Friday, April 6, 2007

The Last Generalist

Are pediatricians an endangered species?

This is the question that was recently posed on a listserv I read, as well as here and here and here. Stagnating or declining reimbursement for primary care and escalating financial pressures (particularly for vaccines) make it harder and harder for pediatric practices to survive. Meanwhile, nurse practitioners and retail-based clinics are claiming they can do the same thing we can, only with more convenience and less cost. The future doesn't look good.

A CEO of a Boston hospital believes insurers will eventually start realizing the value of preventive medicine, and start reimbursing, or shifting funding, accordingly.

But insurers--not to mention the government, via Medicare and Medicaid--have long known how good a deal preventive medicine is. There's even been data to back it all up, for years and years. Just look at vaccines. Yet insurers continue to pay ridiculously low amounts for vaccines (sometimes even under our purchase cost!), or similarly pathetic rates for infant check-ups. Because they can. They know (as I alluded to in my last post) that doctors--especially primary care doctors--are not businesspeople. We are here to help others, and if we have to shoulder some of that burden to care for our youngest and most vulnerable, we do it. The surgeons raise a proper stink if they don't get "fair" reimbursement for that gall bladder removal or tonsillectomy; we just suck it up and see another few patients per day.

There has been talk about creating value. Fight the retail-based clinics by offering evening hours, or open-access appointments (a type of scheduling that basically insures everyone who wants to be seen, is seen, that day). Show the insurers the data that our great care can keep the kids out of the expensive ER, and is therefore worth something to them. Or create programs that offer convenience and value to both patients and insurers--such as weight-loss classes, new parent discussion groups, or asthma education sessions.

These suggestions are great, but they can't be done by a solo pediatrician, or even a small group. Only a large group can do it. And many are doing it, or at least starting.

The days of the solo pediatrician are indeed numbered. The pressures are too great, and the innovations can't be reached, at least not without burning yourself out.

This doesn't spell the end of pediatricians, however. A good friend and colleague of mine likes to say that pediatricians are the last generalists. I don't mean your country doc, cradle-to-grave caregiver, delivering babies in the middle of the night at the Smiths' farm and being paid with a hog and a bundt cake. (There may be a few of those family practitioners still around, but they're not even endangered, they're basically extinct, outside of film or TV.) I mean the I'll-treat-anything-that's-bothering-you doc, the absolute-expert-about-the-whole-person physician. The Save-The-Day kind of doctor who, in this case, is the ultimate authority on kids. The doc who can resuscitate and stabilize a premature infant, start an umbilical line, calculate a drip, bag and intubate, and perform the spinal tap, all at 3 a.m. The doc who can differentiate ADHD from a learning disorder from a simple acting out, and start correcting any of the above. The doc who, even if he can't insert the ear tubes, can still keep straight a chronic serous otitis from a Eustachian tube dysfunction from an acute suppurative otitis media, figure out the right medicine, and--most importantly--explain it all to the mother who never made it past seventh grade. And the doc who might talk to the local PTA about newly licensed vaccines one night, and to the district attorney about a case of child abuse the next.

We may not do all of those things everyday, but we've been trained well enough that we can. If it concerns kids, we can handle it. Period.

And--I know this is going to get me some of my first hate mail--that Medical Degree means something. I'll say this with sincere respect: NP's can do great things, and bring wonderful perspective to the craft of medicine. Both NPs and MDs can follow protocols, develop judgment from a wealth of experience, and communicate well. But the MD has the base and the background to be the Authority. Only the MD has the training in biochemistry, psychology, pathology, pharmacology, epidemiology, research, the whole toolkit, and the mindset to be able to deal with the unexpected. A pediatrician's scope of practice is limited only by what he or she wants to tackle.

As long as that remains true, there will be a need for pediatricians. We are the generalists who specialize in children. We may be practicing in large mega-groups, or employed in government clinics, but we will be around as long as there are kids.

And maybe that's what I like best about being a pediatrician.


Bryan said...

Actually the bundt cake is probably worth more than Medicaid pays on a moderate complexity follow up.

#1 Dinosaur said...

There may be a few of those family practitioners still around, but they're not even endangered, they're basically extinct...

