Primary Care vs. Specialist

The rising epidemics of obesity and diabetes, specially in children, is the first and foremost challenge of the current and future practicing physicians.

Unfortunately, our broken health care system has fueled these problems to the extent that preventive measures are needed to be taken as soon as today. One of the significant solutions to the challenge would be to train quality health professionals and primary care doctors.

The problem becomes even more exacerbated by the fact that insurance reimbursements to primary care doctors are on the decline, while most medical students graduate with ~$200,000 in loans. Since primary care is poorly reimbursed, many physicians are shunted into procedure oriented specialties like cardiovascular or GI, etc.  These docs end-up treating the many downstream heath consequences of diseases like obesity and diabetes, but at the expense of losing front-line workers (primary care doctors) that can more effectively prevent the long term consequences.

Ultimately, the combination of problems like obesity and a

failed health insurance system snowball and lead to serious

consequences for providing care.

Primary Care vs. Specialist

The way our society is going and following the health trends across the world, it is absolutely necessary to have specialists.  There has been huge advancements in technology that has allowed medicine to go to high levels of care and treatment. I feel like many medical students are leaning towards specializing because it is almost necessary to maintain that high status and prestige that was associated with being a doctor.  Now a days, some nurses, PA’s, or Nurse Practioners can make the same amount of money as a Pediatrician or Primary Care Provider.  In most cases, the nurses, PA’s, and NP are working less hours and have less stress. So I totally understand the whole trend that medical students are specializing. Sometimes, I feel like some medical students believe just being a Primary Care Physician is not enough (in our society), it is just being an average doctor.  I mean, when you think about it, most people who enter medical school…they just don’t want to be average.

While I do think that there is a high demand for specialist,  I also feel like there is also a huge demand for Primary Care Physicians.  I also feel like Primary Care Physicians do need to screen their patients more and improve the way patients are receiving care.  I understand that a huge barrier to this is the current health care system, but we are finding that a lot of illness can be prevented with appropriate screenings and education that could possibly be provided by a primary care doctor. More people will see a primary care physician than a specialist because that is the way our health care system works.  So what we really need right now is a lot of really dedicated primary care physicians who will be willing to educate and screen their patients.  But again,  insurance companies expect doctors to only spend like what..ten minutes per patient?  I think to really get medical students to want to choose to become a primary care physician, we really need to fix our health care system and make changes that allow for better primary and preventive care. 

who better to ask than future med students?

To answer this blog I decided to take some time out of my friends who are currently in med school. I know they are busy so I would like to give a shot out to them. Here is the jist of what J had to say: -health care is partly failing beacuse of this choice to specialize, -pay in primary is low comparitively, -that is where system breaks down (lack of financial incentive), -get more students to practice prev/primary(try to give more incentive by help paying off loans by working in rural areas-->Obama's plan?), -aslo, stigma that is associated with PCP (more specialized are held in higher regards not only amongst physicains, but also general public). Here is what A had to say: -pathology is adavnce (more interesting to be involved with) and compensation is more vs. less interesting (in terms of use of knowledged and training) and lower compensation, -give genearlist more atonomy in making decisions and also allow more basic procedures, -there is an issue with payment based on time vs. procedures (PCP paid based on visits and time)

Some additional notes:

-pay per performance-->issue with patient compliance, genetic, SES, etc.--> to many factors to control/are out hands of PCP

-prevention=less need for specialist-->PCP visits should include more interaction w/ other health professionals (bring up example of Lung Transplant Team)

-policy should not only attack who is paying for services (gov, people, both), but should focus on what exactly is being paid for

-without a doubt, PCP are VITAL and I repeat VITAL to the medical system...we can not have people self-diagnosing and referring themselves to specialist...

-also, even though I would like to believe the choice to pursue medicine specialization is an altruistic one, this is simply not the case...there are many factors that come into play such as lifestyle, compensation, stress, interests, etc.

-interesting note: I also spoke briefly w/ two of my other friends who are in medicine E and N. Out of the four, two are specializing (cardiology and undecided), one for pediatrics, and one for general medicine (PCP). Can you guess the reasons why?

Side note: End of Care? How much does US spend in comparison to other countries? This is an interesting point that can be added to our previous lectures in terms of ways in which to drive medical cost down.

Let'em Specialize!!

The rigors of medical school are quite exhausting but if physicians want to continue their education and specialize then I see why they shouldn't. After all, its a personal choice that must be made that entails further commitment and personal funding. If medical students are willing to accept those challenges then I don't see why they shouldn't be able to exercise that freedom. Yes, specialist can potentially make more money than most PCPs but then again many of these doctors have also endured the sacrifices and should be entitled the fruits of their labor.
In reading some of the previous posting there are those that oppose specialization to some degree and many echo the sentiment that there is an overabundance of specialist in our health care system. However, I would venture to say that there are not enough (good ones). The field of medicine is constantly evolving and just as we need good PCPs, we also need qualified and competent specialist to further the science.

primary care is an unattractive field

The practice of medicine has changed dramatically and the doctors of today hardly resemble the doctors of yesterday. Medical students are choosing their fields for the wrong reasons: lifestyle, liability, and leisure (earning potential). "Lifestyle" fields are some of the most competitive residencies to get into. Unfortunately this means that our most apt medical students are going into fields that allows them to work 9-5 with weekends off and lots of money. It's unfortunate that some medical students work hard to be at the top of their class and then become dermatologists (which Jerry Seinfeld so poignantly referred to as "pimple popper MD"). 

Primary care is no easy field. Primary care doctors work grueling hours, do not get paid well, and are subject to liability if they miss anything. There is a severe shortage of primary care doctors in the U.S. and unfortunately part of this shortage comes from the fact that this field is not very well respected.  The US is in desperate need of more primary care doctors and thus we are forced to accept foreign medical graduates and less than stellar domestic grads into primary care residencies. This means that US medical students often feel that going into primary care is akin to accepting defeat.  This also means that the students going into primary care are often not ideal, either because they are from a foreign country and may have language and cultural shortcomings when treating American patients, or because they haven't done very well in medical school. 

