Thursday, December 18, 2008

Thoughts triggered on reading about a recent face transplant

Reading about a marathon 22 hour surgical procedure that involved a face transplant in the Times this morning left me wondering a wee bit about the preponderance of plastic surgery news and their perceived importance in today’s society when we really should be focusing on the looming primary care problem on our hands. Don’t get me wrong, in this case of the face transplant, it was a much needed piece of medical assistance that competent plastic surgeons accomplished in helping a disfigured women get back her dignity. Of course, the bulk of plastic surgeons belong to the ‘nip tuck’ species, the ones who make their millions working on propping up sagging breasts, jowls, tummies and just about any piece of the human anatomy that one might want to fashion after ones vanities. As expected, policy wonk Ezra had a great paragraph on the looming shortage in primary care physicians.

We're about to face an epic shortage of primary care doctors -- we're talking 44,000 or 45,000 too few docs -- which will ensure massive disruption for patients. The problems for primary care are basic: Fewer graduates, more patients. As I understand the issue, there are two problems here. The first is lifestyle. Primary care doctors have too many patients, too little time, too much paperwork, too much administrative hassles, too little satisfaction. The other is money. Primary care doctors make far less than specialists, even though they go through a similarly expensive and rigorous training process. It's no surprise, then, that most doctors opt to become specialists, where they have better incomes and more control over their lifestyle.

In my view, the primary care shortage will only get worse due to the following factors: 1) average longevity of citizens are on the rise across the United States 2) a generation of boomers are staring to enter retirement age and will seek out preventive and primary health care in larger numbers. 3) the looming recession will result in chronic unemployment leading to the ‘laid-off’ patient facing a distinct inability to seek specialist care (which are typically more expensive) and starting to resort to primary care physicians for their health care needs. 4) first year MD enrollment per 100,000 population has steadily declined from 1980

What might logic dictate as solutions in such a scenario? Well, for starters, we must legislate increased enrollment in medical school primary care programs through the use of innovative tools like a) tuition breaks for graduates enrolled in the primary care track 2) better pay prospects as soon as they enter the primary care profession 3) increase primary care physicians participation across larger aspects of the patient health care cycle rather than having them sometimes relegated to being the 'specialist referrers' – this could be accomplished through changes in the classroom training and residency programs.

Of course, that was logic. What does the state of Massachusetts (and 24 other states) do in response to the looming crisis?

From here: For the first time, all health insurers in Massachusetts are required by law to recognize nurse practitioners as primary care providers, allowing consumers to choose them to coordinate and direct their care. The Massachusetts Medical Society recently reported that more than half of all patients presenting to a primary care practice who see a nurse practitioner make a deliberate choice to do so. Massachusetts joins 24 other states that recognize nurse practitioners as primary care providers.

Yes, legislate that a group of nurses with markedly lower training and skillset now start to step up and perform the task of physicians because we as a nation have failed to persuade the youth entering medical school that primary care physicians count critically at a national health care level. One might ask, if there are fewer students graduating out of the primary care program, then what are they actually opting for... Well, as is usual in times where the lure of the lucre is paramount, money does the talking and it seems to literally shout in this case. Accustomed to living their teenage years in an image conscious society and listening to news of 20 somethings make millions as analysts on Wall Street, the first choice for most graduates leaving medical schools is to be dermatologists, plastic surgeons or cosmetic surgeons. So, we as a nation are effectively saying that having more plastic surgeons who takes care of ones looks is better for the common national good than having more primary care physicians who takes care of how one feels. The only problem with this cultural prescription is that the moment we slide down the slope of sanctifying the external aspects of individuals in our plastic society, there is the clear and present danger of our society slowly turning morally bankrupt deep inside.

Full disclosure: My wife is a primary care physician.

Retired orthopedic surgeon turned artist Dr. Anthony Walter created this baroque mirrored hall in his home in Houston, Tex., Image ripped from here.

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