Comments on: Primary care disrespect starts early in medical school

By: Pieter Kubben

Pieter Kubben — Sun, 13 Dec 2009 14:39:44 +0000

I do not really recognize this for the Netherlands, at least not for Maastricht. Yes, they do have lots of administration, but so do we in the hospital. But you are not considered as a loser if you want to go into primary care, it’s more like “one of the alternatives” but among students not really a last resort. It may become so later, maybe.

By: Jenga

Jenga — Mon, 23 Nov 2009 15:05:31 +0000

Research is only a portion of the work force and typically only a small portion of the.science department in your larger central state schools. You have business, mathematics, education, athletics, humanities and so on and so forth that are all salaried and outnumber research positions. The current talk is to LENGTHEN current specialty residencies due to the 80 hour work week restriction. Which was put into effect because some surgical specialties are already extremely difficult, not for onerous family practice residencies. Now if you want to bring all primary care physicians back to residency for two to three extra years of rigorous training, you might have a discussion.

By: Alchemipedia

Alchemipedia — Sun, 22 Nov 2009 16:13:44 +0000

jenga:
I refer back to my previous comment – “The length of a residency or how easy a residency seems does not necessarily reflect the difficulty of the discipline. It simply reflects the standards that have been set for successful completion of the training.”

If you make specialist training very easy and generalist training very hard. Perceptions would change. Anyway it is the personal qualities of the doctor that are more important than the specialty they practice. I am certain there are many very fine primary care doctors nearby you, just look a little harder Jenja.

Re: “I can’t think of a vocation where more training equals less money and prestige …”. Well how about all the very talented highly trained scientists out there who struggle to get postdoc positions, longterm tenure, or even a paying job that utilizes even a portion of their skills?

The example of teachers is also not a good one. Universities don’t tend to employ teachers. They primarily want researchers who attract their own research funds (essentially paying their own and their team’s salaries as well as research costs), with teaching mostly taking second place.

I also believe there are many teachers out there who deserve more prestige and money. Some of these apparent lowly teachers do get some recognition for the important work they do i.e. “Efren Peñaflorida, who started a “pushcart classroom” in the Philippines to bring education to poor children as an alternative to gang membership, has been named the 2009 CNN Hero of the Year.” (from CNN Heroes)

Paul MD – I liked your comment. Very balanced perspective.

hawk – interesting points. My impression is that most docs that go to Australia seem to go for the lifestyle benefits, not so much for academic reasons. I doubt that either UK or Australian speciialists would say that “non-superstars dominate the specialty field” (in UK). It was nice to see Elizabeth Blackburn, one of the recipients of the 2009 Nobel Prize in Medicine & Physiology was born in Australia, though her formative PhD training was from Cambridge University (1975). She did however “brain drain” to the University of California, San Francisco.

Regarding primary care in the UK. Standards are definitely increasing in this specialty. The training is now harder and more rigorous. Some of the brightest and best medical graduates ARE choosing Primary Care over hospital specialties. Also, some of the regional training programs are extremely competitive, with high quality trainees and rigorous selection criteria. Remuneration seems to have something to do with this change. The same could happen in the US with support and the political will.

By: hawk

hawk — Sun, 22 Nov 2009 07:34:44 +0000

Alchem

I take it you are a brit by your comments. I trained in australia,a nd have worked with a lot of highly competent british docs, mostly specialists, who left because they saw the prim cares making more than they did. Maybe the reason the non-superstars dominate the specialty field where you are is that the best and brightest left for ‘greener’ pastures

By: Paul MD

Paul MD — Sun, 22 Nov 2009 05:06:59 +0000

All of these comments are valid. Something that I shared with the chief of medicine at my school in the early 90s when he told me that internal medicine was my forte is the following. I declined his offer (but accepted his unsolicited letter of recommendation) and the following was part of my justification. Sounds simple, but for me it is still relevant today.

I feel at my best, am most content and challenged in a field where I know an awful lot about a very concentrated area rather than knowing a lot about many areas. Global management and a lack of definitiveness made me feel like the floor was always moving. Frankly, I’m pretty sure that I would be a lousy primary care physician. I think sometimes we choose specialties because some of us are hardwired to do so.

By: Jenga

Jenga — Sun, 22 Nov 2009 00:40:51 +0000

Your first statement would be true, if the cases were followed to completion. That rarely happens today. Most primary care physicians now don’t even follow their own patients in the hospital.
Your argument ultimately fails when you factor in how specialists are trained. I can’t think of a vocation where more training equals less money and prestige, otherwise no one would do it. High school teachers probably have a harder job than someone teaching at a university, longer hours and less-motivated students but no one believes they deserve more money and prestige than those at a university.

By: Alchemipedia

Alchemipedia — Sat, 21 Nov 2009 13:37:16 +0000

Yes Jenga tough jobs are tough.

The more general and unselected a clinicians’s casemix, whatever the specialty, the harder the job is likely to be.

I will reiterate my point made earlier. The brightest and best should be encouraged to work in these more general fields. Leave the less talented to be the “superspecialists” with their highly selected patient casemix. Healthcare costs will fall when it is realised that you don’t need as many of the superspecialists with their often very inflated fees.

Alot of the so-called “specialist” work that is undertaken could easily be dealt with by more generalist clinicians. It should also be remembered that generalists tend to be more holistic in their approach to patient care with the benefits that that produces.

I agree with your point about the small town general surgeons. The problem here is more about inequitable allocation of healthcare resources, which unfortunately comes down mostly to politics

By: jimmyz

jimmyz — Sat, 21 Nov 2009 06:36:54 +0000

Jenga,

And for that reason they (general surgeons) probably made a bigger mistake going into general surgery than FP’s.

By: jenga

jenga — Sat, 21 Nov 2009 03:17:49 +0000

All of those domains however are easily referred out and most often are. In my opinion the physicians and, I am not one by the way, that have it the hardest are the small town general surgeon. They are often at it every day, tons of call with no apparent backup. They are often making life and death decisions on trauma patients, managing other critical care patients in the ICU and often have to ride in on the white horse for any mishaps by other members of the medical staff.

By: Blake

Blake — Sat, 21 Nov 2009 02:57:13 +0000

Alex– That’s a good word. I am a medical student and can tell you that there are two factors deterring me from primary care and he nailed one of them spot on the head. I hear physicians rave about their PAs and NPs, and then hear the PAs and NPs say that they can do the same job as the doc… but cheaper. It seems to me, at this point in my education, that being a physician going into primary care might be like a small business taking on Wal-Mart. Sure, maybe we can offer a better product, but people don’t necessarily want better… the success of wal-mart shows that people want average, affordable, available products. Of course there will always be a place for docs in primary care… small businesses succeed too. I just don’t feel like personally picking a fight with wal-mart.

The other deterrent is that, in the current state of health care, primary care docs don’t diagnose; they manage. For anything interesting that walks in the door, say, a person presenting with a chief complain of chest pain–it seems all the PCP does is determine if it is cardiac, pulmonary, neurological, or muscular in origin and then send them to the appropriate specialist. Then the specialists makes the diagnosis and starts appropriate therapy. The PCP might switch meds if there are side effects and makes sure that all these specialists aren’t writing orders that are contraindicated, and that’s about it.