Wednesday, September 30, 2009

Too Many Specialists in Medicine (Updated)

About two-thirds of the medical doctors in the US are specialists, compared to about half in other industrialized countries. The American health-care system prides itself on having so many specialists; however, the results of this dominance of “experts” are far from flattering. For example, the rates of heart surgeries are highest in populations living in Brazil and the USA, intermediate in Canada and Australia, and lowest in Hungary and Poland. Yet, there were no differences in rates of death by heart disease or heart attacks among these countries.[fn1] Plus, the rates of stroke were higher in Brazil and the USA than in the countries with lower intervention rates. In the USA, patients with heart attacks are 1.7 times more likely to be treated in a coronary care unit and receive cardiac procedures, calcium channel blockers, and thrombolytic agents than in Poland, yet the death rates are identical.[fn2]

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A study of 13,270 adults found people with a primary care physician, rather than a specialist, as a personal physician were more likely to report fewer medical diagnoses, have one-third lower annual healthcare expenditures (mean: $2029 vs $3100) and about one-quarter lower mortality. [fn3]


1: Yusuf S, Flather M, Pogue J, Hunt D, Varigos J, Piegas L, Avezum A, Anderson J, Keltai M, Budaj A, Fox K, Ceremuzynski L.Variations between countries in invasive cardiac procedures and outcomes in patients with suspected unstable angina or myocardial infarction without initial ST elevation. OASIS (Organisation to Assess Strategies for Ischaemic Syndromes) Registry Investigators. Lancet. 1998 Aug 15;352(9127):507-14.

2: Rosamond W, Broda G, Kawalec E, Rywik S, Pajak A, Cooper L, Chambless L. Comparison of medical care and survival of hospitalized patients with acute myocardial infarction in Poland and the United States. Am J Cardiol. 1999 Apr 15;83(8):1180-5.

3: Franks P. Fiscella K. Primary care physicians and specialists as personal physicians. Health care expenditures and mortality experience. J Fam Pract. 1998 Aug;47(2):105-9

-From The McDougall Newsletter, April 2006. Read the entire article, "Taking Advantage of the Medical Specialist".

As to the point made by Dr. McDougall at footnote 3, Carol raises a very good question: Do sicker people go to specialists than generalists? If so, then one would expect higher mortality rates. I went to the website of the Journal of Family Practice to find the article, but they have them available on the web back only to 1999. I may order the August 1998 issue to see how that question is addressed, if it is.

MacDougall does not go after specialists for the sake of going after specialists. His comments on the matter are just part of his general program. That program is founded on his major thesis, and that is to stay healthy with a good diet so that one lives longer (or at least better) and has a greater chance of avoiding the medical industry. When I cite the particular points that McDougall makes out of that context, like this one about specialists, I know that they must sound extreme. But it is only part of the larger picture that he draws.


mary said...

Good referenced articles. I haven't read them yet (darn med school reading gets in the way), but a quick skim of the abstracts show that they're in respected, peer-reviewed journals with decent study design. One observation: they are a little dated now, and there is a good possibility of subsequent studies that enhance/refute their findings. When looking at the PubMed abstract, you can reference the articles in which the article you're interested in is referenced. (You can also use for this.)

Also, if you can't find that third article and still want a copy, I'm sure I can get it here.

Finally, Mom would make a good epidemiologist; but of course, that doesn't surprise us.

mary said...

I meant to say: when looking at the PubMed abstract, look at the box on the right of the screen that says "Cited by 27 PubMed Central articles." That's where you find later articles and studies that mention your study.

Paul said...

Thanks, Mary. Dr. McDougall likes the older studies, because he believes newer ones are unduly influenced by the drug companies: this according to a lecture that I viewed on a DVD from him. I will look for an article he wrote on the subject of research being biased by the drug and med-equipment companies. But I did notice that the studies were a little old. Thanks for the suggestions on the updates.

mary said...

I don't know too many specific examples (though I'm sure they exist) of research biased/affected by drug cos. and such things, but I do know that many well respected journals (like NEJM or Lancet, say) have mechanisms in place to check for such bias, which can be monitored via study design and results analysis. I'm not sure that a study done 12 years ago would be any less likely to be biased than one done 2 years ago, and if anything, I would think that the more recent studies might be more carefully scrutinized (esp. in the major journals) for such bias.