by Juliet Farmer
John Geyman, MD, Professor Emeritus of Family Medicine at the University of Washington School of Medicine in Seattle, is a family physician with over two decades experience in academic medicine and 13 years experience practicing in rural communities. Dr. Geyman attended the University of California San Francisco School of Medicine, where he was awarded the Gold Headed Cane Award. He went on to earn the Thomas W. Johnson Award for contributions in family practice education, American Academy of Family Physicians; the Curtis B. Hames Research Award, North America Primary Care Research Group and Society of Teachers of Family Medicine; the Marian Bishop Award, Society of Teachers of Family Medicine; and the Dr. Quentin Young Health Activist Award, Physicians for a National Health Program.
He was the founding editor of The Journal of Family Practice and also served as editor of The Journal of the American Board of Family Practice from 1990 to 2003. Dr. Geyman has written several books, including Health Care in America: Can Our Ailing System Be Healed?, The Corporate Transformation of Health Care: Can the Public Interest Still Be Served?, Falling Through the Safety Net: Americans Without Health Insurance, Shredding the Social Contract: The Privatization of Medicare, Do Not Resuscitate – Why the Health Insurance Industry is Dying, And How We Must Replace It, and his most recent work, Breaking Point: How the Primary Care Crisis Endangers the Lives of Americans.
Why did you choose to become a physician?
For me, medicine brought together science and people, with the chance to make a difference. I wanted to do something useful, and have always enjoyed relating to people, especially from different backgrounds and interests.
I didn’t decide on medicine until midway through my three years in the Navy on a destroyer in the Pacific. Previously I had considered teaching science. But I read a book on anatomy by a gifted professor at the University of Minnesota that set me on the way to medicine. I had been a Geology major at Princeton (and in the Navy ROTC), not a pre-med, so I had to do all the pre-med (except one chemistry course) over a year and two summers at the University of California Berkeley after getting out of the Navy.
If you had it to do all over again, would you still become a physician? (Why or why not? What would you have done instead?)
No question—I would go into medicine again for all the reasons above, and would still find it a fascinating and challenging profession, albeit much changed. Although there are many problems with the health care system, the needs of patients are timeless, more can be done therapeutically, there is a greater need for primary care than ever, and there is a great opportunity to help reform a broken system in the public interest (versus the business “ethic” in a runaway market system). There is a rich legacy of personal medicine in the public interest at its best. This needs to be rejuvenated and brought into the center of mainstream medicine in a reformed system.
What did you like most and least about being a physician and interacting with patients?
I enjoyed every bit of relating to patients of all ages and in all aspects of their illnesses. A few were challenging as “difficult patients,” but I enjoyed the process of shifting gears and trying to be sensitive to their differences and preferences while remaining objective. Each person is unique and each situation different.
The biggest problem was not having enough time, since I enjoyed talking with patients so much. The other big problem, of course, has been dealing with all the hassles of an increasingly complex multi-payer system with some 1,300 private insurers, each with different requirements.
Why did you choose your specialty?
I wanted to be a family doctor in a rural area from the beginning of medical school. I liked all of my courses and clerkships in medical school, and looked forward to serving a small community where the needs were obvious. I took two two-week preceptorships with GPs to confirm that interest (one in a town of 35,000, the other in a mountain town of 2,500).
Graduating from medical school in 1960, general practice (now family medicine) was not yet a specialty in its own right. So I had to put together my own graduate training—a year’s rotating internship at Los Angeles County Hospital (at 3,500 beds, the second largest hospital in the country), followed by a two-year general practice residency at Sonoma County Hospital in Santa Rosa, California. Those three years were excellent preparation for rural general practice, including OB, the broad span of primary care, anesthesia, some surgery, and a lot of emergency medicine. As a GP on the frontlines of medical care, this was exciting, varied and a challenge.
You note in your book (Breaking Point) that going into primary care is not motivated by money. In that case, what do you think is the best way to recruit and retain primary care physicians?
Yes, if money is your main motivation for going into medicine, don’t choose any of the primary care specialties!
The current attraction of ROAD (radiology, orthopedic surgery, anesthesiology and dermatology) exemplifies the pattern of specialty selection by today’s medical graduates, who can expect incomes roughly double those in primary care while avoiding the challenges and pressures of generalist practice.
But primary care physicians will still have an ample income (which will be larger with real health care reform), and new patterns of group practice will allow a better balance between personal and family life and medicine. The challenge (and rewards) of relating to people of all ages remains, and the need for primary care is even greater today in an upside-down system than it was 50 years ago.
So, if one wants to serve, to make a difference, and to become close to patients, family and community, there is no better field than primary care (which I hope one day will coalesce into just one specialty—general practice or family medicine—the foundation of the health care systems in most advanced countries around the world).
How does preventative versus reactive medicine play into the generalist/specialist issue?
