What is a General Practitioner?

Physicians play a fundamental role in the care of the US population (Guteirrez and Scheid, 2002). A general practitioner, also known as a generalist, physician or family physician, does not specialize in one specific area of medicine; instead, they provide care for a variety of health conditions, illnesses and injuries. They perform routine health examinations such as physical exams and immunizations as well.  General practitioners typically have long-term relationships with their patients, and their patients range from infants to the elderly.

Generalists can identify a wide range of diseases and disorders, for example, influenza, strep throat, muscle sprains and bone fractures.  When serious health conditions or other needs for specialized care are identified, the general practitioner refers them to the respective specialist in the required field. Specialists receive additional education and training in a specific area of medicine, for example, cardiology, neurology, or oncology).

Education and encouragement are also part of a general practitioner’s activities, typically in healthy lifestyles, physical, emotional and mental health and good habits. Most general practitioners work in private practices or clinics with a small staff of nurses and administrators, or they may be part of a large group practice with other general practitioners or a health maintenance group (HMO).

What Does a General Practitioner Do?

General physicians diagnose, treat and manage a wide range of conditions, including sprains, infections and the flu, and determine if the condition warrants a specialist or more intensive care. General physicians today seek to promote both emotional and physical well-being by educating patients on healthy lifestyles, encouraging good habits and helping end bad ones such as smoking and overeating, according to the American Medical Association (AMA).

A study of general practitioners and their daily activities was performed by a group of Norwegian scientists in 2003 with the goal of identifying the areas general practitioners spent most of their time, and areas they would prefer to focus their time.  Qualities of primary care include provision of personal and personalized health care, knowledge of patients’ values and preferences, and patient trust that GPs will secure the appropriate care that they need (Halvorsen et al, 2003).  Halvorsen et al (2003), analyzed the activities and preferences of general care practitioners in various countries including Canada, the UK, Netherlands, and Norway, and compared them to the health care policy and reform requirements of each respective country.

Some aspects of health care policies and reforms involved in this study include primary health care teams, blended payment systems, coordination of care and cost containment.  These factors were examined in the extent that they interfere with time available for direct patient care.  The results indicate that the preferences of general practitioners may slightly conflict with the patient’s best interest indirectly, and directly with health authorities and policy makers.

The most meaningful activities were handling common symptoms and complaints (94% scored 4 or 5), chronic somatic diseases (93%), terminal care (80%), chronic psychiatric diseases (77%), risk conditions (76%) and on call emergency services (70%) (Halvorsen, 2003).  It was also determined that general practitioners would prefer to spend less time on emergency services. Items with low priority were health certificates, practice administration, meetings with local health authorities, medically unexplained symptoms, addiction medicine, follow up of people certified unfit for work, psychosocial problems, preventive health clinics for children and school health services (Halvorsen, 2003).

The study concluded that general practitioners prefer to focus on the diagnosis and treatment of disease, and their least favorite area involves administrative aspects of the profession, such as paperwork and regulations.  Most general practitioners would rather have direct patient contact and opposed to spending time on health certification, practice administration, meetings with local health authorities, medically unexplained symptoms, follow up of persons unfit for work, psychosocial problems, drug abuse and addiction medicine, preventive health clinics and school health services (Halvorsen, 2003).

History of General Practitioners

The 1800s

The United States in the 1800s was mostly comprised of newly settled small towns, and agriculture was the main foundation of the economy. During this time, there was no structural healthcare system.  Doctor’s did not have medical training or licensing, although some learned from apprentices and attended courses when they were available. Anyone could call themselves a doctor. Although many doctors were outstanding physicians, there were also many who claimed incredible healing powers; there was a lot of “quackery” and no standards of care to which doctors were held (Gutierrez and Scheid, 2002).

General practitioners during the 1800s made visits to their patient’s home and cared for all members of the family.  They treated illnesses, set broken bones and fractures, delivered babies and performed emergency treatment. Payments were often made by trading goods for the doctor’s services.

