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During the past four decades I have witnessed the rise in power and prevalence of the medical specialist, largely due to incentives that have been brought about by advances in technologies in the medical device and pharmaceutical industries. Unfortunately, the life-improving benefits for the patients from these “advances” have been few and the harms caused have been substantial. However, the well-informed patient can work, to his or her advantage, the present system dominated by specialty care. 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.1 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.2 The desire of Americans for more high tech medicine is based on the common belief that specialized care means better care. All of this expensive and dangerous testing and treating might be acceptable if it resulted in an improved outcome for the patient. 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.3
Why Do Doctors Specialize? Why after 12 years of grade school, 4 to 5 years of college, and 4 to 5 years of medical school, would a young doctor want to dedicate 3 to 7 more years to becoming a specialist? Ideally, the motivation would be altruistic, such as specializing to become a more knowledgeable and skilled expert, better able to help patients live healthier lives. Unfortunately, the drives to make more money and to enhance one’s status are equally correct answers. Being a specialist garners respect from patients and from fellow doctors. As a result, these experts provide the bulk of continuing education for fellow physicians (often sponsored by pharmaceutical companies), generate the vast majority of a hospital’s revenue, have a major influence on health care policy at a local and national level and receive the highest incomes among doctors. The money-motive for specializing is not hidden. Consider what the physician recruitment and staffing company, Martin, Fletcher, writes about cardiology: “New medical developments such as drug-eluting stents are fueling the rise in demand for Interventional Cardiology. The whole market for Interventional Cardiology is expected to double by 2006. Finding a Noninvasive Cardiologist can be extremely difficult as well because most want to expand their practice to include Invasive Interventional Cardiology because of the income potential. Cardiology remains in the top 2 income generating specialties for rural hospitals and top 5 for urban hospitals, so the demand and compensation for Cardiologists will continue to rise at or above the 12% rise that was seen last year.”4
Have a Generalist as Your Primary Doctor Most people have a primary care physician, but 20 to 25 % use a specialist for primary care services.6 If you allow the specialist to take over your general care you are putting yourself at risk. Care of your general health is outside the expertise of a specialist—they rarely have the whole picture in mind. Most people come to their doctor with multiple problems, such as clogged arteries, aching joints, sluggish bowels, and blubbering fat—not just one isolated ailment. It makes sense that a doctor with an all-encompassing view of your conditions—a generalist—should make the initial assessment of your condition. (Of course, the well-informed family-practice, general-practice or internal medicine doctor will quickly conclude that these are all problems of diet and lifestyle—and immediately prescribe a plant-food based diet and an exercise program.) Specialization often leads to narrow thinking. Have you heard the saying that, “If all you have is a hammer, everything starts to look like a nail.” This is one reason that women who have a gynecologist for their general doctor have a much greater chance of having a hysterectomy.7 To many gynecologists, headaches, backaches, bellyaches, depression, painful intercourse, and fatigue are “female problems” best treated by removal of the “useless uterus.” Profitable Gimmicks Lead to Aggressive Treatment Recent technological developments have resulted in high profits for specialists and one of the best examples of this kind of income-building comes from the introduction of fiberoptic scopes and micro-instruments. With these tiny tubular tools, surgery can be performed in the deepest parts of the body through very small incisions. These kinds of devices allow the urologist to work in your urinary bladder, the orthopedic surgeon to repair your torn ligaments, the ear-nose-throat doctor to look into your sinuses, the pulmonologist to exam the airways of your lungs, the gynecologist to remove parts of your pelvic contents, the cardiologist to “burst open” your blocked heart arteries, and the gastroenterologist to take biopsies of your colon. These modern inventions also make for a handsome profit for the doctor performing the surgeries. Also realize that highly profitable medical procedures have led to much over-treatment. One representative example is the laparoscopic