Fixing primary care requires more than free medical school

It’s well known that there is a shortage of primary care physicians which is only going to get worse over time.

To address this problem, Dr. Peter Bach, the director of the Center for Health Policy and Outcomes at Memorial Sloan-Kettering and Dr. Robert Kocher, a guest scholar at the Brookings Institution, propose making medical school free. They argue that medical students would be more likely to choose primary care over specialties if the debt burden of medical school was eliminated. To pay for this, residents in specialty training would, “forgo much or all of their stipends, $50,000 on average.” Residents in training for primary care would continue to receive their stipends as usual.

Though this sounds like an interesting proposal, in reality it wouldn’t work. First off, this is unfair to specialists in training. I’ve gotten into numerous heated discussions about how unfair it is that specialists are compensated much more generously than primary care physicians. That doesn’t mean that I think we need to stiff residents and fellows who go into specialty training; they deserve to be paid for the work they do. Our problem isn’t that any given person becomes a specialist; it’s that too many people become specialists instead of primary care physicians. A better solution would be to decrease the number of spots for specialty training.

Second, the disparity of pay between specialties and primary care wouldn’t change so the economic incentive to go into a specialty would be intact. If the debt of student loans seems manageable by entering a specialty, wouldn’t any debt incurred while training to be a specialist be just as manageable, if not more so? Between moonlighting, family support, and physician loans supporting oneself during specialty training for the promise of a bigger payday is an ever better bet than accruing medical school debt hoping that you can pay it off. In fact, this seems to tilt the scales towards selecting those from higher socioeconomic backgrounds for specialty training since they would have the greatest potential for family economic assistance during specialty training.

Lastly, the authors acknowledge that specialists have been successful over the years in preventing any decrease in the disparity of pay between primary care and specialists. What makes them think that specialists would all of sudden be okay with allowing their trainees to be underpaid or unpaid for their training?

So what do I think we should do? Well, to address student debt we currently have national and state programs that pay off debt for those who enter primary care in underserved areas. We should extend this program to include all physicians who are actively practicing primary care. Loan repayment of $15,000 a year would make the average physician’s $155,000 of debt disappear in 15 years (assuming a 5% interest rate). Such an investment in primary care would certainly be worth the expense. Furthermore, since this is money is unrelated to compensation, it would be outside the political theater that surrounds any change to Medicare. (Medicare sets the compensation for medical services which in turn determines the compensation of all physicians). Decreasing the wage disparity between primary care and specialists is too large a topic to cover here. Suffice it to say, if we’re serious about boosting the number of primary care doctors, we’ll need to address this issue head on.

I applaud Drs. Bach and Kocher for attempting to address the worsening shortage of primary care physicians. But, to really deal with the problem we need to attack the root cause of the primary care shortage, the burden of student debt combined with the large pay disparity between primary care and specialists.

Nilesh Kalyanaraman is a physician who blogs at Progress Notes.

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  • Dave Chase

    As an interested, but outside, observer it seems to be that as long as physicians remain divided, they’ll be “conquered” by continuing to try to address symptoms rather than the underlying cause of the compensation issue for primary care. Rather than focus on a zero sum game between specialists and primary care, physicians should go after where the most fat is in the system. I’m not opposed to the ideas in this piece but I think there’s a way to have a much greater impact that has been demonstrated already.

    If we burdened day-to-day car maintenance the way we burden day-to-day medicine (EOBs, co-pays, deductibles, pre-auths…), we’d pay 40% more for our car insurance than we need to. Just as airbags and anti-lock brakes were once only available to the well-healed (but are now mass market), retainer-based primary care (aka “concierge medicine”) has gone mass market at levels affordable to all income levels.