As the United States began to grow in population, the need to establish formal medical education and standards were recognized as a priority (Gutierrez and Scheid, 2002). In 1846, the American Medical Association (AMA) was established with this goal in mind. The objectives of the AMA were to purify the profession from quackery, establish an orthodox medical education based on natural science, promote standards for public health (sanitation, food and drugs) and standardize medical education (Gutierrez and Scheid, 2002). 

The 1900s

Due to the advanced state of medicine in England and Germany, the AMA sought the help of the Carnegie Foundation for the Advancement of Teaching to provide recommendations for improving medical education in the United States. Abraham Flexner led the project, and the recommendations were known as the Flexner Report. The Flexner Report recommendations provided significant measures for improving medical education: establishing science as the emphasis for education, standardizing curriculum, full-time faculty dedicated to teaching and research and attaching medical schools to universities (Gutierrez and Scheid, 2002).

The establishment of the Flexner Report recommendations led to significant growth and development of medical care in the United States, and the need for specialty fields became evident.  The first specialty American Board was established in 1917 for Ophthalmology, followed by the American Board of Otolaryngology in 1924.  Many more followed throughout the 1930s and 1940s.  These boards provided certification for doctors in those fields and developed examinations to test the doctor’s competency.

Changes to the American Medical Associated mission occurred in 1935 to update the previous requirements for medical education and to include specialty fields. The updated requirements included standardization of pre-doctoral medical education awarding all physicians the same medical degree, specialization based on extended graduate education; i.e. Residency, specialist control over the location and use of technology (Gutierrez and Scheid, 2002).   Also included were the establishment of hospitals as a central location for developing medicine and technology and institutionalizing medical education.

The updated requirements had two significant side effects.  First, they drastically increased the cost of medical education, and second, they emphasized specialized medicine, which began to dominate the medical field. General practitioners began to gradually decline in demand. The AMA establishment of hospitals as the focus for medical treatment prevented general practitioners from participating in those activities.

World War II

World War II led to significant advances in science and technology in the United States and an increased demand for medical services.  With thousands of injured soldiers returning from war and a growing population, more doctors were needed; however, medical school enrollment remained stagnant through the 1960s.  In the 1960s the public began to express their dissatisfaction with the state of medicine, mainly: the shortage of physicians, the inaccessibility of health care in rural areas and inner cities, the high cost of medical care, the increased depersonalization of medicine and the fragmentation of care (Gutierrez and Scheid, 2002).

In response to public concerns and outcry the AMA responded by increasing and extending direct federal support to medical schools through the Health Profession Education Assistance Act and by creating the Citizen’s Commission on Graduate Medical Education which resulted in the Millis Report of 1966 (Gutierrez and Scheid, 2002). In addition to the Millis Report, two other independent documents on the topic of medical care were published, the Folsom Report and the Willard Report.

These independent commissions researched and analyzed the state of medical care in the United States and provided recommendations for improvements. All three reports identified the need for a central physician that focused on comprehensive health of the patient, with knowledge of their social, environmental and emotional environments.  Family medicine and family physicians would provide the continuity of medical care the reports recommended.

The 1960s – 1990s

Indeed, the 1960s brought a sense of social responsibility: The Civil Rights Movement, the peace movement, the Vietnam War Protests, etc. (Gutierrez and Scheid, 2002). This atmosphere of social conscious was a factor in the new emphasis on family medical practice.    The American Board of Family Practice was established in 1969, with certification and examination requirements for practicing general practitioners.

The following definitions for established as related to general practitioners (Gutierrez and Scheid, 2002):

Family Physician is defined as a physician who is educated and trained in family practice -- a broadly encompassing medical specialty.  They provide continuing and comprehensive medical care, health maintenance and preventative services to each member of the family regardless of sex, age or type of condition or illness, be it biological, behavioral or social.  Family physicians have unique attitudes, skills and knowledge which qualifies them to advocate for each patient in health-related matters).

Family practice is the medical specialty which provides continuing and comprehensive medical care for individuals and families to integrate biological, clinical and behavioral sciences, encompassing all ages, sexes, organ system and disease.

