Quantcast

The Future of Primary Care

This forum made possible through the generous support of SDN members, donors, and sponsors. Thank you.

What will be the fate of primary care in America?

  • No future. Physicians will be replaced by mid-level providers. Goodbye family doctor.

    Votes: 48 35.3%
  • There is a future. Shortages will drive PCP salaries up and the field will remain alive and kickin.

    Votes: 60 44.1%
  • Shut up Eric

    Votes: 28 20.6%

  • Total voters
    136
E

Eric Lindros

In the spirit of depressing "state of medicine" news, I wanted to poll the audience to see what y'all think about the future of primary care in America. Maybe we could generate some discussion and leave this in pre-allo (because I'm sure some mod is going to want to move it) so that current pre-meds can get some good information from all the smart peeps here on SDN.
 

LifetimeDoc

EM Attending
10+ Year Member
Joined
Apr 30, 2006
Messages
2,845
Reaction score
61
I think that a lot of primary care will be farmed out to NP and PA positions, but I see them handling patients that don't already see a physician on a regular basis. So I don't see a growth potential in primary care for physicians, just more primary care given to those who can't afford to pay for a physician to do the same thing.
 

dutchman

Full Member
10+ Year Member
7+ Year Member
Joined
Sep 5, 2006
Messages
1,106
Reaction score
6
If physicians dont grow a spine and start fighting back, primary care is going to the crappers.
 

Law2Doc

5K+ Member
Moderator Emeritus
10+ Year Member
Joined
Dec 20, 2004
Messages
30,878
Reaction score
10,057
In the spirit of depressing "state of medicine" news, I wanted to poll the audience to see what y'all think about the future of primary care in America. Maybe we could generate some discussion and leave this in pre-allo (because I'm sure some mod is going to want to move it) so that current pre-meds can get some good information from all the smart peeps here on SDN.

You left out the most likely future outcome -- there will be ample demand and primary care positions, but the salaries will continue to decline and hours increase due to insurer reimbursement control.
 
E

Eric Lindros

You left out the most likely future outcome -- there will be ample demand and primary care positions, but the salaries will continue to decline and hours increase due to insurer reimbursement control.

Wouldn't this eventually lead to extinction, theoretically (option A)? What doctor would go to medical school for, say, a salary of 40K a year?
 

dutchman

Full Member
10+ Year Member
7+ Year Member
Joined
Sep 5, 2006
Messages
1,106
Reaction score
6
Wouldn't this eventually lead to extinction, theoretically (option A)? What doctor would go to medical school for, say, a salary of 40K a year?

No one that I know. But the scenerio that Law2doc points out it very concievable(actually very likely). That is why physicians need to put on their gloves and start fighting.
 

Towelie

Resident Towel
10+ Year Member
5+ Year Member
Joined
Sep 18, 2006
Messages
1,129
Reaction score
2
No one that I know. But the scenerio that Law2doc points out it very concievable(actually very likely). That is why physicians need to put on their gloves and start fighting.

How do you propose we do this? Just curious.
 

LifetimeDoc

EM Attending
10+ Year Member
Joined
Apr 30, 2006
Messages
2,845
Reaction score
61
You left out the most likely future outcome -- there will be ample demand and primary care positions, but the salaries will continue to decline and hours increase due to insurer reimbursement control.

Exactly why physicians will let the NP and PAs take over many primary care positions because those professions don't have the time commitment and educational costs of becoming a MD/DO. The demand for primary care will go up with governmental involvement (one way or another with universal care), but the payments will continue to go down. You can either compete for those declining doctors with NP and PAs, or find a different specialty in medicine that requires the services of a MD/DO trained physician.
 

dutchman

Full Member
10+ Year Member
7+ Year Member
Joined
Sep 5, 2006
Messages
1,106
Reaction score
6
How do you propose we do this? Just curious.

By lobbying to get physicians excluded from antitrust restrictions on unionization. With a union, physicans can take the fight straight to the enemy's doorsteps.

BTW, with a union, you can forget about all these wild cuts you hear about.
 

Towelie

Resident Towel
10+ Year Member
5+ Year Member
Joined
Sep 18, 2006
Messages
1,129
Reaction score
2
By lobbying to get physicians excluded from antitrust restrictions on unionization. With a union, physicans can take the fight straight to the enemy's doorsteps.

BTW, with a union, you can forget about all these wild cuts you hear about.

Sounds good to me. Do you know of any lobbying groups that are proposing this?
 

sunnyjohn

Got Mustard?
10+ Year Member
5+ Year Member
Joined
Feb 24, 2005
Messages
2,697
Reaction score
10
PA's and NP's will continue to increase their ranks. (More power to them).

