How to fix the primary care shortage

by John Horstkamp, MD

The primary care physician (PCP) shortage has attracted a lot of attention recently, and for good reason. Individual Americans are concerned that they will not have timely access to needed medical care, and policy makers are concerned that our specialist-heavy medical system is failing, giving us expensive but disjointed, poor quality care. Many experts rightly think that a robust primary care system would give us better health care for less money. But a thriving general medicine sector is a pipe dream unless we can convince many more medical students to choose careers in general internal medicine or family medicine. How can we do this?

First, why is there a PCP shortage? Why do medical students avoid primary care? The two main reasons are money and working conditions. Money is the more important reason. PCPs earn much less than specialists. It varies by specialty, but a rough approximation is that PCPs earn about $100,000 less per year, or about $3 million less over a career. A study in the Journal of the American Medical Association in 1989 found that the fill rate for residencies in a given specialty was highly related to starting salaries in the specialty. The same author repeated the study in 2008 and got the same results. The main factor influencing medical students’ specialty choice is expected future income.

Working conditions are a problem for many PCPs, for many reasons. Medicine has become more complex over the last several decades, and a typical PCP now sees more elderly patients and those suffering from multiple medical problems. The administrative burden has also worsened significantly. And the shortage of PCPs puts more work on the shoulders of those that remain in the field. These factors and others make for difficult work. Indeed, in a recent article in the Annals of Internal Medicine, 48% of general internal medicine doctors and family physicians termed their work environment “chaotic.” Medical students are aware of this situation, which is not nearly so bad in many specialties, and so they avoid primary care.

What can be done? Some have proposed loan forgiveness. This might help a bit, but a repayment of $200,000 or less in educational loans is small compared with $3 million in foregone income. Others have suggested training more mid-level providers, such as physician assistants and nurse practitioners, to fill the gap. These providers certainly have a role to play, but a general medical system with little physician leadership and labor would be a step into the unknown. Certainly other advanced countries have not embraced such a system. The American College of Physicians has proposed the Patient Centered Medical Home, a concept that aims to allow doctors to use practice organization changes and information technology, among other things, to improve care and doctor satisfaction. Although this idea has attracted much attention from political decision makers, whether it will actually work is questionable. It will take years to know. Policy makers routinely propose such things as more training spots for PCPs and opening more Community Health Centers. These efforts are unlikely to do much good; the problem is a lack of doctors, not a lack of jobs for them.

This year has seen a proposal to increase Medicare payments to primary care doctors by as much as 8% in 2010. While this is a step in the right direction, whether medical students will be impressed remains an open question. The best thing to do to get more family doctors is very simple, although not very pleasant for a debtor nation in economic crisis: we must increase the pay. A significant increase in reimbursement, in the range of 30% to 70%, would attract more medical students. This would lower the burden on the current workforce, allow doctors more time with their patients, and allow for a more manageable practice. It is an open question whether such a significant pay increase would in and of itself give America an adequate supply of generalist physicians, but our current pay structure virtually guarantees a severe and worsening shortage in the coming years.

John Horstkamp is a family physician at Washington State University in Pullman, Washington. The views expressed here are his own and do not reflect the views of the university.

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  • dubious

    Sorry,

    But it’s not just increasing pay. In this day and age, it’s pay AND lifestyle. Unless primary care somehow manages to evade the enforced crunch of seeing a new patient in under 15 minutes, even with a boosted pay schedule I just don’t see that it will have the same draw as other more desirable sub-specialities that promise the “same” pay and better lifestyle.

  • jenga

    It would be much simpler to just close alot of specialty residencies. Eliminate 40% of specialty residency slots.

  • http://drbrenner.blogspot.com irb123

    Glad more people are addressing this issue. I’ve already blogged on the subject with a slightly different take on it: http://drbrenner.blogspot.com/2009/07/primary-problem-with-universal.html

  • Don

    We also have a shortage of specialists in this country so cutting residency slots seems like a terrible idea. I agree that the pay disparity is great but the liability, years in training, and case complexity is also great. Having said that, primary care physicians desperately need a pay increase. My greatest fear is that this increase will come at an unfair expense to specialists.

  • Nuclear Fire

    I agree with dubious. Lifestyle was a strong reasons I choose my speciality that pays about the same as a pcp and less than a hospitalist.

    @jenga: Great. Now you have overworked, underpayed primary care doctors who don’t have anyone to help them with difficult cases. Brilliant.

  • Anonymous

    “But it’s not just increasing pay.”

    For the most part, it is.

  • Nuclear Fire

    The NEJM had an interesting article about in-flight medical situations with specifics about incidence and medicolegal issues:
    http://content.nejm.org/cgi/content/full/346/14/1067

  • guy

    what about just having primary care turning away lower paying insurance plans? That should increase reimbursements? right. If you are overwhelmed with patients then clearly you could tolerate dropping some plans.

    I dropped medicare awhile back. No one takes secure horizons around here because it pays badly so now no one is on secure horizons.

    Let the market control conditions. If you are unhappy with what you get paid for things then drop that plan.

  • doctormom

    It is a little hard to drop Medicare in our family practice clinic when 60% of clinic is Medicare, 70% of outpatients on the hospital side are Medicare, and 85% of inpatient is Medicare. Out in rural areas we would do a great disservice to patients to not accept Medicare – the 90 year olds can’t drive 45 minutes to the next provider…so they’ll just have huge bills and I won’t get paid anything.

    Lifestyle is way more important than money to me…it’s the hassles that are killing me and make me reconsider my choice of primary care…not the lack of reimbursement.

  • Rezmed09

    Simplify the billing for primary care visits. Require one form for all insurers. Audit insurers to make sure that all denial rates are low. Set as a goal to allow a PCP to take home 66% of the gross collections by mandating increases in efficiency of billing (for insurers), free practice management software, and tort reform. The goal should be to flip flop the present situation where PCP’s take home $150K after collecting $450-500K and using up $300K on operating costs.

    Merely increasing payment only feeds into cost escalation. I still marvel at the 20 years of private practice experience my Canadian FP friend has had. He and his wife operate the practice… no armies of billers, coders, nurses to handle calls for pre authorizations…. on and on. We are doing this ass backwards.

  • Tom

    Pay is the prime determinant of value. All other factors are secondary. That being said, there are numerous secondary considerations that enter into decisions. Paperwork hassles, esp. w/ Medicare and Medicaid, are rampant in the PCP setting, as is doctor dissatisfaction, especially in the face of poor patient compliance.

    The reasons to not do primary care go on and on. Pay is a starting point.

