The evolving models of primary care: More harm than good?

The legislation proposals aimed at allowing physician assistants and nurse practitioners to act independently and deliver primary care services in place of physicians is a change in health care that we may face with an impending primary care physician shortage. It is an important topic for patients and physicians to discuss since ultimately those two groups will be impacted most by this change. Patients should be concerned with the quality of care they would be receiving without a physician’s expertise and training. New physicians should consider the possibility of having to face greater competition for business. Medical students may face an environment where the government is less willing to increase residency training programs for the growing number of medical school graduates if the availability of primary care services has seemingly been addressed.

As physicians, we have the utmost respect for the contributions nurse practitioners and physician assistants make, and they undoubtedly add great value to patient care. However, there is one thing that cannot be denied and that is a lack of training. This is where the problem lies. Nurse practitioners receive 5-7 years of education compared with 11 years of education for a primary care physician (and additional years for specialists).  Training and clinical hours required to become a family physician total 21,700 hours compared with 5,350 hours for nurse practitioners. In fact, there have been many first-hand accounts of nurse practitioners that had gone back and went to medical school and who have seen both sides.

For example in a recent AAFP telephone news conference, LaDona Schmidt, MD was interviewed on the topic of the difference between nurse practitioners and physicians.  Dr. Schmidt states, “I didn’t know what I didn’t know until I went through 7 more years of training,”since she was a nurse practitioner before she went back to become a physician. Dr. Schmidt also commented on how she was surprised how difficult medical school was given her previous training.  She goes on and says that it wasn’t until she completed medical school and residency that she realized “how much I did not know about the underlying causes of disease processes.”

The additional training a physician goes through allows for detailed analysis of multi-organ systems and complex patient conditions. The American Academy of Family Physicians articulates this point well in saying that “family physicians are trained to provide a complex differential diagnosis, develop a treatment plan that addresses multiple organ systems, and order and interpret tests within the context of the patient’s overall health condition.  Nurse practitioners and physician assistants, on the other hand, are specifically trained to follow through on the treatment of a patient after a diagnosis and to implement protocols for chronic disease management.” Thus, a team-based system would seem to provide a higher quality of care rather than a greater number of non-physician practitioners.

The problem, however, is that our health care system is facing a shortage of primary care physicians. The proper planning to accommodate the growing elderly population was not done and now it seems that in an attempt to find a solution for lack of planning, the government is considering allowing nurse practitioners and physician assistants to assume the role of primary care physicians. The big question is whether assuming this role independently will cause more harm than good? It’s important to consider. Since most of the data that shows the high quality of patient care received by nurse practitioners and physician assistants have been under physician-led practices, it is difficult to promote this change with any confidence.

A few studies have been performed in Europe, but I have yet to find the conclusive results. A study out of Netherlands was projected to be completed in 2015 and remains inconclusive at this time. Therefore, we should proceed cautiously and utilize evidence-based and collaborative models of care.  The promotion of team-based care should serve the population as greater numbers of both physicians, nurses and physician assistants are trained who will be able to grow this team-based approach.

Sarah Barber is a physician.

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  • RuralEMdoc

    O good, another article about NP’s vs Physicians. Let me start off with the first of 125 viscerally driven comments.

    • Kristy Sokoloski

      I was just thinking the same thing. Another way of beating a dead horse.

      • DD Cross (MD)

        C’mon, there are plenty of ways of beating dead horses, and then there’s the glue factory—It’s going to be a long Brave New World, isn’t it?

    • DD Cross (MD)

      It’s not so much about NPs vs Physicians as how the New Normal with its high deductibles, out-of-pocket costs, supposes the “masses” will elect non-physician providers over EDs. Physicians are a known brand, and despite anecdotal tales of wonderfully kind “extenders” it’s going to be a tough sell to hurry up and wait to see the NP or PA., and pay for it with smart-phone money. Kids, what’re you gonna do?

  • buzzkillerjsmith

    I don’t think it matters a whole lot that we are trained in a certain way and NPs in a different way. The proof of the clinical pudding is in the eating: outcomes. Certainly this has not been studied in a comprehensive way.

    I also don’t think outcomes are not as important as they should be. What matters are the incentives the MDs, NPs, and PAs face. MDs have been avoiding primary care for a long time. Rightly so. Any med student with half a brain know that primary care makes no sense as a practice. Unfortunately I have only a quarter of a brain.

