On the rise of specialists:The latter half of the twentieth century saw American physicians moving briskly away from general practice and primary care toward specialty medicine. This was driven a lot by science. We have more that we know now, and that's more precise and more demanding. So specialization is a great asset and an important facet of our system.
But at the same time, those physicians who care for the individual in a complete sense, who're responsible for coordination and continuity -- the generalist -- used to be the general practitioners, the GP. Today, it's the family physician, the general internist, the pediatrician. They've fallen to the back of the pack. They're less prestigious. They're paid roughly half of what specialists are paid, and medical students tend not to desire those careers in great numbers.
That is a problem, and as science continues to move ahead -- as it will -- that is going to be an even greater problem. The hazard, of course, is that the medical profession will become fractured into multiple enclaves of highly technical, highly competent, but essentially ill-coordinated specialty camps. And as customers of the health care system, all of us want and very often need folks who can put things together, who can coordinate when we have multiple illnesses, as we often do -- when we have problems that aren't strictly medical but are psychosocial in nature that fit into health care.
The generalist in American health care is a very, very important player who gets very little press and very little attention and relatively little positive reinforcement these days. That's a big problem.
That phenomenon is nationwide. Now, folks who are the least economically able, who either have no health insurance or have Medicaid or minimal entree into the system -- what is needed by all of us, and certainly what is needed by disadvantaged folks in America is primary care. You need your basic health care, and that is primary care. In impoverished communities, whether they're inner-city communities or rural communities, the relative lack of primary care provision cuts particularly hard. That's the floor that we've got to put under everybody.
Frankly, in the better-to-do sectors of America, we have problems in this regard, as well. A system built around specialty care is, by definition, expensive. A system built around primary care, with good generalist provision and specialty referral as necessary, is far more efficient and economical. And we have huge problems with costs in America. In our well-to-do sectors we devalue and fail to build in the primary care we need. That reflects in cost escalation and, frankly, a lot of dissatisfaction for patients who can't find a good doctor, which usually means they can't find someone to put it all together.
On doctoring:
By "big doctoring" I mean individuals who are equipped to embrace the human condition. They're prepared scientifically and by personality to deal with the variety of problems that people present with.
There is a struggle, an intellectual, conceptual struggle between people who are generalists, who know a lot about a variety of things but, necessarily, not in great depth, and specialists, who know a great deal, but in a very limited area. Both have valuable roles to play in health care, as in many other walks of life. You can have a highly refined tax consultant and a highly refined banker; but sometimes you need just a general estate planner who can help you figure out how to put things together. The generalist-specialist tension can be found throughout society.
The march of science, the incredibly valuable and fascinating biological phenomena that we are little by little uncovering, create a call for specialization -- people who [bear] down on various things we find within the human genetic code, for instance, or with greater knowledge of neuroscience.
The problem is when that gets out of hand, and when the medical profession calibrates itself largely to provide practitioners of these highly specialized arts and forgets about the importance of the floor that resides under all of us, which is the generalist capability. In failing to value that, a number of things happen. We don't educate people for it. These values are not apparent to young people in medicine or health care. We don't reimburse it. We pay people more poorly when they go into the generalist disciplines than when they become proceduralists, who are highly competent in a small range.
People become entertained with the highly refined, highly glitzy interventions that specialists can carry out. "Glitzy" is too trivial; I mean, these things are very important, but they're also often more easily dramatized than providing good immunization, good prenatal care, good care to people with depression.
A number of things make a specialty practice attractive and leave those of us who are practicing, or teaching, or advocating for the generalist disciplines with a steep hill to climb.
Medical students -- no matter how idealistic -- have at least one eye on the economics of their future. Virtually all medical students leave school with debt. The average indebtedness of medical students these days is approaching $100,000. And when one looks down the road, you don't have to have a doctorate in economics to figure out that if you're a plastic surgeon or an orthopedic surgeon, or a cardiologist, you're going to make a whole lot more than if you're a family physician or a pediatrician. That factors into people's decisions, and medical students are human beings. And that is something that I can't gainsay them.