  • http://sideeffectsmayinclude.wordpress.com Whitny

    I know it’s easy for many doctors to dismiss nurse practitioners as “mid-level” providers. I’ve said it before on this blog and I’ll say it again: that term ain’t PC anymore. Nurse practitioners are independent health care providers with extensive education, experience and training and, as autonomous providers of general (FNP, PNP) or specialized health care (ACNP, NNP, CNM, etc.), are not merely “mid-way” up the medical “chain of command”. Furthermore, what does this “ranking” imply? RNs are low-level, or that nursing care is a low-level version of MD care instead of care provided by college-educated professionals trained to deliver specialized patient care? First-responders might as well not exist? But don’t take my word for it. The American Academy of Nurse Practitioners has released a statement on the use of terms like mid-level provider and physician extender. The statement notes that the role of nurse practitioner evolved not to provide “mid-level” care but to provide high-quality care, and the role CERTAINLY did not evolve as a response to your so-called “physcian leadership” (physicians fought NPs tooth and nail) but rather the role evolved in the 1960s in recognition that nurses with advanced education and training were fully capable of providing high-quality, cost-effective primary care. The role evolved independent of physicians or physcian leadership and NPs are independently educated, licensed, and goverened. If you can’t think of another term on your own, the AANP recommends “clinician”, “primary care provider”, “independently licensed provider”, and “health care professional.”
    Furthermore, your claim that a primary care environment composed largely NPs is a “step into the unknown” is simply not true. NPs have been around for 45 years, and though the role is still evolving in terms of education and specialty (for instance, by 2015 the standard degree will be the DNP, meaning NPs will have 8 years of med-specific education [this goes beyond standard 4 year medical school programs] AND residency programs for new NPs are currently being developed and implemented), NPs have been studied for the past few DECADES and the literature consistently demonsrates that the care provided by NPs is comperable to that of MDs. If you think perhaps I am biased, you should review the literature for yourself. A randomized trial conducted by DOCTORS and published in the Journal of the American Medical Association almost a decade ago found no difference in patient outcomes or quality of care provided by NPs and MDs (Mundinger et al., 2000). These finding remained consistent across two year follow-up (Lenz et al., 2003). Multiple other studies found that, although the role and education of the NP is still evolving, the care provided is of high quality comperable to physicians and patient satisfaction is high (Hoffman et al., 2005; Horrocks et al., 2002; Lambing et al., 2004; Pioro et al., 2001.) Furthermore, nursing remains a vital and independent discipline within health care, with it’s own body of research, theory, practice guidelines, educational standards, and regulatory bodies.

    All that being said, I hope that MDs don’t abandon the primary care field. I know money is an issue (if you want to gripe about that, remember that NPs only get reimbursed 80% of what MDs do), but I agree with dubious and nuclear fire. Lifestyle is key, and doctors may feel more compelled to go into primary care if they didn’t feel like their hands were tied by the legal and financing systems. Specialty is great, especially if you get to spend more time doing your job than doing paperwork, but primary care, if it’s able to be practiced the way its supposed to be practiced, can be very interesting in terms of variety of both patients (newborns to hospice patients) and pathology (infectious disease to managment of chronic illness and everything in between.) It can also be very satisfying in terms of following patients across a lifespan. I think these things would appeal to more med students if the lifestyle were better.

    a few full references:

    Lenz, Mundinger, Kane, Hopkins & Lin. (2004). Primary care outcomes in patients treated by nurse practitioners or physicians: Two-year follow-up. Medical Care Research and Review, 61(3), 332-351.

    Mundinger et al. (2000). Primary care outcomes in patients treated by nurse practitioners or physicians. JAMA, 283(1), 59-68.

  • Nuclear Fire

    I look forward to a world of primary care run by mid-levels. It’ll mean a lot more referrals. I just hope I’ll be able to find an MD/DO for my own medical needs.

    Sorry, maybe that was too mean but you’re deluding yourself if you think that even 8 years of school is going to somehow make PA/NP’s equal to MDs. These days it appears that it’s a race to the bottom as MA’s replace RNs etc. There may not be a measurable outcome difference but would you seriously want to claim an MA is as good as an RN? or an LPN as good as an BSN? One of the glaring differences I notice in referrals from mid-levels is that when a patient comes in for something that should be monitored for awhile to make sure it doesn’t resolve they instead order a shotgun barrage of consults and tests, whereas the physicians make a single referral with appropriate pre-consult orders and actually include a reasonable differential in the referral letter.

    Sure, maybe there was no mortality difference or significant morbidity, but the cost and appropriateness of care is vastly different.

    So seriously, I’m all for PA, ARNP, naturopaths, chiropractors or whomever else wants to practice primary care go it. I figure people will deserve what they get and if it truly turns out that physicians are no better than they’ll get what they deserve. I love dog-eats-dog capitalism. I’d love to see mid-level practices competing with physician practices.

  • http://kidney-beans.blogspot.com/ dennis

    A very simple and nice way of helping others outside the industry understand the underlying cause of why there is a shortage of PCPs.

    Knowing this, both issues would need to be settled or at least make reforms in order to lessen the gap between the pay and lifestyle conditions of PCPs and specialists in order to work.

    Doing one or the other will probably improve things but maybe not to the extent that is needed.

  • Anonymous

    Kevin,

    I do not understand this piece. I get it, that US medical students are not going into primary care, but foreign medical graduates are going into primary care. I do not know of any residency spots in primary care that are open.
    If all the residency spots get filled and the foreign doctors stay and practice medicine (most of these docs do stay in the USA) then why is there is shortage of primary care.

    You might argue that these people then do a fellowship, but the total number of doctors in fields of Internal Medicine and Family practice remain the same, irrespective of, if they do a fellowship or not.

    Then why is their a shortage. Please explain.

    Thanks.

  • Nuclear Fire

    Doctors who do fellowship don’t typically continue to practice primary care.

  • newsdoc

    We need to just import more FMGs from countries that are poor. Steal their medical education funding and personnel. We have the best medical care (sic). And let us have any disgraced specialist say they are a generalist even though being a good generalist requires a much more extensive base of medical knowlege than any specialist and they haven’t seen a diabetic as a patient since training.

  • http://sideeffectsmayinclude.wordpress.com Whitny

    Actually, Nuclear Fire, I know you have experience in the biz with reciept of referrals, but the literature I cited measures outcomes like “cost” and “appropriateness” of care between MDs and NPs, not just morbidity and mortality. These outcomes were found to be similar. I suppose the literature does not measure “eloquence of referral letter” as an outcome… perhaps this will be studied next time?

    I am not dismissing your claim. I have heard other docs scoff at the type of care they’ve seen NPs provide, and I am interested in criticism because I too believe there are deficits in our education and training that need addressing (much like there are certain, albeit different, deficits in the med school education). However, I have also heard many doctors rave about the quality of care that NPs provide. I have heard doctors scoff at the quality of care that other docs provide. I have heard hospitalists bitch about ER docs. I’ve heard surgeons bitch about “those dumb hospitalists.” Everyone seems to think everyone else is an idiot. My point is, personal anecdote doesn’t go far with me. Or with anybody, really, which is why we have research and science and all that good stuff.

    It’s interesting that you say NPs order a “shotgun barrage of consults and tests.” I think our own beloved KevinMD just posted a piece about doctors ordering too many tests and cost escalations due to defensive medicine and inappropriate use of diagnostics/procedures/referrals. Seems to be pretty pervasive problem.

    In my previous post, I was merely trying to demonstrate how the use of the term “mid-level” is really not appropriate and how management of primary care by NPs is not a “shot in the dark,” as the author claimed. I wasn’t suggesting that I want to see a primary care landscape dominated by NPs. I think MDs are absolutely vital and I hope they remain committed to the field (esp. since it looks like you won’t have a PCP that will meet your standards if there aren’t any MDs/DOs to care for you). Furthermore, if NPs can’t provide cost-effective, quality care in a way that is beneficial for the patient and satisfying (as in, decent living and lifestyle) for the NP, I don’t think the practice model will persist. But so far the practice model is thriving. I know you say you look forward to NPs competing against primary care docs, but… um, that’s kind of the status quo, at least in certain parts of the country.

    Personally I have not seen much difference between LPNs, RNs, and ADNs. Even so, we don’t call LPNs “Lesser practical nurses.” They are licensed practical nurses. Where I see a difference, however, is between recent medical school graduates and third or fourth year residents. Hell, I see a major difference between interns and ICU nurses (my dad’s always said that he learned everything in his internship from the ICU nurses). Because of this, I’m pushing for NP residency programs. I think you are right when you say that even 8 years of schooling won’t make up for that.

