Where's the research???

[scubadoc78]

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Hey guys,

Can someone actually give some examples of research that demonstrate why you need an MD to deliver primary care? My FP experience truly left me wondering why I need an MD to manage hypertension, diabetes, hyperlipidemia, etc. I know it's an old debate but it seems people always make arguments from opinion rather than more objective data. Are MDs really any better at giving metoprolol than NPs? In the context of needing to cut costs, why wouldn't it make sense to turn primary care over to a rapidly raised army of NPs and leave inpatient work and/or specialties to MDs? Thanks...

 

[deleted87716]

You tell me. Which do you think is easier to learn: managing patients with multiple chronic medical problems and diagnosing undifferentiated complaints across all ages and body systems...or snaking a scope up someone's ass?

 

[scubadoc78]

I've not met an FP yet who has the depth of knowledge as a pediatrician, internist, ob/gyn, etc. The argument that FPs have to know a little about a lot of things just isn't convincing me anymore despite my wanting it to. Where is the research that demonstrates patients have better outcomes for less cost when visiting an FP vs. a NP/PA?

 

[deleted87716]

I've not met an FP yet who has the depth of knowledge as a pediatrician, internist, ob/gyn, etc.

So, your N=1?

Pretty crappy "evidence" on your part. There's plenty of evidence out there on the value of family medicine, but somehow I don't think you really care.

http://www.aafp.org/online/en/home/policy/familymedvalue.html

 

[scubadoc78]

Hmm, interesting rhetoric. I ask for science and you give me a remark about scoping asses. When I press the issue you cite me for being unscientific!

The question remains, can anybody cite credible studies that demonstrate the cost-effectiveness of MDs in primary care over mid-levels? I keep being told this body of work is out there but no one can tell me where it is. I've done a brief pubmed search and found nothing.

 

[MedicineDoc]

At my unopposed residency program by the time of graduation each resident can just about exactly predict what each subspecialist will do any any given situation. Why don't you come to my residency program and pick a random FP attending to test your theory. I think you would find that each has more knowledge about medicine than you have about all other subjects combined. Congratulations on achieving near perfect stupidity such that can only be achieved by an obnoxious med student with way more ego than brains and about as much knowledge of medicine as a random person off the street.

 

[scubadoc78]

Guys come on, grow up. I'm on your side. I'm simply a med student trying to look for evidence I can take back to classmates to say "hey look, FP is a good field that isn't dying because X, Y, Z." It's an honest question students ask all the time. I never said it's not a naive question. If an ego is so threatened by a newbie asking newbie questions I'm sorry, but that's not my problem.

Thanks for the link Blue Dog. The articles look more like they address the importance of primary care rather than how it should be delivered but I obviously haven't search through in detail yet. I appreciate it though and hopefully will come up with more insightful, and less inflammatory, questions later...🙂

 

[deleted87716]

Well, y'know...there's a reason that this forum has all those stickies at the top. Some people actually read 'em.

 

[scubadoc78]

By the way MedicineDoc, I'm sorry you're so angry. Maybe I can make amends by saving you the time on your next post and just writing it myself:

"I'll kick your stupid little whiny medical student little ass cause my residency kicks ass and your stupid!"

 

[scubadoc78]

Sorry Blue Dog, I'm just a newbie! Still learning the ropes...thanks again...

 

[MedicineDoc]

By the way MedicineDoc, I'm sorry you're so angry. Maybe I can make amends by saving you the time on your next post and just writing it myself:

"I'll kick your stupid little whiny medical student little ass cause my residency kicks ass and your stupid!"

So true. Yours is an example of the burgeoning bladelike intelligence of a subspecialist. Thank you for gracing our forum with such clearly outstanding potential that can inspire even the most seasoned physicians.

