letters

Saving generalist medicine

In response to Dr. James Glazer's editorial "Specialization in Family Medicine Education: Abandoning Our Generalist Roots" [February 2007], I have to ask why are we wasting our time saving generalism? The marketplace has deemed us valueless. Supply and demand has dictated that we are unnecessary. Insurance companies, the government and the public have said we have no worth. I practice in a small town that should be ideal for the Norman Rockwell model, but instead, I am viewed as a general practitioner whose sole job is to refer patients to the specialists in a nearby city, provide end-of-life care to nursing home residents and be the sounding board for every hypochondriac who has been written off by other physicians. Occasionally, I save a life in the emergency department, but mostly I get up in the middle of the night to see patients with minor problems that should have been dealt with in the clinic during daylight hours. I applaud my colleagues who have limited their practices, and I plan to do the same in about five years.

John Baugh, MD
Langdon, N.D.

Dr. Glazer's editorial hit the nail on the head. If we continue to subspecialize, we risk becoming former family medicine specialists. I take pride in thinking of my specialty, among others, as a specialty that represents "real doctors," and I thank you for referring to those with a broad scope of practice as such.

Gerald E. Harmon, MD, FAAFP
Pawleys Island, S.C.

I appreciate the thoughtful and insightful editorial by Dr. Glazer. This is a vital topic for family physicians as well as for the health of our nation and world.

Even here in a rural Appalachian community, many patients feel that anything more than a minor illness needs the input of a specialist. If this perceived need exists here in rural America, it is stronger and more urgent where the availability of specialists is greater.

As part of the same phenomenon, patients want more and more sophisticated investigations. When I suggest that such investigations are not needed, they believe that seeing a specialist would offer them access to their desired test. And in most cases, they are correct! Their impression is that specialists do more and know more, while I am often considered a limiter of care.

I don't mean the above to sound dark and angry. Part of the paradox of life in family medicine is that it would be hard for me to conceive of a more satisfying career. I would never trade my practice life for that of another specialty. Caring for patients with the spectrum of needs that mine have is immensely rewarding.

Still, I'm not sure that today's medical students are willing to meet the demands of family medicine. The financial rewards are likely to be greater in almost every other specialty, and many young physicians have difficulty seeing beyond that.

A larger sense of altruism and doing what's right for the world may be needed before family medicine makes its resurgence.

David B. Bosscher, DO, FAAFP
Williamsburg, Ky.

I am now retired, but having practiced for more than 30 years, developed a family medicine residency program, taught residents for many years and watched the ancillary services once preformed by family doctors disappear, I am disillusioned and afraid for the continued existence of family medicine.

What a joy it was to run to the emergency department and fix a 9-year-old's displaced fracture of the radius and ulna or bring a new life into the world. First we lost fracture care and obstetrics, then critical care and intensive care, and now we've lost hospital care to hospitalists. Family physicians have become mere referral specialists, and in my opinion, if that trend continues, our specialty is doomed.

We need to change our recruiting methods and look for more aggressive candidates. The AAFP needs to spend more time and money pointing out the thrills of being a family doctor in the truest sense of the term, and our training programs have to stop taking the easy way out
by teaching residents to refer and refer.

Walter C. Averill, MD, DABFP
Homosassa, Fla.

Author's response:

Dr. Baugh voices the frustration shared by many primary care physicians. To be sure, the life of the generalist is not now, nor has it ever been, filled with the financial and social rewards that our consultant colleagues enjoy. However, I am regularly humbled and gratified when patients remind me why they come to me even though consultants are available to them. My patients value the perspective, common sense and relationship focus that my family medicine training taught me.

Dr. Averill points out that attrition has plagued our specialty, and I agree with his assessment that action is necessary to stem that tide. However, where Dr. Averill speaks of us "losing" areas of practice such as obstetrics and hospital medicine, I would disagree. My view is that in most cases we have not had those areas of practice taken from us, but rather we have abandoned them. We in family medicine, and especially those of us involved with the teaching of residents and medical students, have an opportunity to maintain our specialty's vitality by modeling and teaching those full-spectrum skills.

Dr. Bosscher comments astutely about many patients' preference for subspecialty care. Let's educate our patients about being wise consumers of health care, just as we educate them about nutrition, diabetes care or smoking cessation. Affecting changes in attitudes is incremental, but each of us can do our part by letting our patients know when other opinions or expensive tests are unnecessary. I've tried to begin this change with my vocabulary. A mentor taught me to refer my patients to "consultants," not "specialists." We use the term to more accurately describe the services consultants render.

By citing altruism and its rewards, Dr. Bosscher adds a crucial dimension to this discussion. Were we to prioritize income to the exclusion of all else, it would be impossible not to conclude that there are far better-paying livelihoods than medicine. Financial gain is not the only basis for choosing a career, though. Most of us became physicians because of the good we can do. I believe we can show our medical students the emotional rewards implicit in family medicine, and we can keep ourselves engaged in our calling by taking pride, like Dr. Harmon, in our generalist practice.

James L. Glazer, MD
Portland, Maine

Medicare and tobacco cessation counseling

Kent Moore's article "What's New in Medicare Preventive Benefits" [February 2007] is a nice review of the preventive services coverage that the Centers for Medicare & Medicaid Services (CMS) provides. As the director of the OhioHealth Nicotine Dependence Program, I noticed a new, important benefit was omitted from the article: tobacco cessation.

In March 2005, CMS determined that coverage should begin for tobacco-use cessation for Medicare beneficiaries. Medicare covers two quit attempts per year, with a maximum of four intermediate or intensive counseling sessions per year (eight sessions per 12-month period). Patients with a tobacco-related condition or symptom are covered as well as patients who are advised to quit because tobacco use is affecting their metabolism or dosing of a therapeutic agent. Documentation of the tobacco-related condition is required.

Hospital-based counseling is also covered by Medicare Part D, but tobacco dependence cannot be the reason for the admission. Physicians and other clinicians recognized by Medicare may bill for tobacco-use cessation services using HCPCS codes G0375 (3 minutes to 10 minutes of counseling time) and G0376 (greater than 10 minutes).

Tom Houston, MD
Columbus, Ohio

Editor's response:

Medicare does not categorize tobacco-use cessation services as a preventive benefit, which is why they were not covered in Kent Moore's article. These services are described in detail in the May 2006 FPM article "An Update on Tobacco Cessation Reimbursement."

Another EHR myth

As a medical informaticist, I read Dr. David E. Trachtenbarg's article "EHRs Fix Everything - and Nine Other Myths" [March 2007] with interest. I would like to suggest a myth that was forgotten: "Purchasing software licenses, hardware, service contracts, etc., is the only way to acquire a good electronic health record system." Don't fall for it!

More and more Internet-hosted EHRs are joining the market each day. These have predictable costs that make it easier to calculate your potential return on investment. These systems offer several other advantages, including much more rapid response time from the vendor - they only have to fix bugs or apply upgrades once, to one system.

I do think there are good reasons not to purchase any EHR: The market is not mature, interoperability is poor, and few products actually deliver value. Yet there is huge potential for EHRs to improve patient care while also cutting costs, improving revenue and making documentation less of a chore. Medicine is simply too complex (and too risky) these days to practice without help, and effective health care information technology will someday be as important as the ultrasound is to us today.

Kevin M. Coonan, MD
Salt Lake City