My health reform opinion in AOL News

in Physician | 62 responses

Thanks to AOL News for publishing my latest opinion piece, Reform’s Great, But We Need More Doctors.

I discuss how health reform’s ultimate success or failure is largely dependent on whether our primary care system can accommodate the millions of newly insured patients:

… having health insurance doesn’t necessarily mean it will be easy to find a doctor. Even before reform, reports projected a shortfall of 40,000 primary care physicians over the next decade. Thirty-two million newly insured Americans, plus the millions of baby boomers entering Medicare age, will only make this shortfall worse.

I also touch upon how nurse practitioners and physician assistants are not immune to the lucrative allure of specialty practice, and how reform doesn’t help burnout prevalent in primary care doctors today.

Thanks also to ABC News for interviewing me on a similar topic, How Long Will You Wait to See a Doctor?

Again, I touch upon the lifestyle deficiencies of primary care, in addition to the financial disincentives:

“There’s really little language in the health reform bill that really improves the lifestyle and the relationship primary care doctors have with their patients,” said Pho, adding that in addition to excessive paperwork, doctors may not feel they can spend enough time with their patients.

Enjoy the pieces.

Comments

http://www.drjshousecalls.blogspot.com Dr. Mary Johnson
Reform is “not great” until it starts taking better care of the physicians & nurses in the trenches (as opposed to the suits and the lawyers in the towers). And right now, in that regard, the system is eating and spitting out its young . . . particularly its young who feel called to primary care and service (as I once did):
http://drjshousecalls.blogspot.com/2010/03/dr-mary-should-have-gone-to-washington.html
Primary care doctors are toast in this bill. We’re just pouring more money into public service & entitlement programs that do NOT effectively police themselves now. Moreover, there’s NO tort reform. NO peer-review over-haul. And (as I learned the hard way) medical whistle-blowers (you know, the ones who might actually step in to stop malpractice or report fraud & abuse) might as well cut their own throats.
As they paraded the sad stories before Congress, Obama & his ilk only wanted to hear patients.
Doctors were just props in white coats.

Ron Hood
My daughter has been a practicing PA in a hospital’s ER for 5 years and would love to go on to Med School to get her PHD. BUT WITH A MASTERS DEGREE PA AND 5 YEARS EXPERIENCE IN THE DIVERSE FIELD OF AN ER, SHE WOULD STILL NEED TO START OVER AGAIN IN MED SCHOOL TO GET HER PHD. Until the Med Schools wise up and find ways to encourage more qualified health professionals, they’re acting like they don’t want to solve the problem of too few doctors!!

Leon
Meanwhile, my daughter who just graduated with her MD, and has what it takes to be a great primary care physician, was unable to match with any residency opportunity in the USA. There are clearly not enough residencies available RIGHT NOW to further train our new graduates, and nothing for them to do for a year (and no way to earn money to repay their considerable debts) while they wait to reapply. The system is messed up right now and I don’t see any signs that it will be fixed in time for her.

fam med doc
dear leon,
may i ask what specialty did she apply in? certainly it wasnt in primary care.
fam med doc in california

Leon
Dear family med doc in CA: My daughter applied for residencies in family medicine and pediatrics. She did not apply to the Johns Hopkins’s and Harvards of the world, rather she tried to select smaller programs that would look favorably on her credentials. What we found was that there are roughly 5000 more applicants than there are available positions overall, and if you have to “scramble” there are 5000 applicant for the 100 spotrs that are still open.

fam med doc
dear leon,
we are missing some important part of the story. in the match program, family medicine DID NOT fill. it only filled 91% of its slots. how did your daughter NOT get in? maybe she did not tell you the whole story.
is she a graduate from a united states medical school?

http://thehappyhospitalist.blogspot.com Happy Hospitalist
If you were unable to match in family practice, there is more to the story. End of story.
Leon
Dear Family Med Doc:
I think I know my daughter’s story pretty well. She is born in the USA. Strike 1: She is a graduate of Ross (in Dominica). Strike 2: She missed passing step 1 on the first try by one measely point. Strike 3: She had to take step 2 three times, on the 3rd try (with no technical obstacles and ample studying) she did quite well. She wanted Peds, and so applied to many Peds programs nationwide, but only to those FP programs located in WI where we live. She had two interviews only and I think she came close to being matched in one of these. We scrambled aggressively on the Tuesday of match week, and on the next day we drove two hours and knocked on the door of one of the WI FP programs that had a couple of openings. They knew of her from her previous application and offered her an interview on the spot (which is highly unusual as I watched with my own eyes as they turned 3 other candidates away) and very nearly accepted her. So she almost made it in there also, she was told as much by the program director. In retrospect, yes, she did not play this game correctly. She should have tried for many more FP programs. But her exam scores do not reflect her enthusiasm, committment, dedication, desire for continual learning, and superlative people skills. Nor do they reflect the superior recommendations she received during rotations in five different hospitals. If you know of any options or opportunities, please share them with us. We are still looking for something that will strengthen her application next year.
Leon
The rest of the story is that, although it took 3 weeks, my daughter successfully landed a very suitable residency opportunity in order to continue her training. Go girl!