Preventive medicine is one aspect of primary care, and lesser so for many non-primary care specialties, which are often more focused on one or another aspect of treatment. In these terms, such specialties as neurosurgery and cardiac surgery might be considered “reactive” to established disease.
Generalists in primary care are involved over a wide range of care, including prevention, early diagnosis of disease, evaluation and treatment of emergency and urgent problems, management of chronic disease, and rehabilitation from illness and accidents.
In regards to specialists, how much of the generalist/specialist struggle lies with the patient’s perception/desire to be treated by an “expert”? How can that be overcome?
We live in a culture that worships the latest in medical technologies, whether proven to be medically useful or not. Within the medical profession, higher status is typically attached to being “expert” in a narrow field rather than being a generalist across a wide body of knowledge and skills, as is required by generalists in primary care.
Likewise, much of the public, in its worship of the latest in medical technologies, sees specialists in narrow fields (especially if they are the providers of newer diagnostic and therapeutic procedures) as likely to be more competent in those areas. (Actually, they often fail to recognize the downside of advice given by specialists concerning questions outside of their areas of expertise, sometimes learning that the hard way).
But the body of clinical knowledge and skills held by a well-trained generalist is much broader than any other kind of specialist. Many specialists recognize that in their respect for primary care physicians being willing to tackle the demands and responsibilities of generalist practice. Moreover, there are a number of studies that show that patients prefer to see a primary care physician first (if they can find one!) for many potentially serious medical problems.
The perception problem of primary care can be overcome over time by a larger part of the public recognizing that the process and outcomes of comprehensive care by a personal primary care physician, with continuity over years, are superior to care fragmented among many specialists who barely communicate among themselves.
How do knowledge of a patient’s character, the psychological setting of an illness, and pattern of health complaints come into play in the primary care versus specialist setting?
Knowledge of the patient over years is an enormous advantage for a primary care physician in sorting through the care options which will best meet the patient’s individual needs.
A specialist seeing a patient for the first time has none of these advantages. Therein lies a big problem in today’s specialist-driven system. Patients often receive a service from a specialist that is inappropriate, ineffective or even harmful to the patient’s continued functioning in his or her particular context. One of the reasons leading to that problem is our profession’s over-emphasis on a cure paradigm when we should have been shifting to a care paradigm. One obvious example that happens every day is the continuation by some oncologists of chemotherapy for terminal cancer without enough quality of life in patients’ last months of life.
What role does trust play in the primary care/patient relationship?
Trust is a very important part of the physician-patient relationship. The more trust, the more effective the physician can be as a healer. Since trust takes time to develop, primary care physicians have an advantage over specialists in providing continuity of care over years and dealing with previous encounters with disease, accidents or other threats to the patient’s wellbeing.
What role does trust play in the specialist/patient relationship?
Trust is equally important in the patient’s relationship with a specialist. Here again the outcome of care will be better with a higher level of trust. When seeing a specialist for the first time with a new medical problem, patients will base that trust on the reputation of the specialist and his or her institution. Specialists seeing patients over years for chronic problems have the same opportunity to build trust with patients as is true in primary care, at least within the limits of their particular specialties.
Regarding the internal snubbing of primary care, how do you think it can be stopped?
As part of the current culture in medical education and clinical practice, the decreased status of primary care vs. the glamour of many specialties is a perennial problem. Although it will not end soon, the continued implosion of our fragmented and dysfunctional health care delivery system will lead to greater appreciation of the need to rebuild and expand primary care. As that happens, generalists in medicine will regain much of the stature enjoyed by generalists in earlier times.
As fewer medical students pursue family medicine and primary care, how does that affect the healthcare landscape for both physicians and patients?
After several decades of over-emphasis on specialization in medical education and in the marketplace of health care, the generalist-specialist balance in the U.S. physician workforce has turned upside down. It is now skewed to about 30 percent in generalist primary care specialties vs. 70 percent specialists. By comparison it was closer to 50:50 in the post-World War II years. Most advanced countries with high-performing health care systems maintain at least a 50:50 balance, with some up to 60 or 70 percent generalists.
As a result of our growing shortage of primary care physicians, patients have an increasingly difficult time in gaining access to comprehensive care that is personal, affordable, and coordinated. Specialists are neither trained nor equipped to provide private care, so a growing part of the population receives fragmented care from a myriad of specialists that is poorly coordinated, more expensive, and of lesser quality than that provided by well-trained generalists.
One of the ethical principles the Tavistock Group purports is that healthcare is a human right. How do you think that belief is regarded in the U.S.?
Unfortunately, there is still a wide political chasm in the U.S. over the concept that health care, as a basic human need, is a right. Most conservatives line up against that idea, instead promoting principles of personal responsibility, that we’re each responsible for ourselves, and that government has no role in assuring a system of universal health care. As such, the U.S. remains an outlier among advanced countries in the world without such a system. The current political battle over the future of Medicare, a key issue in the 2012 election cycle, is a reflection of how deeply these sentiments are held.
