When I was a medical student a family medicine resident told me a joke
"Superspecialists learn more and more about less and less until they know everything about nothing, and generalists know less and less about more and more until they know nothing about everything"
The truth is that specialist need to have some breadth, otherwise they lose perspective and risk becoming technicians. Generalists need to have some depth of expertise; otherwise, they risk becoming triage agents (I have seen that). For generalists, the areas where they acquire depth of knowledge usually revolve around personal interests and the special characteristics of their patient population
If you're a PCP as time goes on you find areas you're more or less comfortable with based on interest and local circumstances. You treat what you can and refer out what you should depending on availability. Hopefully in this process you'll keep the best interests of the patient in mind. But what you are offering to the patient is more than just disease diagnosis and treatment.
If reimbursement is the issue I think the Medicare system is the major problem since it dominates non-Medicare prices as well. Medicare has an elaborate price setting scheme that impacts service availability, but the price setters have no knowledge of the local factors they are impacting. Price setting for physician services should be eliminated or minimized. Patients via the market should decide the relative value of physicians. Some intervention is surely needed for those with low resources or misfortune. Presumably the government should be involved but this would be an important role for organized medicine rather than the tepid one it plays today.
There was a time when patients paid physicians directly and physicians routinely modified their charges relative to the patient's resources.
Adam, ST’s story captures the danger of care organized around specialties: each service can answer its own question while the patient’s real question remains unanswered.
The generalist’s value is not knowing everything. It is refusing to let the whole story disappear between referrals knowing when a hedgehog is needed, asking the right question and bringing the answer back into a continuing care plan.
That is the stewardship role we are building around at YourHealthco. The fox does not need to out-specialize the hedgehog. But someone must remain responsible for the whole forest and for the person trying to find her way through it.
It will not have escaped your notice that the current hospital system is DESIGNED to separate generalists from specialists, and if this was not on purpose it is certainly a very unfortunate accident.
Discrimination against generalist is very real. As a hospitalist I would be talking to a family with a very run of the mill GI problem. The GI specialist walks in, having been contacted by the ER last night when the differential was broader and they saw inflammation on a CT. Upon careful history it is obvious this is not IBD but we usually don’t CT scan viral gastroenteritis.
The family stops talking to me and directs all their attention to the specialist. We all agreed that TPN was useful until the terrible viral enteritis improves. It improves later that day when I checked on the patient again, and I stop the TPN as the patient chows down a turkey sandwich and it stayed in appropriately. GI was scoping or whatever. Family gets mad I made that decision without GI assent and I spend the next 40 minutes apologizing, hoping I won’t get a nastygram written to the administrators.
As a generalist who works a lot on the ED, I have to ask, Where was the Ct/Cta on arrival. The stroke and possible seizure are sequelae. What is the disease? Unlikely embolic unless she had a fib. A two week holter is unlikely to pick that up. Aspirin we are stuck with although the absolute risk reduction is small. I hope someone does not pick up 5 minutes of A fib and decide she needs stronger anticoagulation and metoprolol that makes her next fall fatal. If she did seize, what is the data for length of the anti seizure med that is going to make her tired and perhaps somewhat off balance? Did I mention that her appointment with the neurologist PA for follow up was a month out? Statin, maybe a couple percent but what is the end game? That's the question she is going to ask me in the clinic. I could send her to the cardiologist. Suddenly her grandmother years are spent going to specialists far off, taking meds that are not without risk and worrying when the next big stroke will be. particularly each time she gets a little dizzy or nervous. Have we made her better or just given her a 5 to 10% chance of living longer while increasing discomfort by 15%? I honestly don't know. Did I mention I am a generalist who deals mostly with people over 65? Oh and this story is my story at 62.
Sorry I recognize the story is only there to illustrate the value of both generalists and specialists which I wholeheartedly agree with, but In practice in current day America it does not work. Specialists are harder and harder to get to. The answers are often party line and not patient oriented/taylored. The patient often has trouble getting in to be seen. Medicine focuses on repeat visits versus comprehensive care. we continue to believe we can prevent death when all we can really do is cause small delays and often in the process increase discomfort. Few are helping people to live well and die well. I am not sure what the solution is but turning medicine into a high profit business probably wasn't it.
