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Old 07-14-2009, 05:27 PM   #1
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Default The Death of Primary Care Medicine Is Official

This is quite long. You can: 1) just read my little intro and be done, or 2) just read the italicized section below, or 3) read the whole thing; it’s good and it’s interesting.

The US currently trains about 1000 new primary care physicians a year; about 3000 to 4000 are retiring. If Obamacare becomes law, the inflow will slow to a trickle, and the outflow will accelerate to a flood. This will cement the first step in de facto health care rationing: you’ll get care, but it won’t be medical care, which is provided, by definition, by a doctor.

Why is an article by a physician, written primarily for physicians, in Politics? Because Mr. Obama put it there.

Posted on June 7, 2009

DrRich was both saddened and dismayed to read Bob Doherty’s recent post on the ACP Advocate Blog, entitled, “Do internists have confidence in their own training when compared to N(urse) P(ractitioner)s?” Dr. Doherty wrote this post both to defend the American College of Physician’s enthusiastic endorsement of the Preserving Patient Access to Primary Care Act (H.R. 2350), and to encourage his fellow practitioners of internal medicine to have confidence in their ability to successfully compete with nurse practitioners as Primary Care Physicians Providers - a competition that will be formally launched by H.R. 2350.

H.R. 2350 is Congress’ latest answer to what is becoming widely recognized as a critical shortage in primary care physicians in the United States.* In short, it is now abundantly clear, even to those as isolated from reality as our congresspersons, that there are not nearly enough primary care doctors to provide all the new healthcare that our impending healthcare reform will promise to all our citizens (and others).

Dr. Doherty points out that H.R. 2350 addresses the primary care crisis in a truly comprehensive way, offering more primary care training programs, new scholarships and loan repayments, and additional financial incentives for PCPs who participate in sundry, officially sanctified, “quality” efforts du jour, such as “care coordination” and “medical homes.”

He goes on to note that bill’s treatment of advanced practice nurses “is a sticking point for some” since it recognizes nurse practitioners as PCPs in their own right, that is, as independent practitioners permitted to establish their own, federally reimbursable primary care practices. But to assuage the indignation of potential critics among internal medicine physicians with regard to this latter provision, Dr. Doherty explains that “ACP’s top physician leadership made the judgment that H.R. 2350 merits the College’s strong endorsement, even with the more expansive [nurse practitioner] language, since perhaps 95 percent of the bill is based on ACP policy.”

Further, Dr. Doherty welcomes the competition between internists and nurse practitioners, and, in effect, challenges his fellow internists to “man-up.” Ultimately, he asserts, H.R. 2350 “will help support the value of internal medicine training by providing a consistent way to measure the outcomes, effectiveness and efficiency of care provided by internists, even when compared to nursing-led [practices].”* Under the universal “evaluation benchmarks” provided by this bill, benchmarks designed to measure and compare quality of care, internists (thanks to their many years of advanced training) will surely prevail, and at the end of the day will amply demonstrate to the world their superiority over nurses as PCPs. So, internists, gird your loins, take heart, and leap proudly into the fray! (And, by the way, ask your congresspersons to support H.R. 2350, just as your “top leaders” have urged.)

This is so sad on so many levels, DrRich hardly knows where to begin.

So let us begin with why, exactly, there is a primary care crisis in the first place. Conventional wisdom has it that the growing shortage of PCPs (a category which is comprised, to a large extent, of general internists) is related to their relatively low pay as compared with their more procedure-oriented medical brethren. But while it is true that internists are grossly underpaid, at least in relative terms, this has always been the case. Men and women who went into internal medicine several decades ago were also grossly underpaid, and knew they would be when they decided to become internists, and yet they became internists anyway.* And until the past 10 or 15 years, most of them will tell you that the practice of general internal medicine was sufficiently professionally rewarding as to serve as its own compensation.

But in recent years, as DrRich has described here on countless occasions, our healthcare system has taken exquisite pains to make primary care a completely untenable proposition for American doctors.* To quote from one of DrRich’s more recent posts on the plight of PCPs,

“Their pay is determined arbitrarily by Acts of Congress, not by what they’re worth to their patients or to the market, and indeed in this way PCPs have a lot in common with workers in the old Soviet collectives.

They are directed to “practice medicine” by guidelines and directives which are handed down from on high; guidelines which, being forcibly based on what is called “evidence-based medicine,” necessarily address the average response of some large group of patients to the treatment being considered and do not allow much if any latitude for an individual patient’s needs; and which are often promulgated less to assure the excellent care of patients and more to further the agenda of various and competing interest groups, professional, governmental and otherwise.

