Physicians

An Open Letter to Primary Care Physicians

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Dear Doctor,

The future is in your hands.

You have the opportunity to make primary care better.

More efficient.
More accessible.
And more affordable.

We know you and other primary care doctors have more responsibilities than ever. But you also have great influence, along with the ability and opportunity to change this country’s health care system for the better.

Primary care is essential to the quality of health care, and we need you now more than ever.

Maneuvering the Minefield

According to research firm Harris Interactive, “the practice of medicine is … a minefield. … Physicians today are very defensive – they feel under assault on all fronts.’’* Harris questions, “how much fight the docs have left in them. Some are still fired up … while others have already been beaten down.’’

Those who feel frustration, anger and burnout say they are squeezed by administrators, regulators, insurance companies and more. They worry about the possibility of a lawsuit that could destroy your career.

The question is: What can be done about it? Some of you may choose to remain in the status quo. Some of you have chosen to retire early or otherwise leave the field of medicine entirely. Yet some of you have said enough is enough and found specific solutions that mark a pathway forward. You sought – and found – specific solutions that mark a pathway forward.

If you’ve rejected the status quo and joined your fellows in search of innovations from other practices that you have applied at home, congratulations. You’re a physician leader who’s doing great things for your patients, your colleagues and yourself. You are undoubtedly more satisfied in your work than before, and you are quite likely providing better care.

To those of you who aren’t sure of how to proceed, there is a way out. But you have to act.

First, take a look around at what some of the most highly functioning primary care organizations are doing. Whether your goal is to address access, flow, safety, staffing or other issues, know that these are issues that others have tackled successfully. The solutions to what ails your practice are out there.

To identify and adapt those solutions requires you to actively engage in the Learning Coalition, defined in The Doctor Crisis as “an organic gathering of people, organizations and activities that exist within the fabric of health care today … a dynamic coming together of physicians and other caregivers along with health plans, policymakers and patients with the core mission of turning the best work anywhere into the standard everywhere.”

Seek Out Examples

What does it mean to be an active participant in the Learning Coalition? It means getting outside your own walls and finding solutions in other places that you can apply at home. It means seeking out others who have done excellent work in primary care improvement. It means taking the time to understand what is out there and what might work best in your setting.

There are numerous examples of the power of the Learning Coalition throughout the country. Drs. Chris Sinsky and Tom Bodenheimer and their colleagues authored the Joy in Practice report, which identified 23 high-functioning primary care practices.** Sinsky et al are blunt in their assessment that “the current practice model in primary care is unsustainable.”

They recommend simple solutions that work. One example is proactively planned care with pre-visit planning and pre-visit laboratory tests. One primary care site Sinsky visited was not doing pre-visit planning. She told the team about the work being done at some other clinics and the team subsequently implemented pre-visit labs. “It decreased the number of phone calls for lab results 89 percent, decreased the number of letters sent out with lab results by 85 percent and decreased visits by 61 percent.’’

Dr. Bodenheimer, professor of medicine at the University of California-San Francisco, has conducted a good deal of work in this area and, as we noted in a recent blog post, he suggests that there are essentially two types of adult primary care practices: “bright spots” and “dark shadows.”

He defines the bright spots as having many of his 10 Building Blocks of Primary Care***:

  • Engaged leadership, Creating a Practice-wide Vision With Concrete Goals and Objectives
  • Data Driven Improvement Using Computer-based Technology
  • Empanelment
  • Team-based Care
  • The Patient-Team Partnership
  • Population Management
  • Continuity of Care
  • Prompt Access to Care
  • Comprehensiveness and Care Coordination
  • Template of the Future

How many of these building blocks are present in your practice? If your answer is “too few,” what can you/will you do about it? How do you shift from being in the shadows to becoming a bright spot?

The Learning Coalition is the answer. If you have the courage to stand up and lead, you will quickly find that identifying great practices from which to learn isn’t that difficult. Don Berwick, MD, former head of the Centers for Medicare and Medicaid Services (CMS) for the United States, puts it this way: “It’s not hard to describe the health care system we want; it’s not even hard to find it. … Among the gems and the jewels throughout our country… lie answers; not theoretical ones, real ones where we can go and visit these organizations and see how good they are.”