The US needs more medical schools overall and more schools with a primary care emphasis. This already exists to a limited extend in D.O. programs, but these programs involve a different outlook on medicine that is not for all. Additionally D.O. programs are not yet very well established or respected. We need to de-stigmatize D.O. programs as well as start more M.D. programs with a greater emphasis on primary care. Medical school also needs to be subsidized by the government (the way it is in many foreign countries). This will allow medical students to choose a field without worrying about the 200K+ debt they have amassed in the process of becoming a doctor. 

Take Your Pick?

So... we have door #1 on the left, and door #2 on the right. Take your pick? Both have services that will have an exclusive clientele, exhibit a sense of prestige and expertise, and denote a sense of professionalism beyond the mere "basics." So where does that leave the primary care physician? The "basics" are left behind door #3. The harsh reality is that primary care physicians are lost amongst these doors. They don't have the "titles" on the back end of their names that, in a sense, almost replace their names and give them the ultimate supremacy of "specialist." This leaves a primary care physician with almost having no identity at all; no sense of self; no "real" purpose. Of course, a shortage of primary care physicians is a problem that must be addressed. Maybe tackling the notion in the education sector, within the confines of where the medical profession is taught and honed can be one solution. Using the platform of professors that create Medical Doctors to stress the importance and prestige of the primary care physician might bring some serious life support to a patient whose vital signs don't look so good.

Balance is key

As the blog says, specialization is essential to the medical field. As we begin to understand the details of certain diseases and conditions, we discover a whole new level of complexity of how they come to be and how they must be treated. Nevertheless, it is the primary care physician that must refer patients to the appropriate specialist. Without the primary care physician, specialized clinics would be crowded with self-diagnosed individuals, requesting perhaps very costly procedures, only to find that their diagnosis was wrong. Therefore, there is no question about it - there needs to be a balance. 

primary care vs specialist

In today's world of medicine and technology, it is no wonder why so many medical students want to move past primary care and specialize.  There are so many new, complex diseases and aspects of the human body to be discovered that is is almost a question to some as to why they would want to remain in such a general field as PC.  However, the attraction and desire of specialties does not erase the fact that our healthcare system will always need primary care physicians.  Similarly, our advancement in cures, treatments and diagnoses is creating almost the same level of need in specialization.  So, where does this leave us?  Which is more important?

I don't think it is a matter of importance but rather one of convenience, at least in today's economic recession and busy lifestyle led by so many citizens.  Over the past few years, my work in the clinical field has given me a glimpse of what patients are looking for in terms of their health and treatment.  Surprisingly enough, there seems to be a decline in the number of adults who consider themselves "healthy" that regularly see a primary care physician just for their annual physical.  More often than not, people are only going to a doctor when they feel ill or not themselves.  Yet, still, these visits are not to their PCP (some don't even have one).  If they have a muscle strain, they call the PT or orthopedist directly.  Swollen glands, they're phoning the endocrinologist.  Although many of these specialists require a referral, so many of the patients (especially in cities) use the ER as their referral.  Whether it is because of cost, time, transportation or something else, it is becoming apparent how many adults are moving away from primary care.

However, even though it offers a possible explanation as to the recent shift in accessing care, it does not mean that the need for PCPs is any less.  I don't think it is a priority problem at the present time to implement a policy restricting the number of medical students allowed to specialize, however, it may become an issue in the future.  If and when it comes to that point, serious consideration would have to be given to limit the number of people walking away from general practice.  Perhaps it could be a system like the military-physicians put their time in primary care for a few years and then can continue on in specializing afterwards if they still so desire.  Only time will tell how serious an issue this becomes

To Specialize or Not to Specialize? That is the Question...

And here's the answer...okay maybe not but I'll try...

When we all enrolled in our respective undergraduate universities we went in with a vague idea of what it was that we wanted to do and what we thought our major might be. Then we slowly began to realize what our strengths and weaknesses were, what intrigued us and what put us to sleep, and most importantly, what subjects made us want to learn more. We were no longer undeclared. We had narrowed down our options and chosen one of hundreds of majors offered.

Okay AJ but what does that have to do with doctors choosing to specialize or to simply (relatively speaking) become primary care physicians? Medical students are like undergraduate students in certain respects. They're going to want to learn more about what interests them and what they are passionate about. If I am particularly amazed by the function of the brain, or if I want to help individuals with cancer because I can relate to them in one way or another, why would I want to settle for becoming a PCP? I would obviously want to battle these issues head on rather than tell someone to go to a different doctor to do the same, so why wouldn't I invest a little more time, money, and effort into becoming that specialist. Sure, the incentives are tremendous: the increased pay, the respect from colleagues, etc. But it doesn't come at a cheaper cost and the severity of diseases and conditions is undoubtedly serious. In the end, however, I think it is human nature that ultimately drives one to become a specialist: the tendency to want to do what is most appealing to oneself and most self-gratifying.

With that being said, however, there is an obvious shortage of PCPs and a surge in the specialty department. I think the only way to reverse or stop this trend is to offer incentives to medical students who choose to go into primary care. What type of incentives, you may be asking? I'm not exactly sure to be honest, but there needs to be some sort of reward or acknowledgement that although they may have chosen to go on to specialize, they didn't do so in an effort to help the dynamic of specialists/PCPs in the United States. So then the incentive may become monetary or it may relate to the number of patients seen on a weekly basis. But whatever it may be, it has to be one that equalizes the appeal of both becoming a specialist and of becoming a PCP, such that there isn't a shift in balance from specialists to PCPs that results.

We need balance, but how?

Comparing to a primary care physician, no doubt that being a specialist is a more challenging job, also earning higher pay. I definitely agree that we need specification, in terms of science. Specification is a trend in most part of science and it is good and essential. One can find the disadvantages of such kind of specification like lost of the understanding of the whole scenary, but generally, the benefits of specification is obvious and greater than those disadvantages. Though the understanding of the basic general knowledge is needed, one cannot master the whole thing.

