Should the primary physicians run medicine?

SHOULD THE PRIMARY PHYSICIANS RUN MEDICINE?

I’m a retired neurosurgeon, age 66. While I was in practice it took me a long time to get a primary physician, even though I’m a doctor myself. The only doctor I saw for years was my urologist after I passed kidney stones at the age of 40 and again 14 years later. When I approached 60, he insisted that I get a real primary doctor. Subsequent health events proved him right.

The whole nation may go through the change of doctors I went through. The new health care bill making its way through the Congress encourages a shift in residency training in an attempt to increase the number of family practitioners and general internists. The legislators believe that primary care physicians, unlike specialists, coordinate care among groups of doctors, order fewer tests, and do few procedures and operations on their own, thus keeping down costs while getting good outcomes.

The requirements for family doctors are more rigorous than those for the old time general practitioners. There are residency training programs, board certification and recertification. These doctors see adults and children in their practices. General internists see adults only.

Two main questions arise with regard to the role of the primary physician in the future of American health care. The first involves the effect of putting them in charge. The advocates say that this is not a reprise of the gatekeeper/managed care model. The gatekeeper was perceived, often correctly, as blocking patients from receiving needed care. There was a period of several years during the heyday of the gate keeper system when I saw patients with brain tumors of enormous size that I never thought I would see again in the CT-MRI era. They all had been in managed care settings.The newer model primary doctor both sees to it that needed care is given and that unnecessary wasteful tests and referrals are prevented. The difference between the old and new models is subtle. I have seen the most aggressive gate keepers make needed referrals.

The evidence that primary doctors do a better job running medical systems comes in large part from the study of healthcare abroad, chiefly that in Sweden. Finland and Spain had similar experiences. Following World War II the Swedes decided to make a major investment in the training of specialists and building hospitals. They found that health care costs went through the roof when the number of tests, procedures and operations expanded enormously. The Swedes had more control over the number and types of doctors than we do and they turned their system around to weight it more heavily towards providing primary care. Costs went down as a result but the quality of care remained good. Cost comparisons almost invariably favor primary physicians.

The medical journal papers advocating the expansion of the numbers and influence of primary doctors are especially light on one driver of specialization, the expansion of medical knowledge beyond the grasp of an individual doctor. Little is said also about the hospitalist movement, in which general internists who work for hospitals take care of patients when they are in the hospital separating them from their own primary doctors who are relegated, especially by the HMOs, to do office work only. This arrangement weakens the bond between the doctor and her hospitalized patient. The skills of the office doctor atrophy from the lack of the more demanding hospital work.

This leads to the second overall question: Are the primary physicians really as good doctors as the specialists when outcomes are used as the yardstick? A study on mortality in heart attack patients who received a variety of post hospitalization follow up office care was published in the New England Journal of Medicine in 2002. It showed that specialists provide an important contribution to outcomes. Patients whose follow-up care was exclusively with cardiologists did better than those followed by primary doctors alone. However, patients followed by both primary doctors and cardiologists did even better. The first finding suggests (not proves) that there are aspects of care that cardiologists provide that are superior to what a primary physician alone can do. The second is consistent with a synergy between the two types of doctors.

A study from the University of Rochester School of Medicine in 1998 compared 5 year outcomes and costs between groups of patients whose personal doctor was either a specialist or a generalist. The outcomes in terms of both cost and mortality were significantly better in the hands of the primary doctors.

Another way of finding answers as to how best to treat patients is a metanalysis. This is a default strategy when there are no Class I or prospective controlled studies to provide a solution. Class I studies are the gold coin of clinical research. A metanalysis is a statistical combination of multiple small studies in an attempt to find one big answer. One Harvard based group of investigators looked at all the medical journal papers since 1980 dealing with outcomes in the hands of specialists vs. primary physicians. 49 studies were scrutinized and combined. 24 favored the specialists, only 8 the generalists. The authors concluded, however, that the metanalysis was inconclusive because of problems of method within the individual studies. Furthermore, only 8 of the studies involved integrated systems where primary physicians are most likely to shine. Further research was recommended by the authors.

All the promoters of primary care as a solution to increasing health care costs admit that they are bucking the societal tide. Fewer family doctors are being trained. Family practice residencies have shut down in the last few years for lack of medical graduates to fill their rosters. This phenomenon is tied strongly to lower reimbursements relative to those of specialists. When a brand new physician gets out of medical school with $100,000 or more in educational debt she has a strong incentive to specialize.

There has long been a cultural bias that medical schools in general present against non-specialists, although now many medical schools have departments of family practice. Things changed in the 70s when there were patches of encouragement for people to go into family medicine. The neophytes were told that they were the patients’ real doctors and that they served a great social good. The miniboom in family practitioners went on for a while only to lose a great deal of steam in the past ten years. According to Shannon Brownlee, writing in the Atlantic Monthly in 2007, “Medical schools are now graduating more and more specialists and fewer and fewer primary-care physicians. Between 1997 and 2005, the number of U.S. medical graduates entering family-practice residencies fell by 50 percent, as young doctors headed for more-lucrative specialties like orthopedic surgery and radiology.” At my 400 bed community hospital only one family practice doctor was still active in 2003 and he represented a department of one on the medical executive committee. It had shrunk from 15 members thirty years earlier. With his blessings, we moved him into the medicine department with the general internists and the specialists.

The healthcare reform bill will increase payments for services performed by primary doctors. This has been tried before with limited success. One version of the bill, HR3200, provides for a 5% hike in payments to primary physicians, 10% in underserved areas. Such an increase is unlikely to encourage medical graduates to enter primary care because the earnings gap between generalists and specialists will still remain great. This modest raise has garnered opposition because the specialists fear that they will have to take a cut in reimbursements.

The Dartmouth Atlas, a massive compendium and analysis of regional medical costs, has said that increasing the number of primary physicians would not decrease health costs because other pressures, especially supply sensitive care, the bête noire of the Dartmouth analysts, would block any advantage. Supply sensitive care is unnecessary care driven by the availability of hospital beds and specialists. Sweden, Finland and Spain limited supply sensitive care by increasing the number of primary doctors and stabilizing the number of beds. The modulating role of primary phsyicians had more to do with cost control than just their numbers.

For over 40 years, Medicare has generously underwritten hospitals that employ residents based on the number of residency slots. HR3200 uses this fiscal authority to encourage and support primary care residency programs. At the same time it puts downward pressure on the other training programs within the hospitals where residency slots have been vacant by reducing payments to the hospitals. In a specialty such as general surgery, much needed by the public, there has already been downward pressure on the number of residents nationwide because of low reimbursements. There are 4 per cent fewer general surgeons than a decade ago, which translates to a 20 percent reduction on a per population basis. My concern is that this part of HR3200 could further depress the numbers of general surgeons.

In sum, I believe that in spite of the anecdotal, retrospective, and sometimes contradictory nature of the scientific evidence, primary care needs to be promoted as part of the solution to healthcare costs, but in the right way. The numbers of primary physicians are not as important as their wise system management in promoting health and reducing costs.