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Thursday Feb 28, 2013

Signs of Primary Care Success

When a company or an industry becomes truly successful, one of the first real signs of that success is a new level of criticism aimed its way.

Recently, one of our neurosurgeon colleagues wrote a post critical of primary care that appeared on the Neurosurgery Blog.  It then was picked up by the Association of American Medical Colleges' blog Wing of Zock.

In the blog, Robert Harbaugh, M.D., does a grave disservice to family physicians, medical students, and our country by misrepresenting and attacking primary care medicine.

Unwilling to let his message stand unopposed, I worked with the AAFP's public relations staff to craft a response to Harbaugh's blog as posted on the Wing of Zock blog, and we are very happy that they posted it(See my response at the end of this message.)

As our country begins to move toward investing in primary care as an effective way to bend our unsustainable cost curve of health care, we can expect increasing push back from those who either do not understand the real effectiveness of primary care or who stand to lose in this important  transformation.

Our Academy will respond forcefully to these outliers, for the health of our patients, our practices and our country.



Primary Care Needs Are No Myth

In "The Primary Care Shibboleth: Debunking the Myth," Dr. Robert E. Harbaugh (a neurosurgeon) does a grave disservice to family physicians and medical students who value the professional satisfaction, intellectual challenges and career-long patient relationships of primary care.

Dr. Robert Harbaugh, M.D., is misinformed.

Primary care should be the critical foundation of our health care system. A wealth of published, credible data supports the value of primary care and prevention:

Harbaugh wrote, "The United States has a relatively high concentration of primary care physicians and a relatively low concentration of (sub)specialists compared to the OECD (Organisation for Economic Co-operation and Development) average of all countries." Unfortunately, this statistic is skewed by counting all of "internal medicine" as a primary care specialty, erroneously including medical subspecialists as primary care. The truth is the ratio of primary care and subspecialty care proven to produce the best outcomes is now out of balance in the United States and threatens to get worse. Currently, less than 20 percent of medical students who enter internal medicine residencies go on to practice primary care.

Harbaugh asks if anyone believes that by investing more in primary care, we can prevent people from getting sick and save money. It may come as a surprise to Dr. Harbaugh, but not only do our nation's health care policy experts acknowledge the value of investing in primary care, but so do many of the nation's top business executives.

Harbaugh misses the point of primary care by describing it as "a brief meeting with a physician who tells patients what they already know." Primary care's strength is in continuity, the relationships formed with patients over years that allow early detection and intervention in medical illnesses. Family physicians are trained in effective behavioral change methods proven to make a difference in the health of their patients. Investing in primary care and the patient-centered medical home reduces overall system costs by reducing unnecessary hospitalizations and unnecessary emergency department visits.

Overall, Harbaugh fails to acknowledge the very real cost and patient safety differences in primary, secondary and tertiary prevention. His example from his own practice is the carotid endarterectomy, an example of tertiary prevention. Indeed, if a patient had access to a primary care physician to help control blood pressure, smoking cessation, and prescribe statins when necessary, the patient might even avoid the need for this procedure with its associated high costs and surgical risks.

Furthermore, we cannot hide from the truth. Primary care is among the lowest paid physician specialties in the United States, a travesty given the overall value that primary care brings to our patients, communities and the health care system. This huge income disparity has a profoundly negative impact on our country's future workforce. The average medical student today has more than $161,000 in education debt after medical school. Data increasingly show that debt and earning potential are swaying student specialty choice.

To close the gap in medical student specialty choice, the Council on Graduate Medical Education's 20th report recommended that primary care physicians be paid at 70 percent of subspecialists' pay. When our Canadian colleagues faced a similar decrease in primary care student interest 10 years ago, they increased the mean salary of family physicians and now have more medical students entering family medicine than ever.

Harbaugh interprets the data narrowly and quite selectively. The professional societies representing primary care have never advocated "robbing Peter to pay Paul" by increasing payments to primary care physicians at the expense of surgical specialties and other subspecialties. The AAFP's position has always been that savings from preventing avoidable emergency department use, hospitalizations, readmissions, procedures and tests will more than pay for improved payment for primary care.

Harbaugh says patients are the priority, and we couldn't agree more. If we are to address the toughest challenges in medicine, we must respect the value and expertise of all our medical colleagues -- primary care and subspecialists alike. By bringing physicians together, we can have a profound and far-reaching impact on medicine. But most importantly, we can do what is best for the health and well-being of our patients.

