General Practice revisited

[BolderNewfy]

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So Iam aware that the days of general practice are gone, but my quesion is why? with the shortage of trained physicians out there, it seems physicians have shot themselves in the foot with this one. PA's and NP's have now swooped in to fill a niche of a less specialized medical provider. I know I would rather see an MD with one year of residency over a PA or NP.


Is the barrier to practicing as a GP that you wont be reimbursed by medicaid/medicare or other HMO's along with not being able to get hospital privileges. although if you only wanted to practice outpatient medicine that wouldnt be an issue. Also is it not possible to obtain malpractice insurance.

So really if I am a licensed md i can open a practice but would have to not accept insurance, and wouldnt be able to get malpractice? is that right?

 

[docB]

When you say "GP" I hear "someone with no residency training." The reason that the days of the GP have passed is that the field of primary care has evolved to the point where it requires more than med school and internship to be able to practice it competently. That is why IM and FM have full residencies and board certifications.

Your point about primary care being usurped by MLPs is a valid one. This is being driven by costs, not quality. Patients want to see doctors but they also don't want to pay for it. We will have to see where the chips fall on this.

 

[Law2Doc]

So Iam aware that the days of general practice are gone, but my quesion is why? with the shortage of trained physicians out there, it seems physicians have shot themselves in the foot with this one. PA's and NP's have now swooped in to fill a niche of a less specialized medical provider. I know I would rather see an MD with one year of residency over a PA or NP.


Is the barrier to practicing as a GP that you wont be reimbursed by medicaid/medicare or other HMO's along with not being able to get hospital privileges. although if you only wanted to practice outpatient medicine that wouldnt be an issue. Also is it not possible to obtain malpractice insurance.

So really if I am a licensed md i can open a practice but would have to not accept insurance, and wouldnt be able to get malpractice? is that right?

The answer when competing with crummy cheaper services is not to offer your own crummy cheaper services. It's to educate the public why your services are preferable, ie branding. The goal is never to compete at a lower level, it's to show the customers there isn't really any basis for considering the other option. Part of this is going to require going on the offensive and publicizing examples of bad outcomes when folks get their care at CVS/Walmart rather than from an MD/DO. But the answer is never to try and pass off someone poorly trained.

 

[142348]

The answer when competing with crummy cheaper services is not to offer your own crummy cheaper services. It's to educate the public why your services are preferable, ie branding. The goal is never to compete at a lower level, it's to show the customers there isn't really any basis for considering the other option. Part of this is going to require going on the offensive and publicizing examples of bad outcomes when folks get their care at CVS/Walmart rather than from an MD/DO. But the answer is never to try and pass off someone poorly trained.

This. We should demonstrate our knowledge and expertise and show the public why physicians are not just a step but multiple steps above a mid level practitioner.

 

[BolderNewfy]

Im not sure I agree that someone who hasnt completed a residency or isnt "board certified" is of less quality. An MD is an MD, and by that very fact is going to be superior to a PA or NP. I think I would rather see a GP with 5 years of experience than a board certified FP one year out of training. To me residency is at least as much about being exploited as it is about learning. And I think you learn a whole heck of a lot when you are on your own and cant fall back on the upper level or attending. Also its kind of creepy when people start referring to medicine as a "product" and "branding". we really need to move away from the idea of medicine as a product to be purchased and sold. To me it is a big part of the problem that put medicine in the horrible state that it is in.....

 

[142348]

Im not sure I agree that someone who hasnt completed a residency or isnt "board certified" is of less quality. An MD is an MD, and by that very fact is going to be superior to a PA or NP. I think I would rather see a GP with 5 years of experience than a board certified FP one year out of training. To me residency is at least as much about being exploited as it is about learning. And I think you learn a whole heck of a lot when you are on your own and cant fall back on the upper level or attending. Also its kind of creepy when people start referring to medicine as a "product" and "branding". we really need to move away from the idea of medicine as a product to be purchased and sold. To me it is a big part of the problem that put medicine in the horrible state that it is in.....

This may or may not be true. Its possible a physician who is a GP with 5 years of experience may be better, but what about in those first five years? I remember my knowledge base after internship and I sure as heck wouldn't want to be a guinea pig for someone who only completed an internship and hung up a shingle as a GP. The point of residency and subsequent board certification is to provide the public with an assurance that certain standard was maintained in allowing physicians to practice which cannot be said of a GP.

