Why family physicians are a threat to themselves

In recent months, AAFP President Reid Blackwelder has been editorializing and debating what they see as the encroachment of nurse practitioners (NPs) and other “mid-level providers” (physicians are, presumably, “upper-level”) on the practice territory of family physicians (FPs). Dr. Blackwelder has repeatedly said that NP and physician roles are “not interchangeable.” The AAFP’s position on this issue seems to be resistance to the increasingly common decisions by state legislatures to free NPs of physician oversight. Dr. Blackwelder and the AAFP are misallocating their energies and resources – NPs are not a threat to family physicians. We are a threat to ourselves.

Two vignettes serve to illustrate my point. First, a recent news headline (“Hospital Lifts Ban on Non-Specialists Delivering Babies“) announced that, after a long fight, a Texas FP finally got privileges to deliver babies. This is news? Sadly, yes. Second, while eating at one of my favorite restaurants recently, the waitress and I got to talking about her search for a doctor for her little boy. She knew I was a family doctor, but she was surprised to find out that I, too, take care of children, deliver babies and see patients in the hospital.

What do these anecdotes have to do with the AAFP’s quest against NP independent practice and protection of FP identity?

It is not nurse practitioners or physician assistants who have denied family physicians privileges to practice obstetrics, to do C-sections, to do endoscopy, to practice conscious sedation and to do minor surgeries – in other words, to practice the full scope of family medicine. It is our “partialist” (a delightfully accurate term that needs more circulation) colleagues who see us as a threat to their “turf” (and income) who have restricted our credentials and ability to practice.

It is not nurse practitioners or physician assistants who have done such a poor job shaping and marketing our image as “comprehensivists” that laypeople are surprised to learn that FPs take care of children, deliver babies, practice emergency medicine, do minor office procedures, and see hospitalized patients. It is we who have voluntarily given up our scope of practice in many areas, who are surrendering our hospital, obstetrical and surgical practices either in the name of an easier lifestyle or because of pressure to see more patients per day.

The AAFP is a subset of dinosaurs protesting the approaching meteor. In 2014, millions of Americans will gain health insurance and flood the primary care market. There simply will not be – there cannot be – enough FPs to fill the gap. NPs will serve that necessary role, and do an excellent job. Hundreds of thousands of Americans will soon identify NPs and PAs as their primary doctor. It will happen, it already has happened. There is no way the AAFP can prevent it.

Furthermore, as the family medicine skill set deteriorates, as the trends continue that fewer FPs do obstetrics, endoscopy, minor surgeries and hospital medicine, our practical skill sets (regardless of the oft-quoted “hours of training” differential) will asymptotically approach those of our NP colleagues. To the patient in the exam room, there will soon be no discernible difference between their self-limited family physician or their well-trained nurse practitioner. They just want a primary care clinician who can do a good job – and very soon, either one of us will.

If my professional organization, the AAFP, wants to know who is eroding the identity, role and practice spectrum of family physicians, they need not look at NPs. They need only look in the mirror.

Paul D. Simmons is a family physician.

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  • Mengles

    Dr. Blackwelder has repeatedly said that NP and physician roles are “not interchangeable.”

    ================

    The government feels that they in fact are interchangeable, which is all that matters. Hence all the talk about primary care homes, one-stop Walgreens stores for PC vists, “studies” funded by nursing schools (shocking) that show NP nursing outcomes at 6 months (Ha!) equivalency to doctors, which have more holes than swiss cheese in study methodology, but which the layman/politician will gladly eat up. Primary care is apparently so easy even an NP/PA can do it.

    I have absolutely no sympathy, whatsoever, for the AAFP, for the completely self-induced hole they have dug for themselves. I do feel sorry for their members that now have to face the consequences of the AAFP’s naivete. Compare this to other specialty societies that fight tooth and nail for the good of their members.

    Medical students will believe this is what primary care deserves, after all only the people with low Step 1 scores go in these fields. It’s just sad that primary care will end up being filled by people who are stuck there rather than wanting to be there. Sad.

  • Kaonwarb

    While I don’t know nearly enough about AAFP to comment on whether they have or have not served their members well, I completely agree that FPs should reclaim their roles which have been eroded by specialties – and I would further suggest that they should actively push deeper and deeper into specialist roles, aided by advancing technology which brings previously specialized diagnostic and treatment capabilities within the reasonable purview of a FP. That’s the nature of successful disruptive innovation. Thank you for the thought-provoking article.