So, when we add these elements together, the pathway forward emerges:

  1. Step forward as a leader
  2. Identify problem areas within your practice
  3. Find practices that have done a nice job of solving those problems
  4. Learn from others
  5. Apply what seems like the best fit to your practice

Take comfort in the fact that whatever your most challenging issues are, there are practices out there doing it better than you are. Go out and learn from them. And if it doesn’t work entirely as expected the first time, go back, make adjustments and try again!

If your goal is to improve your practice, then what’s the meta-goal? We think Arnie Milstein, MD, at Stanford University describes it well. “We need to shrink that gap between top performers and all the rest by a lot,” he says. “Think about a race in the Olympics: the last sprinter in the 100-yard dash doesn’t finish two or three seconds after the leader, he or she finishes two- to three-tenths of a second after the leader. All Olympic sprinters are excellent. That’s what we need in medicine — everyone crossing the finish line on the heels of the winner.’’

Gary Kaplan, MD, spoke to a gathering of his Virginia Mason team soon after he became CEO 14 years ago. He looked at where Virginia Mason was at the time, and he looked into the future. Then he bluntly told his team: “We change or we die.”

What will you choose?

* Kaiser Permanente internal study, “US Physicians and the Language of Health Care Reform: Preliminary Findings from Qualitative Research and the SHP Physician Study,” November 2012.

** “In Search of Joy in Practice: A Report of 23 High-Functioning Primary Care Practices,” Annals of Family Medicine, May/June 2013.

*** Bodenheimer, et al, “The 10 Building Blocks of High Performing Primary Care,” Annals of Family Medicine, March/April 2014. 

Jack Cochran, MD, FACS, (@JackHCochran) is executive director of The Permanente Federation, headquartered in Oakland, California.
Charles C. Kenney is a former reporter and editor at the Boston Globe and author of several books on healthcare in the United States.

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46 replies »

  1. Hello!
    I am looking to make my practice more accessible and better. I would like to perform Dexa Scans and ultrasounds for tendons . It is almost impossible to find out if the services will be covered by major medical and Medicare, if performed in the office setting. Do I need to have Radiologist or only technician?, or I can do the tests after certain training?.
    If anyone can help, I will really appreciate

  2. Hello, readers of thehealthcareblog.com! I’m a research assistant from the Department of Psychiatry and Neurology at the University of California, San Francisco (UCSF). At the moment, we are researching how we can reduce suicide rates in primary care settings. If you are a physician, nurse practitioner, or a physician’s assistant in the United States, it’ll be great if you can help us fill out this 5-10 min survey! We already have about 120 responses for this study, but we’re hoping to get more participants for a more extensive study. Here is the link! http://www.surveygizmo.com/s3/1607736/PCP-Perceptions-in-Clinical-Care

  3. Neither author is a primary care doctor. Enough said on that.

    Dr. Bodenheimer’s list is interesting. But a lot of family docs, including me, don’t get enough sleep so will probably not be going down it.

    We can’t solve the problems in primary care. Only the country can, by paying us a lot more money for a lot less work. This is not the direction thing are heading. Medical students have noticed.

    Pretty words are pointless. I see no realistic plan in this article.

  4. Very interesting post and thread.

    Re the HA article on small practices, my guess would be that how long a patient has been in the practice is a very important factor, and that this is a big driver of “people knowing each other better in small practices”.

    Most small practices that I know are well-established and have been staffed by the same docs for 10+ years. (Nowadays, docs don’t go setting up small practices unless they are direct-pay, like mine.) And many of the patients have been there for years. This means they have a good relationship with their PCP, and often the PCP has been along for the ride as the older patients developed their medical complexities.

    If you are older and have multiple medical problems, and you need to find a new PCP, chances are that will be in a bigger practice. It will also probably take the new PCP a while to get up to speed on all your health problems, and figure out the best way to work with you on your health. $42/month may or may not speed up this process.

    We need bigger clinics to have better — and joyful! — processes for working with the Medicare beneficiaries in the HA study: aged 70s, 5+ chronic conditions. BTW these were possibly not the patient population featured in the Joy of Practice article…those patients sounded more broadly primary care, as opposed to older Medicare pts w comorbidities.

    Lastly, agree w Granpappy Yokum: need evidence on docs wellbeing, and joyfulness. Stick some stress sensors — the tech is here — on the front-line PCPs and let’s start following the data.

  5. You got it, but there is too much money and power concentrated in large systems. Not only that, but government likes to deal with a few large entities making both even more powerful.

