Tag Archives: primary medical care

Corporate Healthcare is not Medicine: II. Who Cares?

Posted on March 17, 2025 | 1 comment

“Physicians are many in title but very few in reality.” — Hippocrates

Corporate advertising that puts the customer first hardly begins with VillageMD and its Summit Health and CityMD subsidiaries.  Of course, they “care” about their customers, otherwise known as patients.  How else could they gain market share in the furiously competitive world of retail health services.  Health plan advertising began in the mid-1970s and blossomed in the 80s, when the health industry became a buyer’s market in which consumers played a heightened role in the choice of hospitals, health plans, and even prescription medications.[1]

Boots Pharmaceuticals saw the handwriting on the wall.  In 1983, it undertook the controversial step of airing a TV commercial touting the pain-reliever Rufun (prescription ibuprofen).[2]  Healthcare plans were quick to follow.  In the mid-80s, as managed care plans, especially HMOs, entered the market, UnitedHealthcare (now UnitedHealth Group), sought a competitive edge.  An insurance company with a network-based health plan for seniors, it launched a nation-wide campaign of print advertising and 10- and 30-second TV spots.  The corner had been turned.

In the mid-90s, a new player intent on market share was not content to insist that the customer always came first.  It created an in-house culture of customer obsession.  Indeed, the workplace mantra, “customer ecstasy,” was so omnipresent that company meetings included an empty chair to bring the customer’s voice into the conversation.  Customer obsession, observed a senior executive of the time, “was our NorthStar.”

Was this a rival of UnitedHealthcare looking to bring customers into its fold?  No indeed.  It was Amazon, which opened the doors of its gigantic on-line bookstore in 1995.  Jeff Bezos, brimming with idealism and expansionary zeal, recruited employees who joined him, he later reminisced, in “totally obsessing over the customer experience.”[3]

But Amazon began its odyssey by selling books.  Its customers were book buyers pure and simple.  Amazon did not profess a culture of caring to lull book buyers into the on-line store.  It did not shower the internet with ads insisting that its mission was the intellectual and literary betterment of shoppers.  It was enough to offer them a virtually limitless range of titles, discounted prices, and a hassle-free shopping experience.  The only caring going on was the care of designers and programmers to ensure customers would be happy with the shopping experience and come back for more.

Now we have VillageMD and its affiliates, for whom “the customer comes first” becomes a pledge to provide care for life.  For its customers, book buying gives way to issues of sickness and health – customers who arrive at an office or clinic with preexisting conditions, troublesome symptoms, and, often enough, anxiety at the prospect of diagnoses.  Come to us, urges Summit Health, because our mission, above all else, is to care.  Commerce is  obscured by the radiant glow of beneficent intent. “Care at Every Connection” proclaims the firm’s 2021 advertising campaign.  “Absolute customer satisfaction” is the promise.  Go to summithealth.com and the light becomes blinding.  A Lifetime of Care is the solemn promise given on the homepage in oversized bold font.[4]

Really?   When Tim Barry co-founded VillageMD in 2013, he had a plan:  to use technology, population data, and a network of  health care professionals to provide quality primary care.  The results would be better patient outcomes and reduced costs.[5]  VillageMD would assume financial risk for the healthcare outcomes of its patients and would, he believed, garner market share across the nation.  Financial success was just around the corner.

But things didn’t go as planned.  Low primary care reimbursement schedules and staffing shortages were part of the problem.[6]  Barry stepped down as CEO in November 2024 after Walgreens, its majority stakeholder since 2021, had ploughed a staggering $12.4 billion into new VillageMD clinics adjacent to Walgreens pharmacies.  The main problem?  The primary care clinics simply weren’t drawing patients.

New leadership, in the person of CEO Tim Murray, was necessary to reposition Walgreens for growth and profit. To this end, Murray would help Walgreens reach an “endpoint” in its financially draining commitment to VillageMD.  After an operating loss of $13 billion in the first three quarters of 2024, $12.4 billion attributable to VillageMD, Walgreens apparently had had enough.  Its CEO, Tim Wentworth, was refreshingly blunt about the new plan:  reduce Walgreens’ stake in VillageMD.   Only by putting an end to astronomical losses could Walgreens unlock liquidity, focus on “value creation,” and resume its growth. [7]

When Walgreens became majority owner of VillageMD in 2021, it anticipated 500-700 such adjacent storefronts.  The plan was financially disastrous, and Walgreens began closing VillageMD clinics in 2023. 

   But where was the call to care in all this?  Caring for people, connecting with them throughout the lifecycle – was this not  VillageMD/Summit Health’s own NorthStar in the war for customers and market share.  It was nowhere.  But, then, where could it have been?  In the world of corporate healthcare, how can caring be assessed, much less leveraged to increase profits?

VillageMD, with Summit Health and CityMD by its side, aspired to be a corporate juggernaut swallowing private practices and clinics wholesale in pursuit of profit.  The caring predisposition of its providers and support staffs could not be further from its mind.  It could hardly be expected to screen prospective physicians and nurses for the personality traits and professional orientation that make for caring providers.  Does Summit Health, for example, seek out primary care physicians whose residencies included training in the skill set associated with narrative medicine and clinical empathy?[8]  Does it provide newly hired personnel with any preliminary training, seminar-style, on the type of caring medicine VillageMD/Summit Health/CityMD physicians and staffs are expected to provide?   And further, have practices or clinics in regions of expansion ever been passed over because providers were judged deficient in the psychological and interpersonal prerequisites of the brand’s ethos of care?

Did it occur to VillageMD and its affiliates that the inability of its office practices and clinics to draw customers (read: patients) related to some deficiency in the caring ethos celebrated by its advertisers?  No, of course not.  Merely to pose the question underscores the ridiculousness of a corporate healthcare entity training its gaze on the quality of caregiving in assessing the performance, financially speaking, of its clinics and practices.

