Intended for healthcare professionals

Feature Christmas 2010: Primary Care

A modest proposal

BMJ 2010; 341 doi: (Published 09 December 2010) Cite this as: BMJ 2010;341:c6605
  1. Philip A Mackowiak, professor, vice chairman1, chief2
  1. 1Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland 21201, USA
  2. 2Medical Care Clinical Center, VA Maryland Health Care System, Baltimore, Maryland
  1. Correspondence to: philip.mackowiak{at}
  • Accepted 15 November 2010

“For Preventing Primary Care Physicians in America From Being a Burden to Their Profession or Country, and For Making Them Beneficial to the Publick.” A solution to America’s healthcare crisis inspired by Jonathan Swift’s “A Modest Proposal” (1729)

Once President Obama has at last put the US healthcare insurance crisis to bed, he must then figure out what to do about primary care providers, who are crucial (as those who have more expertise in such matters than I believe) to the success of his healthcare programme. Roughly reckoned, there are some 300 000 to 350 000 of them.1 The question is: how do we continue to train, equip, and maintain this number, much less provide for the even larger number that others have suggested is needed to care for our ageing population?2 The current crop is already hard pressed to cover their overheads, to say nothing of supporting their spouses and children, who, given current levels of compensation for primary care services, are soon sure to become wards of the state.


Fixing the primary care problem (Howard Pyle’s “Walking the plank”)

As to my own qualifications for offering advice on this weighty matter, I have for years read and ruminated over the subject, carefully weighed the myriad solutions offered by others (including but not limited to: comparative effectiveness research, accountable care organisations (ACOs), patient centred medical homes, capitated/global payment schemes, and sentinel networks) and found each of them grossly mistaken in concept. These prior proposals, concocted mostly by PhDs and other nonclinicians, have focused on the primary care physician as the solution to America’s healthcare crisis. I believe a broader perspective is indicated, one in which the primary care physician is recognised not just as the solution to the problem, but also its cause.

In all humility, I offer for consideration the following plan: that a handful of the family practitioners, internists, paediatricians, and obstetricians/gynaecologists self identified as primary care providers currently supported by our system (that is, no more than 1% of the total), be designated for remedial training in dermatology, cosmetic surgery, virtual endoscopy, or some other underserved discipline in which their former training might be of use in refining existing practice guidelines designed to funnel patients to subspecialists.

I further propose that the remaining 352 183 primary care providers be dispensed with in the simplest, most expedient, most cost effective, and most humane manner possible—that they be exterminated.

I am not suggesting that they be boiled, barbecued, or fricasseed as per Jonathan Swift’s ingenious scheme for transforming the children of the poor people of 18th century Ireland from a liability into an asset.3 That would be illegal. Rather, I propose that they be sacrificed on the altar of a new healthcare paradigm by immediately interrupting all payments for primary care services, and that the monies saved by eliminating the cost of training and then supporting primary care physicians be reinvested in a computer based, direct to consumer, healthcare programme in which every American, regardless of race, religion, or ability to pay, is empowered to diagnose and to treat his or her own medical conditions using the most up to date, evidence based clinical guidelines that modern health information technology can provide.

Let me now offer a few thoughts on finances, which I am confident will not raise even the slightest objection. As you are no doubt aware, the annual cost of medical care in America has reached $2.5tn (£1.6tn; €1.9tn).4 Of this amount, some $600bn is spent each year to finance the operations of primary care physicians.2 These are monies that would be used more productively to support my proposal for transforming America’s primary care physician from a liability into an asset and for properly medicating the country. Happily, according to my calculations (formula available on request), this will cost a mere $92.4bn per annum. The beauty of my programme is its ability to reduce cost while increasing patient satisfaction, by eliminating primary care middlemen, who too often meddle with practice guidelines by promoting lifestyle modifications over drugs, altering doses or, worst of all, denying patients evidence based medications because of some perceived so called relative contraindication. What is more, those who are more thrifty (as I must confess the times require) will surely bring the cost of my programme down over time by figuring out how to recycle unused medications, so that they might be sold to needy third world countries at a steep discount, not only to help satisfy the appetite for drugs of our less advantaged neighbours, but also to begin rehabilitating our image as a nation of peace loving idealists.

Some cynics will argue that precious resources will be wasted on lost causes in such a programme, resources that might be used more effectively in maintaining health through education and prevention rather than poured into treating diseases, many of which blossom only during the final year of life. They claim that preventing diseases is vastly more cost effective than treating diseases. I would simply respond to these objections by pointing out that preventive measures can only reduce the cost of medical care if they make it possible for patients to drop dead in perfect health.5 Otherwise, they only postpone the cost of terminal care.