The field of family medicine expanded and thrived through the 1970s, 80s and 90s.  Residencies grew; graduates and diplomates increased in number and it appeared that FM was set to make major leaps toward becoming a strong force within medicine (Gutierrez and Scheid, 2002).  The American Board of Family Medicine was the second largest AMA entity in 2002.

General Practitioner’s Impact on Heath Care Delivery in the United States

The bulk of health care deliver occurs in the community, in the offices of physicians (Gutierrez and Scheid, 2002).  This remains true today, regardless of health insurance (those with or without) or illness.  General practitioners allow for health care access particularly to those in rural communities or inner-cities who may not otherwise seek medical care.

Based on office-based visits in the United States, family physicians see more patients than any other primary care specialty (Gutierrez and Scheid, 2002). This includes patients with heart disease, stroke, diabetes, cancer, emphysema and bronchitis, asthma and anxiety or depression. Although the importance of general practitioners has long been acknowledged, the field continues to face challenges that threaten its vitality.

Despite the significant improvements of the last 30 years, many of the fundamental issues of 1969 remain unchanged; others have worsened and new challenges have emerged (Gutierrez and Scheid, 2002).   The conflicts between generalists and specialists in regard to “turf battles” and the economic disparity in reimbursement between specialists and generalists continue to prevent us from achieving a bigger and more fundamental goal: to provide affordable, high quality and personalized health care to all people (Gutierrez and Scheid, 2002). Not only that, but changes in insurance plans and thus changes in doctors eliminates the possibility of long-term relationships, in addition to the financial strain, and decreased quality and efficiency of care (Gutierrez and Scheid, 2002).  

We cannot separate the economic forces that determine the financial support for health care from their effect on the patient-doctor relationship; or their effect on medical education (Gutierrez and Scheid, 2002). Social and cultural factors also must be recognized as influences on how and where health care is delivered. General practitioners also face challenges in remaining updated in technological advances. Some have chosen to limit their scope of practice in order to maximize proficiency and competency within that scope.

The United States Government enacted the Medicare program in 1965.  This program provided payments for medical education and medical care to hospitals, which were previously funded through private donors, tuition revenue or other state or local government funding. Because of the increasing costs of health care, the government transitioned to paying hospital by diagnosis rather than by treatment, and insurance companies adopted the same policy. Another setback to medical education came in the form of the Balanced Budget act of 1997 whose goal was to reduce payments by 5.6 billion dollars over a 5-year period by decreasing payments to all hospitals for patient care and capital, and by decreasing the DISH (disproportionate share of high cost cases) payments, as well as subsidies for teaching (Gutierrez and Scheid, 2002).

The field of general practitioners in family or internal medicine has made significant accomplishments and advancements since the first horse-and-buggy physicians of the 1800s.  Family physicians are fundamental to providing comprehensive health care in the United States, although they must adapt and adjust to the changing health care reforms and policies enforced by the government. Specialized fields are equally important; however general practitioners tend to be overlook when compared with specialists.

Medical education and training is essential to the continuous development of health care in the United States, for all fields, specialties and sub-specialties. Although the profession of general practitioners has long been established, it must continually evolve based on the economic, social, and environmental factors and impacts. The American Medical Association and the American Board of Family Medicine continue to analyze and research these factors and update their recommendations for standards and requirements to ensure Americans receive the best possible comprehensive health care.

How to Become a General Practitioner

Extensive education and training are required to become a general practitioner. An undergraduate degree, completion of medical school, and a residency program are all required in order to become a licensed general practitioner.  The required education and training takes approximately 10 years to complete. Undergraduate degrees in pre-medical or other science (biology, chemistry, physics) help the student prepare for the Medical College Admission Test (MCAT) exam.  Some students choose to major in humanities or social sciences (sociology, psychology, anthropology, foreign language or literature).

Accredited medical school acceptance is extremely competitive. Volunteering at local hospitals or other medical centers during the undergraduate years is recommended in order to obtain hands-on experience in the health care profession.  Some aspiring general practitioners complete a Master’s degree program prior to applying to medical school in order to display additional education and training on their medical school application.

