I have long suggested that our Pharmacist colleagues who were corporatized long before we were should look at the ACE Hardware model. In that model the local store is OWNED but receives business advice, advertising. inventory, etc., from ACE incorporated or whatever it may be called, probably through a long but acceptable contract benefiting and protecting all concerned. And the difference from the Home Depots of the world is palpable, certainly to the consumer, and probably to the Local Owner. I wonder if Physicians should consider a similar model, as well. (This is all personal observation and opinion, not researched in any way.)
I’d appreciate a better understanding of what this group thinks the “job of a PCP” should be today.
I’m currently almost 40 with no major health issues and my experience with a PCP has been an annual physical and the same advice - and no discussion of changing risks factors for me as I get older, have less sleep due to raising two young kids, and have diabetes risk in my family.
From what I see - if often involves managing more and more medications for aging patients (blood pressure, diabetes, stroke risk, etc).
I also don’t see PCPs addressing acute issues - as their hours are too short - and that is mostly handled by urgent care and ERs.
So what is left? I’m not really sure - though I can say what I really want is a thoughtful and creative professional to partner with me on my current and possible future medical issues.
PS - I wish PCPs were more knowledgeable and supportive of psychiatry. For my age cohort (parents of young kids) this is the biggest heath challenge that we face and we typically have to go to non-medical providers (therapists, acupuncturists, etc) for years before someone we trust finally tells us “I think you may benefit from seeing a psychiatrist”.
Love this list and couldn’t agree more! As someone who is 70 years old, rides a bike 7000+miles a year, swims, lifts weights, eats clean 80/20, the Medicare physicals are ridiculous! Two years in a row, my internist never touched my body, just asked me questions about dressing myself, throw rugs, etc. Thenasking me why hadn’t had flu shots, Covid shots, etc. What a waste of time.
I graduated Med school in 1977. Much has changed, unfortunately in the wrong direction. We used to have camaraderie. Doctors were kind to patients and kind to each other. At one hospital we had monthly meetings with chef-prepared food, and wine, and nobody fussed. Detail people could come to visit, bring free meds and sometimes a little trinket. Nobody fussed.
Today everything is viewed through the coke-bottle bottom of belligerence from pharma, CMS, all payers, our own peers, nurses, med mal, our own CEOs (who used to be helpful until the became health care leaders) Medicare, Medicaid and Medicaid fraud units who can call fraud anything they want to, with an additional fine of $10,000 per imagined event. Police action environment is ubiquitous, from the dumb-ass "routine" irrelevant questions we must ask to not offend CMS or other insurers to the vaxx song and dance.
So not only are we now policed, but worse yet we are required to be police. When I grew up in medicine, our primary goal was to advocate for our patients. Here is the biggest problem we have not only in primary care, but in all medicine. When we are forced to be police for CMS, big pharma, CMS or any insurer we are MUCH LESS EFFECTIVE as advocates, which should be our primary job. When parents lose their kids to SIDS etc a few days or weeks after their latest batch of vaxx, we now must interrogate the parents, accusing them of wrongful death of their own children.
And God forbid, a 75 year old patient requests hydrocodone to do ADLs to stay in their own home rather than a nursing home...everybody benefits, including Medicaid which then doesn't need to pay $15,000 per month for a nursing home. And God forbid again we have informed consent regarding vaxx. Scott Jensen was reported seven times to the MN Med board for the grievous crime of COVID vaxx informed consent.
The real tragedy here I think for healthcare and even more for consumers, is that our young doctors and nurses seem to accept without questions the garbage that is ruining health care.
Thank you. Your comment brought tears to my eyes. I worked in the hospital setting as an R.N. in the 80's - early 90's. The current corporate medical system is anti-human.
Doctors should and need to wear the hat of a nutritionist ,a counselor, an assessor, a nurse for the necessity of a drug or screening testing. It doesn't matter how many years of training and education you have had.
[I spent my years in nursing school training for the critical care and the treatment for a runny nose. Now - many, many years later I disimpact patients, I listen to families squabble and jump in to deflate the situation.].
I propose the following: Rebuking the allotted time per patient/per visit. Spend 5 minutes with mom who brought baby in with runny nose, but spend 25 minutes with the patient because what they present you with demands all of your training.
I propose everyone get out a pad of paper and a pencil and write (legibly) all that went on in the exam room. Be thorough so that the transcriber can apply the correct ICD 10 code in the EHR. With a pencil and paper you can actually face the patient and read their nonverbal. (Unless, of course, that type of intimacy scares you).
