Family medicine MD/DO will be obsolete?

[Notsobad]

Where I am, the hospital employed primary care practices are heavily tilted toward physicians, believe it or not. The corporate owned practices are heavily, heavily tilted towards nurse practitioners with a few doctors. In those practices the doctors change very quickly.

nurse practitioners and PAs are great when used appropriately. Unfortunately, more and more they are being used Instead of and not in addition to the physician .

[legobikes]

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.

You know, the irony of it is this: ideally, it should never have been an aspiring 'assistant to a doctor' that was attached to a doctor in his practice - it should be an 'aspiring doctor' who is attached to a doctor. But the profession has gone the way of most trades and guilds, eschewing actual personal assessments of competency to standardized testing and other universal clerical/bureaucratic standards.

[StarTrekDoc]

PCP here -- there will ALWAYS be enough business for MDs + APPs. plenty of people want the doc (especially a little salt+pepper haired ones) to oversee and direct care. Not worried at all.

We can't hire docs fast enough.

[Turf Doc]

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.

Did you feel like they could bully you/admin into changing that policy? Or people agreed that it was inappropriate to call yourself Dr. if youre not a physician?

[Hank]

Frankly, I just don't understand this phenomenon of MDs signing charts for NPs on patients that the MDs never personally examined and treated. Why would you agree to put your money, your license, and your profession at risk like that?

Would you feel comfortable signing off on charts from your lowest ranked med school classmate without seeing the patient? You know, that guy or gal who might have repeated MS1? Well yeah, that guy or gal still had a higher MCAT score and higher grades in organic chemistry and other hard sciences during undergrad than all the NPs who nominally are under your supervision. Yet who gets named in the med mal lawsuit?

[CM]

Frankly, I just don't understand this phenomenon of MDs signing charts for NPs on patients that the MDs never personally examined and treated. Why would you agree to put your money, your license, and your profession at risk like that?

Would you feel comfortable signing off on charts from your lowest ranked med school classmate without seeing the patient? You know, that guy or gal who might have repeated MS1? Well yeah, that guy or gal still had a higher MCAT score and higher grades in organic chemistry and other hard sciences during undergrad than all the NPs who nominally are under your supervision. Yet who gets named in the med mal lawsuit?

I agree. If I didn't do the work my name doesn't belong on it.

[nastle]

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

Coming back to this
any comments suggestions are welcome

[redsand]

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.

How did the older model work without as many NPs and PAs in office-based primary care practices? Did we have more physicians in primary care than we have today? Or just less demand for services (and therefore fewer physicians in the community were needed to meet the needs of the local community)? I know it was touched on in the thread that reimbursement for PA/NP is 85% of physicians (if I remember correctly) and that reimbursement level influences the business model that may drive how employers structure their practice model, but what has changed about primary care physician workflow that makes it harder to get in to see a primary care physician now compared to before?

[Random1]

This is my experience of 20 years, initially I would see everything , bug bites, ear infections , UTIs. Now patients go anywhere that is convenient for these issues. They dont care , they just think as long as they get something , what difference does it make. In all reality , not much , because most of these issues with go away on their own anyway.

Now fast forward 20 years, almost all the patients come in with a multitude of problems, much less often to I see the simple stuff. When patients start having "real" chronic issues , all of a sudden they start wanting a doctor to manage their care. They get tired of being passed around and not knowing who is actually taking care of them. When their sugar is 105 , they get referred to Endo, when cholesterol is 201 they get referred to Card and so on.

Hospitals have been making a fortune on this. I dont know about your area , but when you have a one to one ratio of outpatient clinics to Starbucks, you know where the money is going. All of sudden when the C suites decides to get into a bundled Medicare contract , the model of free for all , becomes a liability. Our IPA which manages our at risk contracts, can tell us which offices not to refer to because they cost more per episode of care. Big brother has always been watching , now it is just watching a little differently.

