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Specialists or Not

Where are the medical specialists when you need them? Overworked. What happened to our healthcare system to incentivize specialists to provide most of the care to patients with primary care problems? What happened to the gatekeeper mentality of the primary care physician? The healthcare industry has made massive strides to depersonalize the human condition which in turn encourages an economic feeding frenzy related to each diagnosis assigned to patients.

During my medical school days, I had the honor of learning under some of the most benevolent physicians of our time. These were feeling physicians with knowledge and compassion for the practice of medicine. I vividly remember specialists consulting on medical cases in the hospital and their offices. These were physicians in solo or two-physician practices who believed in educating the primary care physician about management of illness as they cared for patients. Their philosophy was simple: teach the primary care physician so they could care for the patient themselves. Specialists routinely returned patients to their primary care doctor with advice on the appropriate therapy. It was up to the primary care physician to administer it. The primary care physician would carry out the treatment if they believed there was no contraindication to the opinion. If something were amiss, the primary care physician would speak to the specialist and clarify the consultation. Specialists desired to consult, not provide chronic recurrent episodic care to outpatients. Specialists were hospital-based and seldom kept office hours. Some would evaluate patients with an acute change in their condition in the emergency department since they did not have a large office setting to practice within.

Primary care physicians were dedicated to caring for their patients and seldom if ever gave up their care of their patient to the specialists. Everyone got alone. There were no turf wars. Patients wanted their primary care physicians to be in their corner and entrusted them with their lives. I do not remember a primary care physician employing physician extenders to care for their patients. Nurse practitioners and physician assistants were rare in the late 1970’s.

What happened? Physicians retired and sold their practices to physicians who assumed their patients. New specialists did not have to build a practice; it was already populated. Reimbursements changed. Medical school instruction changed. Medical schools no longer were funded by State and US Federal Tax dollars. Physician teachers were given patient care responsibilities to generate income to pay for their salaries. Researchers could apply for patents on inventions and new medications which produced a more significant return on their time investments. Specialists rolled out a revenue generation model which meant they had to provide chronic episodic care to their patients instead of a consultation. Primary care physicians embraced the transfer since they wanted less responsibility for each patient. Patients thought they would get better care from specialists which hurt the reputations of primary care physicians.

When I worked at UT Medical Group, I had a conversation with the Dean of the medical school. Incidentally, he is no longer the Dean since he was relatively ineffective at leading the school. The Dean told me to refer patients with various symptoms to specialists for care instead of me working them up, getting the proper diagnosis, initiating appropriate standard of care treatment, and following the patient until I deemed it necessary for them to see a specialist. He was adamant that my approach which focused on fixing the problem instead of managing the disease was a poor choice for running a business. He wanted me to conform to the practice plan and refer any illness I could to the specialists. The referrals generated procedures; procedures generated the revenue. I told him that I would not comply since doing so would create confusion for my patients when they did not need to see a specialist. We both agreed I needed to leave UT Medical Group since I refused to abide by his demands. He said that I would quickly fail if I struck out on my own since I did not encourage frequent patient visits and constant control of writing prescriptions monthly. The rest is history.

Specialists have taken over the chronic care of any patient they can fit into their schedule on a three- or six-month rotation. When I moved to Memphis in 1991, one of the area cardiology groups had eight or ten cardiologists covering six hospitals and outpatient clinics. Now that group has forty-four cardiologists. Their office is cattle call daily. Pharmaceutical representatives come and go all day; patients might wait for hours to see a physician for a five- to seven-minute visit. The specialists have given the responsibility of their facility’s operation to a local hospital so they would not have to fool with managing the non-physician staff and associates. Mostly, they have given up the control of their practice to Mephistopheles.

Most of the specialists in town have long wait periods to see new patients because the chronically ill saturate their practices. The specialists manage disease in a vacuum, paying little or no attention to the other illnesses plaguing the patient. The cure is never an option.

On the other side of the coin, primary care physicians have changed too. They seldom, if ever, provide a diagnosis or render care. Most of them have nurse practitioners see patients; the primary care physician oversees the activity. From what I have witnessed, they provide very little oversight. Patients get their refills and brief encounters of the third kind. The primary care system in general funnels almost every care decision to specialists. The average American has five chronic illnesses when they hit their sixties.

That means five different specialist and one primary care doctor every three months. The economic cost to the healthcare system is overwhelming. The emotional loss to the patient is unacceptable.

How would the system change? The only way is for catastrophe to implode healthcare. And out of the ashes will emerge a better, more sound, individualized care system. Or not!

Doc  

 

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