I propose you or someone with this type of capability find the place where a family physician is really needed. Who wouldn't choose to see a familiar face when ill as opposed to a crammed and backed up ER. The office should be where the need is. His working hours should reflect on the hours kept by that population. If you need to open the office doors at 0400, then do it and close at 1300. If you need your doors open at 1700, then that's what you do, work till 0200.
I believe it's not deciding who gets or doesn't get screened, or who should receive a statin. It's knowing each patient and offering the care they are most likely to adhere to.
I agree. Our primary care physician is a person who I can call and ask any questions I have, and she is a trusted advisor for me as I age. As a retired nurse, I understand all the problems with this, but what most people want is someone they trust, can spend time with, that they feel safe and comfortable with. I have been to Urgent Care at times - last time was because of concerns about a brain bleed after a fall. She has time limits - she is very popular and doesn't take new clients at this time - because she is a good and trusted doctor!
Trust - It is in this note 3 times - 4 now. It is the most important thing in a doctor-client relationship. In a hurry-up environment of overworked doctors and nurses, it is difficult to build trust - which breeds fear, less desire to see the doctor, and it spills over to overworked and less effective urgent and emergency care units.
Michael Orlin, rtd. BSN, also BA in Interpersonal Communications and Communications.
Most of the heart disease, diabetes and cancer screening could be done by lower skilled individuals that could refer people to doctors only if it's a more complicated patient. If they leave the screening without needing a perscription it's a good indication a doctor wasn't needed.
YES -- but it's not just primary care, it's plaguing specialists, too. As a 25+ year family-practice trained NP with the last 20 years mostly in IM and geriatrics, I see my patients who have to see their cardiologist/nephrologist/gastroenterologist/pulmonologist... heck even their podiatrist "every 3 to 6 months" whether they're having symptoms or not. For what? RVUs? Meanwhile my patients who ARE having evidence of increasing symptoms can't get an appointment for weeks or months.
As we move toward value-based care (VBC), why are we not using those VBC providers for primary prevention (since they're not FFS) as the experts who can also incorporate SDOH, behavioral health, home-based care and interventions, and as the early warning system for our long-term, well-managed COPD/CHF/DM/CVD (and often all of the above) patients who seem to be having increasing SOB/fatigue/HTN/increasing glucose despite preventative measures, and get them in to be seen with their doctor/provider/specialist ASAP? Same-day would be ideal if schedules would permit.
While I whole-heartedly embrace the need for both palliative and hospice care, I also see happening an "end-run around" actual illness care and a push to palliative/hospice to reduce cost. But what about the patients' goals? Coming from a VBC perspective (but having spent a good deal of my career as an NP in FFS), I don't see why this isn't an easy, obvious solution to the "crisis" we have in not having enough time/providers to provide illness care when appropriate, and wellness/preventative care in the interim.
"... I see my patients who have to see their cardiologist/nephrologist/gastroenterologist/pulmonologist... heck even their podiatrist "every 3 to 6 months" whether they're having symptoms or not. "
Experienced this very thing with my mother, she made it to 94 and had the good sense to exit in January 2020, before Covid madness took hold. The copious doctor visits were ridiculous, overwhelming and required us, her children, to bring her to these numerous appointments, many of which were completely unnecessary. She had at least 12 doctors, one for each aging body part. And of course, the PCP visits to refer her to all these specialists. She loved it as she was convinced these visits were keeping her alive, it made her not only a hypochondriac but to feel important and since she loved being around people, going to the doctor was a social outing.
I was forced to conclude that the every 3 month follow-up appointments were all about billing and money. Ka-ching!
I am a self-styled nutrition/medical science watchdog. After a back injury in 1977, I began perusing information regarding the connection between nutrient intake and health outcomes. After reading Nutrition and Physical Degeneration by Weston Price, DDS and numerous other books related to health outcomes, I assumed I knew what I needed to eat to protect my health. Unfortunately, for several decades, I didn't know that my linoleic acid intake was excessive. Salad dressings, mayonnaise, and peanut butter were the major sources of excessive intake. Like my father before me, I developed varicose veins and, in 1995, a venous ulcer. Eliminating soybean oil-based mayonnaise and salad dressings and taking large doses of viatmin E was helpful. However, about a decade later my strength and mobility began to deteriorate noticeably. By 2009 I was experiencing considerable leg pain. Fortunately, that year I watched a lecture by NIH scientist Bill Lands, PhD. When he said, "Did you know that peanuts contain 4,000 milligrams of omega-6 in each 28 gram, one ounce serving of peanuts, and 1 milligram of omega-3?", I realized my mistake. In the sandwch I ate almost daily for lunch, I swapped peanut butter for 99% fat-free turkey. Within two months the leg pain subsided and I regained considerable strength and mobility. However, a new set of symptoms emerged, shoulder pain, chronic winter cough, and up to 25 pounds weight gain during the Winter months when I was less active.
