Proposed solution to help FP situation in US

[Dr.Millisevert]

Considering the gradual downfall of the role of the General/Family medical doctor in the US.. and also the upcoming assault from DNP proposal; we need to come up with another plan to help support MD/DO FP/GPs in America.

One option which may be more reasonable is supporting the development of a Full reciprocity of Australian and New Zealand FP training programs with the ACGME.
The ABFM already currently recognizes the FP programs in Australia and NZ as being equivalent to US programs which allows Aus/NZ FP graduates to become ABFM certified, however the Aus/NZ programs are not accredited or recognized by ACGME. So, it’s a bit of a catch 22. Even though the ABFM will allow you to become board certified, and AUS/NZ trained FP will still have to complete 2-3 years of ACGME accredited training in order to obtain a state medical license.

This is not the case with Canada. Canadian FP programs are also not ACGME accredited, however.. they have a FULL reciprocity with ACGME such that their programs although not accredited by ACGME are considered “legal equivalents” through ACGME bylaws.


Proposal:
To help alleviate this problem, I feel we should all email the AAFP who are the representative body for FPs in the United States and urge them to put pressure on the ACGME to develop a FULL reciprocity with the Australian/NZ accreditation bodies identical to the agreement with Canada.

thoughts?

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[exPCM]

Considering the gradual downfall of the role of the General/Family medical doctor in the US.. and also the upcoming assault from DNP proposal; we need to come up with another plan to help support MD/DO FP/GPs in America.

One option which may be more reasonable is supporting the development of a Full reciprocity of Australian and New Zealand FP training programs with the ACGME.
The ABFM already currently recognizes the FP programs in Australia and NZ as being equivalent to US programs which allows Aus/NZ FP graduates to become ABFM certified, however the Aus/NZ programs are not accredited or recognized by ACGME. So, it’s a bit of a catch 22. Even though the ABFM will allow you to become board certified, and AUS/NZ trained FP will still have to complete 2-3 years of ACGME accredited training in order to obtain a state medical license.

This is not the case with Canada. Canadian FP programs are also not ACGME accredited, however.. they have a FULL reciprocity with ACGME such that their programs although not accredited by ACGME are considered “legal equivalents” through ACGME bylaws.


Proposal:
To help alleviate this problem, I feel we should all email the AAFP who are the representative body for FPs in the United States and urge them to put pressure on the ACGME to develop a FULL reciprocity with the Australian/NZ accreditation bodies identical to the agreement with Canada.

thoughts?

A major reason USMGs are not going into FP is that higher and higher debt loads motivate people to pursue higher paying specialties. If you want more FPs they need to be paid better and we need to look at programs to reduce the USMG debt loads.

 

[deleted87716]

Australia and New Zealand are facing doctor shortages of their own: http://www.vedior.com/hr-portal/recruitment-news/australias-doctor-shortage-worsens.html?c=3744

Importing doctors from abroad does nothing to solve the underlying problem of inadequate/declining reimbursement for cognitive services.

 

[MOHS_01]

A few issues come to mind right out of the gates on this.

1. How exactly would full recipricocity help anyone other than the Australian / NZ grads? Not sure....

2. Regarding the competition with DNP's, etc -- "title" and "brand" encroachment is the primary threat with the DNP program. 23 states already allow independent NP practice; more will surely follow in response to any "perceived" shortage of primary care. Competition is no longer avoidable, and it will prove very difficult to economically compete with someone who is willing and capable of working for a lower wage than a duly trained MD. I see legislative and regulatory action with appropriate MD oversight as the only possible winnable solution to this half-trained mid-level invasion.

3. Lastly -- the reasons behind the declining interest in primary care are largely economic; however, debt levels are not the only reason (and, frankly, probably not the top reason). Even if medical school costs were 100% subsidized for students in a primary care track there would be significant "buyer's remorse" with many looking for a way out. Interests change, goals change, life changes.... When you couple that with long term projections of earning potential, etc -- primary care may not seem all that attractive to those interested in material goods, retirement, providing for their children, etc.