Primary Care docs won't go away. The problem is us pre-docs wanna all live in population centers <75000.

Here's my story. I'm a surg tech. I make 3x as much for a two-day gig at a rural hospital than in the big city. I'm paid by the hospital and receive a check from the surgeon, but the hospital check alone is larger than my big city checks.

The ortho surgeon I scrub for leaves his big city practice, comes on down to a rural hospital with 2 ORs and operates (Knee-hip resurfacing, etc) He told me he make more in the small hospital than he makes fighting for market share in the big city. He made more than he ever has last year. The guys is an EXCELLENT surgeon and a fairly well-known name.

That rural hospital's general surgeon only works in that community and has a similar sweet set up. So does the hospital's 3 internists.

I often get these type of rural gigs and make a killing.


If Primary care docs want to make it, they will have to be flexible. The pool of sick people hasn't dried up. There's good money out in the boonies. It's flowing milk & honey out there! :smuggrin:
 

Doctor Bagel

so cheap and juicy
Moderator Emeritus
15+ Year Member
Joined
Sep 26, 2002
Messages
10,910
Reaction score
1,150
PA's and NP's will continue to increase their ranks. (More power to them).

Primary Care docs won't go away. The problem is us pre-docs wanna all live in population centers <75000.

Here's my story. I'm a surg tech. I make 3x as much for a two-day gig at a rural hospital than in the big city. I'm paid by the hospital and receive a check from the surgeon, but the hospital check alone is larger than my big city checks.

The ortho surgeon I scrub for leaves his big city practice, comes on down to a rural hospital with 2 ORs and operates (Knee-hip resurfacing, etc) He told me he make more in the small hospital than he makes fighting for market share in the big city. He made more than he ever has last year. The guys is an EXCELLENT surgeon and a fairly well-known name.

That rural hospital's general surgeon only works in that community and has a similar sweet set up. So does the hospital's 3 internists.

I often get these type of rural gigs and make a killing.


If Primary care docs want to make it, they will have to be flexible. The pool of sick people hasn't dried up. There's good money out in the boonies. It's flowing milk & honey out there! :smuggrin:

yeah, it seems like there's this misguided notion on SDN that rural docs make less money, but that doesn't appear to be true. Rural docs can make more money and still get deals to get their loans paid off.
 

dutchman

Full Member
10+ Year Member
7+ Year Member
Joined
Sep 5, 2006
Messages
1,106
Reaction score
6
Sounds good to me. Do you know of any lobbying groups that are proposing this?

The AMA had a looby for this in 1997
http://www.ama-assn.org/ama1/pub/upload/mm/369/ceja_9a98.pdf

The only problem with the AMA is that some of those older docs just don't have the level of agressiveness necessary for this type of fight. It is time for the younger docs/medstudents to go there and set a new tone. Afterall it is the younger docs that are going to have it worst if the present trend continues. They need to be agressive about unionization. That will at least let the politicians know that doctors are willing to fight. That will be a lot better than status quo, where they push doctors whenever they feel like it.
 

primadonna22274

Senior Member
15+ Year Member
Joined
Jun 6, 2005
Messages
2,284
Reaction score
346
I wish I had a crystal ball. I really do, because then I would know whether it's worth the blood, sweat and tears to give up a regular and comfortable paycheck for another 7+ years to become a physician, or if I should just stay the course as a PA and wait for the winds to change.

There's always some speculation about a bridge program for experienced PAs/NPs to become physicians. Will it ever happen? I doubt it. I'm certainly not waiting around for it.

Or will primary care really become the domain of the midlevel? (I STILL hate that term...midlevel...ugh.) Hard to know. I've worked in family practice the past six years. Moved to EM to try something new. I miss primary care. I did an awful lot as an FP PA, had good autonomy, was trusted by my physician colleagues and my practice resembled theirs in a lot of ways. Differences? I didn't round in the hospital; my patients were, in general, younger and healthier (although plenty of DM/HTN/hyperlipidemia to go around and rx-juggling); and I had the luxury of time to do more preventive care (translation: all the boring well woman exams and well baby exams you could ask for, but the docs I worked with did their share too). But I never felt like I could just take over primary care--I was always very grateful for another doc down the hall when a patient looked crappy or something didn't make sense.