Richard
Kevin,
I read your aol article and I think you are one of the few that “get it”.
We are on the verge of adding 30 million to a funnel that is still too narrow at the bottom, namely primary care physicians. It would have been a more balanced health care bill if they would have funded 10 new medical colleges and made tort reform a reality.
When is the last time you heard someone say, “where is a good lawyer when you need one?”. Or ” I couldn’t get in to see my attorney until two months from now.”
Thanks for speaking out on this aspect of the health care dilemna.
Richard
Tucson, Arizona
http://kevinMD.com vickie
It won’t be perfect …but we finally have a leader in the white house….Don’t you think every state can open up clinics to get started with the extra people?They have already held free clinics around the country.It was unbelievable!…..Some may just need check-ups,some will need more care…When I was young my doctor would make house calls at 2 in the morning….not going to happen ever again…The dedication….its gone….I just think everyone should take a deep breath and stop looking for problems in the reform …including doctors..give it a chance …

Amy
This comment infuriates me. Vickie, you obviously have no experience in healthcare! You want to talk about dedication. I am a 35 year old physician boarded in Family medicine. I started medical school when my daughter was only 9 months old. Despite the odds I graduated in the top 10% of my class and then choose Family Medicine because I felt it was where I could make a difference. I sacrificed much of my daughter’s childhood in order to go into this NOBLE profession. I also came out of school $150,000 in debt. I started practice with the most idealistic views of healthcare. After 3 years, I was in complete burn out. I would be glad to make house calls if just one of my patients had offered me some token of appreciation for the sacrafices I make every day. My own home flooded during hurricane Ike. Not one of the patients that I had gone to the hospital to take care of at 2 am or the patients I had treated for FREE offered to help me in my time of need. The problem with people like You is that you and thousands of others see healthcare as something you are Entiltled to. Well, you are wrong. It takes thousands of dedicated doctors and nurses to put up with things that the great majority of society is does not have the internal fortitude to deal with everyday. I and most other doctors have made sacrafices that you can not even imagine. Do not dare ask where is the “dedication”. What you should ask is where is the “appreciation”…. for listening to your problems and saving your lives. Doctors are intelligent people and we can most certainly find other ways to make a living. Or maybe we should see how you would do without us. The problem of physician shortage and burnout is very real and needs to be addressed. Hope to see more articles like this.

Jody
Amy,
You are absolutely right, and I am not a doctor or nurse, but a very concerned citizen who realizes we are in a serious crises. Everything you stated is correct, while I’m sure there is the occasionally crappy doctor, most are as you descibed, dedicated, compassionate, exhausted and in debt up to their eyeballs. But don’t worry, because now the goverment will be in control of the student loans, and we will be forced to go into the career that they see fit, that is if we want a loan. Perfect isn’t it.

http://kevinMD.com vickie
I really call primary care doctors”sore throat and cold doctors”because all they do is refer you to another doctor if there is anything else wrong with you….unless….. you have a”sore throat and cold” lolololololo….so I really wouldn’t miss them…..

MaryBeth
I disagree. My PCP does so much more…routine physicals, my colonoscopy, minor surgeries, routine labs and medication management. He/his group still rounds at the local hospital. He only refers out when the service is beyond his scope. We need MORE of this type of PCP.

http://www.drjshousecalls.blogspot.com Dr. Mary Johnson
Vicki, my intial thoughts when I read your comment were not printable. “Free”?!? Are you kidding me??? NOTHING is free!!! And patients wonder why, more and more, doctors think of some of them as “the enemy”?
MaryBeth the kind of doctor you describe is the kind of doctor I was and wanted to remain (in my hometown no less) – but I and my partner (both recruited there with Federal money) were literally driven out (in order to facilitate a medical cover-up).
I ALREADY GAVE the government a chance. And they totally BLEW IT.
Moreover, no one (particularly no one in the salivating-over-Obama MSM) cares. If “the dedication is gone”, it’s because it’s been beaten out of us – while the government and MSM slept.
Leon is right. The system is broken – in large part becasue the suits who over the last twenty years have been inserted in the middle (and who largely control the money) think like Vicki.
And they’ve gotten what they deserve.
But the problem is that we PCP’s haven’t. And if we’re out-of-luck, so are patients.
Evalynn
Agree MaryBeth.
Older adults are often dealing with chronic conditions like diabetes, congestive heart failure, etc, that require multiples spealists and PCPs alike to keep them healthy. I read a few months ago about one of the best places to be for older adults concerning health care is Minnesota. Why you ask? Great PCPs, and fewer doctors in general. Houston, which has a fabulous Medical Center, filled with all kinds of specialists and great big hospitals, has poorer health outcomes for these older adults. Older patients, on average, have about 7 different doctors in Houston. These doctors aren’t in constant communication, so all of them are, on some level, unaware of new health problems that come up or have incomplete patient history data.
This is the role that primary care providers seek to fill – that of a home base doctor (and this is a huge job). They know you intimately, and strive to keep a comprehensive history of your problems. They are the “big picture” people and it is their job to collaborate with other specialists to keep you healthy by addressing your illnesses/health issues, and more importantly, educating you on how to prevent health problems. We need more GOOD PCPs!
Unfortunately, preventative treatments and education interventions don’t pay nearly as much as life saving, drastic treatments (which are usually in the specialists’ arenas).

mdcruz
Primary care is done for. There is little incentive to be a family doc now, wait until we have to see even more patients at a lower pay scale. Indeed, we will be replaced by midlevels by and large and/or foriegn J1 docs. I think that there will be some “good” primary docs around, perhaps in the concierge style arena serving the more affluent cash only patients. But, for the regular community docs-doesn’t look too good!
RINurse educator
I don’t understand why PCPs can’t see that primary care doesn’t mean MD’s. Good primary care practices should include nurses, whose training is in primary care. The PCPs I know around here have MA’s and other types of untrained, uneducated assistants who don’t know how to do patient and family education, who can’t complete assessments and triage problems and suggest interventions. Set up your practice to meet the needs of the clients, evenings and weekends, and really do primary care, see what happens. Primary care is happening for free all over the US in clinics and health centers and shelters, on college campuses, in prisons and more. Get real.

fam med doc
dear RINurse educator,
you are wrong. i have a solo private practice and no matter if i see patients in the evenigns or weekends, i get paid by medicare, blue cross, cigna ect THE SAME. im barely paying my bills now. if i opened my clinic in the hours you suggest, i will still only be BARELY paying my bills only i would have no life whatsoever. in addition, i dont have an RN in my office because i could not PAY HER/HIM. there is not enough reinbursement by medicare or insurance companies to pay the salary of an RN. i think it is you that needs to get real.
family med doc
ps: you mentioned that primary care is happening “for free all over the US”. if you would like to work for free for me in my office i could use your skills. please let me know.
.

