Americans will need doctors but physicians are leaving primary care

Everyone understands the need for a robust primary care workforce in making healthcare more affordable and accessible while keeping those in our care healthy.   With the aging of America and healthcare reform, even more Americans will need primary care doctors at precisely the same time doctors are leaving the specialty in droves and medical students shun the career choice.  So as a practicing primary care doctor, I’ve watched with great interest the solutions for the primary care crisis.

I’ve been utterly disappointed.

Patients so far don’t like the patient-centered medical home (PCMH) as noted in Dr. Pauline Chen’s New York Times column.  The changes recommended won’t inspire the next generation of doctors to become internists and family doctors.  Experts understandably look at a dwindling workforce and unprecedented demand to come up with solutions like (from the May 2010 Health Affairs article – Transforming Primary Care: From Past Practice to The Practice of The Future):

  • “physicians can no longer enjoy trusting relationships with all of their patients.  Just as tasks must be shared among the primary care team, the joy of personal interactions with patients must also be shared.”
  • “no contact at all with patients having uncomplicated needs.The new primary care practitioner would function as a team leader and clinical teacher rather than as a healer to all who seek help.”
  • “nurse practitioners and physician assistants could take responsibility for common acute and chronic care issues.”
  • “small practices without a robust team would be limited in their capacity to institute such team-based care [for preventive and chronic conditions].”
  • “the primary care practice of the future must adapt to the reality of large panels – the number of patients under the care of a single doctor.”
  • “models in the United Kingdom that have employed longer visit times with advanced-practice clinicians, patient satisfaction is high.”

I wouldn’t want to do primary care either as a practicing doctor or as a medical student contemplating a future career.  Having a larger panel size isn’t attractive in a field lacking work-life balance. Putting aside the issues of reimbursement and medical school debt, which also need to be fixed, what experts have fundamentally failed to appreciate is that these solutions perpetuate the cottage industry that they so desperately need to transform.

First, Americans are not like people from Great Britain.  Americans are uniquely different. We have our own views.  Note how rapidly we’ve adopted the metric system. Though the British may have high satisfaction with non-physician providers, given a choice and a level playing field of the same amount of time and access, I believe Americans will choose a doctor over a nurse practitioner (NP) or physician assistant (PA).  Telling future doctors that they can’t see young and healthy individuals for acute problems not only makes them highly unlikely to choose primary care, it also will be quite upsetting for the general public.  As other articles have noted, NPs
and PAs numbers are also insufficient to close the gap of an overwhelmed primary care workforce.

Second, stop rebuilding and perpetuating the cottage industry and reinforcing the fragmentation of primary care.  Except for very small medical practices like the ideal medical practice model where there is only one doctor with no staff, supported with technology, and extremely low overhead, having all primary care doctor offices create a team of staff to care for chronic conditions is absurd.  It isn’t scalable.  Three quarters of primary care doctors are in either solo to five person practices.  Each doctor office shouldn’t re-invent the wheel.  Instead, third party organizations should be accountable for managing chronic conditions and reporting to a patient’s primary care doctor if the patient is not compliant with care or not following practice protocols.  Employer groups are leading this change as well. This is a good thing.

The article “Prospects For Rebuilding Primary Care Using The Patient-Centered Medical Home” notes that taking payments to invest in a “community-based organization provides infrastructure, such as care coordination services, that can be shared among several primary care offices” is already occurring in North Carolina and Vermont.  In addition, “local virtual organizations might consist of networks of small independent practices or of practices affiliated with a hospital.  They could be linked through sharing of care management health IT or human resource for case management or care coordination.”

These are ideas that must be pursued.  Few doctors want to be the doctor, the clinical chronic conditions leader, and the IT expert, yet this is what most articles of the PCHM propose.

Having infrastructure that is scalable and seemless via health IT will off load both chronic conditions and preventive care to these other organizations which can assist doctors in providing the right care. As a result, a doctor with an average panel size of 2000 is free of the 17.4 hours per day needed to do it alone.  This time is now available to do what primary care doctors were trained to do, to evaluate patients with problems that don’t quite fit standardization or protocols.   Opportunities to see those who are young and healthy if they wish to be seen even if a protocol could treat a bladder infection over the phone or email are possible.  Patients and doctors would find this encounters far more satisfying.  One thing these third party groups must do is to agree to common reporting standards rather than proprietary ones to make the evaluation of clinical data quick and easy.

