Musings of a Dinosaur

A Family Doctor in solo private practice; I may be going the way of the dinosaur, but I'm not dead yet.

Wednesday, June 06, 2007

Having it Both Ways

I cannot stand specialists who pad their patient load by trying to do primary care in addition to their specialty practice.

There's more to specialty training than just a huge collection of esoteric facts and high-tech procedures on a single organ system. (My father likes to joke about the guy who's a specialist in diseases of the left nostril. If there's something wrong with your right nostril, you're out of luck.)

The essence of specialty training is a mindset: the mindset that you are the expert; the go-to guy; the one who will leave no stone unturned to get to the bottom of whatever is wrong with the patient in front of you.

There is nothing wrong with this mindset. It is necessary and useful when faced with difficult or obscure diseases. Keep in mind, though, that the appropriateness of this approach depends upon two important assumptions that are seldom articulated:
  • Whatever is wrong with this patient requires your expertise.
  • The patient's condition actually falls within your area of specialization.
That is to say, the specialty mindset is appropriate for patients who have been referred by another physician who has either been unable to figure out what is wrong, or who has determined that the patient requires a procedure that the first physician is unable (or unwilling) to perform. This implies that the patient has already been evaluated by another competent physician who has decided that the problem is not within the scope of practice of primary care. That first physician has also narrowed down the range of diagnoses to the point of selecting the appropriate specialist.

Patients who self-refer to specialists screw this whole thing up. They're the ones who are more likely to have common conditions that don't really need the specialist's level of expertise, and in whom an extensive (and expensive) workup is unlikely to yield any useful information. In fact, chasing trivial findings discovered in the course of an unnecessary workup is probably one of the biggest sources of wasted money in health care. The other inefficiency of self-referral is going to the wrong specialist. The classic example is the patient with chest pain who goes to the cardiologist, and only after the negative (but lucrative) cardiac workup is found to have pain of gastrointestinal origin, and vice versa.

Primary care training emphasizes keeping an open mind as part of the process of diagnosis, and the recognition that common things really are common along with the constant awareness of when there is something different enough about a given patient to spur the zebra hunt. We develop a tolerance for uncertainty; the kind of uncertainty that drives a specialist crazy. We can do this, in part, because we know that our ongoing patient relationships means we can trust them to come back if/when the clinical picture changes. Very few specialists are willing to use time as a diagnostic tool.

The nature of their training leaves specialists at a huge disadvantage when trying to diagnosis and manage unselected patients. They know a great deal about their specialty, but their knowledge of other specialties is superficial at best. It's the old adage found, among other places, on Dr. Bob's sidebar:
If the only tool you have is a hammer, you tend to see every problem as a nail.
But what if there aren't enough nails around to make a living?

I'll never forget how pissed I was the first time I heard an Internist say that he did "Family Practice" because it was "better marketing." I also once had an orthopedic surgeon say to me, "I can do primary care. I can take a blood pressure, find that it's high and send someone to the cardiologist." I wanted to answer, "Hey, I can be an orthopod: I can tell someone with a sprained ankle to ice it, wrap it and keep it elevated," but I couldn't actually believe my ears at the time. What better way to illustrate either ignorance of or disrespect for what I do!

This ignorance/disrespect leads many specialists to believe that primary care isn't really that difficult. So when a specialist in an overserved metropolitan area finds he can't fill his appointment book with specialty patients, the decision is made to do things like this:
  • Allergy and Primary Care
  • General Pediatrics and Pulmonology (sorry, Flea; that always bugged me.) (Apologies for the pun, too.)
  • Family Practice and Rheumatology
  • Internal Medicine and Infectious Diseases
The problem is that specialist do not do primary care very well at all. They find high blood pressure and refer to the cardiologist. They see an elevated blood sugar and refer to the endocrinologist. They all say "Stop smoking" and think of it as tobacco counseling. Virtually none of them do immunizations, especially gynecologists, who like to think of themselves as providing Primary Care for women. (Obstetricians can't treat ear infections to save their lives, even in a pregnant patient. I've cleaned up more than one of their misadventures, though most of them just refer to ENT.) "Family Practice" rendered by specialists is nothing more than a circular exercise in mutual masturbation.

Don't jump down my throat with the occasional exceptions: sure, the nephrologists take decent primary care of their dialysis patients, though they're not so good about sending the women for mammograms and other screenings. (They probably figure their ESRD will kill them first, which isn't always the case.)

The bottom line is that the primary care mindset and the specialty mindset are mutually exclusive. A true specialist cannot turn it on and off at will. They can't have it both ways.


At Wed Jun 06, 10:48:00 AM, Blogger Alexis said...