    While Dr. B. and others chat about helping Grandpa FamMed when instead they should be arranging for the funeral.

  • DeceasedMD1

    The fundamental flaw in all this is that they are just legislating lambs to the slaughterhouse. Their denial of the fact they are killing off PC is astounding. Their answer is to create more.

    The recent VA debacle is a great example.
    Do you think it had to do with the fact that the VA management were working under pay for performance? We don’t need any more studies. Pay for performance killed more than a few veterans “waiting” in some sort of medical fantasy land. Then docs leave. Imagine that?? The managers are making more than the docs, who are overloaded and underpaid.

  • JR

    So, for doctors we’re counting bachelors (not a medical degree), then med school (4 years) then residency (on the job experience – people get really mad if you call residents students, then include it as their “medical education,” really which is it?).

    For nurses, we’re counting bachelors, then a Masters in nursing (2 – 3) years, which is sometimes followed by a doctoral degree?

    The thing is, aren’t most Masters of Nursing programs… for Nurses with on the job experience already? Don’t they get a 4 year Nursing degree, or go a BA and a nursing program, work as a nurse for a while (kinda like having a residency, on the job experience) and then go get a Masters and sometimes a Doctoral degree?

    I tell you, I was shocked they had Doctoral Nursing Degrees. Med school is 4 years, so a Masters + pHD is the same amount of time, but they don’t end up being doctors? Man they are getting the short end of the stick.

    Honestly, it makes sense to take Nurses with experience and have a bridge program that puts them into Doctorhood. Doesn’t it make more sense to have young people go get some on the job medical experience as a medical tech or a nurse, decide they like it, and then go become a doctor?

    It makes a lot more sense than having undergraduates hanging around doctors offices “shadowing” to me.

    • PrimaryCareDoc

      Unfortunately, there are now many direct entry NP programs. As long as you have a bachelor’s degree in anything, you can apply to these programs. In three years, you get an RN and NP degree. In 18 states, that would allow you to practice with no supervision.

      Just think about that for a second. Someone with 3 years of nursing school and NO clinical experience beyond that can have a fully autonomous practice.

      There is no way that is safe.

      I live in one of the states that allow autonomous practice for NPs. One of them in a patient of mine. He did a direct-entry program and is a psychiatric nurse practitioner. I started him on a blood pressure medication (an ACE-inhibitor) and he asked me, “so what’s the difference between this and a beta blocker?”

      I was stunned. This is something a second year med student knows- and a second year med student still has a minimum of five years of training ahead of him.

      Be very afraid, people. This is what primary care of the future is going to look like if we’re not careful.

      • DeceasedMD1

        Was the psych nurse practicing autonomously? That is down right scary. Wonder if the Congress members who are docs are going to go along with that law.

        • PrimaryCareDoc

          Yes, practicing autonomously.

          • DeceasedMD1

            Holy sh@#$%^&*(!
            Do you think there is any chance that there being more docs in Congress that they might have a some say in this insanity?

          • Patient Kit

            The legislation in FL to increase autonomy of NPs was sponsored by Rep Cary Pigman (R-Sebring), who is himself an ER physician. It passed the House but not the Senate. He says that, if he is re-elected, he will keeping trying to get a bill passed to expand NP autonomy in FL. I don’t know the details about exactly how much autonomy. But I think it’s interesting that the bill was sponsored by a doctor.

          • DeceasedMD1

            Thanks for that Kit. Pretty amazing. This guy sounds like a perfect fit to work for an insurance company. Are you aware of any other legislation? When i have time i wlll look it up but you seem like you might be more on top of that than I.

          • Patient Kit

            I’m just doing some reading myself on new and pending FL legislation. (My Mom lives in FL.). I can clarify further that the scope of Rep Pigman’s bill would enable some NPs to practice independently without any direct physician supervision. My main point being that, clearly, more docs in Congress, at either the federal or state level, would not necessarily have the effect you might expect. And yes, it’s worth noting that Rep Pigman is a doctor but not a primary care doc.

          • DeceasedMD1

            Pigman. What a great name for a Congressman. Well I see your point. Clearly politics are at hand and ethics be damned. Not sure if the reason is they are specialists, although. You can see there are specialists here on this site, that want to improve HC and get intelligent referrals and care from PC.