You may not like medicine being described as product/branding but that is the reality we live in. Medicine is part of healthcare and that is big business. Physicians need to embrace this reality if they want to be leaders in the future of healthcare policy.

 

[Law2Doc]

...An MD is an MD, and by that very fact is going to be superior to a PA or NP. I think I would rather see a GP with 5 years of experience than a board certified FP one year out of training. To me residency is at least as much about being exploited as it is about learning...

um no. An MD without the training is useless. The training is nearly the entire value, the MD is just the foundation you need to make the training not a useless exercise.

As for complaining about residency being exploitation rather than value, you are perhaps identifying a shortcoming of your particular residency, and while that ought to be fixed, it isn't justification for throwing out training.

You are trying to justify your own situation, but what you advocate makes little sense. You don't learn to be a clinician in med school, and you can't train effectively starting at the attending level. You have fewer willing teaches, unlimited liability, and no net to catch your mistakes like residents have. There's a very good reason training is structured the way it is -- you go from foundation to trainee, and when you are ready you end up in a position where you bear the brunt of the liability. You skip any steps, by definition you are an inferior product -- basically raw cookie dough pulled out of the oven too early.

 

[BolderNewfy]

um no. An MD without the training is useless. The training is nearly the entire value, the MD is just the foundation you need to make the training not a useless exercise.

As for complaining about residency being exploitation rather than value, you are perhaps identifying a shortcoming of your particular residency, and while that ought to be fixed, it isn't justification for throwing out training.

You are trying to justify your own situation, but what you advocate makes little sense. You don't learn to be a clinician in med school, and you can't train effectively starting at the attending level. You have fewer willing teaches, unlimited liability, and no net to catch your mistakes like residents have. There's a very good reason training is structured the way it is -- you go from foundation to trainee, and when you are ready you end up in a position where you bear the brunt of the liability. You skip any steps, by definition you are an inferior product -- basically raw cookie dough pulled out of the oven too early.

Um No. You are completely wrong, no studies to prove any of this. You have been drinking the cool aid way too long. but hey if your ok with being exploited be my guest. Cognitive dissonance anyone...? There is a very good reason training is structered the way it is? yeah so attendings can sleep in their bed at night while we do their work for them.....

 

[142348]

Um No. You are completely wrong, no studies to prove any of this. You have been drinking the cool aid way too long. but hey if your ok with being exploited be my guest. Cognitive dissonance anyone...? There is a very good reason training is structered the way it is? yeah so attendings can sleep in their bed at night while we do their work for them.....

You are that confident to believe that you should be able to take care of patients unsupervised after 1 year of internship? That's a bold statement. There aren't studies to say that its not feasible but anyone who has gone through the medical education system can tell you that you're ill prepared to handle the realities of practice without more training. As a med student you learn the basic knowledge but don't really apply it thoroughly. As an intern you start doing that but its not until a few years in that you really are in a position to understand the whole scenario. After five years of residency, I can tell you that as the years progressed, though I became more knowledgeable and confident, I also was more humbled by how much more I have to learn. Seems you might benefit from a bit of the reality that you don't know much after just 1 year.

 

[142348]

Also, I think its a poor arguement to say that because PA/NPs are out there that we should reduce our standards. In order to show the public our true worth we need to demonstrate the quality of care and what those years of training actually get you not provide short cuts to quicker practice.

 

[docu]

I am a GP. You can still be slightly successful if you try hard enough. I started my own home visiting physician business. It is hard to make money owning your own business because the amount you get for visits hardly give you profit over your overhead. However, if you do nerve blocks you can make the business more lucrative, but that requires all your patients to be in severe pain. Most of my patients are given to me from home care companies where the patient needs PT so I lucked out in that department of the patient being in pain. Also maybe most elderly on medicare are in pain.

In terms of insurance, GP's can take medicare or blue cross blue sheild or PPO's, so yes you can take insurance but it is limited. no HMO's. You can take medicaid but it hardly pays so most people steer clear of that one. as far as hospital priveliges, i think you can get them if you have extremely good/close connections, but it is very hard to.

It is easier to work for a company than it is to own one. you probably would make more money at least in the short run,however, it is hard to find them because most places want you to be BE/BC, which I am not. but if you own one, you get the full reimbursement and get to be your own boss, and your profit grows as your business grows. i met some people who let me be part of their clinic group..so yes you can be successful if you run into the right people. i think they are going to get me credentialed with all insurances so i can work there too. however, as a GP, most companies that are willing to hire me are home visiting physician companies. so it is hard to get away from that as a GP.

