Primary Care docs - a vanishing breed?

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Robert G. Strickland, an Albuquerque physican and governor of the New Mexico Chapter of the American Colege of Physicans wrote so in today's Albuquerque Journal.

This doesn't seem to be a topic only in New Mexico. According to other reports, at least five states will be short of family docs in 2020.

I don't know a lot about the medical system in the USA.

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But e.g. I'm surprised to find internal physicans named as primary care - they are here specialists (although some are doing home visits as family doctors as well), mostly with an additonal special field of work like cardiology, pneumology, allergology, rheumatology etc. .

Usually, you go to your family doctor, a specialist in general medicine. She/he may advice to contact another doctor.

It's not only that such saves money for the health insurance, but it really is a quick and satisfying way.

However, we have the problem with ageing general practioners and and less young doctors replacing them as well - especially in more rural regions, because no-one wants to drive for home visits a long way and time.
Besides, general practioners are said not to earn as much as other doctors.

This seems to be one of the several failures of our system ... and a lot prejudices in the head of young medicine students as well.
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Are the problems resulting from a shortage of primary doctors only a problem for people on Medicare?

And since I read such in other reports: do you have to make- generally - an appointment when consulting a family doctor?

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I have not had a general practitioner as my primary care doctor in decades. All the doctors that I have used are internists.

Here's an interesting article about this:

http://www.thehealthpages.com/articles/ar-pcpdr.html

The last time I had a doctor come to my home was when my in the early 1960's. There is another interesting phenomenon. Many of the internists who are used as primary care physicians now have nurse practitioners or physician's assistants on their staff. These folks take care of minor problems, and can bill under aegis of the (supposedly) supervising doctor.

I have had some nice experiences with nurse practitioners, who are able to prescribe all but the most "serious" medications. I find, that in general, these people are more empathic, and spend more time really listening to the patient than the doctor would.

Quote:

And since I read such in other reports: do you have to make- generally - an appointment when consulting a family doctor?

We have a couple of walk-in clinics in the area where you don't need an appointment. You need to make an appointment to see your regular doctor. Also, if you call the doctor and need an appointment quickly, often you can see the nurse practitioner or physician's assistent.

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Thanks, Phoenix!

(Something like a "nurse practitioner" will take generations until it would allowed here. If ever.)

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Speaking from the veterinary side of things -- and I don't see why this wouldn't be true in human medicine as well -- huge increases in tuition over the past couple of decades and the resultant debt load with which students leave school have somewhat limited the options of new vets. My education will have cost me the equivalent of a fairly hefty home mortgage, and I was fortunate enough to incur almost no debt in my graduate studies.

At last year' Wisconsin Vet Med Assoc conference, a series of round tables were organized where current students and practicing veterinarians could discuss various issues related to practice, and one of them was management of student debt. The veterinarians who came were mostly prospective employers of the older set (that is, over 50), and had no advice to offer us in terms of how to manage our student debt, simply because it was several times the size that they had imagined it was.

When that's the case, there is more of a drive for young practitioners to pursue more lucrative work -- which means more specialization, less primary care.

Which, of course, is anathema to any sort of systemic practice of preventative medicine.

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The first and only time a doctor visited my at home was last year, when I couldn't go out due to what I had - heavily bleeding on (not in) the nose.
(Luckily, a surgeon was on - normal - duty that Sunday as well.)

Our family doctor is an internist, specialised in diabetes - which none of us has. He'd visited my wife once.

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The whole physician's assistant idea is very interesting. It started with the military medics. It was thought that with some more training, these people, once they left the military, could work in neighborhoods where doctors were in short supply.

They were trained to do well baby checkups, and deal with the less serious medical issues. Apparently the idea took off, and now there are many doctors in more affluent areas who use these people to augment their service practice.