In 2016 I read a BMJ article that said, "We now know that major changes have taken place in the food supply over the last 100 years, when food technology and modern agriculture led to enormous production of vegetable oils high in ω-6 fatty acids, and changed animal feeds from grass to grains, thus increasing the amount of ω-6 fatty acids at the level of linoleic acid (LA) (from oils) and arachidonic acid (AA) (from meat, eggs, dairy).” https://pubmed.ncbi.nlm.nih.gov/12442909/
I was not familiar with the arachidonic acid issue so I began perusing arachidonic acid research and commentary. I also swapped the turkey for cheese. The new symptoms subsided but the physiological damage was beyond my body's ability to repair itself. Since 2016 I have had cataract surgery, varicose vein surgery, and a hip replacement. Over the years I have also had a number of teeth disintegrate. In retrospect, if I had known to limit my linoleic acid and arachidonic acid intake earlier in life, I could have saved myself considerable discomfort, inconvenience, and expense. That said, I much appreciate what medical professionals can do in terms of repairing physiological damage stemming from excessive polyunsaturated fatty acid intake.
In 2011 Norwegian animal science researchers proposed a solution to the arachdonic acid problem. "Even though the underlying biochemical mechanisms have been thoroughly studied for more than 30 years, neither the agricultural sector nor medical practitioners have shown much interest in making practical use of the abundant high-quality research data now available. In this article, we discuss some specific examples of the interactions between diet and drugs in the pathogenesis and therapy of various common diseases. We also discuss, using common pain conditions and cancer as specific examples, how a better integration between agricultural science, nutrition and pharmacology could lead to improved treatment for important diseases (with improved overall therapeutic effect at the same time as negative side effects and therapy costs can be strongly reduced). It is shown how an unnaturally high omega-6/omega-3 fatty acid concentration ratio in meat, offal and eggs (because the omega-6/omega-3 ratio of the animal diet is unnaturally high) directly leads to exacerbation of pain conditions, cardiovascular disease and probably most cancers. It should be technologically easy and fairly inexpensive to produce poultry and pork meat with much more long-chain omega-3 fatty acids and less arachidonic acid than now, at the same time as they could also have a similar selenium concentration as is common in marine fish. The health economic benefits of such products for society as a whole must be expected vastly to outweigh the direct costs for the farming sector." https://lipidworld.biomedcentral.com/articles/10.1186/1476-511X-10-16
OMG - this! I constantly hear new tasks being assigned to GPs as they become the 'go to' guru for everything. Despite there not being enough of them, and them having very little time with patients. There is nothing I have seen that convinces me that drastic lifestyle (diet/exercise) interventions can be made in a 12 minute appointment addressing other immediate health issues. Population health interventions need to happen BEFORE someone reaches the GP, and these require environmental changes which are outside the remit of GPs. However in Australia, whenever it is suggested that a billable activity be be performed by another modality (e.g., pharmacist, dietician) the ones screeching the loudest are the RACGP and AMA. These alleged representatives of clinicians are very resistant to doctors focusing on treating only sick people. I am constantly invited back to my GP to 'discuss results or ask questions' despite being in ridiculous good health. I made the mistake of having a 'health check' that GPs can bill a nice sum for at various ages (mine was 45). The finding of a slightly elevated IgE triggered a slew of expensive allergy and respiratory testing which found nothing, so I can see how screening the healthy creates useless burden and expense on the system.
Exactly, primary care is prevention. Prevention of chronic diseases. It's not a profession of taking care of sick people. If one wants to take care of " sick people" go into other specialties like urgent care or emergency medicine. There are plenty of specialties that care for sick people. If physicians are tired of primary care, hand over the specialty to APPs who love and do a great job managing disease prevention, making sure patients are up to date with their HCM, as well as educating patients on lifestyle modification. It would definitely reduce health care costs in the end and MAHA!!
I agree with most of what is said here--I practice general internal medicine part-time currently, and have practiced consistently for nearly 40 years. Two comments: first, we are already increasingly helping our ill patients navigate a difficult system. I am totally fine with this. Second, it seems to me that most of the things you suggest eliminating will actually be taken away from docs as less expensive personnel, or even AI-robots, will be able to provide those services, ie, vaccines, cancer screenings, etc, for/to patients. Recently a pediatrician wrote an editorial in NEJM, "The Pediatrician's Lament" https://www.nejm.org/doi/full/10.1056/NEJMp2414640, which I found depressing. This physician describes her job as one of vaccinating her patients, and had nothing to offer parents who query her about particular vaccines--in other words, she is an automaton doing the bidding of the professional organizations and Big Pharma. Where's the joy and satisfaction in that, if all the patients are the same--just bodies requiring the same intervention over and over? I am very sad for the medical profession.