But the problem is now we are having too many.  And according to an analysis by researchers from the Johns Hopkins Bloomberg School of Public Health and New York University, having too many specialists in the communities actually doesn't help improving the overall health status of the whole population. 

Since all kinds of motivations drive medical students to become specialists rather than PCPs, how can we change people's concepts?  I think we can change policy.  Though it's not easy to figure out the best way to modify the situation, but it's important for policy makers to consider: how could we make people choosing PCP willingly rather than forcing them to?  Maybe by increasing PCPs' salaries but by how much?  A specialty-care physician would probably consider it unfair to see a PCP being paid as same as he is, as becoming a specialist definitely needs paying more effort and bearing more hardship.  

I think the balancing effort would be an everlasting issue...

Primary Care vs. Specialist

There definitely seems to be a shortage of primary care physicians. Rekindling interest in becoming a PCP over a specialist is going to take some major incentives. Medical students, for any number of reasons, may prefer to specialize and see little benefit in not doing so. There is little to encourage them to give up something they may be more interested in, may bring them more prestige and most certainly will bring them more money. 

Because specializations have become so romanticized, many people view being a primary care physician as a bit disinterseting. Specializing also gives doctors the added benefit of a more financially comfortable lifestyle. If more PCPs are needed then the system needs to compete with the benefits that specialized physicians get whether its money, respect or simply a better system to work in that allows them to contribute to their patients health as a whole. I don't know the answer to how we could increase the number of PCPs but it does seem like it would be a double-edged sword. I'd hesitate to lose people willing to spend additional years of their lives studying to specialize, because that is certainly going to be needed but at the same time, PCPs are needed to ensure that the general population is living a healthy lifestyle. Perhaps their needs to be a change in policy and industry? 

The downside of posting so late...

...is that I don't have a single original thought to contribute, as everyone has basically voiced something similar to what I had intended to say.

Nevertheless:

Same as Mary Anne, I also always imagined myself specializing in something upon completing medical school. I think the majority of people who go into med school already have some sort of interest in a specific field--it's the entire reason why they chose to go into medicine in the first place. There's not too many who say "You know, I just want to be a doctor...any kind of doctor. Doesn't matter." Which is unfortunate, because then we have an overabundance of specialists and very few primary care physicians.

I think that schools and teaching hospitals need to put a limit on how many students are allowed to go into specializations each year. It's kind of a sucky policy, where basically only the Paul Farmer-type top-of-the-class geniuses would get to specialize and hence go on to lead glorious lifestyles paid for by 6-figure salaries, but some kind of cut-off needs to be implemented. Does everyone in the teaching profession have to be at the college professor level in skill? No. If they did, then everyone would be sending their kindergarteners to lecture halls to learn the existentialism of 1+1. (Well...maybe only in New York). But my point is, it's a waste of money and a waste of resources.

Overall, society in general needs to recognize the value of primary care physicians. They are the ones we build lasting relationships with as patients, they are the ones who are able to see our bodies as a big picture and are less likely to misdiagnose us, who can catch chronic diseases at the preventable stage and THEN refer us to a specialist if we need it. They are also much, much cheaper to consult. Also, I think the fact that they are general physicians makes them more flexible to work with all kinds of problems. I've worked at several medical outreaches where I've had the opportunity to see PCPs really shine through. They are the ones who can see every single patient that comes to the outreach, whereas the specialists who volunteer with us--as noble as they are for dedicating their time and energy--sort of just sit there and wait for a special case to come up. I can tell you that 99.9% of the time they basically show up, eat lunch, and then go home without contributing any of their expertise.

While we certainly need specialists, I feel another problem is that they are oftentimes misused and abused. MISUSE: In these tech-savvy times, patients like to play doctor and try to diagnose themselves with the help of the trusty, infallible internet. For example, a patient may suspect that he has diabetes. Googling and WebMDing his symptoms confirms his fears, so he goes directly to see a specialist. Yes, the specialist says, you do have diabetes. Good catch. However, this patient may simultaneously have a small brain tumor. The specialist, being all focused on the pancreas and whatnot, will probably completely overlook this. Having gone unchecked, the tumor grows and grows, blossoms into brain cancer, and the patient is left to bemoan why nobody ever caught it early on. Yeah, I wonder, too. ABUSE: I myself am guilty of this. Outside of the occasional emergency room visit, I have never, never ever been to see a PCP in my entire life. My family physician is actually a gastroenterologist. He's a good doctor and we have been together for over twenty years, but frankly speaking, he ain't good at taking care of anything outside of my GI tract. Which encompasses a lot, actually, since GEs have to know internal medicine as well, but there is still a limit to how much he can help me as a whole person and not just a digestive system.

But what I think is most unfortunate is that having too many specialties within medicine ends up drawing several dividing lines through the field. Neurologists will only consult with other neurologists, nephrologists with other nephrologists, etc etc. When there is little cohesion within medicine, the patient ends up being the one who suffers the most. Primary care physicians, at the bottom line, are the front line of medicine that has the capability to see the patient as a whole. Unless something is done to bolster the value and power of PCPs--not just as doctors, but as bridges within the medical field--they will continue to be a dwindling breed.

Primary Care vs. Specialist

Medical students should be able to decide whether they want to specialize in a specific area if they show extraordinary interest and skill, however, they should also keep in mind what patients need most. Usually, (not always), doctors choose to spend countless years in school because they want to help others and they truly care about their patients. At some point in their career, they should think about what services are considered most important and should try to keep that in mind when choosing a path. Perhaps medical groups can provide incentives to those who choose to become primary care physicians. Or doctors should be required to be a general practitioner for a certain number of years during their training or career. Not only would that help with the shortage but it would provide them with a learning experience of non-specialized care.

Specialize This!

Certainly, we have far too many specialists in the United States.  Although specialists play an important role in treating complex and highly intricate health problems, they often create incoherence and confusion, in an already too complex system.  