    The winners are the leaders of those systems along with their political supporters that rake off profits not from treating patients but from denying care while taking a percentage off of those that are doing the work.

  6. From the AAFP article:

    “Physicians in small practices have no negotiating leverage with health insurers, so insurers typically pay them much lower rates for their services than they pay physicians who practice in larger groups or are employed by hospitals,” wrote the authors.

    A fine example of how negotiating on the basis of “quality” is a completely empty farce. Insurers surrender patient values to be churned in large systems, ignoring the true value already blatantly obvious in the system of Primary Care. Why are we being discounted when we are already reducing medical costs and utilization?

    It’s time Primary Care stop being the 99 cent value menu to capture downstream revenue. The large systems that everyone keeps worshiping are the cause of the problems we face. They are not the future, they are the status quo. Independent Primary Care is the answer that everyone keeps looking for. Unfortunately, the dominant system does not want to be salvaged.

  7. I think we need to remember that whatever happens with healthcare, and with all the sweeping changes that are occurring, there are many different types of primary care personalities and practices that can have value for patients and for the nation’s healthcare in general. One size does not fit all.

  8. Thank you. Knowing your patients and stability are unheralded as the quality that patients are really looking for. It is unbelievable to see so many forces working against a model that has been successful for so long.

  9. Perry thanks for the link to the AAFP post, Extremely interesting stuff. Money quote:

    “Specifically, the authors of “Small Primary Care Physician Practices have Low Rates of Preventable Hospital Admissions” found that practices with one to two physicians had 33 percent fewer preventable hospital admissions compared with practices with 10 to 19 physicians; practices with three to nine physicians had 27 percent fewer admissions.”

    This is must read I think especially related to the question of what is it small practices have that produces such results.

    Rob would be vy good to hear from you on this.

  10. Excellent, Perry!

    “But could it be that these small practices have something large practices don’t? That’s the big question, according to Ryan.”

    Yes! Small practices know they will be awakened at night and on the weekend if things aren’t handled before 5:00PM especially on Friday.

  11. Thank you all for joining in this very important and complex conversation and honoring these tough messages. We are getting deep into reality for many and the content and passion of these responses are critical. Yes, the patient’s role, behavior, and responsibility will always be a source of complexity. Yes, the role, behavior, and responsibility of the hospitals and specialists will always be a source of complexity. Sinsky and Bodenheimer are early adopters of the linkage of professional career satisfaction to patient centered excellence of care delivery. While they don’t have all the answers they have helped “start the conversation.” It is up to all of us to embrace, form, and join in an open source, connected network as a Learning Coalition to exchange ideas and share advances to learn how to optimize the career experience for primary care…..our patients need it!

  12. “I think we could get more (smart) poor and inner city kids to become PCPs if we recruited and paid for their education, then made them spend 10 years in their neighborhood area as pay back.”

    If they’re smart enough to go to med school, it’ll take them about 30 seconds to realize that a 300k education scholarship is wiped out in two-three years by the pay discrepancy between PCPs and specialists.

  13. “Do you wait to change the way you deliver care until the manner in which you are paid changes? Or do you make a bet that quality care — the triple aim — will be rewarded/paid for in the future?”

    How many times should we get burned in one career with carrots that vaporize as soon as you reach them? There are plenty of physicians practicing value based care right now. They are known as “underutilizers” and they are being acquired by larger systems who can operate Primary Care at a loss. As Peter1 suggests, your job is going to be “feed hospitals” for the foreseeable future.

  14. ” They charade as PCPs but are really feeding the hospitals with referrals and the usual expensive lab and imaging tests.”

    This is a very important point. By the time many PCPs attempt to adapt to the changing times, they will find it easier to go the “corporate route”, which does nothing to decrease costs.

    “I think we could get more (smart) poor and inner city kids to become PCPs if we recruited and paid for their education, then made them spend 10 years in their neighborhood area as pay back”

    An excellent idea.