 

[deleted87716]

Some evidence exists that mid-levels may provide less cost-effective care due to overutilization of specialty referrals and diagnostic testing.

http://www.rangelmd.com/index.php/2008/11/22/516/

http://www.acponline.org/clinical_information/journals_publications/ecp/novdec99/hemani.htm

 

[EdibleEgg]

Hey guys,

Can someone actually give some examples of research that demonstrate why you need an MD to deliver primary care? My FP experience truly left me wondering why I need an MD to manage hypertension, diabetes, hyperlipidemia, etc. I know it's an old debate but it seems people always make arguments from opinion rather than more objective data. Are MDs really any better at giving metoprolol than NPs? In the context of needing to cut costs, why wouldn't it make sense to turn primary care over to a rapidly raised army of NPs and leave inpatient work and/or specialties to MDs? Thanks...

Are physicians better at prescribing metoprolol? There's probably not much difference, but I do a lot more than refill BP meds. You are suggesting a system where primary care provides less care, with NP's providing very basic services and referring to specialists. I haven't searched for studies on the quality of primary care NP's. I don't employ any. However, there is good research showing lower all cause mortality in areas with higher concentrations of primary care MD's. Cost goes up and care goes down in areas with lots of specialists. A system that further degrades primary care will not improve either.

Depth of knowledge???? Based on what? What are you really saying there?

 

[thethom]

Scuba, because you are only a medical student it is marginally forgiveable that you do not know what primary care physicians do during office hours and when rounding on their inpatients, but know that refilling prescriptions is maybe <1% of what we do...

And I can tell you that my depth of knowledge is greater than ~97.5% of the

pediatrician, internist, ob/gyn, etc

out there; and the same goes for my colleagues...

Dr. T.

 

[scubadoc78]

You're right Edible, I was making an assumption without realizing it. By "depth" I was assuming a pediatrician would have more knowledge of childrens diseases, a pulmonologist of lung diseases, a cardiologist of heart diseases, etc. I guess I assumed this because this is the point of referrals? At my university the specialists do research and give lectures to the generalists regarding their respective disciplines all the time.

I realize from the reaction to my original post that I'm committing some sort of heresy but ignorance is an excuse for venial sins. If my rhetoric sounds arrogant I apologize. Perhaps it's because I'm a non-traditional student and probably fail the "medical student" test in more ways than one. I'd like to think the attendings I've worked with appreciate the open and honest approach.

I enjoyed my FP rotation but when I asked why a system where midlevels work/triage clinics and hospitalist specialists work inpatient they didn't have a satisfying answer. I ask for research because that is what I assume is being used to steer debates in Washington??

I see the enormous pressure for healthcare as a great impetus for considering these alternatives and the data that supports/refutes them. The public is understandably desperate for answers. History says business will capitalize on their fear without regard to quality of care. Particularly if politicians are opening the door. Dick Cheney and Halliburton is a great example of what business and politics can achieve when monopolizing industry. I feel for MDs the way I feel for the generals who had their hands tied in Iraq and Afghanistan despite doing their jobs superbly as well.

Joe Biden spoke at a university not far from my hometown and said the administration has plans to train specialized nurses to do surgeries (i.e. cholecystectomy specialist) because the research indicates it's more efficient than waiting 15 years to educate/train one surgeon. He outlined a similar plan to the one I proposed above for primary care as well. So now you have public (patient/voter) support, business interest and policy makers all interested in a cheaper/faster system. What argument is left but to emphasize the quality will be lost? Which brings me back to my original question, where are studies that support OUR (MD PCPs) side?

 

[scubadoc78]

Actually, I've had time to read the Rangle article so far and admit I didn't find it encouraging. The author says research demonstrates that NPs provide equivalent or even better care than MDs? As someone putting in 11 years of work it's alarming to read the same level of competency could potentially be reaching in half that time and for much less personal cost.

Also, do you think being more cost-effective is really beyond the reach of NPs? Surely if they're already showing the capacity to practice medicine as competently as MDs they can learn how to do it more cheaply?

