Thursday, March 19, 2009

Do surgeons believe that non-physicians can "substitute" for primary care?

Yesterday, ACP President Jeffrey Harris, MD, FACP, testified at a hearing of the House Committee on Small Business examining the impact of President Obama's budget on "small providers."

(Maybe because I am still in the St. Patrick's Day mindset, I keep thinking of "small providers" as being the U.S health care system's equivalent of leprechauns, the legendary "little people" of Irish lore. I digress, though.)

Dr. Harris' statement made a strong argument on why the federal budget should support primary care physicians, especially those in smaller practices, noting that 82 percent of office visits are furnished in practices with five or fewer physicians.

I was struck, though, by the testimony of John Preskitt, MD, who was testifying on behalf of the American College of Surgeons. His statement makes the argument that the U.S. is also facing a shortage of surgeons, including but not limited to general surgeons. Fair enough: I think there is little disagreement that general surgery is also facing a shortage. I found one part of his argument to be quite provocative, though, to physicians in primary care specialties:

"With trauma care and surgical emergencies, there are no good substitutes or physician extenders for a well-trained general surgeon or surgical specialist. Surgical training is vastly different from other physician training programs. Mastery in surgery requires extensive and immersive experiences that extend over a substantial period of time. Surgical residencies require a minimum of five years and often several more years for specialties such as cardiothoracic surgery. However, the prospects of declining payment coupled with rising practice costs; increasing liability premiums and the escalating threat of litigation; a crippled workforce leading to more on-call time, higher caseloads, and less time for patient care; and an uncertain future for the U.S. health care system understandably deter would-be surgeons from making the extra sacrifices necessary to become a surgeon." (emphasis added)

Is the American College of Surgeons really implying that there are good non-physician substitutes for primary care physicians, but not, of course, for surgeons because "mastery" of surgery is so much more difficult and takes so many more years of training than primary care?

The American College of Physicians recognizes that nurse practitioners and physician's assistants are valuable members of the primary care team, working collaboratively with primary care physicians. We have also unequivocally stated that their skills are complementary, not equivalent, and that workforce policies "should recognize that training more nurse practitioners does not eliminate the need nor substitute for increasing the numbers of general internists and family physicians trained to provide primary care."

Today's questions: What is your reaction to the American College of Surgeons statement "that there are no good substitutes or physician extenders for a well-trained general surgeon or surgical specialist ... Surgical training is vastly different from other physician training programs"? Do you read this as implicitly stating that non-physician extenders can substitute for primary care doctors, and if so, how would you respond to this assertion?


PCP said...

This has long been the thinking of the Specialty Surgery Lobby.
The truth is very different. In our small town, I have seen the sad spectacle of General Surgeons (who sometimes take primary care so lightly) attempting to take on the primary care of patients. The outcomes long term are no different to what would ensue had I made an effort at a hemi-colectomy.
Many simple Specialty care procedures can also be delivered by appropriately trained mid-level practitioners, in fact the CardioThoracic surgery PA in our hospital routinely puts in Chest Tubes and does many simple procedures, if that is the argument we wish to have we could each have counter points. Many cystoscopies, endoscopes, along with much else that occupies a surgeons time can be done by technically adept nursing staff with the appropriate training. In fact, they employ such a model in some European countries.
The bottom line is Physicians must lead in any field of medicine. IF Surgery does not want to accept that in Primary care and we as a profession cannot stand united on that basic concept, we have a problem on our hands.
This leads to a another point. Could it be this very sense of superiority, that drives the attitudes of some of our surgical colleagues, and is influencing our medical students as they make their way through their training?
Could that be behind their reluctance to accept that primary care be paid at parity with them?
The root of this goes back to the RUC and its allocation of work RVUs for cognitive services Viz a vie Procedures. Until we fix that mess and find more objective members than Specialty medicine representatives to constitute that committee, we will never address this divide. Primary Care Medicine cannot afford to shirk this fight. We must make it known that the ultimate unbaiased adjudication of this issue, lies with the career choices of Medical Students. Their career choices speak louder than anything we say. As of right now,and looking at todays match results, I see nothing but long queues and filled residency slots for the Neurosurgery, Orthopedics, Anesthesia and other such procedurally driven residencies. Must not be so bad eh Dr. Preskitt. Not so for the Primary care ones as you would surely note.

Unknown said...

The same is true for any medical specialty, Internal Medicine, Dermatology, Cardiology. (Heh, heh, I havent seen physician extenders try to get into radiology.) Physician extenders are EXTENDERS, not physicians and ne'er the two shall meet.

It is much as I recall as an intern; wowed by the knowledge and experience of our attending/faculty level PharmD. He was very clear to point out that once a diagnosis is reached, he can provide information re: pharmacologic choices and data from studies. But he was very, very clear. He is not the one to make the diagnosis.

And that is the point. Even in the old adage about the division of medicine. Internists are the diagnosticians par excellence. We need to work on the training that will also assure that we are the ones to work WITH the patient and family for their empowerment to effect the treatment plans we draw up.

I seem to recall that nurses get into nursing due to an interest in the Education and Care of the patient. Has this changed? Isnt that the focus of nursing, even nurse practitioners (as opposed to practical nurses)?

Dr.T said...

I don't think physicians should attack each other on these grounds.

Rather, we should form our own grass-roots advocacy group and go pound on the doors of the legislators who are using these issues to drive us apart.

We all have parts of our professions that can be performed by less-well-trained and less intelectually prepared individuals.

The real problem is what we are paid. 19 cents out of every health care dollar goes to physicians. If you reduced it to 0 it would have no effect on this whole contrived "health care crisis."

We are all highly trained and we have all given up a lot in our lives to gain our expertise, and despite what the likes of Barney Frank would have you believe we cannot be replaced by Community College diplomates or affirmative action graduates.

What we need to do is fight for what we are paid, and what we are worth. Health care reform is going to make this problem worse -- so I suggest we join forces and fight for ourselves. If we were all paid what we were worth then this discussion wouldn't be had.

furrydoc said...

I think the surgeons and their highly paid liability carriers would much prefer their pre-op clearances be done by physicians.

If no resident is available to do the admitting H & P for somebody having an elective procedure, then the PA will make a perfectly adequate scribe.

The distinction between what requires thinking and reasoning from basic principles and what requires implementation of automatic protocols remains ill-defined. If the American College of Surgeons notion of medical care is one of processing a patient through their hospitalization, then they are probably right, at least until something goes awry. If the concept of primary care is closer to reality, meaning having a patient referred to those surgeons properly evaluated with the role of surgery integrated into a long term plan for each patient, then they probably still need physicians to be doing the medical care.

rich the furrydoc

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