FM vs mid level provider?

[drtongue_danger]

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I am a MS2 wanting to do FM, but many of my classmates and teachers say FM will be replaced by PA and NP. Any info on this, is there any thing other than state law that would prevent this from happening? these people say that a PA or NP with 5+ year experance are as good as a FM

 

[deleted87716]

First of all, this isn't the place to discuss mid-level issues. SDN has another forum for that.

That being said, mid-levels, regardless of their experience, will never be qualified or able to do anything but a subset of a physician's job, in primary care or anywhere else. They're simply not equivalent.

'Nuff said.

 

[erichaj]

With that kind of logic, I can say that any specialist can be replaced by a PA given the right number of years of experience.

GI docs do scopes all day. Well, It's a mechanical procedure, once you do enough of them you get real good. So the PA can do this an get just as good as the GI doc.

I've said it before and I'll say it again, It's not the procedures or the specialty.
It's what we as physicians allow and have allowed to give up and lose.

Quality of care will decrease.

To be fair to a NP or PA, if they have been injectiong joints for the past 5 years in the orthopedic office, they are most likely going to be better that the surgeon. That does not mean that overall they are a well rounded physician.

FP is about being well rounded.

With that said, I can't help but wonder if any other specialist think this way. Most likely not. This would place FP at risk.

 

[deleted87716]

With that kind of logic, I can say that any specialist can be replaced by a PA given the right number of years of experience.

More experience just makes you a better PA; it doesn't make you a doctor.

Anyone can follow a recipe, but that doesn't make them a chef.

 

[Mr. McDuck]

My attending said something to me today that wasn't about PAs, but it fits this discussion. I'm actually a PA right now, but I just applied to med school, so he's been treating me like that more recently. Well, while we were closing up a lap chole, I mentioned that I felt comfortable with the procedure. He told me that he had no doubt that I could do several surgeries on my own.

Anyone can learn to do a procedure with enough practice--learning how to decide what to do when something goes wrong and making clinical decisions takes years of schooling and training, something a PA or NP just doesn't have. That's why they can never fully replace physicians.

 

[erichaj]

This is for the past 2 posts.

My post was trying to (I may have fialed at this) show that procedures are just a part of the medical picture.

One problem I see is that if the lay person goes to the doctor and something is not done to them or a medication is not given to them, they feel like nothing was done. (the insurance comanies seem to see things the same way).

So, we have all heard the saying "oh, you JUST an FP or Generalist".

I went to medical school to be JUST that. lol

I JUST spent 10 + years to get an education.

This does not happen in most other countries. I remember a friend of mine from europe who told me that general docs did most of the procedures there.

In fact there was a study that came out in JAMA (I think it was in 2002) that demonstrated countries with a strong FP presense had much better outcomes in treatment. It also showed that preventive care and maintenance of chronic disease was much better when the FP managed their care.

In the US we are doing things backwards. Too many specialist and not enough FPs.

If we did the right way, there would not be this issue of money or NP/PA taking over. Most FP's would have plenty of time to see their patients because they would be doing procedures that would make up for seeing less patients.

The specialist would be used as a tool to help the patient stay on track or tough cases and cases where a specialist is really needed.

I can say with confidence that the majority of FPs can learn to do joint injections under fluro, or colonoscopies, c-section, Lap colys, Tonsils, egds,
etc.

I can say this becasue we are already doing them and have been for years.

There needs to be more fellowship programs for FP's so that they can SUB-specialize. This way you can tailer your practice.

OK, I'm going to get of my soap box now.😀

 

[Mr. McDuck]

Where are family docs doing lap choles? People say this, but I've never seen it or gotten a straight answer as to where this happens (i.e., middle of nowhere--way to be completely ambiguous).

And, like I said, I think anyone can learn to do a procedure. But, if you aren't training in that field for a while, you aren't going to have the kind of knowledge base to think and act when things don't go as planned. No offense, but I wouldn't want a family doc taking out my gallbladder.

But, I think you may have gotten the wrong impression from my post. I don't have any disrespect for any specialty--especially family medicine. I was just responding to PAs and NPs taking over.

 

[erichaj]

Where are family docs doing lap choles? People say this, but I've never seen it or gotten a straight answer as to where this happens (i.e., middle of nowhere--way to be completely ambiguous).

