Lisa Rosenbaum, MD, is a national correspondent for the New England Journal of Medicine (NEJM). She has just published Is a Long-Simmering Crisis Boiling Over? U.S. Primary Care Today. The easy, and current, answer is “Yes.” But this is not necessarily the final answer. Dr. Rosenbaum begins with the description of the career arc of one Dr. H:
After her internal medicine residency, Dr. H. joined a Midwestern practice, inheriting a primary care patient panel from a retiring endocrinologist. At first, the work was hard for the right reasons. She diagnosed and treated a wide range of diseases, built long-term relationships with patients and families, and — until the rise of hospitalists — cared for them in the hospital as well. Becoming the consummate internist was exactly what she’d signed up for. “Lifelong learning and getting to help people,” she recalled. “It was the best job in the world.”
For the past eighteen years I have been involved in medical education, with the goal of increasing the number of primary care physicians practicing in rural and medically underserved areas. Who are these doctors? Primary care is more than what in my childhood was called the “general practitioner” Or GP. [1] As understood today, the core primary care specialties are Family Medicine, Internal Medicine, General Surgery, Pediatrics, Obstetrics & Gynecology, and Psychiatry, with Emergency Medicine sometimes considered primary care. [2] Emergency Medicine was not a recognized specialty until the 1970s, and when I needed stitches or an x-ray (often enough to know the Emergency Department well) before going off to university, the hospital called one of my two family doctors who then drove the half mile from their nearby houses to care for me.
That was not so long ago in human years, but it is unimaginable in “healthcare system” years. Back to Dr. H:
She didn’t recognize that this traditional generalist role was in peril until about 15 years later, when she joined a multispecialty practice owned by a nonprofit foundation. The work was initially fulfilling, but as the insults to primary care accumulated — shorter visits, unmanageable inboxes, a staff exodus during the Covid pandemic — Dr. H. gradually lost her capacity to function as her patients’ doctor.
Like many primary care physicians (PCPs), she adjusted to the squeeze by working more. Without staff support, she roomed patients, took their vitals, and scheduled tests and follow-up. When leadership threatened to cut physicians’ vacation days if their documentation was late, she started spending hours at night charting, despite caring for a young child and a chronically ill husband. But one change she couldn’t work around was the lost capacity to see her patients when they were sick. Forbidden from double-booking to accommodate them, she often didn’t hear about patients who needed her until after a centralized triage system had diverted them to urgent care.
Urgent care. In my recent family experience, urgent – yes, and expensive. Care, not so much. But the regional for-profit but technically non-profit hospitals are making a killing, which is a story for another time. But this happened to one of Dr. H’s patients:
A patient with recurrent herpes infections, for instance, called seeking a refill of valacyclovir. The staff, following an algorithm, told her she required a clinic visit since she hadn’t seen Dr. H. for a year. With no appointments available, she was sent to urgent care, where the clinician wouldn’t prescribe valacyclovir without a culture. Dr. H. eventually received the message and refilled the medication. But as similar situations, often with much higher stakes, recurred, she began wondering: What does it mean to be someone’s doctor if you can’t be there for them when they need you?
Indeed. This never happened in my family’s experience that I can remember. Our doctors were there when we needed them. Always, from birth to death including general surgery that did not involve the heart or brain or bones. And if they were unavailable, a local colleague was happy to take call for them. It was a different time, when health care may not have been universal but few who needed care were unable to get it. As one internist friend put it (paraphrase), “We usually got paid, but when we didn’t that did not make any real difference to us but was life changing for the patient and his or her family.” And we were providing medical care as it was intended.
Does primary care have a future? Whatever comes, it should. And if it goes away, we will all suffer for its loss, as have those patients who must use urgent care for medication refills or chronic disease management. This is not the way to go, but the slide seems inexorable. Still, what might recover the situation? A massive investment of time and money could work. Primary care receives less than 5% of US healthcare spending but is responsible for 35% of doctor visits.
Nevertheless, many people (except for those who need a PCP) are beginning to believe “primary care can be delivered less expensively by advanced practice practitioners such as nurse practitioners (NP) and physician assistants (PA).” Several friends were some of the first PAs. They were trained well and have now retired after a lifetime of providing good care in partnership with a physician. The same is true of the first NPs. The angels who walked the earth while managing my chemotherapy were oncology NPs and oncology nurses. But this was done in a large oncology practice under the supervision of five oncologists, who worked closely with three radiation oncologists on the first floor of the same building that I got to know too well. It is not clear that NPs and PAs in stand-alone practices are the answer to the shortage of PCPs. And there is good evidence that NP and PA programs are not as rigorous as they were at their beginnings.