You want a healthcare company that subordinates profits to care?   Look to Blue Cross/Blue Shield prior to 1994, when its state plans became for-profits with access to the stock market to raise urgently needed cash.  Prior to then, it was a nonprofit that, in accord with the charitable mission set forth in its charter, accepted anyone who sought enrollment – and hemorrhaged money in the process.[9]  Today, the ethos of care for all lives on, but only outside the healthcare industry.  You’ll find it among nonprofits that make it their business, literally, to care for the underserved, the handicapped, the abused, the homeless and hungry.  Don’t look to corporate giants like VillageMD.

Don’t get me wrong. There are plenty of caring providers among those employed by healthcare corporations.  VillageMD/Summit Health may not take steps to staff its facilities with empathic caregiving, but neither does it chase them away.  One finds very caring physicians in all venues of clinical practice, corporate and otherwise.  But in corporate healthcare, the caring impulse is hardly facilitated by corporate handlers.  For the latter, physician engagement of patient narratives, followed by explanations and interpretations of the stories patients tell, are time-consuming indulgences.  They are the stuff of corporate advertising – and of psychiatry – not the fast-paced realities of frontline primary care under corporate aegis

Yes, many VillageMD and Summit Health physicians care about patients.  Far be it for me to suggest otherwise.   But now more than ever, their caring is hemmed in by protocols, regulations, and lay monitoring.  Time-consuming caring is not part of the corporate gameplan.  Physicians labor under the weight  of lay oversight and “rate” expectations.  The start and stop time of a patient visit is electronically monitored; it is right there in front of them on their computer screens.  To make matters worse, they must yield to “patient relations” personnel who may intrude into the doctor-patient relationship to the point of advising physicians not to contact patients who have reached out to them.  This, in any event, was my experience when I called the Summit Health endocrinology office three times this past September 18th, requesting, with some urgency, that my physician return my call that day.  It was a patient relations staffer who advised my physician not to return my phone calls.

________________________

Who cares?  Many physicians care.  During a period of ocular crisis when my eyesight rapidly deteriorated, my wonderfully caring retinologist returned almost daily phone calls for several weeks to explain newly arising symptoms and provide reassurance.  When I left a message with my ophthalmologist’s phone service  one Sunday evening, reporting symptoms suggestive of retinal detachment, she drove back from a weekend outing and opened her office in the evening to evaluate me.  When she determined I indeed had a detached retina, she went to the phone and made all the arrangements for a retinal evaluation early the next morning, with surgery later in the day.  Now, with limited vision and chronic eye discomfort, she has me come to the office whenever I wish to see her without making an appointment.  My hematologist, who appreciates my work in medical history, gives me all the time I need and encourages me to contact him whenever a medical issue arises, inside or outside his specialty.  He now provides excellent referrals to caring physicians in other specialties.

These physicians are Hippocratic caregivers in an age of corporate pseudo-care.  For them, the patient does indeed come first, and the Hippocratic injunction to practice “the Art” with compassion accompanies them throughout their careers.  None of these physicians, be it noted, practices within a healthcare corporation.

My father, William Stepansky, whose inspiring life story is related in The Last Family Doctor:  Remembering My Father’s Medicine, had a copy of the Hippocratic Oath taped to his dresser, a daily reminder of his calling.  A first-generation immigrant whose parents fled Ukraine during the anti-Jewish Pogrom of 1921, he served in World War II as a surgical tech in the 80th infantry of Patton’s Third Army.  He attended the wounded and dying during the Battle of the Bulge and was part of the unit that liberated Buchenwald.  After the war, He finished pharmacy training and attended Jefferson Medical College.  Following internship, he began his career as a rural generalist in a small borough 30 miles west of Philadelphia.

I asked him in retirement if he had ever turned away anyone who came to him for help.  Without hesitation, he quietly replied, “No.”  His commitment to his patients and their families was total, and intensified during the last phase of terminal illnesses. When a long-time patient passed away, he closed the office and joined his staff at the family’s memorial gathering.  The letter from the daughter of his patient read in part:  “Doctor, your act of compassion crosses the boundary of professionalism into humanity, and into my heart.  I value your gesture of respect for my family – and for our father.”[10]

Nearing retirement, he sold his house and adjacent office building to a group of multi-specialty internists expanding into local communities.  The understanding was that he would continue to see his patients in his own way until retirement, that his practice would be an enclave within the group.  Several months after the arrangement began, an office manager knocked on his door and confronted him with a printout attesting to his low productivity.  He retired the next day.

If VillageMD wants its website tagline, A Lifetime of Care, to be more than advertising drivel, it should have its providers read The Last Family Doctor.  Medicine has changed enormously since my father put out his shingle in Trappe, PA in 1952, but the physician’s commitment to a life of care is, or should be, a constant.  Contemporary physicians laboring under the weight of corporate oversight should be reminded from time to time of what Hippocratic caregiving looks like.  No, they needn’t tape the Hippocratic Oath to their dressers.  But it wouldn’t hurt if they familiarized themselves with a physician whose care of people, not customers, embodied cura in its true Latin sense – a care suffused with compassion, generosity of spirit, and love.  Such cura reduces the care glibly scripted by corporate advertisers to rubble.

_____________________

[1] Richard K. Thomas, Marketing Health Services, 2nd ed.  Chicago:  Health Administration Press, 2009,  11-14.

[2] Dylan Scott, “The Untold Story of TV’s First Prescription Drug Ad,” Stat, 11 December 2015 (https://www.statnews.com/2015/12/11/untold-story-tvs-first-prescription-drug-ad).

[3] All material on early Amazon culture, includes quotations, from “Amazon Empire:  The Rise and Reign of Jeff Bezos,”  Frontline, 18 February 2020 (https://www.youtube.com/watch?v=RVVfJVj5z8s&t=2800s).

[4] “Summit Health Launches First Brand Advertising Campaign”  (https://www.prnewswire.com/news-releases/summit-health-launches-first-brand-advertising-campaign-301364781.html); “Summit Healthcare Solutions – Business Philosophy”; (https://www.summithcs.health/about-us/#:~:text=Summit%20Healthcare%20Solutions’%20business%20philosophy,compliance%2C%20dedication%2C%20and%20timeliness).