An area which is already being carved out of a primary care office is the acute care provided by retail clinics like Minute Clinic as well as start-ups like Zipnosis. Focused on a subset of problems where protocols are developed delivers care more rapidly and at less cost. Primary care doctor offices can either try to replicate this as well or perhaps better would be having the healthcare system virtual integrate these providers offering precision medicine (protocols) with primary care doctor offices who do intuitive medicine (cognitive/clinical decision making).

So what does this all mean?  Avoiding the discussion of the federal government’s role of community clinics, the future of primary care will thrive in three areas: large integrated healthcare systems like Kaiser Permanente, individual doctor offices virtually integrated by third party vendors as well as other non-physician providers like retail clinics, and the solo practitioner doing the ideal medical practice.

My fear, however, is that this won’t happen.  Instead, medical students will be more appalled with the future vision of primary care, fewer doctors will be in the workforce, patients continue to bypass primary care doctors, and the unthinkable crisis that experts are trying to avoid in fact occur more rapidly.

I hope I’m wrong.

Davis Liu is a family physician who blogs at Saving Money and Surviving the Healthcare Crisis and is the author of The Thrifty Patient – Vital Insider Tips for Saving Money and Staying Healthy and Stay Healthy, Live Longer, Spend Wisely.

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  • Maryann

    Why can’t nurse practitioners play a role in managing chronic conditions? Primary care docs shouldn’t have to give up seeing the young, healthy person with an acute problem. With the right kind of teamwork and consultation, an experienced NP may very well want to take on some folks with chronic but straightforward conditions, who might see the doc every other, 3rd or 4th visit and the NP in between. In some systems NPs’ schedules allow for longer visits than the docs’ schedules do – people with chronic conditions might benefit from that extra time. Just sayin’.

    • family doc

      the reason why Nurse Practitiones should not play a role in managing chronic conditions is because they are not trained well enough or have skills to do so. it took 4 yrs of med school and 3 yrs of residency in fam medicine for a total of 7 yrs to become an independent, competent physician. why do somehow midlevel providers think they can do it in 2 yrs? impossible. they simply do not have enough training to safely perform primary care. i am urgently opposed to midlevel providers in primary care.

      • Maryann

        Laurant M, Reeves D, Hermens R, Braspenning J, Grol R, Sibbald B. Substitution of doctors by nurses in primary care. Cochrane Database of Systematic Reviews 2004, Issue 4. Art. No.: CD001271. DOI: 10.1002/14651858.CD001271.pub2.

        suggests otherwise. Not for every chronic condition, and not for every patient. And better evidence is needed. But did you see that I mentioned “teamwork” and “consultation”? NPs are not out there working alone, in fact, don’t want to. They recognize their limits.

        Also – it’s not 2 years. It’s 6 to 7 years for a BS in nursing, followed by a master’s degree or doctorate in the area of clinical interest. Often – usually – there is real-life clinical experience between the BS and the graduate degree.

        This is not to say that all NPs are good clinicians or that all NP education programs graduate only those students who can actually do the work. But you paint all NPs with the same broad brush.

        • family doc

          dear maryann,

          its not 6-7 years of training that NP’s receive. this is exactly the same repeated and faulty argument that advocates of NP’s make. the years prior to their 2 year NP training are done in NURSING SCHOOL. this is a very different scope of training with different goals and agendas compared to the training to become a doctor. medical school and residency had the goal of training docs to become good diagnosticians with capabilities of making treatment plans for that diagnosis. nursing school does NOT do that job. it took 7, yes 7 years for me to feel like I had a good handle on being able to be a competent and good primary care physician. NP’s seem to think they somehow did it in TWO. not possible.

          you wrote “Often – usually – there is real-life clinical experience between the BS and the graduate degree”. that is absurd. that there is experience present i do not dispute. but its NOT the experience and training specific to becoming a DOCTOR. its like a person who works at Delta Airlines doing anything other than flying a plane and adding those years as flight time experience. its artificially inflating their experience in an attempt to look better than they are. so i had 5 years working in nursing by the way in a psych hospital before i went to medical school. doest that make my 7 years 12 years of training and experience? NO NO NO. my 5 years in the psych hospital had nominal, at best, impact on becoming a competent, independent primary care doctor.