    If you don’t mind me asking, what is your specialty? Just curious, since you mentioned it pays similar to a PCP.

  • Nuclear Fire

    You’re correct in many respects. I myself am one of those doctors who’ll rave about PA/NP and deride MD/DOs. The caveat is that I hold the MD/DO to a very strict standard while I hold the PA/NP to a much lesser standard, holding the supervising doctor accountable for anything that goes wrong. If I held all “providers” to the same standard, my evaluation of PA/NP would plummet just as if I held the M3/M4s to the same standard as an R2/R3.

    The reason I cited the example of referral letters is that I’ve noticed over the last couple years getting amazingly bad referrals (easily missed diagnosis, no reason for a consult as it’s a primary care ailment or terrible treatment (malpractice) for a long time) and when I’m muttering “what f-ing moron doctor is killing this patient…” and reach for the letterhead to find out, 9 times out of 10 it’s an NP/PA (that used to be an honor reserved for orthopods).

    I think NP/PA can do a great job in their scope. I think treating sniffles and such things will lead to similar outcomes. In my field, I think a very carefully trained mid-level can do an excellent job in their scope managing stable returns, but not new consults, deteriorating patients or complicated patients. There is a difference between managing a healthy 30 year old with CAP and a 70 year old with afib, CAD, COPD, stage 3 CHF, stage 4 CKD, RA, BPH, sleep apnea and obesity. That’s not a rare patient but my average clinic patient as an IM physician. That takes a Master Clinician not a doc in the box.

    But that’s just my opinion. And I don’t think that it or a few studies is good enough to be gospel or get to the truth, so I truly say let there be competition. The market and the malpractice courts will sort it out.

    Are there truly (non-third world) places where NP/PA practice independently without physician backup/supervision?

    To your questions: specialty of IM, subspecialty rheum.

    My father said similar things about learning from CC nurses. I have a great deal of respect for them and enjoyed working with them, but quite frankly, didn’t learn much from them probably both because we’re both experts at very different aspects of medicine and we’re both too busy doing our jobs. They did teach me that LPN means “let’s play nurse” and I have noticed a huge difference between MA, LPN and RN. Anyone who hasn’t I’d challenge isn’t using the RN up to the full level of his/her training.

  • R Watkins

    Increase “relative values” for primary care E&M codes by 100%. Half of this would go to increased income, half to longer appointments and more manageable patient load (i.e., decreased productivity in terms of charges).

    The PCMH is an administrative nightmare that will only add to the flight from primary care.

  • http://weightlossnyc.com weight loss doctor

    Would be nice to have a cost analysis of insurer income per patient vs the costs providers bear to maintain these plans. It’s high time and the right time to expose how health care has been hijacked by insurers.

  • jsmith

    I hate to beat up on NPs, but nuclear fire is right. I’ve worked with them for years, and their fund of knowledge is minimal compared with MDs. And you have to carry their water. Hire a new doc, orient him or her, and let them go. Independent. It’s not like that with NPs. The one I work with now has been one for 20 years, and she still can’t read a chest xray on her own. And of course she doesn’t take night call–a good thing for the patients.
    NPs are great for the easy stuff. Hypertension, colds. Differential diagnosis or complicated disease, you want a doc. Unfortunately there might not be one.

  • jenga

    All of these ideas are nice, but my idea is the only one guaranteed to work.

  • SmartDoc

    There is one, and only one, way to increase the number of PSPs:

    Encourage the growth of private PCP health care (the grossly misnamed “concierge” care).

    Every other proposal is total deceitful nonsense.

  • IDDOC

    I truely enjoy reading the bakc and forth between Nuclear Fire and Whitney. Personally, I agree whole heartedly with Nuclear Fire. And I definately hold MDs/DOs to a higher standard then NPs and PAs. (Frankly I think the AMA has really done us physicians a dis-service by allowing NPs and PA’s to extend there practice rights and we should fight whole heartedly to scale back there practice rights. They should be restricted to treatment of a few ailments that doesn’t necessarily require a physician to see and the types of drugs they can prescribe should be serverly restricted, some states allow them to prescribe narcotics…I can’t believe that…and they MUST practice 100% under the supervision of a physician). However I doubt this will ever happen…however with our severe physician shortage amongst us….perhaps we should do an experiment and allow PA’s and NPs the right to admit and manage patients in the hospital and lets see the care they provide. I will bet there care will be inferior since they do not seem to think outside a box. Much like the ED physician in which everyone who comes through the door gets a CT of the head EKG and cardiac enzymes for the sniffles. Here is what I know: being in the last year of my fellowship; I have witnessed tremendous inadequacies in the work-up and frankly malpractice like treatment of referrals to my consultation clinic…I mean what kind of idiot would start someone on Bactrim (instead of admitting them) for a bacteremia and then send them to an outpt office for consultation for MRSA????? When I am out in private practice I will NEVER accept a consultation from a PA or NP. My office will screen all referrals, and if the patient HAS NOT been evaluated by the supervising physician or someone with my degree (MD or DO) I will not see the patient, PERIOD.

  • http://sideeffectsmayinclude.wordpress.com Whitny

    JSmith,

    I’m sorry that your NP doesn’t know how to read a cxr after twenty years of practice. That’s certainly an unflattering ancedote for you to relate. But again, I am not one to be easily cornered by personal experience or anecdote, and anyone else who is psycho enough to be following this little debate would be wiser to consult the body of literature (much more than a “few studies” as NF called it) on the subject rather than rely on any of the opinions or personal experiences related here, including mine.

    I don’t know why primary care has become as devalued as it has become, but I believe it goes beyond reimbursement rates and is a part of the culture of medicine itself (sorry to lean back on personal anecdote, but many MDs I know were told they were “too smart” to go into primary care by their educators and members of the profession.) These messages are obviously reinforced by pay and lifestyle differentials between PCP’s and specialists, but I think that seed was planted by the medical community itself. Just my opinion. I haven’t done a genealogy of primary care within medicine or anything.

    NP is still an evolving role, and the education and training advance every year. There is nothing to prevent NPs from learning how to navigate increasingly difficult differentials and complex patients as we continue to define our scope of practice. Perhaps you all think medical knowledge is terribly unique and can only be acquired in one way, but you’re deluding yourselves if you think that humans who pursue independent practice through other rigorous educational and training routes are somehow unable to do what you do. I don’t want to turn this into a battle because I think medicine and nursing both offer extremely valuable frameworks for practice, but the value of the MD framework has never been challenged or questioned (until recently) whereas nusing has had to prove itself as a worthy framework for independent practice every step of the way and NPs have had to fight for every ounce of autonomy that they’ve earned. And yes, NF, there are places other than the “third world” where NPs practice autonomously, without physician back-up. Currently, the states with the most expansive scopes of practice for nurse practitioners are Alaska, Arizona, New Hampshire, New Mexico, Oregon and Washington. NPs practice completely autonomously in these states, and have minimal physcian collaboration in 15 other states as well. Many states, like Florida, California, and Ohio, are considering legislation to expand the scope of NPs.

  • Nuclear Fire

    If you accept that the money, time, and intensity/competition in the training of physicians is much more than PA/NP (or if you at least accept that the MDs think so),
    And, if you accept that PA/NP do just as good a job at primary care (or at least accept that the PA/NP, literature, patients think so),
    Then is it not a natural conclusion that a medical student reading the above would chose not to do something that someone lesser qualified can do just as well and instead chose a “more advanced, difficult, respected” area of medicine? May that not be part of the reason you can’t entice them into PC and why you can’t get insurance companies/government to pay for it?

    Any medical students reading this care to share your thoughts?