I wish GP could take the place of NP or PA, but unfortunately the rules are against that at the moment. it used to be that GP's could work as doctors, even in rural areas, but that has changed over the years. i learned so much being a GP I know I could do as well as if not better than a PA or NP.

 

[142348]

I am a GP. You can still be slightly successful if you try hard enough. I started my own home visiting physician business. It is hard to make money owning your own business because the amount you get for visits hardly give you profit over your overhead. However, if you do nerve blocks you can make the business more lucrative, but that requires all your patients to be in severe pain. Most of my patients are given to me from home care companies where the patient needs PT so I lucked out in that department of the patient being in pain. Also maybe most elderly on medicare are in pain.

In terms of insurance, GP's can take medicare or blue cross blue sheild or PPO's, so yes you can take insurance but it is limited. no HMO's. You can take medicaid but it hardly pays so most people steer clear of that one.

It is easier to work for a company than it is to own one. you probably would make more money at least in the short run,however, it is hard to find them because most places want you to be BE/BC, which I am not. but if you own one, you get the full reimbursement and get to be your own boss, and your profit grows as your business grows. a group of people are making an urgent care and they are GP's and gave me profit share of their company , which was so nice of them. so yes you can be successful if you run into the right people. i think they are going to get me credentialed with all insurances so i can work there too. however, as a GP, most companies that are willing to hire me are home visiting physician companies. so it is hard to get away from that as a GP.

I wish GP could take the place of NP or PA, but unfortunately the rules are against that at the moment. it used to be that GP's could work as doctors, even in rural areas, but that has changed over the years. i learned so much being a GP I know I could do as well as if not better than a PA or NP.

Your last sentence highlights the problem with the GP. You learned so much being a GP; these are things you should have learned in a residency and not on the fly without supervision. Medicine does not need GPs to "do as well" as a PA or NP but to far exceed those qualifications and knowledge base.

 

[docu]

i learned enough in medical school and residency and step 3. i am an IMG so i had 2 years of residency experience, as opposed to just 1 year an AMG has to have, so i do know quite a bit and maybe enough. why can't we work at the same level either? makes no sense. we should. the PA and NP schools just want to make money that way. that's why it is the way it is. PA and NP's have a powerful lobby.

btw i hate how people on this site highlight one little thing out of a paragraph and take things completely out of context. shows pettiness.

 

[Law2Doc]

... i learned so much being a GP I know I could do as well as if not better than a PA or NP.

Agree with wagy, I think this emphasizes the problem with GP. You learned enough to consider yourself equivalent to a midlevel. Most people feel they surpass this mark at some point during a multi-year residency.

 

[Law2Doc]

...

btw i hate how people on this site highlight one little thing out of a paragraph and take things completely out of context. shows pettiness.

it's not out of context -- you were discussing that you adequately learned to practice without a full residency and equated yourself at the end to a midlevel, even suggesting that it was unfair that you couldn't work as one. This is the context. In fact this was your underlying thesis.

 

[142348]

i learned enough in medical school and residency and step 3. i am an IMG so i had 2 years of residency experience, as opposed to just 1 year an AMG has to have, so i do know quite a bit and maybe enough. why can't we work at the same level either? makes no sense. we should. the PA and NP schools just want to make money that way. that's why it is the way it is. PA and NP's have a powerful lobby.

btw i hate how people on this site highlight one little thing out of a paragraph and take things completely out of context. shows pettiness.

The problem is there is no way to verify that you "learned enough" in med school and your abbreviated residency. You have no residency completion certificate, and you are not board eligible/certified. Part of ensuring that those in the field of medicine are doing right by patients is to use things like completion of residency and board certification as surrogates for competency and GPs have none of those. It appears you are using PA/NPs simply to drive your arguement and dont have any support for how your skills are equivalent or superior. Its admirable what you've done with the situation you were in but that doesnt mean we should create a pathway for this, it would be dangerous to patients and reduce the credibility of a profession that needs more credibility not less.

 

[docu]

Agree with wagy, I think this emphasizes the problem with GP. You learned enough to consider yourself equivalent to a midlevel. Most people feel they surpass this mark at some point during a multi-year residency.

