Primary care is worthless, and we're all idiots. Or, haven't you heard?

Blue Dog

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Based on the quality of his writing...er, ranting, I suspect that Dr. Jonathan Glauser is a frequent poster on SDN. Any guesses as to his screen name?

From Kevin, M.D.: The Primary Care Backlash Begins

With the primary care shortage starting to gain traction within the mainstream media narrative, it's inevitable that some will lash back against generalists. (via Bob Doherty)

In this rant, bordering on comical, by unhinged emergency physician Jonathan Glauser of the Cleveland Clinic, he attacks his primary care colleagues for promoting the patient centered medical home. Dripping with contempt, he says that "to fund such a venture for groups that are singularly inept at performing anything of value to society is pure folly and a waste of precious health care dollars."

Failing to realize that the state of primary care is what it is because of underfunding, he accuses most offices of "seeing 25 patients (or 20 or 30) a day, so they and their office staff can knock off at 4:30 p.m."

Not happy with smearing the generalists, he also takes shots at dermatologists ("hardly a field that would be missed by the American public"), surgeons (who "want a patient admitted to general medicine to manage a potassium of 3.4"), and orthopedists (who "consults medicine for a Tylenol order").

Apparently, emergency physicians are the only "real" doctors in his eyes.

The nature of budget-neutral reform means that physicians like Dr. Glauser will take a substantial pay cut to adequately fund primary care.

He's merely laying out the groundwork for a furious specialist assault on primary care that will be sure to come.
A follow-up from Kevin, M.D.: Dr. Jonathan Glauser, Your Reviews Are In

And a not-so-nice followup from Frankie, a left-handed anesthesiologist: Who's the Sex Offender? and The Placebo: Dr. Douchebag
 

Joe Richards

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Based on the quality of his writing...er, ranting, I suspect that Dr. Jonathan Glauser is a frequent poster on SDN. Any guesses as to his screen name?

From Kevin, M.D.: The Primary Care Backlash Begins



A follow-up from Kevin, M.D.: Dr. Jonathan Glauser, Your Reviews Are In

And a not-so-nice followup from Frankie, a left-handed anesthesiologist: Who's the Sex Offender? and The Placebo: Dr. Douchebag

Buckle up. There is going to be more of that. Much more.

If congress starts to take away from the specialist to give to primary care (and that's exactly what they are working on) don't be surprised the next time you go to a show up at the hospital and get a few looks.
 

flumazenil

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Guys, primary care and prevention is the road of the future. No way can the health care industry keep up with such high costs. In fact, with more funding for primary care- that bitter ER doc would probably not be seeing half the things in his ER which could have been prevented or taken care of at a primary care physicians office...
 
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andwhat

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Guys, primary care and prevention is the road of the future. No way can the health care industry keep up with such high costs. In fact, with more funding for primary care- that bitter ER doc would probably not be seeing half the things in his ER which could have been prevented or taken care of at a primary care physicians office...

and offff we go.... yes the ED has significant problems, that I will not delve it into at this very moment..
 
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DaveinDallas

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I'm just a know-nothing 3rd year but I don't see why people look down on Family Practice? I recall hearing one of our top 10% classmates talking about what certain board scores would qualify you to do and one of the phrases used was 'banished into Family Medicine hell'....

Having just completed the clerkship -- which obviously qualifies me to pontificate on all things Family Practice :rolleyes: -- the interns, residents and attendings have to know a lot about everything....at least enough to know when it's time to refer or when it's treatable. It was a real wake-up call my first week and never got any better.

I learned to start developing a thick skin when having to say,'I don't know' when an attending asked about the latest recommendation from the USPSTF/ACOG or whatever.....

Can anyone explain the mindset of the critics to me?
 

Blue Dog

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This is the official response from the AAFP's President, Dr. Ted Epperly.

He's a lot more diplomatic than I would've been.

Criticism by Emergency Physician Misses Mark

By Ted Epperly, M.D.
12/24/2008

A recent opinion piece by Jonathan Glauser, M.D., M.B.A., in the December issue of Emergency Medicine News created a loud outcry of "foul" from primary care physicians around the country.

Glauser's column, titled "The Disgraceful State of Primary Care," took direct aim at primary care physicians with little regard for the overwhelming data that shows how vital primary care is as the foundation for effective and quality patient care.