RINurse educator
There are nurses providing care to patients in grant funded and fee for service venues all over the US. And I am a member of a primary care practice that is viable and uses nurses to deliver care. Our clients pay for services such as diabetes education, health maintenance. We spend our time making sure that our patients are healthy and practice preventive care. We don’t have office hours every day from 9-8pm, we are closed several mornings and open 2 evenings and on Saturday morning. This allows us to have access to young clients with better insurance and to schedule sick visits on the day folks call us. Take the time to look around for some successful models and make some changes.

fam med doc
dear RINurse educator,
I had evening hours for 2 years. I stopped it due to lack of interest- believe it or not, patients in my area wanted to come during the day. I suspect because they wanted to get out of work.
In regard to your comment “We spend our time making sure that our patients are healthy and practice preventive care. ”
So what do you think I do? I spend alot of (unreinbursed) time discussing preventative medicine with my patients. Its one of the hallmarks of my practice.
BTW, you sound really arrogant with your “Take the time to look around for some successful models and make some changes.” Primary care is an unpopular specialty because the pay is so low compared to other fields in medicine. Making changes that you suggest will not address that. Im sure that your practice you are employed in is “viable”, but it doesnt change the reality of low reinbursement primary care doctors. , Med students are not pursing primary care and many current PCPs are leaving. Your note suggests serious naivete on this subject. If it was as easy as you seem to think it is, this problem would not exist. What, you think you and your clinic are the only ones with good ideas and abilities to run a clinic? Primary care in the US is in trouble. You dont seem to understand.
good luck

Mary Waters
Wow. Let’s “celebrate” health care reform. Forget the fact that you probably won’t find a doctor to treat you or a loved one; certainly not the doctor of your choice and not in a timely manner. The American Medical Assoc. posted the statistic that over 46% of doctors will leave the profession when reform goes into effect. Forget the fact that our deficit as a nation is predicted to rise to 20 trillilon by 2020 and we can’t afford a huge entitlement program now. Let’s celebrate!
Matt
“Entitlements?!?” There are some things we are all entitled to…such as clean drinking water, paved highways to drive on, breathable air, national defence, basic education, and yes, access to basic healthcare (to name a few). Before bragging about how hard physicians work, I have first hand experiences with the long hours and hard work Scientists, Engineers, and Technicians (without whose effort many of the medical diagnostic equipment and procedures would not be available) put into their occupation…with about 1/3 of the pay on average and oftentimes more formal education. I agree…Engineers and Scientists are not “entitled” to elaborate lifestyles, but neither are physicians (of any kind). Elaborate lifestyles…if you choose to live as such…must be earned by providing high quality products and/or services to individuals who are obliged to pay the “higher than customary” costs.
Many physicians (including Specialists), whose “employers” are either the Insurance Companies and/or the Federal/State Governments, are enticed with high fees to substantiate high and ever increasing premiums (leading to higher profits and/or higher tax rolls). Higher premiums, excessively high pay to occupations without justification, lead to unsustainable lifestyles, complacency, and mis-guided priorities.
I lost my father a couple years ago due to what I believe (as well as many others familiar with the experience) was poor judgement by an
“Interventional Radiologist (IR)”. My father entered the ER barely 45 minutes following an ischemic stroke. The so-called IR performed a relatively new procedure that incurred 5+ times the cost of the more conventional and proven treatment, and not yet FDA-approved for patients who obtain interventional medicine within 3 hours of onset. My father survived the stroke, but succumbed to the ill-administered procedure.
I do agree there is a lack of primary care physicians, but not a lack of those who are interested and well qualified to become one. If more physicians were added to the government and insurance company payrolls, and according to the fundamental laws of supply and demand, the costs of healthcare, hence profits, would have to be reduced to more sustainable levels – a concept that is beyond the desires and expectations of a broken health care system.
Please…prove me wrong so that I will no longer believe my father to be a victim of our country’s current position regarding “physician entitlements”, “executive entitlements”, and our broken healthcare system.
God Bless.

Ron Hood
It was interesting reading the above comments. Vickie comes across as the typical liberal, full of idealism that everything will work out if we just turn the problem over to the government. Many of the other responders are “down in the trenches” realists that experienced first hand the problems in the health care industry and do not have hopes that the Health Reform Bill will help those problems – mainly a shortage of family practice professionals, along with the reality that many, many health care professionals will choose to leave the field rather than deal with the problems of 30 million more people, many who will be abusers of their newly given “right”, added to the problems they currently face. My prayer is that people like Mary, Evalynn, Dr. Mary, May Beth, Amy, Richard, Leon and Kevin will be appointed to committees formed to correct the problems we are headed for.

http://www.drjshousecalls.blogspot.com Dr. Mary Johnson
Unfortunately, Robin Hood, the Mary, Evalynns, Dr. Marys, Mary Beths, Amys, Richards, and Leons WERE NOT ASKED WHAT WE THOUGHT before the bill was passed (it’s not as if I have not been in this blogosphere screaming at the top of my lungs for five years – only to be told to “get over it” and “move on”) . . . and we will not be asked now. We are pawns on this chessboard of greed and power.
Our opinions and stories are threatening to Obama’s new world order. Like I said in my first comment link – I should have have been called before Congress to testify before Congresss – BEFORE Congress passed legislation that throws many more millions at a program whose much-ballyhooed “mission” completely and utterely failed in my case – because government oversight is a total joke.
Now there will be more and more like me. And yes, the best and birghtest will walk away from this profession – where people like VIcki laugh at our sacrifice and our pain.
Amy is acutally very lucky – she has her own child to feel guitly about neglecting. I didn’t when I could have (so I could concentrate on the care of other women’s children . . . and to fight a legal battle that I thought was worthwhile), and now I cannot. Every dream I ever had has died in small increments while the liberal and entitled masses sneered and spit.
But hey, I’m supposed to just suck it up and keep right on servicing people like Vickie who think I’m a greedy medical dolt . . . oh, and that it’s hysterical.

