By Sarah Arnquist

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.

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.