Most of primary care is routine. What we do most often is where we develop expertise. We all find our niche, something we do exceptionally well and enjoy doing, and we may develop a patient following based on that. But there is a big enough chunk of primary care that requires physician knowledge (you know, the deeper pathophys, basic sciences, the esoteric problems that show up with relative infrequency but nonetheless do occur) that I don't believe midlevels (that ugly term again!) should ever supplant the primary physician completely. A collaborative practice makes far more sense: the primary care physician as team captain, say, and the PA and/or NP as integral members of the team, all working together to provide quality health care (NOT the minions some of you think we are.)

For me, there's a need to know what I don't yet know. Not because my practice as a PA requires it--to do what I do, I've been very well trained--and experience is a good teacher. But it's about personal satisfaction and filling a void, completing the process so to speak. BUT it's becoming more and more expensive to be trained as a physician and the opportunity costs are tremendous. THEN consider will my role as a physician be obviated in primary care, the only place I really want to work? If so, I should have stayed a PA and just made the best of it.

So, anyone have that crystal ball? ;)
 

dutchman

Full Member
10+ Year Member
7+ Year Member
Joined
Sep 5, 2006
Messages
1,106
Reaction score
6
I wish I had a crystal ball. I really do, because then I would know whether it's worth the blood, sweat and tears to give up a regular and comfortable paycheck for another 7+ years to become a physician, or if I should just stay the course as a PA and wait for the winds to change.

There's always some speculation about a bridge program for experienced PAs/NPs to become physicians. Will it ever happen? I doubt it. I'm certainly not waiting around for it.

Or will primary care really become the domain of the midlevel? (I STILL hate that term...midlevel...ugh.) Hard to know. I've worked in family practice the past six years. Moved to EM to try something new. I miss primary care. I did an awful lot as an FP PA, had good autonomy, was trusted by my physician colleagues and my practice resembled theirs in a lot of ways. Differences? I didn't round in the hospital; my patients were, in general, younger and healthier (although plenty of DM/HTN/hyperlipidemia to go around and rx-juggling); and I had the luxury of time to do more preventive care (translation: all the boring well woman exams and well baby exams you could ask for, but the docs I worked with did their share too). But I never felt like I could just take over primary care--I was always very grateful for another doc down the hall when a patient looked crappy or something didn't make sense.

Most of primary care is routine. What we do most often is where we develop expertise. We all find our niche, something we do exceptionally well and enjoy doing, and we may develop a patient following based on that. But there is a big enough chunk of primary care that requires physician knowledge (you know, the deeper pathophys, basic sciences, the esoteric problems that show up with relative infrequency but nonetheless do occur) that I don't believe midlevels (that ugly term again!) should ever supplant the primary physician completely. A collaborative practice makes far more sense: the primary care physician as team captain, say, and the PA and/or NP as integral members of the team, all working together to provide quality health care (NOT the minions some of you think we are.)

For me, there's a need to know what I don't yet know. Not because my practice as a PA requires it--to do what I do, I've been very well trained--and experience is a good teacher. But it's about personal satisfaction and filling a void, completing the process so to speak. BUT it's becoming more and more expensive to be trained as a physician and the opportunity costs are tremendous. THEN consider will my role as a physician be obviated in primary care, the only place I really want to work? If so, I should have stayed a PA and just made the best of it.

So, anyone have that crystal ball? ;)


Nice post.

I don't have a crystal ball, but I can predict based on the recent trends. The politicians want to cut healthcare costs, but they dont want to offend their generous donors(insurance companies, pharmaceutical companies, HMOs etc) who account for the main bulk of the costs, so they attack the weakest link(doctors/healthcare workforce). As they press forward with these cuts, expect PAs and NPs to be affected too.
 

em783

Full Member
10+ Year Member
Joined
Nov 27, 2006
Messages
125
Reaction score
3
PA's and NP's will continue to increase their ranks. (More power to them).

Primary Care docs won't go away. The problem is us pre-docs wanna all live in population centers <75000.

Here's my story. I'm a surg tech. I make 3x as much for a two-day gig at a rural hospital than in the big city. I'm paid by the hospital and receive a check from the surgeon, but the hospital check alone is larger than my big city checks.

The ortho surgeon I scrub for leaves his big city practice, comes on down to a rural hospital with 2 ORs and operates (Knee-hip resurfacing, etc) He told me he make more in the small hospital than he makes fighting for market share in the big city. He made more than he ever has last year. The guys is an EXCELLENT surgeon and a fairly well-known name.

That rural hospital's general surgeon only works in that community and has a similar sweet set up. So does the hospital's 3 internists.

I often get these type of rural gigs and make a killing.


