April 30 2016
Jean Antonucci, MD
There was a recent story in JAMA about an incorrigible patient. Palliative care was called in to set goals. They sat and listened to the patient, and he went home calm and comforted. Funny how this used to be the family doctor's job.
A recent story in the popular press said that we don’t have enough geriatricians. The elderly are complex and need time to prevent readmits, reconcile meds, keep them safe from falls and grieve over losses. Not enough board-certified, trained geriatricians. Funny, family docs used to do this.
Even the family medicine residencies support the idea of specialization. It has meant recruitment into training programs to offer a certificate in sports medicine or a concentration in geriatric care. So I am just wondering: why not have another, have more specialists, not less? Lets have vaginologists. ”The trouble is with your cervix ma’am .I will refer you on.” And is there no one for diseases of the sternum? What about the biceps? Biceps injuries are common.
Though we all know the definition of insanity, we keep doing what Americans know how to do-add complexity. We do it with the tax code. We do it with health care. Too tough to simplify so lets make some more rules to clarify the rules we did not previously understand. Lets solve problems with add-ons. We add codes and specialties, products and pills, while fewer and fewer carry the broad load of the plain old difficult. In primary care we have been living off the altruism of a few, the only few left who will do nuts and bolts, no bells and whistles primary care from newborns to wounds to...Oops.I forgot about wound care clinics. Now, there’s a cash cow for hospitals. Used to be surgeons and nurses could do it but now one needs training to dispense the infinite variety of dressings, after debriding a bit.
The primary care trade groups are silent against specialists and their salaries, or saying what needs to be said. nstead, they let our young be eaten by the demands of an impossibly difficult overburdened and barely paid job while derm goes home at 5. I hear derm has great job satisfaction.
So we might as well finish the job. Lets rid the country of family docs and stop pretending. When I was in school I was constantly asked why a bright girl would waste her brain on a field that shouldn’t exist. Somewhere along the way I must have napped or gone out shopping because I came back to the idea that PCPs would improve outcomes and reduce costs. Save the US health care system from itself even while prior auth’ing vit K and colonoscopies, and changing medicines every January to things we have never used but are required by some corporate giant to prescribe. And still have time to take on population health and do double entry for registries and measurement of mega metrics.
I was told once that I only took care of colds and UTIs. Every PCP I know now would kill for a UTI to come in and replace the short of breath 90 year old with 17 meds, 5 allergies, no money, bad eyesight, deafness and so cannot hear me, and a daughter in California who feels guilty and tries to direct things.
Why bother, let’s just finish off primary care and be done with it. lets do what Americans do: complicate things.
Here’s to the specialists. Spleenology anyone?