And, like I said, I think anyone can learn to do a procedure. But, if you aren't training in that field for a while, you aren't going to have the kind of knowledge base to think and act when things don't go as planned. No offense, but I wouldn't want a family doc taking out my gallbladder.

But, I think you may have gotten the wrong impression from my post. I don't have any disrespect for any specialty--especially family medicine. I was just responding to PAs and NPs taking over.

I think there are three reasons why you would not want a family doctor taking out your gallbladder.

1. You can't find one.
2. You are still brainwashed (i mean that in good terms) by the specialty craze.
2. You don't have enough knowledge of medicine.

Anyone who is trained in doing a lap coly, is also trained in the complications. All surgeons have backups.

FP's use to do all of these procedures and still do in rural areas. They use to do open cholys.

What you need to understand is that the politics of medicine gets in the way quite often.

I did not think that you meant any disrespect.

 

[MacGyver]

First of all, this isn't the place to discuss mid-level issues. SDN has another forum for that.

That being said, mid-levels, regardless of their experience, will never be qualified or able to do anything but a subset of a physician's job, in primary care or anywhere else. They're simply not equivalent.

'Nuff said.

I dont think its that clear cut. I'm doing an FP rotation in a place that has attendings, residents, PAs, and NPs. The attendings patients are the same level of complexity as the PA/NP, and there is no immediate oversight, no cosigning scripts, nothing but a chart review several months AFTER the patient has left. Its a total joke. The residents have WAY more oversight than the PA/NPs do. After each patient they have to give a quick presentation to a preceptor attending.

 

[erichaj]

I dont think its that clear cut. I'm doing an FP rotation in a place that has attendings, residents, PAs, and NPs. The attendings patients are the same level of complexity as the PA/NP, and there is no immediate oversight, no cosigning scripts, nothing but a chart review several months AFTER the patient has left. Its a total joke. The residents have WAY more oversight than the PA/NPs do. After each patient they have to give a quick presentation to a preceptor attending.

It is a joke. FPs gave up the alot when they chose to bring in PAs an NPs to make more money.

In a specialty practice such as say orthopedic surgery, The surgeon is the only one doing surgery. The PA or NP does rounds and visits with patients in the cilinic post op or sometimes even pre-op.
In other words they don't do the physicians job, they Assist in in it.. Like the name says.

However, in a primary care office, the PA and the NP visit with patient in the clinic and do the same things (I don't care how many people say this is not true or they may cook but can't be chefs or whatever) as the physician does. They see patients and evaluate and treat. The complexity is the same.

I think everyone can see where the problem is. PAs came to be because surgeons wanted to do more surgery. so they needed someone to reduce their time spent in the office or rounds.

When primary care saw this they thought they could increase their income by using PAs to see more cases. They thought they could give them the simple cases.

Over the years, like all good lobyist, the PA lobyist have done their job and now they have more priviledges. All of this is also true for NP.

So, FPs have cornered themselves out of the market. The insurance companies know this. They have no real incentive to change anything.

I've heard all the things people say about PA, NP etc. They are not as good, the quality of medicine will go down, etc etc. I agree. however, the reality is that we let them in.

 

[deleted6669]

" Ithink everyone can see where the problem is. PAs came to be because surgeons wanted to do more surgery. so they needed someone to reduce their time spent in the office or rounds.
When primary care saw this they thought they could increase their income by using PAs to see more cases. They thought they could give them the simple cases. "


Actually pa's started in primary care. surgery was later. see the pa hx site at duke www.pahx.org for the timeline of actual events.

 

[erichaj]

But overall, I think we need to get rid of primary care PA and NP.

That may not make many people happy. But they are not qualified to practice at the physician level. Right?

 

[deleted6669]

no, I am not restating what you said. you said pa's started in surgery and spread to primary care due to increased usage by surgeons. actually the polar opposite is true. pa's started in primary care and when surgeons saw how efficient they are and how much money they can save a primary care practice they began incorporating them into surgical care.
yes, most physicians know more than most pa/np folks. no one is debating that. the fact of the matter is that 90% of outpatient primary care can be done safely by midlevels. this has been proven in numerous studies. for the remaining 10% the pa/np consults with a doc for guidance. you may not like it but even the aafp in their new vision of fp for the future talks about the role of the fp doc as the leader of a team who oversees the work of others.
midlevels are not "taking over primary care." new md grads are migrating to specialties and abandoning primary care. midlevels are filling the void because the jobs are still there. if 50% of medschool grads matched to fp/peds/im/ob do you think there would be such a huge demand for midlevels in primary care?
don't think I am anti-md model, I'm not. if I go back to medschool(still a possibility) I will probably do fp, but I will do full scope fp with ob/procedures/inpatient rounds, etc not the practice style of many outpt only fp md's who do exactly what a midlevel does(refer out most specialty stuff).

