Patients in Peril: The Demise of Primary Care in America

By Gregg Coodley

Once, Americans could count on having a personal or primary care physician who would see patients for new or chronic problems, whether in the office or the hospital. The appeal of such a system is more than psychological, for both primary care and continuity of care with a physician over time are associated with improved patient care, great

• Language: English
• Publisher: Atmosphere Press
• Release date: Nov 15, 2022
• ISBN: 9781639887163

Book preview

PRAISE FOR Patients in Peril

"The relationship patients and their families develop with their primary physician has been identified as a key bedrock for the success of modern medicine. Dr. Coodley, in his book Patients in Peril, documents how that fundamental relationship is either crumbling or on the verge of crumbling…Dr. Coodley offers valuable diagnoses and solutions to the evolving crisis, solutions that should provide sustenance to interested citizens and political and educational policymakers alike."

–  Dr. David Rozansky, Professor of Pediatrics,

Oregon Health Sciences University

"In Patients in Peril Dr. Gregg Coodley focuses on the demise of the traditional family physician or primary care physician (PCP) as a leading indicator of the disease affecting American medicine… The book is, in short, a thoroughly researched and experience-based diagnosis of what has become a growing endemic… The good news is that Coodley concludes his diagnosis with a treatment plan of desperately needed reforms. Let’s hope the ailing medical system follows the doctor’s orders."

–  Rick Seifert, Editor, In My Time

Gregg Coodley’s timely expose reveals an issue in primary care medicine that has unfortunately been lurking in the wings of clinical practice for decades, and will only get more complicated or worsen unless changes are made… Coodley outlines the issues, the history and problems and provides solid solution options… Gregg Coodley’s most recent literary effort is a must read for everyone because someday, sooner or later, we’ll all end up needing a primary care physician to care for us and that’s when the hens will most certainly come home to roost.

–  Dr. Barry Albertson

PATIENTS

IN PERIL

The Demise of Primary Care

in America

PATIENTS

IN PERIL

The Demise of Primary Care

in America

--------- Gregg Coodley ---------

atmosphere press

© 2022 Gregg Coodley

Published by Atmosphere Press

ISBN 978-1-63988-626-5

Cover design by Ronaldo Alves

No part of this book may be reproduced without permission from the author except in brief quotations and in reviews.

atmospherepress.com

Dedicated to the Doctors and Staff of the Fanno Creek Clinic

And to the Memory of Drs. Oscar and Eugene Coodley

ACKNOWLEDGEMENTS

I want to credit and thank a wonderful librarian, Sarah Vincuso, at the Providence Medical Library for her unstinting assistance in helping me obtain medical articles from the literature. I also once again want to credit the librarians at the Multnomah County Library for their help in allowing me to effectively use the research tools available to find material relevant to the book.

I want to thank the different primary care doctors, some of whom have chosen to remain anonymous, for their time and insights about their experiences. I need to thank Drs. Louise McHarris and Fred Barken for their thoughts and wisdom. I appreciated the useful insights of my colleagues at the Fanno Creek Clinic.

I want to thank my sisters, Lauren Coodley and Cheryl Coon, for their encouragement and very helpful feedback after reading the manuscript. They continued to make great suggestions throughout the process.

My agent, Susan Schulman, gave useful insight and advice throughout the process. I appreciate her hard work in helping to get the book published.

I want to thank the excellent staff at Atmosphere Press for all their hard work, suggestions and help during the publication process. In particular, I want to extend my thanks to Nick Courtright, Alex Kale, Albert Liau, Ronaldo Alves, Erin Larson and Cameron Finch.

Finally, I want to thank my wife, Karen, for her support, understanding and tolerance for all the time I spent working on the book.

Any errors in the book belong to me alone. I only hope there are not too many.

table of contents

Introduction

Chapter 1:

Primary Care in America: A Background History

Chapter 2:

The Benefits of Primary Care

Chapter 3:

The Decline of Primary Care

Chapter 4:

Medical Training: The Education and Job Mismatch

Chapter 5:

The Devaluing of Continuity of Care

Chapter 6:

The Rise of the Hospitalists

Chapter 7:

The Insurers take over Doctoring

Chapter 8:

The Administrative Burden: Credentialling

Chapter 9:

The Insurers as Doctors: Prior Authorizations

Chapter 10:

The Insurers as Doctors: Referrals

Chapter 11:

Primary Care: Drowning in Trivia

Chapter 12:

The Lure of Quality

Chapter 13:

