I figured it out! I realized what the basic, underlying, fundamental problem is with medical care in this country.
The problem is that it’s too expensive and often isn’t very good, but that’s clear.
The reason medical care in this country is fragmented and overly expensive is that there is a perverse inversion of the correct ratio between primary care and specialty physicians (should be significantly greater than one, instead of significantly less). That, too, is perfectly clear.
But what is the reason for this ridiculous state of affairs, where specialists outnumber primaries 20 to 1 instead of vice versa? Most people point to economic disparities, with towering specialist incomes dwarfing that of primary care, due in large part to the perverse payment incentives for “doing something” (ie, procedures) instead of thinking about, talking with, and counseling patients.
I don’t think that’s it.
Here it is:
95% of American medical graduates don’t have what it takes.
Primary care is medicine in its purest form. Family medicine, pediatrics, general internal medicine; primary care, defined as the generalist physician caring for a patient (as opposed to an organ system or a disease) over the long haul, is what medicine is really about. It’s hard. It’s challenging. But it is rewarding in a more deeply authentic way than any other field of medicine.
The rewards offered by the specialties are more immediate, but they are also short term and finite. It’s no wonder that they attract graduates without the emotional stamina required for primary care.
Most of them try to tell us that we’re the dumb ones; the bottom of the class; the ones who don’t have what it takes. This is nothing but projection on their part. Grade ranking in medical school is a meaningless fiction. You have to be the cream of the cream of the crop just to be admitted. Once you’re in, you don’t suddenly become dumb. Besides, the essence of medical school course work is geared to passing the three steps of the United States Medical Licensing exam. Once you’ve passed those, you’re licensed. That’s all it takes. All the other evaluations and grading schemes that reward top performers with dermatology and ophthalmology training slots are nothing but exercises in meaningless memorization that contributes nothing to caring for actual patients.
I suspect that more students start out having what it takes. It’s too bad that so many of them lose the passion for real medicine as they progress through training, and end up settling for the pursuit of one or another tiny sliver of knowledge that they’ll never fully achieve anyway. Between the inherent challenges of primary care and the naysaying peer pressure, I suppose it’s inevitable.
But it’s still wrong.
Primary care is awesome! The only reason so few people choose it must be that 95% of American medical students don’t have what it takes.
Lucy Hornstein is a family physician who blogs at Musings of a Dinosaur, and is the author of Declarations of a Dinosaur: 10 Laws I’ve Learned as a Family Doctor.