Primary care doctors may no longer be needed

As a primary care doctor, my days are busy. Seeing patient after patient, I try to provide the most patient-centric, evidence based care that I can. But if I read anything about healthcare reform, it will tell me that 80-85% of the patients I see can be seen by a nurse practitioner or a physician’s assistant. So why did I train for an extra 3-4 years as a doctor, incur several hundred thousand dollars in debt, and go through years of residency training to do the same work as someone who has done a fraction of this?

With this as a background, is it any surprise that an article in the December 5th edition of the Journal of the American Medical Association reported that among internal medicine residents, those with career plans in general internal medicine were markedly less common than those with subspecialty career plans?

The term “general internal medicine” may not mean much to those not in healthcare, but these are the doctors who comprise many of this nation’s hospital-based general medicine doctors and primary care doctors. Hospitalist medicine has been at the very forefront medical industry growth for the past several years; primary care, also made up of pediatricians and family physicians, has not. It is not a stretch of the imagination, then, to assume that most of the residents going into general internal medicine will not go into primary care. Study after study supports this.

There are still physicians that go into general internal medicine and choose primary care though. I am one of them. But there are days where I wonder if I would make that choice again. Here’s a big reason why that has not received much attention: I don’t really know if I am needed.

What? A primary care doctor not needed? Whatever do you mean? Let me explain: the Affordable Care Act  is already changing medicine – patient centered medical homes, team based care, care coordination, and value based purchasing are becoming the norm. And all of this is great. It will likely improve care, and may even improve primary care provider satisfaction. So where is the general internal medicine physician in all this? The same place we are now.

If nurse practitioners and physician assistants can see 80-85% of the patients I see, and require only 4 or 5 years of post-graduate training – and not the 7 or 8 that most primary care physicians receive – then we need to develop systems that select the 15-20% of patients that need a physician. As one organization, the American Academy of Family Physicians, which has a huge percentage of its doctors serving in primary care roles, has recently reported, the educational and training differences among these groups of providers profound: nurse practitioners complete 2,300 – 5,350 hours of education and clinical training during five to seven years, compared to physicians’ standardized path of 21,700 hours over 11-12 years.

There are several validated methods that have been used to classify patients as “medically complex” based on diagnoses and combinations of conditions, such as the one using “adjusted clinical groups” developed at Johns Hopkins. These systems should be more broadly employed to preferentially siphon the more complex to those providers with increased training. It would have the potential to provide more efficient care and also provide a more thoughtful, appropriate distribution of limited resources.

I work with several nurse practitioners and physician assistants, and they all do a great job, but in no other industry would three groups with very different levels of training and expertise be asked to provide the same level or service and adhere to the same professional standards. There are some areas in the country where there are no choices, and NPs and PAs must work independently. And I realize that we as physicians do not get fairly reimbursed for providing complex versus non-complex care. But this does not mean the whole situation is appropriate.

In places where there is a mix of PAs, NPs and MDs, their job responsibilities, descriptions and levels of care should reflect the 6, 7 and 11 or more years of training they have had. Not doing this is a systems failure with broad implications for patient and provider satisfaction, healthcare spending, access to care, and healthcare reform. It also just doesn’t make much common sense.

Doug Olson is a primary care physician.  He can be reached on Twitter @doctorolson.

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  • Yvonne

    The dumbing down of medicine!!!

    • ProudOkie

      Hi Yvonne,
      I take umbrage with your statement – assuming you are referring to providers who are not physician health care providers. You have the right to make your blanket statement and to obtain health care from a physician health care professional. I am sure you will continue to do both. There are plenty of customers in my clinic so we won’t miss you too much.

      • Rm

        Would this be one of the pharmacy affiliated clinics where every person with a sore throat walks out with an antibiotic, decongestant, nasal spray, cough suppressant and narcotic syrup prescription ?

        • Suzi Q 38

          Not really. I think that many PA’s and NP’s know the perils of prophylactic antibiotic overuse. I have known doctors that have prescribed antibiotics a bit too often as well.

          The NP debate will be alive and well in California.
          I am not sure about the other states.
          At first business will be patient driven.
          Patients will choose. When given the choice, I think that they will choose the doctor.

          When the health changes come through and there are not enough doctors to see all of the patients, the NP’s and PA’s will gladly assist.

          • ProudOkie

            Suzi, from first hand experience, I KNOW – given the choice and full disclosure, patients will NOT always pick the physician. I live this daily in real life, real time. Customers want competency, kindness, and service – in that order. It may be a hard reality for family physicians, but it is reality. Who would want to admit it?

          • Suzi Q 38

            I believe it. I am only speaking for myself.
            There are patients that get really good NP’s and PA’s, so they are content.
            I feel differently.
            I “triage” myself. If it is an simple ailment, I agree that a PA or NP is fine.
            If I am not doing very well and my condition is more complex, I will ask to see my doctor.

            I don’t view the NP pr PA as a total replacement for my physicians….I view them as part of my health care choice.

          • ProudOkie

            I completely understand! I definitely have no qualms with how anyone chooses to maneuver through their health issues. The best of luck to you! Thanks for the great posts!

          • Kristy Sokoloski

            Proud Okie, I have spent time being a patient as well and there have been times that I can’t get in with my doctor. If I can’t get in with my doctor then I will go with one of the PAs at that time. But the rest of the time I will be picking my personal physician to take care of my medical needs.

          • ProudOkie

            Excellent!! Who could argue with you going where you choose in a free market! I get your point though – “I’ll see an NP or PA in a pinch but my physician is who I always prefer”. Many many other feel differently – that is okay right? If they choose to see me for their primary? Is there a problem with that?

          • Suzi Q 38

            I have met some really good P.A.’s.
            My neurosurgeon employs one, instead of a nurse.
            My dermatologist employs 2 P.A.’s, one really thorough, and one just so-so.
            If it is complicated, I ask to see the doctor.

          • Kristy Sokoloski

            Proud Okie, No, there is not a problem if someone chose to see you as their Primary Care Provider, but I have a question for you. How much training do you as an NP get during your schooling in dealing with patients that have chronic health problems? Some people like some of my friends have multiple chronic health problems and those chronic health problems can change very quickly when it comes to the stability factor. One area that I can think of where this is especially the case is chronic pain itself. It needs constant management, and especially by someone in Pain Management.

        • ProudOkie

          Ahhhhh……I wait for posts like this one. No it would be a privately financed (by me), privately NP owned clinic, seeing 30 patients per day of all sizes and shapes. The true American dream and the free market at work. Awaiting your next snide, useless, meaningless post. Carry on.

      • hansi

        ProudOkie, which statement do you take umbrage with? “all of this promotion of midlevels to do the bulk of the medical work is being pushed w/o adequate science to back it up…” or “historical experience in nearly all professions teach the best trained and skilled do the better job?” they seem to ring true.

        as you noted in the article, multiple providers (PA, NP, MD/DO) often have the same description of responsibilities. yeah, there are some amazingly talented PA’s and NP’s, and some docs that are much less so. but to suggest PA’s and NP’s can replace most of what docs do is going a bit far.

        mostly because it might be not true if there’s something wrong. management of a clinical problem is one thing, but the differential diagnosis/workup may differ in important ways between layers of training. that’s not saying one’s better than another, it’s just different. medical complexity cannot be decided with an algorithm. that’s where the art of medicine is vital.

        • ProudOkie

          Oh good grief here we go again…..
          “all of this promotion of midlevels to do the bulk of the medical work is being pushed w/o adequate science to back it up…” Thankfully, the “art of medicine” is not relegated to medical school. Please stop thinking that I am a robot following a set of guidelines with no inherent ability to deviate from those instructions. I deviate just as often and with the same “art” that the family practice generalist physicians do. Thank you for the good discussion.

    • Terry

      Exactly. As a physician I will continue to seek out ONLY other physicians for myself and family. If the layperson thinks the midlevel can provide the same care as me then they are more than welcome to go to them for care. I do not and never will employ a midlevel. Unless of course they ALL practice independently and are not riding on the coat tails of an MD when they screw up. Actually, I still wouldn’t hire one. I feel bad for my hospital employed colleagues who are forced to supervise and inevitably get thrown under the bus when the midlevel gets in over her head and screws up.

      • ProudOkie

        As I said, a physician’s concern about primary care turns into an NP bashing forum. Shame on you. I carry my own liability insurance – no coat tails, sorry. Try talking about the subject at hand instead of denigrating another profession.

        • nanguneri

          Yes if his database speaks to the claims then we have a gap to address, however, if he starts name calling and denigrating, then whether he is a primary care physician or otherwise, why would somebody visit such a professional who just gets emotional and not stay objective in this forum that is supposedly professional?

      • Sharon Lustro

        There are times when midlevel points out patient problems to the doctor that the doctor chooses not to act on. When the patient crashes, then sues the nurse, the doctor says…”She never called me and told me that the patient needed a transfusion.” Instead, he threw her under the bus. My point is that doctors and nurses are humans and both have the ability to “screw up.”

        • nanguneri

          Indeed, true teamwork results in a higher probability of patent success. In many cases it is “operation success and patient dies”

          How do physicians see non-physicians as non-critical? End of the day one studied it at the university and the other is getting a day-to-day and month-to-month commentary and visual experience, let alone the digital information access. This is why we see operational level folks do very well on the manufacturing line till some PhD comes along and rattles something without any sensitivity to data which is the mantra of the operational teams.

          This is now beginning to happen in the medical field I suppose.

          • Suzi Q 38

            There is room for the nurse practitioner and physician assistant.
            It is the individual states that are determining what is acceptable medical practice.
            Saying that NP’s and PA’s are going to replace GP’s, IM’s, Derms, and peds is a bit over the top.
            I just predict without any data or skill that you are going to see some jobs go to the NP’s and PA’s in an effort to save money and see more patients.

            I mentioned this to my daughter when she got a job at a major hospital. Getting a NP certificate in the state of California would not be a bad idea, especially since health care has passed.
            I acknowledge that she won’t be as skilled or know as much as any board certified physician, but who know’s???
            She may be very good, and therefore good enough to treat the patient in the early stage of a common illness, like a cough, fever, an earache, or the flu…urticaria…..whatever.

          • nanguneri

            No doubt about it and go for it. Kudos to your daughter for making a difference in this economy by cutting down the cost of health care without compromising the effectiveness of patient healing.

          • Rm

            Where’s your data for supporting that care is not affected ? I can understand business managers wanting lowest wage workers but someone with scientific training should realize that years down the road outcomes data may not support statements like the ones you made

          • Suzi Q 38

            LIke what statements? I thought that this was a conversation, not a formal debate to be backed up by solid data. Do you have a specific question about what I have said?

          • Yvonne

            Where I am more and more midlevel practitioners are practicing completely independently or with only superficial supervision. Thus, by your own assertion their patients are being evaluated and managed by a medical professional with only 5300 hours of training rather than an individual with 21,000 hours of training. So then, we are saying to the public you don’t deserve the best trained, we are going to give you the lessor trained (except of course the rich who will always get the better trained)

          • nanguneri

            If the hours of training does matter (let us say they do with all respect), then why do they carry malpractice insurance? Who do pilots get on their set drunk on occasions and cause accidents or increase risk to the passengers and why do they need to be tested for alcohol levels prior to flying out? Let us look at the training records and match the decisions with non-physician professionals and physicians and assess whether there is a statistical difference. If there is one, let us find the gap and determine how we could reduce it if it makes sense. It shouldn’t be based on your word as it then becomes a biased decision coming from your side of it, isn’t it? After all we are saying take the data an analyze without getting into the patient counseling process as of now.
            Your system restricts the number of doctors admitted, doesn’t attract doctors to go to different parts of the country, creates a huge loan and debt for physicians before they graduate and willing to try new drugs with your patients while a sales and marketing professional approaches you (you cover the liability by getting the patient to sign some fine printed paperwork) and then when the cost goes high for having physicians you are not willing to be part of the solution for the problem that you have also created in the first place. How does that work for a society or for a patient who is having an illness without choice?

          • Yvonne


            Do you think you are going to have LESS of the problems that you mentioned with lesser trained individuals? If so, what kind of logic is that based on? I have no problem with doing appropriately designed studies. But all of this promotion of midlevels to do the bulk of the medical work is being pushed w/o adequate science to back it up. Years of historical experience in nearly all professions teach the best trained and skilled do the better job. Yet, w/o adequate data to support the contention you promote unleashing a slew of lesser trained medical professionals to care for the bulk of the American people. It will only back fire. Further, re your comment about drug reps-do you really think lesser trained individuals will be better able to resist the drug reps than fully trained physicians-if you really think so then I want to know what kool-aid you’ve been drinking.

          • nanguneri

            I never said that one would have LESS problems with less trained individuals. I am not sure how you even concluded that Yvonne. I said that the effectiveness of the training has to be validated and there isn’t any database or model available that is transparent enough to support that claim or hypothesis. So please don’t build a case to argue with the wrong assumption. Your question on the drug reps is also redundant and so my response is still the same. The issue is not cost but whether the non primary care physicians can deliver a similar effectiveness for certain type of ailments or situations with patients. Where is the database to prove or disprove it? This has nothing to do with kool-aid drinking although I understand your sarcasm in your response.

          • Yvonne

            Nanguneri- you seem not to realize that malpractice in the US has very little to do with quality of care and a lot to do with poor outcomes capable of generating large payouts.

            The poor outcome need not be due to malpractice. The determination of these torts are by lay jurors who often (if not always) have little experience or background by
            which to determine if malpractice has occurred.

            Are you attempting to suggest that greater training leads to more malpractice? Your comments suggest that either you are a young physician with little experience yet in the real life medical arena or you are not a physician at all.

          • nanguneri

            Yvonne, The malpractice in the US is associated with a high malpractice insurance costs that someone has to cover. This is certainly going to affect the health costs by the provider and he insurance company covering the doctor. The premiums to pay that is going to come from somewhere and so did you think it is being picked from a money-plant city? The poor outcome is also regardless of the malpractice and so I brought that up as a factor in cost and was discussing the issue purely based on cost without any compromise in the effectiveness and efficiency of getting the patient to heal. It is your attempt to suggest that greater training is related to greater malpractice. The question I raised was is greater training necessarily related to a higher effectiveness and efficiency to heal the patient? Instead of addressing those questions and issues you are digressing the conversation to field of expertise.
            If according to you one has to be a Physician to understand the effectiveness and efficiency of a patient healing process, then you are grossly mistaken. Just ask the patient and you will know whether the counsel between Physicians and Non-Physicians have a statistically significant difference or not. They can tell you better regardless of whether I am a Physician or not. If you cannot comprehend this statistical challenge, i am not sure whether your experience or expertise as a physician is valid in this discussion as you cannot discuss a simple hypothesis challenge with data. What will we achieve if we keep name calling and not addressing the point?
            Do I need to be a physician to understand the statistical difference between a Primary Care Physician’s ability to heal a patient as opposed to a non-primarycare physician or can I look at the data and be able to tell. In fact the bio statisticians dealing with drug development and efficacy are all not Physicians, yet you take he drugs as well as FDA approvals and utilize it in your operational areas with the patients signing off the liability as there is always a risk. So why is it that you and I cannot engage in a discussion to estimate the risk in this evaluation between a Primary Care Physician and a non-Primary care physician without getting emotionally attached to our fields or expertise?

