January 2006 | Back to Table of Contents

Editor's Note

Calling the Plays

My high school friend and college roommate, Dave Armstrong, was a 5-foot 6-inch dynamo who could play any sport and excelled at all—state tennis champ, point guard on the high school basketball team, and quarterback on the football team. As a klutzy split end who was assigned more to block than to catch, I envied his calm demeanor in the huddle, his compact and accurate passing, and his improvised play-making. I really wanted to be a quarterback, but, as in all my high school athletic endeavors, glory escaped me. Now, I seem to have landed in the medical specialty for quarterbacks, and it’s not always glorious. Primary care physicians (PCPs), our topic this month, have evolved as medicine’s play-callers, leading their patients past the perils of health care.

The whole team used to be composed of PCPs’ forefathers, general practitioners (GPs), who provided a lifetime of comprehensive care to most of their patients in a time when “comprehensive” was limited to what a doctor could carry in his black bag. The occasional referral to a surgeon for operations more complex than appendectomies or tonsillectomies were the GP’s only venture into “coordination of care.”

As medical science exploded and technology blossomed, medical practice became a maze of subspecialties, requiring extensive training and an ability to perform intricate procedures. In the 1970s and ’80s, internists and family practitioners with access to specialists stopped doing many medical procedures. Because of rising malpractice rates, many family physicians stopped delivering babies. Recent years have seen fewer PCPs in ICUs and even in hospitals. For PCPs, the scope of what they do for their patients has been shrinking for 30 years, and some trends such as declining applications to residencies and threatened reimbursement have suggested that they may leave the game altogether.

So like any species fighting for survival, PCPs have adapted. Internists have become “disease managers.” And family medicine is redefining the role of the family physician (see “Retooling Family Medicine,” p. 28).

Common to most of these new PCP formulations is the idea that they’re still the quarterbacks of medical care. PCPs need to see the whole medical field and choose what their patients need. As their patients age and medical systems evolve, they will need to change future plays on the fly. And, most importantly, they need to communicate with the entire team, translating the specialist’s message for their patients, calling signals to let the guard know what the running back is doing.

A few PCPs such as Kenneth McMillan (see “Minimalist,” p. 24) do it all for their patients, veritable Michael Vicks who run, pass, and play-make with equal aplomb. Most of us, however, fit the mold of Bart Starr—hand off, pass, and lead the team.

Dave Armstrong went on to successful careers as CEO of a sporting goods company and then as headmaster at a prep school, quarterbacking different kinds of teams. Although PCPs may not get the title of CEO or the pay or the press of Michael Vick, their quarterbacking is life-changing for their patients.

Charles R. Meyer, M.D., editor in chief
Dr. Meyer can be reached at cmeyer1@fairview.org