Time to call a specialist when you are very sick? Maybe not.
January 4, 2015
We live in a specialized society. The percentage of doctors training in and practicing specialized medicine has exploded, while the number of primary care doctors continues to dwindle. There are many causes of this process, as I discuss in my book, and nothing in the docket of the ACA and Medicare reformers will reverse the trend. And so we have a medical system glutted by specialists; only about a third of all doctors in this country now practice primary care, and only a fifth of medical students enter the field. Those numbers continue to drop, as the number of specialists increase.
But what is wrong with highly specialized care? As my 90 year old grandmother said, why see a doctor who knows a little about a lot of things (a primary care doctor), when instead you can see experts in many fields (she saw about 9 specialists routinely)? Medicare pays generously for patients to see specialists with regularity, it pays for any tests and procedures the specialists order or perform, and there are enough specialists around to accommodate. But a recent study published in JAMA Internal Medicine (12/22/14, A. Jena, MD) sheds an interesting shadow on the assumption that specialized care is superior. This study, which looked at both academic and community hospitals, assessed outcome of cardiac patients with congestive heart failure, heart attacks, and cardiac arrest between 2002-2011 both during routine times and during times when many of the hospitals’ cardiologists were away at national conventions. Paradoxically, at academic centers, patients fared better when the cardiologists were away. There were fewer stents performed (21% vs 28%), fewer patients with congestive heart failure died (17.5% vs. 25%), and fewer patients with cardiac arrest died (59% vs 69%) during convention dates. There were no changes in outcome of heart attack patients, and no significant trends were noted in non-teaching hospitals.
Certainly, this study is interesting but proves nothing. Still, it is food for thought. Why did the absence of specialists lead to worse outcome under certain circumstances? In fact, the study’s findings are not surprising at all, and are in sync with a plethora of data demonstrating a very real danger of excessive specialization, something I discuss at length in my book. In areas of the country with the highest percentage of specialists patients have worse outcome in cancer, stroke, and coronary heart disease compared to areas with more primary care doctors; they have a higher death rate and higher hospitalization rate; and such specialized care is carried out at much higher cost. Since 60% of the elderly spend time in the hospital during the last month of their lives, with 40% of them spending time in the intensive care unit, for care that they do not want (70% of elderly explicitly state they do not want to die in the hospital), for a poor outcome (death) not impacted by the expensive and often traumatic hospital stay, at a very high cost (25% of Medicare’s total budget is spent in end of life care) means we should be very concerned that we are fomenting a medical culture that is highly specialized and is losing its primary care base.
Fischer and Wenberg at Dartmouth have studied regional variations in health care extensively, using Medicare data that applies to our elderly population. They have found that in highly specialized areas of the country people are less healthy and die earlier despite similar risk factors and demographics. They estimate that 30,000 excessive deaths are caused annually due to excessive specialized care. Other studies show that a more palliative approach (treat symptoms, eschew tests and procedures) can actually lead to better outcome than an aggressive, specialized approach. A Dartmouth study showed that palliative care led to increase quality of life and survival at decreased cost compared to specialized care in many medical conditions. Congestive heart failure patients, in one study, lived almost 3 months longer if they chose palliative care instead of aggressive, specialized care, at lower cost and with improved perceived quality of life.
This brings us back to the JAMA article. While one can make no leaps from the study’s conclusions, and likely cardiologists will find many reasons to question its outcomes, the results are not surprising. Fewer stents were performed when the cardiologists were away, and as we will show, and as I discuss in my book, procedures such as stents can actually lead to worse outcome than more conservative care in many circumstances. Also, aggressive treatment of congestive heart failure is more likely with specialized care, as is hospitalization, and we know that such patients fare worse with that approach to treatment compared to more palliative treatment. No wonder there was a lower mortality in congestive heart failure and fewer stents placed with fewer cardiologists steering patients along a more aggressive road. Certainly there is a very important place for specialization in our medical society. But the overly-specialized culture that is proliferating across our health care landscape can be very dangerous and costly. As the primary care pool shrinks and an army of specialists grows, our elders are being exposed to a system of care that has been shown to be deleterious and which is bankrupting Medicare. So let the JAMA article at least be a wakeup call. It is time for the ACA to realize the scope of our primary care shortage and starting fixing the problem. Answers are easy. Just ask us, or read my book. But it is time we stop ignoring one of the most salient problems with our current health care delivery system: we need to have a more primary-care based approach for it to best help our patients and to not bankrupt the system.