Will Big Doctoring Be Big Enough Quickly Enough in Time to Help Health Reform?

Big Doctoring is about a way of medical life, an approach to health care and healing, a skill set, and a mindset that is called primary care.

Fitzhugh Mullan, MD, Big Doctoring in America, Profiles in Primary Care , University of California Press, 2002

February 13, 2012 – In my last blog, I used the term ”big doctoring” to describe primary care. With the primary care doctor as the entry point of patients into the system and as the point of referral to specialists and hospitals, policy experts believe more primary care physicians will be central to effective health reform and to bringing down costs.

If you don’t believe me, I invite you to read two pieces that appeared today in the media, one out of the U.K. , the other out of Washington, D.C.

• Richard Hoey, editor of Pulse, a weekly magazine for U.K primary care physicians, wrote the first “Minders of the Gap.” Hoey uses the word “gap” to refer to the management of care by NHS bureaucrats versus general practitioners. David Cameron, the British Prime Minister, and his government colleagues believe GPs can handle health reform more efficiently than government bureaucrats. In the U.K,GPs are they lynchpin of the health system. GPs all use EHRs,they often have incomes greater than specialists, they are highly trained in management, and they are valued for their ability to handle as many patients as possible without referral to specialists or hospitals. The UK has handed over much NHS management from bureaucrats to GPs. The thought seems to be GPs can keep referral rates to a minimum. The average is now 4%. The Prime Minister and his team envision a health service run by doctors, not bureaucrats. The British health secretary, Andrew Lansky, believes GPs will make or break the NHS.

• The second media piece appeared in today’s Washington Post under the title “Success of Health Reform Hinges on Hiring 30.000 Primary Care Docs by 2015.” The author never clearly explains why 2015 and where the 30,000 will come from. Enough nit picking, now to the problems. The writer notes that 1/3 of medical students have educational debts over $200.000, that primary doctors earn $29.58 an hour while specialists earn $74.75, and that hospitals tend to hire specialty residents rather than primary care residents because specialty residents bring in about twice as much money per hour. Government seeks to remedy the primary care shortage through various means, including paying them more and a program called Primary Care Residency Expansion in 82 hospitals. This is a drop in the bucket in increasing the number of primary care doctors practicing out there across the country. Besides, will more U.S. primary care physicians be the centerpiece of a more effective U.S. health care system, when one considers certain features of U.S. culture? If the failure of managed care’s gatekeeper campaign in the 1990s to dampen referral to specialists is any indication, probably not. U.S. health consumers do not like to be told where and to whom to go for care. The fact that applications for primary care residencies increased by 20% from 2009 to 2011 is a good sign, but the reality that specialists make on average $150,000 per year less than some specialists remains a powerful deterrent to medical students deeply in debt.

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