Comments on: More ragging on primary care http://www.kevinmd.com/blog/2006/07/more-ragging-on-primary-care.html Tue, 14 Feb 2012 17:18:00 +0000 hourly 1 By: jbhttp://www.kevinmd.com/blog/2006/07/more-ragging-on-primary-care.html#comment-65000 jb Sat, 15 Jul 2006 12:23:00 +0000 http://clients.emmense.com/kevinmd/2006/07/more-ragging-on-primary-care.html#comment-65000 I'll get roasted for posting this, but primary care is reimbursed less than specialty care for numerous good reasons.<br/>1. The training is easier to get into. You don't have to graduate at the top of your med school class to get a primary care residency. All you have to do is graduate.<br/>2. The training is easier to get through. Compare 3 years to five or 7 or more. Compare the intensity of the training (at least until the nannies decided that surgery residents work too hard). Compare the pass rates on certifying boards- it's virtually a formality to pass boards in primary care. It's difficult and by no means certain that a well trained and competent surgical specialist will pass, which for us is a 2 stage process including oral exams, vs. a written test only for most primary care fields.<br/>3. The level of responsibility. Once you determine that your patient's problem is more complicated than costochondritis, you have the luxury of referring to a specialist if you're not "comfortable" or capable of managing the problem. Specialists can't do that as easily.<br/>4. Primary care is easier than specialty care. I was a primary care doc for a couple of years before I did my residency training in surgery. The hours are long, but the intensity of the interventions does not compare. It's not surprising that a good chunk of primary care is being done by PAs and NPs. You can wail all you want about how this lowers the quality of care, ad nauseam, but I don't see them going anywhere. They have proved that with adequate supervision, most primary care can be done by providers who have no more than 2-3 years total training after college. <br/><br/>A lot of the economic woes of primary care are self inflicted. The primary care community embraced the fatally flawed managed care and the gatekeeper concepts, and now can't cut loose. If you can't get adequate reimbursement for a camp physical, it's your onwn fault. Cash based practices are more efficient, and would enable an energetic internist to make a very good living selling his cognitive skills, if he would get rid of all the bureaucartic crap that they surrounf themselves with. I’ll get roasted for posting this, but primary care is reimbursed less than specialty care for numerous good reasons.
1. The training is easier to get into. You don’t have to graduate at the top of your med school class to get a primary care residency. All you have to do is graduate.
2. The training is easier to get through. Compare 3 years to five or 7 or more. Compare the intensity of the training (at least until the nannies decided that surgery residents work too hard). Compare the pass rates on certifying boards- it’s virtually a formality to pass boards in primary care. It’s difficult and by no means certain that a well trained and competent surgical specialist will pass, which for us is a 2 stage process including oral exams, vs. a written test only for most primary care fields.
3. The level of responsibility. Once you determine that your patient’s problem is more complicated than costochondritis, you have the luxury of referring to a specialist if you’re not “comfortable” or capable of managing the problem. Specialists can’t do that as easily.
4. Primary care is easier than specialty care. I was a primary care doc for a couple of years before I did my residency training in surgery. The hours are long, but the intensity of the interventions does not compare. It’s not surprising that a good chunk of primary care is being done by PAs and NPs. You can wail all you want about how this lowers the quality of care, ad nauseam, but I don’t see them going anywhere. They have proved that with adequate supervision, most primary care can be done by providers who have no more than 2-3 years total training after college.

A lot of the economic woes of primary care are self inflicted. The primary care community embraced the fatally flawed managed care and the gatekeeper concepts, and now can’t cut loose. If you can’t get adequate reimbursement for a camp physical, it’s your onwn fault. Cash based practices are more efficient, and would enable an energetic internist to make a very good living selling his cognitive skills, if he would get rid of all the bureaucartic crap that they surrounf themselves with.

]]> By: Anonymoushttp://www.kevinmd.com/blog/2006/07/more-ragging-on-primary-care.html#comment-64858 Anonymous Tue, 11 Jul 2006 21:06:00 +0000 http://clients.emmense.com/kevinmd/2006/07/more-ragging-on-primary-care.html#comment-64858 They are avoiding primary care because it doesn't pay as well. That's it. They are avoiding primary care because it doesn’t pay as well. That’s it.