    Just last week I highlighted Brian Forrest’s success doing this – Before that, Qliance was the main focus of a “Marcus Welby, RIP” piece that showed their dramatic results with lowering costs while having a highly satisfied set of clientele – Finally, a piece in top tech pub entitled “The Most Important Organization in Silicon Valley No One Has Heard About” highlighted MedLion and was one of their most popular posts and generated over 2000 tweets/likes/shares showing the pent up interest for models such as this –

    In those pieces the recurring theme is how these practices eliminated the 40% “insurance bureaucracy tax” which was a win for patients and they all earn at least 50% more than typical primary care physicians. I highlight those three as they all have plans to extend their successful models around the country offering primary care physicians a transition that helps them avoid the fate of the family doctor highlighted in the NY Times ( who literally couldn’t give away his practice. In my view, he’d already given it away…just to insurance companies.

    In contrast, it’s exciting that Drs Bliss, Forrest and Qamar are forging a path that any primary care physician who isn’t interested in working for the man should pursue. As a patient, a relationship as important as my physician relationship is one that I want to have as a direct relationship…not with some middlemen whether it’s their employer or an insurance company. It’s hardly revolutionary…we’re just returning to what it was when I was a kid. That is, a direct relationship between a patient and his/her doctor.

    • Nilesh

      Primary care versus specialists shouldn’t be a zero-sum game but the way Medicare reimbursement is done, a fixed pot of money for reimbursement to be divided up amongst all the providers, leads to the infighting.

      The concierge system you mention does work for a portion of the population but breaks down at a public health level. For many people they may not have the resources or savvy to participate in such a system. The patients in a concierge practice are by and large proactive and very involved in their care. Not everybody is like that but they also need care. I”m not arguing against concierge care for those who prefer it, just that it’s not a model that will scale.

      Lastly, health insurance in other countries is vastly better administrated and minimally obtrusive. There’s nothing that says we should waste a large chunk of our money and effort on dealing with insurance, but we do.

  • http://deleted pcp

    Everybody knows what the problem is, everybody knows what the solution is, everybody has agreed to not do anything about it.

  • ninguem

    The students aren’t stupid.

    They will pay lip service to how they want primary care.

    They will pick the same specialties as anyone else.

  • Kristin

    I want to go into primary care, but am not thrilled with the prospect of a relatively low monetary return, so I guess I’m the target audience for reforms like this.

    And I can tell you that 15 grand of loan repayment a year for working in my hometown (a PCP shortage area) would be a pretty big factor in helping me decide.

    …however, I definitely agree that systemic reform is necessary, and making small changes within the current system is a band-aid at best.


    Why are you assuming 5%? Grad Plus loans are 8.5%, which is what most med students have to take out after the initial ~$20k in Stafford loans. I wish my loans were 5%!

    • Nilesh

      I split the difference between the undergraduate and graduate interest rates just to illustrate a point. But you are correct, the current rate for graduate loans is 6.8% and at that interest rate it would take 17 years.

  • Carrie

    Mr. Chase – I could not agree more with the sentiment that we need to stop creating workarounds to encourage people to do primary care and fix the underlying issue of inappropriately uneven payments for specialty medicine and primary care.

  • Med School Odyssey

    Increase the number of domestically trained physicians, which means increasing medical school class sizes. You want more primary care doctors? Stop telling thousands of qualified applicants that they can’t become doctors.

    • The Scrivener

      Good point, but what happens at the residency level? Unless the GME council finds a pot of gold, “thousands” of newly minted doctors would be unable to complete their training. The Match would just become more competitive all around.

      It’s almost worse to string someone along for 4 years, taking their money and their time, and then land them with debt AND no way to use their skills.

      • Jack

        There are plenty of residency spots that the hospitals cannot fill and use foreign medical graduates right now. If there were more US graduates then they will fill those existing slots.

        One important thing to point out is that when you create more doctors you will drive up overall medical usage and cost. We are already complaining of medical cost being 20% of GDP. It will only go up when access is increased.

