Wednesday, May 11, 2005

Primary Care Brain Drain

This is a story that cuts into my own primary care/internal medicine heart. The percentage of third year internal medicine residents (final year) opting for subspecialties over primary care has increased from 42% to 57% from 1998 to 2003. I see this with our own housestaff here at Harbor-UCLA which I understand given the academic nature of this program.

It is disturbing to me however, that this trend is the norm outside the ivory tower as well. I can certainly understand the reasons. Who wouldn't want the greater income for the same amount of work enjoyed by the procedure-based subspecialties (cardiology, gastroenterology, etc.) over the "cognitive" specialties such as general internal medicine?

On the other hand, I'm wondering how the face of medicine will change if the best and the brightest eschew careers in primary care. I've always felt that if you're a patient, the most best thing you can do to optimize your medical care is to hook up with a bright, talented PCP (primary care provider) who will take "ownership" of you as a patient and as a human being.

Such a practitioner will function as an advocate, will guide you through the medical quagmire that is our healthcare system and will pull you from the fire.

What can be done to improve this situation? As one who believes in a free-market, I cannot recommend any kind of price controls nor any type of quota to rectify this problem. I can only hope that if I'm right about the intrinsic value of PCP's, market forces will prevail and the general public will recognize a benefit to reimbursing them better in parity with their subspecialist colleagues.

Part of this responsibility obviously lies on medical educators such as myself to convince residents of the value of remaining in primary care. However, I also think that internists (as well as family practitioners and pediatricians) also need to strive to do a better job with their patients and provide better "value" to them. PCP's need to take charge of their patients, increase their knowledge bases and become more comfortable with more complex medical conditions (the way it used to be). The modern trend of endless triaging (transferring care to subspecialists) needs to stop if PCP's are to get the respect that I personally feel they deserve.

PCP's also need to demonstrate their financial value to third party payers not so much by functioning as gate keepers but by proving competence in handling a wider range of conditions without expensive referrals. They can also demonstrate their worth by being more aggressive in following widely available health maintenance and screening guidelines. In theory, tighter adherence to such guidelines should keep patients healthier and lower the need for costly medical care down the line. This is obviously beneficial for both payer and patient.

Of course, if I'm wrong and neither payer nor patient sees it this way then the brain drain from primary care will only get worse.


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