Jeff Cain, M.D., is the president of the AAFP.


Where I practice, there are no neurosurgeons, and most of them at the regional tertiary care center have closed their practices to Medicaid patients. These are the patients I see. Who contributes the most to the health of these patients?

Posted by Tom Heston MD on March 01, 2013 at 12:55 AM CST #

Thank you for addressing Dr. Harbaugh's misleading blog post. The only way to combat prejudicial attitudes toward primary care is with articulate, intelligent responses like yours. I appreciate your leadership.

Posted by Greg Stueve on March 02, 2013 at 09:27 PM CST #

Don't waste your time worrying what a misinformed neurosurgeon writes or thinks (oxymoron).

Posted by Paul Ryan M.D. on March 04, 2013 at 10:19 AM CST #

The data is overwhelming re: the value of primary care to the health care system. The 2005 Starfield article is but one of many examples. http://www.commonwealthfund.org/usr_doc/starfield_milbank.pdf

Posted by on March 04, 2013 at 12:17 PM CST #

Dr. Harbaugh unfortunately exemplifies the attitudes of modern medicine and most specialists these days (to include most impressionable medical students); he is everything that is wrong with medicine these days. I applaud you Dr. Cain for having the courage to address this topic; too bad others in AAFP would rather get along then see reality. For years now specialist have been doing their best to outsource primary care to mid level providers in the form of reduced payments for Primary Care Physicians and subtle or outright attack on the primary care professions (RUC anyone?). Although I value and respect said midlevel providers for everything they bring to the table they were never created to supplant the Family Doctor but work in concert with them to address the healthcare disparities facing this nation. This is not about them and our "fight" isn't either...It is with our own. It is time we stop playing nice and realize our profession is most endangered by those from within. The last thing we need are more impersonal, niche specialist more interested in payouts, prestige and ego inflation than quality care. Those in primary care represent the best in medicine and why we all “purportedly” got into this field to begin with….

Posted by Sparta of Phoenix, AZ USA on March 04, 2013 at 12:46 PM CST #

I have not read Dr. Harbaugh's blog; but I find it amusing that he writes "a brief meeting with a physician who tells patients what they already know." My experience is opposite. Usually, it is much more often the specialists who tell my patients what they already know from me. Sometimes it is in a Latin term. I am certain it is the experience of most of my primary care colleagues.

Posted by Saghana Chakrabortty, MD on March 04, 2013 at 07:46 PM CST #

Family physicians face, on a daily basis, enormous problems related to payment, regulation, and administrative burden: problems that the AAFP is either unable or unwilling to address. Dr. Harbaugh's inane rantings are not one of these problems. If the AAFP leadership sincerely believes that this blog squabble is a "sign of primary care success," they are more out of touch with the experience of the general membership than any of us thought was possible.

Posted by D. Brown on March 04, 2013 at 08:41 PM CST #

Thank you Dr Cain for your response to this "missive". A reasoned, factual response is exactly what is needed when someone with Dr Harbough's academic credentials goes on a rant. Although I agree Primary Care reimbursement improvement should stand on its own merits, some of our specialty colleagues are fearful of the effect upcoming changes may have on their income. This will result in some push back that needs to be answered. Our leadership has done a good job I think. (although we could get a bit uglier with the RUC).

Posted by Gregory McCue on March 04, 2013 at 09:24 PM CST #

I am thankful for the above response to Dr. Harbaugh's posting. I am continually grateful for the advocacy that our Academy does on our behalf. He does raise a couple interesting points regarding some of the not-so-evidence-based things that physicians in general (not just primary care) still do because "that's the way we've always done it." But it ends there and I think that they belong in another blog post, not the one in question. I think that Dr. Harbaugh really attached himself to this perceived future where procedure-oriented specialties will be making minimum wage while talented, young medical students are clawing tooth and nail for the promise of mansions and yachts when you become a primary care physician. If you want a career in healthcare that entitles you to a summer home in the Hamptons and a retirement package that includes stock options, then you need to be an insurance executive. AND, bonus, to do it you don't have to give up 12 years of your life just for schooling, you don't have to take call, and don't have to explain to a single patient why some necessary service is being denied (i.e. rationed). Because let's face it, a vacation in the Hamptons and trolling around on the yacht really gets your mind off of the inequities that contribute to the social determinants of health. And when your shareholders are happy, you can justify the whopping almost-20% of every healthcare dollar that goes toward your summer home, yacht, and retirement. Let's not forget to ask the bigger questions of our system that have left us arguing about our salaries and healthcare costs in the first place! And let's swallow a healthy dose of perspective as well: the average per capita income in the US is roughly less than $40K per year... lower than our take-home after taxes. And sure, we have more debt on average, but we could fight to do something about the cost of medical education as well. Just sayin'...