Ron Hood
I’m concerned that the medical profession let the AMA speak for them, while I KNOW the vast majority of health professionals opposed the Health Care Bill. Hopefully, when the push for repeal gets going, the medical profession’s TRUE views will be able to be heard.

fam med doc
Dear Mr Hood,
In regard to your statement ” I KNOW the vast majority of health professionals opposed the Health Care Bill”. WHAT ARE YOU TALKING ABOUT? Most of my collegues approved of the bill, as did I. But i have no delusions that my friends and collegues represent MOST physicians. Allow me to reframe your opinion: some MD’s were for the bill, some against. But to state that a “vast majority” of health professionals opposed the bill is simply inacurrate. You simply have that view since you, yourself were opposed to it and then superimposed that view to everyone else. This is not a sophisticated nor acurrate way to enter into debate. I respect your views and everyones to discuss this important national issue.

Mike G F
Yes you are so right in 1776 the first thought for this great country was to provide health care for all at the expense of all. Who will pay for it? Wow bet not you. Thanks to people like you we just may one day very damn soon be a third world country.
BTW my wife died in my arms and Obama health take over would never change that.

Ron Hood
Mike, I really am sorry about your wife, but am so proud that you are willing to share your message – it’s quite powerful and will help many of us trying to get this repealed to keep up the fight.

Jody
Matt,
You make a very strong and compellig case. One of the main differences between the two groups I think is Scientist, Engineers and Technicians are not often sued when they don’t produce the desired result.

DGS
I don’t even know where to begin. The United States Congress and the President have become a rogue group of socialists who answer to nobody but themselves. I am amazed by how many citizens of this democratic republic are watching socialism being implemented and 1) Don’t even know it and 2) Don’t seem to care. Sorry Vickie but your ignorance is so profound that it is difficult to know how to respond to your comments. Fact of the matter is that most physicians do go into medicine to “help people” and are dedicated – it is so cliché but it is really true. That being said the sacrifices required to get there are enormous. Try at least 7 years of post graduate work and at times like myself 10 years. That is ten years that I have spent training and accumulating debt which I have to try and recoup somehow. Let me take you through those 10 years. During those ten years my debt is accruing and I have not even begun my productive years of labor. While the general public may be working for those ten years I come out of my training at 27-37 years of age not having earned more then minimum wage during residency. I have worked upwards of 120 hrs a week, again making 4-5 dollars an hour as a practicing physician. I made even less as a practicing resident trained surgeon as I elected to pursue one additional year of training; during which time I lived on no interest credit cards and qualified for the government funded program – WIC to take care of my family. Now I am 37 and have 200K of debt before I ever buy a car, purchase a home and start putting away for the future. I now must work for several years to pay off my student loans before I ever see the fruits of my labors. Now I am 37 (and if you are a PCP you may never pay off your student loans) before I can actually start working for myself. Fun ten years huh? Well at least that is over now and I can start practicing medicine. I now face decreased re-imbursements from insurance companies and the government- Medicare/Medicaid (oh yeah they just decided to reduce medicare re-imbursements by 22.3 percent this year) – all the while the cost of practicing medicine goes up and up. Physician’s re-imbursements have gone down 28% over the last 10 years (drug companies/medical equipment companies and hospitals have seen an increase of 188% over the same time period – just to give you a perspective – I won’t even go into the insurance companies) . My employees don’t care if my re-imbursements are going down, they want raises – and now I have to hire more of them to deal the increasing amounts of red-tape that must be dealt with. Attorneys now advertise on TV and savagely attack – unchecked or unregulated – physicians and others alike. So now my medical malpractice goes up and up. The list goes on and on. You might be saying “Cry me a river doctor.” To that I would answer. I agree that I am very fortunate in what I make. I make a good living. However, despite what people think it is not like it was 20 years ago, doctors are not rolling in money. I have been in practice going on three years now. I bought into my practice the first year which meant I made little money the first year. I drive a Hyundai which I purchased from the auction. I do have a home which I purchased 3 years ago, in which there is no furniture as of yet. I still have 150K in school loan debt with interest accruing annually. That being said, although the picture is not as rosy as I initially though it might be 13 years ago when I started down this road I have learned to be content. Oh but wait, things are changing again. Just when I was coming to grips with the current situation the government has decided to make healthcare is a right. There it is folks – it is a right! No longer is medicine provided as a service it is now required by the government. That folks is socialism. I am now an employee of the federal government. No longer is there incentive to be the best or to work harder or to provide better care for my patients. My pay, my practice, my career will be dictated to me by the government. So tell me Vickie where is the incentive to call you at 2AM in the morning? How much does your physician get paid to call you back at 2AM in the morning? Answer – Nothing. All that you get as a doctor is less sleep, more stress and more angry patients feeling like the are entitled. Try calling your attorney, your plumber, your mechanic, your barber etc at 2AM and see if they will do that for free, just to help you out – I mean doesn’t everybody deserve good plumbing or good legal advice or to have a car that works? That should be a right don’t you think? So why do physicians do it now? Because they do care. Why do physicians treat the indigent for free? Why do I operate and treat indigent patients for free and assume the risk of them suing me even though I was just trying to help them out – knowing of course I will receive nothing in return except the satisfaction of perhaps doing some good in the world – all the while laying awake at night wondering if everything doesn’t go exactly right will they sue me? So why do we do it?, because despite all hat we still want to help people. But guess what Vickie? The bill you just helped passed – the one everybody is so excited about – it will most likely suck out what remaining empathy your doctor has. Don’t believe it? I lived in Italy for two years. I watched people die because their physician was on vacation and nobody else would see them. I lived in England and watched people wait for 2 years for an operation that would be done in weeks here. So, Vickie your life is about to change drastically. Don’t expect the call back when your child is sick in the middle of the night. Don’t expect anybody to squeeze you in to help you out. You will be seen between 9AM and 5PM by a foreign medical graduate with less training and less skills to treat you. There is no incentive for the best and the brightest to go into medicine anymore because there is no future in it. You can’t even do it because you want to help people anymore, because the government decides who you get to help and to what degree. So congratulations Vickie you’ll get what you have always wanted. UNIVERSAL HEALTHCARE FOR EVERYONE! YEAH!
Oh and by the way. They still have no clue as to how to pay for it. The bill does nothing to lower health care costs. It only adds 33 million to the payroll. But I guess the government will suddenly find a stroke of genius and despite years of inefficiency magically become Microsoft. Think your taxes are only going to go up a bit to pay for this? Try 50-60% of your income will go to the government when all is said and done. Don’t believe me? – just ask your friends to the north and across the pond how much they pay. Oh and by the way, despite what puppets they put in front of you say. I and my associates still operate on Canadians who come down for better healthcare which can be given to them within a few weeks rather then waiting a few years.
Good luck with all that Vickie.
artistswriter
I live in Arkansas; I’m from Massachusetts, and have lived in California (where I had a hysterectomy and wonderful care); and the writer who cited the problems Massachusetts has faced with trying to keep up with the huge number of patients under their comprehensive health care laws, has it right. My husband and I have not been able to find a PCP/Internist for the past 3 years since ours resigned. Very few docs here will take Medicare patients. With the new health care laws, I think we are doomed.
Suzmash
Maybe it’s time the private sector consideres handling healthcare the way they do in the Navy. The Navy trains their corpsmen to diagnose and treat most things that would present in a family care practice. You can have five corpsmen overseen by a physicians’ assistant and a medical officer. The difficult cases go to the physicians’ assistant and or the MD. Corpsmen were not allowed to prescribe medications those requests had to go to the Physician, but the corpsman could coordinate x-rays, lab work, put casts or splints on. Navy Clinics always ran very smoothley and everyone got taken care of in a timely manner. Often times Naval Hospitals and their corpsmen took care of bases and their staff large enough to be considered a large city of thousands of people. If the model works for the military why not try and addapt some of the new healthcare changes to match that of the military which is working and has worked well for centuries?

