ACP: Primary care education and training: Time for change?

A guest column by the American College of Physicians, exclusive to

by John Tooker, MD, MBA, MACP

ACP: Primary care education and training: Time for change? The Annals of Internal Medicine recently published an article by Mullan and colleagues on the social mission of medical schools. In the article, medical schools were ranked on their record of educating and training physicians to care for the “population as a whole”. Not surprisingly, medicals schools varied widely in graduating doctors who become primary care physicians, are underrepresented minorities in the physician work force, and who provide service to underserved populations.

The Josiah Macy Jr. Foundation, which provided the primary funding for the Mullan article, released a separate report separate report  in April of 2010 on the provision and training of primary care professionals, noting that medical schools and other health professions schools “hold the societal responsibility for the education of health professionals” and “have the opportunity and obligation to increase the size and strength of the primary care workforce”. The report contains many useful recommendations to improve the education and training of the professions who play a substantial role in team-based primary care.

As an internist familiar with medical practice in rural and urban settings, and with academic medical centers and community practice, I see the need, from multiple perspectives, for traditional medical schools in academic medical centers to increasingly value primary care as core to their mission, and to form partnerships with the states, regions and communities where practice is local and the need is greatest. The clinical teaching “partners” can and should include the leading physicians and other members of the primary care team who provide care for patients in these communities.

One such new innovative partnership is the Tufts University School of Medicine – Maine Medical Center Maine Track. In 2008, TUSM and MMC agreed to collaborate on a medical school initiative designed to address patient access needs in Maine, including access to primary care services.

Key Points of the Tufts-Maine Medical Center Track:

  • Well qualified students, most familiar with Maine
  • Appropriate class size (31 students in the Class of 2014)
  • Tuition assistance
  • Innovative and flexible curriculum
  • Experienced and committed clinical faculty
  • Early exposure and training access to a full range of clinical experience, including small town and rural practice and academic medical centers

These students were selected in a competitive process, most with a basic understanding of what living and practicing in Maine might be like. While this is an experiment yet to be validated, it is an important and innovative initiative that began as a “what if” idea, with the commitment and leadership to make it happen. This is the type of experiment being encouraged by other medical schools to meet the needs of the patients they serve.

So, in the spirit of innovation, best practices and shared learning, what ideas or models to improve primary care education and training would you like to share with the readers?

John Tooker is Associate Executive Vice President of the American College of Physicians. His statements do not necessarily reflect official policies of ACP.

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  • madhu singh

    None of this is remotely possible without radical payment reform- as long as there are incentives to do invasive things to patients without clear demonstration of benefit, the medical system will be skewed towards procedures- physicians will be rewarded for doing for procedures not comprehensive care. Primary care is underappreciated and underpaid and students catch on to this early on in their medical education.

  • Chris Schaeffer

    Agree with Madhu. No amount of exhortation for “societal responsibility” will move the needle. There are a small number of people who will pursue their work for it’s intrinsic “value to society” but most students are like the rest of us, who will tailor their desires to maximize their income.

  • Steven Reznick MD FACP

    Naively I went into general internal medicine thirty five years ago with the feeling that if I delivered a quality care product and was a competent and caring physician I would be compensated appropriately. Regardless of how extensive and well trained I was coming out of my residency , I saw my opportunities to generate revenue stripped from me and my generalist colleagues in the name of conflict of interest, economic power plays by specialists not wanting competition and changes in regulations and rules which raised my overhead without presenting opportunity to raise my revenue stream.
    Today’s medical students are far more saavy. They see how the ACP and organization that claims to represent internists is actually a subspecialty society organization that does little to promote the private practice of general internal medicine. They have sold out to the concept of a ” team ” approach to medicine despite the fact that medicine is practiced in small mom and pop offices that currently can’t afford the team. Until payment reform truly pays general internists, family practitioners, pediatricians for E/M services so that they can afford to pay back their student loans, afford a home and support a family then they will choose other areas of medicine that allow them to achieve those goals. No one in primary care asked for the money to come out of the pocket of procedurally oriented specialties. They just wish to be paid fairly for the longitudinal care , coordination of care and patient advocacy that they perform daily.

    • Alina

      In your opinion how much should a PCP earn per year? Nobody seems to be willing to put a dollar amount on this.

