The creative destruction of the American family physician

The creative destruction of the American family physician

Medical knowledge, technology and rapid clinical advances in related scientific fields are expanding in an almost exponential manner. It is thus impossible for any individual or any medical specialty to absorb and implement these strides.  Consequentially we physicians and other caregivers not only tend to specialize in medicine today, we are essentially ordained to subspecialize as a result of this knowledge explosion.

The current medical care environment then, requires revisiting traditional delivery models and such a re-assessment must begin at the foundation: family practice. With increasing demand, access to quality care and the need to make every penny count, the first question we must ask is, “What is the role and necessity of the family doctor in the age of 21st medical challenges?”

Understand that I ask this question as a former family practitioner in Canada. Unlike the United States, where family practitioners have experienced the continuous erosion of their patient care activities, in Canada they deliver babies, treat non-displaced fractures, set some displaced fractures, deliver well-baby care, well-women’s care, provide on-going treatment for chronic disease and many other things that here in the United States are, for myriad reasons, referred to a specialist.

While physicians have earned and enjoyed elevated status, our societal needs have encouraged enhanced training and certification in other non-physician provider disciplines such that an equivalency of sorts has been developed. A well-trained nurse practitioner or certified physician assistant working under the supervision of board certified internist can and does provide this type of equivalency.

In the current practice environment both see the same patients and perform similar clinical services. Yet, the cost of labor for the nurse practitioner is less than the family doctor and the time and price to train the former is less, therefore permitting more to enter the system at lower expenditures in less time.

Additionally, the current and future fiscal constraints placed on medical practice as a result of the Affordable Care Act, or ACA, and the increasing cost of providing care, as well as the flood of people coming into the healthcare system, will require the training of many more providers and physicians. Where will we spend our money how will we distribute our resources?

Training a nurse practitioner for four years costs $49,000/year following a BSN. The cost to train a family practice physician, requiring a three-year residency after an undergraduate degree and medical school averaged $96,000 per year for three years in 1999. This is not to suggest that the knowledge base or requirements of each discipline are the same, but the practical reality is the tasks required of each are very similar.

Thus, if we can train more nurse practitioners in less time and cost to perform similar services and tasks as today’s family practitioner and we re-allocate family practice training funds to train more internists, whose knowledge base replaces and exceeds that of the family practitioner, what then is left for the American family practitioner to treat that a well-trained nurse practitioner or a physician assistant can’t, or at least refer to a supervising internist? As the New York Times recently suggested in a lead editorial, much of the time and for many things, a doctor is not required.

Churchill said, “To improve is to change; to be perfect is to change often; in other words, we must continuously change to improve.” These changes in medical knowledge, healthcare delivery and technology have brought about the creative destruction of American family practice and times and circumstances dictate it will go the way of performing an appendectomy on the kitchen table, house calls and the hometown doctor of a Norman Rockwell illustration.

Mitchell Brooks is an orthopedic surgeon and the host of Health of the Nation on Talk Radio 570 KLIF in Dallas, Texas.  He blogs at Health of the Nation.

Image credit: Shutterstock.com

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  • NewMexicoRam

    If the FP is replacable, why do your orthopedic colleagues keep sending their patients to me for pre-op clearance exams? Sounds to me like we could train nurse practioners the technical aspects of orthopedic surgery over 4 years, and they could send their pre-op clearances to primary care NP’s. Get rid of expensive orthropedists that way.
    Of course, my actual belief is we still need both primary care and orthopedic DOCTORS.

    • http://www.facebook.com/profile.php?id=881580563 Kristy Sokoloski

      NewMexicoRam, good point. Even when I had to have surgery on my feet the facility where my Podiatrist does his surgical procedures wanted me to get clearance from Primary Care too before I could have surgery.

    • newheart807

      Now really, isn’t your comparison silly?

      First, you know very well that today’s litigious society demands that a medically compromised patient be initially cleared by an internist or hospitalist. You must practice in a rural area or in one where their are no hospitalizes or internists. In our urban area, I know of no one who refers to a FP for medical clearance for the simple reason that the internist has more training and depth of knowledge.

      Secondly, orthopedic surgeons do have NP’s working with them. They perform most of the initial post-op evaluations which are then seen by the surgeon, they prescribe the medications and follow-up on all lab and imaging data. They assist in the OR, they make sure the materials required for a particular case are in the room and they coordinate post-operative care with the surgeon and the hospital staff.

      As to your point about NP’s doing the clearance exams, as they will require a PhD to be considered part of their training, they most certainly WILL be able to perform evaluations on normal patients and be able to discern if there is any pathology that has not been discovered.

      Last, the combined training and education of the nurse practitioner as of 2013 will equal and in some cases exceed that of the FP.

      If you have serious issues with this trend, my suggestion is that FPs spend an extra year in training and become certified as an Internist and this discussion becomes academic.

      MDB

      • http://www.facebook.com/people/Jason-Simpson/100001631757606 Jason Simpson

        “Last, the combined training and education of the nurse practitioner as of 2013 will equal and in some cases exceed that of the FP.”

        This is a lie. All the DNP programs do is require an extra 1 year of didactics, consisting of such classes as “healthcare theory”, “social medicine” and other irrelevant BS.

        Until DNP programs add a mandatory 3 year residency with REAL clinical rotations instead of BS shadowing without any real clinical responsibility, they have no chance of equaling the training of an FP.

        • newheart807

          “and in some cases exceed” was the comment. There are some NPs whose training is quite extensive and involves issues that are prevalent in patient satisfaction surveys.

          Additionally, I would appreciate it that if you cannot keep your discourse civil, please do not use this site for your vitriol and frustration. I do not appreciate being called a liar.

          • http://www.facebook.com/profile.php?id=762893788 Dave Miller

            I won’t call you a liar, however I will point out that your statement is nonsense. A NP’s primary training is in nursing, not medicine, which is a different skill set. While NPs gain some additional training in diagnostics and treatment, until they complete 4 years of medical training and 3 years of residency, there is no way one can claim their training equals, much less exceeds, that of an FP.

            Addressing the comment about Internists, while they are indeed well-trained physicians, their scope of practice is narrower than an FP, being trained in Internal Medicine. Indeed, there is, by definition, no one with a broader scope of practice and base of knowledge than an FP.

          • Homeless

            The question isn’t who knows more, the question is how much do you need to know to practice primary care.

            While I agree the family physician has a more training and knows more stuff, I don’t feel that extra training is important when dealing with a simple common problem. When things get complicated, I usually get referred to a specialist, and all that training doesn’t matter.

          • ProudOkie

            New,

            Jason has a history of the worst kind of flaming – review some of his old posts. We will see if he can maintain civil discourse this time. He is really fond of ye ol’ pejorative….

        • ProudOkie

          Wow Jason (I remember you) – not “a lie” just a misunderstanding…NP LENGTH of training, even with a DNP, does not exceed or even come close to the length of training of a family practice resident.

        • painslayer

          Will you help us arrange that 3-year residency? The only reason we shadow is that for the time being we can’t find anything better. But things are changing rapidly … and I suspect that some sort of real residency (v. BS shadowing – I agree) will become a reality.

          • Christopher Baumert MD

            Then why not go through the training that has already been established for that reason? medical school and residency. There is no reason to try to duplicate it through a nursing track and create a whole duplicate medical infrastructure, further confusing patients and having them wonder who they should turn to for medical advice.

          • ProudOkie

            In your opinion for sure….that is the wonderful thing about about the free market. Perhaps there is a more efficient, less costly way to do things? Maybe? You should celebrate innovation. Sometimes new things don’t always benefit us – but it doesn’t mean they aren’t excellent alternatives. And if nursing did “try and duplicate it”, that’s okay, right? Why would it not be okay?

          • http://www.facebook.com/profile.php?id=881580563 Kristy Sokoloski

            ProudOkie, no, in my mind it is not ok for Nursing to try and duplicate what is done in Medicine. The reason? The issue of liability. Also, the poster above says that needing to know cell biology while treating and histology are not a must. I take high exception to that, and the reason I do is because needing to know those things helps the doctor figure out which treatments are going to work best for that patient such as those with gout. Didn’t you have to take Chemistry, and Organic Chemistry at some point in your training both in becoming an RN and then as an NP? From the liability standpoint, who is going to take care of the patients of the NP if they do something that could get them in to so much trouble that they lose their license?

          • painslayer

            Because I am 47 and do not have an extra 200K to throw away … on top of my 100+K in nursing school loans. But I sure could afford to spend a couple of years in paid residency to get this much-needed additional training. I have worked in teaching clinics, side by side with 3rd year medical students and FP residents. I am a firm believer that residency and NOT the medical school (v. nursing school) makes all the difference. While it is nice to know cell biology while treating gout, it is not a must. Neither is histology. Hands-on training is.
            As for your skepticism of my “sixth pathway” to medicine … Should we also get rid of DO, DPM, and OD schools? What about off-shore medical schools? Indian doctors?

          • http://www.facebook.com/profile.php?id=881580563 Kristy Sokoloski

            I have to agree with you on the issue of the duplicate infrastructure that would confuse patients further. A number of people think that NPs (not sure about the PAs though) are doctors when they aren’t. And even with the explanation that the NP is just that that patient is still always going to think that they are the doctor. How does one change the way patients think so that they can stop thinking of NPs are not the actual doctor?

          • http://www.facebook.com/beverly.nuckols Beverly Nuckols

            It’s good that you recognize the benefit of residency. You should get the training — study medicine if you want to practice medicine.

          • ProudOkie

            Man…..and again – nice worldview; but there are others outside the “Southern comfort zone”….

      • http://www.facebook.com/beau.ellenbecker Beau Ellenbecker

        “I know of no one who refers to a FP for medical clearance for the simple reason that the internist has more training and depth of knowledge.”

