The only doctor in town

March is conference time, and this spring our members will descend on Las Vegas to network, to socialize, and, most importantly, to continue our education. It may be that some of the topics are beyond your usual focus or involve clinical pictures you usually refer out. This year my challenge to all of you is as follows: learn all the material as though you were the only doctor in town. As though there were no specialists within 200 miles. As though the buck stopped with you.

For some of us, this is the literal truth: practice in some parts of Colorado or Alaska may involve C-sections and management of viral hepatitis because it is still a frontier of sorts and that standard of care is the family physician. For some of us, there are specialists behind every door and ivory towers on every corner, and we osteopathic family physicians may have gotten a little too comfortable.

My residency was in rural family medicine and afterwards I practiced for several years in a small town in coastal Maine. For over 10 years, I viewed each patient through the lens of what the weather was like, and knew under what conditions the chopper could fly, and how long we would have to manually bag the ventilator patient if the ambulance could not make it through the blizzard. I also knew off the top of my head which surgeon was in town and who was sick or on vacation, and whether we had a magnetic resonance imaging machine that day. I knew how many months it took to get a new appointment for each specialty (3 months for gastroenterology, 6 for rheumatology). My patients loved my partners and me, trusted our judgment, and gave us baked goods or shellfish on holidays.

A few years ago, I relocated to an area of greater population density, and had to start throwing elbows. Local obstetricians shut down my right to deliver babies almost immediately, and intensive care unit nurses looked shocked at the idea that we might help an alcoholic through detox while she was in for a complicated pneumonia. Every headache patient wanted to see a neurologist, even though many neurologists are not trained in headache medicine and I am. When my employing institution was trying to find more people to cover the hospitalist service, the administration had to be reminded that there are physicians other than internists who know how to round on inpatients.

Predictably, I spent the first year or so being huffy and offended on my own behalf and on behalf of my fellow family physicians. I started drafting angry letters to the hospital’s CEOs about their discriminatory policies and tried to get the hackles raised on my peers, who, I assumed, felt as I did were being nudged out of work that was rightfully ours. Then I looked around and started taking stock of some of the family doctors with whom the local specialists are familiar. And I had to concede a few points.

The chair of family medicine at an area hospital asked me, “Do you plan to see any inpatients or do you just do what the rest of us do and leave all that stuff to the internists?” A friend overheard a colleague cheerily explaining to the receptionist, “Oh, I don’t see any patient concerns below the waist, I refer those!” This one does not treat anyone under age 12. That one does not “do” pain management. Another colleague discovered that she was the only physician in a room of 100 who knew how to do a punch biopsy. And of course, everyone is too busy to do osteopathic manipulative medicine.

There may be a great many legitimate reasons for this trend: there are time constraints, volume quotas, medicolegal concerns, and the ever-advancing “patient-satisfaction surveys” which will get us in trouble with our employers if we do not throw antibiotics at every patient who demands them. Some medical staff are genuinely hostile and create career graveyards for any family physician who wants to expand his or her scope. I know those exist and I know they matter and sometimes we just do not feel like engaging in one more battle every time we show up at work.

But I like to be indignant, and I do not get to be indignant when a specialist talks down to me anymore, if the reality is that almost every other primary care doctor this specialist knows has not even tried to problem-solve before sending the patient to a “higher court”. I cannot complain that specialists get paid more than family physicians unless I actually provide something a specialist does not, I can speak self-righteously about the importance of chronic disease management, but if I am managing those diseases with inappropriate antibiotics and innovations that I learned from a pharmaceutical representative instead of a journal, I just sound whiny and self-serving.

We cannot, as a profession, simultaneously lobby to prevent midlevel providers from having practice rights, if we rarely practice at any higher level of complexity than a PA would. We cannot claim, as the American Academy of Family Physicians does, to be “specializing in all of you,” if we choose whole age groups and body parts that we scrupulously avoid managing.

When accountable care becomes a reality rather than a buzzword, maybe then we will see a rebirth of primary care as the leaders of health, where the family physician holds the keys and specialists are more a luxury than a necessity most of the time. But if that happens, we will need to be ready. We will need to be competent. We will need to be up to date, and I do not just mean that we need to be able to search a website with a similar name.

We come together in Las Vegas to see our former mentors and our former students. We are a pretty bright group, and we all work hard and have a lot of tools, even more than our allopathic counterparts have. Once upon a time, when we chose this specialty, we were ready to help our patients through every concern from Alzheimer to zoster. We were ready to treat the newborns and help their great grandparents through their pneumonias and osteopenia. We might even get a tissue diagnosis on a skin condition, or do a little cardiopulmonary resuscitation. We still can. We just need some confidence. We just need some reminding.

We will be welcoming one of my most important mentors to his new role as our president, as we inaugurate Jeff Grove, DO, FACOFP, distinguished. Dr Grove has always led by example, and has been an inspiration to me since 1998 when I was a feisty medical student in Florida. We all have those important teachers who first showed us how diverse and wonderful and important osteopathic family medicine can be, and who first brought us into the fold with them. Seek them out while you are at the national conference. Be reminded once again of the doctors who made you want to seek greatness for yourself.

Seek, too, your former students. Be proud of the physicians they have become, because you helped get them here. Reconnect with the way they saw you when you were the educator and they were still in training. Hope that you can still impress them. Hope that they still have their passion for learning.

And while you are at it, take in a few lectures.

Remember, it is all “your specialty.” See you in Las Vegas!

Merideth Norris, DO, FACOFP
Editor