In Praise of Physicians

The American College of Physicians' (ACP) annual meeting this year aroused deep feelings of admiration for primary care physicians and the challenges they face today...I have been attending ACP conventions for more than 25 years as a medical writer and editor, first for the Journal of the American Medical Association, and then for Medical World News, Medical Economics, and CONSULTANT. And this year's meeting featured some clinical milestones that gave me a sense of having truly witnessed medical history.

But before I get to that, let me admit up front my great respect for the bright young people who go into medicine. Over the years, the overwhelming majority of physicians I've gotten to know have been dedicated, caring, and fun. And the ones whom I met of the 6,000 doctors attending this year's ACP convention in Philadelphia only reinforced those observations.

My admiration was rekindled not only by their willingess to arise in time for 7am lectures but also by the sheer breadth of topics that they were expected to manage. More than 260 educational courses covered virtually the entire range of medicine from allergies to zoonoses.

Several areas of medicine seemed to have achieved long-sought goals. As a young medical reporter, I had witnessed the beginnings of the intensive management programs for type 1 diabetes and the lingering questions whether all the added expense and trouble would turn out to be worthwhile.

It was a pleasure to hear from Dr. Mark E. Molitch, Professor of Medicine in Northwestern's Department of Endocrinology, Metabolism, and Molecular Medicine, Chicago, that the data are finally in, proving that intensive treatment not only reduces the incidence of retinopathy, neuropathy, and nephropathy but also sharply cuts the risk of MI, stroke, and death from cardiovascular disease.

Dr. Stephen A. Paget, Physician-in-Chief of the Hospital for Special Surgery's Division of Rheumatology in New York City, reminded doctors of the impressive results from intensive therapy in rheumatoid arthritis (RA). Early and aggressive use of Disease Modifying Antirheumatic Drugs (DMARDs) has reduced the percentage of knee replacements for RA at his institution from 25% in 1985 to only 2% in 2005. Physicians now rarely see such horrendous manifestations of RA as windswept knees, pericardial calcifications, amyloidosis, Felty's Syndrome, and cervical spine subluxation.

The common thread, of course, is that early and aggressive care confers many benefits to patients who have diabetes or RA. From a managed care/managed cost perspective, however, these approaches are more expensive than less intensive therapy. And as long as employers keep switching health plans, the financial investments made by one organization to stave off these complications may well be reaped by a competitor.

From a patient/physician viewpoint, avoiding these terrible outcomes will certainly seem worth the price. “Savings,” however, are notoriously difficult to quantify, much less use successfully to justify a more expensive therapeutic strategy. Money not spent because complications have been prevented often loses out when opponents simply point to actual dollar “costs.”

While I hope this savings/cost debate will not impede the application of intensive therapy, the ACP meeting also raised another fear-that there won't be enough primary care medicine physicians to initiate and coordinate these complex approaches when the “Baby Boomers” start retiring in large numbers.

See why Steve Murata worries that physicians, and patients, should take seriously the ACP pronouncements on the “collapse of primary care”.

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