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Lost in a System Where Doctors Don't Want to Listen

Society has come up with a partial solution to the growing gap in primary care providers: "physician extenders." These master's level health-care professionals are trained to deal with commonly occurring, easy-to-diagnose problems: a flu, hay fever, a splinter, even severe chest pain. Usually, however, they haven't had enough training to give them the know-how to sort through a complex medical history to arrive at a diagnosis that isn't immediately evident. When they're stuck, they have to call the physician, and by then, the 30-minute visit is very often over. The patient is left hanging and disappointed -- on his or her own to figure out what to do next. The inevitable result: patients falling between the cracks of classical medicine.

There's one silver lining in this situation: the increasing number of women choosing medicine as a profession. Approximately 50 percent of most medical schools' entering classes today are women. This trend may work to offset a major patient complaint -- that doctors don't spend enough time listening to them. Research studies show that women in general and women physicians in particular are better listeners than men. Since the turn toward more women in medicine is relatively recent, I'm not sure which path the young female doctor will choose, but I can say anecdotally that quite a few of my own female students seem to be choosing primary care -- either family or internal medicine. I hope that in the next few years, their presence may help offset the dearth of U.S.-trained doctors in primary care.

Meanwhile, what are patients with an elusive diagnosis to do? If they're fortunate enough to live near a medical school, they can search the doctor list for generalists. Physicians in academic centers are encouraged to see patients as part of their duties, and they often have more time than their colleagues in the community. More important, patients can help themselves by knowing more about their bodies, how they work and what can go wrong with them.

But finally, patients will have to understand that finding a doctor who has the time to listen, diagnose correctly and then know how to treat them is going to get harder and harder. Reversing the trend away from patient-oriented and toward procedure-oriented medicine will require attention by legislators as well as medical educators. Reducing the debt of newly minted doctors who choose primary care might be one way of doing this. Cutting back on both the number of postgraduate training positions in procedural medicine and the salary paid such trainees, while raising the salaries of those in primary care, could be another.

None of this will happen, though, unless patients make their voices heard. Otherwise, they may just find themselves on their own the next time puzzling symptoms arise.

Benjamin H. Natelson is director of the Pain and Fatigue Study Center at Beth Israel Medical Center in Manhattan and author of "Your Symptoms Are Real: What to Do When Your Doctor Says Nothing Is Wrong."

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