Up to the middle of the last century, most Americans could count on good access to generalist primary care physicians with the training and commitment to evaluate and treat their medical problems, whatever they might be. Those days are long gone. The ratio of generalist physicians to specialists in this country reversed from about 80:20 percent in 1930 to 20:80 percent in 1970. Since then we have seen the generalist tradition being carried on by family physicians, general internists, general pediatricians, and osteopathic physicians, but their aggregate numbers today are no more than 30 percent. And that number is falling fast as more medical graduates seek out the higher pay and more attractive life styles of the non-primary care specialties.
These are some of the major ways by which Americans are hurt by the growing deficit of generalist physicians:
1. Can't get a primary care physician.
It is getting harder and harder to find a generalist primary care physician still open to accepting new patients. In Massachusetts, for example, the passage of legislation in 2006 expanding insurance coverage for many people exposed a critical shortage of primary care physicians. (Fitzgerald, J. "State medical group sees severe shortages in 10 specialties." Boston Herald, October 20, 2010) Patients on Medicare and Medicaid have particular problems finding a physician willing to take them on due to low reimbursement through those programs. Under the banner of fiscal austerity, many states are cutting Medicaid to the bone. In California, for example, where Medicaid (Medi-Cal) covers one in five Californians, Medi-Cal payment rates for physicians and other providers have been cut by 10 percent to just $11 a patient visit (Corcoran D. "Doctors say Medi-Cal reimbursement is too low." San Francisco Chronicle, August 4, 2011) Even if one has a primary care physician today, the likelihood of a continued relationship in the future is becoming increasingly clouded due to physician retirements, mobility among physicians, and changes of providers in insurer networks that often force changes of physicians.
2. No access to breadth of primary care.
People without a primary care physician don't get access to the breadth of primary care anywhere else in our "system." Specialists are not trained or equipped to provide preventive services across the board, care for acute and chronic problems for patients of all ages, continuity of comprehensive care for all medical problems for years, with knowledge and understanding of their patients' family and community setting. Emergency rooms and urgent care centers can focus only on the most acute problem at the time, with little follow-up, while so-called "retail clinics" for walk-in care are limited to non-emergency and low-acuity problems. As a result, many of the potential advantages of primary care are not available to a growing part of our population.
3. Higher costs and unaffordability of care.
Specialty care costs more than primary care -- a lot more, for a number of reasons. For new medical problems, specialty physicians have to start "cold," without context or knowledge of the patient, often ending up repeating tests and procedures that have been done previously, charging more than primary care physicians, and in the case of multiple medical problems, typically having to call upon other specialists for care. Since primary care physicians know their patients better, they order fewer tests than specialists, and help to protect their patients from inappropriate and unnecessary care. (Schoen, C, Osborn, R, Doty, M, Bishop, M, Peugh, J et al. "Toward higher-performing health systems: adults' health care experiences in seven countries." Health Affairs (Millwood) 26: w 717-34, 2007)
4. Foregone necessary medical care.
Foregone care is widespread and increasing. These markers document this growing trend:
5. Decreased coordination and integration of care.
Coordinated and integration is a huge problem, especially for patients with multiple medical problems, the norm for older patients. The electronic medical record does not substitute for close communication between specialists for such patients. According to the Joint Commission on Accreditation of Healthcare Organizations, 80 percent of serious medical errors are associated with lack of communication or teamwork among specialists in hospitals. (Health blog. "Joint Commission-Hospital Collaboration targets hand-offs." Wall Street Journal, October 21, 2010)
6. Decreased quality of care with worse outcomes.
Compared to those without primary care, patients with primary care receive earlier diagnosis and treatment of illness and better outcomes of care. (Ferrante, JE, Gonzales, E, Pal, N, Roetzheim, RG. "Effects of physician supply on early detection of breast cancer." J Am Board Fam Pract 13: 408-14, 2000), including lower mortality rates (Baicker, K, Chandra, "A Medicare spending, the physician workforce, and beneficiaries' quality of care." Health Affairs (Millwood) 23: w 184-97, 2004).
Unfortunately, the essential role of primary care in any health care system is not widely understood. In the next post we will consider some of the many misperceptions about it, and how they represent barriers to building a better health care system in this country.
Adapted in part from my recently released book Breaking Point: How the Primary Care Crisis Endangers the Lives of Americans. Copernicus Healthcare, 2011, soon to be available as an Ebook on Amazon.
John Geyman, M.D. Professor emeritus of Family Medicine, University of Washington
Past President, Physicians for a National Health Program
A comparison of outcomes resulting from generalist vs specialist ...
A Comparison of Outcomes Resulting From Generalist vs Specialist ...
