GP Versus Specialist

In the recent discussion about reforming health care much has been discussed about the lack of primary care physicians and the plethora of specialists. It seems that the specialist is being demonized as the source of waste and overspending in medicine while the GP is praised as the saviour. I would like to dispel this myth by describing two recent cases.

The first case is that of a 54 year old male who came to see me complaining of a sore throat. He had been to his primary doctor several times over the previous 4 months complaining of a sore throat and was given an antibiotic each time. This time he decided to see a specialist. His examination revealed a large advanced malignant tumor in his throat.

The second case is a 33 year old female who came to see me for a wax buildup in her ears. I asked her if she had seen her primary care physician to deal with this problem. She answered that her doctor told her he doesn't clean out people's ears and anyway she preferred to see the specialist.

These cases demonstrate the critical and indispensable role of the specialist in today's health care and three forces that ensure this trend continues. The first is simply patient preference. A significant portion of the population want to see a specialist who has greater expertise in a specific disease or region of the body than a GP. The public believes they will receive better and more up to date care from a specialist who deals specifically with their problem. The woman preferred to see me to clean her ears because this is a regular part of my practice and the assumption is that leads to greater skill.

The second force is that in this era of major advancement in medicine the GP is unable to be fully knowledgeable in all disciplines of medicine. He or she will have a cursory knowledge in many subjects areas but cannot attain the depth of knowledge a specialist would have who just deals with one specific area. Therefore, the GP refers his/her patients to the specialist because they are unable to deal satisfactorily with all their patients complaints and ailments.

Thirdly, the GP refers his/her patients to the specialist because they do not want to take the risk of missing a diagnosis as was done in the gentleman I described. They are covering their behinds because they know if they miss a diagnosis they will be sued for a delay in diagnosis.

So what should be the role of the GP? He/she should coordinate the care for the patients by referring them to the appropriate specialist and then oversee and integrate the recommendations of the varied specialists. The other main role of the GP is to be the disease preventer. Instead of being called a GP he should be the DP (disease preventer). All preventive care (obesity, cigarette cessation, immunizations, etc.) and screenings (mammograms, blood pressure, blood test screening, etc.) should be the responsibility of the DP. The role of the specialist is to treat disease as they have greater expertise in the treatment of ailments effecting their specialty than the DP. And this is often preferred by the patient.

So specialty care often translates into better care and this is likely to continue as the patients and the primary care doctor demand it. Yes it is more expensive care but higher quality often comes at a cost. It is similar to the situation where a transmission breaks. Who would be the preferred person to repair it. A general repair shop or a shop that exclusively fixes transmissions. Or a situation where a pipe bursts. Do you call a general handyman or a plumber. The plumber may be more expensive but the outcome is likely more reliable.

Instead of demonizing the specialists they should be recognized as a product of the incredible complexity of modern medicine. They serve a critical role in delivering state of the art care. Both the primary care and specialist need to work together, in their appropriate roles, for the benefit of their patients. The patient must be seen as a series of complex parts (treated by the appropriate specialists) and also as a whole unit (managed by the DP). Specialty care without the oversight of the DP or primary care without the expertise of specialists is substandard care.

Self Definition

So my mother has been reading this blog and I recently asked her what she thought. She answered, somewhat critically, that she was hoping I would write something more from the heart. To which my wife responded that I have no heart. She was kidding. I think. Well, I thought I would try to write about something less dry than politics.

I was watching 60 minutes last week and there was a segment about the repercussions of the Madoff scandal. They interviewed an elderly man who supposedly lost his entire fortune, which was reported to be in the seven figures. Surprisingly, he didn't appear despondent. His main disappointment wasn't about the money he had lost but the money which friends and relatives had lost who invested with Madoff based on his recommendation. The impact of the potential loss of his relationships with others were more important than his own actual financial loss.

Naturally, it made me think how I would feel if I were to lose everything and then started pondering what defines a person. Or better yet how do we define ourselves. Do we define ourselves based on how others define us or how we think others are defining us. Is a person defined by his/her wealth, by the car they drive or by the house they live in. Do we define ourselves based on the clothes we wear or other external manifestations of materialism.

Or do we define ourselves based on our relationships with others. How we relate to our spouses and children. How we relate to our friends and coworkers. Some defined themselves by their relationship with god. Does one define themselves by the amount of money they have or by how good they are as a son/daughter or mother/father. I suspect that most of us get caught up in the rat race and the pursuit of more and more stuff but the truth is that like the old man it is the relationships we build that has a greater impact on us than the stuff we accumulate. And at the end of the day if we were to all lose our stuff it wouldn't matter nearly as much as losing the relationships we build with others. For some reason it is difficult to live our lives with this knowledge as we concern ourselves with accumulating more and more.

All of us are imperfect and have flaws but we should always try to find the positive attributes of those around us and acknowledge their impact on our lives. It is especially appropriate on this father's day weekend to appreciate the sacrifices our parents have made for us. This day gives us an opportunity to give gratitude to our fathers and we should all tell our fathers thank you.
So Dad thanks a lot for all you have done for me and I hope my kids appreciate what I do for them. Okay Mom?

