Why a shortage of primary care physicians?

August 18,2012

YJHM

 Mr. John C. Goodman’s opinion piece: “John C. Goodman:why the doctor can’t see you”: in the August 15 issue of the Wall Street Journal has some interesting ideas but by placing the cart before the horse he overlooks the rarely mentioned fact why a shortage of primary care doctors exists in the first place!

Primary care has withered because it has been forced into the research-oriented programs that were created following Abraham Flexner’s scathing report in 1910 on the deficiencies of medical education that existed. The system that he fostered was based on the German system which was rooted in research. The changes he instituted were good but they were carried to an extreme and research became the core of medical education and finally, its cynosure.

Practical medicine, the best example of which is primary care was relegated to and has remained a second-class entity in the medical hierarchy for the past 100 years.

Sir William Osler a respected physician, teacher, and author differed with Flexner on which direction medical education should take. He preferred a dual path, one for “practical” medicine and one for research. The former would take place in hospitals by part-time community-based physicians and the latter in research institutes.  But Flexner aided by the power and influence of the Carnegie Institute and the Rockefeller Foundation prevailed.

Some believe that the shortage of primary care physicians is one of the unintended consequences of the Flexnerian vision of medical education.  However, it will be difficult to reverse a trend that has been in place for over a hundred years and one which has brought much benefit.

Be this as it may, customizing education for primary care doctors is the first best step to take to addressing the shortage.  How can this be done?  Subjects like organic chemistry, physics, and biochemistry are of little benefit to primary care physicians.  They consume an inordinate amount of time and may even act as deterrents to some who have neither the interest nor the aptitude for them to pursue a career in medicine, particularly in primary care.  If they were customized at least two and maybe even three years could be shaved off the current 12 years it takes to train a primary care doctor.

Unlike many specialties, primary care is practice-oriented not research-oriented. And since primary care physicians learn their practical skills in residency, not in medical school or pre-med, a fact that is never mentioned, customizing the basic sciences by simplifying them or combining or even eliminating some of them would shorten the pre-residency training period. This would not solve the primary care shortage but it would increase their numbers.

Mr. Goodman’s concerns are good but they do not explain the whole problem.

Edward J. Volpintesta MD

Too many checks and balances not good for doctors or patients

August 17, 2012

The New Yorker

 Letter to the Editor

In the August 13 issue  Atul Gawande offers some interesting opinions on how health care could be improved in the hospital setting by copying some of the strategies used by restaurants when they strive to improve their service and the quality of their fare.

Ideally he is right but if the analogies he presents are carried out far enough they begin to wobble a bit. Physicians in hospitals are usually working under difficult conditions that are quite different from those in restaurants. Restaurants do not deal with life and death conditions. They deal with customers  with varying degrees of expectation on the food they eat;  who enter restaurants in a good mood looking forward to a pleasant experience. They do not wonder if they will come out of the establishment alive or maimed or maybe even dead.

Physicians on the other hand often have to deal with not just the patient in front of them but often with one or several family members, many of whom have questions that are hard to answer. Where did the physician attend school? Was he certified by a board? How many times did he do the operation?

What was he/her success/failure rate? Was he ever sued for malpractice? Sometimes they have to answer telephone questions from a relative on the other side of the country; answering them takes time and is wearying. Misunderstandings take place on the phone. Informed consents take time and generate more questions and doubts.

Often it takes days before a diagnosis can be made. All of this is done under the duress of insurers’ regulations hounding them to discharge the patient within the time allotted for the disease being treated.

What if some of these adversities existed in the restaurant business. Imagine a diner after sitting down being told that he/she had one hour to consume a steak dinner but only one-half hour for poached salmon. And that if they didn’t comply they might be ejected from the hospital after only eating part of their meal. Or that if while the meal was being prepared, a relative called and questioned the cook’s qualifications, which cooking school he had attended, and was he certified by the national board of restaurateurs?

Clearly some of Atul Gawande’s ideas are worth considering such as closer monitoring of patients in the ICU.

But I wish he had taken a more sympathetic view of the work that physicians do and the ever-increasing responsibilities they assume every day. Physicians do not have the automaton-like qualities that the reader is likely to assume after studying his informative and thought-provoking essay. Too many checks and balances will paralyze physicians’ thought processes. Check lists will get longer and longer in the quest for perfection.  The patient will become secondary while the check lists will take center stage. Doctors will be judges not only by their results but by how well they adhered to their check lists.

These days it is common and even expected that physicians are in need of criticism. Some of it is fair but some is misguided. There are many pressures brought to bear on physicians from many quarters beside those I mentioned.

Medicine is often referred to as an art. And like any art there is going to be a certain amount of “waste” and false starts and yes, mistakes.

It is important for policymakers to remember as they strive to make medical practice safer not in the words of Voltaire  to make perfection the enemy of the good.

