My take: Mid-levels, health consultants, blogging

1) A reader writes: “I guess I’m just looking for an intellectually honest assessment of what is wrong with the practice model of one or two MDs supervising several mid-levels so the MDs are free to spend more of their time on the intellectually taxing cases.”

There is nothing wrong with that model. Mid-levels play a valuable role in primary care delivery, and moreso in the future, with the ranks of primary care MDs dwindling.

The problem lies with some mid-levels (unconsciously or not) attempting to replace a physician for primary care. The rigor of MD or DO training is not equaled by a physician assistant, nurse practitioner, or doctorate-level nurse.

I agree that most of primary care can be handled well by mid-level providers. Physicians are valuable in picking out those 5 to 10 percent of cases that do not present typically.

The question is, does the public value that?

2) “Private health consultants” charge $7,000 to $100,000 a year for round-the-clock email and telephone consults, and face-to-face meetings with a personal health adviser.

For that price, would a concierge physician make more sense? At least that way, you’ll cut out the middle-man.

3) A number of prominent medical blogs, including Graham Walker, Panda Bear, and Surgeonsblog, recently have signed off.

It seems that the lifespan of a medical blog is shorter than those of other fields. Over the past year, we’ve seen far too many health care voices go silent.

Blogging and practicing medicine often don’t go hand in hand. Most of the media coverage borders on negative, focusing on patient privacy issues. Hospital administrations have shut down physician blogs. Furthermore, practicing medicine is exhausting, leaving blogging at the bottom of the priority list.

We are fortunate that new voices have emerged as these blogs have closed down. That’s important. Physicians are often left out of the healthcare debate, despite the fact that we will play a pivotal role in any type of reform.

Mainstream media reads what we write, and has paid attention to issues that we have blogged about – like the primary care shortage and the physician payment system.

The blogging medium is an ideal way physicians can make our voices matter. It’s in our best interest to keep the medical blogging phenomenon strong.

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  • AD


    I think your take on these topics is spot on.

  • Guy

    i think the insurance companies are blanketing doctors and telling them to not post.

  • The Happy Hospitalist

    I think the argument that extenders can do the vast majority of primary care has about the same implication that extenders can do the vast amount of specialty work.

    An extender could spend a few weeks learning the technique of lap chole and manageing surgical infections. An extender could spend a few weeks learning how to drive a scope for endoscopy or managing crohns. An extender could adjust medications for COPD and learn how to hold a bronch scope.

    If you believe extenders can do the vast majority of primary care just as well as the primary care doc, you must also believe that they can do it just as well as specialists. And I just don’t believe that to be the case.

    While it’s true that both primary care and specialty services by and large spend 80% or more of their time managing 10 medical conditions or less, I argue that those 10 or less conditions have an uncountable number of permutations in management and complications and it takes physician level training to understand how it all works. So, I’m not with you on this one Kevin.

  • DrVal

    I agree with you on the blogging – let’s keep it alive! I’m carrying my torch, brother. :)

  • Toni Brayer MD

    I’ve been blogging for over a year now and it is truly a vast uncharted territory that brings out varied and important opinions. It can only be good for Health Care to have doctors, nurses and other care-givers interacting with eachother and the public. We are truly experiencing the embryonic development of a new way of communicating and influencing change. Thanks for your contribution, Kevinmd


    Re: Number 3. I’m sorry to see these blogs go.

    But, realistically speaking, in order to really change things . . . in order for voices to matter . . . in order for our role to be pivotal in any kind of reform . . . doctors MUST sign their name.

    I’ve been at blogging for quite a while Kevin . . . invited into the blogosphere in 2005 by a local newspaper Editor touting “citizen journalism.

    But “citizen journalism” turned out to be a sad joke. Agenda-driven journalism (that protects local hospitals from scrutiny at all costs) is a far more accurate description.

    I’m here for very specific reasons – I’ve taken on the jerks running the hometown hospital that treated me (as a lowly employed physician in public service) like dirt . . . essentially for whistle-blowing on bad care.

    Hospital administrations were shutting down practices and careers and lives long before they started shutting down blogs.

    I’ve literally bared my soul on my blog. The focus is “hyper-local”, but the issues are universal. I’ve begged for help in getting state and national attention cast my case – which resoundingly demonstrates just how uneven the playing field for doctors really is. I’ve been ridiculed, insulted, spat on, told to “get over it”.

    I make my living as a Locum Tenens and I know it has cost me work.

    But I’m still hanging in there – because hospitals simply should not be allowed to treat good doctors so badly. It’s got to STOP. The only way it’s going to stop is for more doctors to stand firm and say, “NO! You CANNOT do this!”

    You talk about lifting veils.

    Yet on your corporately-sponsored blog, Dr. J’s Housecalls still does not merit a link.

    It’s an observation. I hope you publish it. And I am once again asking you (as one of the the big bad papa-bear aggregators of the medical blogosphere) to link my blog – so others can hear this story.

    Until you do, I have a hard time buying that blogging is an “ideal” medium for ALL the voices in the medical blogosphere.

  • cjd

    Blogging is useful for exposing the world to your complaints. At some point you have to take some real action to change things though. Or you just become one more in the din of whiners out there.

  • medicine girl

    Panda Bear, MD is gone? And no archives to boot. Say it ain’t so!

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