are farmed out to specialists 5) the belief by the overly entitled American patient that ONLY specialists are capable for caring for them.
    So, yes, there is very little money left for expensive EMRs, their upkeep and maintenance, and extensive training that is required. The EMR mandate is another nail in the coffin of primary care.

  6. Good post. As you indicate, one or two difficult prescriptions can eliminate an entire week’s worth of efficiency gained through e-prescribing.
    At this point, e-prescribing is another technology in which almost all of the gain goes to the payers, and the physician is left with the expenses.
    This is an example of why so many of us feel that our professional organizations (such as the American Academy of Family Physicians) are acting as marketing departments of the EMR industry and are thus actively hostile to the needs of practicing physicians!

  7. Dr. Oates, I agree that the demise of the small practice has been discussed before. However, today there are several things happening simultaneously that when combined may render the primary care small practice business model unsustainable.
    For one there is the ever decreasing Medicare reimbursement. The universal health coverage, which I believe is a good thing, will by definition require further cuts in either coverage or actual reimbursement rates. We can only hope that the cuts will not be applied indiscriminately across the board, but there’s no certainty of that. I’m not sure how much more decline in revenue can a primary care physician absorb before he decides to shut the doors. Large clinics, as you pointed out, can adjust better.
    Then there’s the EHR push. Sure, we can hope (again) that reason will prevail and the meaningful use and certification definitions will be simple enough to allow a small practice to acquire and use such tools. I am not at all certain of that. The CCHIT crowd is pretty powerful and many corporations have vested interests in forcing doctors to use these “big” tools, and corporations almost always win.
    Even if we look at the “lightweight” EHR requirements being proposed, what exactly is there that directly benefits the physician?
    Let’s look at e-Prescribe, which according to all (cats and dogs) is a must:
    It definitely benefits the payer, since they get to advice the precriber on what he should prescribe at a lower cost to the PBM.
    It certainly benefits the pharmacy since unlike fax, there’s no data entry needed on that side.
    May slightly benefit the patient, since the prescriber can see medication history (not including cash items, and only if the coverage is verified)
    How about the doctor? Well, he gets to spend an additional 30 seconds (on average) examining coverages and selecting the cheapest alternative. Here’s a benefit: the renewal requests now come in electronically, no more phone calls. Just click on a button and renew, right? Well, not always. If it’s a controlled substance, you have to decline the request and go back and create a paper script, only the patient is not here… hmmmm… so why are the pharmacies sending controlled substance requests? Because it’s the easiest way for them and let the doctor sort it out. Here go another 30 seconds.
    Do this 20, 30 times a day and it translates to one less patient they can see every day, and that is just for e-prescribing.
    Now, I’m not saying that we should stay with paper. All the lofty goals of interoperability and electronic data exchange are valid and positive in the long term.
    However, the technologies are in their infancy and some pain needs to be expected. So, unless we are hell-bent on the extermination of the small practice in the process of creating this brave new world, we must make sure that physicians in small practices are properly supported in this transition. Large, multidisciplinary clinics will be able to offset the costs. Solo docs will give up in despair.
    I’m not talking about giving them money to purchase fancy tools. Both you and I know very well that perfectly adequate tools can be obtained for a very reasonable price.
    There needs to be recurring compensation for loss of productivity and serious incentives for engagement in care coordination and maintenance of good electronic records.
    The reimbursement model must be changed in a “meaningful” way before we define “meaningful use” (to payers, patients, public, etc.). It’s an investment that will pay off, if we really want to provide quality care to all Americans, not just those that happen to live two doors down from the Mayo Clinic.

  8. “Like any good EMR vendor will tell you, you have to get the underlying processes right before you design the IT system. We must look at the delivery system before we invest in IT. Everyone, particularly the Obama administration is looking for a quick fix. They will be disappointed.”
    Good point. Actually any good IT person will tell you that. If you’re looking to automate a lousy process, you get a lousily automated lousy process. If we’re going to do this, we have to start with basic principles, which we’re not ready to do. The question is simple: Do we force everyone to prove that they deserve medical care based on what value our arbitrary society chooses to set on that person’s contributions? Or do we finally say that every person is equally deserving of the attention of a doctor?
    Because, in a “free” market, in theory, a doctor treating someone having a heart attack could set a value of his/her attention based on what the market would bear.
    Imagine arbitrage in the ER. Silly, I know, but it illustrates why market-based medical care payments are equally so. Just pay the Docs to do the job. Pay the nurses to do the job. Pay technologists to do the job.
    What’s the job? To heal the sick. To advise wisely. To respond to need.
    Not sexy and bankable, I know. But necessary. Care is necessary, not optional, and threats of dire financial outcomes are no substitute for considered action.

  9. As with Walmart the lure of “low prices” will kill small business before people realize what they have lost, and then, having forgotten what they had, accept the “new” reality as the best it can be. Quality care continuity with a well trained and insightfull person (the doc) IS the best healthcare model I can think of. “Minute Clinics” come from a desire to make better bucks faster from an expensive system where PCPs have been financially marginalized, not from a desire to provide better healthcare.

