Thursday, December 24, 2009

Improving primary care conditions or increasing the number of physicians, what should be first? the egg or the chicken? - I think both!

 I have been following with particular interest the ongoing discussion about whether increasing the number of residency slots should be sought as a solution for the ongoing shortage in primary care physicians and general surgeons. Several excellent sources such as the direct newspapers as well as many blogs that I list at the end of this post, have been useful for giving myself a good idea of the different perspectives out there.


Many physicians and analysts have completely opposite points of view; some advocate the increase in the number of residency slots to cover the increased demand of physicians; other disagree considering that this will not resolve the problem but just increase the number of subspecialists.

What does this mean? Why is this discussion relevant?

The way Medicine has evolved in the US, has unfortunately given a dramatic importance to therapeutics and not to prevention. It is fancy to show the dramatic improvement in coronary robotic surgery, the fascinating techniques for laparoscopic bariatric surgery (although this one is moving toward the site of prevention of obesity complications), it is fancy to develop newer and more expensive drugs to treat hypertension, hyperlipidemia, as well as the complications of atherosclerosis. A fascinating story is the development of all the drugs to treat smoking; how much money does a self-destructive habit caused to be spent in an attempt to treat it.

Therapeutic medicine is a necessity, however, I believe that Preventive Medicine with a specific focus on wellness is more important. How many trillions of dollars can be saved if people don’t develop diabetes or hypertension, and myocardial ischemia and strokes could be prevented. How many trillions of dollars could be saved if people would not smoke. If people eat well, exercise, avoid drinking and smoking, and just focus on enjoying our planet with respect for humankind and the environment perhaps a lot of money would be saved, but we are not in the position of having wishful thinkings.

There is concern about spending money in medications the patients need. Unfortunately, once you have developed a chronic disease you won’t really cure it, but you can prevent the complications by means of good control and lifestyle changes. For example, if a hypertensive patient complies with the DASH diet and walks 30 minutes per day, aims to be in the ideal body weight, may need fewer medications as weight loss in addition to increased aerobic capacity and decrease in insulin resistance will be in fact therapeutic as well as prevent further complications; for instance, preventing a single stroke that can be devastating, can save millions in a single person lifetime.

But going back to the beginning of the discussion – we need more emphasis in Primary Care; we need good Family Practitioners, Pediatricians and Internists that will have the aim of educating people to prevent the development of complications of chronic diseases, or even, preventing the development of chronic diseases.
As a hospitalist; in addition to our fascination with acute medicine, we all (at least I do) emphasize in-house in teaching our patients regarding lifestyle changes and encourage the follow up with a good Primary Care Physician.

If you realize that you have spent 8 years to become an MD and 3 or four of training, your least desire is to practice a Medicine that will burn you out and crush any remaining passion for healing and helping others. If you are underpaid, focused on filling a lot of paperwork every day, having a suboptimal timeframe to see patients (10-15 minutes) like a robot, without a real possibility of even having a brief conversation that can enhance the human interaction, and as well you live in uncertainty (due to insurance issues, lack of immediate diagnostic resources, etc.), this is a real uninspiring scenario.

What if the bureaucracy that is so heavily involved in Primary Care would be diluted; what if there would be a more streamlined process to help patients and avoid the doctors filling so much useless paperwork; what if there would be more time to enjoy the interaction with the patients and the opportunity to be more careful and thorough in the patient’s assessment; what if the economic compensation would be substantially improved to enhance the fundamental activity of keeping Americans healthy. What if there would be a real focus on physicians wellness; what if there would be real chances for Primary physicians to update themselves with protected time to study (as this do not exist in a lot of practices); I guess, that would definitely be a very attractive job. But not only we need to change the way it is being done, but we need more physicians – if we’ll see less patients per day as we’ll have more time to see them, then we’ll have need for more docs – we need to increase the source of physicians, and this is done by means of training more internists, pediatricians and family doctors.

Yes, the national healthcare bill is going to go up by increasing residencies, but people don’t realize that residents are in fact extremely underpaid doctors (yes, they are MD's or DO's) and even when working 60 hours, will really work hard. (I was trained in the 120+ hours/week era and regardless, I appreciate that they work very hard nowadays); these residents treat patients; these residents are a cheap source of healthcare providers and will be the future physicians. Paving the road with better work conditions that will be witnessed as an attractive choice for practice, will broaden their perspectives and increase the chances that they remain in Primary Care.

I believe that passion should be the engine behind a decision and not just the money factor. But we need to nurture that passion and changing the conditions for better is part of the process. While improving the current work conditions of Primary Care Providers, their availability should be enhanced so that patients don’t need to wait so long to have the chance of seeing their doctor - we need more docs.

Which will be the best way to improve Primary Care retention? – this is a good question – I advocate decreasing paperwork and improving salaries. Cash only practices, retainer models, are both valid choices that are well explained in Dr. Val and Dr. Centor's blogs. The main thing is to look in the first place for the well being of our patients, as our goal is a stronger America; a better world for our children. Because even in politics, the goal of physicians is always primum non nocere.

References:
http://www.medrants.com/archives/5087
http://www.kevinmd.com/blog/2009/12/adding-residency-slots-improve-primary-care-numbers.html
http://www.nytimes.com/2009/12/23/opinion/23brownlee.html?_r=2
http://www.medrants.com/archives/5104
http://getbetterhealth.com/why-concierge-medicine-is-not-the-solution-to-primary-care-woes/2009.12.12
http://online.wsj.com/article/SB125928189292865761.html
http://blogs.wsj.com/health/2009/11/27/would-adding-residency-slots-solve-the-primary-care-shortage/

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