          you write in your last post NP’s are “Not for every chronic condition, and not for every patient.”. Oh really? and just how in a primary care office do you select out for the ones the NP cares for and doesnt? a patient can come into my office with many, many different possible problems. and i have to be ready with what to do with each patient and problem. and THIS is my major concern: since the NP doesnt know how to care for every problem, they dont know what to do. they dont know what they dont know. you have already admitted in your last post that they cant take care of every problem. they make ERRORS. they DELAY the diagnosis. they are DANGEROUS. i have been trained to manage this wide variety of problems that can show up in the primary care setting. please do not take that to mean i know EVERYTHING in medicine, because i do not. but part of the LONG 7 year training was to learn what was within my scope of practice and what was NOT. i had to learn when to recognize when something should be referred, when something is turning out poorly, and when to continue to treat in the outpatient setting. thats why the trainging to become a primary care doctor takes 7, SEVEN, years to accomplish. NP’s do not know what they dont know. therein lies the danger. when i think that the NP down the hall has had 28% of the training I have had, i get very nervous for his/her patients. just because their is a primary care shortage of doctors doesnt mean we provide sub-standard providers to address this issue.

          you wrote “NPs are not out there working alone, in fact, don’t want to. They recognize their limits”.
          OMG, that is so not true. if only what you said was true i woudnt be writting this post! all i professionally see with only one exception (Planned Parenthood if you wanna know) is NP’s with way too much autonomy- working ALONE. they DONT recognize their limits. thats what i have seen professionally for years. they want to, and do, practice pretty much alone. if only what you said was true. (heavy sigh…)

          you wrote “This is not to say that all NPs are good clinicians or that all NP education programs graduate only those students who can actually do the work”. WHAT??!!?? are you telling me that you are admitting that some NP’s are poor clinicians? and that some NP grad programs graduate unprepared NP’s? medical training for physicians is set up to exactly PREVENT that. these are peoples lives. it takes careful planning and preparation to become a doctor. if a medical student is not up to snuff, they DONT graduate. if a resident is not growing and learning, they are NOT promoted to the next year. and medical schools and residency training programs are monitered closely by accrediting boards for ALWAYS reaching a high standard in the graduates they graduate. yes, i saw in medical school and residency people who were NOT promoted due to lack of progression in their skils and knowledge base. it happens, trust me. and i went to a top tier US medical school.

          maryann, your post has only increased my deep professional concern for all the patients of NP’s. you seem to admit the issues i have yet fail to admit the biggest concern i have- NP’s are ill-equiped in the primary care setting.

          lets go back to my Delta Airlines example: lets say it takes 7 years to become a pilot for Delta or any other airline. All the Delta pilots agree to this standard. Yet, there is another group who say 2 years is enough for their “pilot associates”, especially since these pilot associates have worked in administration of Delta, but NOT actually flying the plane. is anyone reading my post really wanting that 2 yr pilot associate to fly his plane ALONE from NYC to Los Angeles? please, i would love to hear others opinions on this. know i want a pilot, not a pilot associate.

          PLEASE PLEASE DO NOT think i minimize what nurses (not NP’s) do. i stand in professional awe of what nurses do in the medical community. they are truly an integral and vital part of healthcare.

          • Maryann

            So doctors are like the children of Lake Wobegon, all above average? I don’t think so. Interesting how you can admire nurses professionally but discount what those same nurses do once they become nurse practitioners. They’re okay as long as they stay in their place? Just like I don’t believe all doctors are incompetent because of the few I know who are, neither should you paint all NPs with the same broad brush, as under-educated, under-experienced and dangerously unaware of their limitations.

            I guess we’ll just agree to disagree.

          • MH

            Maryann

            You’re missing the whole point (intentionally or not). Family Doc clearly explained why the education of the nurse practitioner is inferior to that of a physician yet you answer with tangentials.

  • r watkins

    “Everyone understands the need for a robust primary care workforce”

    I would change that to “everyone gives lip service to the need . . .”

    The AMA, among others, continues with policies that are actively hostile towards primary care.

  • drsof

    The reason why physicians are leaving primary care is simple. You can no longer afford to practice what you were trained to do, both emotionally and economically. Physicians are reaching burn out at an alarming rate. It does not really matter anymore if you are solo or in a larger multispecialty group. PCPs are the worker bees and we are working for free these days. Compound that with med school debt, decreased family time, increased tort worries and decreased job satisfaction, is there any wonder WHY they are leaving?