        Ummm…no. Internal medicine = 3 years. FP = 3 years

        Internists spend more time in the ICU and their choice of sub specialty fields. FP’s spend more time in ambulatory care, pediatrics, and OB/GYN. Many do just as many cardiology and general ward months. ICU patients aren’t getting pre-op’d

        “Last, the combined training and education of the nurse practitioner as of 2013 will equal and in some cases exceed that of the FP.”

        Not even close. An FP resident averages over 70 hours a week for 3 years of residency. Most NP programs require less than 700 hours of clinical time. An FP Intern surpasses that amount in less than four months.

      • ProudOkie

        Based on sheer hours, NP clinicals have never and will never match FP residency – we do have four years of undergrad nursing prior to our NP education. Many of us also have years of experience as an RN…

        • Christopher Baumert MD

          I have never been an RN and wouldn’t trust myself to be one. I thank nurses every day for everything they do for me and my patients. I applaud your years of service to patients, and I know you understand that we are part of a team caring for them, and just as on a football team, different players have different roles, and are trained as such. I think lineman do some of the most important work of the offense…but I would hesitate to let thm play quarterback.

          • ProudOkie

            Hi Christopher, thank you for the kind words! You seem to speak from a position of automatically always being the quarterback of “the team” I assume. This is not your decision to make as customers frequently choose other health care providers to be their quarterback. Everyone seems to want to be the star of the show and you shouldn’t be any different. But I have the education, knowledge, and experience to be a “quarterback” as well to use your example. I have never had a family physician, in all the years I have visited blogs, acknowledge the fact that NPs all over the country are taking care of customers independently without physician involvement. They are doing this successfully, safely, and economically. This is not hearsay or opinion Christopher, as with the physician SHOULD be the quarterback. It is care in action, success that has already been proven; with 40 years of pudding! It is already happening and HAS BEEN happening. What about all of those hundreds of thousands of patients who are ALREADY being cared for without physician involvement – Are they all ignorant? misled? Do none of them have another choice? Forced into a system of splintered “second rate” care? We all know the answers are no. NPs are “doing what they do”. The only thing keeping us from providing the care we are so skillfully qualified to provide (remember, I’m speaking from a position of already doing this for years so there is no questioning or debating the quality of care) are the state medical associations. The last gasp effort of the AAFP to reign in NPs is the team concept of which you speak where only the physician can lead. I work in a team in my privately owned practice already and have for years.This will not be the only model of care and family physicians and medical societies will not squelch the free market which they so dearly love in the end. This isn’t about patient safety either. We all KNOW this. As I have posted in the past, no public health issues because or horrid maiming NP care. There really is no argument left. The elephant in the room is the FACT that the patient safety issue has already been resolved and WAS resolved years ago. It was resolved when NPs began caring for patients independently with zero issues; it was resolved when you went on vacation and left “your” NP on their own to take call and see everything that walks in the door. Consumers are just now beginning to grasp the fact that NPs HAVE been providing independent care for years – even if there is a physician in the office. So all of the old arguments, safety, qualifications, “don’t know what you don’t know”, etc., are all slowly fading away as the curtain is pulled back. And in the end, we will all have plenty of people to care for.

      • FPdoc

        In my “rural” area of about 120,000, I have partialists (specialists) asking me to clear patients for surgery all the time, and we have no shortage of internists. I am not an internist because I like to do well-woman and well-child care. If we move to all internists, will we send all of our skin biopsies to dermatologists — FPs do these. I don’t know many internists who do. Will all of our lacerations need to go to the ER? I suture and do I and Ds in my clinic. I do simple fracture care, place IUDs, remove toenails AND take care of CHF, COPD, diabetes, depression, and much more. You may think we’re obsolete, but I don’t think I’m alone in saying that we lowly FPs still play a unique and vital role. Oh, and I follow my own patients in the hospital, too.

        • querywoman

          Oh gee. I did not realize that family practitioners do skin biopsies. My internist doesn’t! What is so hard about a skin biopsy?
          In the hospital with pneumonia recently, my various serious eczema was flaking off. I showed some to her once and she said, “I’ll leave that alone, since I don’t know much about it.”
          Didn’t ask her to do anything, just look. Kept forgetting to show to pulmonologist.
          I do have a competent dermatologist, but I don’t understand why skin, so obvious, is so incomprehensible!

      • Christopher Baumert MD

        Interesting that an MD requires 10,000 patient contact hours and an NP requires only 500…

        • ProudOkie

          And again….(getting old) that is a total untruth and the sad part is, you know it.

    • newheart807

      Do you practice in a rural area? Are there competent internists in your area?

      As an urban practicing physician (Dallas, Texas), all medical problems for surgical clearance are seen by an internist as the FP’s “don’t want the liability”. Furthermore, given the litigious environment in which we practice, like it or not, the higher level of care is that of an internist so in patients who I believe to be more than an average risk, I refer to an internist for clearance.

      As to your emotional comments regarding your diagnostic prowess, they are irrelevant to the issues stated in the article. Where they are relevant is that we DO have orthopedic PA’s that are certified and do much of the office work and post-operative evaluations. I see ALL my patients but my PA surely lightens the load and enables our folks to be seen on time, otherwise, they do not get charged for their visit.

      Should you choose to respond to the article, please consider the following:

      Several questions:

      1. Of the patients you see, how many do you refer out as a percentage of your practice, who do not have things for which a NP can care?
      2.How many patients do you see a day and what is the waiting time to see you?
      3. Do you deliver babies?
      4. Do you treat non-displaced fractures?
      5. Do you do pelvic examinations and well woman care?
      6. Do you evaluate your female patients for breast cancer?
      7. Do you do well baby care?
      8. Other than acting as a monitor, do you treat and set new levels for your diabetic patients; that is, do you manage all insulin level and balance care?
      9. Are you a member of an independent group or are your hired and salaried as an employee?
      10. Do you have the financial wherewithal to manage and support the IT necessary to practice in accordance with government guidelines?

      Thank you for your remarks,

      MDB

      • http://www.facebook.com/beau.ellenbecker Beau Ellenbecker

        “As an urban practicing physician (Dallas, Texas), all medical problems for surgical clearance are seen by an internist as the FP’s “don’t want the liability”. Furthermore, given the litigious environment in which we practice, like it or not, the higher level of care is that of an internist so in patients who I believe to be more than an average risk, I refer to an internist for clearance.”

        I don’t think you look around much. I practice an the same urban environment (Fort Worth). I am an FP as are several of my colleagues. We all do pre-op clearance.

  • http://womanfoodshinyobjects.wordpress.com/ Brian Stephens MD

    some people think they dont need a primary care doc, until they try to go through our ridiculous healthcare system without one.

    The moment the specialist and the system send them around in circles and through unnecessary test and procedures with an ever expanding list of medications…. and no one is talking to them. They seem to find a use for this lowly family doc once again.

    • http://www.facebook.com/profile.php?id=881580563 Kristy Sokoloski

      Dr. Brian, please explain why it is that there are some out there like some posters we have seen on here over the years have had such bad experiences with Family Medicine (or other Primary Care Providers for that matter) doctors? So much so that they vow to never use them even for situations like you describe? Also, why do some feel that they get more help and care from their specialists than they do a Primary Care Physician? Finally, what needs to be done to make everyone (yes, even including the patients) see that having a Primary Care Physician is so important? The reason I ask this is because maybe whatever some of the answers are it may help everyone to see just how valuable these doctors are? As I posted in commentary to another blog post I have a lot more empathy now for what Primary Care Physicians do because of the time my relative spent in the hospital back in mid January.

      • http://womanfoodshinyobjects.wordpress.com/ Brian Stephens MD

        good point.
        I do believe that family medicine has suffered from a horrendous watering down of our specialty and many are to blame for this (us family med docs included.)
        we drank the cool-aid, allowed our visits to dwindle to 7mins, and allowed our fear of malpractice to replace good medical judgement to the point that Primary care has become referral machines.
        ugly… ugly… ugly….
        and yes, PAs and NPs can do this, just fine.

        But I for one am trying to practice in a different vision. I know I’m not alone and I feel strongly that the disgust that PCPs have with primary care is because most PCPs long for treating patients in a better way.
        And interestingly, I find many patients WANT their Primary care doc to treat most of their problems to be their confidant.
        Something that just can not happen without “TIME.”

        So, to answer your question, yes, many family Medicine doctors and the AAFP included have lost their way. However, it is not dead. Their are still a few of us that would like to see Family Medicine return to what is at the heart of our specialty and that is to be our patients ADVOCATE and their medical confidant.

        When AAFP realizes that our best role in healthcare is that of Advocate and we fight for that…. then we might be able to save ourselves.

        exm:
        one of the best compliments I have gotten from a patient was when I consulted a neurosurgeon in the hospital for an obviously needed surgery. A few hours later the Neurosurgeon called me in a huff because the pt “obviously needs the surgery but they will not do anything until they talk to you first.”
        Im ok with that….

        • http://www.facebook.com/beau.ellenbecker Beau Ellenbecker

          7 minute appointments! That is horrid. How could one provide care? Our minimum appointment length is 15 minutes, which I estimate is about 11-12 minutes with the patient and 3-4 minutes with the EMR. I would move to concierge if I ever was asked to see patients in less time.

          • newheart807

            Several questions:

            1. Of the patients you see, how many do you refer out as a percentage of your practice, who do not have things for which a NP can care?
            2.How many patients do you see a day and what is the waiting time to see you?
            3. Do you deliver babies?
            4. Do you treat non-displaced fractures?
            5. Do you do pelvic examinations and well woman care?
            6. Do you evaluate your female patients for breast cancer?
            7. Do you do well baby care?
            8. Other than acting as a monitor, do you treat and set new levels for your diabetic patients; that is, do you manage all insulin level and balance care?
            9. Are you a member of an independent group or are your hired and salaried as an employee?
            10. Do you have the financial wherewithal to manage and support the IT necessary to practice in accordance with government guidelines?

