COMMENTARY

Quo Vadis? A Dilemma

Monte Malach

Published online: 5 February 2012

� Springer Science+Business Media, LLC 2012

In the United States, where are we going with the explosion

of medical knowledge, technology, and innovative therapy

that is acknowledged worldwide? The journey has been

rapid, comprehensive, and, in some areas of medicine,

spectacular. In the process, we have focused our medical

progeny on specialization and sub-specialization. Mean-

while, there has been scant focus on producing the much-

needed and now disappearing broad-based internists and

family physicians. This is clearly the product of medical

educators, who are almost all specialists and sub-special-

ists. As such, they fail to provide specific role models for

medical students and residency fellows in training with an

interest in broad-based internal medicine and family

medicine.

The current medical education scheme unfortunately has

thus contributed to the wholesale increase in the cost of

medical care. Corrective action would require the devel-

opment of a large cadre of broad-based internists and

family physicians, who, in turn, need the attraction of

proper reimbursement by medical insurers to offset the

huge debt of medical school education that currently drives

many graduates into high paying specialty areas.

Medical insurance providers should properly pay doc-

tors for the time and expertise involved in taking a com-

prehensive medical history and performing a complete

physical exam. This could obviate the standard use of

frequently unneeded, repeated CT scans, at great expense

and with significant radiation exposure concerns.

Moreover, there is an opportunity for significant cost

savings by reducing the unnecessary tests and procedures

on which many sub-specialists rely. Multi-page medical

history forms completed by patients, as a doctor time-

saver, easily miss important clues that are evident in one-

on-one interviews (e.g., when patients are hesitant or

uncertain in giving answers). Furthermore, as a time saver,

physicals are frequently limited only to a patient’s chief

complaint, rendering it insufficient. And because all spe-

cialties in medicine and surgery are now increasingly

segmented into sub-specialties, most patients now have

four or five doctors, rather than a single doctor to coordi-

nate patient care.

It has been estimated that the average debt of graduating

medical students has risen to $200,000. This requires them

to train for and join high-paying medical specialty prac-

tices, rather than going into the lower-paying field of pri-

mary care. In addition, a relatively new concept, medical

homes, will require a larger cadre of broad-based internists

and family physicians. These physicians will provide

constant and continuous primary care and arrange for

specialist services. Already in some areas of the United

States, the shortage of primary care physicians is being

remedied, in part, by nurse practitioners who provide such

care. The factors noted here will only further increase the

current deficit in the numbers of family physicians and

broad-based internists.

Primary care physicians are on the lowest rung of the

ladder of stature and payment in the medical world. This is

unfortunate and unwise, given the important role that these

physicians can play in maintaining high-quality, cost-

effective medical care. Indeed, Braunwald [1] has com-

pared specialists and sub-specialists to the virtuosi of an

M. Malach (&)

Department of Medicine, New York University Medical Center,

455 North End Avenue, Apt. 912, New York, NY, USA

e-mail: mmmdmacp1@gmail.com

M. Malach

SUNY Downstate Medical Center, 455 North End Avenue, Apt.

912, New York, NY 10282, USA

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J Community Health (2012) 37:270–271

DOI 10.1007/s10900-012-9544-1

orchestra. The conductor, like broad-based internists and

family physicians, is best equipped to synthesize the

symphony of tests and treatments that are required to treat

the whole patient. In contrast, specialists and sub-special-

ists are like virtuosi who perform occasional ‘‘solos’’ using

specialized diagnostic and therapeutic options in one spe-

cialty area.

We must reform our medical education system if we are

to restore the prestige, dignity, and pay for the broad-based

internists and family physicians who can provide better and

more cost-effective patient care.

Reference

1. Braunwald, E. (2009). Cardiology as a profession in 2020 and

beyond. ACCEL, American College of Cardiology, pp. 41–11,

Disc 2, Track 1.

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