[5] Kathy Hovis, “VillageMD CEO Named Cornell Entrepreneur of the Year 2024,” Cornell Chronicle, 23 January 2024 (https://news.cornell.edu/stories/2024/01/villagemd-ceo-named-cornell-entrepreneur-year-2024).

[6]  Rebecca Pifer, “VillageMD CEO Tim Barry Steps Down,”  Healthcare Dive, 2 December 2024 (https://www.healthcaredive.com/news/villagemd-ceo-tim-barry-out-walgreens/734247).

[7] Bruce Japsen, “Tim Barry Is Out As CEO Of Walgreens Clinic Partner VillageMD,” Forbes, 27 November 2024 (https://www.forbes.com/sites/brucejapsen/2024/11/27/tim-barry-is-out-as-ceo-of–walgreens-clinic-partner-villagemd).  For Walgreens, the imbroglio over VillageMD capped a decade of mounting losses and, as such,  was prelude to financial collapse.  On 6 March 2025, it announced its sale to Sycamore Partners, a private equity firm, for roughly $10 billion.  This was one-tenth Walgreens’s market value a decade ago.

[8] On the training exercises during  residencies intended to cultivate caring doctors, i.e., doctors with empathic receptiveness to patients and the stories they bring to them, see Paul E. Stepansky, In the Hands of Doctors:  Touch and Trust in Medical Care (Santa Barbara: Praeger,  2017),  ch. 5 (“Can We Teach Doctors to Care?”).

[9] Elisabeth Rosenthal, An American Sickness:  How Healthcare Became Big Business and How You can Take it Back.  NY:  Penguin, 2017, 14-20.

[10] Paul E. Stepansky,  The Last Family Doctor:  Remembering My Father’s Medicine.  Montclair, NJ: Keynote, 2011,  103.

Copyright © 2025 by Paul E. Stepansky.   All rights reserved.  The author kindly requests that educators using his blog essays in their courses and seminars let him know via info[at]keynote-books.com.

 

1 Comment

Posted in Corporate healthcare, Empathy, Family Doctors, Then & Now, General, Healthcare Delivery Systems

Tagged , , ,

The Paradox of Generalist Specialists

Posted on February 4, 2013 | Leave a comment

General practitioners of medicine (GPs), the medical heroes of World War II, returned home only to find their medical standing at their local hospitals in jeopardy.  Specialization made great inroads during the war years, and, while the GPs were fighting the war in Europe, many hospitals reclassified their staff physicians on the basis of specialist qualifications.  GPs of course were low men on the totem pole, and some found that the very hospitals where they had worked before the war had rescinded their surgical privileges after the war.  Stanley R. Truman, the first Secretary of the American Academy of General Practice and chronicler of its founding, recalled this very situation at his own Merritt Hospital in Oakland, CA.  “Some of these men had gone away with major surgical privileges,” he later recalled, “and had been assigned leading surgical responsibilities here and overseas.  They were furious when they came home and found themselves in ‘Class A’ [the lowest rung of the hospital hierarchy, in which surgery could only be performed after consultation and under supervision].”  One day in late 1945, Truman continued,

I met Harold Maloney who had just come back.  He was one of our leading general practitioners; a fine doctor and surgeon; a member of the American College of Surgeons and in ‘Class A.’ We had previously talked about an organization of general practitioners; and this day, in talking the situation over again, we agreed that an organization was urgent.[1]

And so the GPs organized, first into the General Practitioners Association of Truman’s Alameda County; then in 1945 into the Section on General Practice of the American Medical Association; and finally in 1947 into the American Academy of General Practice (AAGP).  The organizers and officers of the AAGP, who assumed the burden of promoting the new organization and encouraging the formation of local chapters, made no bones about the reason for its existence .  It was not about “family practice,” “comprehensive care,” “total patient care,” or any of the other buzzwords that were invoked in the discussions two decades later that led to the creation of the American Board of Family Practice in 1969.  It was about power pure and simple, and power in postwar America meant the power to treat one’s patients in the hospital, including patients who required operative obstetrics and major surgery.

Returning GPs, who, as General Medical Officers, had met wartime needs at both ends of the specialty spectrum – in psychiatry and in surgery – were aghast at rumors that certain stateside hospitals – perhaps their own hospitals – planned to limit their staffs to board-certified medical specialists by the early 50s. Was this their reward for exemplary service to the nation?  “Since the second World War,” intoned the AAGP’s first President, Paul Davis, in 1948, the GP “has been discriminated against in many cases, and had his professional standards encroached upon.”  In 1953, two of New York’s leading GPs recollected:  “It was as if the hospitals were about to put up signs reading: ‘If you’re a general practitioner, keep out!”  A few years later, Eric Royston, another prominent AAGP booster, recalled the postwar feeling among GPs of being discriminated against in their medical associations “and being pushed to the periphery in the metropolitan hospitals.”[2] The AAGP would come to the rescue; it would have the strength of numbers,[3] which meant it would have the power. The AAGP’s resolve to keep GPs in the hospitals and put scalpels back in their hands was baldly stated in Article II of the its constitution, which set forth this organizational objective:  “To preserve the right of the general practitioner to engage in medical and surgical procedures for which he is qualified by training and experience.”[4]

But all did not go as planned.  Although the AAGP stabilized the GP’s hospital status as it existed before the war, it could not protect GPs from the continuing development of specialty medicine, which increasingly took place in hospitals and entailed ever more sophisticated procedures and interventions.  Specialty encroachment of GP hospital privileges might be slowed but never halted.  And along with the organizational support came the stigma, which is exactly what the AAGP sought to prevent.  In the late 40s, many GP-surgeons resisted joining the AAGP lest — publicly identified as GPs – they have their surgical privileges rescinded.  On the other hand, the few GP residency programs that proved successful in the early 60s, mostly in California, were those that taught surgery and permitted GP residents to perform major operations.[5]  It was all about surgery, all about procedures, all about treatment-related prerogatives within the hospital.

