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Readers respond to the primary care crisis

Two recent posts by Matthew and Bob Wachter on the crisis in primary care sparked great debates in the comment sections.

Matthew’s inference that Medicare’s bankruptcy will be fast upon us if everyone with brain cancer received an experimental surgery like Sen. Ted Kennedy recently had evoked this response from Bev. M.D.Tedkennedy

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 one. Therefore, one cannot apply a uniform
and permanent EBM rubric of – gonna die anyway, don’t operate – to all
glioblastoma patients for MEDICAL reasons. However, one COULD apply it
for social/political/economic reasons, and therein lies the basic
conundrum before us.

Deeper in the comments, Peter wrote:

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 discussion goes around in circles forever but there
must be a better way if we are going to avoid bankrupting the "system."

In his post, Wachter wrote that the primary care crisis is not a future problem but one of the here and now, citing evidence that even connected doctors cannot get primary care appointments.

Jeff Goldsmith wrote that part of the solution is for Medicare to pay for relationships and for medical schools to foster a culture of respect for primary care.

So many of the "appointments" we cannot get are for getting
questions answered that if we had a relationship with them, we could
get answered by phone, text or e-mail. … It isn’t just money that PCP’s lack, but respect. So just paying
more may not be enough. A lot of the reason why young internists do not
enter general practice can be traced not only to a lack of money, but a
lack of respect in med. school/teaching hospital peer culture. A lot of
medical school faculty believe that primary care is simply unnecessary,
in part because they triage themselves, so see no need for this
function for the rest of us.

JD thinks that six-figure medical debt contributes to the shortage.

My hunch is that despite all the complaints about pay, if this huge
obstacle to bringing new people into primary care were eliminated, we
would see a surge of new PCPs. It would open up the profession to
motivated people from families in the lower 60% of the income scale. That’s not to say we don’t need to fix the reimbursement system. We do.

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Greg MDanonbev M.D.TomGreg Pawelski Recent comment authors
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Greg MD
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Evidence based medicine will never substitute for a well trained, astute experienced clinician. Throwing more doctors, nurses and money at the problem has not worked in the past nor will it work now. The reason that the U.K. is succeeding in controlling health cost certainly is not for the want of more doctors, though its quite possible that we need more nurses. In my expert opinion, credentials will come later, the reason for the U.K.’s success is that the system is based on getting people on their feet and keeping them healthy. In a report by Wenberg at USC, more… Read more »

Tom
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Bev MD: As a non-clinician I really can’t comment on how Kennedy would have been treated under the NHS. It would be wrong of me to do so. It’s quite possible he would have received world-class care with innovative drugs and procedures (as has happened with folks we know here with serious cancers). I just don’t know. As an American citizen who’s been in the UK for two years with a young family, I can say I’d take the NHS over what we had in the States any day. (Straw poll of one.) There is an inherent tension between populations… Read more »

anon
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anon

Matt Holt’s take in the previous post is spot on. Primary care as a specialty is dead and it’s place is being taken by nurse practioners and other “ancillary” providers of care. Providers who by the way, (mostly) lack the professional self-confidence and moxy to push proceduralist to deliver cost effective care. Nothing wrong with this transition, given how our government pays for care, it is the natural consequence. It is apparently what is desired. I do have to take issue with him on one statement, that these changes are not good for Primary care Physicians. As an MD Family… Read more »

bev M.D.
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bev M.D.

Tom;
I assume you are in the UK. Can you tell us what would have happened to Senator Kennedy’s case there? I think many THCB readers think they know the answer but it would be good to hear it from the horses’ mouth so to speak.

Tom
Guest

[quote]Kennedy’s case is an excellent example of why evidence-based medicine will never translate into a “cookbook” of completely standardized practice.[/quote] +1 I work for a company that provides evidence-based services to help NHS groups optimise the configuration and purchasing of health services. EBM needs to get beyond being seen a tool for ‘cookbook medicine’, and many in the EB community need to get back into the clinical and commissioning trenches where nothing is black and white, cut and dry. Or as one person (I forget who) said: You love NICE until a loved-one in your family is denied a treatment.… Read more »

Greg Pawelski
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Greg Pawelski

In life or death situations, one must make judgements based upon the preponderance of available evidence as opposed to proof beyond reasonable doubt. It seems obvious that evidence-based medicine proponents may fail to apply this common sense standard on a consistent basis. In cancer medicine, there are limitations involved with randomized clinical trials. Perhaps the greatest limitation is that it is predictive of population trends, and is not definitive. Clinical trials provide few black and white answers. The problem with the empirical approach is it yields information about how large populations are likely to respond to a treatment. Doctors don’t… Read more »