  • anon

    how about we do away with the the field of family medicine. change the model of a np and pa so that they are trained to handle primary care from the get go, instead of the nursing model or the somewhat medical school model of pa’s.

    anybody else that a pa/np can’t handle then refer them to the medicine team.

    • Family Medicine Doctor

      As a board certified Family Physician, I can tell you with certainty that mid-level providers can’t be the PCP as you suggest. Not enough training. No where near. Believe me, you don’t want a mid-level as your PCP. Sure, there will be people who diagree w me. Until the mid-level makes a mistake or misses something.

      It took me 4 years of difficult medical school then 3 yrs of a long, long residency of 60-80 hrs/wk. Sometimes more. But mid-levels think they can do it in 2? Impossible.

      • Shahab

        Your absolutely right – Family Medicine Doctor. Mid level providers aren’t good enough. Would you take your child to see a Mid level provider or want a qualified Family Medicine Doctor to see them?

  • Brian Loveless, DO

    My only issue has to do with only limiting repayment to primary care in “underserved” regions. FP’s and internists in suburban and urban regions are struggling just ad much, maybe more due to higher costs of living. In fact, when you take the rural reimbursement factor into account, docs in Buttcrack Nowheresville are probably doing better than most docs in Southern California or New York City.

    • Jack

      There has to be a higher compensation to physicians serving “underserved” areas. Like everyone else, many physicians want to live in big cities and that’s a choice therefore consequence.
      There isn’t a lack of PCP in NYC or Los Angeles compared to Buttcrack Nowheresville.

  • Muddy Waters

    Many don’t choose specialty over primary care just because of the money. I also thought primary care was annoyingly mundane and unstimulating.

    • imdoc

      Certainly that explains the plethora of cosmetic practices. Laser hair removal is so fascinating…

  • JustADoc

    Actually you are quite wrong. I could easily sustain a 6 figure salary with wart care and simple sutures. I get paid more for that than I do for treating a patient who has uncontrolled DM and uncontrolled hyperlipidemia and uncontrolled HTN and COPD and CAD and chronic back pain and Afib and is on 3 blood thinners who is here because they feel weak.
    I love wart patients. They take 3 minutes and pay me more than the 30 minute patient above.
    CPT code for wart removal(17110) pays $103.05 by Medicare.
    CPT for OV(99213 OR 99214) pays $66.13 and $98.21 respectively.
    I could probably do 6 wart patients an hour with bare minimum of documentation for reimbursement of $618.30
    OR i could see 4 99214 patients and run around like a chicken with my head cut off and be reimbursed $392.84.

    The warts pays me $225 more, has much lower liability, and remarkably less stress. I’d probably make an extra $100K or so a year also.

    That’s part of the problem. Procedural medicine is overreimbursed in many cases. By no means should simple wart cryotherapy pay more than treating that multi-comorbid patient above.

    • JustADoc

      Well, and add your complete lack of understanding as to what family docs and internists do. A good PCP rarely refers. As multiple studies have shown, areas with a higher percentage of internists/FPs have lower overall healthcare costs but same outcomes.

  • Mark

    Tony- NP, you must have a very limited amount of exposure to primary care. I’m always amazed at those who think primary care is nothing but flu shots, cuts and bruises, removing splinters, and the like. That is a fairly apt description of a primary care NURSE PRACTITIONER’s role, but not that of a primary care physician. Just today I’ve seen patients with malignant hypertension, head injury with loss of consciousness, brittle uncontrolled diabetes in the setting of multiple comorbid conditions, diverticulitis with abscess formation, polymyalgia rheumatica, and a new patient who probably has Sjogren’s syndrome. I’ve had a couple of sore throats, but those are a minority of my practice. Neither I nor my colleagues serve as triage practitioners; we actually take care of medical problems. That’s the difference between a NP and a physician–having enough training and education to actually do something. Such training costs money, and requires a six figure income to repay the debt and compensate for the arduous job and intense level of responsibility. NPs have a limited role in doing well woman exams, removing splinters (although if it’s not extremely simple one of the docs will have to do it),etc, but they absolutely cannot replace physicians unless their training is expanded to approximate that of physician. When NPs start training an extra 5 or 6 years, with twice as many contact hours per day as they now have, I don’t think they will accept a five figure salary. And for what it’s worth, wart removal CAN sustain a six figure income. In fact, most dermatologists I know earn a lot closer to seven figures than six by freezing things all day long.