Upside Down World

I once asked a friend of mine who is Korean how many Jews he thought existed in this world. I prefaced my question by telling him there were 1.3 billion Chinese and 1.2 billion Muslims. I don't remember the exact number he guessed but it was much higher than the actual number which is approximately 12 million. He was astonished by that fact, and I am astonished by the impact this minuscule percentage of mankind has had, is having, and likely will have on human events. If you look at where Judaism ranks in terms of population, it is behind Juche (19 million), Spiritism (15 million), and Sikhism (23 million). When was the last time you saw these religions and there adherents referenced in the media?
The disproportionate impact of the Jews is demonstrated by the countless contributions made in so many areas. Not the least of which is the basis of all monotheistic religions ie. the belief in a single god. There is a hardly a field in the arts, sciences or any other human endeavor that hasn't been advanced by contributions from Jews. They have improved the lives of so many Jews and non-Jews alike, but this advancement has come at a great cost. It has engendered tremendous hatred and suffering towards the Jews throughout history and continues today. The world is truly upside down when you contrast the positive contributions of the Jews to the entire world versus the suffering inflicted upon them and the hatred and blame directed at them by the same world.
Just look at three examples that are occurring currently, the holocaust museum shooting, the Wright statements, and the Iranian situation. The shooter was an old man who probably never even met a Jew who blamed his shortcomings and the country's ills on the Jews. Wright blames the Jews/Zionists for controlling what the president does and who he talks to. Ahmadinejad consistently blames the Jews and Israel and would like nothing more than their destruction. The common theme that underlies all three is that the Jews are responsible for all the ills of society. It is the age old scapegoating against the Jews, when things go bad blame the Jews.
It seems that this is as bad as it has been in a long while. Any positive feeling that the Jews had garnered from the holocaust, which was actually just pity for what they experienced, has ended. It is now back in fashion to openly express one's hatred towards the Jews. The hatred was never gone, it just became politically incorrect, but now that veil has been lifted and the truth revealed. That this tiny percentage of the world population, the Jews, is the recipient of so much hatred amongst so many people and disparate cultures ( Middle America, Black Americans, Muslims) is a stain on humanity.
What have these 12 million people (0.2% of the world population) done to generate such hatred? Discovered medical treatments to prolong and enhance people's lives? Won more than 130 nobel prizes (out of approx 720 awarded)? Advocated for the persecuted, the poor, and the discriminated? All they want is to live peacefully, to practice their religion, to contribute to society, and to live in their ancestral homeland. It is precisely their disproportionately positive impact that has created such jealousy amongst the nations. For only a truly chosen people could accomplish what they have accomplished and this is too much for some non-Jews to bear.
We really live in an upside down world and we should all fear how it is trending.

Rich Kid Poor Kid

Regarding the Sotomayor nomination, a lot is being made of her story being compelling. I suppose this is the typical rags to riches story and how we are supposed to be so impressed by her ability to have achieved from such humble beginnings to where she is today, a nominee to the supreme court. Yes, this is impressive, but is it any more impressive than someone who came from a more privileged upbringing. I believe that in some ways it is equally or more difficult for the child who has it all to grow up to be successful.

When I was a surgical resident I had the opportunity to be involved in the selection process for applicants in my field. The chairman of the department was very impressed by an applicant who had come from humble beginnings and was given an edge over other equally or more qualified applicants. Although this is anecdotal, I believe that if you come from an advantaged background you are penalized at best or at worst discriminated against. Hard to believe I am proposing bias against the children of the wealthy but I believe the thinking is that since you're parents are rich you don't really need the position. Thus the position is given to the one who supposedly scraped and struggled to get to the same level.

The truth is the poor kid may have received significant advantages along the way to have reached the same level as the rich kid. Affirmative action by definition helps a certain group but this is always at the expense of another group. As fair and noble as it may seem to help a disadvantaged child/person it must always be remembered that it comes at the cost of discriminating against the person who has equal or better credentials but the wrong parents. Yes it is true that the wealthy have connections/money that can and do open doors but this is only reserved for the super wealthy. Most moderately wealthy people do not have this advantage.

The poor child who strives for a better life knows the difficulty and hardship of living with limited means . He/She has a hunger to achieve to attain a better life and rid themselves of that poor lifestyle. The rich kid, on the other hand, has been given everything his entire life and lacks the fire in his stomach. The drive is greater for the poor child.

Similarly, the expectations are lower for the poor child and failing in his/her achievement will result in no change in their standard of living. The pressure on them is low. For the rich kid the pressure is much greater to achieve just to maintain the same living standard. The poor kid hasn't much to lose but the rich kid has alot more pressure on him just to stay even with his parents. Thus the rich kid starts out with less drive and more pressure while the poor kid has a strong driving force with little pressure. In other words, the poor kid has nothing to lose as compared to the rich kid who has much to lose.

Ultimately, a persons upbringing should have no effect on whether he/she is selected for a certain position or job. It is not in one's control to effect this genetic fact. Similarly, selecting someone on the basis of his/her race, sex, religion, age etc. is not fair as it is based on factors that a person cannot control. Proponents of selection based on genes or upbringing will say it provides diversity which is advantageous, but lets be honest about what it really is. It is by definition discriminating against someone or a group that does not possess the correct physical appearance or background.

Somewhere out there is an equally qualified or more qualified white middle aged male judge that was passed over for this nomination because he was neither a Hispanic nor a female. The supreme court has filled its quota for middle aged white men. He was discriminated against due to his genetic makeup and his qualifications were secondary. The country ultimately suffers when it is not the most qualified person who gets the job but the individual who wins the genetic jackpot.