      • Anon


        Research shows that when primary care physicians are paid more per patient, they see fewer patients. So the issue isn’t salary, per se, but working conditions – especially working conditions relative to many specialists (ie. radiologists that have all the access to the latest technology and leave at 5 PM while making twice as much). I think many would be satisfied with what is considered to be the current average compensation for primary care ($180 – $200 K) if it could be done in a high quality comprehensive way. But this is impossible to do while seeing 20-30 patients per day just to keep the doors open. When overhead costs escalate and even the 20-30 patients per day can’t generate that level of income, that’s when primary care docs start looking for the exit.

        I think most of us are acutely aware of our status and that we are highly paid compared to many. However, we generally are not highly paid compared to our cohort of college classmates who are now engineers or in high tech sales or who have started their own companies. Using an average American salary to compare to MD’s who graduated at the very top of their college class isn’t quite fair.

        So there’s your answer.

        Now that I’ve answered your question, since I read on a previous thread that you think primary care physicians are compensated appropriately, even considering the opportunity costs of 7 years out of the workforce and accumulated debt, please tell me the exact monetary value of the opportunity cost incurred by an individual who goes to medical school and goes into primary care compared to his cohort of college graduates who enter the workforce.

        • Alina

          Here is what I think and posted this before on other articles:
          1) Family Practice should be the back bone of the healthcare system. For this however you need to have PCPs willing and prepared to do so.
          2) Specialists should be there for the most complex cases. Btw, you should know that specialists don’t have a high regard for the PCPs who refer the most mild case to them.
          3) I think that some/many specialists are way overpaid for the value they provide
          4) Education in the US is outrageous and there is no good reason for it. Contrary to popular belief professors don’t earn that much at all – you can start with $45,000 with a scientific PhD and postdoctoral research at top schools. The length and rigor of education is similar to the medical one. The medical profession is the only one that demands the society shoulder their school debt. Why should that be?
          5) I don’t care for the insurance companies and I think that we would be better off without them. At the same time I think that concierge businesses are just as wrong.
          6) I know that my PCP makes a good living and he does spend time with all his patients (20 minutes on average). So if he can do it why others can’t?
          7) I like physicians that promote prevention, healthy eating habits, are knowledgeable about their job, educate patients about disease and generally spend the necessary time with the patient. I don’t care to be sent for unnecessary tests – contrary to what some physicians post here, most patients don’t go into a doctor’s office to demand tests, medication, etc.
          8) Competent physicians should be paid more than the rest. It’s called pay for performance.

          • Happy Hospitalist

            Don’t forget to include pension contributions by state Universities when calculating teachers salaries. 20 years of work, followed by 40 years of pension. That’s a lot of money.

    • Alina

      Well, finally got my answer from Dr Reznik’s concierge site. Even top notch specialists would be envy of these fees:

      $1,800 annual fee x 400 patients (maximum) = $720,000 per year

      In addition, Dr Reznik charges a $25.00 fee per visit plus any “extra” services he may perform (e.g., immunization, ECG, etc):

      The practice also accepts Medicare, with the following fees:
      • Medicare fee for the visit
      • Patient’s copay usually paid by medigap insurance
      • $1,800 annual fee just to join the practice

      What I don’t understand is why physicians with such concierge practices feel the need to sell them to others.
      1) is it because they know it’s wrong and think that if they keep talking about it it will make it okay
      2) is it because the business doesn’t catch on and they need to get more physicians on board to make it the norm

      • COO

        I’m curious about your perspective, are you a health care professional?

        • Alina

          Really? If you notice I merely stated the facts from Dr Reznik’s site. You consider that as being “my perspective?”

          • COO

            The intent of my question was not a judgment. I simply wanted to know so that I could write a thoughtful response. “Knowing your audience” is important when communicating with them. This was my first time at responding to a blog. I was just trying to be respectful.

  • Anon

    Since most of the individuals who will be doing primary care in the future will not be graduates of American medical schools (mostly FMG’s and NP’s and PA’s) perhaps their resources could be better used elsewhere.

    In the current environment where primary care commands such little respect and where all manners of specialists earn more than twice as much as the average primary care physician, I believe it is irresponsible for those in academic medicine to suggest that students consider a career in primary care. There are not enough resources devoted to primary care to do the job the way it should be done. The amount of money spent in a cardiac cath lab in a day would run my office for a year. Yet somehow, no one can figure out a way for insurance or government (forget the patients paying as long as they have insurance) to increase payments to primary care so that it can be done in a comprehensive, high quality way. At this point, most of the insurance companies I deal with don’t pay enough for vaccines to cover the cost that I would have to pay for them. Consequently, the patient gets an Rx to pick it up at the pharmacy if they want it.