When I was a medical student a family medicine resident told me a joke
"Superspecialists learn more and more about less and less until they know everything about nothing, and generalists know less and less about more and more until they know nothing about everything"
The truth is that specialist need to have some breadth, otherwise they lose perspective and risk becoming technicians. Generalists need to have some depth of expertise; otherwise, they risk becoming triage agents (I have seen that). For generalists, the areas where they acquire depth of knowledge usually revolve around personal interests and the special characteristics of their patient population
If you're a PCP as time goes on you find areas you're more or less comfortable with based on interest and local circumstances. You treat what you can and refer out what you should depending on availability. Hopefully in this process you'll keep the best interests of the patient in mind. But what you are offering to the patient is more than just disease diagnosis and treatment.
If reimbursement is the issue I think the Medicare system is the major problem since it dominates non-Medicare prices as well. Medicare has an elaborate price setting scheme that impacts service availability, but the price setters have no knowledge of the local factors they are impacting. Price setting for physician services should be eliminated or minimized. Patients via the market should decide the relative value of physicians. Some intervention is surely needed for those with low resources or misfortune. Presumably the government should be involved but this would be an important role for organized medicine rather than the tepid one it plays today.
There was a time when patients paid physicians directly and physicians routinely modified their charges relative to the patient's resources.
Adam, ST’s story captures the danger of care organized around specialties: each service can answer its own question while the patient’s real question remains unanswered.
The generalist’s value is not knowing everything. It is refusing to let the whole story disappear between referrals knowing when a hedgehog is needed, asking the right question and bringing the answer back into a continuing care plan.
That is the stewardship role we are building around at YourHealthco. The fox does not need to out-specialize the hedgehog. But someone must remain responsible for the whole forest and for the person trying to find her way through it.
Chris
It will not have escaped your notice that the current hospital system is DESIGNED to separate generalists from specialists, and if this was not on purpose it is certainly a very unfortunate accident.
Discrimination against generalist is very real. As a hospitalist I would be talking to a family with a very run of the mill GI problem. The GI specialist walks in, having been contacted by the ER last night when the differential was broader and they saw inflammation on a CT. Upon careful history it is obvious this is not IBD but we usually don’t CT scan viral gastroenteritis.
The family stops talking to me and directs all their attention to the specialist. We all agreed that TPN was useful until the terrible viral enteritis improves. It improves later that day when I checked on the patient again, and I stop the TPN as the patient chows down a turkey sandwich and it stayed in appropriately. GI was scoping or whatever. Family gets mad I made that decision without GI assent and I spend the next 40 minutes apologizing, hoping I won’t get a nastygram written to the administrators.
"Funny turns" can be hard to figure out.
As a generalist who works a lot on the ED, I have to ask, Where was the Ct/Cta on arrival. The stroke and possible seizure are sequelae. What is the disease? Unlikely embolic unless she had a fib. A two week holter is unlikely to pick that up. Aspirin we are stuck with although the absolute risk reduction is small. I hope someone does not pick up 5 minutes of A fib and decide she needs stronger anticoagulation and metoprolol that makes her next fall fatal. If she did seize, what is the data for length of the anti seizure med that is going to make her tired and perhaps somewhat off balance? Did I mention that her appointment with the neurologist PA for follow up was a month out? Statin, maybe a couple percent but what is the end game? That's the question she is going to ask me in the clinic. I could send her to the cardiologist. Suddenly her grandmother years are spent going to specialists far off, taking meds that are not without risk and worrying when the next big stroke will be. particularly each time she gets a little dizzy or nervous. Have we made her better or just given her a 5 to 10% chance of living longer while increasing discomfort by 15%? I honestly don't know. Did I mention I am a generalist who deals mostly with people over 65? Oh and this story is my story at 62.
Sorry I recognize the story is only there to illustrate the value of both generalists and specialists which I wholeheartedly agree with, but In practice in current day America it does not work. Specialists are harder and harder to get to. The answers are often party line and not patient oriented/taylored. The patient often has trouble getting in to be seen. Medicine focuses on repeat visits versus comprehensive care. we continue to believe we can prevent death when all we can really do is cause small delays and often in the process increase discomfort. Few are helping people to live well and die well. I am not sure what the solution is but turning medicine into a high profit business probably wasn't it.