Primary care physicians and specialists each play an important role in keeping older adults healthy as they age, but choosing which doctor to visit first can be confusing. On this episode, learn more about the ways generalists and specialists differ in training and expertise, the value of seeing a nurse practitioner, and how to decide if a geriatrician might be right for you.
Primary care physicians and specialists each play an important role in keeping older adults healthy as they age, but choosing which doctor to visit first can be confusing. On this episode, learn more about the ways generalists and specialists differ in training and expertise, the value of seeing a nurse practitioner, and how to decide if a geriatrician might be right for you.
Welcome to the Healthy Aging Podcast from Clover Health. I'm Jason Alderman. I'm here with Dr. Kumar Dharmarajan. Kumar is our Chief Scientific Officer. Kumar, welcome back. Let's talk about primary care doctors versus specialists. Thinking about my parents, should I see my s pecialists all the time for everything I do? When should I know to go to a specialist versus a primary care physician? It seems like we as patients these days are very empowered just to call up a specialist directly and make our own appointment, maybe we tell our doctor o ur primary care doctor or not, how do I know when I should go to a specialist?
Kumar:That's a great question, and I think that's why primary care doctors exist, right? That's one major reason they exist. So if you're a patient, many patients, especially when you are older, you have multiple specialists, right? Four, six, eight...and the issue with specialists, specialists provide great care in their area, but they may not always be thinking about you as an integrated whole in the way that primary care providers are trained to do. And so what I would say is, you really should let that decision fall to your primary care providers unless you absolutely know that you need to see a specialist first, that's part of your PCPs job. There are many things a PCP can provide help with that you don't need a specialist for, whether it's managing chronic conditions, helping you get access to various tests, giving you advice on medications, giving you advice on your diet, exercise, all those things. And really, I think, primary care doctors, they think about the whole patient and sometimes that whole is more important than seeing someone who's more focused on a very specific problem.
Jason:To that end, do we overuse specialists in the United States? Do we pull the specialist trigger when we really can be seen for the same issue by a primary care physician?
Kumar:I think we probably over and underuse specialists. That's a complicated answer. I think there are many cases where a primary care doc can really just handle the issue at hand. So let's give an example. Let's say you have diabetes. You know there are folks with diabetes that's really simple to manage. They might not even need to be on medications, it's about lifestyle or it's about being on one medicine or maybe even two medicines. And then there are folks with diabetes who are on three medicines and complicated insulin regimens and injectable drugs where it's still hard to manage their diabetes. So that former patient should be just fine with a primary care doctor. And the reason is, you know, that doctor can manage it and that doctor knows the other parts of you in ways that the specialist may or may not. And so it's really important to have your care as part of that integrated approach. But on the, you know, the latter side, that really complicated diabetic, you might need an endocrinologist who spends all day thinking about diabetes to get your blood sugars under control. And so I think there are cases where we go to specialists where we don't need to, and I think there are cases where specialists should get involved because it's the best thing for your health.
Jason:But again, go to your primary care physician, let him or her be the one that says, you know what, this is getting complicated. We should send you to a specialist.
Kumar:I think that makes sense. But it also makes sense to be your own advocate. And I think a primary care doctor or any doctor may not always have the right next step in mind 100% of the time. And that's why we're advocates. They may not exactly know what's on your mind, the questions you have, like should I see a specialist? And so as an advocate, if you're concerned that, for example, your diabetes should be managed by a specialist, I think you bring up that conversation with your PCP and say, you know,"Hey, doctor so-and-so, for my diabetes, I've been taking these medicines, we've been working together, but my blood sugar just doesn't seem to get under control. Would it make sense for me to see an endocrinologist or a diabetes specialist who could really work with me?" And I think that providers will give you honest feedback if you really want to see a specialist and that's not working. I think, yeah, go ahead.
Jason:Can there be ever a point of pride either either consciously or unconsciously among the primary care physician where they are reluctant to refer you to a specialist because they think they can tackle this themselves even though that, you know, maybe the, the blood sugar levels have not not come down, but they feel like they still have some tools in their tool bag to try. Does that ever that point of pride ever come into this?