    • buzzkillerjsmith

      Or med students could just not go into family medicine. A much cleaner solution.

    • SarahJ89

      I agree. I miss having a doctor who can do the things FPs used to do. I have no desire to be shunted off to some specialist when I know my FP can do the job but isn’t being allowed to by the “nonprofit” (ha, ha) hospital that now owns every practice in a 30-mile radius.

  • Tracey Marino

    Dear Dr. Simmons: Thank you for your thoughtful post.
    I am an FNP, working in a small, critical access, rural setting, and we serve a large population of uninsured and economically challenged patients. Most specialists are a 2-3 hour drive away. I am the only provider “taking new patients”.
    I do not consider my training to be equal to that of a physician, but I had 20 years of clinical experience in a variety of roles prior to obtaining my FNP. This experience has been most valuable in my development as a provider.
    I wish NP’s and PA’s would stop pushing the independent practice issue—it does nothing to solve the problem of providing primary care to needy patients. I work with a terrific group of dedicated small town docs and “midlevels” who could really care less about your TRAINING—as long as you do an effective job of taking care of patients. Docs should also stop bashing NP’s and PA’s for their lack of EDUCATION. Experience is a great teacher, and is the reason many NP’s and PA’s do a great job in primary care.
    Finally, no one works independently. No one works alone. Any time an FP refers to a specialist, are they not deferring to someone with more EDUCATION than them? NPs, PAs, and all FP’s should work together to raise public opinion and confidence in the practice of family medicine, regardless of the providers’ EDUCATION. Playing dueling creds makes all family providers look bad.

  • Dave Mittman, PA, DFAAPA

    What everyone misses is that good NPs and PAs in family practice provide care that is excellent. AND what we do-we do as well as anyone doing it. Now I did not say we can all provide as comprehensive of services as an FP can-most of us can not, as we do not deliver babies or do some other things family physicians are trained to do. But almost all of what we treat we treat very well. Colds, coughs, sinusitis, anxiety, back pain, headaches, acne, hemorrhoids, etc. I know we can because I have and my outcomes were at the same or higher percentage of resolution as my FP colleagues. Same with the PAs in the VA, or Kaiser, or the Air Force, Army, Navy and the 100,000 of us out there across America. And we all keep learning, we buy the same text books and go to the same CMEs. Fifteen years out, we can all be as good as we want to be.
    There is a real place for PAs and NPs in the healthcare system. Where would the country be without the 250,000 of us providing care today? Surgical services in many areas could not run without PAs. Rural health in many areas is spelled NP and PA. Military primary care, peeds and women’s health is the domain of our professions. People are not dying.
    We need to embrace each other professionally. The AAFP has done little to do that. It has done much to tell PAs and NPs that we are dangerous unless closely supervised, that we do not have the education to do acute care, that we can’t handle complex problems-all the while having their members taking vacation and leaving the PA or NP to run the practice. Enough negativity and telling us how bad we are. It’s not working ad it is making the AAFP look petty and insecure.
    Thank you Dr. Simmons for writing this blog.
    Dave

    • buzzkillerjsmith

      When I started in 1989 NPs and PAs in primary care were relatively rare, but now they provide a lot of the services and generally do a very good job. Their rise is a consequence of docs abandoning primary care, not a cause of it. I expect that med students, no fools, will continue to avoid primary care like the plague. Does the rise of NPs and PAs dissuade some med students? Probably, because they reckon, perhaps correctly, that CorpMed will treat them no better than midlevels. But these providers are a minor factor compared with the extreme nastiness of primary care in general.

      • Dave Mittman, PA, DFAAPA

        Thanks for the nice words. I agree generally. I think NPs and PAs are also going into specialties (PAs more). ER and the surgical subspecialties, urgent care, derm is wonderful. Why argue with the insurance companies for a $14.00 reimbursement fee for a full physical? PAs are going through residency programs-postgrad. It’s sad as I loved primary care. Still do.”Dave

        • buzzkillerjsmith

          Excellent point, Dave. Med students are no fools, and neither are PA and NP students. They realize very quickly that the effort/reward tradeoff is much better in many specialties than it is in primary care.