Quote:

Nurse practitioners provide basic preventive health care to patients, and increasingly serve as primary and specialty care providers in mainly medically underserved areas. The most common areas of specialty for nurse practitioners are family practice, adult practice, women's health, pediatrics, acute care, and gerontology; however, there are many other specialties. In most States, advanced practice nurses can prescribe medications.

http://www.bls.gov/oco/ocos083.htm

http://www.bls.gov/oco/ocos081.htm

Here is some info on PA and nurse practitioners.

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Well, baby checkups are done only by special trained pediatrists here, as well as primary care is such a specila subject (= takes some time/years for doctors to get specialised in it).

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Walter Hinteler wrote:

Thanks, Phoenix!

(Something like a "nurse practitioner" will take generations until it would allowed here. If ever.)

The Board Ceritification exams for Family Practioner and Internist are totally different in the USA.

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Miller wrote:

The Board Ceritification exams for Family Practioner and Internist are totally different in the USA.

That's what I guessed.

They are here, too - because it's a different field of medecine - but both last as long.

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Walter
There is a growing opinion about why physicians, who would like to focus on primary care for low income area patients, are going into specialties rather than primary care.

Medical school has become so expensive that by the time students are interns and residents, they have accumulated such huge student loan debt that they cannot repay it on primary care income. Their salaries during their internship and residency are so low, they continue to accrue debt. They are forced to go into specialties to be able to afford paying off their student loans.

BBB

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I just looked it up - though there are only figures pre 2002 online:

general preactioners get as much as neurologists/psychiatrists; they are at the bottom of the table.
Internists acting as well as family doctors are in the middle field.

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Re: Walter

BumbleBeeBoogie wrote:

There is a growing opinion about why physicians, who would like to focus on primary care for low income area patients, are going into specialties rather than primary care.

Medical school has become so expensive that by the time students are interns and residents, they have accumulated such huge student loan debt that they cannot repay it on primary care income. Their salaries during their internship and residency are so low, they continue to accrue debt. They are forced to go into specialties to be able to afford paying off their student loans.

BBB

Many medical students aren't even paying off their student loans.

As far as I'm concerned, there's no excuse for this. When I took loans out for Law School, I ended up paying an interest rate of 3.5% after consolidation of the loans. At that rate,
any medical school or law school graduate should be able to budget their money and pay off their loans. If they can't, they should not go to either medical or law school.

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Miller
Miller, I'm surprised that you would limit higher education to those from families with lots of disposable cash.

BBB

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Walter Hinteler wrote:

I just looked it up - though there are only figures pre 2002 online:

general preactioners get as much as neurologists/psychiatrists; they are at the bottom of the table.
Internists acting as well as family doctors are in the middle field.

Walter, most GPs team up with HMOs (Health Maintenance Organizations)
whose health insurance plans dictate them to see certain GPs. This insures them a steady income through constant patient flow, however, once contracted with an HMO the GP agrees to capitation fees, and in order to pay for his overhead, it is not uncommon for a GP to see 40 patients per day. Quality is replaced by quantity.

Another aspect is the "laying all eggs in one basket" dilemma. Should
the HMO decide not to contract with a particular GP any longer, his practice is mostly bankrupt.

In order to avoid such pitfalls, GPs and other speciality physicians for
that matter, employ PAs (physician assistants) to see the HMO patients
while the GP or specialist will see patients with better insurance plans.

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Re: Miller

BumbleBeeBoogie wrote:

Miller, I'm surprised that you would limit higher education to those from families with lots of disposable cash.

BBB

I think what Miller implied was that medical student loans are more often
defaulted, as opposed to student loans for other professions.

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A doctor came to our house when I was quarantined with scarlet fever back in 1954. That was the last of doctor visits until quite recently when I had an eye emergency. After my simple cataract surgery ended up taking more than two hours from complications, they checked the eye pressure for me several times a day, me driving to the office myself once the bandage was off. But, the second day after, the pressure shot way up, and plans were made for my business partner to drive me five hours away for a next morning (sunday, first use of the surg theater) surgery by a retinal specialist. The night before, the first eye surgeon came to the house at midnight, checked the pressure, and gave me drops to take hourly until I got to the specialist's office. I was under stress, of course, but was pleased by the doctor's doing that - I've not heard of home visits for years.