Physician compensation is a very (very) complicated proposition, both in concept and in practice. Low volume specialties will be forced to be especially nimble and adaptive with the upcoming changes.

 

[Dr.Millisevert]

A few issues come to mind right out of the gates on this.

1. How exactly would full recipricocity help anyone other than the Australian / NZ grads? Not sure....

2. Regarding the competition with DNP's, etc -- "title" and "brand" encroachment is the primary threat with the DNP program. 23 states already allow independent NP practice; more will surely follow in response to any "perceived" shortage of primary care. Competition is no longer avoidable, and it will prove very difficult to economically compete with someone who is willing and capable of working for a lower wage than a duly trained MD. I see legislative and regulatory action with appropriate MD oversight as the only possible winnable solution to this half-trained mid-level invasion.

3. Lastly -- the reasons behind the declining interest in primary care are largely economic; however, debt levels are not the only reason (and, frankly, probably not the top reason). Even if medical school costs were 100% subsidized for students in a primary care track there would be significant "buyer's remorse" with many looking for a way out. Interests change, goals change, life changes.... When you couple that with long term projections of earning potential, etc -- primary care may not seem all that attractive to those interested in material goods, retirement, providing for their children, etc.

Physician compensation is a very (very) complicated proposition, both in concept and in practice. Low volume specialties will be forced to be especially nimble and adaptive with the upcoming changes.

1. Well... it doesn't help Aus grads financially. On Average FPs in Aus do better financially than their American counterparts. Even as residents Aus FP trainees make more than US residents. So, I wouldn't worry too much. It would however provide US FPs with an opportunity to have a working holiday and make lots of cash. It would also provide US medical graduates with more high quality FP residency spots to choose from.

2. Very true..

3. Agreed. I also feel its a very unfortunate situation in the US.

 

[Dr.Millisevert]

A major reason USMGs are not going into FP is that higher and higher debt loads motivate people to pursue higher paying specialties. If you want more FPs they need to be paid better and we need to look at programs to reduce the USMG debt loads.

Allowing US MD/DO grads to complete FP residency in Aus might help. Residents get paid manytimes 2 or 3 times what you'd make in a US residency.

When presented with the option to complete your residency in Australia possibly near a beach and make more money than doing it in some cold inner city of America.. you don't think this might make more US grads interested in FP?

 

[Dr.Millisevert]

Importing doctors from abroad does nothing to solve the underlying problem of inadequate/declining reimbursement for cognitive services.

Agreed. However, forming a relationship with a country that has a greater support base for their FPs... and a system that allows for better financial reimbursement may be a good thing.

 

[secretwave101]

I can't see how this proposal does anything but confuse the issue in the US, but I would move to Middle Earth in an instant after residency if the pay was equivalent. I would have gone for residency if I could have.

I look at that option all the time and try to make it work economically on paper. Wife's on board too, so it's just a $$ issue at this point - as always.

 

[Dr.Millisevert]

I would move to Middle Earth in an instant after residency if the pay was equivalent. I would have gone for residency if I could have.

I look at that option all the time and try to make it work economically on paper. Wife's on board too, so it's just a $$ issue at this point - as always.

In Australia the money is definitly usually more than equivalent.. many times greatly exceeding what US FPs make. Australian FP(GP) residents usually make at least 2x if not 3x more than US FP residents.

Australian FP training
The Royal Australian College of General Practitioners (RACGP)

In New Zealand the money is more or less equivalent to US. (However, not usually as much money as in Australia.) NZ GP residents still usually make more than US FP residents (maybe 1.5 - 2x).

If you have any further questions regarding NZ GP residency spots you may want to contact Tana Fishman, MS, DO, FRNZCGP. She is an American trained FP who is the current chair of GP resident education for the NZ College of GPs.

 

[secretwave101]

I'm currently in residency. Finishing up my 2nd year in about 2 weeks. The idea of going back and doing it again ranks somewhere just slightly above driving bamboo shoots under my fingernails.