Often times we go to our doctors searching for answers to health problems, and lo and behold, we are then referred to a "specialist" who can specifically diagnose the problem.  The referral system creates a multitude of problems including: people losing their interpersonal connections with their physicians, a strain on the already taxed system with limited primary care, costs escalating as people are forced to now see multiple doctors to treat one illness, and competition occurs where doctors must specialize in order to maximize economic benefits (i.e. specialists have the greatest chance of becoming rich).  

Fundamentally, doctors should strive for health, not wealth.  I think doctors would be better served specializing in holistic medicine, taking a more integrative approach to health and medicine. This allow them to treat multiple illnesses and provide more cost effective treatments to complex health problems.  In terms of policy, more monetary incentives for doctors to heal patients (much like France already does) would create a more harmonious system, in which med students would not feel obligated to get their specialization to maximize their future incomes. Rather, doctors could then focus on what they should be doing all along: that is, treating illness and improving the health of their patients. 

Many Medical Students Will Always Want to Specialize

I feel as if medical students are talented in, qualify for, and are motivated to get into a particular specialty, then they should. According to the American Board of Medical Specialties (ABMS), a not-for-profit organization, there are 24 approved medical specialties. Furthermore, there are subspecialties of medical doctors. Hence, medical students have a lot of specialties to choose from if they want to specialize.
Therefore, although there may be a stronger need for primary care physicians across the country, it would be very difficult to convince many more medical students to not specialize. Personally speaking, I trust the most the medical advice of the specialist especially because primary care doctors follow the advice of the specialists. All in all, unless higher pay is given to primary care physicians, I believe many medical students will continue to want to specialize.

It's Not Them, It's Us

I feel that the general sentiment towards primary care in this country is both sympathetic and apologetic. We're all sympathetic because everyone (from patients to policy-makers) has at least a vague notion that primary care must be important for the healthcare system (even if they've never encountered the now absurdly huge body of evidence that demonstrates why that's the case). At the same time, however, we're also somewhat apologetic (even those of us geared towards primary care) because deep down we feel that general medicine just doesn't hold the same intrigue, glamor, or challenge as specialities such as neurosurgery, oncology, cardiology, or even ones as relatively banal as dermatology or radiology.

Our culture strongly reflects this sentiment: the only pop icon internist is Dr. Gregory House, a misanthropic cripple who has no friends. He's always interested in the rarest, most bizarre cases that verge on medical obscurity (does anyone remember the episode where the patient had lupus? Oh, wait, that was ALL OF THEM), and absolutely despises his actual job (working the outpatient clinic). Similarly, if Scrubs is any indication, the diagnosticians are all categorically dorks, while the surgeons are all jocks. In the real world, the arguments against practicing general medicine always seem to be along the lines of, "medical students should be free to chose a more appealing career," whether "more appealing" means more intellectually stimulating, higher-paying, or just plain more interesting.

Despite this, however, a significant portion of the medical students or residents I've met (no matter what hospital or country they're from) actually became much less enamored with any particular specialty and much more interested in general diagnostic medicine after experiencing each speciality firsthand. They find internal medicine to be more intellectually stimulating, and family medicine (with its strong emphasis on patient interaction) to be most consistent with their original notion of "helping people." The most common reason they cite for not going into primary care is because it doesn't pay well enough--not because it isn't interesting.

This somewhat surprising discovery led me to believe that there are medical students out there who would gladly become PCPs if only the payment structure in our country were readjusted (our reading this week echoes the same sentiment). Reimbursement rates for public programs (on which those for private programs are modeled) are ultimately determined by policy-makers. Thus, it is the notion of primary care in the minds of policy-makers, not medical students, that most needs to be changed. In other words, it's not them, it's us.

Giving more money to specialists seems intuitive. They need more equipment and technical/support staff, and their product is much more tangible: a deformed child who gets a new face, a cancer patient whose tumor is removed, a grandmother who's fitted with a brand new hip, a renal patient whose life is greatly extended by dialysis. Outcomes for these specific procedures are relatively easy to both observe and measure, and funders are sympathetic to the specialist cause both scientifically and humanistically.

However, specialists only really deal with the second half of the clinical process: the part that happens after the diagnosis has already been established. Everything that happens before--the intense intellectual work of parsing out the relevant medical information, identifying the signs and symptoms, and knowing what procedures the patient should undergo out of the mind-numbing variety now available--is hugely underappreciated. This part of the process gets much less press (if any) because it is not tangible. The PCP needs only two assets: the ability to talk and the ability to think, and neither of these captures the imagination quite so well as a scalpel or a bone drill. However, these two abilities are arguably the greatest assets of any doctor, and by far the hardest to teach or train.

For instance, believe it or not, a surgeon could probably teach this entire class how to tie an interrupted suture (a basic surgical knot) in about 45 minutes. If you did this procedure over and over again, hundreds of times a month for several years, you too would become a pro--without the slightest idea of how to practice actual medicine. But if an internist came in and tried to teach any of us how to differentiate between pneumonia, influenza, bronchitis, allergies, and the common cold (a basic exercise in primary care) in just 45 minutes, we would all fail miserably. Even after years of doing this, there is still a chance that we will misdiagnose.

I feel that PCPs need to make this argument to policy-makers in a more coherent and concerted way than they have been doing. PCPs deserve greater compensation for their product, even if they don't need robots or fiberoptoic cables to generate it. But they need to argue their case. Specialists are notorious for banding together (neurosurgeons are sympathetic to neurosurgeons, oncologists to oncologists), and by doing so they gain enormous amounts of lobbying and negotiating power. Even though the size of any particular lobbying group is small (I'm sure the American Gastroenterologists Society is not bursting with members), with so many sub-specialities, the aggregate power of specialist physicians is impressive. Why have PCPs failed to band together as cohesively? If they did so, they may be able to negotiate much better reimbursement rates, which will create the incentive necessary to get more medical students to train in primary care.

Rethinking the roles

I think the issue shouldn't be primary care physicians versus specialists, but more rethinking the way the two realms of medicine interact.  There have been many great points already made in previous posts, so I'll try to keep it short and simple.