in your spare time check out the following articles, many written by physicians:
# "Physician utilization of non-physician practitioners" by Gregory D. Wozniak. Socioeconomic Characteristics of Medical Practice, 1995. Published by the American Medical Association, Center for Health Policy Research

# "PAs/NPs: Forging effective partnerships in managed care systems" by Stephen Crane. Physician Executive Magazine, October 1995, Vol. 21, Issue 10

# Physician Assistants in the Health Workforce 1994. Final report of the Advisory Group on Physician Assistants and the Workforce Subcommittee to the Council on Graduate Medical Education. Published by the Health Resources and Services Administration, Bureau of Health Professions

# National Health Care Reform Policy Preferences and Differential Attitudes of Rural and Urban Americans. Poll conducted by the Gallup Organization for the Rural Policy Research Institute. June 1994

# "Roles of physician assistants and nurse practitioners in a managed care organization" by Roderick Hooker. The Roles of Physician Assistants and Nurse Practitioners in Primary Care. Published by the Association of Academic Health Centers, 1993

# "Why patients love physician extenders." Medical Economics magazine, August 21, 1995

additional References
Hooker RS, Cawley JF. Physician assistants in US medicine. New York: Churchill Livingston, 1997.

Stationery Office. The NHS plan: a plan for investment, a plan for reform. London: Stationery Office, 2000.
Royal College of Physicians. Skill mix and the hospital doctor; new roles for the health care workforce. London: RCP, 2001. (Working party report.) www.rcplondon.ac.uk/pubs/wp_skillmix_summary.htm (accessed 14 Aug 2002).
Schneller ES. The physician: innovation in the medical division of labor. Lexington: Lexington Books, 1978:18.
Hooker RS, Potts R, Ray W. Patient satisfaction: comparing physician assistants, nurse practitioners and physicians. Permanente Journal 1997; 1: 38-42.
Counselman FL, Graffeo CA, Hill JT. Patient satisfaction with physician assistants (PAs) in an ED fast track. Am J Emerg Med 2000; 18: 661-665.
Miller W, Riehl E, Napier M, Barber K, Dabideen H. Use of physician assistants as surgery/trauma house staff at an American College of Surgeons-verified level II trauma center. J Trauma 1998; 44: 372-376.
Hooker RS, McCaig LF. Emergency department uses of physician assistants and nurse practitioners: a national survey. Am J Emerg Med 1996; 14: 245-249.
Ruby EB, Davidson LJ, Daly B, Clochesy JM, Sereika S, Baldisseri M, et al. Care activities and outcomes of patients cared for by acute care nurse practitioners, physician assistants, and resident physicians: a comparison. Am J Crit Care 1998; 7: 267-281.
Oliver DR, Conboy JE, Donahue WH, Daniels MA, McKelvey PA. Patients' satisfaction with physician assistant services. Physician Assist 1986; 10(7): 51-54, 57-60.
Cawley JF, Rohrs FC, Hooker RS. Physician assistants and malpractice risk: findings from the national practitioner data bank. Fed Bull 1999; 85: 242-246.
Hooker RS, McCaig LF. Use of physician assistants and nurse practitioners in primary care, 1995-1999. Health Aff (Millwood) 2000; 20: 231-238.
American Academy of Physician Assistants. Into the future: physician assistants look to the 21st century. Developed for the Department of Health and Human Services, Health Resources and Services Administration, Bureau of Health Professions. April 1999. (accessed 14 Aug 2002.)
Cooper RA, Laud P, Dietrich CL. Current and projected workforce of nonphysician clinicians. JAMA 1998; 280: 788-794.
Cooper RA, Henderson T, Dietrich CL. The roles of nonphysician clinicians as autonomous providers of patient care. JAMA 1998; 280: 795-802.
Cawley JF, Jones PE. Nonphysician clinicians in the health workforce. JAMA 1999; 281: 509-510.
Cawley JF. Nonphysician supply and requirements in the health workforce: personnel and policy. N Y Health Sci J 1998; 2: 117-127.
Jones PE, Cawley JF. Physician assistants and health system reform: clinical capabilities, practice activities, and potential roles. JAMA 1994; 271: 1266-1272.
Hooker RS. Cost-benefit analysis of physician assistants [thesis]. In: Portland: Portland State University, 1999.
Pew Health Professions Commission and the Center for the Health Professions. Charting a course for the 21st century: physician assistants and managed care. San Francisco: Centre for the Health Professions, University of California at San Francisco, 1998.