Of course, the AAGP could not prevail, given the great impetus to specialization provided by the war.  When, in the mid-1960s, efforts to upgrade the status of the generalist centered around creation of a new residency-based specialty, “family practice,” it was no longer a matter of surgical privileges within the hospital.  No, family practice would be a new and different kind of specialty, one less concerned with procedures and surgeries than with holistic, patient-centered, intergenerational caregiving.  The retreat from proceduralism was codified in the “Core Content” of family practice adopted by the AAGP in 1966.  The family practitioner (FP) of the future, it held, would assume “comprehensive and continuing responsibility” for his or her patients.  This meant that family practice would be a  “horizontal specialty” that cut across the other specialties.  It would fall back on “function” rather than a “body of knowledge.”[6]

What was lost in the new rhetoric of patient-centered caregiving was the very thing that mattered so much to the AAGP two decades earlier:  safeguarding the GP’s prerogative to perform those procedures and interventions that fell within the domain of the practicing (as opposed to the caring) generalist.  The proponents of family practice could no longer hope to wrest control of a piece of the medical pie, so they elaborated a new – and, they fervently hoped, specialized – gloss on the pie in its entirety.  This amounted to proposing a “sort of a focus”[7] for the residency-trained FP of the future.  What FP proponents and educators failed to do was delineate in a conventional manner the procedural correlates of the FP’s “focus” – the things that all FPs would be trained to do that qualified as specialist interventions, not just attitudinal correlates of caregiving that meshed with their person-centered ideology.

The question-begging nature of early definitions of family practice is nowhere more evident than in the matter of surgery.  By the mid-60s, the founders of family practice realized full well that the American College of Surgeons would never cede residency-trained family practitioners the prerogative to perform major operations in the hospital. Furthermore, adding insult to injury, the AAGP was beset with a schism within its own ranks:  there were GPs who did considerable surgery (including operative obstetrics) and GPs who did not.  The former believed family practice should include a strong surgical component; the latter did not.  The former were concerned about the exclusion of surgery from “modern” family practice, and for this reason they opposed the development of a family practice specialty board through the early 60s.  The pragmatic (non)solution to this quandary was simply to leave the issue open.  The AAGP’s vision of the new family practice specialist, as spelled out in its “Core Content” position paper of 1966, assigned family practitioners the nebulous domain of “applicable surgery,” meaning that “the physician in family practice should be trained to do the types and kinds of surgery he would be required to perform after graduation.”

There is irony in this nebulous manifesto:  the very effort to transform old-style general practice into specialized family practice hinged on a willingness to fall back on a pre-1930s notion of specialization in which generalists would somehow know, in advance of practice, what kinds of techniques they would need to master for their future work.  They would then “pick up” these techniques during residency or after residency in the world of everyday practice and occasional postgraduate courses.  Family practice, in these mid-60s deliberations, increasingly looked like a specialty that was not only “different,” but antithetical to the very meaning of specialization.  That is, if family practice is a medical specialty of any kind, then all FP residents should receive common training in a range of diagnostic and treatment procedures that, in their totality, add up to specialist interventional care.  The willingness to localize procedural skills, to leave it to individual practitioners and/or training programs to determine which skills would be “appropriate” to practice, was a nod to the surgical specialists, whose advanced training and control of hospitals was shored up by the postwar climate of opinion.  But it had the paradoxical effect of marginalizing the family practitioner out of the gate:  once you begin localizing the procedural, hands-on component of any specialty, medical or otherwise, you risk gutting the specialty, cutting away the shared procedural content that coalesces into expert knowledge and sustains a common professional identity.  What kind of specialty leaves it to the individual to fill in the procedural content of the specialty as he or she proceeds through training and practice?

Here we have a central dilemma of family medicine.  I invoke it here in support of the need for a new kind of generalist physician who is procedurally empowered in the manner of GPs of the 1940s and 50s.  We need to oscillate back to generalists who can do many things and away from generalist physicians who hypothetically know their patients “better” but are increasingly content to “coordinate” their care.  The family practice movement failed because it sought the impossible: to create a new kind of specialty that would not delimit expertise in treatment-specific ways.

The family practitioner of the 1970s was to be an interpersonally embedded, empathically attuned, total-patient provider.  He or she was to provide comprehensive care that was intergenerational, mind-body care.  Proponents of the movement spent years debating what “comprehensive care” meant, and ultimately had to beg the question.  The result was a medical specialty that, until recently, lacked consensually agreed on procedural requirements.  The semantically strained, even oxymoronic, vision of a non-specialty specialty, a specialty that rejected specialist values, was an amalgam of 1960s counterculture, the social sciences, and a dash of psychoanalytic object relations theory (per Michael Balint), all abetted by the dearth of “personal physicians” and the emergence in the 1970s of the patient rights movement.   Family practice was of its time – it was entirely admirable and terribly ill-fated.  This is why only eight percent of non-osteopathic medical students now choose to “specialize” in it.[8] It is also why some top-tier medical schools — Harvard,  Yale, Johns Hopkins, Columbia, and Cornell, among them —  do not even have departments of family medicine.

If we are to address the primary care crisis within rural America, we need a new kind of doctor – call them specialists in procedural rural medicine (PRM) or rural care proceduralists (RCPs) – who can actually take care of people in rural settings where specialists are sparse.  Such physicians will not do many things, certainly not the kinds of surgeries that GP-surgeons of the postwar era felt within their province. But they will be trained to do much more than the majority of contemporary family physicians.  Their connection with their patients will rely less on prescribing and coordinating than on what W. R. Houston, in his justly celebrated address to the American College of Physicians of 1937, termed “the line of procedure.”[9]  We need primary care physicians who do things to their patients’ bodies.  Such physicians will “touch” their patients in the dual sense of activating an inborn biological pleasure (contact touch) and allowing such pleasure, through symbolic elaboration, to become a touchstone of a trusting doctor-patient relationship.[10]  A renewal of procedural medicine will not make indifferent caregivers caring, but it will fortify in the realm of action what Houston termed the “dynamic power” of the doctor-patient relationship.  It will make it easier for caring doctors to doctor.

