We need more generalist physicians. And a new health system so that they can be effective.

We don’t have enough primary care physicians in the US to properly (or, often and in many places, even improperly) care for our people. We all need a primary care doctor, and some of us need specialists. But rarely does a specialist have the time, interest, or expertise to manage all of your problems, and also do the recommended preventive work. Unfortunately, primary care physicians rarely do either, especially when it involves managing the care delivered by many different specialists, who can be unaware of what treatments the other is recommending and of how it might conflict with treatment they are giving. Doing this properly takes a lot of work and time.

For example, you mention to your cardiologist that you have knee pain. They say “I don’t do knees; here’s a referral to an orthopedist”. They’re done. If you go to your primary care doctor, they will examine you, try to figure it out and maybe treat it. But if they refer you to an orthopedist, they will follow up, read the report, look at the x-rays, read the recommendation, and try to explain to you what it all means. In short, a specialist referring to another specialist saves time and work; a primary care doctor referring to a specialist generates more work for themselves.

But there are not enough primary care doctors to do this, and those that exist are not given sufficient time by their employers (most are employed by hospital systems or large groups, often owned by private equity) to do it right. Because – and this is the most important thing – these hospital systems and especially private equity are, like insurance and pharma companies, in the business of making money, and only incidentally providing health care. Yes, many doctors are also interested in making money, but this is not their only or primary concern.

So, because most doctors are employed, and because primary care doctors may work much more for much less money, we have a dramatic shortage of primary care doctors in the US. A recent issue of Your Local Epidemiologist describes this in some depth.

One approach to primary care is that which Sweden has adopted, as documented here by the Commonwealth Fund.

Sweden is aligning primary care access goals with physician workforce policy more explicitly. Rather than treating physician training as separate from care delivery, Sweden is using workforce policy as a tool to strengthen continuity, accessibility, and person-centered primary care. To support this goal, the Swedish National Board of Health and Welfare analyzed primary care workload and physician capacity, established a benchmark of one primary care physician per 1,100 residents, and issued recommendations to guide regional workforce planning toward that target.

The Commonwealth Fund notes that

The United States faces a similar problem. Although physician training strongly influences where physicians ultimately practice and what specialties they choose, federal graduate medical education (GME) financing remains largely tied to algorithms based on hospital funding patterns established decades ago. The Centers for Medicare and Medicaid Services lacks authority to measure workforce outcomes associated with the nearly $21 million in Medicare funding that supports physician training. The result is a system that often produces workforce outcomes misaligned with patient needs, specifically not enough primary care physicians, general surgeons, and psychiatrists.

Commonwealth adds “Sweden’s recent reforms suggest a different model: define national access goals first, then align workforce policy around them.”

What a novel idea! Imagine figuring out what you are trying to achieve and then designing a system of achieve it! This is completely different from how health policy, including (or perhaps especially) physician supply and makeup is done in the US. (Well, except for for-profit companies who know what their goal is – make more money by any means necessary, which is never providing you with the best, most comprehensive and effective, or accessible, healthcare.) The system we use is to … do the same old thing. Pay subspecialists more, allow students to choose which specialty they want, and expect that somehow enough will choose primary care, despite the fact that they will make far less and often (not always, depending on the other specialty) works more, will almost be always employed by a large hospital system or group practice owned by private equity, and be on a hamster wheel of “productivity”, which means they cannot see enough patients, cannot deliver adequate care to the people they do see, and for themselves achieve limited professional satisfaction in having the control necessary to influence positively the health of their patients. 

As I have written before (e.g., Changes in the RUC: None.. How come we let a bunch of self-interested doctors decide what they get paid?, July 21, 2013; Pay primary care more: Kennedy may be getting this one right!, July 23, 2025 ), there is no mystery on how to change the income levels of primary care physicians relative to subspecialists. The Medicare payment “pie” is divided up between specialties mostly on the recommendations of an AMA-appointed group of physicians called the “RUC”, which is dominated by subspecialists. CMS, whichadministers Medicare, doesn’t have to follow the RUC’s recommendations, but usually does. And the RUC’s makeup of about 15% primary care physicians guarantees that primary care will be underpaid by Medicare. And, since almost all insurance company reimbursements are based on multiples of Medicare payment, this translates to the whole system. CMS could set up, or require the AMA to set up, a RUC that was, say, half primary care doctors!     

