Why don't we have many General Practitioners anymore?

[907914]

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So I got to thinking, if primary care is where we need physicians the most and the lack of primary care physicians has led directly to the rise in prevalence of PA and NP...Why don't we encourage general practitioners? Outside of the Navy and other military branches, very very few people just go in to medicine after an intern year. Why is this? Like....Family Medicine has only been a board specialty since the mid-70's?

Every study I can find (there are not many of them and they are all fairly old) suggests that while yes, board certified family practice physicians are more knowledgeable than GPs, there is little to no correlation between having completed an FM residency and increased patient outcomes. So, if people don't go in to FM because of the low wage: training period time, and the patient outcome will be the same either way, and primary care is where we need the most doctors, like 47 out of the 50 states allow practice without residency....why do we not encourage general practice?

 

[993444]

The one thing everyone can agree on (whether it's students, professors, faculty, administrators, etc) is that the purpose of medical school is to get into a residency. This is why medical schools bend over backwards to make sure their students are placed in a residency. So the thought of not doing a residency at all seems like a very uncomfortable thought.

Also, imposter syndrome is very real in medical school, and likely transfers over to residency. The thought of being a licensed physician with only 1 year of training after graduating medical school seems like a very scary thought. I certainly wouldn't do it.

 

[907914]

The thought of being a licensed physician with only 1 year of training after graduating medical school seems like a very scary thought.

Is it though? This was very much the norm up until the last couple decades. It is a 'scary thought' to us as premeds nowadays, but like....It was reality for a century. Also, I would disagree with the notion that the only purpose for medical school is to get in to a residency. I would say it is in order to prepare one with the clinical and scientific knowledge basis to enter the practice of medicine.

The practice of medicine is typically entered via a residency, but that is not necessary. Look at the Navy general medical officers. They serve as primary care providers. Why don't we see this civilian side anymore?

 

[Isoval]

The short answer is because going into Family Medicine these days is treated like going to a low-tier backwater college Nowhere, Montana.

 

[993444]

Is it though? This was very much the norm up until the last couple decades. It is a 'scary thought' to us as premeds nowadays, but like....It was reality for a century. Also, I would disagree with the notion that the only purpose for medical school is to get in to a residency. I would say it is in order to prepare one with the clinical and scientific knowledge basis to enter the practice of medicine.

The practice of medicine is typically entered via a residency, but that is not necessary. Look at the Navy general medical officers. They serve as primary care providers. Why don't we see this civilian side anymore?

With the increased complexity of medicine and legal system, more training seems to be valued.

You have to have clinical and scientific knowledge to get into a residency.

IIRC, the legal system makes it extremely difficult to bring a malpractice suit against a military physician, which changes things.

 

[907914]

The short answer is because going into Family Medicine these days is treated like going to a low-tier backwater college Nowhere, Montana.

So if going into family medicine is viewed so negatively, why even go in to family medicine? Why not just do an intern year and then go practice medicine?

 

[907914]

With the increased complexity of medicine and legal system, more training seems to be valued.

You have to have clinical and scientific knowledge to get into a residency.

IIRC, the legal system makes it extremely difficult to bring a malpractice suit against a military physician, which changes things.

We let NPs do primary care and they have no scientific knowledge and little clinical knowledge in the context of what a physician does. Do we wanna say that NPs can do primary care but a GP couldn't? I guess it is just confusing. Is the answer purely a legal/cultural/insurance one?

 

[IgEdoc]

Its may also be tied to bonuses and hospital privileges to be Board certified > Board eligible

 

[993444]

We let NPs do primary care and they have no scientific knowledge and little clinical knowledge in the context of what a physician does. Do we wanna say that NPs can do primary care but a GP couldn't? I guess it is just confusing. Is the answer purely a legal/cultural/insurance one?

I dunno man, I'm just a pre-med. I bet @gyngyn could provide what you are looking for.

 

[DO2015CA]

We let NPs do primary care and they have no scientific knowledge and little clinical knowledge in the context of what a physician does. Do we wanna say that NPs can do primary care but a GP couldn't? I guess it is just confusing. Is the answer purely a legal/cultural/insurance one?

