Comments on: Can primary care doctors actually increase health care costs?

By: jsmith

jsmith — Wed, 18 Nov 2009 18:35:49 +0000

Tom You must not be in medicine. Your faith is specialists is misplaced. Some are great, some are horrible, most are in the middle. I know it’s counter-intuitive, but it’s true. We do lots of things just as well, just as well being defined as equivalent morbidity and mortality endpoints . And it’s not me, I’m not special. Most generalists can do lots of things as well as or better than specialists, and of course much more cost-effectively. Anecdote: I once had an infectious disease fellow at the University of Washington try to tell me to treat MRSA with IV vancomycin–thousands of dollars. Of course I gave the pt oral antibiotics and she did fine. Last time I’ll consult with that guy. Remember that we too are specialists–in common problems and in the management of multiple problems in a single patient. A partial list of where we do better or just as well:: Management of hospitalized patients (most hospitalists are general internists or family docs), stable heart disease (not unstable )diabetes, hypertension, obesity, osteoarthritis (not rheumatoid arthritis though), thyroid disease, stable asthma, allegies not requiring immunotherapy, common skin disorders, acne, stable COPD, pneumonia, acute respiratory infections,acute gi disorders, most cases of laceration management, wound management, minor burns not require skin grafting, acute musculoskeletal disorders that don’t require surgery, migraine, other headaches, depression, anxiety, personality disorders, etc, etc, etc. The list goes on and on.
Where do I do poorly relative to the specialists? Epilepsy, multiple sclerosis, any disease that requires major surgery, major burns, major trauma, cancer treatment with chemo or radiotherapy, bipolar disorder. The list goes on and on.

By: Tom

Tom — Wed, 18 Nov 2009 04:43:45 +0000

“I can diagnose a lot things as well or almost as well as most specialists. Treatment is another issue of course.”

You seem very confident. What if you’re wrong? Are you so sure that you won’t send them to a specialist for evaluation?

Regarding specialists doing what other specialists do, there is a phrase, “Reasonable and prudent member of the profession” that should resonate.

By: jsmith

jsmith — Wed, 18 Nov 2009 02:14:59 +0000

Peter’s argument sometimes holds water but not always. Why not? A lot of times specialists do things because other specialists do it, not because it is the right thing to do. Examples: See the post on mammography from today. I guess all those radiologists pushing mammograms missed the mark. And if you think that urologists screening for prostate ca is better than that of generalists, well, you’d better think again.
Another reason is of course pre-test probability of disease. If that is low, specialists are less cost effective, given their tendency to engage in more extensive workups and their higher baseline fees.
Yet a third reason is management of pts with several diseases. Here one generalist blows a team specialists out of the water in terms of cost-effectiveness.
Also Peter writes about precision of diagnosis. Not so fast. I can diagnose a lot things as well or almost as well as most specialists. Treatment is another issue of course.
Finally, this issue has been studied up and down, right and left. A HC system with lots a generalists and relatively fewer specialists is more cost-effective and has lower mortality rates than the other way around. It’s a settled issue.

By: R Watkins

R Watkins — Tue, 17 Nov 2009 21:55:51 +0000

A primary care doc will treat the allergies during the same visit that the patient is being seen for diabetes, hyperlipidemia, depression, and low back pain.
Have you ever seen the work-up an allergist does on a patient with hay fever, to be followed by years of immunotherapy? Very cost effective!

By: Richard

Richard — Tue, 17 Nov 2009 20:16:26 +0000

One if the problems of primary care is finding doctors who want to do it. Maybe the answer is to have more specialists with easier access that will reduce the load on generalists.

By: JustADoc

JustADoc — Tue, 17 Nov 2009 18:42:42 +0000

If there is something unusual about the patient’s complaint or findings or they are not responding to normal treatment than it is reasonable to go to a specialist. However, as much as it is popular to say otherwise, the majority of people respond to the standard treatments quite well. Oftentimes when I have a patient demand a specialist for some relatively normal disease and I send them they come back having had a lot of normal tests and procedures and the same(or equivalent) medicine to what I already had them on or recommended. Well, except that they come back on brand-name Xyzal instead of generic certrizine. So at least the pharamcy companies are happy.

By: Peter

Peter — Tue, 17 Nov 2009 15:02:09 +0000

Specialists are trained to be experts in a narrow field within medicine to the point that they can diagnose and treat with efficiency and precision far better than any primary care physician, knowing the wide range of literature on the subjects to which they devote their careers. Why attempt to manage patients which are not within the physician’s specialty and spend visit after visit trying new things and not succeeding, when a referral out to a specialist could have solved the issue with one consultation? Of course I am being optimistic with this, but there is certainly realistic merit to the article’s hypothesis that specialization can optimize patient management.

Think about the converse: does the article’s argument make less sense than the oft-held argument that someone who does not have extensive training in a specialist’s field should be more capable and more efficient than the specialist?