I simply said what you say below: whether MD/DOs like it or not, medical practices are businesses, and to function in a business-savvy way means you've got to either do lots of procedures or move quickly so you can see a lot of patients. I'm not sure that equates to anything being ingrained; it's just reality.
Which is fine, and the reality we work in, but what I don't think is fair whatsoever is when certain people blame DO/MDs for this, or assert that they like it this way. Furthermore, I find it even worse when certain groups, like the DNPs, use it as a platform to nudge their way into independent practice, which just ends up generating more physician referrals (because these individuals don't handle anything above routine), most cost on the system, more of the same, and less patient safety.
You likely, and rightfully so, think about this more than I do, so I'm inclined to believe you. But I'm not sure I agree completely. Isn't it plausible that as family medicine becomes less and less profitable, it becomes less and less popular among med students, which leaves a void that is getting filled by other provider groups, particularly DNPs? As I said, I haven't thought a lot about this, so I'd be interested to hear your thoughts as to WHY primary care is being encroached upon.
Like I said before, a decline in the popularity of PC fields is 3 fold (in my novice opinion):
1. Payment issues (discussed)
2. Midlevel encroachment (the old dogs in the field can deny this all they want, my generation of peers is aware and concerned about it. Look at Anesthesiology and the CRNA issue if you need any reassurance).
3. A perceived lack of respect in the field - like it or not, it's viewed as uncompetitive, and many, many med students are in this game for the 'respect' associated with the turf.
As far as why midlevels are STARTING in primary care:
It's the easy way to get their foot in the door - med students aren't going into primary care for the reasons listed above (long hours, bad reimbursement compared to other options, undesirable practice models, etc), so NPs/DNPs see this as a way to utilize the talking point 'filling a crucial void in primary care.' People know there is a primary care issue, NPs fund and conduct their own studies proving they are equal to physicians (you want to see some bias and laughable models, check out these sometime), go on a very well greased/militant PR and lobbying campaign, and boom ... they are in. They also know that they can handle a lot of the primary care cases (though the problem is that they'll do fine with the horseys but likely miss the zebras) and the malpractice is reasonable.
However, like I said before, they are only starting here. They are already moving into areas that are more desirable, more profitable, but also carry a similar private practice model where they (believe) they can handle a lot of cases. Dermatology is a prime example. Recently a 'nursing dermatology' residency opened at the university of south florida. Of course it's a joke, but because it's open to DNPs, you now have nurses who introduce themselves as doctors and claim to be certified in dermatology pumping botox in south florida. Definitely filling that crucial gap.
It will also be interesting to see how/if this affects the competitiveness of derm among med students.
Now, a cynic would say that certain DCs who are pushing for more of a primary care role and make statements like 'physicians can't properly counsel patients on nutrition regiments because they don't have our special training' are doing a similar thing. However, it's well established that I'm not a cynic.
I don't have any reason to believe that the MD/DOs I know 'bend over' for big pharma. What I'm saying is big pharma exerts it's influence further up the chain, at the policy-making level. Big Pharma also exerts its influence over what research gets funded and which doesn't; more research, more published findings, more on-the-minds of MD/DOs. By the same token, no research, no credibility, no wide acceptance among MD/DOs.
If it's any consolation, we took a big class my first quarter of medical school called 'evidence based medicine' that essentially taught us how to properly view, review, and utilize studies. One big section of the course was identifying and interpreting bias in the study. From what I've seen, many of the publications in reputable journals either don't suffer from this fate as much (though I suppose you could argue that the chain goes up further than any of us can comprehend), or admit the bias outright. Since this was taught in the first quarter of school, I can only assume I'll receive more training in this as time goes on and learn to spot and interpret this bias and make sure it isn't affecting the way I treat patients.
Your example patient is what I'm talking about. I'd much rather see our healthcare system keep that guy from becoming the 300 lb diabetic in the first place. It's a complex issue, obviously, and doesn't solely fall on the shoulders of any individual physician. There are many factors, such as socioeconomics, the food industry, etc.
Not to play devil's advocate too much, but my point was that it's going to essentially take an entire cultural shift to make this occur. Frankly, this kid was probably given coca-cola and feed hamburgers 3 nights a week as a kid while his dad smoked unfiltered ciggies in front of the TV. Docs can hark about it all they want, but this guy naturally grew into what he was, and I think this type of intervention may be outside the realm of the health service industry.
Granted, I really, really do believe in preventive measures, but I don't even know how possible it will be for our health service industry to switch from reactionary to preventive without our society as a whole (within the realm of generations) switching to wellness. Furthermore, this is probably outside of any physician, DC, nurse's control.
These are things I've picked up along the way over 2 decades in healthcare and as a thinking human being. I have no hospital experience, to answer your question. And it's funny to see you bring up 'conspiracy theories' because I had written something about that in my last post but deleted it; the 'conspiracy' thing usually comes up eventually in these discussions.
(Level-headed discussions like this are always more productive in my view.)
I was more curious than anything else. Many times I just hear the same incorrect statements regarding hospitals, studies, bias, etc repeated on this site, and I wanted to see where you were getting your info. I didn't mean any disrespect by it, just wanted to make sure you weren't reading articles in homeopathic monthly about the evil MD playing 18 holes of gold in the Caribbean with the hot pharm rep, because from my very limited experience, this just isn't the case (note: exaggerated to make myself clear).