            Also, you did not address any of the issues raised in the body of the editorial. Answering the above queries honestly will enable you to formulate a relevant response.

          • Christopher Baumert MD

            A great list that shows just how much the primary physician cannot do everything alone these days…I have never once referred a patient for diabetes management or well-woman care, but I certainly can’t do everything myself. A perfect reason to reimburse family physicians more and embrace the Patient-Centered Medical Home (PCMH) model and give me extra funding for lower-cost personnel to do my splinting and my IT work so I can perform my job better.

            Hurrah for your comments – and now don’t forget to advocate with your legislators for more reimbursement for family physicians and their practices so that they can all become PCMH’s!

          • ProudOkie

            In our state Medicaid program, there are about 700 practices that are PCMH/Medical Homes. Less than 40 of those are Level III PCMHs – the highest designation…. And yes, of all the Physician/PA/NP clinics that are credentialed by Medicaid, our privately owned NP practice is one of those Level III homes! It’s not the best way to deliver care – but it is an acceptable alternative..

          • http://www.facebook.com/luchiayoung Luchia Young

            Exactly. How do you provide care? Just double booked by the ones answering the phone in the front. That leaves about 7 minutes or less.

        • Norman M Canter MD

          Rather than “docs”, try Drs. or MDs ..more respectable and takes the same space. If we do not respect ourselves who will respect us?

        • Christopher Baumert MD

          Agree Brian – and perhaps my patient, in consultation with their family, realizes they really don’t want to go through the surgery after all (but might not be given the chance to say so in an arena where their personality and family life is not known as it is from my continuity care)

      • http://www.facebook.com/beau.ellenbecker Beau Ellenbecker

        You ask a lot of questions there but I will help:

        Everyone can have a bad doctor or a bad day. Some doctors don’t keep up with their studying. Some patients don’t like to face the reality of their situation and are then upset when they meet a PCP that doesn’t give into their demands (I had a patient call upset that I didn’t give her daughter antibiotics for her viral infection. Despite reassuring and educating, she was still upset enough to think about moving to a new provider). Personality goes along way in developing a patient-provider relationship. Some times people just don’t gel. On the whole I think the people you note are few and far between. Also those with complaints tend to speak loudest. I have met many a patient that are unhappy with their specialist just like their PCP. Let me pose this to you though. Did it occur to you that some people may be more satisfied with the specialist because he had a 40 minute visit dedicated to only one problem? Most patients know that the referral doctor can not (or will not) treat other unrelated issues. They don’t bother to ask them. I have 20 minutes to refill 7 medications and discuss three medical problems. That specialist has 30-40 minutes to discuss a single issue of which I may have already provided the diagnosis (and possibly treatment) for.

        • http://www.facebook.com/profile.php?id=881580563 Kristy Sokoloski

          Actually that does help a lot in answering the questions. What I do know for sure is that the job you all have is not an easy one and I thank you for all that you do. The part about what most patients know when it comes to specialists I find especially intriguing and wonder what then must be done to let the others who don’t know this learn to know and accept that fact. And that as you said that the referral doctor cannot or will not treat other unrelated issues. Yes, a lot of work stll needs to be done. Thank you very much.

      • Christopher Baumert MD

        Also perhaps because Family physicians like me are not reimbursed nearly as well as specialists and thus sometimes cannot spend the time we need with our patients to best coordinate care and address our patients’ needs fully. There is so much behind the scenes unpaid work we do (discussing labs over the phone, taking home call), and yet the U.S. reimbursement system is skewed towards reimbursing for procedures that could have been prevented had it been for a few more visits with me and recognition of the real issues that are keeping these people from achieving healthy lifestyles.

        • http://www.facebook.com/profile.php?id=881580563 Kristy Sokoloski

          When I watched my relative’s PCP (who is an FM doctor just like mine) take care of her while she was in the hospital the reimbursement factor came in to mind as well. And I just found myself shaking my head and thinking they need to be paid better because this is just one of the many things that they do for their patients (for those that still do rounding on their own patients when in the hospital).
          You are also correct about all the behind the scenes unpaid work that goes on in offices such as yours throughout the country. I got to see some of that when I went on externship in an FM office when I was going to school for Medical Assisting. In the 6 weeks I spent there I got a huge understanding of what really goes on in the office setting, something that so many just don’t get. Thank you Dr. Chris and to all of your colleagues around the country for all that you do for your patients.

          • http://www.facebook.com/luchiayoung Luchia Young

            Yes, remimbursement is based on face to face time but it is impossible to provide care without all the behind the scenes phone calls, reviewing past med records, labs, test, etc which can take much more time than the face to face time.

        • http://www.facebook.com/luchiayoung Luchia Young

          This is well said.The payment system is upside down. The generalist no longer exists….he/she has almost needed to become a specialist at everything……..

    • Homeless

      I have already gone through the healthcare system with and without a primary care doctor and navigating the system without a PCP was more productive and less stressful.

      • http://www.facebook.com/profile.php?id=881580563 Kristy Sokoloski

        Homeless, how was not navigating the healthcare system with the help of a PCP much more productive and less stressful? Also, what happens if you need to see a specialist and they want to talk to your PCP about the care you are getting, or if you need to have surgery that requires clearance from a doctor? Not all facilities on the forms that they require to be filled out to be cleared for surgery can be filled out by a Nurse Practicioner or a Physician’s Assistant (depending on the State law of wherever someone lives) although I heard once recently some are accepting that it be filled out by a Physician’s Assistant or Nurse Practicioner. I could see where that could work for someone who doesn’t have a lot of health problems that need to be managed, but if someone does and it’s a complicated history at that they would need to have a doctor do that for them.

        • Homeless

          When I got sick, my PCP failed to recognize my illness, belittled me for complaining about symptoms and didn’t provide me with the care I needed. By the time I referred myself to a specialist, I had developed several secondary issues, including insomnia, depression with suicide ideation, and weight loss.

          I saw several specialist at a hospital based medical center who worked together to solve my problems, and helped me with my secondary issues. This was before EMR. More productive to skip the PCP…less stressful because I get the treatment I need.

          The next PCP I saw failed to read my chart, told me I didn’t know what I was talking about and prescribed the wrong treatment. I went back to a specialist for proper treatment and learned a valuable lesson. More productive to skip the PCP…less stressful because I get the treatment I need.

          I live in a state where Nurse Practitioners can practice independently. I often seek medical care at a clinic staffed my NP’s for those common limited issues. I have four chronic issues…I have been told my family practice doctors I can only discuss one at a time. If I don’t manage them, no one will.

          • http://www.facebook.com/profile.php?id=881580563 Kristy Sokoloski

            Thank you for explaining. I am sorry to hear that you went through all that. However, I am glad that you found something that worked for you so that you could get the care you need. Are any of your conditions ever going to require some kind of surgery?

          • Homeless

            I am sure if someday I am faced with surgery, the surgeon won’t tell me he won’t do the surgery because there is no family medicine physician to do a physical. And if the family physician disappears, someone else will do pre-surgery physicals.

        • ProudOkie

          I clear all of my patients prior to surgery at my privately owned NP clinic. I treat them as a family physician would – if they need more, refer to internist.

          • http://www.facebook.com/profile.php?id=881580563 Kristy Sokoloski

            ProudOkie, that’s great that you are able to do that. How many of those patients that you get to clear for surgery are ones that have multiple chronic health problems that make for a very complicated medical history?

          • ProudOkie

            Good Morning Kristy,

            I understand why you are asking the question. Most of my patients who need clearance are stable from a CP standpoint. I have many older patients in my clinic who have multiple chronic issues – an example would be a 63 year old patient with severe PVD, chronic angina, emphysematous COPD, and chronic osteoarthritic pain. Her providers include a wonderful cardiologist and me. Should she need surgery, for say an endarterectomy, she would deserve a full evaluation by the cardiologist I refer to. She shouldn’t be cleared by me, a family practice physician, or a PA. And, I know, almost all generalist physicians wouldn’t attempt to clear her.
            So, what is an example of the type of patient I would clear for surgery? Well, I manage all of my own diabetics – I refer none out. So let’s say I have an adult diabetic with microalbuminuria, and mild venous insufficiency, along with controlled hypertension who needs a hip replacement. I would evaluate this patient (considered complex by anyone I would assume) and clear (or not) for surgery. I would make pre/post surgical recommendations to the surgeon as well. I frequently utilize Goldman’s criteria for clearance and some other CP risk indexes. In my opinion, the “pre-surgical clearance” is nothing more than a specialist asking the one person who knows the most about the patient, me, the primary care delivery point, if there is anything they should be concerned about before operating. No one knows more about this patient than me – their medications, quirks, chronic issues, and fears. Once they have my recommendation, they will either accept it, ask more questions, or request further specialty evaluation (internist or other) based on something about the patient they are not comfortable with.
            The “complex” part is subjective to many physicians and NPs and I know it is a “sticking point” with the AAFP and many physician groups who feel NPs are only capable of managing “simple” cases while the “complex” cases should be referred to an internist. I do lots of eye rolling when I read on here and other blogs when physicians and patients alike make passing comments about NPs only being capable of managing minor issues – the patients who say it are clueless and the physicians who say it know better. The truth is and always has been – NPs manage complex healthcare issues. We all know this, we just like to pretend we don’t. Without me in my area, many patients would have no access or their access would be greatly reduced.
            I hope none of this sounded offensive. If any of it does, I apologize in advance. Thank you family physicians for all you do.