A word on the term “primary care”. While it has become the standard phrase in the US, and we can’t get away from it, it is not a great one. It was popularized by internists (adult medicine doctors) to distinguish those more properly called “general internists” from their internal medicine brethren who did mostly hospital work (“secondary care”) including intensive care (“tertiary care”), and then expanded to include general pediatricians and family physicians. Of course, family physicians are mostly all (90%) in what is now called “primary care”, and they (or the also commonly used “general practitioners”) are the mainstay of outpatient care physicians for the populations of most countries. Family physicians differ from other “primary care” physicians in that they are trained to provide comprehensive care for people of all ages, with all problems (referring when necessary) across the lifespan, including caring for children, old people, delivering babies, caring for folks in the hospital, in nursing homes, and doing lots of different procedures.

Unsurprisingly, it is hard to find even family physicians doing all these things now, except sometimes in rural areas where there are fewer physicians in other specialties. It has always been true that the privileges granted to family physicians have been largely determined by how much other physicians can make doing that work; many will be “first assistant” surgeons (fairly well paid) except when their communities have a glut of surgeons who “need” the work = income. Many years ago, it was discovered that only about 10-15% of graduating family medicine residents in Texas were interested in delivering babies in rural Texas; however, this was compared to 0% of OB-Gyn residents!

So let’s start with identifying what we want to achieve: enough primary care physicians, distributed broadly enough across the country in rural and urban areas, for every single person to have one. For those primary care (or family, or generalist) physicians to be paid enough relative to subspecialists that students are attracted to the field. For them to have enough time budgeted to manage complex problems and even more complex interactions between patients and other doctors. This is especially a need for older adults, who are most likely to be seeing multiple specialists for multiple problems. Relying on ERs or Urgent Care is a very poor and inadequate alternative.

That requires a complete reworking of how our health system functions. Covering everyone, such as by the improved and expanded Medicare for All system called for by the S. 1506 and HR 3069 bills, is an absolutely necessary part of this, but is not alone sufficient. We also need to restructure physician payment to encourage enough primary care that people can easily access it and it can be effective, implementing completely Starfield Four Pillars of Primary Care: [first] Contact, Continuity, Comprehensiveness, and Coordination (Starfield B. Primary Care: Concept, Evaluation, and Policy. New York, NY: Oxford University Press; 1992). If ANY of these are missing or incomplete, we have an inadequate health system – as we in fact do.

No messing about at the edges. No "reforms" that reform little. No saying we cannot afford universal health care, something every other developed country does, because our insurance companies need to make huge profits. No denying the need for an immediate steps to ensure an adequate primary care workforce because we don’t want to pay subspecialists less.

This must happen now, happen yesterday. There is no morally acceptable alternative.

 

                                       

"Take this, it's good for you!" Or maybe it isn't.

“Take this, it’s good for you!”

 You probably heard this growing up from your parents, or grandparents, or others, about lots of things. Medicines, foods, supplements, and even activities (“Do this, it’s good for you!”). You probably have continued to hear this from other people even if you are now grown: friends, family, people you have just met, and that most reliable of all sources, random posts (I was going to say “random people” until I realized that many or most of them could be bots) on the internet! So, should you take it? I mean, is it good for you?

I know my answer is going to be shocking: “It depends.”

On what? On a whole lot of things.

The whole idea that there is a general concept of things that are “good for you”, whoever you are and what you are hoping to achieve, is nonsense. What is good for one person – say an infant or a toddler – may well not be good for a middle-aged or older adult, and vice versa. And, of course, the most important question is “good for what?” What do you seek to have happen to you that this nostrum is “good for?” Do you even share the interest in achieving the end goal that the recommender presumably does? Lower cholesterol, lower weight, more muscle mass, stronger bones, having better balance or more stamina, improved sexual function, looking younger, better bowel movements, avoiding a deficiency disease like rickets, scurvy, or pellagra? Sometimes even cheap and easily available things from which big corporations or influencers do not make a lot of money, and that in fact do work well, are also unnecessary. Parents and grandparents may push things that their parents and grandparents told them were good for them, and they might have been, back once, but are not now. Back then, when our diets were often lacking in essential vitamins, scurvy, pellagra, and rickets were real issues in the US (and may still be in some parts of the world), but are not, generally, here now. In the not-too-distant past parents gave their kids castor oil, either as a treatment for a condition that the child might or might not have, like constipation or worms, but there are much better, safer, less unpleasant, and more effective treatments for both now. (That is not considering those who gave it as punishment!)

