In an age of highly specialized medicine, primary care is vulnerable to the Rodney Dangerfield syndrome of getting no respect. That's a mistake, perhaps best demonstrated by what can happen when primary care isn't provided. Some years ago, I was practicing primary care internal medicine, and saw a medical student for an acute visit because of worsening back pain. When their son's pain first developed, his parents -- both physicians -- took matters into their own hands. They arranged for their son to bypass humble primary care and get right to the specialist -- in this case, an orthopedist.
I don't recall off hand the details of the orthopedic workup, but the basic conclusion was that the patient had a severe strain of the muscles in his lower back. He was referred for physical therapy, which played out over a period of a couple of months. It was at the end of this period, when the pain suddenly got worse, that the patient wound up seeing me.
Being a primary care doc, I did the things we do: took a general and reasonably comprehensive medical history, and did a comparably general physical exam. The history was notable for certain peculiarities -- the patient at times perspired at night for no apparent reason. The exam was noteworthy for hard lymph nodes ("swollen glands" in the vernacular) in the neck and elsewhere.
The patient had advanced lymphoma. The back pain was the result of massive inflammation of internal lymph nodes, progressing the entire time the patient was receiving physical therapy for a back injury he didn't have. Fortunately, cancer treatment was started in the nick of time, the patient responded, and his life was saved. To my knowledge, he is well to this day.
But now, let's be careful about the moral of this story. The orthopedist didn't do anything wrong, and would eventually have seen the patient again and realized this wasn't muscle strain. Generally, though, since specialists such as orthopedic surgeons see patients who have already passed through the filter of primary care, they can be fairly secure in the knowledge that what they are dealing with is an orthopedic problem. If it weren't, they wouldn't be seeing the patient in the first place.
It should come as no great surprise that if you see and treat muscle, bone, ligament and tendon injuries all day, every day, that's what you tend to think about. Similarly, cardiologists would not be faulted for the tendency to think that chest pain is related to the heart; infectious disease specialists think the patient referred to them is apt to have an infection. And of course, when you have a hammer, the world tends to resemble a nail.
The value of specialization is that it allows a great deal of concentrated expertise to be focused on specific problems within a given domain. The inherent limitation is some degree of tunnel vision. My role in the story of the medical student is no particular credit to me -- I did what any primary care provider would have done. Rather, it's testimony to the importance of primary care.
Because primary care providers are the initial contact for patients with a wide array of conditions, we are, in some sense, the proverbial Jack of all trades, master of none. But we make up for that liability by thinking broadly about what may be wrong. In fact, we are all taught to consider not only a wide array of specific diagnoses, but a wide array of categories of illness, represented by the mnemonic "VINNDICATE": vascular, infectious, neoplastic (cancer), neurological, drug-related, etc.
Sometimes the condition is something we can treat ourselves; sometimes, it warrants referral to a specialist. That tendency to refer for specialty care has resulted in the often denigrating term, "gate keeper," for the primary care role. But a gate keeper may, in fact, be of vital service to you if you are at risk of going through the wrong gate on your own. The above anecdote exemplifies this.
Unfortunately, along with a potential lack of respect for primary care comes a lack of financial reward. The cost of medical education -- generally well into six figures -- is the same for a family practitioner as for an ophthalmologist specializing in Lasik surgery; but their salaries at the end of training may differ ten-fold!
This discourages many medical students -- particularly those paying for medical school with loans -- from choosing primary care. They would be stuck with enormous debts for years -- limiting their ability to buy a home, support a family, or take a vacation.
The cost of these disparities is an enormous national shortage of primary care providers, estimated at over 40,000 by the American Medical Association. Inadequate primary care in turn means delayed access, higher costs, a burden of preventable illness, and the potentially tragic consequences of patients guessing wrong when choosing a "gate" on their own.
Fixing this requires loan forgiveness and other potential incentives for medical students choosing primary care careers, expanded reliance on non-physician providers, and medical reimbursement rates that show as much respect for good thinking as for procedures. It also requires the appreciation of patients, among health care's greater rewards. Health care reform legislation addresses some of this, but not all, and does not go far enough according to most authorities.
So please, care about primary care -- and advocate for the respect and rewards it deserves. No matter how expert, care cannot be good, or do you good, if it isn't the care you need. Sometimes, we all need a little help right at the starting gate.