Great comment. The NEJM article is behind a paywall. I wonder about the current crop of pediatricians and PCP's blithely lumping in mRNA injections with traditional vaccines. Thus, anyone asking questions about still rather novel mRNA technology risks being branded "anti-vaxxer". It does not seem that asking questions is allowed or encouraged, parents and patients must simply obey and "trust the experts".
From what I understand, we are the only country in the world whose government medical "experts" (CDC) recommend three mRNA doses to infants by 6 months of age. We've known since end of July 2021 that mRNA injections do not stop transmission or injection yet are called "vaccines". We have also heard that children are at extremely low risk of "serious disease, hospitalization and/or death". Yet, all humans - even brand new ones - must be injected.
I'm guessing the pediatrician is pro-mRNA because CDC recommends it. I experienced this deference to CDC when I, at age 60, requested a valid medical exemption from "vaccination" in fall 2021 and was denied by my then PCP who consulted a neurologist who never met me. The reply: "No. Neurology said they can virtually guarantee you will not have an adverse reaction. You Do Not Meet CDC Guidelines for exemption". This, at a Harvard teaching hospital. That was a jaw dropper. I later realized these M.D.'s had been threatened by the FSMB if they provided "misinformation" regarding Covid "vaccines". My PCP who initially wanted to help me admitted to me in a phone call: "It's a very strange time. The medical board is breathing down our necks".
I do wonder: Are there long-term studies to prove that mRNA technology is safe or effective for infants and children? Is the author concerned about possible adverse reactions her patients may risk? Or, as you said, is she and other M.D.'s simply following orders and carrying water for governing medical bodies and Big Pharma.
There’s so much going on with the medical profession. We have for decades believed in our professional and academic organizations—it was Covid that opened my eyes fully to their conflicts of interest and agendas—power, money etc. Also in the US at least a religious, fanatical belief in vaccines as some sort of miraculous intervention—it’s a dogma we are not supposed to question. Finally, we are not listening to patients—this started before Covid but Covid made it quite clear to me how much it is happening—it’s really the great tragedy of current medical practice to me because that is where the satisfaction can come from—the doctor truly connecting with a patient in a human way. I bet a lot of young docs have never heard a story from a patient about a vaccine-related adverse event, and if they had they may not have taken it seriously. I believe there are No long term data on the safety of modified RNA products like what’s in the Pfizer and Moderna products. But there are data on the lipid-nano proteins (LNPs that are in those vaccines)—they have been known for years to travel all over the body.
Couldn't agree more. Preventive medicine is wishful thinking. Doctors are trained to diagnose and treat disease. I don't like the term "healthcare". Health doesn't need care---illness does. I spent years in medical practice telling patients to avoid the medical system if they feel well. If you have a problem, see a doctor and get a diagnosis along with options and recommendations for treatment, if necessary. Doctors can't tell you how to "maintain health" or avoid disease. Their recommendations on lifestyle modifications have no real evidence to back them and probably don't differ much from what you hear from the average layman with common sense.
Most preventive counseling is highly ineffective. The number needed to counsel for clinically meaningful weight loss is probably 500. Meanwhile when I am sick I am forced to go to urgent care and see a stranger, rather than a doctor who knows me.
I love the NNC but it should be number of attempts to counsel. How may times is each patient counseled? Side effect in most is a glazing over of the eyes.
Medicine 2.0, as someone else called it, is pharmaceutical-based and profit driven. The incentives and structure are perverse.
In ancient China, doctors were paid when their patients were healthy -- not when they were sick. How's that for a proper incentive?
One of my nursing instructors summarized the difference between medicine and nursing this way: "Doctors treat diseases; nurses treat patients." Why should doctors be primary care providers, then, if they're not going to spend time with their patients? If healthcare is to be patient-driven, then patients should be able to choose their primary care provider and preferred treatment methods. Primary care providers can refer as needed and desired.
Why blow off all the disciplines that would be perfect for primary care -- the ones that focus on prevention and health, the ones whose practitioners enjoy spending time with patients? You know, the ones that so many doctors roll their eyes at: chiropractors, naturopaths, nurse practitioners, acupuncturists...
