Nails in the coffin
To the Editor : Dr. Lansdale’s commentary depicting the plight of general internal medicine struck a heartfelt, emotional chord with me. I am a 59-year-old general internist with 30 years on the job as a hospital- and office-based practitioner. I’ve enjoyed the opportunity of being the chairman of the hospital’s department of medicine, president of the medical staff, chair of the quality committee, and other assorted hospital responsibilities. I was the associate director of a medicine residency program for 3 years, so I share some of Dr. Lansdale’s issues regarding “bureaucratic lunacy.” The three other generalists in my practice have done the same. We all love practicing medicine in spite of the demands. Our incomes are 20% to 30% less than they were 10 years ago. We have 35,000 charts (not all active) but still accept new patients, even Medicare. Caring for an octogenarian with five to eight active medical ailments who is taking 12 medications, mostly prescribed by several different subspecialists, is more challenging than ever. I’m saddened when I see a patient who has had two or three recent MRIs ordered by different physicians for a back, chest, or abdominal complaint when some simple remedy with the proper dose of time, observation, and follow-up was all that was needed. In spite of the problems, I enjoy practicing medicine as much as ever, but the future appears dim.
What has caused this impending collapse of primary care, and what is the cure? The answer is simple. The value that exists between patients and their personal physicians has been forgotten. The payers have cunningly refocused the values elsewhere, and the medical community and the public have let them do it with almost no resistance. I won’t mention the facts or history of this disaster, as we all know the story pretty well. I will mention, however, some scary things that may seal the primary care coffin forever. Insurance ratings, tiering, pay-for-performance, and evidence-based economics will all be the nails, and not much hammer effort will be needed.
What can be done to stop the bleeding, or do we really care? When the system changes to reimburse primary care physicians as much as subspecialists, then the coffin will open. I believe the decision to do this will come from pressure on the government from the public. Somehow, the medical community must convince the public to initiate this pressure. In the meantime, primary care physicians must continue to render compassionate care to the patient. After all, isn’t that why we went to medical school in the first place?