Will Primary Care Be There When We Need It?
Posted by WhiteCoat on November 7, 2007
Interesting article in today’s New York Times details a system where physicians are paid based on the quality of care they provide and how well they manage chronic conditions. There is a lot of support from medical organizations, insurers, and several large pharmacy chains.
If we keep headed the way we are going, we’re gearing up for the perfect storm. People are living longer, Baby Boomers are about to inundate the system, and we’re treating primary care physicians like second class citizens. We have to re-examine our priorities. This new model is a good first step.
According to the NY Times article:
Health policy experts say that unless payment and practice rules are changed, the financial squeeze on primary care doctors threatens to produce a crisis for patient care. As the population ages, it needs more care, but primary care doctors are becoming scarce in many parts of the country. Less than 8 percent of medical school graduates chose family medicine this year, according to the academy of family doctors.
What’s going to happen if less doctors want to go into primary care and those that are already in primary care decide to cut back on their practice to engage in cosmetic medicine or other higher-paying specialties? (Hat tip to Kevin, MD for the links).
Bring a good book and head to the ED, folks. You’re going to have trouble getting timely care anywhere else.
Anne said
Or go see family nurse practitioners who are designed for family primary care
SeaSpray said
How could they measure quality of care? Isn’t that often times subjective based on many variables? How can you put a Doc in a box when so many things in life happen outside the box? And who determines the final outcome AND who gains by not paying the Dr what he is worth? And will there be incentives for Docs to strive to meet the “new and improved” standards that will ultimately compromise pt care?
Is the appropriate way to manage chronic conditions basically anything that fattens the wallets of the ins.co.CEO’s vs ordering necessary tests, etc. for the pt?
Every day my little blog gets the most hits from people inquiring about the pros and cons of socialized medicine. That and a lot of people are interested in peeing, but I digress. It does seem that many people are concerned with the future of health care. Why can’t there be something like a health care summit in which the think tanks representing all facets of the medical industry participate? Also where is the logic in biting the hand that feeds you? And by that I mean that if they make it so that FP seems less desirable to practice in, resulting in a greater influx of patients to the ERs…then won’t the exorbitant ED prices cost them more in the long run?
Sorry this is so long Whitecoat and I don’t pretend to be as savvy as all of you med professionals in this area but I am concerned and I do think a lot of Americans are.
The Happy Hospitalist said
Anne. As a physician I will be the first to say that part of being a great physician is knowing what you know but more importantly knowing what you don’t know. I am a physician, someone who devoted a great part of my youth(my entire 20’s) to learning the art of medicine. I trained in the footsteps of other great physicians, who themselves have devoted a great deal of their entire lives to training people like me. I am a physician, not a provider.
I am separated from providers by my vastly superior knowledge base, (let me repeat that, vastly superior knowledge base), my integrative training capabilities, my wide range of developing the differential diagnosis, my understanding of horses and zebras and when to look and when to look the other way. Medicine is not a book. It is an art. No matter how hard you try to package medicine, it will never be a book. I have learned the art of medicine and will continue fine tuning that art for the rest of my career. My service to you, as a physician is to promise you the art of medicine. You can think of me as a highly scientific painter.
No painter, no matter who hard they try will ever be able to paint the exact same painting, ever. Anne, you are my painting, for which my artistic brush has created, what I believe, to be the best possible picture of health, based my my artistic abilities. You are different from every other person on this earth. You are living art. And a great physician will treat you as their greatest painting ever, every time.
There is no provider of medicine, no matter how many years of practice, that will ever be able to promise you the art of medicine.
Anne, you can read a medical book yourself, but you will never be able to practice the art of medicine without the intense training, experience and knowledge base that medical doctors achieve by way of their rigourous training. Any provider who claims otherwise fails the first rule of being a great physician. You must know what you don’t know. Nobody can google their way to great painting, no matter how great the internet is.
Having providers assume the role of primary care is flawed on so many fronts.
A doctor is so much more than prescribing drugs, ordering labs, and reading xrays. It is understanding when, why, why not, how, how much, how little, how come, how do you do, everytime, all the time. When you see your doctor for that 10-15 minute visit, so much is going on through your doctors mind that involves the art of medicine, every time, all the time. Something a provider will never understand. What you see from a doctor of medicine is but the sliver of a tip of that ice berg of knowledge in your doctors mind, something a provider will never be able to offer.