The first two years of medical school includes coursework in anatomy, biochemistry, medical law and ethics, microbiology, pathology, pharmacology, physiology and psychology. Additional training may include procedures for physical examinations, examining medical histories and diagnostic testing. The last two years consists of hands-on experience under the supervision of a licensed physician. Rotations allow students to receive training in a variety of areas including internal medicine, family practice, obstetrics and gynecology, pediatrics, psychiatry and surgery.

Graduates of medical school receive a Doctor of Medicine (M.D.) degree and go on to complete a 1 to 3-year residency, which involves additional training with direct patient interaction. Some aspiring general practitioners complete a 1-year internship prior to residency in order to receive a Doctor of Osteopathic Medicine Degree (Ph.D.). When residency has been completed, the general practitioner must pass a licensing examination in the state they wish to practice in.

If they choose, a licensed general practitioner may become certified through the American Board of Family Medicine (ABFM) or the American Board of Internal Medicine (ABIM). Although general practitioners, by definition, do not specialize in one field, they may choose to focus on family medicine or internal medicine. Certification requires 3 years of experience as a general practitioner, in addition to passing an examination.

Family medicine practitioners offer complete and comprehensive health care to patients of all ages, and they are trained to diagnose and treat common and un-common conditions. Their training focuses on pediatrics, internal medicine, obstetrics and gynecology, psychiatry, geriatrics, preventative medicine and behavioral science (Swierzewski, 2015).  Practitioners of internal medicine to not treat children or adolescents.

There are opportunities for sub-specialization for family practitioners and internal medicine, although additional training and examinations are required. Family medicine sub-specialties include adolescent medicine, geriatrics, hospice and palliative medicine, sleep medicine and sports medicine. Internists may sub-specialize in allergy, immunology, cardiology, endocrinology, gastroenterology, hematology, infectious disease, nephrology, oncology, pulmonary and rheumatology fields (Swierzewski, 2015).

Those aspiring to become physicians must work well under pressure, possess compassion and be willing to accept long hours and the responsibility for the life of another human being (BLS, 2016).  A general practitioner should also have high moral and ethical standards.

Job Prospects for General Practitioners

The Bureau of Labor Statistics (BLS) predicts a 14% job growth through 2024, and a decreasing number of general practitioners entering the field. Other medical specialties tend to have higher salaries than family practice or internal medicine, and medical school graduates are trending toward the higher-paying medical fields. Although a general practitioner’s job is demanding, it can be rewarding as well. Physicians find fulfillment in assisting their patients, have a variety of career options and serve their community.

Source: Bureau of Labor Statistics

General Practitioner Assistant

A general practitioner assistant, or physician’s assistant, is not required to complete medical school. They must complete an accredited physician assistant program and/or a master’s degree. This profession is expected to have a job growth of 30% through 2024 (BLS, 2016), and the average annual salary for a physician assistant is $98,180, as of 2015 (BLS, 2016).  Physician’s assistants will be in high demand in the near future.

An assistant to a general practitioner serves multiple functions, which may vary depending on the type of medical center where they are employed. The physician assistant may document patient medical history, suture small wounds, and interpret blood or urinalysis testing results. In some states, they are also allowed to prescribe medications. A general practitioner assistant must be licensed in the state they choose to practice in by passing the Physician Assistant National Certifying Examination (PANCE).

References

Swierzewski, Stanley J., M.D. What is a General Practitioner? September 18, 2015.  Retrieved September 15, 2017 from: http://www.healthcommunities.com/health-care-providers/what-is-a-general-practitioner-gp.shtml

Halvorsen, P.A., Edwards, A., Aaraas, I.J., Aasland, O.G. and Kristiansen, I.S. What professional activities do general practitioners find most meaningful? Cross sectional survey of Norwegian general practitioners. BMC Family Practice, 2013;14:41.

Gutierrez, Cecilia, MD and Scheid, Peter, MD. University of California San Diego Department of Family and Preventive Medicine. The History of Family Medicine and its Impact in US Health Care Delivery. May 2002.

Bureau of Labor Statistics (BLS). Family and General Practitioners, May 2016. Retrieved September 15, 2017 from: https://www.bls.gov/oes/current/oes291062.htm#ind