Doctors who don't see you

Your Name
I am a family physician. I performed the joint injection, did the physical, and evaluated the obstetric patient. I deliver babies. I perform skin surgery. And I work in a small town in New England, where a few of my call group partners employ nurse practitioners, who do not used for their employers as you noted above.

Yes, sounds like what I said.

Furthermore, it is the standard of care here to set aside several appointments daily for urgent care visits by physicians. Insurance companies ask us to do this, patients need this, so we do it. There is no waiting for weeks to be seen by your physician.

If you're saying your town doesn't have a shortage of doctors, good for you. The nation, however, has a pretty serious one.

On the other hand, people who have had hypertension for 10 years can wait a few more weeks to see someone who can both diagnose and treat the medical conditions.

Really? Even though they've just had symptoms of something that might be hypertension, but, OTOH, it might have been a mild heart attack? You don't want a NP to check their heart, give them an xray?

Note I don't know anything abut hypertension, but I do know what when people choose to go to the doctor, something has usually changed in how they feel. Yes, it could be some chronic condition getting slightly worse...or it could be something very bad. People are not doctors, they do not know.

Incidentally, in Boston, your 'few weeks' is actually 'two months'. That's how long it takes for someone to get a GP appointment there.

Doctors who work in small towns, as I do, have *more* variety in their practice, not less. My practice is far from being the medical equivalent of tire rotation and oil changing, *because* I am further away from specialists.

You misunderstood my analogy. You are the only auto repair shop in town, and, hence, you end up doing all auto work, including the stuff that could be done by trained monkeys like oil changes. All of it, every single bit.

Which is fine if you have time. If you, as a doctor, have time to give someone a physical or a flu shot, and still see everyone, everything is currently fine.

If you do not have time, if you are one of the doctors overworked because we've got a serious shortage of doctors, someone needs to open a quick lube near you so you don't have deal with that stuff.

And even if things are currently fine, we're about to dump somewhere around 10%-15% more people into the system via Obamacare.

The more rural the practice, the greater the scope. In rural Oklahoma, where I trained, family doctors do C-sections and appendectomies.

I don't know where you got that I said they has less variety in their practice. I actually said they were doing everything, including stuff NPs could do. That was rather my point, with more NPs you can have slightly less doctors.

Now, if your town has enough doctors via some miracle, obviously this doesn't really apply to you.

I have no problem with physican extenders (no need to use scare quotes, this is medical parlance) being used as a point of entry into the medical system. But the idea of training more NPs as a substitute for training more family doctors makes no sense. In a medical world that is becoming more complicated, with greater variety in medications, procedures, etc., we're going to train people with *less* training and experience?

In a medical world that is, as of now, strained to the breaking point, and is about to have millions more people dumped into it by the government who previously couldn't afford medical care?

Yes. Yes we should, indeed, send some RNs off to get their masters via night classes instead of waiting for doctors to graduate medical school. Because it's about, oh, four times faster. And probably ten times cheaper. (The reason we don't have GPs is that medical school is so expensive, resulting in new doctors heading off into specialties where they can make more, but that's a problem I don't know much about.)

Seriously, I have no idea why people seem to be misunderstanding what I'm saying: Train more NPs as a stopgap for doctors, and if we use them correctly we could reduce the demand for doctors. Because right now we have doctors doing what NPs could do, and hell, wasting their time on people who should have been given an aspirin and sent home.

I suspect this is because I failed to mention what I assumed people knew: We have a huge shortage of doctors that is projected to get much worse over the next several years. And even if we came up with some miracle to get more GP doctors, we'd have to wait eight long years before they actually graduated medical school.

Whereas RNs can get master degrees in about two years if they already have a bachelor's, or three to four if not, and become NPs. We just need to actually start using NPs in the manner I said, thus creating more jobs for RNs to get a degree for. And stop treating existing RNs like crap, so they actually stay in the field.

Also, I have no idea where I was supposed to have been 'wrong' in what I said. The only place you disagreed with me is by saying that you, personally, were not experiencing a GP shortage. Whatever. We as a nation are.

Mary Russell
1. You thought I was merely an observer of my patients' visits, because I used the word "saw". This marks you as a non-medical person.

I am not in the medical profession, no, and I've never said I was, it is you who keeps trying to bring that up. And I know what it means for a doctor wee see patients, that does not mean I knew you were a doctor and using it in that sense. For all I knew you were a receptionist.

2. You thought I practiced in an urban area. I practice in a semi-rural area.

No, I guessed that you worked in a hospital or large city.

Neither, of which, incidentally, is disallowed by what you just said. Hospitals obviously exist in semi-rural areas, and there are plenty of places that could be called 'large cities' and 'semi-rural' at the same time. For example, near me, Forsyth county could be described as both, it being a fairly spread-out suburban area of Atlanta.