If Primary care docs want to make it, they will have to be flexible. The pool of sick people hasn't dried up. There's good money out in the boonies. It's flowing milk & honey out there! :smuggrin:

Well-said. I don't think enough people realize how much demand there is for all types of specialists and primary care physicians in rural/small-town areas. But of course, like you said, the problem is possibly sacrificing quality of life by living in a less than desirable town or having to commute long distances. Then again, the difference in checks should be enough to sway some and would de-concentrate physician numbers in urban centers and allow a more even spread.
 

sunnyjohn

Got Mustard?
10+ Year Member
5+ Year Member
Joined
Feb 24, 2005
Messages
2,697
Reaction score
10
Another thing to consider-

What kind of 'quality of life" or "lifestyle" will you have when you have $300k in debt, kids 17 years away from college and the mortgage for a decent home in your metropolis cost $300K?

Yep,I'll leave others to duke it off for turf among the 40 gazillion medical practioners in Gotham. I'll set up shop in some nice little community, where I'm the cat's meow. I'll be grinning the whole time I mow my 2 acre front lawn and catch a mess o' fish in the stream running through the back woods of my 100 acre spread I paid less than 2 million for. :smuggrin:

Even the swanky stores have an internet presence. UPS, USPS and FEDEX do deliver to small town America. As long as I can get to Tar-jay twice a year and the ballet/opera once a year on my vacation, I'm happy!


Modern day Doc Baker's don't get paid in chickens people. They get take in cold, hard green.
 

MonkeyNuts!

Even Kal has bad days...
10+ Year Member
Joined
Jun 23, 2005
Messages
3,646
Reaction score
14
How do you propose we do this? Just curious.

I'm up for a literal interpretation. Let's go and seriously beat the crap out of the insurance people. I was almost TKOed this weekend but I'm back up to fight speed now. If we waltzed into a corporate insurance building, put up a sign that said premeds at work and just started clocking people left and right, no one would stop us. I have a homemade baseball bat covered in nails and shards of broken glass for this day.

When u guys free to do this?
 

MonkeyNuts!

Even Kal has bad days...
10+ Year Member
Joined
Jun 23, 2005
Messages
3,646
Reaction score
14
I'm thinking maybe the Monday after National Beat the Sh1t out of Gunners Day.

I have a set of rusty brass knuckles and a lead pipe for NBSGD.
 

em783

Full Member
10+ Year Member
Joined
Nov 27, 2006
Messages
125
Reaction score
3
Another thing to consider-

What kind of 'quality of life" or "lifestyle" will you have when you have $300k in debt, kids 17 years away from college and the mortgage for a decent home in your metropolis cost $300K?

Yep,I'll leave others to duke it off for turf among the 40 gazillion medical practioners in Gotham. I'll set up shop in some nice little community, where I'm the cat's meow. I'll be grinning the whole time I mow my 2 acre front lawn and catch a mess o' fish in the stream running through the back woods of my 100 acre spread I paid less than 2 million for. :smuggrin:

Even the swanky stores have an internet presence. UPS, USPS and FEDEX do deliver to small town America. As long as I can get to Tar-jay twice a year and the ballet/opera once a year on my vacation, I'm happy!


Modern day Doc Baker's don't get paid in chickens people. They get take in cold, hard green.

Haha. Yet another well-stated commentary.
 

dutchman

Full Member
10+ Year Member
7+ Year Member
Joined
Sep 5, 2006
Messages
1,106
Reaction score
6
I'm up for a literal interpretation. Let's go and seriously beat the crap out of the insurance people. I was almost TKOed this weekend but I'm back up to fight speed now. If we waltzed into a corporate insurance building, put up a sign that said premeds at work and just started clocking people left and right, no one would stop us. I have a homemade baseball bat covered in nails and shards of broken glass for this day.

When u guys free to do this?

:laugh: :laugh:
 

sunnyjohn

Got Mustard?
10+ Year Member
5+ Year Member
Joined
Feb 24, 2005
Messages
2,697
Reaction score
10
I'm thinking maybe the Monday after National Beat the Sh1t out of Gunners Day.

I have a set of rusty brass knuckles and a lead pipe for NBSGD.

Hold up! When did we set a date for "National Beat the S*&# out of Gunners Day" and WHY was I not informed??

*Sunny pulls out her nunchucks and straps on her 45...crouching tiger.. hidden non-trad*
 

DropkickMurphy

Membership Revoked
Removed
10+ Year Member
Joined
Sep 13, 2005
Messages
9,729
Reaction score
25
Hold up! When did we set a date for "National Beat the S*&# out of Gunners Day" and WHY was I not informed??

