I pose that question for an honest discussion. The Philadelphia Business Journal labeled nurse practitioners as a primary care specialty. I disagreed and discussed my thoughts here.
One nurse practitioner responded with the belief that family medicine is not a specialty. Perhaps with the belief that NPs can practice medicine with equal educational and clinical ability as MDs, of course, just not "specialty" medicine.
America, do you believe that family medicine is not a specialty? I can only assume that this NP feels the same about internists and pediatricians, since all three fields encompass "many different facets of medicine".
The way I look at it, that is exactly what makes family medicine, internists and pediatricians specialists. Because the knowledge base must be broad, the training must be intense. The ability to understand all organ systems and how they interact must be learned. I don't believe that four years of nursing school and a couple years of NP level residency is capable of providing NPs with the foundation educationally, nor clinically for independent practice across the vast scopes of adult or pediatric medicine. And because the intensity is not equal, the education is not equal. And because the education is not equal, the ability to practice independently in the same scope isn't either.
It's like me saying I can be an independently practicing gastroenterologist or cardiologist because I have internal medicine training in many diseases that they manage. For me to make that statement would be as foolish as a NP saying they could do my job (my WHOLE job) with equal capability. It's utter foolishness. But that's what I'm hearing when you say NPs will become complete primary care providers. Perhaps they will. But I don't see it as being complete. The scope may be the same. The practice won't. The reason is education, or lack there of. I am no more a cardiologist as you are a complete independent provider of primary care. Unless you believe I can be a competent independent cardiologist because I manage cardiac issues. Then I fear for us all.
If in fact the training tracks of internal medicine and family medicine and pediatrics were all able to be learned with NP level residency training, we should be abandoning MD programs forever, in favor of NP level education.
I disagree that that kind of action is wise. These are some of the hardest specialties to learn. The argument that they don't focus on one organ system so there for they aren't specialties is flawed. They focus on all organ systems, all the time. That's what makes them difficult.
I've heard many specialists tell me over and over again, call the hospitalist, that is out of my training. Well, guess what, just about everything you can imagine is in my training. In many ways, being a subspecialist is far easier than being an internist, clinically speaking. Tis far easier to focus on one medical problem for a patient with ten active issues.
Most physicians, of all specialties, practice 80% or more of their practice in a hand full of common conditions in their practice. You get really good at diagnosing and managing those 20 medical conditions. Could I manage many conditions as good as a cardiologist or a gastroenterologist? Yes. Does that make my scope the same as theirs. Hardly. Would I call myself a cardiologist because I can manage heart failure or atrial fibrillation? Of course not. Would I call myself a gastroenterologist because I can manage acute hepatitis or ischemic colitis by myself? Of course not. My scope is not their scope, even though my scope overlaps their scope.
The extra three years of training they receive accounts for the 20% of the long tail diagnosis, and the long tail management of the common conditions. I would never in a million years consider myself competent to practice gastroenterology or cardiology independently. That requires the ability to manage more than just the 80% of common diagnoses.
Unfortunately, you are asserting that you can do the same to primary care. By asserting your ability to be a complete provider of primary care. I'm here to tell you you can't. You don't know what you don't know. I am not a cardiologist because I am not trained to be a cardiologist. My scope of practice in cardiology is different than a cardiologists. Just as you are not an internist, nor a family medicine specialist, nor a pediatric specialist for the same rational. However, you wish to practice independently with the same scope as a family medicine specialist or an internist or a pediatrician. And that is my beef.
Being a specialist in all medical fields requires the intensity of medical residency level training to practice independently. If your scope of practice is undifferentiated from mine, then our credential process and education should be equal. Otherwise, the process is deeply flawed.
Just the other day I had a woman with an acute change in vital signs. The subspecialist was on the floor bedside. I got paged to come up pronto. As soon as I walked in the door, the doc says "Thank God you're here. I only manage XXX(take your pic of organ system)." I hear this rational day after day after day. It's easy to ignore the rest of the body when you focus on just one. I don't get that luxury, or patients would die. That's what makes me a specialist and thats what makes a family medicine doc a specialist and that's what makes a pediatrician a specialist.
They are specialists of the entire body. When I get consulted by a cardiologist for nausea. When I get consulted by plastic surgeon for hypertension. When I get consulted by general surgeon for electrolyte disturbances, I am a specialist of everything at any time. Day or night. I don't get to pick my organ system. They are all in my scope of practice.
With that said, I will have to strongly disagree with this NP that family medicine is not a specialty.