They are limited to between 7.5 and 12.5 minutes per patient encounter (depending on the third party that controls a given patient’s medical care), and the content of what must occur during those 7.5 minutes is strictly determined by sundry Pay for Performance checklists, so as to strictly limit any interchanges between doctor and patient that do not meet the approved agenda for such encounters.

Their every move must be carefully documented according to incomprehensible rules, on innumerable forms and documents, that confound patient care but that greatly further the convenience of healthcare accountants and other stone-witted bureaucrats who are employed specifically to second-guess every clinical decision and every action the PCP takes.

They are expected to operate flawlessly under a system of federal rules, regulations and guidelines that cover hundreds of thousands of pages in immeasurable volumes that are never available in any readily accessible form. If they do not operate flawlessly according to those rules, regulations and guidelines, they are guilty of the federal crime of healthcare fraud. Furthermore, the specific meanings of these rules, regulations and guidelines are not merely opaque and difficult to ascertain, but indeed they are fundamentally indeterminate - that is, no individual or group of individuals in existence can say what they mean. So, PCPs operate under a massive quantum cloud of rules as best they can, but their actual status (regarding healthcare fraud) is, like Schrodinger’s cat, fundamentally unknowable - until the “box is opened” (typically through criminal prosecution), whereupon the meaning of the rules is finally crystallized in a court of law, and doctors who had been practicing in good faith find that they have at least a 50- 50 chance (like the cat) of learning that they are actually professionally dead.

Worst of all, PCPs have been charged with the duty of covertly rationing their patients’ healthcare at the bedside, and they have been pressed to nullify the classic doctor-patient relationship, by the healthcare bureaucracy that determines their professional viability, by the United States Supreme Court, and by the bankrupt, new-age ethical precepts of their own profession.”

The healthcare system has (intentionally, DrRich argues) rendered primary care medicine such a soul-wrenching, personally and professionally demeaning endeavor that it has pushed most PCPs beyond mere anger, frustration, or resignation. Most American PCPs over the age of 50 with any measurable degree of self-respect are desperately looking for a way to retire early, and the ones under 50 are looking for some feasible way to change careers. Any medical student who spends more than 15 minutes with a typical PCP “gets it” right away - if not directly from the PCP’s mouth, then from their hollow, far-away looks of desperation - and as a consequence, even those who entered medical school badly wanting to become primary care physicians quickly begin exploring alternative career paths, ones that might keep them at least an arm’s length from the soul-eating bureaucratic overseers for at least a few years.

And so, the concern that our political leaders now profess for the plight of primary care medicine amounts to mere crocodile tears. They have the primary care doctors right where they wanted them all along.

Viewed in this light, H.R 2350 can be accurately perceived as a cruel joke on internists. Sure, the legislators have thrown them a few irrelevant crumbs. (Who, for instance, really cares that more training slots for PCPs will be created, when training programs can’t even fill their current slots?)* And if these crumbs address 95% of the policies promulgated by the ACP’s top leadership - well, DrRich will leave it to the internists to decide* what that says about their leadership.

The capstone of H.R. 2350 is the provision that renders nurse practitioners full-fledged PCPs. This, indeed, is what the healthcare bureaucracy has been striving to achieve all along.* It’s the main reason primary care physicians have been systematically degraded and humiliated virtually out of existence. (Indeed, if not for our current fiscal meltdown, which has reduced the retirement savings of PCPs - just like everyone else - by 40%, the prospect of imminent “healthcare reform” would have driven many more PCPs into early retirement over the past 6 months.)

Controlling the behavior of primary care practitioners is absolutely critical to controlling healthcare costs - which is to say, to covert rationing. And despite 15 years of coercion (some of which is cataloged above) American primary care doctors still insist on spending too much money. It is the fervent belief of the healthcare bureaucrats (DrRich asserts) that getting rid of physician-directed primary care,* and replacing it with primary care provided by nurses, will give them the control they must have. H.R. 2350 is the culmination of all this effort. (DrRich will quickly note, before he offends his deeply-respected colleagues in the nursing profession, that he has already expressed the opinion that nurses are too smart and too ethical to fall for this ploy, and that even this grand scheme for rationing healthcare will ultimately fail.)

With this background, let us now revisit Dr. Doherty’s admonition to his fellow internists to strap it on - to summon up their confidence, to rely on their extensive training in internal medicine, and to show everybody who’s who when it comes to delivering quality primary care medicine.

DrRich is still shaking his head in wonderment at this call to battle. The very idea that highly trained internists should be chomping at the bit to prove to the world that they are better at practicing medicine than nurses ought to be at least a little astonishing.

