Mr. John C. Goodman’s opinion piece: “John C. Goodman:why the doctor can’t see you”: in the August 15 issue of the Wall Street Journal has some interesting ideas but by placing the cart before the horse he overlooks the rarely mentioned fact why a shortage of primary care doctors exists in the first place!
Primary care has withered because it has been forced into the research-oriented programs that were created following Abraham Flexner’s scathing report in 1910 on the deficiencies of medical education that existed. The system that he fostered was based on the German system which was rooted in research. The changes he instituted were good but they were carried to an extreme and research became the core of medical education and finally, its cynosure.
Practical medicine, the best example of which is primary care was relegated to and has remained a second-class entity in the medical hierarchy for the past 100 years.
Sir William Osler a respected physician, teacher, and author differed with Flexner on which direction medical education should take. He preferred a dual path, one for “practical” medicine and one for research. The former would take place in hospitals by part-time community-based physicians and the latter in research institutes. But Flexner aided by the power and influence of the Carnegie Institute and the Rockefeller Foundation prevailed.
Some believe that the shortage of primary care physicians is one of the unintended consequences of the Flexnerian vision of medical education. However, it will be difficult to reverse a trend that has been in place for over a hundred years and one which has brought much benefit.
Be this as it may, customizing education for primary care doctors is the first best step to take to addressing the shortage. How can this be done? Subjects like organic chemistry, physics, and biochemistry are of little benefit to primary care physicians. They consume an inordinate amount of time and may even act as deterrents to some who have neither the interest nor the aptitude for them to pursue a career in medicine, particularly in primary care. If they were customized at least two and maybe even three years could be shaved off the current 12 years it takes to train a primary care doctor.
Unlike many specialties, primary care is practice-oriented not research-oriented. And since primary care physicians learn their practical skills in residency, not in medical school or pre-med, a fact that is never mentioned, customizing the basic sciences by simplifying them or combining or even eliminating some of them would shorten the pre-residency training period. This would not solve the primary care shortage but it would increase their numbers.
Mr. Goodman’s concerns are good but they do not explain the whole problem.
Edward J. Volpintesta MD