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.

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Jose CRalph HuntTiffany MatthewsR WatkinsPookieMD Recent comment authors
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Jose C
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Jose C

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… Read more »

Ralph Hunt
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Ralph Hunt

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… Read more »

Tiffany Matthews
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This is a wonderful article. It is completely shameful the way things are going now.

R Watkins
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R Watkins

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… Read more »

Margalit Gur-Arie
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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?

PookieMD
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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… Read more »

R Watkins
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R Watkins

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!

Margalit Gur-Arie
Guest

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… Read more »

Rob
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Rob

“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… Read more »

Peter
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Peter

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.

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

Deron S.
Guest

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.… Read more »

Randall Oates, M.D.
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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… Read more »

John Ballard
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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… Read more »