The other part of your rational is that because there is a shortage, NPs will evolve into complete primary care providers. Why does this rational not work for a cardiologist? Or gastroenterologists? Could not a NP do one additional year of fellowship training in cardiology (truncated just as it is for family medicine NP training), attend to the minimum number of required procedures and become certified in independent cardiac management? To practice cardiology independently?
Perhaps you could go on and do a four month (again truncated) subfellowship in EP cardiology and attend to the minimum number of required procedures to become an EP cardiologist? Perhaps your truncated training affords you the ability to put shock boxes in without assistance after just three years and four months of post undergraduate nursing training. This is the type of logic that is employed when you assert that your training affords you independent practice capabilities on par with my scope of practice.
Doesn't it sound foolish? Do you believe you could be an EP cardiologist with just one year and four months of NP cardiology level fellowship training? If you don't believe you could, you cannot also believe you are equal in scope and practice as board certified specialists in family medicine, internal medicine and pediatrics.
This is the same kind of logic that you use when you truncate MD level primary care into a truncated NP educational experience and call yourself equal in scope and practice.
Do you believe that family medicine, internal medicine and pediatric tracts of training, four years of medical school, 12,000 hours of residency, should be abandoned in favor of the NP model?
Do you believe your skills are equal to a board certified family medicine doctor, internist or pediatrician in terms of diagnostic capability and management.
If you believe that, then you have to believe that medical school and residency in these fields are unnecessary. That your training is adequate to practice a full scope of medicine across all organ systems, all the time. Unless of course you feel you are not qualified to handle many aspects of primary care. If that is the case, do you feel your duty as a NP provider is more of a triage artist? To refer cases of management that can be handled by an MD level family medicine doc but not you? If that is in fact the case, than you must believe that your scope of practice is also limited? That you have less diagnostic capabilities and fewer management skills that are played out in your mind on a case by case basis, but not on paper as a defined scope of practice.
I really am open to discussion on this matter. But you have to be able to explain to me what I as an internist, or Dr Dinosaur as a family medicine physician bring to the table that you don't for me to understand how you consider yourself equal in scope and practice as us. Because being a complete provider of primary care indicates to me that you believe your scope of practice is the same. Unless of course your definition of complete primary care is different than mine. In which case this whole discussion is moot. Perhaps complete is however you want to define it, on a case by case basis.
Perhaps it's only complete for some patients, and not others. Perhaps the decision on complete care will be decided every day for every patient based on your skills and knowledge base at that moment. Perhaps the deficits in your knowledge base, compared to mine, will create an equal scope, in theory, but far different in reality. Perhaps that what this is all about. Equal scope, different reality.
That I can understand.
I am being generous here. NPs and PAs at BEST have the equivalence of a 3rd year medical student. That is actually giving them a compliment. I shudder at the fact that we look down upon a GP, or non-board certified FP or IM when even their level of training and expertise blows theirs out of the water. Rediculous, insulting, and a bloody shame for Americans. I just hope their are still physicians around for my family and future generations.
ReplyDeletehttp://bmgoodsolutions.blogspot.com/2009/01/3rd-year-medical-students-for-everyone.html
Said, that is the most ridiculous thing I have heard. Most physicians in my department would tell you that our PA's and NP's, at least the more experienced ones, are equivalent to a senior EM resident. Are we equivalent to an attending, NO! But I can honestly say, that I would certainly feel comfortable with, and DO manage about 80-85% of the complaints that present to the ED on my own. Jesus, you guys act like medicine is rocket science.....it isn't, it's rote memorization regarding treatment algorithims. The toughest part, is recognition, actually making the diagnosis, which is where experience comes into play. PA's at least, know their limitations. It was interesting, I was just recently reading a study regarding PA and physician comparisons, and one interesting factoid stood out. Physicians, to a degree, of I believe three to one, had much harder time understanding, and knowing their own limitations, than PA's did. The UK, Taiwan, Germany, Ireland, Scotland, Canada, and Denmark all have PA training programs now, and will be utilizing them as primary care providers. As I have said on my blog, I have serious questions about NP's training (Too varied) and their quest for complete independent practice, but primary care in the next ten years will almost solely be delivered by PA's and NP's. A policy meeting I was recently at, had a discussion about the future of primary care, and one model that was heavily discussed, was a clinic that is staffed almost solely by PA's and NP's, with one or two supervising MD's to help with more complicated cases and to provide some level of supervision. This is the future, you can not like it, but unless physicians take a MASSIVE pay cut, this is the future of primary care.