    • Family Medicine Doctor

      Well said. Better than I said it above.

      But let’s be honest. When a doctor or a loved one has an illness, notice how s/he wouldn’t dream of seeing a mid-level? The doc knows the mid-level is poorly trained.

      • e-patient

        For me, primary care is flu shots, bumps and bruises and prescriptions. All of the major medical problems I have had were initially diagnosed and treated by specialists. When changes need to be made to my treatment plan, I go back to specialists because my PCP doesn’t have the time or expertise to work with me.

        • Mark

          That may be your experience but generalizing it to primary care in general is simply not valid.

  • Family Medicine Doctor

    “Wart removal can not sustain a six-figure income. Flu shots can not sustain a six-figure income. Cuts and bruises can not sustain a six-figure income. Splinter removal can not sustain a six-figure income. Yet, PCPs want to claim the status of a doctor that performs heart surgery.”

    THATS what you think ptimary care is? How wrong you are. You only heighten my fear of mid-levels performing primary care. What you describe above is the simple stuff. Most of my day is filled w complex stuff that took years to learn how to manage correctly.

    You haven’t been given those years of training. You scare me.

  • Alan D. Cato MD

    I am in total agreement with Mark’s and family medicine doctor’s reply to Tony-NP. Making a wrong diagnosis and subsequently choosing an ineffective or harmful therapy is almost always due to the clinician not possessing sufficient physiological, biochemical, and pharmacological knowledge base, or not approaching the case with the physiological and biochemical mindset that is so necessary for successfully practicing medicine. This should give us pause for reflection today with “physician extenders”, possessing only nursing education credentials, being permitted to serve as first contact primary care providers. The formal contact medical science training of these individuals is frequently shockingly disparate, to the education and residency specialty training of primary care MDs (i.e., not even in the same ball park).
    Without proper education and knowledge, a license is only legal authority for engaging in an activity for pay. It is certain that, if our healthcare system is to become the economical, efficient and quality one we are wishing for, it will be necessary to return primary care MDs to their preeminent position in the system. It is just as certain, however, that addressing the now very real primary care MD shortage, via primary care physician- substitutes (physician assistants and nurse practitioners), is neither a satisfactory economic solution for cost control, nor a satisfactory qualitative solution for services being provided to consumers. The formal contact medical science educations and clinical skills of NPs are simply not commensurate to the task of serving as unsupervised first contact primary care providers.
    Frontline triaging of patients (i.e., the first person evaluating a patient’s complaint) is the most important, difficult and high-risk task in all of clinical practice, and the task requires a physician to draw on his/her extensive education and training more often than any other area of medical practice—for differentiating the “routine”—from routine-mimicking life threatening catastrophes! Under no circumstances should this vital responsibility be left to a physician extender, as is so often being done today in busy clinics and emergency rooms throughout the nation. . —Alan D. Cato MD, F.A.A.F.P.(past), and author of The Medical Profession Is Dead and the Doctor Is “Critically ill!” (Oct., 2010)

  • e-patient

    “Frontline triaging of patients (i.e., the first person evaluating a patient’s complaint) is the most important, difficult and high-risk task in all of clinical practice, and the task requires a physician to draw on his/her extensive education and training more often than any other area of medical practice—for differentiating the “routine”—from routine-mimicking life threatening catastrophes!”

