The changing face of health care

Is health care being reformed, or is it being changed? Do any of us know how reform will affect us individually?

Gary McDowell, administrator of Family Practice Medical Center, says he doesn’t have any answers, but he provided plenty of fodder for discussion today in the final installment of Bethel Lutheran Church’s speaker series on health care reform.

"There are no experts, in my opinion, today when it comes to health care reform," McDowell said. "We’re all learning as we go through it. What the changes will mean for your care – I have no idea and that’s as honest as I can be."

McDowell suggests reframing the discussion as one of health care improvement, rather than reform, “because I truly believe that is the direction we are going.”

Here’s how one clinic does it: In 1997, Family Practice Medical Center owned one computer. Today there’s a computer in every exam room. The clinic has an electronic medical records system, uses electronic systems for claims and scheduling, and recently added an electronic system for ordering and reporting lab results.

"Is that reform? I don’t know. It certainly is change," McDowell said.

The family practice clinic is a microcosm for how health care has been adapting and changing. Take evidence-based medicine, for starters. Family Practice Medical Center adopted the guidelines of the Institute for Clinical Systems Improvement in 1998. In 2001 the clinic implemented open access, allowing patients to see their doctor the same day. Two years later the electronic medical records system was added.

Family Practice Medical Center isn’t the only clinic taking these kinds of steps. Other organizations, such as Affiliated Community Medical Centers, are tackling many of the same initiatives. From a national perspective, however, many of these changes are still cutting-edge; for instance, only about 35 percent of medical clinics in the U.S. use electronic medical records.

McDowell offers some of the maxims that help shape his clinic’s strategic direction: "Today’s solutions will be tomorrow’s problems." "If you always do what you’ve always done, you’ll always get what you’ve always gotten." ‘The only constant thing is change."

The approach, he said, has been to try to adapt earlier rather than later.

Nevertheless, providers are anxious about the prospect of health care reform legislation and how it’s likely to affect them, McDowell said. In Minnesota, the picture is even more complicated because of the 2008 health care reform bill which seeks to remake the health care delivery system.

"It’s out there and it’s legislated and it’s coming," McDowell said.

I attended the entire speaker series at Bethel this month. When I counted the number of people in the audience each time, there were never fewer than at least 20. People were engaged. They had good questions. The folks at Bethel who organized this series deserve a thank-you for taking the initiative to cut past the hype and misinformation and give the community some worthwhile food for thought.

Primary care: the next generation

If everyone in the United States who’s uninsured could get health insurance tomorrow, what would happen? Would there be enough primary care doctors to handle the demand?

The answer is probably no, Dr. Kevin Pho writes in a commentary that appeared last week at

Uninsured patients often delay preventive care, waiting to seek medical attention only when their conditions worsen. This leads to more intensive treatment, often in the emergency department or hospital where costs run the highest.

Universal health coverage is therefore a sensible goal, and the reforms being considered all make considerable effort to provide everyone with affordable health care.

But expanding coverage cannot succeed as long as there remains a shortage of primary care. After all, what good is having health insurance if you can’t find a doctor to see you?

Much has been written about the woes facing primary care: the low pay compared to specialists, long hours, tons of paperwork, the need to churn patients through the exam room every 15 minutes. (Technically speaking, primary care consists of family medicine, general internal medicine, pediatrics and obstetrics/gynecology, but for the purposes of this discussion, we’ll focus on family medicine and general internal medicine.)

One of Dr. Pho’s commenters sums it up: "No student in his right mind would choose primary care as his specialty, unless he is already independently wealthy."

There’ve been numerous ideas put forth on how to fix the situation. Scholarships, free tuition or forgivable loans have been suggested to help ease the financial burden for medical students who want to go into primary care. Many observers think tort reform would help. Improving the working conditions for primary care doctors also would go a long way toward making the practice of primary care more rewarding, Dr. Pho writes:

Primary care clinicians routinely face unreasonable time pressures, a chaotic work pace, and bureaucratic impediments. Onerous paperwork requirements that obstruct patient care have to be reduced. And instead of the current system which encourages doctors to rush through as many office visits as possible, physicians who take the time to counsel, guide and address all of their patients’ concerns should be rewarded. Better valuing the doctor-patient relationship will increase satisfaction, not only for physicians, but for their patients as well.