  • eddoc

    Whoa IDDOC! Hold on – I’m not sure what you mean by the “AMA extending [PA's] practice rights. As one who has a hand in educatiing PA’s, I can say that they are not nor do they have plans to be anything other than dependent providers. Scope of practice in most states is determined by the physician’s scope of practice with the specifics determined at the practice level – if you want the PA with whom you work to see only sniffles, then that is what he or she will see. If you want them to discuss every patient with you before discharge, then that is what gets done. At some level, seeing what they learn in school and over time, I think that is a waste of time, but ultimately, that is between you and the PA. As to NP’s, different ball of wax as the DNP seems to have increased the call for “independent practice.” I have to say, though, that sometimes the issue of dependent vs independent practice (legal definition aside) becomes a bit of a red herring as who among us has not discussed a perplexing patient with someone whose opinion we trusted?

  • jsmith

    NF makes a great point. Will NPs and PAs drive out the those MDs who might otherwise consider it? It could happen. Can you imagine being a doc and having an NP as a supervisor because he or so has been there longer and what the hell, you’re all just primary care providers? This would be a catastrophe for medical care in this country, because, with all due respect for Whitney, most NPs don’t know much medicine. They just don’t. Even though they don’t want to hear this, they should be supervised. Otherwise lots of inappropriate consults, ER visits, missed diagnoses, etc, etc. Talk to your local ER doc about NPs practicing alone. I’ve done it. It’s funny. They roll their eyes. Every time. Cleaning up the mess. Unfortunately this is the way medicine is going. Whitny’s side might very well take over, and NPs will be turned loose en masse on America. A lot of the remaining FPs and internists will go concierge, for those who can pay for a “real doctor.”
    Sorry to be such a downer. On the positive side, US life expectancy has just hit its highest level ever.

  • jsmith

    Nuclear Fire, See post by DMS student at Kevin’s CNN article of today at CNN. He/she discusses the issue of midlevels dissuading med students from primary care.

  • http://sideeffectsmayinclude.wordpress.com Whitny

    With all due respect to NF and JSmith, y’all continue to rely on your opinions to make support your arguments. It’s amazing that neither of the two practicing MDs in this debate have entered any evidence for consideration. I’m going to give you the benefit of the doubt here and assume this is NOT how y’all make your clinical judgments. “Well, I talked to some ER doc friends of mine and this is what they believe. Screw the literature.” If I were forced to play devil’s advocate, I could make your argument about NPs being unprepared to practice independently far better than either of you have. By the way, what is your argument? Are you claiming NPs are unprepared and underqualified for independent practice, or that NPs are not as “good” as MDs, or both? And whatever your argument is, why don’t you try supporting your claims with something other than opinion or conjecture? If you are saying it’s inappropriate to measure NPs using the physician yardstick, I’d probably agree with you. But neither of you have said that. You just keep raggin’ on our “minimal” medical knowledge. You make it sound like we learn about medicine from Men’s Health magazine or something. And also, can you all please learn to differentiate between PAs and NPs? I know everyone “beneath” you sort of blends together into one large inferior class of provider, but NPs hold bachelor degrees in nursing and are licensed as RNs before going on the pursue masters or doctoral degrees and advanced licensing that prepares them for independent practice. PAs are now master’s educated health professionals who have received advanced training in accordance with the medical model and work in collaboration with physcians. Both are independently licensed.

    By the way, you are contradicting yourselves. You are suggesting that med students stay away from primary care because it actually is too easy and can be performed by NPs, but you are also saying that NPs are a disaster and can’t perform the job without someone to clean up their mess. Wouldn’t this imply that primary care is in fact a challenging field, and should therefore claim the respect of the medical community? So which is it, guys? Easy? Challenging? Degraded by the inclusion of NPs or degraded from within? Do you really even care or is this just an opportunity to make fun of NPs?

    And allow me to repeat an argument I made in my original response to nuclear fire. I’m sure ER docs roll their eyes and claim to clean up the mess after surgeons, primary care docs, intensivits, ENT, allergists, OB/GYNs, orthadontists, orthopods and everybody else out there. This is standard procedure in medicine. Nurses roll their eyes and claim to clean up after sloppy docs. Techs roll their eyes and clean up after nurses. Housekeeping folks roll their eyes and clean up after everybody. But the issue of NPs in independent practice is important enough that it’s actually been studied. For years.

    Without something to substantiate your claims, your position is completely predictable. Nobody on top takes kindly to redistribution of power, and nobody enjoys being associated with groups of people that they have been taught are “lesser.” Doctors being subjected to nursing leadership? Oh, what an insult! Who cares if the nurse has an RN, an MSN, a DPN, a residency, many years of experience, and arsenal of skills and excellent clinical judgment ? It still LOOKS bad. It inverts the “natural” power equation. God forbid! BTW, nobody has responded to my argument that the value of the medical framework has never been challenged whereas nursing has had to fight for everything its earned. Do you really think nurse practitioners would have won independent practice with the medical community fighting us every step of the way if we really provided the care that’s as shitty as you’ve characterized with your little anecdotes? And shame shame shame on you for implying that NPs are somehow responsible for the PCP shortage by dissuading med students from joining the field. NPs have stepped up to the plate to help solve the PCP shortage, and it is terribly irreponsible of you to suggest to readers that we are somehow responsible for creating this mess. And if your med students are so egotistical that they think primary care is beneath them because NPs are also primary care providers, shame on them too (though I’m sure most med students would distance themselves from your claim). Your implication is about as fair as me suggesting that the nursing shortage should be blamed on MAs and techs because nurses don’t want to associate with them.

    Anyhow, this debate is a moot point. Primary care shortage means NPs are here to stay, at least for now. This is not “my side,” this is just today’s health care landscape.

  • Nuclear Fire

    Quite frankly, you don’t seem to be paying attention very well and maybe you just have too much of a stake in this to be objective. This will be the last time I bother to reply unless you start actually reading what people are writing and stop using ad hominem attacks.

    First of all, I don’t have any dog in this fight. I’m not a primary care provider; I love my subspecialty job; I quite clearly stated that I think they should let any one including chiropractors etc practice PC if they want and let the chips fall where they may. (It’s the ultimate clinical trial.) It won’t affect me at all on the other hand this clearly is a conversation related to your job. That whole diatribe attacking my character was a straw-man argument and suggesting this has to do with power or prestige is insulting and dishonest.

    Second, the point that was raised about mid-levels possibly dissuading medical students from entering PC, and if you look at today’s CNN post comments you’ll see much more about it including medical students who verify that hypothesis, is that the implicit aim of these future physicians is to do something challenging that requires skills and knowledge that others do not posses. No one claimed that NP are “responsible” for the PCP shortage and I in no way think that, but rather it was questioned if the influx of NP may lead to a choice of the MSs to avoid that. Medical students have been at the top of their class since before high school, competing against the best in a cut throat system and now are looking at what to do with a significant portion of their life. The same M4 who ends up going into neurosurgery, plastic surgery or whatever very difficult field is at the same level as the M4 that may be considering PC. That M4 has the ability to be the neurosurgeon or the next “House.” As a naturally competitive person, I thought that this hypothetical med student might forgo something that he/she considers not exclusive based on skill.

    Third, your claim about contradiction is invalid. In the first place, I did not say that med students should stay away from primary care because it is easy. This is another example of your continued use of straw-man arguments and you’re missing the dichotomy from the hypothetical. The point was made that IF primary care is not hard enough to require the full talents/knowledge of an good physician THEN this might dissuade medical students from choosing primary care. Good or bad, those MS in their clinical years now are looked down on who state they’re going into primary care with the implicit assumption being that they must not be smart or hard working. My personal beliefs are that the BEST physicians should go into primary care (and in my class three of the top ones did but had to have strong personalities to put up with the hit to their reputation) because it takes a Master Clinician to do such a tough job, taking care of so many issues at once and trying to be constantly vigilant to pick up on the 1 case of Churg-Strauss in the 100,000 of asthma they will see.