          • http://www.facebook.com/profile.php?id=881580563 Kristy Sokoloski

            No, it’s not offensive at all. Thank you for answering my question.

          • http://www.facebook.com/luchiayoung Luchia Young

            I have had patients that need several clearances….maybe cardiac, pulmonary, etc. but will only clear for their speciality. I am expected to put it all together as the primary and officially sign the final clearance.

          • http://www.facebook.com/luchiayoung Luchia Young

            As for me and surgical clearances….. all of them. Most of the patients I see have 7++ chronic diagnoses easy. Probably more like 10+++.

          • http://www.facebook.com/profile.php?id=881580563 Kristy Sokoloski

            ProudOkie, you mentioned that if they need more care then you would refer them to an internist. Why not recommend to them that they permanently stay under the care of the internist since they need more because of the complicated medical history? Just curious.

          • http://www.facebook.com/luchiayoung Luchia Young

            Simply internal medicine will not perform your woman’s health for just one item. They won’t fix the bronchitis, UTI, or rash or anything that is not internal medicine.

          • http://www.facebook.com/profile.php?id=881580563 Kristy Sokoloski

            Luchia, The Internal Medicine doctor may not perform the well woman visit for just one item but they are trained to take care of the primary care needs in strictly adult patients such as a regular annual well woman visit and physical if they choose to do so. As for the fixing the bronchitis, UTI, rash, or anything else that is not Internal Medicine related I find that very interesting. The reason is because in the short time that I spent with IM they did help some problems I had at the time (don’t remember what they were at the time, but as I stated before when it comes to comfort level I prefer FM doctors.

            I have had my UTIs taken care of before by my gyn, and in fact that is who took care of most of them. I haven’t had a UTI in a several years thank goodness as they are quite uncomfortable to deal with. But back to your statement about them not fixing the various things you mentioned or anything unrelated to IM I wonder then why it is that there are some people out there that prefer IM doctors over FM doctors? I have my FM PCP’s back.

          • http://www.facebook.com/luchiayoung Luchia Young

            The way I see it now with universities shoving out NPs anyway they can there needs to be a stairstep NP level. I was a nurse many years before becoming a
            FNP in 1999. Since as a FNP I have been in the military, Indian Health Service, frontier health, rural health, community designated health, worked in a few different states, done hospital inpatient, etc, etc, school health, inner city. You can not compare my experiences with a NP that worked OB for 2 years, did the 750 hrs of clinical/practicum, and now has the title of FNP.

    • newheart807

      Are you saying that the only reason today for a FP is to perform an administrative function in passing the patient on to the specialist which they choose to see in the first place?

      Are you suggesting that the role of the FP is to “talk to” the patient, as if NO ONE ELSE can perform that medical function?

      If the use for the FP is as you seem to suggest, then it appears that you support the position taken in the blog.

      As medicine in America becomes more and more centrally controlled, the need for the FP and the cost to train one will be superseded by the need for “physician extenders” and internists. What we ARE dealing with here is a cost-benfit analysis, and as the scope of practice of today’s American FP becomes even narrower, that equation has a negative number.

      MDB

    • Norman M Canter MD

      Referring to doctors/physicians as “doc” is demeaning and pejorative in my opinion. Think of the time and effort it took to become an MD!

      • http://www.facebook.com/luchiayoung Luchia Young

        I see “doc” and as a term of respect and love coming from the military and probably then into civilian life. I think that still holds true. Actually the term should be physician. There are many doctors and not doctors of medicine.

  • http://twitter.com/EdKwood Edward Wood

    To become a nurse practitioner in Oregon now requires a doctorate. Another leadership fail.

    • http://www.facebook.com/profile.php?id=881580563 Kristy Sokoloski

      The same is going to be occurring in other States throughout the country as well.

  • http://onhealthtech.blogspot.com Margalit Gur-Arie

    Properly manufacturing a quality stainless steel fork could cost a dollar or more, while manufacturing a plastic fork costs less than a penny and “the tasks required of each are very similar”. And when we have a “flood of people” wanting forks, plastic is the way to go. Or is it?

    What is “required” and what is actually delivered may not be quite same. Try eating steak with a plastic Walmart fork…. but then again maybe some people shouldn’t expect to ever eat steak.

    • http://womanfoodshinyobjects.wordpress.com/ Brian Stephens MD

      “We are to poor to buy Cheap things.”

      In my experience, PAs and NPs make referrals and order test at a much higher rate than I. Seems to me that the “cost” of this cheap care is pretty steep indeed.

      Im not bashing NPs and PAs… they defiantly have a place in healthcare, but it is foolish to pretend that the levels of care are equivalent. if they are, then why are we not making all NPs and PAs go to medical school and just stop this silly arguement?

      • http://www.facebook.com/people/Patricia-Kelly/56303697 Patricia Kelly

        I would like to see some kind of reasonably well done study that demonstrates NPs and PAs order more diagnostic tests and referrals. The studies I have seen indicate that they seem to model the test ordering behavior of their supervising or collaborating physicians, just like groups of physicians model similar test ordering behaviors.

        I do know of a study being done on this subject.

        • http://womanfoodshinyobjects.wordpress.com/ Brian Stephens MD

          I did say it was “my experience” and I concede I have no such study to quote. would be nice, but such a study would be extremely hard to do in an unbiased way.
          Your probably right, I suspect there is some mirroring of the groups that PAs and NPs work for.
          maybe that is a commentary on how crappy many primary care offices are run these days? i dont know….

          I can only speak for my experience and I stick by what I said. a Good primary care doctor can and should head off many unneeded referrals and procedures.

        • Close Call

          Here’s one:

          http://www.acponline.org/clinical_information/journals_publications/ecp/novdec99/hemani.htm

          It’s old and not the one that first came to mind. They’ve done a more recent one, showing the same thing – referrals and imaging are increased w/ NPs. Labs, not so much. I can’t seem to find it though! Will keep looking.

          When Kaiser starts replacing their family medicine and internal medicine docs en masse with NPs, then I’ll believe they’re a good deal. But Kaiser isn’t doing that. They’re aggressively hiring FPs. They must know something we don’t.

        • ProudOkie

          There are some NP studies in process concerning this very topic – as many of you “believe” NPs refer more, I “think” it depends on the provider. I also “think” I refer much less than my physician colleagues in my area – and we see exactly the same type of patients.

    • newheart807

      Your last sentence is precisely the point and the end result of a single payer system.

      The creative destruction of family medicine is merely a waypoint in that process.

      MDB

  • http://www.facebook.com/easton.jackson Easton Jackson

    Mighty confident words from the subspecialist. What will you say when orthopedic PA’s are competent to do everything that you do? It’s coming.

    “A well-trained nurse practitioner or certified physician’s assistant
    working under the supervision of board certified orthopedist can and does
    provide this type of equivalency.”

    • newheart807

      How silly!

      When orthopedic PA’s are certified to do what we do, they will be called Board Certified Orthopedic Surgeons.

      Enough of this nonsense. If you read the article AND you are a family doctor, then consider the following:

      Several questions:

      1. Of the patients you see, how many do you refer out as a percentage of your practice, who do not have things for which a NP can care?
      2.How many patients do you see a day and what is the waiting time to see you?
      3. Do you deliver babies?
      4. Do you treat non-displaced fractures?
      5. Do you do pelvic examinations and well woman care?
      6. Do you evaluate your female patients for breast cancer?
      7. Do you do well baby care?
      8. Other than acting as a monitor, do you treat and set new levels for your diabetic patients; that is, do you manage all insulin level and balance care?
      9. Are you a member of an independent group or are your hired and salaried as an employee?
      10. Do you have the financial wherewithal to manage and support the IT necessary to practice in accordance with government guidelines?

      If you answer in the negative for most of these, then please tell me what you can do that is cost effective and provides added value that a well trained PhD NP cannot do?

      By the way, he or she will now also be called Doctor. How does that work for you?

      • http://www.facebook.com/people/Jason-Simpson/100001631757606 Jason Simpson

        There’s already several programs in Africa to use non-MDs as “field surgeons” to do simple procedures like lap cholys and bowel obstructions without any doctor present.

        That will be coming to the USA eventually too.

        Surgeons may be protected more than primary care, but their day of reckoning is coming as well.

        • newheart807

          I would suggest that, at least not at the present time, will the standards in Africa be accepted as “the standard of the community” in the United States.

          “Day of reckoning” and other emotive comments aside, I would still ask that you respond to the above queries.

      • http://www.facebook.com/beau.ellenbecker Beau Ellenbecker

        1. I refer less than 2%, usually they are for confirmation or optimization of treatment (I.e. – history tells me they have epilepsy but they need EEG and appropriate seizure meds). I would say an NP or PA would be no more able to handle what I refer.
        2. Between 16-24, wait time is less than 10 minutes
        3. Use to, don’t desire to anymore but could if I wanted
        4. Use to, don’t see them often anymore as I live in an area with high specialist load
        5. Yes, daily
        6. Yes daily
        7. Yes, daily
        8. Yes, daily. I also focus much more on nutrition and exercise than the average provider. None of my diabetics see specialists for diabetes.
        9. A large group, currently salaried but only for the next year or so
        10. Not without the group.

        An MD/DO has more patient care training than any NP or PA. They also have more education than either as well. It makes a difference. I have worked with many NP/PA’s, some are excellent some are not. But in my experience the amount of NP/PA’s treating patient incorrectly and/or inappropriately is higher than that of the MD/DO’s.

        You asked, I answered. I am not worried about NP or PA replacing me or my colleagues. I fully plan to hire a PA or NP within the year as well. Most are excellent providers.

      • southerndoc1

        What are you going to do with all this “data” you’re collecting? (You do know you come across as a crazy person?)

