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Commentary: A Specific Recommendation for Improving Healthcare – the Rural Generalist

I recently received an advertisement from a prominent medical journal. It read, “Clinicians Are the Heart of Healthcare.” 

My first thought was – yes, of course. My second thought was – why is it necessary to make such an obvious statement? 

Perhaps the answer can be understood by exploring changes in the traditional, patient-centered model of practicing medicine in the U.S. Where are the physicians who still practice in this way? How have they managed to survive in today’s harsh and often homogenizing medical climate? Why is it even important that a physician be a central figure in each patient’s care? And, above all, how is it that an older and effective model of care has been replaced by a newer one that is largely inferior?

This older, “traditional” model of American medicine is perhaps most evident in the work of certain rural physicians. In the best of these cases, you will see a physician who still “does everything” within their field. You will see the general internist who performs colonoscopies, the family medicine physician who delivers babies, the subspecialist who tries to manage as much as they can under one roof. 

In all of these cases, you will also see someone who understands a core challenge for rural physicians and patients alike – namely, that many people in rural communities cannot regularly make a trip to a remotely located tertiary care center. 

Besides keeping care local, another indispensable goal is to keep that care centralized. This means ensuring that there is a central gatekeeping clinician for each patient and that each member of a patient’s medical team approaches that patient’s care with a broad and team-based perspective. It also means that there is a very clear goal of accessibility. Appointments and medications are minimized, care teams are kept small, communication is prioritized, and technology is used as an adjunct rather than a crutch. At its core, centralized care emphasizes simplicity for both patients and team members alike. 

Smaller and well-integrated teams are often more suited to the goal of providing centralized care than the large and often bloated teams that many health systems tend to assemble today. But this approach is endangered. When a medical team becomes too large, a Who-Is-the-Captain-of-the-Ship problem emerges. 

This is the dilemma that arises when medical care is parceled out to too many subspecialists. You have a doctor for your diabetes, a doctor for your heart failure, a doctor for your osteoarthritis, a doctor for your kidney disease, a doctor for your liver disease, a doctor for your neuropathic pains. And yet no one seems to understand your entire case. The result is often a lack of communication among your physicians, a list of medications that is larger than it needs to be, and a large number of medical appointments that can feel overwhelming and even unnecessary. This problem is so common today that for many of us it has become the norm.

This is a rotten model. How did it get this way, and why does it feel like things are only getting worse?

There is no simple answer, but there are some larger forces that can be identified. Of these, an important one is in the current direction of medical training. As medical science advances, it can be challenging for a physician to keep up even with the changes in their own specialty. Now combine this with a hypercompetitive academic research climate in which funding is scarce and where physician researchers must focus largely if not exclusively on their research in order to survive. Combine this further with a training environment in which academic departments, the prestige of which typically increase in direct proportion to their overall research funding, are under pressure to produce more physician researchers. The result is an atmosphere in which trainees and junior faculty members are often encouraged and even guided to become microspecialists, which is another term for physicians with a deep and narrow area of expertise.

The microspecialist model can be easily seen in any top academic medicine department, where you will find physician researchers who may work as little as zero to four hours a week seeing patients and who, when they are seeing patients, often focus on a single disease or even just a part of one disease. As someone who has been on both sides of the fence (initially as a “research track” trainee on an NIH training grant in a large academic center, and now as a rural subspecialist), my strong feeling is that this is a model that works well within the bounds of an academic department, but often not so well outside of those bounds.

Another important driver of the microspecialist model is that of time. When physicians waste in many cases the majority of their working hours dealing with electronic medical record systems that are designed to satisfy the requirements of insurance companies rather than patients, a classic resource problem arises. What busy person would want to do a simple task when it might require five minutes and 50  to 100  mouse clicks just to get it done? 

Now imagine doing hundreds of these tasks a day, all while trying to competently, compassionately and efficiently meet the needs of patients who you know are also frustrated by what feels like an increasingly incompetent, uncompassionate and inefficient health care system. 