  • http://www.brucehopperjrmd.com Bruce Hopper Jr MD

    There is only one answer in turning primary care into a profession again: direct cash practice, which can take on many forms, many models.
    Patients are angry, primary care docs are angry, med students flee primary care like the plague, and I don’t blame them. Insurance companies will NEVER value primary care. Our “leaders” over time lost the RBRVS game because they were too timid and allowed specialty groups to shove us out of the way.
    The beauty of direct cash practice is that it is the only model in primary care that aligns the patients’ incentives with the physicians’ incentives.
    If a patient wants to overeat, smoke, drink excessively, and not exercise, fine; who am I to judge them? If they consult me, they will hear me say they are overweight, they need to stop smoking, cut back on drinking, and start exercising. But I will also tell them they have 24/7 access to me, and if they have an emergency at 3:30 in the morning, I insist they call me. If they value my service, then they will pay my fee. If they don’t, I will not judge them, and they will go elsewhere. There is nothing better in our profession when there is mutual trust and respect between patient and doctor. There are millions of patients out there yearning for us to bust out and offer these services at a price we both agree is fair.

  • TrenchDoc

    We are burning out because our overhead is 70% of collections and we have to see an average of 27 patients a day just to cover the overhead and take home a salary of $150 K . Then we get the privilege of being sued
    Most of us are getting tired of this gauntlet so we are expressing our anger and frustration by leaving.

  • jsmith

    Dr. Liu, You must be young. Although your diagnosis of the problem is good, your prescription falls into the same trap that I have seen starry-eyed young docs fall into for the last 21 years. The “seamless infrastructure via health IT” is never going to happen. It simply will not. It is propaganda designed by those who would fool med students into self-enserfment. Hear me now and believe me later. This hoped-for system will be inadequately funded and staffed and will fail, and we’ll be left holding the bag, being responsible for acute care, chronic care, health maintenance of those who don’t even show up in the office, and, yes, keyboarding into the medical record. I’ve seen it happen at Kaiser in California, in Duluth MN , in Roseburg, OR, and now in WA state. I’ve seen it happen in almost even locum tenens I have ever done. It is not getting better, it is getting worse.
    Give up your false dreams and face reality: Doctors will abandon primary care to the NPs and PAs. Their lives will get worse, as will the lives of the pts. Docs’ lives will get better.

    • http://www.davisliumd.blogspot.com Davis Liu, MD

      Younger, but hardly naive. The Kaiser you speak of was from over 15 years ago and no longer exists in the organization today. The work life balance of Kaiser doctors is far better than those in the community and work continues to make professional satisfaction even better. I am optimistic that the future is bright for primary care, but I fear that experts have oversold the patient centered medical home as the solution which as I point out in the piece will hardly attract the next generation of doctors. The nation cannot afford (literally) the primary care crisis to get worse.

      Davis Liu, MD

  • http://www.medbillingncoding.com Adam Alpers DO

    After almost twenty years in primary care I believe that there is a disconnect between the cuts in reimbursement and the cost of overhead. The constant chopping away of our income and the requirement to purchase more and more technology continues to force us to rethink what and how we are doing what we do.

    If we don’t maximize what we can receive, it makes it difficult to capture what we deserve. The system forces us to leave money on the table with the billing process, the collecting process and the authorization process.
    In other day’s gone by, it was the patient who paid and then filed their own insurance and wait for their money. I believe in bringing that system back to the forefront and let us capture the income we work for up front.

    We should be in a better place to practice medicine the way we were trained and not have someone non-medical telling us whether we can get a needed test for our patients because we didn’t give the right key words for that authorization.

