General practice gets a second wind

General practice gets a second wind

By Howard Larkin

GPs were thought to be fading out, thanks to managed care.Now their ranks are stabilizing--thanks, again, to managed care.

General practice, which dominated the medical profession until the 1950s,has declined rapidly in recent decades. But a recent stabilization in thenumber of GPs--largely because of the shift of some specialists to primarycare--suggests that general practice won't give up without a fight.

Based on certain statistics, you might not think GPs stand much of achance. In 1970, there were nearly 58,000 GPs--more doctors than in anyphysician specialty. By 1997, according to the AMA, that figure had plummetedbelow 17,000, and more than two-thirds of those doctors were 55 or older,compared with only about a quarter of all active physicians.

Given the rise of specialization and family practice, the trend awayfrom general practice isn't surprising. Many doctors traded in the GP badgewhen board certification in family practice became available to them from1969 through 1978. Meanwhile, new physicians flocked to specialty trainingprograms that promised greater prestige and higher pay.

Another strike against GPs: Nowadays, many hospitals require residencytraining or even board certification as a precondition for granting staffprivileges. Similarly, many health plans won't let doctors participate,and many group practices won't hire them, unless they're either board-certifiedor -eligible. These requirements give young doctors even more incentiveto take postgraduate training. And they leave many older physicians, whoentered practice before family medicine training was available, at riskof being squeezed out of longstanding practices.

Osteopathic physicians who've served one-year internships may still takethe osteopathic family practice boards after completing six years in practiceand 600 hours of continuing medical education. But that window of opportunitywill close soon. After 2001, all osteopaths will be required to completea one-year rotating internship and a two-year residency to qualify for thefamily practice exam.

For newly graduated and future doctors, the prospects of succeeding withouta residency are even dimmer. Three years of residency may soon become alicensing requirement for new doctors if states follow a recent recommendationby the Federation of State Medical Boards.

"It's become very unusual for physicians to do what we did in the'50s and '60s, which was to go directly from medical school and internshipinto practice," says GP Thomas R. Reardon, president of the AMA.

Nonetheless, it may be too early to write the obituary for general practice.In fact, between 1995 and 1997, the number of GPs barely changed, accordingto AMA data. Although the flow of doctors entering general medicine viaone-year internships has dwindled to a trickle, it appears that the GP ranksare being refreshed from other sources. Doctors with training in surgicaland other nonprimary care specialties are moving into general practice,for a variety of personal, professional, and economic reasons. These includea desire to have longer-term, more fulfilling relationships with patients,to wind down practices as retirement approaches, and to get out of someoversupplied specialties, such as pathology and anesthesiology.

The drift from specialties to general practice is reflected in the membershipof the American Academy of General Physicians, an association founded in1995. "About half of our 3,000 members have completed a residency insome area," says GP Harry D. Watkins Jr., officer of general practicedevelopment for the advocacy organization.

Whether residency-trained or not, general physicians face many challengesin today's medical market. How they cope with them could determine whethergeneral practice will survive--not just as a historical oddity, but as aviable alternative for doctors buffeted by rapid changes in the world ofmedicine.

Practice opportunities for GPs still exist

GPs certainly aren't widely sought today, says David Johnston, directorof recruiting services for Merritt, Hawkins & Associates in Irving,TX. During the past year, the search firm received no explicit requestsfor general physicians.

However, Johnston's firm did find spots for a handful of GPs with employerswho were seeking family physicians. "We place general practitioners,but usually the choices are limited as to geography and practice style,"he says. The more underserved an area is, the more likely group practicesand hospitals are to accept doctors without residency training, Johnstonsays. Rural areas are often the most promising for GPs who want to practicein an office-based or hospital setting.

In urban and suburban areas, general practitioners are often relegatedto urgent care facilities or inner-city clinics, because most urban hospitalsrequire residency training to get on staff or work in the emergency department.Not all GPs find this to be an obstacle, however. Harry Watkins, for example,began work in an emergency department in 1983, following a one-year internship.After five years in emergency medicine, he went into general practice forfive years. He now works as an attending physician in several nursing homesin the Atlanta area. He has discussed getting privileges with one hospital,but has chosen not to. When he needs to admit a patient, he refers to hospitalistsat various facilities.

