What is it that primary care has to offer?
In two simple words. Brain Power.
Like most primary care, it doesn't offer a product. It offers a service.
An opinion. An impression. A recommendation. An evaluation. A coordination.
These are intangible.
When you go to a department store you buy "something".
A shirt.
Jeans.
Socks.
Underwear.
When you go to a restaurant, you buy "something"
A drink
An appetizer
A meal
Dessert
When you go to the grocery story, you buy "something"
Produce
Meat
Oil
Cans
Eggs
Milk
Bread
When you pay your monthly mortgage check, you buy "something"
A roof
Equity
A tax deduction
When you pay for your kids activities you buy "something"
An activity for your kid
An activity for you
When you buy a vacation, you buy "something"
A hotel
A plane ticket
Activities
Memories.
The world is a product. We work to earn money.
We earn money to spend money.
We spend money by buying things. Materialistic things.
We buy things to make our lives easier, more exciting, more interesting.
The motivation to buy is different for everyone, but ultimately the cycle continues.
So where does primary care fit into all this?
Well, primary care doesn't have a product. You can't take it home with you. It doesn't fill your belly. It doesn't keep you entertained. It is not a product.
It is a service.
Primary care is different from other fields of medicine in that the satisfaction of services rendered must compete with the illusion of Google MD phenomenon:
That the service primary care offers is of little extra benefit than looking it up on the Internet yourself.
For free.
That information is readily available and free.
Music should be free to download.
Movies should be free to download.
Books should be free to download.
There is no respect for the masters of their craft.
If it's on the Internet, it should be free.
That is the American Way.
What primary care offers is a service of information. It, on average does not offer a tangible take home product.
And unfortunately, many believe that this "service" should be discounted, since it is readily available on the Internet.
It also builds a belief that since primary care has nothing to offer but information, which is readily available on the Internet, that as a patient, I must see a specialist because the illusion of free information is not carried onto the specialist.
It is as if there is a separate library of information, that only specialists have access to, not available to primary care, not available to the Google MD.
And don't forget.
Specialists do procedures.
Now, THAT'S a tangible product.
Something worth paying for.
If I'm going to the doctor, then I should get something out of it. Something worth my money.
A report. A picture. A biopsy. An image.
If you invade my body and tell me its OK, THEN I'll believe you. A picture, I believe. Your opinion? We'll,
I can get that from Google.
Just this week, I took care of a patient who's family had unmanaged expectations. They demanded a cardiology consult for
get this...one premature atrial contraction.
Just one.
I shit you not.
There could have been a thousand of them and a cardiology consult would never cross my mind.
What I have to offer is my mind.
I have come to believe that there is a significant population of entitled ME and NOW patients and their families out there who honestly believe that having a specialist for every possible ailment some how equates to better care.
What it equates to is more expensive care. But the illusion is there. And it's a powerful one. It is perpetuated by the unmanaged world of fantasy television with all the fancy gadgets, gidgets and miraculous recoveries seen only on prime time. It is perpetuated by they constant barrage of television ads from specialty groups and hospitals that tout the latest gidgets and gadgets and being the best in the region for this and that.
The commercials are always the same. A guy with scrubs and a hair net with a fancy fluoro table , an imaging device, and a few aptly placed fancy angiogram images flying through the background.
It's enough to make any lay public believe that THAT is medicine. Which I believe would be the point of the commercial.
Not a visit to your primary care doctor.
There is so little respect for the mind these days, and medical education in general. When you can Google your health and play doctor in your mind, that some how extrapolates to a dumbing down of the cognitive physician.
It's almost as if the patient believes that since they "know" what's going on, or they can "figure it out" on line, that somehow their primary care doc is just as simple minded. They seem to foolishly believe that 7 years of post graduate training is not as simple as playing Google MD.
And they forget, when they come in with one complaint, the primary care doctor has an encyclopedia of knowledge related to that one chapter in Google that you read but also the entire rest of the internet of medical knowledge that you have no idea even exists. And then some. That's where the seven years comes from. Just a tad more than your one hour Google search. You pay for all the knowledge, even though your primary care doctor only exposes you to a tiny paragraph in one chapter.
If you want a paragraph out of a chapter, go see the extender.
That's the difference in knowledge base between extender and MD.
Without procedures, primary care is a service, not a product.
And everyone knows that the service industry only survives when you kiss your customers ass. Because, if you don't, somebody else will. And they will take your customers.
Take for example the giant ass kissing going on in all hospitals all across this country going country club style. Just today I read about an orthopaedic hospital that offers your own butler and filet mignon as part of their "service".
Their kissin' your ass for your FREE Medicare money.
Unfortunately, I don't know many docs who will kiss ass to their patients. And as a result:
Welcome to a world of fragmented minute clinics, dis conjugated specialists and ER's.
Service is not accomplished by 8 minute contacts and 1 hour waits in the front office.