But more importantly, the primary role of the PCP is to be the generalist who understands the needs of her patients through long and continuous contact and care, as the one doctor who coordinates multispecialty care when that is needed. The PCP is the captain who leads the team providing the care. Without him a gaggle of oncologists, surgeons, and radiologists can be like the committee of blind men describing an elephant. But these specialists are absolutely essential. Where they are present condition-specific outcomes are better, and I have my ENT, medical oncologists, and radiation oncologists to thank for my current good health. But my internist diagnosed the problem in the first place and started in motion the plan that resolved my cancer. Despite difficulties the modern hospital system has put in place to improve “efficiency,” my internist continued to monitor my care until I was released by my specialists. This was a team effort from start to finish, even if I had to pay close attention at times to all the moving parts.
These relationships may be called the “paradox of primary care”:
Despite better disease-specific outcomes for individual patients treated by specialists, population-level data suggest that places with higher ratios of primary to specialty care have healthier populations, better-quality care, greater equity, and lower costs…U.S. states with a higher density of generalists spend less and deliver more effective care than specialist-heavy states. Others suggested that patients with multiple chronic diseases have similar functional health status whether treated by generalists or specialists, but that generalists use fewer resources.
Of course, confounders may exist and could explain these results at the margin. A community that is willing to invest in primary care will probably invest in social services that improve health in general:
These limitations, however, seem less relevant than the belief that primary care’s true value can be captured by measurement to begin with. And this misunderstanding is accelerating its demise…
Reinvention requires health systems to recognize the generalists value in the first place. They don’t. Instead, primary care has been atomized into its revenue-generating parts, leaving many PCPs unable to build the longitudinal relationships essential to this integrative function. The specter of extinction thus looms large. Primary care’s sustained relevance depends on offering a service people can’t obtain from specialists, retail clinics, or virtual substitutes. If its relational core is removed, will the public get their health and well-being needs met elsewhere? In other words, will traditional primary care’s value become invisible to the rest of us too?
This is where the naked truth of the Neoliberal Dispensation enters the discussion. [3] We have described Neoliberalism as the dogma that “the market is the measure of all things, including those that cannot be measured.” When it comes to health and wellbeing, MAHA and its minions beg to differ. Only those health metrics that can be measured count, beginning with your plasma glucose level, right now:
This belief…contributes to widespread misunderstanding of what primary care is (care for the whole person from before conception to death). And this misunderstanding is accelerating its demise. As (Dr. Kurt) Strange told me, ‘In trying to improve the parts of primary care, we’ve actually killed the whole thing.”
And in the meantime, so-called influencer culture “has rendered the idea of a long-standing doctor irrelevant,” especially when a wearable will tell you everything you need to know, right there on your smart (sic) phone. Just ask the current Secretary of Health and Human Services.
But, it could be that an escape from corporatized medicine may be possible. From Dr. Rosenbaum:
Given the high rates of burnout among PCPs, one of the more surprising findings in my reporting was the sense of joy and gratification described by some of the rural PCPs with whom I spoke. Though practicing in resource-poor settings is challenging, constraint evidently breeds creativity. An uninsured patient in florid heart failure who’s declining the hospitalization that would bankrupt him and force him to sell his farm? He makes a plan with his trusted physician to come to the clinic daily for IV diuresis and weight and electrolyte checks. A woman with nephrotic syndrome who can’t get to the nephrologist at the academic medical center 3 hours away? Her physician emails with the nephrologist and learns to manage her disease himself. Does rural physicians’ gratification arise from autonomy, opportunities to treat widely varied diseases, their central role in their communities? Yes, probably all those things. But most strikingly, these physicians “meet patients where they are” regardless of circumstances. Most of U.S. primary care, constrained by large health systems, has been denied this crucial ability.
It’s no mystery why. Health care systems often profit from hospitalizations, specialty referrals, and testing. As Larry Green, a family physician and distinguished professor at the University of Colorado, told me, “Good primary care is increasingly bad for business.”
