Who will be the gatekeeper?

I can clearly remember my grandfather waxing on about the good old days at a time in my life when anything anyone over the age of 20 had to say was something south of boring. My grandfather, however, was persistent, in-your-face opinionated, and tempered no sign of disrespect. His favorite soliloquy involved a list of what was wrong with today. In his day, a dollar went further, people had more time to think and talk about things that mattered (like politics and hockey), friendships were important, family had pre-eminence, and doctors were the backbone of a just, caring society. He lamented that everything had changed and he was glad he wasn’t going to have to be around much longer. The one bright light in his gloomy exposition was that doctors, particularly family doctors, remained the trusted, caring professionals of his now-distant memories. My grandfather’s consistent, abiding trust and high regard for doctors, irrespective of his dire predictions of the fate of the rest of humankind, left a lasting impression on me and likely played a role in my eventual decision to do this work.

Now that I am a grandfather I find that I just can’t help recapitulating my phylogeny. I find myself expounding to anyone who will listen (I suppose this editorial is another facet of this compulsion) about the good old days. I can remember clearly a time not so long ago when all the family docs in my community had hospital privileges. We all delivered babies, assisted at surgery, did morning hospital rounds, and took seriously the commitment that we had all made to be the gatekeepers of medicine. We all spent untold hours ensuring that our patients (particularly our hospitalized patients) were referred to the appropriate specialist as quickly as possible and that lab and imaging results were checked at least once daily. There was no doubt who was in charge of the ongoing care of the patient. Nurses, lab techs, X-ray techs, respiratory techs, etc., all knew who they should call with results because the family doc had it all under control and would ensure the right things would happen. I know, I should take off my rose-colored glasses because this was not always the case, but it did work pretty well, and any way you cut it the patients for the most part felt that their care was being managed and monitored by someone who had an intimate connection with their medical history (and their family) and had more than a pedestrian professional interest in their well-being.

Doc Wilson’s Elysium Fields view of medical care 30 years ago obviously finds itself in sharp contrast with today’s medical care reality, where in many communities there are only a few family docs who have hospital privileges, very few deliver babies or do surgical assists, many offices leave a phone message at the end of the day directing patients to the emergency room, and the hospital uses hospitalists to carry out in-hospital functions previously provided (essentially for free) by the community family docs. This trend to erase family physicians as the gatekeepers of medicine appears to be gaining legs, and I’m not the only one concerned that the applications to family practice residencies are declining, the numbers of mature family docs leaving to do something else is increasing dramatically, the numbers of medical students who see family practice as a fulfilling career choice has dramatically decreased, and most importantly, the numbers of graduating family practice residents entering real family practices vs. walk-in clinic work are frighteningly low.

I understand all the economics, ethics, and basic philosophical tenets of the decision-equation today’s family docs are staring down the barrel of. I’ve been there and I’m now one of the mature docs doing something else, but that doesn’t stop me lamenting the fact that fewer and fewer people are choosing the profession that I so enjoyed.

Finally, I wonder who will become the gatekeepers of medicine if today’s family docs are no longer willing to fill that role. Will it be a new generation of young, committed family docs (today’s stats make this an unlikely possibility), nurse practitioners, foreign medical graduates, or some kind of computer-assisted licensed medical technician employee of the local medical authority (in my humble opinion, this is the most politically likely group)?

I just hope that when my grandchildren become grandparents they can look back and say they’re so glad the “bad old days” were only a distant, unpalatable memory and perhaps their attentive grandchildren will think about a fulfilling career like their great-great-grandfather.

—JAW