    Finally, the articles you cited have nothing to do with the points that were raised, which is not that mid-levels don’t do as good a job at certain parts of primary care but that when the high level of critical thinking is needed, or a complex diagnosis made, or “outside-of-the-box” thinking is required, I do not believe that the vast majority mid-levels can do so at the same level as most physicians. This is my opinion but since I cannot prove it and since I really don’t care and kinda don’t mind if a really talented mid-level worked hard an educated themselves to a high level, I have repeatedly stated that let every one complete and the best will win. On the other hand, you cannot show me an article that has addressed my hypothesis nor do I think anyone will ever do such a trial any more than they’ll do an RTC to see if parachutes prevent gravity related illnesses. Your articles are not addressing the issue being raised. Still, if you want your articles to be addressed, they were poorly done studies at best, which you would know if you did any kind of critical analysis on them or even read them yourself. To make it easy for you, the Cochrane review consluded thus “The findings suggest that appropriately trained nurses can produce as high quality care as primary care doctors and achieve as good health outcomes for patients. However, this conclusion should be viewed with caution given that only one study was powered to assess equivalence of care, many studies had methodological limitations, and patient follow-up was generally 12 months or less.” Not exactly a ringing endorsement. You can read the review yourself to find out all the methodological problems with the studies you cited.

    PS, your pathetic cry to “please differentiate between PAs and NPs” is silly and trite just as I would be to say “please differentiate between MD and DO.” While there are differences, for the purpose of this situation it is unimportant.

  • radphys

    Why is it that physicians, who so quickly remind us they enter this profession out of care and compassion, gravitate to monetary arguments more quickly than any other professional? I would argue they do so more quickly than lawyers, teachers, even MBAs. I believe this rises from a deep hubris engrained from medical school and perpetuated through residency and onward.
    There is no other profession in this nation that rewards mediocrity as does the medical profession. Why do you think you deserve minimum 300-400k income a year when you occupy a profession in which there are tens of thousands exactly like you, doing exactly the same thing in the same way, no creativity required? Your argument of increased compensation is exactly what is wrong with health care in this nation at the pinnacle of which sits the physician. Your argument for a better, more efficient and more meaningful health care framework I accept completely.
    Read through the physician responses to this posting and tell me you can’t smell the hubris? Most of us who work hard to get somewhere are prideful, but the pervasiveness of physicians (especially in private practice) with attitudes of financial entitlement is overwhelming. I spent over 10 years at prestigious universities obtaining degrees all the way up through the Ph.D. My field is one of clinical service, teaching of residents, graduate students, and research, much like that of a physician scientist. My profession is certified by the same governing board that certifies two other physician specialties. For all of my education, experience and board certification I command a salary near or slightly more than PCP/hospitalists, devoting similar or more hours and, though perhaps different, a similar level of frustration. There is one glaring difference… I am not in business for myself, I do not believe I am entitled to $100-200k more in income because my specialist physician colleagues make that, and I never went to medical school. My academic upbringing in both clinic and research was one of service and inquiry, first and foremost.
    Physicians are hardworking and competent members of our society. However, their occupation at the medical and economic pinnacle of the United States is a result of historic inertia. Nuclear Fire makes points out that medical students have been the top of their class since high school. I agree. And why do they go into medicine? Historically, and this hasn’t changed, they have a high quality of life, primary care or otherwise. How many PCPs spend their weekends in the office writing grants because their research time is monopolized by a “top of his class” specialist who doesn’t understand radiation physics (and he is now a radiation oncologist) as he only took the time to memorize it to pass the boards (so he could continue his “top” grades and get in medical school)? Not many, I’ll tell you where they are, most of them are playing golf. There is nothing intellectually challenging about PCP or most specialties—in fact, I don’t believe specialists should in general really be physicians at all anymore—leave that to the generalists. We had a patient code recently… not a single attending in my department knew how to proceed… they were deer in headlights. Only a resident who moonlights in the ED knew what to do.
    So, I sound bitter. Yes, I am bitter. I am finished listening to physicians many of whom are of mediocre general intelligence, who had good grades from some crap college, who in general are significantly overpaid, act as if they are entitled to the elevated status and economic prosperity they so enjoy in this nation. Yes, increasing the net income of PCPs will persuade more medical students to enter the field, but isn’t that part of the problem?
    Here’s a thought. Why don’t we infuse some government money into accrediting more medical schools/adding residency slots? I think there are armies of high school students willing to memorize Newton’s Laws and the metabolic pathway, in exchange for a PCPs salary. Again, there is little intellectually challenging about clinical medicine. It is simply a requirement of scale—if it were that challenging, there would be no consistency.
    All that said, the bigger problem here is the cost and pay structure. Let’s make this such that PCPs can actually practice medicine rather than herd cattle. Increasing their pay will not do that. In addition, let’s bundle many of these specialist charges, and put an end to self-referral.
    All end my rant with what I think is a rather telling anecdote. I once asked a physician colleague as we worked together late on a Friday evening, “What do you think about the idea of ending pay per procedure, about physicians receiving a salary? Instead of being a partner in a private practice, you work for a non-profit entity. You would still make an excellent income but be relieved of these business aspects of medicine.” Let me preface this with two thoughts: 1) I think this man an excellent physician and respect his ethic, 2) I don’t necessarily agree with the oft-Obama-touted Cleveland Clinic model. His response was, without a moment’s pause, “What incentive do I have to be here at 10pm on a Friday if I am being paid a salary? I would be at home.” My response (which I kept to myself), “Then why am I here? I get paid a salary, and a damn good one at that, but I am here to fulfill an obligation that I have to a patient and a profession, even though in my case the patient either doesn’t know I exist or thinks I’m not a “real” doctor.”
    These problems will not be fixed. The government will do something that will either 1) amount to nothing or 2) cost our children fortunes we as a nation cannot afford. The real problem with no practical solution is that of hubris bred into our physicians starting even before medical school, and money. The above answer from my colleague says it all. That is not the answer of a medical practitioner but rather of a shrewd entrepreneur. And why no practicable solution? Inertia. I’m sure many of you physicians memorized what that means for the MCAT. (After that insult, I must say I believe as individuals most physicians are ethical, competent people, many of whom I count among my friends—my frustration is directed more at the profession than the individual).

  • http://sideeffectsmayinclude.wordpress.com Whitny

    Yeah, I read the CNN comments. And I am sorry, NF, for lumping you in with the other docs who have expressed outrage at being associated with NPs. My last post, although addressed to you (since this debate here sort of began between you and I), was not really directed at your specific arguments. I agree with you: let the chips fall where they may (as long as this approach does not harm patients). However, I don’t want to duke it out with docs for the primary care market because I’d rather partner with docs in fixing our health care crisis, but it does not sound like docs are too interested in partnering with me unless a clear hierarchy, in which I am assumed to have minimal training and to be somehow less intelligent and capable, is established. If you think this has not been the tone of the debate then you haven’t, uh, been reading. And yes, I take this tone personally. It’s unnatural to hear your field being slandered and to not want to raise objections.