          And yet we all hear the chatter in the mainstream media about how NPs and PAs are going to save PC even though the docs are bailing out. I shake my head.

          Get the effort/reward ratio right and MDs, PAs, and NPs will come. I don’t expect that to happen soon.

    • Robin Schaffner

      Well said, Dave!

  • trinu

    Those “studies” consisted of looking at how likely a patient is to spontaneously develop diabetes and/er hypertension after visiting urgent care centers, mostly for minor things like stitches. They did NOT evaluate diagnostic skills or ability to decide treatment regimens for the acutely or chronically ill, or for those with more serious injuries.

    • http://ckrn.tumblr.com/ Courtney Kasun

      Glad we’re arguing about something only tangential to the actual post. The AAFP will never have to be accountable for some of the claims above when health care professionals are so easily distracted by these sorts of arguments

      • Dave Mittman, PA, DFAAPA

        Totally agree.
        AAFP is a union. They are trying teir best to spin the facts for them. No argument will win either way. We have to set a new paradigm.
        Dave

        • T H

          The AAFP is no more a union than the AAPA is.

          If the AAFP were a union, the US would be a very different place.

    • crnp2001

      Did you really READ the studies? Seriously…they were NOT only seen in urgent care centers. Again…get your facts straight!

    • Dave Mittman, PA, DFAAPA

      Trying to be “right” about this is not going to get any of us anywhere. Out of 250,000 of us PAs and NPs, many are very good.

  • Guest

    “There is a plethora of research stating that NP outcomes are equal or superior to physicians.”

    A plethora of something means an over-supply of something, an excess, a surfeit — it is not simply a synonym for “a lot”. Do you really mean there is an over-supply of research on this topic? If not, you should probably steer clear of using words you don’t understand.

    • Robin Schaffner

      The word, plethora, can also denote ” a very large amount of something”. You really do yourself a disservice, by illustrating your pomposity.

  • Keith Williamson, MD

    A challenging essay, hitting some good points and missing on others. The Academy has indeed been a little too late and a little off kilter on their/our approach.

    Family Medicine is being squeezed in the middle between NPs and PAs, and the “partialists.” Throw in federal health agencies and one has almost the entirety of those doing and paying for the research that yielded the oft cited “…NP outcomes are equal or superior to physicians…” Hardly unbiased as all these groups have their agendas, agendas in which the FP can be seen as an inconvenience.

    When one steps back to examine the context, it is not so hard to see that we are all one people with normal self interest and ambitions. That said, physicians do distribute to the high end of the intelligence scale (to be blunt, much further to the right than most non-physicians (Meritocracy, Cognitive Ability, and the Sources of Occupational Success – 2002)). Add to ability years of the best education and most rigorous training, and it yields a superior professional… either that, or my medical school owes me a refund. In my experience, roughly 1/3rd of FP’s are the best doctors anywhere; 2/3rd’s are FP’s by default.

    To digress, I attended a top ranked medical school in the 80′s, did very well, was recruited by Internal Medicine, ObGyn, Pediatrics, and related “partialities” derived from those fields. I chose Family Medicine because it suited my personality and because of the public hue and cry for family doctors. I am now witnessing a transition from serving the public to being devoured by the public on the alter of access.

    To digress further, access will not improve the public health. Patient behavior drives the majority of premature mortality and morbidity (Shattuck Lecture: Improving American Health – NEJM 2007). Not a lack of knowledge mind you, just the ability to change behavior in our culture and environment. Likewise it will do little to reduce cost except in that payers will use the conflict to criticize, demonize, and reduce payments.

    But, in association with not having my head in the sand, I continue to work with mid-levels and teach in the local university program. The NP school values quantity over quality students, and I do my best to protect their future patients. Some are excellent, and should have gone to medical school (I can already here the reflexive “but I didn’t want to be a doctor, I wanted to be a nurse…” spare me, you couldn’t get in or you couldn’t bear to commit to the rigor…). I am well liked and considered a supporter in the community. I have consistently worked as chair of credentials at the hospital to develop mid-level role, and I am married to an NP.

    Mid-levels are indeed the darling of almost all in an environment of access over discernment. Rather than the ongoing triumphalism of mid-levels in the environment that values access over excellence, mid-levels should value education and training. Go to medical school if you want a genuine terminal degree in delivering health care, or acknowledge the validity of a unifying team approach with a physician in a sponsoring leadership position.