These practitioners should be taught what's needed for proper referrals, e.g. red flags and such. (Keep licensing frameworks intact.) Doctors should learn to play well with these other disciplines -- not because they like them or agree with them, but because they respect a patient's right to choose them. The creation of the AMA in the mid-1800s (for the purpose of elevating doctors' position, power, and wealth) is a significant factor in how we got to where we are now because its members stigmatized everything but the "doctor" as they defined it. Dissenters either shut up and played along or were kicked out. The increasing interest in holistic and natural medicines is just a natural re-emergence of what was suppressed ~175 years ago. (A drop in the bucket of human history, mind you.)
The doctors-and-drugs-as gods model is so young, and, as Vinay points out frequently, gets more things wrong than right for decades before making corrections. Besides paying attention to patient preference, evidence-based medicine can only be good and useful if it's based on a correct understanding of physiology, not just information that someone has spent enough money to pay for its creation and publication.
I understand your point. Of course on an individual person or event basis my reference doesn't seem logical.
I am not in any way versed in economics, and don't pretend to have an answer on how to structure details. But it seems to me that, at a philosophical level, if hospitals were paid a bonus on how few re-admissions they had, that would incentivize more cautious and thorough care. (I recall coming across some data showing that nurse practitioners, for example, tend to have fewer re-admissions than doctors.) Or, if providers were paid a bonus based on how few of their patients developed chronic diseases, or how few medications their patients needed...
And that doesn't exclude the possibility of getting extra pay to go the extra mile -- literally and figuratively -- to help someone at home and, hopefully, prevent them from needing to go to the hospital in the first place.
Does that make more sense?
From what I can tell, the hospital that I am at now incentivizes the hospitalists to discharge patients as quickly as possible. This creates unhappy patients who don't feel seen, tended do, or cared for. It creates conflicts between doctors and nurses, who aren't only looking at the patient from the point of view of "medical stability". This results in an often-antagonistic situation between doctors and nurses.
Wouldn't it be better to have an environment where the goals -- good patient care and outcomes -- are shared and everyone is on the same team?
It’s not that “lifestyle modifications” are not worth doing, per se. It’s that they are, generally, not based on high quality evidence AND their absolute benefit generally tends to be small. So they are LESS worth doing than many other things a primary care doctor could be doing, per unit time.
The key question remains, of “if not the PCP, then who?” And I don’t think that will be a one size fits all scenario. But I think taking things off a PCP’s plate is the functional first step….with the next steps being finding an alternate place for all those things to be addressed, by someone other than physicians.
Also appreciate the reference to EBM. Always good to remind people that “the evidence” is only 1 part of the 3 part Sackett framework. Too often, pt preferences and clinical experience (comorbidities) are given short shrift. Not that those other 2 spheres alter the evidence itself; but they certainly impact the relevance of the evidence, and how that should be applied (or how applicable it is) to the patient at hand.
I have long suggested that our Pharmacist colleagues who were corporatized long before we were should look at the ACE Hardware model. In that model the local store is OWNED but receives business advice, advertising. inventory, etc., from ACE incorporated or whatever it may be called, probably through a long but acceptable contract benefiting and protecting all concerned. And the difference from the Home Depots of the world is palpable, certainly to the consumer, and probably to the Local Owner. I wonder if Physicians should consider a similar model, as well. (This is all personal observation and opinion, not researched in any way.)
I’d appreciate a better understanding of what this group thinks the “job of a PCP” should be today.
I’m currently almost 40 with no major health issues and my experience with a PCP has been an annual physical and the same advice - and no discussion of changing risks factors for me as I get older, have less sleep due to raising two young kids, and have diabetes risk in my family.
From what I see - if often involves managing more and more medications for aging patients (blood pressure, diabetes, stroke risk, etc).
I also don’t see PCPs addressing acute issues - as their hours are too short - and that is mostly handled by urgent care and ERs.
So what is left? I’m not really sure - though I can say what I really want is a thoughtful and creative professional to partner with me on my current and possible future medical issues.
PS - I wish PCPs were more knowledgeable and supportive of psychiatry. For my age cohort (parents of young kids) this is the biggest heath challenge that we face and we typically have to go to non-medical providers (therapists, acupuncturists, etc) for years before someone we trust finally tells us “I think you may benefit from seeing a psychiatrist”.
Love this list and couldn’t agree more! As someone who is 70 years old, rides a bike 7000+miles a year, swims, lifts weights, eats clean 80/20, the Medicare physicals are ridiculous! Two years in a row, my internist never touched my body, just asked me questions about dressing myself, throw rugs, etc. Thenasking me why hadn’t had flu shots, Covid shots, etc. What a waste of time.
I graduated Med school in 1977. Much has changed, unfortunately in the wrong direction. We used to have camaraderie. Doctors were kind to patients and kind to each other. At one hospital we had monthly meetings with chef-prepared food, and wine, and nobody fussed. Detail people could come to visit, bring free meds and sometimes a little trinket. Nobody fussed.
