Extinction

Every morning in Africa, a gazelle wakes up.
It knows it must run faster than the fastest lion or it will be killed.
Every morning a lion wakes up.
It knows it must outrun the slowest gazelle or it will starve to death.
It doesn’t matter whether you are a lion or a gazelle.
When the sun comes up, you better start running.

Thomas Friedman, the New York Times columnist, quotes that African proverb in his bestseller The World Is Flat. He got it off the factory wall of an American auto parts manufacturer in China. Friedman thinks it is a metaphor for life in the 21st century, and it is not without truth. Radiologists in Bangalore are now reading digital x-rays for American hospitals while Americans sleep.

Family practice in America is in trouble. Some people think it’s because we need to start running. I’m not so sure about that. Most family physicians think we are running hard enough already. A lot of you older folks – like me – have been rolling your eyes about New Models of family practice, Practice Redesign, stuff like that. I’m going to try to give you some perspective. If you think most of it is a pile of horse manure, you’re right. But like the boy in the old joke said, “There must be a pony in there somewhere.” We’ll try to find it.

If I were adapting the proverb to the life I live, it would go something like this:

Every morning in Africa, a gazelle wakes up.
It knows it must find an impenetrable thicket to hide from the fastest lion.
Every morning a lion wakes up.
It knows it must find a secluded perch to cut off the slowest gazelle heading for a thicket.
It doesn’t matter whether you are a lion or a gazelle.
When the sun comes up, you better start planning.

Or these words from Solomon in Ecclesiastes:

The race is not to the swift
Or the battle to the strong,
Nor does food come to the wise
Or wealth to the brilliant
Or favor to the learned;
But time and chance happen to them all.

This is a blog about planning. You may have thought that you were going to receive enlightenment from a futurist. That’s humbug, like the Wizard of Oz. I can’t predict the future any better than you can. But I can give you some insight and perspective from 33 years of family practice. I can warn you what to look for, and what it might mean. And I can tell you how to be successful, and happy, practicing what to me is the best profession on earth.

First some perspective. My great-grandfather Dan Iliff was an honest-to-God horse-and-buggy doctor in Cherokee, Kansas. As a boy he picked up artifacts from the Civil War battle of Mine Creek, which was fought on the family farm. The doctors of yesteryear were true heroes. Every generation has had an easier job than the last.

Don’t kid yourself that there was a golden age of medicine when reimbursement issues were never a problem. According to family legend, Dan cared many years for a widow with four children, never receiving any pay in return. One day he happened to be in Pittsburg, Kansas, and happened to spy the widow taking her children to a movie. They were all eating ice cream.

He was so incensed at this profligate waste of money, perhaps combined with memory of his repeated charity, that something snapped. He went straight to her house, untied the milk cow, and led it home as payment for past services.

Those were the good old days. Those of us who have chosen a career in family medicine really ought to stop griping. It gives the specialty a bad reputation, and it gives us dyspepsia. But we’ve got bigger problems than a bad attitude.

All of the experts agree that family medicine is facing a crisis. Here it is, in a nutshell:

Source: 2008 Match results: Family medicine shows slight improvement. Fam Pract Manag. April 2008.

The important line is the blue one at the bottom. It shows that only half as many American medical students match a family practice residency as they did ten years ago. Maybe we use the word “crisis” too freely. Sometimes we just mean “problem,” or “issue.” But this graph is a little chilling. The Ice Age was not a problem for the dinosaur. Extinction is a crisis.

And that is an absurd state of affairs. Family physicians are the only hope for American health care, which is an economic freight train heading for a downed bridge. The real threat to the federal budget is not the war on terror, or Social Security; the real threat is Medicare funding. And family physicians are the only viable answer, unless internists decide to quit fleeing for subspecialty niches and join us.

There are lots of implications. That's what we'll be discussing.  Keeping up your end of the dialogue is important; that's the only way we'll blunder into the right answers.

Posted at 02:05PM Oct 29, 2008 by Doug Iliff  |  Comments[44]