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PRIMARY CARE MAY BE well on its way to the endangered species list of contemporary American medicine. A recent article in the prestigious New England Journal of Medicine observed that while primary care – which includes family practice – accounts for about one third of the physician workforce, “Far fewer U.S. medical students are interested in careers in adult primary care than were a decade ago.”
The reasons for this trend may be numerous, but, as the Journal article astutely notes, they most often are economic: “As compared with graduates who become oce-based generalists, those who become specialists, hospitalists or emergency care medicine physicians can often expect to have greater control over their lives, a wider variety of professional experiences, sucient funds in the short-term to pay o student loans and higher incomes over the long-term.”
For anyone whose vision or remembrance of the Norman Rockwell-esque “family doc,” making a midnight house call with his black bag, tongue depressors and stethoscope, this news is disturbing at the very least. To long-time Lowcountry primary care physician Dr. Mitch Feller, it’s a sad commentary on the trend away from patient-oriented doctoring and toward more lucrative specialization.That’s not to say that Dr. Feller has any quarrel with doctors who choose to specialize. It’s simply that he has dedicated his own life and career to primary care and believes that the eld he has chosen is the heart and soul of medical practice. For him, primary care has clearly worked – and worked well. Although he himself is only 59, his Mount Pleasant practice has already, in some cases, served ve generations of local families. “It’s a heart-expanding feeling to have such an ongoing connection to generation after generation of these families,” he commented.
A native of suburban Philadelphia, Dr. Feller was an excellent student in high school, with an interest in science. He enrolled at Franklin and Marshall, a Pennsylvania college renowned for sending nearly half its graduates to prominent medical schools. Graduating with honors, he earned acceptance at numerous graduate programs, including the University of Pennsylvania School of Medicine.
At Penn, a well-endowed private medical school, the focus was on specialties and sub-specialties, and its graduates were considered to be among the best of the best in every area. Despite this heady atmosphere, Mitch Feller something was missing. He knew he loved medicine, but he was uncomfortable with what he perceived as an emotional and empathetic disconnect between the physician and the patient.
As a result, he dropped out of medical school, worked for several months on a farm in Lancaster County – a return to his roots as the son of Mennonite farming parents – and eventually hitchhiked to California. Once on the West Coast, he did “the basic hippie thing,” winding up in Berkeley, where he got a closer look at a dierent kind of practice model – one that emphasized primary care. Family practice, a new specialty, was highly valued in Northern California, and its emphasis on the patient armed his notion that there was a better way to conceptualize the doctor-patient encounter.
Thumb out once again, he returned to Philadelphia, where he was welcomed back by the School of Medicine, and began a series of primary care clerkships because, “I had found out where my heart really was.”
After receiving his medical degree in 1977, Feller was accepted as a resident in the Department of Family Practice at the Medical University of South Carolina, a newly developed program that was attracting many of the brightest and most dedicated students from medical schools throughout the nation.
“The focus of our training was on the doctor-patient interaction, as well as on the diagnosis and treatment of particular disorders. Particular attention was given to teaching the essentials of the interview, or oce visit, which was a revolutionary innovation at the time. Most important was how you spoke to patients, how well you listened to them and what you could do to facilitate their compliance. We learned to develop a long-term care plan for each patient, based on where you hoped their health would be in 20 or 30 years, and how you could help them get there. You learned to use everything at your disposal – your senses, your sense of humor, the power of hope, and, most of all, your undivided attention and ability to listen.”
His residency in family medicine included such innovations as training in family dynamics and family therapy, group therapy and role playing, virtually all of it videotaped and critiqued by more experienced attending physicians.
“The acute awareness that every part of the encounter mattered and aected the outcome of the whole constantly forced your awareness into the matter at hand at that moment. We learned to be truly engaged,” he commented.
“In Family Practice,” Dr Feller believes, “you have to let people tell you what’s wrong with them. And it’s never a linear story. There are always detours and side trips. The goal is to sort through the dialogue and shape a coherent interview with a plausible theory as to what’s wrong. In the words of medical icon Sir William Osler, ‘if you listen carefully to the patient, they will tell you the diagnosis.’ I think that for people to feel like their encounter with their doctor has been productive, they need to feel like they’ve been heard.”
In Dr Feller’s experience, a high percentage of patients have emotional, psychological, socio-economic or family-related issues that impact their health and are important to any meaningful diagnosis. That’s why a planned 15-minute consultation can often stretch to an hour or more, and that’s one of the reasons primary care is attracting fewer and fewer practitioners.
“The problem is how to allocate enough time for your patients’ more complex emotional as well as physical needs while struggling with a payment structure that rewards for procedures, technical services and the sheer number of patients you can see. Cognitive services are the key to primary care, and cognitive services are not seen as worthy of compensation by governmental and private insurers. I could see four sore throats in the time it takes to counsel a patient with a more complex problem, like anxiety or substance abuse or marital discord. I could signicantly increase my income in doing so. But if I feel like that one patient needs an hour of my time, then that’s what I’m going to give them. To me, medicine is more of an art than a trade; a calling, not a business. I’m grateful to have found my calling. I enjoy going to work each day. I’m blessed in that regard.”
Dr. Feller thinks policymakers don’t value the time it takes to care for the individual, rather than simply treating the disease. Primary care physician groups such as the American Academies of Family Practice, Internal Medicine, and Pediatrics, have been lobbying lawmakers in Washington for years to pay their physicians for the cognitive services they perform, without much success. As a result, fewer and fewer medical students are entering primary care residencies to rebuild the ranks of physicians who retire or leave medicine for another profession entirely. With more immediate concerns about higher income to repay medical school debt and lifestyle more conducive to family life, a higher percentage of medical school graduates are entering the higher-paying specialties such as dermatology, radiology and anesthesiology.
“My concern about the health plans under consideration in Washington is that if 40 million citizens are suddenly insured, who are they going to go to? Access to insurance is not the same as access to a doctor if there is a scarcity of primary care physicians,” Dr. Feller pointed out.
Dr Mitch Feller’s advice to the medical school, college and even high school students he mentors is simple: “If you feel that primary care is your passion, and you seem to have an aptitude for it, follow your heart. Primary care is extremely rewarding. You learn something from every patient you encounter. You make a dierence. And every day is unique. Just do your best, and you’ll end the day with no regrets.”
Dr. Feller has been in private practice in Mount Pleasant since 1982. He has also participated in numerous research activities and made several professional presentations and holds two U.S. patents for medical devices. Three of his four daughters currently are in college.. He and his wife, Vanessa, live in Mount Pleasant.
by Bill Farley