The Electronic Medical Record: Unintended Consequences

Chapter 14:

The Demonization of Fee-for-Service

Chapter 15:

Severity Adjustment and the Gaming of Medicare

Chapter 16:

The Advent of the Physician Substitutes

Chapter 17:

Skimming the Fat: Urgent Care and Pharmacy Clinics

Chapter 18:

Losing Vaccines

Chapter 19:

The Shrinking of the Independents

Chapter 20:

Between Scylla and Charybdis: Private versus Public Insurance

Chapter 21:

Restoring Rhyme and Reason: Some Solutions to an Impossible Task

Appendix: List of Proposed Reforms

Bibliography

A painting of a family Description automatically generated with low confidence

The Village Doctor by Felix Schlesinger

(Courtesy, Wiki Commons)

INTRODUCTION

Once, Americans could count on having a personal, or primary care, physician. These doctors would see patients for new or chronic problems, recommend specialists and be there for patients both in the office and hospital. These days are ending, for primary care in the United States is rapidly disappearing. Where once 80% of American doctors were in primary care, now less than 20% of new graduates enter the field. Existing primary care doctors are retiring prematurely or changing fields to something easier or more rewarding. Many of the remaining primary care doctors feel demoralized, dispirited and defeated; rates of burnout and depression are at all-time highs. Experts predict increasing shortages of primary care physicians, a problem that already afflicts small towns and poorer sections of the cities.

It is patients who will lose most from the disappearance of primary care doctors. For primary care, and continuity of care with a physician over time, are both associated with improved patient care, greater patient satisfaction and lower overall costs. This book will endeavor to explain the roots of the problem, the travails of primary care in America, and how it affects patients. At its end, at what is the eleventh hour, it offers solutions to tame and reverse the crisis.

Primary care results in a long-term relationship between patient and doctor over time. In many cases this relationship expands to include the doctor caring for several family members of the first patient. This ongoing relationship is what most Americans want from their doctor. They want their primary care doctor to guide their care, suggesting referrals to specialists and tests based on the doctor’s medical judgment.

This has been the pattern of most medical care in the United States over the last two hundred years. Primary care doctors remain the foot soldiers in the fight for health, delivering the basic and most personal part of each patient’s care.

Primary care is distinct in another way, stressing the importance of the whole patient rather than a particular organ system or disease. More than any other aspect of medicine save psychiatry, it stresses the relationship between doctor and patient as the key to good health.

There is extensive evidence that access to primary care is associated with better outcomes, including more timely access to care, better preventive care, lower costs and mortality. The World Health Organization stated, Evidence at the macro level is now overwhelming (that) countries with strong services for primary care have better outcomes at lower cost.¹ Increasing evidence demonstrates the value of primary care for patients. Having a primary care doctor means more preventive care, fewer emergency room visits and hospitalizations, and less costs for the health care system. It also leads to greater patient satisfaction and compliance with treatment. Studies among children, adolescents, adults and seniors all show these benefits.

Nowhere is primary care so threatened with extinction as in the United States. Almost all of the other developed nations spend far more on primary care than America. The amount of health care spending for primary care dropped even further in recent years, going from 6.5% of total US health care expenditures in 2002 to 5.4% in 2016.²

In 1940, 76% of doctors in the United States practiced primary care. Today it is less than a third of American doctors. Among new graduates, the number going into primary care is projected to drop below 20%.³

Meanwhile, the drop in the number of independent doctors in recent years is astonishing. In 2006 two thirds of primary doctors worked in independent practices. Today these are a rapidly declining minority of PCPs. From 2010 to 2018, unnoticed by the public, the number of PCPs employed by hospitals or other large corporations went from 28% to 50%, effectively doubling.⁴

The changes in the last twenty years have been rapid, overwhelming and yet little noticed by the public. In the olden days, say the year 2000, a patient would see her primary care doctor (PCP) for any new issue. Both PCP and patient would assume that their relationship would be long term. The primary care doctor would refer to specialists as needed. The emergency room doctor would call the PCP if their patient came there and discuss whether admission was needed. The PCP would also manage the patient if she was hospitalized. The PCP would see the patient for any acute illness as well as provide ongoing care for chronic illnesses. The primary care doctor would prescribe whatever medications the patient needed. The patient would get their vaccinations from the PCP. The PCP, circa 1980, would spend double the amount of time as they do today in a patient visit. They would draft a brief paper note that would take a fraction of the time they spent with the patient.