A physician without a completed residency is an unfinished product. We shouldn’t decrease our quality just because NPs do it. It has been stated time after time that NP qualities range so much. Residency is what standardizes physicians, why would we want to cut that short. I for one don’t want to be associated with a profession that doesn’t require a completed residency

 

[907914]

A physician without a completed residency is an unfinished product. We shouldn’t decrease our quality just because NPs do it. It has been stated time after time that NP qualities range so much. Residency is what standardizes physicians, why would we want to cut that short. I for one don’t want to be associated with a profession that doesn’t require a completed residency

But not having a residency was pretty standard up until a few decades ago, right? Even looking at the kinds of residencies we have...FM didn’t catch on until the 70s, EM didn’t catch on until the 80s, and so on. So from 1936 (when IM became a residency) until 70s and 80s (40-50 years!) we had IMs running ERs and GPs running the clinics along with IM...so why don’t we do that now?

 

[DO2015CA]

But not having a residency was pretty standard up until a few decades ago, right? Even looking at the kinds of residencies we have...FM didn’t catch on until the 70s, EM didn’t catch on until the 80s, and so on. So from 1936 (when IM became a residency) until 70s and 80s (40-50 years!) we had IMs running ERs and GPs running the clinics along with IM...so why don’t we do that now?

Our care has gotten a lot better throughout those years and medicine has exponentially increased. You need the time to learn it.

 

[993444]

But not having a residency was pretty standard up until a few decades ago, right? Even looking at the kinds of residencies we have...FM didn’t catch on until the 70s, EM didn’t catch on until the 80s, and so on. So from 1936 (when IM became a residency) until 70s and 80s (40-50 years!) we had IMs running ERs and GPs running the clinics along with IM...so why don’t we do that now?

Our care has gotten a lot better throughout those years and medicine has exponentially increased. You need the time to learn it.

Medicine has changed since then.

 

[ndafife]

Medicine has changed since then.

It's pretty easy to be a doctor when you only need to know 5 antibiotics and 3 blood pressure medications

 

[907914]

It's pretty easy to be a doctor when you only need to know 5 antibiotics and 3 blood pressure medications

But does someone fresh out of intern year nowadays have such limited clinical scope of knowledge? This is a serious question as I do not know. I would assume that, because medicine has changed so much in the last several decades, that a 2020 intern likely knows more then a fresh IM attending did in 1975...

 

[907914]

It's pretty easy to be a doctor when you only need to know 5 antibiotics and 3 blood pressure medications

Also, medicine has changed a lot even in the last decade let alone the last half century. So even someone who finished their residency in 2009 isn't up to date. So...isn't this the purpose of continuing GME, board certified or not? The whole "Lifelong learner" thing?

 

[Obnoxious Dad]

But not having a residency was pretty standard up until a few decades ago, right? Even looking at the kinds of residencies we have...FM didn’t catch on until the 70s, EM didn’t catch on until the 80s, and so on. So from 1936 (when IM became a residency) until 70s and 80s (40-50 years!) we had IMs running ERs and GPs running the clinics along with IM...so why don’t we do that now?

You obviously have not been paying attention to the credential creep of the last 50 years. In almost every healthcare field the time and expense required to get a working credential has grown significantly since 1970. The vast majority of registered nurses used to be trained in hospital driven diploma programs. The course of study was three years and the cost to the student was chump change. Since 1970 almost all of the hospital based programs have shut down. The witches who run the nursing establishment now want to turn away the RNs with associates degrees. Pharmacy school used to be five years long and now the minimum is six years and the norm is eight years. In 1978 Nurse Anesthetists required two years of training and got a certificate, later it was 2.5 years and the CRNA got an MSN. Now it takes 3.5 years to be a CRNA because the CRNA gets the august title of DNP. It was common in the 1950s for people to go to medical or dental school without a bachelor's degree as long as they had the course prerequisites..

All of this nonsense has occurred without a shred of tangible verifiable evidence that costs would be lower and patient care would be improved. The ultimate loser in this fraud is the patient because it creates artificial shortages of healthcare staff.

 

[PA_dud3]

I think if anything, the time spent in undergrad should be reduced, if we are going to remove time barriers to practicing. I know everyone is going to hit me with the tired "maturity" argument but I see no reason why two years of basic sciences prior to matriculation would produce any less of a physician. This was commonplace for DO schools atleast up until the 40's. The only reason the bachelor's was made a requirement was so legislators would award universal practice rights, as they were worried about the caliber of people entering DO schools compared to MD. I think residency is too vital of a step to cut out.

