Primary Care Progress is a two-year-old Cambridge-based nonprofit that seeks to revitalize the primary care field and motivate more medical students to enter the primary care fold — with passion.
One of those students, Joe Nelson, in his third year at Baylor College of Medicine in Houston, recently wrote eloquently about why he is pursuing a career as a family physician and why primary care is the key to fixing the broken health care system.
Nelson’s “aha” moment, he writes, involves his own father, a biomedical engineer who lost his health insurance and so delayed seeking followup medical attention on an abnormal colonoscopy that revealed some pre-cancerous polyps. A few years after the test, Nelson’s dad, now experiencing some troubling symptoms like weight loss, weakness and fatigue, sought advice from his medical-student son.
In what kind of health care system can a learned, health-literate individual make an educated decision not to seek medical care in such a high-risk situation? Why is a man like my dad relegated to asking medical students for health advice?
In the medical community, we talk about access to care as though it were a separate issue from medical costs. In fact, we usually refuse to discuss cost at all. Instead, we have behemoth yet inadequate government programs like Medicaid, CHIP, and Medicare to help improve access to the care that we’ve been told is fundamentally expensive. But the elephant in the room is that if medical care were inexpensive, everyone would be able to access it.
A generation of physicians who saw the advances brought to medicine by science in the 1940’s and 50’s have discounted the physical exam and built a pedestal for the p-value. Sub-specialty care has exploded. And with the creation of expensive tests to replace free physicals, specialists to replace primary care physicians, and the ubiquity of health insurance to blind us to cost, money has poured into medicine like never before.
Physicians today bring home five and a half times the average American’s salary. Hospitals have changed from charity organizations built for the poor into marble-walled, multi-fountained glittering glass edifices. And out of the staggering medical bills footed by the nation, at least $750 billion per year – more than we spent on the entire Iraq war – is unnecessary. If you started saving one million dollars per day on the day Christ was born, you still wouldn’t have $750 billion. And the estimated waste in medicine would be even greater if it took into account our abhorrent lack of preventive care.
So what has been the net return on our great investment in our health? Lower life expectancies than our parents and even more dismal forecasts for our children. Obesity is rising like a tidal wave, trailing heart disease, diabetes, liver and kidney failure in its wake. Proponents of the sub-specialty paradigm are sounding the alarm for more cardiologists, endocrinologists, gastroenterologists, and nephrologists than ever before, somehow failing to mention that virtually all of these conditions are preventable.
Primary and preventative care can help fix all this, Nelson writes, but only when medical schools become more enlightened:
From our first day of medical school, we are trained almost exclusively by the physicians most entrenched in the sub-specialty paradigm that caused this crisis. At many schools, a student can go two years without meeting a family physician or general internist. And on the surface this approach makes sense. The heart is taught by a cardiologist; the kidney by a nephrologist; hormones by an endocrinologist. This supposedly deepens our study of each system. Unfortunately, it also undermines our ability to think in terms of the whole organism. As a candid ophthalmologist put it, “The purpose of the heart, liver, kidneys, and brain is to support the eye.” When this myopic viewpoint, although amusing when stated outright, is the norm, teaching takes a backseat to outright recruitment.
It is easy to be swayed by the lifestyle and high salaries inherent to sub-specialization, especially in contrast to the outdated models of primary care most med students see: a doctor-who-does-all spending five to ten minutes with each patient only to stay perpetually behind on appointments and paperwork.
Students are never told the true story of primary care: that it can be whatever we make it. Emerging new models, such as the patient-centered medical home, change the way primary care is practiced and reimbursed, increasing quality for patients and job satisfaction for physicians and lowering costs for all.