It is here that we find the beginnings of the impulse to refer away those cases that a physician might otherwise be able to treat on their own.

There is also the resource problem of dealing with the insurance companies themselves. When a large percentage of a physician’s prescriptions are denied by an insurance provider (perhaps because the medicine isn’t on a patient’s insurance plan’s formulary or because, in the case of a rarer disease, the medication is being used off label because there simply aren’t any FDA-approved medication options that are available), there arises an additional disincentive to taking on more complex cases. 

If, furthermore, it will take several hours of work (in the form of multiple appeal letters, peer to peer conversations, etc.) to reverse these insurance company decisions, and if most of these decisions are irreversible in the first place, and finally if a microspecialist is the one most likely to have an expensive medication in their field approved, then the cycle is completed. 

The generalist, already impossibly busy, their time already wasted in innumerable moments of the day, steps away, makes a referral, and lets the microspecialist (the only one with the wherewithal to even get the medication in question to the patient) take over.

In a system like this one, physicians often have little incentive to take on the work of doing complex care. It’s no wonder that we are regressing, and it’s no wonder that we are increasingly seeing more microspecialized care and, paradoxically, less centralized care. 

Let’s go back to the model of the rural generalist physician. The reason this is such an important example today is not because most Americans will ever see it. The great majority of Americans live outside of rural America, and so for most of us the model of the traditional rural doctor is something typically observed in books and films and essays such as this one. 

The reason this model should matter to everyone is the uncomfortable and almost never discussed fact that complex care can sometimes be better delivered in under-resourced areas with a small group of very involved physicians than in well-resourced ones with a larger group of more peripherally involved physicians.

To return to the advertisement that opens this essay, clinicians are still the heart of healthcare. If you need a reminder of this undeniable fact, just look at what happens when an older and very effective model of practicing medicine is replaced by one in which no single physician plays a central role in a patient’s life.

Somehow, we must bring this model back. We will need to start by thinking about how to adapt it to modern medicine. To do so will require both looking to the past and working towards the future. In both cases, there’s nothing that offers a clearer view than rural settings. They can teach us deep lessons about why and how medicine has changed and, through this, they can teach us deep lessons about ourselves. 

How is it that American medicine became so overspecialized? How, in turn, has this overspecialization contributed to the decentralization of care and the subsequent degradation of the patient physician relationship? How can we train more generalist physicians (both primary care doctors and, perhaps most importantly, subspecialists), and how can we help them work together in networks that enable better delivery of care? How can we help these physicians overcome the logistical barriers to completing their jobs? How can the model of the last rural generalists be preserved not only in rural America but in all of America, and how can this model be improved and refashioned to meet the needs of today’s patients? Finally, what is it that we want from our doctors, and why does it feel like they are no longer the heart of healthcare, even when we all know that they obviously are? 

There are many answers to this last question, but let me offer just two. It feels this way because somewhere along the way we came to believe that advances in science necessitate a narrower purview for physicians. In the process, we lost sight of the real holy grail in medicine, which is centralized, local and effective care in which clinicians and patients communicate easily with one another, time is rarely wasted, and patients have a better chance of both recovering and maintaining their health. We also forgot that to deliver this kind of care, we also need to protect physicians from a variety of forces that have now rendered their jobs busier, more machine-like and, tragically, less human. In the process, we forgot how much physicians matter and how much they do and know. 

Clinicians are the heart of healthcare. Of course they are. They always were, and in spite of all of our best and worst efforts, this will never change. That such an obvious statement now needs repeating is a signal that we have to take a new look at what has gone wrong in our own story. The best way to do this is to look first backward and then forward, and through this to remember who we once were as patients and who we still want to be.

Eyal Kedar, M.D., is a rheumatologist who is medical director of the Department of Clinical and Rural Health Research at St. Lawrence Health in New York. One of his chief interests is in developing strategies for improving healthcare delivery to rural communities. 

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