by Danielle Ofri
New York Times
“What’s your specialty?” That’s the question people always ask, as soon as they learn that you are a doctor.
My specialty? This question continually flummoxes me. This is the moment that I experience a brief surge of envy toward my cardiology and dermatology colleagues who have simple one-word answers to this question that any lay person can understand.
But what do internists say? What is our specialty?
I sometimes say, “general internal medicine.” But that’s a mouthful. Plus many people have no idea what general internal medicine actually means.
I usually end up saying that I’m just a regular doctor, but it always feels deflating to have to add that “just.”
The American College of Physicians, the professional group for internal medicine, started an ad campaign several years ago to address the confusion. They came up with the slogan of internists as “doctors for adults,” wanting us to credibly sound like specialists, people with more training than the old-fashioned G.P.s. But it just didn’t catch on. I don’t fault the A.C.P. or its Madison Avenue colleagues who came up with this lusterless campaign; there’s just not a lot of pithy material to work with.
Internists, along with the others in the primary care field — family physicians, pediatricians, gynecologists — make up the bulwark of the medical system, though nothing we do or say or represent is especially snappy. No one is rushing to make an edgy cable TV series about adjusting blood pressure medications or treating constipation.
But the need is surely there. Anyone who’s tried to get an appointment with his or her doctor already knows about the primary-care crunch. The Affordable Care Act has highlighted the need for more primary care doctors, with the shortage only likely to grow more acute with a growing and aging population.
In most other countries, the vast majority of physicians are primary care doctors, in recognition that they deliver the vast majority of health care. It is only in the United States that the free market for higher-paid fields results in the number of specialists actually surpassing that of primary care doctors.
We all know the stats — primary care doctors get paid less than specialists, have more administrative headaches, more paperwork, and are generally viewed as lower on the totem pole. Reputation always has it that the smartest medical students go into the specialties; the generalist fields get everyone else who couldn’t make up their mind or who didn’t want to compete in the big leagues.
Dr. Wayne Riley, the president of the American College of Physicians, strongly disputes this characterization. He notes the wisdom acquired by physicians who are required to take both the long view and the wider view of medicine. “I proudly tell people that my specialty is internal medicine.” And if people are still confused, he humorously describes an internist as, “Like television’s Dr. House, but without the bad manners or ethical issues.”
The stereotype of specialists handling the more complex and intellectually challenging cases makes many generalists fume. Generalists observe that specialists get the “simplicity” of handling very narrow slivers of medicine. It’s much easier to be an expert when you only have a handful of diseases to worry about. And any issue that a specialist doesn’t want to deal with can be permissibly kicked back to the generalist.
The generalist, however, gets no dispensation. Every issue that the patient raises must be addressed. Every symptom from any organ has to be acknowledged. Plus, every medication prescribed by every specialist must be accounted for. Every competing interest between the many medical cooks in today’s fragmented health care environment must be integrated.
A recent study regarding patients with diabetes illustrates this reality. In a review of more than 4,500 patients with diabetes, 80 percent of visits to specialists involved only one diagnosis. However, only 45 percent of visits to generalists involved a single diagnosis. Of patients with four or more diagnoses, 90 percent fell to the generalists.
Specialists also get the added ease of pre-screening. A patient referred to a gastroenterologist is generally known to have a GI issue. A patient sent to a cardiologist has some type of heart condition. But the patient who walks into a generalist’s office will often just report pain somewhere in the middle of the body. The generalist has to figure out if the source of the pain is cardiac or pulmonary or gastric or muscular or inflammatory or infectious or hematologic or autoimmune or psychosomatic — a tall order that is somehow considered less intellectually rigorous, and less worthy of reimbursement, than specialty care.
To me, primary care and specialty care are equally demanding. They perhaps represent different types of intellectual challenges, but there’s no reason for one to be thought of as more worthy of respect (or pay).
Primary care doctors, the generalists, won’t be likely to achieve parity in pay or respect until the economics of American medicine changes drastically to reflect more realistically the needs of our patients. Right now, the system values procedures far more than talking to the patient, and so generalists — who do far fewer procedures — continue to rank at the bottom.
But generalists can take heart in the fact that they are what people usually have in mind when they say that they need a doctor. So now when people ask what my specialty is, I say that I’m just a regular doctor. Though I try to remember to leave out the “just.” (from the New York Times)