  10. Hi! I thought your blog was cool and will visit often. In the meantime I can recommend women’s sexual health.

  11. If PCPs were paid appropriately for cognition, it wouldn’t matter what size group they belong to. They would spend more time with patients and better coordination of care would result. The more specialties and subspecialties we create, the more complex and uncoordinated the system becomes. There are too many hands touching patients within the system.
    Like any good EMR vendor will tell you, you have to get the underlying processes right before you design the IT system. We must look at the delivery system before we invest in IT. Everyone, particularly the Obama administration is looking for a quick fix. They will be disappointed.

  12. The notion that small and independent medical practices are on the way out has been a recurring theme that cycles up and down. I remember in the early 90’s when managed care ensured their demise. Late in the 90’s the prediction that physician management organizations were the future was a common theme at conferences and in the media. Anyone remember Phycore? Meanwhile the numbers of small and independent practices has remained fairly stable, and they continue to provide the overwhelming majority of patient care.
    It is understandable why this is such a strong and recurring theme. The big vendors, consultants and policy makers primarily come from the world of larger systems, and those are the ones that primarily have the resources to go to conferences and get the media attention.
    This time, the prediction that small and independent practices are doomed may or may not be accurate. It all depends on which entities provide the most cost-effective medical care, and I am not making any bets as of yet.
    Based on the evidence as to what provides cost-effective care with high satisfaction, I predict the variables that will determine the winners are primarily related to which entities adopt approaches that focus on primary care, best practices, and that have information technology that facilitate the doctor-patient relationship. This description is just about the opposite of what is in place in both the typical enterprise and the typical small practice, but for different reasons.
    Big players tend to have adopted information technologies, but their systems have a tendency to interfere with the doctor-patient relationship, and are often all but hostile to primary care. However, in spite of growing evidence of this fact, this group largely remains in control of health care policy development to date.
    Small and independent practices tend to not have adopted information technologies. When they have, they mostly have systems and work flows that can’t create or deliver either adequate data or adequate volume of services. Unlike the big players, they haven’t yet figured out that data is power, and this reality is only going to accelerate. Too many of them are still having physicians doing what they should have delegated long ago. For example, they should be delegating much of the need for data collection to medical assistants and patients via best practice guidelines. Also, they would be wise to collaborate with each other to provide a more complete suite of coverage and services.
    After much travel, research and direct experience, my perspective is that the evidence is growing that the most successful approaches to cost-effective health care (that has high satisfaction rankings by both patients and doctors) tends to come from systems providing care consistent with what is being called the Patient Centered Medical Home. The PCMH is most commonly delivered best by smaller practices. Even in large enterprise settings, the tendency is to split into smaller groups (or pods) in order to be able to better deliver the personalized care. So, will the larger systems scale down, or will the smaller practices scale up? Probably both will happen, but it is typically easier for small and independent groups to scale up by adopting the necessary changes and by creating the various types of relationships that are necessary.
    Another big challenge for the larger systems is going to be that most of them will have to fundamentally redesign their care delivery systems as payment systems evolve from rewarding “doing things” to patients to “better managing” patient’s care. A dirty little secret that few of them disclose is that they lose, on average, $80,000 per primary care physician every year. However, they can’t afford not to have their primary care to serve as feeders into their profit centers. In the short term, as the economics get tighter, it may be increasingly difficult to justify the current expenditures on their primary care networks. The information systems that are common in these settings have usually only added to the red ink on the primary care side. For example, these systems probably cause an average of an hour of lost primary care physician productivity on a daily basis. At their core, the information systems in enterprises tend to be more industry-centric rather than patient-centric. Perhaps, many of the current, most successful health care delivery systems (and their vendors) are more likely to be Titanics headed toward icebergs, than the next big wave? They could still sink in spite of the current vendor/government/big-system control of the system.

  13. Bleak as your picture is, I’m afraid you may be right. Nevertheless I still have hope.
    My wife and I both qualified for Medicare last month. After plowing through the maze of insurance/non-insurance options we finally settled on a supplemental plan for her and an “advantage” plan (what a misnomer) for me. The only bright spot is that we can escape every fall if we’re not happy.
    Having been in okay health so far (three days missed for sickness in forty-plus years of work) my plan is this: I’m going to look for an internist who will agree to be my ombudsman if my health indicates a need for any kind of specialist (heart, circulatory, ortho, etc.). I understand being referred to a specialist, but I don’t want to be sent off on my own. I really want a medical pro to guide me among several options… and if possible, I want his second opinion about anything a specialist would do if it is anything other than trivial or an emergency.
    My skin (like others in my family) has a bunch of moles, spots, tags and such. I don’t want a dermatologist to take one look at me and see endless payments to his lake house. All I want is a professional opinion aimed at spotting life-threatening conditions and the cosmetic stuff can go. We all know getting old is not about becoming better-looking.
    For forty-five years I have lived with a chronic orthopedic disease (Kienback’s disease) that to this day is still painless and does not interfere with my life. I asked a retired surgeon a few years ago if I should have it operated on. He asked me if it was giving me any problems and I told him NO. His very wise reply was “If anyone does surgury on you he would be operating on an x-ray, not a patient.” I was very impressed with his candor.
    I don’t know if I will succeed in finding the PCP of my dreams, but I know I can’t put it off forever. If you have any suggestions, I’m open. Meantime, all I know to do is start with the group closest to where we live and go from there.
    In my case expertise is less important than a personal willingness on the part of a professional to advise me on matters I can’t learn on my own.