RINurse educator
that is the idea, rather than continue to assume that the MD’s need to be at the top of the health care delivery system, lets give each profession credit for what they are able to do. Nurses, PA’s, NP’s, etc. can all contribute significantly, lets use them.

Amy
I do believe that midlevels and nurses are a valuable resource. However, this enormous void can be filled with them. Then doctors will be doing nothing but supervising them all day. Never actually seeing patients. I did not go into medicine to be a preceptor to midlevels. The is no substitution for our years of education and formal training. Midlevels do not have the experties of a physician. One particular concern that I have is the growing trend for nurses to get their NP degree online. Do you really think that the training is the same for a physician (who has at least 4 yrs of undergraduate studies, 4 years of medical school, and 3-7 years of residency) and a NP (who went to nursing school and then took some courses online). NOOOO! Medicine can not be learned ONLINE. I’m not saying that their services are not useful. But, they are NOT doctors. 90% of medicine is pretty straight forward, but what about the 10% that is not easily recognized. Things that only a physician is trained well enough to recognize as something that is out of the ordanariy.

RINurse educator
My practice is not “SUPERVISED” by an MD. I have an independent license. I don’t mean to imply in any way that we can do without medicine, what I said was that there was a place in health care for all of the mentioned professions. Many of things that happen in a primary care practice are better managed by someone other than the MD. ALso, even if a nurse did become an NP using an online program, there are a great deal of clinical hours attached to that course work, no one becomes an NP “online”.

Amy
In Texas, midlevels must have a supervising physician to practice. As it should be. And yes, you are right, there is a place for all healthcare professionals. But there will still be the need many more DOCTORS for the current healthcare reform to be viable. As I said before, it is not something that can be resolved with midlevels. I’ve worked with several of these “online” taught NPs. Even after they have their clinical hours ( which is not even close to the type of training in a medical residency) they still are not prepared to independently manage patients with complicated problems. Do you really think that nursing educators have found a way to cram all the medical knowledge a physician has into a nurses brain without the 8 years of schooling and 3+ years of residency. Maybe we should all go to nursing school and just do away with training for doctors all together. Would love to see how that would turn out.
RINurse educator
I don’t think any one is trying to cram all the info from med school into anyones head except for the Physicians. But not everyone who needs primary care needs an MD. That is all I am saying. I am a perfectly healthy 52 year old woman who gets all my annual screenings, exercises regularly, doesn’t take any medications and follows a good diet. My annual physical can be accomplished by a nurse
fam med doc
you grow more delusional by every post you put up. when you write “Many of things that happen in a primary care practice are better managed by someone other than the MDn you write “, it shows how inaccurate your opinions are. Most inteligent people will strongly disagree with you- they want an MD to take care of their health care. Not some NP with limited experience and training. You write about “a great deal of clinical hours attached to that course work”. Try my 3 years of residency and 1 year of a fellowship at 80 hrs PLUS a week. As many mid-level providers I know you OVER estimate your knowledge base and skill set. This makes you are dangerous. Whats frightenting is you dont even know what you are missing in your knowledge base.
scary
Amy
OK, so all the easy, well exams, colds, sore throats, etc (the easy stuff) could be managed by the midlevels. The problems with this is that this leaves all the complicted cases to the doctors. And it can be absolutely draining to see those complicated patients all day long. The fact is is that there is not THAT much difference in the reimbursement for a treating a cold and treating a 80 year old lady with SOB and a history of CHF, COPD, anxiety/depression and uncontrolled diabetes . If we give all the midlevels the easy stuff, you will be making twice as much as MDs and with 1/10th of the stress and liability because you can see 30 of the easys in a day and we can only squeek by with 8-10 of the complicated ones. WTF!

