The New York Times recently ran an article on primary care and why it is perceived as ‘not cool’ in America. Journal of Medical Case Reports is accepting more and more fascinating case reports from general practice, so can this be true? I put this question to two of the journal’s Deputy Editors from both sides of the transatlantic pond: Dr Geoff Wong – himself a practising NHS General Practitioner; and Dr Christian Koch a practising US physician specialising in endocrinology: does primary care have an image problem in the UK?
Geoff Wong – London, UK
“My own relatives still wonder why I decided to become a GP!” opens Geoff Wong. He believes the situation in the US, as described by Pauline Chen, for primary care doctors reflects that of the situation here in the UK where the hierarchy of specialist vs. generalists still exists.
“I am no historian, but I suspect that this hierarchy is a historical ‘hangover’. In the old days, discrete diseases killed people and patients needed a specialist to save them from their illness. Nowadays, people have multiple morbidities and whilst there is still an important role for specialists (e.g. I have no idea how to resect a colonic tumour) there is also a new type of care that is needed, which is neatly captured by the author’s call for a medical home (something Dr Wong points out has been raised before by Babara Starfield et al.)”
In the US where their healthcare system operates as a commodity and free choice rules, the role of the generalist is clear and much needed. They are at the front line and have the ability to guide patients through the correct course of care. For example, would a specialist neurologist be able to recognise when a recurrent headache is just a simple tension headache or if it is indicating depression? This might be a simple example, but when you add in multiple morbidities where would an average patient turn? Geoff Wong’s Deputy Editorship on JMCR exposes him to a broad range of medical case reports and patient stories from general practice and specialist cases so he know first hand the challenges the healthcare system in its current format presents: “When you then add the growing issue of multiple morbidities, you then need to decide which ‘disease’ is causing or contributing to what. An elderly lady with COPD and IHD may be short of breath on exertion, what does she do if there is no one to help her work out what to do next, see a cardiologist and then a pulmonologist and then who next, the respiratory physio?”. Geoff’s own experience as an NHS GP practising in London reveals that his patients want to see a familiar, competent, nice and friendly person they can trust who makes it their job to sort out their problem – even if it’s not medical. “It’s a jungle out there working out what is wrong with you and we all need all the help we can get. Dare I say it, that person in the UK is the NHS GP.” So, perhaps the profession is still unfashionable but in order to deliver effective patient care in the UK, they are in some sense the ultimate physician; in Geoff’s own borough – it’s working and here to stay.
Christian Koch – Mississippi, USA
“My answer for all states in the U.S. is YES, there is an image problem in primary care” says Christian Koch. Christian works as an endocrine specialist in Mississippi, US – a state with high poverty rates and unemployment. He also has previous experience in Washington DC and Ohio.
It’s clear from talking to Christian that underlying the image problem in the US is not surprisingly the economics behind their healthcare system: “With many people not having any health insurance, many people being eligible for health insurance but choosing not to purchase insurance to save money, many elderly people with medicare, and some people with good private insurance, the rate of physicians is usually determined by competing for patients or "customers" whose insurances pay the highest reimbursement.” To achieve this, more and more medical students are choosing to turn their backs on general practice where the financial reward is lower, and pursue specialist training: “As a primary care doctor the pay is even lower and taking care of the many uninsured or underinsured patients in the U.S. often can only take place by government programs, e.g. by creating working environments where billings and payments do not matter in regards to the physicians salary, as long as any patient is seen and taken care of.”
Chief residents in Christian’s state in the Us this decade have been opting for more lucrative careers in dermatology, cardiology, pulmonary and critical care – with many avoiding a path in general practice altogether: “The only way to increase the incentive to become a primary care doctor I can see for the United States is to make sure the primary care doctors get paid well or as well as sub-specialists.”
It will become more difficult for American physicians, including primary care doctors, to maintain financial security if they are faced with seeing increasing numbers of under or uninsured patients. Physicians want to see patients with better health insurance as those are the ones who will offer higher reimbursements and will have a positive affect on their salary structure. What Christian described to me is a situation where the primary care physician becomes the “gatekeeper” who is left to care for patients who are no longer seen by sub- specialists, which is hardly an incentive to seek a career in primary care.
The Obama administration are supporting and driving a controversial health care reform in the United States, and incentives for doctors from all areas of health care are a prominent feature of the reform strategy. Just last week, it was announced that senior officials are getting ready to introduce an amendment to the Senate health-care bill that would add 2,000 new medical residency slots in a bid to increase the number of primary care doctors and general surgeons. The future of primary care medicine is complicated and one to watch; whether health care reform bills will be effective and have a positive impact on primary care practice remains to be seen.
My thanks to Geoff Wong and Christian Koch for their comments and thoughts.
In-house Editor, BioMed Central