What Happened to The Country Doctor?

Paging Dr. Welby and More Doctors Like Him.

Many of us grew up watching (and still watch) old Westerns where every little town has at least one saloon, one hotel or boarding house, a jailhouse and a doctor. That town’s doctor does everything from surgically removing bullets to splinting a fractured leg and then rushing off in the night to deliver a baby at a farmhouse several miles outside of town.

These Hollywood ideals were based on more truth than fiction when it came to the small town physician. I grew up in a small town, so the “town doc” of the Westerns was not unusual to my family or me. Doctor Holtzman took care of all of us, and he did the best he could under the circumstances.

During my family medicine residency, I was fortunate to experience a four-week rotation at a small Navajo reservation’s medical clinic in New Mexico. I saw firsthand what a family physician could do with very limited resources, including treating patients who had no running water or electricity.  Later in my career, two Russian physicians wanting to study our “rural” clinic in central Illinois visited me. These doctors were overwhelmed by the resources we had in our clinic, knowing there was no financial ability for them to imitate our model in their rural areas of Russia.

With all our advances in technology and medical support resources, you would think our medical care system would be the best of all time. We can diagnose a heart attack in a matter of minutes, treat an evolving stroke as it is occurring, have radiologic images read by someone miles and miles away and surgically treat with robots. But for all our advancement in technology, has it improved our relationship skills or instead, has it lead to devolution of our communication abilities?

What price has the medical community paid to enjoy these technological advances? Most people can’t even see their physician face to face these days when having an office visit, much less experience home visits or calling their personal physician on the phone. How far we have come from the accessible and personable small town doc like my own Doctor Holtzman?

It is not only inter-personal skills that have waned, but also the diagnostic skills of many primary care physicians have suffered from years of being encouraged to refer to specialists. Unfortunately, this “trend” has led to the point that diagnosing some of the most common human conditions are passed off to other physicians and the treatment of these diseases are left to others as well.
At one time, there was a great push for the primary care physician to be nothing more than a gatekeeper—performing a type of triage and only treating the acute “Urgent Care” medical problems, while referring off all the others.  Fortunately, my residency programs did not buy into that concept.

Nothing against specialists—one never appreciates a surgeon quite as much as when a surgeon is desperately needed! When I have a particularly tough case—for example a patient with external signs of cortisol excess but all the laboratory readings of cortisol deficiency—I am grateful for the existence of knowledgeable specialists, such as endocrinologists, to help me sort it out.

However, I fully expect myself to be able to recognize cortisol excess in the first place. Solving the puzzle is one of the most rewarding aspects of my career choice, and I love being able to quote The A Team with, “I love it when a plan comes together!”

It is human nature to want to mechanize or standardize a process. It would not be very helpful if we got totally different results from laboratory to laboratory when processing blood work, or varying results from hospital to hospital when getting mammograms. Standardization helps to keep results similar regardless of where the testing is done. But, the interpretation of results cannot be truly standardized, nor can the treatment.  The interpretation and treatment need to be individualized to the person from whom the result was obtained—and dependent upon each individual situation and constellation of symptoms.

Attempts at standardization results in the construction of a wall or barrier. Each regulation placed on the standardization results in further structure to the wall; and the next thing we all know, we can’t even find the patient due to the thick barrier of “stuff”!

Robert Frost wrote in his poem Mending Wall, “Something there is that doesn’t love a wall, That wants it down.”

Something, indeed. When we find that our technology, that our regulatory bodies, that our very way of diagnosing and treating patients has come between us—the physicians and the very people we are attempting to help—it is our duty and struggle to break down that wall so we can be reunited with those we serve. It should be our attempt to reinvent ourselves in the likeness of Marcus Welby MD and Doc Adams, even if it should mean giving up some of those “advances” in medicine.