The impact is often felt far upstream. All too often, what happens is that someone who’s eminently suited for primary care opts for another specialty instead. Maybe the demands of primary care are a turn-off; we’re all seeking more balance in our lives, after all, and we shouldn’t begrudge physicians for wanting the same for themselves. Maybe they have enormous school loans and simply can’t make the numbers work on a primary care doctor’s paycheck. It’s hard to calculate how many future primary care doctors are being lost early in the game, but the numbers must be considerable.

Even if primary care were more attractive, however, would more medical students make it their career choice? More to the point, should they?

Awhile back, a humorous flowchart was making the rounds on the Internet, outlining how medical students should pick their specialty. (Afraid of the light? Become a radiologist. Nonexistent attention span? Go into emergency medicine.) It’s good for a laugh but it also underscores the importance of ensuring future doctors are a good fit for their chosen specialty. Not everyone is cut out for primary care. And if everyone did primary care, we wouldn’t have any specialists, so we need to be wary of short-sighted solutions.

I don’t see any fix in the near future for what ails primary care. The situation is likely to grow even worse in rural areas, where primary care doctors are in short supply. We can throw money at the problem in the form of scholarships and forgivable loans, but it’s not clear whether this will help with some of the deeper issues, such as reimbursement and working conditions.

In the midst of this rather negative news, it’s worth remembering that there are still plenty of primary care physicians who manage to run a good practice and even thrive, despite the odds – physicians like Dr. Jim Selenke, the lone doctor in Hudson, Iowa, whose inspiring story can be found here. There are probably hundreds more like him, some of them in this very community. If we sat down and talked to them about the future of primary care, what do you think they would tell us? What do you think we could learn?

Update, Aug. 26: For another physician’s view on this issue, read "Why primary care doctors are fed up."

A gulf of disparity

Geographic disparities in Medicare payment rates have long been talked about – and complained about – among the nation’s rural health care organizations and practitioners, especially in the rural Midwest. But it took an eye-opening article in The New Yorker, and the looming prospect of health care reform, to finally get policymakers to sit up and really take notice.

In his now-famous article, Dr. Atul Gawande uses McAllen, Texas, as an illustration of the wide regional differences in how much Medicare spends per person:

It is one of the most expensive health-care markets in the country. Only Miami – which has much higher labor and living costs – spends more per person on health care. In 2006, Medicare spent fifteen thousand dollars per enrollee here, almost twice the national average.

There have always been geographic variations in health care spending, physician practice patterns and health care consumption patterns. The rural Midwest, for instance, tends to be more conservative, both in its use of high-dollar health care services and its overall spending on health care.

Even so, most people are taken aback when they see these patterns visually represented on a map:

The map was developed by the Dartmouth Atlas of Health Care, which has been tracking this data for more than two decades. The darkest areas on the map show where Medicare reimbursements per enrollee are highest. You’ll notice the lightest areas, where Medicare spending is lowest, include almost the entire state of Minnesota.

If you were to go back in time to 1965, when the federal Medicare program was established, the map likely would look very similar. In fact, Medicare payment rates were originally established using a formula based on prevailing costs in a given geographic area. Over the years, these regional variations have become more or less cemented into place, and in many cases the gap has widened even further.

The Dartmouth Atlas Project notes, for instance, that between 1992 and 2006, inflation-adjusted spending on Medicare rose 3.5 percent each year. In Miami, however, it grew faster, at the rate of 5 percent a year. In San Francisco it grew a slower 2.4 percent annually. If Medicare spending in all other regions in the U.S. grew at the same rate as that in San Francisco, a cumulative savings of $1.42 trillion could be achieved by 2023, the Dartmouth analysts estimate.

What’s especially intriguing is that the quality of care doesn’t appear to be any better in high-cost regions of the U.S. than it is in the regions that spend less on health care. In fact, the lower-cost regions usually score better on quality measures.

There can be many reasons why health care spending is higher in certain communities. Perhaps the population is older or sicker or has a higher incidence of chronic disease. Maybe there’s a higher concentration of medical services or medical specialties. In areas that spend less, poverty may be more prevalent.

The Dartmouth researchers believe there’s an overriding reason, however, for the geographic variation in health care spending. They sum it up in two words: local context. It’s in how local physicians run their practices and the types of interventions they provide for their patients. It’s in how local hospitals and health care organizations make strategic decisions, such as acquiring new technology or adding new services. It’s hard to imagine that patient expectations – surgery, for instance, vs. trying more conservative treatment first – don’t contribute as well.

Put another way, it’s about local culture – the values, attitudes and behaviors that often are so ingrained, we rarely notice or question them.

