Dying Specialties by Steven Mussey MD
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Those of us in primary care like to drone on about the death of our specialty. Yet, another group of specialists is also growing scarce. These are the doctors who provide thoughtful assessments, yet lack the advantage of expensive procedures. Specifically, I include Endocrinology, Rheumatology, Neurology, and Infectious Disease specialists in this vanishing category. Existing large groups with large patient bases and older experienced hardworking physicians in these fields are surviving. Yet, newer groups and younger physicians in these fields are either not appearing or must leave town within a few years.
The scenario plays out like this:
- A new “cognitive field” specialist arrives. The doctor expects a substantial salary because… well… a specialist warrants such a salary. If there is any doubt, the specialist references the inflated salary guarantees listed by the recruiting firm.
- Hospitals and groups desperate to recruit realize they have little choice but to offer the high salary.
- The specialist is hired and the medical community rejoices.
- Soon, a problem develops..
- Successful and experienced primary care doctors know a key survival fact: They have to see a certain number of people per day in order to survive.
- Spending 30, 60, or 90 minutes of time with a complex patient would be great but it does not pay the bills..
- Remember, the specialist reimbursement differential vanished a few years ago for Medicare and most insurances. The “cognitive specialists” are in the same boat as primary care doctors.
- Unfortunately, specialists often get patients because the patients are really… well… complicated. Plus, the patients are on a lot of expensive drugs which require all sorts of prior authorizations.
- The doctor cannot keep up with the minimal amount of patient flow to survive. The employing group or hospital keeps running the numbers and finds the practice is losing their shirts on this thoughtful new doctor.
- Eventually, there is the difficult conversation: “You make too much money. Either you see more patients or we cut your salary.”
- The indignant specialist rightly responds: “I CANNOT CUT QUALITY! You are asking that I put lives in jeopardy! All you care about is money and your own ridiculous hospital administrator pay!”
Of course, you know it is all downhill from there.
- Soon the embattled, but thoughtful specialist is talking to recruiters again, all of whom promise a fabulous salary at another location. Sure, the salary offer at the new location is absurd, but try to explain that to the knowledgeable specialist.
- The town loses its specialist and the physician employer has second thoughts about repeating the whole terrible money-losing process again.
- Referring doctors and patients complain about the lack of such specialists in their town.
- The hospital and big doctor groups shrug their shoulders. What can they do?
- On the other hand, we can always hire another invasive Cardiologist, Orthopedic Surgeon, or Vascular specialist or anyone doing lots of expensive procedures.
So, you think silly ACO’s, practice networks, and other such nonsense will fix this?
Keep drinking the Kool Aid and it will be okay…
Add geriatricians. And then somehow the same thing or something similar must be happening at teaching hospitals. In the eighties I assumed that geriatrics would be the wave of the future, and they’d have some influence on what everybody learns in every specialty. Now I presume they are even less a part of things there, and their absence could kills us all – and break the bank. At least the other dying specialties have drug company support at the research level.
Have watched this occur in my community several times but hadn’t really thought about what was happening until you nailed it.
I work every day in the world of the blind. Patients come in bearing odd and contradictory labels, or no labels at all. One man had chronic diarrhea for 11 years. It was one of those things – nobody had an answer for it. It had no name. This is the level of medicine I expect from cultures that have witch-doctors; in fact, witch-doctors were probably far more savvy and intellectual than most places of medical practice.
Medical training seems to be a paradox. Schools exist for the blind, in order that they may more effectively integrate into a world where far more people are sighted. Medical schools seem to exist for the sighted, so that they can become blind – if not actually blind, more of a hysterical blindness, the brain’s renunciation of the capacity to see.
This prevails in the “disappearing specialties.” We allow things to slip out of our culture, and become foreign and unrecognized. For instance – I used a fountain pen in filling out a Federal form. Once completed, the form was immediately rejected. The HR person had not seen a Fountain Pen. She declared it an Unauthorized Writing Instrument, as though it were a cuneiform chisel. I was given a ball-point pen, for that is what a pen IS, in her scope of recognition.
Technologies reasonably allow more primitive tools to suffer extinction. But the fiction that what is forgotten is inferior, is an absurdity we never seem to think of. The wheel, for instance, being strictly an expression of technology, only improves. An old wheel of centuries past may be a museum piece – it is never better than the newest design.
Medicine is not technology. When diagnoses and ways of thinking are gone, they are gone forever, no matter what the Forms and Guidelines may suggest in return. Erythema multiforme will forever be a diagnosis of experience and observation. The technological approach is to photograph and biopsy it, and send the patient for a Dermatology consultation – expensive and wasteful proceedings that neither cure the disease or help the patient. They only conform to what is increasingly becoming a religious liturgy in our civilization – that Evidence-Based Procedures are to be followed, and the human mind is merely a faulty carbon-based, inefficient creation.
I recently diagnosed a patient with broad-spectrum Em, found the culprit cause and gave the inexpensive drug Reassurance, applied several times. Because in this particular instance there was no office charge, and no prescription, the entire burden on the healthcare system was $0.00 and the outcome was perfect – the patient was satisfied and the condition went away.
We are racing away from such medicine into a Cost-No-Object medicine, where one sends a patient to the ER for medicolegal reasons, time after time. If Evidence Based Technocracy were EITHER better OR cheaper, there might be something to argue for it. Since very often – so often – it is neither, it is fundamentally no different than a superstitious liturgy, a sacrifice of a goat to the waning moon as our tribe stands on the riverbank, trying to appease the Winter God.
Humans tend to do these things; humans tend also to be terribly inaccurate in our self-understanding of our cultures and civilizations. This is a phenomenon of the species. We should, however, try a bit harder to be insightful about our fallacies and vanities.