Tuesday, March 29, 2011

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?

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