  15. Charles I have been saying for some time to my colleagues that the sure sign of a true paradigm shift in health care will be when you begin to see the income gap between specialists and PCPs begin to narrow considerably, ie., specialist income is being transferred to PCPs. Until this happens, there will be only cost shifting but no actual “health” care vs “sick” care taking place and our broken, backwards system will continue. And how to get there? It starts with reconfiguring the group who advises Medicare on what should be charged for certain procedures/treatments. Right now, that group is predominantly specialists, therefore, procedural medicine is reimbursed at a premium compared to “cognitive” medicine. But as with all things in medicine, this is highly political and specialty societies do no want this to happen. But until this change takes place, nothing will improve. This is one of the main reasons I am quitting clinical practice and joining the “dark side” of the insurance industry. As a PCP, my income has a ceiling while in the insurance industry, there may be a ceiing, but it is much higher.

  16. Sure Bobby, I’m guessing it’s the exception not the norm in that area? Try getting an appointment with Rob as well, especially when he maxes out on needed patients. Here in Chapel Hill NC my wife is having a terrible time getting an independent PCP as well – no salary here. Of course there seems no problem with hospital based PCPs from the Duke and UNC systems which are popping up clinics everywhere. They charade as PCPs but are really feeding the hospitals with referrals and the usual expensive lab and imaging tests.

    I think we could get more (smart) poor and inner city kids to become PCPs if we recruited and paid for their education, then made them spend 10 years in their neighborhood area as pay back.

  17. Rob, Jack and I and many others have learned a good deal from your writings. Yours is an important voice in the health care debate. But I am not so sure about the drowning man analogy. There are primary care practices out there making the kinds of changes we discuss in the post and finding benefits in both quality for patients and professional satisfaction for providers. Examples include North Shore Physicians Group in MA as well as some groups within Atrius Health also in MA; Virginia Mason, and a large group in Hartford. I do not pretend that this is a tidal wave but the course seems so obvious — particularly if the payment shift to value-based care accelerates — that I cannot help but think that there is a tipping point somewhere in the not too distant future.

  18. “I’d like to see PCPs paid salary with benefits and pension, then they could concentrate on patients – all patients”
    __

    Mayo model. But, just TRY to get an appointment.

  19. Joe you make the critical point about payment. You write: “We cannot expect them to act differently until and unless they get paid differently.” In a way I think this gets to the heart of the matter: Do you wait to change the way you deliver care until the manner in which you are paid changes? Or do you make a bet that quality care — the triple aim — will be rewarded/paid for in the future? I do not suggest that this is an easy choice but if you look at the survey results from McKesson (I noted them above in response to Vik) then there is hope that the payment system may change more quickly than we had thought.

  20. Potentially a useful shift, but lingering in the background are the concerns expressed by “pcb” below. The measures matter, and if they are ephemeral — get a physical, know your numbers, get screened — we will have simply shifted the way we pay for the same desultory effects. Only time will tell.

  21. I found this survey from McKesson interesting. (“The State of Value-Based Reimbursement and the Transition from Volume to Value in 2014’’)*

    – “The reimbursement landscape is changing faster than many had anticipated, with payers and providers decidedly aligned on embracing payment with value measures.

    – Remarkably, 90% of payers and 81% of providers are already using some mix of value-based reimbursement (VBR) combined with fee-for-service (FFS)…

    – Providers using mixed models expect FFS to decrease from about 56% today to 34% five years from now…

    *http://mhsinfo.mckesson.com/rs/mckessonhealthsolutions/images/MHS-2014-Signature-Research-White-Paper.pdf

  22. “put their money where their mouth is and financially recognize that primary care docs are the bedrock of medicine in this country and compensate us at the same rate as specialists”

    JEB, better start with your own profession – they’re screwing you.
    http://www.washingtonpost.com/business/economy/how-a-secretive-panel-uses-data-that-distorts-doctors-pay/2013/07/20/ee134e3a-eda8-11e2-9008-61e94a7ea20d_story.html

    Frankly I don’t want to pay PCPs the same as specialists, I want to take pay from specialists and give it to PCPs. The “same pay” argument just keeps your colleagues mollified, it does not help us with costs or better care.

    Rob has a good alternative, for those who can afford the club membership. Most complaining PCPs can go cash if they have the guts. I don’t think it will improve access, but it may improve outcomes.

    I’d like to see PCPs paid salary with benefits and pension, then they could concentrate on patients – all patients, even those on Medicaid.

  23. Scott – calling the ACA (which is the law) the “Government Health Care Bill” is so 2013 of you…

    Ron

  24. Charles, thanks for your reply. Yes, your last sentence is really the crux of the issue. It seems to me, however, an incredibly tough hill to climb. The FFS reimbursement system, with its dysfunctional cascade of retrospective utilization review processes, which do little to rationalize physician or hospital administrator behavior, has created an army of clinical and administrative cowboys who insist on doing things their way, evidence be damned.

