The Collapse of Primary Care

Sandra Lee Visner Howell:
No doubt that "general surgery" is more acute and sensitive comparing to primary care burden.Yet,i saw during my career 4 cases of "intusscception" ,all of them died either due to failure to diagnose or failure to treat !.The first case was a young man who presented initially by "abdominal colic",after a while was transferred to emergency due to "haemodynamic unstability".After being declared as "acute abdomen" case,necessiatig "laparatomy",the surgon delt with his problem in "one phase" surgey i.e: resection and anastomosis",and the result was "renal failure" followed by death !.The second case was a young child who also died.The third case was a man who was known to have "intestinal neoplasm" in advance.Yet on presenting with "abdominal pain",nobody pick the point and the end result was death.The fouth case actually did not die,simply because the father of the victim was a doctor,who supposed that his child's abdominal pain is not a "medical problem",and the young child was saved by early surgery.I am sorry to tell you that many surgons
"overlap" between what is "real surgery" and those problems solved by "conservative" measures.

Dr. Ornish's comments are well presented. However, I think that it is no longer beneficial to keep explaining a shortage of primary care doctors on the draw of the more ''lucrative'' specialties, like surgery and cardiology. I am a General Surgeon, and I was drawn into the field because of the awesomeness of it, as well as the challenge of learning enough and performing my skills well enough to significantly alter a patient's status, usually for the better, sometimes with a one hour operation. It is dramatic, to take a very ill child to the operating room, remove a badly infected appendix, and send them home the next day, smiling and laughing. It is very satisfying, professionally, to be able to do this. There is also a smaller margin for error, an increase in the range and seriousness of a possible poor outcome, as evidenced by higher malpractice premiums. In fact, General Surgery is considered ''primary'' surgical care, and there is also a shortage of General Surgeons. The crisis in the General Surgery shortage may mean that you have to take your child with appendicitis many miles to receive, what is, I would unabashedly identify, as lifesaving care. It is certainly not productive to continue to paint all of us who embrace the challenge of becoming surgeons, as money grubing, opportunity seekers. Dr. Ornish, my income has slipped by more than 25% in the past five years, so it is misleading, and counterproductive, to indicate that primary care is taking a bigger hit than other specialists during this turbulent time in medicine.
Sandra Lee Visner Howell, M.D., F.A.C.S.

In ???The Collapse of Primary Care,??? Dr. Dean Ornish correctly identifies many of the economic challenges confronting the primary care workforce in this country, and also accurately points out the fact that so long as reimbursements devalue primary care services, more and more medical school graduates will opt for more lucrative specialties. I support Dr. Ornish???s excellent analysis and would like to use this opportunity to tell some good news on the primary care front.

The nation???s colleges of osteopathic medicine have a proud heritage of producing primary care physicians, and a plurality of their graduates continues to pursue careers in one of the primary care specialties. In spite of their sometimes significant debt burdens, nearly 30 percent of 2007 graduating osteopathic medical school students plan to specialize in the primary care specialties of family medicine, general internal medicine or pediatrics.

Today, nearly one in five U.S. medical students is studying in an osteopathic medical school, a number that is growing each year. The number of osteopathic medical school graduates is projected to increase from 2,849 in 2005 to more than 4,000 in 2015.

Osteopathic physicians (DOs) are fully licensed to practice the full scope of medicine in all existing medical specialties. But historically, DOs have had a special commitment to providing primary care, particularly to the nation???s rural and underserved populations. Some 45 percent of the nation???s more than 55,000 DOs practice in one of the primary care specialties.

The American Association of Colleges of Osteopathic Medicine (AACOM) is advocating with federal agencies and legislators for increased tuition scholarship and loan-forgiveness programs that are tied to needs for primary care physicians, as well as to implement changes in federal tax laws that would maintain and expand deductions for medical student loan interest. We also are working with a variety of other physician and medical education organizations to prevent the type of downward pressure on physician income represented by the current reimbursement formulas.

I am hopeful that, with the help of the nation???s growing number of osteopathic medical colleges and the primary care-focused physicians they graduate, and with support from the federal government agencies that are focused improving the funding and delivery of health care, we can avert a primary care crisis.

The American Association of Colleges of Osteopathic Medicine (AACOM) represents the 25 U.S. colleges of osteopathic medicine and their faculties, students, and administrators.