Today everything is viewed through the coke-bottle bottom of belligerence from pharma, CMS, all payers, our own peers, nurses, med mal, our own CEOs (who used to be helpful until the became health care leaders) Medicare, Medicaid and Medicaid fraud units who can call fraud anything they want to, with an additional fine of $10,000 per imagined event. Police action environment is ubiquitous, from the dumb-ass "routine" irrelevant questions we must ask to not offend CMS or other insurers to the vaxx song and dance.
So not only are we now policed, but worse yet we are required to be police. When I grew up in medicine, our primary goal was to advocate for our patients. Here is the biggest problem we have not only in primary care, but in all medicine. When we are forced to be police for CMS, big pharma, CMS or any insurer we are MUCH LESS EFFECTIVE as advocates, which should be our primary job. When parents lose their kids to SIDS etc a few days or weeks after their latest batch of vaxx, we now must interrogate the parents, accusing them of wrongful death of their own children.
And God forbid, a 75 year old patient requests hydrocodone to do ADLs to stay in their own home rather than a nursing home...everybody benefits, including Medicaid which then doesn't need to pay $15,000 per month for a nursing home. And God forbid again we have informed consent regarding vaxx. Scott Jensen was reported seven times to the MN Med board for the grievous crime of COVID vaxx informed consent.
The real tragedy here I think for healthcare and even more for consumers, is that our young doctors and nurses seem to accept without questions the garbage that is ruining health care.
Thank you. Your comment brought tears to my eyes. I worked in the hospital setting as an R.N. in the 80's - early 90's. The current corporate medical system is anti-human.
I disagree.
Doctors should and need to wear the hat of a nutritionist ,a counselor, an assessor, a nurse for the necessity of a drug or screening testing. It doesn't matter how many years of training and education you have had.
[I spent my years in nursing school training for the critical care and the treatment for a runny nose. Now - many, many years later I disimpact patients, I listen to families squabble and jump in to deflate the situation.].
I propose the following: Rebuking the allotted time per patient/per visit. Spend 5 minutes with mom who brought baby in with runny nose, but spend 25 minutes with the patient because what they present you with demands all of your training.
I propose everyone get out a pad of paper and a pencil and write (legibly) all that went on in the exam room. Be thorough so that the transcriber can apply the correct ICD 10 code in the EHR. With a pencil and paper you can actually face the patient and read their nonverbal. (Unless, of course, that type of intimacy scares you).
I propose you or someone with this type of capability find the place where a family physician is really needed. Who wouldn't choose to see a familiar face when ill as opposed to a crammed and backed up ER. The office should be where the need is. His working hours should reflect on the hours kept by that population. If you need to open the office doors at 0400, then do it and close at 1300. If you need your doors open at 1700, then that's what you do, work till 0200.
I believe it's not deciding who gets or doesn't get screened, or who should receive a statin. It's knowing each patient and offering the care they are most likely to adhere to.
I agree. Our primary care physician is a person who I can call and ask any questions I have, and she is a trusted advisor for me as I age. As a retired nurse, I understand all the problems with this, but what most people want is someone they trust, can spend time with, that they feel safe and comfortable with. I have been to Urgent Care at times - last time was because of concerns about a brain bleed after a fall. She has time limits - she is very popular and doesn't take new clients at this time - because she is a good and trusted doctor!
Trust - It is in this note 3 times - 4 now. It is the most important thing in a doctor-client relationship. In a hurry-up environment of overworked doctors and nurses, it is difficult to build trust - which breeds fear, less desire to see the doctor, and it spills over to overworked and less effective urgent and emergency care units.
Michael Orlin, rtd. BSN, also BA in Interpersonal Communications and Communications.
Well said. I totally agree. And the USA healthcare system is moving forward on a hamster wheel.
Most of the heart disease, diabetes and cancer screening could be done by lower skilled individuals that could refer people to doctors only if it's a more complicated patient. If they leave the screening without needing a perscription it's a good indication a doctor wasn't needed.
YES -- but it's not just primary care, it's plaguing specialists, too. As a 25+ year family-practice trained NP with the last 20 years mostly in IM and geriatrics, I see my patients who have to see their cardiologist/nephrologist/gastroenterologist/pulmonologist... heck even their podiatrist "every 3 to 6 months" whether they're having symptoms or not. For what? RVUs? Meanwhile my patients who ARE having evidence of increasing symptoms can't get an appointment for weeks or months.