But beyond this, Dr. Doherty’s (and by extension, the ACP’s) bland acceptance of universal “benchmarks” of quality by which internists and nurses are to be judged is quite revealing. These benchmarks, of course, are defined by bureaucrats who are rooting for the nurses, and for whom quality means compliance with bureaucrat-approved guidelines. DrRich believes that in a show-down between an excellent nurse and an excellent internist, under such benchmarks there is at least an even chance the nurse would “win.” The result of a competition on these grounds might well render* Dr. Doherty another Charles VI at Agincourt, urging his much larger, better equipped, well-mounted army of French knights against Henry V’s small rag-tag mob of English yeomen. When the rules of engagement are suddenly different than they have ever been before, the result might not be as pretty as Charles VI (or Dr. Doherty) have envisioned.

But ultimately, the mere fact that the ACP embraces the notion that internists (and other primary care physicians) should enthusiastically engage in competition with nurse practitioners is the final nail in the coffin for primary care doctors. That notion itself is capitulation. For if nurses are qualified to compete with internists, it matters little what the actual “quality scores” of that competition turn out to be.* By acceding to the competition, the ACP has agreed that the two professions belong on the same field of play, and thus, where primary care is concerned, has rendered nurse practitioners functionally equivalent to internists.

This is true whether H. R. 2350 actually becomes law or not, and whether or not the internists can actually outscore the nurses in a rigged “quality” competition.* (One might even question how good a thing it would really be for internists to out-duel nurses in a guideline-compliance contest.)

There are few medical students anywhere in the known universe who would look at such a thing - the idea of going through 8 - 10 years of post-college medical training merely to be considered functionally equivalent to a nurse practitioner - and still voluntarily decide to become a primary care doctor. Indeed, one would have to question the sanity of a medical student who would make such a choice, and certainly ought to hesitate before letting such a person make life and death decisions on one’s behalf.

The field of primary care medicine is dead for internists.* The death certificate came in the form of the American College of Physicians’ endorsement of H.R. 2350.

DrRich is very sorry to break this news to those of you who are general internists. Some of you are the smartest people DrRich has ever known. But somebody needs to tell you the truth, and your top leaders are too busy supervising the capitulation to do that.

But the truth, in this case, need not be all bad. Indeed, it can be quite liberating.* In his next post, DrRich attempts to elaborate on why, and how, general physicians can embrace the death of primary care medicine.

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Old 07-14-2009, 07:24 PM   #2
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Here 'tis:

Embracing the Death of Primary Care Medicine

If DrRich was correct in his previous post when he decreed primary care medicine to be officially dead, the death certificate having been duly executed by one of the main physician organizations charged with defending the practice of primary care medicine, then DrRich’s pronouncement seemingly has left many good American doctors high and dry.

For, if primary care medicine is dead, that is, if the designated functions of a primary care doctor have been devalued to the point of officially having been made equivalent to what a competent nurse practitioner can do, then what’s the point of becoming (or having become) a primary care physician? Why, save for a lack of viable alternatives, would anyone practicing primary care medicine continue to do so? And why would any medical student choose such a career path?

It seems clear to DrRich that they would not.

But this does not mean that primary care physicians (or current trainees in primary care programs) should despair. For, when one takes a careful and analytical look at what has just transpired here, it becomes evident that the actual clinical value provided by primary care practitioners has not been diminished one whit. They are every bit as valuable, every bit as critically important, as they have ever been - and even more so. And by summoning up their resolve, reinforced by an abiding confidence in their extensive training, these physicians can re-define a strong position for themselves within the healthcare system, and can finally demand the pay they deserve for the service they provide.

But to do so, they will have to abandon primary care.

This will not be a loss, because actually, primary care has abandoned them. Whatever “primary care” may have once stood for, it has now been reduced to strict adherence to standards, 7.5 minutes per patient “encounter,” placing chits on various “Pay for Performance” checklists, and striving to cause high-and-mighty healthcare bureaucrats (who wouldn’t know a sphygmomanometer from a sphincter) to smile benignly at their humble compliance with the dictates of “quality healthcare.” This is not really primary care medicine. It’s not medicine at all. It’s something else. But whatever it is, it’s what has now been officially designated as “primary care,” and the people who do it (doctors, nurses, high-school graduates with a checklist of questions, or whoever they may be in the future) are all Primary Care Practitioners.

While there has been much earnest back-and-forth in the medical blogosphere about nomenclature, specifically regarding the definition of “primary care,” that question is now settled. Primary care is the provision of routine, standards-based healthcare to the masses, following prescribed quality guidelines, with limited or no latitude allowed for clinical judgment or individualized care. Since this is now the true definition of primary care, DrRich can think of no rationale for forbidding nurse practitioners to provide it. Indeed, once physicians and their professional organizations (such as the American College of Physicians) gradually allowed this to become the de facto definition of primary care, it became inevitable and proper to admit nurses to the field, and rear-guard actions to the contrary merely amount to the mindless, guild-like behavior so often attributed to physicians by those intent on diminishing and demoralizing the profession.

