Primary Neglect

Considerable media attention has been given in recent times to the dearth of primary care physicians in our country, by comparison with a relative oversupply of specialists. The plethora of high-priced specialists is just one factor among many that is given for our financially troubled health care system. In a recent New York Times article, one of the commentators, a medical student, revealed one of the obstacles to primary care from the perspective of the medical student. Trained in academic institutions, medical students' mentors are academicians who tend to place a premium on the highly unusual cases - so called "fascinomas" and have little interest in the quotidian tasks of the primary care physician -- runny noses, sore throats, and garden variety aches and pains. Primary care is accorded a low prestige value, whereas more arcane and specialized subject matter is accorded high prestige. Indeed, one of my colleagues, a pediatrician, reported that about 90% of his pediatric residency group went on to subspecialize and only about 10% went directly into primary care.

The fact that primary care does have a lot of paperwork, phone calls, and commonplace acute treatments alongside indolent, incurable chronic illness, all accomplished at a lower pay rate per hour does not help. Overall, the outlook for primary care does not seem very bright, even though health care reform is going to create the need for even more primary care physicians in the imminent future.

I was discussing this state of affairs with two of my colleagues, co-bloggers Dr. John McGonigle and Ann McKay, RN and we were addressing the fact that with homeopathy in your treatment armamentarium, primary care can actually be remarkably exciting and intellectually as well as morally satisfying. Even a case of athlete's foot, as I was saying to Dr. McGonigle, could be fascinating, if there were some unusual aspects to the case. I found myself wishing that more medical students could be awakened to the exciting possibilities that were available in primary care. Yet, on later reflection, I could see several serious obstacles to homeopathy being introduced into primary care or into the medical world in general.

Homeopaths tend to have trouble restraining their enthusiasm for their field, because we all find it immeasurably and unfailingly fascinating, but in our enthusiasm, we sometimes overestimate the receptivity of our audience. In fact, although it does not seem to daunt many of us, homeopaths are used to being responded to with blank stares as they wax lyrical about their beloved profession. But for all of its charm homeopathy has many weakness as a for-sale item to the medical establishment. Here are some of them:

1. It is hard to learn. It take a lot of time, money, and commitment to become even moderately competent. Many people are unwilling or unable to spend the time or money to pursue any goal, no matter how lofty, or how important to them. It's just too difficult.

2. It lacks face validity. Unfortunately, it takes a lot to overcome the bad reputation that the mudslingers have succeeded in establishing for homeopathy, and the fact that we deal with infinitesimal dosages makes us unpalatable to many and indigestible to most.

3. It requires a great deal of thinking. In these days where we are all trying to make a quick buck, taking a long time with your patients and exercising one's brainpower to the max is not a popular pastime, notwithstanding idealistic medical students' proclaimed desire for interesting work. In medical school, one learns a simple aphorism that epitomizes medicine's relationship to cogitation: "See one, do one, teach one." This self-congratulatory shibboleth might well be translated: "I'm so smart, I don't even need to think to be smarter than you, and I certainly will act as if I'm that smart, even if I'm not." With this kind of hauteur, who wants to struggle to find a simillimum?

4. Many medically oriented professionals are science-oriented in their professional ethos and attitude. Homeopathy, for all of it's empiricism, is better suited to those who are willing to think less geometrically and linearly. Homeopaths need to embrace poetic approaches to understanding reality, and must be able to appreciate and value communicated rather than numerical understandings of human suffering. This weltanschauung simply is a poor match for the average biochem major who wants to pursue the highest heights the techno-medical world has to offer.

I continue to try to promulgate homeopathy, because it is such a wonderful gift to the world, but I can't help wondering about the folly of my efforts from time to time. It simply is too hard to let such a precious gem go unappreciated, I suppose.