3. Nurse practitioners are needed, and more or them, sure nuff, but they are not a replacement for physicians. They either do one thing very, very well (like taking care of the 10 or so problems that babies in a NICU have), or do a broad area of things like family medicine with a cookie-cutter approach.

Yes, if only I was suggesting that they do those things, to let doctor be free to do the actual doctoring of complicated problems.

4. People with "symptoms of a mild heart attack" need more than to have their "hear checked and an x-ray ordered". For the record, these people need to go to the ER.

I think you've lost the context of that statement, in which you said that someone who had been suffering from hypertension for years could wait a few weeks if they felt they needed to see a doctor, and I pointed that, if people felt they needed to see a doctor about a problem they had for years, their symptoms had usually just got worse to some extent.

And I then pointed out that some hypertension symptoms 'getting worse', (Namely chest pains, shortness of breath, sweating, nausea, etc.) could, indeed, be someone's hypertension getting worse...or they could be a heart attack. (As you seem intent on imagining I claim to be a doctor, let me mention I am at risk for a heart attack and hence know the symptoms, although I did have to google hypertension.)

Saying 'People can schedule an appointment with a doctor in a few weeks' doesn't cut it. I know it's how we've been operating damn medical care for decades in this country, but it has to fucking stop.

People need to be able to walk into some inexpensive place with no more than a few hours wait, and see someone who can say 'You'll be fine' or 'Holy shit, I'm calling an ambulance and getting you to an ER', or anything in between.

NPs can do that. They can say 'Your heart is making some weird sound that, because I am not a doctor and especially not a cardiologist, I can't diagnose that, but I know that hearts do not sound like that, so I'm getting you to an actual doctor, a cardiologist if I can find one, and while he's getting here I'm getting you an x-ray.'.

5. The 2month waiting period in the Boston area is for people who don't have a doctor. People who are already established in a practice, as my patients are, can come in for same-day appointments or have a blood pressure or diabetes check-up set up within a few weeks. This difference seems to have escaped you. I never said there is no shortage of doctors in my area.

...have a blood pressure check set up in a few week?

Okay, that's officially the weirdest thing I've ever heard. Fricking RNs can do blood pressure checks. Automated machines can do them! I can check my damn blood pressure.

But plenty of people, at this point in time, do not have a primary physician, because they cannot afford one.

6. People without doctors also do not have nurse practitioners, because NPs work for doctors. AGain, this fact has escaped you. One can go to the local Walmart for urgent care, but this is hardly a medical home.

I don't know what you mean by 'NPs work for doctors', but that's a pretty silly statement, especially considering you then instantly mentioned one who had not. Likewise, there are plenty of NPs in home care that don't work for doctors.

And plenty of them work in hospitals, where they do not 'work for doctors'. They work under doctors, following instructions they've left, but not for a specific one, and they are not employed by doctors.

And I have no idea what your objection that it's not a 'medical home' is supposed to mean. The quickcare place exists because people cannot afford primary care physicians, and a place in Walmart is a lot cheaper than an ER.

7. A nurse practitioner, again, with 2 years of training, does not have the depth of understanding that an M.D. has, with 7 years of experience and training. Most patients seen in primary care are complicated. You are throwing around this 90% thing without a wit of evidence except, possibly, your own limited experience of how things work in medicine.

Most patients seen in primary care showed up there rather too late, because they had to, apparently, wait several weeks to get their blood pressure taken.

And again I point out, of the things you actually mentioned you did, I pointed out that two of the three could, in fact, have been done by an NP. You may not want to admit that a major portion of your job could be done by someone with 1/3rd the experience of you, but that doesn't make it wrong.

And, again, you're operating in the universe where people actually have PCP. I, OTOH, am not. I don't have one, because I can't afford one.

8. The shortage of primary care docs will be corrected when PCPs are reimbursed for their work better. In the UK, for instance, where there is no shortage of GPs, family physicians earn more than specialists.

This is possibly the first reasonable thing you've said, and if you want to assert that doctors will switch back into primary care once the system is less broken, thus covering the shortage, that is a perfectly reasonable assertation.

I don't think it's true, mind you, but it's at least a reasonable claim.

That said, we need nurses anyway. At least RNs, and encouraging that naturally will result in more NPs.

The poor performance of the US was recently confirmed by a World Health Organization study, which used different data and ranked the U. S. as 15th among 25 industrialized countries.

Lack of technology is certainly not a contributing factor to the United States 's low ranking.

Among 29 countries, the United States is 2nd only to Japan in the availability of computed tomography (CT) scanners and magnetic resonance imaging (MRI) units per million population.