Family physicians were vocal in their disdain for Glauser's viewpoint, and they were joined in that position by their primary care colleagues at the American College of Physicians and the American Osteopathic Association.

In response, I, along with my contemporaries at the ACP and the AOA, wrote letters to Emergency Medicine News. Following is the text of the letter that I wrote.

In his column, "The Disgraceful State of Primary Care," Jonathan Glauser raised a number of issues about the U.S. health care system. But it is the system, not primary care, that has fallen into disgrace.

This is a system that pays for procedures, rather than medical expertise, and results in financial, geographic and time barriers to health care for the underinsured, the uninsured, and those who live in geographically underserved areas.

But the solution is not to discredit primary medical care, which -- according to research dating to the 1990s -- undergirds all high-functioning health care systems in the world. Instead, the solution is to rebuild primary care in the United States so that doctors have the time to be doctors and patients receive the right care at the right time in the right place. And the best vehicle for rebuilding the U.S. health care system is the patient-centered medical home.

The patient-centered medical home is a concept of care, not a payment system. The medical home is a medical practice that gives patients a personal physician who works with a team of health professionals to care for the patient. That care is coordinated across all elements of the health care system, including subspecialist care, hospitalization, home health agencies and community services. The medical home professional uses information technology to exchange health information with pertinent colleagues and institutions, to establish registries, and to design office practices to ensure open-access scheduling, extended office hours and convenient online communication with patients. As a system of care, the medical home can provide health services to patients regardless of their insurance status or ability to pay.

Family medicine -- the only specialty that focuses only on primary care -- trains physicians in virtually all areas of medicine. Family medicine residents complete rotations on all hospital units, including surgery, inpatient care and maternity care. As a result, family physicians have the medical expertise to provide several levels of care themselves and to know when a patient requires subspecialist attention. The 2008 survey of American Academy of Family Physicians members reported that 77 percent see patients in the hospital, 38 percent see patients in coronary care units, 45 percent see patients in intensive care units, 40 percent provide emergency room care, and 30 percent do surgery, in addition to their office practices.

These services are particularly valued in geographical health professions shortage areas, where family physicians are the only source of medical care for millions of Americans. The AAFP survey reported that 77.5 percent of respondents provide care in rural areas. Moreover, respondents reported providing free care to an average of 9.5 patients per week. One of every 10 of survey respondents' patients had no health insurance.

It is this commitment to ensuring that patients have access to comprehensive care that makes primary care uniquely capable of improving health care outcomes, reducing disparities in health care among underserved populations and controlling health care costs.

This has been demonstrated repeatedly in studies by researchers ranging from Johns Hopkins University's Barbara Starfield, M.D., M.P.H., to the Commonwealth Fund's Commission on a High Performance Health System. Pilot programs such as North Carolina's Community Care program for Medicaid patient demonstrate the success of the primary care, patient-centered medical home in caring for low-income patients. Projects such as IBM's patient-centered primary care initiative with Pennsylvania's Geisinger Health System prove that a patient-centered medical home can improve outcomes and rein in costs. Throughout the country, private insurers, state governments and health systems themselves are testing this concept and, to date, determining that the medical home improves patient access to care, the quality of care, outcomes of care and cost control.

The uniform outcomes of these pilot projects demonstrate that the concept of a primary care, patient-centered medical home does, in fact, work to the benefit of all stakeholders. Family physicians and their primary care colleagues are proud to move beyond pointing out the serious flaws of America's health care system and, instead, help lead the movement that is helping to solve the very problems cited by Dr. Glauser.
 

zmeister22

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and offff we go.... less money to ER docs would totally make sense... sad sad people in my opinion, like triage nurses at times.. I mean stabilize, usually without even making a correct diagnosis (more than 90% of the time from what I have seen), and move it along.. what kind of career is that?
My medical assistant in residency could be more beneficial to me, than alot of the ER "docs" that I have ever worked with. She could make a correct diagnosis, unlike alot of the 'docs' working in the ED.

So you respond to the doctor-who-bashes-others by doing the same? Quite professional. Yes, I do realize that primary care needs a MUCH stronger role in US health care, but managing an ER where you have up to 40 patients at one time is not easy. They did just as much school as did, so please play nice.
 