Let me now consider the advantages of my proposal, which should be obvious to all but those most resistant to innovative solutions.

Firstly, as I have already pointed out, it will solve America’s healthcare crisis decisively and permanently by eliminating the primary care physicians responsible for it and the need for the services they provide. Of course, it would leave a not insignificant number of patriotic Americans out of work—but certainly not without prospects. Given their connections and conservative life styles, primary care physicians would be ideal organ donors and might sustain themselves, at least for a time (not to mention alleviate another of our healthcare crises), by auctioning off spare kidneys, left hepatic lobes, lungs, and such.

Secondly, those millions of marginalised members of our great society, who heretofore have lacked adequate medical care, will have access to a programme of medical care more comprehensive, more accessible, more uniform, and more satisfying than any yet devised.

Thirdly, this would be a great inducement to patient autonomy. Patients would now not just participate in decisions related to their healthcare, they would make those decisions themselves—intelligently, using evidence based data from every conceivable source virtually the minute it is generated. In time, they might even be empowered to perform their own diagnostic tests, perhaps also minor surgical procedures (on themselves, family, and friends), making possible the additional extermination of clinical pathologists and general surgeons.

Many other advantages might be enumerated. For instance, what better way to apply evidence at the point of care? With primary care physicians out of the way, clinical judgment will no longer hamper the narrow interpretation or rigid enforcement of practice guidelines. Variations in clinical practice will be eliminated completely. With immediate access to pills of every ilk, sick patients will be made well, and people who are not sick will be made better than well once given unlimited access to Prozac, Levitra, and such. Our entire population will have a personalised electronic medical record from which mountains of data can be mined. Accountable care organisations will be able to run everything-against-everything on hundreds of millions of patients being treated for and/or prophylaxed against every conceivable disorder. Countless statistically significant associations will then be translated into a host of new performance measures and practice guidelines used to monitor and manipulate patients’ activities and also to harass subspecialists as relentlessly as primary care physicians once were.

Some might object to my proposal by quibbling over the limitations of evidence based medicine or fretting over the theoretical problems of adverse drug events. With regard to the former, they would have us believe that all evidence is imperfect, and that our answers to life’s great questions (for example, hormone replacement therapy, low fat diets, erythropoietin in patients with cancer, and so on) are no more likely to withstand the test of time than those of earlier generations. They claim that much of the evidence upon which clinical decisions are based comes from studies in which industry has exercised undue influence, that publication of investigations in medical journals endows their results with a veneer of certainty that is inappropriate and potentially dangerous, and that our expectations for the benefits of treatments are so high we fail to recognise that they sometimes do more harm than good, and that doing nothing is occasionally the best treatment. Some have even gone so far as to question the sanctity of the P value. They argue that hierarchies of evidence, in which randomised controlled trials occupy the highest rung, attempt to replace judgment with an overly simplistic, pseudo-quantitative assessment of the quality of the evidence presented.6 Still others would have us believe that journal editors favour positive results over negative results and, like the general public, readily believe what they earnestly hope for.

To those obsessed with such concerns, I would simply ask: which is worse, knowing what might not be so, or knowing nothing at all?

With regard to adverse drug effects, there can be no doubt that there will be a few. Fortunately, we have drugs with which to treat most.7

To be sure, this programme, like all innovative programmes, will face not a few challenges during its implementation. Even so, I know of no cheaper, fairer, more comprehensive system of medical care yet proposed. That being said, I am not so violently bent on my own plan as to reject one offered by another that is as cheap, easy, and effectual. But, I humbly request that before some other scheme should be advanced in place of my own, at a minimum, evidence based data from a randomised pilot study involving no fewer than several million participants per arm be conducted to select the best one.


Cite this as: BMJ 2010;341:c6605


  • Presented as the Nicholas E Davies Memorial Lecture at the ACP Annual Meeting on 24 April 2010, Toronto, Canada.

  • The author has completed the Unified Competing Interest form at (available on request from the corresponding author) and declares: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous 3 years; and no other relationships or activities that could appear to have influenced the submitted work. None of his friends or associates stand to profit from his proposal. Only his ex-wife is uninsured, and thanks to their acrimonious divorce, she refuses to have anything to do with the medical profession.

  • Provenance and peer review: Not commissioned; externally peer reviewed.