Sunday, August 14, 2005

"Awash In Information," and Without Primary Care

The NY Times just ran a prominent front-page story entitled "Awash in Information, Patients Face a Lonely, Uncertain Road."
It's basic focus is on patients forced to make their own decisions about health care in the face of conflicting information and disagreeing sub-specialists. The first vivid story it chronicles was of a patient with metastatic ovarian cancer given conflicting opinions by medical and surgical oncologists. One of the latter told her, "none of us knows what you should do. So you have to make the decision, based on your values."
The patient responded, "'I'm not a doctor!' she shouted. 'I'm a criminal defense lawyer! How am I supposed to know?'"
The job of being a modern patient includes not only decision making, of course, but often coordinating doctors, medical records and procedures, as well as negotiating with insurance companies, who are often the ultimate arbiters over which treatment options will be covered.
Like many patients, Ms. Gaines did not turn to a primary care doctor to help coordinate her care or aid with decisions. Increasingly, that soul-healing doctor-patient relationship has become harder to sustain. Whipsawed by insurance plans, patients frequently switch physicians. Pressed by diminishing reimbursements, those doctors are building ever larger, more unwieldy practices, with less time for each patient.
The strain has left doctors themselves feeling exhausted, angry and heartbroken.
"My visits are almost ludicrous," said Dr. John Russo, an internist in West Orange, N.J., who sees 5,000 patients a year. "But economically you have to see so many more patients than you should, just to keep the lights on. You can't sit and talk and really get an entire history. So you do what you were taught as a resident: do more tests, don't spend more time with patients, getting to know them."

Read the whole thing. It's a vivid reminder of why having a personal, generalist physician is important, and yet that fewer and fewer patients have one.
Unfortunately, it doesn't deal very well with why this is happening:
But though that primary relationship is so fundamental for patients, the medical establishment is gradually turning away from it. The number of medical students eschewing careers in internal and family medicine and instead pursuing specialties is increasing. Among the reasons they give are the declining prestige of primary care doctors, the eroding doctor-patient relationship, the financial hardships of maintaining a practice and the drain on family life.
Maybe later the Times will get to how concentration and abuse of power in health care seems to have had a disproportionate impact on generalist physicians. One cause is probably the wooden-headed reimbursement policies of government agencies and managed care organizations we discussed previously. With any luck, the general public will notice this problem before there are no generalists left.

Addendum: See the Medical Rants take on this, "What This Patient Needs is a Doctor," here.

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