I disagree. No doctor, BE or BC says they surpass that level. I think most PA's/NPs know as much as a BC/BE family physician from what I"ve seen, they take care of HTN, DMII, know as much as step 3, give nerve blocks, i mean they get to do a lot. NP's can even have their own separate practice. A lot of autonomy has been given to NP and PAs. they even get to work in a hospital and i don't. is that fair to a GP? no. its just that you are unaware of this fact because you haven't even gotten to work with them. In fact I'm hiring an NP/PA to work for my company. They replace MD's for a cheaper price.

 

[Top Gun]

I disagree. No one says they surpass that level. I think most of them know as much as a BC/BE family physician from what I"ve seen.

Um, no they don't. They may be comfortable managing routine things like HTN, DM, or osteoarthritis, but they are clueless when it comes to managing a less common condition or even a common condition with an unusual presentation. They can't come up with a broad differential like most physicians can. What's more, half of them failed a watered-down version of Step 3, which is the easiest of the licensing exams that all physicians are required to take. There is no way they could be equivalent to a board-certified family physician.

I have also seen some really boneheaded mistakes by nurse practitioners who thought they knew everything. I had a patient who transferred to me from a nurse practioner once, and this NP was giving steroids to treat her gastritis!😱 Hello?!

There is no way you can compare an NP/PA to a BE/BC physician.

 

[docu]

Um, no they don't. They may be comfortable managing routine things like HTN, DM, or osteoarthritis, but they are clueless when it comes to managing a less common condition or even a common condition with an unusual presentation. They can't come up with a broad differential like most physicians can. What's more, half of them failed a watered-down version of Step 3, which is the easiest of the licensing exams that all physicians are required to take. There is no way they could be equivalent to a board-certified family physician.

I have also seen some really boneheaded mistakes by nurse practitioners who thought they knew everything. I had a patient who transferred to me from a nurse practioner once, and this NP was giving steroids to treat her gastritis!😱 Hello?!

There is no way you can compare an NP/PA to a BE/BC physician.

If this is the case, I dont see why there is no niche for a GP where they can't even enter a hospital, while NP's and PAs are allowed to do so much more. Maybe GP's should drown out NPs and PAs from the system like they have done to GP's. Because of them, GPs don't even have a niche anymore.

 

[142348]

If this is the case, I dont see why there is no niche for a GP where they can't even enter a hospital, while NP's and PAs are allowed to do so much more. Maybe GP's should drown out NPs and PAs from the system like they have done to GP's. Because of them, GPs don't even have a niche anymore.

Your arguements keep going back and forth. First it was GPs are good beause they have as much skill as a PA/NP and maybe more and now when the limitations of PA/NPs come up you say GPs should have a niche becasue they have more knowledge. The reality is that knowledge you have obtained is relatively limited in practicing medicine because you are not board eligible/certified and hence can't be on most physician panels and you havent dont the pre-requisite schooling to be a PA/NP. Yes you are stuck in medical no mans land but the reality is you are the one who put yourself there. You are trying to justify your way out but the reality is, I and most insurance companies/hospitals wouldn't trust a patient with a minor issue to you because there is no one willing to back up your training with a certification of your competency.

 

[Law2Doc]

Your arguements keep going back and forth. First it was GPs are good beause they have as much skill as a PA/NP and maybe more and now when the limitations of PA/NPs come up you say GPs should have a niche becasue they have more knowledge. The reality is that knowledge you have obtained is relatively limited in practicing medicine because you are not board eligible/certified and hence can't be on most physician panels and you havent dont the pre-requisite schooling to be a PA/NP. Yes you are stuck in medical no mans land but the reality is you are the one who put yourself there. You are trying to justify your way out but the reality is, I and most insurance companies/hospitals wouldn't trust a patient with a minor issue to you because there is no one willing to back up your training with a certification of your competency.

The dude is trying to justify his own lot, I get that. His arguments however as you have noted have a lot of flaws, and the end result is I think we all realize that his situation is not something we want to promote more of. His arguments make him the poster boy for why the GP is maybe not something we want to promote.

 

[Arcan57]

If this is the case, I dont see why there is no niche for a GP where they can't even enter a hospital, while NP's and PAs are allowed to do so much more. Maybe GP's should drown out NPs and PAs from the system like they have done to GP's. Because of them, GPs don't even have a niche anymore.

The first NP program started in 1965, family medicine (which really is what killed the GP) was recognized as a specialty in 1970. FM became a specialty because existing GP's were concerned that medicine had become too complex for med school + 1 yr of internship to be sufficient training. So almost 50 yrs ago, the people that were actually practicing as GPs thought they were undertrained to deal with modern medicine and were concerned enough to create a new specialty to provide adequate training and ensure quality.

