Strangely, healthcare reformers — both the Obamacare and the emerging Trumpcare varieties — still speak in pious terms about the importance of the primary care physician to whatever plans they have in store for our American healthcare system. These people are lying. Many of them are members of the enlightened leadership that has purposely and systematically wrecked primary care medicine. The primary care physician is dead, and the reformers know it. The obituary has not only been written, but has been duly published in the Federal Register as the law of the land.
The death of primary care was a culmination of two fatal disorders. The first was a chronic, debilitating illness that systematically deprived the practice of primary care medicine of its very purpose and meaning. This illness took hold long ago, back when Mr. Obama was still organizing sundry communities, and Mr. Trump was still enthusiastic about the casino business. Consider the long-term effects of this illness. if you ask a primary care physician what their medical practice is like today, you are likely to get an answer like this:
“Our pay is determined arbitrarily by Acts of Congress, like workers in the old Soviet collectives. We are directed to “practice medicine” strictly according to directives (quaintly called “guidelines”), handed down from on high by panels of sanctioned experts, and accordingly we are enjoined from taking into account our professional experience, our intuition informed by judgment, or our specific knowledge of our individual patients when we advise them about their medical issues. We are strictly limited to 7.5 minutes per patient “encounter,” and the content of this brief encounter is determined by certain Pay for Performance checklists which have been given to us by yet other expert committees. These checklists assure that most of our 7.5 minute encounter is spent asking about important medical topics such as the storage of handguns in the home and sodium in the diet, for if we skip any items on the list we define ourselves as substandard caregivers. This expediency has had the effect of greatly limiting any discussion of topics or concerns that are not on the list, and thus do not meet the approved agenda. Our every move must be carefully tabulated according to incomprehensible rules, on innumerable computer forms and other documents, that confound patient care but that greatly further the convenience of the stone-witted bureaucrats and forensic accountants who are employed specifically to second-guess every clinical decision and every action we take.
“We are expected to operate flawlessly under a system of federal rules, regulations and guidelines that cover hundreds of thousands of pages in immeasurable volumes that are never available in any readily accessible form. If we do not operate flawlessly according to those rules, regulations and guidelines, we are guilty of the federal crime of healthcare fraud. Furthermore, the specific meanings of these rules, regulations and guidelines are not merely opaque and difficult to ascertain, but indeed they are fundamentally indeterminate — that is, they have no inherent meaning. So, we must proceed under a massive quantum cloud of rules as best we can, but our actual status (regarding healthcare fraud) is, like Schrodinger’s cat, fundamentally unknowable — until the “box is opened” (such as, through criminal prosecution), whereupon the meaning of the rules is finally crystallized in a court of law, and we who had been practicing in good faith find that we have at least a 50- 50 chance (like the cat) of learning that we are actually professionally dead.
“We have been given the overriding charge of becoming the primary mediators of covert, bedside healthcare rationing, and to this end we have been pressed to ignore the classic doctor-patient relationship by the healthcare bureaucracy that determines our professional viability, by the United States Supreme Court (see Pegram et al. vs Herdrich (98-1940), 530 US211, 2000), and by the bankrupt, new-age ethical precepts of our own profession, that require us to practice for the benefit of the collective instead of the individual patient.”
By such insults, even before Obamacare became the law of the land, primary care medicine had been reduced to one of the most frustrating, enervating and demeaning endeavors a physician could imagine. Many if not most practicing PCPs even then were looking to either retire early or change careers. Medical students — even the most idealistic ones who were actually not lying when they said on their applications that they wanted desperately to practice primary care medicine — end up avoiding primary care in droves, especially if their training exposes them to the palpable despair radiated by actual primary care physicians in the wild.
But the second fatal disorder (either of which would have been sufficient) has nothing to do with policy or politics. Even if doctors had perfect control of the healthcare system and the political realities, primary care medicine (as we know it) would still be in trouble. This is because of an axiomatic truth revealed by the annals of human progress, to wit: As knowledge increases and technology improves, activities that used to require the services of highly-trained experts become available to non-experts who have much less training. A lot of what PCPs have traditionally done — check-ups of well patients, screening for occult disease, controlling cholesterol, advising on diet, weight loss and exercise, managing hypertension and diabetes — really can to a large extent be reduced to a series of guidelines and checklists, which can be adequately followed by individuals with much less training than these doctors receive.
When any area of expertise evolves to this level, it is inevitable (in a free economy) that lesser-trained individuals will inherit it. This event greatly increases productivity, makes the services in question more readily available to many people at lower cost, and (ideally) frees up the experts to take on more challenging endeavors. While this kind of transition is nearly inevitable, it is often painful and disruptive. The pain and disruption are being experienced by PCPs today.
It is in fact true that medicine has advanced to the point where it really would make sense to turn over to non-physicians many of the routine, mundane, and reducible-to-checklist tasks that PCPs traditionally perform. PCPs who are fighting against this inevitability are wasting their time and energy. They are fighting both history and the laws of economics, so in the end it is a losing battle. It is time for PCPs to move on.
It is of course immaterial whether you agree with me on this point. It is immaterial because this is how the Central Authority sees it, too.
My dear PCPs: Having painstakingly reduced you and your fellow PCPs to tools of the state — whose chief job is to follow the guidelines and place chits on the checklists, &c. — it is only natural for the Central Authority to eventually notice that you really don’t need all that training to do the kind of job they have invented for you. Nurses and other non-physicians, who can be “trained up” much more rapidly than you, and who will work for much less money than you, and who will be much less recalcitrant about following handed-down directives than you — will fill the gap.
And you, doctor, can go pound salt.
So it was really only a formality when the Obamacare legislation made the death of primary care official. The new law did so by stating explicitly that PCPs and nurse practitioners and physicians assistants are now legally equivalent, one and the same. They are all PCPs under the eyes of the law. The actual language of the obituary is as follows:
The term ‘primary care practitioner’ means an individual who —
(I) is a physician (as described in section 1861(r)(1)) who has a primary specialty designation of family medicine, internal medicine, geriatric medicine, or pediatric medicine; or
(II) is a nurse practitioner, clinical nurse specialist, or physician assistant (as those terms are defined in 9 section 1861(aa)(5))
What this means is that today there is more than one pathway to becoming a PCP. You can spend four years in college, four years in medical school and three years in a clinical residency — or you can go to nursing school and do another year or two of clinical training; or go to college and train for two years to become physician assistant. Anyone who wants to become a modern PCP might reasonably find themselves having to defend their intelligence if they still, after this obituary, chose the former pathway.
And so the issue is decided. PCPs: by virtue of your specialty you have been formally (and legally) reduced to the status of a nurse-equivalent. Your specialty, as you have known it, is dead. It is time to decide what you’re going to do about the demise of your chosen career.
There are, of course, several options. Maybe we will look at them another time.