HEALTH CARE” When Credentials Count

   There is currently a Health Care bill pending in Congress that would, hopefully, provide medical care for most of the people in the United States. Even if it passes, though, there remains a significant problem. Fewer than 10% of the 2008 medical school graduating class chose a Primary Care Specialty. In essence, there are barely enough people in Internal Medicine and Family Medicine as well as Primary Care Pediatrics to treat the patients that we have now. Adding the remaining fifty million uninsured into the mix will require many more Primary Care Physicians than we will have.

   Why should a young man or woman graduating medical school enter “Primary Care?” Suppose I presented the “job” this way: would you like to enter the exciting field of Primary Care medicine where you are paid a fraction of what procedure oriented specialties are paid (e.g. surgery), work longer hours than nearly any other field, spend half of your time dealing with insurance bureaucracies, and are the figurehead who, since you are most visible, gets blamed for everything that’s wrong in medicine today? What if I added that these specialties carry with them the lowest prestige from both the general public and your colleagues, and that at least 30% of the time you will have to spend hours every week arguing with a teenager with a checklist at an insurance company, just to “allow” you to treat your patient properly (and usually lose)?

   Would you want to enter such a field or would you opt, as most do, for a high paying, high prestige job? By the way, when thinking about these “low pay, low prestige” jobs in Primary Care, remember what they had to go through to get there. There was four years of college, four years of medical school, and at least three years of internship and residency (at least 11 years after high school). An Internist does not begin to earn a living (and pay back hundreds of thousands of dollars in loans) until they are well past age 30, while their friend who began as an investment banker after college may already be a millionaire. A general surgeon, who has an additional two years of residency, will make several times what the Internist makes, and spend many fewer hours doing it while maintaining that high prestige that is so important to a physician.

   So, what will happen? The void will end up being filled with Nurse Practitioners. Now, let me state at the outset that I am in favor of such “mid-level” practitioners. They usually do a wonderful job and can treat most lower level problems and chronic illnesses while reducing some health care costs; but with only about six years of education after high school, they should not be allowed to practice independently, without supervision. They simply do not have the educational background or experience to do so.

   Finally, there is the question that will inevitably arise at some point. When they make a mistake, will they be held to the “standard of care” for nurses, nurse practitioners, or physicians performing the same functions? I’m sure the initial answer would be to hold them to the standard of a nurse practitioner because that is what they are, but if they are performing functions that have traditionally been considered part of the practice of Medicine, and the patient is given no choice, shouldn’t they be held to the same standards as the physician whose role they usurped or were given? If I were prosecuting such a case, that would be at least one argument I would use and, if successful, it would find that Nurse Practitioners (“CRNP’s” and “CRNA’s”) malpractice insurance premiums may be even higher than a physician’s. I don’t think this solves the problem for anyone but the insurance company who gets to pay the CRNP significantly less for doing the same things as a physician.

   The answer is simple; value medical services by the credentials and experience of the physician and the complexity and time spent providing the service, as well as the use of preventive medicine and outcome analysis. That would mean that, for practical purposes, an Internist and a General Surgeon who each spend an hour with a patient, will get paid for that hour based upon the criteria noted above. Clearly, the internist will get substantially more, and the surgeon would get somewhat less, but the system would become more equitable and encourage more physicians to enter Primary Care specialties. Moreover, if physicians were considered to be Federal Employees, and are eligible for malpractice coverage under the Federal Tort Claims Act as well as Cost of Living fee increases and a federal pension, then overall medical fees could be reduced and the entire system cost less, yet the physicians would make more and therefore it would be a win-win situation for everyone but the insurance companies.

   Should we worry about the insurance companies? CAN YOU SAY, ‘AIG?”