Kumar:Hopefully it shouldn't happen. Anything could happen, but I would like to think most doctors have, or pretty much all doctors have their patient's best interests at heart. And I think that's where actually being an advocate is important, which is have that conversation. Don't necessarily bring it up-- hey, I think you're being too prideful, but you know, this is what we've tried so far and based on the feedback I'm getting from you and my blood test results, how I'm feeling, whatever the right thing is, you know, I'm not sure that it's working. And I think having that discussion is very helpful.
Jason:A question I've always wondered, which is how do, cause I've been referred to many specialists in my time from my primary care provider, is how do primary care providers get their roster of specialists to refer people to like what, how do they know that? Oh yeah, you should go see Dr. Smith. You know, she's terrific for this problem. How can they build up that roster?
Kumar:I think it depends. So if you're a primary care doctor as part of a large multispecialty group, so a multispecialty group is a group of physicians and other providers that includes primary care plus additional specialists. So the large group may include cardiologists and pulmonologists and nephrologists and pick their-ologists. In many cases a PCP or primary care doctor will refer within the group because they know those people. They're probably all on the same EHR and in many cases that makes sense. You know, for a solo provider, you know, I think they build relationships over time frankly. Right? Which is they get to know people, colleagues of theirs, you know, they talk to their friend, who do you refer to? And I think over time people build a data set is, you know, which specialists seem to provide really great care, which specialists was really responsive to me. So I sent my patient to see you, I want to hear back from you, what did you think? What are you doing about my patient? How are you helping my patient? And so there's that real relationship component to it, like anything in life, and I would say medicine is no different.
Jason:That's helpful. I always wondered where those names came from. I have read, there's been a chronic shortage of primary care physicians and I often hear about in the context of really urban settings or very rural settings, there just aren't enough doctors to go around, primary care doctors, and one of the things I believe I heard was that it's because when people go to medical school, they want to be specialists, they don't want to be a primary care physician. Is this, is this a real issue?
Kumar:Yeah, I think there's truth to that. A couple of things. So one, I don't know, if people always going to medical school wants to be a specialist and not a PCP. Some that might be true for sure, but I think there's a real issue of medical debt, which is that PCPs in general are paid less than specialists. That's just how our healthcare system seems to value services, right? So, you might spend a long time with a patient as a PCP in your office, but if you're a specialist who does a procedure, you're just paid much more on a per minute basis. And I think that creates part of the challenge of PCP visits being so short because the payment is lower, you know, folks have to see more patients in the same amount of time. And this is just to be clear, a very U.S. Phenomenon. There are other countries in the world where that discrepancy is not there. For example, I know primary care provider, a GP as it's called in London and she came to the US and she was shocked about the income differences between the different fields and you know, the regard by which, you know, different types of doctors were held. And so coming back to the debt issue, when a lot of people graduate medical school, it's significant. So if you, paid for college and med school, you might be in debt$250,000. Right? And that can be crippling for many people. And so people are going to gravitate towards fields that frankly pay more. Uh, I think that's a reality. And so
Jason:They go with the best of intentions. They want to, you know, they want to be a pediatrician, but they see how much money they owe, they see what we're getting ready to go out into the real world. And then you can make a lot more, more money if they start specializing in some area that pays more. And so they change just because of the economics of it.
Kumar:I think it's a powerful force that you just can't ignore. But I'm not trying to oversimplify. Some people do go to school and they love the eye and so they want to be an ophthalmologist or you know, they had an unfortunate health experience in their family-- let's say someone had cancer and passed away, let's say a loved one, a parent and they say, no, I want to be an oncologist because I've been through that, and those are the people I want to help. I think everyone goes in with the best of intentions, but financial realities are actual realities.
Jason:So do you, do you see it in your yourself that do you think either either as a doctor or here at Clover health, it's still hard to get enough primary care physicians to go around? Is that still a concern?