    I want to believe that your vision can come to fruition. I am doubtful. Undoing 50 years of rewarding doing more because that’s what pays more so that we can pay for safety (probably objectively measureable) and effectiveness (probably much more ambiguous and variable depending on perspective) is, sadly, radical. The saddest part is that we are hanging our hopes on “thoughtful organizations” as you put it. In my experience with hospital and health system administrators (up to and including the C-suite), they are a small minded and generally doltish lot.

  25. Vik a number of your points are well taken particularly your comment on annual physicals. I want to offer another viewpoint on Arnie Milstein’s analogy to Olympic sprinters. His goal of shrinking the “gap between top performers and all the rest by a lot” makes a lot of sense and, in many respects, is reachable. No, not everyone graduates at the top of the med school class but in thoughtful organizations that identify and define standard work for a wide variety of conditions, improvements among all docs is possible. Focusing on and reducing unwarranted variation is an important step in that direction.

  26. ” that primary care physicians are critical to any better future for healthcare”

    They are and if they want to advance the cause of Medicine and their patients they have to recognize that most of the stuff mentioned has little evidence and little to do with the practice of medicine except for the generalizations made. The specifics we are all too frequently hearing are promotions or advertisements and should be looked at as such.

  27. The same people that whine and cry about EBM forget about evidence the second they promote their pet projects.

  28. I can think of no other industry that exists today where a valued and (becoming) rare service is so poorly compensated. As PCP’s we are told time and again how critical we are to a well-functioning medical system, yet our salaries are not reflected by these comments. As soon as the powers-that-be stop with the lip service, put their money where their mouth is and financially recognize that primary care docs are the bedrock of medicine in this country and compensate us at the same rate as specialists, NOTHING will change. And no–creating more primary care training programs is NOT the anwer, as any practicing doc will tell you.

  29. “What the system has done is forced physicians to behave in ways that they don’t want to behave,” he says. “No medical student goes to become a doctor to become a businessperson, but the system is so dysfunctional today that it has created this business mentality among doctors.”

    Jauhar says the system needs to be fixed to accommodate the needs of more ordinary patients.

    “The system is wonderful if you have a rare disease or if you require very high-tech care, but if you’re a run-of-the-mill patient who has a chronic disease that needs to be managed by multiple doctors, the level of coordination and communication in the American system is so weak, so lacking,” he says. “Today, if a politician says, ‘we have the best medical system in the world,’ he doesn’t sound patriotic, he just sounds clueless.”

    http://www.marketplace.org/topics/health-care/no-medical-student-goes-tobecome-businessperson

  30. I keep waiting for JF to not get it right. Still waiting. As far as HC “economics,” they continue to look like Gould’s “Drunkard’s Walk.”

  31. That is your path forward?
    Step up, like yourself and network?
    All this cloud talk is going to get us nowhere.
    JF is right. Help get the economics straight, or get back on the hamster wheel and help us out.

  32. For many responders, this post (like many) is just one more Rorschach blot test. They see what they are primed to see. Some take it as another opportunity to rail against Obamacare (which the post does not mention). Others take it as another opportunity to rail about the requirements of the official definition of the patient centered medical home (which the post does not directly mention or recommend).

    Yes, it is an idealistic call to action. But its central point — that primary care physicians are critical to any better future for healthcare, and that to make that difference they have to re-think the way they practice — is manifestly true.

    The key part that Cochran and Kinney do not directly address is hinted at by Vic and Rob: The core of the question is economic. We are paying PCPs to be “code factories,” to do unneeded visits, annual physicals, screenings and tests. We cannot expect them to act differently until and unless they get paid differently. As Rob points out about his own practice, the first step is changing how you are paid, in one way or another. And there are many ways that work better than the current code-driven fee-for-service model.

  33. I’ve said it before but:

    Drs. Sinsky and Bodenheimer offer not one shred of evidence – nothing, nulla, nada – that the physicians in the practices they profile are more joyful or less burnt-out than their peers.

    What they offer is really an administrator’s guidebook on how to get your physician-hamsters to run faster on the wheel.

  34. “Apply what seems like the best fit to your practice.”

    This may, or may not be the PCMH.