So here’s the really big question: If some states, such as Minnesota, can spend below the national average yet still provide good care, why can’t all states do this? If all states did this, could costs be lowered without sacrificing quality?

One of the fears being voiced at town halls and in online forums is that if we reduce health care spending, someone will have to go without. But if the Dartmouth Atlas data is any indication, many states are already doing this and managing to preserve some quality besides.

Changing local culture can be incredibly hard, especially when so many Americans have been conditioned to think that more health care is invariably better. And when all is said and done, the culture of local health care communities is still a single small slice of an enormous, complicated system. Achieving genuine change will take far more than realigning local or regional habits and expectations of how health care should be provided.

The point, though, is that we often overlook the local. We tend to search instead for outside explanations and solutions, when all along we could be looking a lot closer to home.

The overselling of mammography

The Minnesota Department of Health’s latest get-your-mammogram campaign is designed to tug at the heart. On the front of the flyer is the fictitious Robinson family – dad and three nice-looking kids. Then you turn the page to learn that mom is literally out of the picture, apparently because she didn’t get a mammogram, developed breast cancer and died.

The message: Mammograms save lives, and you are foolishly and selfishly putting yourself and your family at risk if you don’t get screened.

If it were only that simple. In real life, however, the connection between mammography and happy outcomes is not necessarily a direct and unbroken line. You can be screened and still get breast cancer. Early detection helps save many lives but it’s not a guarantee.

Have the benefits of mammography been oversold? This question is starting to be asked by a growing number of researchers and organizations. A recently published study found that in Europe, many people significantly overestimated the benefits of screening for breast and prostate cancer. In fact, an oncology expert with the Dana-Farber Cancer Institute in Boston came right out and said it in a recent story in the Los Angeles Times:

Dr. Eric Winer, director of the breast oncology center at the Dana-Farber Cancer Institute and chief scientific advisor for Susan G. Komen for the Cure, acknowledges that messages about mammography may need revamping.

"As painful as it is to admit, we have oversold mammography to the American public," he says. "Frankly, I don’t know what to do with this. On the one hand, I don’t want to push people away from mammography, but I don’t want to encourage them to have misconceptions about mammograms either."

It’s a relevant question. It’s probably safe to say that millions of mammograms are done in the United States each year. Many organizations that track health care quality, such as Minnesota Community Measurement, consider the screening to be a standard marker of good care.

But as the LA Times article points out, there’s such a thing as overdiagnosis:

A routine mammogram can find cancers that would never have become life-threatening, subjecting women to painful and toxic treatments they never actually needed.

Conversely, some types of breast cancer are aggressive enough that even if they’re caught on a mammogram, they can still be in an advanced stage and can ultimately be fatal.

The words "screening" and "prevention" often are used interchangeably, and in the minds of many people they probably mean the same thing. But they’re not the same. And as the health care reform discussion turns to prevention and evidence-based medicine, it’s important that we start making this distinction, otherwise we run the risk of spending time and money on ineffective public policies.

None of this means mammograms are a waste of time or that women should stop being screened. The U.S. Preventive Services Task Force, which is probably the nation’s most authoritative body on the pros vs. the cons of screening, recommends mammograms every one to two years for women 40 and older. Its conclusions, after weighing the research: There’s "fair evidence that mammography screening every 12-33 months significantly reduces mortality from breast cancer."

By all means, let’s recognize the benefits – and there are many – of mammography. But it’s not a silver bullet, and we need to be aware of its limitations.

HealthBeat photo by Anne Polta

A field guide to the health care reform bills

Although there’s a lot of talk about "the health care reform bill," there actually are multiple proposals floating around Congress. They’re all slightly different, and at some point they’ll have to be reconciled before a final bill can arrive on the president’s desk for his signature.

Understanding what’s in each of the key proposals is challenging, says Chris Conry, the health care field coordinator for Take Action Minnesota. "We’re having a debate about very complex issues… Not every one of us is going to become a health care policy expert by the end of the year," he said.

For the people who attended Bethel Lutheran Church’s health care reform speaker series today, however, Conry provided a useful overview of the legislation – and also sparked some good questions and discussion.

H.R. 3200, the bill that has received most of the attention, is a tri-committee bill that’s being hammered out in the House of Representatives. Its official name: "America’s Affordable Health Choices Act." In the Senate, there’s an "Affordable Health Choices Act" whose main sponsor is Sen. Edward Kennedy. The Senate Finance Committee, chaired by Sen. Max Baucus of Montana, also is working on its own draft proposal.