Kumar:I think we could always use great primary care physicians. Patients could use it, you know, Clover could use it and our health system, because there's really strong data out there showing that where there's more primary care physicians on a per capita basis, parts of the United States, overall health seems to be better. I think primary care that serves a very useful role in the health system in that they are really that home that integrates care across specialists. Um, that is the first point of contact in many cases and really think about the patient in a holistic way. And it's not that specialist can't or don't do that, but a specialist has additional training that's very intentional to focus on a specific part of the body or a specific disease. I think the linkages and the integration that good primary care provides is indispensable.
Jason:I mostly see primary care providers, but you know, who I normally see is I get a nurse practitioner, I go into my doctor's office and there's a doctor there, but the vast majority of the time I, for my regular stuff, I see a nurse practitioner. Quality care seems good, maybe in some ways even better. Um, uh, is that a problem? Should I be seeing a doctor? Is it, is it better to have a doctor versus a physician's assistant versus a nurse practitioner? From a practical standpoint, what's the difference?
Kumar:No hard and fast rule. I know some great NPs and physician assistants that I'd rather see you than other physicians. And I also know some great physicians. So there's no one rule. At the end of the day, the main difference between a nurse practitioner, a physician assistant and a physician is length of training. The physician has gone through more years of school and other forms of medical education. So in theory, can handle additional medical complexity because they've just gotten more training for it. So for a patient with, you know, 10 medical problems and you know, 15 medications, in some cases they may be better served with someone with additional training. But in other cases it doesn't matter. And so most doctor's offices now, or many, are set up where the physicians might see a certain percentage of the folks who could potentially benefit from that additional training. And so NPs can be great, PAs can be great and these can be great. And so no hard and fast rule.
Jason:So I shouldn't feel like I'm getting pawned off on a lesser person if I'm seeing an NP. This isn't about me getting a lower quality of care.
Kumar:Absolutely not. And I find sometimes there's personally, sometimes NPs and PAs, they've actually had more diverse health experiences than a physician has, so many NPS, to become an NP as an example, you first have to become a nurse. Some of them are RNs first, they do additional education to get the NP and for example, many nurses have experience in the hospital, the ICU, in the clinics; some of them have worked with visiting nurses that do home care, they have had experience in nursing homes, hospice, all of these experiences and in many cases those diverse experiences I think make them excellent providers for various roles like house calls program. They've just been used to do many years of home visits and they're, for example, not many physicians who've been used to doing that for many, many years. And so I think sometimes an NP or PA can be better suited for a role than a physician.
Jason:So then thinking about a senior, which is who we focus on at Clover Health, what's the best kind of primary care provider for them? Should, you know, geriatrician, an internist? How if I'm, I'm looking for a new primary care provider for my, if I'm a senior or if I'm trying to help my parents, what's the right kind of provider?
Kumar:Again, I'm going to push back on the right and wrong, and best or worst. There's some excellent internist, family medicine docs and geriatricians which care for older adults, middle age adults and young adults. I think what a geriatrician offers at the end of the day is they've had additional training. They've had formal training in many cases in how to care for older adults. So they pay attention to common issues that older adults face, that may not get sufficient attention from other providers who see the full spectrum of patients. Things like urinary incontinence, falls, cognitive impairment, dementia, and they're also trained to minimize medications. So it's no secret that many older adults on too many medicines or on a wrong combination of medicines and geriatricians through their training are really supposed to be paying attention to the meds and removing unnecessary meds or reducing the dose when such high doses are unnecessary or changing meds. Because most geriatricians want to focus on nonmedical solutions to things like exercise or physical therapy as an example, rather than a medication. So I think in terms of your first question, which is when is a geriatrician the right choice? So for me it's, you know, when someone has more advanced illness, when the goal is not really curing someone of a disease, but it's maximizing mobility, maximizing functioning, are they able to live independently and take care of themselves rather than like extending life expectancy to the greatest extent, I think geriatricians are well attuned to those topics.