First off, I don't think restricting people from specializing is the answer to anything.  I don't think it has really been proposed, but hypothetically, if it were, that would discourage people from excelling in specific fields, and being the best doctor they could be.  Bad idea.  I do think there should be a shift in the way that people think of primary care physicians.  Naturally, because specialists are just that - specialized in a particular field - they are more highly regarded.  People don't credit their PCP with curing them of cancer - that credit, as it should, goes to the oncologist.  But what if more people viewed their PCP as the reason they were referred to the specialist - like the gatekeepers to the more specialized fields.

It has been proposed in various health care reform bills to make it mandatory for everyone to have a PCP, internist, or pediatrician, from whom they would receive referrals to specialists when the need arises.  This makes perfect sense to me.  Why would you, the generally non-medically educated person, be able to just call up your local whatever specialist at will, if there may not be anything "special" wrong with you?  If your PCP had to refer you, you'd have to go to them first, which would create a higher demand for the PCP, as well as making sure they were thought of as necessary in medicine.  If medical students saw the future of a PCP career as essential as a cardiologist in this nation of extremely high cardiovascular disease rates, maybe it would make the medical students view the primary care field a bit higher.  Also, with requiring referrals, PCPs could get paid more, where specialists may make a bit less, but it could even out the "pay gap" between PCPs and specialists across the board.

I think that a lot of people do specialize because they are extremely gifted, which I highly commend and think specialists are a vital part of medicine.  But if becoming a PCP was made very essential to the medical field while these future doctors are in medical school, maybe we'd have a bigger pool of primary care physicians entering the profession.  Maybe the medical schools in this country should think about this as they try to increase enrollment by 30%, as the AAMC has suggested is necessary to offset the rising demand for physicians.  I think PCPs are somewhat undervalued, not just simply monetarily, and that if the payment/referral system changed, the PCP issue could change as well.

let medical students choose themselves...

These days, most every medical student wants to specialize in something. There are good reasons for this, including the challenge a specialization presents, the prestige involved, and higher pay. This country certainly needs specialists because of the growth in complex chronic conditions (e.g., heart disease, diabetes, and autism), but one has to wonder what this does to our system if we have most medical students choosing to specialize. What are your thoughts?

It is difficult and unfair to ask medical student to change their decisions and become a primary care physicians though we found a need to have more PCPs. However, medical schools could give their students a very detailed and clear introduction of what each specialist doctor and PCP do when the students first enter medical school, and have another similar kind's seminar when the students were about to choose their professions/specialties. From the seminars we could emphasized that PCPs are in great need since there is an obvious decline of students wanting to be PCPs. It will help students to pay more attention to the importance and job duties of PCPs, and they might choose to be PCPs if they think it can help the society by having them as gatekeepers.

Primary vs. Specialists

There is definitely nothing wrong with a medical student choosing to specialize in a certain area. Everyone has different interests, skills, and motivations for choosing the careers they do. Money and prestige may not always be the main reasons that drive a med student into a certain specialization. Backgrounds, personal experiences, and family history often motivate people when choosing their careers. If prestige and money come with that career, it is more as an extra reward that comes with it. People should not be judged for choosing the careers they do (especially when they are ultimately helping people). However, I do think that there is an emphasis on specialty care rather than primary care in the way healthcare is run in the U.S. If a system were designed with a greater focus on preventive or primary care then there would also be more incentives for students to become primary care physicians. It would have to be a system where the focus is to keep people healthy and doctors get paid more for actually keeping people from getting sick. Of course, specialists will always be needed, regardless of any healthcare system or incentives offered. People will always have certain conditions that can only receive the best treatment from a specialist, and for this reason alone will acquire a well-deserved respect.

Well hey.. I gotta get paid.

Yes.. there is a shortage of PCP's in America and yes medical students might be more willing to specialize and sub-specialize to earn more money or have a more prestigious occupation (if being a general physician wasn't enough). but in all honesty there are medical students who truly have a passion for a specialization of some sort and they may be more gifted in that field. It would be unfair to put stipulations on how many medical students are allowed to specialize. The truth is that in order to specialize a medical student must excel in their board exams. Those who are given the opportunity to be resident specialists have earned the right through years and years of hard work. No matter what their motivation may be, (i.e. higher status, better pay, or a true passion for a particular specialty) they have rightfully made their way to that position. So there is a lot of competition that effectively weeds out less qualified individuals. With that being said, it seems that there is and will be in the future, a shortage of primary care physicians.

So what does this do to our system? There is definitely potential that some folks in America will be deprived of quality care from a general practitioner. The scary thing is that there is a shortage of PCP's and the ones that are there often times practice in the same areas- which effectively leaves a lot of people with few or no options for seeing a doctor. In some instances, they may be forced to travel several miles to see a doctor for a general check-up- many people may elect to not even go see a doctor in those situations. That is a serious problem, I think. But I do think that there are "solutions" to this shortage of PCP's. Many medical schools have the option that medical students can obtain federal grants that will essentially pay for their medical school on the condition that the medical students practices a few years in an inner city area as a PCP. Certainly this is a huge motivation for a student- I think this is a great way to increase the number of PCP's in America.

With the rising costs of health care and insurance it's pretty obvious that something needs to be done to bring those costs back down. How can we do that? Increase the number of PCPs and decrease the number of specialists. Not to take away from the skill and necessity of specialists, because of course they do fill an invaluable position in the health care system. No doubt, there will always be people in need of a cardiologist, neurologist, or neonatologist since illness is inevitable. However, the role of the PCP for a typical person precedes the need for a specialized physician. The average person will probably not need to seek out the services of a cardiologist until they're well into their 50s or 60s (one should hope not any earlier) and may not even ever seek out the service of a neurologist in their lifetime. But, each and every one of us will most definitely NEED the services of a PCP. No ifs, ands, or buts; we WILL visit a PCP all throughout our life. In addition, (and someone let me know if I'm wrong on this) but I've never heard of a dire need for specialists. It seems that there has always been a hefty supply of specialists when the need arises. With this staggering difference in necessity I think that there needs to be some type of incentive that would motivate medical students to take on a career as a PCP as opposed to a specialist. One way this can be done is to have hospitals appropriately limit the number of available positions for fellowships. That way only a certain amount of specialized physicians will emerge each year and the rest of these residents will either have to wait until next year to apply for these fellowships or choose instead to become a PCP. I think that one possibility to increase the ratio of PCPs to specialists would be to provide some type of incentive to medical students for choosing primary care as opposed to specializing. Maybe they could be given higher priority when it comes down to matching for residencies or even a contract that would already secure them a position at a hospital once they finish their residency. In the long run, increasing the number of PCPs seems to be the best solution to bring our health care system up to par with those other countries who have a superior system to ours.

primary care vs specialist

What’s the difference between a general practitioner and a specialist?