When you see your doctor for one medical problem and you get upset that the fee is too high for the information received, understand that your information is but a miniscule aspect of thousands of bits of knowledge in your doctors mind, which he/she is interplaying with each other to determine the best drug, the best lab, the best test to evaluate. You are paying for the artist, not the book. And beautiful art priceless.
I have seen more cases of everything you can ever imagine in a vast array of situations (acute and chronic), in my seven years of post graduate training than any provider will see in a life time.
A provider is the single chapter of a library of books, but will never be the art. Wishing for providers to take over primary care, is like wishing for a field full of chapters of knowlege, but no artists.
Artists create a beautiful world by thinking outside that box of knowlege, driving innovation and forcing greatness.
If you pay a provider, understand what you are getting, but more importantly, what you are not getting. I am not arrogant, I am not eggocentric. And I am not God. I am reality. I am an artist and a damn good one.
I will leave it at that.
SeaSpray said
Oh happy Hospitalist! What a visual. I love the Analogy. So eloquently written. Wow!
#1 Dinosaur said
Well said, Hap.
Anne, did you know that FNP’s order far more studies and consults than FP MDs? More than makes up for the “cost savings” of your lower salary.
Nurse K said
For the record, I changed degrees from neuroscience to nursing after being rather inspired by the NP at my OB’s office. I got knocked up unintentionally, shall we say, when I was 19.
Being terrified and embarrassed, it was nice that the NP (who I saw every-other-visit there) took the extra few minutes to ask thoughtful questions such as “how are you doing with this pregnancy” [meaning, emotionally, etc] and taking the time to care about me as a person. This is probably as a direct result of the NURSING background of the NPs. I felt 100% confident that she knew about pregnancies (even my high-risk one), but the added bonus of the caring attitude really helped me personally.
The doctor did his thing down there every other visit, declared everything to be okay, and went on his way. Doctors can certainly do the nice, caring thing too, but it’s just not as prevalent based on my observations.
So you can say NPs are a waste of money or order too many tests or whatever, but remember there is something special about a really well-trained NURSE that a doctor just doesn’t necessarily have because the training is different.
If it wasn’t for her, I’d be doing whatever 4-year neuroscience degree-holding people do (selling pharmaceuticals, waiting tables, working as a lab grunt for $11/hr).
William E Yoe said
Happy Hospitalist,that’s the best description of a true physician I have ever read.I agree completely.May all your works be masterpieces.
Dx:Ddx said
I agree with the concerns re Primary Care. I am living it.
http://poemd.blogspot.com/2007/02/primarily-careless.html
As to Dinosauer’s comment re cost savings/ efficiency of FP MD’s…if this is Truly the case, why don’t insurers line up Fp’s and pay them to save money…One model I know, Group Health does require “enrollees” have a PCP…But I haven’t seen their model overwhelming the market…
The art of it is the problem…as HapHosp so well said. It’s the “fun” (creative)part of it, and the part where we can be oh so sloppy…
SeaSpray said
Happy Hospitalist-I copied what you wrote so that I could give it to a couple of my favorite physicians. It will probably validate what they already feel and will appreciate what you have written. I’m saving it for me too. If your eloquent comment doesn’t champion the cause for being supportive of physicians then I think the people that read it don’t want to acknowledge these things because they want it their way regardless of the consequences.
I am a doctor, an artist, not a provider….. « The Witch Doctor said
[...] WILL PRIMARY CARE BE THERE WHEN I NEED IT? [...]
Anne said
That was a great description of a physician. I was commenting on primary care of which it takes sometimes 6 weeks for the patients I refer to you to get in. In the meantime I live in Idaho which has the lowest physician/capita ratio in the 50 states. Maybe you could move here to assist the patients of Idaho but in the meantime we are breaking our backs trying to find “primary” care physicians here.
sara said
Beautiful, Hospitalist. That should be spread around quite a bit…turn into one of those pieces that gets widely passed from email to email.