Like Phoenix, I've always gone to internists. That may have something to do with my background of working with internists in my earlier lab career, and something to do with my insurance, which until now has let me choose my own physicians. I agree that family practitioners are another branch of medicine with its own lengthy residency (not sure of variations in that among all the different speciaties now).

I'm less sure what Primary Care means - I think of it as an HMO term having to do with a weeding process before letting a patient see a specialist. I don't know if those physicians are simply g.p.'s - it used to be that once you finished your internship, you could then practice as a general practitioner, and that probably still is so - or people with further training who prefer to see patients at the screening end/preventative care end of the practice spectrum, for whatever reason.

On physicians' assistants and nurse practitioners, it seems like a good idea to me within a group practice as long, of course, as there is a solid review system.

My last internists' office, back in California, had, usually, six internal med specialists, with separate areas of expertise, plus a physician's assistant, plus nursing staff. I was quite happy with them.

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BBB
I was a representative with The Union of American Physicians and Dentists for ten years during the 1970s and 1980s in California. As a result, I learned a lot about medical education and practice in the private and public sectors throughout the United States. I came to know and understand the career goals of a wide variety of medical care providers and the professional and economic challenges they face. Among those doctors were those I admired and those I loathed. Just as in any profession.

BBB

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Walter Hinteler wrote:

I just looked it up - though there are only figures pre 2002 online:

general preactioners get as much as neurologists/psychiatrists; they are at the bottom of the table.
Internists acting as well as family doctors are in the middle field.

Neurologists/psychiatrists -- and any specialist, for that matter -- can pursue careers in research in the private, public, or academic arenas, a route that is not available to the GP.

As for the money thing -- I bring it up because of what I see happening. Some folks will always pursue the path of greatest monetary profit. Some folks will always pursue more or less altruistic career paths. But the majority are somewhere in the middle, wanting to do good but also wanting to be comfortable. Back when in-state tuition was a couple grand, you could come out of your professional program with a meager debt load. Now, with in-state tuition over $15K per year (at my school, anyway) and out of state around $24K, the middle ground folks have fewer options to reach that "comfortable" level.

It's not a question of defaulting on loans (though certainly a higher debt burden will lead to more defaults; that's a no-brainer); it's a question of the impact of the debt load on career decisions and on practice decisions.

The short-visit/many-patients-per-day is something I see in the vet med, too, and it's frustrating. Patient/client education is crucial in medicine -- it can be the difference between prevention and early detection and full-blown disease. All you can do in the standard 15-minute visit is figure out whether the patient is currently clinically diseased, and if they are refer them or schedule a future appointment. There's no opportunity to educate the patient/client about how to maintain and monitor their own health.

Again, not a lament, just the state of affairs.

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Re: Miller

BumbleBeeBoogie wrote:

Miller, I'm surprised that you would limit higher education to those from families with lots of disposable cash.

BBB

I never said anything of the kind.

What I said:

Quote:

...
any medical school or law school graduate should be able to budget their money and pay off their loans. If they can't, they should not go to either medical or law school.

I was referring to the low interest rate for the Federal student loans, 3.5%, which I am now paying.

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Quote:

There's no opportunity to educate the patient/client about how to maintain and monitor their own health.

These duties are now being taken over, clinically by RNs and PharmD, as they should be.

Also, with the internet available to most, who have computers, MDs now would like to have patients
educate themselves, as incidentally may are doing on A2K.

Back to student loans, a woman recently graduated from Tufts Medical School in Boston , with an MD and a loan debt of about $184,000. She promised the US Army to serve in the Army following her education, if the Army would pay her way through Medical School. Well, the Army did pay her way through med school and recently called her up for duty in the military.

Guess what? The woman now has told the Army that she can not serve, because her religion
Christian Coptic?) prohibits her from doing so.

Twisted Evil

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Primary Care docs - a vanishing breed?

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