Primary care physicians and specialists as personal physicians: can there be harmony? - Editorial

Journal of Family Practice, August, 1998 by Joseph E. Scherger

The people of the United States cherish many freedoms of choice, including their choice of doctors. For a time, managed care has attempted to restrict physician choice, mostly in the name of saving money, and now Americans are fighting back. Health-plan executives are fervently trying to come up with financing mechanisms that will keep them solvent, even profitable, while granting access to the American smorgasbord of physicians.

Fortunately for family physicians, we are popular among many Americans. We are specifically trained to be comprehensive personal physicians, and that results in an efficiency of care that saves money. When we are well-trained, experienced, and skilled in our relationships, primary care physicians do a great job. We are challenged to keep abreast of modern medicine so that our patients receive the latest, best, and most appropriate health care. Family physicians are joined in the US primary care arena by comparable numbers of general internists for adults, pediatricians for children, and, largely by patient demand, obstetrician/gynecologists for women of childbearing age.

Our specialist and subspecialist brethren are often skeptical that primary care physicians are up to the task of modern medicine. This skepticism can be partly attributed to the era in which many of them trained; in the 1950s, 60s and early 70s very few of their medical school classmates and fellow residents chose primary care careers. This skepticism may also be driven in part by survival, since many specialties have an abundant supply of practitioners, and the current rise of primary care is threatening their very livelihood. As Franks and Fiscella[1] report in this issue of the Journal, specialists have done research that argues for their superior performance. But now, primary care physicians are defending themselves with research of their own.

How are we to resolve this battle between primary care physicians and specialists? The study by Franks and Fiscella helps counter the tide of disease-based research favored by specialists. By utilizing data from the 1987 National Medical Expenditure Survey, they report that the population that uses a primary care physician as their personal physician have lower mortality (better outcomes by implication) and lower health care expenditures than the population that relies on specialists. In a similar study that reviewed Medicare claims data in Washington state, Rosenblatt et al[2] reported that they found patients receiving their primary care from specialists were less likely to have continuity of care and less likely to have influenza immunization than those patients using primary care physicians.

Primary care physicians are likely to celebrate the Franks and Fiscella findings because of their favorable results and reasonably sophisticated methodology. I suspect, however, that specialists will cry foul, claiming that apples and oranges have been compared. Franks and Fiscella did say that they adjusted their two study populations for characteristics such as health perceptions, smoking habits, and reported diagnoses, and admitted they could not ensure the populations were comparable in all respects. I am sure that I will quote the Franks and Fiscella study to primary care advantage, but I also understand the specialists' argument. To postulate that the population using primary care physicians as personal physicians is comparable to that using specialists, even with the attempted adjustments, is quite a stretch.

We all have anecdotal examples of healthy people stating proudly that their personal physician is a cardiologist, which supports our desire to see this study for more than it is. My greatest disagreements with this study are the authors' categorization of women who report an obstetrician/gynecologist as their personal physician into the primary care cohort, and the resulting conclusion that women are more likely to use primary care physicians.

Will the research battle over superior outcomes between primary care physicians and specialists ever have a winner? I think not. The academic and public spoils of such a battle come at an expense. If our recent experience with managed care is any indication, Americans are not likely to look favorably on this professional quarrel. Our patients will chastise us for not getting along with each other. Our patients want to feel confident about, and have access to, both types of care. If fully informed Americans were pressed into choosing between having a primary care physician as a personal physician or having access to specialists, I am afraid that the majority would choose the latter. The belief that their health care is the best available is important to many patients when they make health care decisions. Primary care physicians must remember that many of the miracles of modern medicine come from the specialists' domain. If you or your loved ones ever need a new hip or a coronary stint, you may suddenly want access to those specialists you are throwing stones at.