Saturday, February 3, 2018

The Luddites Are Always At The Gate

Prevalence of Multimorbidity with Age (left) and Sex (Right) from Reference 2 per Creative Commons Attribution License.

I noticed a Twitter feed about a blog piece on the complexity of multiple illnesses and the need for primary care (1).  If the post would have stopped there it would be impossible to disagree with.  Unfortunately in the usual manner of the blogosphere - for every group elevated another needs to pay the price.  In this case, the natural target would be the specialists.

The basic argument is that as people get older they end up with more chronic diseases. That should not be surprising to anyone - see the graphic above and click on it to enlarge.  People who accumulate more of these chronic illnesses are the most expensive people to care for in the health care system.  Also no surprise, but somewhat of an overstatement.  In the USA, it is quite easy to be sailing along disease free and suddenly develop an illness that places you in the top tier of treatment costs.  Cancer is a clear example.  One of my colleagues told me that the total cost of treatment for breast cancer in one of his relatives was over $1 million dollars.  That explains the main motivation for health insurance in the USA, any serious illness can lead to bankruptcy without insurance.

The argument continues that the predominate model of care is that physicians diagnose, treat, and cure illness in episodes of care rather than maintaining people with chronic illnesses.  The author concludes that physician specializing in organs or parts of organs are not equipped to deal with the problem.  He refers to remorseless specialization and subspecialization as being the problem.  He concludes that doctors and patients seem to be going in opposite directions because of this.

That is not what I am seeing.  In the USA, one of the main metrics followed in surgical specialties these days is the volume and outcomes of surgeries.  Several references point out that surgical volumes and good outcomes are directly correlated.  For that reason I found a neurosurgeon who was doing two transphenoidal pituitary adenoma resections per day for years rather than one who had done a total of 9 lifetime when my wife needed resection of a growth hormone secreting adenoma from her pituitary gland.  It has been 9 years since the resection and no recurrence of the tumor or endocrine markers.  She has not seen the surgeon again in that time but is followed by a primary care physician and an endocrinologist.
The beauty of the American health system if there is any is that you can see a broad array of specialists in any moderate population center.  The author was astonished to find that the British Journal of Ophthalmology has a different editor for every layer of the eye.  I think that it is equally astonishing that in most American cities you can wake up with symptoms of a retinal detachment and be seen by an eye specialist within hours. If it looks like you have a true acute retinal detachment - you will be referred to a retinal or vitreous specialist and have definitive treatment the same day or the next.  The laser surgical technique is far superior to what was being done 20 years ago and can be accomplished in an office in as little as 20 minutes.  That surgery prevents blindness and the need for riskier surgery.  Within a few decades, ophthalmology has evolved to a very effective and efficient specialty that covers a broad range of eye diseases with relatively few physicians.  The advantage of specialists in this case is clear cut and directly addresses patients needs.  In fact, the problems that ophthalmologists treat are barely addressed in medical schools.  The problem is not that the specialists don't know primary care.  The problem is that it is impossible for primary care physicians to recognize and diagnose eye conditions and treat them.

With regard to the knowledge in each specialty, a late friend of mine who happened to be an ophthalmologist put it this way: "Each specialty expands to cover roughly equal amounts of information."  At the time of his statement - books were the standard and he pointed out that each specialty had 2 - 3 volume sets of several thousand pages.  I haven't seen an information age comparisons - but I think that the concept is a good approximation.

That is not to say that specialists are "better" than primary care physicians.  If anything. primary care physicians and specialists count on the fact that those primary care physicians can manage all of the patients health problems except for the one being addressed by the specialist.  Specialists count on primary care physicians for preoperative physical exams, referrals, and ongoing care after they have completed the consultation. The problem for some is that it sets up specialists and subspecialists as the superstars of medicine.  I am speculating about the problem because I certainly don't see it that way.  There is no doubt that some of these specialists are very highly compensated and I won't argue that is right or wrong.  Personal observation tells me that they work as hard as anyone and really don't have glamorous lifestyles.  Being on call to all of the emergency departments in an area for rare problems is not an easy job.  They are there to solve very specific problems, manage one particular illness, or advise the primary care physician about how they would do it and turn the care back over to them.   

Even with the inefficiencies of the American health care system - I think there is evidence of a reasonable distribution.  The neurosurgeon I referred to sees a catchment area of the entire Midwest.  Anyone with a pituitary tumor has access to his expertise.  The retinal specialists can be found generally in any area where there is a city of 50,000 people.  Since retinal tears/detachments, various retinopathies, and macular degeneration are widespread and in many cases age-related these clinics have a much broader representation and provide good access to large segments of the population.     

Over the years that I have been in practice there have been many primary care initiatives. The first initiative was actually threatening to put specialists out of business.  That turned out just to be a managed care organization (MCO) tactic.  The second wave was forcing MCO primary care physicians to authorize all approvals for specialty care - the so-called primary care gatekeeper approach.  I can't imagine how much time that wasted.  After managed care organizations realized that they could hire specialists and monopolize them - they also realized that they could make money by "managing" them.  That was not 100% effective because now specialists realized they finally had some leverage against managers and could take their business off campus and manage it more effectively themselves.  I have seen many variations of pro-primary care and anti-specialist rhetoric over the years.

