Seeing all doctors as equals

January 25, 2011

As a primary care physician, this author says he has experienced a condescending attitude from physician specialists, and he sometimes feels that they look down their noses at those who are in primary care.

For example, I was once made into a "villain" when I complained to the hospital administration about a specialist on call who refused to come to the hospital on a weekend to do a consult on a patient. I have also had patients scheduled by one subspecialist only to see another without any explanation sent to me other than telling the patient to contact me for the referral.

Not long ago, I had to confront an orthopedic surgeon who postoperatively prescribed warfarin for a patient reasons not explained in the discharge summary. He told the patient to see me for management without so much as a phone call to explain to me why the patient was taking the medication. The surgeon told me that he thought a nurse would call me about the warfarin. He didn't even seem to be aware that his communication was poor and that he was treating me in a disrespectful manner.

A NEED FOR RECOGNITION

Those of us in internal medicine used to be valued for the assistance we could provide in the management of complicated cases. We are now being treated more like lowly interns by some specialists. This is especially true for hospitalists, who are in many situations now being used as professional "interns" by specialists. I believe much of it has to do with the fact that internal medicine and family practice physicians long ago were made into "gatekeepers" for managed care by the insurance industry, which made us appear to be no more than triage for referrals to "real" doctors in the various specialties.

Those of us who are physicians in primary care are no longer being recognized in the same way as other physicians and are now being treated as though we know little more than a midlevel provider. Nurse practitioners and physician assistants are included with us by insurance companies as primary care "providers" so that there is little distinction between doctors and midlevels. (Even the pharmaceutical industry contributes to this problem by encouraging people to ask their "prescriber" or "provider"-not their "doctor"-to prescribe their brand of medication.)

We are also constantly bombarded by memos from insurance companies telling us what tests we can order and what medications we can prescribe. We have to ask for permission via prior authorization for anything else.

We are further insulted by the number of subspecialty consults being provided by a nurse practitioner rather than by the physician we send a patient to see. I would like to think that we are capable of doing a more thoughtful and comprehensive workup than a midlevel, and it's insulting when a subspecialist thinks his or her midlevel is more competent.

WHAT CAN WE DO?

The future of primary care as a specialty is threatened not only by low reimbursement issues but also by the way we are being treated by others. What can we do as primary care physicians? Here are some suggestions:

If primary care is to survive, other doctors and insurers need to demonstrate more respect for what we have to offer. Otherwise, new medical school graduates will migrate into other specialties, leaving only midlevels to be the sole primary care providers. Some would say this is already happening, particularly as the primary care physician shortage in many areas worsens. This is a bleak forecast, but it does not have to turn out that way if we stand up for ourselves.

The author is a board-certified internal medicine physician and a fellow of the American College of Physicians with more than 17 years of practice experience. Send your feedback to medec@advanstar.com
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