In the next essay in this series, we will look further at procedural rural medicine and how it would differ from family medicine as it currently exists.

[1] S. A. Truman, The History of the Founding of the American Academy of General Practice (St. Louis: Green, 1969), p. 16.

[2] P. A. Davis, “The American Academy of General Practice,” Southern Med. J., 41:651-55, 1948, at p. 654; W. C. Allen & S. A. Garlan, “Educational motivation in the field of general practice,” NY State J. Med., 53:1243-1245, 1953, at p. 1243; E. A. Royston, “The American Academy of General Practice:  its origin, objectives, growth and outlook,” S. Afr. Med., J., 30:298-99, 1956.

[3] The AAGP had well over 2,000 members by the end of 1947, the year of its founding.  By 1968, membership had grown to 30,000.  Truman, op cit., pp. 54, 60.

[4] N.A., Family Practice: Creation of a Specialty (American Academy of Family Physicians, 1980), p. 34; Truman, op cit., p. 43.

[5] Family Practice: Creation of a Specialty, op. cit., pp. 12, 20.

[6] Family Practice: Creation of a Specialty, op. cit., pp. 37-38.

[7] Family Practice: Creation of a Specialty, op. cit., p. 42.

[8] W. S. Biggs, et al., “Entry of US medical school graduates into family medicine residencies: 2011-2012,” Fam. Med., 44:620-626, 2012.

[9] W. R. Houston, “The doctor himself as a therapeutic agent,” Ann. Int. Med., 11:1416-1425, 1938.

[10] See, for example, N. S. Lehrman, “Pleasure heals: the role of social pleasure—love in its broadest sense—in medical practice,” Arch . Intern. Med., 1993;153:929–934.  Contemporary physicians writing about primary care have little to say about the salience of the laying on of hands – even when mediated by instrumentation – as a component of care-giving that mobilizes patient trust.  But there is much to be gleaned from contiguous literature, e.g., G. Pohl, et al., “’Laying on of hands’ improves well-being in patients with advanced cancer,” Support Care Cancer, 15:143-151, 2007; S. Jain, et al., “Healing touch with guided imagery for PTSD in returning active duty military: a randomized controlled trial,” Mil. Med., 177:1015-1021, 2012;  and T. Jones & L. Glover, “Exploring the psychological processes underlying touch: lessons from the Alexander technique,” Clin. Psychol. Psychother., Nov., 2012 (Epub ahead of print).

Copyright © 2013 by Paul E. Stepansky.  All rights reserved.

Leave a comment

Posted in Family Doctors, Then & Now, General Practice, Medicine in WWII, Procedural Rural Medicine

Tagged , , ,

Re-Visioning Primary Care

Posted on January 2, 2013 | Leave a comment

Existing approaches to the looming crisis of primary care are like Congressional approaches to our fiscal crisis.  They have been, and will continue to be, unavailing because they shy away from structural change that would promote equity.  I suggest the time has come to think outside the financial box of subsidization and loan repayment for medical students and residents who agree to serve the medically underserved for a few years.  Here are my propositions and proposals:

  1. We should redefine “primary care” in a way that gives primary care physicians (PCPs) a fighting chance of actually functioning as specialists. This means eliminating “family medicine” altogether.  The effort to make the family physician (FP) (until 2003, the “family practitioner”) a specialist among specialists was tried in the 70s and by and largely failed – not for FP patients, certainly, but for FPs themselves, who, by most accounts, failed to achieve the academic stature and clinical privileges associated with specialist standing.  It is time to face this hard fact and acknowledge that the era of modern general practice/family medicine, as it took shape in the 1940s and came to fruition in the quarter century following World War II, is at an end.  Yet another round of financial incentives that make it easier for medical students and residents to “specialize” in family medicine will fail.  “Making it easier” will not make it easy enough, nor will it overcome a specialist mentality that has been entrenched since the 1950s.  Further policy-related efforts to increase the tenability of family medicine, such as increasing Medicare reimbursement for primary care services or restructuring Medicare to do away with primary care billing costs, will be socioeconomic Band-Aids that cover over the professional, personal, familial, and, yes, financial strains associated with family medicine in the twenty-first century.  Vague and unenforceable “mandates” by state legislatures directing public medical schools to “produce” more primary care physicians have been, and will continue to be, political Band-Aids.[1]
  2. As a society, we must re-vision generalist practice as the province of internists and pediatricians.  We must focus on developing incentives that encourage internists and pediatricians to practice general internal medicine and general pediatrics, respectively.  This reconfiguring of primary care medicine will help advance the “specialty” claims of primary care physicians.  Historically speaking, internal medicine and pediatrics are specialties, and the decision-making authority and case management prerogatives of internists and pediatricians are, in many locales, still those of specialists. General internists become “chief medical officers” of their hospitals; family physicians, with very rare exceptions, do not.  For a host of pragmatic and ideological reasons, many more American medical students at this juncture in medical history will enter primary care as internists and pediatricians than as family physicians.
  3. Part of this re-visioning and reconfiguring must entail recognition that generalist values are not synonymous with generalist practice.  Generalist values can be cultivated (or neglected) in any type of postgraduate medical training and implemented (or neglected) by physicians in any specialty. There are caring physicians among specialists, just as there are less-than-caring primary care physicians aplenty.  Caring physicians make caring interventions, however narrow their gaze.  My wonderfully caring dentist only observes the inside of my mouth but he is no less concerned with my well-being on account of it.  The claim of G. Gayle Stephens, one of the founders of the family practice specialty in the late 1960s, that internists, as a class, were zealous scientists committed to “a mechanistic and flawed concept of disease,” whereas family physicians, as a class, were humanistic, psychosocially embedded caregivers, was specious then and now.[2]  General internists are primary care physicians, and they can be expected to be no less caring (and, sadly, no more caring) of their patients than family physicians.  This is truer still of general pediatrics, which, as far back as the late nineteenth century, provided a decidedly patient-centered agenda for a cohort of gifted researcher-clinicians, many women physicians among them, whose growth as specialists (and, by the 1920s and 30s, as pediatric subspecialists) went hand-in-hand with an abiding commitment to the “whole patient.”[3]
  4. We will not remedy the primary care crisis by eliminating family medicine and developing incentives to keep internists and pediatricians in the “general practice” of their specialties.  In addition, we need policy initiatives to encourage subspecialized internists and subspecialized pediatricians to continue to work as generalists.  This has proven a workable solution in many developed countries, where the provision of primary care by specialists is a long-established norm.[4]   And, in point of fact, it has long been a de facto reality in many smaller American communities, where medical and pediatric subspecialists in cardiology, gastroenterology, endocrinology, et al. also practice general internal medicine and general pediatrics.  Perhaps we need a new kind of mandate:  that board-certified internists and pediatricians practice general internal medicine and general pediatrics, respectively, for a stipulated period (say, two years) before beginning their subspecialty fellowships.