Edward J. Volpintesta MD

Physicians are more than medical scientists

In a recent Wall Street Journal article, a recognized expert overseeing physician certifying exams recently wrote that physicians” are at their core” medical scientists. No one would deny that physicians depend heavily on scientific evidence.

But the best physicians’ dependence on science is tempered by an equal dependence on things that cannot be categorized as scientific because they are not measurable. Compassion, ability to talk and listen to patients, and the ability to form long and trusting relationships with them are just a few of the humanitarian qualities that are necessary to round out the “complete” physician. My response follows:

July 10, 2012

Wall Street Journal

Letters to the Editor

In her letter “The Right to Health Care Means Little Without Doctors” of July 10 Christine Cassels, MD mentions that doctors are essentially scientists and that they are accustomed to being tested. She implies that scientific prowess defines the competent physician.

But scientific competence alone is not what many patients are looking for in their physicians. They want a doctor who is compassionate, listens and talks to them, and who acts in their best interests regardless of any regulations imposed by insurance companies. These are humanitarian qualities that cannot be measured and have little to do with scoring high on performance tests. Any discussion of a doctor’s capability that ignores them does a disservice to those physicians who resist insurers’ regulations and struggle to keep a humanitarian outlook.

A renowned physician-ethicist once wrote that medicine is the most humane of the sciences and the most scientific of the humanities, underscoring the duality of medicine.

Improving medical conferences

March  28, 2012

 JAMA

Letter to the Editor,

Dr. John P.A. Ioannidis ¹ raises some interesting opinions about the value of medical conferences.

However, among the many criticisms that he set forth I was surprised that he spared the modus operandi that prevails in most conferences. Specifically, many of them have devolved into “slide shows”. The presenters are usually well-versed in their subjects but the number and complexity of the slides that they use often over tax the average physician’s ability to concentrate on the enormous amount of material that is presented. 

Sometimes, I get the impression that the presenter is more concerned about displaying his/her knowledge than in actually teaching.

Conferences (and hospital presentations and grand rounds) would take a quantum leap in effectiveness if presenters would limit the number of slides they show and also limit the bits of information on each slide.

It might be said that the availability of audiovisual equipment has diminished the need for presenters to be true communicators.

1.Ioannidis PA. Are medical conferences useful? And for whom? JAMA. 2012;1257-1258.

Edward J. Volpintesta MD

Shortening the training period for primary care physicians

May 27, 2012

Amednews.com

Re “Med school on the fast track” (amed news, May 7): It is a good idea to have primary care physicians receive their medical degrees in three years instead of four. I have been an advocate for this for years.

 But I would also reduce the pre-med education by a year or two as well.  This can be done by customizing the science courses.

Most primary care doctors have little need for whatever knowledge they may have retained from the time spent on physics, organic chemistry, and calculus in college. Worse some of these courses “weed out” students who could have gone on to become excellent primary care physicians.  

If the college/medical school programs were combined it should be possible to prepare students for primary care residency programs in five years. This could lead to turning out a full-fledged primary care doctor in a total of eight years instead of the customary 11.

Edward J. Volpintesta MD        

Shoreni

In praise of a great humanist

April 2, 2012

YJHM

As much as I am honored I am equally humbled to have the opportunity to write a few words in praise of this great man.

Howard once told me that he loved to read Ralph Waldo Emerson. Like Emerson he was an idealist and like Emerson he spoke his mind. His personable nature, his wide range of knowledge in philosophy and literature and of course in medicine instructed and entertained as he articulated clearly with passion and sincerity. Most of all, I enjoyed the essays where he went against the grain in his desire to provoke a response in the reader.

Howard will always be remembered for his unswerving dedication to reminding doctors of the importance of preserving the human factor in medicine—an issue that medical educators are beginning to understand.

I will miss Howard very much.

He frequently would send me a short email after reading one of my pieces in Connecticut Medicine medical journal.  The more I railed against the forces that diminished the human factor in medicine the more he encouraged me.  Coming from someone who I had admired greatly for years, his encouragement meant a lot to me, and I often told him so.

I will miss Howard very much.

Edward J. Volpintesta MD

Federation of State Medical Boards Misguided in Making Relicensure Dependent on Its Certification Program

Re “Don’t make licensure dependent on board certification” (amednews.com, July 2): It is good that the American Medical Association has taken a strong stand against the Federation of State Medical Boards’ plan to intertwine re-licensure with its maintenance of certification program. The FSMB or any organization that claims to help physicians fulfill their continuing medical education (CME) requirements is seriously misguided if it uses its resources in any manner that stands in the way of any physician from being re-licensed. The Federation of State Medical Boards ought to help physicians sharpen the knowledge they need in their individual practices. But the punitive approach which it seems set on casts a chill over the education process and actually perverts the whole idea of CME. It adds worry and expense, it consumes time and it needlessly complicates physicians’ already over-complicated lives. I like many other physicians am happy that the AMA has made this a top-priority issue. Edward J. Volpintesta MD