ReplyDeleteOH, btw, I've seen today already, a perirectal abcess, that is likely fistulous based on exam, and 2 MVA's, a chest pain, several lacerations, 2 pneumonias, and one infected renal calculus. on my own, no doc has seen any of those patients, but I did have a young pregnant female with a constellation of symptoms that I did not recognize, and asked my attending to see that one......he didn't know either.
I see another point here Happy. As a specialist, you are trained to connect unconnected, aynschronous data points and connect them into a pattern no one else can recognize. That ability to place discrete unrelated data and make then relate and connect to an answer comes from exposure/experience with the conditions, AND the training/teaching to understand the meaning.
ReplyDeleteI see it all the time in my specialty as a vascular surgeon. I am a low level on hearing a S4 or a pericardial rub. I am all over hearing pulsitile venous flow with a doppler (a sign of fluid overload vs. CHF). I have felt pulses in feet no one else can, and similarly, have the confidence to say there are no pulses in feet that a lesser experienced person says is there - thus missing critical ischemia. I can connect hypotension, full body mottling, afib, abdominal pain and peritonitis with ischemic bowel and an SMA embolus (with an urgent trip to the OR), or back pain, hypotension and a pulsitile mass to a rupturing AAA (also a crash to OR). Others will get a CT scan, with the attendant delay being game over. I am sure you and others here have similar analogs in your fields of expertise.
Specialty training is longer for a reason. I worry about midlevels without the 12000-26000 hours (my time for surgical training)having that experiencial and training database to 'make the call';. I also fear for the future for MDs, with decreasing training hours.
Your skill as a hospitalist comes from that very experience and training you reference. You will see the answer in seconds to minutes, when someone of lesser exposure will not and call a consult for the morning.
I greatly respect my hospitalist where I am. I also respect my fellow MDs of other specialties for their expertise, due to their training and skills.
I unfortunately see midlevels in my area acting merely as a waypoint on the refer for consult expressway.
I hope to be healthy until I die in my sleep!
DocInKY
Well, you should rest easily then in regards to PA's. We have NO desire to practice completely independently, our motto as been from day one...DEPENDENT practitioners.
ReplyDeleteNP's...are a little different in that regard.
As I just posted a question to ALL physicians on my blog. I would ask that you read that. And if you have data to support that, well, then please present it. Cause I have studies suggesting the opposite.
You are really obsessed with NPs and PAs. Let it go!!!! Do your work and let them do theirs!
ReplyDelete"As a nurse, I didn't agree that Med/Surg is a specialty either"
ReplyDeleteActually med/surg is a floor.....
PA's and NP's clearly have significant role in medicine. Experience is clearly important in medicine.But to say an experienced NP/PA is "equal" to a senior EM resident. That is just arrogant and essentially in the author's mind means that four years of med school/3-4 years of residency can just be done in a two year PA program with a little "experience" thrown in. Sometimes I think the authors of these statements need to try going through the med school/residency process before making rather uneducated statements.
PS: What the difference between a new attending EM doc and senior EM resident? Anywhere from 11.5 months to a week.
That comment about a more experienced EM PA being equivalent to a senior EM resident is something that has been told to me by EM attendings. You can scoff all you want, but I'd put my assessment skills up against a senior EM resident any day of the week.
ReplyDeleteyou'd put up your assessment skills?
ReplyDeletewhat about the knowledge base?
what about getting the job done? it's not always about assessment.
as said earlier, it's not all about algorithms and protocols. you have to know when to use them, and know when not to.
if someone's having a stemi... but an acute upper gi bleed, do you give the aspirin? do you give the heparin? integrillin? do you drop in a blakemore tube? do you go immediately to cath 1st? do you go to the gi lab 1st? do you give blood? do you give a proton pump inhibitor drip? do you give the beta blocker? do you give an octreotide drip?
that's not an everyday occurence, i'll give you that. but you need to be prepared for it. saw plenty of it in my internal medicine residency, preparing to be a hospitalist.
if someone's got a gross lower gi bleed, blood just pouring out... do you call the surgeon asap? do you give ffp? platelets? vitamin k? is the patient dnr? is the family around? do you handle the pressure? or do you just call to admit?
i've had er attendings literally just call me to admit. me taking care of everything... as a resident.
if you're admitting someone with pneumonia... but they're septic... but they have a penicillin allergy... and they're from a nursing home... what does the protocol sheet say? is there a protocol for that situation? should there be a protocol for that situation?
don't get me wrong. pa's have their place in healthcare. they have their role in the ed. but as has been said before, they also don't know what they don't know.
it's easy to say, i didn't know, so i asked my supervisor. anything you don't know, can be asked or referred out.
it's a whole different ballgame, sometimes difficult, to be the one who questions are asked of, or referrals are sent to.
