The author of this article is a cardiologist and a pediatrician. He pretends to know what it is like to be a primary care physician - family practitioner, general internist, pediatrician. He fails absymally when he defines the necessity of reviewing the literature on interventions contemplated in primary care. He has NO idea of the magnitude of his demand here. He has belittled ALL primary care physicians by implying all of them are country bumpkins, unaware of the literature and unwilling to spend time in patient education. He has a very poor grasp of practice realities and probably does not even know the literature in his own field of pediatric cardiology per his own standards - see my other posts.

Primary Care in the USA deserves better. We are under assault from CMS. Bush continually tries to cut out all Title VII funding from the budget. Politicians allow a malpractice situation to continue that places an incredible burden of guilt and the real prospect of financial ruin on the primary care physician who does not do EVERYTHING in the evaluation and management of patients in the office setting. The Medical Home model is proposed as a solution and what is the increase in reimbursement per patient that goes along with all the requirements built into the Medical Home model? Two dollars and 50 cents per month per patient. Whoopee! That will not even pay for 1/5th the cost of a reasonable EMR for the practice, much less its super customization to meet the Medical Home standards.

When Primary Care in the USA implodes as it surely will sooner or later, we will see the consequencies of stupidities as are exemplified in this article.

Abysmal, abysmal article. This article does not meet the reality test standards set up by the author. Shame on you cardiologist. Go write another popular press book with your free time rather than venting your spleen on primary care physicians.

I don't really understand your anger.

You are absolutely right that primary care is underpaid and under great stress, esp. when compared to most specialist physicians. If reimbursement was fair, PCPs should make as much as nonsurgical specialists, and surgical specialists/radiologists should make not much more than double of what nonsurgical physicians make.

What the author pointed out are deficiencies of a great number of physicians, be they specialists or PCPs.

And I personally think you should not start a barfight by telling an academic subspecialist that he does not know his own field. I did not check out your claims in that regard, but you are almost certain to loose that fight.

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..

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.

Lets look at the main point here and ask any true clinician is s/he agrees:

However, the sheer abundance crowds out an important—in fact, the only—skill that matters in treating a patient: how to critically appraise published clinical trials. Few doctors ever read them.

Only is the cardiologist's highlighted term. That is a patently simplistic view of the treatment skills of primary care physicians. The most important skill in my opinion is to do a qualitative analysis of the visit and intersect that analysis WHILE the patient is being seen with efficacious interventions that could do the patient much more good than harm based on: 1) evidence in the literature (that evidence NOT being definable de novo by each PCP); 2) experience - whether you realize it or not doctors do learn by experience; 3) expert opinion - I respect the opinion of the medical student to fellow to senior physician collegue. ALL can contribute to the care of the patient. In fact I have seen an LPN make tow BIG time diagnoses that had major therapeutic implications. The diagnoses and therapeutic possibilities were missed by BIG TIME cardiologists and would have been missed by yours truely if not for the LPN's super astute observations. EVERYONE on a good primary care team can be an "expert". Therefore I take this cardiologist to be much less than a competent PCP based on the above statement.

In addition to challenge him on his own turf:

What is your dosing regimen cardiologist for ACE-I in African American and Hispanic teenagers with hypertension?

What is your routine thiazide diuretice for African Americans?

Answer those two questions and we shall see if you know your own literature and practice what you preach in cardiology if nothing else.

I couldn't agree more - see my post from today, "Is this clown for real?"