Monday, April 04, 2005

Specialists versus Primary Care....
From American Medical News:Work force study tackles specialty vs. primary care
As policy-makers and medical community leaders determine the best response to physician shortage predictions, the question of whether the public will need more primary care physicians or more specialists is back on the table.

Work force experts and organized medicine leaders remain divided on how to answer that. And with no national health policy to guide medical school expansion, state legislators and medical educators likely will follow the discussions closely.

The latest salvo in the debate comes from Barbara Starfield, MD, MPH, with the Johns Hopkins School of Public Health. Her study's conclusion: The greater the supply of primary care physicians, the lower the mortality rate. She also found that a higher specialist-to-population ratio did not decrease mortality rates. In fact, she determined that too many specialists negatively impacts communities because patients are more likely to have unnecessary tests and procedures.

The nationwide study, "The Effects of Specialist Supply on Populations' Health: Assessing the Evidence," released in a Web-only March 15 edition of Health Affairs looked at mortality rates at the county level.

"Decisions about the physician supply should be made on the basis of evidence for their utility in improving health and reducing ill health and deaths," Dr. Starfield said. "Currently, the United States has many more specialists than do other comparable countries with better health levels."

Robert L. Phillips Jr., MD, MSPH, director of the Robert Graham Center, supported the study in his own commentary in Health Affairs.

"If we want our health care system to be an economic engine, we are headed in the right direction," Dr. Phillips said in an interview. "If what we want is a healthier population, we are headed in the wrong direction."

Specialists aren't bad, he said, but if the physician work force is going to expand, there is an opportunity to ask how it should be configured to make Americans healthier.

"Increasing the supply of subspecialists is not the way to go," he said. "This is not an indictment, but we have an option here, and physicians should weigh in on what's important to them."

Haven't we heard this before? Weren't we told years ago that there were too many specialists? Has anything changed?
Some disagree with the study and point out some flaws:
In his critique, also published in Health Affairs, Salsberg questioned the validity of looking at the number of specialists by county and linking that to mortality rates.

Specialists, Salsberg said, tend to concentrate in urban areas that draw patients from large geographical areas, so they can see enough cases to be clinically sharp and financially viable. At the same time, the population that dominates urban areas tends to be higher risk and has higher mortality rates.

An analysis of mortality rates also does not capture quality-of-life improvements that specialists provide, he said. Ophthalmologists might not save lives, but cataract surgery can make the difference in a person's ability to see to drive or read.

In addition, he argued, many scientific advances have come from greater specialization. Achievements might mean drugs or treatments that primary care physicians can provide for patients, but they also result in highly complex treatments best handled by the subspecialists themselves, he said.

For good or ill, patients belive that specialists deliver better care. In the medicine side of the house that is subject to debate. But in the proceduralist wing research shows that more of a procedure you do (i.e. specialize in doing something)the better outcomes you have. (See the "Practice Makes Perfect" posts to the right).
Mr Holt opines here.
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