I'd like to practice there, not train there. Almost done with that.

 

[EdibleEgg]

I don't think this kind of agreement would benefit the US. The number of Oz/NZ GP's making the move would be too small to make a real difference, and the training is not exactly equivalent. The medical training is basically the British system (the Kiwi docs I know are very well trained, but with a different focus). The docs there (at least in NZ) are basically outpatient only with no OB. I understand there is a similar shift in the US, but I'm not in favor of anything that enables that change to happen faster. I think that kind of agreement would open the doors wider for DNP's.

The primary care shortage is multifactorial, but money has to change if the situation is going to change. You can talk about global warming, carbon footprints, whatever until you are blue in the face, but consumption didn't decrease until gas prices increased.

If you want go to NZ/Australia for a working holiday, the option is already there. The money is better than locums jobs in the US, and middle earth is beautiful (the locals in Kaikoura always raved about a left break at cove just north of the city, I'm not a surfer, but it's apparently not too shabby secretwave). As far as the average salary, I doubt there is much of a difference when you factor in cost of living/exchange etc. Austrailans do a little better on average than Kiwi's. However, nothing in New Zealand that bites will kill you, and the only thing that's really poisonous hopped ship from Australia.

 

[secretwave101]

the locals in Kaikoura always raved about a left break at cove just north of the city, I'm not a surfer, but it's apparently not too shabby secretwave).

Who said anything about surfing? Come, now. My motivation to live there is purely, um, professional. It would be good for my career and all that.

Anyway, the problem is the locums thing. My kids need a bit more stability than a new job every year or so will bring. Sure would work for me, though.

 

[EdibleEgg]

As long as you are willing to work in an underserved area (pretty much anywhere outside of Christchurch, Wellington, and Auckland) for a couple of years, you don't have to work as a locums.

 

[secretwave101]

OK, so where was that left break?

 

[NewmansOwn]

If FPs do better financially in Australia than they do in the US, why would Australian doctors come to the US under such an agreement?

 

[EdibleEgg]

There would be just as many, if not more, US doctors leaving as there would be Australian/Kiwi docs immigrating.

 

[Dr.Millisevert]

If FPs do better financially in Australia than they do in the US, why would Australian doctors come to the US under such an agreement?

overseas working experience... to complete a fellowship.. etc. Same reasons many of them used head to the UK for a year after residency.

 

[Dr.Millisevert]

There would be just as many, if not more, US doctors leaving as there would be Australian/Kiwi docs immigrating.

Yeah, but again.. these countries have a better system in place to support FPs professionally and financially. Developing a closer relationship and reciprocal agreement with them may rub off on the US.

 

[EdibleEgg]

"Yeah, but again.. these countries have a better system in place to support FPs professionally and financially."


I don't think this is totally true. I'm not saying the system in the US is better, but the two are different enough that you are comparing apples to oranges. First off, there really aren't FP's in these countries. Primary care is handled by GP's (I know that's sort of splitting hairs, but there are differences). Pediatricians/internists are considered specialist and don't do primary care. There really are no midlevels. Pay is pretty good now, but the pendulum has only recently changed directions. I worked with a group that averaged 90,000 NZ/year in the late nineties (about 30K$ US per year at the time). There are lots of great things about the medical system there, but there are lots of problems as well. We could definitely learn a few things, but we could also import some problems. I'm not totally opposed to a reciprocal agreement, but given that US physicians can practice there now I don't see much benefit.

 

[deleted87716]

I don't think this kind of agreement would benefit the US.

Ditto.

If you want go to NZ/Australia for a working holiday, the option is already there.

Yep. Details here: http://www.aafp.org/ihcop/organizations.html

 

[Dr.Millisevert]

Yep. Details here: http://www.aafp.org/ihcop/organizations.html

That is the exact same reciprical agreement that I have already previously posted.