Faebinder

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and offff we go.... less money to ER docs would totally make sense... sad sad people in my opinion, like triage nurses at times.. I mean stabilize, usually without even making a correct diagnosis (more than 90% of the time from what I have seen), and move it along.. what kind of career is that?
My medical assistant in residency could be more beneficial to me, than alot of the ER "docs" that I have ever worked with. She could make a correct diagnosis, unlike alot of the 'docs' working in the ED.
While I do agree that they seem to be so simple now a days with them just consulting and doing nothing....the answer to the primary care problem is not "reducing ER physician fees". What needs to be done is killing the incentive for people to go to the ER or fixing EMTALA to allow ER physicians to kick people out as opposed to just treating them and consults. The typical ER case that needs to be kicked out but still requires $2000 worth or work up is "Toothache" and "Ran out of meds" and of course my favorite "I have a tootache and I ran out of pain meds".
 

andwhat

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So you respond to the doctor-who-bashes-others by doing the same? Quite professional. Yes, I do realize that primary care needs a MUCH stronger role in US health care, but managing an ER where you have up to 40 patients at one time is not easy. They did just as much school as did, so please play nice.
Please do rotations first, and then understand what I mean. ER is a complete dumping ground. It is awful. I do not at all discredit your opinion, but it is a liability issue, that needs to be rectified.
 
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andwhat

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That much I agree with you. The rest is colleague-bashing, which I will not get into.
I agree, inappropriate.... however, I do prefer better communication than

"a NH guy with weakness cum and get it, his urine looks dirty its a simple UTI!"

ummmmm for what exactly? How long has he been weak? Why is he in the NH? What would the patient and family like done? Did you conveniently forget to tell me about the Troponin of 8.7?? Is it me, or did you notice that his right side is not moving, and he has stuttering speech, OH WAIT that probably just happened while I was coming down the elevator to see him correct? Man... it is unbelievably frustrating at times let me tell you..
Admitting 13-15 at night (from all over --- different counties, including our own overburdened ED system), plus cross covering over 100 patients, is significantly more challenging than seeing 40 patients (mostly acute care) in the E.D.
Overall it is very nice -- however it presents its own unique challenges.
 
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secretwave101

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He's a lot more diplomatic than I would've been.
Had a chance to meet the guy last summer. He really is as cool as his letter suggests. He's also a true believer in FP. The guy travels over 250 days a year, or something insane like that, evangelizing for primary care in America.
 

andwhat

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EMTALA already allows those people to be kicked out. All EMTALA requires is a Medical Screening Exam (looking for an emergency medical condition) and Stabilization. There is no requirement that these patients receive diagnostics and treatment.

The fact that the ER plays CYA by working up every potential medical problem, ordering endless tests that are both costly and useless, and calling specialty consults for every little nothing case is not the fault of EMTALA. It is the fault of ER doctors who cover up ignorance with diagnostic testing.

You want to reduce the cost and wait time of ER patients? Fire all the ER docs, set up a table manned by an RN and a phone, and have her call the appropriate physician for their problem.

please don't forget the hospitalists ;-)) consulting every single physician in the directory to cover up negligence, is more like it.... needs to stop, and will not stop unless people make a stand for it.
ER is a complete and utter nightmare. Discombobulated circus. I am not being sarcastic, stating that my Medical Assistant in residency had a higher level of thinking some of these ER "docs". That is serious -- and it is shameful. Something that I am not at all proud to be a part of.
 
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MedicineDoc

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I am not surprised there are uninformed mentally unstable jackasses. After all I saw them sprinkled about all through medical school and beyond. I am surprised that the garbage was actually published. It is wrong on so many levels. Hospital care and outpatient care are very intertwined and not only on the front end. Hence the direct admits bypassing the ER completely and the hospital followup visits helping to shorten and prevent hospital stays.
 

medicienne

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I hope nobody applies to Family Medicine, and I am the superstar in all the interviews and ranked #1 in all programs! :D
 

ghost dog

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As a Canadian family doctor, you have my sympathy and respect. It seems that it is becoming progressively more difficult to practice proper family medicine in the U.S. with each passing year. Antagonistic ER MD jerks who write articles about family medicine being "a waste of resources" hardly help this issue.
 
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