Family medicine MD/DO will be obsolete?

[Kamban]

Agreed. I wouldn't see a PCP that isn't a physician. So really hope they don't become obsolete!

Unfortunately soon you might have no choice but to see a mid-level unless the PCP is your close buddy. Most PCP's with 2-3 mid levels under them hardly have any time to see routine follow up or even less complex visits and they are only seen by the mid-levels. That is the reality of primary care today.

[Lithium]

I think PCP will still exist but in greatly reduced numbers. mainly to supervise the mid levels and see some complex patients. This also applies to many specialists, as their numbers needed will be less. They will be paid more, but th overall numbers will be far fewer than today.

As to NP practicing independently, a few do. But most don't want the hassle. They like to punt the responsibility and risk to someone higher. They might get paid only 100-150K compared to a PCP who might make 250K, but they don't compare their salary to a M..D. They compare it to their former self, a R.N., who gets paid only 50-60K and does hard work will less status.

In Oncology you see a minimum of one NP to an oncologist. I think the trend is now to have 2 to a physician. Soon the oncologist will only be seeing initial consult of complex cases and few tricky follow ups. The rest of the work, including putting in orders for chemo, follow up and all other grunt work will be done by mid levels.

I am not sure the NP is comparing their salaries to RN as much these days. So many NP’s are getting their credentials after practicing for barely a year or two and basically using it as a backdoor way to becoming an MD. For my first year as an attending I felt rich compared to my resident salary, but it didn’t take long before I started comparing myself to my colleagues who were generating more RVUs and the surgeons in the doctors’ lounge.

[Lordosis]

Unfortunately soon you might have no choice but to see a mid-level unless the PCP is your close buddy. Most PCP's with 2-3 mid levels under them hardly have any time to see routine follow up or even less complex visits and they are only seen by the mid-levels. That is the reality of primary care today.

Maybe it is regional but our ratios are not so dire (Yet?) My office has the equivalent of 4 FT MDs and 1 NP. Across my health system in outpatient FP it is closer to 2:1. The IM group in town is 1:2 and everyone I know who goes there complains they cannot see their doctor. It is one of the reasons I was able to fill up so quickly. A lot transferred here and I make it a point to see my patients for everything. I do not care if it is a trivial issue and the NP has more openings. Some of it is economic. But mostly I treat people the way I would like to be treated.

[Random1]

I find I am in a similar situation. There are several hospital owned practices within spitting distance, staffed with 1 doc to 4 APCs, they can get a new patient in 1 day. I typical book out 60+ days. I may be a better doc, but most of the new patients have the same complaint, I would rather wait and see a real doctor.

[NumberWhizMD]

PCP here as well. My clinic is similar to Lordosis . I will say many of my patients have also transferred here, as they could never see their PCP. Although it is getting harder to get in to see me as a new patient, I still have that availability.

For chronic follow-ups, I tell my patients that if they have a specific day and want to see me, they should schedule before they leave to guarantee their slot. I can often see at least a few patients for same day/acute needs. Working in a chronic follow-up last minute can be more challenging.

I didn't become a PCP to have someone else see my patients. I appreciate our APP help, particularly for some of the overflow/acute needs. I hope I don't lose my value, but nothing would surprise me. I know my patients appreciate the continuity as well, which is why there have been transfers of care from other clinics.

I will say I see APPs in all fields, and I don't see this going away. For instance, there is a dermatologist in town that has 1MD:8APPs. If you want to see the MD, you will wait months. As a patient, if I am going to a specialist, I want to see the MD. That is becoming harder to do without a significant wait (depending on the field).

[cards67]

I think there will always be a place for MD/DO PCP's. People want to be seen by doctors. I constantly get new patients who were tired of seeing an NP or get referrals from doctors who want their patients to see a doctor. And if hospitals only employ midlevels, PCP's will go private and take patients with them. Employed midlevels will create more work for specialists and you'll hear complaints from specialists and/or specialists telling their patients to go see a real PCP. Insurance will notice more testing and referrals and get involved. Financially, I actually think it doesn't make sense to hire midlevels (ignoring the revenue from excess testing and referrals) since midlevels get reimbursed at 85% and are less productive.

[Dusn]

I try as much as possible to go to groups with no midlevels. Because, if they have midlevels, I know I’ll see the physician for routine visits, where I’d be fine seeing a mid level. But when I really get ill and want to see someone urgently who can come up with a full differential, I’ll get added on to the midlevel’s schedule.