Similarly, managed care isn't as big a barrier to GPs as one might expect.Although health plans prefer board-certified doctors, GPs around the countryreport they're being accepted on HMO and PPO panels. Louis Barber, for instance,has practiced general medicine in Stockton, CA, for 20 years. He says he'shad no trouble getting managed care contracts. Trained in both the medicaland surgical treatment of pulmonary disease, Barber says he turned to generalpractice as straight thoracic surgery increasingly gave way to cardiothoracicsurgery.

GP James J. Bass of Rolla, MO, similarly reports, "I've had no problemswith managed care, and neither have the other general physicians in town.The plans mostly look at your record in practice." Bass, who completeda residency in emergency medicine but is not board-certified, says his managedcare business accounts for about 20 percent of his practice.

Bass says UnitedHealthCare has credentialed him and several other GPsin his rural area. United spokesman Phil Soucheray confirms that the HMOdoesn't require board certification or residency training for participationin its networks. "We look at it on a case-by-case basis," he says.

Higher standards are moving into Rolla, however. The local hospital,Phelps County Regional Medical Center, recently began requiring new staffphysicians to have residency training. But the medical staff may waive thatrequirement for a doctor with experience, Bass says. "You can't justtell someone with 10 years in practice that they don't have the clinicalskills and experience to practice medicine. You have to look at the record."

Both the raising of standards and the willingness to consider non-board-certifiedcandidates are characteristic of rural health systems, says family physicianThomas M. Dean of Wessington Springs, SD, a town of 1,100. He is a pastpresident of the National Rural Health Association, based in Kansas City,MO.

In his role as medical director for Horizon Health Care, a network ofseven rural clinics, Dean has been recruiting physicians for 20 years. Hehas talked to several general physicians, but currently has none on staff.Dean tends to agree with those who say the future looks bleak for GPs. Yetdespite such prevailing sentiments, many GPs continue to practice in thinlypopulated areas where there are few other doctors.

Inner cities beckon general physicians

The other stomping ground of GPs is the inner city. Susan Black has beenpracticing in Tewksbury, MA, a mostly blue-collar area, for the past 30years. Although she did a residency in internal medicine, she regards herselfas a family physician; she was never board-certified in either specialty.

Nevertheless, she says she's had minimal problems with HMOs. Severalyears ago, HMO Blue told her she could stay on its panel only if she completed50 CME credits a year from the American Academy of Family Physicians. "Noneof the other plans I have worked with has ever questioned me not being board-certified,"she points out. "That's because I was in practice before there wereboards."

But Black knows of many other physicians who have been dropped by healthplans because of their lack of certification. "They have to get certified,"she concludes. "There's nothing else to do."

Some choose general practice for personal satisfaction

For many physicians, the decision to practice general medicine is boundup with their personal goals and inclinations. The desire to have fulfilling,long-term relationships with patients is often a major factor.

That was the case with James Bass. After completing his emergency medicineresidency, he worked in an emergency department at a large Kansas City hospital."It was horrible," he recalls. "I never knew what happenedto my patients after I saw them."

The physical demands of rotating shift work also didn't agree with him.So in 1983, after six months of emergency room practice, Bass packed upand moved to Rolla, which is about 25 miles north of Salem, MO, the smalltown where he grew up.

Over the next five years, Bass built a successful general practice. Hedoesn't believe his lack of training in a primary care specialty affectedhis practice. "It's all related to the quality of care you deliver,"he says. "If you spend time with patients and make good decisions,you'll develop relationships with them, and they'll come back to you."

Bass attributes much of his success to his ability to get along withthe other physicians in his community. He shares call with three other primarycare doctors and refers patients to hospitals and specialists in St. Louis,Columbia, and Springfield. "You have to know your limits and know whento refer and seek a second opinion," cautions Bass. "You can'tbe there all the time for everyone. If you try to be, you're going to workyourself into the grave."