http://www.drjshousecalls.blogspot.com Dr. Mary Johnson
Matt, very respectfully, in addition to my dance with government medicine in public service, I’ve been the victim of surgical malpractice twice (which had to be surgically corrected both times). And I too believe that my Dad might be alive today had the physicians treating him after a motor-vehicle accident been more vigilant. So I know something of being angry with one’s physician. But as I pointed out in my first comment on this post, medical peer review reform (which is integral to real accountability AND fair tort reform) did not get so much as a blink from Obama, Rahm & company – despite the fact that some of us have been screaming for it for years.
If we had better mechanisms of peer review – and JCAHO oversight that was not a joke – you might not have to “believe” something about how your Father died, you might KNOW. But the politicos in Washington have not cared.
RINurse educator, primary care is most certainly NOT happening “for free” ANYWHERE (unless it’s outright charity). The labor – of anyone – costs money to provide. The facilities and equipment cost money. The American people have actually been insulated from the true cost of medicine for a very long time – by Federal entitlement programs and private co-pays.
Moreover “access to care” and “paying for care” are not the same thing – nor is healthcare a Constitutional “right”. It is a commodity – just like the labor of the Engineers and Scientists and Technicians Matt cites. And the labor of each professional has a value in society.
Get real. If you want people to do what it take to be a doctor (any kind of doctor), and provide medical care and cover call (particularly in rural or underserved areas & conditions), you are going to have to given them real incentive to do that. I didn’t get in this game to get rich or enjoy an “elaborate lifestyle”. But I most certainly didn’t get into it to be treated like crap either – by people who think all I do is wipe little noses or dry off babies.
Obama’s version of healthcare reform is like putting a Bugs Bunny bandaid on malignant cancer . . . or a blind/drunk surgeon operating on a brain tumor.
Vaughan Wenzel, PA-C
Dr Kevin,
HELLOOoooo….. Am I missing something here regarding the “tremendous shortfall of Primary Care Physicians” (and any other specialty for that matter)… Is Everyone forgetting about the tremendous resource of nationally certified PHYSICIAN ASSISANTS (PA-C), who are trained in the same ‘medical model’ as their supervising physicians (vs. the ‘nursing model’ training of our sisters in the Nurse Practitioner career field)???
Remember us? Your ubiquitous “Partners In Health Care”, who can do 80% of the functions performed by medical doctors including: Examining; ordering, performing and interpreting lab tests; diagnosing; treating; prescribing medications (even DEA controlled substances); and managing that patients overall health care needs. They practice primary care medicine, they specialize and sub-specialize, and assist in all of the surgical disciplines.
Is no one?… Is anyone?… taking this valuable, existing resource (since 1965) into account? …not to mention the relative medico-economics of the federal and state government only paying the equivalent 85% reimbursement of the allowable rate normally paid to MDs ? (i.e. – We cost the taxpayers less for virtually the same medical treatment WITHIN our scope of practice.)
Someone should recount this ‘shortfall’ of physicians that everyone is lamenting, and include the hundreds of thousands of mid-level providers (including Nurse Practitioners) who have the equivalent of a “Masters Degree in Medicine” (vs. the Doctorate in Medicine) – who are all trained, certified and individually licensed to practice medicine.
Am I missing something here… or is this resource not part of the solution? HELLOOOooooo…. We’re here.
V. Wenzel, PA-C
Physician Assistant

http://www.kevinmd.com Kevin
I addressed the role of PAs in the op-ed: “Nurse practitioners and physician assistants, who can help alleviate the shortage, are also enticed by the lucrative allure of specialty care. As Newsweek recently reported, “almost half of current nurse practitioners and physician assistants work in specialty practices, where the money is.”
Kevin

Ron Hood
One of the provisions PA’s in Nebraska face is that they physically have to be in the supervision of a physician. Many physicians don’t hire PA’s because of the supervision requirement. This is one thing the government should look at if they’re trying to get more health professionals interested in family practice.

fam med doc
Dear V. Wenzel,
We Physicians (I am a board certified Family Medicine doc with a fellowship in HIV Medicine) are aware of the mid-level providers presence, but most MD’s rightfully are suspicious of the knowledge base and skill set of these professionals. It took me 4 yrs of med school, 3 yrs of a residency, and 1 yr of a fellowship to acquire my skills. Yet somehow mid-level providers think they can do it in a 2 yr masters program with a clinical supervision period? That is grandiose. Mid-levels are just as smart as MD’s but just as in need of the lenghty time it takes to become a qualified clinician.
No, we are not forgettign you folks. We just dont trust mid-levels except in the most basic clinical events. As it should be.