[Kamban]

Maybe it is regional but our ratios are not so dire (Yet?) My office has the equivalent of 4 FT MDs and 1 NP. Across my health system in outpatient FP it is closer to 2:1. The IM group in town is 1:2 and everyone I know who goes there complains they cannot see their doctor. It is one of the reasons I was able to fill up so quickly. A lot transferred here and I make it a point to see my patients for everything. I do not care if it is a trivial issue and the NP has more openings. Some of it is economic. But mostly I treat people the way I would like to be treated.

You and NumberWhizMD are anomalies. Most PCP's here have at least 1:1 ratio of Physician to APP. The more common ratio is 1:2 or 1:3. And we might want to see a true M.D but most patients won't be able to differentiate us from Dr. Betsy ( I can guess that easily) or from Dr. Taylor ( that is harder to determine as a NP but I can gleam that from their website). Even educated people like engineers ( of which there are many in my town) can't spot the difference. Or maybe they don't care. They want to be seen today or tomorrow, not a week or two later.

In specialist care, the ratio is sometimes worse.

[childay]

If and only if value based care and population health starts to matter — then docs will show value compared to mid levels. A specialist friend goes crazy because an NP sees a patient with chronic cough and refers to allergy pulmonary and ENT at same visit (true case). C-suite sees $$$. I’m afraid for primary care— and by extension for our health care system — we will end up with yet worse health outcomes at higher overall expense

This and its not just primary care.
C-suite doesn't care about quality of care unless it affects their bottom line positively.
I can't imagine there won't eventually be downwards pressure on physician salaries, or less jobs or both.
Around here a staffing contract company replacing many of the inpatient psych docs at various hospitals with telemedicine APRNs. Hospital saves by not paying a MD, contracting company pays supervising MD tiny stipend and takes the rest.

[nastle]

I think this an existential threat to PCP only because the quality of care MD DO provide is hard to quantify with most metrics that are currently used
in my organization ratio is 1 :1 but in most places I see its far worse

real question what measures can primary docs take to stay competitive and survive in this environment?

[Turf Doc]

I also see people talk about taking these supervisory "gigs" for like 5k/year. how could anyone be that desperate/ignorant??

[K82]

Why would this be primary care specific? I booked a hand appointment the other day for my daughter. Guess who saw her? Guess who does all the procedures in IR? There are now APC only EDs. This trend (including the online NP school phenomenon you've likely noticed) has nothing to do with primary care and everything to do with economics.

It's beyond me why an insurance company or any other payer would pay the same rate to an APC (with a chart signed later by a doc) as a doc, but until that changes, you're right. Medicare only pays 85% of what it pays a doc if you are only seen by an APC, but I don't think that premium is high enough. When a hospital/clinic etc is paid 50% for an APC visit, there will no longer be the economic incentive to use APCs that exists now. Then they'll only be in places that can't recruit a doc, which is how independent practice is generally sold to state legislatures.

NPs are not doing all the procedures in IR ( I assume you mean interventional radiology). There are some groups (not mine) that hires them to do some minor stuff like para's or thora's or simple bxs maybe, but IR Rads do some very high end complex stuff like stroke thrombolysis, aortic stent graffs, tumor ablation and on and on. There's no way NPs are going to be doing that stuff.

[childay]

NPs are not doing all the procedures in IR ( I assume you mean interventional radiology). There are some groups (not mine) that hires them to do some minor stuff like para's or thora's or simple bxs maybe, but IR Rads do some very high end complex stuff like stroke thrombolysis, aortic stent graffs, tumor ablation and on and on. There's no way NPs are going to be doing that stuff.

*Yet*

[highdoseamox]

Primary care pediatrician, all outpatient. Our department is 98 MD/DO, 2 NPs (and when they retire zero NP). We're salaried. NPs cost not much less, are unionized so they're not in the evening/weekend urgent care pool (since that would be overtime), see fewer patients (bc they have to have lunch break, can't work past 5:30), etc etc etc. Our broader medical group seems to have very few PA/NP in primary care, more in surgical specialties (I don't think our pediatric medical specialties have any).

[K82]

I was Chief of Staff at my facility a few years back and the NPs in the hospital who had DNP degrees started calling themselves "Doctor X". This was confusing to pts since they didn't know who was a physician and who was an NP. We put a policy in place that NPs could not call themselves Dr. in the hospital. I had a few NPs argue with me that they were just as good as a physician in caring for pts and they said there were studies to prove it. This stuff is only going to get worse.