C. Jan Dyke is another physician who came to general practice after trainingin a different field. Following a residency in general surgery at WalterReed Army Medical Center and a tour of duty in Vietnam, he returned to Moline,IL, in 1970 to practice surgery. Dyke kept up a busy practice for years,often operating six days a week. But a desire to forge deeper relationshipswith patients led him to take on more and more of them as a general physician.Dyke's father, with whom he practiced until nine years ago, also split hispractice between surgery and general medicine. "It used to be thereweren't as many doctors in rural areas," says the younger Dyke, "andgeneral surgeons were often the only physicians available, so they did alot of general practice as well as surgery."

Now 65, Dyke devotes about 40 percent of his practice to surgery and60 percent to general practice. He anticipates the proportion of generalpractice will rise as he moves toward retirement.

So far, Dyke has had no trouble getting health plans to credential him.He says it's because he's board-certified in general surgery. But he hasseen other doctors without board certification pushed aside by insurancecompanies. "It's ironic that they'll allow physician assistants tosee patients, but not GPs who have 30 years of experience," he says.

Should all doctors be allowed to do primary care?

For most physicians who split their practice between the specialty theywere trained in and general practice, the main stumbling block is gettingcredentialed as a generalist. Stockton, CA, urologist Ronald A. Allison,for example, has a general practice that accounts for about 20 percent ofhis time. But he finds that the local HMOs won't accept him as a primarycare doctor.

Allison enjoys the relationships he has with his general practice patients.But he also has a professional reason for wanting to do primary care: Hebelieves male patients should be allowed to see urologists as primary carephysicians, just as women see gynecologists. "On average, men die earlierthan women," he says, "and it's partly because they don't getregular medical care."

He believes that managed care policies restricting him from seeing moreprimary care patients are unwarranted and do patients a disservice. "Everyphysician was taught to do primary care in medical school, and most do someprimary care," he says.

Primary care physicians, however, feel just as strongly as health plansdo that specialists aren't necessarily qualified to provide general care."To be competent in family medicine, one needs to complete a three-yearresidency in family practice," states FP William E. Jacott, head ofthe department of family practice at the University of Minnesota MedicalSchool. While many medical schools offer training in primary care, he notes,it's basic compared with the training FP residents receive. Residents areexposed to a broad range of medical issues and take increasing responsibilityfor diagnosing and developing long-term treatment plans for patients. "Ittakes a lot of experience with a broad case mix of patients to have thecompetence to deal with whatever comes in the door," he says.

The fight for recognition promises to be long and hard

Regardless of their background, general physicians believe they deserverecognition for their experience, skills, and on-the-job training. Theirdesire to gain more respect within the profession was the impetus for thefounding of the Canton, GA-based American Academy of General Physiciansin 1995, says Harry Watkins.

The academy sponsors a 12-part course designed to be taken over threeyears. It prepares general physicians for an examination and certificationby the American Board of General Practice, which has close ties to the AAGP.Both Bass and Dyke are taking the course.

Acceptance of the ABGP certificate is mixed. Watkins says many hospitalsand health plans recognize it, but at least one HMO, PacifiCare of California,does not. The National Committee for Quality Assurance, similarly, doesn'tcount ABGP when it measures what percentage of a health plan's physiciansare board-certified. For this purpose, the NCQA recognizes only specialtyboards sanctioned by the American Board of Medical Specialties or the AmericanOsteopathic Association.

The ABGP has no plans to apply for recognition by the ABMS, partly becausethe ABGP's members believe that general medicine is not a specialty. However,the American Academy of General Physicians does plan to apply for membershipin the AMA House of Delegates. The earliest it will be eligible to do sois 2001, Watkins says.

However the battle for official recognition turns out, some specialistswill continue to shift into general practice. "I don't think the interestin primary care will ever vanish," Bass says.

But other observers believe that regulatory and market restrictions,combined with larger supplies of residency-trained, board-certified physicians,will ultimately kill general practice. "It's no longer as big a problemto get board-certified doctors to move into rural areas," FP Tom Deansays. "General practice is destined to die out."

The author is a freelance writer specializing in health care financingand management.

This is the third in a series about primary care fields. The earlierarticles were "Internists: In search of their true identity" (March22, 1999) and "Why tomorrow's FP won't look like today's" (Sept.6, 1999).



Howard Larkin. General practice gets a second wind. Medical Economics 1999;18:48.