V. Wenzel, PA-C
Dear “Fam Med Doc”
Re 1 Apr 10
Thanks for the response… We (PAs) are not trying to be your ‘peers’. It just seemed to me (the reason I wrote my original comments) that everyone was lamenting “where’s my glasses – I can’t find them anywhere ?!” ( when they were crying out – ‘where will medical providers needed to meet the new demands of health care reform come from’ ?!) When your metaphorical glasses were right there – pushed-up on your own forehead… I.E. the gap-filler is right here in our PA’s – and no one seemed to acknowledge “the help” that was right there (on their foreheads). I may be ‘out of touch’ with your concerns as a PA with 15 years experience in a wide variety of medical fields (Fam Practice – ER – Onc/Hem – Occ Med – even C-T Surgery), and just can’t remember how ‘green’ I was back then… But so were you as a young resident. Would it help your mind-set if you thought of us as ‘perpetual residents’ capable of MANY tasks, but still under the supervision of the attending and staff physicians… and include us in your practice for the value-added skills we bring to your clinic ??
I am also terribly biased in favor of PA’s trained in “the medical model”, often along-side first year med students (during our first year of PA school, earning a ~3-yr Masters), and totally share the concerns and complaints of others about “online” and “night school” NP degrees (trained in the traditional “nursing model” by other nurse educators) who think they are now entitled to ‘hang a shingle’ and practice independent medicine. The PA profession made a very deliberate decision about 6-7 years ago, when all the NPs started showing up on the radar screen, to continue to be proud of the fact that we are “Physician Assistants”, and the smartest ones of us, know or practice limitations. (I know all this will offend NPs and Nurse Educators and draw-fire… but that’s MY opinion based on observations in the past 10 years of seeing proliferating NPs in the clinical setting – with the possible exception of a Career OB/GYN NP ‘on the floor’)
I’m sorry you (many MD’s) continue to be suspicious and ‘don’t trust mid-levels’ but please don’t lump PAs and NPs into a single, mutual stereotypical mid-level category…. there is a difference. That being said … I believe both PAs and NPs Do have a role in relieving the tremendous burden that ‘the new health care reforms’ will place on MDs (and all of medicine for that matter) and would appeal that you (and MDs in similar mind-set) to ‘open the curtains of trust’ by drawing us in to what you’re doing and teach us the way YOU want it done – - we are capable of doing that… and can replicate / duplicate your skills in that “certain percentage” of tasks you permit us – as your “assistant” – to perform… many of which will be BEYOND “the most basic clinical events”, as you put it. I read some of your other posts – and it sounds like you could use the help…
That’s what MY ‘scope of practice” (that YOU establish) is all about.
Respectfully,
V W, PA-C
RE: Reply from -
fam med doc April 1, 2010 at 10:51 am
Dear V. W.,
We Physicians (I am a board certified Family Medicine doc with a fellowship in HIV Medicine) are aware of the mid-level providers presence, but most MD’s rightfully are suspicious of the knowledge base and skill set of these professionals. It took me 4 yrs of med school, 3 yrs of a residency, and 1 yr of a fellowship to acquire my skills. Yet somehow mid-level providers think they can do it in a 2 yr masters program with a clinical supervision period? That is grandiose. Mid-levels are just as smart as MD’s but just as in need of the lenghty time it takes to become a qualified clinician.
No, we are not forgettign you folks. We just dont trust mid-levels except in the most basic clinical events. As it should be.

Art
Kevin’s point about the Mass experience was right on. Mainly because of the primary care shortage in Mass, ER visits have not declined since they enacted their reform. Wasn’t this one of the ways reform was to be paid for: reduced ER visits?
Steve
Cheer up everyone because while the bill adds no money for doctors, nurses’ or to build facilities like hospitals it does make sure that there is funding for 16,500 new IRS agents. But we no thats not an assault on our liberty. It also does nothing to control out of control lawyers nor does it do anything to provide competition in the market. And as a business owner that has always provided health benefits I now have to decide how this mess will play out on my employees, business and bottom line. Also, I’m sure my employees won’t be able to wait to pay the taxes on their cadillac plan something I’ve worked very hard at providing. It’s also nice to know that my Aunt will see Medicare cuts fopr her dialysis treatment. That is if she lives to 2012. No there is virtually nothing good about this plan. It would have been far better to have sent out out a check for those who needed insurance instead of bringing more government intrusion. Feeding the Leviathan is never the answer.
Thank you
anonymous
A couple of comments in response to Dr. Johnson’s initial comment that started this thread:
Do you think reform of the peer review process should have been in this bill? Do we seriously want the government involved in policing the profession? I think it’s appropriate that peer review reforms were not included.
As to tort reform, the bill contains grant money for demonstration projects that address patient safety and alternative dispute resolution mechanisms. While it sounds piddlingly small, I would submit this is the correct way to go – give us some viable alternatives so people don’t have to slug it out in a courtroom.
JMHO. And for the record, the vast majority of the physicians I know are very dedicated and hard-working and care very much about their patients. I try to let them know I’m grateful, as much as a 7-minute visit will allow.

http://www.drjshousecalls.blogspot.com Dr. Mary Johnson
Anon, to answer your question, absolutely YES!!!
Medical Peer Review, as it is conducted in this country – is a joke – and that’s a result of the “unintended consequence” of another sweeping bill (HCQIA) passed back (as a knee-jerk reaction to a legal case) back in 1986.
And/so the government is ALREADY involved in policing the profession – in fact it CREATED the current problems . . . by throwing due process for doctors right out the window, and giving blanket legal immunities (the kind that facilitate cover-ups) to hospitals (in favor of “risk management) . . . and by giving over-blown/easy credence to the notion of “disruptive physicians” (without doing anything to define what makes them “disrutpive” . . . without protecting medical whistle-blowers . . . and without holding executives & suits to the same standards as physicians). It’s a legal rabbit hole if you fall into it. And I totally appreciate that you cannot possibly understand it unless you’ve fallen in.
I mean, within days of completing a public service obligation, I was fired for REPORTING and INTERVENING TO STOP medical badness to peer review!?!? On what planet and in what nation is that okay? I’ve been begging for help – from an apathetic/careless Federal government for well over a decade (please don’t get me started on the oversight of the US Attorney’s office, USDHHS or the IRS). They’ve done NOTHING. It’s just OLD.
But hey, let’s give ‘em MORE to do! That will solve everything!!!
We are not going to have decent tort reform until we over-haul the way we police our own – and convince the general populace we can do that. We as a profession have had years to do it, and have totally dropped the ball (the AMA has been utterly useless on this issue). The token “demonstration projects” in this bill are “piddlingly small” and will just prolong the agony – for everyone.