So to summarize:
1) There were not enough NPs in America in 1970 for that to have been a significant motivator for the creation of FM and the abandonment of the GP as a mark of minimal competence.

2) Medicine is significantly more advanced now (even accounting for the impact of peripheral brains) then it was when the GPs decided their training had been insufficient to deal with what they faced in practice.

You may be a competent doctor, but you've never been able to prove it to a level accepted by the medical community. And the end of pyramid scheme residencies means that there are fewer and fewer legitimate reasons for not finishing residency.

 

[docu]

its funny how it turned into some arguement, when my original intent was to answer the OP's question of how it really is possible to work as a GP and that it is possible to take some insurances, using my situation as the example.

 

[BolderNewfy]

Um, no they don't. They may be comfortable managing routine things like HTN, DM, or osteoarthritis, but they are clueless when it comes to managing a less common condition or even a common condition with an unusual presentation. They can't come up with a broad differential like most physicians can. What's more, half of them failed a watered-down version of Step 3, which is the easiest of the licensing exams that all physicians are required to take. There is no way they could be equivalent to a board-certified family physician.

I have also seen some really boneheaded mistakes by nurse practitioners who thought they knew everything. I had a patient who transferred to me from a nurse practioner once, and this NP was giving steroids to treat her gastritis!😱 Hello?!

There is no way you can compare an NP/PA to a BE/BC physician.

Um, this like so many posts on this thread is pure opinion. I have seen "board Certified" internists make enormous mistakes, and PA's that were far superior to board certified internists. you need to mellow out on stroking your own ego. After residency I have to take another ridiculous examination, the ABIM. If I can pass that right now wouldnt that suggest that I have seen and learned enough to practice? you guys are sooo indoctrinated its creepy.

 

[BolderNewfy]

hospitals and HMO's dont trust a medical doctor (bachelors plus a doctorate degree) with one year residency but they trust someone with an associates degree and one year "residency" to practice in a hospital? this makes no sense.

 

[BolderNewfy]

Um, no they don't. They may be comfortable managing routine things like HTN, DM, or osteoarthritis, but they are clueless when it comes to managing a less common condition or even a common condition with an unusual presentation. They can't come up with a broad differential like most physicians can. What's more, half of them failed a watered-down version of Step 3, which is the easiest of the licensing exams that all physicians are required to take. There is no way they could be equivalent to a board-certified family physician.

I have also seen some really boneheaded mistakes by nurse practitioners who thought they knew everything. I had a patient who transferred to me from a nurse practioner once, and this NP was giving steroids to treat her gastritis!😱 Hello?!

There is no way you can compare an NP/PA to a BE/BC physician.

i had a board certified internist, who was a veteran by the way, tell me to immediately stop fluids and was screeming at the ed doc for giving IVNS wide open on a patient with a sodium of 122. She saw the blood glucose was over 1000 and didnt even realize that it was pseudohyponatremia.....corrected to normal Na level. person coulda died....thank god for all those residency programs, that protect us from all those dangerous untrained doctors, even though medical care in america is rated like 47 just below croatia......

 

[docu]

hospitals and HMO's dont trust a medical doctor (bachelors plus a doctorate degree) with one year residency but they trust someone with an associates degree and one year "residency" to practice in a hospital? this makes no sense.

👍 'like'....

 

[Law2Doc]

Um, this like so many posts on this thread is pure opinion. I have seen "board Certified" internists make enormous mistakes, and PA's that were far superior to board certified internists. you need to mellow out on stroking your own ego. After residency I have to take another ridiculous examination, the ABIM. If I can pass that right now wouldnt that suggest that I have seen and learned enough to practice? you guys are sooo indoctrinated its creepy.

Knowing an internist who made a mistake is not exactly a compelling argument in favor of folks with less training. It means one idiot slipped through the cracks, not that we should have everybody operate at the same dismal level. And yes, the average residency trained person knows a ton more coming out of a 3 year residency than the typical PA or NP coming out of their programs. Part of the reason the PA has the A in it is because they aren't trained to be independent practitioners, they are trained to assist folks who are trained to function independently. The hurdles are lower, the expectations are lower, and the end result is a less complete product. It has nothing to do with ego. It's a function of the training. And no, passing a test is just a final minimal hurdle, not a demonstration of competency. Completing the training itself is the true demonstration that you are ready to take the next step in your career.

