Work force study tackles specialty vs. primary care

As policy-makers and medical community leaders determine the best response to physician shortage predictions, the question of whether the public will need more primary care physicians or more specialists is back on the table.

Work force experts and organized medicine leaders remain divided on how to answer that. And with no national health policy to guide medical school expansion, state legislators and medical educators likely will follow the discussions closely.

The latest salvo in the debate comes from Barbara Starfield, MD, MPH, with the Johns Hopkins School of Public Health. Her study's conclusion: The greater the supply of primary care physicians, the lower the mortality rate. She also found that a higher specialist-to-population ratio did not decrease mortality rates. In fact, she determined that too many specialists negatively impacts communities because patients are more likely to have unnecessary tests and procedures.

The nationwide study, "The Effects of Specialist Supply on Populations' Health: Assessing the Evidence," released in a Web-only March 15 edition of Health Affairs looked at mortality rates at the county level.

"Decisions about the physician supply should be made on the basis of evidence for their utility in improving health and reducing ill health and deaths," Dr. Starfield said. "Currently, the United States has many more specialists than do other comparable countries with better health levels."

Robert L. Phillips Jr., MD, MSPH, director of the Robert Graham Center, supported the study in his own commentary in Health Affairs.

"If we want our health care system to be an economic engine, we are headed in the right direction," Dr. Phillips said in an interview. "If what we want is a healthier population, we are headed in the wrong direction."

Specialists aren't bad, he said, but if the physician work force is going to expand, there is an opportunity to ask how it should be configured to make Americans healthier.

"Increasing the supply of subspecialists is not the way to go," he said. "This is not an indictment, but we have an option here, and physicians should weigh in on what's important to them."

Currently, the medical education system is set up to produce more specialists, he said, and medical students are shying away from primary care.

Perry A. Pugno, MD, MPH, director of the division of medical education at the American Academy of Family Physicians, said the United States is producing enough family physicians for the moment, but without increases, the numbers won't keep pace as the population expands.

While there are clear shortages in some medical fields, he said, the most cost-effective way to improve the public's overall health is to increase the number of primary care physicians.

Some question study's findings

Primary care is unarguably a critical foundation for an effective health care system, according to Ed Salsberg, director of the Center for Workforce Studies at the Assn. of American Medical Colleges. But he disagreed with much of Dr. Starfield's work.

In his critique, also published in Health Affairs, Salsberg questioned the validity of looking at the number of specialists by county and linking that to mortality rates.

Specialists, Salsberg said, tend to concentrate in urban areas that draw patients from large geographical areas, so they can see enough cases to be clinically sharp and financially viable. At the same time, the population that dominates urban areas tends to be higher risk and has higher mortality rates.

An analysis of mortality rates also does not capture quality-of-life improvements that specialists provide, he said. Ophthalmologists might not save lives, but cataract surgery can make the difference in a person's ability to see to drive or read.

In addition, he argued, many scientific advances have come from greater specialization. Achievements might mean drugs or treatments that primary care physicians can provide for patients, but they also result in highly complex treatments best handled by the subspecialists themselves, he said.

Salsberg also disagreed with the idea that having more specialists results in more unnecessary services. This theory blames the specialists, when it may be a system problem.

"The author [Dr. Starfield] suggests the specialists are the problem, and if we had more primary care physicians we'd do better, and if we had less specialists we'd do better," Salsberg said in an interview. "The challenge for the health care system is 'When is it best to use primary care physicians or specialists?' We need to do a lot more research. I'm not convinced the overuse of specialists is as serious as they portray it."

Kim Eagle, MD, a clinical director at the University of Michigan cardiovascular center, also took issue with the idea that expanding the number of specialists could be harmful overall. Dr. Eagle is a member of the American College of Cardiology and has been active on work force issues. The ACC holds that there already is a cardiologist shortage, which will get worse as baby boomers age.

Dr. Eagle agreed that unnecessary care was a system issue. He said patient access to specialists is vital.

"We need to demonstrate value through guidelines and performance measures," he said. "We need to do things in the right situation for the right reason. The nation can't afford to overtreat. ... The debate is good, but specialists in the right situation can provide tremendous value, and that's the reason patients go to them."

The American Medical Association has taken a neutral stand in the physician shortage discussion and is doing its own study on the matter. Its existing policy states that the AMA believes that there should be a sufficient supply of primary care physicians and that it supports voluntary efforts to expand primary care programs on the undergraduate and graduate level. The AMA Council on Medical Education is expected to release a report on the physician work force matter in June, which likely will be used to update the AMA's stance.