    Warmest regards.

    • http://ckrn.tumblr.com/ Courtney Kasun

      It would seem to me, that we so-called “mid-levels” do value education and training. That is exactly why we are working to increase the rigor of our programs, and the minimum time needed to enter practice.

      Your assertion that all NPs were incapable of matriculating into, or of commiting to, medical school is not only offensive, it’s just ridiculous. There are NPs who chose the profession of nursing for its different frame, culture, and perspective, just as there are physicians who chose DO schools because those programs offer education in line with what those professionals wanted. Indeed, it’s similar to the way you chose to be an FP, even though you assure us–at great length–you were smart enough to do something else.

      Teaching NPs and being married to one doesn’t make you an expert on what it means to actually BE a nursing professional, clearly.

      I’m smart enough I didn’t HAVE to go into nursing, it’s what I WANTED.

      • Keith Williamson, MD

        I reread my post, and I agree, my unedited comments are offensive. I really do apologize as we won’t get through this without civil discussion. I further apologize for any offense caused by the term “partialist” which is in no danger of displacing the term “specialist,” but was funny and does shed some insight. Furthermore, I do not wish to offend by using the term “midlevel,” which is admittedly awkward but is common usage and shorter than NP’s and PA’s and CNS’s and CRNA’s and the constellation of characters we find in health care currently. I’m not sure that the Joint Commission term “advanced dependent practitioner” would please any better.

        I stand by my comment’s intent though. Nurses who go to nursing school to be nurses are drawn to bedside nursing. Bedside nurses are of incalculable value to the healing and safety of patients. Nurses who go to nursing school to be NPs are drawn to diagnosis and treatment are pursuing the traditional role of the physician, with an abridged education. Of those I have interviewed on the subject (easily hundreds of undergrad and graduate student nurses), the reply to the query ‘why not medical school’ is most commonly some variant of “I failed chemistry and made a C in A&P,” followed in frequency by “I don’t want to go to school that long,” or “I don’t want that much responsibility,” or “I can’t afford it.” For some psychosocial, developmental, or economic reason, they do not commit to full medical education. All these reasons are valid, and all these reasons persuade me that nursing students view the NP role as a short cut to taking on the role of a physician without having gone to medical school. PA’s, of course, do not do a nursing education and are trained in diagnosis, treatment, and the scientific approach… and they specifically associate with a fully trained physician.

        It is understandable in anyone with adequate self esteem to experience confirmation bias: this is what I did, and it is the best of all possible words (which phrase always makes me think of Voltaire). And it is a commendable role to play, and honorable. Me too, I know, but sometimes I wonder if I should have taken the PhD route or pathology… but I like to talk to people!

        But, (and you knew a “but” was coming) of what differences can be objectively determined between a physician’s preparation and a nurse practitioner’s preparation… the candidate, the education, the duration, the rigor, and the product… all strongly favor the physician as the best prepared to deliver diagnosis and treatment. Thus my contention, which correlates well with the AAFP, is that a physician should be at the head of every medical team.

        Tangentially, I would suggest that medical schools have for a multitude of reasons (but primarily economic) practiced “professional birth control” limiting the number of doctors, and steered large numbers of graduates into “specialties” when the functional and productive members of the public still needed family doc’s. The legislated environment and medical schools self interest have had a large role in the under supply of primary care physicians; what little incentive there is for a fully trained physician to go into primary care will be gone if the 4 years of nursing school and 2 years in a graduate nursing program earn the same “…rights, privileges, and honors, as well as the obligations and responsibilities…” as it says on my degree.

        • http://ckrn.tumblr.com/ Courtney Kasun

          I, in turn, would like to apologize for my rebuttal, worsmithed out of a place of immense frustration. As a professional who works hard to take care of patients, and is passionate about my profession, it is always frustrating when discussions about our health care system devolve in to what feel like attacks, rather than discussions of important issues.

          We will have to agree to disagree about your thoughts on nursing. I too, teach nursing students, and my informal sampling, also of hundreds, would have different results than yours.

          What we can agree on is that NPs shouldn’t have the same scope of practice as physicians. That is not what I want, nor what I will be qualified for when I finish my DNP. There are conditions that I will be able to diagnose accurately and manage well, but there are also conditions that will be above and beyond me. That is fine with me. I look forward to getting to work closely and collaboratively with my physician colleagues who enhance my practice and whose company I enjoy.

