Physicians

Bitter doc wants more respect for primary care

A primary doctor ranted anonymously this weekend on Kevin MD’s blog about the lack of appreciation for primary care in his small Midwestern town and predicted its future demise.

The doctor practices in a medical shortage area, where the hospital administration has failed to sufficiently recruit and retain hospitalists. Here’s a portion of what he wrote:

"Not surprisingly, the recruitment and retention problem hit the hospitalist program simultaneously. Three hospitalists are now expected to manage 24-hour coverage with no relief in sight. And instead of offering the degree of compensation necessary to bring more physicians on board, the administration exploited the sense of crisis to convince the medical staff to consider opening the doors to Advanced Practice Nurses. This was the only solution, we were told, to the hospitalist shortage. The only way to stop taking extra call for free.""At this meeting, 100% of the subspecialists voted for allowing APNs to practice in the hospital. 75% of the primary care physicians dissented. The vote was overwhelmingly in favor of the measure. This happened in a system where some primary care doctors are making less than they would if they took a new position in a major city, and more than a couple subspecialists make seven figures. The abandonment of the greater medical good by our specialist friends eager to expand their already-overflowing coffers has filled me with renewed vitriol."

His rant has struck a chord in the medical blogosphere.

The Physician Executive wrote this response:

"Many U.S. doctors feel that primary care is the choice of students
with no other choice. Even Canada’s social conscience cannot mask the
prejudice entirely. … It is a nearly universal phenomenon in a world
where progressively greater expertise gets more respect than being a
generalist. Why else would family physicians so urgently proclaim that
they are specialists and not generalists? Paul Starr characterized
physicians as inveterate social climbers. A disregard for fellow human
beings, especially well-educated colleagues, is a hallmark of the need
to climb a social ladder."

"Medical science at the turn of the last century had so much
promise. As a profession, we are accountable, but we lost our way
during the 50’s, 60’s and 70’s. Medicine got more technical, more
complicated and we forgot that William Osler human ability to listen to
the patient’s story and consider the context of a life before
recommending treatments. We did not meet the expectations of many
stakeholders, no matter the fact that some of those expectations were
unreasonable to begin with. Some of us sacrificed the profession’s
autonomy and its beneficent role in society, with full wallets and a
family legacy, but not much else."

Are these just angry, bitter doctors, or are they being honest about the dismal prospects of primary care? People speak in platitudes about reforming the physician reimbursement system to value primary care, but if the reality is that the medical community views primary care as "the choice of students with no choice," any reform is dead before it has begun.

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xhamsterTalaStaffimumsapetryHockeyrefMELclyde  (Hearts and Minds) Recent comment authors
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xhamster
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Oh ! Good I have read your topic I’m really super success Written … !
Thanks admin Very Nice Blog

TalaStaffimumsapetry
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TalaStaffimumsapetry

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Hockeyref
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Hockeyref

I am the very proud spouse practice manager of one Family doc, PCP and you guys just blow me away. It is just amazing how much all you specialists seem to disrespect the primaries who feed your practices their daily bread. It sure has been interesting sitting here on the wall like a fly hearing you all throw your trash around. You should all be ashamed of yourselves. And then to pass judgement on these same folks who can’t afford to pay off their med school debts, care for their own families or afford to slow down on the hamster… Read more »

MEL
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MEL

I am a board certified Family Physician who is changing from her third-party-payer-dominated solo primary care practice into a low cost, low overhead, direct practice, where patients pay me directly for their care along with a low monthly fee (less than 1/2 pack of cigarettes per day). I agree with Dr. Malpani, MD. Unless individuals take responsibility for their actions, inactions, choices and daily health, pain and sufferring from many preventable ailments will continue to spiral out of control. Paying a monthly fee is one step in taking responsibility for the direction of an individual’s health. I have recently opted… Read more »

clyde  (Hearts and Minds)
Guest

My brother graduated number one in his class from one of the top med schools in the country, became an internist, and spent his entire career as a primary care physician. Full, proper, and accurate diagnosis of patients presenting with subtle, mixed signs, symptoms, and a wonderfully varied history is as challenging as any esoteric specialty in medicine. Actually, it’s more challenging, in my opinion. And informed, careful, experienced, complete and precise initial diagnosis (and follow-up) is the number one key to good patient outcomes and quality of health care today. Find out what’s wrong and what’s right and do… Read more »