    Look at the Hospitalist movement. One need look no further to see how the current payment scheme discriminates against primary care. Only because primary care is so undervalued can a concept like the Hospitalist thrive. What is so “primary” about primary care when you don’t even see your patients in the hospital when they need you the most and where the relationship you have developed over time is supposed to pay off?

    Additionally, government and insurance company policies are saying that primary care midlevels are the same as primary care MD’s. If someone wants to pursue a career in primary care, they should go to PA or NP school.

  • Ajay MD

    A sad discussion.
    Primary care MD, has been “DEGRADED” and compared to the care provided by NPs, and PAs.
    And, the graduates of American Schools @Anon, compare the FMGs to Nps, and PAs.
    What a discrimination, or I should say ignorance, or may be arrogance of a red neck.
    Just look around, the staff of any hospital (for FMGs)
    You really expect the ‘imported docs’ will buy into your plot.
    Several highly qualified FMGs are migrating back and starting new ventures else where.
    Have to heard of “medical tourism” – a flourishing “outsourcing of QUALITY medical care” at a much cheaper cost.
    Several European countries recognize the value of such excursions even Canada, and the insurance companies have seen the light (greens). A loss for the American “specialists”
    Need a ‘cath’ get on a jet to Singapore or India, get the procedure in Delhi and go for a rehab on the beech in Bombay, all inclusive.
    Whereas here:
    More and more regulations have been SLAPPED on to the workings of primary care MDs. eg, EMR, PQRI, MOC, MOL, RAC, pay for performance, etc, etc. just to name a handful.
    The ACP owns up to some of them, and AMA takes rest of the cake, eg CPT, billing and coding requirements.
    The medical world here is being controlled by the insurance industry, and the trial lawyers. Our organizations have been bought.
    How in the world one could expect FMGs may be attracted to coming here, leaving there country of origin and buying into a failing (or failed) medical system here, (was true in 1960s – not any more) when they can do much better elsewhere, a SHAME.
    You give example of a hospitalist; that, I think is the BEST thing which has happened to primary care.
    The hospitalist is there 24/7 and gets paid by the hour, no overhead, no staff to deal with , no billing, no collection. Just render quality care and go home, without a beeper.
    As a practitioner, if you are so dedicated to follow the patient you can still pay them a social visit while they are in the hospital.
    Most of my FMG colleagues do.
    The medical system was “cracked,” now it is “broken,” and it is about to FALL APART !!

  • Catharine Clark-Sayles

    Our current system trains Internists in a hospital-based, inpatient setting which leaves them competent and comfortable taking care of inpatients. The not-so-subtle message is that the best and brightest will go into academic medicine and the less stellar become “PCPs”. Not surprising that most graduates with any attraction for internal medicine choose to stay in hospitals as hospitalists, usually on a salary better than most of us still in private practice are managing. Medicaid sends me letters addressed to “Dear Vendor” and the local visiting nurse agency addresses me as “Dear Referral Source”. Not much incentive to go into office-based internal medicine aka primary care.

    • Happy Hospitalist

      The current national cash compensation average according to the 2010 SHM/MGMA hospitalist compensation survey about $215,000 (99% community based hospitalist medicine in the survery). That doesn’t include, retirement contributions, health insurance, malpractice, CME, vacation.

      How does that compare with outpatient internists and family medicine docs?

      • Alina

        Since I couldn’t reply to your post above, I’m writing to you here:

        “Don’t forget to include pension contributions by state Universities when calculating teachers salaries. 20 years of work, followed by 40 years of pension. That’s a lot of money.”
        So you’re saying that physicians would be content to start on a salary of $45k after finishing residency in the hopes that they would get this “lot of money” pension sometimes down the road? Let’s be serious. People that are motivated solely by money would never be happy no matter how much money you throw at them. You either have the work ethics and passion to do the job right or you don’t.