However, we've structured a system that says somebody who does something that's highly refined, often in a highly repetitive way -- ophthalmologists who do cataract surgery day after day -- that's fabulous surgery, but it's a very limited domain. We value it and pay them $500,000 a year. With your family physician, one patient has depression. The next patient has HIV disease. The next patient needs immunizations. The next patient has an alcoholic spouse. Each one of those calls on a whole different set of capabilities. Very complicated, very difficult. We pay that person a fifth what we pay the ophthalmologist who's doing the same thing over and over again. This isn't to say that isn't a valuable and highly skilled discipline, but we've tilted the field against the generalist. And that's a big problem, because it replicates itself. Once the field's tilted, people go in the direction of gravity. They go where the money is.
On government's role:
Much of medical pricing is based on Medicare reimbursements, which are set as part of a national Medicare program. While limited efforts have been made to balance between what is reimbursed for people who do procedures -- that's where the big money is -- and people who don't do procedures -- that is, internists and pediatricians and family physicians who, by and large, talk and write prescriptions -- there have been efforts to equalize, but those efforts have been modest. We need to equalize far more the reimbursement, and the only national reimbursement is Medicare. Medicaid follows on that somewhat. Those are the two national [re]imbursement programs.
We do not have among all the very important research institutions of government -- mostly at the National Institutes of Health -- a National Institute of Primary Care Research. We do not have a National Institute of Family Medicine Research, for instance. We have a Nursing Institute and an Arthritis Institute and a Cancer Institute. There's a great deal that could be done to improve our knowledge base in the area of primary care, and having a research enterprise there would be important.
In terms of scholarships and support for medical school, a great deal more could be done. The National Health Service Corps pays scholarships for individuals to go to underserved areas in primary care. It is a good program, but it's small. They give away maybe 500 scholarships a year. There are 16,000 medical students, many more of whom would take these scholarships.
Nurse practitioners and physician assistants are important nonmedical, nonphysician providers. Programs for them would be another very important activity. Reimbursement, research, and student support are three important areas.
Role modeling and teaching young people in medicine and nursing in primary-care settings, particularly in underserved communities, is very important to the selection process for people going along through medicine, through nursing and picking careers. Teaching and training programs in community health centers, in rural health centers, in the Indian Health Service and the like are very important. A modest amount of that goes on. The government funds maybe $100 million of that. They put billions of dollars into other kinds of support for medical education and academic health centers, but very, very little ($100 million sounds like a lot; divided across the country and all the students it is very little) in this area. Teaching and training, and support for teaching and training in primary care, in underserved areas is a very important area that we could do a lot better in.
On the impact of managed care:
All care has to be managed. There is a finite health-care dollar. With few exceptions, we don't have enough money to buy everything we'd like in the health arena. And over time, we're going to have to learn to live with[in] our budget. Managing care, which means making intelligent choices about how we spend our health-care dollar, is an important concept.
The managed care companies and various manifestations of medical care over the last number of years have often been ham-handed; and many people have had bad experiences, and managed care has developed a bad reputation. The idea is a good one, an important one. Managed care, early on in many of the plans, chose primary care as a very important, central element for what it was doing, because it has been proven to be efficient. It's been proven to be effective moving patients between specialists and generalists, and using the dollar intelligently, and providing good prevention and good, long-term health care.
Because many companies chose primary care, and then people began to dislike managed care, primary care has suffered collateral damage from the public's reaction to managed care. The two ideas need to be seen as separate. They are not by any means the same. Primary care is terribly important. Figuring out how to manage care, live within our health care budget, and provide care equitably to all of our citizens remains an unmet part of the American agenda, so that some form of managed care is going to be essential. Some form of managing care is going to be essential to having fair and effective health care for all of our population.
On human healers:
The horse-and-buggy physician is a powerful image out of our past. The idea was that this was a caring person who rode out in the night, in the rain, and came to your bedside and healed you. It's an important image. It probably is a bit fictitious. Surely, there were people who did that. Their science was certainly very limited. Their effectiveness was probably pretty minimal.
