Matthew Holt

The result of the primary care crisis

Over at Spot-on I’m writing about the primary care crisis in partial response to the great stuff from Bob Wachter last week on THCB and also from Maggie Mahar and Brian Klepper. Hopefully, it’s a primer for the politico types over there about the primary care crisis and also what the likely results of it are. Hint, no pay equality, but more retail clinics and online visits.

Meanwhile, my piece at Spot-on two weeks back about the Two Ted Kennedy’s appears rather smarter than it probably was given the long piece in the NY Times today about exactly how risky his surgery was and exactly the level of agreement (i.e. not much) that existed among the wide medical team he convened. Evidence based medicine? Well let’s just say that the oft heard rumors of Medicare’s impending bankruptcy may be truer than I tend to believe if every patient wants that level of service.

At any rate, please take a look at the new piece and the older piece and as ever come back here to comment.

Ask any health care wonk and they’ll tell you that within the larger
health care crisis is a primary care crisis. There is more and more
demand for primary care physicians – the person you probably call your
"family doctor" – but America’s medical schools are producing fewer of
them.


Why? Well in a word, money.

It’s not actually medical school that’s the problem. It’s what happens next. A newly graduated physician, looking a big chunk of debt used to pay for medical school tuition gets to chose their residency and, as such, decides what type of doctor to become.In the U.S. we let medical students choose what to do. Not being dummies, most of them notice that diagnostic radiologists and orthopedic surgeons make three times what primary care doctors make, and choose their career path accordingly. Why the vast difference in compensation? Doing something to a patient – fixing a broken hip, reading an x-ray – has always been better rewarded more than talking to them about their high blood pressure or their son’s excema.

Read the rest.

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RyanG
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RyanG

With the primary care crisis pending, there is also a major allied healthcare skilled worker shortage. According to a new study by the Imagine America Foundation, the U.S will need to fill the jobs of nearly three million healthcare professionals. To find out more about the study on the impact of career colleges on America’s skilled shortage, see http://www.imagine-america.org

Tom Leith
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Tom Leith

> It would be interesting for someone to eventually do
> a calculation on the cost of Kennedy’s surgery and
> current adjuvant therapy vs. the
> radiation/chemotherapy recommended initially.
This is the kind of thing England’s NICE does, but they don’t name names . My bet is they’ve already got it done for the Senator’s condition. They probably have a QALY estimate for both treatment modalities as well.
t

Barry Carol
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Barry Carol

If we ever move from a fee for service payment model to capitation, I can envision hospitals bidding up salaries for primary care doctors who can keep patients healthy and out of the hospital while hospitalists are paid to manage and coordinate care for inpatients. In the meantime, there is no reason why we cannot make much greater use of NP’s and PA’s. There are already over 1,000 health clinics in retail stores staffed mainly by NP’s, and there hasn’t been a single malpractice suit so far. Health plans offer hotlines staffed by nurses using computerized decision support tools. They… Read more »

MG
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MG

There may indeed be a shortage of specialists coming but those projections numbers have been notoriously flawed and inaccurate. Plus, you have to look at the sources of the projection data as some have a very vested interest in generating sensational numbers.

bev M.D.
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bev M.D.

Peter and Tom – actually, that was precisely the point I was trying to make (obviously, not very well) – that there is accumulation of evidence on a given condition and then there is interpretation of that evidence – multiplied by the variables within each individual case, and the chronologic evolution of medical technology. This is one reason why evidence-based medicine is so difficult – there is rarely a black/white dichotomy between what is the best treatment for a condition and what is not. Also, the evidence-based best treatment is continually evolving with new knowledge. Who knows if a policy… Read more »

Chuck
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It is true that there is a financial disincentive for people to choose primary care out of medical school. However, this alone does not explain the shortage of primary care physicians. As it turns out, there is a projected shortage of physicians in general (see the AAMC website at http://www.aamc.org/workforce/). Interestingly, even specialists are in short demand. In the AAMC report listed above, it is noted that many states report shortages in specialties including allergy and immunology, cardiology, child psychiatry,dermatology, endocrinology, neurosurgery, and psychiatry. In 2004, Merritt, Hawkins & Associates, a health care staffing and consulting firm, predicted a shortage… Read more »

Tom Leith
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Tom Leith

Gee, Dr. Bev, I think you’re confusing two concepts:
1) developing evidence
2) applying evidence
Medical Research probably should not be thought-of as “medicine”, and probably should be carried-out by doctors courageous-enough to work for academic salaries. Therefore one may indeed apply a uniform and permanent EBM ruberic for MEDICAL reasons.
t

Peter
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Peter

Bev, I agree to a point, but why should there be only two people involved in the decision – the doctor, who gets paid when he/she operates using someone else’s money, and the patient, using someone else’s money, and therefore has nothing to loose. If we went with this thinking then who stops all the Mickey Mantle decisions? Is every Terri Schiavo worth keeping on life support waiting for God to perform a miracle? Would a medicaid patient get to go to Duke and obtain the same try? I know this dicussion goes around in circles forever but there must… Read more »

docanon
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docanon

From Matt’s spot-on piece on primary care: “And the U.S. is not seriously going to tackle – let along address – this problem as a matter of public policy until the whole system breaks so severely that more people demand massive reform.” This was one theory expressed at Academyhealth’s scientific meeting in June. It was loving designated the “cockroach scenario.” After the U.S. health care apocalypse, only primary care will survive…or so goes the theory. I’d hate to think this was our only option to fix physician payment policy. I agree that this whole issue will always be relatively invisible… Read more »

bev M.D.
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bev M.D.

Kennedy’s case is an excellent example of why evidence-based medicine will never translate into a “cookbook” of completely standardized practice. As a pathologist who has looked at this nasty tumor under the microscope too many times, glioblastoma is almost uniformly fatal within, at most, a few years. But each patient’s tumor, and each patient’s age and medical background, and each patient’s will to fight, is different. Also, many medical advances are made by doctors courageous enough to defy standard opinion who achieve good results and then over time develop a track record to make their treatment an accepted and evidence-based… Read more »