This is my response to Anne on WhiteCoat Rants as he worries about "Will Primary Care Be There When We Need It?
Anne. As a physician I will be the first to say that part of being a great physician is knowing what you know but more importantly knowing what you don't know. I am a physician, someone who devoted a great part of my youth (my entire 20's) to learning the art of medicine. I trained in the footsteps of other great physicians, who themselves have devoted a great deal of their entire lives to training people like me. I am a physician, not a provider.
I am separated from providers by my vastly superior knowledge base, (let me repeat that, vastly superior knowledge base), my integrative training capabilities, my wide range of developing the differential diagnosis, my understanding of horses and zebras and when to look and when to look the other way. Medicine is not a book. It is an art. No matter how hard you try to package medicine, it will never be a book. I have learned the art of medicine and will continue fine tuning that art for the rest of my career. My service to you, as a physician is to promise you the art of medicine. You can think of me as a highly scientific painter.
No painter, no matter who hard they try will ever be able to paint the exact same painting, ever. Anne, you are my painting, for which my artistic brush has created, what I believe, to be the best possible picture of health, based my my artistic abilities. You are different from every other person on this earth. You are living art. And a great physician will treat you as their greatest painting ever, every time.
There is no provider of medicine, no matter how many years of practice, that will ever be able to promise you the art of medicine.
Anne, you can read a medical book yourself, but you will never be able to practice the art of medicine without the intense training, experience and knowledge base that medical doctors achieve by way of their rigorous training. Any provider who claims otherwise fails the first rule of being a great physician. You must know what you don't know. Nobody can Google their way to great painting, no matter how great the internet is.
Having providers assume the role of primary care is flawed on so many fronts. (You are making the assumption that they would even want to based on the current decimated reimbursement scheme, but that is an entirely different post)
A doctor is so much more than prescribing drugs, ordering labs, and reading xrays. It is understanding why, why not, how, how much, how little, how come, how do you do, every time, all the time. When you see your doctor for that 10-15 minute visit, so much is going on through your doctors mind that involves the art of medicine, every time, all the time. Something a provider will never understand. What you see from a doctor of medicine is but the sliver of a tip of that ice berg of knowledge in your doctors mind, something a provider will never be able to offer.
When you see your doctor for one medical problem and you get upset that the fee is too high for the information received, understand that your information is but a minuscule aspect of thousands of bits of knowledge in your doctors mind, which he/she is inter playing with each other to determine the best drug, the best lab, the best test to evaluate. You are paying for the artist, not the book. And beautiful art priceless.
I have seen more cases of everything you can ever imagine in a vast array of situations (acute and chronic), in my seven years of post graduate training than any provider will see in a life time.
A provider is the single chapter of a library of books, but will never be the art. Wishing for providers to take over primary care, is like wishing for a field full of chapters of knowledge, but no artists.
Artists create a beautiful world by thinking outside that box of knowledge, driving innovation and forcing greatness.
If you pay a provider, understand what you are getting, but more importantly, what you are not getting. I am not arrogant, I am not egocentric. And I am not God. I am reality. I am an artist and a damn good one.
I will leave it at that.
NPs and PAs cant "solve" the primary care problem because SHOCKINGLY they like the big cities and the specialties just as much as the MDs do.
ReplyDeleteOver 60% of PAs out of school are going into specialty fields.
The NPs and PAs are running away from primary care just like everybody else so I always laugh when I hear that they are goign to take over everything.
happy Hospitalist - I am so impressed by your comment in Whitecoats blog and have left you two in response.
ReplyDeleteI mentioned that I am giving copies to 2 of my favorite docs.
I have never done this before but would it be ok if I posted your comment as my next post? i would of course link to you and whitecoat.
if you prefer that I don't that is alright too.
Have a great day! ;)
Your very welcome. One of the best descriptions painted so beautifully that even I a lay person can understand. :)
ReplyDeleteAre you being serious? Or, are you simply parodying the typical ridiculous, self-infatuated, overly impressed, utterly deluded physician? You make a good parody. I laughed. If you're serious, well, then you're pathetic.
