Let’s End the Primary Care-Specialty Schism and Solve the Physician Shortage – A Short Essay

In his new book about Lincoln as a writer, Fred Kaplan describes Lincoln’s disdain for the “linguistic dishonesty” of leaders of the Confederacy, who attempted to divide the nation with “a barrage of verbal propaganda that corrupted the relationship between language and truth.” Strong words, but not unlike the verbal propaganda that has been used to create a schism between primary care physicians and specialists and that is impeding solutions to the nation’s physician shortage.


We are told that patients in areas with more primary care physicians and fewer specialists spend less on health care but receive better quality care, use fewer hospital and outpatient services, incur lower end-of-life expenditures and achieve better health status. They even have lower mortality from cancer, heart disease and stroke, decreased infant and maternal mortality, decreased all-cause mortality and increased life spans. All quite remarkable. And while one can find a kernel of “statistical truth” in some of these studies, it generally disappears once race and poverty are considered. And when these are considered, the associations apply to family physicians but not general internists or pediatricians, who practice in the same manner, a curious anomaly that results from the preference for family practice in states along the northern tier. Indeed, the superior outcomes have everything to do with the merits of Minnesota over Mississippi and nothing to do with the merits of primary care.  fp-map21


But what about the old saw that primary care physicians can deliver specialty care better and cheaper than specialists?  Greenfield, who led these studies in the 1990s, acknowledges that they lacked adequate risk adjustment, and subsequent studies have shown that specialty care generally yields better outcomes, particularly for patients at greater risk, although with greater costs.  But these conclusions run headlong into the Dartmouth’s Atlas, where outcomes in “regions” with more specialists and more spending are said to be no better and sometimes worse. Yet even a casual inspection of the Dartmouth map shows that the “region” with the most spending is a scattered collection of America’s densest urban centers, while the “region” with the least encompasses the vast northern tier, from Alaska to Maine (see “The 30% Solution”). Yet these two vastly dissimilar areas have equivalent outcomes.


Even more curious are the statistical gyrations used by members of the Dartmouth group in claiming that “states where more physicians are general practitioners have higher-quality care and lower costs, whereas states where more physicians are specialists have lower-quality care and higher costs.” While widely cited, these claims are simply false (see “Less is Less-Mississippi” March 26th). States with more specialists actually have higher quality care. Mississippi and Nevada, where quality is low, do not have an abundance of specialists, as portrayed, but the fewest in the nation. 


Take note. Obama has arrived from the land of Lincoln with the clear message that language and truth must be reunited. And Lincoln would probably add something about what happens when a profession is divided against itself. Primary care physicians don’t need to be advertised as better “specialists” than specialists, nor as the fountain of long life, and falsely denigrating specialty care doesn’t make primary care physicians more valuable. Patients know their value already. And experts know that health care is better when primary care physicians and specialists work together and best when there are more of both. The tasks at hand are to end the “verbal propaganda” that divides disciplines and concentrate on expanding physicians supply overall so that future generations will have access to the technologically advanced, socially equitable care that they will want and deserve. 

For references, contact cooperra@wharton.upenn.edu


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