quinta-feira, 6 de outubro de 2011

Yes, Alex, There Are Smart Primary Care Doctors!!!!!!!!!!

Yes, Alex, There Are Smart Primary Care Doctors

Robert M. Centor, MD; Larry Culpepper, MD, MPH; Bradley P. Fox, MD; Harvey B. Simon, MD; Robert W. Morrow, MD; Charles P. Vega, MD

Posted: 09/23/2011

Introduction From the Editor

This summer, Alex Folkl, a Medscape student blogger, wrote an entry called "I'm Too Smart for Primary Care", which concerns his interest in going into primary care and the opposition that he has encountered by other individuals who say he "can do better." We asked our Primary Care Roundtable members to respond to this young man with some advice. As always, they were not shy with their opinions.

Advice From the Academic PCP

Robert Centor, MD

The "hidden curriculum" in most academic medical centers creates an atmosphere that encourages inane statements like "you are too smart for family medicine."

We live in a society that overvalues subspecialization and undervalues the generalist. Yet when patients have an undifferentiated presentation, the expert generalist has the breadth necessary to solve the diagnostic puzzle.

Patients need both subspecialists and generalists. Both outpatient medicine and inpatient medicine patients do best with a generalist most of the time. Some diagnoses benefit greatly from a subspecialist. Patients with less common diagnoses (eg, system lupus erythematosus, diffuse interstitial pneumonitis, Crohn's ileitis, hypertrophic obstructive cardiomyopathy) can benefit from a physician who sees a larger number of such patients taking primary responsibility for care. As a generalist, I just will not see enough of those diagnoses to know the latest therapeutic data nor the complications that one might expect. Volume does matter, and thus our patients do best when they see a physician who has seen the appropriate volume of that diagnosis.

But this is not an intelligence question. I believe that being a great generalist requires smarts. We have to know a great deal about many things. We have to become great diagnosticians, because patients do not present with diagnoses stamped on their foreheads.

Family medicine requires great intelligence and great patient skills. Our healthcare system would benefit greatly if our best and brightest entered family medicine, pediatrics, or internal medicine. To suggest otherwise shows an arrogance, disdain, and poor understanding of the daily work of generalists.

Charles Vega, MD

Dr. Centor is spot-on in his appraisal of generalism. There are excellent studies that demonstrate that the presence of primary care physicians helps people live longer and better lives. Furthermore, primary care physicians frequently provide care in areas in which specialists are few and far between.

Having spent some extra minutes in the hospital this afternoon to help a medical student with her personal statement, I'd like to address a different aspect of Mr. Folkl's thoughtful post. Just who are these physicians who demean other specialties, and how does that behavior jibe with any notion of professionalism and teamwork in a medical or teaching environment? Mentoring students is a tremendous honor and not something to be taken lightly. A responsive and understanding mentor can make a tremendous difference in helping students find their path to success.

But we should keep in mind that it's their path. As mentors, we may advise and nudge, but tearing away at the fabric of a student's goals because of our personal biases is unacceptable. The saddest thing to read in the comments following Mr. Folkl's post is that this practice appears to be all too common around the world. That says something about human nature and the profession of medicine.

I would hope that we can transcend specialty-bashing. It serves no one. Medical students received all those outstanding grades for a good reason -- they're intelligent. And they can easily sense that unnecessarily denigrating another physician, care center, or entire specialty speaks more to the insecurity and weakness of the person doing the bashing than any true deficiency in those people or systems.

Provide constructive feedback, encourage the next generation of caregivers, and let them follow their dreams. It's a tremendously rewarding experience. And save the vitriol for your pet (he or she will surely understand you) or some blog that no one will care to read.

Mark Williams, MD

Geriatrics is an important subset of primary care. When I entered the field in the late 1970s (please do not do the math) I was greeted with the same reaction: "Why would someone like you want to go into geriatrics?" Things have not changed at all over 30 years and the gap between trained geriatricians and the demographics of our elderly population grows more compelling with each census.

Larry Culpepper, MD

While I agree wholeheartedly with the prior comments, there is an additional dimension to explore: What is the role of the mentor/faculty regarding career counseling of students?

An approach that demeans another specialty is highly suspect to say the least, and egocentric, immature, self-defeating, and unprofessional as well. A faculty member's role should be to help students discover the paths that are best for them, which often means supporting students in looking inside as well as out.

The conversation really ought to be about the student -- what aspirations, interests, and motivations drive them. What is their tolerance for ambiguity and imperfection? For midnight or weekend hours? For complexity? What is their need for status? For money? For quiet moments with patients and human connections? For the sense of accomplishment from perfection on technically difficulty procedures? Do they have the capacity to emotionally support others? Can they draw strength from providing such support or is it only draining?