Myths and Misperceptions About Primary Care - PNHP's Official Blog
Generalist versus specialist care for acute myocardial infarction ...
This importing of persons for jobs need to stop. we have plenty of unemployed people with education who could be trained for a year to be registered nurse in community college. The nursing/other medical fields training needs to be expanded in community college, this is where the congress could create jobs in a field where there is demand, with the population getting older.
Medicare has much lower administration costs than insurance companies. If we could all(all ages) buy in medicare if we wanted too, we could push healthcare prices down.
Employers pay you less in salaries and charge you more for health insurance as the insurance companies charge more. The employers can take a take a tax deduction on their taxes but the rest of pay more taxes to make up the difference.
Corporations are probably moving overseas for China paid healthcare for their employees as well as low wages.
Medicare has a notional lower cost of administration but has demonstrated now better ability to manage the growth in healthcare care costs. The real problem with the system is around growth in costs. Medicare has been unwilling/unable to change the system from fee for service and as such it continues to balloon costs. Further, Congress has a mandated reduction in Physician fees that it has for 7 years continually punted on and is now mandated to reduce comp and therefore impact costs by 30%. It will again punt on this. The Gov't has demonstrated itself to be a terrible manager of costs.
You are wrong,,, there are 2 year associate science degree nursing programs that allow graduates to take Registered nursing test to get a license and make pretty good money. The colleges also do not have enough room for all the students who can qualify to get in the program. Verify for youself. visit St Johns community college, Florida and other community colleges.
As a patriot, if you were in the military, don't you believe hospital corpsman have had plenty of practical experience on members in war zones and them and their families in clinics and hospitals???? Don't you think A year of extensive training to qualify for taking the registered nurse license would help the corpsmen have a good job when they get out.
How is it any different than letting military members take a few courses and become teachers although they did not all take teacher training???.
Check some community colleges near you and see what they have to offer in the medical field where the job demand is high.
The population is getting older and they can't export us to China for care, can they?? We just need to stop importing people to take our jobs.
Forcing the public to purchase health insurance under penalty of fines is counter-productive... if access is to be truly universal, it must be equally available to every tax-filer and all dependents.
In order to survive in a capitalist society, any realistic plan must integrate with the private sector. Here is just such a plan... http://americanprogressive.org/2011/08/28/a-progressive-health-care-agenda/
I encourage the reader to consider its merits, and look forward to your comments.
http://www.youtube.com/watch?v=4YJz5wvt2bk
Thoughts?
to check people with common ailments. What you need if you have earache is someone to look to see if infected, use swab to check for strep for sore throat, check urine for urinary infection etc. They could work under a doctor who could see anyone who needed more.
The business plan for those companies has always been... charge what the traffic will bear, then deny as many claims as possible, and cancel policies whenever possible, and then keep whatever is not paid out in benefits as profit. This has been the driving force behind all those nightmares...
Now, profits are tied to the total amount of benefits paid out. The only way to increase profits is now by increasing benefits. To deny any specific benefit coverage, or to cancel a policy on the basis of cost of benefits, now has a negative impact on profits.
Look for insurance companies to now cover absolutely everything imaginable, and to never again cancel another policy, in order to maximize the bottom line.
It is up to all of us to care for one another at the local level.
During the great "Health Care Reform" debate, it was finally determined to leave things pretty much as they were, in the hands of the "for profit" insurance cartel.
Why?
According to many who replied to my earlier comment, Doctors now make squat, and things will soon be getting worse.
In the meantime citizens of the United States are paying nearly twice the amount per capita then most of our industrialized world competitors for health care.
That makes no sense.
When health care reform was first proposed, I did a little online research into programs that apparently actually work. Places like Switzerland, and New Zealand.
IMPO the US could learn a lot from either country.
In New Zealand all doctors are government employees. They work a 40 hour week, with two weeks paid vacation to start (more with seniority). Starting salary is $150,000 a year, often with housing provided. They have a generous pension, and cannot be sued.
A patient with a bad outcome?
Treated by a special team of government doctors, who do nothing else, at government expense. This allows them to keep track of, and either re-educate, or eliminate those few "bad doctors" that ruin it for everyone.
Course it's "socialized medicine" and that's terrible....................isn't it?
Maybe we'd be better off to ignore the labels, and investigate what works?
Unfortunately for us, our commercial news media feel that they are better off continuing to rake in billions in prescription-drug and for-profit-hospital advertising revenues (by studiously avoiding coverage of "what works"); and most of our politicians* feel they are better off continuing to enjoy millions in contributions, not to mention lucrative personal and family private-sector opportunities, from for-profit health concerns (by barring advocates of "what works" from hearings and refusing to vote bills based on "what works" out of committee).
