case42tlc:

It seemed to me that this article was more of an indictment of the medical education system than an attack on individual PCP's. Your post comes off as more than a little thin-skinned..

Precisely. as pointed out to me a few years back (by a pcp who went on to various chief of medicine jobs) medical education today is still using the old apprentice system; medical students learn everything from some few individuals and replicate their "masters" as much as possible, then carry that with them through their practices, with only minor updates or changes. That's pounded into their heads. Every medical school produces graduates who follow somewhat different rules; they can't all be right. Big published studies of the US and small internal studies of individual health plans find the same thing; clusters of treatment 'styles' which correspond to regional variation, not any sort of underlying clinical reason. whether it's rate of mastectomies or coronary bypass, adjusted for underlying factors, or rates of antibiotic prescription for childhood ear infections, the determining factors are what each doctor learned in med school, what the local 'big shot' doctor(s) (either regional, or even just in his/her practice) is doing, and what his peers are doing. The influence of evidence-based medicine is slow, and has to filter in through these sources, not directly. That's what gave the managed care movement its initial success; the variation in practice is high enough that intervening in the ones that were 'way out there' would pay off. By comparison, you don't see 'managed engineering'; folks who come out of engineering school are pretty much universal in their understanding of the tensile strength of steel and the oscillatory components of the load on a bridge in a windstorm. Sure, every human being who comes in for medical care is an individual; but every bridge or big building is also individual with individual peculiarities which have to be dealt with.

The thing is that doctors are fairly limited in what they can do. Most patients are going to get better on their own; the doctor can speed this up or hinder it a bit, but that's it. Another group is not going to get better, or will get worse, or will die; and there's not a lot the doctor can do other than slow it down or speed it up. The third group, where proper care from the doctor makes the doctor makes the difference between life and death, or even just a permanent improvement in status, is a pretty small fraction of a doctor's patients. You can give every kid with an ear infection antibiotics for your whole medical career, or give none of them antibiotics, and the odds are pretty good that none of them will die.