    And this task is given to the receptionist that answers the phone. I once had the routine-mimicking life threatening catastrophe and the next available appointment was next Monday. Fortunately the nurse at my insurance company was more saavy than the receptionist.

    I have also had a routine-mimicking not life threatening problem that was categorized as routine by a physician. Luckily, I found the answers I needed on the internet but only after years of suffering.

    • Mark

      Sorry you’ve had bad experiences but that doesn’t mean it always works that way for everyone else or that all primary care doctors are bad. What do you expect? Are you saying doctors should personally answer all calls for appointments and triage them? How long do you think it would take you to get an appointment if your doctor spent his time doing that? If your solution is to have nurses schedule all appointments, well you COULD have that, if you were willing to pay for it, but I’m guessing you aren’t….And if you are ill and suffering, you need to find another doctor or get a second opinion before letting many years pass.

      • e-patient

        “you were willing to pay for it, but I’m guessing you aren’t…”

        That may be your experience but generalizing it to all patients in general is simply not valid.

        My point is the doctor doesn’t triage patients as stated above. Why isn’t a nurse practitioner able to do what you trust the receptionist to do? If it’s too expensive for a doctor to triage patients on the phone, why isn’t it too expensive for a doctor to be the first contact primary provider? And if the most knowledgeable provider is preferable, why see a generalist when a specialist is more qualified and is more likely to find that routine-mimicking life threatening catastrophe?

        • Hospice and Palliative Care Doctor

          Dear e-patient,

          I’ve read your comments before on other articles here on So, yes, I’m aware how useless you feel primary care is. The ENTIRE western civilization medical communities (that means the US, Canada, Europe, Japan, Australia etc) DISAGREES with you, but you are more than welcome to your incongruent-opinion-with-the-rest-of-the-modern-world.

          But I wanted to answer what I thought was actually an excellent question you posed:
          “And if the most knowledgeable provider is preferable, why see a generalist when a specialist is more qualified and is more likely to find that routine-mimicking life threatening catastrophe?”
          Yes, I already know you will disagree, but here goes: a specialist isn’t looking at the big picture, which in this case the big picture is you. The specialist focuses on one organ system. Yes, they get more in-depth training in the diagnoses & management of diseases that affect that organ, but if it doesn’t affect that organ, they may not be able to help. This is not meant as a criticism of specialists-they are amazing & essential- but once they get out of their scope of practice, they can’t/wont participate in the management of that patient. In addition, sometimes the specialist is so focused on that organ that s/he won’t consider outside possibilities. It takes someone thinking bout the whole picture, meaning your primary care doctor, to put the big picture together. NP’s & PA’s don’t have enough fund of knowledge to do that (to all you mid-levels who disagree w me you only had 2 years of training while I had 7 so please dont try to say you can equal me cuz it’s not logically possible).

          “routine-mimicking life threatening catastrophe (s)” are rare, but the primary care doc is trained to work thru that & refer appropriately. Mid-levels don’t know enough to accomplish that tricky balance. For example: I may treat 19 hypertension cases, all quite well, but then I get to #20 & s/he is so complex it’s better for a specialist.

          So primary care can manage most diseases (and I’m not talking about vaccines, cuts & scrapes, and colds- I mean the real stuff like CHF, HTN, DM) but the real sick stuff goes to a specialist.

          • e-patient

            Just to clarify, I believe that a primary care could be a wonderful resourse, as evidenced in other countries you site. I even would support a health care system like those countries you site. We have considered moving to Canada partly because of the health care we recieve in the United States. Here comes the socialist comments and how horrible government run health care is.

            The AAFP has endorsed a model of care where family physicians are just coordinators of a medical team-triage as you put it.

            The primary care I have received in the US has not been stellar. I continually see articles on how to be good patient, bringing in only one complaint at a time, not expecting over 15 minutes because my insurance doesn’t pay enough. Most of the primary care physicians in my area employ nurse practitioners that you consider so unqualified. I am good patient. I take only 15 minutes. I bring only one issue at a time. I take my medicine as prescribed. I see the nurse practitioner for my urgent needs. I am careful not be be harmed again by this situation.