So I have a question for you. I'm a neophyte medical student, but I spent enough time in other worlds before returning to school and I have a fairly certain idea of "what I want to do." It is, of course, one of the things you're pointing out as "a bad thing." I don't want to be that person who is so pigheaded that they ignore valuable insight, however, so I'd love any additional advice you might have.

In the end, I want to see lots of general practice patients, but I also want to keep my more academic affiliation to infectious disease. Not basic research (gods, no), just access, and a few patients perhaps on a hospital rotation once a week or so. Where I am, there's plenty of opportunity for exactly this sort of medicine, if you get an Internal med residency and do the ID fellowship. I know a few people who do exactly this, and seem more than competent.

Conversely, I'm working in family practice this summer, doing some patient care and some research. So far, I can honestly say I enjoy it. It's nice to know I could do Family Practice or Primary Care and also be hooked into community-based research (which is really the only kind I like, after years of doing benchwork).

What are your thoughts? Do you really think it's impossible for me to be a good internist and a good ID specialist at the same time? Do you think it's better to be in a field like Family Practice and keep my ID hand in via community-based research or to split my time between clinician and hospitalist?

At Wed Jun 06, 04:24:00 PM, Blogger DDx:dx said...

I attach a link. I know you are busy, but...

You got a rant going about the specialists...
If it's all just a marketplace and the patients are customers then why can't they self refer, make their choices. Sure it's bad medicine, self aggrandizement, popularity,,,but sometimes that's what sells.
The way I see it , burned out family doc, is that I have been abandoned by my guild. I think the "specialist faction" of our guild has decided midlevels could replace me and they are just waiting for us to all die off.

I believe good primary care is a wonderful, fulfilling life. I'm just not too sure i want to pay the guild dues anymore...

At Fri Jun 08, 01:21:00 AM, Blogger Dreaming again said...

Excellent excellent post.

I did not know that it was *normal* for a rheumatologist to decide to be a family practice or internist. In our area, there is only one.

I know from having seen him, knowing 4 people who've been to him, that he does neither well. Fortuneatly, 3 of the 4 also know he does not do it well and figured it out quickly.

Of the one who cannot see it, what I saw was that she was using him as her primary care doc as well. There was no system of checks and balances.

When I saw him and what he said didn't jive with my blood work or my symptoms, my PCP said "do you agree?" I said "Uh no!" and we found me a new doc.

(she was trying to be diplomatic)

There is no other doctor to educate this one patient on what should be going on when the specialist and pcp are one in the same.

At Fri Jun 08, 04:05:00 PM, Anonymous Anonymous said...

The Netherlands would be paradise for you. Here there is a strict segregation between primary care and specialists. I have never heard of any doctor doing both. Also you cannot go to a specialist (not even gynaecologists) without referral by your primary physician.

At Fri Jun 08, 05:50:00 PM, Anonymous Anonymous said...

Family care practioners are specialists. They are the coordinators of health care. I always go to my family practioner because she is the only one who can put the whole picture in perspective and take care of me as a human being, she is my most important doctor.

That being said, you're rant can be read in reverse. As a specialist, I have picked up the pieces of a mess created by family practioners who didn't know the boundries of their professional competence numerous times.

Your tag applies on both ends.


At Sun Jun 10, 03:01:00 AM, Anonymous Anonymous said...

I see it as another sign of the lack of respect that primary care physicians get from many specialists. It's an institutional thing actually. Most reimbursement policies are set up to reimburse procedures, and specialist procedures in particular, at a far more profitable rate. Someone told me that this is because the AMA gets a lot of specialists on the committee that decides Medicare reimbursement rates, and then a lot of private insurers model their own reimbursement rates after Medicare. I don't know if that's true, but whatever the case, reimbursement schedules are usually designed in a way that ends up rewarding specialists.

As a result, many specialists are arguably overpaid, while primary care providers are probably underpaid, when in fact primary care is a specialty by itself, and it's arguably the most important medical specialty of all. This causes many medical students to view those going into primary care with disdain--they must not have gotten good grades, or else why would they be "settling" for family practice? And those attitudes of disdain lead those physicians to think, if a primary care physician can do it, and surely I'm smarter and got better grades than they did (I don't need to tell you that's a load of crap), then of course I should also be able to do it! God forbid my lowly classmate doing primary care might actually know many things that I don't!

But please take solace in knowing that many many people view their primary care physicians far more fondly than they view many specialists they've seen. I really like my PCP because, after ten years, I know that she sees me as a real person--she greets me when she sees me in the supermarket, asks relevant questions about my life during my semi-annual visits (e.g., how is your sister doing? did you end up buying the car you were talking about last time?), and seems to genuinely care about me and my health. She might be making less money than her specialist colleagues, but to me, she's making more of a difference.


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