Posted by Josh Raines, D.O. on March 04, 2013 at 10:12 PM CST #

"a brief meeting with a physician who tells patients what they already know." Well, perhaps I should refer my patients with headaches to neurosurgery. A glioblastoma is a glioblastoma. A headache is many times anything but a headache.

Posted by Man Nguyen on March 05, 2013 at 12:29 AM CST #

Dr. Harbaugh has blasphemed the church of primary care. Outrage! We are all insulted to the bone. Let's not get all bent out of shape. He has some points to think about. An ounce of prevention is not always worth a pound of cure. His points about screening for ovarian cancer and prostate cancer are well taken. Decisions about prevention should yield to evidence basis, and our USPSTF keeps us informed about this. He misinterprets the conclusions of the Dartmouth atlas project. Yes, rates of mandatory surgeries like hip fractures don't vary across regions as do more elective procedures. However, OF COURSE getting paid for procedures influences surgeons to perform them! Primary care is not only about prevention. Managing multiple complex medical problems is a huge part of my day as a family doc. I keep the big picture of the patient's health in mind. I add efficiency and value to the complex system that otherwise drops balls, duplicates, and ignores implications of actions of one specialist to those of another. I'm quite comfortable with the value I add to our health care system, and am not really suprised that a neurosurgeon doesn't see the big picture.

Posted by Evan Ballard on March 07, 2013 at 02:29 PM CST #

A famous Baylor cardiac surgeon once said to me that what he did was paid high because it was dramatic and sexy, but if I didn't find the problem to refer to him to be treated more people would be dead. He said it is just unfortunate that more people don't understand that and primary is not paid what it is worth. A good primary should carry in his quiver of knowledge at least 95% of that of a variety of subspecialties. The big separator is procedures. In that regard an FP is a primary medical doctor and I believe should be called an FMD or PMD. Words matter and we all have seen how colleagues, and still many of the public, look at FP still as GP although we all do at minimum what all internists do (Notice term is Internist not Primary Adult Medicine). I fought for along time before I was able to get the hospital and staff I was on to recognize a separate dept of FP. How many staffs still have FP as division of Dep Internal Medicine? We do the medical side of most subspecialties and handle more diagnoses than any neuro surgeon. We need and use the whole ICD-9 book. Unlike this neurosurgeon I see the need for scientific understanding but intertwined with the human understanding of caring about the person. It is not a disease attached to a carrier(patient), it is a human being with a problem and a misery and all the worries and fears that attach to it. This surgeon's attitude may make him a fine technician but to my mind not a complete physician. I have found over my years of practice that most of the time when a surgeon can't remove the whole tumor it is most often the primary doc who eases the transition and works with everyone, professional and family, to deal with the situation. That is what a DOCTOR does. But as that cardiac surgeon said: it is not awe inspiring or sexy, it is just hard work. It is the human touch that one cannot code or find a fee for. It may not be brain surgey or rocket science but somehow I think it is the whole payload. When I graduated from my alma mater (Tulane University Medical), many yeras ago, they gave me a large copy of the Hippocratic oath. They didn't ask if you were going to be a primary or secondary doctor. They only cared that they made you into a complete doctor. For that I thank them. I also thank that cardiac surgeon and all the other subspecialists I have had the fortune to meet, famous and not, who believed we were all colleagues working for the good of the population and to move our profession forward. The oath has hung framed on the wall of my consult room ever since I entered into private practice and has been a reminder to me of my profession and for some patients, who have informed me having seen it, that seeing it is a source of comfort to them.

Posted by J.S. Kaufman, MD, FAAFP on March 07, 2013 at 02:36 PM CST #

Thank you, Dr. Cain. We as a specialty have been much maligned, and I appreciate your strong position and the position of the AAFP to support our "specialty of depth.". No specialists have to address the multiple problems patients present to us, and NO other specialty does the generational care of Family Practice (sorry, but I don't like "Family Medicine").

Posted by Margaret A Conte on March 10, 2013 at 11:48 PM CDT #

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