            I have never been treated like a whole person in primary care. It takes too much time to discuss how all my medical issues intersect. I took my routine-mimicking non life threatening catastrophe to a specialist. He took care of me…the whole me, not just that one symptom that fell into his specialty. That should have been my PCP’s job but she couldn’t keep up.

            My routine-mimicking life threatening catastrophe was referred (by my doctor) to a specialist. My PCP now handles my medication. If something goes wrong, back to the specialist. A nurse practitioner could handle this just fine.

            “I mean the real stuff like CHF, HTN, DM”

            I find that primary care has become the specialtly of the lifestyle diseases. Every example include a diabetic.

        • Mark

          Let’s just point out the obvious, which you apparently missed…. It’s not the doctor’s responsibility to figure out what’s wrong with you before he even sees you, and if you have an emergency it’s your responsibility, not his or his receptionist’s, to either ask for an earlier appointment or go to an ER. Do you realize that primary care doctors are actually doctors? They went to medical school? Passed tests? Completed a residency? Have to maintain board certification? Is it such as stretch to contemplate that at least some of them are able to treat a disease or condition at least some of the time, without spending 100% of all working hours making referrals to other doctors? Again, you seem to be letting whatever happened to you overwhelm any sense of logic or reason.

          • e-patient

            “if you have an emergency it’s your responsibility…”

            It’s my responsibility to know the difference between a routine condition and and routine-mimicking life threatening catastrophe. It’s my responsibility to know the advice my doctor who went to medcial school, passed tests, completed a residency has misdiagnosed me. If this is all my responsiblity, why do I need to see a doctor?

            Anyway, your point that care cannot effectively be provided by a nurse practitioner. If it is my responsibility to make sure I get the care I need, does it really matter who I see?

  • JustADoc

    The more you write the more obvious it is that you don’t have a clue what an internist or FP does. Nor do you understand how fee-for-service medicine works.

    The PCP you denigerate so much isn’t in office removing warts except as a welcome reprieve. But he isn’t managing chemo regimens either. Your strawmen are getting old.

    And in fee-for-service the PA/NP charge for wart removal is the same as the PCPs(as long as incident to) and therefore saves the system no money at all.

    And as you just said, if you don’t know then refer it out. A FM/IM is far more likely to know than a PA/NP and therefore less likely to add cost by unnecessary referrals.

  • Hospice and Palliative Care Doctor

    “Actually, what is really scary is the thought of having a PCP treating glaucoma or a PCP treating an out of control diabetes condition or a PCP treating cancer”.
    You argue poorly, don’t understand when things are explained to you even by several people, & attribute to others arguments they never claimed. PCP’s DO NOT treat cancer. Where are you coming from?

    ” Meanwhile, because we have highly trained doctors removing warts and drawing blood and delivering flu shots, work that an NP could easily do, consumers pay more.”
    Uh, my medical assistant draws blood & gives the flu shots. So I’ve solved the problem: get rid of the NP. See, consumers are paying even less.

    “We need to stop rewarding fee-for-service volume and start rewarding wellness and outcomes. Wellness and good outcomes equals value for the consumer…The hand writing is on the wall. Get use to it. Health care is moving in a different direction. Fee-for-service medicine is ending soon. ACOs will be the model for the future.”
    Yes, healthcare is changing, but the players are not. Doctors will still be the best ones to provide primary care, NPs don’t know enough.

  • Family Medicine Doctor

    The disparity between american medical school graduates more likely to go into specialty care rather than primary care will continue. There is nothing to suggest in Obamacare or any other idea that might, or might not come down will address the difference in pay. The medical community has been discussing for decades that the pay needs to increase for primary care, but nothing has changed. Why do you think that will change now?