What of 2021? For a new problem, if they are lucky, a patient might see their PCP if they have one, or they might go to the quickie clinic in one of the pharmacy chains that have largely replaced local pharmacies, or to an emergency room. In the urgent care clinic, they could be confident of getting an antibiotic for their viral upper respiratory infection.

The bonds between patient and PCP have diminished. Patients who change to a different insurance often have to change PCPs. The insurer would insist that they see a physician in that insurance network. In addition, the decisions a PCP could make on behalf of his or her patients have greatly decreased. Referrals to specialists now take insurance company approval, as do many diagnostic tests. A rapidly growing number of prescription drugs now require insurance company approval as well.

If a patient is hospitalized these days, he would be managed in the hospital by a hospitalist or, more usually, a different hospitalist for each day he was in the hospital. Neither the emergency room physician nor the hospitalist would ever talk to the patient’s regular doctor. Many times, the PCP wouldn’t even get a timely report about the hospitalization afterward.

Vaccinations are different now. For some immunizations, Medicare will only pay for them in a pharmacy but not in the doctor’s office. When the Covid pandemic struck, the powers that be relied on pharmacies as well as large municipal facilities as the site for a new vaccine, with PCPs being a poor later afterthought.

Primary care doctors’ visits with patients often feel rushed for both parties. The PCP has to spend at least as much time completing the electronic health record as they actually spend with the patient. PCPs might want to call their patient about issues, but first they have to respond to a blizzard of questions, advice, admonishments and tasks from the insurance companies.

Chapter 1 lays out the history of primary care in the United States from colonial times up until the end of the twentieth century. For many of the changes we see today started then. As technology and financing increased, hospitals and the physicians who worked there rose in primacy. Since most specialists worked at hospitals, the increased money flowing to hospitals and for procedures benefited the specialist physicians most. American health care shifted from general practitioners delivering primary care to a system focused on the now more numerous and better paid specialists, helping to drive increased use of technology and generating higher health care costs. The personification of the best doctor shifted from Dr. Marcus Welby to Dr. House.

Chapter 2 goes into the evidence for the critical value and importance of primary care as well as the benefits of continuity of care for the patient with a single physician. The evidence is overwhelming and yet ignored.

The book then details in Chapter 3 the decline of primary care, showing both the decreasing numbers of primary care doctors and the unsuccessful efforts to reverse this. The academic bias against primary care, the massive debt load of new doctors and the huge disparity in income between specialists and primary care doctors all contribute to this worsening deficit in the number of new primary care doctors. In addition, existing primary care providers are increasingly dissatisfied, often quitting practice in their prime or retiring early. Causes of this unhappiness include loss of autonomy as independent physicians become employees of large corporations, the increasing insurance company interference in practice and the decreasing time, given the other demands, with patients. The rate of depression among these doctors is setting records.

Chapter 4 explores the increasing mismatch between medical training and what doctors do. In no area is this disconnect greater than in primary care. Primary care doctors principally were and are trained in inpatient medicine, even if it was always the lesser part of what they did. Now with the advent of hospitalists, primary care practitioners are effectively exiled from the hospital, leaving much of their training worthless, both a wasteful and unhappy state of affairs.

Chapter 5 explores the devaluing of continuity of care. When a patient’s employer changes health insurance, the patient’s long-time relationship with their doctor must yield to whoever is on the insurance company panel. It is clear which relationship is more important. While Americans accept this rationale for having to change doctors, it is not a feature of health care in any other major nation. Insurers often see both doctors and patients as interchangeable widgets. Yet this view does not lead to the best care or even the cheapest care. Dr. Eric Cassell eloquently wrote, The belief that medicine involves the application of impersonal facts to an objective problem that can be seen separately from the person who has it is the cardinal and emblematic error of twentieth-century medicine.⁵

Where once most patients who were hospitalized were cared for by their own doctors, they have now been replaced by hospitalists, doctors employed solely for inpatient care by the hospitals. This change is the focus of chapter 6. Hospitals argued that hospitalists would be more efficient. The hospitals have indeed saved money by reducing the length of patient stays, resulting in increased hospital profitability. Subsequently, hospitals recruited hospitalists wholesale, creating a whole new specialty that diverted tens of thousands of physicians from going into primary care.

The consequence is that patients are no longer cared for by their own doctors when they are hospitalized. Hospitalists very rarely ask primary care doctors about their patients or communicate to them about the events in the hospital. The chain of continuity is broken. Yet evidence of better outcomes when patients are cared for by hospitalists is minimal. At least one large national study showed a markedly higher death rate for patients cared for by hospitalists compared to PCPS.