    You are right that there are some methodological limitations to some of the studies within the body of literature investigating this issue… (this does not mean they are all “poorly done at best”, however.) If you look closer, you’ll see that the specific studies I cited include longer than 12 month follow-up and a few have the statistical power to detect differences between MD and NP activities and care. Still, I’m aware of some of the limitations (though thanks for talking down to me, and for quoting a brief section from the 2005 Crochane abstract you found on PubMed, which reviewd 25 of over 4,000 articles on the subject). I suppose I just wanted to get one of you to actually investigate the issue for yourself rather than rely on your opinions or what a handful of eye-rolling ED docs think. I have my own objections to these types of studies, because I do not think it’s appropriate to measure NPs with physician standards. NP education is designed to address approximately 80% of what a primary care doc is expected to handle. Just because we are taught to refer that 1/100,000 case of Churg-Strauss rather than diagnose and treat it ourselves does not mean we can’t practice independently within our own scope of practice. I think there are better outcomes to measure in order to determine the value and capability of NPs than “similar to a physician.”

    You were not the one implying that NPs are responsible for degrading primary care, but most other MDs in the larger debate happening here (as in on the CNN page) have. You snap at me and say that no one has claimed that NPs are responsible for the shortage, but I stated that I was responding to the implication, not the claim. This is not unreasonable since NPs have been cited as a reason why reimbursement for PC is crappy and for dissuading med students from PC, which are root causes identified in the PCP shortage. Therefore, NPs have been implicated in the shortage. You may think this is fair since today’s med students speaking up on the CNN article are saying that the evolving nature of NPs make primary care unattractive, but I think this is unfair because I believe NPs are a response (and a solution) to the PCP shortage and that the devaluing of PC began within the medical community itself. I may be willing to grant that NPs and PAs evolved as a solution but have become an aggravating factor in the shortage of primary care DOCTORS (though, I would not fault NPs or PAs for this phenomenon, and how do you measure this outside of one or two med students commenting on the CNN debate? And do the contributions that NPs make to primary care outweigh the fraction of a percent that they contribute to dissuading med students from joining PC?). I certainly think the implication that NPs have devalued the field is pretty shameful. It’s a multifactorial problem and I don’t want readers to latch onto the soundbite the NPs ruined it for all the med students.

    It is not “pathetic” for me to ask that NPs and PAs be differentiated. Most docs don’t seem to have a problem with “midlevels” who remain beneath the supervision of a doctor. Currently, NPs are the only “midlevels” functioning with complete autonomy, and NPs are the only “midlevels” seeking to exand our scope of practice in states where we don’t function completely autonomously. At this point, PAs aren’t. This may be because nursing had a long history of self-governance and the education and training of NPs and PAs are very different. At this point, the trajectory is different. Unlike MDs/DOs, where the educational model, the training, and the trajectory are similar. These differences are not unimportant, like you claim, because MDs are objecting to the NP model of practice, not the PA model of practice.

    “Medical students have been at the top of their class since before high school, competing against the best in a cut throat system and now are looking at what to do with a significant portion of their life.”

    I suppose I would only like to remind people that “the best” don’t always end up in this “cut throat system” Most of the “best” never even have access to all of the advantages of your typical med student. I’m going to come across as an asshole by citing myself as an example here, but I did my undergrad on a full ride because I was my high school valedictorian (not at some tiny school. At a big school considered one of the best in the state). I wound up in nursing because I found undergrad bio and chem classes uninspiring and I wanted to get my hands on some patients before med school. I still intended to use nursing as a launching pad to med school. I finished all my med school prereqs and took my MCATs before deciding that the “cut throat” system didn’t nurture “the best” or necessarily contain “the best” to begin with (not to say that many med folks aren’t deeply admirable. But they’re not the only admirable folks on the planet.) Since nursing is an evolving field full of amazing people and amazing opportunities, I thought I’d be of more use here. I thought I could contribute more. My dad, who is a physician, seemed to agree. I know I’m not moving anyone to tears with my life story or anything. But my story is certainly not unqiue, because nursing is full of accomplished people who, for one reason or another, decided to stay here. If I, along with so many others that boggle my mind with how amazing they are, made the decision to stick with nursing, I believe “the best” should be going into primary care as well. The contradiction I pointed out is not invalid because it was not meant as a response to your hypothetical. It was meant as a response to a sentiment you reiterated yourself: “…those MS in their clinical years now are looked down on who state they’re going into primary care with the implicit assumption being that they must not be smart or hard working…” On the one hand, a doctor is not smart or hard working if she chooses primary care because apparently primary care is not challenging enough to attract smart and hard working people, but on the other hand primary care is beyond the scope of an NP because it is too challenging and should be the job of a smart and hard working physician. Embedded in this is either a contradiction or an ugly assumption about NPs being dumb and lazy. I don’t know how else to interpret this argument.

    “That whole diatribe attacking my character was a straw-man argument and suggesting this has to do with power or prestige is insulting and dishonest.”

    I did not attack your character specifically. I’m critiquing the collective MD response to “midlevels.” If you (or others) think that MDs resistance to NPs is not an effort to protect the power and prestige of medicine, I don’t know how to illuminate the matter for you. Here’s what JSmith said: “Can you imagine being a doc and having an NP as a supervisor because he or so has been there longer and what the hell, you’re all just primary care providers? This would be a catastrophe for medical care in this country.” Here’s what IDDOC said: “Frankly I think the AMA has really done us physicians a dis-service by allowing NPs and PA’s to extend there practice rights and we should fight whole heartedly to scale back there practice rights.” Note that he says the AMA has done PHYSICIANS a disservice, not patients. And by the by, the AMA never “allowed” NPs to extend “there” practice rights. The AMA fought this. And I’d also like to direct your attention to all the docs posting on the CNN article who have said that allowing NPs into primary care is an insult, because MDs work too hard to be so devalued. ? How is this not about power and prestige? I never suggested that this was unnatural or unexpected in any way. It’s what people do. It’s how they react. But for the medical discipline to lack any insight into its motive to protect its own power and prestige is… um, limiting. Dishonest. Whatever you want to call it. My motive is to protect the hard-earned autonomy and the reputation of NPs. I made this clear from the start and never claimed to be objective. I even said I could make arguments against my own case if I needed to, and I’d at least rather hear those arguments than “I once knew an NP who sucked.” That’s all.

    Anyhow, I’m tired and don’t feel like being on the defense anymore. This has been an interesting, if depressing, exchange. I’m not interested in seeing nursing go the way of medicine (because nursing is amazing and I think “cut throat” is abusive, discriminatory, and not as effective as other alternative frameworks), but I am interested in making sure our clinical judgment and skills are up to snuff for today’s health care environment and for the future. Maybe I’ll see you on the free market, NF, and pepper you will all sorts of lucrative referrals. Perhaps my whole approach to this debate has been too reactionary, since MD feedback on NPs (whether good, bad or ugly) is useful to those of use who are interested in shaping the discipline for the future.

  • jsmith

    i admire Whitny’s and radphys’s energy, but the fact remains: med students are abandoning primary care to the nurses, which is a bad deal for our HC system in the long term. Med students have competition from nurses on their radar screen–another in a long list of reasons to specialize.

  • jsmith

    Whitny talks about power and prestige. Well, duh. I’ll spell it out for you: if a primary care has no power or prestige or money, then medical students won’t go into it, and there will be a primary care shortage and then patients won’t get needed primary care (unless the nurses take over completely, a very scary thought to docs but a great thought for nurses, at least until it actually happens) and will instead get overspecialized care which will be less effective and cost even more. And you are completely unable to understand that medical students, after all they have been through, are simply not going to be satisfied with the power, prestige, and money of a nurse. You’ll never get that.