Here’s what all three have in common: They propose the creation of an insurance exchange, they would require individuals to have health insurance, they would require health insurance plans to take everyone regardless of health status or pre-existing conditions, and they would offer premium subsidies based on household income.

H.R. 3200 and Kennedy’s Affordable Health Choices Act both contain a public insurance option and an employer "pay-or-play" mandate. The Senate Finance Committee’s draft proposal does not contain either of these provisions.

There are a number of differing details, such as whether the insurance exchanges should be state-based or national, or whether health insurance premium subsidies should be offered to households at 400 percent of the federal poverty level or 300 percent.

The health care reform measures being proposed are looking at a broader picture than insurance coverage, however. H.R. 3200 also takes aim at controlling costs, promoting health and wellness, and investing in the future health care workforce. The specifics aren’t clear; indeed, there’s some question as to whether prevention will truly help lower health care costs. After all, prevention costs money too.

To complicate the picture, there also a number of smaller health care-related bills orbiting around these huge, blockbuster reform bills.

The comparative costs, using estimates from the Congressional Budget Office, are $1.34 trillion over 10 years for the Kennedy bill, $900 billion over 10 years for the Senate Finance Committee proposal (but with a goal of cost savings by 2019) and $1.042 trillion for H.R. 3200 over 10 years.

One thing none of the bills contains is a fix for primary care or support for rural health care, Conry said.

The State Health Access Data Assistance Center at the University of Minnesota provided part of the information Conry shared with the audience in Willmar today. Because health care reform legislation is still evolving – and will continue to evolve over the next several weeks – the Data Assistance Center Web site, here, will be a useful source for the public to keep track of what’s going on.

There’s been a good turnout at each of the speaker sessions hosted by Bethel this month. The final event in the series will feature Gary McDowell, administrator of Family Practice Medical Center, on how this clinic has been meeting some of the current challenges in health care. It starts at noon on Wednesday, Aug. 26.

Photo: Dirksen Senate Office Building, courtesy of Architect of the Capitol.

Linkworthy 1.2

Some interesting reading that captured my attention recently while wandering around the Internet:

Do doctors make too much money? Kent Bottles of the Minneapolis-based Institute for Clinical Systems Improvement asks this question on his blog. American physicians, after all, are paid two to three times as much as doctors in other industrialized countries, Bottles notes.

The reason for this is the manner in which physicians are paid, he explains:

In the United States most physicians are paid in a fee for service system that pays piecemeal for each test or procedure they perform. Most American physicians are not on salary. In such a system, physicians have financial incentives to perform procedures that drive up health care spending.

Bottles follows this up with a second post that looks more closely at the tradeoffs between paying physicians a salary vs. fee for service.

Dana Jennings, an editor at the New York Times, has been writing eloquently for several months now about his experiences with prostate cancer. In his latest entry, "Whispers from the Cancer Foxhole," he writes about the hush of the oncology waiting room, where "a sense of exhaustion hangs in the air, and it’s not unusual for the healthy spouses to look more inconsolable than the patients." If you haven’t yet read the rest of this excellent series, you can find it here.

In an impressive example of what the media can do, given time and the right resources, comes this compelling series, "Dead By Mistake." The project was put together by a team of more than 35 people from Hearst newspapers and television stations. It not only tackles the persistence of medical error but also exposes state laws that are weak, underfunded and invite underreporting of patient deaths due to errors in care.

This is an issue that doesn’t get much public attention. No one likes to think something will go wrong with their care. Health care is very complex, however, and no one should ever assume that a grievous error won’t happen to them or to someone in their family. (In case you’re wondering, Minnesota was the first state to require hospitals to report "never" events. Two other states now have similar laws.)

Should doctors friend their patients on Facebook? Well, maybe – but they’d better keep a clear separation between their personal and professional profiles, Dr. Kevin Pho blogged recently:

… Some doctors have information that may conflict with their professional appearance on Facebook, including "the medical attending whose clinical judgment is questioned because of photographs posted online, showing him in progressive stages of apparent inebriation at a department holiday party." That’s just unwise.

Dr. Pho’s post sparked an interesting comment thread about Facebook etiquette. If patients want to friend their doctor, will feelings be hurt if the doctor declines? What if the doctor wants to friend his or her patients? Would this be creepy? Social media can be a useful tool for marketing and being connected with patients, but Dr. Pho’s readers conclude there’s a line that should be drawn.