  • Steven Reznick MD FACP

    Alina apparently doesnt like the idea that after practicing general internal medicine for 25 years in a traditional practice of 3500 acitve patients when the ” median ” income for internists never peaked above $153,000 , and the cost of doing business was never less than 55% while seeing 40 patients on average per day, I decided to limit my practice and charge a membership fee. I might add that many of my patients who started with me in their forties and fifties are now in their eighties and nineties and require significantly more time to care for them than they did as younger patients. When I converted my practice I gave and continue to give free scholarships to 25% of the membership who are my elderly patients with limited fixed incomes who could not afford to pay the membership fee. At sixty one years old I have earned the right to see fewer patients a day but still follow all my patients in the hospital , in rehab units and in their homes. My patients seem to appreciate the availability of reaching me easily and quickly and having same day appointments when they are ill or troubled. I would love to have my practice fully subscribed but in this recessionary period doubt that it will happen soon. I now have the time to teach medical and nursing students, participate in care at several annual free health screenings and work for the stewardship of private medicine rather than having to squeeze in an additional 3 more patients per day each year to cover the overhead so I could meet the weekly payroll and pay the rent. Last time I looked the cost of a latte coffee at Starbucks was more expensive than the cost on a daily basis of joining my practice.
    In answer to the question of why direct pay physicians and concierge physicians encourage these type of practices , its because it allows us to do the thorough and complete type of evaluation and care we were originally trained to do. It allows us to develop long term relationships with our patients and act as their advocates as they move through an increasingly complex health care system. After thirty years of trying to accomplish providing excellent care and advice for my patients in a traditional setting while having insurers and Medicare whittle down my payment per visit while raising my costs of doing business annually I found another delivery model that works. It may not work for the whole populace in my model but it does in my locale. More and more patients like Alina will find out that if her health insurance covered catastrophic illness only and she paid out of pocket for her medical care she would be a far more saavy consumer and would probably receive far better treatment by office staff and physicians.

    • Alina

      Okay, so it is #2: business doesn’t catch on and you need to get more physicians on board to make this concierge business the norm. Just what I thought.

      “More and more patients like Alina will find out that if her health insurance covered catastrophic illness only and she paid out of pocket for her medical care she would be a far more saavy consumer” Honestly, you’re the one trying to increase everyone’s healthcare cost with YOUR “concierge” business charging people these outrageous fees making $720,000 not counting copays, and other “services” just so patients could have your cell phone #. And you’re the one trying to lecture and blame me and other patients that WE are not savvy consumers? You just proved my point that no money on earth would ever be sufficient for someone who is motivated merely by money. In fact, there were a couple of articles on this subject on Kevin’s blog.

      Bottom line is that concierge businesses are just like the high deductible or health savings plans. I knew they were garbage from the moment they came to market.

      • COO

        Let me first say, I am not a health care provider. I do however work with the health care industry on a non-partisan basis. As you are aware, the health care system as become dysfunctional. Furthermore, we have a physician shortage while fewer and fewer medical students are entering primary care. Add in the aging population and we have a volatile mix. Physicians, by and large, are burned out because of the complexities the system. They are seeking alternatives.

        In a landmark 2008 Physicians Foundation Survey, sent to over 250,000 physicians in America, 49% of the respondents said they will either reduce the number of patients they currently see, or stop seeing patients altogether in the next several years. Many plan to retire. Some will cut back on hours and the size of their patient panel. And, over 7% said they will switch to a concierge / retainer based model. Additionally, 60% of the respondents said they would not recommend medicine as a career to young people based on the current system.

        No one, including the association for concierge / direct access practices (AAPP – American Academy of Private Physicians) has claimed that direct access practices are the answer to the health systems failures. What these practices do offer is simply a choice. As consumers, let’s face it, patients are consumers, we have the choice to stay within the system or find alternatives.

        Interestingly, if you look at the common characteristics of concierge physicians, a high percentage of them have been recognized by their peers within their markets as being “Top Doctors”. The vast majority of those peers are s=in traditional, not concierge practices. Furthermore, the majority the concierge physicians are giving back to their community by volunteering their time a health clinics for the economically challenged, accepting scholarship patients in to their practice who do not have the financial means, teaching, etc.

        For those who believe the retainer based model is strictly for the affluent, think again. Across the board, more consumers are seeking alternative practice models (not to be confused with alternative medicine). Concierge practices are seeing more and more patients from across the socio-economic spectrum. Also, new retainer based models are evolving (I.e., in Seattle, Houston and elsewhere) that are priced at a point where more people find them to be affordable.

        If you think concern businesses are garbage you are definitely uniformed. In the last year, Proctor and Gamble, the nation’s largest consumer products company, purchased MDVIP. MDVIP is the largest concierge company with over 350 physicians in their model. Also, in a recent capital raise, another concierge company received substantial investments from the investment companies owned by Michael Dell (of Dell Computer) and Jeff Bezos (founder of

        As a nation, we are fortunate that physicians, overall, are passionate and caring individuals. Regardless of their practice model, physicians like Dr. Reznick are needed in their communities.

        We’re all consumers. Choose whichever health care model fits you best. The important thing is, you do have a choice.