Unfortunately, reimbursement via RUC/RVU/SGR has turned the service of primary care into a disservice. With unhappy patients willing to Google their own health and go straight to a specialist for their tangible procedural invasion and primary care docs more than willing to play that game and keep the volume train rolling.
Since the only way to survive, is volume, volume, volume.
In essence, against their will, primary care, a service industry, has been economically forced into a role not compatible with service industries. To provide the type of service required to bring satisfaction to their customers would require a large increase in reimbursement from the FREE=MORE Medicare National Bank, OR it will require a balance billing approach from the patients who are willing to pay to get service.
For primary care to bring back value to their field, they will have to provide a service again.
That is the idea behind concierge medicine. Providing a service.
And make you feel like you are buying "Something"
9 Outbursts:
it's always darkest before the storm. america has voted.
primary care is out
"They seem to foolishly believe that 7 years of post graduate training is not as simple as playing Google MD."
That's Scenario #1; here's Scenario #2:
Internist meets with healthy 39yo patient after a resting ECG as part of a routine biannual physical.
"You have a blip on your ECG that is very common and almost certainly nothing, but I want you to take a stress test and echocardiogram."
"What is it?"
"Just a blip. It usually vanishes in the stress test, which means it's nothing."
"No, I mean what is it? Write it down so I can Google it when I get home."
I respectfully submit that the physician is the obnoxious one here, not the patient.
We may not have "7 years of post graduate training," but some of us do have a vocabulary that is more expansive than "blip" and "nothing."
sometimes, there is no other way to describe a blip, than to call it a blip.
7 years of education, blah, blah.
It is an empirical question whether google/ computerized expert system outperform doctors.
Is used to take a decade for a weaver to move from an apprentice to master. The jacard loom (a sort of predecessor to the computer) outperformed the master weavers. By your argument, hospitalist, that would not be possible--because education always trumps machines.
for anon 440
Thank you for displaying the lay public's gist of my post.
Education is the cure for ignorance.
I was going to comment on the post, then I see your reply to "KipEsquire," and I slapped my hand to my forehead. That's EXACTLY the wrong answer for the wrong reasons. A blip is a blip when it's a blip; when it's something known and "common," (as per the example) if a patient asks for clarification, it should be given --especially if the patient has already shown a high degree of intelligence and/or interest in their care. Nobody's talking about having to give a background in cardiac physiology, but repeating a brushoff answer with no further explanation--especially considering all the "brains" you mention that go into care--is inexcusable.
What I was originally going to type is this: Where are you coming from when you claim that people want to do away with primary care because they can get that information from Google? If Google was a substitute for primary care, they wouldn't be in the IM/FP clinic with printouts; they would have solved it on their own. The very fact that they still "go to the doctor" means that people aren't comfortable putting their health in the hands of a Web 2.0 site.
I don't disagree with the overall problem of people looking up stuff online and thinking they are going to "shortcut" their own care with their "research." There's a fine line between empowerment and stupidity, but this is not in any way limited to primary care. You don't think people walk into their GI doc's office with printouts of "organic IBS cures" or whatnot?
enrico, there was a huge tongue in cheek with the blip comment.
You are correct, the Google generation does not discriminate between primary care and specialist.
It's just, in my experience, the patient is more willing to believe a specialist because the word "special" carries more mystical qualites than the word "primary".
I deal with the "Aren't you going to consult the cardiologist?" question on a more than regular basis.
How often does a specialist hear:
Aren't you going to consult a primary care doctor?
Happy hospitalist - first, I enjoy reading your blog, keep up the discussion!
Second, as a primary care physician (outpatient internal medicine), I agree that that there are lots of patients who bring printouts and preconceived diagnoses from the internet when I see them in the outpatient setting. Sometimes, they bring some good points to the discussion and to their differential diagnosis. Othertimes, I need to explain to them that their internet self-diagnosis is unlikely, and explain my rationale for my alternate diagnosis. I usually encourage them to research their condition - especially if it makes them feel more comfortable - and if they have further questions, they can always follow up with me.
With this approach, and having
established a prior relationship of trust with the patient and explaining my thinking will successfully satisfy my patient in at least 90% of cases. Of course, there were always be the 10% that still feel more comfortable seeing the specialist and so if my approach doesn't work, I will make the referral for them.
Also, in my experience, I find that patients will sometimes come back to me after seeing their specialist for "my opinion" - especially if the specialist doesn't take the time to explain their thought process, so I don't think we are completely powerless!
Of course, avoiding routine "baseline" testing - also helps minimize the above discussions. Unless there is some sort of family history or cardiac symptoms, I don't think that getting a "routine EKG on a biannual physical on a 39 year old man" is recommended by any organization/task force (and for that matter, neither is getting a biannual physical unless there is some other sort of chronic health problem).
Thanks for listening.
I think people are missing the
message. The message is that PCP
are not well compensated for using their brains. The message is that Health Care does not reimbursed enough and does not recognized cognitive medicine.
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