Finally, for anyone who’s ever dreamed of being a cardiac surgeon,  here’s your chance. No, not for real; it’s a simulation. Your patient: a stuffed bunny named Fred. Your tools include a defibrillator, a scalpel and a retractor. I unfortunately failed to save him, but perhaps you’ll do better.

Just the facts

One of the things that has made the health care reform discussion so challenging is the amount of information that’s circulating – on the airwaves, in print media, in e-mails and on the Internet. After awhile, it becomes difficult for people to sort out what’s fact, what’s opinion, what’s speculation and what’s spin.

So here’s some help to get you started. The following Web sites are primarily nonpartisan and fact-based. They are good places to go if you’re looking for basic information or want to check out whether something you’ve heard is true. is an independent project of the Annenberg Public Policy Center. It examines claims, analyzes who’s saying what, and even answers readers’ questions. A couple of current good reads on the site include this takedown on "Seven Falsehoods About Health Care" and a rebuttal of the claims that H.R. 3200 will promote euthanasia for seniors. The site also offers an analysis, such as this one, of what the president and Congress are saying and then compares it with the facts. is sponsored by the St. Petersburg (Fla.) Times. Its best feature: a Truth-O-Meter that helps sort fact from fiction at a glance. What about the claims that health care reform won’t affect veterans’ benefits? True, according to the Truth-O-Meter. What about Obama’s statement that the health care plan for members of Congress is "no better than the janitor who cleans their offices"? That’s true as well.

Kaiser Health News. This site offers a good roundup of health care in the news. It also offers links to other media outlets, such as this q-and-a on the major issues in health care reform.

I’m posting the link to the official White House site, because it’s hard to have a worthwhile debate about the issues if you don’t know what the president and his White House team have actually said. Ditto for the president’s official health care reform site,

The entire 1,018-page text of H.R. 3200 can be found here.

I was at the town hall meeting that Rep. Collin Peterson hosted in Willmar this past Friday. People are passionate about this issue; health care is something that’s personal to all of us. MinnPost took a look last week at why health care reform has brought so much angst to the surface. Americans have been buffeted by social change and they’re fearful about the economy and about their future, writer Sharon Schmickle explains.

But it goes deeper than that, she suggests:

Brush aside the fear, and you find Americans engaged in a tradeoff of ideals.

On one hand, we’ve been taught to help one another. Other major nations take care of their sick and we should too, the argument goes.

On the other hand, many argue convincingly that America is best served when individuals look out for their own interests and don’t wait for government to do it for them.

Polls suggest that most Americans care about the uninsured. But what if the fear-driven national mood tilts toward individual interests, if the millions who have coverage choose not to risk rocking the system for the sake of the uninsured?

Tough questions. But if we’re going to debate them, we ought to at least know some of the facts.

The empty kitchen

Chances are you recognize the vegetables in the photo above: onions and carrots. But do you know what to do with them? How do you remove the onion tops? Do the carrots need to be peeled? What about those green carrot tops – are you supposed to eat those too? How should you prepare fresh carrots – bake them, steam them, saute them? Can you leave the carrot whole or does it need to be sliced? Crosswise or lengthwise?

For an increasing number of Americans, especially the younger generation, the answer to these questions is, "I don’t know."

There are many reasons why fewer of us are preparing our own meals these days. Often we don’t have the time to cook at home. Or we don’t have the interest, or we have other priorities.

The result: The average household relies far too much on fast food, takeout and convenience food, and what’s being lost are basic, fundamental cooking skills.

Foodmeister Michael Pollan laments this fact in his books. While Pollan can be a bit of an elitist regarding how our great-grandmothers used to cook, he’s not far off the mark when he suggests we can do better:

While it is true that many people simply can’t afford to pay more for food, either in money or time and both, many more of us can. After all, just in the last decade or two we’ve somehow found time in the day to spend several hours on the internet and the money in the budget not only to pay for broadband service, but to cover a second phone bill and a new monthly bill for television, formerly free. For the majority of Americans, spending more for better food is less a matter of ability than priority.

There does seem to be a growing consciousness that our eating habits need to change. It’s also heartening to see there are some local groups and initiatives trying to do something about it. (If you’d like to read the article that appeared in the West Central Tribune’s Healthy Families section this week, drop me an e-mail and I’ll send you the link.) (Update: The story, which originally appeared only in print and in the Tribune newsroom’s internal online archive, is now posted on our Web site.)

Good intentions aren’t always enough, however. We also need the know-how, and this, I believe, is a significant barrier that often goes unrecognized. How are you supposed to eat fresh vegetables if you aren’t quite sure what to do with a fresh zucchini? If you haven’t learned these skills at home, who’s going to teach you?