The problem is that the money never follows the rhetoric.  Instead of just paying lip service to primary care why not actually pay them for managing multiple morbidities in an aging population? Why not recognize their expertise?  There is no health care company that I am aware of that comes close. MCOs are trying every way possible to reimburse primary care at rates so low - they barely cover the overhead.  Government payers are doing the exact same thing.  The government programs like Medicare are so bad that many primary care MDs are disenrolling and engaging in a cash only practice.

On the academic side, where are the primary care centers of excellence?  Where are the mission statements about managing multimorbidities and being the best possible specialists to do that?  Primary care specialists need to own and promote their expertise, especially how they interface with specialists.

It turns out that there is plenty of room for both primary and specialty care in modern high tech medicine.  Specialization should be remorseless and managing multimorbities is as specialized as laser surgery on a retina.  Once again it appears that the real problems of health care systems are being projected on physicians when they have developed critical treatments that were not around even 20 years ago.

The idea that we should travel back to that point in time - is totally unacceptable to me and the tens of millions of other patients who have benefited from these developments.

George Dawson, MD, DFAPA


1:  Richard Smith. Doctors and patients heading in opposite directions.  BMJ Opinion. BMJ Feb 1, 2018.  Link.

2: Violan C, Foguet-Boreu Q, Flores-Mateo G, Salisbury C, Blom J, Freitag M,Glynn L, Muth C, Valderas JM. Prevalence, determinants and patterns of multimorbidity in primary care: a systematic review of observational studies. PLoS One. 2014 Jul 21;9(7): e102149. doi: 10.1371/journal.pone.0102149. eCollection 2014. Review. PubMed PMID: 25048354; PubMed Central PMCID: PMC4105594.


  1. My father was an optometrist. Eventually he could not compete with low cost chains like Pearl Vision. Now private practices cannot compete with Costco. CVS Minute clinics will do the same to primary care. I see nothing but constant competition and salary cuts and status reductions for anyone going into primary care going forward. The economics are just too dismal. I see no reason Costco cannot do BP and A1c checks and the like since CVS has already staked that out. Maybe elite academic internists can thrive but that's a small niche.

    1. BTW - I have purchased eyeglasses at some of these chains. "Buy one get one free." The catch is the first pair costs a grand.

      Once the competition is gone - monopoly pricing again.

    2. The reason eyeglasses are so expensive is that Luxottica is exactly that...a monopoly that has somehow managed to escape what should be an easy antitrust suit. Costco however, does have decent glasses including Alexander Julian frames at good prices.

  2. Quite possibly - the commoditization of medicine started about 30 years ago. As I have posted here - CEOs everywhere (including Bezos, Buffet, and Dimon) would like nothing more than to replace MDs with anything else. I can recall some arrogant business man making that prediction 20 years ago in a financial magazine. I can see the lists of docs on the Amazon web site right now with a list of 1-5 star ratings.

    This is a political battle and most of organized medicine is really ignorant about how to approach it. I picked up my copy of Psychiatric News and read it over dinner tonight. There was a story on page 4 that I consider to be emblematic of this cluelessness. John McIntyre wrote "PCPI Helps Organizations Produce Clinically Valid Quality Measures." In it he talks about the PCPI ( as a consortium of "75 member organizations including the APA". Members are not listed on the web site, suggesting to me that there are business members. The key statement:

    "PCPI partners with APA and other member groups to develop clinically relevant measures, and the broad scope of PCPI membership translates into leverage with the federal government and other payers."


    Apparently the APA and the physicians in the organization really don't understand the politics of quality measurement. There really hasn't been any since the 1990s. There are no valid quality measures only political ones that are used as leverage against physicians to reduce their productivity and pay them as little as possible. Instead we are told that it is important to recognize that payers are paying for quality and that depends on the quality measures that the PCPI comes up with.

    I guess the PCPI doesn't recognize the fact that 99.9% of state hospital beds have been shut down, the 4 largest psychiatric hospitals in the country are county jails, inpatient psychiatric treatment based on dangerousness is almost completely meaningless, and there is no access to psychiatric services.

    It takes a lot of nerve to come up with "quality measures" in that landscape. You have to actively collude with both the government and industries that dismantled psychiatric care. It makes about as much sense as using Bezo's 5 star ratings off Amazon. They are probably as valid as any PCPI rating.

    I agree that medicine and physicians cannot compete with the race to the bottom. Thank God we were not trained that way.

    I think that's what an MBA if for.

  3. As I wrote in a comment at my site last night, who's going to be a physician in 2020 that really cares and can provide services as trained?

    Also, again, who the hell belongs to the APA when they sabotage us at every turn?! For some strange and bizarre reason, I get that stupid newsletter and I'm not a member. While there's a couple of articles of interest, most of them just spew the garbage that organization packs in their rectum and then expects us to eagerly grab and rub on us with glee.

    Perhaps a bit unrelated but I feel a technology issue in general, I just hope this rush to want to use ketamine without pause comes back to bite all those providers in the butt!

    1. The APA will never be effective because the leaders are operating in a different ivory tower Skinner box. Academics are not subject to the realities of clinical practice or they wouldn't be favoring nonsense like Collabocare and Obamacare and not (with one exception) opposing mangled care. As I have pointed out before, it is absolutely hypocritical for people who have never taken Medicaid in their lives to be advocating Medicaid for all in mental health.

      That the rank-and-file keep electing them is the real problem. They are turkeys voting for Thanksgiving.

      I have not been a member since about 1985, and that has been money well-saved as it is a tax on the mental inertia of being a reflexive joiner and a tax on the inability to hold leadership accountable.