One treats what you have, the other thinks you have what he treats.

With the current state of our health as a whole, specialists are an essential and intricate part of the medical field. However, general practitioners are as well. Due to the increasing interest in specialized care, many PCPs have taken the role of gatekeepers as a priority. There is nothing wrong with referring a patient to a specialist, however it has become a common theme for PCPs to concentrate on just keeping people healthy and relying on other experts for the acute care. So PCPs focus on maintenance and are all too eager to refer a patient to a specialist the minute an acute episode arises. In the past, PCPs were better equip to handle patients conditions. But now, because specialists are in abundance, it is easy and convenient to refer a patient out and have another doctor deal with the problem. The New England Journal of Medicine states that the amount of time primary care doctors spend in a hospital has gone from 40% a generation ago to 10% today. In order to improve health care efficiency, primary caregivers should extend their roles beyond evaluators and give each patient more continuity by working toward the fewest possible hand-offs. I believe this idea will increase the value of PCPs and naturally increase medical student's interest in the field.

S P E C I A L I S T vs. PCP’s or S P E C I A L I S T & P C P’S

It’s good to know that medical professionals are specializing in areas that are critical to understanding chronic health diseases/conditions. However, if there are too many specialists then this will result in a shortcoming of primary care physicians in the near future. Many medical students have not been in the workforce for approximately eight years and are eager to make a buck. However, when they see the difficulty in navigating the medical system (such as ordering labs, medications, etc.) and weight the compensation they will receive the alternative is more glamorous so they choose to continue their path towards specialization. As a specialist, they have more freedom to order tests in order to determine the underlying causes of illness. Now, if we have a short supply of PCP’s then what should we do? First off, I think it is wrong to import physicians from other countries that need their own physicians to help with spread of infectious diseases and other terminal illness endemic to their countries. So for the U.S., I suggest that specialist be required to provide at least a given amount of hours during the month to the PCP field so that we don’t end up with a deficit of PCP’s. The medical field is a collective and I see nothing wrong with a specialist helping a fellow PCP to serve the American population which is their work base. Let’s distribute the work load so we as a nation can strive towards quality improvement in our health care system one step at a time.

Back to the Limelight!

Primary care has been one of the best jobs in medicine, and it can be again. In fact, primary care must recapture its attraction for the next generation's best trainees....................

There are formidable challenges for graduating Medical students, backbreaking debts, and a need to establish themselves at that high point in life when most others have cozy incomes, so what can attract them more than a procedure oriented facility offering high income.

It is important that Primary care practice as it is looked upon today as gatekeepers of the Health system undergo some radical changes. It could start with making the Primary care practice more lucrative, better incentives and redesigning the system with a little creativity so that a Primary care Physician can take care of the patient with the disease as a whole instead of referring to specialists. In a recent article in NEJM by Thomas H. Lee, experts in Primary care debated on the issue and Roland suggested it would be worthwhile to adapt certain features of the UK. Primary care system.

With its combination of care for acute, undiagnosed illness and complex, multisystem disease, as well as the provision of extensive preventive care, all in the setting of a long relationship
built on mutual trust and knowledge, primary care has long been a deeply rewarding profession.
But in recent years, this once-extraordinary specialty has seen its ranks diminish as doctors struggle with an increasing amount of paperwork, the explosion of therapeutic options, and a dramatic expansion in preventive care responsibilities. Care is increasingly fragmented, leaving patients angry and doctors frustrated. What is needed is a reinvention of the system where continued trust can be the basis of care and not disappointment.

It is said ' In the era of specialisation the organ is saved but the patient sacrificed' we need to save the patient first and who could be better at that than the Primary care Physician.

Let them specialize

     Although I do agree with everyone that primary care physicians are very important and lacking in our hospitals, I believe that if people want to specialize then they should. It's pretty rare that someone comes out of medical school being interested in generally everything rather than one specific field of medicine. Many people find out during rotations that they are either interested in one subject more than the other or may even just understand it more. If these people excel in one area and are more fascinated by it, why shouldn't they be allowed to specialize in it? Generally, people tend to do better at their job if they enjoy it and are truly interested in what they're doing. They tend to work harder, focus better, and pay more attention to their work if they truly care about it. In the case of medicine, wouldn't it be better to have someone specialize in neurosurgery if that's their forte and what they truly care about rather than just being a primary care physician? I actually think its a smart move in health care to have those who excel in specific areas pursue those specialties. This way, we have the best of the best in each specialty and those who don't really stand out in one field to become primary care physicians. 

     In no way, however, am I saying that they should JUST become primary care physicians. I don't think those who specialize are in any way better or smart than those who don't. I'm just saying that some people are generally good at a lot of different things and others are really good at one thing, and that those who are good at a lot should become primary care physicians. These people are very important for health care and are pretty much keeping everything afloat.

Wanted: Primary care docs

After completing years of schooling, followed by a grueling residency program, medical students seek the financial payoff for all of their hard-work (and a way to start repaying their debt) And how can you blame them? 

Personally, I think that one of the benefits of becoming a primary care physician is the unique relationships you build with each patient. However, medical students who find this quality important to them, find that they can also develop a repore with their patients by choosing to specialize, not to mention, make more money. Doctors who specialize in something have a rewarding career that provides better financial rewards. 