  • radphys

    @jsmith

    I agree with you that nurses running primary care is not good for our system. They are useful in their own right, but they lack the training to parse complex information… at least that has been my experience. I think the physician training model is a good one, but i have a problem with the entitlement and general attitudes. Many professions require a similiar level of skill, many years to obtain, etc., but i see no other professionals so entitled.

    Airline pilots can spend up to 20 years to make captain of a widebody jet for a major. They deal with furloughs, loss of seniority, and meager pay as a way of life (and don’t give me the “it’s the same as driving a bus argument”). They make approximately 50-60% of a PCP 20 years into their career. The hudson river hero, Sullenburger, probably makes about $100-$120k.

    I agree med students are leaving because of the money. It amazes me that no one sees an ethical dilema with this… This is exactly the problem. Medicine should be about treating and averting illness, not money. I think PCPs could stand to make a little more, but honestly, …$200,000 is not a bad living, and again, they don’t have any more training than many other professionals.

    In fact, I think most medical professionals are artificially over-valued (perhaps even myself included) as a result of CMS, not in spite of it. I said it before, there is no other profession in which one is guarranteed such a high standard of living for simply completing a training program. Yes, it is difficult, but you need to realize, you are special, but not that special.

    Again, nurses simply lack the classical training in complex systems and higher order reasoning. I think increasing the nurse component is wrong. But, with that said, many people who go into nursing or perhaps engineering, or whatever, could be excellent physicians, primary care or specialist. We create an articifial system that, in my opinion, has led to the attitudes I have discussed. Medicine is not that intellectually challenging and doesn’t require the over-achiever personality types that become successful applicants. It is not medicine that requires such, it is the process of getting into medicine. In addition, the process scares away many students who are more concerned with real problems are results, who certainly have the aptitude but don’t have the stomach for some of the hoops. We need to siginificantly expand medical school enrollements, add new schools, and add more residency slots. If we do these things, you can have primary care physicians rather than nurses. And in so doing, perhaps over time some of the entitement will fade. Don’t get me wrong, the cost structure and reimbursement scheme must be fixed as well, but increasing the the supply would help.

    Here;s another thought off-the-cuff, why don’t we consider bifurcating the path? Medicine may have arrived to a point where we can do away with standard 4 years for all. How about you narrow your decision up front. Your want to study primary medicine or you want to specialize. You get the same degree but take different courses with more targeted rotations for the furture specialists. I’m sure if you did it on the front end, you would get more PCPs.

    However, this could all lead to a shortage of dentists in the world…

  • jsmith

    radphys, Re; nurses; agreed. Your comments about docs being no smarter ( and maybe a lot less smart) than a lot of others are correct, but that’s not the issue. The issue is what has to be done to get an adequate supply for our nation’s HC. This is an empirical question, not one based on Just Price Theory. What a pilot makes is irrelevant. What a doc makes in France or England is irrelevant. My sense of entitlement is irrelevant. That’s Just Price Theory stuff. And Just Price Theory often leads to gluts and shortages.
    The fact is that current income is demonstrably inadequate to get America enough PCPs. Horstkamp thinks a raise of 50% or so would do the trick. I don’t what the number is, but a little (or a lot) of experiment would tell.
    Adding a lot more slots for docs is in process. The AAMC recommends about 5000 more slots, I think. But as the situation stands now this will result in a lot more specialists, only a few more PCPs, and a lot more costs for little HC gain. The whole point is to decrease HC cost inflation.
    Sure, widen the applicant pool. One of the best family docs I know used to be a sociology professor and never took organic chem or physics. (He went to med school in Canada at a school that didn’t require those. His wife wanted more $ than a sociology prof could pull in, but then divorced him anyhow!) But as things stand, they’ll still specialize once they’re in med school and face the current incentives.
    We already have a truncated pathway–midlevels. Also, a good PCP should know more than a specialist, not less. Truncation is a step in the wrong direction.

  • jsmith

    radphys, A few more thoughts on medical culture. You write about a sense of entitlement and you are right. A lot of docs are absolute jerks. But this comes not so much from our belief about how smart we are but from all the abuse we put up with, combined of course with “pre-morbid” personality factors. Premed, med, residency, and practice: make no mistake, we work a lot harder and with more stress than most. You know this if you work with docs.
    Can this change? Should medicine be a more mellow job that attracts more mellow people with less of an attitude? Well, they say they’ve gone that route in Europe. But the mellow-doc route has costs: less driven people work less, resulting in, you got it, more of a shortage. Cultural change in medicine has costs as well as benefits. Indeed, one of the purported causes of the PCP shortage is the desire of med students for a more manageable lifestyle. My point is that entitlement and drive are linked in medicine. Hard to get rid of one without the other. That said, I’ve been a doc for 24 years, and docs are less of jerks now than they used to be. Maybe there’s some hope.

  • http://sideeffectsmayinclude.wordpress.com Whitny

    Radphys, no one is talking about nurses “running” primary care. We have been talking about licensed MSNs or DNPs, who have nursing backgrounds and RN licensure but have since gone on to attain master’s or doctoral degrees and advanced licenesure for independent practice, CONTRIBUTING to primary care. You wouldn’t diminish the education and training of a doctor by referring to her as a resident or a med student, so why ignore the additional education and training of advanced practice nurses by referring to them as nurses?

    Furthermore, no one is talking about APN’s taking over primary care. Docs are still critical for advanced diagnostics or managment of complex clients across a lifespan. But you see your FNP for your pap smear, for your blood pressure or diabetes management, for your STD screening and treatment, for your immunizations, for your UTI, your leg laceration, your community-acquired PNA, for your prostate exam, for your prenatal care and delivery (if your FNP is also a CNM, which many are), CHF management… you get the picture? Your FNP should know when to refer you to oncology, to endocrinology, to cardiology, to ophthalmology… whatever. Your FNP will know when a routine client becomes a complex client. Your FNP should be able to recognize a medical emergency, and if you experience cardiac arrest in your FNP’s office, she or he can run a code on you (unlike many docs) since most of us have so damn much bedside experience. ABC’s, baby. Complex patients with multiple comorbidities, multiple system dysfunction, etc (still a significant percentage of the artery-clogged, addicted, depressed, anxiety-riddled, socially-isolated Amercian public) should be cared for by physcians, at least until the DNP becomes the standard degree for NPs (2015) and new NPs receive additional training during a one, two or even three year residency. Will this make the primary care doc obsolete? Maybe. Maybe not. Maybe anybody considering a career in primary care will go to nursing school instead. Or maybe it’ll actually be easier for a college grad with a degree in bio to just apply to med school than to earn another bachelor’s degree in nursing before embarking on a 4 year doctoral degree. I don’t know. If that med student graduates with the understanding that specialization is a more attractive option open to either him or her, then they will take it. If they believe strongly in the value of primary care and want the variety of patients and pathology available to the PCP, they’ll consider that route. If there’s a shortage of PCPs, maybe specialists will receive the overflow and be forced into providing what is actually primary care, thus making specialty less attractive as well, and the incentives won’t remain. Maybe the “nurse-free” incentive of specialty won’t remain if DNPs, armed with additional training and still in possession of that valuable nurse framework, begin specializing as well (NPs can already specialize in neonatology, acute care, geriatrics, pediatrics, midwifery, and they can do research and become educators and theorists and all kinds of stuff.) Maybe the market for specialists will reach a point of saturatation while the deficit in primary care remains such that a med student actually stands to make more money in primary care than in specialty because of competition for patients. Nursing can help meet some of the primary care need but can’t solve the problem by itself because advanced practice nurses are pulled from the pool of registered nurses and there’s already a major nursing shortage. Maybe the whole system will implode and you’ll have to meet a dude behind a dumpster to get penicillin and birth control. I don’t know. But I feel like much of this debate is hampered by this little mental box in which medicine is conceptualized as something based on what it has been versus what it could be and what nurses and doctors are based on what they have been versus what they are becoming and by what the “medical model” has been versus what it will be. JSmith said that there are fewer jerk doctors now than there has been in the past, indicating that the culture is capable of changing (via selection of med school applicants, increasing attention to bedside manner and contributions of other members of the health care team, and relaxation of some inhuman expectations). I know JSmith automatically links this reduction of jerk doctors phenomenon to a primary care shortage that has somehow caused by “less driven” people, but in my experience, the non-jerk doctors are just as driven and capable as their jerk counterparts (more so, actually). Furthermore, I would bet that doctors will soon be saying that NPs are sharper clinically and more capable now than they used to be, indicating that the education and training can expand to meet the needs of the health care environment. These things are not static. It’s silly to keep rehashing the status quo and defending turf. It’s time for vision. One thing I love about nursing: it’s a discipline with major, major vision.