ReplyDeleteWhether or not NPs or PAs provide as good care as doctors is an empirical questions. Are outcomes better or worse in practices in which the dominate? That's a serious question about which we can argue.
As for your nonsense about physicians and art--remember what public health teaches us. Once you get passed sanitation and vaccination and once you factor in exercise and diet --medicine does very little to increase life span. What doctors do probably matters VERY little.
Anonymous - it it weren't for doctors, I would have died in childbirth or the babies would have or been severely damaged if they made it.
ReplyDeleteI would have died from complications with the 1st kidney stone that I had and had to have it removed in the OR because it wouldn't have passed and I would have died of sepsis 19 mos after that which was caused by a closed ureter do to scarring from that 1st stone.
It matters very much to me if my life or that of a loved one is hanging in the balance and is dependent upon the skills of a good doctor. There are outcomes and then there are outcomes.
I shall be forever grateful to my wonderful doctors.
Thank you for your touching stories, Seaspray, but do tell, what is the basis of yr claims about the dire results of lack of medical care? The doctors themselves . . . . hmmm.
ReplyDeleteNo doubt in individual situations medicine does do some good. But, in the aggregate, serious empirical evidence fails to link expenditures on most medicine to significant, quantifiable improved health. Here's a somewhat polemical link making that point:
http://www.cato-unbound.org/2007/09/10/robin-hanson/cut-medicine-in-half/
That being the case, it's a serious issue whether we should spend so much money so that we can let our medical "artists" paint pretty pictures.
Do forgive my naivete Anonymous but I vehemently disagree that doctors are unnecessary if societies complied with the 4 prerequisites you listed.
ReplyDeleteA world without doctors? What specialty shall we do away with?
And even if we had the perfect world of no sickness or disease until death do us part...we still would have people getting injured.
Oh of course we will always need doctors! They do save lives!
I did book mark the link you provided and will come back to it tomorrow as it is a long read,
I saw your comment over there and had to pop over and tell you that you really should submit it as a letter to the editor or even small column to a major newspaper. It is a piece that deserves to be widely circulated.
ReplyDeleteAnd to the other comments - anyone in medicine for any amount of time is very well aware of the minimal ability to change the long term course of things, the fiction of medical heroics. And I am much more in favor of public health measures than angioplasty.
But as far as the value of the individual doctor goes, the secret is being able to pick out the times when a small intervention makes a massive difference: identifying the kid with meningitis rather than just a sore throat, the case of TTP hidden among all the other kidney problems or strokes, the stomachache that is an abdominal crisis and not just a stomachache. For this, you do need broad, extensive training.
Thank you for writing that essay.It hits the nail so well.I wonder if anonymous would continue to think doctors do very little if his child or spouse did not die from meningitis because of a physician's skill and efforts, or if his leaking cerebral aneurysm was clipped by a skilled neurosurgeon or if his shattered leg was put back together by an orthopedist.
ReplyDelete"As for your nonsense about physicians and art--remember what public health teaches us. Once you get passed sanitation and vaccination and once you factor in exercise and diet --medicine does very little to increase life span. What doctors do probably matters VERY little."
ReplyDeleteMaybe for the population as a whole, but my little sister would've died at birth because she was so premature. It certainly matters quite a lot to her that medicine has come a long ways.
I see a lot of concern from physicians that the dreaded mid-levels are taking over their profession. Let's be clear here, income is huge concern for most physicians. Anything that threatens their revenue stream will be met with criticism at best, legislation at worst - the AMA is one of the biggest and richest lobbying forces in the country and they will do what they (and their members)can to protect their money. Well, for as many good docs as there are out there (there are a s!!t load), there just as many arrogant, cruel, lazy, uncaring, up-coding, arrogant and/or uninterested docs.
ReplyDeleteI agree that some docs are artists (grudgingly using OP's analogy) who wield an endless palette with amazing prowess but some are common subway taggers who fumble with a handful of paint cans and markers.
I would never describe my work as art, unless it were art. That IS pretentious and you are arrogant.
Anon, less than 20% of practicing physicians are a part of the AMA
ReplyDeleteThe AMA represents all physicians like Border's represents all people that are literate.