Organized "Specialty" Medicine   7,8/95

by Del Meyer, MD

The American Thoracic Society had nearly 13,000 members and guests at their recent National Meeting in Seattle. Of these, 43% were from 45 foreign countries. Our national meetings are truly becoming more international with a much higher quality than international pulmonary meetings. In an era of attrition of organized medical societies, the ATS continues to grow at least 10% per year, over 40% in the last three years. With as many as 20 concurrent sessions from 7 am to 9 pm, it is possible to get as many as 40 CME credits in 4 days out of 500 hours offered.

One of the more popular seminars was "Adapting Pulmonary and Critical Care Practice to Managed Care." There was also a number of other sessions on managed care as well. The address by Dr. Kimball, the president of the American Boards was the most sharply focused. He stated that about 40% of all specialists are excessive to HMO requirements (CV & GI about 50%, Pulmonary and Hem/Onc about 30% excess). Pulmonary is the third largest (after cardiology and gastroenterology). Dr. Kimball discussed how generalists and specialists look at "medical uncertainty" in a totally different manner. Specialists do NOT make good generalists. The one caveat may be if managed care organizations would allow specialists to do primary care in their specialty and related diseases in which they feel comfortable. One of few studies did indicate that a pulmonologist is able to avoid 50% of asthma and COPD hospitalizations. No one could state whether or not the procedure-heavy specialists such as cardiology and gastroenterology could avoid costs. Pulmonologists who are doing primarily critical care aren't even on the radar screen yet.

One presenter traced medical practice evolution from the authoritarian and autonomous to managed control which he divided into four stages. Stage I was totally unstructured and the doctors word was law. Stage II represented the early loose frameworks that developed over many years as doctors became aware of and concerned with costs. Stage III is the period of consolidation of groups to decrease overlapping areas of coverage. This is where Sacramento and dozens of other cities were listed. Stage IV is totally managed competition with only one group in each specialty or if two groups, no overlap. Only three areas were listed in this group: Minneapolis/St. Paul, San Diego, and Los Angeles. In stage I, a population of 63,000 is required to support one pulmonologist; in stage IV, a population of 125,000 is required to support one pulmonologist.

The cause of our present excess specialty dilemma was attributed to what "organized specialty medicine" did to itself. In the 1970's, a number of the physician groups lobbied congress for increased fellowship/research support of specialty training for an anticipated shortage of specialists. The fellowship slots increased dramatically to 40% over the number of US medical school graduates. These were then filled by foreign and offshore medical graduates. This was justified by projecting that the foreign fellows that did not return to raise the level of medical care in their homeland, would go into primary care and others into underserved areas. All projections proved wrong. We now have about a 40% excess of specialists. One presenter estimated that 130,000 specialty physicians are not needed as we transform to a managed care economy. GI is the most aggressive in changing their projections. They have eliminated one-third of their fellowship positions next year and will have half eliminated in three years.

Why did "organized specialty medicine" get us into this predicament? I remember the presentation by the university leaders at an ATS meeting about twenty years ago. The only resistance was given by one of our own members. Deane Hillsman suggested we allow the market requirements dictate the growth in each specialty. This fell on deaf ears. It is unfortunate that "organized...medicine" caused the problem we now face with excessive specialists -- almost the identical number in excess that our leaders thought was our deficit only twenty years earlier.

Deane loaned me his tapes from the meeting in 1985 when the specialty societies were beginning to see the results of their folly and to make efforts to pull back. But the momentum was too great. One discussant in 1985 predicted that specialists would be so desperate within 10 years that they would work for almost anything, sign almost any contract, and become survival oriented which would allow outside control of medical practice. When I went to a local staff meeting in the early 80's I heard several surgeons "joke" about operating on each other's mother. I was reminded on these tapes that some of our leaders in 1985 predicted that cardiologists would have to do cardiac caths, gastroenterologists do colonoscopes, and pulmonologists do bronchs on each other to maintain competency of technique. Already they recognized that this would not maintain decision making skills.

When the source of livelihood of 40% of any group is threatened, it seems like a crises. But an external crises is different than one we personally cause. In this case is was disregard by leaders of the opinions of rank and file dues paying members. During these 25 years of the crises in the making, many of us have paid over $25,000 in dues to our county, state, and AMA. We also have paid $10-15,000 in dues to our specialty societies. How can rank and file doctors on the front lines be heard? Do we need policy in the arena of the market place except to allow the market place to insure the best environment in which to care for our patients?

Leaders at the Seattle conference stated that the medical market rather than the government is transforming the environment in which we work. But it is the market place of industry contracting with carriers for health insurance that tried to totally ignore patient involvement. That's a very distorted market place. Market place medicine has to include the patient purchasing our skills. Until the patient does that, even a small percentage of the costs, both physicians and patients will be out of the loop. Both patients and physicians will suffer because there is no true patient-doctor relationship. We did it in 1965 when we insisted that patients pay 20% of our charges for part B of m-Medicare. We're even losing that now. The choice is ours. Are we up to it?