Stephen C. Shannon, DO, MPH
President
American Association of Colleges of Osteopathic Medicine

Weesie,
You don't know what you are talking about when it comes to Physician Assistants and Nurse Practitioners. All Nurse Practitioners have a Master's Degree, and the vast majority of PA's also have Master's Degrees. I believe that all PA Programs must be transferred over to a Master's Program in the very near future. I know of NO program in the USA that confers a PA certificate within two years of graduation from High School. If you know of one, name it and I'll be more than happy to check.

Other facts: Nurse Practitioners can work independently of a Physician. That means they can hang their own shingle up on the door and see patients. PA's work under the supervision of an MD or DO. Most states allow a physician to supervise up to five PA's at a time. PA's and NP's are trained in Family Medicine and for the most part do an outstanding job. I work with several of them and they provide a high level of care. Of course, there are ALWAYS those stories where somebody made a mistake. It happens all the time, to Doctors, Nurses, PA's and NP's. Medicine is an art.....not a science. If it was as simple as 1+1=2, there would be no mistakes. Add in long hours, lack of sleep, etc., and mistakes are going to happen. Generally, if a PA or NP has seen a patient a couple of times for the same complaint, it's time to pass that patient on to a physician to see if there is something the Mid-Level Provider may have missed. I will tell you that we converse about patients regularly in my practice and discuss various treatment options amongst ourselves. Many times, it is a group approach to medicine.

Bottom line: If insurance companies refuse to raise their rates of compensation for Primary Care Physicians, then the Mid-Level Providers (PA and NP) will be tasked to pick up the void left in Primary Care. Physicians will go where the money is.....and that's a fact. It's hard to be altruistic and live the lifestyle of a Family Practice Physician when you know you could be living a much better lifestyle as a Specialist.

The real question is: Are society and the government ready to increase the compensation to pay Family Practice Physicians the same compensation as they do a Specialist? Yes, insurance rates will increase; and, yes, Medicare rates will need to also increase. If that is acceptable, then you will see more physicians in Primary Care. If that is not acceptable, then you better get used to seeing PA's and NP's in the Primary Care role. Pretty soon, that's all that is going to be left.

I happen to be a PA practicing in pediatrics. Most PA programs are the equivalent of 3 years education consolidated into 27 months. The majority are now master's programs that do require a bachelor's degree as well as the same required science courses required of pre-med students. I am not aware of any that allow for a high school graduate to be accepted and then practicing medicine 2 years later - that would be ludicrous. I don't claim to have an equal knowledge base as an MD, especially relating to the residency programs required of medical doctors. I do feel very comfortable providing quality medical care to children and their families just as any medical doctor would. The examples given of mistakes made by PAs are likely just as common among doctors. We are all human and make mistakes. I work among an equal number of PAs and doctors and I feel like PAs are even more cautious and less likely to make a major mistake because we are not under the same time constraints as doctors and if we question a decision, we can always consult with a physician. Finally, the future of medical care is leaning more and more to the use of mid-level providers, especially in primary care because medical schools are not putting out more doctors, not to mention the lack of incentives for those who do graduate from medical school as discussed here. I would hope that we would be more objective in our evaluation of PAs and their role in medical care and realize that they play a crucial role now and in the future of our country's healthcare, especially relating to primary care.

I agree with the article that primary care is a great need in our society at a time when primary care physicians are becoming scarce. Nurse practitioners and physicians assistants are increasing in number and have the skills and experience to care for patients in a primary care role. Sure, if you have complicated symptoms you may want to go to a specialized physician. But a lot of what PCPs do (or need to do) is manage chronic health issues. NPs & PAs can fill vital roles of educating and helping the diabetic patients manage their diabetes and foot care so that they will not be the ones getting an amputation. Health care is changing! Physicians need to understand their roles are changing as well, becoming more specialized. "Doctor" cannot be the only trusted name in health care. The health care team needs to become more complex, allowing for other professionals like NPs and PAs to fill the roles physicians are moving out of because of money.

I figured out the course of the family physician as soon as they quit making house calls. It's not about the well being of the patient it's only about the bottom line. Welcome to American the new third world country.