        • Alina

          “…work with the health care industry on a non-partisan basis” I think we know when, why and how the whole non-partisan word got coined….do I have to say more?

          Consultants, which I have a lot of experience with, are people that companies hire in order to be told what they want to hear. Never really understood this concept as this is not in a company’s best interest. If people are not willing to even uncover the issues, how can they expect for anything to improve. Companies (quite big ones) went down the drain for this very reason.

          Now, about the study that you mentioned:

          1) Perhaps you should also mention the actual stats so people can make their own decision on what the situation really is.

          The study was sent to 270,000 primary care physicians and 50,000 specialists and the Physicians Foundation said it was “virtually every physician engaged in active medical practice in the United States today.” Not really everyone, but let’s say that’s the case.

          The foundation continued on saying: “ The total number of responses received was 11,950” with a possible error of less than 1%. If you do the calculation you have a response rate of 3.73% (11,950 divided by 320,000). This is of course a very low response rate, fact that is conveniently overlooked. I wonder why…..

          2) Let’s analyze the “findings”

          “The Physicians’ Foundation depicts widespread frustration and concern among primary care physicians nationwide” First, it would be worth noting that this is not really an independent association and it would safe to assume it’s there to advance a certain agenda.

          “The resulting findings show the possibility of significantly decreased access for Americans in the years ahead, as many doctors are forced to reduce the number of patients they see or quit the practice of medicine outright.” If these doctors have the opportunity to see less patients or quit their job that means that they are not as destitute as they claim and they must have plenty of resources to take such measures.

          “An overwhelming majority – 78 percent – of physicians believe that there is an existing shortage of primary care doctors in the United States today.” Interesting they do not mention the cause of the shortage and the fact that this is managed by some doctor’s associations.

          “Additionally, nearly half of them – 49 percent, or more than 150,000 practicing doctors– say that over the next three years they plan to reduce the number of patients they see or stop practicing entirely.” Right so let’s apply the 1.9% to the entire universe – please no lecture on statistics.

          About the “Top Doctors” comment – I believe I’m not alone in saying this, as many doctors have the same sentiment even on this site – this whole “contest” is more about politics than anything else.

          Back to the whole concierge business…..words cannot begin to describe how wrong these businesses are. Actually there more than a few words that could be used but tried to keep the comment “E” for everyone.

          There are doctors who have criticized this practice – Dr Michael Stillman published an opinion in the Annals of Internal Medicine earlier in the year.

          BTW, thanks for making my point by bringing up that P&G, Michael Dell, and Jeff Bezos are associated with the concierge businesses. You just proved that this is not about the physicians “spending more time with the patient” but rather is about making lots and lots of money. Checkmate!


          NOT Joe the Plumber

          P.S. You guys should fire your marketing people. Telling “the masses” that the annual fee is less than a tall latte it’s really dumb.

    • HJ

      A $3 daily latte at Starbucks is only $1095 compared to the $4.93 per day for your practice.

      I find much of the counseling by primary care physicians can be found on the internet for free. For more customized lifestyle issues, physical therapists, dieticians, personal trainers, psychologists, massage therapist, lifestyle coaches are better equipped and less expensive than a concierge practice. One would probably be better off buying a membership to a gym and purchasing high quality food.

      Last year I saw my PCP 4 times, which makes the office visit $450 in Dr. Reznick’s concierge practice plus another $100 in additional fees. And what about the medication costs, radiology costs, lab fees, etc. Then there are insurance premiums and specialist fees.

      “she paid out of pocket for her medical care she would be a far more saavy consumer and would probably receive far better treatment by office staff and physicians.”

      As a cash paying saavy customer, I would not chose a physican for primary care. There are cheaper providers out there.

  • Sad Consumer

    It’s not sexy, it’s not high tech but we must start focusing on keeping people healthy and thus not needing to spend time on an office visit to “fix” them. We would not need specialists if folks did things like walk 30 minutes daily, eat better, watch portions, get their preventive health checks done, and maybe meditate, volunteer, or pray to help their stressed mental status. This goes for the doctors and other providers also!! How many overweight practioners who never exercise (and maybe smoke!!) are out there? I am an ancient nurse and in my day the nurses focused on health promotion to prevent illness whereas the “medical model” was always trying to put humpty dumpty back together again. So, maybe the medical community should advocate for policy change that makes it easier to live a healthier lifestyle and quite relying on the latest and greatest technology or pill to cure everything. As for the practioners who compare themselves to college buddies making more in a different career, try practicing gratitude for the gift of healing that they don’t possess. I don’t believe it is the obligation of the average consumer to pay back medical providers in a manner they feel entitled to as a way to make up for all the years of schooling, expense and hard work put in. Better to get out of the profession than to be a bitter and disinterested provider. Late in life careers are not impossible and could lead to a happier life.

