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:

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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