    JSmith talks about entitlement being linked to drive in medicine. One of the reasons I chose nursing over medicine (even though both were open to me) is because there is a distinct absence of the “entitlement” meme in nursing. I don’t know. There is a defensiveness that comes from being constantly questioned and put down or assumptions that we are sweet brainless little angels, but I guess wiping ass and helping old people walk around the unit and constantly following orders from doctors, patients, and families rids you of your entitlement. But the drive remains. If you doubt the drive within nursing, ask yourself how nurses went from a diploma or certificate based vocation to a major professional discipline with advanced practice and research, theory, and educational arms within 60 years? The evolving nature of medicine played a role, but nursing is a self-governing field that directs its own education, licensing, and professional trajectory. Even with these advances, nursing remains inclusive. The shortage of nursing spots usually means that nobody with a college GPA below 3.7 or so is admitted to a university-based nursing school, but ADN programs are still wide open and there are many routes for “advancement” in nursing, so, unlike MDs, not everyone who goes into nursing is an academic all-star or a person bred since infancy for professional “success”. I view this as a strength of nursing but I suppose some die-hard medical “realists” will cite some Darwin-esque philosophy and disagree with me, saying that unless a person gets an A+ in advanced OChem and engineering physics (which I did. Piece of cake compared to my ICU rotation in nursing school), they should be weeded out. Unless a person can stay awake and alert for 30 hours in a row for four years, they shouldn’t practice medicine. Whatever. A nurse who likes being a nurse or who hates the idea of more schooling or who can’t afford to go back to school (usually the case) can continue being a nurse, and a nurse who wants learn other skills or perform a different job can go back to school. I think that some med people, given the idea that they have somehow been specially selected, don’t like idea of this alternative route to advanced practice. Oh well.

    I don’t know why the abuse the med school students and residents suffer breeds entitlement, but I have noticed that the medical model does confuse rigor and professional expectations with bodily, emotional, and social abuse, while at the same time sending this conflicting message that the person is being treated thus because they are a cut above, or because they are being bred for superiority. The medical model should certianly persist if it remains effective, especially if it’s the only path that’s going to nurture the brilliant type A future neurosurgeon, but a person’s preferred learning style does not correlate with raw intelligence or passion or drive and there’s no reason why the medical model and the nursing model can’t both educate people for careers in medicine.

    JSmith, I understand that someone who has invested in themselves (or has had parents or society or whatever invest in them) enough to complete medical school would want a return on their investment. I don’t know why a return must equal $400k a year, but whatever. I’ve invested in myself and would like the opportunity to continue doing so, so lifestyle is more important to me. Power and prestige are nice, and I think it’s natural for MDs to protect theirs. I said that from the beginning. I only asked that this motive be acknowledged by docs fighting against NPs rather than them trying to pin their arguments all on the “minimal medical knowledge” of NPs. I have provided and defended evidence that characterizing NPs as having “minimal medical knowledge” or an lack of training or ability to function as independent health care providers is false and inappropriate. Still, I understand why MDs defend “their turf,” and even demand power and prestige… I’m not sure to what degree this should be accomplished by denying others power or prestige, or deluding oneself into believing that doctors are the only ones who experience hardship, abuse, stress, advanced education and training, etc. I’m not sure if professional power and prestige, or at least prestige, is a zero-sum entity in which the success of others depletes your own. I think doctors should ask themselves these questions before maligning all the “idiot” NPs they’ve worked with on a public forum under the benevolent guise of “just wanting to fix the primary care shortage.”

    Anyhow, I’ve said my say. G’night y’all.

  • radphys

    @whitny

    Sorry to lump MSNs and DNPs together with more traditional nurses. I understand there are differences. My insititution houses a well regarded nursing program and has added a DNP pathway.

    My own field of radiologic physics is adding a path of “doctor of medical physics”. I have mixed feelings about this. Our field was traditionally split into MS and PhDs, where the MS generally stick to clinic and PhDs a combination of clinic, teaching and research. However, there are some glaring differences between my field and primary care of patients. We are perfoming a service that cannot be fulfilled by any other professional. The are no nurse physicists or physician physicists.

    My problem with these nursing programs and the idea of NPs taking a bigger provider role, is that physicians have an impecable training program. I have problems with the attitudes and entitlement as well as the artificial shortage, but I cannot argue they are not well trained. That’s why they call medical school undergraduate medical education… it is very broad and yields a deep understanding of the normal and abnornal human condition in general. In my training as a rad physicist, my first introduction to anatomy and physiology was a nursing class (the MD class was too much time committment on top of the graduate radiation and physics coursework). It was a bit of a joke–and this is a top 15 institution in the US. The med students, however, spent 20 hours a week in lecture and gross lab.

    I’m not saying DNP students couldn’t go through the MD training. In fact, I’m arguing that they SHOULD… there should be more students in med school… and there should be incentives for them to become PCPs… but, I don’t think the DNP or MSN training begins to compare to the physician training. If we can restruction the system such that it accomodates more students, I don’t think we need an army of DNPs. They are a result of a broken system, not the prospective route of choice, in my opinion.

  • IDDOC

    I recently had the opportunty to have an NP shadow me around twice a week for 6 weeks and then was asked to evaluate her. Her advisor stated to me: we make it a point for our NP’s to sepnd a significant amount of time with doctors in your field.” I then asked “how many rotations is one required to do in my field?” Her response was one, yours. I was shocked and told her that I didn’t feel the NP student met the requirements for having a significant exposure to my field.

    In short I felt the NP was quite incompetent and a 3rd year medical student knew more then her. Plus I spent a whopping 12 days with this NP (for a 6 week rotation) and this was significant exposure? Hmm…no wonder they can’t even properly intrepet the results of a urinalysis and know when a U/A is positive and when it is inconsequential.

    I say this: physicians should stop training NP’s. Let the NP’s train their own. Furthermore, physicain specialist should REFUSE to accept any referrals from an NP. Instead, they should insist that the patient be first seen by an MD or DO Internist, Family Physician or Pediatrician before they would ever consider seeing the patient. That way, the PCP can do the higher cognitive function that is necessary in medicine and stave off the inappropriate referrals thus driving up health care costs and we serve to strengthen our profession against the onslaught of Physician Wannabes i.e. NP’s.

  • jessant

    My family and I started seeing an NP. The difference I noticed immediately was that the NP over prescribed on drugs. I now have a wonderful primary doctor, a blessing indeed. Who does not hand out medicine like candy. I would choose a visit with him over an NP. I’m starting on my path in the health field and I am going to be a radiologist. Let the NPs of the world keep dishing out unneeded drugs. You pay for what you get. I’d rather not take my chances.

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