A century of primary care transformation, chapter 1: 1923 vs. 2023: A doctor’s daily life

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Click here to read the introduction to a century of primary care transformation.

How have these changes played out in terms of everyday medical practice? We can gain some sense of that by comparing a 1923 practice with one from today. Because firsthand accounts of a 1920s medical practice are scarce, this picture is drawn from secondhand sources and interviews with medical historians:

The 1923 doctor — we’ll call him Dr. Smith; most doctors were men — begins his day by going to his office, which was near his home. Some doctors had only to walk downstairs; having the office on the first floor of the house while the family lived upstairs was a common arrangement.

After arriving, he consults his daily calendar to see who is coming in and the reason for their visit. Like the great majority of physicians then, he is a general practitioner, so he would have been called on to treat a wide variety of medical problems. Sometimes he might have to perform minor surgery, particularly if he practiced in a location without a nearby hospital.

His office probably has a reception area and several examination rooms. In his 1923 book “The Successful Physician,” Verlin C. Thomas suggests that an urban practice should be equipped with an operating table, sterilizer, instrument cabinet, examination chair, dressing stand, medical preparations and “instruments of treatment and examination.” Among the latter should be:

• Specula for the eye, ear, nose, vagina and rectum.
• Catheters from No. 6 to No. 30.
• Dressing forceps.
• Assorted needles.
• Sutures for minor wounds.
• Medicines, antiseptics, bandages, gauzes, splints.
• Stomach pump.
• Office antiseptics.

Although Dr. Smith’s schedule might include house calls, those were becoming less common, due in part to the recent increase in car ownership. It was simply more efficient for patients to come to his office for treatment rather than to spend time traveling to patients’ homes. And thanks to the growing use of telephones, patients could call ahead to make appointments, further enhancing his productivity.

“For doctors, the appointment system made each day more predictable and productive,” notes a 2022 Annals of Internal Medicine article tracing the evolution of scheduling in outpatient practices. “A physician could minimize his ‘idle time’ between patients in order to see as many as possible.”

Because Dr. Smith has a well-established practice, he employs an office assistant/secretary (nearly always a woman) to manage it. Thomas described the responsibilities of the position thus: “She can make appointments for you, keep out idlers, agents you do not want to see, assist in keeping a record of your appointments, and in general be your representative when you are not in the office.”

More often than not, the person taking on these responsibilities was the physician’s wife, says John Frey, M.D., a medical historian at the University of Wisconsin School of Medicine and Public Health in Madison. “Medicine then was largely a family business, and it was a low-cost way of running the business,” he said.

Dr. Smith’s accounts and schedule are, of course, kept on paper, although they are becoming more complex and requiring increasing amounts of time. As Thomas noted:

“Every (record-keeping) system has certain features connected with its operation that may not be ideal. This may be said of the old systems — they are not suited to present-day requirements. The Daily Journal Ledger and pocket visiting list, so long employed … are no more practical or efficient than the methods of surgery in vogue a hundred years ago.”

In place of old-fashioned record-keeping methods,
Dr. Smith follows Thomas’s advice and uses a system developed for physicians by the McCaskey Register Company. Known as the “One Writing” method, it was essentially an all-in-one medical chart, daily schedule and financial ledger. It included instructions for recording, updating and filing both types of information including past-due accounts, so that they could be easily located.

Unlike his present-day counterpart, Dr. Smith doesn’t have to carry medical malpractice insurance. Although doctors did get sued in the early 20th century, it occurred much less frequently and for dollar amounts that were relatively far smaller than those of today.

Dr. Smith earns a comfortable, though not extravagant, living. In 1929, the average net income for an independent physician was $5,224, or approximately $93,000 in 2023 dollars. By comparison, the average American family’s income that year was $2,300. He is paid directly by the patient on a fee-for-service basis. He sets his fees according to what was considered “usual, customary and reasonable” for the community. These are negotiable, especially if — as is often the case — he knows the patient and their financial circumstances.

Like all good doctors of the modern era, Dr. Smith is singularly committed to his work. Here again he follows Thomas’s advice. “You must pay the strictest attention and give all your devotion to your practice,” Thomas wrote. “Attending to your practice means that you must have no other form of interest that will interfere, even in the slightest, with any part of the line of endeavor in which you are engaged.”

What of the primary care doctor in 2023? For that we have a firsthand account from an activities log kept by Melissa Lucarelli, M.D., FAAFP, a Medical Economics editorial adviser. Since 2001, Lucarelli has been president and medical director of Randolph Community Clinic in Wisconsin, where she oversees a staff of 10.

Lucarelli’s workday begins when she arrives at the clinic, usually around 7:15 a.m. (She arrives later on days when she virtually attends staff meetings at one of the two area hospitals where she has admitting privileges.) She prepares to see the patients on her schedule by reviewing notes from previous visits, recent lab results and correspondence from other providers. She also messages clinic nurses about which patients are due for vaccinations, need depression screenings or require tests such as an electrocardiogram.

Other tasks before seeing patients include reviewing messages received via the clinic’s patient portal, such as from retired “snowbirds” seeking prescription refills or medical advice. She forwards several of them to a nurse with instructions to set up telehealth appointments.

Morning patient visits include well-child checkups, medical evaluations and annual physicals, and a transitional care visit with a patient recently discharged from the hospital. The visit is conducted via telehealth because the patient can’t get transportation to the clinic. Following the visit, Lucarelli sends an e-prescription for a medication the patient needs to a pharmacy, which will deliver it to the patient’s home.

Over lunch Lucarelli meets with the clinic’s other providers, a nurse practitioner and physician associate. Agenda topics include vacation call coverage, a new contract with a medical translation service, updated guidelines for treating chronic obstructive pulmonary disease and reimbursement for home telemonitoring.

In the afternoon, Lucarelli visits an elderly patient who recently had been admitted to a nearby nursing home and discusses starting hospice care with the patient’s family members. Upon returning to the clinic, she logs on to the server of one of the hospitals where she has admitting privileges — one 17 miles away, the other 22 miles away — to sign her medical records. The clinic manager comes to her with some new patient requests (because of its limited resources, the clinic limits how many new patients it will accept), recredentialing paperwork to sign and news that an HMO with whom it contracts is upgrading the clinic’s ranking, for which the clinic will receive a lump-sum bonus.

Her last patient of the day needs treatment for warts. Lucarelli likes that the visit involves a procedure because “it feels like I got something tangible done today,” she writes.

Lucarelli leaves the clinic about 6:30 p.m. but her workday isn’t over. At home she talks on the phone to a patient who forgot to take insulin at dinner and now has an elevated glucose level. Her final tasks are to finish her charts and review lab results in her electronic health record. For her efforts, Lucarelli earns approximately $260,000 per year. By comparison, the annual average wage for family physicians in 2022 was approximately $224,000.

The differences in the daily work lives of Drs. Smith and Lucarelli encapsulate much of how medical practice has evolved since Medical Economics published its first issue. Many factors drove that evolution, but four factors of special relevance to our readers have been the rise of the specialist, the role and influence of third-party payers, the threat of malpractice lawsuits, and the decline of independent practice.

Click here to read chapter 2: Rise of the specialists

A century of primary care transformation: Table of contents

• Introduction
• Chapter 1: 1923 vs. 2023: A doctor's daily life
• Chapter 2: Rise of the specialists
• Chapter 3: How insurance changed everything
• Chapter 4: The malpractice threat
• Chapter 5: The vanishing independent physician
• Conclusion: What the future holds
• 'Holding onto the primary care dream:' An interview with Melissa Lucarelli, M.D.