          • medicalstudent

            I get the sense that you’re a troll and an idiot. I’m seriously concerned for your patients. Wow!

          • ProudOkie

            Hmmmm……I was thinking the same thing about you. Again, so ironic.

          • Rm

            I think you give drug reps too much credit. We may enjoy the free lunch but we dont write a drug prescription because someone (in the past) gave us a free pen. Stop being sanctimonious.

          • nanguneri

            Hi Rm, I am not giving drug-reps any credit. I am only asking you how the process works as I have seen doctors take free drug samples from drug-reps so that any type of testing in a real hospital can be done only when the doctor and patient agree with the test drug. Again I am not saying that you are prescribing such drugs but quoting that you are with the knowledge and agreement of the patient (who has no other choice in most instances) experimenting these new drugs at no cost of the drug to you from the drug rep. So what tests with what risks have been passed on to the patient assuming the non-drug issues on your hospital environment have no impact on patient healing or drug efficacy? The patient has not much choice and we all sign papers to eliminate the liability for the hospital as well as the physician isn’t it? So there is nothing sanctimonious about it other than you not addressing the issue I am bringing up.

          • Suzi Q 38

            Drug reps are not allowed to do a whole lot anymore.
            There are rules.

          • nanguneri

            The length of training hours may or may not be linearly correlated with the effectiveness and efficiency of the physician or non-physician when it comes to healing the patient. By that same token length of studying should be directly correlated with success in the examinations, and level of educational qualifications should be directly correlated to ability to solve or lead in solving problems in a given field and so on. Not necessarily so isn’t it? If training were a pure measure of being effective in the field with a real patient, why then do doctors carry such high malpractice insurance in the US? One of the root causes for high costs of health care I suppose.

          • Steven Reznick

            I practice primary care for 34 years now and do not feel particularly threatened by experienced and well trained nurse practitioners or physician assistants displacing me . Sharp caring practitioners are always a pleasure and privilege to work with. I am a bit concerned about new non physician practitioners with little or no clinical experience other than the 4500 ” clinically supervised ” hours they receive prior to being able to open a practice with no supervision in my state. That 4500 includes ” shadowing” existing practitioners without always having to make a decision or use judgement that is questioned and challenged by more learned and experienced practitioners regularly. I am also concerned about the move to cut medical school to three years and cut years off of post medical school residency training to cut the cost of their education and the amount of money we subsequently have to pay them. Medicine has more data and technology than ever before so creating an army of lesser and more narrowly trained docs and blurring the difference between them and NP’s does nothing but cost less.

            As for why a personal doc is a good idea. When I suggest an orthopedic surgeon for my patient’s problem I usually have spoken to other orthopedic surgeons in my community and ask them who they would go to if they had this problem and why? I usually speak to the OR nurses or recovery room nurses or surgical ICU nurses about who they would use for a problem and why? Then I try to talk to the individual about the problem and try to make sure they are a people person who can communicate and empathize with a non medical patient. When I attend a national conference and hear the leaders in a particular field, the people who teach us doctors how to treat diseases, I like to hear their responses and see their behavior in the question and answer sessions. If I can, I approach them after the lecture and meet them to judge their people skills before I will send them a patient. Its called personalizing your care. Most of my primary care doctors do the same thing for their patients . This is the data that is not on line and not registered with the state or federal government or insurance company data bases. It is the human side of the profession and only one example of why a well versed and educated non medical individual does better having a doctor who knows them and works with them.

          • Suzi Q 38

            It is nice that you know all of the specialists.
            My problem was beyond the local doctors and specialists.
            My Internal Medicine doctor had no clue, as my symptoms
            were severe and escalating.
            I needed a neurosurgeon, a neuroradiologist, and an M.S. neuro.
            I had to decide for myself who was good, based on credentials, experience, teaching hospital, and how I felt during our visit.
            Clearly, in my case, I know to pass up the PA or NP.
            I am the patient, so I get to choose at this point.
            I don’t know what the concern is over these professionals having their “place” in medicine.

          • ProudOkie

            “Clearly, in my case, I know to pass up the PA or NP”
            The free market at work – love this. Bravo!

          • Suzi Q 38

            Yes. There are a lot of sick people out there. Myself included. I will choose what is best.

            I do want to point out that my internal medicine doctor had no idea of what to do next.

            I have had the same Internal Medicine doctor for the last 12 years. He was the one that said that it was probably the result of diabetes….do I want a prescription for Neurontin. Not bad, but his solution did not get to the crux of my problem.

            I finally had to tell HIM what I was going to do next, in order to get to the root of my problem. I wanted his approval, because I needed a referral to get to a teaching hospital that specialized in neurology. Once there, I met both a neurosurgeon and an M.S. neurologist, and had my MRI taken and then evaluated by a neruoradiologist.

            If my internal medicine doctor had no idea about my complex and unusual problem, how would a PA or NP help me at this point?

            As it was, the person that helped me the most was a gastroenterologist, who told me to tell my neurologist that the problem was in my C-spine.
            I loved it, a doctor willing to call out another doctor on his error for the good of the patient.

            I believe in the free market, so I think that there is a “place” for NP’s and PA’s.
            For example, I couldn’t see my famous M.S. neuro for 2 months. I was told that he was totally booked up.
            I called about 3 times, just to check to see if he had a cancellation. My symptoms were bothersome, but not at a crisis point. I was told that if I physically declined further, to go to the teaching hospital ER.

            Anyway, an NP or PA trained by him would have been helpful. I could have gotten to see the N.P. while I was waiting to see the specialist. He or she could have written me a prescription for pain medication, told me to put ice on my right leg at night, and given me instructions for exercise.

            I would never had viewed the N.P.’s help as a replacement for the complex expertise of my M.S. Specialist. I would have felt the same about my Internal Medicine doctor.

            Again, I think that there are many different ways that the NP’s and PA’s can exist and work in our rather large world of patient care.

          • ProudOkie

            Believe me Suzi – if you came to my clinic, it would not have taken 12 years to get you to neuro. And Neurontin would not have been first line for you. You underestimate the understanding of a seasoned clinician in spite of their credentials.

          • Suzi Q 38

            Hi proudokie,

            I hope you didn’t misunderstand me.

            I didn’t wait for 12 years to see a neuro. I had already seen 2 other neurologists. I wanted to see a certain famous neuro that was the chair of neurology, specializing in M.S., at the local teaching hospital in a rather large, metro city.

            I didnot want a surgeon operating on my spinal stenosis and it turn out instead to be M.S.

            I did not feel that the neuros, who cleared me for my surgery by ruling out M.S. were as skilled as an M.S. specialist at a teaching hospital.

            I even knew the wife of the CEO, LOL.
            He could not even get me in sooner, although I did not beg for him to try too hard. Ethics…….

            I imagine that if I had seen an NP or PA in the initial stages of my condition, I may have gotten luck with some direction to take as far as navigating my future care. My symptoms were new and scary.

            Like I said, my internal Medicine doctor knew he was in over his head early on, but did not want to lose me as a patient.
            I explained that I will be back. I don’t want to be seen by specialists for the rest of my life.

          • nanguneri

            Indeed Dr. Reznick,

            The fact that there is lack of availability of data and NOT lack of data is causing this problem where one has to rely on judgement and feelings. Given that you yourself admitted that there are vast GBs of data available it would not be difficult to put together a database and a simple model to show effectiveness and efficiency of the patient healing process by disease or infection or issues by doctor, by medical degree university attended and even by gender plus hospital that they are associated and many other factors that one can slice and dice. However, are the primary care physicians who hold ownership of this information even going to accept this challenge and allow themselves to be characterized by a probabilistic model? It takes a lot of salt to batter up to that kind of curve ball. However, regardless of cost, the patient wants to know the probability of his healing based on primary care physicians alone and even without bringing the topic of Non-Primary Care Physicians there isn’t any model out there. Just like how many engineers who were professional certified built structures that failed due to poor design or commissioning or whatever are willing to come forward to be associated with the results we find and trace back? Similarly in the medicine field most of the primary care physicians are not going to even subject themselves to such a characterization let alone to allowing non-primarycare physicians to delve into their profession. It is about power, wealth, and control. Even if you take the three year and the traditional medical degree program, where is the model to show that they do require a program of this content and length? Someone came up with a program of a certain sort and we all now have to follow this grandfather rule of what was said and done centuries ago and are unable to question the validity of such models int he education program. Such is the state and the people suffering are those who have to go into debt or sacrifice their dreams if they wanted to go through this program and simply cannot afford it no matter how qualified they are.

          • ProudOkie

            For an honest post and a reality check, read Dr. Reznick’s post.

          • Kristy Sokoloski

            Dr. Reznick, I was glad to see that you addressed the issue of cutting back on the number of years that one goes to Medical School. I just recently read something about this through an article in the New York Times. When I read it I couldn’t help but cringe. I know in other parts of the world some go to Medical School for 6 years total. And then others are 4 like here.

            As for the reason to have a personal physician you make some excellent points, and was glad to see how you go about choosing a specialist to help your patient. However, what happens if the doctor that you want the patient to go to is not the insurance plan the patient has? Also, could you please tell a bit more about what exactly goes in to coordination of care for a patient such as one with multiple medical conditions, especially chronic ones? The more information I have to take back to this lady that I had the discussion with about Primary Care if it comes up again the better.

          • medicalstudent

            Please. The length of training is DIRECTLY correlated to efficiency and quality of care provided. To suggest otherwise is ridiculously misleading.

            As a 4th year medical student, I’ve had more classroom hours of training in actual science (not “fluffy” classes like nursing theory) AND I’ve had more clinical hours of training than ANY NP or DNP program in the US offers. Third year alone, I’ve had nearly 4000 clinical hours of training. That’s without taking into account any of clinical training over the last 6 months (easily another thousand or two). I don’t see why I’m not allowed to practice independently, but these newly graduated midlevels are allowed to do so. My H&Ps are better and more thorough, my knowledge-based is many times superior to that of nursing midlevels, I generate better and stronger differentials than the NPs I work with do. So, why can’t I practice completely independently?!

            If you truly believe the BS that you spout, you should be lobbying for giving medical students full independent rights! I bet they’ll be even cheaper than midlevels are. Plus, you get a better-trained individual! It’s a win-win for the general public.

          • ProudOkie

            I enjoy all of your posts medstudent. All of the time you spend as an all knowing medical student lowering yourself to argue with such a dumb ignorant NP like myself brings a smile to my face. Ready for this? You couldn’t hang with me in my privately owned clinic. And your H&Ps? No one cares about them and how much better they are than a lowly serf of a sham provider like me. It’s ironic that you must even tout to the whole world that your brain is singlehandedly much smarter than my whole profession combined. You don’t even know what you don’t know yet. All of your seasoned MD/DO colleagues on the site can easily see you have years ahead of you to learn to control yourself. You kind of remind me of the piece of cheese on the Cheese Nips commercial. It’ll come for you – it’ll come. Please keep it up. It’s almost embarrassing for you. I was wondering when you would show back up.

          • DixieAngel_76

            I have to disagree with your accusation of nursing theory classes as being “fluffy”, they’re not. Ask anyone who has taken them. No one in their right mind would suppose that they accomplish the same purpose as the medical studies that MDs must take, but then again, there do seem to be a whole lot of doctors these days who think nurses are expendable (look at the rising use of MAs in their offices instead of nurses) so maybe that’s where you’re coming from. At any rate, I feel that neither are expendable, and both are necessary if there is to be a balanced and well rounded approach to healthcare, and better success at treating patients. Finally, my guess as to why you can’t practice independantly is the same reason that we nurses are not paid for our work when doing clinical rotations in nursing college; we’re students for a reason.

          • DixieAngel_76

            One can’t ignore the prevalence of attorneys either, or their tendency to litigate for the smallest of reasons.

        • cyu

          This only happens in movies and on TV. 99% of the time the midlevel is wrong or inexperienced and the suggestion as you say, is incorrect. The midlevel is usually guessing or going with something they’ve seen before, and not justified by the evidence based research. I’m not trying to bash any nonphysician professionals, only stating my experience with them., that 99% of the time when they disagree with the physicians they are wrong.

          And by the way, throwing the nurse under the bus doesn’t work in a courtroom. You see, the buck stops with the doctor, no one else

          • Lata Potturi Schaedler

            I have to agree here based on my own personal experiences. Every recent interaction I’ve had with a midlevel (either when I was the patient or one of my children was the patient) the midlevel suggested a diagnosis and therapy that was wrong. One suggested an additional, unnecessary surgery for my child! That’s scary and unacceptable. I work with many intelligent, capable midlevels that are supervised by physicians. However, I personally will not be seeing them as a patient.

          • DixieAngel_76

            I don’t have much faith in them either. I’m sure there are many examples of good and competent midlevel professionals, but the two experiences I’ve had with two different ones left me feeling more than disappointed, I was actually insulted by the second one as she looked down her nose at me and in the rudest and most condescending tone she possibly could, she shook her head and asked me “what makes you think you have diabetes”? I guess that having pointed out to her my fasting blood glucose level of 235 wasn’t enough for her. Finally, she grudgingly had an MA give me a blood glucose test, and a urine stick test. She actually told me that my glucose level was “only” 175, and so that “proved” I was wrong (no matter that I had yet to eat all day, due to anxiety over my fasting glucose test, and that I “couldn’t possibly be diabetic, because there was no protein in my urine”. Maybe one of you doctors can clarify that for me, because I never knew that ALL diabetic patients had protein in their urine. Does EVERY patient present with EVERY symptom? She dismissed my complaint of having to get up at least three times a night to urinate (since when is THAT not something a medical professional should look into)? Like a stern school teacher she demanded to know where I had gotten a glucose testing kit. When I told her that I had purchased it to monitor my glucose level, due to the rampant diabetes in my family, and the fact that over the last five years I have gained about sixty pounds (another issue she failed to adress, or even ask about) she smugly told me that “we can’t have you looking for things”. I never bothered telling her I was a nurse myself, because I got the distinct impression she didn’t really care about my health and well being. Case in point: when I told her that I had asthma, she never ordered an incentive spirometry, tidal capacity, or even a pulse oximetry test. Never ordered any respiratory related laboratory testing, but instead promptly sent me down the hall for an Xray. The next day it was the Xray technician herself who called to inform me that supposedly a doctor had looked at my Xray and decided I couldn’t possibly have asthma because my airways “weren’t constricted”. The NP herself never called, I guess she was too busy and disinterested. She never even listened to my breathing with her stethoscope, though I told her that I usually had wheezes and crackling when breathing. I felt that she didn’t even care, having collected the money for the visit, and the Xray, she just wanted to dismiss me. I know it’s foolish to judge all NPs by the uncaring and arrogant attitude of the last one, and I also know that there are doctors like this as well, but unfortunately for me, I have soured on NPs because of the last two that I’ve seen being like this. Sorry for the long post, I just wanted to give an example for feeling the way I do.