  • http://www.BocaConciergeDoc.com Steven Reznick MD FACP

    There seems to be a tone in this article that general internists and family practitioners would prefer to see challenging cases with a degree of complexity than a simple acute problem like a pharyngitis or urinary tract infection. Being available to treat the brief problem and using that visit as an opportunity to get to know your patient better while you and your staff review preventive benchmarks and schedule followup time to discuss those issues when the patient is better is what helps to build long term relationships. Its your opportunity to involve yourself in preventing that individual from becoming the complex chronic problem of the future.
    Since organized medicine has allowed the practice of medicine to be kidnapped and held hostage by employers and insurance companies the elements of a complete and thorough brief problem directed visit have been lost on the new generation of practitioners whether they be PA’s , NP’s or MD’s. Each contact with your patient is an opportunity to build trust and to review the chart and make sure your patient has had their gynecological and obstetrical checkups, their skin checkups, their vaccinations and immunizations etc. Its an opportunity to look at your patient as a person and get to know what makes them tick. Passing that off to a NP or PA just does not contribute to longitudinal care and a strong doctor patient relationship which is as important for the patients future health as it is for the clinicians professional health.
    Primary care remains underfunded and underappreciated and as the baby boomers age, their care will suffer unless this discrepancy is rectified.

    • http://www.davisliumd.blogspot.com Davis Liu, MD

      I believe that if you review the piece again that I agree with you, but that experts have positioned the future of primary care as handing off acute uncomplicated problems to non-MDs, which I feel will make primary care even less appealing to medical students. This is a fundamental problem with the Patient Centered Medical Home.

      Davis Liu, MD

  • rich

    Why not go work for the VA – that have EMR, decent pay now, and less patient load! gov’t work is the way to go for pcp’s right now…

  • Sandra

    I work at Kaiser and for the past several years was part of a national innovation project wherein we attempted to get a medical home model up and running. Thus for the past 4 years I have been running my IM practice very differently than before. I have been seeing 6-8 pts/day and have 80+% of my pts actively emailing me. We have a large cental call center that rapidly books appts with no triage for virtually any and all callers for 15 clinics; at our local clinic and specifically my practice, I then view the schedule and stated needs and direct my RN to call folks whom I feel can be managed with RN advice & meds with an appt later if needed. We also have the luxury of Direct Physical Therapy, and that with RN advice offloads about 1/3-1/2 of incoming needs. It all worked so very well, with high pt sat ratings. Most Americans are actually willing to use common sense and don’t actually want an office visit if it isn’t really needed. But now, a new primary leader has come into the organization, and has failed to see how far along toward the idealized medical home our innovation-project clinic was, and has shut down our project and reverted our clinic back to the way it was. This has resulted in 120% exodus of doctors from the clinic, with replacement by FMGs. I myself am now leaving also as I no longer have adequate RN support and really can’t face this insult of factory-based practice rather than the visionary information and knowledge-based practice that we had so very nearly achieved. Am going to do hospital medicine now.

    • http://www.davisliumd.blogspot.com Davis Liu, MD

      Appreciate your comment. I believe, however, when you say Kaiser, you should indicate which region (if you are comfortable) because the Northern California region, I understand does not share the same experience.

      Davis Liu, MD
      Author of Stay Healthy, Live Longer, Spend Wisely: Making Intelligent Choices in America’s Healthcare System
      (available in hardcover, Kindle, and iPad / iBooks)
      Website: http://www.davisliumd.com
      Blog: http://www.davisliumd.blogspot.com
      Twitter: davisliumd

      • Sandra

        I don’t know what you mean that Northern California does not share the same experience. I would prefer not to say which Kaiser region I’m in, will say NOT Northern California.

  • Jennifer DerKazarian

    I believe as an NP, that those of you who are skeptical, have not yet had a positive experience with an NP. We are fabulous at allowing physicians to gain balance in their practice. If you know how to work with us, and teach, support, and engage us, we will do the same for you.Communication is paramount, last I checked we were on the same team! There is nothing better than an integrated practice. Embrace the teamwork and you will be enlightened. Happy providers leads to happy and well cared for patients. There is plenty of room for both. Great article other that that little bump!

    • family doc

      dear jennifer derkazairan,

      yes, i have worked with NP’s through residency, fellowships, and for several years after. believe me, i know what you can do as i have worked along side of NP’s for many years. no longer. the experience was not positive.

      in regard to your proposed benefits to the doctors that NP’s provide:

      1) NP’s are “fabulous at allowing physicians to gain balance in their practice”. i would like you to expound on this as i never saw it. what is it that NP’s SPECIFICALLY BRING to the primary care office? please be very specific.
      2) “If you know how to work with us, and teach, support, and engage us, we will do the same for you”. another example of how a midlevel slows me down. if i have another MD alongside me in the office hallways, i dont need to do any of what you suggested. s/he comes prepared and self-sufficient. but if you are there, i need to hold your hand? and ultimately, the MOST IMPORTANT POINT is i cant teach you YEARS of knowledge, skills, and training in a simple meeting, or in a month, or in a year for that matter. hence the emphasis on years. it took 4 yrs of med school and three yrs of residency to gain my knowledge and skills for primary care. thats 7 yrs. SEVEN. and you did it in 2 yrs? you have 28% of the training i have experienced. it is for this reason that i STRONGLY HOLD THAT NP’s are too LIMITED in their training to provide safe and adequate care in the primary care setting. over and over again i make this point and no midlevel is able to address this concern. why?

