Canadians also have a primary care problem
In rereading this rant, the one comment provides much more useful information –
Well, it isn’t all about the money, but given the general decline in esteem with which physicians are held in the recent generation, outright abusive treatment from insurers and the government, market preference by patients for specialty referral, wrought not so much by real quality advantages as much as by consumerist mis-perception and indifference to cost or real need for referral, and frank preference for subspecialization from day one among most faculty at medical schools, the trends are hardly surprising. Except for the fact that the Canadian system is starting from a position of a larger relative percentage of generalists, the trend shouldn’t be any different than it is in the U.S.
If the perception of generalist practice is one of strained finances, abusive insurance treatment, hectoring administrative burdens, patients demanding early subspecialty referral and the implied disrespect that that carries, the message of career satisfaction can be hard to hear.
I really don’t blame generalists for closing the door to servicing abusive plans, or even requiring patients to pay retainers for access to a practice that affords better than sweatshop conditions for the practitioner. What is particularly galling is to hear the berating assessments coming from the “scholars” of the IOM and elsewhere–many of whom are highly isolated from the realities of any kind of medical practiice, telling the front line physicians just how much they are not doing right, or to read the critical news reports saying what technological foot-draggers most physicians are by not embracing EMRs and other high-cost innovations. I would encourage those same scholars to embrace a better understanding of economics, and bring us some solutions, instead of pointing fingers at problems all of us already know about.
Readers know that I continue to argue that the serious semantic drift which the phrase primary care has suffered leads to the decreased interest in the field. The semantic drift – simple care, quick referral care – leads administrators (either here or in Canada) to disrespect primary care physicians. Once you have decreased respect, work conditions deteriorate.
Patients understand better than the suits do. Retainer medicine thrives. The President of SIMPD said this in his presidential address:
Every American could have a private, personal, secure, real medical home for around $2 a day without third parties snooping in their records. Students, senior doctors and some specialists would flock back to primary care, the original love they were driven from by third parties. The primary care shortage would vanish, perhaps almost overnight. The incentive to do procedures would be reversed. Instead we would be incentivized to form relationships with our patients and treat them as friends as did Russell Anderson. What a concept.
That is our goal. Presented this way who could object to it? Who could not afford it? Those few in need could be helped to join such a practice by charity or government with donations or the medical equivalent of food stamps. But we have to get the third parties out of the way of primary care and basic office practice. Help us get the message to America, Congress and the White House during this important national debate on health care. You at this meeting have much more power than you think. Exercise it.
Should we continue to flog failed systems? We try; we advocate; we write papers about the primary care ideal. Can we win that fight or should we change the rules?
SIMPD would not exist, and would not thrive if our system was not so dysfunctional. We should not ignore their words or their ideas. As thought leaders, we must examine all ideas for their strengths and weaknesses.
These physicians successfully avoid the black hole of primary care – as so beautifully described by Bob Doherty yesterday – How much health care might be purchased with the $31 billion spent annually by physicians on health plan interactions? Our current insurance system sucks the life essence from too many physicians. Ask any internist or family physician about this issue and watch them get angry.
I hope we can get legislative answers, but I have a healthy skepticism about Congress. Whatever successes we have will likely have significant unintended consequences.
So I too will advocate tomorrow for internal medicine and primary care. I remain optimistic yet skeptical.