          • Suzi Q 38

            Sorry you had such a bad experience.
            Your NP is not a good one.
            There are good ones out there.
            You have a chronic set of health problems, not suitable to be treated by an NP at this time.
            I had the some of the same problems, and I think the best thing that you could do for yourself is find yourself a really good internal medicine doctor.
            One that can get in your face a bit and tell you that “You are waaay too fat and you need to lose weight.”
            I have hat the same internal med doctor for over 10 years.
            He actually said the above to me. I am quoting him.
            He said it out of caring and desperation. I was just getting way too fat. I weighed 190 pounds.

            After swallowing my pride, and not getting angry with his angry words, I went on a diet and exercise program.
            The exercise program may have made an existing spine problem worse. On the other hand the diet and exercise did wonders.
            I lost 40 pounds, and my fasting blood sugars went down to about 82 most mornings, A1c was about 5.5-6.
            My asthma when I was overweight was a little out of control, I was coughing too much. I needed my little inhaler (albuterol) too many times in a day. They also added a inhaled steroid once a day to help me.
            After I lost the 40 pounds, the asthma went away.
            I have weight 150 for a year and a half, and I have NOT pulled out the little inhaler in the last year or more.

            My daughter is a nurse too, and she says that weighing too much is a huge problem.

            We read about this everywhere.
            I now wear a size 8, so I look a lot different.
            I can’t exercise anymore, but I can control the food that I eat.

          • DixieAngel_76

            Thank you for your thoughtful answer. I realize that I weight too much, it’s a problem I have been trying to get control of for a very long time. Part of it is due to stress, I’m sure. I appreciate your ideas, and congrats on getting your weight down. Happy New Year.

          • Darryl Miller

            I know exactly what you mean. My wife and I have same problem with her doctor and my doctor. My wife has been suffering for 5 years with a problem and her doctor refuses to acknowledge the fact that she has only gotten worse in those five years and refuses to except the fact that my wife’s problem may not be what she thinks it is and refuses to look at anything else.

            I, myself went to a new doctor, told him that I was stressed and my shoulders and neck ached all the time and I had a headache 24 hours a day to one degree or another for years. He instantly put me on antidepressants. After trying “5″ different kinds that did not fix my neck, shoulder and headache problem and only left me lethargic, laying on the couch he was done, even though I bring up my shoulders, neck and the headaches he just ignores me, gave me some kind of stress medication. So long story short. Four years later and my wife and I are only worse than we where when we first started going to “doctors” My wife and I are convinced that our doctors are only concerned with money and could care less about us as patients.

      • nanguneri

        To Dr. Terry,
        The question here is cost and not anything to judge on the effectiveness. So since you have such a large database to tap into, why don’t you just simulate conditions and use mock patients to see where they would arrive at decisions for the same patient issue? Then you have a predicted result and an actual one made by the non Primary Care Physician. You can then look at the residuals and develop a model to minimize the error? By doing this and having them be able to take over certain types of situations to relieve your capacity and cut cost so long as the effectiveness, and efficiency are held intact at the similar statistical levels of significance.

        Now which primary care physician would be against this approach? We have to figure that out.

        • Yvonne

          patients are not the same as real patients and while using mock patients is
          useful in training relying on that kind of information in the real world can
          lead one astray just as relying solely on guidelines without the education and
          skill of the trained physician can lead to poor care.

          The point is that, now, because of “cost” so many are willing to
          excuse the lesser trained as equally capable as trained physicians. It wasn’t
          true before and it is not true now.

          There are ways to address the cost issues in medicine w/o proclaiming by our
          actions and discussions that the lesser trained are adequate to meet the needs
          of the public.

          This same error was occurring in the airline industry when they began to
          require less training of pilots- but many avoidable disaster lead to rethinking
          that erroneous approach. The same kind of disasters due to lack of training and
          experience are occurring in medicine just not on the grand scale but individual
          patient by patient.

          • nanguneri

            Mock patients are being used when you get trained with cadavers. So why is it acceptable to you? When the non-physicians do well with the mock situations (rather than mock patients, which I should have phrased better) then we can expect they would do better in a real world. If they don’t function well with the mock situation then they need additional coaching to get there. Once they pass through the mock situation, then they get exposed to the real situation and yet depend on your counseling and guidance for the patient to receive their counsel approved by you as mentioned all along.
            As for pilots being trained, if the system is ineffective in training, it doesn’t mean training wouldn’t work. By the same token your claim also tells us that trained pilots should never have accidents or trained and certified physicians should never make mistakes int he first place. If that were true, I would ask you humbly if you are willing to give up your malpractice insurance. Apparently not as no sane provider or patient or hospital accept your practice if you didn’t carry this – Am I right?

      • Brett

        I am an Acute Care NP, and I have my own malpractice insurance. The law also states I am as culpable for screw ups as any physician. Considering that, a supervising physician will wipe his/her hands of me as soon as any mistake is made that points in my direction. No one gets thrown under the bus. The one who screws up takes the heat. I would hope that you at least treat “midlevels” as human beings. If you cannot even muster that, it is no wonder people have started to lose respect for physicians. Believe it or not, most of the people you see as patients have less medical training than I do. When they see you treat us as morons, what do you think they believe you think of them?

      • Aaron Furey

        Terry, your arrogance/ignorance is rather frightening. I wish you the best of luck in your solo career.

    • Suzi Q 38

      Medicine is changing.
      Change is difficult.
      I thought we were supposed to have one G.P., and now I can see a gyn/oncologist without getting a referral. Direct. Just like that.
      We have so many different specialists as far as M.D.’s. i don’t even have to drive 50 miles and wait 3 months to get to see one.
      Nurses used to care for the total patient.
      Now we have PCN’s that care and bathe the patients, and the R.N. manage their meds and other care.
      My N.P. (GYN) gets my PAP.
      I had another N.P. that assisted the urologist with a urine test that I needed.
      More change is to come, and the changes will definitely NOT be agreeable to all.

      • Kristy Sokoloski

        Suzi Q, I remember the days well when going to my Gynecologist required me to have a referral. And then about 10 years ago that all changed. I was very glad of that. In the provider directory for my insurance plan they put OB/GYNs under the Primary Care Providers instead of in the specialty section. However, my gyn has wanted to focus more on being the specialist so over the last number of years she hinted that I need to go back to Primary Care for a lot of things. Which I have done including for annual physicals.

    • Suzi Q 38

      Really? I say it is the elevation of medicine with regard to nursing care (N.P.’s).
      Figure out how to work together as it will happen.
      Be prepared for changes…this is just the beginning.

    • Aaron Furey

      Yvonne, your statement seems to assume that EVERY MD graduated top of their class, and not one every barely squeaked by with a C.

  • andymc12342003

    Why is this only applying to time primary care? The Dermatologist office where I go, PAs give roughly 50 % of the care and overall, it seems to work well for them. I would dare say, an experienced PA could Provide competetant care for most office visits in a general dermatologists office. Save the complex cases and diagnostic delimna for the dermatologist, let the PA see the bulk of acne , eczema, tinea, the acute self limited rash, etc..Lets Develop those “methods for classifying complex cases “for derm, cardiology and other specialty offices where PAs already have a role. Lets have a broad based expansion of PAs role, across all specialties, not only in primary care. If it holds such promise for primary care, it must also have some potential to improve patient access and experience in specialty clinics, right?

    • buzzkillersmith

      You’re right. I could go the rest of my career without seeing a cold. But having immediate access (same clinic) to a physician is a good thing. See my post. But I suspect that turning primary care most over to the midlevels will occur first. It’s a learning process.

      And, hey, if the midlevels can do primary care just as well, great. We docs no longer give shots. We’re doing other stuff. Maybe primary care is like immunizations. Time will tell.

    • ProudOkie

      Uh oh……here it comes!

    • ProudOkie

      The issue is not that the PA can provide the competent care. That is already proven. It’s the idea of the PA (NP in my case) having their own bank account and the checks being deposited there. Physicians would NEVER be able to review even a minute amount of cases seen by an employed NP in their clinic. They are too busy peddling their own tricycle! When I need help (and I care for 30 patients a day of every kind in my clinic without issues), I do what a family practice physician does – refer them to a specialty level of care. Healthcare is evolving – some think for better, some think for worse. My customers must think for better as they keep coming back with three LARGE primary care clinics around within a 10 mile radius.
      I don’t know really what else to say to soothe all the anger. There was a need; I have the expertise and knowledge of 20 years as a registered nurse and coupled that with advanced training to fill that need. And it is working well. Now I expect all of the indignant anecdotes to follow this post, but nothing anyone says will change the fact that my customers are well managed and happy. Insurance companies track my care patterns as they do all other providers – no issues.
      I think it is mainly the indignance and attitude that keeps me fighting. For example, I would work side by side with Buzz to provide care any day. We disagree on many issues I suspect but I don’t really care. He is level headed and speaks from street level and not from the clouds. He even uses the term mid-level but I can tell he does it as a convenience and not as a demeaning label. Hope this helps…..looking for some valuable responses – have already heard all the trash talk from on high.
      For the hotheads – usual disclaimers:
      - I know what I don’t know
      - I despise the term “mid-level” which will cause angry posters to use it twice as much

      • andymc12342003

        Okie, The specialist can still be on site. Again, back to the example of my dermatologist office. They have roughly 50% PAs, 50 % MDs in their clinic. This likely could be expanded to ever greater PA %. An experienced PA in derm is already seeing a full clinic. Waiting time to see the MD-3 months, time to see the PA – less than a week. Expanding the PAs role could allow better access and proper supervision for procedures, complex cases quetions with the MD, etc .. could still be maintained. Again, I ask – why is the push for greater PA presence limited to primary care?? In some aspects, a PA may be better suited for a specilaist practice than in a primary care practice ( see the missed skin ca from an PA in a primary care office above). And Dr. Altman, I am afraid this is what medicine is coming to. I deal with medical students daily and the idea of being a ” coordinator of care and a team leader ” has never and will never appeal to med students.

        • Sharon Lustro

          A friend of mine is a pediatrician, and she said that she lost out on a job because the clinic hired a P.A. instead to save money.

  • Dr. Emily Altman

    As a dermatologist, I take care of many patients with complicated medical problems. I usually involve different specialists in the care of such patients. I need excellent primary care physicians to be the center, the ones who hold all the information together, the ones who coordinate and manage the patient. The ones I can turn to for advice. No nurse practitioner or PA can possibly do that. I sincerely hope this is not what medicine is coming to. We need you!

    • Steven M Hall, MD

      Thank you, Emily, I’ve always seen that part of my job as the FP on the team is to be the “hub of the wheel” where all the specialty spokes come together. Thanks for valuing that.

      • Kristy Sokoloski

        Good morning Dr. Hall. I find Dr. Emily’s and your comments to be very interesting. I had a conversation with a lady one time not too long ago about the issue of having a Primary Care Physician. In the course of the conversation I found out that she does not have one. And that she coordinates her own care (others who have posted on this blog in the past have also mentioned that they coordinate their own care). I mentioned to her that she needs to have a Primary Care Physician. Then she asked me a question that I have wondered about myself at times: Why do I need a Primary Care Physician to help me coordinate my care? The reason that she doesn’t have one and prefers to coordinate her own care is because of the things that she values. And then there are others like myself who prefer to coordinate our own care.

        • Docbart

          A good primary care doc will likely do more comprehensive physical exam and testing than subspecialists, and will get to know the patient better than subspecialists. Coordinating one’s care, if there are serious medical issues, requires a level of expertise that the patient does not have. The patient is also not in a good position to judge which specialist can best deal with different problems and who are the best people available in each field. I say all that as a subspecialist who tries to convince all patients to have a primary care doc. If the patient needs hospital admission, and chooses well, their primary doc will care for them in hospital and provide continuity and comfort, rather than abandon them to the care of hospitalists that don’t know them and will not see them after discharge.

          • Kristy Sokoloski

            Docbart, thank you for your response. Could you please give an example of the kind of expertise that would be necessary that a patient does not have? I would like to take this information to her if we discuss this subject again. And on the issue of the not being in a good position to judge which specialist can best deal with the different problems or who is the best available in each field good point. But how would you explain this further to them why this is necessary if they don’t agree with you? The reason I ask this is because she felt like she was in a better position to know what doctors she needed and she turned out to be correct. Hopefully she will understand this better in the future as well if we talk about this again.

          • Docbart

            As an example of knowing which specialist one needs to see: I recently saw a vigorous older man whose legs were giving out. One might assume that there was a problem with his knees, since they buckled. Therefore, one might seek out an orthopedist. A physician would be likelier to suspect a neurologic problem, and refer accordingly.
            Another example was a middle-aged man I saw who was prescribed testosterone, thyroid and supplements after seeing a very slick high-priced practitioner. In fact, his tests showed no need for any of it, but he was duped. He couldn’t see through it, but any good primary care doc would never have referred him there to begin with.
            Doctors are trained to approach problems in a certain way, using a knowledge base that takes a long time to acquire and maintain. Patients don’t have that knowledge base and are mostly not trained diagnosticians.
            Hope this helps explain.

          • Kristy Sokoloski

            Docbart, thank you. It does explain a lot. Hopefully this will help her see why she needs to have a Primary Care Physician. It is amazing just how easy it can be for people to hold on to various ideas no matter what.

          • nanguneri

            So long as your profession allows you to hold all information to an elite group and quote one example here and another one there to just make an argument, yes of course your ideas will look good on paper, while insignificant in statistical form. You can also argue that others on the other side of the fence have ideas to themselves no matter what. This is what your Docbart has done to make us believe by commenting on a forum like this. Are you saying this is how he makes his clinical decisions by just quoting something out of memory? God bless the patient.

          • Doug Olson, MD

            Kristy, docbart: Great discussion and the role for PCPs is clear. Linking optimal primary care provider coordination and knowledge with patient engagement would be the ost cost-effective treatment out there! Forbes called patient engagement “the wonder drug” of our time for this reason. I have so enjoyed this example and your discussion. Thanks!

          • Kristy Sokoloski

            Dr. Olson, thank you also for sharing your thoughts and also this article with all of us. I think there’s a way to make room for everyone so that the patient gets the best care, but I haven’t quite figured out yet just what kind of a solution we need to make this work. I express this also as a Nursing Student. I am going through my General Education classes now but won’t get to the core of the program until the Spring.