Can we remedy the shortage of primary care physicians through the conduits of internal medicine and pediatrics?  No, absolutely not.  Even if incentive programs and mandates increase the percentage of internists and pediatricians who practice primary care, they will hardly provide the 44,000-53,000 new primary care physicians we will need by 2025.[5]  Nor will an increase in the percentage of medical students who choose primary care pull these new providers to the underserved communities where they are desperately needed.  There is little evidence that increasing the supply of primary care physicians affects (mal)distribution of those providers across the country.  Twenty percent of the American population lives in nonmetropolitan areas and is currently served by 9% of the nation’s physicians; over one third of these rural Americans live in what the Health Resources and Services Administration of the U.S. Department of Health and Human Services designates “Health Professional Shortage Areas” (HPSAs) in need of primary medical care.[6]  Efforts to induce foreign-trained physicians to serve these communities by offering them J-1 visa waivers have barely made a dent in the problem and represent an unconscionable “brain drain” of the medical resources of developing countries.[7]  The hope that expansion of rural medicine training programs at U.S. medical schools, taken in conjunction with increased medical school enrollement, could meet the need for thousands of new rural PCPs is not being borne out.  Graduating rural primary care physicians has not been, and likely will not be, a high priority for most American medical schools, a reality acknowledged by proponents of rural medicine programs.[8]

Over and against the admirable but ill-fated initiatives on the table, I propose two focal strategies for addressing the primary care crisis as a crisis of uneven distribution of medical services across the population:

  1. We must expend political capital and economic resources to encourage people to become mid-level providers, i.e., physician’s assistants (PAs) and nurse practitioners (NPs), and then develop incentives to keep them in primary care.  This need is more pressing than ever given (a) evidence that mid-level practitioners are more likely to remain in underserved areas than physicians,[9] and (b) the key role of mid-level providers in the team delivery systems, such as  Accountable Care Organizations and Patient-Centered Medical Homes, promoted by the Patient Protection and Affordable Care Act of 2010.  Unlike other health care providers, PAs change specialties over the course of their careers without additional training, and since the late 1990s, more PAs have left family medicine than have entered it.  It has become incumbent on us as a society to follow the lead of the armed forces and the Veterans Health Administration in exploiting this health care resource.[10]  To wit, (a) we must provide incentives to attract newly graduated PAs to primary care in underserved communities and to pull specialty-changing “journeyman PAs” back to primary care,[11] and (b) we must ease the path of military medics and corpsmen returning from Iraq and Afghanistan into PA programs by waiving college-degree eligibility requirements that have all but driven them away from these programs.[12]  Although the Physician Assistant profession came into existence in the mid-1960s to capitalize on the skill set and experience of medical corpsman returning from Vietnam, contemporary PA programs, with few exceptions, no longer recruit military veterans into their programs.[13]
  2. Finally, and most controversially, we need a new primary care specialty aimed at providing comprehensive care to rural and underserved communities.  I designate this new specialty Procedural Rural Medicine (PRM) and envision it as the most demanding – and potentially most rewarding – primary care specialty.  PRM would borrow and enlarge the recruitment strategies employed by the handful of medical schools with rural medicine training programs.[14]  But it would require a training curriculum, a residency program, and a broad system of incentives all its own.

In the next installment of this series, I will elaborate my vision of Procedural Rural Medicine and explain how and why it differs from family medicine as it currently exists.

[1] D. Hogberg, “The Next Exodus: Primary-Care Physicians and Medicare,” National Policy Analysis #640 (http://www.nationalcenter.org/NPA640.html); C S. Weissert & S. L. Silberman, “Sending a policy signal: state legislatures, medical schools, and primary care mandates,” Journal of Health Politics, Policy and Law, 23:743-770, 1998.

[2] G. G. Stephens, The Intellectual Basis of Family Practice (Tucson, AZ: Winter Publishing, 1982), pp. 77, 96.

[3] See E. S. More, Restoring the Balance: Women Physicians and the Profession of Medicine, 1850-1995 (Cambridge: Harvard University Press, 1999), pp. 170-72.  Edith Dunham, Martha Eliot, Helen Taussig, Edith Banfield Jackson, and Virginia Apgar stand out among the pioneer pediatricians who were true generalist-specialists.

[4] See W. J. Stephen, An Analysis of Primary Care: An International Study (Cambridge: Cambridge University Press, 1979) and B. S. Starfield, Primary Care: Concept, Evaluation and Policy (Oxford : Oxford University Press, 1992).

[5] The percentile range denotes the different protocols employed by researchers.  See M. J. Dill & E. S. Salsberg, “The complexities of physician supply and demand: projections through 2025,” Association of American Medical College, 2008 (http://www.innovationlabs.com/pa_future/1/background_docs/AAMC%20Complexities%20of%20physician%20demand,%202008.pdf); J. M. Colwill, et al., Will generalist physician supply meet demands of an increasing and aging population?  Health Affairs, 27:w232-w241, 2008;  and S. M. Petterson, et al., “Projecting US primary care physician workforce needs:  2010-2025,” Ann. Fam. Med., 10: 503-509, 2012.