As we move toward value-based care (VBC), why are we not using those VBC providers for primary prevention (since they're not FFS) as the experts who can also incorporate SDOH, behavioral health, home-based care and interventions, and as the early warning system for our long-term, well-managed COPD/CHF/DM/CVD (and often all of the above) patients who seem to be having increasing SOB/fatigue/HTN/increasing glucose despite preventative measures, and get them in to be seen with their doctor/provider/specialist ASAP? Same-day would be ideal if schedules would permit.
While I whole-heartedly embrace the need for both palliative and hospice care, I also see happening an "end-run around" actual illness care and a push to palliative/hospice to reduce cost. But what about the patients' goals? Coming from a VBC perspective (but having spent a good deal of my career as an NP in FFS), I don't see why this isn't an easy, obvious solution to the "crisis" we have in not having enough time/providers to provide illness care when appropriate, and wellness/preventative care in the interim.
"... I see my patients who have to see their cardiologist/nephrologist/gastroenterologist/pulmonologist... heck even their podiatrist "every 3 to 6 months" whether they're having symptoms or not. "
Experienced this very thing with my mother, she made it to 94 and had the good sense to exit in January 2020, before Covid madness took hold. The copious doctor visits were ridiculous, overwhelming and required us, her children, to bring her to these numerous appointments, many of which were completely unnecessary. She had at least 12 doctors, one for each aging body part. And of course, the PCP visits to refer her to all these specialists. She loved it as she was convinced these visits were keeping her alive, it made her not only a hypochondriac but to feel important and since she loved being around people, going to the doctor was a social outing.
I was forced to conclude that the every 3 month follow-up appointments were all about billing and money. Ka-ching!
I am a self-styled nutrition/medical science watchdog. After a back injury in 1977, I began perusing information regarding the connection between nutrient intake and health outcomes. After reading Nutrition and Physical Degeneration by Weston Price, DDS and numerous other books related to health outcomes, I assumed I knew what I needed to eat to protect my health. Unfortunately, for several decades, I didn't know that my linoleic acid intake was excessive. Salad dressings, mayonnaise, and peanut butter were the major sources of excessive intake. Like my father before me, I developed varicose veins and, in 1995, a venous ulcer. Eliminating soybean oil-based mayonnaise and salad dressings and taking large doses of viatmin E was helpful. However, about a decade later my strength and mobility began to deteriorate noticeably. By 2009 I was experiencing considerable leg pain. Fortunately, that year I watched a lecture by NIH scientist Bill Lands, PhD. When he said, "Did you know that peanuts contain 4,000 milligrams of omega-6 in each 28 gram, one ounce serving of peanuts, and 1 milligram of omega-3?", I realized my mistake. In the sandwch I ate almost daily for lunch, I swapped peanut butter for 99% fat-free turkey. Within two months the leg pain subsided and I regained considerable strength and mobility. However, a new set of symptoms emerged, shoulder pain, chronic winter cough, and up to 25 pounds weight gain during the Winter months when I was less active.
In 2016 I read a BMJ article that said, "We now know that major changes have taken place in the food supply over the last 100 years, when food technology and modern agriculture led to enormous production of vegetable oils high in ω-6 fatty acids, and changed animal feeds from grass to grains, thus increasing the amount of ω-6 fatty acids at the level of linoleic acid (LA) (from oils) and arachidonic acid (AA) (from meat, eggs, dairy).” https://pubmed.ncbi.nlm.nih.gov/12442909/
I was not familiar with the arachidonic acid issue so I began perusing arachidonic acid research and commentary. I also swapped the turkey for cheese. The new symptoms subsided but the physiological damage was beyond my body's ability to repair itself. Since 2016 I have had cataract surgery, varicose vein surgery, and a hip replacement. Over the years I have also had a number of teeth disintegrate. In retrospect, if I had known to limit my linoleic acid and arachidonic acid intake earlier in life, I could have saved myself considerable discomfort, inconvenience, and expense. That said, I much appreciate what medical professionals can do in terms of repairing physiological damage stemming from excessive polyunsaturated fatty acid intake.