          • nanguneri

            The patient is smart enough to judge who is the best and most effective and efficient if they were provided access to such information, database without revealing patient name and just focus on patient situation that was treated or cured. So what exactly do you mean by “a good primary care physician” other than what is mentioned here? Assuming federal regulations are also in compliant here by either the specialist or phsyician.

          • Docbart

            If you think that current metrics can reflect what makes a good “provider”, then go for it and good luck to you. See the PA, NP or whomever you like. Those of us who are experienced in the field wouldn’t pick that for ourselves or our families, by and large, because we have learned from our experiences.

          • nanguneri

            Apparently current metrics is what you professionals go by unless you are telling us that your residing and instant memory pays a role in the primary care physician’s functions. As non-primary care physicians get trained and used to the knowledge so will their ability to depend on their memory as well. Secondly you talk about experiences excepting that we have to trust that claim by your word. Why not have a forum where we can document that find what works well and what needs improvement? Finally, you are also claiming that the best non-Physician is worse than the least experienced physician. Is that true and can it be validated? We are again talking about certain ailments and have provided a cap of protection by having the physician validate the counsel. This is being done to protect the patient and NOT just your own families and friends. In conclusion what exactly is “families” being referred to? Is this what your employer defines as immediate members by law or blood relatives or include friends who are like family? This list can be very confusing as it usually never ends easily. We are referring to a system where the process is efficient and effective regardless of who the patient is and how they are related to you. The methodology shouldn’t be biased just because someone is related to you. By the same token you are claiming that when it comes to traditional practice you are more likely to pay more attention to this “family” you are referring to than anyone else. Is this true?

          • Docbart

            You are putting words in my mouth, and lots of them. I gave examples because Kristy asked for examples. It’s obvious that you have some issues that I won’t resolve for you. In fact, metrics are imposed on professionals by bean counters. If you want to use them as a guide, good luck to you. I try to give good advice when asked, whether to patients or family. I have to go see patients now.

          • nanguneri

            Yes, it wasn’t too difficult to understand that you were trying to give examples to Kristy. However, if you give examples to tilt the discussion your way and not validate the inference with the adequate sample size of examples how would you expect the decision to be non-biased based on a biased sample size of examples? Yes I am putting words in your mouth so that we can challenge ourselves statistically just the way you do when you either validate a new surgical technique or new drug application. What is so different here? This has nothing to with the bean counters and let us engage in a discussion regardless of health care cost reduction and determine that even if there were money to throw away what is the value add of a primary care physician if a non-primary care physician can execute the same statistically with adequate training or access to a database? This is not about good luck to but about the luck ascribed to the patient who has to heal efficiently and effectively. Yes, you have to go see patients now and thus there are other patients waiting in line and cannot even get your attention and when there is a proposal to pilot an effort to test the validity of someone trying to assist you to increase your capacity, you are unwilling to support it even if we state that the final decision and approval is based on what you can see and agree or disagree with data and not just emotionally or personally. So what has this go to with you having to go see patients? Don’t you think that the non-primary care physicians also have things to to do? Why should their time be considered as less important than that of yours? You get the same 24 hrs and 7 days a week as we all do. We are not asking for your advice, but for the information and database you hold that will tell us whether your advice is valid or not in the first place. Instead of releasing the database and teeing up to the challenge you are hiding behind the fact that you want to go see patients. Who doesn’t realize that you have to go see patients. Any person who even doesn’t go to college, let alone bear a medical degree knows that a doctor has to go see patients.

          • Docbart

            My reply meant to tell you that I don’t have the anger or the time to write long screeds like yours. Good luck, hope you work out whatever issues you have. Maybe ask your family doc for a referral.

          • nanguneri

            Hi Dr. Docbart,
            Thanks for the response. Glad you are not angry over this and are looking at things objectively. Second, we don’t have the time to write long screeds as my earlier comments were brief.

            You then started getting into it and so there is no way to explain it in the magical 4 lines as shown above in your short screed. Finally, I don’t have any issues to solve and was supporting the concept in the article discussed on the reducing needs of a primary care physician in the near future. It is you and a few others that have had an issue with this.

            So by writing this short screed above which is either unrelated or directly in conflict with the topics discussed you are creating more work and issues for others. Thus I am not looking to contact a family doctor for a referral for this discussion or direction in this forum.

            Thanks for your positive response though and wishing you the luck in your profession in 2013 and beyond.

          • ProudOkie

            Free market – love it. Many others who are “experienced in the field” feel differently. Physicians would like to see physicians. Makes sense. That provides no relevant information for the rest of the population.

          • Docbart

            Physicians are probably the most informed medical consumers. (I use the best local docs I know for me and my family and friends.) Don’t you think it makes sense to derive some clue from the choices they make for themselves and their family members? No? Then go wherever you like or where your “insurer” sends you and good luck.

        • nanguneri

          Effectiveness, Efficiency and customer patient delight in health, healing, and recovery takes over your preference on any any day anywhere provided these patient needs are not compromised.

          • Kristy Sokoloski

            Excellent points nanguneri. That’s why I had told about what happened to the lady that turned out to be right about her situation. I know some others that have posted on here regularly have made similar comments. That they turned out to be right about their situations as well. Thanks for your input.

          • nanguneri

            Yes and so when one combines all these situations and starts categorizing them into groups that make sense at a micro and macro level, at some point in time. someone with common root cause analysis should be able provide a statistically similar counsel, advice, or treatment for maybe minor situations or major based on the effectiveness of the model and the database. Agreed?

          • Kristy Sokoloski

            I agree with that. Which is why I feel that PAs and NPs are good for helping take care of some situations. I have used PAs in the past to take care of some of those minor situations, and a few of the complex ones as well. I think that there is room for everyone.

          • ProudOkie

            In a nutshell…..

    • ProudOkie

      Hi Emily,
      I do it every single day in my private practice clinic. I “hold all the information together, coordinate care, and manage the patient/customer.” Not sure where you get your data that “no NP can possibly do that.”

      • nanguneri

        To ProudOkie,

        Precisely, and let the physician professionals share the data transparently without the names of patients and just patient demographics and in less than 2-4 weeks one can have professionals like you be able to achieve significant strides in decisions relating to primary care.

        Ms. Emily is getting her data from pure emotions or a database that she is only looking at partially and unwilling to take a holistic view as in a mathematical model.

        “In God We Trust, Everyone Else Brings Data”

    • nanguneri

      To Dr. Emily Altman,

      Think about what the author is stating. There are times when someone other than a doctor can address the needs of the patients if the process is followed on how to diagnose and provide advice, counsel, treatment or next steps. In any case you are going to approve it being there physically or virtually.

      Are you saying there is no such areas where the other professional can (based on your history of advice, counsel, and treatment of course if documented well by the medical professionals) provide on your behalf and be very close to what you can conclude?

      I understand that the medical professionals document their steps very well on a system to be transcribed and if this was made available to other professionals in their field, there is a very good chance to support and be an alternative of course with the primary physician approving it.

      This is not about replacing the Primary Physician, but about increasing the capacity of the latter in a given day and attend to patients who are in a higher state of need where the other professionals would increase the risk or error that the Physician has to now rework.

      We faced the same situation at GE when we kicked off Lean Six Sigma and the principal scientists in the Plastics business refused to let the project leaders into their process information based on some emotional or false sense of job security being eroded away. Later as projects closed regardless of the title or functional role the process excellence skills kicked in and most of us could solve problems in different areas rapidly and with a higher rate of success allowing the scientists to focus on innovative solutions.

      Your first statement itself states it…”I take care of many patients with complicated medical problems” and so when you do this, do you just pull it out of your memory and provide a solution or do you refer to a nicely well put database that others don’t have privy to? Exactly, the ones who all the information together and coordinate and manage the patient. This has nothing to with the medical degree you hold (no offense to your education here Dr.). Yes, no nurse practitioner or PA can possibly do that and this is why they need your final approval so that you can attend to cases where they are pending (hard to even get an appointment easily – got to wait months in some instances) or need attention.

  • Fun Doc

    Tell these PA’s and NP’s to pass USMLE 1,2,3 and the internal medicine board exam, if they don’t have to take it to practice independantly why should physicians.

    • ProudOkie

      I completely agree…..

    • nanguneri

      That is NOT the question here Fun Doc. The question here is what is the linkage between taking the exam and being certified as a Physician and the Effectiveness, Efficiency in the patient healing process? Does it vary significantly if performed by physicians and non-physicians? The hypothesis and claims supported by the non-physicians is that the examination and certification in many instances is non-value-added. You can always go and argue with the board of certification of physicians as to why they need the examination in the first place? Let them defend it.

      The argument of Fun Doc is that when a college degree person performs a certain task based on an examination, it then means that no one else other than such professionals without that examination qualification is qualified to be effective and efficient with similar patients in their healing process. This is already proven to hold no water in many other fields and is growing today.

      If you wish to know why your examination has been set, maybe it has been to weed out to many being interested in doing what you are doing. Just as you have GRE (Graduate Record Examination) scores or even SAT scores to weed out students in their admission process, can you statistically quote that low scores (meaning lower than the cut off point) on such tests indicate poor performance in college? Hopefully you wouldn’t say, it means lower performance.

    • Suzi Q 38

      They don’t have to, because they are not asking to have the initials M.D. after their names. They are working with M.D.’s.

    • Matthew Edwards

      Fun Doc,

      I agree, except PA’s aren’t trying to practice independently, so you either misinformed about our role in the health care system, or you are attacking a straw man.

    • medicalstudent

      DNPs already took a watered-down version of the easiest USMLE exam, Step 3. And 50% of them FAILED!! These were the best DNPs in the country, from Columbia. And 50% of them failed the easiest Step exam that first-year residents take without studying at all and have a 97% pass rate!

      That, right there, tells you how “good” these nursing midlevels are and how well their “training” prepares them.

      • ProudOkie

        Again, as I said earlier, you couldn’t hang with me in my privately owned private practice clinic. Stop with the madness!

  • Steven M Hall, MD

    There is another issue to consider: the depth of care. “Simple” healthcare problems may be the harbinger of deeper issues that take more digging to uncover and treat. The presenting problem may not be the best way to determine what level of provider sees the patient; and symptom-suppressive therapies often just delay the real solutions to the patient’s problems. No healthcare problems exist outside the context of the patient’s entire life. Primary care docs are the best trained to treat within that context.

    • Homeless

      I actually found that primary care doctors don’t look beyond the limited problem. I had several issues going on at the same time and my primary care doctor refused to even consider how each issue interacted with the others and how the sum of them was causing a great deal of distress which eventually lead to suicide ideation. The person that provided the care I needed was a independently practicing nurse practitioner.

      • Steven M Hall, MD

        Homeless, I agree with you. My above comment was edited and further info removed. The main reason docs focus only on one problem is because of the way insurance companies pay for visits. Unfortunately, most docs have given their power to the ins companies and changed the way they practice. The professional response would be for the physicians to tell the ins co’s where to stuff it and still treat patients to the best of their abilities. If the physicians led, the ins co’s would have to follow.

        • Kristy Sokoloski

          Dr. Hall, I have also found that with several of my doctors the reason they tackle one problem is because of time in their busy schedule. I try to make sure that when I am there that if it’s for one problem that I am there just for that one problem. I have had friends and family say to me that I can talk about however many things I have going on with me at each visit. Yes, I could do that at each visit with my Primary Care Physician but I know that even though he spends time with me it takes away from the other patients that need him as well.

    • Suzi Q 38

      I agree with this.
      I was given nerontin for numbness in my hands and feet.
      I refused to take it for the very reasons that you cited.
      I wanted to know WHY my hands and feet were getting numb in the first place.
      I still don’t know why, but after seeing 2 neruologists an M.S. neuro, and two neurosurgeons, my diagnosis is going to be VERY complex.
      Spinal stenosis due to a degenerating spine or M.S.
      Not easy.

      I would not have wanted to rely on an N.P. to deliver a diagnosis, that would be expecting too much.
      On the other hand, my IM told me it was “just diabetes, eat less sugar.”
      My Neuro got a bit closer, at least he ordered an MRI of my L spine.
      It took a gastro to figure it out, how unexpected.
      My point is that you make a good point.
      I say that it is still going to happen….they will be using more and more N.P’s for the first line care.

      Kind of like using a broad spectrum antibiotic for a respiratory infection and feeling certain it will work the first time around.
      Many times it does, with out the diagnostic tool of a culture.

      Many clinicians treat symptoms.
      Many times it solves the problem, bit if it doesn’t the next appointment is with the IM doctor.

  • Brian Stephens MD

    Medicine will get what it pays for.

    my mother in law says, “We are to poor, to buy cheap things.”

    wise words.

  • buzzkillersmith

    Much of what you write is true, doc, but unfortunately much of it is irrelevant. I suspect you know this.

    What matters in the short run? Economic exigencies. The government is freaking out about health care costs, and rightly so. They are casting about for solutions. These folks, mind you, are not experts on health care. Far from it. Most of them are number crunchers. The midlevels say they provide great care and they do earn less than we do. Low hanging fruit to the government. Add to that the fact that med students, no fools, are avoiding primary like the plague, and midlevels start to look pretty darn good. We’d all think the same way if we were in the decision makers’ situation, with their levels of knowledge.

    Of course you know and I know and we all know that saving a few bucks in primary care on the front end might result in paying a lot more on the back end. I say might, not will. But here’s the thing: Any money saved is a drop in the ocean compared with money wasted on inappropriate care. But getting rid of inappropriate care is hard, so what the heck, pointless activity is better than no activity at all.

    We are also to blame. Your post mostly made sense, but look deep into your soul and try to tell yourself that the PCMH is not anything but a scam by the primary care specialties to try something, anything, to pull the fat from the fire. Medical students, no fools, will scoff at the idiotic job description. And once it becomes readily apparent that this white elephant because, would you believe it, seeing more sick people will cost more money, we’ll be on to the next ineffectual fad. Anything to keep from paying enough to induce large numbers of highly intelligent people to provide primary care.

    But at this blog and elsewhere I always like to spread a little sunshine. The long term prognosis for primary care is probably pretty good. Americans are slow learners but are not complete morons, at least given enough time, and will see, perhaps a decade or more from now, that having a robust primary care system headed by physicians is a good thing. Only 4 decades or so later than most western countries.

    • ProudOkie

      Always insightful, level headed….want to work with more physicians like you.

      • buzzkillersmith

        Thanks for the kind words.

    • Margalit Gur-Arie

      I appreciate your understanding of the “number crunchers”, but there is an inherent level of dishonesty in the decisions they make, and they need not be health care experts to realize that.

      The system they are designing is not one that they, their family or their mighty associates will ever use. The system is designed for the “population”, formerly known as masses. And the deafening PR is designed to convince said masses that there is no difference in “quality” between an NP staffed Walmart clinic and a 5th Ave doctor, which makes the NP clinic a greater “value”, and value is what “consumers” are always seeking. Problem solved.
      I do agree with your sunny long term prognosis, but it seems that there will be needles pain, suffering and waste of resources before we get there.