    As a capitalist, I’m therefore against increasing primary care residency slots. It’s the simple laws of demand. If there are less of us primary care docs, our value increases & therefore so does the salary we can negotiate. You think I’m a selfish bourgeois capitalistic pig? Maybe I am, but if we DONT increase the number of primary care residency slots, and primary care pay then increases, & more docs go into primary care, you would like that, wouldn’t you?

    Sure, I may be a pig, but in my scenario everyone access to a primary care physician. We both win.

    • e-patient

      I predict in the capitalist model, most primary care will be handled by nurse practitioners or physicians assistants. Consumers won’t have “their doctor” but a home clinic with their medical record staffed my mid-levels. Insurance companies will save money by pricing geared toward care provided by nurse practitioners. As more people chose high deductible insurance plans, there will be more demand for the cheaper services of nurse practitioners. Fewer medical students will chose primary care because of falling reimbursements and loss of prestige. Family medicine will disappear as a specialty for physicians. Those that remain in primary care will cater to the elite with concierge practices. Salaries will go up for these physicians.

      It’s funny how the “socialist” health care model is held up as a shining beacon for primary care.

      • Solomd

        E-patient may have many correct points in the above posting, but in gleefully predicting the demise of primary care physicians, he/she may not fully understand the inevitable sequence of unintended effects that follow government intervention. The future of primary care may easily be as follows: patients, once used to seeing one person in whom they had gradually learned to trust with sensitive or complex medical conditions now find themselves assigned to an ACO clinic in which they see a different provider (MD, DO, NP, PA, witch doctor) every time. No one is familar with the patient’s history, so the patient spends a lot of time repeating his/her history and reminding the provider that a certain medicine can’t be taken because of GI side effects. The provider doesn’t notice the notation about the GI side effects in the government-approved electronic chart because most of his/her attention is focused on making sure that the checkboxes are clicked for the patient being screened for depression, wearing a seatbelt, not being a victim of domestic abuse, having had a pap smear in the past year, and brushing teeth three times a day. Because of the tremendous increase in patients getting onto the government’s healthcare insurance plan (Medicaid expansion), of which the ACO is obligated to cover, the provider has to cut short any get-to-know-you chit chat or the famed patient education that the NPs and PAs are so well known for. Also, the NP/PAs are noted to be less cheerful and outgoing after being told by their employer that they must again spend even less time with their clients (I mean patients) because of the government again cutting payment for their services. The NPs and PAs are grumpy and feeling betrayed because even though they were welcomed with open arms by the government and told that they would be appreciated and respected as full and complete healthcare professionals, they have found that the initial feel-good pep talk has worn off with the almost regular announcements of payment cuts and an overwhelming increase in government red tape. As a result, many NPs and PAs consider alternative employment opportunities, especially after learning about a recent government-funded pilot project in which community college students coupled with super computers were shown to provide superior and cost-effective outpatient healthcare.

      • Family Medicine Doctor

        “Insurance companies will save money by pricing geared toward care provided by nurse practitioners. ”

        No, actually, mid-level providers cost the insurance companies MORE money cuz they refer to specialists much more than board certified Family Physicians or Primary Care Internists. The mid-level NP & PA will also miss some diseases, misdiagnosis, & wrongly treat more often than the primary care physician. Don’t believe me? Just read: I had 4 years of a long medical school experience followed by a grueling 3 yr residency program- count this now, SEVEN years. A mid-level has only TWO years. They will miss alot more & ultimately cost the system alot more cuz their training is so much less. Most people intuitively know this.

        No, your idea won’t work. But BTW, may I ask, and I really wanna know, & with utter respect: how do you arrive at such ideas? Do you work in healthcare? Do you have advanced degree in public health? It just doesn’t seem like you have enough experience to know very well where health care is going to have such a strong opinion. I could be wrong. Please let me know.

        Warmest regards

        • e-patient

          It’s not my idea, nor do I am I advocating for this model of care. It’s what I am experiencing right now.