[6] See the Federal Office of Rural Health Policy, “Facts about . . . rural physicians” (http://www.shepscenter.unc.edu/rural/pubs/finding_brief/phy.html ) and J. D. Gazewood, et al., “Beyond the horizon: the role of academic health centers in improving the health of rural communities,” Acad. Med., 81:793-797, 2006.  In all, the federal government has designated 5,848 geographical areas HPSAs in need of primary medical care (http://datawarehouse.hrsa.gov/factSheetNation.aspx).

[7] These non-immigrant visa waivers, authorized since 1994 by the Physicians for Underserved Areas Act (the “Conrad State 30” Program), allow foreign-trained physicians who provide primary care in underserved communities for at least three years to waive the two-hear home residence requirement.  That is, these physicians do not have to return to their native countries for at least two years prior to applying for permanent residence or an immigration visa.  On the negative impact of this program on health equity and, inter alia, the global fight against HIV and AIDS, see V. Patel, “Recruiting doctors from poor countries: the great brain robbery?, BMJ, 327:926-928, 2003; F. Mullan, “The metrics of the physician brain drain,” New Engl. J. Med., 353:1810-1818, 2005; and N. Eyal & S. A. Hurst, “Physician brain drain:  can nothing be done?, Public Health Ethics, 1:180-192, 2008.

[8] See H. K. Rabinowitz, et al., “Medical school programs to increase the rural physician supply: a systematic review,” Acad. Med., 83:235-243, at 242:  “It is, therefore, unlikely that the graduation of rural physicians will be a high priority for most medical schools, unless specific regulations require this, or unless adequate financial resources are provided as incentives to support this mission.”

[9] U. Lehmann, “Mid-level health workers: the state of evidence on programmes, activities, costs and impact on health outcomes,” World Health Organization, 2008 (http://www.who.int/hrh/MLHW_review_2008.pdf).

[10] R. S. Hooker, “Federally employed physician assistants,” Mil. Med., 173:895-899, 2008.

[11] J. F. Cawley & R. S. Hooker, “Physician assistant role flexibility and career mobility,” JAAPA, 23:10, 2010.

[12] D. M. Brock, et al., “The physician assistant profession and military veterans,” Mil. Med., 176:197-203, 2011.

[13] N. Holt, “’Confusion’s masterpiece’:  the development of the physician assistant profession,” Bull. Hist. Med., 72:246-278, 1998; Brock, op cit., p. 197.

[14]H. K. Rabinowitz, et al., “Critical factors  for designing programs to increase the supply and retention of rural primary care physicians,” JAMA, 286:1041-48, 2001; H. K. Rabinowitz, et al., “The relationship between entering medical students’ backgrounds and career plans and their rural practice outcomes three decades later,” Acad. Med., 87:493-497, 2012; H. K. Rabinowitz, et al., “The relationship between matriculating medical students’ planned specialties and eventual rural practice outcomes,” Acad. Med., 87:1086-1090, 2012.

Copyright © 2013 by Paul E. Stepansky.  All rights reserved.

Leave a comment

Posted in Family Doctors, Then & Now, Health Care Reform, Healthcare Delivery Systems, Primary Care, Rural Medicine

Tagged , ,

My Doctor, My Friend

Posted on January 10, 2012 | Leave a comment

In a piece several months ago  in the Boston Globe, “Blurred Boundaries Between Doctor and Patient,” columnist and primary care internist Suzanne Koven writes movingly of her patient Emma, whom Koven befriended over the last 15 years of Emma’s life.  “Emma and I met frequently to gossip, talk about books and politics, and trade stories about our lives,” she remarks.  “She came to my house for dinner several times, and my husband and kids joined me at her 90th birthday party.  When, at 92, Emma moved reluctantly into a nursing home, I brought her the bagels and lox she craved – rich, salty treats her doctor had long discouraged her from eating.  Here’s the funny part:  I was that doctor.”

Koven writes perceptively of her initial concern with doctor-patient boundaries (heightened, she admits, by her status as “a young female physician”), her ill-fated efforts to maintain her early ideal of professional detachment, and, as with Emma, her eventual understanding that the roles of physician and friend could be for the most part “mutually reinforcing.”

As a historian of medicine interested in the doctor-patient relationship, I reacted to Koven’s piece appreciatively but, as I confessed to her, sadly.  For her initial concern with “blurred boundaries” and her realization after years of practice about the compatibility of friendship with primary medical care only underscore the fragmented and depersonalized world of contemporary medicine, primary care included.  By this, I mean that the quality of intimacy that grows out of most doctoring has become so shallow that we are led to scrutinize doctor-patient “friendship” as a problematic (Is it good?  Is it bad?  Should there be limits to it?) and celebrate instances of such friendship as signal achievements.   Psychoanalysts, be it noted, have been pondering these questions in their literature for decades, but they at least have the excuse of their method, which centrally implicates the analysis and resolution of transference with patients who tend to become inordinately dependent on them.

My father, William Stepansky, like many of the WWII generation, befriended his patients, but he befriended them as their doctor.  That is, he understood his medicine to include human provisions of a loving and Hippocratic sort.  Friendly two-way extramedical queries about his family, contact at community events, attendance at local weddings and other receptions – these were not boundary-testing land mines but aspects of community-embedded caregiving.  But here’s the rub:  My father befriended his patients as their doctor; his friendship was simply the caring dimension of his care-giving.  What, after all, did he have in common with the vast majority of his patients?  They were Protestants and Catholics, members of the Rotary and Kiwanis Clubs who attended the local churches and coached little league baseball and Pop Warner football.  He was an intellectual East European Jew, a serious lifelong student of the violin whose leisure time was spent practicing, reading medical journals, and tending to his lawn.