 

[Catalystik]

Outside of the Navy and other military branches, very very few people just go in to medicine after an intern year.

Outside of government institutions, malpractice coverage is harder to come by if you haven't completed a residency. Many states won't give you a licence to practice independently without at least two years of residency training. Many hospitals and practices seem reluctant to accept docs without board eligibility or certification.

 

[907914]

Many states won't give you a licence to practice independently without at least two years of residency training. Many hospitals and practices seem reluctant to accept docs without board eligibility or certification.

Any idea why this culture and these laws have developed in the last couple decades when it was pretty standard practice barely 30 years ago?

We are pretty accustomed to it being “just how it is” nowadays, but why did the change occur? Everything I can find basically just says because insurance companies started refusing to reimburse simply so they could stick to the developing “managed health plans”

 

[Catalystik]

Any idea why this culture and these laws have developed in the last couple decades when it was pretty standard practice barely 30 years ago?

-Information overload
-Fear of poor outcomes that were preventable

 

[Obnoxious Dad]

-Information overload
-Fear of poor outcomes that were preventable

Sorry. I disagree. It's the union mentality of all of these professions that extends training. The CRNA credential creep is a perfect example. Thanks to improvements in protocols, drugs and equipment, the incidence of anesthetic complications has declined by approximately 95% over the past 20 years. In a rational market when a process becomes less risky and more routine, the amnount of training should decline and become less expensive. Pharmacy is another example. Improvements in packaging, computer technology etc have made pharmacy jobs,, easier and less risky. The chief problem is boredom. A friend of mine who is a pharmacist says she starts clock watching five minutes after she starts a shift.

 

[993444]

Sorry. I disagree. It's the union mentality of all of these professions that extends training. The CRNA credential creep is a perfect example. Thanks to improvements in protocols, drugs and equipment, the incidence of anesthetic complications has declined by approximately 95% over the past 20 years. In a rational market when a process becomes less risky and more routine, the amnount of training should decline and become less expensive. Pharmacy is another example. Improvements in packaging, computer technology etc have made pharmacy jobs,, easier and less risky. The chief problem is boredom. A friend of mine who is a pharmacist says she starts clock watching five minutes after she starts a shift.

She's talking about why the laws developed. You're talking about the after effects.

 

[AnatomyGrey12]

Is it though?

Absolutely.

Also, I would disagree with the notion that the only purpose for medical school is to get in to a residency. I would say it is in order to prepare one with the clinical and scientific knowledge basis to enter the practice of medicine.

It's like learning to be a pilot. Medical school is the part where you learn what all the buttons do, how they work, the theory behind flight, etc. Towards the end of this time maybe they take you on a flight where you can be copilot and the main instructor asks you questions about what you might do in certain situations while they are the one actually doing any flying. Intern year is when they hand you the wheel and your job over the next X amount of years is to learn to go from them watching over your shoulder constantly to you being able to make a transatlantic flight while they sleep in the back.

Medical schools produce residents, residency is what spits out the polished product.

We let NPs do primary care and they have no scientific knowledge and little clinical knowledge in the context of what a physician does. Do we wanna say that NPs can do primary care but a GP couldn't? I guess it is just confusing. Is the answer purely a legal/cultural/insurance one?

Eh this is a bad argument because NPs aren't competent. Just because they lower their standards doesn't mean we should.

Because medicine has come along way since then

But does someone fresh out of intern year nowadays have such limited clinical scope of knowledge?

Yes. Medical knowledge has absolutely exploded in the last few decades. One year of training doesn't really give you the experience necessary to be able to be independent. Interns lean heavily on their senior residents and attendings to make decisions, and it's not just the actual medicine side of things. Medical school doesn't teach you crap about coding, billing, how to do documentation. I mean stuff like, "Oh Bidil is a great drug for this patient but it's going to be too expensive for them so you need to think of an alternative". This is something I've even seen fellows still not have complete mastery of. There are a LOT of nuances in medicine that are learned throughout a complete training process that honestly can't be short circuited.

