Today’s medical students are being inducted into a culture in which their profession is seen increasingly in financial terms. Add in such pressures as the need to pay off enormous debts, and it is not surprising that students’ choices are dictated by the desire to maximize income and minimize work time.
Pamela Hartzband, MD, and Jerome Goodman, MD
“Money and the Changing Culture of Medicine”
New England Journal of Medicine, 1/08/09
I have a confession to make. I think the cause of high American health costs is straightforward, but it is not simple. It is American culture in general and the physician culture in particular. There is nothing wrong with this, and I point no fingers.
The Way We Are
It is our culture. It is the way we are, the way we’ve been for 232 years. It is our distrust of government and high taxes. It is our want to be free to choose. It is our belief in for equality of opportunity for access to the latest and best of care.
It is the notion, stemming from frontier days and conquering of the West, that action speaks louder than words, that if you do something specifically, it is better than doing nothing generically. “Don’t do nothing, do something,” as the saying goes.
Specialty-Dominated Care
Which brings me to the nub of this essay: specialty-dominated care. We are the only nation in the Western World with more specialists than generalists. Our health costs are roughly twice those of other cultures, and our health statistics lag.
I do not reflexively attribute these results to our health system faults – we have a richer mix of immigrants, who tend to have poor health outcomes and who hail from different medical cultures; we have higher accident rates and dreadful levels of violence; and our market-driven culture lets some people fall through the cracks. But our blind belief in specialists leads to a sometimes crazy quilt system that may be good for certain problems – advanced cancers, rare diseases, heart disease, debilitating crippling arthritis, and other chronic common diseases – but bad and bewildering for the general population.
Educational Costs
And let’s not forget our educational system. It’s expensive. The rate of rise of college tuition costs exceeds health inflation. Our government does not subsidize undergraduate or post-graduate care as generously as other nations. Yes, Congress indirectly helps academic centers finance medical education and residencies. But it’s often too little and too late. Upon graduation, the average medical student carries a debt of $150,000, and many students are married to one another, which may double the debt burden.
Small Wonder
Small wonder, then, that our culture causes medical students to favor high paying specialties over low-paying primary care. Small wonder, then, that our culture propels primary care doctors to re-enter specialty training, perform procedures in their offices in search of more revenue, become hospitalists and proceduralists in hospitals, and seek refuge in newer, more lucrative and less time demanding practice models.
Small Rewards for Cognitive Services
But alas, there is no easy way to change American culture, no way to decrease rewards for doing and performing and to enhance rewards for empathizing, commiserating, advising, and just plain discussing. It is easier and quicker and often more appreciated to biopsy a skin lesion, prescribe a highly promoted drug or antibiotic for a viral infection, order a CT or MRI scan, order the latest diagnostic test, than to counsel watchful waiting or behavioral change, or to click onto an EMR armed with best practice information, refer to a specialist, or do something, anything, that can be defended in court.
Concierge Practices
There are options, of course, out of the primary care rat race. Here is what our two Harvard medical school professionals, have to say about primary care.
“Some established primary crew physicians are making career choices in response to this new culture and fleeing to concierge practices, often citing their desire to escape the constant pricing of every aspect in their days. Since concierge practices collect yearly premiums from patients, such doctors may ironically be less “primed” by money at each encounter and may avoid feeling “ nickeled and dimed” by insurers. This arrangement creates an environment that can foster social interaction more than market exchange. But concierge medicine is unaffordable for most Americans, and it drives much-needed primary care providers away from the larger populations.”
Medical Homes
Our two Harvard professors suggest a more reasonable answer to the specialty-dominated culture may be medical homes. “The medical home,” they say, “is envisioned as a ‘compassionate partnership’ of primary care providers and patients, with coordinated care for patients’ ongoing problems and increased attention to preventive measures.”
Perhaps the medical home is a good fit for the American culture, which yearns for the good old days of Marcus Welby, and the family doctor who knew everybody in the family, its history and its dynamics. “Success in such a model,” assert our Harvard commentators, “will require, collegiality, cooperation and teamwork – precisely the behaviors that are predictably eroded by a marketplace environment.”
A Pragmatic View
In my view, it will require more than “collegiality, cooperation, and teamwork.” It will require solid backing by state and local government, major employers, and specialists; reimbursement to the tune of $50 for each patient managed, lowering of bureaucratic red tape for medical home physicians, and simpler, less expensive, more utilitarian electronic records. The obstacles and troubles and expenses of qualifying to be a medical home practitioner may winnow the number wanting to be such practitioners by 50% or more.
Coming to Grips with Reality
American health authorities will have to come to grips with the reality that broad based primary care systems are less costly and have better outcomes than specialty-dominated systems. We also need to pay primary care doctors more and to reward them for the right reasons – more time spent with patients, quick respond to one day appointments, prompt answering of e-mails and phone calls, proper guidance through the medical maze, and more efficient, effective, personal, and practical care.
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