As an American FP graduate you can't just walk into Australia and take a high paying job. Yes, you may be able to do short locums... but you won't be eligible for private practice in Australia. You may however work within a public clinic.. usually in a rural area (designated area of need). If you want to obtain an Australian medical license and work in private practice you will be required to sit some exams and usually redo at least 1-2 years of residency.

Australian/NZ FPs can also become ABFM certified via this reciprical agreement. However... this doesnt mean they will be given a US state license without doing a couple of years of ACGME residency.


If as I'm suggesting... if the ACGME were to develop an agreement with the AMC (Australian Medical Council). Then FPs from both countries would be able to come and go without doing extra residency years.

 

[Dr.Millisevert]

Pay is pretty good now, but the pendulum has only recently changed directions. I worked with a group that averaged 90,000 NZ/year in the late nineties (about 30K$ US per year at the time).

I'm not totally opposed to a reciprocal agreement, but given that US physicians can practice there now I don't see much benefit.

well.. at the moment. $1 USD = $1.05 AUD = $1.32 NZD
Even after the exchange rate is taken into consideration.. (at least in Australia..) FPs there are on average doing much better financially than US FPs. (those salaries you've quoted look like they are 1) outdated concerning currency exchange and 2) more than likely quoted from a clinic that takes predominatly public patients in NZ.. compare that to an avg of maybe 150-250k NZD for a private practice in New Zealand or 300-500k AUD for private practice in Australia).

Again.. US FPs can technically work in these countries .. but, only within the public system and the only way to obtain full private practice benefits is to sit all their exams and usually do 1-2 years of "supervised practice" or resdency years there.

 

[EdibleEgg]

I commend you for thinking outside of the box, but your original post concerned "the gradual downfall of the role of the General/Family medical doctor in the US." I still don't see how this really helps, unless you mean that all the disenfranchised US docs could easily flee to Australia.

The salaries I quoted were from the late nineties; things are much better there now. I mentioned those numbers to point out that higher pay is a recent phenomenon. Exchange rate aside, the other issue is cost of living. I'm not sure about Australia, but in NZ the cost of living is much higher than the US. When you compare salary to average income, there's not much difference.

I don't think you completely understand how the medical system there works. For primary care, everything is basically public.

It is true that you can't walk right in and join a practice in downtown Sydney or Auckland. You are not limited to short term locums though. You would be required to pracitice in a supervised role in a needs area before applying for your unrestricted registration. For me, the supervised role was varied, but it was never more involved thant a chart review. It was nothing like repeating a year of residency (although that is an option).

I don't think the system is unreasonable. The differences in training aside, the differences in system, medications, etc. are different enough that a supervisory period is warranted.

 

[Dr.Millisevert]

I commend you for thinking outside of the box, but your original post concerned "the gradual downfall of the role of the General/Family medical doctor in the US." I still don't see how this really helps, unless you mean that all the disenfranchised US docs could easily flee to Australia.

Well, it would open more FP residency spots to US graduates in very desirable places and pay residents double their current GME funding. ...making FP a more desirable choice for many US graduates, which in turn will help. Also, as I said before.. developing a relationship with a country who seems to have been able to maintain a better role for the FP within their healthcare system. It will be interesting to see how things pan out over the next 10 years in the US and which way our health system will turn. If we take on a more public system ourselves and we do not also increase medical school tuition subsidisation, reduce malpractice costs, etc, etc. You may well and truly see many more disenfranchised US docs fleeing elsewhere..

Exchange rate aside, the other issue is cost of living. I'm not sure about Australia, but in NZ the cost of living is much higher than the US. When you compare salary to average income, there's not much difference.

True, however if you also consider other sources of cash outflow for most US physicians (malpractice insurance, their own families health insurance, their children's education, etc, etc) You'd be saving so much in other areas that it would more than make up for 15-20% higher gas prices or the luxury car tax on your BMW.

I don't think you completely understand how the medical system there works. For primary care, everything is basically public.

This is true more so in NZ than Australia. Regardless, they are doing better financially than most American FPs.