          • Patient Kit

            Pigman is a perfect name for a politician. It has a nice satirical Orwellian ring of truth sound to it. I didn’t mean to imply that no specialists care about good primary care. I certainly hope they do. But this particular Congressman-doctor does support independent NPs as a solution to the primary care doc shortage. Not sure if his bill is specific to primary care or if specialist NPs would be able to practice independently too. Are there specialist NPs? I know there are specialist PAs because my GYN ONC has one.

          • DeceasedMD1

            Pigman-just take off the man part at the end. Orwellian is spot on. LOL.
            Yes there arespecialty NP’s such as NP anesthesiologists.

          • Patient Kit

            A couple more pieces of FL legislation that recently failed:

            (1) A bill that would have allowed out-of-state doctors who don’t have FL medical licenses to diagnose and treat patients in FL via telemedicine; and

            (2) A bill that would have closed a loophole in FL law that currently allows medical clinics to remain unlicensed and uninspected, if they don’t accept insurance but only take cash and credit. The loophole remains. Luckily, my Mom only sees docs who accept Medicare.

            I don’t know whether both or either of these bills will be re-introduced next session.

          • DeceasedMD1

            Thanks Kit. I am becoming more interested as well to see what legislation is being put forth. What do you think of it? Honestly sounds lame to me. Telemedicine is not a great answer to anything. I guess a stopgap but full of all kinds of problems as I am sure you can see.

            The unlicensed clinics-any idea what they are going after? I know there are illegal clinics that sell drugs for cash but I am guessing that is not the issue?
            But none of these really address any fundamental problem.
            In california Boxer is trying for a gun restraint law for family members of the mentally ill after the recent mass shootings. Absurd to me as taking away guns from a violent mentally ill person, leaves a violent mentally ill person. No mention of treatment. Politicians are really not equipped to handle deep issues as they seem to make decisions often without really using reasoning. And in an election year I am told not to expect any important bills to get passed. What a bunch of weasels.

          • Patient Kit

            I think telemedicine is a great use of technology for emergencies in remote locations in situations in which there is not enough time to move the patient or the doctor. But I do not see it, as the FL legislation does, as a general solution to a local doctor shortage. Personally, I’m not a fan of the idea that doctor and patient don’t have to be in the same room together, meeting in person. Widespread use of telemedicine can only further erode the doctor-patient relationship. I believe that human contact, even too brief, is an essential part of both the healing process and building human relationships of any kind.

            As for the unregulated, uninspected clinics that only take cash/credit but no insurance, they have a reputation of pushing unapproved products and questionable services. I’d love to know who/what was behind getting that loophole into the law in FL. I know that regulations have a reputation of being overdone but no regulations? Not good.

            I agree that politicians and politics can be frustrating and maddening. And I say that as someone who has spent a good chunk of my work life as an activist advocating for people and issues in the political arena. Even politicians that I personally know, like and respect — I often can’t stand listening to them speak. But politics is our process and power corrupts even some who start out with good intentions, so it’s very important for regular citizens who aren’t career politicians to be actively engaged in the process. Otherwise, we just let those politicians make all those big decisions for us with no input from us. Use it or lose it definitely applies to both our voices and our votes.

          • DeceasedMD1

            if you care to, I’d love to hear about your take on politicians you have met. You seem very rational and level headed. What did you like or see as far as respect for these politicians you have met. I personally don’t see that being engaged helps. I recently tried to contact with issues and despite that I had something very valid to say, felt like no one was listening. It was a rather sobering experience to be honest.

          • Patient Kit

            Ah, yes, of course. How did I forget NP anesthesiologists? Not sure how I feel about that. As a patient who has been through 3 major surgeries in the last couple of years, I want someone who really knows what they’re doing to be the one putting that intense general anesthesia cocktail of drugs through my brain.

          • DeceasedMD1

            Although most of the time they say that 99% of cases are boring/easy and only 1% is terror. But whether rare or not, it’s only a matter of life and death. Choose wisely.(Instrumentation is getting better so it is getting to be safer than it already was.)

      • Arby

        In his defense, maybe the psych tract was really different than what is expected in medicine. Of course that is depressing as far as the program he enrolled in. And, what is more depressing is that I as a lowly hospital pharmacy tech [years ago], know the difference between the two.

      • JR

        It seems that psychiatrists are a weird field all together – they spend all this time learning medicine, and then it seems they learn the actual psychology stuff only on the job during residency… the people I know have had bad luck with psychiatrists and much better luck with just plain ol’ masters of counseling graduates.

