Joseph Scherger, MD, MPH
I attended a health care forecast conference recently and learned a sobering new reality. In the near future, Americans will be getting their primary care services in many different locations.
Walmart has announced that it soon will be offering comprehensive primary care in many of its stores. Walgreens, already the largest provider of immunizations outside the government, will expand its Take Care clinics and manage four common chronic diseases: diabetes, hypertension, hyperlipidemia, and asthma. A longtime colleague and family medicine educator recently went to work for Kroger’s new clinic system, The Little Clinic. Large employers are setting up workplace clinics to provide common health services while keeping their employees on the job.
Discount department stores have already started to dominate certain areas of health care. The most convenient place to have hearing and vision testing and treatment in our area is at Costco. The pharmacies in Walmart, Target, and Costco are gaining market share rapidly over the traditional pharmacy providers. What is to stop these institutions from offering primary care?
All of these nontraditional primary care services are likely to be at lower cost than through traditional providers and be delivered in most cases by mid-level providers. How will a patient’s medical record be kept whole? What is the future of the traditional family physicians’ office? How many of our residency graduates will take positions as medical directors or providers in these nontraditional settings?
There has always been a distinction between a primary care physician and primary care services. The primary care physician, especially a family physician, provides continuity of care through a relationship. Primary care services include preventive services, common acute problems, and chronic disease management. Ever since the emergence of Urgent Care centers in the 1980s, primary care services have expanded beyond the primary care physicians’ offices. Increasingly, the family physician has had to gather information from the patient about what and where they have received various services such as immunizations and procedures. The decentralization of receiving primary care services is likely to explode in the drive to deliver care faster and cheaper.
There are not many answers to this new reality of primary care. Only the patient will be able to keep an intact medical record. One thing that trumps care in a discount store is being available to patients online anytime from anywhere. Calling for the next available appointment will not suffice. The role of the family physician increasingly will be that of a health coach and advisor rather than the mandatory provider of primary care services.
Medical societies will fight against the expansion of primary care and other medical services to different providers, but it is likely that many new physicians will find that joining these convenience care teams is satisfying work. It may turn your stomach now, but your residency program may be giving out a Walmart award at a future graduation. How does family medicine education prepare us for this future?
Posted in Education, Family Medicine Stories, Public Health
Tagged education, Family Medicine, family medicine education, future of family medicine, health, health care, healthcare, medicine, Patient, primary care, Walgreens, Walmart
Joseph Scherger, MD, MPH
Many educators are lamenting today that the scope of family medicine is shrinking.
They refer to fewer family physicians working in hospitals and doing procedures. Warren Newton, MD, MPH, chair of the American Board of Family Medicine, recently sent out a letter expressing this concern. Such a grave outlook is dangerous to our specialty at a time when we are struggling to motivate medical students to go in to family medicine.
I think just the opposite. Family medicine today is more complex and expansive in some ways than ever before. Sure, fewer of us are delivering babies and doing hospital medicine, but family medicine is first and foremost a primary care specialty. Primary care is expanding and becoming far more complex in this new age of medical homes and the advanced use of information systems.
The Willard Report that set the stage for the transition from general practice to family medicine called for the creation of a new primary physician. That doctor would be the personal physician to individuals and their families. It is that personal physician role that is the essence of our specialty. New models of primary care, from concierge medicine to team-oriented medical homes to populations of patients, are deeply complex and expansive.
What do I mean? Prevention became part of primary care in the 1970s and continues to expand. Primary prevention includes all efforts to prevent disease, and since lifestyle causes 50% or more of disease, motivational counseling toward lifestyle change is a new and vital part of being a personal physician. Secondary prevention is the early detection of disease and knowing and applying all aspects of the US Preventive Services Task Force recommendations requires good information systems and skills. Tertiary prevention is the prevention of complications of chronic disease and is far more complex than when I finished residency 30 years ago.
Chronic illness drives about 75% of all health care costs so effective management of these problems is vital to our health care system. The routine visit of a type 2 diabetic patient is far more complex than before and requires much more time. Acute problems are still a major part of family medicine and if we are available to our patients online, we can manage or coordinate care much more efficiently. Relationship-centered care calls on us to know our patients well and provide the counseling services our patients need to deal with what life brings to them, attending to the biopsychosocial and spiritual dimensions of illness.
So, let’s stop this talk about the scope of practice of family medicine shrinking. I am grateful to have more time to take a deep dive with my patients and be their personal physician with much greater complexity and effectiveness than ever before. Let’s train our residents to do the same and show off this rewarding specialty to our students. What can be better than being a family physician?