That's why we have supervising physicians, so we CAN ask when we get in over our heads. What a bunch of BS, "you don't know what you don't know"....that is a load of cr*p, of course we can, or at least, we should be able to recognize when we are encountering something that is outside of our scope of practice, and then we consult with our attendings, but you can think what you want.
ReplyDeletephysasst, all 3 scenarios were presented to me by ed attendings... when i was a resident.
ReplyDeleteadmitted as mi. lower gi bleed. community acquired pna.
no call to anyone but me. not sure if that reflects well on me, or poorly on the ed attending... or a little of both.
admits for temp of 104. forgot to look at the line sticking out of the chest. the osteo of the foot since the shoes weren't removed. that's the point. it's not always the urine or the blood or the pneumonia.
it's not always a straightforward mi. it's not always a straightforward gi bleed.
you find what you look for, you look for what you know.
if you don't look for it, you won't find it.
if you don't know it...
http://thehappyhospitalist.blogspot.com/2009/01/unprepared-for-expected.html
Of course, just as are Internists and Pediatricians, Family Medicine physicians are specialists.
ReplyDeleteWithout further training, none of the above are subspecialists, such as a cardiologist or gastroenterologist.
Regarding equating NP's and PA's with Family Medicine physicians, I say poppycock.
The reality may indeed be, as has been asserted, that these lesser trained individuals may eventually completely take over primary care medicine, but that is 100% driven by economics and political expediency. It is a mistake of majestic proportion to swallow the Kool Aid that says this somehow makes them "just as good" in the arena of clinical acumen.
The reality is that the average citizen doesn't know enough to recognize any real difference on their end as a patient.
So, when they go to the NP with their viral upper respiratory infection and get an inappropriate prescription for an antibiotic, as they have demanded, they are satisfied. They think to themselves, "This one is just as good as a doctor, and cheaper too."
They think to themselves, "The regulating authorities are allowing this person to treat me independently and allowing them to prescribe medicines, so they must be just as good as a doctor."
Their viral infection gets better, just as it would without the antibiotic, and their feelings are confirmed in their minds.
Remember however that these are the same people we all bitch about because they show so little judgment when they rush to the emergency room every time they get a headache or a hangnail.
That same lack of judgment, born of lack of knowledge and understanding, is behind the general public's acceptance that PA's and NP's are equivalent to a board certified physician.
Politicians, hospital administrators, third party payers, and what I consider unscrupulous physicians, NP's and PA's all seize upon this ignorance on the part of the public to serve up this toxic Kool Aid for one reason and one reason only.
Profit.
dr sam, I never said we were equivalent of a "board certified" physician, and PA's have always maintained that we are dependent practitioners, and that we need physician supervision, in contrast to NP's.
ReplyDeleteAlso, and this is to everyone, if you want to characterize our care as unsafe, or somehow, not up to snuff. Please present data to support such an assertion, otherwise, all you are doing is sounding like a bunch of arrogant MD windbags. BTW- I have studies that suggest that various disease outcomes are no different when managed by a PA versus and MD. So, if you have contrary data, please provide it.
Oh, and it's not just "100% driven by economics and political expediency". It's also driven by the fact that there simply aren't enough physicians to meet the need, particularly in rural areas.
some patient came to the ED, he got fever, he got a sinus infection but guess what, i look at his arm and there was hyperpigmentation, when i started to interrogate him, he got diarrea, weakness, ortostatic hipotension, for a long time, we run some test and in the end he got addison disease but he came for a sinus infection. a patient with two different affections one bothersome but quite harmless, another one asytomatic but mortal if its not diagnosed early, a NPs and PAs cant diagnose that you can put them on a clinical enviroment but they will miss a lot.
ReplyDeletea headache can be a simple headache, but there are more than 250 causes, in a ER you should at least determine the risk factors for mortal ilnesses, the ideal would be the cause.
the main problem is when you dont see a potential sign of ilness you can easily discharge a patient, especially when you see comorbity associated.
if you dont recognize, you discharge untreated ilnesses, if you dont recognize it properly you would think is something else.
