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Whoa.  The sabers are rattling.

In an opinion piece , Dr Jonathan Glauser (who works at the Cleveland Clinic) lashes out against primary care.  His belief is that funding primary care is a mistake because it is “a group that has failed in providing care.”  His argument is one you will hear a lot from specialty organizations and hospitals, so I will address it head-on.

Here is what he says:

The patient-centered medical home is an approach to providing comprehensive primary care for children and adults. This is touted as facilitating partnerships between individual patients and their personal physicians and, when appropriate, the patient’s family. This is the brainchild of a consortium of organizations, including the American Academy of Family Physicians, the American Academy of Pediatrics, the American College of Physicians, and the American Osteopathic Association. These worthy groups claim to represent approximately 330,000 physicians….

I should mention that the concept is not new; it was introduced by the American Academy of Pediatrics in 1967. It’s on all patient-centered medical home web pages. Obviously, these organizations will be pressing for funding to promote their ideas of primary care. They want money, money that might go to other elements of our flagging health care system.

Say what? Fund physicians to promote primary care? Why throw good money after bad? If ever there was a group that has failed in providing care, it is our primary care system. To fund such a venture for groups that are singularly inept at performing anything of value to society is pure folly and a waste of precious health care dollars.

This guy is not arguing, he is ranting.  Why?  My suspicion is that he sees the fact that increased reimbursement for primary care physicians means potentially decreased reimbursement for emergency physicians.  That does not mean you shouldn’t trust his arguments – he could use the same against me.  So his main point is this: primary care gives nothing of value and so should not be funded.  Funding primary care is a waste of money.

How does he back up this attack on my profession?  First, he gives examples of bad primary care he has seen.  I can give plenty more examples of bad primary care…and bad cardiology, bad surgery, and bad emergency medicine.  There are bad physicians out there – we all know that – but the bad physicians don’t mean that the whole profession is bad.

He goes on as follows:

I have never encountered a plea for health care reform that did not extol the benefits of detection and treatment before some disastrous outcome ensues. In the long run, of course, preventive care does not save society money; we all get some terminal illness eventually. But it does enhance the quality of life we have if we can go though our days without aphasia, hemiparesis, or an ejection fraction of 20%. Where is it in the plan that everyone gets a doctor regardless of ability to pay? Clearly, the uninsured, the working poor, and the people currently without access to care would benefit most from such a program. What happens to the patient-centered medical home when the patient can’t pay?

Much of the degeneration of primary care in this country, in fairness, is not due to these doctors themselves. After all, their office visits have been booked solid for months. They get paid for seeing 25 patients (or 20 or 30) a day, so they and their office staff can knock off at 4:30 p.m. Any appointment they see on February 26 was booked in November. They never see anyone who is acutely sick so it wouldn’t even make sense to add an appointment on as an emergency.

I think the points here are as follows:

1. Prevention is good, but does not save money.
2. It may be worth it, as it improves quality of life.
3. The problems with primary care are caused by appointments not being available.

So what do I think about these arguments?  Prevention in the general public may not save money – at least in the short-term.  Yet preventive medicine does not just occur in healthy populations – it is far more cost-effective in people with medical conditions.  For instance, preventing heart disease in diabetics (who are high-risk) – even if it is simply making sure they take aspirin – saves money and lives.  There are a large number of preventions for high-risk patients that would have a quick return on investment.

The opinion piece degenerates from her, saying:

• Primary care doctors don’t see acute illnesses, but send them to the ER.
• Pediatricians shouldn’t take care of fever, because it could be serious problems that require lots of lab tests/x-rays.
• Primary care physicians “can’t manage simple chronic illness, cannot definitively treat acute illness or injury, often has no skills to save lives and no access to equipment if he had the skills, and does not even see patients at their own (the customers’) convenience”
• Medical home involves doing things that just require computer systems and can be done by anyone.
• Primary care doctors can’t “differentiate splenomegaly from lymphoma or a direct from an indirect hernia suspect”
• Primary care is a “sham” and putting money toward it would be equivalent of throwing the money away.
• Surgeons, dermatologists, and orthopedists are bad too.

I could go through each point and argue them, but they are honestly so silly that I think most of my readers see this is nothing more than a rant.  It offers no solutions, just a shotgun blast at his colleagues – insulting their competence.  It got my blood pressure up, and I would ask my reasonable Emergency Medicine colleagues to protest such rancorous slander from one of their own.

Still, there are lessons to be learned from this:

1. There are some really angry doctors out there.  Any time people are fighting over their share of money, you see their worst.  This is a prime example of it.  This physician sees (probably correctly) that increased money for poorly-paid primary care physicians will have to come from somewhere – and that somewhere will probably be from decreased specialist reimbursement.
2. There are many physicians out there who don’t respect primary care.  They seem to think that we do our job because we couldn’t get into “better” specialties.  I think my job is much harder than that of most specialists.  I have to know the range of disease – from newborn to geriatric – and be able to identify the seriously ill ones from the long line of people who have common ailments.  I refer to specialists 5-10% of the time.
3. Any reform will be met with stiff resistance.  The likely result will be watered-down solutions.  A medical home may work if done correctly; a medical dog house probably won’t.  Reform needs to re-form medicine; not just rearrange things without substantial change.
4. Denial is well-entrenched.  This physician spends a lot of time pointing fingers time with no alternative solutions offered.  He is complaining about the wallpaper on the Titanic as it sinks.  I don’t think the medical home is perfect, but screaming seldom fixes things.
5. We really need the Obama administration to get good people.  Shrill voices like Dr. Glauser will doom healthcare reform and turn our profession into a bunch of children fighting on the playground.  I am very thankful that the emergency medicine bloggers I know are much more grown-up.

Emergency Medicine News should edit more carefully.

This is destructive ranting at its worst.

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Tagged as: Medical Home, Primary Care, reform