After you have answered the question of “good for what?” and decided that that “what“ is something you want to achieve or more toward, the next set of questions are “will it do that, does it actually work?”, “does it work for everyone the same or are there some groups of people (based on age, gender, health status, etc.) for whom it works better or not as well, and “what are the untoward effects that may, or even are likely to, happen, which may be far worse than the benefit?” Anabolic steroids, for example, do work to increase muscle mass, endurance, and power (see: sports stars) but also cause serious bad things (liver disease, testicular shrinkage, and a host of others). If it is legal and you are not competing in a sport where it is banned, it is up to you to decide whether the risk:benefit ratio is one you are willing to take (provided you are an adult, since in this area as many others, teens are poor judges of risk:benefit and do not have a good long view). Psyllium seed powders can be good for your bowels, lowering cholesterol, and helping to control your appetite, but some people have problems with the side effects. Testosterone, now being pushed by the Secretary of War who is competing with the Secretary of HHS and the President for being the administrations most macho ignoramus, can be good for some people who are deficient who should not be, but is far from a panacea that turns regular people into mindless Orcs (many medical professionals disagree, Doctors question evidence behind Pentagon testosterone plan). By the way, this is a good time to note the intrinsic contradictions in the “men’s health” movement. Its two big issues are prostate disease (especially cancer) and “low T”. Testosterone will not only make prostate cancer (or even benign prostatic hypertrophy) worse, blocking endogenous testosterone is the mainstay of treatment for prostate cancer. Oh, well, let’s see what it does for Pete Hegseth.

Some things generally are good for you. For example, age-appropriate vaccines are good for almost everyone (except those with known allergies to its components or previous severe reactions, by which I mean things like Guillain-Barre Syndrome, not a sore arm or short-term fever). Virtually all vaccines for children and adults (MMR, DTP, meningococcus, chicken pox, H. flu, influenza, Covid, shingles, polio, etc.) are really wonderful miracles that save thousands (sometimes millions, see: “Covid” and influenza) of lives, even more thousands or millions saved from serious morbidity, and with a very low rate of any significant negative effect. This is true. If you hear different information from your favorite TikTok star or Facebook friend, or Secretary of HHS, they are wrong.

Some things are generally bad for almost everyone, like taking dangerous drugs for unapproved indications (e.g., ivermectin for Covid), not to mention drinking or injecting bleach! The internet is full of recommendations for magic bullets that will cure whatever ails you or doesn’t even ail you but tells you it will or might if you don’t buy their solution. These claims are no more reliable than the clothes, makeup, hardware, and amazing items that will solve all your household worries. That is, some may be of value, for some people, in some circumstances, but often are not and even are dangerous, but all make money for those selling them (or in the modern world, selling their ability to influence others to the companies that make the products).

A big issue, it seems, is whether to take drugs, especially prescription drugs, manufactured by big, evil, pharmaceutical companies and heavily advertised by them, or to take “natural” over-the-counter drugs made by any-old-person or company and pushed by – any-old-person (or bot). Pharmaceutical companies are evil, as are most huge for-profit corporations (and they are usually the most for-profitable!) because their profits, not your health, is their main function. This does not mean that their products (or at least all of them) are not effective or safe when “used as directed”. They have two important characteristics non-prescription, even “natural” remedies, do not. First, they are tested, and approved after an extensive process, by the FDA (or were, before the FDA was decimated by the administration), which other remedies are not. Second, the doses are standardized, so you know what you’re getting. Even when plants (natural) are the basis for the drugs – say willow bark for aspirin – dosing is an issue. How much willow bark? From how old a tree? Growing in what setting? An aspirin tablet is standardized. Taking unregulated medication is akin to taking street opiates – you cannot be sure what, and how much you are getting. Plus, remember “natural” is not intrinsically good, safe, or protective. There are at least as many natural poisons as beneficial substances. If something you ingest, “natural” or manufactured, has a biologic effect that you desire, it also can (and likely does) have biologic effects that you do not desire (“side effects”, a term meaning biologic effects you don’t want). Testing and standardization are keys. Not that this in any way excuses the rapacious profit-taking of Pharma, but neither does it of those selling unregulated nostrums.

Finally, and I have said this before and will say it again, when thinking about whether something is “good for you” and whether you should take it, anything that sounds too good to be true probably is.

If you hear a health claim sounds too good to be true..

We all have things we believe without evidence. We particularly have things we believe without good evidence. I am not even talking about religious beliefs, which are, by definition, acts of faith, but what we can call lay beliefs about the world. One area in which this is both important and widely variable is health and medicine. There is a tremendous amount of information out there, and much of it is correct, and much is not, and sometimes some correct stuff seems, on the surface, to contradict other correct stuff. If that is true, what is a person to do?

One option is to learn about things in detail, understand the scientific method, understand statistics, and understand how “truth” evolves and changes with new discoveries. Or, alternatively, to know that there are people who do know and understand these things, who have spent years and decades learning about them, being trained in the subtleties of science and research, and listen to what they say. For decades, say roughly from WWII, this is how our public health developed. We didn’t just trust scientists, we trusted science. We could see the progression of scientific knowledge, and how it positively impacted ourselves, our communities, and our nation and world.