        I do agree that 3 year programs for students with no previous experience graduating out independent practitioners is a problem.

    • JR

      I guess I’ll just note there was a lot of comment editing.

  • Kristy Sokoloski

    That’s not what I heard. I heard it was being considered, but I haven’t heard anything about it passing. I doubt that it will ever pass here in Florida.

  • Mike Henderson

    a lot of what I learned in my third year of residency was what I didn’t have a clue I didn’t know the first two years. we learn in layers.

  • Dave Mittman, PA, DFAAPA

    I can speak for PAs. Our training is suburb. Average PA program is eight weeks LESS in hours than a four year medical school. Then you work and keep learning just as physicians do. After many years, you are capable to provide care in many specialties-some not. Primary care is one of them. And we all have back up. There are many great PAs and NPs out there. You know not all physicians are excellent either.
    Sad you are bashing us all. Unfair.
    Dave

    • DD Cross (MD)

      “Great,” is a relative term. And the phrase: “Not all physicians are excellent,” is accurate. However all physicians went to medical school.

      • Dave Mittman, PA, DFAAPA

        Yeah. So what does that mean? Sure adds to the relative sophistication of the conversation-whatever that was. So I suppose we did not know that?
        And all PAs went to PA school.
        Dave

        • RuralEMdoc

          It means that there is a standard of a minimally competent physician that is guaranteed if they have completed medical school, residency, and are board certified. That is our weakest link.

          That standard is not reflected in NP/PA training. Proponents of increased autonomy for these professions always refer to the best of their profession as an example of the care they can provide, and I would be more than happy to receive my medical care from the top of the PA/NP profession.

          Those of us who are skeptical are more concerned about the lower ends of the ladder. The fact is that the “weakest link” of the PA/NP’s can be very inexperienced, with very little comparative education to the “weakest link” of the physician group.

          The mantra of the NP/PA who wants independent practice is “we are better than bad doctors!!!”, and I think that is a poor argument.

          • AB MD

            Very well put!

          • Shawn Huecker

            You note that you would be more than happy to receive your medical care from the top of the PA/NP profession. The point here then would seem to be not to determine if NP/PAs should be able to independently practice, but instead how to identify and certify those that are qualified by their combination of education, skill and experience to practice independently. I’m uncertain if the population of NP/PAs who would meet that bar, along with the administrative and bureaucratic burden to identify and certify them, would make for a good value proposition, but I think it’s a question better asked than “should they or shouldn’t they?” given the PCP shortage that all seem to agree is real.

    • AB MD

      Definitely not bashing NP’s or PA’s. I have worked with many who are wonderful. However, as you know, additional training/education on the job for PA’s and NP’s may happen, but is not required as it is for doctors in residency and fellowship. Also, the expectations are not the same.

  • DeceasedMD1

    Yes. After all, it’s only life or death. What’s all the fuss about?

  • JR

    So, you wake up in the morning and you can’t feel your hands. Which do you want:

    1. The doctor who has you pee in a cup and tells you there is nothing wrong with you, and even laughs at you while you’re in the office, because in a 10 minute visit they decided you were a hypochondriac, even though it’s your first visit with them?

    2. The NP who gives you a physical, runs a bunch of tests, finds stuff that’s wrong, and diagnoses you with something, then puts you on a treatment plan that makes you feel better than you have in your entire life?

    Top test scores =/= better care.

    • RuralEMdoc

      The people from your high school who went to the Ivy league/Stanford actually were smarter than everyone else. That is why they went to the best universities in the nation.

      They may have been lacking in social skills, but you will be hard pressed to argue intelligently that they were academically comparable to the rest of the pack. They weren’t.

      • HJ

        So if we intention is to evaluate a provider based on where that provider went to school, the University of Washington is ranked #1 for primary care.

        All those doctors who went to Yale probably are specialists. Does that mean your argument includes seeing specialists over primary care because they are smarter and went to Yale?

        • RuralEMdoc

          You misunderstand my assertion. The comment I replied to stated that the people from his high school who went to the Ivy league were not actually smarter than anyone else, they were just more competitive. I disagree with this.

          I am stating that they are, most likely, more intelligent, as those schools have a policy of taking the nations best and brightest. It would be silly to argue otherwise.