Is going to urgent care or to the hospital to be seen by someone the patient has never met really the best care? Evidence shows that it is not.

Perhaps the greatest source of unhappiness for primary care doctors is the increasing involvement of insurance companies in every aspect of medicine. The insurers claim that all of their interventions are designed to save money or improve care. Yet this claim is manifestly false. This is the subject of chapters 7-10.

Every physician had to be re-credentialed with each payor every year. Thus, the physician, already approved by their medical board and their local hospital, must repetitively fill out different forms for each insurer. There is a darker motive here too. By controlling who they credential, insurers can cut out troublesome doctors and force the others to be less troublesome.

Increasingly, for patients to get the medications their doctor prescribes, insurers require that the doctor’s office fill out prior authorizations, special requests as to why they are needed. Doctors know that their opinion about what is best for the patient no longer matters. Nor is this micromanagement confined to the most expensive drugs where there is at least some excuse of cost saving. Doctors must do frequent prior authorizations for inexpensive generic drugs. This is so the insurer, who may have gotten a slightly better deal on a comparable drug, can make a few dollars more. No one discusses how it is legal for the insurance company drug purchasing agents to accept what is, in effect, ‘kickbacks’ from drug companies to put their medications on the preferred list. Estimates are that doing prior authorizations costs $60-70 billion dollars a year. The available data suggests that while prior authorization programs may reduce drug costs slightly, the overall health care cost often increases as patients have increased emergency room use and hospitalizations, not even including the cost above to the doctors to do these authorizations

Denials of patient medications creates excess paperwork for doctors, but those really at risk are patients. What happens when a patient develops a complication because the insurance refuses to pay for their regular medication because it is too expensive? For example, a patient with a well-controlled seizure disorder had her long-time medicine denied by her insurer as too expensive. She promptly had a seizure, fortunately not while she was driving.

Insurers increasingly determine which tests doctors can order for patients. What if the insurance refuses to authorize a CT scan, and the patient is later found to have a cancer that might have been detected earlier? Many times, the insurer makes the process of obtaining approval for tests so difficult and onerous that the doctor gives up. The loser from the ever more intrusive medical management by the insurance company is the patient.

Patients don’t realize that the reason that their doctor cannot spend more time with them is the horrendous and increasing amount of time that must be spent providing information to insurance companies. The primary care doctor today sees fewer patients than twenty years ago, as the typical doctor now spends two hours on administrative work for every hour face to face with the patient. How much of that administrative work is beneficial to the patient? In truth, almost none benefits the patient, who suffers from their doctor being diverted from caring for them to caring for the demands of the insurer and the government. With each PCP seeing fewer patients, the shortage of doctors is exacerbated. Chapter 11 explores some of the ways primary care is drowning under trivia.

Chapter 12 explores how much insurance company involvement in patient care results in less time to care for patients. Increasingly, health care insurers, both public and private, are taking over medical decision-making under the banner of improving quality. The insurers assume that by guiding what the doctors do, they are raising the quality of care. Yet there is shockingly little evidence for the plethora of quality measures that doctors now must try to meet. Evidence suggests that primary care doctors would need more hours than in their whole work day just to meet these measures, with none left over for actual patient care.

The insurers, including Medicare and Medicaid, have piled on a rapidly growing list of quality measures, essentially unfunded mandates, adding work to the doctor without adding income. Different insurers choose from over 2500 measures that they mandate primary care doctors must address. If only it all improved patient care. Doctors spend hours and hours trying to meet quality measures. While some measures, such as mammograms or diabetic eye exams, do benefit patients, studies have shown many others are flawed and of dubious or marginal value to patients’ health.

The electronic medical record was sold as a measure to improve efficiency and the sharing of information, yet the net effect has been to reduce patient care. The payors require so much data to be reported that almost all doctors see significantly fewer patients than in the days when they used written charts. The requirement that doctors use such systems or accept decreasing payments from Medicare forced many smaller practices to close and doctors to retire. Thus, the electronic record has contributed to the shrinking number of independent physicians. Evidence of improved outcomes or health care savings is almost non-existent.

Figuring out how best to pay physicians is the subject of chapter 14. Paying doctors for each service they deliver, called fee-for-service, has been blamed for the rapid increase in health care costs over the last fifty years. Like democracy, fee-for-service is the worst system, except compared to everything else. The innovations in payment over the last twenty years have minimal evidence of improving quality, while always trending toward reduced physician autonomy, and massively increased administrative costs.

