THR Web Features   /   December 16, 2021

What Happened to Family Medicine?

Too few doctors now have the inclination or time to win their patients’ trust.

Anna Keating

( Marcelo Leal via

It was in the middle of a workday, but the funeral was standing room only at Colorado Springs’s largest downtown church when my friend Sean O’Donnell died in 2018. Sean wasn’t a politician or celebrity; he was just a family doctor. He had been my doctor since I was four years old, and he took care of my parents, my children, and my grandmother during the last years of her life.

I liked going to his office because we knew and trusted each other. I felt comfortable there. I knew that Sean’s wife Cathy, who ran the business side, would come into the waiting room to ask about my kids and our furniture business. To my mind, Sean O’Donnell represented the ideal physician. Perhaps he had a gift and was born to be a healer; without question, he was a man with a sense of place and community.

That community was his hometown of Colorado Springs, where he lived, worked, and sent his three children to public school. Unlike most doctors today, he chose family practice over a specialty like orthopedic surgery. Accepting even those patients who had only Medicare or Medicaid, Sean elected to spend time with them rather than join a larger practice where doctors follow time-management metrics. Sean needed to set his own pace, because he always did a hands-on exam. When he looked in my babies’ ears, he would make a chirping sound and ask if there was a bird in there. After listening to their hearts, he would take off the stethoscope and let them listen to his. “Do you hear that little drum?” he would ask. And solemnly they would nod. Part shaman like every good family physician, he knew the importance of such small rituals to health and healing. And because he saw patients over a lifetime, he was also able to notice little changes in how they spoke or acted, things that rotating providers in a group practice might easily miss.

Sean O’Donnell had more agency at work because he owned his own business. His risk was greater, but his overhead was lower. He didn’t pay an MBA to tell his staff what to do. He paid himself, his wife Cathy, a couple of nurses, and a physician’s assistant, and together they created a work culture that prioritized care and flexibility rather than profit. It was difficult, especially in the early years, to keep the business going. Cathy says, “We would use our house as a line of credit. Sometimes it could feel overwhelming.” But at the end of Sean’s life, his practice was doing great and was highly profitable.

Sean was a generalist. He cared for people of all ages. He did sports medicine, travel medicine, inoculations, pediatrics. The goal of the family medicine movement, according to Robert B. Taylor, was to “train family physicians who could provide quality health care for 85–90% of the health-care needs of their patients.” Sean could have referred me to a dermatologist to get some precancerous moles removed but he said it was a simple procedure. Why waste my time driving across town? He didn’t want me to have to make unnecessary appointments. That was part of “do no harm.”

I can’t help contrasting Sean’s understanding and practice of medicine with those of so many other health-care providers today, including a nurse practitioner I recently spoke with. Employed by a large practice in Colorado Springs, “Anne” told me she is required to see three patients per hour, ten hours per day. Every hour, she has two fifteen-minute appointments and one thirty-minute appointment. If patients run late or take too long to complete paperwork, the appointments are even shorter. “I spend a lot of time preparing to see patients, and charting afterwards, and almost no time actually speaking to them,” she said.

Among nurses and doctors, burn out, depression, and work-related stress are on the rise. Record numbers of health-care workers are quitting, and America is facing an acute shortage of registered and practical nurses. As Anne put it, “It’s really taxing to think about how exhausted I feel every day and how hard I work, and to question if I’m moving the needle meaningfully for patients who are really sick. I honestly don’t know that the system as it currently stands is helping people. To be a willing participant in that is complicated.”

In such depersonalized settings, patients as well as health-care providers recognize what crucial element is missing: trust. Study after study has shown that patients who see the same doctors over time have generally better health, fewer emergency hospital admissions, and shorter hospital stays. Those patients perceive their doctors as “more knowledgeable, thorough, and interested in patient education.” But since most of us don’t have a village doctor we have come to trust over time, we increasingly turn to the Internet and other sources of authority when we have questions about medical symptoms or diagnoses. Even more troubling, we now feel we have to make our own decisions about who to believe and what treatments to follow. If some celebrate this is as “self-empowerment,” we should not forget that this exalted gain results from a loss of trust in professionals who once made the time to earn it.

Trust plays an important role in public health. We’re told, for example, that people need to “trust science” when it comes to COVID-19 vaccines. And that is true. In discussions about the problem of vaccine hesitancy, the success of the polio vaccine is often appealed to as laudatory example of what can be accomplished when people set aside their misgivings and trust science. Your parents and grandparents trusted the experts. Why can’t you? And yet such misgivings can’t so easily be brushed aside; the sources of distrust run deep. One source of that lost trust can be found in the changing character of the medical profession. Even by 1950s and 1960s when the polio vaccine was being rolled out, medicine was well on its way toward becoming a profession of specialists. The goal of a specialist is usually not to know a local community or to form the deep and long-lasting relationships on which public health depends. On the contrary, specialists get on a career trajectory that often charts a path across the country and sometimes around world. Two thirds of American physicians today are specialists. This is not a critique of specialization, to be clear. If you need a top notch hand surgeon or oncologist, you want a specialist. But if you are a first time mom who is afraid that vaccines cause autism and you need someone who can talk you through your fears, maybe over the course of several years, you need a generalist.

Growing income inequality has only widened the gap between physicians and the people they serve, further diminishing patient trust. Because many physicians entered the profession to join the One Percent, working-class people often prefer nurses and nurse practitioners for primary care, simply because they feel more comfortable around them. And even if such people do have a primary care physician of record, how often do they have contact with that person? Do those physician live in the same neighborhoods as the patient, send their kids to local schools, dine out at local restaurants? Sometimes, patients feel they don’t even speak the same language as their doctors. According to a recent Atlantic article, the American medical profession has become so politically attuned that “two leading medical organizations are proposing a lot of language policing that presumes far-left answers to a host of thorny questions.” What this amounts to is an increasingly technical and politicized language spoken by doctors already viewed as distant and untrustworthy.

As medicine has become more standardized and factory-like there has been a corresponding rise in so-called alternative medicine such as Reiki, energy healing, naturopathy, herbalism, acupuncture, and chiropractics. The merits of such approaches aside, alternative medicine clearly meets a need—one for which Americans paid, mostly out of pocket, to the tune of some $30 billion in 2016. People do this in large part because they want to be cared for by an accessible person they like and trust, someone who will listen to their concerns and provide hands-on, affordable treatment.

Even after Sean O’Donnell’s former practice was taken over by a large medical group, I stayed on because it at least reluctantly accepted Medicaid. But now when I go to the building where Sean once practiced, I approach the appointment with a keen sense of dread. There are different providers every time, of course, and since they know neither me nor my kids, it is always like starting over. The atmosphere is anything but friendly, even stressful, and, paranoid as it may sound, I always feel judged by the kind of insurance I carry.

For their part, I know, so many health-care providers now feel like cogs in a machine. Drowning in mountains of documentation and fearing malpractice suits, they are hesitant to make even small decisions at work despite having studied so many years to become qualified clinicians. Sean wanted none of that. He struggled to make ends meet in the early years of his practice, but he ended up making a comfortable life for himself and family precisely because he earned the trust of a loyal core of patients. And again and again at Sean’s funeral, I heard these patients express the same sentiment: They wanted the kind of care that Sean offered but now rarely exists, provided by a breed of doctors that may be close to extinction.