Stated passionately by Internist X, the outpatient internal medicine perspective from the front lines. I will let his/her comments speak for itself. Something has to change on the current state of outpatient internal medicine. How about another study, or perhaps another working group, or committee, or perhaps another demonstration project. Here's your demonstration project...
- Happy, you nailed it. And as a true general internist, AND a specialist in HIV medicine, I can see both perspectives. Your point has some merit, it does take a team, BUT you are also glorifying catastrophe medicine--a system in which the high-tech, procedure-based subspecialty medicine is fetishized and glorified and rewarded financially, while the low-tech, non-sexy preventive THINKING medicine is cut to within an inch of its life. That cardiac cath you're asking for has been proven, now, to be no more effective than intelligent use of medications--but it is a fancy procedure that costs a lot of money and keeps hospital cardiac labs in business. My Canadian MD friend laughs cynically at how many of her "snowbird" patients come back from the USA wintering having had their unneeded and expensive cath procedures. You've been brainwashed by high tech medicine into thinking that expensive poking and prodding is needed. Often, it isn't. It *is* a team effort--but increasingly, the reductionist subspecialists are behaving as if their job is to do a very expensive procedure, send me a note saying, "We didn't find anything," and send the patient back to me. Most of them don't appear to think about the case at all. That this is the case, despite the fact that they are paid 2-3 times what I am, and have 4 times as much time with the case, is infuriating to me. I have found most of them to be useless to me--aside from that poking and prodding you referenced, which is only critical in a minority of cases. And almost none of them spend any time discussing their assessment, treatment plan, or the patients' questions about their conditions with the patient--that falls to me. Even though they have a hell of lot more time to do this than I do. I have often said, if someone would freakin' pay me enough per case so that I didn't have to see 25 people a day to stay above water, I'd be able to do a hell of a lot more for my patients. When you're a hammer, everything looks like a nail. That is my lived experience of many currently practicing specialists. So: If the subspecialists refuse to do any thinking on the case, and refuse to spend any of their much-better paid time explaining the assessment, workup, or care plan to the patient, that leaves the only working medical brain left on the case to do that, as the primary internist. Mid-levels are NOT that brain. They can carry out protocols, but their depth of analysis is not the same. I did not have this opinion when I came to practice 5 years ago; I developed it, reluctantly, after having mid-levels under my supervision miss cancers, miss iatrogenic renal failures (and nearly kill the patient), botch hyponatremia workups, and fail to act on HIV viral load breakthroughs. In fact, the iatrogenesis case I mentioned above is a good example of what I'm talking about. The patient had seen 3 specialists in ID, cancer, and ortho for diffuse body pain over 12 months. The previously supervising MD was nowhere to be found. The PA gave me a garbled 20 minute rambling presentation of the case. I was struck that the patient had known kidney disease, and was demonstrating symptoms of rickets--a disease that anyone who's taken the internal medicine boards can recognize. I thought the PA was putting me on. "Did you check a Vitamin D level? He has rickets." And this had been missed by the 3 subspecialists (hammer/nail). The real problem was: I did not ask the PA *why* this patient was a kidney patient. It was because 18 months earlier he had been put on a nephrotoxic HIV medicine--and his slowly increasing creatinines were ignored. He nearly died of catastrophic kidney failure a month later. Happy is right--"solving" the primary medicine crisis by unleashing a bunch of workers who cannot do primary medicine is not fixing the problem. It *is*, however, drastically changing the DEFINITION of what "primary medicine" actually means. I've developed a hypothesis that the critical errors I've seen mid-levels make in the primary medicine setting is due to their lack of sufficient inpatient training in their all-too-brief instruction. When you've watched someone vomit out their life's blood into your lap, you have a somewhat greater sense of danger in dealing with truly sick patients. Yes, sometimes a headache is just a headache--but sometimes it's a brain tumor. Your primary better be able to tell the difference. Even the most experienced PA's in my building do not demonstrate that ability. And as the theoretical supervising MD, I don't want their clinical misjudgments jeopardizing my license. The mid-level "solution" only works if you change the definition of what primary care is. My patients want intelligent problem-solving. Mid-levels can follow protocols; they do not, however, demonstrate the depth of analysis of an internist, period. I was willing to believe they could; they don't. And cases suffer for it. If your primary is a non-doctor, and the subspecialist MDs are hyperfocused on their small part of the picture, what you wind up with is a "zombie team"--lots of running around and poking and prodding, but no hub to pull it together, synthesize the workup and treatment plans, and (duh) answer the patients' questions. In other words: A medical workup and treatment plan needs a leader. Without one, you wind up with a very frustrated and unhappy patient and family. I've inherited patients from practices that use mid-levels as the bulk of their primary care providers. The patients transfer to me because they want an internist running their case, not just taking orders from subspecialists and (rarely) from their over-worked, barely-present theoretically supervising MD (whom the patient has never seen). My HMO recently got in touch with me. A neighboring practice that uses mostly PAs to see patients has 3 times the hospitalization rate as does my practice; meanwhile, I have such a low admission rate the hospital asked if I was sending my patients to some other hospital! There is a reason. I spend very long days crossing the T's and dotting the I's on my cases, and the devil is in the details. I keep the patients out of the hospital. And therefore, I save the system TONS of healthcare dollars. My reward? UHC cut my pay 50% 3 years ago. Medicare plans a 25% pay for me this year. I am doing superb medicine, and I am being punished for it financially. The pay of primary internist needs an earthquake of reform. Health economist Kevin Grumbach has observed that countries whose physician supply mostly consists of true primary internists have better care outcomes for much lower costs than does our country. That is not an accident. I've seen the truth of it in my own little hospital campus.