You don’t have to be a statistician and understand all the intricacies to understand, for example, the basics of probability. When something is more likely than something else, that doesn’t mean it will always happen. When you throw a pair of dice, it is more likely to come up 7 than any other single number (6 of the 36 possibilities – 1 in 6 -- are 7). This does not mean it will always be 7, or usually be 7, or even be 7 a majority of the time, but (given enough throws) it will be 7 more often than any other number. If you understand this, you are on your way to interpreting scientific data. If you don’t, don’t shoot craps.

In medicine, a diagnostic test or treatment that works only 1/6 times is not likely to be used, so the probability that it will give an accurate diagnosis or a successful treatment is going to be much higher. But almost never 100%. 99% is very good; 1% is a small chance, and if you had a 1% chance of getting 7 and crapping out, or getting a wrong answer on a test, you’d go for it. But if something is done a million times, 1% is 10,000. You, or a loved one, could be one of the 10,000 in whom a test is inaccurate, a treatment fails, or even a side effect kills you. That is terrible for you, but doesn’t increase the likelihood of it happening to the next person. If you throw dice, the odds of a certain combination are the same every single time. Even if someone, say, rolls 11 six times in a row it doesn’t change the probability (1/36) of getting an 11 the next time. There is no such thing as “hot dice” or a “hot shooter”. If you don’t understand that, don’t play craps.

Enough of probability now. The main point is that because something bad sometimes happens with a test or treatment doesn’t make it bad. Some of the issues in health that are most controversial now, like vaccines, are phenomenally and overwhelmingly good. Most of the bad things attributed to it are completely made up (not that the bad thing happened to someone, but that it was the result of the vaccine), and the others are very rare, far more rare than the bad things happening to the unvaccinated.

While truth does evolve and change with new discoveries, those changes are usually logical and stepwise. We know about something, and new information increases our knowledge. It rarely completely contradicts everything we know; it theoretically could and there have been some discoveries that did, but if a claim seems to it is very unlikely. It is usually internet spam, promulgated by people who think you are a sucker and may pay them for something that magically solves a problem. If you have a health problem, this is almost never the way to go. Sure, pharmaceutical companies are scum-sucking parasites who would kill their mothers, not to mention you, to make a buck, but that doesn’t mean the medications that they make are bad, ineffective, or more dangerous than what you can buy over the internet because somebody says it works. The FDA (at least historically, before it became decimated) required rigorous testing of medications before they are released to the public, while the miracle cures you see on the internet have not. In addition, the doses are standardized and consistent. You can know what you are getting, and if you cut the dose in half or double it, that is what you are doing. With unregulated drugs, you don’t know.

Yes, there are many natural substances that can help, and indeed many prescription and regulated drugs have their origin in them. But even though aspirin may have originated from willow bark, how much willow bark is the right dose for you? From what age tree? Growing in what conditions? In what season? What about next time? Or your next door neighbor? Or your kids? A good rule of thumb is the old saying: If something seems too good to be true, it probably is. “Magical” cures on the internet never are. Another old saying, attributed to P.T. Barnum, is “a sucker is born every minute”. No one wants to be that sucker, but people are remarkably inconsistent about when they will be judicious and when they will swallow the Kool-Aid whole.

If someone you hate and think is stupid tells you something that sounds ridiculous and unbelievable, you probably won’t believe them. But what if it is a friend? If what they say is something that you already think might be true? Looking things up on the internet (sometimes called “doing your research”) is actually not a bad way to start. You usually find accurate information. This is really different from reading something sent to you or spammed out by bloggers (like me) or “influencers”; if someone is “reaching out” to you, it is basically marketing. Think of the difference between you calling your bank to find something out about your account and getting a call from someone that says that they are your bank!

How does this relate to social justice? Are there not believers and non-believers in data and science in both majority and minority groups, among the young and old, among the rich and the poor, among liberals and conservatives? Sure, but the impact is different among these different groups. Many people are not only acting on their own fringe and unscientific views, but pushing and promulgating them to others. And, as always and as in almost everything, it is the poorest, least empowered, least educated, most marginalized, those with the thinnest safety net, who suffer the most. We may occasionally read of someone who has been hoist on their own petard, refused vaccination and died of the disease, followed a wacko diet or taken unregulated medication who gets ill or dies from it, but when the society or government rejects science in favor of public health policies based on fringe beliefs, it is the least well off who are most often harmed.

Remember, there may be magic in the movies, but there is not real magic in the world. If something sounds to good to be true…