Doctor's Delima

Everybody knows that problems plague the healthcare system, but few are aware of the glaring statistics. The US is 37^th in the world for longevity and 36^thin infant mortality. Part of the problem is lifestyle and part of the ranking results from the developing world catching up and surpassing us. Many experts believe that our lack of primary care physicians and a maldistribution of physicians underlie the problems.

Unfortunately, efforts to improve the situation included the perception that there were not enough doctors. As a result educators and legislators expanded enrolment in medical schools and promoted physician extenders. Physician assistants and nurse practitioners came into vogue. This may have been a help whilst they practiced under the direct supervision of a physician. Nurse practitioners prove invaluable in many isolated small villages where only an itinerant-physician might travel, but when we authorized them to practice independently in direct competition with primary physicians, we unwittingly further aggravated the economic problems at the primary care level.

The only way primary care physicians can charge modest fees and stay in practice requires a modestly high volume of patients. Today primary care finds itself displaced by public health clinics, Planned Parenthood, midwives, mobile mammograms, pharmacist consultations and and other less scientific providers once thought of a quacks. It would be an over statement to compair us with Rome when Aesclapian physicians were called in to fight the plague, but there is a paralell.

The physician extenders follow ridged but limited protocols. This results in missed diagnosis and early referrals to specialists both creating added cost. These providers receive the same highly discounted fee for service that primary care physicians receive. This practice, now well entrenched, tends to solidify the discounting of pediatricians', internists' and family doctors' services. In addition, many patients elect to receive care only from sub-specialists, further eroding the qualified base of primary care physicians. Why would any graduating physician elect primary care under these circumstances? As a result we have too many specialists and not enough primary care doctors.

Too many specialists, leads to, too many procedures -- both diagnostic and surgical. The better specialists have plenty to do in that patients tend to channel to the physicians with the best reputation and outcomes. Less successful specialists tend to over treat to make up for lack of volume. Patients who go only to specialists find it difficult to choose which specialty to go to with multiple problems. Specialists find it difficult to diagnose or treat patients outside of their own specialty. Thus, patients fall through the cracks between specialties.

Too many specialists results in an overwhelming and immediate increase in medical care costs. The not so simple solution involves specialty training on a pyramid system as was once used in leading medical schools. Only the top residents progress to the next year of training. Thus, only one resident emerges as chief resident in the last year. The dropouts then migrate to either another specialty program or to primary care residencies. The primary care residency should be every bit as demanding as the surgical or sub-specialties but without the pyramid system.

Something needs be done to reduce the enormous reimbursement discrepancy between primary care physicians and surgical specialties. Otherwise, we will have a serious sub standard level of primary care.

We must also curtail the plethora of so called alternative care practitioners and unsupervised physician extenders. The “Home Base Physician” proposal in the Affordable Care Act goes a long way, but does not address the economic discrimination against primary care, the maldistribution of physicians or the issue of too many specialists.
|