I like reading you blog but I'm not sure your comments are really creating a groundswell of anger to be honest with you because not enough people are paying attention. Again, I tell you this pointing out that I often read this blog.
ReplyDeleteNice comments. I've never, and nor has any PA I've ever known claimed to be "equal" to a board certified internist. You guys are looking at this from the wrong perspective. Not every internal medicine problem needs to see a board certified internal medicine specialist. They just simply don't need to. Some problems need to. PA's are trained to recognize when problems are more extensive or complicated than they can handle. Which is why we are DEPENDENT providers. We always work under the supervision of a physician. It does not need to be direct. For example:
ReplyDeleteOne of my best friends, best man at my wedding, and classmate of mine from PA school owns his own primary care practice in Florida. He has hired his supervising physician who visits once weekly on Friday mornings. ANY patients who wish to see the physician can see him at that time. Also, any patients who have puzzled my friend (rare, but occasionally happens)will be scheduled to come back for evaluation at that time.
I appreciate internist x's comments, and perhaps she does have a lower admission rate, however, when you look at visits overall, PA's are cheaper. Can we see EVERY single problem without physician involvement, no, of course not. However, we can help see the bulk of problems that are seen in an internists office, and help provide continuity of care.
The data supports this. Again, rather than providing anecdotal stories, that mean nothing. Provide substantial REAL data that shows that PA's are providing substandard care, or that they are causing a statiscally significant rise in expenditures when compared with their cost savings, or that they are incurring greater malpractice occurences....anything....any REAL study or data.
To Internist X, I apologize if you have encountered some PA's that were substandard, there certainly are some out there. Just as there are Internal Medicine physicians who can't manage a cold. And yes, ANECDOTALLY, I have met some.
I wish this person were my doctor! I’ve been seen by several very good PAs and NPs. Sometimes I prefer them. Why? In my experiences, many of these providers have been better listeners and their recommendations have worked better than a doctor’s. Not always of course, but I find plenty of docs in a big hurry to hear the problem and write the first prescription that comes to mind. Works for simple problems, good luck if you have something that medicine doesn’t have all the answers for.
ReplyDeleteNo matter what anyone cares to believe, your thought process is right on.
ReplyDeleteMost people in this country if and when they take a minute to ponder the evening news or President Obama's last speech conveniently divert the reality of our current healthcare situation and focus on only the players within the system, when in reality we are dealing with a cultural tsunami that will not be resolved by just changing our delivery system.
Yes, we will and must ration care with our current cultural environment...which will take years IF EVER, no probably NEVER to change.
The cultural greed and need and desire for "more is better" whether it be food, happiness, money, or healthcare never will be changed by your doctor focusing on primary prevention and wellness.
Internist X is correct, there won't be enough of us PCP's around to do the work, and how do you think that PA's and NP's are going to fill that gap even if they intelectually could? They can help but there aren't enough of them. So make more NP's...and rob from the RN's who are nearly non existent in your care
already...driving the lpn's to do the RN's job and MA's and STNA's to do the LPN's job. Maybe the high school core of volunteers can fill the gap then.
Your care will NEVER be better than it has been in the past... as deficient as it was and as improved it could have been. No EMR/EHR data system or computer will save your care, because we just don't have the resources to do what our society expects us to do.
When our norm is 30+% of people eat themselves into oblivion, and/or smoke, drink, live sedentary lives thinking their standard of living is substandard compared to the rest of the world when in reality our poorest are the worlds middle or upper middle class. When our standard of care is only defined by the expert witness testifying against us in the court of law, as a jury of diabetic peers relate to the poor care they were given at some time and sympathize for a judgement. When the resources are literally drying up before our eyes in primary care and we are asked to do more and more with higher and higher expectations from patients who do not take personal responsibility for their lives, yet we should...save them from themselves?
As this is already a nearly impossible task, I ask How...How... with less resources via rationing and an UNWAVERING/UNCHANGED LEVEL OF EXPECTATION OF CARE FROM PATIENTS...How will we do it then? We already act as the resource manager and prime rationor of care for managed care and managed medicaid. What happens when Medicare/Medicaid togeter set the benchmark for rationing standards? And ALL payors follow. How many of us will stick it out to see it through, explaining to every patient why they can't get this and can't get that at every visit not just for a routine drug or expensive mri. And it will be framed in the light that the physician has discretion so blame and responsibility can be displaced, again making us the HEALTHCARE RESOURCE MANAGER. How many of us will stick it out then? How many of us will survive the tsunami?
great letter/write up by internist x!
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