          The OP’s attempting to state that intelligence isn’t everything in being a good physician, which I fundamentally agree with. However, attempting to back that up by stating that those who attend top universities are not more intelligent is a silly argument, and I could not help but refute that. They are smarter, but it only matters a little bit.

          I did not go to Yale. Any Yale doctor is probably smarter than I am, but I am still pretty bright (if I do say so for myself).

          Intelligence in medicine is like weight in NFL lineman. Their is no relationship between weight and skill among NFL lineman, the heaviest players are not necessarily the best ones. That being said, if you don’t weigh at least 300 lbs, you probably can’t be an NFL lineman.

          That being said, I think it would be a mistake to attempt to evaluate a provider based on where they went to school (especially when we are using the US News and World Report’s Best Medical Schools, which is a flawed ranking system btw).

          But then again, I never made that argument, you did.

          • HJ

            The deleted comment indicated nurses don’t go to Ivy League schools.

            There is an underlying tone to the conversation that nurses aren’t smart enough to be good primary care providers. An of course, there is the anecdotal nurse who didn’t understand something a second year resident does.

            George W Bush went to Yale.

            So since intelligence isn’t everything, nor is education…I am not sure what the problem is with nurses…or physicians assistants.

          • JR

            “At Harvard, 45.6% of undergraduates come from families with incomes above $200,000 — in other words, incomes in the top 3.8% of all American households.”

            http://www.forbes.com/sites/maggiemcgrath/2013/11/27/the-challenge-of-being-poor-at-americas-richest-colleges/

            I’ve always heard the reputation of Ivy League as being “rich” or “prestigious” but never intelligent, high performing, anything like that. I certainly don’t respect anyone just because of what college they went to. I’m surprised anyone does.

          • RuralEMdoc

            You are assuming that they go to Harvard because they are super rich.

            I think that it is just as likely that an individual is rich and successful because they are smart, and then they have smart successful children who get into Harvard.

            Also, Harvard tuition is ridiculously high, which could also account for that statistic. Smart people may get in and not afford to matriculate. Even if I had the SAT to get into Harvard (I certainly did not), I would never been able to afford it.

            Also, the statistic is irrelevant as your initial statement was that the people in your high school who went to Ivy League weren’t smarter than you were. People tend to live (and attend school with) people in similar income brackets as themselves. Therefore it is likely that you either weren’t wealthy enough for Harvard, in which case those individuals who went there were truly exceptional, or you were wealthy enough to attend, and you didn’t have the grades to get in, in which those who did go were still academically superior.

  • JR

    People who are highly ambitious die sooner than their less ambitious counterparts:

    http://news.nd.edu/news/29204-go-getters-fall-short-in-happiness-and-health-new-study-shows/

    But I think you completely missed my point. The hardest part of learning to become a doctor isn’t memorizing a bunch of data, but learning to work with and relate to patients.

    Wouldn’t it make sense to have all future doctors start out – before med school – working with patients and learning the hardest part of their job? It’s the on the job experience of working with patients that provides the best training.

    • RuralEMdoc

      So you want to add more time to become a physician?

      As far as “working with other people” goes, I find that individuals either have the trait, or lack it. You can’t really teach it, per se (Not to say that we don’t get better at it over time).

      • JR

        In most industries, someone doesn’t graduate from college and immediately go and get top earning job, UNLESS they already have job experience.

        Most college graduates take entry level jobs and work their way up.

        It’s weird that physicians aren’t that way. I suppose you can argue residency is similar.

        To me it makes a lot more sense to have a career progression from tech or nurse, since that’s pretty much what every other career field does.

        • PrimaryCareDoc

          college—>Med student—>internship—>residency —->fellowship—->actual job

          Not exactly graduating from college and going to a top earning job.

          The job of a tech is nothing like the job of a doctor. Just because something is in the same industry doesn’t mean that it’s a natural career progression. That’s like saying it’s a logical career progression to go from flight attendant to pilot.

  • JR

    Ok you made me look – University of Chicago and University of California beat Yale:
    http://en.wikipedia.org/wiki/List_of_Nobel_laureates_by_university_affiliation

    But still – that has nothing to do with my comment.

    Being a physician is specifically a career where you need to be good with people.

  • JR

    Seriously, the comments you’ve left that have been deleted were worth of /b/ or reddit. It doesn’t speak to a lot of skill with “human interaction” – even the fact that you call it that speaks pretty loudly.

