Accountability

Kevin, MD's recent posting of an anonymous primary care physician from the heartland seems to have struck a cord with a whole lot of people, judging from the comments.

Let me tell you how much it resonates with me.

Our own administration is pretty incompetent and think it knows all that is required to run a community health center without the physician leadership. But I'm not sure. Our chief executive is a nurse who once told me she did not want the providers' input. Power relationships reign supreme and integrity is scarce.

But frankly the biggest problem is two physicians bred and steeped in a traditional specialty philosophy which seems oddly out of date, but apparently still prevalent in some areas. They are both sub-specialties with their training overseas, who came to this primary care facility on J-1 visas. Their feeling about primary care is similar to a Greek doctor who responded to my explanation of what a primary care doctor is by saying, "I think we have some in the villages, you know, in the mountains."

Many of US doctors feel that primary care is the choice of students with no other choice. Even Canada's social conscience cannot mask the prejudice entirely. I was once recruited by a cardiovascular surgeon who said I was too good to settle for family practice. It is a nearly universal phenomenon in a world where progressively greater expertise gets more respect than being a generalist. Why else would family physicians so urgently proclaim that they are specialists and not generalists? Paul Starr characterized physicians as inveterate social climbers. A disregard for fellow human beings, especially well-educated colleagues, is a hallmark of the need to climb a social ladder.

My personal value system is to give the generalist at least as much respect as the boring old, extreme and arcane specialist, to provide the poor as well as the rich and to try and love people who are hard to love as much as people who's company everyone seems to enjoy. But such is the world and I wish I'd known then what I know now. Wealth is built by having uncommon skill or knowledge, especially in a cut-throat capitalist culture.

Medical science at the turn of the last century had so much promise. As a profession, we are accountable, but we lost our way during the 50's, 60's and 70's. Medicine got more technical, more complicated and we forgot that William Osler human ability to listen to the patient's story and consider the context of a life before recommending treatments. We did not meet the expectations of many stakeholders, no matter the fact that some of those expectations were unreasonable to begin with. Some of us sacrificed the profession's autonomy and its beneficent role in society, with full wallets and a family legacy, but not much else.

So disease management, patient navigators, care managers and medical homes are all "new" ideas supposed to help this ultra-specialized medical world provide coordination of care and help combat increasing fragmentation. Although I grieve for this mess of a system, I must reluctantly acknowledge that the world must be unfolding exactly as it should. For those who care, having an impact is no simple task.