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We Have Too Many Specialists and Too Few General Practitioners

We Have Too Many Specialists and Too Few General Practitioners

©Amir Ridhwan/
"It's more important to know the patient who has the disease, than the disease the patient has." This was true when Hippocrates said it 2500 years ago—and it remains true today.

Unfortunately, doctors no longer know their patients. GP'S are overworked, underpaid, and must shuttle patients in and out of the office in less than ten minutes. Specialists tend to treat the test, not the patient, and earn their living doing procedures that often are unnecessary.

Wherever I travel around the world, I find the same problem—too few GP's, too many specialists. The doctor/patient relationship has lost its healing power. Doctors are too busy doing the wrong things. Patients have been reduced to a collection of lab test results.

Medical mistakes are far too common because each specialist is treating (or more likely over treating) her own pet organ. No one is considering the whole patient to organize a global, integrated, safe, and effective treatment plan.

The less time doctors spend talking to patients, the more unneeded, costly, and often harmful are the tests and treatments they order.

How did medicine get so specialist-dominated and what forces prevent primary care from assuming its proper central role?

It all started with the Flexner report in 1910. Previously, medical education in the United States was a disorganized mess that promoted, rather than prevented, quackery. Rarely has one report had so much influence. Admission and graduation requirements became stringent. Medical education was based more on science, less on anecdote. Medical school teaching was standardized and quality controlled. More than half of the existing medical schools were closed.

The Flexner reform of medical education resulted in such quick and dramatic improvements that soon the new US model became influential throughout the world.

But there was a serious flaw in this otherwise wonderful and foundational medical reform—a flaw that now haunts and distorts medical education and practice throughout the world.

Flexner based his ideal model on the medical school at Johns Hopkins University, then and now a leader in medical education. Hopkins was one of the first universities in the US and placed great emphasis on departmental specialization and research productivity.

©Sebastian Kaulitzky/
The most powerful departments in any medical school became the ones that attracted the most research dollars and produced the most clinical revenue by doing highly reimbursed medical and surgical procedures. Primary care teaching and practice has always been deeply devalued by medical centers because it does neither.

Primary care is best at the unglamorous and financially unrewarding task of taking good care of patients. Primary care is worst at promoting institutional prestige and profit.

We have too many specialists and too few primary care doctors because specialists are highly valued by medical institutions, even though primary care doctors are more important for good patient care.


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