 

[simpler2]

scuba,

Its difficult to answer your question because it is based on a specific (i would argue misguided) reality of primary care. I think a more appropriate question, and the one I hear being asked more often, is what should be the difference between the roles of the DO/MD and the midlevel provider.
In patient populations where compliance and health are relatively high it might be feasible for the midlevel to provide most primary care (though this population is likely to resent such a move). The reality is that most care settings have a mix of patients, many with complex medical issues that warrant a provider with more clinical knowledge than that provided by midlevel training. In many areas the PCP is also expected to take on multiple roles at the same time (admitting physician, ER coverage, outpt. clinic, nursing facilities,...)
There is also the issue of primary care research. I guess that midlevels could take that on as well but I think this would be a stretch considering coming from a philosophy of training that is more technical/skills based and not science/academics.
The backlash your getting is not defense to your question, the question really isn't appropriate. The backlash is more from the assertions you made about primary care while asking the question in the FM forum.

 

[iswitched]

To the OP...

The benefit of MD/DO over the mid-level is obviously the broader scope and depth of the physician over the mid-level. When is the last time a mid-level thought of Kawasaki's disease when presented with a 4yo with cold symptoms? But, I think practically the distinction in reality is become blurred. If you are a FP who spends 7 minutes with a Pt you must be some kind of wonder-doc who can recognize a zebra without talking to or examining it.

I see FPs (in my residency and community) partaking in a lot of bad habits of the mid-level counterparts...e.g. copious consults, shotgun labs, ordering CT/MR like they own stock in GE.

As a resident I admit for community docs who have given up hospital practice. Maybe I'm in family medicine's bermuda triangle, but reviewing the records of the pts we admit leaves me without a lot of pride in our specialty.

Mind you this applies not just to FM but frankly all specialties. But not all specialists proclaim to have the ability (or willingness) to handle 90% of what walks through the door.

 

[deleted87716]

The backlash your getting is not defense to your question, the question really isn't appropriate. The backlash is more from the assertions you made about primary care while asking the question in the FM forum.

Pretty much.

As many have said before, primary care is easy to do poorly, but difficult to do well. Many of those who seek to "do our jobs" really only want to do a piece of it...the easy part, naturally.

Half of all mid-levels already work in specialty practices, not in primary care, and the trend is moving more in that direction. Why? Like Willie Sutton said, "That's where the money is." If primary care is unattractive to physicians, it will be equally unattractive to mid-levels.

http://www.kevinmd.com/blog/2008/12/why-mid-level-providers-will-not-take.html

http://www.kevinmd.com/blog/2008/12/why-nurse-practitioners-and-physician.html

 

[lowbudget]

Hey guys,

Can someone actually give some examples of research that demonstrate why you need an MD to deliver primary care? My FP experience truly left me wondering why I need an MD to manage hypertension, diabetes, hyperlipidemia, etc. I know it's an old debate but it seems people always make arguments from opinion rather than more objective data. Are MDs really any better at giving metoprolol than NPs? In the context of needing to cut costs, why wouldn't it make sense to turn primary care over to a rapidly raised army of NPs and leave inpatient work and/or specialties to MDs? Thanks...

None of these types of studies are that great quality anyways to draw any kind of conclusion.

There're studies done with FM's and IM's doing scopes just as well as GI and CRS. There're studies that I've read that say FM's and IM's who know their patients do better inpatient care than IM hospitalists who don't know their patients. There're studies that say NP's/PA's who do primary care just as well as IM/FM's. There're studies out there that say if specialists (particularly OB/Gyn & EM) provide primary care, outcomes are actually worse. There's also the international data that support the FM outcomes are better if you support the primary care model. There're studies out there that say that closed ICU's are better than open ICU's, but then there are local data/experience that says that it doesn't matter.

All of these studies have something you can criticize.

And... even if you could design a good study, NO ONE knows how to accurately measure health outcomes (endpoints) that truly reflect what's going on. Our understanding of health care metrics are really poor. So there's no way you can design a good study because no one knows what's the best way to measure what you're studying!