Still a few of us stumbling around, trying to avoid the tar pit for at least a few more years.

Anonymous said...

Every thing you say is true, but fails to recognize the truth.

In 1983, I can remember the cries that pediatricians would be extinct by 1990 because "health care extenders" as they were then called would replace us.

Pediatricians are recognized for what they are. Good Guys and Gals. With an increasing number of women and part time practitioners. The majority of the Members of the AAP are women. When women become the majority of any health care specialty, reimbursements go down. Look at the world of veternary medicine before you start howling.

Part timers make less and can demand less than full timers. When pediatrics becomes majority part time specialty, reimbursements will fall further.

By the way, who says that pediatricians have to administer vaccines? If you lose money on a service give it up! If you can not prove to yourself and your patients that you have value with out providing vaccines, than your MD degree is really not worth what you think!!!

Pediatricians are great business people. They are lousy capitalists. Pediatricians of my generation have survived and in some case thrived through several payment paradyme, 3rd party payers, gate keeper HMO, to deeply discounted fee for service.

My father always said,if the only tool you have is a hammer, every problem begins to look like a nail.

Are there no other solutions to reimbursement other than to see more patients? Clearly some individual pediatricians have found other ways. Search them out and see what they have done that you can copy and retain your identity.

Lastly, as some one who went into solo private practice in 1988, it is tough. But remember what it is that you are trying to do. You have to take care of yourself as well as take care of your patients. Pediatricians have to be like camelions. They can change their outer colors to fit in better with the environment that they are in, but they never change who they are inside.

Good Luck.

The rest of the dinosaurs are rooting for you to stay true to your self. Remember that when you often have to tack to reach your destination.


Rich Gorman,


Spot on.

DrGwenn said...

"We may not do all of those things everyday, but we've been trained well enough that we can. If it concerns kids, we can handle it. Period."

Well said!!

Dr Scott said...

Good to hear from you, Rich! (Jan told me you might come calling!)
I appreciate your insight from the long-term perspective, and I do hope you are correct that these pressures are another case of "everything old is new again."
My pessimism about the survival of the solo pediatrician is tainted by my experiences here on the Gulf Coast; I am increasingly convinced that private practice is not a viable option in a disaster zone.
That being said, does anything generalize to the "normal" world out there? My concern/fear is that all primary care docs are facing these same pressures, just not in such a compressed time frame as we've experienced here. Is it all any different than it was 20 years ago? Who knows. Maybe the system has been stretched as far as it can go, the efficiencies have been squeezed to the maximum and we are approaching a breaking point; think chaos theory, nonlinear feedback, and inflection points...
I have no doubt that peds will survive, and some solo peds will still hang on, but I've been converted to Herschel Lessin's gospel that the only way to actually do well is to band together.
I do take issue with one comment: I actually think a good many docs are both terrible capitalists AND terrible businesspeople. I know many peds who have made terrible business decisions and who could barely run their practices. You and I have a mutual acquaintance who would probably fit that description. I believe there are relatively few docs who are also good businesspeople, let alone capitalists, let alone "good guys (and gals)."
Still, one can try...

Anonymous said...

Pediatricians may be generalists but they are also specialists. Specialists in kids. It really annoys me today how people throw around words and use them generically when they are not. My sil talks about her kid’s pediatrician. But he’s not. He’s in family practice. His card says the he specializes in “family practice, pediatrics, obstetrics, gynecology and internal medicine.” What doesn’t he do? She had to take her child to a pediatric urologist. We have one in town. But, her insurance wouldn’t fully cover a visit to the expert so she took her child to an adult urologist. She then specifically mention going to the “pediatric urologist”. I corrected her. I said there is only one in town, that’s the one we use and you didn’t see him. Well, she stammered. There is a difference.

My children use a pediatrician. They also need an ophthalmologist so they see a pediatric ophthalmologist. One needs a urologist and a nephrologist so we see pediatric urologist and a pediatric nephrologist. The term pediatric means “kids”. (Ok, so not technically) So, in the end while you may be a generalist, you are also a specialist.

Anonymous said...

You have to express more your opinion to attract more readers, because just a video or plain text without any personal approach is not that valuable. But it is just form my point of view

Chester said...

What namely you're saying is a terrible mistake.
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