 

[erichaj]

Just so there is not confusion:

1. The reason med school grads are going into specialties is because the money is not in fp and that is the reason there is an opening for midlevels to get into this.

2. Primary care did indeed screw up in a major way when they brought in PAs and NPs. The new primary care docs are now paying for this.

3. In my opinion, regardless of all the studies or the aafp (which I feel is a joke anyway) I STILL FEEL THAT THERE IS NO PLACE FOR MIDLEVELS IN A PRIMARY CARE SETTING. If I can do what they do, then I don't need them.

In short get out of my wallet and if you want to play doctor go to medical school.

 

[deleted6669]

3. If I can do what they do, then I don't need them.

I have a # of friends who are midlevels who feel the same way. they opened up their own clinics and compete directly with md practices by being open more hours, doing more minor procedures and charging less for the same services. they refer out as needed to the same specialists who take md pts. they hire a token physician to review charts who never sees pts or delivers any care.......let's see which model works in 10 years......last I checked my friends were each making 150k after expenses working 2 twelve hr days/week and taking no call, doing no ob, and seeing no inpts.

 

[erichaj]

3. If I can do what they do, then I don't need them.

I have a # of friends who are midlevels who feel the same way. they opened up their own clinics and compete directly with md practices by being open more hours, doing more minor procedures and charging less for the same services. they refer out as needed to the same specialists who take md pts. they hire a token physician to review charts who never sees pts or delivers any care.......let's see which model works in 10 years......last I checked my friends were each making 150k after expenses working 2 twelve hr days/week and taking no call, doing no ob, and seeing no inpts.

Interesting, How can you have more hours, charge less and only work 24 hrs per week. the math does not work. even if you did minor procedures.

If you are refering to the clinics that are opening in the surpermarkets. they will work.

All I said is that we should have never let you in, in the first place.

No more wanna be docs. lol

 

[deleted6669]

Interesting, How can you have more hours, charge less and only work 24 hrs per week. the math does not work. even if you did minor procedures.

If you are refering to the clinics that are opening in the surpermarkets. they will work.

All I said is that we should have never let you in, in the first place.

No more wanna be docs. lol

3 pa's in the group. each works 24 hrs/week. closed 1 day/week. 12 x 6= 72 hrs of availability for pts/week. they are open 8a-8p. pts like being able to see a provider after work at 7 pm when all the md practices in town are closed and they get a recording that says "go to the er." they do fp, urgent care, occupational medicine, routine gyn(no ob), cosmetic procedures, etc
they have an on site lab and an xray machine.
this is not a "supermarket practice". they are the busiest fp practice in a town with several other md practices.

 

[deleted87716]

In short get out of my wallet and if you want to play doctor go to medical school.

No more wanna be docs. lol

Debate is fine, controversial or differing opinions are fine; but let's try not to get personal, OK?

Back to your corners. No hitting below the belt.

*DING!* 😉

 

[erichaj]

3 pa's in the group. each works 24 hrs/week. closed 1 day/week. 12 x 6= 72 hrs of availability for pts/week. they are open 8a-8p. pts like being able to see a provider after work at 7 pm when all the md practices in town are closed and they get a recording that says "go to the er." they do fp, urgent care, occupational medicine, routine gyn(no ob), cosmetic procedures, etc
they have an on site lab and an xray machine.
this is not a "supermarket practice". they are the busiest fp practice in a town with several other md practices.

Do You know what will happen in ten years?

The FPs will figure this out way before then, and will do the same.

Except, they will put in LARGE PRINT.

"WOULDNT YOU RATHER BE SEEN BY A REAL DOCTOR THAT HIS ASSISTANT"

When the public realizes that they have that CHOICE, they pick the best one. The real doctor. It's a no brainer.