cholecystectomy which allows gallbladders to be removed through three tiny holes placed in the abdomen, rather than the traditional foot-long incision. After the widespread introduction of this technique in 1991, the rate of gallbladder removal in North America increased almost overnight by 30% to 60%.8 Visiting a cardiologist for any pain anywhere between your belly button and your nose, often leads to a treadmill stress test, followed by an angiogram. An angiogram is a preoperative procedure—so expect an angioplasty (heart surgery) to follow. This letter in the Annals of Internal Medicine (a very prestigious medical journal) explains how the cardiology business works, “The popularity of angioplasty is puzzling, given the high rate of restenosis (meaning the closure of a heart artery following the surgery) and the absence of controlled trials comparing angioplasty with coronary artery surgery or medical treatment (no survival benefits have been shown from angioplasty). We suggest that the combination of three factors, never so closely associated before in the history of medicine, have been synergistic in promoting coronary angioplasty: It is very lucrative; patients are mostly self-referred; and it is fun to perform.”9
How to Use a Specialist to Your Advantage A generalist must serve as your doctor—the specialist serves only as a consultant to you and your general doctor. When additional knowledge or skills are needed, then an arrangement—a referral—is made to see a specialist. The expert then gathers information about you, comes to conclusions and recommendations, and then sends a report back to your generalist. Together, the two of you, then discuss this valuable information and decide on the next courses of action. This may be to go ahead with the recommendations or to seek other opinions from different kinds of specialists. After sufficient research—such as you do when you buy an expensive car or home—a decision can be made by you with the aid of your advocate generalist on the proper course to take. Ping-ponging the Patient around the Clinic The bigger the business you are dealing with, the more you have to be on your guard. Medical groups consisting of many doctors present a special challenge. You go in for a sore throat and you are notified that you are overdue for your PAP smear and must see the gynecologist—this doctor then sends you for a colonoscopy—and from there you are referred to the group’s dermatologist for a discoloration on your thigh—and the process continues until you have seen every possible professional in the medical group. This profitable business practice is known as ping-ponging. Get Out of the Medical Businesses I once owned a 560 SL convertible Mercedes (a used car, but helpful during my 40s midlife crisis). I soon became all too familiar with my Mercedes’ repair shop. I knew my mechanic on a first name basis. After multiple visits, I learned about his wife, his kids, and the intimate details of their summer vacation. I will never buy another Mercedes. You don’t want to have a doctor as a familiar friend either. All of the challenges you have faced with various medical businesses may have left you overwhelmed and confused (See previous newsletters with discussions below). You have questions about: what doctors to see, which medications to take, what tests to choose to avoid future diseases, and much more? There is one simple answer to these dilemmas: Get out of the medical businesses. Don’t have a doctor, take pills or tests. And the only safe and effective way to get out of the medical businesses is to become healthy. Sick people take drugs, undergo multiple surgeries and examinations and know many doctors. Healthy people live outside of these businesses. The surest way to be healthy is to eat a low-fat, plant-food based diet (The McDougall diet), exercise a little, and have clean habits. Freed from the medical businesses you can focus your life on your career, family, sports, and hobbies. Now that’s living.
References: 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. 4) (Annual Physician Compensation and Benefits Report May, 2003 http://www.martinfletcher.com/reports/Physician_Comp_Benefit_Report_2003.pdf) 5) From Martin,Fletcher http://www.martinfletcher.com/reports/Physician_Comp_Benefit_Report_2003.pdf 6) Xakellis GC. Are patients who use a generalist physician healthier than those who seek specialty care directly? Fam Med. 2005 Nov-Dec;37(10):719-26. 7) Roos N. Hysterectomy: variations in rates across small areas and across physicians’ practices. Am J Public Health 74:327, 1984. 8) Legorreta AP, Silber JH, Costantino GN, Kobylinski RW, Zatz SL. Increased cholecystectomy rate after the introduction of laparoscopic cholecystectomy. JAMA 1993;270:1429-32. 9) Nicod P, Scherrer U. Money, fun, and angioplasty. Ann Intern Med. 1992 May 1;116(9):779. <<< Return to Newsletter Home Page
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Taking Advantage
of the Medical Specialist 