      • buzzkillersmith

        You’re absolutely right.

        When I’m feeling bad about my profession, which is less often than people might think from my posts, I re-read parts of Ray Porter’s “The Greatest Benefit of Mankind.” It is a medical history that remind us (me at least) why we’re in this. We all complain about the costs and hassles and blah blah blah of treating people who will die at 80 of dementia, but that’s a hell of a lot better than having people die at 8 of pneumonia. That’s the signal. Lots of this other stuff is noise.

    • Faxon

      I am not employed in health care.The blog states that NPs and PAs can treat 85% of the cases just as well as a doc. Based on what evidence? Do 85% of the people going to the doc have head colds? My experience, anecdotal as it is, tells me NPs and PAs have no business replacing a good doc. They have never been able to diagnose as accurately as my current internist does, and I do not trust their judgement regarding when to send me to a specialist and when not to.

      As long as I have the money and the insurance, I will not allow a mid-level to take the place of a primary care doc. I am sorry that nurses and PAs have a chip on their shoulder, but no they do not have the level of education and expertise that a doctor does. They have a role assisting doctors, not replacing them. The solution is to pay internist MDs much better than they are now paid, and reimburse some specialists less if necessary. The responders to this blog who think overpaid PCP are a central problem to health-care costs are simply uninformed.

      This entire discussion is just insane to a person my age. When I was young, arrogant tin-god GPs who expected to be obeyed and never questioned seemed to be the problem. Now here I am, a lay-person, defending the absolute importance of GPs and concluding they are not paid enough. Madness.

      • ProudOkie

        Again, free market – stay away from PAs and NPs. Good choice for you.

        • medicalstudent

          If you’re truly in the health care field, you should know that the delivery of care is NOT a free-market. And it should never be an unregulated free-market. The risks of hurting patients in a free market is insanely high. There’s a reason that medical training is so rigorously controlled with checks and balances all over the place. It’s to ensure a minimum level of competency.

          NPs have found a way to short-cut through this, unfortunately, by calling their practice of medicine “advanced practice nursing.” They’ll admit to your face that they practice medicine, but when push-comes-to-shove, they’ll hide behind the APN answer to protect themselves from being regulated by the Boards of Medicine.

          • ProudOkie

            So let’s use the term “free choice”. Do you approve of that? Again, stop the madness. Your absolute inability to control your anger and hate that I will never be controlled by a Board of Medicine is all over your posts. You have got to learn to control yourself!

      • Matthew Edwards

        “My experience, anecdotal as it is, tells me NPs and PAs have no business replacing a good doc.”

        I agree, but PA’s aren’t trying to replace doctors.

        • Faxon

          You may not be. However, I have been to several clinics where there was no primary care MD and a PA was seeing all the patients and writing prescriptions. Also,if you look at the history of PAs,you will see that the purpose was to train men to fill in for MDs who were gone to war. So PA training is rooted in replacing the PCP.

          • Kristy Sokoloski

            Faxon, a friend of mine was using a PA for the care of several problems including one of her specialists. She made mention that most of the time she saw the PA except for when they were planning to do actual surgery. Then she saw the doctor. But on the Primary Care front she did not have a very good experience with using PAs. But I am glad to have a PA available if I need to be seen right now about something when I can’t get in with my own doctor. Otherwise it’s like I stated before, most of the time I will be seeking out my personal physician for my medical needs.

      • Doc Barnes

        Funny you should make the statement of ” They have never been able to diagnose as accurately as my current internist does, and I do not trust their judgement regarding when to send me to a specialist and when not to.” as I have trained as a NP with a physician and not an NP, REMINDING you that NP’s on a average have 5-10 years experience as a nurse or paramedic prior to entering into any post graduate program where as most MD’s have no medical background and the first two -three years is theory only, no hands on ” We are hands on from start”. We complete a residency of two years with a physician where we are to diagnose, treat and prescribe along with knowing when to “punt” a patient to the correct practitioner specialist. I will tell you that ANY practitioner can be an idiot, long program, short program, good tester, bad tester it is the practitioner you look at not the training. I have met Docs that made me SHIVER “thinking” Jesus, how did you pass medical school? On another note….here in Florida we have a horrible drug abuse problem… do you think we have so many addicts… I will tell you that it isn’t us NP’s because we cant prescribe narcs :)

        • medicalstudent

          No they don’t. The average NP/DNP these days does a direct-entry program, entirely online. They get their “doctorate” within 2.5 years without ever touching a patient prior to that. And they have full-independence in many states. This is your average NP/DNP in current times. The days of NPs having decades of prior nursing experience are long, long gone.

          NP and DNP diploma mills are popping up left and right.

          • ProudOkie

            Finally!!! A rational comment! It is not true that the majority of my colleagues go directly from RN to NP. But it IS true that some of them do. I am not for this at all.
            I appreciate you separating the last comment from the rest of your post. It helps us to easily see which personality is typing.

          • Suzi Q 38

            Not for my daughter.
            She applied at the UC schools and got into UCLA and others. She was accepted and she now attends a UC school in California.
            I do not imagine it will be done online, nor will it be easy.
            She has been working at a major hospital as a regular R.N. to get some clinical experience before she graduates.

      • buzzkiller

        I will not argue with you on the merits, but I do precept first-year medical students at the University of Washington, the number 1 rated primary care school in the country. They all tell me they’re going into primary care. Over the years I’ve precepted about 15 and 2 have wound up in PC. That’s the reality.

      • Kristy Sokoloski

        Family Medicine doctors also need to be paid more. My Primary Care Physician is a Family Medicine doctor, and he has been a big help to me especially the last couple months. I am very grateful to him for that help.

        • Faxon

          Agreed! When I lived in Seattle, my PCP was Family Med. Now in the Midwest, the PCP specialty I see most often is internist.

          • Kristy Sokoloski

            Interesting. Throughout my life (with the exception of when I was a kid until about 12 or 13 when I had the Pediatrician and for a short time several years ago) my Primary Care Physicians have always been Family Medicine doctors. I have found that when it comes to the care I get from Primary Care that I am more comfortable with them. Have you noticed a difference in your comfort level when it comes to comparing the two specialties?

          • Faxon

            none. if i had children, i might choose a family doc as my internist doesn’t treat people under 16 yrs old.

          • Kristy Sokoloski

            That’s good. I am glad that you have a doctor you like. I wish that for everyone.

    • Matthew Edwards

      “The government is freaking out about health care costs, and rightly so. They are casting about for solutions. These folks, mind you, are not experts on health care. Far from it. Most of them are number crunchers.”

      I am a soon to be PA and I am getting job offers in my inbox DAILY and I haven’t even graduated yet. Mind you, these are not from “number crunchers,” but from doctors who understand the value of having well trained medical professionals on their staff to help them manage their patients. As far as I can see, the demand for midlevels has been driven by doctors themselves.

      • buzzkiller

        I agree completely that PAs working with docs is a wonderful idea. We’re in the process of looking for a NP or PA right now as our wonderful NP of 27 years up and retired on us.

  • Mark

    A few years ago I called to make an appointment for a skin lesion with my PCP. As he was not available I took an appointment with the physicians assistant (PA). He looked at the spot and said it was just due to age (I was 51 at the time) but that he would freeze it off for cosmetic purposes. He said he was more concerned with the red, scaly patches (actinic keratosis–AK). He also froze some of those off. I asked for a referral to the dermatologist to consider a cream for the AKs.

    During the 3 months I waited for the dermatologist appointment the original lesion came back. Imagine my suprise when the dermatologist entered the examination room and from a distance of 10 feet pointed at the lesion and exclamed, “That is a basal cell carcinoma!” Yes, the lesion identified as an “age spot” by a PA (who was clearly out of his depth) was actually cancer

    The dermatologist removed the cancer and prescribed 5-FU cream for the AKs. I see him yearly now for followup visits.

    I will never again trust a PA for more than a sore throat, and maybe not even then.

    • ProudOkie

      Anecdotes and isolated incidents…generalized to an entire population. Why would the dermatologist hire such an “incompetent” provider? Might want to question that judgement as well. Interesting how you remember the exact name of the medication.

      • Mark

        I remember the exact name of the medication because I have a tube of it
        in the drawer. I am instructed to use it on any new rough, red, scaly
        patches that show up.

        As for the PA, he was hired by the HMO,
        not the PCP. In my opinion (due to numerous other interactions), the
        PCP was an excellent physician. He has, unfortunately moved to another

        • ProudOkie

          Thanks for the clarification. There are bad providers in every field. I have grown weary of well meaning articles about the concern over the demise of prmary care turning into NP bashing forums. Won’t tolerate it without taking a stand. Thanks again.

          • medicalstudent

            They turn it into NP bashing sessions because your representative organizations have idiots like Mary Mundinger stating publicly that NPs, with a fraction of the training that physicians get, are superior to physicians. Remember this: it is YOUR profession that initiated this fight and annoyed current med students, residents, and attendings with the statements and comments it puts out. If you’re looking to stop NP bashing, all you have to do is let your ANA or AANP or whatever know to stop making dumb comments publicly. It’s as simple as that.

          • ProudOkie

            In your last departure from reality concerning the last big article where you showed your immaturity and were kindly reprimanded by patient and physician commenters alike, I never commented on anything you had to say. But as you started to get your snowball rolling here, I just couldn’t pass it up. I am amazed that someone of your stature and academic gigantism spends your time arguing with someone like me. Either I’m really smart and you can’t stand it or you are just angry and can’t face reality. Just let it be student. We all know the 154,032 hours for you versus the 15 minutes of education for me. Move along to the next argument. You are wearing us all ount.

    • nanguneri

      Exactly, why did you accept the decision of the PA without the Physician’s approval or knowledge? Would you do that if it were your Grandmother who is aging and having other complications? You took it very lightly and assumed that the PA was having a model to go by when he or she just rattled off something without even calling you back and finding how things were coming.

      The fact that they did not call back or check back or even document and let the doctor know let alone copy you on an email should have forewarned you that this is a high risk.

      Secondly, you are again quoting a negative experience and trying to make a statistical model out of it.

      One is a coincidence, two are suspicious but three or even four are no coincidence!

      So ask the PA on what other occasions has he or she done this successfully. Once you get that information, then you can take a decision with the least risk or similar to the risk associated with what a Physician would have concluded for the same issue you have had.

      BTW, hopefully your situation has improved and you have healed for good.

  • DavidBehar

    See the remark of Mark below, about a skin cancer identified by a dermatologist in a second from 10 feet away, called an age spot by an NP.

    NP’s are good for routine follow up of treatment going well. Patients may also be pretty good at self care. Most medications should be over the counter, and routine care should be done by patients.

    New problems, care not going well, relapses require expertise from experience. Common conditions responding to first treatment can be managed by family practice. All others not going well require specialists.

    Experience can be obtained by anyone. It is possible a NP limiting practice to Dermatology could have identified the above cancer. What is scary is the NP or FP who doesn’t know, but doesn’t know he doesn’t know, and fails to refer, as in the case of Mark.

  • ninguem

    As long as there is a tedious task to be done, something time-consuming, unpaid, and requires forms to fill out, there will always be a need for primary care.

  • Mason D

    I am a patient but I agree with Doctor Altman. She perfectly articulates the importance of primary care physicans ” I need excellent primary care physicians to be the center, the ones who hold all the information together, the ones who coordinate and manage the patient..”

    I think the primary care physican is the most important a doctor a patient see as he or she is the first doctor a patients see and the initial practitioner a patient sees should be high qualified and intelligent to ensure proper diagnosis,a patient receives urgent care when needed and proper referrals to specalists. It requires an in-depth knowledge of medicine and training that as this article’s mention is less for nurses and physican assistants. Competent pcps will always be needed playing a crucial and irreplaceable role in medicine.

    It is well known their is a shortage of PCPs in America; if anything we should further support their role and increase incentives for doctors to become pcps.

  • Samir Qamar

    The government typically goes for the “lowest bidder.” In this case, replacing primary care physicians with less-trained, less-paid mid-levels as long as the “job gets done” may very well happen. It is up to us as primary care doctors to keep our industry alive. At MedLion, my company, we asked a major employer (2,000 employees) if they had any preference for an MD/DO vs NP/PA to serve as their primary provider at an on-site clinic we are building for them. Immediately, the response was “physician.” The general public wants access first – if no physician is available (cost being equal), most will opt for a good mid-level to sort out their health issues. But, what if access WAS available to a physician, at the same cost? What would patients do? At MedLion, we are trying our very best to revive primary care as a profession. In 2012, we began a grassroots effort in several medical schools to educate medical students about the possibilities that lie ahead if Direct Primary Care is chosen. We put our money where our mouth is – for medical students who choose family medicine and opt to start their own private MedLion clinics, we reimburse them to help pay for student loans. We educate them that even after MedLion’s licensing fees, they can gross up to half-a-million a year. We are in a pendulum swing, and the subject is supply-and-demand economics. If we play our cards correctly by innovating new, more appealing models of health care delivery, primary care physicians may actually have a very bright future.

  • andrew wolf

    In your article you argue that physicians are more qualified to manage medically complex patients than nurse practitioners because of many more years of training. That argument is like comparing two drugs based on the time taken to develop them in the lab. For example, imagine if a drug rep told you to use their anti-hypertensive because their company spent 15 years developing the drug, versus the 7 years spent by their competition.

    Outcome studies have shown time and time again that patient outcomes cared for by nurse practitioners is equivalent to (or better than) patients cared for by physicians. Irregardless of medical complexicity.

    I’m sorry you spent 12 years in training, whereas I spent about 5. As a nurse practitioner, I have the same ability to provide patient care based on the evidence.

    • Samir Qamar

      Mr. Wolf, would you mind citing some of the outcome studies demonstrating NP care is equivlalent to (or better than) physicians’? Thanks so much.

      • Suzi Q 38

        I doubt that he can do that.
        You know there is no such article of study, LOL.
        As annoying as it is, the service for patients are good enough.
        Maybe the P.A. or N.P. tries harder, not sure.
        On the other hand, I prefer the doctor most of the time.
        I have PPO insurance, and so I can ask for the doctor and I will get him or her.
        I am not sure if this is true of all types of insurance.

    • Homeless

      Actually, your argument is stronger if you focus on what you have been trained for. Sure an MD does more training but why do I need a practitioner that can deliver a baby when I have a URI? Isn’t it like saying a person with a PhD is quantum physics the optimal person to teach science to middle school students.

      One aspect that doesn’t get mentioned is nurse practitioners also have training as nurses…something very valuable in primary care.

    • WhiteCoatRants

      Andrew –

      You’re right about all the studies, I’m sure. In fact, I bet there aren’t any studies showing that treatment rendered by grade schoolers is any worse than that rendered by nurse practitioners, so next down the line to help patients save money will be gifted grade school student phone advice and then Shaman Skype toddlers with their magical rattles of health. Goo goo ga ga.