      • ticktickdoc

        Sorry Newheart, but your questions are poor attempts at getting reactionaries going. Passive aggressive nonsense. Taking a snapshot of the present and forming leading assumptions is as pertinent as reading the National Enquirer.

        Any discipline of medicine could have it’s training thinned out and be made more cost effective. Nurses across the world could easily be trained to do a bulk of any specialty’s work, yours included. Surgeons are not ‘geniuses’ or some rare breed of human that have golden hands. They chose a path.

        I find it intriguing how many specialists show their true colors on forums. It’s amazing how many have that fractured child still hiding in their big boy skin. They are just begging to show the world that when their mothers told them they were ‘SPECIAL’ that she wasn’t lying. These statements that claim they have working knowledge about the path they DIDN”T have the guts to go down are only hurting themselves.

        It’s true. Agendas are eroding FM. Politics and business analysts are destroying healthcare.

        For the little picture specialists that want to play armchair speculator: Who do you think is next? Try asking WHY?

        Do you really think big business is going to leave you alone if they succeed in taking down the field that has the MOST working knowledge in the industry?: Family Medicine.

        If you help the analysists dumb down Family Medicine and farm it out to the cheapest provider you are lighting the fuse to destroy the foundation. The foundation that your room sits on.

        It’s about quality, not numbers. Why not just have NP surgeons if it costs less? Let them have 75% of the training and pay them half as much. Why wouldn’t they do just as well of a job as a surgeon. It’s not like the scope is all that wide right?

        Heck…let’s train MA’s to do the physical part of surgery and just consult about the procedure. Specialists can get paid 75 % less and decide what needs to be done, and the infantry will do the grunt work. Please tell me what YOU can do that a well trained MA PhD cannot do? Where is your value if we reclassify what it takes to perform surgery?

        Or do you think the field of medicine needs….*gulp*….QUALITY.

        Do yourself a favor…quit thinking about the little picture you are seeing now and try thinking six moves ahead. Help defend the strong resilient foundation so that you can stay safe and cozy in your room. Or you can continue to pontificate and come across like Thurston Howell and get your comeuppance in time.

        How about we just alleviate the world of all primary care and let the specialists be “know it all’ practitioners. That would be painful to watch.
        “Wait…it’s fourth down…but I can’t….PUNT?! NOooooooooo!”

      • SCFamilyDoc

        I’ll take a stab at this one…

        1. Of the patients you see, how many do you refer out as a percentage of your practice, who do not have things for which a NP can care? Easily less than 5%, I would say I usually refer out 2-3 patients per week which includes patients whose sole purpose in coming to see me is “I want a referral”
        2.How many patients do you see a day and what is the waiting time to see you? 17-20, I keep 4-5 same day slots open so waiting time is usually about 1 day give or take. As far as appt time v. when I enter the room, usually within 5 minutes.
        3. Do you deliver babies? No, but that’s a local hospital policy
        4. Do you treat non-displaced fractures? Yep
        5. Do you do pelvic examinations and well woman care? Yes
        6. Do you evaluate your female patients for breast cancer? Of course
        7. Do you do well baby care? Yep, I also still do nursery rounds
        8. Other than acting as a monitor, do you treat and set new levels for your diabetic patients; that is, do you manage all insulin level and balance care? The only diabetics I refer out are those with insulin pumps, I start, adjust, and stop all other DM meds both oral and injectible
        9. Are you a member of an independent group or are your hired and salaried as an employee? Employed by a hospital system, production based pay
        10. Do you have the financial wherewithal to manage and support the IT necessary to practice in accordance with government guidelines? As my clinic is less than 1 year old no, but give it a year or two and I probably could

      • http://twitter.com/clicky03 Danny

        The words “irony” and “double-standard” are foreign to newheart807.

        Irony: I, a Board-Certified FP, must answer questions formulated by newheart807 (an orthopedic surgeon) and have a sufficient number of “yes” responses, in order to justify my “value” as a Primary Care Practitioner to newheart807, who is non-Primary Care Practitioner.

        Double-standard: newheart807 recognizes the potential for FNPs/PAs to operate on the same level of FPs (after sufficient training) while still being FNPs/PAs, but fails to recognize the potential for orthopedic PAs to operate on the same level as Orthopedic Surgeons (after sufficient training) while still being orthopedic PAs.

        I will answer all your questions once you answer my one question:

        How can you reconcile the logical fallacy inherent in the fact that you want others to agree with your ideas and viewpoints, while you hold to irony and espouse a double standard? (Which in itself is ironic).

        • Suzi Q 38

          I think it is a little more complex to cut through skin, muscle, and bones in the OR, rather than to see a patient of an FP in a clinic setting.
          I am not advocating that an NP replace the PCP, just see the patients that are no so complex with regard to medical conditions.

      • http://twitter.com/clicky03 Danny

        The words “irony” and “double-standard” are foreign to newheart807.

        Irony: I, a Board-Certified FP, must answer questions formulated by newheart807 (an orthopedic surgeon) and have a sufficient number of “yes” responses, in order to justify my “value” as a Primary Care Practitioner to newheart807, who is a non-Primary Care Practitioner.

        Double-standard: newheart807 recognizes the potential for FNPs/PAs to operate on the same level of FPs (after sufficient training) while still being FNPs/PAs, but fails to recognize the potential for orthopedic PAs to operate on the same level as Orthopedic Surgeons (after sufficient training) while still being orthopedic PAs.

        I will answer all your questions once you answer my one question:

        How can you reconcile the logical fallacy inherent in the fact that you want others to agree with your ideas and viewpoints, while you hold to irony and espouse a double standard? (Which in itself is ironic).

  • ninguem

    If the midlevels are such a great cost-saver and all that, why aren’t they a key part of healthcare in the UK’s NHS, in Canada, Continental Europe?

    • http://womanfoodshinyobjects.wordpress.com/ Brian Stephens MD

      Because they are not.

    • newheart807

      They are. I suggest you check your facts.

    • newheart807

      The “midlevel” in these areas IS the family physician. The Internist acts as a consultant only. As stated in the piece, the FP’s in the areas you note do most of the things you do not.

      Consider the following:

      1. Of the patients you see, how many do you refer out as a percentage of your practice, who do not have things for which a NP can care?
      2.How many patients do you see a day and what is the waiting time to see you?
      3. Do you deliver babies?
      4. Do you treat non-displaced fractures?
      5. Do you do pelvic examinations and well woman care?
      6. Do you evaluate your female patients for breast cancer?
      7. Do you do well baby care?
      8. Other than acting as a monitor, do you treat and set new levels for your diabetic patients; that is, do you manage all insulin level and balance care?
      9. Are you a member of an independent group or are your hired and salaried as an employee?
      10. Do you have the financial wherewithal to manage and support the IT necessary to practice in accordance with government guidelines?

      The answer to all these queries in the UK is usually yes. In fact, mid-wives deliver many babies as most babies are normal deliveries.

      So if you do not do any of these things AND you are not employed by a hospital or an insurance company, then what do you do that a well trained PhD NP cannot do?

      That is the question. What is your value-added statement in an age where in which you are referred to as “a downstream vendor”? Vitriol and emotional tantrums will no longer cut it. Unless and until you can answer the above in the affirmative, then the process of creative destruction will continue its unstoppable march across your path with the results suggested in the last paragraph of the blog.

      • Marni

        If you’re going to write such inflammatory stuff, at least try to get your facts right. The degree is a DNP, not a PhD. Also, FP and internal medicine residencies are both 3 years.

    • ProudOkie

      They are. I don’t know about mid-levels, but do know about NPs – do a google search for “Nurse Practitioners Canada”….

  • drgg

    Who the H*** wrote that NY times article editorial? The fact is that everyone’s job can be delegated.
    In fact CEO’s jobs can be delegated too. After all being a CEO is not necessarily a difficult job. It can be delegated.
    Monty python said–how to play the flute? Just blow on it and move your fingers up and down. Right?

    • http://onhealthtech.blogspot.com Margalit Gur-Arie

      Read that article, and all similar rants, carefully. This type of “medicine” is for the legendary influx of uninsured masses, people that live on reservations and Medicaid members. This modus operandi where medicine is practiced by pharmacists, nurses, grocery stores and “trusted community aides” is not intended to be used by the writers of NYT articles, or any other planners of health reformation.
      This is an attempt to create two systems of care, separate but equal or equivalent, whatever that means, with a constant barrage of divisive messaging to frighten folks into inaction. I find it distasteful, to put it mildly.

      • ProudOkie

        The “uninsured masses, people that live on reservations, and Medicaid members” will all be just fine as long as they have access to a qualified provider. And, Margalit, I am much more than a plastic fork and will place my clinical skills, diagnostic ability, ability to generate “differential diagnoses” and sheer ability to treat whatever comes in the door up against you any day of any week of any year. I just get worn out with the rhetoric spouted by you and others. It makes me smile to know you are even talking about NPs and taking the time to compare yourself to us…..stainless steel vs. plastic – I’ve heard it all now. Do you think because you showed up in my clinic or city that all of my patients would rush to you? It would never happen. They would stay right where they are with full knowledge of what type of licensed individual is caring for them.
        I semi-apologize for being so snarky, but you are so demeaning and hateful to the hundreds of thousands of NPs in this country – most of whom see patients without any constant oversight.

        • http://onhealthtech.blogspot.com Margalit Gur-Arie

          I apologize if you perceive this as demeaning, but you shouldn’t. I am NOT a doctor, so I have no dog in this fight.

          For better or worse, we decided to require certain education attainment and licensure from those entrusted with life/death decisions of individual people. Medicine is not unique in this respect. I am pretty sure that there are people who can argue in court rather well without going through law school and without taking the bar exams. I am also certain that some folks can fly jumbo jets without taking pilot exams. I know for a fact that many people can write software code without a degree in engineering (and this one is unfortunately allowed).

