There are all sorts of problems with primary care. General surgery is really just a training program, not a specialty. Truth be told, I am not even sure what the point of emergency medicine even is anymore.
So these last couple of days I have been off trying to survive an ulcer and find a primary care doc who actually understands more about medicine than simply handing out OTC meds regardless of history and despite my excessive distress prescribing pills for menstrual cramps for pain control. Basically these doctors are absolutely worthless. They follow guidelines like some bum on the street with no medical knowledge or patient care experience.
But in my anger and frustration, I remembered that is what primary care actually is! Antibiotics and referrals. None of them do anything except follow the least aggressive guidelines. It is what they are trained to do in residency. I would cut them some slack, but it is no wonder they get sued all the time. They deserve it.
Now that I have vented my anger with a harsh truth about primary care, I would like to explore the problem of “modern” medical specialties further.
One of the people I correspond with on an email list is a professor of cardiac surgery who also has his own cardiac intensive care unit. He likes to say “surgeons are not technicians, they are doctors who also know how to operate.” I like that, because I hope to “specialize” (if you can call it that) in surgery and intensive medicine. But taking a look at surgery as a profession, the first 2+ years of residency is basically like being a medical student. You do nothing, you learn nothing, it is completely a waste of time. If you eliminated it, you would actually start “learning surgery” about the 3rd year. Some have said there is education in watching, but from experience I can tell you, you can watch until you fall asleep at the table holding retractors (I did) or until your eyes bleed, but once you put a tool in your hand, everything you “knew” goes right out the window and you look like you never seen or heard of what happens in surgery before. (Even if you practiced the basics on everything from banana peels to cups, did that too.) When it is all over, you are a general surgeon. Aka, now you can actually do a specialty, because unless you work in an austere environment, there is no point on earth for a general surgeon.
What about primary care? It doesn’t really matter what country you are in, and I have been to a few, they do lots of the nothing I already described, if you have timely access or even access to them at all. In some countries like the USA, it has been made obvious that this is not a job that even requires a doctor. There are studies showing nurse practitioners and physician assistants do an equally effective job. What then is the point of having a doctor? Just like general surgery, there is no point at all. You could eliminate GP from all of medicine and replace them with less educated people, who cost less money, who get the same results.
Most of emergency medicine is not really an emergency. But it is not primary care either. The big problem with that is that it is ineffective at primary care, which as discussed, doesn’t require a doctor at all. So basically the whole emergency specialty and system revolves around not doing as effective a job as a “specialist” at anything they do. Sure they can reduce a fracture and put on a plaster splint like ortho, but they don’t follow up at all, despite many people using the emergency system for primary care. They might be expected to handle a “true emergency” except than the “initial resuscitation” techniques might make the patient totally unviable in the ICU. Having an MI, they will call somebody to help you. So basically they just do part of the job of primary care, which as we know, can be totally replaced with non-physicians.
I could go on and on. Trauma surgery? Yea, except more traumas can be treated non-operatively in 2014 than is actually operated on in the civilized world. Even those requiring operative therapy, might be better served by a vascular surgeon or interventional radiologist. Not to mention the fact that unlike military and 3rd world surgeons who practice “damage control surgery” on a regular basis, my general observation of surgeons who do not “specialize” in trauma, attempt to definitively repair people in one operation, and if they don’t survive, well… “It’s trauma and you can’t save everyone.”
Even intensive medicine doesn’t make a good specialty without another specialty first. For example, in neonatology and pediatrics, the knowledge of those disciplines actually determines which intensive therapies will be effective and when. An intensivist who is simply following a guideline or script for things like ventilation, nutrition, water balance, etc, isn’t going to have much success, at least not nearly the success of a specifically specialized pediatrician. My experience with internists trying to do intensive care just makes my head spin while I close my eyes and pretend to see, hear, and speak no evil. Ineffective treatments, under medication for pain, even in palliative care, I could go on for hours, I will sum up. They suck at it.
So we are left with only one logical conclusion. Modern medical specialties do not benefit patients. They benefit providers. They limit the knowledge required down to a mere fraction of medical knowledge. Great if you weren’t actually a complex organism with symbiotic organisms, but a single cell or organ with one or two pathological processes that have no effect on anything else.
Of course as a “specialist” you can charge more. But even with your “extreme” knowledge of a few things, you might be tempted to just mindlessly follow whatever scale or guidelines your fellow “specialists” (read narcissists) have agreed upon as being able to live with, not necessarily best. What’s more, most specialists do not actually talk with other specialists nor share research. They claim that magically what one specialty discovers has no bearing on their specialty because “it is not the same” or “they don’t understand what we do” or “we have a different environment.”
So what does that leave us with? Simple, medical practice that doesn’t benefit patients or keep up with modern medical treatments. Medicine that is confusing or inaccessible/navigatable by patients. No wonder homeopathy is making a comeback. No wonder physicians are not the most trusted profession anymore. No wonder they don’t vaccinate their kids because they doubt our “expert” knowledge.
Modern medicine is broken. The systems do not work well. The economics are totally off. The treatment plans aren’t effective. What are medics trying to do to fix all of it? Double down on what already isn’t working. It is a mess.
Solutions? No acceptable ones. Perhaps start by getting rid of residencies all together. All they seem to do is supply cheap labor to hospitals while reinforcing old treatments and stifling medical advancement and free thinking. At the very least it might be time to reduce the amount of residency time to the actual 1 – 2 years where something is actually learned. Realistically, if you can’t learn surgery in a couple of years, then nobody is, because like I said, the first 2 years are a waste of time easily replicated by a few hours a day on YouTube.
Perhaps we need to worry more about being doctors with a broad and in depth knowledge?
Perhaps we need to stop subdividing medicine into a few repetitive psychomotor tasks?
Lots of “maybes”, little chance for change, one ultimate fact; Medicine doesn’t work for people anymore.
And take special note. A majority of flaws I pointed out are in disciplines that are very dear to me. We must first admit there is a problem if we ever want to fix it.