In most professions, the pecking order is clear, even when there’s no formal designation.

Take pro football. Although nothing in the rulebook grants status or authority to certain players, everyone knows the starting quarterback is the most valuable person on the field. That’s because no other player can do more to win (or lose) a game.

You might assume the same type of logic applies to medicine. If saving a life is the most valuable thing a doctor can do, then surely the physicians who save the most lives would garner the most esteem.

That’s not the case.

Instead, the relative rank of specialties is decided by an unwritten and outdated rule — the fourth such rule highlighted in this series, “Breaking The Rules Of Health Care.”

Rule 4: Doctors achieve high status by doing the impossible

Throughout history, desperate patients have come to doctors hoping for a miracle. Physicians responded with incredible acts of healing — at times seeming to possess supernatural powers that defy known science.

Doing the impossible not only elevated the prestige of the medical profession — it has also become the criterion for ranking people within it.

This explains why, for most of the 20th century, primary care (internal medicine) doctors were held in the highest esteem. Their superpower, which set them apart from colleagues, was the ability to unravel medical mysteries.

When cardiologists, pulmonologists or orthopedists couldn’t diagnose an ailment, they turned to primary care for expertise. Time and again, these brilliant diagnosticians did the impossible and, in doing so, held their position atop medicine’s hierarchy.

However, this unwritten rule — the one that enshrined primary care in the 20th century — is the same rule that sent the specialty crashing down in the 21st.

The 20th century ended with an eruption of medical innovation. This period brought about the widespread use of MRIs and CT scanners, along with improvements in the quality of ultrasounds.
These tools digitized diagnosis and radically improved medical practice. But they also turned a renowned skill of primary care doctors into an average and unremarkable ability.

Meanwhile, surgeons and interventional subspecialists had embarked on a period of relentless innovation — boosting their status in medicine by doing what was once thought impossible.

Orthopedists, whose 20th-century job was to reset and cast broken bones, could suddenly replace hip and knee joints with space-age implants. Ophthalmologists, who historically wrote prescriptions for eyeglasses, invented a way to restore the vision of patients with cataracts by removing the opaque lens. And incredibly, interventional cardiologists could now reverse myocardial infarctions bypassing catheters into the heart, unblocking the occluded blood vessels.

These unbelievable advancements flipped the health care hierarchy on its head. Specialists were now seen as heroes, capable of impossible feats, while primary care physicians were demoted in both status and pay. Today, specialists earn two to three times more than internal and family medicine doctors.

The unwritten rule of status makes no sense today

As medicine evolved in modern times, so did the needs of patients. Today, our nation now faces a growing epidemic of chronic diseases (heart disease, diabetes and asthma). These lifelong illnesses account for 7 in 10 American deaths and have caused the relative flatlining of life expectancy over the past two decades.

This deadly health care crisis won’t be solved with surgeries and procedures of ever-greater complexity. It will be solved by doctors who can prevent disease, improve overall health and preserve life.

To make it happen, physicians must first break the outdated rule of status.

Breaking the rule: Achieving high status by saving lives

If status in medicine were determined by saving lives (rather than doing the impossible), primary care physicians would quickly re-ascend the hierarchy.

Consider the results of a study by Harvard and Stanford researchers in 2019. The team found that adding 10 specialists to a population of 100,000 people correlates with an average life-expectancy increase of 19.2 days. But when adding an equal number of primary care physicians, longevity increased by 51.5 days. That’s an increase of 250 percent.

This happens because primary care doctors don’t just treat medical problems as they arise. They also help patients avoid heart attacks, cancer and strokes in the first place.

Primary care’s focus on preventive medicine and chronic-disease management may not inspire awe quite like cutting into the heart or brain, but these approaches can and do save more lives.

Restoring the value of primary care

In any profession, those with power and privilege are slow to cede either. But hierarchical change is possible.

Returning to football, there was a time when offensive linemen were as undervalued as primary care physicians are today.

Sometime in the last century, some smart coaches realized that a skilled left tackle was central to a team’s success. After all, this player’s job is to protect the quarterback’s blindside and prevent a potentially season-ending injury. With this realization, offensive tackles were soon being selected in the first round of the NFL draft. Today, they’re the highest-paid players on offense.

Once the basis for status in medicine shifts to saving lives, primary care will receive the esteem and income it deserves.

How to break the rule

To update the rule of status for the 21st century, health insurers and doctors will need to institute two important changes:

1. Adequately fund primary care

To effectively prevent and battle chronic disease, doctors need more resources. Today, however, only 6 percent of health care spending goes to primary care. Bumping the total to 9 percent (a 50 percent increase) would allow these physicians to hire more support staff, spend more time with each patient and help people manage their chronic illnesses. The resulting improvements in patient health would drive down overall health care costs.

The hard part will be convincing public and private insurers to foot the bill. Payers will demand reliable performance data that tie their financial investment directly to lives and dollars saved. This brings us to the second change.

2. Identify and reward the physicians who save the most lives

Not all primary care doctors achieve the same life-saving outcomes. In fact, some U.S. physicians are 30 percent more effective at preventing deaths from stroke, heart attack or cancer than others.

Because of this gap in outcomes, insurers won’t be willing to increase primary care payments across the board. They’ll want to reward doctors who achieve the best results.

Unfortunately, past attempts at this (via “pay for performance” programs) failed to lower mortality rates. The incentive structure forced doctors to focus on only a few clinical areas — usually the ones with the highest incentives.

A better approach ties incentives to improvements in longevity and overall health.

Artificial intelligence (AI) could help with that. AI apps can analyze tens of thousands of medical journals to identify approaches that most effectively increase life expectancy. It could then compare the performance of physicians against these opportunities.

And instead of rewarding doctors for testing for high blood pressure or enrolling people in diabetes-management programs, AI would assess whether the patient’s blood pressure and blood sugar were normalized.

Over time, AI will develop greater predictive accuracy: tying life-saving approaches to lives saved. As more patients participate — and fewer people develop complications from chronic disease — insurers will see fit to invest more in primary care.

Over time, with better pay and greater recognition, primary care’s status will increase — and so will the life expectancy of all Americans.

Robert Pearl is a plastic surgeon and author of Uncaring: How the Culture of Medicine Kills Doctors and Patients. He can be reached on Twitter @RobertPearlMD. This article originally appeared in Forbes.

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