          The point here is not to attack the abilities of this or that person, but to question an inequitable system in the making, which is stating that those who provide medical care for the poor need not be as qualified (or expensive) as those providing care for the wealthy. To draw a parallel, this would be like saying during an arrest that poor people are entitled to a paralegal, but not a lawyer, which is only reserved for the rich.

          This is what you should find insulting. I know I do.

          • ProudOkie

            That makes a lot of sense to me. However, one cannot make direct and equal parallels to an attorney and a paralegal and a physician and an NP. Although physicians are not interested in recognizing ANY studies over the last 30 years, the fact is that study after study shows care provided by NPs is safe, and competent. Anyone in direct clinical practice also KNOWS that most NPs, even those with “supervision” practice independently a majority of the time. So patient’s who say they will only see the NP when they are supervised by a physician are STILL seeing an NP who is in reality, not supervised by a physician. So what does all of this have to do with anything? This – there are no lawsuits, deaths, negligence, malpractice, etc., in great numbers by NPs. They are on the front line providing DIRECT care to patients every single day. There are no news reports of increasing patient injuries or deaths because of care provided by an NP. There are NONE (I’m talking about an epidemic of horrid third world care because of NPs). In my own private clinic – 7,000 visits a year without ANY physician involvement, except for referrals – which are not very common. No deaths, injury, and thankfully no suits (knock knock). So if I can care for 80% of what a physician can care for, that would leave 1,400 a year that should be out of my purview of care. So over a 10 year period I would see 14,000 patients that I am incapable of caring for! One would think there would be a death, a maiming injury, a lawsuit…..something!! But there is nothing!
            So, I don’t know where that leaves the physician who completed a family practice residency. We need them, we need NPs – but our care is competent and more than competent. The proof is in the pudding and at this point the evidence is overwhelming. Thank you for the comment explaining your meaning.

          • Homeless

            Why do you think the care from a nurse practitioner is inferior?

            Does that mean every time my doctor doesn’t have time to see me and I get shuffled off to see the NP, my doctor is providing inferior care?

            Would you have made Bill Gates get a licence before he started writing software? How about Mark Zuckerberg?

  • http://www.facebook.com/beau.ellenbecker Beau Ellenbecker

    “we re-allocate family practice training funds to train more internists, whose knowledge base replaces and exceeds that of the family practitioner”

    That may be the most pompous and brash thing I have ever read on this site. I would put my knowledge base as an FP up against any internist with equal practice experience. An internists three years of education with minimal at best training in pediatrics, obstetrics, and gynecology is no better than family medicine provider. The difference is the fields they chose to study.

    Its exactly that attitude that causes patient after patient to leave the two internal medicine groups near my practice and come join mine. You can continue treat diseases, I will take care of the patients.

    • http://www.facebook.com/profile.php?id=881580563 Kristy Sokoloski

      I have been under the care of an Internist in the past a couple times, and I found that I was more comfortable with the Family Medicine doctor being my Primary Care Physician.

  • http://www.facebook.com/profile.php?id=100002068609139 Michael Brown

    If the US is going to find a patient-centric outcome-oriented way to control the rising costs of healthcare, it is going to have to happen through empowered PCPs. The discipline of physician who is best-prepared to reduce hospitalizations, reduce surgeries, and reduce the development of life-long chronic co-morbidities is the PCP. By the time a patient is hospitalized for CHF, having an osteoporotic fracture repaired, or being prepped for gastric bypass, the medical cost has already spiraled out of control. As my father says, “It doesn’t make much sense to lock the barn door after the horse runs away.”

    For the last generation, PCPs have been pigeon-holed by HMOs and hospital systems into being the “front desk secretary” of medicine. Ridiculous capitation schemes have goaded PCPs into referring every possible procedure to specialists. If you were a PCP, making 60 or 70%, less than your buddies from medical school who specialized, would you stay late to suturea cut or drain a knee for a reimbursement of $0.00? I suspect you would probably refer the patient out.

    Slowly Medicare is creeping towards common-sense reimbursement for PCPs. New codes allow PCPs to be reimbursed for various common-sense prevention measures including high-risk CVD-prevention counseling, weight loss counseling, smoking cessation, STI-avoidance, or alcohol misuse assessment in addition to an office visit. (To name just a few)

    We’ve spent the last 30 years paying top-dollar for doctors to “do stuff” to patients. Perhaps it is time to pay PCPs a bit more to “talk with” their patients. Just maybe if we “talk” more, we’d need to “do stuff” less.

    • Homeless

      Aren’t physicians assistants, nurse practitioners, life coaches, dietitians, personal trainers, diabetes educators, substance abuse counselors, just as capable in helping patients with these issues?

      Don’t some of these providers have a greater expertise in their field than a family medicine doctor? Don’t all of these providers cost less than a family medicine doctor?

      • http://www.facebook.com/profile.php?id=100002068609139 Michael Brown

        I think personal trainers and life coaches can be tremendously valuable. However, I think physicians are uniquely qualified to manage the inevitable complexities of chronic health conditions. A personal trainer can certainly give someone guidance on exercise routines. However, I don’t think a personal trainer or life coach is prepared to adjust the dosing of long-acting insulin for a type-II diabetic who has improved their diet and lost weight. (I could rattle off a hundred similar examples, but won’t for the sake of brevity)

        As for cost, specialists are far more costly to the healthcare system than a Family Physician. Please consider in PA in 2009 the average Family Physician made approximately $150k whereas the average Orthopedist made in excess of $510k.

        • Homeless

          How much overlap is there between a orthopedist and a family physician?

          A personal trainer is not the right person to adjust the dosing of long-acting insulin but a nurse practitioner can. The dietitian is better equipped to help with those dietary changes.

          You could rattle of a hundred similar examples and I would guess most of those could be done by a nurse practitioner or a physicians assistant or one of the other experts, listed or not have more training than a family physician in their areas. It’s still more productive for the diabetic to work with a personal trainer than go to a family physician with exercise questions.

          If it makes you feel better, a good physical therapist beats an orthopedic surgeon for non surgical problems any day. I haven’t had a family physician provide anything but pain medication for athletic injuries…or a referral.

          • http://twitter.com/shihjay2 Michael Chen

            @Homeless,
            I would reframe your question as to what benefits does a family physician have in the greater scheme of the health care system. There are no apples to apples comparisions between the knowledge base and skills between that of an orthopedist, family physician even if you break down the different subtypes of topics that pertain to all orthopedic or sports injuries. The point is that family physicians, at least what I was taught as one, is that we see the patient from a holistic perspective. Not just the pathophysiological perspective (that would be just a conglomeration of all the specialists) but also from a emotional, family, and community based perspective. I would argue that there are many effects these aspects bring to the health status of an individual and(esp. chornic disease). Problem is, the limitations of time and poor reimbursement of these services negate the true value of this type of care in our health care system, which in my opinion, do provide cost-effective care, particulary in the long term (see other countries where they do promote strengthened primary care and promote a health doctor/patient relationship).

          • Homeless

            RE: is that we see the patient from a holistic perspective. Not just the pathophysiological perspective (that would be just a conglomeration of all the specialists) but also from a emotional, family, and community based perspective.

            So a nurse practitioner can’t do this?

            During a very difficult time, I sought treatment from a naturpathic physician because I needed a holistic perspective. Not just the pathophysiological perspective but also from a emotional, family, and community based perspective.

    • http://www.facebook.com/beau.ellenbecker Beau Ellenbecker

      You do get paid for suturing a cut and draining a knee if you know how to code.

      And last I checked, its about treating the patient.

  • http://www.facebook.com/people/Steven-Reznick/100000549195050 Steven Reznick

    I am told by some in the orthopedic product manufacturing industry that we can replace our orthopedic surgeons with factory trained technicians who actually go into OR’s now and train the orthopods how to use the new products by actually doing the surgery. You can bring this logic to any branch of medicine. While we are using this logic we can shorten medical school despite the exploding amount of information produced daily and new technology and we can shorten residency training as well. If we really want to save money for the system we can reintroduce the old Communist Bloc Cold war philosophy of pushing tobacco, alcohol, promiscuity and violence so that very few reached old age and had to be cared for.

    • newheart807

      I am afraid I do not see your point as it relates to the article.

      You can train a monkey to do anything; the question is do you want a monkey to do it? Can the monkey deal with the complications?

      In fact, given the practice scope of family medicine in the US, most of what FP’s do can be done by PhD NP’s and as competently.

      Considering your initial statement, I wonder if that same Rep could handle the complications? Hmmmmm. The situation described, unfortunately, falls under the “see one, do one, teach one” scenario and certainly is NOT the standard of practice. As such it is a false comparison.

      • http://www.facebook.com/people/Steven-Reznick/100000549195050 Steven Reznick

        My point is that we can train anyone to do anything but if you wish to stay healthy and regain your health from illness you are better off having a physician who has been well trained and evaluated. Having an experienced and caring family practitioner or general internist who provides longitudinal care in the office, hospital , home visits, rehab facilities and provides continuity between locations and illnesses is a major plus. There are forces in the world of medicine and medical industrial complex looking to maximize their personal gain by cutting down on the training and depth of post graduate training of young doctors today. They will train less expensive physician extenders who bring little pre professional school or pre training medical experience to the table and then want to send them out into the field with the hopes that they provide care at or above the level of experienced practitioners. It will not work. My suggestion was a cynical black comedy suggestion. As people age and their problems become more complex and their treatments more complex the cost of maintaining them increases. The only way to eliminate those costs is to encourage an adverse lifestyle that eliminates a majority of older chronically ill patients and their costs as the Soviets did in their heyday. Geriatric care becomes very inexpensive if no one lives to the senior years.