By the way, I did not argue with you about the Practice model of care. I argue about who is giving the care.

I know for a fact, that patient would much rather be seen by a real doctor than a PA or NP.

I'm not trying to be mean to you, and I know you have to defend your job, but the reality is that PAs are best utilized by surgeons or specialists.

Primary care docs don't need your services, unless they want to increase their bottom line buy paying you less and taking the rest.

Also, the examples you mentioned are just a few. It's hard enough to get a primary care doc to open his own practice, think how much harder it is to get a PA to do that. Just because you know a few does not make it the rule, it makes it the exception. 🙂

 

[deleted6669]

Primary care docs don't need your services, unless they want to increase their bottom line buy paying you less and taking the rest.

Maybe, but many pts in rural areas where there are no md clinics are quite happy to see the pa at the only practice in town....without the pa they drive > 1 hr to be seen "in the big city"....
I don't work in primary care so this issue doesn't affect me personally....I work in em.
I would be the 1st to agree that md/do level care is the gold standard but the fact of the matter is that there are not enough docs to go around.
peace-e

 

[MacGyver]

Maybe, but many pts in rural areas where there are no md clinics are quite happy to see the pa at the only practice in town....without the pa they drive > 1 hr to be seen "in the big city"...

I'm calling BS on that. There is no community in the United States that is an hour removed from an MD/DO primary care practice. Specialists, maybe, but not primary care.

 

[deleted6669]

I'm calling BS on that. There is no community in the United States that is an hour removed from an MD/DO primary care practice. Specialists, maybe, but not primary care.

EVER BEEN TO EASTERN OREGON, EASTERN WASHINGTON OR MOST OF APPALACHIA....YOU ARE SO CLUELESS......this took me 30 seconds to find.....
The City of Fossil, Oregon is Desperately Looking for a PA-C interested in Practicing Solo in their community Funded Clinic. Clinic is Freestanding and fully staffed... The current PA has been their for 3 years... but now has to move due to ailing parents. This is a ranching community. The nearest Hospital is 70-90 miles away... but a helicopter will land 40 feet from the front door of the clinic. The PA is IT...!!! FP...UC... EM... Trauma...!!! OB is contracted out to a distant clinic. The PA also serves as "medical control" to the 4-6 volunteer EMTs. The clinic is beginning to implement a EMR. The clinic has 3 exam rooms and 1 large treatment room for traumas and codes, has limited x-rays, lab the usual stuff. Pay range is $58,000 to $68,000.

 

[erichaj]

I'm calling BS on that. There is no community in the United States that is an hour removed from an MD/DO primary care practice. Specialists, maybe, but not primary care.

Unless maybe you are in the middle of alaska or something like that, where there might be a shortage.

I do have to say that the rural areas may need more primary care docs but you can find one if you need one.

By the way, EM is really acute primary care. Even if the ER docs don't want to admit it.

In fact for many years the ERs were run by FPs.

 

[deleted87716]

YOU ARE SO CLUELESS

*Clears throat* AHEM...!

Keep it on-topic, please. The topic is not each other.

 

[erichaj]

*Clears throat* AHEM...!

Keep it on-topic, please. The topic is not each other.

Kent you should be a psychiatrist. I'd hate to have your job in here. 😉

 

[deleted87716]

Kent you should be a psychiatrist.

Gah...! 😱

No way, man...I don't do crazy. 😉

 

[McDoctor]

I dont think its that clear cut. I'm doing an FP rotation in a place that has attendings, residents, PAs, and NPs. The attendings patients are the same level of complexity as the PA/NP, and there is no immediate oversight, no cosigning scripts, nothing but a chart review several months AFTER the patient has left. Its a total joke. The residents have WAY more oversight than the PA/NPs do. After each patient they have to give a quick presentation to a preceptor attending.

Alot of specialists offices I'm exposed to in my residency operate in the same manner. GI, Endocrine, Nephrology, you name it, a large chunk of patient care is carried out by mid-levels with little oversight. As far as I can tell, reimbursement is the same whether patient is seen by PA or CRNP vs. MD or DO. Ultimately, this will never change unless insurers decide to reduce reimbursement for these visits not provided by a doctor.