elizabeth
What healthcare reform will do to primary care: people will show up for their “free” annual physical – things will be discovered that will call for a follow up visit, blood tests, imaging. These bills will go unpaid. End result: overburdened doctors, less compensation in the end, more noncompliant patients, more worries about stupid lawsuits – more headaches. People won’t be healthier in the end because most of the things discovered during the physical would have resolved on their own or are of no real concern. Lifestyle changes prevent disease but people already know that being overweight and inactive are bad for them. Heck, they may indulge even more now because they can get it fixed right up because now healthcare is free! Throwing more people into a bloated, inefficient system WON’T FIX ANYTHING. And future generations will pay (think social security). Healthy, young people will be forced to buy into the same policies as the fifty-year-old who never took care of himself. The fifty-year-old will be taken care of but when the young person finally needs some care years down the road … what will things be like then?
Stephen
Do what I did. I left medicine with my Medicare-funded graduate education. I won’t be putting in longer hours, weekends, etc away from my family while the auto worker gets his 12 weeks vacation/year and comes in asking for samples after he tells me he was just at Disney. Guess what? I get that 12 weeks/yr now. Feels good. And the fact my education was in part funded by Medicare makes me feel even better. I took this job and shoved it. I actually hope more of my colleagues do the same. Hey, America asked for it and now they’re gonna get just what they asked for. I’m making popcorn for the show from the outside now.

Amy
Good for you! Can you tell us what you do now? I went to a CME conference last year and one of the talks was about what doctors can do once they decide they are tired of all the B.S. in medicine. I was floored that people were dicussing this so openly. And also amazed at how they found interesting ways to use their skills to find jobs that they were actualy HAPPY with.

Stephen
Amy,
Let me just say your medical degree and residency/fellowship is proof of your hard work and dedication that any number of industries would be ecstatic to have you. They can pass bills that affect medicine and physicians but you know something? They can’t force you to work and practice medicine. They can affect the receiver of medical care and the payor but they can’t force the main engine of health care, the *provider*, work. I encourage you and other physicians and medical students to look around.

Ron Hood
What scares me:
1) Medical professionals talking about retiring NOW!!
2) Promising young people passing up spending 8 years
or more in training for a profession filled with so
much uncertainty.
3) The shortage of quality health care that is for certain
to take place under ObamaCare.
4) Small businesses talking about being health care taxed
into oblivion.
5) The disappearance of concientious, hard working medical professionals who have stayed with their professions due to personal pride.
Joke Post
I’m an aspiring medical student, I’m very committed to making achieving my goals. One thing that I DO NOT WANT TO SEE is the rise of midlevels. Nursing has it’s place and it’s not at the side of a physician. Nurses != Doctors. If nurses want to practice medicine than they should have considered going to Medical School and should instead apply to get in. What solution exists to reducing this shortage? There a pie and other people will get pissed off if they lose their share of the pie.

anonymous
Thanks for saying this. My experience with PAs, NPs and the like is that they can be very good *within their sphere of knowledge.* But they are not a replacement for a physician, so let’s not gull the public into thinking they’re getting care that’s “just as good.” They’re not.
I’m sure I’m going to offend every PA and NP who reads this. Well, tough. Within the past year alone, I’ve seen both my aging parents get into trouble because of PAs who didn’t have the training or the knowledge base to recognize unusual complications or to comprehend that what’s good for 95 percent of patients doesn’t necessarily work for the other 5 percent.
There’s a reason why medical school is so intense. The training and experience that physicians bring to the table just can’t be compared with NPs or PAs. I’m not saying this to demean the mid-levels; it’s just a fact and we all need to recognize it.
fam med doc
Dear Jake,
I wish you the best. And I agree with you- NO MORE MIDLEVELS. They dont know what they are doing and are very limited in their knowledge base. I have seen FRIGHTENING cases managed by the very basic of trained NP’s. Think on this, if you have completed 2 yrs of medical school, thats how much time they have to become a clinician. I knew nothing after 2 yrs. It wasnt until the middle of my 2nd year of residency i began to see a light at the end of tunnel and realized i would someday become a knowledgeable, safe physician. These mid-levels replace that knowledge with fervor that they are competent and safe. What can you do about it? Refuse to employ or supervise mid-levels when you are out. In the real world, you cant verbalize too loudly the views I just wrote as i wound not be politicaly correct. What most of do is just not hire them. And I dont refer patients to practices that hire mid-levels. No way.
Good luck to you. I wish you the best.
Are you considering primary care?

jsmith
I’ve been a family doc for 21 years, and these are by far the most uncertain times I’ve seen in primary care medicine. It could go one of several ways, and maybe you know what’s going to happen, but I sure don’t. Some possibilities:
1. PC Medicine will limp along , with a lot of shortages and a lot unhappy docs and pts. Sometimes things will be better, sometimes worse.
2. A death spiral. Med students will see things like poor pay, long hours, competition from PAs and NPs and turn tail. In 20 years we’ll be left with a few hard core survivors and some well-compensated concierge docs, but the bulk of PC will have been handed over to midlevels.
3. Re-vitalization. The US will do what most advanced democracies have done and will put physician-based PC at the center of its health system.
Right now we’re in a slowly accelerating death spiral. Will we pull out of it ?

Ron Hood
JSmith:
Sad commentary, but unfortunately, undoubtedly true. I only wish that someone would organize health professionals that share your views in opposition to the AMA.

Ron Hood
JSmith
I apologize for misinterpreting your position on Health Care Reform. When you referred to “shortages of PC docs” and “Right now we’re in a slowly accelerating death spiral”, I’d be interested in hearing how you feel the provisions of the Health Care Reform Bill are going to correct those.

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