      • Jennifer DerKazarian

        Dear Family Doc,

        I am sorry that you have been so burnt…it happens, but your anger is palpable. We can agree to disagree. I did hesitate whether or not to respond to this blog initially, but it pains me to watch my colleagues in all departments fighting this battle when we really are facing a larger battle in maintaining the integrity of our practice and patient care on a whole and at the end of the day, we “should” all be on the same team.

        To answer your first question, I do not work in primary care, and do not have direct experience with your practice model, (so you can stop reading now if you like….;) I speak of an integrated MD/NP model in which we share the practice. Clinics can be managed together, allowing for high volume (50 pts in an afternoon) to be seen. I think there is a place for shared appointments with patients which are really education sessions in which the MD pulls patients out for a short consultation and the NP facilitates the education, prescription renewal, etc… In our practice we manage a very heavy inpatient service as well, mornings are spent exclusively on the ward so we are constantly fielding issues/consults and questions while our MDs are seeing patients in clinic or doing procedures. I may touch base with my MDs for advice 5 times a day and we all consider the day a loss if we don’t learn something new (MDs and NPs alike).

        Your second point is sort of lost on me. Why would you assume that I am not self sufficient? Why would you assume I would slow you down? I would ask that you be specific about that. I have years of knowledge and skills, a lot more that seven. And I am fully aware of your training as I am part of a family full of healthcare providers.

        It is like anything in life, there are some good eggs and some bad. The ability for the healthcare profession to blog/share views via the internet for the first time in recent years, has opened the doors for much bitterness and frustration with the amount of time spent training and dissatisfaction with careers, this has also started some of these other discussions which are enlightening. I just hope that is does not ultimately damage the profession, as it is easier to type words without face to face accountability.

        I work in Cardiac Electrophysiology and with my 28% of your education and many years at the bedside, I would be more than happy to take you into my practice and teach you anything you want to know. The door on my end is always open. I hope that in good time you will open yours up as well.

        I would also add that you would probably get a primary care NP to address your concerns very directly, if you were a little more receptive to the discussion. It is a bit like looking into a threatened lions den.

        Best,
        Jen

  • http://www.touchingsoulsintl.org Tahmina Sultan

    Although primary care doctors manage vast majority of medical issues that are not complicated enough to be passed on to specialists, patients are not satisfied, primary care doctors are not happy with their reimbursement. Medical students are not interested to be in primary care, because Insurance companies do not give right incentive for primary care doctors.

  • family doc

    dear maryann
    this is for your post dated:
    September 2, 2010 at 5:26 am

    i am more than excited to welcome a nurse into primary care. they might bring a welcome breath of fresh air with a new perspective.

    AFTER they go to 4 yy MEDICAL SCHOOL, then an accredited 3 year RESIDENCY in fam med or internal med.

    please do not be so insulting that i want nurses to “stay in their place”. we need more primary care doctors- i welcome them all. but not nurse practicioners- they dont know enough.

    and you didnt explain how a NP with 28% of my training and education could match and properly care for a patient in the primary care setting.

    yes, i strongly believe that mid-level providers are “under-educated, under-experienced” to be providing such autonomous and depth of care they do in the primary care setting. its just that after 7 yrs of education and training, i deeply see how difficult doing good primary care in regard to knowledge base and skills. in my office there are times when i scratch my head and wonder what to do with a challenging patient and it takes all my training to find the right diagnosis and treatment plan. but somehow an NP found those skills in just 2 yrs where it took physicians 7?!!? impossible. but please discuss how in your eyes it is SPECIFICALLY possible in the primary care outpatient setting. so far, i have never heard a logical, well thought argument from the NP point of view.

    really, i will listen, and respectfully respond to that one.