As we continue to discuss cost-effective medicine, the need for health insurance reform and other topics
du jour, I'd like to take a moment to focus on a rather relevant aspect of health policy. This is a topic that everyone probably has heard about, but one that no one is quite sure how to address. Current evidence suggests health systems focusing on primary care provide greater access to higher quality care and at lower costs. As current health reform continues to be debated, this issue becomes particularly important for primary care physicians seeing the effects of the current system every day. It is one thing to discuss support of health for every American, it is quite another to actually do it - and I'm not talking just about insurance. We need support for physicians who are going to go into general practice - either general internal medicine, general pediatrics, or family medicine. It isn't realistic to expect highly trained specialists to manage multiple social issues and address the complex nature of multiple chronic medical problems for all their patients, but as the majority of medical graduates go onto practice in specialties like cardiology, orthopedics, radiology and anesthesia, there are fewer generalists to go around.
I'd like to make the case that generalists - be they internal medicine docs who see adults, pediatricians who see kids, or family physicians who do both, are best suited to address the health care needs of the majority of patients of all ages and in all geographic areas throughout the United States. In fact, we already know that health systems which emphasize generalist ("primary") care provide higher quality care at lower cost (1, 2). Other studies are finding evidence that obesity and related medical conditions decrease when there are enough generalists practicing in a community (3). Communities in which there is a higher proportion of generalists also benefit from:
- reduced all-cause mortality
- decreased emergency room and hospital utilization rates
- reduced medical waste from unnecessary testing and procedures
What is interesting to know is that not all generalists are trained in the same way, and so the number of practicing generalists tends to vary by type of training program. For example, statistics about graduating and practicing physicians demonstrate that the doctors most likely to practice general ("primary care") medicine throughout their careers are family physicians. Approximately 90% of family medicine physicians-in-training ("residents") go on to practice general primary care medicine for their entire careers. For pediatricians, only 75% of pediatrics residents continue to practice primary care, and only 19% of internal medicine doctors continue to practice general medicine while the remaining group of trainees go on to specialties or sub-specialties in particular areas of care like cardiology, nephrology, sports medicine and the like (4). Family medicine is the only discipline where training is exclusively dedicated to primary care. Family physicians receive training in six major clinical areas: pediatrics, internal medicine, obstetrics/gynecology, psychiatry/neurology, surgery and community medicine. They also receive instruction in geriatrics, emergency medicine, ophthalmology, radiology, orthopedics, otolaryngology and urology. As a result, family physicians are capable of providing a majority of health care that people need on an ongoing basis. These types of physicians are also more likely to practice in underserved areas, like rural areas or inner-city community clinics, where the need is greatest. Our society needs general practitioners. We are not made up of organs only, we are human. We need someone to be looking at the whole picture, someone to help us discuss end-of-life care issues with our families and elderly parents. Someone who can explain why it is important for a family member to see three different doctors to control her diabetes and heart failure. The system is too complex to assume patients can navigate the waters on their own...which may be why patients with chronic conditions often see the progression of their disease as something beyond their own control.
I believe that until we truly support incentives to increase the number of general practitioners, the health needs of our country will continue to go unmet - whether health insurance reform passes or not. I am not suggesting that we choose which areas of medicine students select as their specialty, or even that we require service in primary care of every trainee. What I am suggesting is that we need to recognize that the results of health care personnel shortages, increased need for doctors that practice in rural areas, and increased need for doctors who can care for the elderly and geriatric population, will place a heavy burden on our already crippled health system. We must decide how to address the issue creatively, so that we have an adequate supply of generalists who can treat chronic disease and work with their patients to prevent complications of those diseases. These are not conditions that can be easily fixed by a surgeon or a heart doctor working in a specialty group. We need generalists who can coordinate care for the elderly, who can work directly with social services and other members of the health care team, and who can devote a 15 minute visit to a discussion about quitting smoking or lifestyle changes to increase a persons level of activity. Otherwise, we risk becoming a population of overweight amputees on dialysis as a result of "poorly controlled" chronic disease.
(1) Macinko, J, et al. The Contribution of Primary Care Systems to Health Outcomes Within OECD Countries, 1970-1998. Health Serv Res 2003 June; (3):831-65.
(2) Starfield B, et al. Contributions of Primary Care to Health Systems and Health. The Millbank Quarterly, Vol 83 (3) 2005, 457-502.
(3)Gaglioti A, et al. Primary care's ecologic impact on obesity. Am Fam Physician. 79(6):446.
(4) Althouse, L and Stockman J. Pediatric workforse: a look at general pediatrics data from the American Board of Pediatrics. Journal of Pediatrics 2006, 148(2): 166-9.