Ignoring for now the choice between bankruptcy and healthcare, this is a roundabout way of making the essential point that the rural primary care physician must be the best doctor. Otherwise, his patients will simply die according to the first rule of neoliberalism, “Because markets, go die.” It is heartening to see that many of our graduates come to see this naturally, and then return home to take care of their community that comprises their patient population.
And yes, by neoliberal calculations, good primary care is likely to be bad for business. The question is, however, “Whose business?” Big Medicine and Big Pharma, that’s who. But it could be that as the world gets smaller as the climate changes for the worse, rural life, including rural medicine, will provide the way forward.
And what became of Dr. H, with whom we began:
She and her colleagues wrote several emails to practice leadership describing lack of staff support, missed messages, their sense of failure over letting patients down. “I cannot in good conscience with consideration of the oath we have taken as Physicians continue to practice this way for very much longer,” Dr. H. wrote. But no one seemed to care. That’s why the message I found most haunting was one about the fundamental mindset shaping primary care’s trajectory. “Perhaps this is what the administration wants,” Dr. H. wrote: “to replace the ones who know with those who do not know better, those [who] have been indoctrinated into your system which has eliminated humanity from the equation.” Dr. H.’s pleas reflect primary care’s contemporary paradox: if primary care’s survival depends on advocacy by doctors and patients, then as exposure to true primary care becomes rarer, fewer will know what’s missing.
Well, some of us will know what’s missing. Specialty care is essential. Many of us here today are living proof of this. But primary care (OED) – of the first order in time or temporal sequence; of the first or highest rank – is the solid foundation of the practice of medicine. Whether it disappears or not, this will remain true. We cannot live well without it.
One evening while finishing her notes, Dr. H had a premonition that she would die early. “You always hear about the doctors who really care,” she told me, “the ones who tried really hard and then fall over and have an MI.” So when she glanced over at her unread journals and noticed a flyer seeking physicians for a concierge practice, something clicked. “The universe had answered my prayers for a long and prosperous career,” she said. She picked up her phone and made the call.
Funny thing about that. The family doctors of my youth, from the GPs to the surgeons to the occasional pediatrician and psychiatrist, practiced what can be fairly called “concierge medicine.” When you needed them, they were there. They were also paid well enough to be at the top of the local wealth pyramid, not too different from the bank president or the children who inherited one of the lucrative local businesses (until they ran it into the ground in the third generation). They were pillars of their local world, at times somewhat apart as befit their natural and earned authority, but nevertheless always an integral part of the community. A surgeon was on my chemical worker father’s team in the scratch bowling league. They were also sometime fishing partners. This was not unusual then. Oh, and those doctors, they all had long and prosperous careers lasting from the 1950s into the 1990s.
Final note: According to Dr. Rosenbaum, “Next time: Does concierge medicine spell a rebirth – or the death – of primary care.” I’ll be on the lookout. This should be good, sort of.
Notes
[1] I was very fortunate in my medical history but not all that unusual. Until I needed a dermatologist/MOHS surgeon in my early 50’s because our sunscreen was Hawaiian Tropic that probably had an SPF of minus-500, I had never seen a specialist of any kind. When I needed stitches or an x-ray (often enough to know the Emergency Department of the 1960s and 1970s very well) before going off to the university, the hospital called one of my two family doctors who then drove the half mile from their nearby houses to care for me, as they did for all their patients.
[2] Given that the only care many of our fellow Americans can get is in the Emergency Department of a hospital that is required by law to treat everyone who comes through the door, Emergency Medicine may be a legitimate core primary care specialty. Every emergency room has its “frequent flyers,” most of whom are in desperate need of sustained primary care.
[3] Oddly, the thorough neoliberalization of the practice of medicine is rarely recognized by the many physicians of my acquaintance. However, they have no difficulties seeing how the big health systems are squeezing them while at the same time making it difficult for them to treat their patients as their Hippocratic Oath requires.
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It’s only a small sample, but my brother and his wife graduated from medical school a couple years ago. I’ve also become acquaintances with some of their closer friends from medical school so I know a solid handful of new doctors. Only 2 chose general surgery. No other general medicine was specialized by the rest and no family medicine. My brother is a urologist, one friend is a dermatologist, another went into plastic surgery and the last one I can’t recall what he specialized in but I know it wasn’t any of the general medicines.
It’s clear that there is a problem here, but I fear
that any changes will only be to funnel more
money into the corporate medical systems,
and just make things worse.