  • RuralEMdoc

    You are mistaking the exceptions for the rule.

    The point of all this is thus:

    There are undoubtedly tons of PA/NP’s who are more intelligent than some ( and maybe many) physicians.

    There are undoubtedly tons of PA/NP’s who are more personable than many physicians

    However, none of those exceptional medical professionals actually went through the gauntlet of becoming a physician, and that makes all the difference.

    Medical education is an arduous process. It is more than just classes taken, facts memorized, and years of experience. It is sacrifice, exhaustion, blood, sweat, tears, moments of incredible elation and of indescribable sadness. It is missing Christmas morning, and missing your child’s first steps. It is putting almost everything in your life on hold to achieve mastery of your chosen field so that you can earn the right to treat patients independently.

    The reality is that unless you have gone through the process, you can not understand how the experience changes you.

    So you will forgive me if I scoff at your notion of what it takes to be a “good doctor”, and make the ridiculous claim that independent practice by non-physicians is “better for the patient”

    • JR

      I’ve never claimed independent practice by non-physicians is better for the patient.

      Rather, that just because someone has MD by their name doesn’t mean that they are providing good care. There are many barriers to good care. Some doctors simply assume that if they run a test and it’s negative, it’s case closed, nothing wrong with the patient. Some are pressed for time. Some don’t believe their patients. Some are jaded and broken and take it out on their patients. Some of it is frustration when a patient can’t be helped, or a problem can’t be identified. Increased “Intelligence” doesn’t solve any of those issues.

      Let’s look at outcomes:
      1/3 of ICU patients have PTSD a year after being released from the ICU.
      1/10 of new mothers have symptoms of PTSD.

      There is in an insistence that the only role for a Doctor is pure medical knowledge, not for “care” of the patient as a whole human being, including physical and mental well being. “Care” is beneath a doctor. Medical health is all they should be concerned with.

      This attitude is spitting out broken patients.

      Does it really not matter? Many doctors tell me it doesn’t, it’s not their job, case closed.

  • Patient Kit

    The best docs have both — intelligence and people skills. I seek out those docs. It’s hard to imagine being able to be a doctor without intelligence, which is not just the ability to know a lot but, more importantly, is the ability to think critically and decide how to use what you know wisely. I wouldn’t want an unintelligent doc.

    Equally important to me in a doc, is people skills such as the ability to communicate, feel and express compassion and just be human. I wouldn’t want a doc with no people skills. But I also wouldn’t want a doc with great people skills but questionable intelligence.

    I’m in awe of what it takes to be a doctor, even more in awe of what it takes to be a good doctor. And I’m mystified at why so many people, in general, these days seem to struggle with just being human with each other.

    • JR

      Just to clarify: I’ve never stated intelligence doesn’t matter.

      I just don’t think you can judge intelligence solely based on where someone went to school. Or GPA. OR a test score. Those all help us judge intelligence, but they are gross over simplifications.

  • Patient Kit

    Interesting. Thanks for posting the link. My former female GYN who, while I was in stirrups on Election Day 2012, told me I likely had ovarian cancer and that, if I voted for Obama I would get what I deserved, can stand as an example though of not to assume political leaning based on gender.

    In general though, I’m happy to see more docs leaning left politically. That fact can be used to support the assertion that most docs don’t only care about money. Personally, I’ve never believed that myself.

  • PrimaryCareDoc

    Nurses aren’t a “lower rank” at all. They’re in a totally different job. Yes, one doesn’t transition from one job to the other, because they are different job. I’m not sure why you’re having such a hard time with this concept.

    Medicine is not easy. There are no shortcuts to doing it right. Again, it’s the flight attendant/pilot analogy. Same industry, different jobs. If a flight attendant wants to become a pilot, should he get to do the training in half the time?

    • JR

      I think its clear we have different views of what primary care is.

      I think a doctor should be focused on producing healthy, well adjusted people.

      I’m guessing you think of a doctor as someone who finds a problem and solves it.

      There is a problem with that definition though. A patient has surgery on their wrists, and while in once sense they are “fixed” – that patient spends the rest of their live having trouble with their wrists and having to manage occasional swelling, pain, etc. Their dream of being a professional musician has to be put on hold, and a new career chosen. (true story, someone I know).

