1) why does the US have IM/Peds/FP all as PCPs? For example, in england theres only ONE specialty of breadth (General Medicine).
2) ive heard a group of med students talking (just fooling around maybe) that IM/peds should become take more of a hospitalist role than PCP. They think that FP specialty would benefit from it (more interest in it since ALL ). They said theres no REAL reason to have a child ONLY PCP and an adult ONLY PCP. (note child/adult PCPs....not specialists of child or adults). Discuss.
Money & Politics.
We don't live in a command economy in health care where some administrator sits down and plans everything out. Things exist because of evolution. For those old enough to have lived throught this, correct me if I'm wrong. From what I've read:
Once upon a time, IM & Peds were consultants to GPs. That was also back in the day when if you sick, you were admitted to the hospital, stayed there for days-weeks, had every test done, and you got paid what you billed. IM & Peds were not responsive to the public's primary care needs and GPs were not keeping up with scientific and technological advances to be relevant. Med-Peds came about in 1967 to address these needs but failed to gain widespread adoption, and FPs came along in 1969 because of declining numbers in GP. There was government pressure to keep costs down (Nixon-Ford era?). Part of the cost containment programs aimed at reducing hospital costs, because that's where the expenses are. Doctors scrambled to adapt. It just so happens that IM & Peds were politically powerful in East Coast hospitals. In the Midwest/West Coasts hospitals, GPs were the politically powerful ones. Late 60s/70s, government passed an HMO act which established HMOs based on hippy principles of prevention and wellness, in traditionally closed/staff models. Most successful ones were the ones in the West Coast, where people bought into the philosophy.
Fast forward, late 80s/90s. Retrospectively, they looked at cost data and found that HMOs with FP/GPs/PCPs did a better job at keeping costs lower. The HMO act protected insurance companies from being sued, a provision placed in the 60s/70s to protect a fledgling industry. With a little political support, they tried to duplicate the California style HMOs across the country. FPs were to be the focal point of the model. IM & Pedi stepped forward and said that they were "generalists" as well and wanted designation to be, in the HMOs' eyes, PCPs. You started to see more "General IM" and "General Pedi" residencies.
So the whole idea of PCP came from insurance companies writing into their policies that their patients must see a "PCP" before they can see a specialist.
That scared the OB/Gyn's, who were traditionally a surgical subspecialty. They were afraid of losing their turf/patients, so they lobbied and got included as PCPs for women. (Ever ask why Urologists are not PCPs for men?). To this day, OB/Gyns have an identity crisis within their academy. Are we surgeons? Are we physicians? My personal opinion is that the answer depends on how much you want to pay for malpractice. High? Surgeon. Low? PCP.
All in the while, patients got pissed at benefits being denied, doctors paid to under treat. It's what movies are made of. Insurance companies offered "choice" plans and Congress passed the "Patient's Bill of Rights" and "HIPAA" to counteract the pendulum swing to protect patients.
Doctors 1-2 generations ago abused the system, made a ton of money, and "sold out". So this environment is what we inherited: Patients are managed more in the outpatient setting than ever before. Federal budget/insurance companies can't handle the huge volume of elderly without a younger working base to feed it. The only way for them to control spending is on price and playing cash flow/timing games. So practices have to hire more people to make sure they get paid. To make up for the drop in price, PCPs find themselves scrambling to increase their volume of patients.
Specialists are starting to realize that it doesn't make sense for them to do PCP work. It's funny because PCPs don't want to be PCPs anymore (hospitalists, mid-levels), OBs don't want to do OB anymore. Nobody wants to be an FP. And Pedis are stuck because there are too many of them, not enough kids, and not enough pediatric hospitals to make a living as a "consultant". The environment is simply not in favor of the PCP. But if you believe in buying low and selling high, if you don't follow the crowd ("momentum buying") and *believe* in the fundamentals ("value buying"), now is the time to be an FP. Crises shape changes. And change takes time. In time, we'll be in the best competitive position.
Basically, in my opinion for what it's worth, when it comes to money & politics, there is never rationale. It's about power. And opportunity. The only thing that is certain is that evolution never stops. For me in history, in economics, and in biology, the key to being relevant is to be versatile and adaptive. That's why I think FPs will never die.
