A gathering storm
I’ve been seeing more stories in the news about problems with primary care. For example, since the new universal health insurance law took effect in Massachusetts, so many new patients are looking for doctors that primary physician shortages have made it impossible to get care. And for physicians who accept managed care, life is a continuous hassle. Insurance reimbursements are steadily dropping while the cost of running an office keeps going up. As a result, fewer and fewer medical school graduates are going into primary care, the lowest-paid specialty.
Dean Ornish, M.D., is an esteemed cardiologist and creator of the Ornish Diet, which has been proven to reverse years of atherosclerosis (arterial narrowing due to cholesterol). In a September 2008 column in Newsweek, he warns about the coming collapse of primary care.
A recent article in the Los Angeles Times describes how one local primary physician gave up, closed her office, and moved to Baltimore. Many other doctors are abandoning their practices.
Indeed, the American College of Physicians (ACP) is worried too. The ACP is the primary specialty society for specialists in internal medicine. I’ve been a member for many years. The ACP recently published an alarming report: “The Impending Collapse of Primary Care Medicine and Its Implications for the State of the Nation’s Health Care” (17-page PDF). In the essay “Primary Care — Will It Survive?” the esteemed New England Journal of Medicine points out the following:
- People who live in areas with more primary care doctors are hospitalized less often, have a lower cost of care, and demonstrate better health outcomes.
- Given their crushing burden of educational loans ($100,000 to $200,000), medical students can’t afford to enter financially stressed specialties like primary care. Specialists make double the income of generalists. Indeed, inflation-adjusted primary care incomes declined by 10% from 1993 to 2006. (Most insurance companies’ authorized charges are about the same as they were in 1980.)
- So it’s no surprise that American-trained medical graduates fill fewer than half the U.S. training positions for family practice physicians. Foreign medical graduates fill most of these positions.
- Because so few new doctors enter primary care, primary care physicians are disproportionately older and closer to retirement. Over the next few years, it will become increasingly difficult to find a primary care physician who accepts new patients.
So what? Why should you care?
Let’s face it, if you have back pain you can see an orthopedist. High blood pressure? Go to a cardiologist. Upset stomach? Consult a gastroenterologist. Sure, specialists may be expensive, but they probably know more about your problem anyway.
In the same way, if you have a problem with your car, don’t even think of taking it to a general-service garage. What do they know? If the transmission is rough, take it to a transmission shop. Brakes squeak? Go to a brake specialist.
Whatever you do, never get the car fixed unless you’re sure it’s broken. It’s such a pain to change the oil regularly, so wait until your car starts acting up.
Oops: almost everyone knows that if they follow this advice, their car will grind to a halt within 10-20 thousand miles. Your car needs regular maintenance to keep it running properly. And what if your rough ride is because your engine needs a tune-up, but you take your car to a transmission shop? Can they diagnose and fix your engine? What’s the chance that they’ll do thousands of dollars of transmission work you don’t need?
Some of my patients think that if you’re sick you should see a doctor, but if you’re really sick, you need a surgeon. It’s certainly true that a good surgeon can fix your hernia or take out your appendix or gallbladder. But the list of illnesses that need surgery is relatively small. Most surgeons don’t want to care for your pneumonia or diabetes or heart attack or high blood pressure.
You would think it’s obvious that one physician should know all about your health and help coordinate whatever additional treatment you may need. Otherwise half a dozen doctors are treating different parts of your body, and no one knows what the others are doing. Moreover, most physicians become specialists so they can do procedures, which pay many times better than seeing patients in the office. For example, in Boston, Medicare pays $103.42 for a half-hour office visit but $449.44 for a colonoscopy, which takes the same amount of time. (Rates in Los Angeles are about a third less.)
Americans’ love of procedures is one of the main reasons medical care in the United States costs so much more than in other countries. Just as taking your broken engine to a transmission shop will needlessly run up your bill, having procedures you don’t need is a great way to waste money on your care. My favorite example is MRI scans. Often they’re essential, but you’d be surprised how often they are done needlessly. Moreover, MRIs often turn up subtle abnormalities that aren’t really a problem, but you have to do further tests to ensure they are harmless.
The only way to make an accurate diagnosis is to take a thorough history and physical examination and then order whatever tests are required. Often after a thorough evaluation, the number of tests is a lot smaller than it would otherwise be, because the likely diagnoses are clear. And it should be no surprise that a thorough history and physical often leads one to very different conclusions than would seem to be the case upon first hearing someone’s symptoms. Indeed, I often see patients who have never had an accurate diagnosis: no one took the time to listen to them.
So what can a primary care physician do for you anyway?
One of the most important aspects of your relationship with a primary physician is they get to know you. You don’t see a different doctor every time you need care. You don’t have thirteen people making mistaken assumptions about your condition. You don’t have to explain yourself every time you need treatment. Now medicine can do so much more to keep people healthy and manage chronic conditions like asthma, high blood pressure, diabetes, and heart problems. That’s why ongoing longitudinal care with someone who knows you well works so well.
Coordination of care
Not every specialist is best for every patient, and some specialists are better at some problems than others. Some specialists are great at providing care but communicate poorly, making them harder to work with. I’ve practiced in the Glendale area for over twenty years and have a great panel of specialty referrals. I meet with patients as they progress through specialty treatment and help them work through any questions that may arise.
Just as your car needs oil changes and other regular maintenance, everyone should have preventive health care. Often this type of care is reimbursed the best by your insurance company, because they know keeping you healthy saves money in the long run. Young adults don’t need regular visits very often: every five years in your 20s or every four years in your 30s will suffice. We recommend every three years for people in their 40s and every two years for healthy adults in their 50s. Patients receiving treatment for chronic conditions, and those over 60, should have a comprehensive evaluation annually.
As I describe in more detail, preventative health care is scientifically proven not only to save lives, it helps maintain full function. It turns up certain hidden health problems and prevents them from causing illness. And I’ll get to know your health and your situation in detail, making it easier to care for you in the event of illness.
A skilled diagnostician takes the time to assess multiple aspects of your health and see how they tie together. A detailed history and physical is almost always the best first step in figuring out the cause of an illness and determining the best treatment.