          We could go back and forth til the end of time on regulating the degree to which NPs should be able to diagnose and treat. Really, what it comes down to, is just like any other health professional, CNA through physician, NPs should know what they know and are prepared for, and have the sense to ask for help and seek appropriate collaboration when they are over their heads.

          Beyond just diagnosis and treatment, and preparing for primary care delivery in the community, I certainly don’t want, nor would I be qualified for, so many of the other skills family physicians train for – OB, endoscopy, etc. This, I believe is Dr. Simmons’s point. Yes, physicians have unique skills and things they do that NPs shouldn’t. But there IS overlap. However, the more that family physicians let go of, or are forced out of some of the non-overlapping skills, the harder it will be, especially for patients, to differentiate NPs/PAs/Physicians because of the things that do overlap.

  • Maura Cupo

    I wish Dr. Simmons and other FP would stop using the term “partialist.” It is beyond insulting and the continued divisive rhetoric only continues to divide medicine at a time when there is an emphasis on increased care cooridination and communications. Its petty and doesn’t help your cause.

    • Cyndee Malowitz

      While they’re at it, they can quit referring to NPs as “midlevels” or “physician extenders.” I’m a NP and I’m not “mid” anything – I’m a full blown nurse practitioner. Physician extenders – well that just sounds pornographic.

      • Robin Schaffner

        I am in complete agreement with your assessment, Cyndee!

  • James E. Lewis, PhD

    Much of what is being discussed here stems from the way FP training has evolved over the past 40 years. See my July 16 Wing of Zock “Pattern Analysis” post “Do Academic Medicine Practice Financial Structures Inhibit Primary Care and Practice?” FP physicians have been stripped of skills that would make them what I call “whole” physicians, e.g., OB, office imaging, office labs, pediatrics (upper age limit now at age 25). FP training has to take a new look at itself and make serious changes, especially with respect to incorporating current (e.g., hand held ultrasound) and future (e.g., lab on a chip, smart phone EKGs, and hand held MRI) technological advances into their skill sets. Otherwise, it will just become more and more difficult to distinguish FP’s from NP’s and PA’s and once valued medical specialty will have been lost.

    • Stephen Sutherland

      Praise and Questions! Excellent article Dr. Lewis; I agree with everything you shared. I believe the narrowed scope of practice is the primary cause of the misperceived overlap between NP and FP skillset. I read 2 of your articles —- they are excellent and make a powerful case for an extraordinary Rise of Primary Care rather than its demise as other commentators and articles present on this site. Very encouraging articles.

      I believe FPs should make a concerted/organized effort in this regard – I think all PCPs should hear this message and work in a unified manner.
      What do you think are the next steps to make this a reality?
      Here are my questions

      (1) Many PCPs have lost their private practice which would have made such efforts easier. Do you have any thoughts about how they might resume practice in the current environment while transitioning in this manner?
      I ask because we are still under a system that penalizes PCPs for anything more than the 7-10 minute visit. Decreasing one’s volume as one adapts the real model for PCP, might adversely impact revenue and practice viability. Curious to hear your thoughts on this. Although it might be a silly question. I’m new to this.

      (2) I am curious to hear your thoughts about concierge medicine. Prior to hearing your views, concierge medicine was my only hope but in examining it a bit closer, I was a bit disillusioned by the fact that some concierge practices charge patients routinely beyond the monthly fee for 100/month and up. I thought charges for labs, imaging etc might be too much for an average person especially in the current environment – but I guess I remembered your technology point which could make it available to patients at no cost. Either way I’m curious to hear your thoughts about concierge medicine as an entry to the new model for PCP.
      S

  • LIS92

    For whatever reason, the doctor-patient relationship is not longer a key element for family practice. I never feel like I belong to the nurse practitioners I see and don’t see my family physician often enough to have a relationship. The only person in the office I have a connection with is the phlebotomist.

