Sunday, May 08, 2011

Guest post: Nostalgia and the small-town GP (by Skylanda)

In the era of rapid change in the medical field, not more than a few days go by before another major news outlet produces a heartfelt ode to the dying breed of the small-town family GP. Hard-working, ever-suffering, delivering babies from their mothers and the elderly from the bonds of the earth, this backbone of America is as vaunted as a Norman Rockwell painting and – sometimes – only slightly less fictional.

Take the New York Times last month on this imminent extinction:

Dr. Sroka’s fate is emblematic of a transformation in American medicine. He once provided for nearly all of his patients’ medical needs — stitching up the injured, directing care for the hospitalized and keeping vigil for the dying. But doctors like him are increasingly being replaced by teams of rotating doctors and nurses who do not know their patients nearly as well. A centuries-old intimacy between doctor and patient is being lost…

Aside from the bizarrely reverential allusion to the mythical centuries of family-doc intimacy (given that this is historically a rather recent arrangement, and neatly overlooking a rich amalgam of barber-surgeons, midwives, and other messy players in the not-so-remote history of medicine), the article and discussion hash over the usual suspects – and the usual ups and downs – in the transition from the one-man solo practitioner to group and hospital practices with specialist care, hospitalist coverage for inpatient services, and less personalized services. Over-capitalization, too much technology, falling reimbursement, the push to require basic technologies like electronic medical records, and the like all make requisite appearances. But missing in this idyllic picture of times a’passing is two key concepts that no one mentions in these greener-pasture revues.

One is that the America’s doctors are changing, but so is America. We are no longer a nation of small-town doctors who care for their neighbors from cradle to grave, but that may be disproportionately a product of the fact that we are no longer a nation of stationary agrarian townships. I may not have the same GP that birthed me, but that is largely because I have called four states and two continents home since I turned eighteen years old. Even a move across a major urban metropolis may be geographically far enough to justify changing to more convenient medical provider. Increasing mobility is even more pronounced in the class of folks that graduate medical school; doctors have the same pressures of spouses’ job transfers, sick parents back home, better offers elsewhere, and all the other quirks of life that make their patients pick up and move every few years.

Even more pronounced – but less overtly discussed – is the reliance of the traditional GP on strait-jacket gender roles that read like a primer out of frontier America. Many small-town GPs of yesteryear (including the one profiled above) relied on the assumed labor of wives who played secretary, billing specialist, nurse, medical assistant, phlebotomist, lab tech, and office manager. Clearly this arrangement could benefit a couple mutually, pulling in a lifestyle that neither individual could arrange alone, but it fails in the face of any independent career notions from the female half of the couple, and fundamentally relies on the good will of the male half to provide for the financial good – a notoriously insecure place for women to find themselves. On top of that, in an era of decreasing revenues, a stark note in the NYT article is the pink-collaring of the jobs that do not remain in the family: the subject of that story hired half a dozen part-timers with no health benefits themselves to cover the work load that the wife could not cover.

But the gendering of old-time GPs is not limited to their own families. These old-timey GPs of such esteemed nostalgia are almost invariably male, and they are usually the only provider for miles around. They talk fondly of stitching up little Bobby after hours with his Little League mishap, and of being at the bedside of old Miss Jackson as she succumbed to her third heart attack, but these are politically neutral conditions. The most vulnerable populations do not always do well with a solo male – often older – GP who knows everyone in town: teens seeking birth control, pregnant girls and women seeking difficult options, gay kids needing honest information about risks, victims of molestation by the local power brokers. That is not to say that any given small-town GP is incapable of entirely appropriate behavior toward all of the above (indeed, I have known many who are) – but the intimidation factor alone may pose an untenable barrier for the most vulnerable population as much as the familiarity factor may help.

An assumption runs through both articles and comments that everyone would of course want such a small town GP, but I disagree: when I have something personal on my mind, I don’t want familiarity – I want anonymity, and I want choice (factors which – besides low cost – help explain why Planned Parenthood is such a wildly popular option among teenagers, even those who have established providers elsewhere). A larger portion of Americans are now the product of an extraordinarily cosmopolitan culture, and there is equal legitimacy between those who long for the intimate markers of small-town life and those who prefer the anonymity that an urbane lifestyle can provide. A universal desire for the small-town GP is a dangerous presumption at best, leading to models of care that harken back to times that many of us would prefer not to return to.

As with most nostalgia for perfection in times that never existed as we want to believe they did, the glossing over of these imperfections turns a notably rightward bent. Women didn’t need their own careers, because managing their husband’s office should be satisfying (and secure) enough. Girls don’t need to worry about feeling intimidated about asking a white-haired gentleman for birth control pills because, gosh, they shouldn’t be having sex. These questions do not arise in the hang-wringing over the loss of the small-town GP because if they were acknowledged, that would give into the admission that this idyllic world of small-town America was not perfect, if indeed it ever existed.

There is no fundamental evil in the small-town GP model; indeed, in the name of diversity, it deserves its place among small group practices, community health clinics, and behemoth hospital corporations in the pantheon of choice. It just does not deserve to be held up as the only model that serves, or serves universally best.

Cross-posted from my recently re-located and re-launched blog, now found at America, Love It or Heal It.