Too many specialists
Our healthcare system is like an inverted pyramid.
Rather than having a strong base of primary care doctors—family medicine, internal medicine, pediatrics—and a decreasing number of specialists, we have more and more specialists and a dwindling number of primary care docs.
Roughly two thirds of our doctors are specialists. And subspecialists. And sub-subspecialists.
Why is that a problem?
One, because specialists cost more money, which adds to our country’s already breathtaking medical expenses (on track for 20% of GDP by 2026).
And, two, because having our medical care compartmentalized leads to unnecessary diagnostic tests and treatments. Sometimes specialists even miss the correct diagnosis because the problem is outside of their “body part.”
That’s what I call healthcare tunnel vision.
To a hammer, everything is a nail
A specialist should rarely be the first person you see for a problem.
Specialists filter a patient’s chief complaint (what brought you to the specialist) through their own training and experiences. They are less likely to see you in context as a “whole” person. That’s not bad medicine, just human nature.
An office visit with a specialist can cost three to four times as much as a primary care provider, and specialists are much more likely to order additional tests, perform procedures and write prescriptions.
Specialists get paid to “do” stuff. They don’t like to spend a lot of time talking—that costs them money. Again, it’s not that they are evil or love money more than their patients. They have hard-earned skills they want to use, and they have bills to pay just like we all do.
And all doctors suffer from too little time. A specialist pressed for time may zero in on a diagnosis rather than consider a list of possible diagnoses and rule them out one by one.
Here’s a common example. A patient experiences heartburn for several weeks. Rather than make an appointment with his primary care doctor, he decides to go straight to a gastroenterologist. He has good health insurance, so he can do this.
(In his excellent book, How We Do Harm: A Doctor Breaks Ranks About Being Sick in America, Dr. Otis Brawley writes that there are two groups of people most at risk of being harmed by our healthcare systsem: those without insurance, who can’t get care, and those with good insurance, who get too much care.)
The gastroenterologist is a busy person. She hears the patient talk about his heartburn symptoms, how they affect his life and keep him up at night. She’s heard it a thousand times before. She knows what to do: schedule an endoscopy to make sure there’s nothing more threatening going on, and then write a prescription for a proton pump inhibitor (PPI), most likely Nexium.
What she doesn’t hear, either because she has already made her diagnosis and is no longer listening, or because she interrupts the patient who is taking too long and getting off topic (and she has 20 more patients to see today), is that the patient has been under more stress than usual. He lost his job, he’s worried about money, his marriage is suffering. He isn’t eating well or taking care of himself. He’s started smoking again.
A primary care doctor, on the other hand, is allowed more time to talk (by the administrative overlords who determine such things). Maybe she’s seen this patient several times and knows more about his lifestyle, job and relationships. Regardless, she asks broader questions that help her see the bigger picture.
She discusses the different ways to manage heartburn, most of them lifestyle: a better diet, quitting smoking, seeing a counselor, losing weight. She suggests an over-the-counter antacid he can try first. If that doesn’t work, they can try something else. She explains why a PPI like Nexium should be the last resort, not the first.
She wants to see him again in a few weeks to see if diet and stress reduction are helping. If his symptoms are getting worse, then they can talk about seeing a specialist.
The patient leaves her office feeling listened to, cared for, and hopeful that he can make the necessary changes that will improve his health.
And he didn’t have to pay a lot of money, either.
Embrace primary care
Primary care doctors get a bad rap.
I have friends (again, those with good insurance) who think primary care doctors are a waste of time. “They don’t know anything. Besides, they’ll just refer me to a specialist, anyway.”
I admit I used to think this way, too.
Now I know differently. Primary care doctors are the unsung heroes of healthcare.
Their medical training is grueling and expensive, and they don’t make nearly as much money as specialists. They usually start their careers with a mountain of debt (we really need to change medical training in this country), yet they choose to be primary care physicians anyway.
They love the challenge of seeing all types of patients with all types of problems. They want to nurture relationships and get to know their patients and ideally care for them over a long period of time.
Sure, the current system makes it tough, but they are committed to caring for the “whole” person, not just a body part or single system. That is not only more cost effective, it’s better healthcare.
If you aren’t happy with your primary care doctor, or don’t trust him or her, find a new one. Read one of the books I have listed below to learn how to communicate better with physicians and be more in control of your healthcare and healthcare dollars. It’s not easy, I know, but it’s worth the effort.
In the last few years I’ve had to change my primary care doctor several times. Not by choice, but because the individual insurance market is so volatile with ever-changing networks. Sigh.
But now I understand the value of that doctor-patient relationship and hope I can find it again.