Whatever Happened to the Family Doctor?

“I’ve had patients who said, ‘I stopped smoking because you told me to,’ or ‘I stopped driving because you said I shouldn’t,’ or ‘I started volunteering because you said it would be good for me,’ ” says Macken. “It’s a little overwhelming sometimes, the power you can have in your patients’ lives. But I can also tell you that going into the hospital room of someone who is in severe pain or frightened—if that patient knows you, you’ve just given them something that’s better than any pain medication. There’s a palpable relief in the room.’’

The health benefits of having a so-called “medical home,” a place where the physicians and medical staff actually know your name and your story, may explain why IBM employees in Denmark say they are so much happier with the health care they receive than their counterparts in the United States. Primary care there is given a higher priority and patients spend more time with their physicians during visits and can schedule appointments more easily. These findings prompted IBM, which spends $2 billion a year on health care for its more than 300,000 employees, to join the Patient-Centered Primary Care Collaborative, a collection of large companies and health care groups campaigning to shift our health system to the primary care model.

A similar push is gathering speed in Minnesota. During the last legislative session, an alliance of physician groups, health care providers, and policymakers introduced the “Healthy Minnesota” bill, a sweeping health care reform plan that included a call for universal coverage for all Minnesotans by 2011. Though the bill didn’t survive the session, one piece of the plan that still has legs is a proposal to create a medical home model for adults and children on medical assistance programs. This summer, the state will start with a handful of pilot projects to determine what happens when primary care physicians are established as a patient’s “first point of contact 24/7.”

While this notion may sound similar to the “gatekeeper” role family docs were expected to play for HMOs decades ago, George Schoephoerster, a family physician in St. Cloud and president-elect of the Minnesota Medical Association, says there’s an important difference. “The physician as gatekeeper worked for the insurance companies,” he says. “In the medical home, the personal physician works for the patient.’’ Instead of being a barrier patients must hurdle to reach a larger array of health care options, family physicians in medical homes could function as highly trained health care system experts who also understand a patient’s unique history.

“Why is it better to have a family doc taking care of Grandpa with his heart problem than a cardiologist?” asks Schoephoerster. “The reason is that it’s not just a heart failing, it’s a patient with a failing heart, which is a different kind of issue. What happens when the silos of medicine attack a patient? They take care of a specific [problem], and if that’s not done in the context of the patient’s history, it leads to things being done more than once, things that don’t make sense.”

Asking primary care doctors to coordinate this care may seem paradoxical, considering that there aren’t enough of them to go around, but many supporters of the medical home believe the model could actually rebalance that equation. A new emphasis on the importance of primary care could make family physicians feel less like they’re at the bottom of the medical hierarchy. And a different form of reimbursement—perhaps monthly payments for coordinating the care of patients over the long-term—could relieve some of the financial pressure family physicians feel now.

“Our goal is to improve the health of our patients,” says Jeff Schiff, MD, the state’s medical director of Minnesota Health Care Programs, who adds that raising the status and the job satisfaction of primary care physicians could be a welcome side effect of the medical home. Three years ago, the Minnesota Children with Special Health Needs Section at the Minnesota Department of Health received a federal grant that included organizing and facilitating a learning collaborative that now includes twenty-one primary care physician–led teams to develop and implement medical homes for children and youth with special health needs in their community-based clinics. “What we’re hearing from them is that this is a more satisfying way to practice medicine,” says Carolyn Allshouse, who coordinates the project for the health department’s community and family health division. “They’re able to provide the kind of care that they went into medicine for in the first place.”

“If we can get beyond the mode of churning patient visits and get involved in caring for patients over time that will be something that will
attract skilled physicians,’’ says Schoephoerster. “You need the best and brightest, and that would be one way to do it."