Health reform’s prejudice against specialist physicians

Have you noticed the recent trend against specialty physicians? Policy experts have determined that primary care needs incentives to attract medical students away from those “highly lucrative” specialties such as plastic surgery, orthopedic surgery, interventional cardiology, and neurosurgery.

Our federal government believes in equal opportunity — if you wish to become a family doctor. There are incentives sponsored by cities, states, Indian reservations, public health service, and more if one wants to become a family doctor in turn for serving in a community. There aren’t many of those for specialists, except perhaps for psychiatrists.

All students have equal opportunity to specialize provided they can navigate the competition for residency spaces in their chosen specialty.  Three specialty groups qualify as primary care in certain settings, OB/GYN, pediatrics, and internal medicine. Wikipedia defines a PCP as a physician who provides both the first contact for a person with an undiagnosed health concern as well as continuing care of varied medical conditions, not limited by cause, organ system, or diagnosis.

Arguments about the quality of care comparing PCPs to specialists have abounded since I  began practicing 40 years ago.

Studies that compare the knowledge base and quality of care provided by generalists versus specialists usually find that the specialists are more knowledgeable and provide better care.However, these studies examine the quality of care in the domain of the specialists.

Studies of the quality of preventive health care find the opposite results – primary care physicians perform best.

I have nothing against primary care doctors. In fact I practiced general medicine in the Navy, and following that for several years in family practice and emergency medicine. I had an exceptional clinical training during medical school, and also in internship.  I had a chance to practice independently in the Navy as well with my duty station on a Naval Aircraft Carrier.  Perhaps I am biased now, because today I see few specialists who are capable of practicing general medicine. They rely on PCPs to screen their patients for surgery thereby increasing their work load significantly. Specialists know more and more about less and less as time goes by.

It takes a smart doc to practice general medicine. It is a very interesting and varied practice, but also quite demanding.

Most specialists do not pick their specialty based on income alone. It is a mixture of lifestyle, knowledge base and the proven ability to exceed or show interest in the specialty to have attracted the attention of a mentor or department head of an elective rotation earlier in their career, usually in medical school. Our current medical education system is now throttled by the fact that there are few free standing PGY-0 programs (that’s medical-ese for internship).  Thus a medical student by the first part of the fourth year has to make a decision based upon medical school experience in an academic environment, which in most cases, is not like real clinical practice in the real world.

The ultimate slap in the face for specialists is the blatant prejudice in the HITECH Act and stimulus funding for electronic medical records and meaningful use.

The Regional Extension Centers (RECs) are specifically designed to develop an HIT workforce and to assist doctors in developing EMRs and funded by the feds allows primary care doctors to use the resource for free, while specialists are required to pay a fee for service. That’s outrageous.  We specialists pay our taxes as well.

The entire structure of HITECH is biased toward publicly funded entities, and community health centers.  The stimulus mandates that the Secretary of HHS allot these funds at his discretion within the parameters of the act.

Is it too late to change these limitations for incentives, and/or RECs? The regulations blatantly discriminate against more than 3/4 of all physicians, and they prioritize PAs. NPs over MDs.

All of the above are issues taking place in the setting of this:

Health reforms prejudice against specialist physicians

Shortages of primary care physicians are an increasing problem in many developed countries. In the United States, the number of medical students entering family practice training dropped by 50% between 1997 and 2005. In 1998, half of internal medicine residents chose primary care, but by 2006, over 80% became specialists. A survey Research by the University of Missouri-Columbia (UMC) and the U.S. Department of Health and Human Services predicts that by 2025 the United States will be short 35,000 to 44,000 adult care primary care physicians.

In 2004, the median income of specialists in the US was twice that of PCPs, and the gap is widening. Causes parallel the evolutionary changes occurring in the US medical system: payment based on quantity of services delivered, not quality; aging of the population increases the prevalence and complexity of chronic health conditions, most of which are handled in primary care settings; and, increasing emphasis on lifestyle changes and preventative measures, often poorly covered by health insurance or not at all.