What you are looking for is a universal truth... something to hang your hat on to dispel all the opinions out there. It doesn't exist, the universal truth nor the compelling evidence.

Nobody knows.

Well, my response to scubadoc78 is show me the evidence that MD/DO's provide worse care than NP's.

Some of you guys think you're so scientific and academic. And you go out and do these Evidence Arms Race. Everybody knows that these social science evidence aren't that scientific to begin with and yet you want to make these broad generalizations/universal truth arguments using these data to support it.

Personally, I don't even think it's an "old debate" because there is no debate.

The problem here is your presumption. It's YOUR burden to show me that NP's/PA's are superior (1-tail blinded study) to MD/DO's in providing care, using good measurements of health status. Design a trial with MD/DO's provision of primary care as your control group (i.e. the status quo). And show me, beyond a reasonable doubt (p<0.05) that they are superior (1-tailed). And do it in a multi-center, multi-community trial, in all States & territories. Only then would it be convincing, to me, that we should, as public policy, endorse your mere hypothesis (nay, "opinion", questionably "educated guess").

Then, I'd be more inclined to listen to you. That being said, I'm not doing your homework for you.

 

[scubadoc78]

Simpler2/Blue Dog: reading it again i see what you guys are saying about my initial post. i apologize for coming across that way. i didn't even think about it when i wrote it. my only excuse is i'm currently on my emergency surgery rotation and sleep deprivation + the climate may possibly be turning me into (a bigger) a**hole.

you've all made great points covering the spectrum of my questions. i'm sure a lot of my concern has to do with insecurity. i've seen some pretty surprising things to me like NPs changing physicians orders without consulting them and our team not finding out until the next day when the pt was supposed to go home. frankly, that would frustrate the hell out of me!

thanks again...

 

[Amoeba]

And I can tell you that my depth of knowledge is greater than ~97.5% of the pediatrician, internist, ob/gyn, etc out there; and the same goes for my colleagues...

Dr. T.

I have lots of respect for family physicians; I'm worked with some truly terrific ones. I'm not trying to flame or to be a troll. But I'm not sure I understand this post. Perhaps I missed some sarcasm or subtlety in it; if so I apologize. Are you truly saying that you and your colleagues, presumably other family docs, all have a greater depth of knowledge of pediatrics than 97.5% of pediatricians, a greater depth of knowledge of IM than 97.5% of internists, and a greater understanding of ob/gyn than 97.5% of ob/gyns? This grandiose claim is simply untrue; as much respect as I have for family docs who practice these three fields well, I'd lose all of that respect for one who claimed to me with a straight face that he is likely the best pediatrician, internist, and ob/gyn that I'd ever meet all rolled into one. Even if it happens to be true for some extraordinary individual, perhaps even you (would be a particularly impressive claim as you do not seem to my view to have completed a residency in peds, IM, ob/gyn, or family medicine), I am turned off by the sheer arrogance of voicing it.

 

[lowbudget]

I have lots of respect for family physicians; I'm worked with some truly terrific ones. I'm not trying to flame or to be a troll. But I'm not sure I understand this post. Perhaps I missed some sarcasm or subtlety in it; if so I apologize. Are you truly saying that you and your colleagues, presumably other family docs, all have a greater depth of knowledge of pediatrics than 97.5% of pediatricians, a greater depth of knowledge of IM than 97.5% of internists, and a greater understanding of ob/gyn than 97.5% of ob/gyns? This grandiose claim is simply untrue; as much respect as I have for family docs who practice these three fields well, I'd lose all of that respect for one who claimed to me with a straight face that he is likely the best pediatrician, internist, and ob/gyn that I'd ever meet all rolled into one. Even if it happens to be true for some extraordinary individual, perhaps even you (would be a particularly impressive claim as you do not seem to my view to have completed a residency in peds, IM, ob/gyn, or family medicine), I am turned off by the sheer arrogance of voicing it.

I think he's referring to his board scores. Judging from his signature, he hasn't started intern year yet.