  • http://www.thehappymd.com/ Dike Drummond MD

    I am struck (nearly) dumb by the ignorance of this orthopedic surgeon equating a board certified family doctor to an appendectomy on the kitchen table. There is nothing so useless as an orthopod facing a patient with a medical complication. We always have to save their butts. All the family docs in his home town should immediately stop all referrals to Dr. Brooks.

    Now, we all realize that a primary care doc is a needless speed bump to a lucrative surgery in the eyes of a surgeon … we always have been. And the cases when having someone who knows the whole person working as a team with the surgeon have saved lives and prevented complications … far outweighs any proposed benefit of getting rid of the family doc.

    Just one sign of the lasting value of the primary care physician is the popularity of concierge and direct care practice … which is booming. People can see and are willing to pay for the privilege of having their own doctor – a generalist, NOT a partialist – care for them when they need medical attention.

    Destroy family practice at your own peril. And if you do so … don’t ask an orthopedic surgeon to guide your design of healthcare 2.0. BBMF

    Dike
    Dike Drummond MD
    http://www.thehappymd.com

    • http://www.facebook.com/beau.ellenbecker Beau Ellenbecker

      I believe what comes to mind is the old saying ” ‘twice as strong as an ox but half as smart” was what you were trying to say…

    • http://www.facebook.com/luchiayoung Luchia Young

      Well said!

  • andymc12342003

    · In fact, given the practice scope of family medicine in the US, most of what FP’s do can be done by PhD NP’s and as competently.”

    In the dermatology clinic I go to, most of the care is rendered competently by PAs. So, lets replace most dermatologists with a well trained PA (why limit this trend to primary care??) Much of what general dermatologist do (acne, eczema, viral rashes, initial ca screening, etc.. can certainly be handled by a competent mid-level (and already is in a lot of clinics). Save the complicated stuff , surgeries, consultations, etc. for the dermatologist. A narrower scope of in a specialty practice may be even better suited for the PAs.Other specialist could follow suit. Again, I ask,- why should only primary care MDs be replaced with mid-levels???

  • http://www.facebook.com/shirie.leng Shirie Leng

    I’m glad I’m not the only one getting castigated on this site for writing about physician extenders, NPs, etc. We can argue all day long about who is qualified to do what, but the day is coming, so lets learn how to work together.

    • ProudOkie

      Hi Shirie,
      Much of the animosity between the professions comes from the way some physicians talk when referring to NPs. I would like to use your post as an example – “…writing about physician extenders, NPs, etc.” We are quite open to criticism for the most part – except for when we are referred to as though we are inanimate objects and “etc.”. I like to refer to physicians as “physicians”….except for when they refer to me as a “tool” or a means to an end. I highly respect your profession; but when I am not shown respect – which we all prefer, you then become a “just another healthcare provider” in my book. You are more than a provider – your are a physician. I am a Nurse Practitioner…it’s all so simple. I mean no disrespect – just wanting to perhaps help you see where “we” come from.

    • Suzi Q 38

      I so agree with Shirie.
      Even if you have your own practice, the NP can help you see patients under your supervision.

  • http://www.facebook.com/beau.ellenbecker Beau Ellenbecker

    Well that does suck for you. I also wasn’t implying that you couldn’t code (although I do see how my comment inferred that).

    I would like to point out though that you did get paid. It came in the form of the capitation payment.

    I admit it sucks, but I don’t deal with a lot of true HMO’s either or capitation payments. Mostly fee for service insurance providers here.

  • buzzkillerjsmith

    Interesting article. The process that Dr. Brooks describes is well underway. Med students know the score. They know that actions speak louder than words and that the corporate entities that will soon be the masters of always all of us have little interest in what we consider to be primary appropriate care.

    The med students will drive this. Doctors will be fine. Can the same be said for patients? Time will tell.

  • katennp

    FYI, certified Nurse Practitioners, Doctors of Nursing Practice and Advanced Practice Nurses are not “supervised” by any doctor in most states in the US. Collaborative practice (which is slowly being unmandated in many states as well) is just that COLLABORATIVE, not SUPERVISORY. I do not need to ASK my collaborator if it is ok that I make a diagnosis or prescribe an intervention as long as I working within my LEGAL SCOPE OF PRACTICE.

  • ProudOkie

    So right….I have NO contracts with HMOs.

  • ticktickdoc

    Dr. Brooks gives 1 hour and 20 minute appointments. This is on top of his radio show and blog. But remember:

    “Although we do no accept insurance as payment, we will be delighted to file your insurance for you as a courtesy on your first and subsequent visits. Call your carrier in 72 hours to validate claim receipt.”
    I wonder how much that office visit costs.

  • http://twitter.com/comunidadysalud Steve Rothschild

    I am really horrified by some of the comments here. I am writing as a Family Physician who has practiced and taught medicine in a university hospital in Chicago for the past 25+ years. My colleagues and I do pre-op exams on a regular basis, as well as manage patients with heart failure, diabetes, HIV, etc. We do colposcopies, skin biopsies, and other procedures. Many of our patients have been under our care for years, and I often take care of three and four generations of the same family — infants through the elderly. Our patients range from physician colleagues and business executives to homeless individuals, persons with multiple disabilities, and persons on Medicaid (the latter three groups often shunned by my specialist colleagues). We collaborate with NPs in our practice but the roles really are distinct.

    People are more than a collection of individual organs and pathologies. In the last day I have seen an alcoholic man for whom we diagnosed thyroid cancer 4 years ago — and supported to sobriety… an 88 year old woman whose cardiologist increased her diuretic and put into ARF… a mom with MS and her 21 year old daughter with intractable migraines (both of whom see me for their neuro symptoms, because they don’t feel heard or helped by their neurologists)… a 94 year old woman who wishes to die in peace at home but whose family is freaked out by end of life care…a 10 year old girl with leg pain following competions in national Tae Kwon Do championships… you get the picture. Complex differential diagnosis, diagnostic uncertainty, treatment of multiple systems, human relationships, the whole messy scope of primary care in all its glory.

    I won’t generalize about orthopedic surgeons or dermatologists — sure there are a lot who fulfill the stereotypes, but that’s all they are, stereotypes. Please don’t generalize about Family Physicians.

  • querywoman

    I don’t know what destroyed the FP, but the FP’s will love this post. It’s a long one. I met this GP over 20 years ago. Years later, he is board certified. I live over 35 miles from him now. I recently told my home health LVN about him. She lives in his city.
    I was in my early 30s and became very ill. He was an osteopathic GP, a little older than I was, and a couple of year out of med school. I first met him in a minor emergency clinic when I had a very serious earache. During the next 2 years, he would open his own minor emergency clinic.
    He was young, but seemed like an old wise family doctor. It was all through him. He did tell me once that he had wanted to be a veterinarian. My mother told me she saw on TV that vet school is harder, since they have to learn about different animals, and some go to med school instead. We higher animals got lucky.
    I was seeing internist-type endocrinologists, a conventional allergist, an unconventional allergist, and umpteen gynecologists.
    I often though the young GP had more sense than any of them.
    After a thyroid dosage adjustment, I began to bleed 15 days a month. An endo put me on Provera, and it was worthless. I had repeated ear infections and umpteen neck spasms. Once I was in the hospital dehydrated after umpteen ear infections. The young GP didn’t do hospital work.
    The specialists were all too in to their limited fields. The gynecologists really didn’t care about me, since I wasn’t having a baby or a hysterectomy.
    The young GP often mentioned birth control pills for me. I didn’t do it. After the hospital trip, I let him do blood work. I had fired the endo who had me in the hospital. My young GP told me that my iron levels were close to the bottom level of normal, and he usually suggested a supplement at that level.
    Eventually, I would pay a gyn for a DC about the bleeding. I had to get the D&C report forwarded to another OB/gyn with extra fertility training, who put me on birth control pills. For some other reasons, I then had it forwarded to a reproductive endocrinologist, an insensitive woman who upped the estrogen in my BC pills, also placed me on Provera for the 3rd week of the pills, and prescribed Ponstel for premenstrual muscle pain. Then, with the help of yoga and her meds, I got better.
    A 2nd internist-type endocrinologist didn’t think I needed iron pills because my red blood cells were fine. A year or so later, I had real anemia from the bleeding and started taking iron.
    My young GP was sensitive to women, but he didn’t have a lot of extra training. His instinct was BC pills, and he was right about the iron.
    The GP was not a gatekeeper. I had a new PPO and was free to go where I wanted. But, I began to discuss my care with him and let him manage it. He told me what his limitations were, and what I needed to do. He did not like the way the first endocrinologist had done me, and wanted me to get another. There is no substitute for having a good general doctor to manage your care. I despise the term, “PCP.”
    I had to quit my job, and move back with my mother over 30 miles away. Eventually, I lost my private insurance, after paying for COBRA 18 months with cash advances on a credit card.
    Then I went to a public clinic, where the board-certified internist I saw continued the reproductive endocrinologist’s treatment. That internist managed me quite well for over a year till I got insurance again.
    I’ll never be well enough to see one doctor again. But the young GP and later the public internist were the best.
    I’ve always found that a little knowledge in medicine is dangerous. My current home health aide knows more about my illnesses than most of my doctors do.
    Now I see mostly specialists, and they are good, but I have certainly been through a bunch to get them.
    Does a nurse practitioner have less knowledge than a new GP graduate?
    How long did medical training last in the 1950s and 1960s? Are the new NP’s and PA’s similar to the old GP’s? I’ve never seen that question answered, and I don’t know how to research it.

  • mabia

    Librarians’ is a noble profession. If you are looking for money there are many other places
    to look at. Many may rate this profession as worst.. but its important as a working Librarian,
    he/ she should not to be looking low at this profession. Ours is a supporting role and we are
    here to build other professions. If one of your user grows, your work is done.