 

[Law2Doc]

hospitals and HMO's dont trust a medical doctor (bachelors plus a doctorate degree) with one year residency but they trust someone with an associates degree and one year "residency" to practice in a hospital? this makes no sense.

It makes perfect sense. Physicians need to do a better job of branding and marketing themselves. Right now the public has no clue how big a training difference there is between midlevel and doctor. And nobody is highlighting the shortcomings and lapses of care of midlevels (yet). The public just sees someone in a white coat and is clueless. The hospital just looks for the most cost effective option the public will accept. If the public knew the truth and clamored for doctors, hospitals would employ doctors. All this means is that medicine is doing a lousy job of branding itself as "better". But it isn't an argument in favor of GPs. The answer to midlevels is not to promote your own undertrained offering, it's to make the public understand the need for more training. Sorry but this argument doesn't really support GPs, it echoes the fact that the public needs to be better educated.

 

[Top Gun]

Um, this like so many posts on this thread is pure opinion. I have seen "board Certified" internists make enormous mistakes, and PA's that were far superior to board certified internists. you need to mellow out on stroking your own ego. After residency I have to take another ridiculous examination, the ABIM. If I can pass that right now wouldnt that suggest that I have seen and learned enough to practice? you guys are sooo indoctrinated its creepy.

Ego has nothing to do with it. Yes, there are a few incompetent internists out there who coasted through residency through political rather than clinical skill, and who, by some miracle, managed to pass the boards, and are now endangering patients left and right. They are hardly representative of all residency graduates who pass the boards. Rather, they are outliers who slipped through the cracks. By the time a typical physician graduates from residency, s/he knows a great deal more than an NP/PA who completed a much shorter period of training.

 

[BolderNewfy]

Bottom line is that studies have shown that PA's and NP's , who can actually practice independantly in some states and situations by the way, have delivered comparable quality of care to medical doctors. The public is indicating that there is a need for a medical professional that is capable managing illness and is trained to a certain level. Doctors are responding by saying that what the public really wants is a more expensive, more extensively trained physician or complete product that in many situations doesnt do any better of a job at delivering medical care. I dont deny the need for highly trained physicians, but there clearly is a need for a doctor that is not as highly trained. And there exists thousand of unemployed physicians who are more educated and more highly trained medical professional than a PA or NP, and yet they are denied the right to practice while at the same time we allow a "lesser product" to act basically as doctors.

The GP is THE answer to the PA and NP moving in on the physician territory. The public is indicating the need by the high employment and demand of the midlevel provider. Dont respond by telling the public "no no you dont want that, you want a much more expensive but better trained physician even though we cant demonstrate that board certified physicians are any better", becuase that "argument" just doesnt hold any weight....

 

[BolderNewfy]

Ego has nothing to do with it. Yes, there are a few incompetent internists out there who coasted through residency through political rather than clinical skill, and who, by some miracle, managed to pass the boards, and are now endangering patients left and right. They are hardly representative of all residency graduates who pass the boards. Rather, they are outliers who slipped through the cracks. By the time a typical physician graduates from residency, s/he knows a great deal more than an NP/PA who completed a much shorter period of training.

there are a lot more than a "few" bad internists, family practice doctors, surgeons etc.. who are horrible physicians making dangerous decisions everyday. I dont contend that board certified physicians know more than a PA, but the question I pose is is that extra knowledge allowing them to provide better care, because right now there is no evidence to show that it does. Also where do we draw the line, maybe if we made residency longer and required more board exams then there wouldnt be ANY bad doctors "slipping through the cracks".
How long is enough. Nothing to do with ego...."top gun", seriously?

 

[VA Hopeful Dr]

Bottom line is that studies have shown that PA's and NP's , who can actually practice independantly in some states and situations by the way, have delivered comparable quality of care to medical doctors. The public is indicating that there is a need for a medical professional that is capable managing illness and is trained to a certain level. Doctors are responding by saying that what the public really wants is a more expensive, more extensively trained physician or complete product that in many situations doesnt do any better of a job at delivering medical care. I dont deny the need for highly trained physicians, but there clearly is a need for a doctor that is not as highly trained. And there exists thousand of unemployed physicians who are more educated and more highly trained medical professional than a PA or NP, and yet they are denied the right to practice while at the same time we allow a "lesser product" to act basically as doctors.

