A Prophet Is Never Recognized

"I have often wondered why it costs so much to give care to the poor. The answer, I believe, is that health care service is no longer a special calling but increasingly a for-profit-business."

The above quote is from Dr. Lynn Carmichael, one of the founders of modern Family Medicine, who died this past Friday at age 80. I had the privilege to work with and learn from Lynn for more than 30 years here at the University of Miami Miller School of Medicine. Few outside of Family Medicine know of Lynn, but he is a giant in American medicine. In a time of increasing specialization, he clearly foresaw the need for well-trained generalists who could treat patients through the lifespan, provide continuity of care and apply the bio-psycho-social model of care, as well as knowledge of family dynamics, to the holistic provision of preventive, curative and palliative health care services. Lynn founded the first Department of Family Medicine here at Miami in 1966 and the first residency training program in Family Medicine in 1967. He also founded the Society for Teachers in Family Medicine. If, as the old expression goes, "success has a thousand fathers," Lynn would certainty be named in the family medicine paternity suit!

Lynn was also a pioneer advocate for social justice in health care delivery, founding clinics in several of Miami's poorest communities and serving as the inspiration for the family medicine and community health programs we've established in Haiti. Indeed, he saw the well-trained family doctor as a critical factor in health and social justice. "Poor communities just can't afford the luxury of one doctor for the kids, one for the pregnant women and one for the old folks!" he would often opine. His decline and death is not sad enough in itself, but even more so, for his mind, voice and heart have been lost exactly when we need them the most.

The sentiments expressed in Lynn's opening quote, written over a decade ago, could not have been more prophetic. The debate on health care reform has focused on costs, insurance coverage and public versus private options. Meanwhile, there are fewer and fewer physicians who see their profession as what he termed a "special calling." Rising debt, lifestyle concerns and malpractice worries have made not just family physicians, but any physicians who see our profession as a special calling an endangered species. Ironically, the same forces that are driving doctors away from primary care are the ones driving up costs, which paradoxically threaten the prospects of meaningful health care reform by making it unaffordable under the present system to expand coverage to the uninsured.

Shortly after Lynn conceptualized Family Medicine, policy markers embarked on a futile quest to control costs -- first with peer-review, then Diagnosis Related Groups, then HMO's, followed by "managed care". All of these policy interventions failed to restrain costs, while making the lives of primary care doctors progressively more intolerable -- shredding patient panels, disrupting continuity of care, increasing paper work and eroding income. At the same time profits for the health industry giants -- insurance and pharmaceutical companies -- soared, as did the numbers of uninsured and the "dissatisfaction quota" of patients and their employers, who, in our system, get stuck with most of the bills.

The Obama administration is intent on health care reform, with an emphasis on the need for primary care and prevention. Behind this focus, however, is an even keener focus on controlling costs. Lynn's vision of medicine as a special calling has been forgotten.

If we could bring back Lynn's vision and voice to help shape true health care reform, what would he say? At least the following:

1. Health care reform, workforce reform, tort reform and reform of medical education must all go hand-in-hand. Workforce reform must promote primary care careers and medical education must instill those values that will return our profession to its special calling.
2. Fee-for-service or insurance-based capitation simply won't work to compensate primary care physicians. Unless family doctors are compensated on a relative par with specialists, all attempts at workforce reform are doomed. My own suggestion is to keep it simple - pay them a salary (in 2009 dollars300,000 a year sounds about right) in exchange for providing continuing primary care for a panel of about 2,000 patients. Do this, and waste, unnecessary tests, hospitalizations, emergency room visits and procedures will plummet, patient and physician satisfaction will rise and costs of care will dramatically fall.
3. In all of the debate about reform, let's not forget Lynn's issue of health and social justice. If things are bad in the suburbs, be assured they are much worse in our economically and geographically disadvantaged communities. Medical schools need to do a better job of recruitment and training in these communities. Finally, to reduce debt and emphasize the special calling that is our profession, we should consider a mandatory national or international health service, coupled with loan repayment, for all U.S. medical school graduates prior to specialization.