*Sunny pulls out her nunchucks and straps on her 45...crouching tiger.. hidden non-trad*
*cleans Remington 700* Just call me Whitefeather. :laugh: (*waits patiently for someone to figure out this analogy*)
 

sunnyjohn

Got Mustard?
10+ Year Member
5+ Year Member
Joined
Feb 24, 2005
Messages
2,697
Reaction score
10
*cleans Remington 700* Just call me Whitefeather. :laugh: (*waits patiently for someone to figure out this analogy*)
White Feather is the only authorized biography of Gunnery Sergeant Carlos Hathcock II, who was recognized as the most successful sniper in the Vietnam War with more than 93 confirmed kills. The book White Feather is written by brothers Roy and Norm Chandler, who publish military shooting publications through Iron Brigade Publishing, a Jacksonville, North Carolina based corporation. As Marine Sniper, a best seller for nine years relayed his heroism in Vietnam, White Feather covers Carlos' entire career and the other details not found in any other title. Written in true "Chandler" format, this volume covers, from beginning to end, the story and tales of a true Marine Corps legend and last American Hero. As far as biographies go, this book will forever immortalize Hathcock, who passed away Feb. 1999.



Gunners shoot indiscriminately. They miss more than they hit.

Snipers take aim. They conceal themselves from a choice vantage point.

I don't want to be a gunner, I wanna be a sniper!
 

MonkeyNuts!

Even Kal has bad days...
10+ Year Member
Joined
Jun 23, 2005
Messages
3,646
Reaction score
14
Gunners shoot indiscriminately. They miss more than they hit.

Snipers take aim. They conceal themselves from a choice vantage point.

I don't want to be a gunner, I wanna be a sniper!

haha are you aware that "sniper" is a term for someone who never comes to class but then comes for exams and then rocks it, breaking the curve
 

Miami_med

Moving Far Away
Moderator Emeritus
10+ Year Member
7+ Year Member
Joined
Apr 13, 2006
Messages
2,084
Reaction score
9
By lobbying to get physicians excluded from antitrust restrictions on unionization. With a union, physicans can take the fight straight to the enemy's doorsteps.

BTW, with a union, you can forget about all these wild cuts you hear about.

I'm just going to point out that union membership is at a low since before the 1930s. This isn't because modern workers are more against unions. It is because the majority of the big union businesses have been hemorrhaging workers or going out of business. Be careful. Costs have to be contained. It shouldn't be out of your salary, but all union attempts regarding government reimbursement have led to out of control costs (think public education). Your attempts should be to put medicine back in touch with the supply and demand curve.
 

resxn

Full Member
10+ Year Member
Joined
Oct 2, 2006
Messages
912
Reaction score
26
I'm gonna pop some popcorn for this question/comment as I'm sure it will raise some ire.

One reason I went into a surgical subspecialty (ENT) was that I felt that anyone with time and a brain can read a book and learn how to do primary care.

The only real advantage I hold over any particularly smart patient is that I have the skills to operate. For someone who wanted to learn medicine on his or her own and had the brains to put it together, surgical skill and training is the only thing I hold over their head.

All docs have this advantage: physical exam experience (but anyone can read Bates and learn a few things), access to labs/radiology/diagnostic tests, and the ability to prescribe.

The longer I've been in medicine the more I've come to realize that dx is 85% history, 10% physical exam, and 5% diagnostic tests.

Let's face it, plenty of med students never attend class and pass Step I with flying colors. I was not one, but there were 3 in my class who never came to lectures, never read notes, never listened to the tapes (as far as anyone could tell) but always did well. I was too paranoid to try that. So what's to stop a smart patient from doing the same.

I have the same advantage over the increasing intrusion on medicine that is being caused by CRNA's, dentists, NP's, PA's, and psychologists. They can't operate.

So my question is this. What other than the 3 things I've said above is the advantage of being a PCP?

Now don't take that as being demeaning. I hold the highest respect for PCP's--many of whom I consult myself when I have patients with conditions I can't treat. I'm not trying to say that their intelligence is less (most are probably smarter than me), I'm not trying to say their skills are weak (most are definitely well-trained in my experience), nor am I saying they don't provide an important and needed service (they most certainly do). But what's the advantage?

Feel free to personally attack now.
 

Blue Dog

Fides et ratio.
15+ Year Member
Joined
Jan 21, 2006
Messages
13,287
Reaction score
7,018
One reason I went into a surgical subspecialty (ENT) was that I felt that anyone with time and a brain can read a book and learn how to do primary care....I hold the highest respect for PCP's--many of whom I consult myself when I have patients with conditions I can't treat.