The GP is THE answer to the PA and NP moving in on the physician territory. The public is indicating the need by the high employment and demand of the midlevel provider. Dont respond by telling the public "no no you dont want that, you want a much more expensive but better trained physician even though we cant demonstrate that board certified physicians are any better", becuase that "argument" just doesnt hold any weight....

Are you currently in a primary care residency in America? Have you ever been in one? I'm finished up my 2nd year in family, so I can speak with perhaps more first-hand knowledge compared to my surgery collegues who've posted so far in this thread.

To practice competent FM/IM/peds, 1 year of internship doesn't cut it. Period. If that were not true, I wouldn't be awake at this hour supervising my intern as she admits patients. I've also worked with a few NPs in the residency clinic. They're not stupid by any means, but their knowledge is far inferior to mine and I'm not even done with my training yet (nor am I the best resident we have).

As for all of those "studies" comparing NPs and MDs... post them. I've taken them apart before (search my post history), and I'd be glad to do it again.

 

[Law2Doc]

Bottom line is that studies have shown that PA's and NP's , who can actually practice independantly in some states and situations by the way, have delivered comparable quality of care to medical doctors....

if you are going to make this kind of statement, which I doubt many on this thread are going to buy into, you are going to need to reference such studies, and define what is meant by "comparable".

The public has demonstrated that they will go to any practitioner wearing a white coat. They are totally uneducated as to the various healthcare degrees. They are not doing this because studies have demonstrated that they are getting " comparable quality". I think we all know they aren't. In fact most NPs and PAs I know probably wouldn't even describe themselves or their training or knowledge base as comparable, rather they are providing a hopefully adequate, cost effective option - and as such, they tend to be fairly quick to refer patients to a "real doctor" if they get a whiff of something medically significant. So no, you lost me on this first sentence here, and I think this is the sticking point at which you can't win this argument. Midlevels are mid. Doctors are upper level healthcare employees. It may be cheaper to push midlevels into a greater role, but it's never going to be comparable.

 

[Law2Doc]

there are a lot more than a "few" bad internists, family practice doctors, surgeons etc.. who are horrible physicians making dangerous decisions everyday. I dont contend that board certified physicians know more than a PA, but the question I pose is is that extra knowledge allowing them to provide better care, because right now there is no evidence to show that it does. Also where do we draw the line, maybe if we made residency longer and required more board exams then there wouldnt be ANY bad doctors "slipping through the cracks".
How long is enough. Nothing to do with ego...."top gun", seriously?

Out of the thousands of folks who go into IM every year, sure there are going to be some bad apples. Most still will be better trained and make fewer mistakes than midlevels with significantly less training. And it's not like even more bad apples don't slip through the significantly lesser requirements and become NP or PAs.

You ask "how long is enough", but I think each specialty board has already answered that. If you want to advocate longer residencies, particularly in light of decreasing duty hours, you wouldn't be alone, but I don't see how that helps your argument -- it would make the GP even further from the mark.

 

[Top Gun]

there are a lot more than a "few" bad internists, family practice doctors, surgeons etc.. who are horrible physicians making dangerous decisions everyday. I dont contend that board certified physicians know more than a PA, but the question I pose is is that extra knowledge allowing them to provide better care, because right now there is no evidence to show that it does. Also where do we draw the line, maybe if we made residency longer and required more board exams then there wouldnt be ANY bad doctors "slipping through the cracks".
How long is enough. Nothing to do with ego...."top gun", seriously?

First off, my username is not based on ego. I took it from a favorite movie of mine. That's all.

Second, there are also plenty of bad PA's/NP's who slip through the cracks in their training. Granted, there are plenty of excellent PAs/NPs who provide great care, but they probably wouldn't compare to a competent board-certified physician. They might be better than the worst physicians, but that is all. Their training is limited compared to ours.

 

[142348]

Bottom line is that studies have shown that PA's and NP's , who can actually practice independantly in some states and situations by the way, have delivered comparable quality of care to medical doctors. The public is indicating that there is a need for a medical professional that is capable managing illness and is trained to a certain level. Doctors are responding by saying that what the public really wants is a more expensive, more extensively trained physician or complete product that in many situations doesnt do any better of a job at delivering medical care. I dont deny the need for highly trained physicians, but there clearly is a need for a doctor that is not as highly trained. And there exists thousand of unemployed physicians who are more educated and more highly trained medical professional than a PA or NP, and yet they are denied the right to practice while at the same time we allow a "lesser product" to act basically as doctors.

