The Disappearing Family Doctor – Is It a Bad Thing?

The New York Times recently published an article titled the Family Can’t Give Away Solo Practice wistfully noting that doctors like Dr. Ronald Sroka and “doctors like him are increasingly being replaced by teams of rotating doctors and nurses who do not know their patients nearly as well. A centuries-old intimacy between doctor and patient is being lost, and patients who visit the doctor are often kept guessing about who will appear in the white coat…larger practices tend to be less intimate”

As a practicing family doctor of Gen X, I applaud Dr. Sroka for his many years of dedication and service.  How he can keep 4000 patients completely clear and straight in a paper-based medical system is frankly amazing.  Of course, there was a price.  His life was focused solely around medicine which was the norm of his generation.  Just because the current cohort of doctors wish to define themselves as more than their medical degree does not mean the care they provide is necessarily less personal or intimate or that the larger practices they join need to be as well.

The New York Times article and many patients typically confuse high quality care with bedside manner.  Not surprising.  In the November 2005 survey by the Employee Benefits Research Institute, 85 percent or more of the public felt that the following characteristics were important in judging the quality of care received:

The skill, experience, and training of your doctors
Your provider’s communication skills and willingness to listen and explain thoroughly
The degree of control you have in decisions made regarding your health care
The timeliness of getting care and treatments
The ease of getting care and treatments

The first three items relate to the ability of a doctor to translate knowledge, training, and expertise into the ability to listen, communicate, and partner with a patient.  This is bedside manner.  The last two items relate to whether a patient can be seen quickly and easily when care is needed.

But beyond bedside manner and ease of getting care, both which are very important, does the public care about getting the right care or just assume that it is a given?  My suspicion is that they assume all medical care provided by doctors is the same, yet research demonstrates the contrary.  One study found that 75 percent of primary care doctors provided the wrong type of colon cancer screening. Those most likely to do the wrong test after a positive stool screening test?  Those who graduated from medical school before 1978, who were not board-certified, and who were in solo practice.

Personal relationships between doctors and patients are important, but that should not be the only criteria regarding high quality care.

I love primary care.  I’ve worked at Kaiser Permanente (KP) in Northern California since 2000, a “larger practice”.  The number of patients a full-time doctor cares for is about half of the 4000 patients of Dr. Sroka’s.  Doctors have access to a comprehensive electronic medical record that provides real-time information about a patient’s lab work, imaging studies, and medications 24/7.  Primary care doctors and specialists can collaborate working off a common database and eliminating the uncertainty that exists in a paper based medical system and when doctors work in isolated solo practices.  Our primary care doctors are supported with a call center which is open all year round day and night to provide patients advice on symptoms and advice on when problems can be safely cared at home, when a doctor’s appointment is needed, or when medical care is more emergent.

In other words, doctors can be doctors.

Let’s not assume or confuse the rising trend of large group practices or the implementation of more electronic medical records and technology in doctors’ offices as automatically dooming doctor-patient relationships to becoming more impersonal.  The rise of social media like Twitter and Facebook have increasingly made society more connected than ever.

If Americans and doctors want solo practices, then they will demand them.  Certainly there are successful solo practice models like the Ideal Medical Practice, which also supported by information technology, that can provide patients with a doctor who is a sole proprietor.  To say all primary care doctors should join large group practices should be absurd because doctors like patients are individuals and one type of practice does not fit all.

Yet, the fundamental problem with this New York Times piece is the implication that solo practices provide doctor-patient relationships that are more intimate and where patients have a level of trust and confidence in doctors that perhaps exceeds that of thoughtfully designed larger practices.  It offers no evidence if the quality of care delivered is as good.  Let’s not use a practice model which was prevalent in the 1960s and assume its passing is a bad thing.  It may not be up to the challenges of the 21st century.

Davis Liu, MD, is a practicing board-certified family physician and author of the book, “Stay Healthy, Live Longer, Spend Wisely – Making Intelligent Choices in America’s Healthcare System.” Follow him at his blog, Saving Money and Surviving the Healthcare Crisis or on Twitter, davisliumd.

4 replies »

  1. To the person who posted above me. I’m confused why you believe the author wants to destroy patient/doctor relationships? Please elaborate….

  2. Of course it is a bad thing. This author has a vested interest in the destrution of the intimate relationship between doctor and patient. Soon patients won’t care, which will be good for the big practice in which he is cozy and for the style of practice that is a job rather than a profession.

  3. The point of this article is at the hub of why healthcare is not as easily making the transition to standardization and modernization, as the rest of the industries have. As a PCP myself, I have oft marveled at the importance my patients have made of ‘bedside manner’ – despite the fact that it apparently has little to do with expertise or scientific acumen. Dr. Liu is right to recognize both that the old-fashioned, highly-personal approach might well be neither empirically nor socially feasible for modern healthcare, per se. To my own practice, the ‘bedside manner’ is my way of extracting empiric data that I need in order to provide the scientific analysis for diagnosis and treatment…with a huge caveat: for the purpose of fulfilling my Hippocratic Oath to the patients. It is that last part that makes it more than mere science; and I think patients are looking for that when they value bedside manner so highly. However, this simple formula no longer works with the unmanageable numbers of patients and pieces of data we now have to handle: we need a standardized system, partly automated (EHR/ HIE), if we are to do right by patients nowadays. But there will always be a need for true physicians (in every sense of the word) to provide leadership within this new system on a macro and micro scale. Hence, the family doctor won’t disappear…(s)he will just be redefined.

  4. Dr. Liu,
    I don’t quite understand why you qualify the following as “bedside manner”:

    “The skill, experience, and training of your doctors
    Your provider’s communication skills and willingness to listen and explain thoroughly
    The degree of control you have in decisions made regarding your health care”

    To me “bedside manner” is holding someone’s hand or telling jokes or making small talk and such.
    Certainly skill, experience and training can come with or without “bedside manner”. I am not certain how one delivers better care with inferior, skill, experience and training, regardless of practice size and characteristics and regardless of the existence of electronic documentation tools.

    As to the other two items, and excluding communication skills, which can be labeled “bedside manner”, isn’t this what we want doctors to do in order to facilitate patient-centered, participatory medicine?
    If willingness to listen, explain and facilitate patient’s decision making is not that important, then what exactly does patient-centered mean?

    I do appreciate the value of electronic evidence support, and I do appreciate the value of seamless communications with other physicians, but in these computerized times, I think that it is infinitely easier to bring those tools to doctors in small practice, than it is to bring doctors in small practice to big and centralized medicine.