Although patient satisfaction is high in other countries with universal access, why do you think the U.S. is resistant to it?
Patient satisfaction indeed is high in countries with universal access, higher than that in this country. And in fact, public surveys over the last 50 years have consistently shown majority support for national health insurance. Citizen “juries,” sequestered from time to time to consider the major options for health care reform, have come to the same conclusion. But powerful stakeholders in the present very profitable market-based system, working closely with their lobbyists and willing politicians, have so far blocked a publicly financed single-payer system assuring universal coverage for the whole population.
Do you think the FHT program could, if it had support, work in the U.S.? Why or why not?
The Family Health Team (FHT) model of primary care, established in Ontario, Canada, in 2005 is a very interesting approach that would well work in this country if we can achieve the necessary reforms in financing and payment mechanisms.
Although Canada has had a national single-payer system for many years, it has been facing many of the problems in medical education and medical practice that we confront on this side of the border concerning the balance between generalists and specialists. The FHT model is based on interdisciplinary primary care teams, with each practice having at least seven family physicians for a panel of 1,400 patients. Together with nurse practitioners, pharmacists, social workers and health educators, they provide year-round 24/7 care, handle the majority of care, and coordinate care by specialists and other community resources.
There are now more than 1,500 family physicians in almost 200 FHTs serving almost 2 million people in Ontario, and the concept is growing rapidly. Canadian medical graduates are entering family practice at a much faster rate, and the income gap has narrowed between generalists and specialists. The average annual net income of family physicians in FHTs is about $250,000 (CA), about 80 percent of annual specialist salaries.
What is the biggest obstacle to physician payment reform? Why?
The biggest obstacle to significant reform of payment for physician services is the amount of money currently being made by a well-entrenched fee-for-service (FFS) mechanism that rewards procedures and higher-technology services far above evaluative and cognitive care that is such a big part of primary care. Coordination and integration of care are poorly reimbursed under existing payment policies, as are many preventive and counseling services. While the AMA is supportive of increased incomes for primary care physicians, it joins most specialty organizations in opposing any changes in payment mechanisms that would reduce specialists’ incomes, as is being signaled already by the battle over how accountable care organizations (ACOs) will work.
How do you think medical schools can be encouraged to re-establish a generalist orientation?
Since money talks, perhaps the single most important way to move medical schools toward a greater investment and commitment to primary care at all levels of medical education would be the establishment of a major new federal funding stream for that purpose (e.g. for development of Departments of General Practice or Primary Care). That would be even more effective if accompanied by changes in physician reimbursement that value primary care services more highly. And, of course, another powerful shift toward primary care will occur when present reimbursement policies that overvalue many specialist services are reduced, thereby making many surplus specialties less attractive.
Do you think medical schools would/will ever change admissions policies? Why or why not?
Many medical schools have revised their admission policies over the years in an effort to identify students with the values, traits and motivation compatible with future careers in primary care. A few schools have even taken an approach that accepts their responsibility to prepare medical graduates for the needs of their particular region (e.g. University of Minnesota at Duluth).
But, of course, most medical schools have a long way to go in this respect. Provided there is adequate funding for primary care programs and strong leadership at the top, much more can be done along this line. A considerable body of research has already identified the personal qualities and backgrounds of applicants who will make excellent primary care physicians, so this is a soluble problem.
Medical malpractice liability often gets a spotlight in healthcare discussion. Do you think it should? Why or why not?
The magnitude of the medical malpractice liability issue has been exaggerated in the ongoing debate over health care costs and system reform. Although it is an issue, it is by no means as big a part of health care inflation as is claimed by many. The annual costs of the medical malpractice system are on the order of 2.5 percent of total health care costs.
For perspective, it is estimated that inappropriate and unnecessary care account for up to one-third of health care costs. These are driven much more by perverse incentives (doing more volume begets higher physician and institution incomes!) than defensive medicine in response to fear of lawsuits.
Do you think the healthcare community will reach a breaking point soon? Why or why not?
Primary care and its infrastructure are already at their breaking points, and the trends going forward are not favorable without major reforms in financing and delivery of care. The present behemoth health care system is not sustainable in its present form, so reform will happen, whether today’s market stakeholders like it or not. It is just a matter of time.
We cannot afford the costs of an exploitative multi-payer financing system and an unaccountable profit-driven delivery system. A growing part of the population is being left out of even basic and necessary health care, and whatever safety net we have had is frayed more every day in this time of serious economic downturn. The rebuilding of primary care as the foundation of a better-performing health care system is a critical part of health care reform that is yet to come.
The Patient Protection and Affordable Care Act of 2010 is a small step in this direction. More significant reforms are needed. They will come, and those entering medicine today should find primary care a highly rewarding and satisfying career that can and will make an even greater impact on U.S health care than in the past.