MD Face-Off: Generalists vs. Specialists

Much has been written about the shortage of primary-care doctors needed to treat the influx of patients anticipated when the Affordable Care Act is fully implemented in 2014. To help solve this problem, Kaiser Health News reported today that some states are expanding the role of nurse practitioners to serve as a patient's primary care provider. The KHN Daily Report also cited a Chicago Sun-Times article about the increasing number of medical school students who choose to enter primary care fields ("More young doctors choosing careers in primary care"). These students are spurred on by health care reform's financial incentives for this choice, such as increased Medicare reimbursement.

But like many things in medicine (heck, in life as well), fixing the problem is more complicated than it first appears. More doctors alone don't always mean better patient care. In February, The Commonwealth Fund reported that a nationwide survey of about 2,500 Medicare patients found that patients with more doctors in their area weren't any happier with their care than patients with fewer doctors in their area. Improving health policy and organizing health care networks better might be more effective than adding more doctors to the mix, the survey's authors said in Health Affairs, which posted the study.

And when we look at the "doctor shortage" problem, should we focus on supporting generalists or specialists? Fierce Healthcare recently reported that a shortage of surgeons (not general practitioners) in some areas of the country leads to higher mortality rates after motor vehicle accidents. A recent study in the Journal of the American College of Surgeons found that in areas with fewer surgeons, accident victims are less likely to receive timely life-saving surgery.

Not that every doctor should specialize, though, because specialization in medicine has its own limitations. The title of a March report from the New England  Journal of Medicine shows the absurdity of current specialization trends: "Specialization, Subspecialization, and Subsubspecialization in Internal Medicine." The report's authors explain that formalized specialization fragments care, and the time spent maintaining certification might undermine a doctor's broader knowledge of his or her field. Patients, on the other hand, are impressed by the skill set implied by specialization. Health plans promote specialization as a marketing tool to attract more patients. There must be a reason to create each specialty, though, the authors write. "A proliferation of specialties without adequate justification may simply confuse the public without creating a social good," they conclude.

Ultimately, the problem of generalists versus specialists comes down to policy: what mix of generalists and specialists will best serve the public good? And what policies need to be in place to provide a steady supply of each type of doctor needed, and to help both types of doctors provide the best possible patient care?

Japan and America, Post-Quake

I'm not a morning person, but on Friday, March 11 I woke up fast when I heard the news announcer on the clock radio say something about a 9.0 earthquake in Japan, and a tsunami afterward, heading for the West coast where I live. The tsunami arrived a few hours later, around 8:00 a.m. PST, smashing boats together in Santa Cruz.

Since then, I've been following the news out of Japan as closely as I can, both because I've been writing about it for work and because I live in California. First, there were fears of another major earthquake on the West coast, at the other end of the Pacific plate. Then the worries shifted to the damaged Fukushima Daiichi nuclear reactors in Japan that were leaking radioactive materials, a scenario made more vivid by a somewhat misleading New York Times forecast of the jet stream whipping its way east from Japan. Stories about panicked Americans buying potassium iodide began to pop up in the media.

There's a certain myopia at work here, though. With Japan 5,000 miles away, for example, the radiation risk to the West coast is minimal. People in Japan are obviously much, much closer to the source. Furthermore, some of the daily aftershocks in Japan are bigger than some of the big earthquakes we've had out here, such as the Loma Prieta quake in 1989, a 6.9 on the Richter scale. Our troubles are small in comparison to Japan.

I worry about natural (and manmade) disasters as much as the next person. I've got my earthquake kit - I put it together long ago - and water bottles stashed around the house. But right now it's Japan that needs our help, and whose problems loom the largest.

How to Live Longer

Over the past two decades, aging institutes have sprung up in many states, often affiliated with academic institutions. These institutes look at how to live a long life and how to extend seniors' healthy years and decrease their disease and disability rates.

Improving the quality of life among seniors is not a strictly altruistic goal; keeping seniors healthy offsets the considerable expense of caring for a large aging population. As the roughly 80 million Baby Boomers start to enter retirement, the question how do you live a long and healthy life? is being asked with increasing urgency.

A new book, The Longevity Project, by psychology professors Howard S. Friedman and Leslie R. Martin, tries to answer the first part of that question. The authors analyzed data from a study of the lives of 1,500-plus Americans, begun in 1921 by Stanford psychologist Louis Terman.

The authors took a rigorous approach to their analysis, which they conducted over 20 years. As they explain on the book's website:

We used both sophisticated statistical models and a variety of examinations of personalities, social relations, and behaviors. We looked at people who shared characteristics—those with similar personalities, say, or a history of divorce—to see whether those traits predicted their health over time. Many of our findings took us by surprise.

Friedman and Martin found that people who are persistent and prudent in their approach to life tend to live the longest. Helping others helps you live longer, but having pets doesn't. Marriage benefits men, but not women. The most upbeat, happy people don't necessarily live the longest.

I'm interested in the book, as it looks at what habits contribute to a long life - a topic in which everyone has a personal interest. I'm also curious about how much it addresses the second half of the question - how to make long lives healthy ones - a topic in which society has a vested interest as well.

Surrounded by Lefties

I have a very personal interest in Tara Parker-Pope's blog post about lefties, based on a New York Times article about left-handedness by Perri Klass, "On the Left Hand, There Are No Easy Answers." Not because I'm left-handed - I'm not - but I am surrounded by lefties at home.

I'm sympathetic to the problems of being a leftie in a world dominated by righties (who make up about 90% of the population). But my three lefties get their revenge in my household. When I reach for a pair of scissors at home, half the time they don't work (for me) because I grabbed the left-handed ones. When we eat out, I need to make sure the lefties are sitting to the left of me, or we will bump elbows, possibly setting off a tantrum, depending on the leftie's age.

My lefties are a very creative bunch, though, I have to admit. They've turned tinfoil and Kleenex boxes into robot shoes, created a computer keyboard out of a piece of cardboard, and made their own fake iPod which they taped my real headphones to (hint hint, Mom). There's an endless procession of plays, songs, stories, and artwork, and we're always running out of glue and tape for projects, which disappear as fast as any office supplies that I accidentally leave lying around. And musical instruments are piling up so fast at our house that I've started to trip over them.

Of course there's lots of (somewhat self-serving) leftie-spotting in my family, usually identifying highly educated or highly creative lefties. Look - that doctor is a leftie! Obama is a leftie! My teacher is a leftie! Mark Twain, Gandhi, Benjamin Franklin - the list goes on.

I grew up in a family with no lefties, and my husband's family was evenly split. Here, though, they're in the majority. I like my pack of lefties, and the leftie refuge that is my house. When I go out, I'm among my rightie kin, but at home, the wild, mysterious (and often inexplicably sticky) lefties rule.