Where are the AMA and the other societies in this mix? I haven’t heard much about protesting this inequality. Perhaps we should involve our patients in this quest for equal opportunity.

Gary Levin is a physician who blogs at Health Train Express.

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  • md

    I do not understand why specialist physicians must take a hit in order for primary care to become more attractive. Why not make primary care pay higher without touching the specialists? Pay part of their loans. Offer more attractive practice opportunities. What do specialists have to do with the lack of attraction of primary care for medical students? Specialists have longer training in many cases. Specialists often take on more liability and risk in much of what they do. Primary care is also extremely demanding. Why not make primary care more attractive. Leave the specialists alone. We are already taking a beating every day!

  • solo fp

    Under Medicare, since it has fixed total costs, the only way to pay primary care docs is to cut somewhere else. Radiologist and Anesthesiologist have felt the cuts. Hospice and oncology docs are getting hit. It would make more sense to revise the payment system.

  • pcp

    The pay gap between primary care docs and sub-specialists has widened every single year since the RUC was formed. After gobbling up an increasingly large share of the fixed Medicare pie for almost two decades, it’s a little late for the sub-specialists to ask us to all hold hands and sing “Kumbaya.”

  • Angela Caffaratti, MD

    We need to band together. The politicians want to divide and conquer. Obviously, they want to change how we are payed. So if rules change- it doesnt have to be a no sum gain. They really can’t reform without our input. While we can’t form a union, we certainly could unite our efforts. We could come up with something better than we have now.

    • MarylandMD

      If by “we”, you mean the medical profession, I disagree. The system has been dysfunctional for quite a long time and “we” have done nothing to fix it. In fact, physician groups have only been good at saying no to any significant change, or at most just stand by and not oppose. If “we” had it in us to fix things, we would have done it many years ago.

  • MarylandMD

    Wait, is this a joke or something? I feel like I am reading something from The Onion! This article complains about the government creating financial incentives to help primary care physicians, then in the last few paragraphs makes a great argument for why that should be done!

    The government is making baby steps to try to help out primary care and specialists are now whining that they aren’t getting a big enough piece of the pie. As a family physician, it is hard to refrain from venting my spleen or resorting to biting satire, so I will just say this: if you gave this as a talk at an AAFP meeting, you would get laughed out of the room! [If you do give this as a talk at the next AAFP meeting, **please** let us know, because I so want to be there for the "questions" you get at the end!]

  • Steven Reznick MD

    The government, insurance companies and employer sponsored lobbyists of employers who purchase health insurance have already divided and conquered the medical profession. We now have a payment system which robs Peter to pay Paul with increases for one group by law coming from the pocket of another group. When this was created the AMA was struggling to determine how to stay relevant and representative when well funded specialty societies gained tremendous lobbying clout and power. The Medicare payment review commission which essentially sets fees in this country is heavily stacked in favor of specialists vs generalists.
    The issue is attracting candidates to primary care and compensating them fairly so that they can pay off their medical school debt and practice startup costs and still afford a family and a slice of the American dream. Its time to stop the infighting and stop letting the politicians and insurers rip us apart as a profession. Government discrimination against specialties and reduction of pay and benefits is as wrong as the disparity in pay growing larger between generalists and specialists.

  • Angela Caffaratti, MD

    I don’t think we as physicians put our money where our mouth is. We should lobby better. If every family doctor gave fammedpac $1000 a year, we would have more lobbyists than AMA. Needless to say, I think pay needs to reflect the costs of doing business. This is where generalists lose out. It can’t be about which doctors deserve more. It has to reflect costs of doing business. I think we need to work together.

    • stitch

      Glad you have an extra K around to give. I don’t. And if I did, I’d certainly have a problem giving it to lobbyists who would wind up making more than I do.

  • inchoate but earnest

    Dr Levin, you really have to stop personally sampling all that stuff in your medicine cabinet…..

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