I can really relate to the primary thesis of this
article on a personal level. I’m an infrequent
user of healthcare, but recently tried to get an
appointment with my Primary Care Provider.
The practice’s policy is apparently kick out a
patient after two years, so I had to go through
some hoops and a few days to get my doctor as
my approved PCP (again). And after this, the next
available appointment was in November 2026!
What’s even the point of having a doctor, then?
Short of nationalization, what could be done in
the current system? Maybe some militant
medical boards yanking licenses for violating
the hippocratic oath? (They could start with the
allegedly rubber-stamping claims deniers
working for the HMO/health insurance
companies. Then perhaps graduating to all
licensed practitioners working in systems that
prevent them from upholding that oath.)
It is really difficult for me to imagine anything
getting better on this front, in the really real
world.
I can echo your experience.
Many of the doctors who deny claims for HMO’s are retired from practice.
In our town, the State Physician Association makes more money selling insurance (a top seller in the state) and “how to bill” doctor courses, than from membership fees. Not surprising, they cater to insurers.
“The family doctors of my youth,… …practiced what can be fairly called “concierge medicine.” When you needed them, they were there.”
With the caveat that ‘concierge medicine’ as practiced these days requires an often-significant upfront payment (generally not reimbursable by insurance) and ongoing annual fees to ensure that the doctor will see you. Let’s not equate the modern term with the older practice.
The family doctor in one of the three places we lived in my toddlerhood made house calls. But one time when he came to treat me when sick, he turned around and left after he saw Michael, my mother’s 27 lb tabby, on the stairs to my room.
Odd things happen when the system is so ill. The rise of HMO’s and hospitalists shrunk or nixed primary care long-term relationships. Narrow networks and Medicaid changed primary care docs for patients regularly, and hospitalists often changed daily during an admission. However, specialists usually continued to follow patients throughout, especially sub-specialists (few in the city). In the hospital, the specialist was often the only person who saw the patient every day, so ended up being the one informing the hospitalist of the day, and ended up assessing changes and highlighting missed nuance.
Similarly, the specialist, with a real long term family relationship, could address sensitive issues – like weight gain/loss and family stresses. Though preventative care is unpaid for specialists, these issues are sometimes addressed by subspecialists, when neglected/unknown by/to the primary-care-for-this-year/episode.
Consolidation of practices into giant chains is not helpful for patients or caregivers (except for dealing with oligopoly contractors/mandates). This also alters the effectiveness of staff, who historically personally knew the family, tendencies and backstory of patients, so were able to triage faster and better than fixed phone trees.
Efficiencies are typically developed for the corporates (hospital, lab, pharmacy), but decrease efficiency for patients and practitioners. The same goes for rigid algorithms, and that was before AI.
Another issue, as I understand it, is the Resource‐Based Relative Value Scale (RBRVS), which provides insufficient payments for primary care.
Committee Representation and Medicare Reimbursements—An Examination of the Resource‐Based Relative Value Scale
conclusion
Not mentioned here, but I suggest as being very pertinent, is the rise of the Cult of Saint Luigi.
The basic creed of this Fellowship is the differentiation of the actual care givers and the management cadres. Per the Augustinian doctrine of “The Just War,” the “liquidation” of the management cadres is acceptable since it is a means to regaining a moral balance within the society. We must recognize that the management cadres are actively working to kill a significant portion of the general population. This is an overt “act of (social) war.” As such, equally “terminal” acts in response are not only permitted, they are absolutely required of the socially conscious person.
The ongoing activities of the Confraternity of Saint Luigi the Adjuster will be recognized by future historians as a “crowdsourced” social reform movement.
Stay safe.
But how much of it is simply causal indifference, or the necessity of working for renumeration to survive in a capitalist system? This certainly doesn’t absolve any particular healthcare CEO from understanding how the underlying business model works and its consequences; at that point, you have the wealth to simply opt-out of participation. At what point is evil not merely casual but rises to malicious indifference? Participation in capitalism, however slight, might make everyone dirty to some degree. If there is to be some great liquidation, who’s a target and where does it end? There be dragons here, to be sure.
There be dragons tis certain. The cleansing fire of Ye Subitil Worms is not catholic in its application.
To misquote Saint Luigi: “Adjust them all and let the finance department sort them out.”
I do not know if a maximalist position will be needed for this social engineering project. It could well be that a “kill the chicken to scare the monkey” scenario would be sufficient.