 

[907914]

Yes. Medical knowledge has absolutely exploded in the last few decades. One year of training doesn't really give you the experience necessary to be able to be independent. Interns lean heavily on their senior residents and attendings to make decisions, and it's not just the actual medicine side of things. Medical school doesn't teach you crap about coding, billing, how to do documentation. I mean stuff like, "Oh Bidil is a great drug for this patient but it's going to be too expensive for them so you need to think of an alternative". This is something I've even seen fellows still not have complete mastery of. There are a LOT of nuances in medicine that are learned throughout a complete training process that honestly can't be short circuited.

Thank you for the very thorough response. This very much makes sense. However, how do we reconcile this notion with the Military GMOs and the at-home-cash-only docs, or the multitudes across Florida practicing with just an intern year?

In the military case, is it just "They can't sue us so we will use what we got cus we need'em"?

In the at-home-cash-only types is it just that there is such a limited scope that can be performed "in house" that there really is not worry?

And then...just...because it is Florida for the third one?

 

[Cornfed101]

Thank you for the very thorough response. This very much makes sense. However, how do we reconcile this notion with the Military GMOs and the at-home-cash-only docs, or the multitudes across Florida practicing with just an intern year?

In the military case, is it just "They can't sue us so we will use what we got cus we need'em"?

In the at-home-cash-only types is it just that there is such a limited scope that can be performed "in house" that there really is not worry?

And then...just...because it is Florida for the third one?

In the first two cases, billing and coding are, respectively, simplified and nonexistent. That is a huge part of what has to be learned in medicine today that isn't taught in medical school.

I guess Florida will be the guinea pig...

 

[907914]

In the first two cases, billing and coding are, respectively, simplified and nonexistent. That is a huge part of what has to be learned in medicine today that isn't taught in medical school.

Then follow up question: Will GPs make a comeback if we switch to universal healthcare/single payer?

 

[DO2015CA]

Then follow up question: Will GPs make a comeback if we switch to universal healthcare/single payer?

Hopefully we never have to find out. But most likely no. This has become the standard and it’s hard to deviate from the standard unless there is data supporting it.

 

[907914]

unless there is data supporting it.

I mean, as has been stated earlier, there was no data to support the transition away from GPs and it has mostly been driven by cultural/systemic changes in how we bill for medicine, not how we practice it.

Also, want to make clear I am not arguing for arguments' sake. This is genuinely confounding to me.

 

[Cornfed101]

Then follow up question: Will GPs make a comeback if we switch to universal healthcare/single payer?

In theory, maybe. In practice, no. My previous job was in claims and remittance working with 4 major hospital networks and, unfortunately, 75% of the issues we dealt with were Medicare and Medicaid. They have asinine requirements for claims that change frequently. I don't think that would change if they became the only payors.

 

[907914]

They have asinine requirements for claims that change frequently.

I believe that all of these asinine issues (which are very real, unfortunately [I know, I am on state insurance]) are deliberately created by legislation written either directly or indirectly by the hands of those who have a hand in profiting from these issues (ie. Pharma, insurance industries). I feel like if we were at a place in this country where we could get rid of private insurance, then restructuring medicare/medicaid would be the easier task. I know when I had tricare reserve select I could walk in wherever, get treated, walk out and never take out a card/cash/worry about a bill. That is how I imagine universal healthcare.

 

[907914]

This would be evidence of the information overload aspect as with NHS, it doesnt appear to be insurance driven

Right on, did not realize this. So it really is just doctors need to know more, insurance/billing excluded, in order to doctor than they did in the past. That is interesting, not totally unexpected but still fascinating to me. I don't know enough about this, but if there is an almost mandatory increase in training time due to "information overload" have we seen a corresponding increase in FM or even specialty pay? More knowledge and education required should = more pay, right?

 

[DO2015CA]

Right on, did not realize this. So it really is just doctors need to know more, insurance/billing excluded, in order to doctor than they did in the past. That is interesting, not totally unexpected but still fascinating to me. I don't know enough about this, but if there is an almost mandatory increase in training time due to "information overload" have we seen a corresponding increase in FM or even specialty pay? More knowledge and education required should = more pay, right?

You have seen an increase in pay. But I’d rather have the 1980s pay, cost of living, and paperwork than today’s

 

[907914]

and paperwork than today’s

Is it possible, in any specialty, to NOT have the paperwork aspect? Like....that is probably the part of medicine I am least looking forward to (and it will likely be a completely different world in a decade when I am *hopefully* an attending...)

