We need fewer specialists

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Expert Perspective by Grahall’s Arlene Brewster, Licensed Psychologist

expert perspective telescopeIn the continuing health care debate, changing the way medical service is delivered continues to take a distant back seat to the financing discussion. Yet changing health care delivery is critically important in trying to control the rapidly escalating costs. While controlling “waste and fraud” are admirable goals, that phrase is also stand-in for not doing anything to fundamentally change the system.

One of the many important aspects of controlling medical care delivery has to do with the need to address the imbalance of specialists to primary care physicians in this country. It is a topic that I rarely hear about outside of primary care circles.  Not only would increasing the ratio of primary care physicians to specialists save money, but it would make medical care both  more coherent and efficient. It would also help address the question of who is going to care for the influx of previously uninsured new people entering the medical care system under insurance reform.
In other advanced industrialized countries, the ratio of primary care physicians and medical specialists to the patient population is more tightly controlled than it is in this country. 

In the United States, less than ten percent (that’s right, less than ten percent) of medical school graduates go into training to become family doctors.  The United States partially makes up for that shortfall by importing physicians from other countries. This means that we are not only exporting, but importing desirable jobs. It also means that many of the imported physicians do not speak English as a primary language and do not know the cultural norms of the United States, which negatively impacts their relationships with patients.  Even with this importation, there remains a serious shortfall of primary care physicians that will only worsen as the baby boomers age.

The reason for this imbalance is simple: specialists can make up to five or six times as much as a primary care physicians. The spread in compensation can be justified in some specialties where   post-medical school training requirements are very long.  In the case of some specialized surgeons, for example, their post-medical school training  can be as long as ten years.  But other specialties requiring few or no additional years of training are reimbursed at a far higher rate than are primary care physicians.

Why the discrepancy? The reimbursement system pays higher rates for procedures than for cognitive medicine. Talking to patients is the least profitable way for a physician to make money. So not only are these physicians paid less, but they are rushed to try to maximize their income by seeing more and more patients in less time. Fifteen minute appointments may be adequate in the case of simple problems, but not in the case of a patient with multiple medical problems, or undergoing a crisis, or having psychological difficulty dealing with his or her condition. Physicians do not have time to hear the ongoing narrative of the illness –  what is happening, what has changed, and how the patient is coping – in fifteen minutes. Without time to explore those issues, a physician cannot get that important information. .
Many medical students enter medical school wanting to be primary care physicians. They value the long term relationship with patients and their families. But by the time they leave medical school, the mounting debt, the low regard in which primary care physicians are held largely due to poor pay, and the stress of having to see so many patients and take so many phone calls dissuades them from following this path.

Part of the overheated rhetoric in the debate over health care has to do with the quality of medical care in this country. Often people will say that we “have the greatest medical system in the world and that is why people from other countries come here to get medical care.” Others point out the failures of the system. In fact, we are talking about two sides of the same system.  If you need high tech, highly skilled specialized care with very sophisticated, technical procedures, and you can pay for it, the United States is the best place in the world.    If you need continuing long term care that treats, controls, and helps prevent the deterioration resulting from inadequately treated conditions, then we are doing a lousy job and rank behind most industrialized countries.

Personally I want both. But I am guessing that the chances of my dying from some long term condition rather than from a complicated trauma or some rare disease are greater. So I vote for paying primary care physicians competitively with other physicians. I think it will be a better investment than another CT or MRI machine, or the development of yet another medication for erectile dysfunction.   

Contact Arlene at arlene.brewster@grahall.com

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