Nature 371,552,1994.
Sir -- In an article "Primary care is not the answer" (Nature 370, 501;1994), Barbara J. Culliton draws attention to some "less visible provisions" in President Clinton's health care plan; like forcing 50 per cent of physicians into general practice. She believes that this "50 percent solution" will fail, since modern medical practice is beyond the skills of the general practitioner. Medicine should be provided mainly by academic medical centers.
Primary care has always been the preferred way to practice medicine. Unfortunately it was abandoned by academic medicine. Diseases do not exist as such, there are only sick people, and yet our education systems produce mainly disease specialists. They may understand "basic biological phenomena", and know how to treat some diseases, yet the crucial question is not only how to treat but when to intervene. The latter is generally ignored since withholding treatment is regarded as unethical, and many patients receive therefore unnecessary treatments. Academic medicine turned "primum non nocere" into malpractice, and palliation into non-science. And yet most patients do not need more than that, seeking help from alternative medicine.
An important objective of President Clinton's plan is to mobilize competent "academic generalists" and place them where they are needed most; in the community. To restore the lost dignity of the family physician who faces now new responsibilities; to protect his patient from academic medicine. Medicine became extremely complex and the family physician has to decide what is best for his patient; in the same way as a lawyer does for his client. The threat of academic medicine to the patient is real. The family physician has to protect him from unnecessary treatments, experimental remedies, and clinical trials that study disease and ignore patient suffering. Academic medicine is the main source of iatrogenesis, e.g., drug sensitivity and antibiotic resistance (Hospital strain). It is also the main cause of the rising medical care expenditure, since indiscriminately applying technological innovations, when in reality the patient could benefit without them. As patient protector the family physician will obviously reduce also medical expenses.
G.Zajicek