          Most doctor’s in my area work with nurse practitioners already. Payment for primary care is inadequate to satisfy primary care physicians. There are forces in place promoting the nurse practitioner model, including the AAFP with their medical home. While my parents might insist on a doctor, my kids have grown up in a medical system where they see a nurse practitioner for many medical issues. My kids have no childhood memories of a doctor/patient relationship. There are primary care shortages already in certain areas and prices aren’t going up for primary care. The electorate is unwilling to put more money in Medicare and specialist aren’t willing to give up their piece of the pie. Insurance executives want to maximize their profits. There are those that want patients to have high deductible insurance plans, encouraging patients to find the cheapest care-ie nurse practitioners. Nurse practitioners already practice independently in many states.

          My chronic conditions can be managed by a specialist for the same price as a family physician so why does it really matter if the nurse practitioner refers out more often? I have seen studies comparing the care by nurse practitioners to physicians and patients are more satisfied and the outcomes are comparable.

          I understand that doctors are highly trained. I wish I had a doctor that I could call when things go wrong. I wish I had a doctor that knew all my quirks and could base my treatment on what is best for me. I don’t. What I have is a medical home where I can see a nurse practitioner that I barely know when things go wrong. There is no glee here. I have already been harmed by this model. I am an e-patient because I don’t want to be harmed again. I am the only one familiar with my medical history.

        • e-patient

          “Just read: I had 4 years of a long medical school experience followed by a grueling 3 yr residency program- count this now, SEVEN years. A mid-level has only TWO years. They will miss alot more & ultimately cost the system alot more cuz their training is so much less. Most people intuitively know this.”

          Do you have scientific studies to back this up? Intuitlivey, it doesn’t matter that you know how to deliver a baby when you are stitching up my knee.

  • http://deleted pcp


    You make some excellent points. The AAFP, with its promotion of the administrator-centered medical home, is gleefully encouraging its members to commit professional suicide. Pathetic.

    • e-patient

      I am sorry.

    • ninguem

      pcp – “Administrator-centered medical home”.

      I like that. You’ve captured the very essence of the concept.

      Can I use the phrase? I’ll put it to good use. Where do I send the royalty checks?

  • Shahab

    The Bottom Line in my opinion is MONEY.

    In UK more Doctors go into Primary Care then any other specialty and the reason for this is that (in most cases) Primary Care pays the same as a Specialist or Hospitalist – with a few exceptions of course. If the pay for both choices is the same then this gives the Graduate more freedom to pursue whatever their heart contents.

    Until this is changed in USA, Graduate will always wish to pursue a career where there is more money and rightly so – they have spent years of hard work, time and money getting to where they are.

  • JustADoc

    Actually removing the wart pays much better than treating multiple acute exacerbations of multiple chronic illnesses.

  • e-patient

    It’s cheaper for a team to remove a wart?

    We can add ACO’s to the nurse practitioner model. The team will make more money if nurse practitioners do most of the work while doctors coordinate…kind of like the hospital setting.

    • Family Medicine Doctor

      Dear Danny,

      Just wondering. Not questioning your credentials or knowledge base, but with respect, what are your credentials? Or experience in the healthcare field? Are you a doctor? An advanced degree in Public Health? Really, I’m curious.


  • Angela Caffaratti, MD

    I find it hard to believe agar nurses and physician assistants will want to pursue primary care that isn’t well-rewarded or properly staffed. How exactly are they different from medical students? Anesthesiologists make many times over more money and work much less than family doctors just as the same as nurse anesthetists make many times over more money and work much less than family nurse practitioners.

    • e-patient

      Why would anyone ever chose to be a nurse? Or a social worker? Or a teacher? Or a minister?

  • pcp

    “When wellness and good outcomes become the object of rewards, consumers will be valued”

    And who will value the chronically ill and unhealthy?

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