Since we all have the same amount of time, I guess that means either you don't have a brain, or you couldn't find the right book. I'll assume the latter. ;)
 

resxn

Full Member
10+ Year Member
Joined
Oct 2, 2006
Messages
912
Reaction score
26
Since we all have the same amount of time, I guess that means either you don't have a brain, or you couldn't find the right book. I'll assume the latter. ;)

Well said, I stand ripped as expected, but my question still stands.

I could treat those conditions, but ethically I find it outside my scope of practice. I don't treat those who I think may receive better care from another provider just as I would hope my own physician would refer me if he didn't feel he could provide the best care.
 

Blue Dog

Fides et ratio.
15+ Year Member
Joined
Jan 21, 2006
Messages
13,287
Reaction score
7,018
The only real advantage I hold over any particularly smart patient is that I have the skills to operate.

I'll bet this guy thought the same thing. ;)

Steve%20Martin-Theodoric.jpg

Theodoric of York
Medieval Barber


Theodoric of York: [ steps toward the camera ] Wait a minute. Perhaps she’s right. Perhaps I’ve been wrong to blindly follow the medical traditions and superstitions of past centuries. Maybe we barbers should test these assumptions analytically, through experimentation and a “scientific method”. Maybe this scientific method could be extended to other fields of learning: the natural sciences, art, architecture, navigation. Perhaps I could lead the way to a new age, an age of rebirth, a Renaissance! [ thinks for a minute ] Naaaaaahhh!

Announcer: Tune in next week for another episode of “Theodoric of York: Medieval Barber”, when you’ll hear Theodoric say:

Theodoric of York: A little bloodletting and some boar’s vomit, and he’ll be fine!
 

ForbiddenComma

Tanned for Bowling
10+ Year Member
7+ Year Member
Joined
Oct 16, 2004
Messages
929
Reaction score
23
Theodoric of York: [ steps toward the camera ] Wait a minute. Perhaps she's right. Perhaps I've been wrong to blindly follow the medical traditions and superstitions of past centuries. Maybe we barbers should test these assumptions analytically, through experimentation and a "scientific method". Maybe this scientific method could be extended to other fields of learning: the natural sciences, art, architecture, navigation. Perhaps I could lead the way to a new age, an age of rebirth, a Renaissance! [ thinks for a minute ] Naaaaaahhh!


Oh, you mean Theodoric the Naturopath? :D
 

Whodathunkit

Senior Member
10+ Year Member
15+ Year Member
Joined
Nov 6, 2003
Messages
338
Reaction score
0
I don't treat those who I think may receive better care from another provider just as I would hope my own physician would refer me if he didn't feel he could provide the best care.

You know, I find that a legitimate answer. And yet no one has answered: What can a PCP do that an aged/well trained/well read NP or PA couldn't do?

Because ultimately, this is what PCPs will have to defend to Congress and insurance companies. And I'm not sure that they've done a good job of it as of yet.
 

Miami_med

Moving Far Away
Moderator Emeritus
10+ Year Member
7+ Year Member
Joined
Apr 13, 2006
Messages
2,084
Reaction score
9
You know, I find that a legitimate answer. And yet no one has answered: What can a PCP do that an aged/well trained/well read NP or PA couldn't do?

Because ultimately, this is what PCPs will have to defend to Congress and insurance companies. And I'm not sure that they've done a good job of it as of yet.

The reality is here, that there is a gradient. The best NPs probably do function at the level of some lower end MDs. However, the best are almost universally physicians. The real trick here, is that with the modern insurance and government payment schemes, the actual quality of medical care doesn't mean anything in terms of payment. Thus, the NP can look much like an MD in a non-acute setting where most people aren't going to immediately die. The best physician isn't able to openly show the quality of his work in the way a professional in any other field would. Pay for performance is a disaster that will check only certain indicators, while completely ignoring the actual quality of patient care.
 

Whodathunkit

Senior Member
10+ Year Member
15+ Year Member
Joined
Nov 6, 2003
Messages
338
Reaction score
0
The best physician isn't able to openly show the quality of his work in the way a professional in any other field would.

How would you suggest that physicians be able to show quality over quantity or benchmarks to show overall that cutting monetary corners to increase "health care access" is a bad idea?
 

Miami_med

Moving Far Away
Moderator Emeritus
10+ Year Member
7+ Year Member
Joined
Apr 13, 2006
Messages
2,084
Reaction score
9
How would you suggest that physicians be able to show quality over quantity or benchmarks to show overall that cutting monetary corners to increase "health care access" is a bad idea?

