Getting Real About Specialists and Primary Care Doctors

Keywords - Specialists, primary care, Medicare, entitlement

Doctors do what they

are educated and

Trained  to  do.

Veteran Nurse

Roses are red,

Violets are blue,

Doctors do what

They want to do.

Whimsical verse

August 13, 2012 – I’ve always felt that strictly dividing doctors into specialists and primary care practitioners is an artificial distinction that doesn’t hold water in the real world.

The truth is that specialists practice some primary care, and primary care doctors practice some specialty care.  There is a significant crossover. Both have a common educational background and understand needs of each other and patients.

Most medical specialists have initial  training in general internal medicine, and most generalists have been exposed to medical and surgical thinking.

The financial deck is stacked against primary care. Medicare approves the RUC (Rembursement Update Committee codes, which favor specialist.  Specialists dominate medical school faculties, from which medical students pick their mentors and heroes.  Hospitals favor specialists, who supply the bulk of their revenues. Americans are a specialist-oriented specialists. Among seniors,  a study indicates those with chronic illness see seven doctors – six of whom are specialists.

Reformers keep saying we must expand our primary care base – by paying generalists more, by acknowledging that primary care doctors require  broader knowledge than specialists, by narrowing the payment gap between specialists and generalists, by opening  more medical schools, some devoted entirely to primary care; and by recruiting and rewarding medical students who say they want to enter primary care in physician short areas

All of these efforts are to be commended.  As for me, I am four square behind the primary care renaissance . But let’s get real. Solo and small group primary care is on the decline.  As much as we lament the passage of the Marcus Wellby era,  it is gone and not likely to be reborn.

Americans prefer specialists.  This is not new.  As Alfred North Whitehead (1861-1947) observed in Science and the Modern World, 

"Another great fact confronting the modern world is  the method of training professionals who specialize in particulary regions  of thought withig their respective limitations of subject..This situtation has its dangers. It produces mind in a groove.”

As cynics are fond of noting, “Specialists no more and more about less and less, until they know everything about nothing.”  I am not one of these cynics.  I believe specialists and generalists know more and more about more and more, and where the lines of specialists and generalists intersect.

The American people know this.  So do most doctors this brief article from the Washington Post attests.

More Than a Third of Our Primary Care is Delivered by Specialty Doctors

Sarah Kliff on August 22, 2012

“ Under reasons our health care system is expensive: 41 percent of our most basic health care needs, the fevers and colds we all get, are taken care of by higher-paid specialty doctors.”

“Mount Sinai’s Minal Kale lead a team of researchers that combed through data on more than 20,000 doctor visits in 1999 and 2007. All of it had information on why the individual turned up at the doctor’s office, whether it was a runny nose (not so serious) or a heart attack (decidedly more serious).”

“Their results, just published in the Archives of Internal Medicine: 59 percent of those with primary care needs, the people in the runny nose group, were seen by a primary care doctor. Forty-one percent sought out care at a specialist.

“To be fair, some people went to specialty doctors who tend to handle a heavy primary care case load such as gynecologists and internal medicine physicians. Exclude those two groups and you still have 27 percent of primary care appointments happening in specialty offices.”

“ ‘Patients have been shown to prefer specialist physician care and believe that specialists are better able to treat specific conditions,’ Kale and his colleagues write. ‘These preferences and beliefs may drive some patients to seek all of their care from specialists, including basic primary care services.’ ”

“They may also drive up prices: Andrew Seaman points out a 2010 study finding that primary care doctors earn a $69 hourly rate, compared to the $92 per hour and $85 per hour that surgeons and ob-gyns earn, respectively.”

Tweet:  Of Americans requiring primary care,  59% are seen by generalists and 41% by specialists,  indicating many specialists practice some primary care.