Footnotes
Readers are encouraged to respond to Paul Blumenthal, MD, Deputy Editor of MedGenMed, for the editor's eyes only or for possible publication via email: pblumen@stanford.edu
. 2007 May 30;9(2):47.
letter MedGenMed. 2007 May 30;9(2):47.
To the Editor,
The analysis of the problem of alarmingly low interest in primary care careers offered by Carolyn Clancy, MD, in a recent Medscape Webcast is at least 30 years out of date.[1] The real problem is that solving this mess will require multiple obvious steps that people in power are unwilling to take.
Problem #1 is disparity in reimbursement. Medical students can read and they follow economic incentives. A correlation between income and competition for residency slots in various specialties was published in JAMA several decades ago.
Problem #2 is the value system exhibited by the news media and internalized by most Americans. It's all about technology and innovation, and that gets the interest of smart, young people. It's unrealistic to expect that doing basic medical care very well will ever have equal emotional appeal for future physicians.
Problem #3, the academic value system, has similar characteristics. Research is about doing new stuff, not about excellence in doing old stuff. Even more important, in this writer's view, is the almost total rejection in academia of the quaint belief that there is a functional connection between the brain and the rest of the body, that human nature and life stress may have a significant impact on the experience of illness. Good primary physicians tend to care for people, not just for diseases, and they should not be disparaged by narrowly focused academics for doing so.
Problem #4 is the paucity of suitable role models of primary care in the medical academic system. Even the model ambulatory practice units required in family medicine education standards are failing in this role, for reasons that include limited practice experience among faculty members and economic pressures to see a lot of patients every working day.
Problem #5 is the adverse effect of marketplace values on the healthcare system.
Primary care will never bring big bucks into an institution. Everybody knows that and acts accordingly.
The solutions to these problems are obvious but politically impossible at the present time. Level the reimbursement “playing field.” Focus on providing the best health outcomes for the most people, rather than giving some patients high-tech, high-cost treatment while almost totally ignoring the needs of others. Honor physicians who focus on doing what their patients need rather than on looking for more people on whom to do high-reimbursement procedures. Above all, let the human side of healthcare back into academic medicine.
Reference
- 1.Clancy C. Primary care physicians: a vanishing species or a profession reinvented? MedGenMed. 2006;8:36. Available at: http://www.medscape.com/viewarticle/544701. Accessed May 24, 2007. [PMC free article] [PubMed] [Google Scholar]
letter MedGenMed. 2007 May 30;9(2):47.
To the Editor,
Dr. Clancy's presentation does not specifically address what I see as the main reasons primary care physicians (PCPs) are so discouraged.[1] These are declining net income (and low income relative to specialists) and lack of respect, from patients and specialists. These, in turn, make primary care very unappealing to medical students, many of whom are over $100,000 in debt when they have to decide whether to go into primary care, with a relatively low income; innumerable hassles; and little respect from the specialists who taught them vs a specialist career with 2-3 times the income.
This is ironic considering the findings of Dr. Elliott Fisher and colleagues[2,3] at Dartmouth [Hanover, New Hampshire], who concluded that regions of our country where PCPs predominated gave as good or better care to Medicare patients at 40% lower cost compared with regions of the country where specialists predominate. Our healthcare system reimburses procedures, whether or not supported by reliable evidence or beneficial to the individual patient, so much better than a good history and physical; it is no wonder, though sad, that young American physicians are choosing to go into specialties in which they can do lots of procedures, rather than primary care in which they don't. With the accelerating expansion of medical knowledge and medical options, when most patients are in desperate need of a personal physician to oversee and coordinate their care and help explain what's best for them in the long run, the PCP is increasingly shunted aside. The corporate promoters of “consumer-directed medical care,” who think – probably correctly – that this new insurance scheme will bring them big profits, have convinced some gullible people, including patients, that they can now make all of their medical decisions by surfing the Internet or watching Oprah. Many patients have been convinced by TV, magazine, or Internet sources, mostly written by or featuring specialists, that it is vital to see a specialist for every problem. Now that HMOs [health maintenance organizations] and “gatekeepers” have gotten such a bad press, most insurers allow patients to see whoever they want without a referral, or else any referrals required because the PCP has every incentive to sign, even when the referral is almost certainly unnecessary. Specialists often refer patients to each other, bypassing PCPs completely, so that the PCP is seemingly unnecessary. Specialists realize that their income no longer seems to depend on pleasing or sending notes to PCPs, so many don't. Ironically, the patients' outcomes are often very poor, as the specialists' orders are never carried out, or the patient never fills the prescriptions because they're too expensive, yet the specialists often don't seem to care because their income is the same regardless. They can always blame the patient for not following doctors' orders.
