Monday, September 1, 2008

Bias Against Primary Care; Tilt Towards Specialists:

There has long been an institutional bias in medical education against primary care. Many doctors we have spoken with have recounted how they were steered away from primary care by preceptors in medical school. The general sentiment conveyed to medical students long has been that surgical and diagnostic specialties are for the most accomplished students and that primary care is for the less accomplished

Allen Dye and Troy Fowler, “The Recruiting Challenges for Internal Medicine, “Healthleaders Media, August 28, 2008

In the course of human events, the pendulum may swing too far, over-shifts may occur, and reality may become distorted.

No where is this more true than the bias against generalists and the shift toward specialists. Today only 1/3 of American doctors are family physicians, general internists, or pediatricians. Seventy percent of internists subspecialize. Only 40 percent of those trained in primary care deliver direct care, and 40% are employed, rather than practicing independently.

Many factors and forces drive these imbalances – more money, prestige, intellectual security in the specialties, and usually shorter hours and more balanced lives. Moreover, it is easier as a specialist to master a circumscribed sphere of knowledge, and to be better at what they do. Further, most technology innovations are geared towards specialists, and specialists provide most profits and marketing edges for hospitals and health systems.

But buried in these obvious truths, clear to doctors young and old, are consequences.

• Relentless cost rises, for medical technologies make up 70% of health inflation, with talk of “disruptive technologies” lowering costs remaining a fantasy.

• Over reliance on information systems and informed consumers as a cure-all for what ails the system.

• Fragmented overspecialized care with patients failing through the cracks, unable to find a personal physician to guide them through the maze.

• The hard truths that aging patients with multiple chronic illnesses are the single major cost to the system – costs that can only be reined in by intelligent, coordinated, and comprehensive care delivered by personal physicians with the breath of knowledge and commonsensical humanity.

• Technology, no matter how sophisticated, and data and information, no matter how honed, analyzed, and aggregated, has limits.

• There are no magic replacements for clinical judgment and wisdom, talking to patients and spending time with them, a broad liberal arts education as opposed to premature specialization, and the dawning realization that those who treat themselves, as the old saying goes, may have fools for doctors.

Context in sometimes necessary for understanding and treating and comforting humankind, and that can only be supplied by sufficient numbers of generalists who look at health care through broad angled lens.

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