And yet to his patients, he was always a special friend, though he himself would admit nothing special about it:  his friendship  was simply the human expression of his calling.  He did not (to my knowledge) bring anyone bagels and lox or pay visits to chat about books or politics, but he provided treatment (including ongoing supportive psychotherapy) at no charge, accepted payment in kind, and visited patients in their homes when they became too elderly or infirm to come to the office.  Other routine “friendly” gestures included charging for a single visit when a mother brought a brood of sick children to the office during the cold season.  And when elderly patients became terminal, they did not have to ask – he simply began visiting them regularly in their homes to provide what comfort he could and to let them know they were on his mind.

When he announced his impending retirement to his patients in the fall of 1990, his farewell letter began “Dear Friend” and then expressed regret at “leaving many patients with whom I have shared significant life experience from which many long-term friendships have evolved.”  “It has been a privilege to serve as your physician for these many years,” he concluded.  “Your confidence and friendship have meant much to me.”  When, in my research for The Last Family Doctor, I sifted through the bags of cards and letters that followed this announcement, I was struck by the number of patients who not only reciprocated my father’s sentiment but summoned the words to convey deep gratitude for the gift of their doctor’s friendship.

In our own era of fragmented multispecialty care, hemmed in by patient rights, defensive medicine, and concerns about boundary violations, it is far from easy for a physician to “friend” a patient as physician, to be and remain a physician-friend.  Furthermore, physicians now wrestle with the ethical implications of “friending” in ways that are increasingly dissociated from a medical identity.  Many choose to forego professional distance at the close of a work day.  No less than the rest of us, physicians seek multicolored self states woven of myriad connective threads; no less than the rest of us, they are the Children of Facebook.

But there is a downside to this diffusion of connective energy.  When, as a society, we construe the friendship of doctors as extramedical, when we pull it into the arena of depersonalized connecting fostered by social media, we risk marginalizing the deeper kind of friendship associated with the medical calling: the physician’s nurturing love of the patient.   And we lose sight of the fact that, until the final two decades of the 19th century,  when advances in cellular biology, experimental physiology, bacteriology, and pharmacology ushered in an era of specific remedies for specific ailments, most effective doctoring – excluding only a limited number of surgeries – amounted to little more than just such friendship, such comfortable and comforting “friending” of sick and suffering people.

And this takes us back to Suzanne Koven, who imputes the “austere façade” of her medical youth to those imposing 19th-century role models “whose oil portraits lined the walls of the hospital [MGH] in which I did my medical training.”  Among the grim visages that stared down from on high was that of the illustrious James Jackson, Sr., who brought Jenner’s technique of smallpox inoculation to the shores of Boston in 1800, became Harvard’s second Hersey Professor of the Theory and Practice of Medicine in 1812, and was a driving force in the founding of MGH, which opened its doors in 1821.  Koven cites a passage from the second of Jackson’s Letters to a Young Physician (1855) in which he urges his young colleague to “abstain from all levity” and “never exact attention to himself.”

But why should absence of levity and focal concern with the patient be tantamount to indifference, coolness, the withholding of physicianly friendship?  Was Jackson really so forbidding a role model?  Composing his Letters in the wake of the cholera epidemic of 1848, when “regular” remedies such as bleeding and purging proved futile and only heightened the suffering of  thousands, Jackson cautioned modesty when it came to therapeutic pretensions.  He abjured the use of drugs “as much as possible,” and added that “the true physician takes care of his patient without claiming to control the disease in all cases.” Indeed he sought to restore “cure” to its original Latin meaning, to curare, the sense in which “to cure meant to take care.”  “The physician,” he instructed his protégé,

“may do very much for the welfare of the sick, more than others can do, although he does not, even in the major part of cases, undertake to control and overcome the disease by art.  It was with these views that I never reported any patients cured at our hospital.  Those who recovered their health before they left the house were reported as well, not implying that they were made so by the active treatment they had received there.  But it was to be understood that all patients received in that house were to be cured, that is, taken care of” [Letters to a Young Physician, p. 16, Jackson’s emphasis].

And then he moved on to the narrowing of vision that safeguarded the physician’s caring values, his cura:

“You must not mistake me.  We are not called upon to forget ourselves in our regard for others.  We do not engage in practice merely from philanthropy.  We are justified in looking for both profit and honor, if we give our best services to our patients; only we must not be thinking of these when at the bedside.  There the welfare of the sick must occupy us entirely” [Letters to a Young Physician, pp. 22-23].

Koven sees the Hippocratic commitment that lies beneath Jackson’s stern glance and, with the benefit of hindsight, links it to her friendship with Emma. “As mutually affectionate as our friendship was,” she concludes, “her health and comfort were always its purpose.”  Indeed.  For my father and any number of caring generalists, friendship was prerequisite to clinical knowing and foundational to clinical caring.  It was not extramural, not reserved for special patients, but a way of being with all patients.  And this friendship for his patients, orbiting around a sensibility of cura and a wide range of procedural activities, was not a heavy thing, leaden with solemnity.  It was musical.  It danced.

In the early 60s, he returns from a nursing home where he has just visited a convalescing patient.  I am his travelling companion during afternoon house calls, and I greet him on his return to the car.  He looks at me and with a sly grin remarks that he has just added “medicinal scotch” to the regimen of this elderly gentlemen, who sorely missed his liquor and was certain a little imbibing would move his rehab right along.  It was a warmly caring gesture worthy of Osler, that lover of humanity, student of the classics, and inveterate practical joker.  And a generation before Osler, the elder Jackson would have smiled.  Immediately after cautioning the young physician to “abstain from all levity,” he added: “He should, indeed, be cheerful, and, under proper circumstances, he may indulge in vivacity and in humor, if he has any.  But all this should be done with reference to the actual state of feeling of the patient and of his friends.”  Just so.

Copyright © 2012 by Paul E. Stepansky.  All rights reserved.

Leave a comment

Posted in Doctor-Patient Communication, Nineteenth-Century Medicine, Primary Care, Psychoanalysis

Tagged , ,