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.