Under fee-for-service, the physicians are blamed for doing too much. Yet since the proportion of all health care costs due to primary care doctors is only 5%, it is ludicrous to assess excessive primary care visits as the cause of health care inflation. Twenty primary care visits cost less than a single day in the hospital. Thus, the basic premise, that fee-for-service payments to primary care doctors are a major cause of increased health care spending and must be changed, is flawed.

The alternatives of instead emphasizing value, quality and cost control sounds appealing on paper. In reality, the straightforward system of being paid for what one does has been replaced by increasingly byzantine, complicated formulas, requiring immense statistics and reporting to try to calculate quality, costs, use of technology and labor. The actual result of these complex machinations is a disproportionate benefit to the largest practices, such as doctors employed by large health care systems, at the expense of smaller, independent, rural and safety net physicians.

Patients don’t realize how much of the current payments to primary care doctors comes from NOT PROVIDING care or services to patients. While the old system never paid doctors for more referrals or testing, the new arrangements pay them more if they refer less and test less.

Chapter 15 explores how the corruption of the new systems is invisible to the great and the good and the public. For example, private Medicare plans, known as Med Advantage, receive increased dollars the more complex conditions their patients have. Thus, these plans emphasize doctors finding and reporting such conditions so that the payors will get more money, with some trickling down to the doctors. Seniors think these plans want to improve their health care when they send nurse practitioners to their homes to do exams. Often insurers suggest these in lieu of annual exams by the patient’s own doctor. There is no charity or kindness involved. The sole purpose of these visits is to game the system by recording more high complexity conditions, raising the money companies receive from Medicare.

Even as the insurance companies act as doctors, sending more and more advice, suggestions and mandates to primary care doctors, the latest payment plans want primary care doctors to act as insurers. These contracts make PCPs responsible for downside risk. If a patient costs more than is budgeted, it is to be the PCP, not the insurer, who must pay money to cover this overage. All the incentive is to do less. Perhaps large health systems could tolerate such a risk, but the independent smaller practices don’t have such deep pockets and will most likely be forced out of business.

Noting the increasing scarcity of primary care doctors, health care systems turned to physician substitutes, nurse practitioners and physician assistants. Many of these turn out to be wonderful, smart, compassionate health care providers. Many health maintenance organizations and public health clinics treat them as equivalent to doctors, often at a considerable cost saving. Yet their training is but a tiny fraction of the time required of physicians. Nurse practitioners receive 500 hours of clinical training compared to 20,000 hours for physicians. Treating them exactly equal to physicians with the idea that primary care is simple care devalues the training and work asked of physicians, leading to further demoralization and arguably worse care for the sickest patients.

Another innovation for patient convenience and profits is the twenty-first-century creation of urgent care and retail clinics, many run by huge corporations. They effectively skim off the healthier, more affluent patients who can meet their demand for cash on the spot while often refusing to see Medicare or Medicaid patients. Nor is this one-time visit always equivalent in quality to that provided by a patient’s private physician who knows their history, their needs and wants and weaknesses. The very definition of primary care includes being the first contact for a patient with a new illness. The outside urgent cares interfere with continuity of care, frequently not even communicating about the visit to the PCP.

Primary care doctors traditionally took the lead in vaccinating their patients against different diseases. Yet the passage of the Medicare D program had the consequence that many patients could only get certain vaccines through their pharmacies. The change in policy has been so accepted that when the Covid vaccines became available, policymakers looked to the big pharmacy chains to expand vaccination efforts. In many states, primary care doctors had no role, despite their willingness, to give Covid vaccinations. Traditionally, doctors have had the greatest influence on their patients’ willingness to accept vaccines. However, now only a few rare articles suggest that they could play a vital role in convincing hesitant patients to be vaccinated. Is it any wonder that primary care doctors feel forgotten and disrespected?

Thus, the death of primary care is a function of fewer and fewer and unhappier PCPs, each seeing fewer and fewer patients. Who wants to be a PCP given the loss of autonomy and increasing paperwork to increase insurance profits or meet mythical goals of quality? Nor do massive medical school debt and the reduced respect given to PCPs encourage new doctors to practice primary care. The result is patients who can’t find a PCP.

This is not a theoretical future risk. Already there is a shortage of PCPs, particularly in small towns and poorer areas in the cities. This problem will worsen as the PCP shortage increases in the coming years.