      For a surgeon, it’s a successful surgery, job well done. For the patient, their need for on-going care continues past the surgery. That’s where those primary care doctors come in right? To me, continuing care of ongoing problems is a big part of medical care. Her doctor can’t really give her any magic solutions. He can’t give her back her dream. But he does continue to provide her with on-going care.

      To me, that’s what’s important. It’s the “care giving” part after a diagnosis with no quick fix is the type of care the people I know need.

      • PrimaryCareDoc

        We do have differing opinions of what primary care is. My job is to maintain health, not “produce” health. I can’t produce health anymore that I can pull a rabbit out of a hat. “Producing” health requires getting rid of poverty and giving health care access to all. Making good, healthy food affordable to all. Getting people off their butts and exercising.

        My job is certainly not to produce well-adjusted people. That’s their parent’s job. And maybe their therapists.

        In short, I think you have primary care doctors mixed up with social workers and public health experts.

        • JR

          If it’s not your job…

          Why do have a problem with NPs or PAs doing it then?

          • PrimaryCareDoc

            It’s not their job, either. Again, I think you’re confused about what a doctor does.

          • JR

            Funny enough –

            Some doctors ARE doing it.
            Some nurse practitioners ARE doing it.

            And they love their jobs too.

            Of course, what I mean is practicing in a way that supports the whole person, not just seeing them as a disease, or an object, or something to be fixed or cured. Just seeing the patient as a whole. Not seeing them as “something to fix” or “a problem to be solved”.

          • RuralEMdoc

            Please illustrate how we can better “practice in a way that supports the whole person”. Examples please.

            How about something like “5 ways to make your approach to medicine more holistic”, or the like.
            You just make abstract statements like “Doctors need to provide better care”, and “Doctors just need to stop dismissing the patient”. It doesn’t mean anything.

            The whole world of is full of people who state how things “should” be, but no plan on how to make them so. You have abstract ideas, but no concrete plans.

            We know the system is broken. We are all frustrated about it. That is why I frequent an online forum where I can vent my frustration anonymously.

            But unless you have an actual solution, you need to lay of the whole “Doctors are the root of everyone’s problem’s theme” you’ve got going on here.

          • JR

            If we want doctors that are more caring, doesn’t it make sense to recruit people with experience providing care to become doctors?

            I’m not convinced that a high school student deciding to become a doctor and going through the current process produces the best doctors. Our current system was originally designed to take take empathetic students and teach them to be detached, separate, and above the patients because it was felt that was the best way to provide medical care. While society’s concept of the role of doctors and their relationship with patients have changed, have many students are still learning paternalistic views as change is slow.

            Example: I has spoken with a teaching physician this year that walks his students in and out of operating rooms for patients that don’t know it’s happening. He had no idea what kind of consent his college gets from patients, but at a minimum, he’s never been introduced to the patients and neither have any of his students. What message is that conveying to the student about the patient?

            Example: The article on KevinMD about the anatomy class. What message was conveyed to the students about how to treat patients?

          • RuralEMdoc

            How should they be recruited then?

            They are not even recruited at all. Med schools do not come to the house of a promising student and offer them a benefits package. The applicants come to them.

            Thousands and thousands of people apply every year and try to show an admissions committee at a medical school why they would make a good doctor. More than 50% are rejected to every school that they apply to.

            Our current system is designed to select for the best and brightest. Do you think that another group other than the best and brightest should be selected?

            Regarding the students at teaching hospitals……

            How else should students learn? You learn by seeing patients. All patients consent to treatment, which at a teaching hospital means that students/residents will be involved with their care.

            Where should we learn the profession then?

            Do you think doctors grow on trees, and you can just pick them when they are ripe. They have to learn somewhere.

          • PrimaryCareDoc

            You are so wrong about medical school and the training process. So wrong. Maybe in the 50′s and 60′s and 70′s, but not today. Google the biopsychosocial model of medical education and see how long it’s been used.

            I’m curious- what is your experience with medical education? You have a lot to say about it.

            And regarding the anatomy class article- did you read the comments? I suggest you do so.

          • JR

            The example I gave is from a professor who described that is how he is teaching students this year. It’s current.

        • JR

          So, patient is the hospital and starts hallucinating and is convinced their nurse is trying to murder them. Hospital doesn’t care, they refuse to switch nurses, leaving the patient terrified. Eventually, smarter heads prevail and they switch the nurse and the patient calms down.

          Of course, they shouldn’t have switched the nurse right? The patient’s mental well being isn’t the duty of the hospital, only the patients physical health matters!