Of course, you should, and I would like to think that I would have recognized the hyperpigmentation as well, but without seeing the patient it is of course, impossible to know.
ReplyDeleteLook, I always keep the tenet:
Assume the worst
when seeing any patient in the ED, and usually in fast track, with a careful history and physical, you can exclude the dangerous stuff, other times you need to test, and still other times you need to consult your attending.
We do learn how to recognize physical exam findings you know.
well said drsam
ReplyDeletePandora...we have opened your box.
ReplyDeleteDr Sam, thank you for the kind words, my quoting of having those studies that show equivalent ouctomes was born out of a frustration with many posters insisting that PA's are not able to see ANY patients independently.
ReplyDeleteWe are born out of an economic need. Dr Eugene Stead, the founder of the PA profession, noted that physicians in the late fifties, and early sixties were abandoning rural areas to practice in larger more urban settings.
We do more than many people realize. When I practiced in Ortho years ago (yes, I am old) I would perform all the openings, closings, and even parts of the case (reaming out the canals, placing screws, applying the hardware, etc.etc.etc.) Was I an orthopedic surgeon, NO!, but I sure wasn't an incompetent buffoon. I taught the 3rd and 4th year residents how to make certain approaches, and I handled many of the postoperative problems, and some of the preoperative screenings, as the surgeon I worked for was gone frequently.
I don't say this a form of bragging, but merely to point out that we are skilled providers.
Anon- I don't like anecdotal examples, however, they do have their place. One of our PA's is now in his first year of med school, and is constantly picking up extra hours to work at night in the ED, cause he says he is kinda bored. I've never been to med school so I can't qualify that statement, but this is what he says.
Perhaps I should have phrased the comparison with a senior level EM resident differently. Many of the consultants here, say that when they are working, they view a senior level PA and a senior level EM resident as interchangeable. Perhaps that is a more apt description.
training is necesary, you can not diagnose something without the proper training, as simple as that. if not you dont need to be a doctor. the problem is that everyone think is right, thinking you are right, doesnt means necesarry you are right. thinking you got diagnosis doenst make you think you got the proper diagnosis, you could be wrong or right dependy on your training, you wont notice it, if you screw up. formal training is necesarry, we need to be very aware of our limitations. i find fast track and ED particular challenging cause you can find a moster disgused as a flower, and a flower disgused of a moster, apareances can be misleading sometimes.
ReplyDeleteCall from a NP ( I am a hospitalist that admits for her practice) in our community about a patient with CAD s/p PTCA and stent about 3 months ago on ASA and plavix with a slow GI bleed. She had seen him in the office a few days earlier, stopped his ASA and plavix and was rechecking his cbc. His Hb was continuing to drift but he was hemodynamically
ReplyDeletestable. She wanted to know if he needed to come in to the Hospital right away or could she watch him a few days as an outpatient with GI referral. I asked her some details, including what kind of a stent does he have, bare metal or drug eluting? She said, " I don't know, let me check his chart, does it matter?". Enough said.
Alexy, I completely agree, which is why you have to practice with a high index of suspicion. I've had a cough that turned out to be a STEMI, a sore throat that turned out to be a new onset DKA, and a recurrent migrainous headache that had some VERY subtle neuro deficits on exam, and ended up having a small SAH.
ReplyDeleteAnon, you simply ran into an idiot for an NP, I'm sorry, I can't really explain it any better than that. But, I've also known physicians I wouldn't trust to treat my dog. Each practitioner needs to be evaluated independently.
Physasst:
ReplyDeleteI do think you need to remember that consultants and EM attendings at Mayo have the luxury of having everything all the time. The attendings also have the luxury of having residents, fellows, PA's do the majority of their clinical work for them. It is indeed the rare academic attending who sees anywhere near the volume that a private practice person does. Overseeing a bunch of other people is not the same thing, though I agree it brings out it's own issues. In the real rural world it just doesn't work that way. You have to get used to being on your own.
THIS IS SPARTAAA!!!! ROLF, such topic, such discussion, people get sensitive, when it comes to their field of work. if we do backwards it wouldnt be cheaper for the country prepare physcians for any sort of procedure through 10 or 20 years. cheap decision comes with bad conclusions.
ReplyDeleteYeah and "bollocks" has an "o" so what's your point?
ReplyDeleteBoard certification does indeed mean FP is a separate specialty just like a hospitalist is not a separate specialty from IM (yet). You can disagree all you want, it doesn't make it so.
