Primary Care Doctors Aren't Just GatekeepersI read Dr. R...

SATURDAY MAIL BOX

October 16, 1993

Primary Care Doctors Aren't Just Gatekeepers

I read Dr. R. Ben Dawson's testimonial (The Sun, Oct. 2) to specialty physicians with great interest. However, I think he misses the mark on a number of his conclusions.

My training has been in general internal medicine and I, like his "primary care" physician, was at the top of my class in medical school (Maryland) and was also picked to be chief resident at the University of Virginia Hospital.

However, I do not consider myself a mere "gatekeeper" and am skilled in the diagnoses and treatment of a great many illnesses, as are my colleagues.

I also have the advantage of knowing my patients well and, therefore, can guide them through the maze of specialists and technology to get the most appropriate care, or to help in the decision to withhold treatment.

Dr. Dawson claims that common and rare problems are best handled by a specialist. Specialists by nature have a narrow focus which at times can turn into tunnel vision (like so many blind men when asked to describe an elephant by the part their hands had touched).

He cites the example of chest pain which turned out to be an esophageal problem and had been exacerbated by the heart drug he was taking. Why is he still going to his cardiologist if there was no heart problem to begin with? Is it just to be sure that one doesn't develop? And, what is the cost of that?

In my own residency, I remember a man who saw a "super-specialist" (electrophysiologist) because he had a past history of a cardiac rhythm irregularity and had begun to feel quite ill. The specialist pronounced his heart in good working order and sent him on his way.

The next day he was brought to the emergency room near death and was diagnosed by his family physician as having a severe hemolytic anemia (unrelated to his heart), and appropriate treatment was rendered.

Efficiency in diagnosis was also an issue that Dr. Dawson raised. An ear, nose and throat physician quickly diagnosed his chronic sinus problem after his internist had been unsuccessful. No reasonable physician would argue that referral in that case was appropriate.

Nevertheless, most illnesses can be handled quite well at the generalist level with judicious referral to specialists for recalcitrant or difficult cases.

Further, initial contact with specialists may be expensive as they may frequently want to rule out more arcane causes of an illness.

Also, patients inevitably present multiple problems, and I have seen more than one person shuttled by referral from one special ist to multiple others. Frequently, these problems can be handled more efficiently and cheaply by one visit to a primary care doctor.

Finally, there are some patients who collect specialty physicians like many trophies, going initially to the neurologist for a headache, the orthopedist for a sprained wrist and the gastroenterologist for a "bellyache."

They also insist on every high-technology test, whether appropriate or not, and often specialists are loathe to refuse them. Is this really quality care? Maybe a good generalist could help the patient select a more appropriate approach. Obviously, this requires top-notch primary physicians, not mere gatekeepers.

To practice this type of high quality general medical care is difficult, demanding, requires long hours and, unfortunately, is not compensated very well.

However, it can be done, and the quality of medical care will be enhanced, not diminished, by the training of more generalists. While I would agree with Dr. Dawson that specialty is extremely important, I believe it has been over emphasized.

The change has to start with medical institutions and the funding they receive. Governmental and private agencies tend to give money to narrowly defined research projects, usually at the laboratory level. The dollars for clinical projects are rapidly drying up. In turn this serves as a disincentive for faculties of medicine to hire professors who cannot bring in this type of funding.

Thus, the mentors of today's students become more and more specialized, fostering the same attitudes and beliefs in their young charges.

Physicians, especially generalists, should be able to deliver quality care in an environment that does not reduce them to gatekeepers or insurance clerks. The primary care doctor should be a sophisticated and compassionate adviser to his or her patients and have the freedom to consult specialists when appropriate.

In that, I share Dr. Dawson's concern over managed care. Unfortunately, these institutions may introduce countless layers of bureaucracy and actually drive up the cost of medical care, while decreasing the amount provided. I don't like that, either.

Also, generalists need to be paid what they are worth. Previous attempts at that, including the oft-quoted relative value scale, have fallen short of the mark. If we are to have any hope of attracting the best and brightest to become primary physicians, this must be changed and changed now.

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