The GP is THE answer to the PA and NP moving in on the physician territory. The public is indicating the need by the high employment and demand of the midlevel provider. Dont respond by telling the public "no no you dont want that, you want a much more expensive but better trained physician even though we cant demonstrate that board certified physicians are any better", becuase that "argument" just doesnt hold any weight....

The studies you mention are methodologically flawed and really there is really no good data supporting your statement. PA/NPs are an issue that physicians have to deal with but rather than dumping a set of underqualified physicians (GP) on the community and sullying our profession, we are better off highlighting that our profession is about far exceeding what a PA/NP knows and can do. The GP was phased out (as previously mentioned) for a reason. Not all board eligible/certified physicians are perfect, and some can slip through; however, with a GP we are letting all the bad actors through because for one reason or another they couldn't get into or stay in a residency program and complete the training. That's a recipe for disaster.

 

[142348]

there are a lot more than a "few" bad internists, family practice doctors, surgeons etc.. who are horrible physicians making dangerous decisions everyday. I dont contend that board certified physicians know more than a PA, but the question I pose is is that extra knowledge allowing them to provide better care, because right now there is no evidence to show that it does. Also where do we draw the line, maybe if we made residency longer and required more board exams then there wouldnt be ANY bad doctors "slipping through the cracks".
How long is enough. Nothing to do with ego...."top gun", seriously?

You dont think that board certified internists know more than a PA? Really, what is your justification for that statement.

In terms of training length, this is decided by the colleges of each specialty. The designate a length that they believe produces competent physicians, who they are willing to certify following completion of training and boards. That is the key, GPs dont have anyone willing to stand behind their competency and the reason for that is no one has vetted their competency.

 

[142348]

its funny how it turned into some arguement, when my original intent was to answer the OP's question of how it really is possible to work as a GP and that it is possible to take some insurances, using my situation as the example.

The arguement started when after describing your situation you added this "I wish GP could take the place of NP or PA, but unfortunately the rules are against that at the moment. it used to be that GP's could work as doctors, even in rural areas, but that has changed over the years. i learned so much being a GP I know I could do as well as if not better than a PA or NP."

 

[docu]

The arguement started when after describing your situation you added this "I wish GP could take the place of NP or PA, but unfortunately the rules are against that at the moment. it used to be that GP's could work as doctors, even in rural areas, but that has changed over the years. i learned so much being a GP I know I could do as well as if not better than a PA or NP."

doesn't mean it should become an arguement. its just a statement. and i have every right to say whatever i want, just like you have.

 

[Law2Doc]

doesn't mean it should become an arguement. its just a statement. and i have every right to say whatever i want, just like you have.

Of course you do. And other posters have the right to say why it's folly. It's a discussion board, not a soap box. You put out a statement it becomes fair game for responses.

At any rate, unless you have some good justification for why we need GPs as opposed to generalists with longer residency training like FP, for reasons other than simply to compete with NP/PA at their own level, I think you aren't going to find many allies. It's unfortunate that folks end up in this position, and I'm happy for you that you are eking out a living, but you aren't going to ever convince me, wagy, or most of the SDN community that this is something to strive for or establish more of. I think this discussion may have run it's course.

 

[docu]

Of course you do. And other posters have the right to say why it's folly. It's a discussion board, not a soap box. You put out a statement it becomes fair game for responses.

At any rate, unless you have some good justification for why we need GPs as opposed to generalists with longer residency training like FP, for reasons other than simply to compete with NP/PA at their own level, I think you aren't going to find many allies. It's unfortunate that folks end up in this position, and I'm happy for you that you are eking out a living, but you aren't going to ever convince me, wagy, or most of the SDN community that this is something to strive for or establish more of. I think this discussion may have run it's course.

just because you and wagy disagree doesn't mean the rest of the world or the rest of the SDN community agrees. it just doesnt make sense that you on the one hand dog NP/PAs that they're less than a doctor, at the same time, say a GP knows more or at least equivalent, and in the end a GP can't do anything at all, but run a clinic or home care, not even enter a hospital. it makes no sense at all. they used to. you just want to keep it as is, but that's not going to help improve helathcare whatsoever. anyways im done here. you can argue all you want but I still wont be on your side.

 

[smq123]

I feel like people are just talking in circles and nothing really useful is being said. Closing.