Curiously, FP seems to be the only field where this anxiety about being replaced by mid-level providers exists. I've never heard a GI doc or Endocrine doc concerned about the presence of PA's in their field. Come to think of it, I've never heard any FP's too worried about it, either, except here on SDN. Our clinic in my residency program has an NP who sees many patients without oversight. Given the paltry reimbursement of Medicaid, this is the only way to keep the clinic afloat. Mid-level care still beats no care. But there is no comparison when it comes down to complexity of thought processes between a doctor vs. a mid-level. Anybody in the medical field outside of these forums knows this.

 

[deleted87716]

FP seems to be the only field where this anxiety about being replaced by mid-level providers exists...Come to think of it, I've never heard any FP's too worried about it, either, except here on SDN.

What's that I feel...? Ah, yes...

...a breath of fresh air. 😉 👍

 

[deleted6669]

Unless maybe you are in the middle of alaska or something like that, where there might be a shortage.

I do have to say that the rural areas may need more primary care docs but you can find one if you need one.

By the way, EM is really acute primary care. Even if the ER docs don't want to admit it.

In fact for many years the ERs were run by FPs.

FUNNY THAT YOU MENTION ALASKA....
I have 6 friends who work at 3 different sites in the aleutians as solo providers. nearest md...6 hrs by fixed wing plane to anchorage...they are closer to russia than the u.s.
THIS ONE IS FUN TOO:http://www.rayjobs.com/index.cfm?NavID=103
CLICK ON RUSSIAN FEDERATION


partially agree about em...maybe 80% is "acute primary care" and 20% is too acute for any outpt primary care clinic...ortho clinic maybe, but not fp. don't know too many fp guys who reduce fractures in their offices. not too many acs workups in primary care either....or multisystem trauma....or acute tox emergencies....or acute gi bleeds....or aloc workups.....but yeah, most of it could be handled by a competent primary care provider....

 

[deleted6669]

Alot of specialists offices I'm exposed to in my residency operate in the same manner. GI, Endocrine, Nephrology, you name it, a large chunk of patient care is carried out by mid-levels with little oversight. As far as I can tell, reimbursement is the same whether patient is seen by PA or CRNP vs. MD or DO. Ultimately, this will never change unless insurers decide to reduce reimbursement for these visits not provided by a doctor.

Curiously, FP seems to be the only field where this anxiety about being replaced by mid-level providers exists. I've never heard a GI doc or Endocrine doc concerned about the presence of PA's in their field. Come to think of it, I've never heard any FP's too worried about it, either, except here on SDN. Our clinic in my residency program has an NP who sees many patients without oversight. Given the paltry reimbursement of Medicaid, this is the only way to keep the clinic afloat. Mid-level care still beats no care. But there is no comparison when it comes down to complexity of thought processes between a doctor vs. a mid-level. Anybody in the medical field outside of these forums knows this.

actually care reimbursed by medicare is at 85% for midlevel care vs the md rate.

 

[deleted87716]

actually care reimbursed by medicare is at 85% for midlevel care vs the md rate.

If the mid-level charges are billed using a physician's Medicare ID (which is the way it's usually done in offices where there is MD oversight), Medicare will reimburse at the physician rate.

 

[deleted6669]

If the mid-level charges are billed using a physician's Medicare ID (which is the way it's usually done in offices where there is MD oversight), Medicare will reimburse at the physician rate.

This only applies if the physician personally evaluates the pt which occurs in only a small % of primary care visits involving midlevels. midlevels all have their own medicare and national provider id #s
a # of physicians have been audited/fined for billing at the md level for care delivered by midlevels when they are away from the office, on vacation, etc....it's a big no-no.....

 

[deleted87716]

This only applies if the physician personally evaluates the pt which occurs in only a small % of primary care visits involving midlevels.

Well, as with most things related to Medicare, it's complicated.

This article provides some clarification.

 

[deleted6669]

Well, as with most things related to Medicare, it's complicated.

This article provides some clarification.

thanks!

 

[McDoctor]

What's that I feel...? Ah, yes...

...a breath of fresh air. 😉 👍

I think its important to point out to the OP that his/her classmates as well as full time med school faculty have little interaction in the real world. Its discouraging to hear that "teachers" are giving this kind of bad info.

