When there is no doctor: Reasons for the disappearance of primary care physicians in the US during the early 21st century

Abstract

Primary care doctoring in the USA today (2007) bears little resemblance to what existed just 25 years ago. We focus on what is likely to unfold in the U.S. over the next several decades and suggest that by about 2025, primary care doctoring in the U.S. could be rare, possibly unrecognizable and even nonexistent.

Seven reasons for the probable disappearance of primary care doctoring are identified. The most important reason is medicine's loss of state sponsorship: the U.S. state has shifted from a pluralistic orientation to a New Right approach. With less state protection medicine has become even more attractive for private interests.

Six additional reasons include: (1) the epidemiologic transition (chronic diseases reduce doctors to a palliative role and monitoring of incurable conditions); (2) the overcrowded health care playing field (non-physician clinicians are supplanting primary care doctors); (3) the unintended consequences of clinical guidelines (the art of doctoring is reduced to formulaic tasks, easily codified and performed by non-physician clinicians); (4) the demise of the in-person examination (in-person examination is being replaced by impersonal testing); (5) primary care doctoring is becoming unattractive (physicians are dissatisfied, alienated and experiencing income declines. Applications by U.S. graduates to primary care programs continue to decline); (6) patients are not what they used to be (Internet access and Direct to Consumer advertising are changing the doctor–patient relationship).

By 2025, many everyday illnesses in the U.S. will be managed via the Internet or by non-physician clinicians working out of retail clinics. Some medical problems will still require a physician's attention, but this will be provided by specialists rather than by primary care doctors (general practitioners).

Introduction

Doctoring today bears little resemblance to the work of “the” profession just 25 years ago. The medical profession reached its zenith around the middle of the 20th century, the so-called “golden age of doctoring,” when it was the dominant profession. Different reasons have been offered for this historic dominance (Carr-Saunders and Wilson, 1933, Freidson, 1970a, Freidson, 1970b, Larson, 1977, Parsons, 1951, Torstendahl and Burrage, 1990, Turner, 1984) and these are the subject of continuing debate (Johnson, 1972, Krause, 1999, McKinlay, 1977, McKinlay and Arches, 1985, Parkin, 1974). The last quarter of the 20th century witnessed what was for Starr (1982) “the social transformation of medicine,” and for others, “the end of the golden age of doctoring” (McKinlay & Marceau, 2002). Few anticipated the magnitude of the unfolding transformation and most appear surprised by the rapidity with which it occurred. The seismic changes in doctoring are reflected in popular TV programs—Marcus Welby MD began as a community-based solo practitioner, transitioned to hospital practice and is replaced today by shows like ER, House, and Grey's Anatomy. In the UK the autonomous personal practice of the 1960s, reflected in a program like Dr Finlay's Casebook, is now unrecognizable in programs like Green Wing.

Sociological analyses of modern doctoring focus on the present and/or the recent past—they either: (a) describe what is presently happening to medicine/doctoring (the demise of professionalism, corporatization, encroachments on clinical autonomy, the emergence of competing health workers, and the erosion of the doctor–patient relationship); or (b) they offer competing theoretical reasons for the dramatic changes that have already occurred (Hafferty and Light, 1995, Light, 1993, McKinlay and Marceau, 2002). This paper takes an entirely different approach: rather than focus on what has already occurred we speculate on the likely future of primary care doctoring in the U.S. by the year 2025 (Davis et al., 2005, Frist, 2005). By that time we expect most primary care physicians in the U.S. will have disappeared from the medical care scene. Our goal is to explain why this will have occurred. Just as doctoring at the turn of the 20th century was unlike anything that existed just 25 years earlier, so too will medicine by 2025 bear little resemblance to what exists today. Indeed, the transformation during the next several decades could be more remarkable than what occurred over the past 25 years (Nettleton & Hanlon, 2006). This paper contemplates the unimaginable—a time, in the not too distant future, when there are few remaining primary care doctors. The reasons why this will happen are the subject of this paper.