I think that in order to increase the number of primary care doctors, a lot more incentives need to be offered to them. There should also be a better system to address/fix the administrative inefficiencies (i.e. billing system). If primary care physicians were better compensated, then they would be more satisfied with their jobs, which would be one way to help influence medical students into primary care. 

A relevant article was published in the New England Journal of Medicine titled "Primary Care- The Best Job in Medicine?" for those that are interested: http://content.nejm.org/cgi/content/full/355/9/864

Primary Care is Needed

Specialists are needed in this country and there services help many people, but the first steps to reach a specialist are to be seen by a primary care specialist. I believe that much importance has been given to specialized doctors. This respect is earned due to their many years of training, but that however does not mean that the hard work done by primary care physicians should be downplayed. Primary care physicians are the beginning of healthcare and are the ones to have more interaction with patients. However they usually are disregarded and not praised for the hard work that they do. This in turn causes many medical students to opt out of this option and pursue a more prestigious and high paying job.
With less and less people pursuing the field of primary care it causes the system to have overworked and underpaid primary care physicians. The amount of work that each primary care physician has to put in has increased significantly. The system needs to improve the way that primary care physicians are treated and the respect that they get because without them the health care system would be nonexistent.

There has certainly been a great deal of discussion about the increasing need for primary/general care practitioners recently, as most medical students and new physicians opt to specialize in one field or another. Primary care physicians are an integral part of the healthcare system, and often seem to be thought of as the "first line of defense." However, the growing number of specialists also allow for a more skilled and better informed generation of physicians to treat particular illnesses with years of knowledge and practice in a given field. That does not mean to say that the need for primary care physicians has diminshed, however if we wish to see more medical students persuing careers as general practitioners, it might be beneficial to provide more incentives and make general practice more appealing.

We are over-specialized

Unless primary care providers are better acknowledged for their work and valued as highly as specialists, medical students will find no incentive to choose specialty care. Ditto to everyone elses comments on the competitive and over striving mentality of medical students- they are galvanized to push their academic career further by specializing for higher pay, gradiosity, financial security, etc. Focusing on a specialty is attached to prestige, higher pay, and a more challenging career. Primary care providers are indeed over worked. They deal with a higher volume of patients, burdened with more paper work, and are held with the responsibility of a comprehensive and wholistic outlook on the patient. Sad to say, the role of the family physician is quite crucial for preventative medicine and the overall health of a person, yet their salaries are staggeringly lower compared to specialty doctors. Like teachers and social workers who are over-worked and under paid, primary care providers too are in the same boat- they are seeking to be regarded as vital professionals of society who care for the population but are recognized with less value. With less medical students entering into primary care, I have heard that is one of the reasons why physician assistant and nurse practitioner programs are being offered in universities and colleges. Thus, PA's and NP's can share the responsibility of providing primary health care for large populations who do not have family doctors. What is ironic with that solution is that PA students are allowed to specialize as well! They can specialize in surgery, dermatology, OB/GYN.... we are over-specialized.

link

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Primary care doctors have to do more, see more patients, and get paid less.

Specialists get paid a lot more.

Both have to go through the same preliminary training and years of schooling.

Thus, a lack of primary care doctors = longer lines, less time to see patients, worse care.

everyone likes a challenge

Even though medical school is an enormous feat in itself, many graduating M.D.s still want to push themselves and learn more by specializing.  This desire is admirable to people like me, who would probably need a good dose of R&R in the form of a long vacation.  Admirable as it may be, the medical field as a whole needs to realize that while specialized doctors are important, primary care physicians numbers are decreasing steadily in this country.  It is an individual's choice to decide what career path to pursue but if there is a shift in thinking by putting more emphasis on the need for primary care doctors somehow, maybe we will see a change in the numbers.  A specialized doctor is definitely more glamourous in that they know more, get paid more, and save lives more specifically, however if we had more emphasis on primary care in general then maybe we wouldn't need all these specialized services.  I feel like this shift is comparable to the shortage of teachers in this country, where if we focused more on a stellar education for our youth, we would reap many more downstream benefits, rather than focusing on rehabilitating them once they have been through our somewhat broken system.  The country as a whole needs to focus more on primary causes in all aspects of health instead of creating newer and better ways to deal with the repercussions of a failed system.  

will work for love

All the trials and tribulations of getting into medical school, along with all the crazy stories of being in medical school, should be enough justification to be able to get paid the big bucks when you get out right?  Most people think that the specialists are the ones who are gonna get paid the most, and most of the time have the sweetest schedules.  Now who doesnt want to get the cash, have the easy career, and have enough time to go home and play golf, tennis, or rock band?  Sure it all sounds good, but lets think of it again.  Where are you getting all of your patients?  Who is referring all these patients to specialists?  Of course there are gonna be some people who get into the ER and have to be rushed to certain specialists, but otherwise, isnt the primary care physician in charge of who goes where?  Arent they the ones who tell the patients where theyre going to go?  Who's looking over the pcp's back 24/7?  The big guys with the big money, the medical groups, the insurance companies, the hospitals.  So youre saying the specialists get paid more right?  However im sure that these big dudes dont want to pay the specialists the big money if they dont have to, I'm sure that theyd want the cheaper PCP to handle all the cases they can without having to refer the patients out, or else up goes the amount that theyre going to have to pay for that patient.  

Let's just say that your mom is buying you a new Playstation 3 for your birthday.  You tell her how much it costs, and oh its going to be awesome!  She says ok, just because she wants you to be happy, and she loves you.  So you get to Best Buy, and you grab the first PS3 that you see in the electronics section.  Your mom turns around and starts walking towards the register in the front of the store.  But then you think... I don't even have a game to play yet, I need extra controllers for my friends, I'm going to need an HDMI cord to connect if I want to play in hi-def, and I'm going to need a headset cause I'm gonna be a nerd and play online too!  So you tell your mom what's on your mind and she sighs, but she only agrees to buy the game and the extra controllers because she decides that those are the only things that needs to be purchased, and she needs to save money because the family is also on a budget.  So its a no go on the HDMI cord and headset.  