I also think that the post regarding the teaching clinic where NP's and PA's have no oversight is also not exactly a reflection of how most practices operate, though I'm not in practice yet. Our teaching clinic operates like this. However, reimbursement is primarily based on a capitated system utilized by medicaid in pennsylvania. More than 95% of our patients are medicaid. The clinic would never survive financially if it had to pay physicians to see all patients. I'm certain the capitation model employed in our area does not discriminate between care provided by MD/DO vs PA/CRNP, (however an MD is always present during patient hours so that may be required per contract by payors).

Primary care reimbursement is not capitated in this manner outside of training programs. I think students get a skewed perspective of what Family Medicine actually entails based on the environments where most of their training takes place. I'm in the process of interviewing for positions and have been presented with a number of great opportunities. Things are far from bleak in primary care.

With all the pessimism and disinformation spread here about the downsides of family med, its refreshing to have KentW dish out the straight dope from time to time.👍

 

[Mr. McDuck]

I think there are three reasons why you would not want a family doctor taking out your gallbladder.

1. You can't find one.
2. You are still brainwashed (i mean that in good terms) by the specialty craze.
2. You don't have enough knowledge of medicine.

Anyone who is trained in doing a lap coly, is also trained in the complications. All surgeons have backups.

FP's use to do all of these procedures and still do in rural areas. They use to do open cholys.

What you need to understand is that the politics of medicine gets in the way quite often.

I did not think that you meant any disrespect.

Well, I've assisted on PLENTY of lap choles over the last couple years, so I know what it entails. I've also seen them go bad and go on for 6, 7, 8 hours. What makes you think an FP would be better able to handle those situations than someone who has been doing them multiple times a week for the better part of a decade?

I'm sorry, but a surgeon is definitely the better choice for any major operation. Could a FP do a lap chole? Of course. I never said they couldn't. I just wouldn't have one do mine--just in case.

And no, I meant no disrespect.

 

[deleted87716]

Could a FP do a lap chole? Of course. I never said they couldn't. I just wouldn't have one do mine--just in case.

Ditto, frankly.

You sure you guys aren't thinking of appys? Few cholecystectomies are emergent. Even in a remote area, it'd be prudent to send the patient to a general surgeon for elective surgery. As for laparoscopy, that takes a lot of practice, not to mention a lot of expensive equipment that most rural hospitals aren't going to have. A cholecystectomy in the boonies is probably going to be done open.

Now, if somebody's got a hot appendix and you're the only game in town, that's another kettle of fish. There are programs out West that train FPs for that sort of thing. Dunno 'bout gallbladders, though...

 

[Mr. McDuck]

Ditto, frankly.

You sure you guys aren't thinking of appys? Few cholecystectomies are emergent. Even in a remote area, it'd be prudent to send the patient to a general surgeon for elective surgery. As for laparoscopy, that takes a lot of practice, not to mention a lot of expensive equipment that most rural hospitals aren't going to have. A cholecystectomy in the boonies is probably going to be done open.

Now, if somebody's got a hot appendix and you're the only game in town, that's another kettle of fish. There are programs out West that train FPs for that sort of thing. Dunno 'bout gallbladders, though...

LOL. I hope I know the difference between a gallbladder and an appy.

I wasn't talking about emergent surgery, I was referring to elective lap choles. I've seen a few lap choles go not according to plan and end up taking a long time, even after converting to open. But, this whole thing is because I questioned where FPs are doing lap choles, as I've never seen it done.

As far as a hot or perf'd appendix, if I were in the middle of nowhere, I don't care who takes it out as long as they know what they're doing.

 

[deleted87716]

I know the difference between a gallbladder and an appy.

That's not what I meant.

I questioned where FPs are doing lap choles, as I've never seen it done.

That's what I meant.

 

[Mr. McDuck]

Hey, your quote makes me look like I was being an a-hole. Way to leave out the "I hope I" and the laughing smilie.

Jeez.

Also, I have heard of FPs doing appies in rural places. If that's what he meant, then I really don't have anything to say, lol.

 

[deleted87716]

your quote makes me look like I was being an a-hole.

I don't think so...unless that was your intention. 😉

Chill. You're among friends.

 

[Mr. McDuck]

Ha. I guess the joking tone of my posts didn't come across too well in text. Oh, well. Sorry to hijack the thread.

 

[deleted87716]

Sorry to hijack the thread.