Primary care doctors are less and less entrepreneurs or skilled artisans, instead becoming industrial workers, part of the proletariat, albeit a well-educated and well-paid variety. Chapter 19 explains how the majority now are employed by huge care systems, having opted for financial survival over independence. This rapid change has been driven by several well-meaning twenty-first-century government interventions in health care that end up rewarding the large and powerful at the expense of the small. Even as this change occurs, evidence suggests that bigger may not be better for patients, either in terms of care or cost.

The consolidation of medicine as smaller practices close leaves patients with fewer and poorer choices. Patients will confront the consequences when all health care in their town comes from a single hospital that employs all the doctors and is part of or allied with an insurance company. Monopoly or even oligopoly situations damages consumers, in this case, the patients, most of all.

The damage to primary care hurts patients the most. There is myriad evidence of poorer care when patients don’t have a regular primary care doctor. Poor communication between hospitalists and primary care has been demonstrated to result in poorer outcomes and increased medical errors. When patients are hospitalized, without having their personal doctor there to act as the patient’s advocate, the worth of patients who appear sick and diminished is often discounted.

Ironically, the decline in primary care is happening even as illness increasingly shifted from acute episodes to chronic diseases in the United States over the last one hundred years. Putting aside the Covid pandemic, the vast majority of Americans die from chronic diseases. Never would a regular doctor who knows the patient be more valuable than over this extended period of disease that most people encounter.

Some experts have long predicted that primary care will shift into a three-tiered model.⁶ The very wealthy will still be able to see personal doctors under a concierge model, under which the patient pays a premium for extra attention from the doctor. On the bottom will be the poor, largely covered by Medicaid, with a large amount of care provided by community health centers. The rest of patients, if they can find a PCP, will have briefer visits with such doctors who are increasingly beleaguered by insurer and government demands for paperwork and demands to reduce costs and increase quality. I don’t think this is a good outcome for patients.

In authoring the book, I have read the chronicles and arguments that others have written about primary care over the last thirty years. I have found much wisdom that I will try to share.

I have added to this background interviews with current primary care physicians from the three primary care specialties of general internal medicine, family medicine and pediatrics. This allowed me to understand better the experiences of other PCPs. In each chapter, I have reviewed and included recent writing and a huge gamut of the medical literature to see if it offers factual and statistical support to my arguments.

I come to this as the son and grandson of generalist physicians. My grandfather came to the United States as a teenager, taught himself English, somehow went to medical school, and practiced as a general practitioner in Los Angeles. My father graduated from medical school just in time to serve as a doctor in the Army in New Guinea and the Philippines during World War II. He took over his father’s practice when his dad became ill, then later, as a general internist, added teaching to practice.

I went to the University of California for medical school at a time when it was almost free. I have been lucky enough to work in an HMO, practice and teach in an academic medical center and finally be the manager of and practice full time in a group of great independent primary care doctors for the last twenty-four years. I have enjoyed long relationships with many patients for decades. Even as I list the aggravations of practice in 2022, I still enjoy patient care.

There is an alternative future to the death of primary care in America. There are solutions to each of the problems discussed in the book. Many of these solutions would decrease the cost of health care for both the patient and the nation. Embracing simplicity can also allow existing PCPs to see more patients. Addressing the problems can also correct the imbalance between specialists and PCPs, encouraging more future doctors to become personal physicians for patients. The solutions would also create more satisfied PCPs, which is correlated with more satisfied patients.

Fixing this problem will help not just the doctors, but more importantly the patients, for health care is ultimately about them.

A picture containing text, picture frame Description automatically generated

Dr. Benjamin Rush

Stipple engraving by W.S. Leney, 1814

(Courtesy, Wiki Commons)

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Doctors Providing Care in a Tent in Seattle after Fire of June 6, 1889

(Courtesy, Wiki Commons)

Chapter 1

Primary Care in America:

A Background History

Doctors and medicine have been viewed very differently in other societies. The Romans considered doctors, who were mainly slaves and freedmen, an occupation of little esteem, while in the Soviet Union, doctors, who were mainly women, earned less than industrial workers. ⁷ Other societies esteemed physicians greatly.

When the American colonies gained independence, doctors stood somewhere between the two extremes. Originally, in Britain, there was a distinction between physicians who ranked above the lower level surgeons who did most of the hands-on work. This distinction did not last in America. Historian Paul Starr wrote, All manner of people took up medicine in the colonies and appropriated the title of doctor.⁸

Medicine was a largely unpoliced profession. While some