          So even though this patient goes home with PTSD, signs a DNR, and refuses future medical care and dies within a year, all because they are terrified of the hospital, man, that doesn’t matter right?

          The hospital was doing their job: Physical health. End of Story. They should have refused to switch that nurse!

          • PrimaryCareDoc

            If I have a patient in the hospital who is hallucinating and is convinced the nurse is going to murder them…I find out why the patient is hallucinating and fix it. I don’t switch the nurse and say, “Problem solved!” “Smarter heads prevail and they switch nurses?” No. Only an idiot would think that that’s a solution to an obvious pathology.

            Practicing medicine is not about taking the easy way out. It’s about trying to fix a problem and solve pathology.

        • buzzkillerjsmith

          Very well put, confusing physicians with social workers and public health folks.

          People don’t know what we do for living, what we should do for a living. Diagnosis and treatment. A little bit for prevention of a few specific diseases mixed in. Whooping cough comes to mind.

          Saving the world and keeping everyone happy happy and healthy healthy is beyond our powers. You and I both know it will always be this way.

      • buzzkillerjsmith

        Are you a doc? If so you should know that the idea of us producing healthy people is absurd because producing healthy people is impossible given the current state of medical technology. Our job is to diagnose and treat disease. Disease.

        Sure, there is some screening stuff but for the most part if you’re not sic you should stay out of my office.

        Did you know that annual physical have no medical benefit?

        Curious how few people understand this. Perhaps it is the propaganda of the media, and, sad to say, many docs and health systems that over-promise.

        • JR

          When you have someone who is sick and you can’t help them, what is your responsibility then?

          • buzzkillerjsmith

            Your first paragraph is off-topic snark. You know the answer to your own question. And you it has nothing to do with producing healthy, well-adjusted people.

            Your third paragraph also has nothing to do with your stated view of what we should do for a living. Kicking up dust might be great for defense attorneys, but it won’t work here.

          • JR

            It wasn’t snark, I was serious.

          • buzzkillerjsmith

            Agreed.

  • PrimaryCareDoc

    I think you lack a fundamental understanding of what delirium is.

    • JR

      The first step in dealing with delirium is to “provide a reassuring environment for the patient.”

      • PrimaryCareDoc

        No. The first step in delirium is to remove the trigger. The trigger is not the nurse, for God’s sake. She’s a symptom. The trigger might be the noise or lights. It could be a medication or drug interaction. It could be pain. It could be a UTI…

        So, should we try to fix the problem, or “reassure” the patient? What do you want, a doctor who tries to help someone get better or one who pats someone’s hand and says, “there, there.”

        • JR

          Or – you could implement measures to prevent delirium in the first place? It’s in the current medical literature, it’s just not implemented yet.

          • PrimaryCareDoc

            Says who? Many, many places, including my hospital, have implemented measures to prevent delirium. But it’s a complex issue and not so easily solved because it’s so multifactorial.

            Again, I ask you what your medical training is. You’ve got a lot of opinions of how things should be done, but seem to have very little knowledge about the actual practice and implementation of health care.

          • JR

            Do you really think that medical doctors currently working in medical schools are lying about the way they are teaching students? Do you think medical students currently in medical school are lying about the way they are being taught?

            And do you think that preventing delirium and ptsd is the ICU isn’t the job of a physician, because they are mental health issues and mental health issues don’t matter, only physical health issues matter? When other doctors state that preventing delirium or PTSD in patients isn’t their job so they do nothing about it, do you think they are lying?

  • JR

    Of course you can’t fix all the ills in the world.

    But we can expect doctors to provide “care” and not just “mechanical diagnostics”. I really prefer not to be seen as a “thing”.

    If doctors are only allowed 10 mins with a patient, then they really aren’t really getting a chance to use their diagnostic skills, build a relationship, or provide followup. They are being reduced to a mechanic. Maybe others are ok with that. I’m not. The building of the doctor/patient relationship is an important thing to support if we want a healthier society.

  • RuralEMdoc

    Your kinda proving my point here.

    It does not seem unreasonable that someone should have Post TRAUMATIC Stress Disorder after going through a TRAUMA………

    We are empathetic. We are compassionate. We care.

    Some things can only be healed through time.

  • AB MD

    Totally agree!

  • JR

    It doesn’t. It’s a response to comments that have been deleted.

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