What does a sick child, a pregnant woman, and your grandfather have in common? In the first half of the century these people would have been treated by a general practitioner, a position that almost fell off the map but has since found new life as primary care. These "big doctors," primary care practitioners that evolved out of the legacy of general practitioners, now find themselves an endangered species in a health care system that favors new doctors choosing high-tech, narrow, specialized practices.
In his book, Big Doctoring in America: Profiles in Primary Care, Dr. Fitzhugh Mullan conveys the need for primary care practitioners through the firsthand accounts of 15 "big doctors" from Maine to California including family physicians, internists, pediatricians, nurse practitioners and physician assistants.
A Pediatrician by training, Dr. Mullan is Vice Chairman of the National Health Museum’s Board of Trustees, a contributing editor for the journal Health Affairs, and former Assistant Surgeon General of the United States. He is professor of pediatrics and public health at The George Washington University and a co-founder of the National Coalition for Cancer Survivorship. In addition to Big Doctoring in America, Dr. Mullan has authored Plagues and Politics: The Story of the U.S. Public Health Service (1989), Vital Signs: A Young Physician's Struggle with Cancer (1983), and White Coat, Clenched Fist: The Political Education of an American Physician (1976).
I recently sat down with Dr. Mullan to discuss the future of medicine in America and the role that students of today could play as "big doctors" in shaping the core of the ever-changing health care system.
Q: What inspired you to go into medicine?
A: My father was a psychiatrist and I thought what he did was fascinating and really helped people. I started by wanting to be a psychiatrist but when I got to medical school I discovered that I also wanted to be an internist, a pediatrician and a surgeon.
Q: What inspired you to get involved with the National Health Museum?
A: I first became involved with the Museum idea many years ago when I was serving as the historian of the U.S. Public Health Service. I worried then – as I worry now – that we are not looking after the fabulous history and legacy in health science that this country enjoys. Although there are a few health museums and a number of science centers around the country, we do not have a true national health museum to look after our health history and tell it to current and future generations. We have museums in Washington that serve this function for air and space, for fine art, for natural history, and even for the ball gowns of the wives of the Presidents. But nothing for medical science and health.
More recently I have become convinced that the Museum can be a powerful educational center that brings health, research science, prevention strategies, and global health into focus for children and adults, individuals and families. Additionally and importantly, the National Health Museum would be positioned to talk to potential doctors, nurses and research scientists of the future. It would provide an experience to young people that would invite them to join the history of health innovation, discovery, and service that will be on display in the Museum. No mission can be more precious than recruiting and stimulating the next generation of healers and explorers.
Q: What factors or people influenced your decisions with respect to a specialty?
A: Obviously, I couldn’t be everything. I graduated from medical school in 1968 at a time when the general practitioner was considered an idea of the past and the transformed and up-dated idea of the family physician of today had not yet been created. If it had, I think I would have been a family physician. I chose pediatrics because I love kids and I thought that pediatrics could make big changes for kids, families and communities. I have not been disappointed.
Q: What opportunities are available for today's students with limited resources to pay for university and medical school?
A: Medical school is expensive. But that shouldn’t stop anyone from going. There are multiple sources of loans and scholarships to help with medical school tuition and living costs. Since doctors make good incomes, it is not hard to secure loans. The best program, I believe, is the National Health Service Corps that has both scholarships and loan repayments for medical and other health professions students willing to commit to a period of work in primary care in underserved communities.
Q: What advice would you give to someone who wants to be a physician but remains undecided about being a primary care practitioner or entering into one of the many medical specialties?
A: If you like patients and all their complexities, then primary care is for you. If you are interested not only in the biology, but the psychology and sociology of people and families, then you will find primary care a rewarding way of clinical life.
Q: What are the advantages of being a "big doctor?"
A: The most gratifying aspect of primary care is being able to take care of people over time; to be able to take care of several generations in one family, to be able to be a long term player and a long-term persona with people and families. The full tool box of medicine is available to you as well. You will deal with prevention as well as treatment, the sick and the well, young and old, rich and poor.
Q: Why are "big doctors" on the decline in America, and why is it important for them to be at the center of the health care system?
A: Our reimbursement system pays more for procedures and technology than for good clinical judgement, good diagnostic skills, and good patient counseling. It's important for big doctors to be at the center of the health care system because primary care is an efficient and humanistic way to manage health care. It's efficient because the generalist can screen and treat very effectively, and it's humanistic because the generalist provides continuity, coordination of care and comprehensiveness.
Q: Talented medical students are being told to specialize. What can be done to combat this trend and attract the best and brightest to become "big doctors?"
A: We need more primary care role models in medical school and nursing school. We need a payment system that rewards primary care equitably, and we need the next generation of primary care doctors to be outspoken about their mission.
Q: If you could share one thing with a science student about your experiences with the many people profiled in the book, what would it be?
A: A common theme among the people I interviewed was enormous satisfaction with the roles that they played with patients and with communities. Many of them had been leaders in school health, HIV screening and treatment, healthcare for the underserved and women's health.
Q: What kind of personality must one have to succeed at a career in primary care?
A: You've got to be able to deal with uncertainty because you are going to be treating all manners of problems from appendicitis to depression, from head lice to diabetes. You've got to be prepared to deal with some amount of uncharted territory with some patients. People in primary care are prepared to undertake the whole enterprise.
Q: Could you dispel some of the myths regarding primary care practitioners being less qualified, not as smart, essentially less valuable?
A: It's often believed that specialty work is difficult and primary care is easy. Specialists often deal over and over again with a narrow set of conditions with which they can become very familiar and very expert. The primary care clinician (doctor, nurse, and physician assistant) has to be prepared to deal with an uncertain and variable set of conditions. Not only the knowledge base, but the decision making that has to be exercised by the primary care physician is very difficult and challenging. The “skill set” is the extensive knowledge about clinical conditions. The “mind set” is the ability to deal with complexity and uncertainty. Primary care definitely requires a skill set and a mind set that comes from rigorous training and constant reinforcement. These are very valuable assets that patients recognize immediately when they encounter them. But these competencies are undervalued and poorly reimbursed by the medical system as a whole.
Q: What is the difference in schooling and training for someone who becomes a "big doctor" versus someone who specializes?
A: All disciplines require residency training. Primary care residencies are three years. Nurse practitioners and physicians assistants spend less time in school, but train with a similar curriculum. Surgical and medical specialists have the same medical school training as primary care physicians but spend more years in residency training.
Q: What type of activities would you recommend young students participate in to help prepare them for life as a "big doctor?"
A: First, anyone interested in primary care should find opportunities to shadow generalist clinicians to see what the work is like. Second, I would encourage them to participate in health related community activities, such as health education campaigns and health fairs, to get a feel for community health. Students should seek out volunteer opportunities in the clinical setting of hospitals and nursing homes to get a sense of the full, rich, and complex mix of patients.
Q: Why did you write the book?
A: I wrote this book to make the case for primary care; to promote and celebrate the work and lives of people practicing generalist care.
The book is called Big Doctoring in America: Profiles in Primary Care. Check out Dr. Mullan's Web site featuring the book at http://www.bigdoctoring.com/