Wednesday, September 9, 2009

The Specialist Strikes Back!

This academic nephrologist from Penn named Stanley Goldfarb MD has an interesting piece in the Weekly Standard this week. He's apparently outraged that healthcare reform proposals circulating on Capitol Hill include numerous provisions that would emphasize the importance of primary care providers. He's apoplectic about this. His gist is that mere primary care providers are in over their collective heads when it comes to managing most common medical problems. He cites some obscure studies that seem to support this thesis and then drops this paragraph (and please don't let Kevin Pho read it):
Many individual primary care physicians are highly capable and knowledgeable and can provide high quality preventive care. As a group, however, they apparently do not achieve those goals. In truth, they really cannot be expected to given the growth in new information in each field of medicine. They must rely on specialists to support them and to achieve the highest quality care. To rely on guideline-driven, primary care to solve the problems of the high cost of medical care is an example of the triumph of hope over reality.

So....we need MORE SPECIALISTS! Even 2% of medical students going into primary care is too much! It's all a great conspiracy!

It's really a silly opinion piece. For some reason Dr Goldfarb thinks the logical solution to improving patient outcomes is to just refer everyone to nine different specialists rather than to implement strategies that would make internists/primary care providers more accountable for their patients and would encourage practice patterns more in tune with the "standards of care". But this is the Weekly Standard, after all, the head cheerleaders of the Cheney torture program. Why would you expect anything nuanced and well-reasoned from them?

4 comments:

Frank Drackman said...

You wanta talk about torture, watch what happens to your Buckeyes Saturday.. And hey, ever see what Woody Hayes did to that Clemson player??? Dude wasn't even a terrorist, just mindin his own business, showin y'all how Footballs played...

Victor Lazaron said...

I agree, it's an odd essay, to say the least. The choices cited for things primary docs are apparently unable to do - are all things primary care docs do and specialists do not do.

Dr. Goldfarb believes that the data shows primary docs are incapable of managing hypertension correctly. They cannot recognize when to refer patients with kidney disease to a nephrologist. They don't know to get an endoscopic exam on patients with occult rectal bleeding, and they can't correctly manage risk factor modification for coronary artery disease.

So what this essay purports to show is that primary docs are idiots and cannot do correctly the main things they do every day. Therefore we need more specialists - to do what, exactly? To do the things primary care guys are too dumb to do right? To do the primary prevention type of care which we all know is not compensated for adequately? Right, I thought so.

We have this same specialist problem in surgery, of course. We have all had patients who want their gall bladders taken out by the hepato-biliary surgeon, their right hemi-colectomy done by the colo-rectal guy, and their lumpectomy (!) done by the breast surgeon. And we have all see the self-serving literature supporting this lunacy.

When the counterattack starts I hope someone calls me to lend a hand.

Bob Mulcahy said...

Interesting perspective from a specialist who sees a limited spectrum of problems over and over. He laments the fact that we poor primary care physicians have to rely on specialists to adequately care for our patients.

I assume he's never consulted a urologist for a patient with obstruction, a surgeon for dialysis access, a cardiologist for a patient in CHF or an endocrinologist for diabetes management.

In an undercompensated visit for follow-up of diabetes, hypertension and hyperlipidemia the typical patient also has complaints such as impacted cerumen, some pain somewhere, URI/allergy sxs and a question about their significant other's recent headaches which they want treated without any visit or eval.

Does he really think the patient or the system (using the term loosely) would be better served by specialist visits for each of these issues?

Bob Mulcahy said...

Interesting perspective from a specialist who sees a limited spectrum of problems over and over. He laments the fact that we poor primary care physicians have to rely on specialists to adequately care for our patients.

I assume he's never consulted a urologist for a patient with obstruction, a surgeon for dialysis access, a cardiologist for a patient in CHF or an endocrinologist for diabetes management.

In an undercompensated visit for follow-up of diabetes, hypertension and hyperlipidemia the typical patient also has complaints such as impacted cerumen, some pain somewhere, URI/allergy sxs and a question about their significant other's recent headaches which they want treated without any visit or eval.

Does he really think the patient or the system (using the term loosely) would be better served by specialist visits for each of these issues?