]]> By: Anonymoushttp://www.kevinmd.com/blog/2006/07/more-ragging-on-primary-care.html#comment-64852 Anonymous Tue, 11 Jul 2006 20:17:00 +0000 http://clients.emmense.com/kevinmd/2006/07/more-ragging-on-primary-care.html#comment-64852 If you base your job choice on your test scores alone then you are going to have a miserable existence so long as you are working. If you base your job choice on your test scores alone then you are going to have a miserable existence so long as you are working.

]]> By: Anonymoushttp://www.kevinmd.com/blog/2006/07/more-ragging-on-primary-care.html#comment-64848 Anonymous Tue, 11 Jul 2006 19:31:00 +0000 http://clients.emmense.com/kevinmd/2006/07/more-ragging-on-primary-care.html#comment-64848 chalk one up<br/>I nailed my step 1. And based on my score i am NOT going into primary care. I refuse to put up with that crap. Leave it to the foreign doctors.<br/>.Paul chalk one up
I nailed my step 1. And based on my score i am NOT going into primary care. I refuse to put up with that crap. Leave it to the foreign doctors.
.Paul

]]> By: DNR Bflohttp://www.kevinmd.com/blog/2006/07/more-ragging-on-primary-care.html#comment-64834 DNR Bflo Tue, 11 Jul 2006 14:13:00 +0000 http://clients.emmense.com/kevinmd/2006/07/more-ragging-on-primary-care.html#comment-64834 "all the things you're not paid for -- the camp physicals and the work excuses"<br/>Ah yes, that reminds me of the week when I saw 3 guys in their early twenties who needed "full physicals" to participate in their job's bowling league. How do you bill and get paid for that? Thank you "Gecko" car insurance, for your CYA! “all the things you’re not paid for — the camp physicals and the work excuses”
Ah yes, that reminds me of the week when I saw 3 guys in their early twenties who needed “full physicals” to participate in their job’s bowling league. How do you bill and get paid for that? Thank you “Gecko” car insurance, for your CYA!

]]> By: Anonymoushttp://www.kevinmd.com/blog/2006/07/more-ragging-on-primary-care.html#comment-64819 Anonymous Tue, 11 Jul 2006 01:48:00 +0000 http://clients.emmense.com/kevinmd/2006/07/more-ragging-on-primary-care.html#comment-64819 The emergency department is one alternative - it's already many people's PCP!! The emergency department is one alternative – it’s already many people’s PCP!!

]]> By: Anonymoushttp://www.kevinmd.com/blog/2006/07/more-ragging-on-primary-care.html#comment-64816 Anonymous Tue, 11 Jul 2006 00:26:00 +0000 http://clients.emmense.com/kevinmd/2006/07/more-ragging-on-primary-care.html#comment-64816 Scenario for the future:<br/><br/>Joe Blow has chest pain. He is 44 years old. He tries to find a primary care physician, but can't, they are all gone. He makes an appointment to see a cardiologist. A cardiologist orders EKG, stress test, maybe goes all the way to the cardiac catheterization. Studies are all negative. Cardiologist refers patient to gastroenterologist. Gastroenterologist performs upper endoscopy, orders abdominal ultrasound, etc. Studies are all negative. Gastroenterologist refers patient to... and it goes on and on. Patient's final diagnosis: costochondritis. <br/>All the specialists' bills and diagnostic tests - costing thousands - could have been avoided with a visit to the primary care physician. Without primary care physicians, medical costs will skyrocket. Scenario for the future:

Joe Blow has chest pain. He is 44 years old. He tries to find a primary care physician, but can’t, they are all gone. He makes an appointment to see a cardiologist. A cardiologist orders EKG, stress test, maybe goes all the way to the cardiac catheterization. Studies are all negative. Cardiologist refers patient to gastroenterologist. Gastroenterologist performs upper endoscopy, orders abdominal ultrasound, etc. Studies are all negative. Gastroenterologist refers patient to… and it goes on and on. Patient’s final diagnosis: costochondritis.
All the specialists’ bills and diagnostic tests – costing thousands – could have been avoided with a visit to the primary care physician. Without primary care physicians, medical costs will skyrocket.

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