OP-ED

Et Tu, Dr. Noseworthy?

 

 

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PeterPerryBarry CarolNiran Al-AgbaNortin Hadler Recent comment authors
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Peter
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Peter

“…in light of the looming physician shortage.”

Seems all I can find is the AAMC making this claim. Self serving?

Niran Al-Agba
Member

I figured this would come up when I wrote this piece. I think the shortage depends on where you live. 10% of physicians practice in underserved areas despite the fact 25% of the U.S. population live in those areas. Today, I felt more like a family doc than pediatrician. I saw 15 patients, and 4 were adults ranging from ages 25-49. All have private insurance and excellent jobs. They cannot find any local MD’s taking new patients. I have provided 6 physicians names to one guy and all are retiring or have closed panels. When adults are seeking out a… Read more »

Barry Carol
Member
Barry Carol

Have the rural areas you describe EVER been adequately served by MD’s as opposed to NP’s at least since 1965 when Medicare and Medicaid became law? Doctors, their spouses and families, at least for the most part, prefer to live in an urban or suburban environment. They like being reasonably near a big airport, concert venues, sports arenas, museums, good restaurants, shopping, etc. There may be students coming out of medical school who grew up in a rural area, like the lifestyle, and want to practice medicine there but probably not nearly enough to serve the rural population which is… Read more »

Niran Al-Agba
Member

I cannot answer if the area was served “adequately” but it was certainly closer to “adequate” than the situation is now. When I first came back to practice in my hometown there were 25 pediatricians and now we are down to 15 FTE pediatricians to serve a population of 250,000 in this county and surrounding areas. If I could find a pediatric NP willing to come to this area, it would be great!. The studies do show those raised in rural areas tend to settle back in rural areas so that is an effective way of trying to recruit applicants… Read more »

Peter
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Peter

“10% of physicians practice in underserved areas despite the fact 25% of the U.S. population live in those areas.” That may not be solved with more docs. Rural poor areas with little good insurance are not places docs want to practice. I read a report that most doc practice close to where they were trained – hence over supply there/under supply elsewhere. Find out where their wives want to live and you’ll know where they go. Giving docs more money so they can see less patients is not going to solve this either – although I agree with more money… Read more »

Niran Al-Agba
Member

Well at least you agree that paying PCP’s more to spend longer amounts of time with patients face-to-face is worthwhile. That is a place to start. Correct that business doubles for the two physicians in the same town, but in reality if patients are established with a PCP, have trust and rapport, then they tend not to over utilize health resources. They are less likely to be hospitalized and more compliant according to most studies as well. Again, it is as good a place to start as any. Thanks for reading.

Niran Al-Agba
Member

Barry, I am not Japanese and have never been involved with their health care system. As for #2, you are making numerous assumptions about your hospitalized care. There will always be ‘handover’ mistakes or issues that get lost in translation while going from provider to provider, until something goes wrong. Only then, will you become all too aware of the pitfalls of not knowing your physician intimately. Mayo Clinic may make fewer mistakes by looking over each others shoulders, however this autonomous lone ranger has been voted best physician in the county for the past seven years! That includes all… Read more »

Barry Carol
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Barry Carol

Niran, Thanks for your response. I understand everything you said about the personal rewards from primary care, including pediatrics. There’s lots of variety in terms of the issues that you have to deal as well as the opportunity to build personal relationships and make a positive difference in individual lives which is very satisfying. I get all that. However, with all due respect, I think different people have different personalities and different skill sets. They find personal satisfaction in lots of different ways. In medicine, I never met any of the radiologists that read my images over the years but… Read more »

Niran Al-Agba
Member

Barry, I suspect you and I see eye to eye on many things. I agree with you that different physicians are motivated by different things and specialists tend to have more intermittent relationships with patients. However, those of us who went into primary care tend to thrive on these long-term relationships and will miss that part of medicine. Your desire to print out your lab results and other records has many potential solutions. First, I photocopy any labs a patient would like and hand them directly to the patient. Second, is to develop a device where you could store or… Read more »

Barry Carol
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Barry Carol

Niran,

Thanks again for your response. I suspect at least part of the problem on the payer side is that Medicare’s Resource Based Relative Value System Update Committee (RUC) is dominated by specialists and they have the political power to protect their reimbursement rates at the expense of primary care. In theory, commercial payers have more room and opportunity to innovate as they move toward more value based payment approaches as opposed to pure fee for service. Presumably, if it were an easy problem to solve, we would have solved it a long time ago.

Niran Al-Agba
Member

Agreed. If it were simple, we would have fixed the healthcare system already. And, yes, primary care docs did not step up to the plate back when the RVU system was being updated and we have paid for that dearly.

Barry Carol
Member
Barry Carol

As a patient, I wonder about a few things. First, as I understand it, a typical patient encounter with a primary care doctor in Japan lasts about three to five minutes and they seem to be OK with that even if they have to wait several hours in the waiting room to see one of the more popular doctors. How do patient expectations get set in different cultures? Some primary care encounters are simple and can be easily addressed in five minutes or less. Others are more complicated, especially if they involve elderly patients with multiple co-morbidities. Second, if I… Read more »

Perry
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Perry

Barry, I think there is a distinct difference in expectations of the current generation of practitioners and the newer grads/applicants. When I and my colleagues attended med school and did residency, we were training for assessing, diagnosing and treating individual patients. We had some autonomy, although at that time HMOs were the rage and managed care was beginning to creep into the physician-patient relationship. Over the course of the last 5-10 years, being a physician has evolved into becoming a data-entry clerk, with more stringent requirements and strictures that take away from the physician-patient encounter, and in my opinion actually… Read more »

Perry
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Perry

Barry,
You might find this essay interesting:

http://www.kevinmd.com/blog/2016/10/art-medicine-dead.html

Barry Carol
Member
Barry Carol

Thanks Perry for your insight and perspective. The blog post you linked to is very interesting as well. I’m curious about what you and your colleagues think about the growth in the number of NP’s, their willingness, through training, to follow rules and protocols and the increasing political pressure in many states to allow them to practice at the top of their license without direct physician supervision. Nurse hotlines operated by health insurance companies are also increasingly prevalent. Is all of this good, bad or indifferent as far as you can tell and do you see it as an attempt… Read more »

Perry
Member
Perry

I have worked with both PAs and NPs and respect their appropriate use. As with MDs there are good ones and bad ones. While I don’t have any problems with them being used collaboratively, I do have a big problem with NPs being totally independent. For one, you are correct, medicine has more chance of becoming “cookbook”, although I think it’s headed that way anyway. Secondly, what’s the use of someone going through all the years of med school and residency, plus MoC and taking tests every ten years, when one could get NP certified for much less time and… Read more »

Barry Carol
Member
Barry Carol

Sounds reasonable to me.

Nortin Hadler
Member
Nortin Hadler

Dear Niran. I hear and share your plaint. All we can hope is that all is not lost: http://www.necn.com/on-air/as-seen-on/WEB-the-take-a_NECN-398292291.html
Nortin Hadler

Niran Al-Agba
Member

All is not lost. Our patients and ourselves hold the power to change this system and its disastrous misdirection. The time is coming– my hope is we recognize the moment, step up, and take control of what ails us. Thank you for reading and commenting. Wow! 5 board certs; I am impressed.