      I don’t care how good you think you are, if you can’t pass a doctor’s board exam, you shouldn’t be treating patients, so lose the ego. Actually, the law says that you can treat patients, but you damn well better tell the patients that you aren’t a doctor and then let the patients decide whether they trust you with their lives. But lose the ego, anyway. It’s a team sport and you don’t get to be the captain just because you think you’re better than everyone else. When there’s an emergency in the hospital, no one goes running to find the nurse practitioner.

      • Suzi Q 38

        “When there’s an emergency in the hospital, no one goes running to find the nurse practitioner.”

        I have though, gone to a clinic or doctor’s office and seen the N.P. without a problem. For a cough or a rash I was fine and went home happy with my prescription.
        There are several NP’s living in our neighborhood and they are doing very well. Two work at clinics and the other one works at a major hospital in our area.
        I believe that especially with the new health care, NP’s are here to stay.
        The hospitals, private offices, and clinics are all going to do what they can to save some money and therefore hopefully make some money.

        I will admit that if it gets more complicated, I ask for the doctor.

      • ProudOkie

        Come on White – in an emergency in a hospital, I want the ER physician! And it IS a team sport; differnet leaders lead the team at different times. Okay with that?

    • kjindal

      pet peeve of mine – please avoid using “irregardless” incorrectly.

      • Suzi Q 38

        Thanks for the grammar lesson.

        • ProudOkie

          I have engaged in conversations with kjindal in the past; he is being VERY civil throughout this discussion. Hi kjindal. Just to get you fired up – :) pet peeve of mine – please avoid using “midlevel”. Use Nurse Practitioner or PA.

  • Chris Holm

    Basic patient with Colitis here. Good to see some conversation on this.

    • Samir Qamar

      Mr. Holm, as a patient, your viewpoint would be considered extremely valuable. If cost and access were held equal, would you feel more comfortable with a doctor as your main primary care provider, or a nurse practitioner? Thanks very much.

      • Chris Holm

        I just want someone who gives me good health care. Now as I understand it the primary care doctor is supposed to be the person that reminds me to get a physical or colonoscopy each year and knows me as a patient so I would prefer that.

        • ProudOkie

          So, Samir, he wants the clinician who provides the best care for HIM. Gosh, the lengths some will go to in order to try and prove a useless point. “IF the sky were green, and the grass was blue, and blah blah blah.”

    • Suzi Q 38

      You keep interviewing doctors or NP’s in clinics until you find the best combination of health providers for YOU.
      This isn’t a date, where you feel bad when you don’t go out again.
      This is your health and your life.

      My gyn/oncologist was very good right before and after my hysterectomy.
      When it was discovered that I had complications after surgery, he was very difficult to get ahold of.
      After trying different doctors related to my condition, a gastro doctor had the answer for my neuro condition!
      Go figure.
      Sometimes, no matter how brilliant they are in medical school, diagnosing difficult conditions can be challenging.
      My point is that finding a really good physician is easy, but finding a physician that is also an excellent clinician is difficult.
      Passing exams are necessary, but learning how to treat patients can take a lot of years….or if you are gifted in this area, the better for both the doctor and the patient…word of a good doctor gets around.

      • ProudOkie

        Well stated.

  • Samir Qamar

    Primary care physicians will always be needed.
    Our silence as a whole is many times misunderstood for indifference. Others, like retail clinics and mid-level providers, are taking advantage of the lack of primary care access, and succeeding as a result. Fix the reason(s) for the primary care shortage, and the industry will make a big comeback.

  • Sharon Lustro

    With all of this talk about all the P.A.’s N.P.’s, and specialists, I still see the value of the internal ned doctor that can get me the proper help sooner.

    A really good Internal med doctor is “gold.”

    I have one. I have seen him for the last 12 years.

    I like the fact that i get him every 3 months, and not an N.P.

    The fact remains that he can not afford to hire one. He just works feverishly fast, but knows when to slow down and talk to me when I need him.

    My parent’s Int med doctor rarely saw them. “Tina,” the P.A., was all they got whenever they went to the doctor. I have asked the doctor to call us on their behalf numerous times, but to no avail.

    We finally had to switch doctors.

    Therefore, I understand your concern.

    The NP’s and PA’s will definitely provide some competition for jobs and patients.

    They are not as educated or experienced, but they might be fine for minor medical problems.

    My daughter is a nurse studying to be an N.P. while working at a major local hospital.

    I told her that there should be opportunities for future jobs for her with the advent of Obamacare, so she is working on that degree.

  • WarmSocks

    Primary care needs to be provided by physicians. It would make more sense to train mid-levels to help subspecialists than to eliminate doctors where they are most needed. The cardiology PA only needs to learn about cardiology; the rheumatology NP only needs to learn about rheumatology. The primary care provider needs to know everything, and too many things get missed by midlevels in the primary care setting.

    When Congress and the president see a PA or NP instead of an MD, maybe they’ll have a better chance of selling mid-levels.

    • ProudOkie

      Who staffs the “congressional medical clinic”?

  • Janie Rosman

    I disagree. The PCP will become part of a team. When mom or dad, or I, see, that specialist asks who is the PCP. However, the way doctors and medical professionals are paid will definitely change, and has been, with Integrated Care Delivery System – payment is based on quality care, not quantity. Good bye multiple tests, duplicate procedures, etc., and now each specialist will have to discuss the patient with other specialists taking care of that patient.

  • reader112

    Nearly every one of these comments is full of anecdotes. “One time this…” “I remember when…” Malarkey. It has been said that 1000 anecdotes does NOT data make. Look at the research – done by health policy people, physicians, and nurses – that show care given by NPs is comparable to that which is given by physicians. I’m not an NP (I am a PhD nurse scientist who has taught research and EBP to physicians, NPs, and nurses), but if everyone is following EBP guidelines, then what’s the problem? Is it the “art” part of medicine, where we start prescribing drugs for off-label and untested purposes, running unnecessary tests, and otherwise searching for the obscure?

    • WhiteCoatRants

      Then why does *anyone* need medical training and licensing to follow EBP guidelines?
      Ones’ significant other or family member could just print out a list of medications to take for dyspnea or anyone could download DIY instructions for self-guided appendectomy.
      What is the basal amount of training necessary to treat patients and why?
      Or are we just using NP training to render “simple” care? Whatever that is …

    • Faxon

      Can you direct me to examples of such research? I am not in the health care field so I would appreciate it if you are able to let me know where to look for this type of research. Thank you.

      • Suzi Q 38

        Research is valuable.
        Sometimes, it is so biased.
        Just ask any patient or participant in a clinical trial.
        They weed out the weak patients, or ones that will not respond well to whatever drug…
        A nursing journal would have a different conclusion than a medical journal on this very same topic.
        Let’s be realistic.

    • Suzi Q 38

      That’s why they call it “practicing medicine….”

  • Peter Mancini

    Good morning, this article is very distressing to read. Unfortunately
    it will all be the reality with the new health-care law. Medical practitioners
    will become surrogates of the government and eventually like going to the DMV. You
    mentioned vacuums created by the system, well the government will decide how to
    fill that vacuum, and another agency will be created to take care of that for
    us. Training will not increase for NP, PA, but decrease for those primary care
    MD in your field because as was stated in the article there are others that
    perform the same level of care. I agree that the level of debt incurred really
    makes you think about entering the medical profession. By level I certainly
    don’t mean quality, as in I am a firm believer that the primary care physician
    should remain an integral part of the health-care system. I want my MD to make
    money, I understand his responsibilities and if turning a profit to pay down
    his debt, to earn a living that he chooses makes him a better doctor then so be
    it. But the goal of this bill was never
    to improve quality of care as much as it was about governmental control of the
    system. The government will decide who you should see and the level of
    education required in order for you to provide the service that they deem
    necessary. This is just one of many articles that should alarm everyone in the
    health-care profession as well as patients in their later years that depend on
    the familiarity, relationship, trust and loyalty they have developed over the
    years with their primary care physician. As much as I respect PA, NR and what
    they do, the primary care physician with their level of education, and contact
    hours as stated in the article can’t be overlooked. There is no substitute for
    experience. This is why many will no longer enter the profession, creating a
    larger pool of the so-called “defined care”, defined by whom? Education
    and experience will need to be accelerated/curtailed in order to meet the
    growing demands thus decreasing the quality of care. This was never about
    improving quality of care, but equality of care. Even if the quality has to
    decrease to meet that goal.

    Peter Mancini

    • Homeless

      I find experiences at the DMV wonderful compared to a visit to the doctor.

  • ASG

    Lots of vitriol here. So first, full disclosure – I am an NP working with advanced heart failure patients. In terms of career, first 8 years or so as an RN, last two as an NP – all with cardiac patients. I see patients in both the acute and ambulatory setting. I have worked hard to get the respect of my collaborating attendings and of my patients as I know how people view my role – and if I had any doubts about the latter – the comments accompanying this article certainly curtailed them.

    I feel competent in my area of care, though I acknowledge there still is and always will be more for me to learn. None-the-less, I know when my patients are sick and need acute interventions. This will never come from a book or class but experience. I think my physical exam skills aren’t that bad either – I can differentiate many types of murmurs and hear and explain the difference between S3, S4, and P2 and understand their implications as well. I am not sure how well my non-cardiac colleagues, at all provider levels, can do that. My point is not to inflate what I do or belittle what someone else does because the same can be said about me. My knowledge base outside of my area expertise is marginal at best. Thus, I don’t diagnose or treat outside of my realm (as small as it may be.) Even inside heart failure, I consult with my attendings all of the time. Again, I strive for competence and patient safety.

    For the record, I do not see new patients. I see intra-attending visits for symptom checks and med titrations, I see patients within 7 days of being discharged from the hospital, and occasionally, some semi-urgent visits. The MDs I work with can not see more patients as they are often triple booked as it is; they may be incentivized to see more new patients but they don’t always want to – they have limits. Instead, they read ECHOs, providing them with the RVUs needed to compensate for not having more patients. I can’t say I blame them. They have forgone raises for years as a result. (I blame this on Medicare and the bean counters – we don’t yet have a way to estimate cost saving by preventative care visits, thus, in my opinion, these visits are grossly under-reimbursed)

    None-the-less, my point remains that a competent mid-level can safely care for a patient. Moreover, given specialization of health care and the complexity of the our system we need more health care professionals at all levels and we will need to continue to work out the details of who plays what role and to what extent. For anyone, on any side, to make blanket statements about quality of care vis a vis professional level is being nothing more than dogmatic. Our health-care system is way too complex to put singular blame on any one person or profession. Yes, there are real differences in educational hours between physicians and non-physician providers, but realize that, for NPs at least, we are limited to the patient population we can work with by our training (I can only work with acutely or chronically ill patients.) I can’t work in a general, family, or pediatric practice (so reduce that total # of hours from the overall total.) I also know that I will never be paid the salary of a physician, nor do I ever expect to. But please take some solace in knowing that with each patient I see, I hope and fear just as much as the next provider, that I am doing right thing.

    To address the article itself, the crux of it was not patient outcomes themselves, but rather was there still a role for the primary care physician if his work can be done by those without the same length of training. I can’t answer for him but I can say I am glad he did. I rely on his expertise to fill in the gaps of mine. Perhaps he might see himself as a steward to those around him ensuring continued high medical standards. We all need mentors, physician, NP, PA or otherwise.

    I think the issue too is that more young residents aren’t turning to internal medicine. I can only speak anecdotally, but most that I’ve talked to say it comes down to money; they would prefer to go into more lucrative fields. Another sign of the time, perhaps.

    None-the-less, those NPs and PAs around you have earned the right to be there. Medicare recognizes them as providers and pays them as such. Instead of directing our energies into finding each others faults, how can we become better allies. Studies have already shown that mid-levels provide can provide the level of care needed to maintain patient health and safety (one came out of the MICU at Columbia recently and there are many others.) So, let’s move past that or else we can’t move forward.

    I stand firm in my education and experience, and will defend it. f you don’t want to send a patient to a mid-level, that’s your preference as it is a patient’s preference if they want to see one or not. As mentioned, I am acutely aware of the biases that exist out there. However, I will always take issue with anyone who wants to throw flames on the NP/PA vs MD fire; there are competent and incompetent, ethical and unethical ones on each side. Our energies need to be continually directed towards addressing the larger issues of how to create a more efficient health-care system (both in delivery and administration) with meaningful, achievable, appropriate goals and incentives that don’t create more burden on providers.

    • Suzi Q 38

      Well said. Thank you.

    • William Hudson

      You may “Feel” you know and do a good job, but what is reality? I was an RN for 17 years before going to medical school and I found out that you if you want to be a physician do not go to Nurse practitioner school for 2 years then practice, go to medical school for 4 years and a residency for 3 to 4 years then practice. By the way I take issue with the murmurs I have studied murmurs myself all through medical school and during clinicals and have hours of classroom and hands on. How would you know classroom time would not teach you how to treat patients better if you have not done more time? If its from being in Nurse Practitioner school then try medical school, its different.

  • Rosemary McHugh

    I am a family physician. I went to medical school in Ireland and then did more years of training in England, before coming home to Chicago. In Ireland and in England, there are many family physicians, in fact, family physicians are the backbone of medicine in other countries. Nurses in those countries have many options open to them in nursing, including being midwives. The nurses that I worked with in Ireland and England were happy to be nurses, in focusing on the nursing needs of the patient. When I came home to Chicago, I was surprised to notice that nursing schools attached to the large medical schools were pressuring the nursing students to become nurse practitioners, rather than general nurses. Many nurses that I spoke with were torn emotionally, because they really wanted to be nurses and to be closer to the patients. I think we are failing as a country to realize the great importance of the nursing profession. Real nurses are critically important in patient care. There is a great shortage of real nurses. I read that hospitals are trying to recruit nurses from Africa and other countries, because our nursing schools are producing NPs, who want to compete with doctors, instead of living up to their mission of producing really good and caring nurses. I hope this will change under Obamacare, so that nursing schools will focus on their true mission of educating real nurses.
    Sincerely, Dr Rosemary Eileen McHugh, Chicago, Illinois

    • Kristy Sokoloski

      Dr. McHugh, I am currently in Nursing School going through my second semester of General Education classes. I am not looking to be a Nurse Practicioner. I am looking to stay in the Nursing field whether it’s patient care, or on the administrative side of Nursing. Still don’t know where I want to end up although I have two specialties in mind. We’ll see when I graduate.

  • Matthew Edwards

    As a soon to be PA, it dismays me to see my chosen profession so grossly misrepresented in these comments. PA’s are trained to practice medicine as part of a team with physician supervision. We are not here to displace the role of physicians, but to extend their reach, be more efficient, and make more money. PA’s have been working in this capacity for over 50 years and this model has proven to be fruitful for physicians and patients alike. This is not “the dumbing down of medicine,” but a more efficient way to practice.