Is their perspective on various specialties realistic? Do they understand the difference between the academic medical center and real life for most physicians? And especially for primary care specialties?

Simply, to give advice we need to know the person inside the student. And once we do we must not betray the trust that usually accompanies the revelation. It needs to be about them. Not us.

Advice (With a Bit of a Tussle) From the Practicing PCP

Robert Morrow, MD

So a patient walked into my exam room this week. I say "walked," but his gait was markedly more ataxic than usual. An 82-year-old schizophrenic with tardive dyskinesia, he was upset because he could no longer walk with security.

What happened? Seems he went to a cardiologist, who decided that with a normal echocardiogram, and no pain, he needed a cardiac catheter, which revealed 1-vessel disease, which is best controlled by medication. But the dye and the long procedure left this marginal gentleman, the patient, with a large setback.

A university cardiologist -- what's up with this? Perhaps the need for a July patient for the new fellows?

Likely, the cardiologist saw the patient through his own frame and did what he thought was right. Which is why we need primary care practices to look after the health and well-being of our patients. No, I was not called, and still haven't received a consult note.

Some call this the Barber Rule: If you go to a barber, you get a haircut. This is the intellectual myopia of the proceduralist. They see the world through the lens of how they address a symptom complex.

Barbara Starfield wrote well about this organification of symptoms.[1] She pointed out that diabetes is not specific to an organ but to a biosocial matrix, among other things. Organification makes life easier for proceduralists, who then don't need to be smart. Ever pass a colonoscope? I used to do sigmoidoscopies. Not as hard as assessing dementia. Or depression.

Primary care is the intellectual matrix that protects the health of people. It needs smart scientists and smart practitioners to succeed. It is unpredictable. It is the area where innovation must be implemented, and the same-old is never good enough. This burning need to elevate the US infant mortality rate from dead last of industrial countries is why we must seize the intellectual high ground in academic centers. We have the political high ground, and no health systems scientist feels otherwise. But our work is seen as intellectually the equivalent of flipping burgers.

So let's cut the nonsense about students being "too smart" for primary care. It's the schools that are too undertrained to teach real population care and quality improvement, and which settle for the low-hanging -- but highly reimbursable -- fruit of routinized procedures. That's not intelligence; that's greed. To err is human; to deny care to a population through training yet another ophthalmologist is somewhat less.

Dennis Salisbury, MD

The question is, of course, flawed. Medicine and patients suffer when students are led to believe that primary care or partialist (specialist) care requires smarter doctors. A better question, I think, is whether there are any fields in medicine that don't require a huge level of intelligence. Some, like primary care, require higher degrees of emotional intelligence, systems thinking, ability to see widely and not narrowly, etc, while still having high traditional IQ. If there is a field in medicine that doesn't require high levels of intelligence, then why is it there at all and not relegated to some other discipline?

The question comes, I believe, because in med school various partialties have required very high grades for entrance, and primary care specialties have had to "scrounge" to fill program seats available. This, however, reflects much more on payment schema and status than the inherent need for high IQs in the respective areas. It also reflects on the culture of academic medical centers. I'd be surprised if most of us didn't hear some similar statement during school, even if it has been so many years ago that it is hard for us to cut through the haze and remember.

The problem with partialists is that they believe they are smarter and therefore see "the big picture" better than the unwashed primary care masses. If they would believe they see only a part of the picture -- an important part, but a part nevertheless -- we could all provide better care and patients -- and the healthcare spending of the United States -- would be better off for it.

Just had my Medicare discounted to 80% of allowable, soon to be 29.5% lower.

Brad Fox, MD

For the sake of making a different statement, I am going to play a different angle on this. I agree with all of the other commentators, but how about a little cynicism?

Within the current medical paradigm, where physicians are paid to fix problems and where healthcare is relegated to illcare, and the sustainable growth rate (SGR) controls physician payment, and the Relative Value Update Committee (RUC) decides what service is more valuable when compared with another, the smart physician will choose to subspecialize or become a proceduralist because that is the pathway to financial success.

Think about it: "Too smart" can be looked at from a business standpoint. When you are coming out of medical school with debts in the $200,000 range or more, is it smart to go into primary care? I think not. The real money is in LASIK surgery. The real money is in super-subspecialization.