Now think of this:  You are the primary care physician, your mom is the big insurance company, the PS3 is the primary care patient, and the accessories are the specialists.  Your mom is always going to be in charge of deciding what goes through and what doesnt, and these extra PS3 accessories are only going to be bought if the PS3 really needs it.  Now wouldnt it be much easier if the PS3 already came with all those things already?  If the PCP was able to handle everything him/herself, then it would save your mom (the big companies) money, so specialists are no longer in control of their own destiny.

The future looks less promising for specialists, because these days the big guys are trying to get the PCP to do as much as possible without having to refer out.  It wouldnt make sense for everyone to want to go out and buy controllers, games, and other accessories without even having a game console, right?  

Strike one, Strike two, Strike three....

It’s true that we need specialists for complex chronic diseases. But, with recent projections like

• There will be a generalist physician shortage of 35,000 to 44,000 by the year 2025 (Health Affairs) and

• Just 2 percent of graduating medical students are choosing to enter general internal medicine (The Journal of the American Medical Association),we can’t afford to have shortages of them in total physician workforces. And, we can’t take this issue lightly.

What will be the consequences of these projected shortages for patients?
According to the Health Affairs report, either primary care doctors will be seeing many more patients than they do now, or several million people will be without a primary care doctor, no matter how accessible health care might be for the rest.

Strike one

To look into perspective of primary care physicians, as Tim Norbeck, the executive director of the Physicians’ Foundation, has said of a study of survey on 12,000 physicians, (majority of whom are primary care physicians); "Doctors feel they can’t spend enough time with their patients because of the paperwork and red tape hassles.” In the study, nearly half of them said they planned in the next three years to reduce the number of patients they see or to stop practicing altogether. Over three-quarters felt they were at “full capacity” or “overextended and overworked.”

Strike two

The health care reform will not be successful without adequate number of primary care physicians and effective primary care system. The crisis in primary care must be addressed before any real health reform changes can occur; otherwise, the flood of new patients may instead turn out to be a final strike for our ailing health care system. Take a look at the situation in Massachusetts for example. Since a landmark law was enacted in 2006, which mandate requirement of health insurance for nearly all residents, the state has struggled to provide primary care to the estimated 440,000 newly insured.

As New York Time has posted in December 11, 2008,

“People can survive one organ system failing and even two,.........but when that third one goes.....”

And, at that point for all of us, doctors and patients, the game would be over.

Possible solution

In an attempt to prevent the potentially devastating public health implications of primary care physician shortages, the American Medical Association is currently vowed to support financial incentives for medical students who choose to go into primary care.

And, personally, I think physician payment reform and reduction of the amount of payment discrepancies between specialists and primary care physicians are needed to be done.

PREVENTION

The first concept that comes to mind is PREVENTION ... it has been the main concern/focus/goal for public health professionals for some time now. Primary care physicians are allies when it comes to prevention as they do not specialize in one disease or realm of health and can educate their patients in all areas of health. Specialized practitioners are already targeting and helping those "with disease." The problem that most medical students specialize is due to money. The academic and economic stress, and overwhelming responsibility that comes with applying to medical school and becoming a doctor can only lead a student to get the most out of their situation. In this case, money. Therefore, specializing will get them more money because this country's health-care system is not focused on prevention. Solution: provide more incentives for primary care providers and there may be a shift into primary care practice for medical students.

Care's Discrepancy

Medical students around the nation are used to pressure. Having completed cutthroat premed classes, taking the grueling MCAT and spending months on essays upon essays, these kids are aware of what they’re getting themselves into. Once they gain admission, all the pressures that built up in their previous experiences seem to have a lingering effect, as the competitive nature of the field can become somewhat encompassing. In the end of course, medical students want to do their best to make sure they offer the best possible care to others (or at least we hope so.) After they gain admission, questions of what they plan on specializing in are almost automatic. Why work so hard and spend so much money if you’re not going to be good at one particular thing? Whatever the reasoning may be, these students are favoring specialization over primary care in numbers that have some questioning the possibility of a shortage of primary care doctors in the future. The two paths differ not only in their pay, but also their responsibilities. While specialty doctor visits are short and intense, primary care doctors are the gatekeepers to further care; focusing more on the person as a whole rather than one specific problem. The problem with less primary care doctors becomes more glaring when we notice that they average more patient visits per week over other specialized doctors (approximately 20 more visits per week.) The numbers speak for themselves: with fewer doctors forced to take more patients per week; quality of care and subsequent patient and even doctor satisfaction begin to decline. I cannot fault today’s medical students for pursuing specialization, but we must address the discrepancy with incentives for those students who choose to travel the road less traveled.

Three solutions to ponder

While it is good to have more specialists (more doctors that can help you), each specialist needs a certain amount of patients to support his practice, both from a financial and an experience standpoint. For example, a neurosurgeon needs 100,000 people to support his practice. An isolated town of 200 simply cannot support a neurosurgeon. What if a specialty was had by every PCP? Like a "major" for every college student?

Solution: 1. Maybe. The idea of every doctor being a specialist can work; where every doctor is both a primary care doctor to his regulars and a specialist. Using this scenario, consider a hypothetical doctor's firm where there are 5 doctors that all specialize differently. If they need to, they can refer their primary care patients to their colleague down the hall. Ultimately, we will have greater access to both primary care and specialty care. The real life problem here is that each specialist doctor would still not get the practice that is looked upon in specialist.
2. Historically, the more money a profession makes, the more students it will attract. So we might pay our PCP's more money, but the problem with this is that mid-level professions, like physician assistants, can usurp its roll in the industry.
3. Many students choose pharmacy or dentistry because the working hours are more desirable. So lets adopt these conditions to PCP's instead of increasing their pay even more, though I do not want a PCP to be unavailable at nights, like most dentists. [I am just bitter because I have had 2 painful toothaches start on Friday nights.] This may be able to increase the proportion of PCPs to specialists.