    • medicalstudent

      I love PAs. They are far, far, far, far superior to the NPs and DNPs I see on the wards. You guys (PAs) actually learn real science and clinically-relevant topics. The nursing midlevels spend entire courses on doctor-bashing and how to influence politics instead of learning how to take care of patients.

      Rock on!

      • ProudOkie

        Well goodness – we are all very concerned about who you love and who you don’t. Your opinion and my opinion don’t make a wave in the bigger picture of healthcare – the difference between us? you think your does.
        Turn it up to 11!

  • GS61

    A physician does receive substantially more training than a NP or PA. For instance, this could not be more true today with many nursing students not wanting to get their hands dirty doing bedside patient care as an RN before pursuing NP school and certification. We are seeing a trend toward NPs that graduate with minimal or no bedside experience. What kind of foundation is that for providing safe, efficient, and effective care? It use to be that one would go to nursing school for two, three, four years, work in the trenches for a while, and then go back to school for a graduate nursing degree or two. Cutting out the bedside experience between those activities effectively cuts down on exposure to the patient dynamic and real world nursing experience in my opinion. Even when nurses become NPs and DNPs, I believe they still have to have an RN license. So why not put that RN license to use before going into graduate nursing? I truly feel that working at the bedside for some years after initial RN training gives nurses an edge for training at the graduate level. Having the years of work experience in my mind reduces the need for extended hours of training as physicians are required to undergo. However, the current minimalist mentality, in my opinion, undermines overall quality patient care in a time when phyical and mental issues are more complex. More training hours for nurses should be required. The basic two and three year and in some cases four year programs are not adequate.

    I understand that nursing residency is a topic of discussion today and with the trends, a revamp of nursing education should take place sooner rather than later. Physicians have every right to be concerned about the fate of primary care and their position in it. They do go to school for many years and many of them pay big bucks for training only to get undercompensated in the real world. Nurses have every right to be concerned as well. Let’s face it, both professions have a distinct body of knowledge but as far as I can tell still need each other at this point and time. I applaud both professions and ask that the battle end.

  • Todd Solomon

    You can train a high school senior to satisfy “core measures” and fulfill the new definition of “quality” medical care.

  • heytherehardy

    Shunting care of the complex patient to mid-level practioner is absurd, I agree. However, if a patient is non-complex, healthy and only needs a physical once a year (and maybe treatment of a sinus infection or something simple) why shunt their care to an MD. It’s a waste of the MD’s time that could be better spent with the complex patient on 20 meds and a waste of money (either private insurance or the government’s). If the non-complex patient (like me) needs further more focused care for complex problem management then refer them to the MD. Otherwise, let NPs and PAs practice as they were originally meant to as an extension of the physician to mediate issues in the non-complex patient rolls.

    • Suzi Q 38

      I agree. There is a place for NP’s and PA’s.
      So many offices and hospitals are hiring them already in our state.

  • solanacea

    This country needs more physicians. Physician professional organizations are against this as they fear lower income but this could be balanced out by reductions in debt burden and malpractice insurance costs. Here is my plan: (1) allocate Medicare funds for more residency training positions; this will allow (2) more medical school spots and opening of new medical schools; competition between medical schools will (3) lower the cost; with more doctors carrying less debt burden, (4) Medicare can make small downward adjustments in physician pay since someone will have to accept Medicare with more doctors around. Finally, (5) radical malpractice reform, perhaps a constitutional amendment removing the right to a jury trial for professional malpractice cases, will allow states to experiment with innovative ways to lower malpractice premiums and compete for the best doctors in the country.
    Overall, median physician pay may become slightly lower. Still, it is worth it. No offence to NPs and PAs but in no other rich country do you have to have complications to be able to see a physician if you so choose.

    • ProudOkie

      I think those are all excellent ideas!

  • medicalstudent

    My conclusions are pretty sound. I would make the argument that M4s across the nation are, as a whole, superior in the delivery of quality care than NPs/DNPs with 5 years of experience after graduation.

    I’ll use the same tactic that the nursing organizations employ: show me the data that provides conclusive evidence that medical students are more dangerous than nursing midlevels. Otherwise, the statement that med students are equal/superior to nursing midlevels is completely accurate and needs to brought to the attention of politicians.

    • ProudOkie

      And I would argue that you are wrong….so that leaves us where?

    • ProudOkie

      Aaaaaaand finally medstudent – when you do get around to responding to every one of my posts in the next 15 minutes (and I know you will because you are close to edge of the cliff), make sure you are mean and nasty and make sure the posts are looooong and vitriolic and full of words like “stupid” and “inferior” and “you could never”. You are pitiful and are an example of what is lacking in our healthcare system. Your inbred attitude of “I’mism” is sickening. Get all of your last licks in on this backwoods, inbred, small-brained, hillbilly of an NP because I’ve said all that needs to be said to you.

    • Suzi Q 38

      You provide some very good points.
      It is up to you and other medical students to make your argument and therefore suggest more opportunities for service to the general population of patients that will need you.
      I have always said that data is everywhere and nowhere.
      Why? you can get data from any given group, and depending on their agenda, the data is already slanted to a certain outcome before the work to obtain the data begins.
      In the end, you will find advantages and disadvantages to both sides of almost any argument.
      NP’s and PA’s have been here for years.
      They are going to have a larger piece of the patient workload in the future…at least here in the state of California.
      Be content with the fact that they will not be making the money you will, nor will they be treating all of the same illnesses that you will be treating.
      I do remember the first NP that treated me. She was working at a GYN office. The next one treated my son at the pediatricians office. The next one worked in geriatric care at my parent’s doctor’s office. We had to switch doctors because the NP was doing everything, and my parents had not seen the doctor himself for about 2 years! Recently I had a PA treat me at my dermatologist’s office for a fungus on my toe.
      At my gyn/surgeon’s office there were NP’s that took my pap smear and gave me instructions for an upcoming surgery. The NP’s were highly utilized at the cancer teaching hospital.
      Anyway, I know that it is so frustrating to think about all of this, but this NP and PA presence is here to stay.
      The places that they are allowed to work are just fine with me as a patient and have been for years.
      This is why my daughter decided after being a nurse for a couple of years to apply to NP programs at the UC schools here in California.
      I think that there will be work for everyone, especially since it is getting rarer to see a young physician choose internal medicine as a final career. So many are specialists.

  • medicalstudent

    Sorry, I don’t argue with trolls. Especially, nursing midlevel trolls, who are oh-so-common these days. We just had 2 NP students on-service the other day. They’re months away from graduating with their MSN and having full independence (because of my state laws). They did NOT know the difference between Gram negative and Gram positive bacteria!! Yikes! One of them literally said “Who cares what it is?! We treat them with the same antibiotics, don’t we?” The attending with me was speechless while the resident and I looked at each other and just shook our heads.

    • nanguneri

      Yes, no one asked you to argue not am I arguing with you or others here. I am only challenging the fact that only primary care physicians can be effective and efficient on patient healing process and asking for the data transparency to validate certain claims by primary care physicians. So in this context there is no need to talk to any troll if you produce the data to support claims. As far as NP students go yes they may not know the difference between Gram negative and Gram Positive. Now who do you think exactly gave them the freedom to treat patients with the antibiotics? Possibly the doctors running the business there who also came from a similar training program as that of yours? So who are the trolls you are referring to, your management or senior or alumni who approved of these NPs in such decisions or the medical students who would one day report to people who would approve of such people to treat patients? Now you seem to be a confused troll by your definition. This means you shouldn’t be talking to yourself let alone others.

    • userid

      Not surprised. I work in a laboratory and nurses have called and asked “who is Ziel-Neelsen that performed this test on this report?” People keep saying to me that I need to apply to nursing school. Well I am applying to medical school now bc that is just plain scary.

      • Kristy Sokoloski

        At one time in my life I wanted to be a doctor, but things happened in life. Plus, I also realized that I would have a problem with the higher levels of math. The higher levels of math is what also kept me from getting an Associate’s Degree in Health Information Management, in particular the algebra. About 15 years ago I then figured out that what I really wanted was to be a nurse, but I knew I was going to have to deal with the higher math. Things happened in life again that kept me from that for a time until now. Now I am in Nursing School working on my second round of General Education classes. And that higher level of math which in this case was algebra? I passed it thanks to who I had as a teacher. He was absolutely amazing. In this second semester I am now taking A&P II, Chemistry, English, and Human Growth and Development. I love Anatomy. Would I like to go to Medical School now? No. I am happy with the path that I have chosen. And one reason that I would not choose Medical School now is because I am too old for Medical School: 41. As far as specialties in Nursing I don’t know which one for sure I will choose, but I have a couple in mind. We’ll see where I end up afterwards when I discover what I like as I go through Clinicals.
        But having gone to school to become a Medical Assistant (did this in 2010-2011) I learned a lot. Especially when it comes to how hard the doctors and their office staff work each day. So that now when I am on the patient side of Medicine I will at times ask my doctors how they are doing, and even ask about their families.

        Thank you for all that you and the other doctors do on a daily basis. Too bad that not everyone fully understands that.

  • Shirie Leng

    Maybe we don’t. Or maybe medical training should reflect what medicine doctors do and not what old-fashioned curricula force us to memorize. Or maybe residency shouldn’t be such a de-humanizing experience. I bet there are alot of people who would make great primary care docs who know the 10 years of training aren’t necessary and not worth it. I know a lot of great nurse practitioners who are very smart and skilled and made an informed decision not to spend their 20s and $100,000 for an MD. Maybe MDs are a little upset that they’ve been sold a bill of goods.

    • Suzi Q 38

      My daughter is one of them.
      Being a physician is so difficult. Kudos to many of you.

      My daughter loves treating and caring for patients, but she doesn’t want long hours. She loves working, but also loves a good amount of time spent at home. She didn’t want to spend the $200K (plus how many years?) for an M.D., not sure that she would get in anyway, with all of the competition to get into medical schools these days.
      One of my friends from high school was so smart, but her family had no money for school. She got her M.D. through the Navy.

      I have another friend, who was a nurse, is married to a physician.
      Their son could not get into a medical school here, so he is in another country getting his M.D. I think he is studying in Grenada, not sure.

      My daughter has two other school friends that are married to each other. They BOTH wanted to be doctors. He got accepted first, then they moved to that state. During that first year, she worked at Starbucks. Then she got into a D.O. medical school nearby.
      Now they are both in med school, and the bills are are piling up.

      I am not sure what specialty she wants, but he ended up in psychiatry. It was not his first choice. I am not sure how you get to choose, based on test results for various specialties.

      This all gets truly complicated, so in a way, I understand some of the uproar.

      My point is that she doesn’t have to be a doctor to get the satisfaction of working in medicine. A nurse practitioner is just fine for her.
      Hopefully it will be the right choice for her.

  • Timothy

    Interesting. I agree with many of the points made here, but unfortunately, our healthcare delivery system is not homogenous across the board. I work in a rural healthcare setting, where many of those we see have no access to healthcare except through a network of clinics, where there are a mix of MD’s, NP’s and PA’s. In our area, there are no Nurse Practitioners or Pysicians Assistants practicing in the hospitals. Only MD hospitalists. Primary physicians have received the short end of the reimbursement stick for many years. This is because the CPT coding is geared toward specialty medicine. It is far easier to code a specific procedure than codify all of the factors and comorbidities that a primary or family practice doctor must coordinate. Additionally in our region, there are just too many patients for a physician to see in a day under the circumstances. One of the major issues in the hospital setting is the propensity for doctors to look at the admitting diagnosis for patients who fall under the JCAHO “core measure” criteria. In many cases, these are repeat patients, and almost without fail, the tendency is to ignore past history (in many cases, recent) and begin treating and testing as required by the protocol.
    Consider patients with a diagnosis of congestive heart failure (CHF). Most patients with CHF have a cardiologist outside of the hospital, and yet the doctors hardly ever ask, “do you have a cardiologist?”, and if they do, when they last had a visit to that doctor. If nobody asks, then the patient is on the hook for an echocardiogram, or the hospital eats the charge, and the patient is discharged before the study is even confirmed by a cardiologist. I have been asked to do echocardiograms on patients who have discharge orders, just so the hospitalists can say that they followed protocol. It had absolutely no influence on the patient management in or out of the hospital. Our problem here is multi-faceted but waste is waste, no matter where and in what setting.
    I believe that primary care doctors are the unsung heroes of the system. But NP’s and PA’s are labile in that a good doctor will use them within their abilities and audit their performance occasionally and shape them into good providers that can be relied on to help shoulder the burden. Nobody is a born healer.

    • Kristy Sokoloski

      Timothy, I have a question about this part of what you said, “This is because the CPT coding is geared toward specialty medicine. It is far easier to code a specific procedure than codify all of the factors and comorbidities that a primary or family practice doctor must coordinate”

      Interesting. I did not know that. I thought that the comorbidities fell under the ICD-9 coding system that coders also use to make sure that things are billed correctly. I don’t understand why it would be more difficult to code the factors and comorbidities that are seen in the Primary Care field. Please explain further. I ask this because of some of what I learned when going to school for Medical Assisting before I entered Nursing School.

      • Timothy

        Kristy, the point I was attempting to make was that CPT coding favors specialty medicine as opposed to general or family practice. CPT coding was developed by the AMA in the 60′s and adopted by Medicare and other payers. CPT coding is updated every year. The assigned values are higher for surgical or invasive services rather than “cognitive” or primary care. These values are based on recommendations of the AMA Relative Value Scale Update Committee, which is dominated by specialists. In my opinion, this committee and its influence over reimbursement for CPT coding are at the heart of efforts to repeal the IPAB requirement of the Affordable Care Act, because it takes some of the influence away from the non-federal lobby. ICD-9 was developed in 1977 by the World Health Organization and American officials thought that it was more appropriate for health issues seen in developing countries. The original coding was required at one time to be used for Medicare part B patients, but the requirement was subsequently repealed. We use ICD-9-CM which is the current “collaborative” iteration in use here. ICD coding is reviewed only every ten years, which means that there is some stasis in reimbursement rates. Additionally, we are supposed to go to ICD-10 in late 2013. ICD coding guidelines are used with Healthcare Common Procedure Coding System as required by Medicare and is divided in two levels. Level I, which is what you are probably familiar with and Level II which is for medical equipment vendors. Incidentally, the United States is the only modernized country to not be using the ICD-10 which was developed in 1992 and should equate to better efficiency in many of the 24 classifications used in ICD coding. Also of interest is the fact that the ICD-9 was not adopted in the U.S. until 1995. The take home point here is that a specialist will earn twice as much over the course of their career in medicine as an internal medicine or primary care practitioner due in part to the disparity between CPT and ICD coding.

        • Kristy Sokoloski

          Timothy, thank you for your explanation. Now that makes a lot of sense.