No matter...it was on its way to Cuba before you got here. 😉

 

[Faebinder]

Alaska screws itself by itself... you can call it the exception of the US... why is it screwed... look at its requirement.

http://www.fsmb.org/usmle_eliinitial.html

Alaska and Idaho are the only states that impose a license limit on step 2. And they are the lowest of the list....two attempts.. no more...

Now you might laugh and think this is a joke... if they failed then who cares what happens to them..... No you are wrong there. It's well known that you are more likely to practice in the state where you finish your residency and this is more likely to be true for primary care physicians. So by putting a bigger dent limit than every other state on top of the fact that no one wants to move from lets say... Florida/New Jersey/California... to Alaska or Idaho.. then you start to really push physicians away and leave space for mid levels to occupy. Worse, your dent is on step 2/1 not step 3 like most states, meaning you wont get weaker graduates applying there, so basically no chance in growth (Yes the weaker graduates go first... and when a market is established, better graduates follow).

So why are both those states who lack so much primary care limit their license more than all the other states in the US that obviously have better supply of physicians? Probably someone trying to monopolize the system in those two states.

If you want to be a PA/NP and want to be the doctor in those two states... more power to you... they deserve whatever they get since they are the one stopping physicians.

 

[sophiejane]

No matter...it was on its way to Cuba before you got here. 😉

You know, Kent, I REALLY have a problem with you singling out Cuba. I mean, what's with that? What did the poor Cubans ever do to deserve such degradation???!!

😉

 

[deleted87716]

You know, Kent, I REALLY have a problem with you singling out Cuba. I mean, what's with that? What did the poor Cubans ever do to deserve such degradation???!!

😉

I'm showing my age again.

It used to be that practically every hijacker wanted somebody to fly them to Cuba. Dunno why...probably so they could buy cigars or something.

Now, they all want to set their shoes on fire and blow up the plane.

Ah, the good ol' days... 😉

 

[MacGyver]

EVER BEEN TO EASTERN OREGON, EASTERN WASHINGTON OR MOST OF APPALACHIA....YOU ARE SO CLUELESS......this took me 30 seconds to find.....
The City of Fossil, Oregon is Desperately Looking for a PA-C interested in Practicing Solo in their community Funded Clinic. Clinic is Freestanding and fully staffed... The current PA has been their for 3 years... but now has to move due to ailing parents. This is a ranching community. The nearest Hospital is 70-90 miles away... but a helicopter will land 40 feet from the front door of the clinic. The PA is IT...!!! FP...UC... EM... Trauma...!!! OB is contracted out to a distant clinic. The PA also serves as "medical control" to the 4-6 volunteer EMTs. The clinic is beginning to implement a EMR. The clinic has 3 exam rooms and 1 large treatment room for traumas and codes, has limited x-rays, lab the usual stuff. Pay range is $58,000 to $68,000.

Try again dude. Simple internet search reveals that Fossil Oregon does in fact have a family practioner there by the name of Robert Boss, MD on 712 Jay St.

 

[deleted6669]

Try again dude. Simple internet search reveals that Fossil Oregon does in fact have a family practioner there by the name of Robert Boss, MD on 712 Jay St.

who apparently has left or sees no pts as the ad specifies no md within 70 miles as this is the only local practice....

 

[secretwave101]

Also consider litigation. The main risk for lawsuits against FP's is missed dx.

Thus, the best-trained are the most appropriate to assume litigation risk. Because they have more experience (when each is compared to the other out of training), FP's have a better sense of how to approach a given set of symptoms. They tend to order more appropriate tests (huge cost-savings long-term) and tend to have a more elegant index of clinical suspicion than those who are trained less. Plus, it's harder to sue the guy who hired a top-trained doc rather than a under-trained doc.

So, theoretically at least, a strong case can be made that the best-trained are also the cheapest. And in the business world, cheap sells.

Never thought I'd say something good about the litigation climate of this country, but in may help keep family docs in business for many years.

 

[MacGyver]

who apparently has left or sees no pts as the ad specifies no md within 70 miles as this is the only local practice....

Sorry your info is mistaken.

Oregon state medical board lists multiple doctors in surrounding towns.

Here's one:

Timothy Herrick, family practice, Antelope OR (about 20 miles from Fossil)

Also, the oregon state medical board states that Dr. Boss is currently active license and registered at Boardman, OR, which is only about 40 miles away from Fossil.

There are obviously many doctors within an hour's radius of Fossil.

Shall we continue this charade?