How Doctors Think - Lack of Recognition For Gatekeepers

Lack of Recognition For Gatekeepers

Groopman also serves as an advocate for primary care physicians in his book. He argues that gatekeeper physicians are underreimbursed for their work, believing this to be a legacy of the period earlier this century when surgeons headed the medical societies that negotiated with insurers about what a 'customary' payment for services was to be.

He suggests that the poor reimbursement and lack of recognition for primary care physicians is fundamentally flawed. He quotes Dr. Eric J. Cassell's book, Doctoring: The Nature of Primary Care Medicine, to defend his assertion:

A common error in thinking about primary care is to see it as entry-level medicine...and, because of this, rudimentary medicine...This is a false notion. One should not confuse highly technical, even complicated, medical knowledge--special practical knowledge about an unusual disease, treatment, condition, or technology--with the complex, many-sided worldly-wise knowledge we expect of the best physicians.

The narrowest subspecialist, the reasoning goes, should also be able to provide this range of medical services. This naive idea arises, as do so many other wrong beliefs about primary care, because of the concept that doctors take care of diseases. Diseases, the idea goes on, form a hierarchy from simple to difficult. Specialists take care of difficult diseases, so, of course, they will naturally do a good job on simple diseases. Wrong. Doctors take care of people, some of whom have diseases and all of whom have some problem. People used to doing complicated things usually do complicated things in simple situations--for example, ordering tests or x-rays when waiting a few days might suffice--thus overtreating people with simple illnesses and overlooking the clues about other problems that might have brought the patient to the doctor.