[Kamban]

How did the older model work without as many NPs and PAs in office-based primary care practices? Did we have more physicians in primary care than we have today? Or just less demand for services (and therefore fewer physicians in the community were needed to meet the needs of the local community)? I know it was touched on in the thread that reimbursement for PA/NP is 85% of physicians (if I remember correctly) and that reimbursement level influences the business model that may drive how employers structure their practice model, but what has changed about primary care physician workflow that makes it harder to get in to see a primary care physician now compared to before?

A combination of things compared to 30 years ago, according to some of my colleagues as PCP in PP.

1. Better reimbursements in the past.
2. More paperwork and documentation, hence more unreimbursed time.
3. Higher expenses like EMR and all things related to running of an office that are not reimbursed.
4. Less number of better paying insurance and plenty of Medicaid and medicare advantage plans.
5. Older patients with multiple problems that take up a lot of time with proportionately less money for that extra time.

The only way to be the hamster on the wheel is to employ extenders.

[Kamban]

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?

One of my good friends is an internist in PP with 2, sometimes 3 extenders ( unfortunately there is a high turnover). He states that the only way he survives is to

1. Limit low paying insurances.
2. Charge for everything. Bill and collect. Collect upfront if possible.
3. No undercoding at all.
4. Monitor his extenders while he also sees patients.
5. Work 5 days while he can. Have saturday AM hours run by one extender.

Another one does the above and also has opened up a urgent care / FP combo staffed only by extenders. He practices 5+ miles away, reachable by phone. I think only one is doing it solo without extenders and is barely making it.

[CordMcNally]

This is my experience of 20 years, initially I would see everything , bug bites, ear infections , UTIs. Now patients go anywhere that is convenient for these issues. They dont care , they just think as long as they get something , what difference does it make. In all reality , not much , because most of these issues with go away on their own anyway.

I don’t think this can be understated. We utilize midlevels in our ED and a decent amount of what they see don’t require a big workup (or any at all) and the issue is likely to go away on its own without any specific treatment. These are also the people that typically want a specific medicine (for 90+% of these people it’s an antibiotic or steroid). These people would go see a penguin if that penguin could write for the script that they want.

[Lordosis]

I don’t think this can be understated. We utilize midlevels in our ED and a decent amount of what they see don’t require a big workup (or any at all) and the issue is likely to go away on its own without any specific treatment. These are also the people that typically want a specific medicine (for 90+% of these people it’s an antibiotic or steroid). These people would go see a penguin if that penguin could write for the script that they want.

I hear that there is a penguin run urgent care that does just that!

[GlassPusher]

I have a few midlevels in my family...father is a PA from one of the initial programs that started the field; he never intended to be a 'physician light', and always understood his role, though after 20 yrs in the ER developed quite a bit of skill. FWIW he feels the PA field at least doesn't (or didn't) seem to be continually trying to extend their scope of practice compared to NPs, particularly a la the DNP nonsense...and we have a soon-to-be DNP in our family as well, who I gather views the job as A.) more money, B.) more 'prestige'...i'm sure she'll tell her kids she's now a 'doctor'...C.) less typical RN work / more specialized practice / better hours.

Most physicians and a large number of patients perceive value in primary care physicians, but the people that pay the bills (ie. insurance companies and the federal government) will place a higher value on economics...and don't have any medical acumen/knowledge...which is why they'll pay for chiropractic and allow naturopaths admitting privileges.

[K82]

Did you feel like they could bully you/admin into changing that policy? Or people agreed that it was inappropriate to call yourself Dr. if youre not a physician?

Several NPs thought they should be able to be called "Dr." in the hospital, but not all of them. When I pushed this policy through all the channels the only resistance I got was when I presented it at the Board of Governors meeting to get final approval. It was a near unanimous vote with the only vote against the policy coming from the president of the college that was training DNPs! (the Board consisted of local business owners for the most part along with college presidents. I had no idea who she was at the time, it took me by surprise with her push back) She was upset about it and didn't think it was right. The rest of the Board totally got it and supported it. Its hard to believe this is occurring in medicine. Sanity still reigns in some places.