The Shoeshine Stand and the Renaissance of Primary Care

Dear Editor,

We read Dr. John J. Frey's article, "The Shoeshine Stand and the Renaissance of Primary Care," with great interest. His reflections on the transition from independent practices to employed physicians in the United States offer valuable insights into the evolving landscape of primary care in this country.

As family physicians practicing in Spain, we find his observations particularly thought-provoking when contrasted with the Spanish healthcare system. In Spain, the majority of physicians, especially those in Family Medicine, are employed by the public health system under the National Health System (Sistema Nacional de Salud). This system provides universal coverage and is primarily funded by taxation, ensuring that healthcare remains accessible to all citizens.

While Dr. Frey highlights a loss of autonomy and personal accountability among employed physicians in large systems, the situation in Spain presents a different perspective. Spanish family physicians, though employed by the state, often experience a significant degree of professional autonomy within their practices. This autonomy is facilitated by a strong emphasis on primary care as the cornerstone of our healthcare system, allowing physicians to tailor care to the specific needs of their communities.

Research has shown that the Spanish model, with its focus on primary care, leads to better health outcomes and higher patient satisfaction [1]. Moreover, the continuity of care provided by family physicians in Spain contrasts with the fragmentation often seen in more commercialized systems. This continuity fosters stronger patient-physician relationships, which are essential for effective preventive care and chronic disease management.

However, challenges remain. Bureaucratic demands and administrative tasks can impede the ability of physicians to focus on patient care, echoing some of the concerns raised by Dr. Frey. A study by Bouza et al. [2] found that administrative burden and an excessive workload contributes to physician burnout in Spain, suggesting that employment within a public system does not entirely mitigate the issues associated with large organizational structures.

Dr. Frey's call for a renaissance of primary care through small, adaptable, and community-responsive practices resonates with the principles of Family Medicine in Spain. Our system demonstrates that it is possible to balance employment within a larger system with the autonomy and personal accountability that physicians desire. By fostering a supportive environment that values primary care, we can enhance physician satisfaction and improve patient outcomes.

In our humble opinion, while the orientation of healthcare in the United States presents unique challenges, the Spanish experience offers an alternative model where employment and autonomy are not mutually exclusive. Embracing the core values of primary care—accessibility, continuity, and community orientation—can lead to a more satisfying practice for physicians and better care for patients.

References:

[1] García-Armesto S, Abadía-Taira MB, Durán A, Hernández-Quevedo C, Bernal-Delgado E. (2010). Spain: Health system review. Health Systems in Transition, 12(4), 1–295.
[2] Bouza E, Gil-Monte PR, Palomo E, Cortell-Alcocer M, Del Rosario G, González J, Gracia D, Martínez Moreno A, Melero Moreno C, Molero García JM, Montilla P, Peñacoba E, Rodríguez Créixems M, Rodríguez de la Pinta ML, Romero Agüit S, Sartorius N, Soriano JB. (2020). Work-related burnout syndrome in physicians in Spain. Revista Clínica Española (English Edition), 220(6), 359–363. https://doi.org/10.1016/j.rceng.2020.02.003.