Quality of Care

Primary care provided by physicians specifically trained to care for the problems presenting to personal physicians, who know their patients over time, is of higher quality than care provided by other physicians. This has been confirmed by a variety of studies comparing the care given by physicians in different specialties. When hospitalized patients with pneumonia are cared for by family physicians or full-time specialist hospitalists, the quality of care is comparable, but the hospitalists incur higher hospital charges, longer lengths of stay, and use more resources (Smith et al., 2002).

In the United States, a 20% increase in the number of primary care physicians is associated with a 5% decrease in mortality (40 fewer deaths per 100,000 population), but the benefit is even greater if the primary care physician is a family physician. Adding one more family physician per 10,000 people is associated with 70 fewer deaths per 100,000 population, which is a 9% reduction in mortality. Specialists practicing outside their area have increased mortality rates for patients with acquired pneumonia, acute myocardial infarction, congestive heart failure, and upper gastrointestinal hemorrhage. Specialists are trained to look for zebras instead of horses, and specialty care usually means more tests, which lead to a cascade effect and a greater likelihood of adverse effects, including death. A study of the major determinants of health outcomes in all 50 U.S. states found that when the number of specialty physicians increases, outcomes are worse, whereas mortality rates are lower where there are more primary care physicians (Starfield et al., 2005).

McGann and Bowman (1990) compared the morbidity and mortality of patients hospitalized by family physicians and by internists. Even though the family physicians' patients were older and more severely ill, there was no significant difference in morbidity and mortality. The total charges for their hospital care also were lower.

A comparison of family physicians and obstetrician-gynecologists in the management of low-risk pregnancies showed no difference with respect to neonatal outcomes. However, women cared for by family physicians had fewer cesarean sections and episiotomies and were less likely to receive epi-dural anesthesia (Hueston et al., 1995).

Patients of subspecialists practicing outside their specialty have longer lengths of hospital stay and higher mortality

18.2

17.5

28.1

19.9

11.9

10.4

Arthritis

Chronic renal failure1

COPD12 Depression1 Diabetes1 Hypertension1 Obesity1

Chronic condition

"'Significant difference in percentages between 1995 and 2005 (p <0.05). 2COPD, Chronic obstructive pulmonary disease.

Figure 1-2 Percentage of office visits by adults 18 years and older with selected chronic conditions: United States, 1995 and 2005. (From CherryDK, WoodwellDA, Rechtsteiner EA. National Ambulatory Medical Care Survey: 2005 summary. Advance data from vital and health statistics. No 387. Hyattsviiie, Md, National Center for Health Statistics, 2007. www.cdc/gov/nchs/ahcd/oficevisitcharts/htm.J

rates than patients of subspecialists practicing within their specialty or of general internists (Weingarten et al., 2002). The quality of the U.S. health care system is being eroded by physicians being extensively trained, at great expense, to practice in one area and, instead, practicing in another area, such as anesthesiologists practicing in emergency departments or surgeons practicing as generalists. Primary care, to be done well, requires extensive training specifically tailored to problems frequently seen in primary care.

As much-needed changes in the American medical system are implemented, it would be wise to keep some perspective on the situation regarding physician distribution. Beeson (1974) commented:

I have no doubt at all that a good family doctor can deal with the great majority of medical episodes quickly and competently. A specialist, on the other hand, feels that he must be thorough, not only because of his training but also because he has a reputation to protect. He, therefore, spends more time with each patient and orders more laboratory work. The result is a waste of doctors' time and patients' money. This not only inflates the national health bill, but also creates an illusion of doctor shortage when the only real need is to have the existing doctors doing the right things (p. 48).

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