I never said that cutting corners to increase "access" was a bad idea. On the contrary, doctors are like any other professional, with vast differences in skill and quality. However, those with less skill and quality in most professions end up garnering a lower salary, thuis increasing access to their services. It's a lot cheaper to hire the ticket clinic than a corporate lawyer. Medicare/Medicaid pay the same to specialists in the same specialty regardless of whether they are good or not. The government isn't able to omnisciently look from Washington to make the same sort of quality determinations that you and I make every day in our purchase decisions. Pay for performance, which will supposedly address this, will be a disaster, as general rules will hurt those that are the exceptions to them and doctors rig their practices to meet requirements. Who gets hurt? The people who are actually sick.
 

Whodathunkit

Senior Member
10+ Year Member
15+ Year Member
Joined
Nov 6, 2003
Messages
338
Reaction score
0
Most healthy people only need "simple care".
 

Miami_med

Moving Far Away
Moderator Emeritus
10+ Year Member
7+ Year Member
Joined
Apr 13, 2006
Messages
2,084
Reaction score
9
Most healthy people only need "simple care".

My somewhat limited experience in the observation of primary care medicine has shown me that the vast majority of people who frequent the doctor are NOT healthy. Most doctor's visits are not the domain of healthy 23 year old college students.
 

Whodathunkit

Senior Member
10+ Year Member
15+ Year Member
Joined
Nov 6, 2003
Messages
338
Reaction score
0
Most healthy people

A general PCP check up to a cursory physical and blood work for LDL, cholesterol, BP, and HIV testing, with safe sex counseling, nutrition counseling, and exercise encouragement does not need 4 yrs of college plus 4 yrs of medical school plus 3 yrs of FP residency.

I'm a rather healthy 33 yr old who wanted to just get my regular check up as I hadnt had one in...oh...I don't know....4 yrs or so. I was sorta offended that I went through all the trouble of choosing a physician, looking at where they went to school, how old they were, etc only to have a PA end up seeing me in total.

But then I thought about it and said "Well...did I really NEED to see a physician? Did my health care suffer because I saw a PA instead?"

Don't get me wrong. I'm a strong supporter of FP. I'm just playing devils advocate. And the advocate in me questions these things constantly in my mind.
 

Faebinder

Slow Wave Smurf
10+ Year Member
Joined
May 24, 2006
Messages
3,507
Reaction score
11
Most healthy people

A general PCP check up to a cursory physical and blood work for LDL, cholesterol, BP, and HIV testing, with safe sex counseling, nutrition counseling, and exercise encouragement does not need 4 yrs of college plus 4 yrs of medical school plus 3 yrs of FP residency.

I'm a rather healthy 33 yr old who wanted to just get my regular check up as I hadnt had one in...oh...I don't know....4 yrs or so. I was sorta offended that I went through all the trouble of choosing a physician, looking at where they went to school, how old they were, etc only to have a PA end up seeing me in total.

But then I thought about it and said "Well...did I really NEED to see a physician? Did my health care suffer because I saw a PA instead?"

Don't get me wrong. I'm a strong supporter of FP. I'm just playing devils advocate. And the advocate in me questions these things constantly in my mind.


You wont know you suffered till you are that one person who didn't get his Hodgkin Lymphoma diagnosed early and instead was given an antibiotic, told it was a virus and sent home.

The common person is not fit to determine what is good quality healthcare if all they look at is their own health when they are 30.
 

MJB

Senior Member
Moderator Emeritus
10+ Year Member
Joined
Apr 12, 2005
Messages
2,846
Reaction score
25
You wont know you suffered till you are that one person who didn't get his Hodgkin Lymphoma diagnosed early and instead was given an antibiotic, told it was a virus and sent home.

The common person is not fit to determine what is good quality healthcare if all they look at is their own health when they are 30.


That happened to me...It took a trip to an MD in FP...one in ENT, then finally a trip to an IM guy to get it right..
The first two were arrogant and clueless, it seems.
 

ForbiddenComma

Tanned for Bowling
10+ Year Member
7+ Year Member
Joined
Oct 16, 2004
Messages
929
Reaction score
23
In my ACLS class a few weeks ago, an NP said flat out that doctors will be "obsolete" in primary care soon enough.

It was hard to find a reason to disagree.

If you run an HMO, which would you rather hire... an NP for 75k or an FP for 150k? Especially if you are for-profit and couldn't care less about the level of training of your minions as long as they don't get into too much trouble?