  • http://twitter.com/DrTolbert Gerry L Tolbert

    I still do house calls…

  • http://www.facebook.com/beverly.nuckols Beverly Nuckols

    I would have thought that a physician who dared to criticize his colleagues would have researched his “facts.” Family Physicians, indeed, ‘deliver babies, treat non-displaced fractures, set some displaced fractures, deliver well-baby care, well-women’s care, provide on-going treatment for chronic disease and many other things that here in the United States are, for myriad reasons, referred to a specialist.” Come to New Braunfels, Texas, Doctor.

  • http://www.facebook.com/virginia.scanlan Virginia Scanlan

    My dad was a GP for 50 years. He served his internship at Cook County Hospital and then spent five years in the Pacific Theater during World War II and became a surgeon there. He delivered babies, did appendectomies, removed tonsils, made hernia repairs, and practiced general medicine. Yes, he made house calls. He worked seven days a week. . When he died at 82, hundreds of patients attended his funeral. This is what they talked about: He listened to them. He settled family disputes. If they were very worried about something, he’d help them think it through. He gave hell to errant husbands and naughtly children and they listened. He threw their bills in the trash if they couldn’t pay him. My father delivered many of the people who attended the funeral and their children.You could understand why they were devoted to him. When he sat down to talk to you, he immediately grabbed your wrist as if he was taking your pulse. You had his complete attention.At the bedside, he’d hang on while he talked to you.”When Dr. Clem came to the house, then we knew that everything would be OK,” a patient said. This is not a romanticized version of his life. This was my Dad. Patients want and need one thing — somebody to really care about them and to know them intimately throughout their lives. If you do not want to do that, quit. If you do want to do it, do not let anyone — your college, the government, hospital bureacrats, EMR purveyors, or anyone else stop you. No one from Blue Cross will attend your funeral.

    • ProudOkie

      Ms. Scanlan,
      Thank you so much for the post. There is so much enouragement for me personally there. I want to be that and more for all of my customers and it is working so far. Thank you again!!!!

      • http://www.facebook.com/virginia.scanlan Virginia Scanlan

        Thank you. You must be willing to fight for your patients and for your profession. Good luck.

  • henry franceschi

    I think the numbers for US primary care suggest that its death is imminent for several reasons.

    1. The problem started when Nixon proposed that the services doctors provided were driven by “market forces” and policy was shaped to fit that grid.

    2. I’ve worked with doctors who, every “quarter” (got the business lingo?) were told by their accountants what the most “profitable” area of their practice was. They then told them what parts of their practice they should spend their time on to “speed up movement towards The Plan,” meaning the pension and retirement plan the accountant had set up for the good doctor. Patients of course were told that, “Doctor (got it? God) will be transferring you to another group next month. We’re sorry but (and everyone was given a polite but nonetheless lame excuse as to why).”

    3. If you don’t know what “ICD-10” is and what its codes are, you have no idea how broad and deep “market forces” run in American medicine. ICD-10 codes are the diagnostic and service categories on the basis of which providers are paid on a pre-set payment schedule cast by the
    patient’s carrier. All doctors who want to survive in “market forces” driven medicine have a “billing (ICD-10 coding) specialist” who does all the billings. For instance, while in fact a patient’s symptoms may fit a trivial code – which pays, say $52.50 per visit – a good “billing specialist” knows a better code that pays $112.75 per visit. Thus are “market forces” wisely and legally managed.

    4. But despite the apparent “feeding trough,” primary care is really slave labor. They have to care for all seniors – all 77 million Baby Boomers who are turning 65, qualify for Medicare, and are starting to show up to see a rapidly declining number of primary care physicians (See 5 below) for endless visits and endless amounts of time. Why? Because seniors
    usually have not just one but multiple “chronic diseases.” They have to care for all “acute” cases (that last less than 3 months), all house-bound geriatric cases, all mental health cases that used to be seen by psychiatrists (but are now too expensive!), they are expected to care for all chronic diseases (that last more than 3 months), plus they’re expected to see patients “throughout the life cycle” (read “forever”) and thereby offer the “continuity of care” few doctors want to be saddled with (come on, think business!) BECAUSE the highest paying ICD-10 codes are those linked to the comprehensive work-up that takes place at the first
    visit and becomes your permanent medical record). High billings are not associated with follow-up visits but first-time visits And for all this, primary care physicians are the poorest paid of all American physicians.

    5. Do US primary care docs like US primary care? No they don’t. A full 85% are dissatisfied with US primary care. A study by primary care docs’ American College of Physicians states the supply problem in primary care that puts into question American primary care’s future as a “viable business:”

    – “From 1997 to 2005, the number of U.S. medical graduates entering family medicine residencies dropped by 50%. In 2007, only 23% of third-year internal medicine residents, planned to practice general internal medicine compared to 54% in 1998. Among first-year internal medicine residents, only 14% indicated that they planned to pursue careers in general medicine. Even more disheartening, a 2007
    study of fourth-year medical students’ career decision making revealed
    that only 2% of students intended to pursue careers in general internal
    medicine.”

    6. These numbers indicate that US primary care is “old tech.” It’s error-laden, dabbling in things it’s not qualified to do, and its performance – at an absurd cost – is poor. If primary care were really run like a business, primary care would have been closed down as a failed venture. There’s more. Thanks to its self-indulgent-never-give-it-up lifestyle, America has the world’s “biggest” people who, when they are involved in “injuries” (ranging from falls and unintentional injuries to forces of nature and war) 42% (133 million Americans), develop chronic non-cancer pain. This
    is pain that is disabling, and leads to unemployment, medical bankruptcy and premature death, mainly because there are no qualified doctors to treat it effectively and inexpensively. Primary care docs have been terrible about taking the AMA “mandated” continuing medical education (CMEs) or specialty training courses on the “fifth vital sign” (pain) that would make them reasonably competent to treat chronic pain. But most never get the training because they “don’t have the time.” So, primary care’s performance with chronic pain has been abysmal. Then recently, rigorous research on the human genome has shown that 90-95% of all chronic diseases are caused by lifestyle and personal choices and only 5-10% have biological causes. What qualifies primary care docs to treat chronic diseases? Their causes are outside primary care docs’ area of practice. It’s nothing chronic because they lack the training or the causes of the disease they are expected to treat are outside their area of practice. At 7 minutes the average amount of time a primary care doc can give a patient, any chronic condition is out of the question.

    Finally, to the sate of the business. When a product is challenged by a new more effective, less expensive “new, improved, less error-laden or risky” alternative – like the horse-and-buggy vs. the automobile – “market forces” put an end to the “old tech.”

    Today the world is rapidly distancing itself from the US primary care model and moving to inexpensive Universal Primary Care. I conclude from this that primary care should be allowed to have a quiet demise soon and be turned over to Starfleet Enterprise’s “Computer” to diagnose with less
    error, and to treat and manage at with far greater effectiveness, while delivering return to work and optimally restored functioning, quantity of life, and safety, now. But above all, with far greater self-management, self-sustainability, individual responsibility and dignity which today US primary care is so sorely lacking.

  • FMLYDOC

    You’re wrong, I’m a Family Physician in Rural Kansas, a long long way from any specialty care. I do all the things you said you used to do in Canada and more, including some surgery and operative obstetrics, and for a small fraction of the money you make. I am absolutely needed here. I don’t have the pleasure of specialists (or partialists, I call them) across the street to help me. I have 18,000+ hours of on-the job training. The nurse practitioner I supervise has fewer than 500. When you have an emergency as you drive through the heartland, who do you want taking care of you in our ER? YOUR CALL..

    Furthermore, your assertion that an internist’s “knowledge base replaces and exceeds that of the family practitioner” is pure ignorance. I do what internists do, and so very much more.

    Open your eyes, look at the country’s needs. In my part of the country, Family Physicians save lives and are and absolute necessity.

    • http://twitter.com/clicky03 Danny

      I am a Board Certified Family Physician practicing close to the San Francisco Bay Area, and agree with you FMLYDOC.

      I find that Internists sometimes have a chip on their shoulder and look down on Family Physicians. These Internists may not see the irony that sometimes some specialists look down on Internists, who are viewed as inferior.

      Here’s further irony. I started working recently as a hospitalist (previously I worked in a FP outpatient clinic, performing all the job responsibilities in newhear807′s crazy question list). I admit the patients for Internists who no longer have hospital privileges (I wonder if that drives them crazy).

      In conclusion: if an internist’s “knowledge base replaces and exceeds that of the family practitioner”, then it is largely irrelevant, as “the practical reality is the tasks required of each are very similar.”

  • http://www.mightycasey.com/ MightyCasey

    FPs who move to a direct-care model are the ones who will survive. Sad truth.

  • SBornfeld

    Hey, Mitch–a lot of what orthopedists do can be handled just as well and for a lot less money by chiropractors–whaddaya say?

  • http://www.facebook.com/nashvilledoctor S Steve Samudrala

    Family Doctors will slowly & surely be Medical Directors as well as MDs

  • Dr. H

    Funny how Dr. Brooks, an orthopedic surgeon feels qualified to slam the specialty of family medicine with no training in general medicine other than medical school. “Training of internists exceeds that of family medicine?” Having trained both in a preliminary IM yr for a Neurology residency with later switching to a comprehensive unopposed FM residency Which included ICU rounding on FM patients I find Dr. Brooks statements to be absurd in light of my experiences. In fact my unopposed FM training was far and away better than my IM training. Also, a common thread that ran through both training programs was the general preception of the inability for ortho docs to perform general medicine adequately by themselves hence the running ortho joke the acronym “LOFD” or the patient looks okay from door. As an FM hospitalist I am completely unimpressed with this article and its sweeping ignorance.

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