Aniruddha Malpani
Guest

I think the basic problem is that patients expect their doctors to do everything for them ! There will never be enough doctors – either PCPs or specialists – to meet demand for medical services. This is because doctors create demand for their own services !
Until patients learn to manage their own medical problems – and to manage their doctors – we’ll never make any progress !
Dr Aniruddha Malpani, MD
Medical Director
HELP – Health Education Library for People
Excelsior Business Center,
National Insurance Building,
Ground Floor, Near Excelsior Cinema,
206, Dr.D.N Road, Mumbai 400001
Tel. No.:65952393/65952394
helplib@vsnl.com
http://www.healthlibrary.com

rbar
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rbar

Anonymous, you may be entitled to be proud of you medical skills and your practice management … but being the apparently very well paid concierge doctor for few very well off is, in my personal opinion, not particularly laudable from an ethical perspective. Almost everyone (and I include myself) likes to be well paid, and I do think that physicians, burdenend with long and costly training and usually also with a lot of on call duty, ought to be well compensated. But in a country where 45 million have no health coverage, I find such a selective practice model nothing… Read more »

anonymous
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anonymous

As a Board certified Family Physcian who practices as a concierge, 100% private pay physician, the best evidence that my training is adequate and my knowlege is valued is that my patients are willing to pay me out of their own pocket for my services. Though my services are fairly traditional ( I do not, for example accompany my patients to specialists to interpret), I have been turning away patients for years, all the while raising my fees. I have still not found the maximum price point associated with my services. Although I do not live in an especially affluent… Read more »

J Bean
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J Bean

I absolutely agree with rbar. Training probably needs to be expanded to at least 4 years. I believe that there are some nascent “general medicine” fellowship programs out there. Certainly my IM training left me quite capable as a hospitalist, but I’ve done a lot of OJT since then.

Dr. Mag
Guest

Me also agree that lack of health knowledge leading to the use of specialists that will drive medical costs higher and result in the unnecessary use of the procedures that specialists specialize in.

rbar
Guest
rbar

The good point Dr. Bourdain made – I otherwise disagree almost entirely with his (somewhat bitter) post – is that the training of generalists and all PCPs could and should be improved. All PCPs should have short rotations and practice relevant exams in all or most medical subspecialties plus ortho, neurology and maybe psych as well as longer rotations (e.g. as electives) into OB and peds if they choose to later practice in these areas as well (obviously, gen. IM PCPs should do mainly medical subspecialties and Neuro rotations). The specialty rotations should not be just a grossly truncated version… Read more »

botetourt
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botetourt

Docanon hits it on the head. How often have we encountered an older friend or relative who has become the victim of being treated by multiple (but very talented) specialists? It only gets worse if one or more of those talented specialists is a bit aggressive about making a buck. I am not a doc but am pro-doc as I think most docs do bust their tails and want to do right by their patients. The compensation system arguably should acknowledge specialties in some ways, but clearly is way out of hand. Procedural medicine is not always complicated medicine, and… Read more »

J Bean
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J Bean

I pretty much had my choice of subspecialties as a resident, but I chose — for multiple reasons — to be a generalist. I currently have several retired physicians as patients too…. A lot of acute and chronic conditions can be more than competently managed by generalist physicians. This week I saw a new patient. She had recently moved from the east coast where she saw an endocrinologist for her hypothyroidism, a gastroenterologist for her IBS, a rheumatologist for her fibromyalgia, a gyne for her menopause symptoms and yearly post-hysterectomy Paps (benign hys!), and a pulmonologist for her BOOP (okay,… Read more »

docanon
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docanon

It’s really not fair to pick on a post as ignorant as Andy Bourdain’s. Poor guy…seems never to have met a competent generalist. (and as long as he’s making sweeping judgments, perhaps he’d like to enlighten us on this thoughts concerning other categories of people) Rbaer is right on the money…the uncoordinated zig-zag is a real problem. I’ve seen this too many times in my own clinic. A patient comes in–usually at the urging of a family member at wit’s end–with hundreds of pages of medical records documenting the sad, sad path of uncoordinated care. Dozens of specialists, duplicative imaging… Read more »

Peter
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Peter

Agree rbaer. The lack of health knowledge leading to the almost exclusive use of specialists will drive medical costs higher and result in the unnecessary use of the procedures that specialists specialize in. If you want your knee operated on see a knee surgeon, if you want your back operated on see a back surgeon, as that is what you will get because specialists don’t make money NOT doing what they do. The best diagnosis and least cost treatment may not be seeing a specialist but a good GP. Unfortunently again money is driving this system, not healthcare.