To dianepy:

It is interesting that you would believe that I would not know what a PA or NP is or what level of training they have. As I mentioned I have been in practice for 12 years after completing a 6 year residency in a surgical specialty. You are certainly free to have your opinion, but I can assure you that you are naive if you think that a PA or NP have equivalent training compared to an MD or DO. The fact that theirs is a "graduate" level program is irrelevant. No one should imply that NPs or PAs are less intelligent that physicians, but the quality of a physicain, NP, or PA is intrinsically a combination of the intelligence and experience, and the most intense experience is almost always gathered in a quality training program. The number of encounters, the sheer time engrossed in patient care, and clinical decision making is significantly greater in physician training programs. This is supplemented with subsequent experinece gained in practice. That being said, I have known a number of excellent PA and NP practioners, but that doesn't translate into a level of trust in their abilities that would make me prefer to see them instead of a physician. I, and most if not all of the physicians I know, see fellow physicains for our own healthcare needs. If I scheduled an appointment to see a "doctor", that is exactly what I expect. I can assure you that most physicians do not trust their own care to NPs or PAs, but you are free to do as you please.

Pardon my verbose response, but I ran out of room on my previous comment. The conclusion of my comment is the following paragraph:

Perhaps it would be reasonable to have a tiered system of primary care, with a tiered system of reimbursement. More extensive postdoctoral training would allow greater reimbursement. It is a poorly kept secret that there is already a tiered system of delivery, with nurse practitioners and physicians assistants seeing patients and billing under the "supervisory" physician's name, generating reimbursements at the same rate as a physician's evaluation, when in fact the physician frequently never sees the patient (but he receives the income). This practice is rampant in primary care. Unfortunately there are some specialists who also employ this type of proxy medicine, but I disagree with it, as do many specialists. Dr. Ornish may not employ physician extenders (nurse practitioners or physicians assistants), but I think he needs to carefully consider that complaining can often bring about an airing of dirty laundry that his primary care colleagues may want to be kept out of the spotlight.

Before responding to Dr. Ornish's comments, I feel obligated to admit that I am a surgeon in a specialty field. There are many reasons why a specialist may make more money than primary care doctors. This is not to say the specialists are smarter, more dedicated, or in any way shape or form better people. The difference in income is due to multiple factors, including the more extensive training, the much longer residency programs, the significant risks that we often take when performing procedures that could be life-threatening or have a significant and immediate adverse impact upon our patient' s well-being. Additional elements include the requirement that we are usually available 24 hours a day seven days a week to handle emergency situations, and I'm not talking about taking telephone calls, I'm talking about being in the hospital, in the emergency room, in the operating room, in the intensive care unit, etc. Dr. Ornish also omits the fact that while we are performing procedures, primary care physician such as himself may be able to see 10 or 20 times the number of patients that we are dealing with during the same time element. I have respect for primary care physicians, but the hard fact is, in my 12 years of practicing medicine after residency, I believe that most specialists work longer hours, with a more intense workload, taking on greater risks, and sometimes incredible stress when dealing with the complications that can arise from procedures we perform. At some point in our training we all make have to choose what type of medicine were going to practice. I don't think any one in the right mind would take on a postdoctoral training program that may last typically at least five years, and sometimes as long as eight years, in order to earn the same amount as a primary care physician, who trains for three years in a less intense environment with less personal sacrifice. This is a debate that can rage on in an unending fashion, depending upon your point of view. Needless to say I find Dr. Ornish's point of view, extremely one-sided, if not jaded.

No disrespect intended, but I see many patients who have been incorrectly treated or misdiagnosed. It is not because the primary care physician was negligent, intended to miss the diagnoses, or that I'm smarter than they are. The reasons have to do with the breadth versus depth of knowledge they are expected to master. Frankly, I don't understand the rationale of anyone expecting three years of postdoctoral training to be adequate to take care of the entire body, versus five or six years of postdoctoral training to become a surgical specialist in a particular anatomic area or organ system. I do think it would be reasonable for primary care physician to make equal income, provided they have a similar level expertise and ability. This would unfortunately require significantly longer residency programs for primary care physicians.

This is absolutely true. Primary care doctors are so pivotal to health care, and have to be proficient in recognizing an array of pathologies in their patient population. Almost every medical student I know agrees with this. Yet, NONE of us are choosing to go into it. The ones who are choosing Internal medicine definitely want to specialize. This is mainly because after all the loans, sleepless nights, years of education and high stress, primary care is just not worth it. Also, there is too much paperwork, it takes away from patient care. During my medicine rotation, I spend 70% the time making phone calls, and writing notes, and about 30% of time actually caring for patients. As much as I absolutely respect primary care doctors, and think it is vital, I am planning on applying to either Anesthesia or Radiology. In my honest opinion, primary care docs deserve to get just as much or more than some of the specialty fields!