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.