Learning how to cook requires an investment. You need basic equipment such as a skillet, a sharp knife, measuring cups and measuring spoons. You need time to learn. You need patience and you need to be accepting of failure once in awhile – not an easy lesson when there’s a hungry household waiting for dinner and the meal doesn’t turn out or the kids and/or spouse don’t like the food.

I learned how to cook by watching my mother (who’s a fantastic cook, by the way). But in a lot of households, skills aren’t being passed on like this anymore. Nor can we assume kids will learn these things in school; in many school districts, home economics and consumer science courses aren’t even required for high school students.

I don’t think we can lecture people to stop eating fast food and then not help them gain the skills that would allow them to prepare their own meals. I don’t think we can take it for granted that they’ll somehow, through trial and error, figure out how to make a tasty stir-fry or homemade soup that they – and their family – will actually want to eat.

I think we’re going to have to show them, mentor them and even cook alongside them, if that’s what it takes. Is there any community group out there that’s doing this? If not, why not?

Our kitchens are stuffed with microwaves, refrigerators, convenience foods, beverages and snacks. But sadly and all too often, they’re empty of what really matters.

West Central Tribune photo by Anne Polta

A day in primary care

How do primary care doctors spend their day? I’ve been following an interesting online discussion about this issue.

It started here with Dr. Timothy Malia, who decided to blog a couple of weeks ago about the variety of problems he encountered among his patients in a single day. The list he put together ranges from ringworm, low back pain and bronchitis to alcoholism, unexplained weight loss, asthma and thoughts of suicide. He writes, "Essentially every patient that particular day had 2-4 issues to address."

Dr. Malia’s list then got picked up by the Well blog at the New York Times as an illustration of the important role family doctors hold in the health care system.

Dr. Malia added to the discussion this week with yet another post, this time on "Why patients go to the doctor."

It has sparked some thought-provoking online conversations about the nature of primary care, the need for primary care doctors, and why doctors choose to go into primary care.

Some people might see the family doctor’s day as excruciatingly mundane. "A routine and rather boring list of symptoms" is how one commenter described it. Someone else wrote:

The list of conditions described seems very similar to what I saw in my brief stint as a PCP and is why I could not get out of the field fast enough. Many of the problems seem rather trivial and self-limiting, and as already noted, could likely have been handled equally well by a physician assistant or nurse practitioner.

But this isn’t how family doctors view it. "It’s what makes primary care so challenging and interesting. Our specialty is probably one of the most difficult!" one of the commenters, Dr. Davis Liu, wrote. Another physician comments:

Being a family medicine physician is simultaneously rewarding and frustrating. The list above is quite similar to what I see in a day. I do not see myself as a "jack of all trades, master of none." I, being an extensively trained and experienced outpatient physician, am an expert at managing a multitude of conditions. We should encourage our best and brightest to go into primary care – it is a lot more difficult to be good at a wide spectrum of things.

Are there some pieces of the primary care physician’s day that could be better managed by a mid-level practitioner? In rural and underserved areas, this is often seen as one of the solutions to a pressing shortage of physicians. When resources are in short supply, it makes sense to use the doctor’s time as effectively as possible and to have mid-levels handle patients whose issues are more routine and less complex, or so the argument goes.

To be sure, there’s a place for mid-level practitioners. But here’s where the online discussion goes off onto an interesting tangent: Are mid-levels truly an effective substitute for the primary care doctor? Dr. Malia gives us his opinion:

Let me say, I have no doubt many of the PROBLEMS could have been cared for by a professional with less training or experience than I have. But let me also say that I don’t treat problems, I care for PATIENTS. Those are the real people who present with problems.

Dr. Davis Liu has more to say on his own blog:

Primary care is often seen as easier and hence replaceable by other less expensive providers when it should be looked at as a very cognitive specialty that deserves the same level of respect as others.

It seems to me this entire discussion illustrates one of the issues facing primary care nowadays. Particularly in policy-making circles, primary care either isn’t understood or isn’t fully appreciated or valued. Of all the medical specialties, it’s the least well paid. Fewer and fewer medical students are opting to go into family medicine or general internal medicine. And when I read the eloquence of people like Dr. Malia and Dr. Liu, who clearly are devoted to primary care and to their patients, I wonder how we could ever have allowed primary care to sink into this predicament.

West Central Tribune file photo by Bill Zimmer