Future of primary care

The OMA House of Delegates meeting was this weekend at the Salishan lodge. We, the students, proposed a resolution to establish a student leadership fund with a $10000 budget and to change our membership status to full members. The delegation approved the budget, which is great news for future students who will have plenty of seed money to grow interest in the OMA.

There are a lot of gray hairs in the organization, which is all the more reason for students to get involved. The more I consider the various stresses on the profession and how it is changing, the more I believe that doctors need to get their crap together and start advocating for their own interests and for their patients.

Saturday night was spent over some beers thanks to some former presidents of the OMA and a continuation of the heated discussion about compensation parity between primary care and specialists.

The larger question beyond income parity is access. Fewer med school grads are choosing primary care - I put myself in that category right now. But it is not, I believe, due to low income as many people argue. $150K may be a fourth of a cardiologist's income, but this is still enough money to make a good living, even with a large loan debt load. People who really want to do primary care are going to do primary care; the main reason (there are many, including income and loan burden) I think many do not is because the biomedical sciences for a few decades now have become so information-dense and the growth of new knowledge (and procedural skills) so rapid that it is extremely difficult to be good - or possibly even competent according to community standards - without being a specialist.

The health care "system" and market understand this and therefore reward specialists much better than generalists because it is specialists who more less produce the results we want. In a larger urban area, such as Portland, it is standard of care for someone to see a specialist if they have complex organ-specific pathology. My primary care preceptor last year refered virtually every "difficult" patient to a specialist. Those who remained were patients with chronic diseases, aches and pains, psychosocial issues, common infectious diseases, and other non-acute, non-serious problems. For me this was all pretty boring from a medical point of view (although the patients as people were always interesting). It struck me as a waste of resources for an internal medicine physician to treat these kind of patients as his bread and butter (it requires 7 years of training for internal medicine). I think many young doctors-to-be feel the same way. A specialist career track will allow them to earn money that is more commensurate with their extensive training, and provide them with a job that is challenging and that lets them work on the leading edge of medicine.

So the question remains: wherefore primary care? My personal feeling is that the progress of medicine will require more specialists to deliver competent care, and these can only be MDs. So we are going to have to look towards lesser trained health care providered to fill the primary care vacuum: nurse practioners and physician assistants. For much of the ailments I saw in my primary care preceptorship, I am pretty confident that a NP or PA working under an MD could provide just as good of care. In fact, for low grade complaints - the majority of primary care visits - the quality of care is often determined by factors irrelevant to technical training, such as so-called bedside manner and listening skills. That said, there will still be chronic disease patients who should be managed by an MD, such individuals with diabetes or hypertension.