 

[DO2015CA]

Is it possible, in any specialty, to NOT have the paperwork aspect? Like....that is probably the part of medicine I am least looking forward to (and it will likely be a completely different world in a decade when I am *hopefully* an attending...)

No. And there was paperwork back then but just a lot less

 

[907914]

No. And there was paperwork back then but just a lot less

I guess I meant the "mountains of paperwork" kinda thing.

Do new and developing EMRs help this at all?

 

[getdown]

I guess I meant the "mountains of paperwork" kinda thing.

Do new and developing EMRs help this at all?

The point of all the paperwork is not only to document what you did so that someone else knows what happened but to also cover your ass that you did everything appropriately in case, God forbid, the patient decides to sue you for whatever reason. Will you remember what you did specifically on a patient you saw some random wednesday 6 years ago for a procedure you do hundreds of times a year? Hell most people don't even remember what they ate 2 days ago for lunch. The lawyers would absolutely destroy you if you had poor documentation. And your family would be the ones paying the price.

 

[IgEdoc]

The real point of the current avalanche of paperwork is BILLING. One does need to be very observant and document pertinent information that could turn around and bite you, especially in patients that come with an attitude, seem angry, or hostile

 

[907914]

current avalanche of paperwork is BILLING

And this is the current avalanche I don’t want to deal with....

 

[AnatomyGrey12]

In the military case, is it just "They can't sue us so we will use what we got cus we need'em"?

According to my buddy here who just finished paying back his time in the Navy as a GMO, yeah pretty much lol. And like was mentioned above the environment is different with the coding and such.

In the at-home-cash-only types is it just that there is such a limited scope that can be performed "in house" that there really is not worry?

Yeah these people are either the ones who truly just keep their scope to the basic bread and butter they know they can handle and have a good grasp on what they can't, or they are the people out there advertising themselves as "surgeons" doing hair transplants and all sorts of stuff they aren't really qualified to do.

And then...just...because it is Florida for the third one?

Lololololol this made me laugh. Probably true though honestly.

So it really is just doctors need to know more, insurance/billing excluded, in order to doctor than they did in the past.

I would say yeah. There is just so much medical advancement every year. One example is how the number of drugs for certain disease states has exploded.

Do new and developing EMRs help this at all?

Not really

 

[DO2015CA]

And this is the current avalanche I don’t want to deal with....

Lol then you don’t want to get pain. The more we bill the more we get paid

 

[907914]

Lol then you don’t want to get pain. The more we bill the more we get paid

Yah..I’ll just be a salaried employee then...lol

 

[DO2015CA]

Yah..I’ll just be a salaried employee then...lol

You don’t bill. You get fired. You don’t bill, the company doesn’t make money and your contract renewal is for less.

That is the absolutely wrong way to look at it. This is also why physicians have sold out medicine to businessmen

 

[907914]

You will be measured by average billing per unit time and per patient as well as average time spent with each. In a corporate practice You may start with 6-7 hours a day with 20 minute scheduled per moving with in a year to 15 min per at 7 hours a day. You will be expected to get history, examine, discuss and chart within that time. I am sure bonus is based on achieving metrics or exceeding. You may have no say in your nurse, MA, office staff, etc but expected to mesh well. You will be reviewed by senior medical staff, directors, billing, charting, etc

Sounds fun to me. Certainly more leisurely than the practice I work at where the doctor spends maybe 10 minutes between non-procedure visits...

 

[DO2015CA]

Sounds fun to me. Certainly more leisurely than the practice I work at where the doctor spends maybe 10 minutes between non-procedure visits...

A large portion of not being in private practice is you don’t get to dictate your practice. You are report to a boss with 1/3 of your education and they slowly keep piling things on you without the pay to back it up. Private practice you take the whole pot even if you are required to do more charting. Hire a scribe. Hire a good billing and coding person. Great office managers will make a practice and make your life easier.

Like said above if you don’t get to hire those people then you may not have a choice and life begins to suck

 

[Catalystik]

One SDNer's plan to become a GP, (theoretically) circumvent the negatives, and make bank: MD - Starting a solo cash-only private practice after internship year (Good for some LOLs.)