One of last week’s behavioral science lecturers put forth a hypothetical scenario – when a patient sits in front of you, musters up his or her case, and tries to sway you to their end of the doctor-patient relationship, listen to your gut feeling. If your conscience tells you that “this isn’t right” or you’re just not comfortable with the situation, don’t continue to treat. Every patient deserves a physician who can adhere to the finest standard of healthcare, and if you can’t provide it, there’s nothing wrong in referring the patient elsewhere.

So what if this patient is a member of your family or a close friend? Are you obligated to treat, should you avoid the case entirely, or is it a toss-up?

I imagine most physicians prefer not to treat people they’re closely acquainted with for various reasons:

• Scared they might mess up and jeopardize the relationship.
• Might cause other family members to also seek help.
• Relationship might interfere with medical judgment and ethics due to inherent bias.

I’ve always been the other way. If I’m a specialist in some field ‘X’, and a loved one needs to see someone with ‘X’ training, I want to be the physician in the room. I really don’t intend to sound arrogant, but I just wouldn’t trust anyone else in this case. Yes, there’s the possibility that I could kill a loved one, but it’s a decision that, at the current time, I can see myself still making. Though this could change once I actually start practicing, I think that having a family member’s well being in the hands of another family member is the best situation… for both parties. Again, this is just my humble, first-year medical student opinion and by no means do I wish to sound arrogant.

Primary care physicians, on average, get paid less than their specialist counterparts while many work just as many hours. Sure, the residency programs are shorter, but when it comes down to paying off debt accumulated throughout college and medical school… a cosy salary really helps. Plus, one approach to resolving the healthcare system’s growing costs is to place primary care physicians as the “first stop” for patients, so it should be an important focus for the government.

The chart above shows how we’re not the only country facing this problem (though we do have a considerable lead). With a growing population and progressively longer life expectancy, healthcare will continue to consume a large portion of our GDP. No one really knows how much wasteful spending is built into our national budget, but Washington really needs to tighten the rope and do something… fast.

Primary care has never crossed my mind as a career possibility as I’ve been set on neurosurgery for quite some time. Surprisingly, this inclination towards specialty residencies is shared by the overwhelming majority of my class, and in comparison to previous years, the number of residents in primary care is gradually dwindling. The New York Times published a fantastic article addressing this very issue which I highly recommend.

Now let’s consider a hypothetical scenario. You wake up one morning with unbearable pain localized to your upper left abdominal quadrant (stomach region). You’ve got two logical choices: visit a gastroenterologist (specialist) or your regular physician (primary care). You end up choosing the gastroenterologist because, after all, he/she has been trained to deal with abdominal symptoms for years. After a plethora of expensive tests, you’re diagnosed with a mild case of stomach poisoning. What if the primary care physician could have told you this same diagnosis for less than half the cost?

A few observations can derived from this:

• The specialist had to take time to examine a relatively simple case.
• The patient (and insurance companies) had to spend more than required.
• The primary care physician could have made this diagnosis… probably with less time spent scheduling an appointment.

An interesting proposition made during the presentation was using primary care physicians (PCPs) as a buffer between patients and specialists. In other words, a patient would always present to a PCP and then, if necessary, be referred to a specialist.

This suggestion implies that without an increase in PCPs, the current generation will be working extended hours to meet the increased patient inflow. At this point, an inevitable question must be brought up – how do we adjust physician salaries? The two students argued in favor of increasing PCP salaries (currently, one of the lowest paid physician salaries) while simultaneously decreasing specialist salaries. I’m under the impression that some specialists wouldn’t have been specialists if it wasn’t for the cozy paycheck, but in any case, we have to consider several factors.

• Specialists receive more training (and accumulate more debt)
• Specialists tend to deal with more risky cases (higher malpractice)
• Both specialists and PCPs tend to work roughly the same number of hours

Reducing the compensatory gap between specialists and PCPs is a touchy subject indeed, but what better incentive to attract aspiring medical students towards primary care than an increased salary? Why not focus on primary care physicians to lower healthcare costs from the get go – the patient coming in for treatment?

I really have no fair argument for or against this, but I thought it was an interesting perspective which I had never thought about before. Hence, a blog post.