References
- 1.Clancy C. Primary care physicians: a vanishing species or a profession reinvented? MedGenMed. 2006;8:36. Available at: http://www.medscape.com/viewarticle/544701. Accessed May 24, 2007. [PMC free article] [PubMed] [Google Scholar]
- 2.Fisher ES, Wennberg DE, Stukel TA, Gottlieb DJ, Lucas FL, Pinder EL. The implications of regional variations in Medicare spending. Part 2: health outcomes and satisfaction with care. Ann Intern Med. 2003;138:288–298. doi: 10.7326/0003-4819-138-4-200302180-00007. [DOI] [PubMed] [Google Scholar]
- 3.Fisher ES, Wennberg DE, Stukel TA, Gottlieb DJ, Lucas FL, Pinder EL. The implications of regional variations in Medicare spending. Part 1: the content, quality, and accessibility of care. Ann Intern Med. 2003;138:273–287. doi: 10.7326/0003-4819-138-4-200302180-00006. [DOI] [PubMed] [Google Scholar]
letter MedGenMed. 2007 May 30;9(2):47.
To the Editor,
I recently read and listened to your editorial on Medscape.[1] It just motivated me as a private practice physician to comment myself on the dismal situation in which we find ourselves. Also, I would ask you to use your power and position to make clear to the Washington bureaucracy why the implosion is taking place and will undoubtedly accelerate at a greater rate.
We are tired of being beaten up by government, big business, lawyers, and the public that do not care about our problems and stresses so long as they can have that $10 copayment at the checkout desk. And, our costs for providing care keep climbing while our reimbursements continue falling. It's pretty sad when a well-dog visit at the vet pays far better than a well-woman visit.
We need:
Freedom to practice medicine in the best interests of our patients: Pay for performance is a ruse; it is truthfully pay for compliance with government guidelines – “our way or no pay,” even possibly sanctions, fines, or worse. This comes under the heading of the semantic euphemism, provision of medical services, rather than the practice of medicine, which has at its core the Hippocratic Oath and allows for independent physician judgment.
Obliteration of the government “hassle factor.”
To be treated with respect and appreciation for our service and sacrifice: In part this would mean killing the Kennedy-Kassebaum law from a decade ago, which presumes us guilty until proven innocent under RICO rules. I don't know about you, but I am not a racketeer or mobster or drug runner, and I resent being lumped into this category by the hypocrisy of the senator from Massachusetts who killed Mary Jo Kopechne and then got his family to cover it up.
To return to mutual accountability with our patients in the doctor-patient relationship: This cannot be achieved with huge, bungling, and obtrusive third parties sandwiched in-between the patients and ourselves.
To be treated as other than simply a commodity that can be used and then thrown away at the altar of political expediency and political correctness: Abuses in these areas have taken the joy out of practicing medicine and left us with a sense of slavery, drudgery, and no appreciation. I am certain that these matters had better be addressed rather quickly. Otherwise, the ugly truth is that more K-Y Jelly won't ease the pain, and quitting appears to be the best option.
Reference
- 1.Clancy C. Primary care physicians: a vanishing species or a profession reinvented? MedGenMed. 2006;8:36. Available at: http://www.medscape.com/viewarticle/544701. Accessed May 24, 2007. [PMC free article] [PubMed] [Google Scholar]