    • Stephen Sutherland

      This happens only due to pressure from the current reimbursement system created by the RUC which rewards a primary care physician on a per visit basis at a greatly discounted rate. This forces some physician to decrease the time of visit and increase the patient load per day — in order to pay for the overhead. This creates frustration for primary care physicians, as well as patients and it might have a tendency to narrow their scope of practice since they try to move so fast. – to the point that a nurse practitioner feels she can do the same job — and give us a hard time and say they can be doctors too after an 18 month online course. — As soon as this problem is solved once and for all, physicians who love that doctor-patient relationship will once again shine.

  • Stephen Sutherland

    This is the best article on the issue. I’m a medical student who would love to pursue Family Medicine, these issues need to be resolved but I think it would be easy to resolve.
    As Health Education evolves, every midlevel practitioner is pushing to extend their scope of practice to include services normally provided by Physicians. 3 Examples: (1) Optometrist are performing Eye Surgeries like Cataract and Laser Surgeries, and they’re always eyeing new procedures to perform. Likewise they are creating doctoral programs to facilitate the blurring of the lines. (2) Physical Therapist are all pursing Doctoral Degrees and patients can now bypass a PM&R doctor entirely. (3) Nurses are assuming the role of physicians in fields such as Anesthesiology and Family Medicine etc and new Doctoral Degrees are being created to better facilitate role takeovers. Evolution is completely normal. Some of it is appropriate and some of it is inappropriate. A ton of embarrassing Lawsuits will make appropriate corrections. But while, mid-level fields are evolving, the role and scope of practice of Family Medicine should evolve otherwise the niche occupied by FMs will be swallowed up by ambitious midlevel practitioners and their lobby groups. Instead of pushing back on mid-level practitioners, Let the lawsuits do it. Family Medicine needs to push forward in training for and offering more comprehensive services and procedures. Do those derm biopsies, treat those easy derm bread and butter causes that are making them rich – and their lobby protects. The list goes on. those are my thoughts.

  • Stephen Sutherland

    Paul D. Simmons — what kind of legacy will you leave? Prophet of doom ? doomsday prognosticator? — How about leader or supporter of one of the most amazing RUC corrections in history. There are positive movements underway to resolve the RUC crisis such as: Rep. Jim McDermott (D-Wash.) new bill the Accuracy in Medicare Physician Payment Act (HR 2545). How about trying some positive contribution and careful analysis rather than delivering doomsday Requiems etc.

    KevinMD is a shock value blog – which welcomes outrageous articles and shocking titles. Helps the million dollar day count. But it can also be used as a positive forum for clear thought and solutions.

    Also everybody should leave the NPs alone – meaning stop mentioning them. Just like the Optometrist was awarded the physician title in Louisiana this year, this is all an inevitability of a shortage. It is inevitable to have someone join this space. Anesthetist have CRNAs, Ophthos have Optometrist; Obgyns have Midwives so we need to just leave it alone and let Excellence commend our services :)

  • Stephen Sutherland

    Some schools like Georgetown offer an online course for nurses to become a nurse practitioner in just 18 months. That’s right just 18 months of an online course.
    The challenge is that the current legislation is in some places makes the possessors of the NP degree equivalent to a physician – with the ability to prescribe and diagnose without physician oversight. —- Time during those nursing years were not spent doing diagnostic work. Actually it is programs like those 18 month online programs that are going to help correct this whole thing. It is going to become extremely obvious to lawmakers that an 18 month online course as ones first exposure to diagnosis, does not qualify one to function as a physician.
    – the current skill level among nurse practitioners is extremely wide because the training has not been standardized across the nation in the way an MD/DO’s training has been standardized for years. If you say that NPs can perform equal or superior to physicians — it’s going to create massive amounts of agitation. Additionally in 3 states, maryland, mass and michigan, NP’s functioning as physicians are reimbursed at 100% the physician rate. With the new 18 month NP courses going online — this is cause for great concern. This is truly inappropriate — and it needs to be corrected. Perhaps you might have some excellent training but if you say these things as a generality — it’s going stir up serious backlash. Part of the challenge is that over the years to keep up with the crazy reimbursement scheme physicians have often narrowed the scope of practice far below their training to keep up the volume to keep the lights on. This great narrowed scope of practice is what the NPs are saying they can do. We need to seriously fix health care reimbursement and process and let the Physician work to the full scope of training and the NP to the full scope of her training.
    Likewise physicians should not attack NPs, remembering that we should nurture that team spirit necessary to work together Let’s stop the fighting on these blogs and seriously and intelligently figure out how to fix the health care crisis .