The primary care backlash begins

With the primary care shortage starting to gain traction within the mainstream media narrative, it’s inevitable that some will lash back against generalists. (via Bob Doherty)

In this rant, bordering on comical, by unhinged emergency physician Jonathan Glauser of the Cleveland Clinic, he attacks his primary care colleagues for promoting the patient centered medical home. Dripping with contempt, he says that “to fund such a venture for groups that are singularly inept at performing anything of value to society is pure folly and a waste of precious health care dollars.”

Failing to realize that the state of primary care is what it is because of underfunding, he accuses most offices of “seeing 25 patients (or 20 or 30) a day, so they and their office staff can knock off at 4:30 p.m.”

Not happy with smearing the generalists, he also takes shots at dermatologists (“hardly a field that would be missed by the American public”), surgeons (who “want a patient admitted to general medicine to manage a potassium of 3.4″), and orthopedists (who “consults medicine for a Tylenol order”).

Apparently, emergency physicians are the only “real” doctors in his eyes.

The nature of budget-neutral reform means that physicians like Dr. Glauser will take a substantial pay cut to adequately fund primary care.

He’s merely laying out the groundwork for a furious specialist assault on primary care that will be sure to come.

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  • Rob

    Absolutely astoundingly naive. Sounds like the tit for tat we had during residency. You are right; we are going to have to face this – not to mention the lobbyists from specialty groups flooding Capital Hill.

  • Marc

    I guess. But in my limited anecdotal experience sometimes specialists resolve an issue better, faster, and with less stress than by having PCP’s coordinate anything. After my daughter unexpectedly failed a hearing screening at her pediatrician’s office we worried for the better part of a year, having her re-tested by a school nurse and again at the pediatrician’s office before taking her to an audiologist, who did much more extensive tests and confirmed her hearing was in the normal range. We should have just taken her to the audiologist after the first failed screening, instead of continuing with PCP visits about it.

  • Anonymous

    I don’t know why you call him “unhinged”. The guy is right, you know?

  • The Happy Hospitalist

    The fact that places with a higher density of primary care and a lower density of specialists have equal or better quality outcomes data at a lower costs says volumes about the importance of internists, family medicine specialties.

    It also says a lot about the value of specialty care in many situations.

  • Anonymous

    Somebody is about to become _very_ unpopular in Cleveland.

    Poor guy.

  • Anonymous

    When you throw rocks, some are going to come back at you. I have long warned PCP’s about the foolishness of being baited into attacking specialists, about how RVS is set up just to instigate that and destroy the unity of medicine. Now that it has been accomplished with a bit of help by this web site, you will reap what you have sown. The real enemy to primary care was never specialists.

  • Anonymous

    I think Marc has a great idea. Why not just skip the PCP in every case and go to the specialist you think is right? (sarcasm)

  • Anonymous

    Polemical tone aside, I think the author makes valid points.

    I just don’t know whose office he is referring to.

    My family medicine office never turns away a patient in need of acute care. We do suturing. We splint and occasionally cast. We are available 24/7 for acute needs and see patients after hours when the need arises.

    We are our own worse enemy. Every time we trimm back on our scope of practice, we kill a little bit of ourselves, and therefore make ourselves less valuable and more easily replaced.

    That is why I do not agree with the hospitalist movement; the ability to care for our patients when seriously ill should be cherished, not strewn aside.

  • Anonymous

    Cool, I can go into the emergency room to have this weird rash on my ankle checked out…

    Thanks Dr. Glauser!

  • Anonymous

    Anon 6:26…are you kidding? This guy is a complete loser. Nobody–least of all the thoughtful ED folks in my hospital–will give him any credence.

    Primary care is 100% on the right side of this issue. The position of those who oppose meaningful payment reform is completely indefensible, and they will lose. If you’re with them, you will lose. (and buck up, if you’re a rich procedurist, “losing” means still making a very nice income…just not quite enough for the Ferrari)

    So let’s double-down on the positions that have been articulated in this blog:
    Down with the AMA, which has stabbed primary care in the back.
    Down with the procedural and imaging lobbies who, in defending a corrupt payment system, generate enormous pain, morbidity, mortality, and waste.

  • Anonymous

    Holy crap. This is the kind of antagonism that’s found within medical community? Maybe I should think twice before continuing with my pre-reqs…

    PCP’s are right though. Damn the AMA. Damn the RVS. Damn congress.

  • The Happy Hospitalist

    My position to the end of time. The RVU system is intrinsically flawed. In the setting of a fixed pot of money, known as Medicare Part B, for every winner there is a loser. As long as reform is instituted within the confines of the fixed pot, there will always be a winner and a loser.

    If the pot is the problem get rid of the pot. Until then, reform, will have to create winners and losers.

    In the fixed pot where value is skewed towards procedural interventions, the reason specialists make far more than generalists on a time based axis, far exceeding the educational value of their contribution, is because their value comes at the expense of devaluing primary care. They collect what they do because primary care is undervalued. And when you undervalue one aspect of care in a fixed pot, the other aspect reaps the benefit.

    Behold the massive procedural economic advantage of specialist medicine.

    Arguing than my central lines are worth twice as much as my ICU work is ludicrous. But that’s the reality. That’s how RVU values things. Specialists make more because they train longer, yes. True. BUT, they make MUCH MORE because generalists make less. That concept escapes many specialists who choose to take a blind eye towards to inequitable treatment of procedural medicine on a time based axis, when compared with cognitive based medicine.

    It’s all relative. Change the value of the pot, or change the distribution of the pot. One or the other or both has got to occur for reform to take shape. Or get rid of the pot all together. The pot was intended to control costs. It has done everything but. Why try and reform a broken system within the confines of a broken formula. That’s what Congress does best. I would expect nothing less.

    Until Congress OK’s changing the value of the pot, the size of the pot, or abandons the pot, reform within the confines of the pot will always be a WIN-LOSE.

    There is no other way to say it.

  • Anonymous

    And ER docs like him are so valuable because there’s nothing they can’t fix with their finger and the phone.

  • Anonymous

    If you don’t like the reimbursement of the pot, vote with your feet. Leave it, and seek the reimbursement of other payers who value your services. Why is this so hard to grasp? Are you so tied to government money that you can’t imagine another payer?

  • Anonymous

    I suppose we can all just email Dr. Glauser our thoughtful concerns about his piece.

  • Anonymous

    Actually, they are. And now they’re turning on each other because of their failure of imagination.

  • Evan Falchuk

    Dr. Glauser sees a symptom but has misdiagnosed the cause.

    He’s right that primary care is in crisis, but misses that those docs see those 30 patients a day not so they can knock off early, but because they aren’t getting paid enough per patient to cover their expenses.

    That means they can’t spend enough time with each one, which leads to some of the problems he complains of and many others with more serious consequences, like incorrect diagnosis and treatment. There’s plenty of data of the same problems at the specialist level, too.

    Dr. Glauser compounds his error by describing his conclusions in a way that makes it difficult to engage in thoughtful conversation. That’s too bad, because he likely has valuable insights from his experience.

  • The Happy Hospitalist

    Anon. If you have read my blog, you would know that hospitalist medicine has left the contraints of the fixed pot of Medicare Part B.

    That’s why it’s thriving. As far as leaving the program, that’s exactly what doctors are doing.

  • Anonymous

    Good luck specialists. Those newly elected hope to create more of a primary care based system like those in Western Europe.

    that means less for you, and more for those delivering the primary care. And there’s ultimately nothing you can do about it.

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