Tuesday, April 05, 2005

Here we go again!

I kind of feel like I'm stuck in a time warp...it's 1980 and Ronald Reagan is telling Jimmy Carter in a debate, "There you go again!" It seems that every 5-10 years, many in the public health arena start taking potshots at specialists, stating that we have too many/they charge too much/they are only out for money/etc. Now comes this study which takes the position that mortality rates are better when there are more primary care physicians and fewer specialists. The author of the study, Dr. Barbara Starfield, states

"Decisions about the physician supply should be made on the basis of evidence for their utility in improving health and reducing ill health and deaths...Currently, the United States has many more specialists than do other comparable countries with better health levels."
She also found that a higher specialist-to-population ratio did not decrease mortality rates. In fact, she determined that too many specialists negatively impacts communities because patients are more likely to have unnecessary tests and procedures.

I have not had the chance to read the published article, but on the face of it, it is difficult to get a grasp of how the methodology of such a study can be accurately constructed to achieve meaningful results. There are a whole host of factors that must be taken into consideration, not the least of which is where specialists congregate:
Specialists, Salsberg said, tend to concentrate in urban areas that draw patients from large geographical areas, so they can see enough cases to be clinically sharp and financially viable. At the same time, the population that dominates urban areas tends to be higher risk and has higher mortality rates.

An analysis of mortality rates also does not capture quality-of-life improvements that specialists provide, he said. Ophthalmologists might not save lives, but cataract surgery can make the difference in a person's ability to see to drive or read.

Clearly, there are a number of problems with the health care system in the United States, but I think it is pretty hard to argue that an over supply of specialists is the main problem. Medical students are going to go into the fields that attract them the most, and I truly believe that potential income is a secondary, but very important, motive in the choice of a specialty. It would be naive to think that physician reimbursement has very little to do with what and how doctors practice, just as it would be naive to believe that the omnipresent threat of lawsuits leads physicians to practice defensive medicine. In fact, I suspect that if tomorrow it was mandated that all patients were required to have all of their care delivered by primary care physicians, the rate of "unnecessary tests and procedures" (as Dr. Starfield describes them) would go up dramatically. It is unreasonable to expect every primary care physician to feel comfortable with, for example, differentiating between postoperative discomfort and postoperative pulmonary embolism.

Additionally, who is a primary care physician? A large percentage of patients referred to me have never met their PCP, and are cared for by a nurse practitioner or PA employed by a PCP. Should we do a study comparing mortality rates in locations where there are more nurse practitioners and PAs and fewer PCPs compared with the obverse?

As I have stated before, the primary care community as a whole has also actively worked to abdicate responsibility for the care of very sick patients. Who do patients see in the hospital? Hospitalists, rather than PCPs. What do those hospitalists do? Order more tests than their PCP or specialist counterparts, frequently duplicating tests already performed in the outpatient setting.

I believe that a strong primary care base provides good quality, comprehensive patient care. It cannot, however, supplant the need for a good specialty care base. The economic factors involved have driven much of our current trend towards specialization, as primary care physicians have been inexorably squeezed by Medicare and insurers. That, rather than a perceived excess of specialists, should be our main focus of concern. It should be a basic tenet of reimbursement that physicians should get paid for caring for patients, and the sicker the patient, the greater the pay.

For another surgeon's viewpoint, check out A Chance to Cut is a Chance to Cure.