I'm curious how anyone knows the right amount of training needed for treating patients. I mean, it sure *seems* intuitive that someone who went to medical school and did a residency is going to do a better job than someone who has had less training. But is there evidence about this, in terms of better outcomes for comparable patients?
ReplyDeleteThis question kind-of hangs over all these discussions of shorter hours in residencies and the use of PAs/NPs, right? How much difference does it make in patient outcomes if you get the MD with 15,000 hours of residency, or the one with 10,000 hours due to work-hour restrictions, in terms of outcomes when they're practicing? How much difference does it make if it's a PA instead of an MD? Is there good data about this?
It would be pretty remarkable if the historical numnber of hours of training happened to be optimal, right? That number is pretty clearly a tradeoff between economics and the advantages of training.
labatross you cant messure that cause the outcomes on the long run of 15 000 of residency on subjet A, could be different from subjet B, i suppose the more time you train the gap between subjet A and B get smaller dispate the differences, even though it depens basically on motivation, previous knowledge and how much you studying off the residence, those are individual traits, if making comparisons between doctors is difficult, because you can find crappy doctors that even medical students are better than them, as you can find outstanding physicians that excels everyone, imaging doing doctors vs PA/NP in terms of outcomes, is difficult to compare, im agree with you there is a critical point where the learning procces get a plateu, still the more the merrier, you wil always be learning, from an obvius point of view seems like doctors do better than PA/NP, but there is not evidence about this, and it wont.
ReplyDeleteLadies and gentlemen, I think we're all going to have to learn to get along, whether infilitration of NPs & PAs into healthcare comees from economic and/or political forces, or electron ray beams from Mars. It's a fact.
ReplyDeleteI'd be curious to hear how a specialty that uses NPs a lot, say OB/GYN knows when to use 'em, vs. knowing when to hold 'em or fold 'em.
Perhaps it's some peculiarity of my patient population, but I'm continually "going off the grid" with patients, even with simple stuff like UTIs, URIs, gastroenteritis. Maybe half the time I don't actually have to get my brain out of the coffeepot for these easy appointments (and that's good because it gives me the strength for the other half). Often, however, the refractory insomnia, pale mucosa, the uncontrolled diabetes, and chest pain show up with the strep throat. I have to go get my marinating brain out of the coffee pot, dagnabbit.
One other daily, hourly job of mine is figuring out what the hell happened to a patient in the hospital, then what happened with the cardiologist appointment two days later, which happened right after the patient saw the lung doc who mysteriously stopped the Coumadin, while the patient was on route to the ENT, stopping first for their nursing home admission, for which I need to do the admission physical during their 10 minute follow-up appointment. I might not be as smart as Happy, but I'm not stupid, I've been at it for a while. This stuff neither easy nor straightforward, and there's certainly no algorithm to follow.
I think, you know, PAs in ERs have the luxury of filtering out much of what travels along with a perirectal fistula, so maybe, just maybe the job is a little more straightforward than my office with butt nastiness, plus diabetes (which I need to worry about), and whack hypertension. Oh, and he just lost his job and has insurance for 30 more seconds, so hurry up, Dr. Latte.
I think probably, maybe? there's some patient self-selection with NPs, too, so maybe to SOME NPs the task of providing COMPREHENSIVE primary care seems more linear than it is. My patients rarely present with one or two problems, it's 3 or 4, and I'm continually juggling a little of this, little of that, crossing my fingers and throwing salt over my shoulder while waiting online with a specialist, while looking up articles about diseases I haven't seen since medical school. Where the hell is the grid?
In fact, who the hell are these easy patients, and why aren't they coming to my office? I need some easy patients to allow hair regrowth at the bald spots I have from pulling my hair out over 80% of my most white, mostly suburban, mostly squarely middle class, supposedly easy patient population. I keep hearing about these mythical straightforward patients. I want some!
Lastly, I suppose realistically I could pass the easy stuff over to an NP or PA, but I like it. It's not a stressful encounter. I get a chance to visit with the patient a little bit. I can breathe in the space I'm not beating the patient about uncontrolled hyperglycemia and ask about kids. I can fill in the blanks about preventative stuff, and gasp, do some education! In any event, I often get a chance to increase my fund of knowledge about a particular patient, which down the road often provides invaluable when more chronic problems develop. Easy visits with me vs. an NP or PA also help me cement a relationship that will endure (hopefully) over time. That is, if insurance will continue to let me.