Dr. David L. Katz, www.davidkatzmd.com
Follow David Katz, M.D. on Twitter: www.twitter.com/DrDavidKatz
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I agree with you 100% about the importance of primary care. Your case beautifully illustrates it in practice. Specialization has its place but when health knowledge and practice get fragmented and separated, there is no one to put Humpty Dumpty back together again. Every practitioner sees the person from their own narrow specialty and everyone is promoting that view. They can't talk to each other. We need more general practitioners available in communities.
Dr. Andrew Weil once told me in an interview that our biggest problem is that we need more generalists. I'm a generalist myself as a health journalist, and there is great value in having a larger perspective. We see things that are visible only when we widen the focus.
Alison
www.healthjournalist.com
http://www.accelerationphysicaltherapy.com
I wish all of you with access to health care the best of luck. I think primary care is important to all those who have the financial ability to save their lives or improve quality of life.
"For at least the final two years of their medical program, students intern in clinical settings under the close supervision of licensed professionals, learning various therapeutic modalities including:"Botanical medicine, Clinical nutrition, Counseling, Homeopathy, Laboratory & clinical diagnosis, Minor surgery, Naturopathic physical medicine and Nutritional science"
http://www.aanmc.org/education/academic-curriculum.php
So when a patient is seen by a naturopath, the treatment method picked by the naturopath can range from the ridculous and impossible, homeopathy, to minor surgery. Seems like a great idea to have them become more a part of real medicine. Not.
Small business people know when fees decrease, the only way to meet payroll is to increase "through put." History, physical exam, diagnosis, discussion with patients all suffer. A CEO bemoaned his in-store retail clinics fax reports to PCPs – a non-reimbursable activity. MDs often don't break-even on vaccines. They provide many hours of unreimbursed paperwork, phone calls and care coordination for patients behind the scenes. Estimates now: ~ 1:1 patient face-to-face time : pre/post visit "paperwork/prep."
Patients say "I don't care if there's a sick child, my appointment's now - I demand to be seen now." Another patient, "I changed from Dr Y to Dr X because Dr X was always on time. I often waited >1 hour for Dr Y. Now my child is sick, Dr X won't spend > 10 minutes, but I need to talk." Now she knows why Dr X's on time!
There are excellent, seasoned mid-levels. But, when there's a tough case, midlevels turn to MDs - trained differently with more years of "apprenticeship."
BTW, mediocrity is nondiscriminating – it poisons all industries.
Here is the best part:
In a news release, Horizon maintained that executive pay is in line with what other, similar companies would pay. The company said that executive pay is only "0.24% of our members' monthly premiums."
A couple things to note. I agree that the executive pay is in line with other companies but that is because other companies continue to use each others numbers which causes a never ending cycle of increasing executive pay. Second, since they were so quick to point out how little of the members' monthly premium was eaten up by the CEO's salary, I was wondering how much all the ADMINISTRATORS added together cost each member. It would probably be astronomical.
The vast majority of the specialists out there are competent, and there is not a huge disparity between the best, and the worst. If I feel someone is not competent, I don't refer to them. I have my favorites, and friends, but it works to my advantage to spread the wealth around.
I do not use "specialty" drugs, as you put them, and any PCP that does would be open to potential legal action. I don't believe the use of these is at all common. If you have evidence to the contrary, please share.
THe number of american medical schools is growing, but without active financial support of primary care, it's a tough sell. About 4% of american medical grads choose primary care.
Wah? What do all of the above have in common? A transfer of decision making from people into the hands of bureacrats - these suggestions have zero to do with effective primary care (The Burdicks - show me the "evidence" that your suggestions will work)
All the Burdicks wants is government to keep sleeping with medicine - kind of like big oil and the government. Disaster looms on the horizon.
Medical care will be medieval at best in the US in the very near future.
Lose 20 pounds, go for a walk, get out of debt - and cultivate relationships. And above all stay away from hospitals and healthcare providers (physicians, nurse practitioners etc)
About 1/3, or 12 to 15 million, of the people expected to be "insured' under the new Health Insurance Profit Protection Act are to be funneled into Medicaid. Medicaid is severly underfunded today and in many areas it is nearly impossible to find a PCP accepting Medicaid because of low reimbursement rates.
We will shortly have 12 million plus additional alledgedly insured people with insurance that no one will accept.