One pertinent question is; what level of violence is necessary to induce systemic change? I am certain that this very question is being asked by The Organs of State Security. They, however, are serving the status quo, essentially the bean counters and oligarch overlords.
Every serious attempt at social change requires a demand, and behind that demand must lie a credible threat to the status quo.
“Saint Luigi the adjuster, defend us in battle.”
“Be our protection against the wickedness and snares of the corporations.”
Etc., etc.
Stay righteously safe.
Oh boy can I relate to this article! As a long term private practicing Internist, I’ve seen and experienced it all since the ’70’s.
And as much as I hate to say it, it was and is the money. Back in the ’90’s all the writing was on the wall, and we did our best through our medical societies to get a Medicare reimbursement COL started. Of course it never happened, and this led to the introduction of the Hospitalists, the demise of complete and caring 24/7 in/outpatient personal medical care. And the eventual inability to maintain a conventional private practice without the outside financial support of a hospital or other big business.
Of course during this transition, there were enough lazy docs, too hard to reach at any hour, as well as more direct support for Hospitalists by the hospital staff, surgeons and specialists. Making their day to day hospital lives easier. But by and large, if they pay us we will come. Back in the ’80’s I was taking home over $300k. With inflation, over $900k today. Today’s primary care doc is more on the order of $2-300k. Of course just 9-5 outpatient work. But then there’s all the expenses of the Hospitalists and their salary. I can’t tell you how much medical money was wasted during that transition when my patients began to get lost to me through this ‘new’ hospital care paradigm.
-sigh-
I was glad to read Dr. Lisa Rosenbaum’s The Primary Care Puzzle. I agree with her in regards to what’s going on, my take is a little different. I thought everything was financial. My wife says I think everything is financial.
I was a neurologist with my own practice, for 30 years. I retired about 3 years ago. Had I wanted to continue working, financially I would not have been able to continue in an independent practice. I would have needed to be employed, set up a concierge practice, or something.
Suppose my practice revenue is $500,000. I’m told by insurance and the government that my pay is going to decrease by 1% next year. So, my pay is going to go down by 1%, right? No. My revenue is $500,000, my expenses $300,000, my pay is $200,000. So, my pay goes down by 2.5%, right? No. Because of inflation and other things, like increased work battling prior approvals, expenses rise to $309,000. My pay goes down 7%.
It wasn’t always a 1% decrease in revenues. Sometimes it was flat, or a 1% increase, but basically this went on year after year. This is a type of financial leverage. It works against doctors in independent practice.
Again, all this is my personal view and could be wrong.
My operating ratio, if you include my pay as an expense, was 0. Hospitals now commonly hire doctors. Our local hospital group separates out health care providers into a separate non-profit. I don’t know why they do this. It’s called a “Medical Group.” Their operating ratio in 2023, according to their 990, was -58%. There’s a lot of potential reasons why their operating ratio is worse than mine was. I don’t think though that my local hospital Medical Group is much different from other hospital Medical Groups across the nation.
It looks to me like the American Hospital Association (AHA) is aware of this problem, particularly since hospitals now commonly employ doctors. The AHA has established the idea of “facility fees” to try to increase revenues. I’ve heard that hospital-employed doctor revenue is a separate line item for Medicare, and that the revenue changes for them aren’t as severe as for independent physicians.
The ludicrous thing is that a lot of health care is based on doctors and other health care providers. They write prescriptions, order tests, perform surgeries, and who knows what all. Health care, which is nearly 20% of the GDP, is based on these people.
So, if a community loses a doctor or health care provider, financially they’ve lost more than just the revenue and expenses of the practice. The total economic cost is a lot more. Not to mention the personal cost.
I suspect that the memories of Marcus Welby MD doctors are more nostalgia than reality. To expect such selflessness from doctors, nurses and teachers and others who serve us is unrealistic. Every generation is allotted only limited numbers of saints. The materialism of our postmodern age current age discourages those who have a sense of duty and higher calling.
