Primary Care Matters

Internal medicine doctors train predominantly in our high-tech academic medical centers, yet most will provide outpatient care. Here, Dr Andrew-Morris Singer frames one of modern healthcare’s greatest disconnects.

Recently, my wife and I received a gift certificate for one of our favorite restaurants, and we wasted no time in using it. The food and conversation were delightful, and the meal turned out to be exciting and enlightening on many levels. A patron of the restaurant, who was celebrating his 55th wedding anniversary, sustained a witnessed, public cardiac arrest. The experience led to an analysis of my involvement in the resuscitation.

Looking at contemporary medicine’s complex landscape, especially in regard to soaring costs, can make practitioners dizzy. For example, if primary care physicians were asked whether it is cost-efficient and reasonable to screen with prostate-specific antigen (PSA) measurement for early-stage prostate cancer in men with terminal pancreatic cancer or to perform colonoscopy for early diagnosis of colon cancer in women with stage IV lung cancer, the answer would be a quick and uniform no. Unfortunately, a recent publication suggests that in the real world the answer has been yes, as disturbing and wasteful as that may be.

Since continuing technological advancements are going to add to rising costs (dialysis, for example, with more “baby boomers” coming of Medicare age), one has to wonder what the something is that “has to give” in the future.

We live in a litigious society. Unfortunately, that statement may be most accurate in the setting of medical practice. Did you know that 40% and 34% of family practice and general internists, respectively, have been sued for malpractice? One in seven primary care practitioners have been sued at least twice. A recent "Business of Medicine Report" offered some very helpful advice that may keep practitioners out of court.

In many instances, our patients receive invasive and aggressive subspecialty care at or near the end of life. Such care can become burdensome and painful without a favorable outcome. As advocates for our patients, we must ensure that their pain, shortness of breath, and other bothersome symptoms are alleviated, thus leading to a “good death.”

Avoidance of guidelines because they are “cookbook” is no longer an adequate excuse—especially when we are doing things incorrectly and expensively, while adding to potential complications.

This generation’s diabetic control is preceded by the ever-present adjective “intensive.” Although a lower A1c seems to be a rational, and in many instances a proven target for type 2 diabetes with its constellation of micro- and macrovascular complications, are there downsides when prescribing exactly how low one’s A1c should go?

In the December 14, 2009 issue of The New Yorker magazine, Atul Gawande observed, “Cost is the specter haunting healthcare reform.”