    • Alina

      Couldn’t said it better myself! So, so true.

  • Steven Reznick MD FACP

    The last time I looked at the figures my percentage of patients requiring in patient hospital care each year had dropped to under 2%. This is significantly less than a traditional medical practice or my traditional medical practice when I had 3500 active patients. Health care experts will tell you that the real expensive side of medicine is in patient hospital care. By spending more time with patients and being able to be more comprehensive I am hospitalizing fewer patients, ordering fewer imaging studies and keeping my patients healthier at less cost to the system than most physicians or NPs or PAs in their traditional practice can. Spending time with patients is invaluable.
    Telemedicine, the internet and social media sites can not replace focused time with your physician. If you truly believe you do not need a physician, or you truly believe primary care physicians can be replaced by NP’s and PA’s or that we dont need highly trained and experienced surgeons and medical specialists I feel sorry for you and your loved ones.

  • HJ

    The last time I had pneumonia, the family physician I saw refused to listen to me, refused to review my chart and told me it was post nasal drip. Anyway, there are other providers that can prescibe antibiotics and if hospitalization is needed, it’s very likely that I would not be admitted by my PCP but would be admitted through the emergency room. My PCP would not care for me while I was in the hospital.

    Anyway, I don’t pay cash. If I did pay cash, I would chose an NP. They can prescribe medication, send me to the emergency room when I need hospitalization and refer me to specialists a lot cheaper than $1800 a year. And as for an oncologist, I didn’t know they did primary care. I am also not saavy.

    “I don’t really have time to think about those who aren’t coming in for care.”

    Nor those that can’t afford it. I have multiple health care problems, and was a fool to trust the doctors I was seeing. Five misdiagnoses, a preventable permanent injury, unnecessarily irradiated. spending a lot of money, I had nothing to show for it. At one point I considered letting nature take it’s course…the worse part of being sick is not the pain, the fatigue, the fear of the future…it’s dealing with the medical community. My internet search lead to a correct diagnosis. If the only solution is for me to spend my kids college fund to get medical care, then I would rather do without.

  • Anon

    @HJ wrote, ” I am also not “saavy”
    For your information, oncologists treat cancer, rarely would they ever diagnose cancer. Not a single patient of mine who developed cancer was ever diagnosed by an oncologist – not a single one.

    “Nor those that can’t afford it.”. Why is it that you and nurse consumer think that you know anything about my practice? I treat many patients in my office for free and volunteer at a shelter clinic one-half day a week. If you have a problem with primary care MDs that’s fine, but it’s your problem and doesn’t generalize to the entire universe of primary care MDs. And maybe the reason you have had these experiences is because of what I said in my first post here, there are not enough resources devoted to primary care to do it in a comprehensive, high quality way. Again, you have helped me to make my point.

    If you want to see NPs, see NPs! If you get substandard care, complain to the medical board. Exercise all your rights as a citizen and a consumer.

    • HJ

      “Not a single patient of mine who developed cancer was ever diagnosed by an oncologist – not a single one.”

      Your patients are diagnosed by a pathologist, or a radiologist or a surgeon. I have never had a primary care doctor do any direct cancer screening. When I found a breast lump, I was referred to a surgeon for followup and it was this surgeon that made the diagnosis. I believe now, radiologist are doing some of the biopsies.

      “Why is it that you and nurse consumer think that you know anything about my practice?”

      Why is it you think you know anything about me? Why can’t I point out that quality cost effective care can be found with other providers without comment like, “Please visit your massage therapist the next time you get pneumonia or cancer or the like. I’m sure it will be real cost effective when you are dead.”

      Clearly, you don’t understand the role of a massage therapist in health care.

      • The Happy Hospitalist

        That’s a pretty warped sense of reality. Make sure you schedule a yearly cancer screening with your local radiologist next time. Maybe they’ll do a head to toe CT scan for you.

        Might even biopsy a 0.5 adrenal nodule for you while they’re at it.

        • HJ

          “Make sure you schedule a yearly cancer screening with your local radiologist next time.”

          I am not required to see my PCP before making an appointment for a mammogram. If I wanted a mammorgram, I would call my radiogist, he would send me the results. If the mammogram was abnormal, I could see the appropriate provider. I can do this all without a visit to a PCP. Please explain how this is warped.

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