Until a critical mass of ordinary citizens becomes aware of and demands "what works," we're going to hear very few genuinely cost-effective healthcare reform proposals on the mainstream news or from our politicians. Balanced information about healthcare in our peer countries reaches so few Americans that it's going to be a very tough slog to reach that critical mass. With over 50 million completely uninsured and over 500,000 filing for bankruptcy each year because of medical bills, you'd think we would have reached that point by now...
* With the notable exception of the Congressional Progressive Caucus.
Can't be sued personally.
The government compensates people who are injured by medical malpractice directly.
They can, however, be fired. Which literally means they'll never work in that country again. And probably not any other as the government will be quite forthcoming about why they were fired.
I'm a generalist. Different field entirely but the point is I'm a generalist surrounded by specialists. I make an end-to-end design and then work with a team of specialists to implement it. Each of the specialists is better than me ... in their specialty. I'm second best but the point is I'm second best *at everything*.
Specialists can get into all manner of trouble without generalists to give them reality checks.
Specialists, in my experience, perceive everything through the lens of their specialty. This is great when they are right but exceedingly bad when they are wrong.
For example, a specialist may misinterpret strange behavior (a symptom) to be a problem with their code (specialty). And then waste large amounts of time (money) trying to fix a bug(condition) that isn't there. They don't have enough general knowledge to realize that while it *could* be that problem it is much more likely to be this other problem over here.
Even worse they may obscure the real problem by "curing" the "symptom" creating quite a snarl to unwind later as the underlying issue has not been addressed.
I can all to easily envision this happening in medicine. And the common complaint of over-ordering tests and unnecessary testing would be, ah, symptomatic of these problems.
In 1950 - when people were still being sold camel cigarettes as the most popular brand amongst doctors - about all a primary care physician could do would be check vaccinations, listen to the concerns of a patient, and give them news of their particular terminal prognosis when the time came.
The need to manage, coordinate and broker care is indeed very great, but the model of a local guy in a tweed jacket doing this job is probably no longer a viable one.
50 years ago, men and women got into medicine because they wanted to help people.
Now it seems, too many of them get into it, because that's where the "big bucks" are.
7 out of 10, of the "Best paying jobs in America", are in the field of medicine.
I submit that this attracts the wrong type of people.
My solution? Government sponsored education at no cost for any student willing and able to maintain an acceptable grade level, with the proviso that after graduation and licensure they be required to work at a Government run low cost clinic, paying a small but livable wage for 4-6 years.
Students win, because they are no longer saddled with exorbitant loans before beginning their practices.
Government wins, because the clinics could be run at a much lower cost then charged by a private practice, I have never understood why the most expensive health care delivery system in America (the hospital emergency room) is the treating facility of choice for the indigent.
Society wins, because the pool from which to draw new doctors will be vastly expanded, to those most capable of learning the profession, rather than just those who can afford it.
no?
Its a circular conundrum. You have to be paid so much money *because* the cost of medical school is so high and the cost of medical school is so high *because* you can make so much money.
And to make it worse people who want to study medicine are turned away to maintain an artificial shortage.
http://wallstreetpit.com/5769-the-medical-cartel-why-are-md-salaries-so-high
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In 1963, there were only 135 law schools in the U.S. (data here), and now there are 200, which is almost a 50% increase over the last 45 years in the number of U.S. law schools. Unfortunately, we’ve witnessed exactly the opposite trend in the number of medical schools. There are 130 medical schools in the U.S. (data here), which is 22% fewer than the number of medical schools 100 years ago (166 medical schools, source), even though the U.S. population has increased by 300%.
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We need to *reduce* the cost of a medical education and open it to anyone who wants to attempt it so long as they do well. This would also remove the pressure to specialize.
Specialists are great don't get me wrong, but you need generalists too.
Just thought it was a funny moment while I stood there ironing my shirt.
My son said that the very first day of medical school they told all the students that if they were after money they should move over to the business college.
CEO (and other top executive) salaries make physician's pay laughable.
My son is out of medical school, working about 100 hours per week for $40k per year. And I won't mention the $275,000 in school loans.
The problem is not that we are lacking doctors, it's just that Medicine has become so complex that it is truly difficult to manage all the information. If you set your bar at a level that can treat a common cold, it's easy, but to recognize when what looks like a common cold is actually Leukemia, that's a different matter.
Not trying to cloud the issue, just trying to point out that you can't just "make more doctors" and make the problem go away.
The current trend seems to be "Just let them die" No one seems to understand "suffering"