  • drmpray

    The challenge of primary care, the patient in the next exam room – part of the 80 percent or the 20 percent?

  • Lisa Cunningham

    You make very good points. I was leery about seeing a nurse practitioner at first but my sister, an R.N., talked me into it. I know that NPs don’t get as much training. Patients will have to be even more assertive about getting the right tests and doctors when they are seriously ill. Who is advocating for us?

  • Dr Helen Terrell

    I completely agree. Much of my current job could be done by someone with less training but the complex patients really benefit from someone capable to give an overview and balance pros and cons of treatment. This work takes a lot of time but is satisfying.

  • Aaron Furey

    Dear Dr. Kevin,

    I understand your frustrations, but I would like to clarify a few points for your readers.

    Your current plight is the direct result of the formation of large insurance companies, not the existence of mid-level practitioners. Big insurance, especially HMO labeled insurers, have whittled away at your reimbursement over the years, so that now you have to work much harder, for much less money. Couple that with the rising cost of education/training, and MDs have been flooding into the higher paying sub-specialties for decades.

    Since the 1950/60′s there has been a shortage of Primary Care MDs in rural areas, not because you weren’t needed, but because you didn’t want to work/live in those areas, or felt the compensation/lifestyle was not good enough. This is why PAs came to be, to fill in an MD gap that already existed.

    Physician Assistants are NOT independent practitioners, nor do we aspire to be. We are trained to work with a Supervising Physician as a team. We are trained in the medical model, and we complete the same number of clinical hours as MD students. (NP’s are trained quite differently, and belong in their own special category IMO).

    Currently we are not required to do a residency program after graduation, although there are programs available should a PA desire more formal training. For the most part, we are expected to learn on the job, but once again, this is under MD supervision. Our supervising MD is not going to let us do anything he or she does not deem us fully capable of handling.

    Therefore, the only fair comparison would be to compare the abilities of an MD, fresh out of residency, with a PA whose been on the job at least 4 years. Still, I readily defer to the Board Certified MD as the expert in his or her specialty (at least in terms of book smarts).

    One of the great strengths of a PA is our humility and willingness to ask when we are not sure about a diagnosis or treatment plan. We are trained to seek help without ego, from day one. This assures that every patient can feel confident that they will be properly cared for when they see a PA/MD team.

    Using PA’s as a scapegoat for your current frustrations is really not surprising, or new to us. We hear it all the time. It is a mixture of ignorance, arrogance, fear, and lashing out at the only thing that might be in your control. Unfortunately, discriminating against a PA is not going to change the fact that BIG Insurance has all the power to dictate when and how much you will be paid, for each service provided, nor will it change the fact that our current, “pay for procedure” model of healthcare, does not produce results justifiable to the high costs.

    AF, PA

  • Dr. Jeff

    There is a reason M.D.s are portal of entry. To discuss decreasing or ending the role of M.D.s as P.C.P.s is strictly for financial reasons with no concern for the health of the patient.

    • James Massey

      I agree totally. But it is also the reason there are not more medical schools and why there are not enough physicians from other countries that are not allowed to move here and practice. In an ideal world, we would all be physicians, and every patient would be seen by MDs/DOs exclusively but there are entirely too many restrictions for that to happen.

      And those restrictions have to do with money. If the medical world was wash with physicians, and every mid-level became a physician the AMA would have a stroke. Why? Because the supply vs. demand would no longer be in favor of physicians anymore. Doc’s wouldn’t be as “valuable” anymore. Why do you think med students are abandoning primary practice and seeking specialization? For “financial” reasons.

      So, medical academia and the AMA have given the patient and the insurance companies no other choice. Everyone settles for less trained HCPs. The people that are blessed to go to med school are NOT superior people, I’m every bit as smart as your average physician, but I could not afford med school. And that’s a shame, both for me, and my patients.

      • Dr. Jeff

        In 2010 President Obama met with the American Association Of Indian Doctors after which barriers were removed to make it more easy for them to come here and practice as P.C.P.s. Gone are the days when medical physicians came from other countries and had to take the foreign medical board (which made the US medical board look like an 8th grade spelling test) before they were allowed to take the US boards and hope they would be accepted to some residency program (which would be their second after having completed residency in their home country). There is one and only reason for the push to using NPs PAs and whichever else entity instead of an M.D. D.O. is money. M.D.s & D.O.s are dropping out of practice bc of the low and no reimbursements from 3rd party payers. Fewer students are applying to medical or osteopathic schools and even fewer are applying to the residency programs bc again money. NPs and PAs are overjoyed bc they want to be doctors but didn’t put in the work. Insurance companies are overjoyed bc they will pay even less. Hospitals and clinics will be overjoyed (as long as the malpractice does not go up) bc they also will pay less. It’s all about the money and not the best, established and accepted care for the patient.

  • brendaNP

    I am reading the comments and it seems like constant fighting, this guys is just saying, hey I went to a billion years of school and I want credit for it! Am I not right? Ok, you got the credit, good for you, congratulations on all those years of school you went to. As an advanced practice NP I can tell you that the research supports your statement. Advanced practice NP’s can indeed handle 85% of primary care. Yep we can and we do and we are not really given a choice are we? no MD’s want to work this hard, they want to specialize make a lot more money. who wouldn’t? The NP’s (and the role is no longer called a mid level, this is an outdated ,offensive terminology as we do not give mid level care no matter what this doctor has to say). I would appreciate all of you using the correct term which is Advanced Practice Providers. The NP is being given the primary care practices all over the USA because the MD’s do not want it, so get a grip people, we are here, there are 106,000 advance practice NP’s in the US and it is stated to be one of the top predicted job seeking roles for the next 10 years. Just try to get in one of the MS programs in the US, good luck!

  • Jim Gogek

    I believe this column is incorrect, according to every other expert I’ve talked to. Health care reform will mean the integration of all forms of healthcare, including behavioral care. So, everything must first go through the primary care doc for referral. Millions of people who today do not have insurance will be going to primary care docs after 2014, when nearly everybody must have health insurance. That means a lot MORE work for primary care docs. Yes, nurse practitioners can do some of it. But by every account that I’ve read, there will be more work than all the primary care docs, nurse practitioners and PAs today can handle once health care reform kicks in. In fact, one of the problems with healthcare reform is that there will not be enough primary care providers to handle the avalanche of newly covered people.

  • James Massey

    I find it very interesting that most of the rants posted here against mid-levels by physicians tend to wind up being against nurse practitioners, and not physician assistant’s. Why? Both have comparable education, and do the same job. I not convinced this is merely a coincidence. I think that, at least on a subconscious level, physicians want nurses to “know their place” and not be “uppity”.
    While a lot of PAs were once nurses, they quit being nurses when they became PAs, and for most, to quit being a nurse was intentional. PAs aren’t associated with having to catch vomit, empty bedpans and wipe butts like nurse practitioners are. Nurse practitioners are still nurses, after all. Everyone of them, even if some of them like to think they aren’t one anymore. I think this bias/prejudice goes beyond physicians and into healthcare in general, and has a lot to do with the fact that PAs usually make $5,000 or more a year than NPs do, even with comparable education, production, and accuracy in diagnosis.

  • disqus_NLfwXOQ6Ys

    Hi, Khairunnisa!
    Recall my comments when in the “Managing Physicians” class, I had said that I found the acceptance of Physicians’ Assistants and Nurse Practitioners by US Doctors paradoxical.
    We tried to explain this by arguing that, based on data available, the quality of care had not really suffered, mid-level care was definitely more economical for patients and that the MDs were really happy to use some additional leisure time as the norms of desired quality of life changed for them.
    As evidenced by the comments from patients, mid-level care may NOT be considered as optimal. I stand by my experience in the Forces … aspirin was the Corpsman paramedic’s answer to most complaints! But he never figured out why the old Commanding Officer had to evacuated because of hematemesis!
    A doctor is a doctor … and we need atleast 10,000 primary care doctors here!
    Dr Tariq uz Zafar.
    Karachi, Pakistan

  • DrJ

    I just retired from solo Internal Medicine after practicing since 1975. I predict that within a few years, there will be no more solo practice doctors. The young doctors coming out now see all the hassles that now confront private practitioners… electronic records, Medicare audits, managed care, pre-authorizations, and on and on. And our government is not treating small businesses very well these days either. Instead, young doctors decide to work for a large clinic or a hospital so they won’t have to deal with the hassles. Whether you think this is bad or good is your own opinion, but that’s the reality.

  • Doctor Hart

    I’m not going to read 205 comments but the reason NP’s or PA’s can see 85% of primary care patients is because a large percentage of these Visits NOBODY needs to see. What makes my day intolerable from enjoyable is the 5-10 URI’s and acute uncomplicated low back pain and minor musculoskeletal trauma that is all going to get better no matter what anyone does. Without this clogging my schedule, my day would be manageable and I would be spared the fight over antibiotics for typical viral uri symptoms for 2-3 days or better yet, the MRI for 2 days of acute uncomplicated low back pain, “just to see what’s going on”. So of course an NP or PA would be just as good – as would a pharmacist, my MA of 20 years or a high school student who paid attention in biology. But whoa be to those who don’t make room for these visits- these are cash paying customers – get them in and keep them satisfied!

  • Samir Qamar

    Mr. Wolf, I could not find the outcome studies you were referring to. Please be specific.

  • Sam MD

    I had to pass steps 1, 2, and 3 of the USMLE. Why did I need to study for and worse yet, pay for them in order to practice medicine?

  • Sam MD

    So why did I have to study for and even worse, pay for steps 1 2 and 3 of the USMLE?

  • Diane Lewis

    I respect your professional integrity and the exhausting and expensive
    journey you had to achieve to become the invested Healer within your
    industry. I come from an era when my MD was willing and empathic to
    provide health care to myself and my family, and His medical wisdom was
    never questioned. I too was required to invest 10 years in training to
    be at the top of my professional status. Then one day, I became very
    ill, with the dreaded, doctor’s will not speak the name of this
    disease? I have been near 7 years being passed from one specialty to
    another, on 30 palliative interventions. and my health is worse now than
    before I was forced to take a medical retirement and SSDI. Now, I am a
    Truman Fellow, I have a Masters Clinical Degree, am Licensed for
    independent practice/reimbursement, Registered Supervisory status, a have a
    MBA, and 15 years of experience. My professional status has been
    destroyed because MD’s of all specialties will not take the time to
    invest in understanding and learning to treat Myalgic
    Encephelomyelitis. Millions of patients suffer, and surrender to this
    disease because we are told “it is a Complex Disease”. If MD’s wish to
    retain the upper strata of the General Internal Medicine Industry,
    perhaps accepting the Patient’s actual debilitating condition and
    focusing on interventions that have been used by outstanding physicians
    who have been helping people improve over the last 30 years would retain
    the well deserved MD’s respect and wisdom. Creating distress in
    patients with complex chronic neuron-immune pathology by forcing them
    into a Psychiatric Specialty simply serves to minimize your value by
    demonstrating your passivity. Of course, a PA-C is much less qualified
    than a well trained Medical Doctor, but my PA-C has remained empathic,
    invested in my symptoms, and has listened to be able to provide help
    that all the MD’s push away. That is a very sad way to minimize the
    value of both you and myself as professionals. You fear being reduced
    equal to an NP or PA-C, yet I can’t get more than two-three good hours
    out of bed to even practice my professional skills. At least you are
    still in the game! Would you be willing to find out how to get me back
    in the game? It only requires that you invest in learning, and at least trying to help.

  • Julie Carpenter Long

    This is a tired discussion. I had over ten years of hospital RN experience before I became a NP which provided me with advanced assessment skills and extremely valuable knowledge I use on a daily basis. Most of the NP’s I know also have years of nursing experience behind them before becoming a NP. The training is different of course, but not nearly as “profound” as you state. Both professions bring different and valuable training to the table. I would go so far as to say NP’s are far better at engaging patients in their own health care. Patient engagement plays a much larger role in chronic disease outcomes than most realize and is a major reason the NP profession has become so successful. I understand it is difficult for many physicians to understand that an advanced practice nurse could provide equally competent and as high of quality care as their physician counterparts. That is unfortunate, but it is time to wake up because it is happening everywhere. There just aren’t enough primary care physicians to meet patient needs- period. Instead of belittling, you should be thanking your fellow nurses for stepping up to the plate and offering solutions that improve the health and quality of life for millions of Americans each year. For the sake of the millions of patients out there without adequate access to quality health care it would be more responsible of you to really do your research on the impact of NP’s and the value they bring to the health care system in the United States. One obvious observation is there would not be such success in the NP profession if they did not positively impact American society. There is always more than one way to accomplish a goal and those who are resistant to change hinder progress. The goal here being improved patient access to medical care and improved patient outcomes. Physicians aren’t the only ones capable of providing this and studies have proven it. We aren’t here to take your place. We are here to help because that is our job and we are good at it. If we weren’t so good at it you wouldn’t have written this article. So please stop feeling threatened, stop complaining and do something to help the situation like the good doctor I am sure you are.

  • Sherry Reynolds

    “Several hundred thousand dollars in debt” – odd since Medicare and Medicaid pays for nearly all residency and internship training in the US – IE they are on salary working for hospitals that are paid by the US govt for their actual training.

    We all pay to go to college so that isn’t unique to being a doctor. The only additional debt a doctor would have would be two more years of medical school beyond that required to be a nurse or say a social worker (and they make on average $15 / hour).

    The debt is because doctors choose to go to private graduate schools in order to maximize their income down the line and it is hardly 100′s of thousands of dollars. If you however choose to not treat medicare or medicaid patients you should be forced to pay back the 400k to 1.1million that taxpayers spent to train you.

  • Lisa M. Peto

    Dear Sirs and Madams, I am an experienced RN with over 20 years practice experience currently pursuing my Family Nurse Practitioner certification and graduate degree. I think that you are looking at the NP, PA, or MD situation from an incorrect viewpoint. NP’s are not dumbed-down MD’s, nor do we desire to be an MD (otherwise we would go to medical school). We are nurses, and rather than replace MD’s we desire to work cooporatively with them to provide holistic, patient-centered, evidence-based health promotion and maintenance to patients. Nurses use a different approach to patient care and diagnosis, not better or worse than MD’s just different. There is room enough in health care for all of us. The school that I am attending is one of the founding Nurse Practitioner and Midwifery programs in the US. Frontier Nursing University and nurses like Mary Breckinridge worked with physicians to provide care to patients and families in rural areas of Kentucky that were inaccessible to physicians due to locale and lack of numbers of physicians. She, nor none of her colleagues, ever strove to replace MD’s in providing care, only to provide care where it was needed. Can you be so arrogant not to see the value of nursing in the promotion of health and the maintenance of patient well-being? I am saddened that some of our most educated citizens do not see the value of cooperative care. Does the FBI and CIA say that local police are dumbed down law inforcement? I would hope not. We are all in this together and we need to wise up and work together.

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