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In the Balance |

Too Smart for Primary Care?

Eric J. Warm, MD; and Celine Goetz, MD
[+] Article, Author, and Disclosure Information

From the University of Cincinnati, Cincinnati, Ohio, and New York-Presbyterian Hospital, New York, New York.

Potential Conflicts of Interest: None disclosed. Forms can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M13-0801.

Requests for Single Reprints: Eric J. Warm, MD, University of Cincinnati, 231 Albert Sabin Way, Mail Location 0557, Cincinnati, OH 45267-0557; e-mail, warmej@ucmail.uc.edu.

Current Author Addresses: Dr. Warm: University of Cincinnati, 231 Albert Sabin Way, Mail Location 0557, Cincinnati, OH 45267-0557.

Dr. Goetz: Department of Internal Medicine, New York-Presbyterian Hospital, 525 East 68th Street, New York, NY 10021.

Author Contributions: Conception and design: E.J. Warm, C. Goetz.

Drafting of the article: E.J. Warm, C. Goetz.

Critical revision of the article for important intellectual content: E.J. Warm, C. Goetz.

Final approval of the article: E.J. Warm, C. Goetz.

Ann Intern Med. 2013;159(10):709-710. doi:10.7326/0003-4819-159-10-201311190-00009
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This commentary discusses the shortage of primary care physicians, framed by encounters where mentors have asserted that students are “too smart” for primary care. The authors discuss how this assertion discourages medical students from seeking careers in primary care.

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Re-envisioning primary care
Posted on December 8, 2013
Ian Jenkins, MD
University of California, San Diego
Conflict of Interest: None Declared
As a hospitalist—an inpatient primary care doctor—I sympathize with most of what Warm, Goetz, and Kussmaul wrote in their “In the Balance” pieces on primary care.1,2 Of course primary care is intellectually challenging, difficult work; of course no one is “too smart” for the field. I choose not to specialize so I could face the challenges of all medical specialties. But none of the authors admit what we all know: an important fraction of primary care is intellectually un-stimulating. I eliminated clinic work as a career option when, frustrated by several cases of cold viruses and uncomplicated hypertension on a primary care rotation, I learned the talented program director spent many visits per clinic day performing pap smears. We don’t need doctors with seven years of medical training plus extensive clinical experience doing procedures that take an hour to learn. As we face a shortage of primary care clinicians, a healthcare cost crisis, and insufficient respect for this crucial field, we need our generalists supervising midlevel providers who handle straightforward cases, while they focus on diagnostic and management challenges.

1) Warm E, Goetz C. Too smart for primary care? Ann Intern Med. 2013;159(10):709-710.
2) Kussmaul W. Too lazy for primary care? Ann Intern Med. 2013;159(10):711-712.
The Unsurprising Decline of U.S. Primary Care--and What We Can Do About It
Posted on December 16, 2013
Caroline Poplin MD FACP JD
Arlington Free Clinic, Arlington Virginia
Conflict of Interest: None Declared
Alas, I think the specialist-speaker who demeaned primary care as not intellectually challenging was generally correct.1 I am a Board-certified general internist; I have practiced primary care for twenty years. I spend too much time with the Worried Well, doing “check-ups” on healthy people, counseling about diet and exercise, tending to self-limited, acute illnesses, especially URIs, and following patients with easily controlled hypertension, hyperlipidemia, and non-insulin-dependent diabetes. These may be important tasks, but they does not require seven years of intensive medical training: that is why health reform policy gurus Drs. Ezekiel Emanuel and Scott Gottlieb confidently assert that nurse practitioners and pharmacists can and should provide “comprehensive primary care.”2

This situation is not primarily because of funding choices at NIH, the leadership of academic faculties, or poorly designed training: I think it has more to do with the recent history of Western medicine. Back in the day, when medicine was straightforward but (surgery apart), not terribly effective, a general practitioner could handle most medical problems, and referred only the most difficult patients to specialists, often internists. No more. Medical knowledge has expanded exponentially since then, and continues to develop at an ever-accelerating pace, far beyond the ability of any one individual to master. Therefore most physicians focus instead on a narrower area about which they can be confident of their expertise.

The American tilt toward procedural rather than cognitive skills has also played a role, as has the coding paradigm, based on 1950’s acute care medicine: we can be reimbursed better for a single chief complaint with many symptoms and physical findings, than a complex but stable patient continually at risk for big-time complications. So increasingly, generalist physicians pass along the difficult patients to multiple consultants, and focus instead on “prevention” and “wellness”. But this does not require physician-level training, and today’s insurers won’t pay physician rates for nurse-practitioner work.

Our leaders would solve this problem by turning primary care physicians into closely-supervised managers of “medical homes”. 3

However, there are patients who desperately need precisely the expertise we have: the complex, chronically ill, whom our super-specialized, fragmented system fails today. Only a highly trained physician can integrate all the information from multiple specialists, tests, hospitals, family, etc. to ensure that each patient gets treatment that works for him. We should change coding to pay us more to care for these complex patients, less for the worried well.

1. Warm E, Goetz C. Too smart for primary care? Ann Intern Med: 2013; 159(10):709-710.
2. Gottlieb S, Emanuel EJ. No, there won’t be a doctor shortage. New York Times 12/5/2013.
3. Poplin C. No direction home: a primary care physician questions the medical home model. Health Affairs blog 3/24/2009. http://healthaffairs.org/blog/2009/03/24/no-direction-home-a-primary-care-physician-questions-the-medical-home-model/ accessed 12/15/13.

Posted on February 20, 2014
Edward Volpintesta
Bethel, CT
Conflict of Interest: None Declared
In their stimulating essay “Too Smart for Primary Care” in the November 13, 2013 issue Eric Warm MD and Celine Goetz MD say that one reason why students are unlikely to choose primary care is because “the culture of academic medicine” acts as a deterrent.
But medical students are not necessarily steered away from primary care by their teachers. Many students reach that decision on their own. They see that compared to specialists, primary care doctors do not have the in-depth cutting-edge knowledge to share with them that they seek and get from specialists. Thus it is only natural that in an academic culture, primary care doctors are not seen as worthy of emulation.
To add to the problem, most primary care doctors use hospitalists and rarely go to the hospital. They have become “invisible” to many medical students.
Although some teaches may deter students from primary care, the real problem is the rise of the science of medicine and the fall of the diminishing of medicine’s humanistic roots, a process that began over fifty years ago. It has created a deep rift between specialists and primary care as role models in the teaching environment. This is a dissociation from which medical education has never recovered.
Unfortunately, dealing with the medical and the personal factors of their patients’ illnesses (along with an inordinate amount of administrative and clerical work) takes its emotional toll on most primary care doctors, \leading many students see them as hassled, overworked, and in some cases, burned out. Clearly, there is no reason to believe that a confederacy of rogue physicians exists in academia purposely plotting to turn the minds of medical students against primary care.
Perhaps my view of the history of primary care in academia is prejudiced, but on the other hand it may explain why some students just may be “too smart for primary care”.
Edward Volpintesta MD
Bethel, CT

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