What generalist physicians (heretofore known as primary care physicians) need to realize is that “primary care” has been dumbed down to the point where abandoning it is no loss; indeed, it ought to be liberating to walk away from it.

The beauty is that to survive and flourish, you don’t really need to change your medical ideals or even your medical behavior (unless, of course, you have bought in to the strict adherence to guidelines, checklists, etc.) You simply need to practice medicine exactly as you were trained to practice it - taking all the time needed for careful, thoughtful attention to detail; seeking meaningful nuances; personalizing both diagnostic and therapeutic recommendations not only for the individual’s medical condition, but also for their psychosocial and economic circumstances; relishing the challenge of making the difficult diagnoses, and managing the complex medical disorders that so often break from the designated norm; and treating guidelines as just that, as often-helpful guideposts, rather than mandates; and most important of all, embracing the classic doctor-patient relationship in all its particulars, and having the latitude to become a true advocate within a hostile healthcare system for the benefit of your individual patients. In short, you can go back to being a real doctor, and not a cipher in some bureaucrat’s database.

There are only two things you need to do to move in this direction.

First, abandon the “primary care” label. Remember, primary care is now the standards-based, checklist-driven, one-size-fits all, “high-quality” system of practice imposed by insurance companies and government bureaucrats, which is open to both doctors and nurses (and, in the future, most likely to others). That’s not what you do anymore. Primary care medicine is dead. So find a new name for yourself.

The choice of nomenclature is yours, of course, but DrRich humbly suggests “Advanced Care Medicine.” What you do is not primary care; it’s far more advanced than that, and nobody could do it without the sort of extensive training you have. Advanced Care Medicine captures that notion. It also opens the possibility of referrals from the new-style PCPs, who occasionally will recognize that at least 20% of their patients (the ones DB writes about as the long tail) will present as clinical puzzles that do not fit very well with any of the standard medical diagnoses with which they are familiar, and another 20% will not respond to the recommended therapy as the guidelines say they must. These patients obviously will need advanced management. Why not refer them to an ACM practitioner?

Second, you need to establish practices whereby you are paid by your patients. A few years ago doctors who did this sort of thing were called “concierge physicians.” This elitist terminology was later changed to “retainer practitioners,” which at least rendered the economic model no more reprehensible than that favored by attorneys. But nowadays this kind of practice has been rechristened with the much sweeter title, “patient-centered practices,” and practitioners are paid by a variety of methods including the retainer model, or by the hour, or by the visit, or or by the service. Payment models can be established that will allow most patients to participate (and thus blunt the obligatory attacks of “elitist!” which will be aimed your way in an attempt to shame you into remaining safely within the primary care gulag). You can set up your practice and your payment model any way that suits you. There really ought to be nothing particularly revolutionary about this kind of practice, since it was the norm throughout most of the history of medicine until 40 years ago. It is likely that many patients who today would never consider paying any doctor out of pocket will eventually change their minds, once it becomes apparent to them what primary care medicine has devolved to in the United States.

In any case, when you are paid by your patients, you answer to your patients (not some hostile bureaucrat), and the quality of the care you deliver is measured by your patients (and not some hostile bureaucrat). There are no externally imposed time-limits to your office visits, no checklists you must complete, no bizarre documentation rules you must follow for reimbursement, no guidelines you must obey even if it makes no sense for the patient sitting in front of you. Those things are for the primary care practitioners to concern themselves with, poor souls, and you do not dwell among these unfortunates anymore.

And happy it is that primary care medicine is killed off now, because time is of the essence. DrRich has already pointed out that an essential feature of universal healthcare will be to make it illegal (in the name of fairness) for individuals to spend their own money on their own healthcare. For Advanced Care Medicine (or whatever you may choose to call it) to become a viable path, you’ve got to begin now making it a fait accompli - establishing it as something patients value, and which they fully expect as a personal healthcare option, and furthermore, as an indispensable referral resource for those sad souls - physicians, nurses and others - who retain the label “PCP.”

So at the end of the day, the fact that the American College of Physicians has now brought primary care medicine to a merciful end, whether that result was intentional or something bumbled into during a misguided attempt to remain politically relevant, can be seen as a positive thing. “Primary care” having been irretrievably defined down into something less than the actual practice of medicine, for the ACP or any other physician organization to engage in a rear-guard action to ward off the inevitable advance of nurses and others into this diminished realm would have been quite enervating.

Worse, fighting this unwinnable fight would have wasted much of what little time you have left to establish yourselves as practitioners of the exciting “new” specialty of Advanced Care Medicine, before it’s too late.
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