  35. Ever wonder what’s really in store for you involving Obozocare ? Bring up this Youtube portal page and type in the following search criteria:

    Know the TRUTH about the Government Health Care Bill

    Click search – then click on one video icons on the left margin

    This is video reading of the law word for word. No propaganda just the facts.

    This ends today’s lesson

  36. An Open Letter to Dr. Cochran and Mr. Kenney

    Most of the bullets in your article are requirements for recognition as a Patient Centered Medical Home. As I pointed out in my THCB article about PCMH, there is no guarantee that function follows form in today’s healthcare. In fact, there are so many mandates and requirements to have formalized systems that true innovation is only something we allow ourselves to consider after we have conformed to all the payer and certifier mandates. You, yourselves, tout the use of technology without first declaring it needs to be functional.

    A poignant example of how the mandates hamper physicians is that Dr Sinsky herself uses a paper (!) routing slip that takes ten seconds to complete, instead of ordering tests and follow-up appointments in the computer. If you really want physician-led care and innovation, don’t be so quick to define the parameters for them (us).

    https://thehealthcareblog.com/blog/2014/02/09/pcmh-certification-and-designing-the-perfect-car/

  37. There are huge problems when systems are run by the high-cost centers of care: hospitals. The percentage of practices that are being run by hospital systems is on the rise, and this creates a tremendous barrier to high-quality care. Hospitals, in the end, are where most of the money in health care is wasted (owning many of the ancillaries and profiting off of the overuse of these services). If primary care is to be of value to patients and to society as a whole, they will inevitably decrease the waste which fattens the pockets of their employer. This is the ceiling which limits the degree of patient-centeredness a PCP can achieve.

    Furthermore, many of the profitable physician owned practices are built to get the most money from the payor while spending the least amount of time with the patient. This also contradicts the idea of being centers of responsible care and cost consciousness.

    Most PCP’s out there (the ones I’ve met) are either becoming code factories that spend little time with patients or are selling themselves to the hospitals. I don’t see many taking the time to look to the ideas suggested here.

    I wonder if the optimistic ideas put out in this post are akin to shouting swimming instructions to a drowning man. I’m not sure they can learn to swim before being exhausted by the effort and pulled permanently under. My practice meets many of those criteria, but I did so by leaving the water altogether (no longer accepting insurance). While I am optimistic that my future will be far better than that of most PCP’s, the question is whether a new model can emerge that will offer a legitimate alternative to the soul-sucking system that is out there now. I think it can be done, but I confess that the effort required to do so is quite large.

  38. “How about explaining that fallacy to patients along with educating them about the differences between relative and absolute risk?”

    Right, so we can get lower “quality numbers” when patients make educated decisions to forgo testing/screening (and heaven forbid those newly educated patients then decide to take fewer meds for their diabetes, lipids, htn, whatever…..)

    No way! I’m sticking with: “Get yer tests, take dem pills. Get to those goals. It’s important fer yer health. We don’t want to do nuthin when sumthin can be done.”

    (My ACO ranking (and paycheck) depends on that sort of doctoring.)

  39. It’s impossible to trust a PCP (or other physician) who is taking “financial risk for the populations they manage.”

  40. To the list of five steps in the pathway forward, I would add this: push back against government and health plan/health system dictates that waste time and money, don’t save lives, and often result in overtreatment and overdiagnosis. In the primary care setting, the most glaring example is the idea that generally healthy adults need annual checkups, a recommendation that is baseless.

    Likewise, primary care leaders need to step and do something that no one else does (or wants to do): talk to patients about the national obsession with screenings and about how screenings neither reduce spending nor improve mortality…although they do improve five-year survival rates. How about explaining that fallacy to patients along with educating them about the differences between relative and absolute risk? Teaching people these fundamentals is going to be crucial in an environment where PCPs are expected to take financial risk for the populations they manage. People not only need to trust the explanation, they will need to trust that PCP has judged their risk level wisely, based on a good H&P, not just a different round of testing.

    “All Olympic sprinters are excellent. That’s what we need in medicine — everyone crossing the finish line on the heels of the winner.’’ — That strikes me as a very naive, Lake Woebegone view of the world. The reality is that someone’s PCP graduated last in his class, and he is never going to be one of he cream of the crop (of which there can only be a limited few, just like in the Olympic sprinting finals). For the rest, you just have to hope that they don’t do too much damage.

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