The main thing protecting FPs are remaining legal barriers to NPs including supervision requirements... but trust me, those last barriers will dissolve soon enough between the nursing lobby, the HMO lobby and the socialized-medicine lobby. Just ask some of the midlevel regulars around here like emedpa... he honestly considers himself the equal to EM physicians and for all intents and purposes, he is.
 
D

deleted6669

"Just ask some of the midlevel regulars around here like emedpa... he honestly considers himself the equal to EM physicians and for all intents and purposes, he is."

appreciate the compliment but not exactly my thinking;
I know more em than the vast majority of physicians who are not em docs so I am a better fit for working in an emergency dept than say an fp or im doc without extensive em experience, BUT
I know less em than a residency trained/boarded em doc, HOWEVER, in 90% + of cases there is no difference between my care and that of most em docs.
I think I probably know more primary care than most em docs because of the nature of my training and recertification requirements (which are primary care focused) but less primary care than someone who does that full time.
make sense?
as for the future, I see more pa/np folks working in primary care as members of multidisciplinary teams with oversight and collaboration provided by family medicine physicians. the doc will always be the captain of the ship but that doesn't mean the executive officer can't run the ship most of the time.
 

Blue Dog

Fides et ratio.
15+ Year Member
Joined
Jan 21, 2006
Messages
13,287
Reaction score
7,018
In my ACLS class a few weeks ago, an NP said flat out that doctors will be "obsolete" in primary care soon enough.

It was hard to find a reason to disagree.

No disrespect intended, but that's more indicative of your lack of knowledge regarding the scope of primary care than anything else.

That NP is dangerous, by the way. The worst kind of ignorance is not knowing what you don't know.
 

Faebinder

Slow Wave Smurf
10+ Year Member
Joined
May 24, 2006
Messages
3,507
Reaction score
11
No disrespect intended, but that's more indicative of your lack of knowledge regarding the scope of primary care than anything else.

That NP is dangerous, by the way. The worst kind of ignorance is not knowing what you don't know.

No kent.. there is worse... the DK-Cube aka DK*3. They don't know that they don't know what they don't know. Sounds like that NP qualifies.
 

Whodathunkit

Senior Member
10+ Year Member
15+ Year Member
Joined
Nov 6, 2003
Messages
338
Reaction score
0
That happened to me...It took a trip to an MD in FP...one in ENT, then finally a trip to an IM guy to get it right..
The first two were arrogant and clueless, it seems.


so you saw not one but TWO physicians who missed a diagnosis.


You wont know you suffered till you are that one person who didn't get his Hodgkin Lymphoma diagnosed early and instead was given an antibiotic, told it was a virus and sent home.


So it looks like midlevel providers aren't the only ones that do incomplete workups.

emedpa said:
HOWEVER, in 90% + of cases there is no difference between my care and that of most em docs.

Somehow, I think he believes that he was being rather reserved in his 90%+ and probably believes it to be much higher, but doesnt want to start that type of debate.
 

Faebinder

Slow Wave Smurf
10+ Year Member
Joined
May 24, 2006
Messages
3,507
Reaction score
11
so you saw not one but TWO physicians who missed a diagnosis.





So it looks like midlevel providers aren't the only ones that do incomplete workups.


Somehow, I think he believes that he was being rather reserved in his 90%+ and probably believes it to be much higher, but doesnt want to start that type of debate.

Would you rather he saw 2 NPs first? Either case.. in the end he got diagnosed by a primary care physician.. You can comment that both the FM doc and the ENT were crappy docs... well you will find that in all levels of education and we can argue that the first time you come to a doc for a lump, should you get your lump sampled? Now we are being specific and going into that debate.

But if you are going to try and convince us that you would rather see an NP and not an FM/IM/Ped about your not so obvious Hodgkin Lymphoma... then hey by all means... when you get a lump or a sore throat... you know where to go.
 

Whodathunkit

Senior Member
10+ Year Member
15+ Year Member
Joined
Nov 6, 2003
Messages
338
Reaction score
0
But if you are going to try and convince us that you would rather see an NP and not an FM/IM/Ped about your not so obvious Hodgkin Lymphoma... then hey by all means... when you get a lump or a sore throat... you know where to go.


It's not a matter of who I'd rather see, it's a matter of who I'm going to see. After all, I intentionally chose a Family Physician as my PCP with my new insurance, and instead received a PA. I'm not even sure the physician was even in the clinic that day. I'm sure the physician does this to bring in more revenue for his practice.

Until physician's start agreeing that they cannot be replaced my midlevels, this argument is moot to begin with. We are in large part causing our own undoing.
 
Top