I long for the day when those who pay the medical bills realize what most other countries in the civilized world understand: The best healthcare is preventive care -- health management rather than illness treatment; when the payment scales reflect the value of prevention à la the patient-centered medical home concept; and when the physicians who can work with the whole patient to manage disease states and prevent complications are the ones who will take home the higher payments for services. I look forward to this change in paradigm because then, and only then, will we hear the comment "You are too smart to specialize; you really should go into primary care."

Not as profound as Bob's comments, but I believe this touches on a point not yet spoken.

Dennis Salisbury, MD

Brad, points well made and -taken. I agree that we don't all make our decisions financially and then find ourselves stuck with the results and have to find a way through. However, I still think it is smarter to choose what you love and remember that paying down mountainous debt can still be done in primary care, as long as a Porsche and a second and a third home aren't high on one's list of priorities.

Brad Fox, MD

Well, Dennis, when I went to medical school, I actually made some smart choices. I went to a school with a tuition of $5500 per year (yes, year -- not month) and I then could financially afford to chose the specialty that did not offer the highest remuneration (which happens to be the specialty which I was born to join). I then was able to negotiate a contract after residency that paid off my $60,000 in loans over the first 3 years of employment. So I guess it is not bad to jump into a field where I am still in the top 10% of income in the country since I did not start out far in the hole. I would argue that parents should make all their children actors or athletes or politicians if they want more money than they can use and lifetime security for minimal work.

I digress. You are correct: The smart ones do not go into medicine if they want to make money, but once they have made that one flawed decision to attend medical school for whatever reason, it is the smart ones who go for the best damage control and, therefore, the best financial gain.

I am not sure if that is good for the roundtable, but it felt good to say it.

Robert Morrow, MD

That's all well and good, Dennis, that we choose a pathway that fits our life choices. But we swim in an economic ocean, and the salinity has changed over the last few years as health plans have become larger corporate monopolies, and the health centers have followed along, building proprietary empires and brands.

These monopolies have driven down the fees for primary care over the last 10 or so years, creating wider disparities than when I made my choices in the '70s. I feel this reflects the reality that health plans make a percentage of the health trade. So if they get, say, a $22 taste for each $100 spent on care, is it better for them to have the system spend more or less? You do the math, but a broker makes more with a higher selling price.

So how do we fight this pollution of our business environment? How do we make the system stand on a primary care foundation that is attractive again to students? Strict limitations on health plans and strong incentives for primary care. This is not an individual's decision. This is an economic and social phenomenon and requires the right incentives.

Intellectual rigor historically has had quite little to do with these decisions, except in the sense that NIH panels have very little knowledge of the science of primary care and a very great desire to fund scientists like themselves, yielding disproportionate funding of narrow subspecialty enterprises.

Harvey Simon, MD

Primary care is the backbone of American medicine. It has always been that way, whether we are called GPs, internists, family docs, personal physicians, or PCPs. But in the 21st century, primary care is under pressure from many quarters.

At one extreme, HMOs treat us as gatekeepers and not caregivers, as providers who supply services to clients and not as physicians who take care of patients. At the other end of the spectrum, we are challenged by what Dr. James Li of the Mayo Clinic calls "the tyranny of the objective."[2] Good doctors have always been guided by the best available science. But as evidence-based medicine spawns standardized guidelines and the pay-for-performance system that will soon take effect, the science of medicine threatens to squeeze out the art, the human element that is also vital for patient care. Add packed office schedules, piles of paperwork, a litigious atmosphere, the crush of phone calls and emails, and the onrush of new information and it's easy to lose sight of who we are and what we do best.

Let's spend a moment thinking about what makes the specialty of primary care both special and primary.

Primarily, it's caring. "One of the essential qualities of the physician is interest in humanity, for the secret of the care of the patient is in caring for the patient." Dr. Francis Weld Peabody accompanied his famous dictum with some equally important wisdom: "The treatment of disease must be completely impersonal; the treatment of a patient must be completely personal." The great Harvard physician's insights are as important now as they were in 1926, but his goals are harder to achieve in today's complex healthcare environment.

Primary care specialists know that medicine is a science but healing is an art. Our task is to master both, to learn the science and apply it wisely and also to build durable, trusting, therapeutic relationships with our patients. Our patients want and deserve both, and so do we. At the end of the day, caring physicians gain as much from their patients as they give.

All medical specialties are worthy, valuable, and important -- but ours is the only one with "care" in its name.


  1. Starfield B. Family medicine should shape reform, not vice versa. Fam Pract Manag. 2009;16:6-7.
  2. Li JT. The quality of caring. Mayo Clin Proc. 2006;81:294-296.

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