Family medicine is neither the most prestigious nor the highest paid medical profession. Is that appropriate, or should it be the opposite? Should GPs actually be treated as the stars of medicine? As a general practitioner and primary care researcher, it was always fascinating for me to delve into the scientific literature to investigate this issue. Here are the key results.

1. GPs Are the Backbone of Effective Healthcare Systems

Countries with a stronger focus on primary care and family medicine, rather than on hospitals and specialists, enjoy better health,1,2 lower health inequalities,2,3 and prevent hospitalizations.2,4 I believe this is crucial and that all politicians should know about it. The following graph shows the striking difference in premature mortality between countries with weak or strong primary care:

2. More GPs = Higher Life Expectancy

Did you know that people in areas with more GPs live longer? Studies from the USA showed that adding one GP per 10,000 inhabitants was associated with 2-5 fewer deaths5,6 and 4 fewer hospitalizations5 annually. On average, life expectancy increased by 52 days.7 Overall, such an increase in the number of GPs could have prevented 127,617 deaths per year in the USA.6 This graph shows the association between primary care physician density and life expectancy among US states:

3. Having Your Own Long-Term GP Can Save Your Life

Patients who choose a GP rather than a specialist as their primary care provider have a 19%8 lower mortality and produce 22%9-33%8 lower healthcare spending. Also, systematic reviews on ‘continuity’ found mortality reductions in most included studies.10,11 In other words, having your own GP and contacting him or her first (rather than a specialist), might just save your life and save us money. A fantastic study from Norway12 (based on 4.5 million people in 2018), shows that the longer you know your GP, the better off you are. Patients who know their GP for over 15 years decrease acute hospital admissions by 28%, out-of-hours services by 30%, and even their risk of dying by 25%. This graph illustrates that the benefit of long-term GP-patient relationships is even dose-dependent (longer GP-patient-relationship = lower risk of dying prematurely):

Why do long-term GP-patient relationships improve health and reduce costs?11,13

• Over time, GPs come to know their patients well. You no longer need to review all medical records or repeat the whole medical and personal history.
• Over time, GPs put their patients into context. You know your patients’ evolving story as well as their family, friends, coworkers, and the peculiarities of their local community.
• Over time, more trust develops. Adherence to medical advice improves and unnecessary self-referrals to other doctors decrease.
• Over time, communication improves. Patients share personal issues more easily and medical errors are more easily avoided.

4. GPs Provide Most Healthcare

The following graph shows that by far most patient/doctor contacts are with GPs. On average, twice as many patients have contact with GPs than with all specialists (in offices and/or outpatient clinics) combined. While the media and politicians talk mainly about heroic intensive care or impressive new technologies, the real work happens nonetheless in family medicine offices.

Family physicians provide accessible and comprehensive care for most healthcare needs, most diseases, and all organs. They are therefore the foundation of every healthcare system. The numbers above leave no room for doubt.

5. GPs Improve Chronic Disease Management

We live in a world of aging populations, with rising chronic diseases, multimorbidity, and polypharmacy. Family medicine today is therefore more important than ever. Why? Because chronic diseases are largely managed in primary care and are therefore the GPs’ daily business:

• Patients with multimorbidity account for 78% of GP appointments (based on 100,000 UK patients).21
• More than 45% of primary care patients have multimorbidity (based on 700,000 US patients).22
• Family physicians are the sole care providers for 86% of hypertensive patients and for 71% of diabetics (based on 2.7 million Canadian patients).23
• Patients with multimorbidity who usually visit primary care rather than specialists showed 2% lower mortality, 6% less hospitalizations, and 9% lower healthcare costs (based on 4 million US patients).24

6. GPs Prioritize Prevention

One reason why GPs can improve health and save costs is their stronger focus on prevention. A recent study of almost 3 million US patients showed that those who visited primary care were much more likely to receive preventive services: 127% more vaccinations, 122% more colonoscopies, and 75% more mammograms.25 As the following graph shows, patients with a primary care doctor are much more likely to receive preventive checks:

7. GPs Save Money

GPs can save money by:

• Improving prevention and chronic disease management
• Avoiding potentially harmful diagnostic and therapeutic procedures
• Reducing unnecessary specialist visits and hospitalizations

That’s why a recent study of 5 million US patients showed that the first primary care visit saves $3,976 and each additional visit saves $721 per year.27 A further study of 6 million veteran patients showed, as mentioned previously, that having your own primary care provider reduced healthcare costs by 22%9 (another study showed a 33% reduction8). Also, healthcare systems with stronger focus on primary care might be associated with lower costs28 or at least with slower growth in costs2. In Europe, countries with stronger primary care had less unnecessary hospitalizations, especially concerning Asthma, COPD, and diabetes.2 This is a remarkable statistic, especially as GP visits are relatively inexpensive. As shown in the following graph, primary care services amount for only 8.1% of healthcare costs in the EU 2018.29

8. GPs Counteract Health Inequalities

The chances of living a healthy life are not distributed equally or fairly. Life expectancy is hugely influenced by education, income, and occupation as illustrated here:

As shown above, stronger primary care orientation3 and higher GP densities31 are both associated with reductions of health disparities. But why? Well, strong primary care improves access for deprived populations, it offers more comprehensive services, and GPs know their patients longer and better. In other words, patients can get more services, more easily, more appropriately. All of that is especially important for disadvantaged individuals with more risk factors, more chronic diseases, more medications, and lower health literacy.32 Last year, I was honored to interview Sir Michael Marmot, former Chair of the WHO Commission on Social Determinants of Health and former President of the World Medical Association, about his perspectives on primary care and health inequalities. Here you can find his answers on YouTube.

Mechanisms

So, in a nutshell, WHY are GPs so important and HOW do they improve health and save money?

• GPs know their patients well, which improves diagnostic accuracy.
• GPs are highly trusted, which encourages adherence to medical advice.
• GPs improve prevention, which avoids diseases.
• GPs improve early detection, which improves treatment outcomes.
• GPs improve chronic disease management, which prevents complications.
• GPs avoid unnecessary duplications of diagnostic procedures.
• GPs avoid unnecessary and potentially harmful medications.
• GPs prevent unnecessary specialist visits and hospitalizations.
• GPs offer the same services more affordably than specialists or hospitals.
• GPs offer guidance and coordination within a complex system.

Conclusion

Healthcare systems which focus on family medicine and patients who have their own long-term GP enjoy many benefits. GPs know their patients best and are highly trusted, which results in better outcomes. They are easily accessible and offer more affordable services. Also, because by far most healthcare happens in primary care offices (rather than in hospitals), that is where the quality of prevention and chronic disease management is really determined and where unnecessary and potentially harmful procedures can be avoided. Without a doubt, primary care is the backbone of all effective healthcare systems and family physicians are the actual Stars of Medicine. Do you agree that GPs are the actual Stars of Medicine? If so, please share this article!

Afterthoughts

As I am not only a physician but also a researcher (here more about me), I feel obliged to point out some of the scientific limitations related to this blog post:

1. Keep in mind that correlation is not causation and that much of what we know about primary care today is based on observational evidence.
2. Each issue I addressed above would require a systematic review to present the available evidence entirely, which is not feasible for a blog post.
3. Each of the cited research studies has its own specific limitations.

If you have any criticisms or suggestions for improvement or suggestions for future blog posts, you are very welcome to contact me. Also, consider joining my short and informative e-mail newsletter (‘Golden Nuggets of Family Medicine’).

https://family-medicine.org/blog/stars_of_medicine