I recalled a quote attributed to Max Weber something like that ” Professionalism is a ghost of religious faith.” I checked with Google, and the provided AI said that is a paraphrase of his ideas from his “The Protest Ethic and the Spirit of Capitalism” and his lecture “Science as a Vocation.” A summary of some of his ideas about professionalism followed. One is that the direct link between religious belief and worldly action is lost leaving behind only the economic system and work ethic. The AI comment describes an “Iron Cage” where individuals such as the doctors described in the NC essay are trapped by the “technical and economic conditions of a system that no longer has a higher spiritual purpose” This is managerialism. The concluding sentence of “The Protestant Ethic” describes the inhabitants of the Iron Cage as highly specialized but have lost their connection to spiritual and cultural values, “Specialists without spirit, sensualists without heart.”
Traditionally new medical graduates swore the Hippocratic oath to affirm their fealty to the profession’s
ethics. The beginning of the oath affirms the spiritual basis of a physician’s ethics. ” I swear by Apollo Healer, by Asclepius, by Hygeia, by Panacea, and by all the gods and goddesses, making them my witnesses, that I will carry out, according to my ability and judgement, this oath and this indenture.” This version of the oath has been replaced by modern secular versions removing the notion of service as a spiritual, sacred calling and duty.
Sadly, there is little room for idealism in our current health system.
See my comment above. My toddlerhood doctor made house calls. Many doctors cite the moral injury they feel by having their patient care curtailed by corporate bureaucrats and insurers as the reason for retiring early. And IM Doc is definitely an old-school doctor who cares passionately about his patients.
OMG, this is so timely for me.
I have recently experienced a both a marked decline in sleep quality and increase in anxiety and irritability. (I’ve worked hard and not entirely successfully at not being a hysterical bitch lately.) I had been forced off an SNRI that worked for me for decades—Lilly stopped making Cymbalta and generics were terrible—and I had my first bout of COVID in September. Yesterday I had an appointment with my psychiatrist of many years, who has grown increasingly skeptical about the pharmaceuticals in her arsenal of treatment options, and who had encouraged me to go SSRI/SNRI free.
We hemmed and hawed over how to proceed: I might need to add a new drug, but I should definitely get my heart checked out to make sure that COVID hadn’t damaged it. Go see your primary care doctor immediately, she urged.
So I called the primary care practice that I generally avoid because it is so bureaucratic and was told that my previously assigned doctor had left—the last time I darkened their door was in 2021–and as a “new patient” the earliest available appointment would be February 9. I said no thanks and that I would consider other options.
This morning I had decided that I probably should enroll in concierge care. A friend who has multiple chronic conditions just made the switch last month. I’m so much healthier than she is but not getting any younger, and not having any access to primary care—which is obviously the case for me now—seems unwise.
I live in DC—a major city with multiple teaching hospitals—and I am lucky enough to have amazing insurance coverage. It floors me that I am in this situation.
Fortunately I can afford to go the concierge route and there are well regarded practices available here. FOR NOW. How long will that even last? I expect private equity will roll up and crapify them as soon as it can. But perhaps I can get a year or two of routine care out of it.
I wonder if the computerization of every facet of doctor-patient interaction now has actually made things worse for quality of care rather than better. I was there in the beginning when thick folders of patient notes and lab results got carried around in the hospital, and, yes, that was incredibly awkward and sometimes adverse to care (as when one doctor couldn’t decipher the handwritten notes of another). But I’m not sure all the technology has been as beneficial as advertised and it seems to be enabling excessive complexity in what medical professionals are expected to do. Some of it is the crappy software (and most software is pretty crappy these days), but a lot of it is normalizing computer interaction as the major activity of every single person you as a patient have to interact with at a medical facility. Often the first thing that happens is someone hands you an iPad with some meaningless questionnaire you have to fill out before you can even talk to a human, and then every human you talk to has their nose in a screen, a laptop or iPad or whatever.
Another thing about my PCP – he doesn’t have a computer in the exam room, and only brings a pad if there is a need for it.
Thank you for the reference to the NEJM article as well as your comments, much appreciated.
My PCP is in an independent practice. He is an MD with two NPs in the office. When I have an urgent problem I can be seen within 24 hours. The only drawback is that he isn’t there when I’ve been hospitalized. My adult children have been with industrialized primary care and I feel their pain, as well as a number of my friends.
Hopefully he will be able to continue for the limited time I have left.
KLG thank you for an outstanding article about being a primary care physician and the current state of medicine. In my experience with medical education, practice of IM/GI, experience in Vietnam and retirement, what you have written coincides with what I have seen. The monetization of medicine has been and is a disaster for the patient- physician relationship and medical-health care in general. Your writing keeps one in touch with the current reality of medicine as do the above comments.