My college chum, a dermatologist who once practiced internal medicine in a small Western city, doesn't think primary care as we know it is needed today. Dave didn't abandon primary care out of pessimism. He developed a chronic disease that threatened to put him in a wheelchair, so he took a dermatology residency. Now, with his disease in remission, he makes a good living, part time, doing Mohs surgery and general dermatology as a locum tenens. That's the nature of life and the nature of prophecy. Stuff happens.

A specialist now for around two decades, Dave thinks the patients of the future will continue to demand more and more from the health care system – more procedures, fancier hospital suites, more convenience and direct access to specialists, whom they consider the apex of the medical pyramid. He has a point.

For primary care, he would envision readily accessible walk-in convenience clinics staffed with midlevel providers who could competently diagnose and treat a restricted set of complaints. In the event of uncertainty or complications, it would be off to the emergency room, or the specialist. This scenario also sounds plausible and is, in fact, occurring on a small scale at retail clinics across the country.

Here is the cross-examination.

1. It may be simply worldwide coincidence, but his vision of the future is backwards from present reality. Third-world countries use the system he describes. First-world countries all have a system more or less like ours, which is based on a strong supply of primary care physicians. Our system must be more expensive than dispatching physician assistants and nurse practitioners to handle everything outside the city limits, but it seems to be what free people choose to do with their money, once they have money. I have learned over the years to trust the free market to tell me what real people really want.

2. The AAFP Web site provides us with a stack of references proving the cost-effectiveness of primary care.¹ We could certainly envision a system with three times as many midlevel providers working under the supervision of one-third as many primary care physicians, which might be even more cost-effective. But that runs up against the part of Dave's vision that is undoubtedly true: Patients want an authority they can trust, and we live in a ticket-punching, degree-worshipping society. My physician assistant is as competent as I am in any number of ways, and through long association with both of us my patients will see him when I ask them to. They would rather see me and usually do. I wouldn't try to stretch that trust too far.

3. All modern physicians walk in the shadow of the giants of our profession. On a recent trip abroad I spent most of my time in the air, and an hour or so every evening, reading a very humbling book: The Horse and Buggy Doctor by Arthur Hertzler, MD, a patchwork auto biography of a small-town Kansas physician bridging the turn of the previous century. The things he managed to do, and the time required to do them, make me feel like a pastry chef in comparison. Because of the extremely limited scope of most specialty practices, I have even less admiration for my consultants than I have for myself. On the other hand (if their verbal professions are taken at face value, and not as sucking-up to a referral source), specialists actually hold generalists in high regard. They look at us like I look at Dr. Hertzler, thinking, “How in the world do they manage to deal with so many complaints from so many irritating complainers over an extended period of time?” They are right. Compared to doing 14 endoscopies and seeing four patients with irritable bowel syndrome in a typical – and highly remunerative – day at the office, what I juggle daily is intellectually complex and emotionally exhausting. Do specialists really want to deal with all those extra patients referred by midlevels in the boonies? When hell freezes over.

4. The biggest challenge of primary care is distinguishing the life-threatening problem, which is rare, from the background noise, which is common. I am haunted by the prospect of the crisis in masquerade, which I fail to perceive because I am intellectually benumbed by the hundred-odd routine decisions I make every day. We sort the wheat from the chaff. By the time I refer my patients to the specialist, the dangerous job has often already been done.

5. We once had an instructive experiment proving my point from a monetary angle. It was called “full capitation,” and in my town the ob/gyns lobbied to be included as primary care providers in what looked to them like fast action and easy money. After a year of experience, they found that primary care gave them financial fibroids, and they lobbied for a return to the limited responsibility of specialty practice. These are the folks who will bear the extra burden when primary carewinds down? Not in my lifetime.

6. Managed care had one big concept right. It put responsibility squarely on the shoulders of primary care physicians, who pulled off the impossible. We brought medical inflation to its knees, and provided better quality to boot. The system failed because, in the end, the stubborn independence of Americans and the bad example of a few greedy HMOs undermined our mandate to ration care rationally. But the experiment clearly indicated the fundamental value of primary care. We take the responsibility; we bear the bulk of the burden; we stand in the gap; the buck stops with us. The midlevels and the specialists are equally dependent on what we do.

Here's the kicker

Assuming these six points are true, it's no wonder the number of U.S. seniors matching in family medicine residencies has dropped by more than 50 percent since 1997.² One of them was my partner's son, who abandoned primary care under the burden of medical school debt. Why bear all that responsibility while begging for financial crumbs under the table? No mystery there. But from all I am led to understand by people who sit at that table, primary care is forever locked out of control over Medicare's Resource-Based Relative Value Scale (RBRVS) decisions – consistently voted down by the specialty societies representing a minority of physicians with a smaller minority of ultimate responsibility for the health of a nation. In turn, insurance companies have come to base their payment schedules largely on RBRVS.

And it gets worse: As Dr. Thomas Felger (the AAFP's representative to the Relative Value Scale Update Committee) discovered,³ the private insurance reimbursement in Indiana is substantially higher for procedural codes than for evaluation and management codes. We have, in effect, no control over the duopoly that determines our finances. And we take it – year after year – sending our Academy representatives to Washington to beg for crumbs from the Big Cigars.

How strange is that? Everyone knows that medicine is a guild with little response to the free market. But here we have a situation in which a critical commodity (primary care) is systemically and significantly undervalued in a command-and-control economic system.

If I am wrong, and primary care is unnecessary, family medicine (and perhaps internal medicine, as well) will no longer exist in another 20 years. If I am right, the status quo is inherently unstable and ripe for revolution. The revolution will begin when our colleagues in leadership abandon conciliation and discover the guts that have allowed the proceduralists to dominate the herd.