The sad thing about our current circumstances is that government-sanctioned dietary advice perpetuates the linoleic acid problem. https://www.asbmb.org/asbmb-today/science/110212/an-essential-debate
Worse yet, current animal husbandry practices cause the flesh and fat stores of livestock to acquire excessive amounts of linoleic acid and arachidonic acid prior to processing. https://journals.biologists.com/jeb/article/224/8/jeb232538/256572/The-under-appreciated-fats-of-life-the-two-types
In 2011 Norwegian animal science researchers proposed a solution to the arachdonic acid problem. "Even though the underlying biochemical mechanisms have been thoroughly studied for more than 30 years, neither the agricultural sector nor medical practitioners have shown much interest in making practical use of the abundant high-quality research data now available. In this article, we discuss some specific examples of the interactions between diet and drugs in the pathogenesis and therapy of various common diseases. We also discuss, using common pain conditions and cancer as specific examples, how a better integration between agricultural science, nutrition and pharmacology could lead to improved treatment for important diseases (with improved overall therapeutic effect at the same time as negative side effects and therapy costs can be strongly reduced). It is shown how an unnaturally high omega-6/omega-3 fatty acid concentration ratio in meat, offal and eggs (because the omega-6/omega-3 ratio of the animal diet is unnaturally high) directly leads to exacerbation of pain conditions, cardiovascular disease and probably most cancers. It should be technologically easy and fairly inexpensive to produce poultry and pork meat with much more long-chain omega-3 fatty acids and less arachidonic acid than now, at the same time as they could also have a similar selenium concentration as is common in marine fish. The health economic benefits of such products for society as a whole must be expected vastly to outweigh the direct costs for the farming sector." https://lipidworld.biomedcentral.com/articles/10.1186/1476-511X-10-16
OMG - this! I constantly hear new tasks being assigned to GPs as they become the 'go to' guru for everything. Despite there not being enough of them, and them having very little time with patients. There is nothing I have seen that convinces me that drastic lifestyle (diet/exercise) interventions can be made in a 12 minute appointment addressing other immediate health issues. Population health interventions need to happen BEFORE someone reaches the GP, and these require environmental changes which are outside the remit of GPs. However in Australia, whenever it is suggested that a billable activity be be performed by another modality (e.g., pharmacist, dietician) the ones screeching the loudest are the RACGP and AMA. These alleged representatives of clinicians are very resistant to doctors focusing on treating only sick people. I am constantly invited back to my GP to 'discuss results or ask questions' despite being in ridiculous good health. I made the mistake of having a 'health check' that GPs can bill a nice sum for at various ages (mine was 45). The finding of a slightly elevated IgE triggered a slew of expensive allergy and respiratory testing which found nothing, so I can see how screening the healthy creates useless burden and expense on the system.
Internal medicine as a consult service?
Exactly, primary care is prevention. Prevention of chronic diseases. It's not a profession of taking care of sick people. If one wants to take care of " sick people" go into other specialties like urgent care or emergency medicine. There are plenty of specialties that care for sick people. If physicians are tired of primary care, hand over the specialty to APPs who love and do a great job managing disease prevention, making sure patients are up to date with their HCM, as well as educating patients on lifestyle modification. It would definitely reduce health care costs in the end and MAHA!!
I agree with most of what is said here--I practice general internal medicine part-time currently, and have practiced consistently for nearly 40 years. Two comments: first, we are already increasingly helping our ill patients navigate a difficult system. I am totally fine with this. Second, it seems to me that most of the things you suggest eliminating will actually be taken away from docs as less expensive personnel, or even AI-robots, will be able to provide those services, ie, vaccines, cancer screenings, etc, for/to patients. Recently a pediatrician wrote an editorial in NEJM, "The Pediatrician's Lament" https://www.nejm.org/doi/full/10.1056/NEJMp2414640, which I found depressing. This physician describes her job as one of vaccinating her patients, and had nothing to offer parents who query her about particular vaccines--in other words, she is an automaton doing the bidding of the professional organizations and Big Pharma. Where's the joy and satisfaction in that, if all the patients are the same--just bodies requiring the same intervention over and over? I am very sad for the medical profession.
Great comment. The NEJM article is behind a paywall. I wonder about the current crop of pediatricians and PCP's blithely lumping in mRNA injections with traditional vaccines. Thus, anyone asking questions about still rather novel mRNA technology risks being branded "anti-vaxxer". It does not seem that asking questions is allowed or encouraged, parents and patients must simply obey and "trust the experts".
From what I understand, we are the only country in the world whose government medical "experts" (CDC) recommend three mRNA doses to infants by 6 months of age. We've known since end of July 2021 that mRNA injections do not stop transmission or injection yet are called "vaccines". We have also heard that children are at extremely low risk of "serious disease, hospitalization and/or death". Yet, all humans - even brand new ones - must be injected.
I'm guessing the pediatrician is pro-mRNA because CDC recommends it. I experienced this deference to CDC when I, at age 60, requested a valid medical exemption from "vaccination" in fall 2021 and was denied by my then PCP who consulted a neurologist who never met me. The reply: "No. Neurology said they can virtually guarantee you will not have an adverse reaction. You Do Not Meet CDC Guidelines for exemption". This, at a Harvard teaching hospital. That was a jaw dropper. I later realized these M.D.'s had been threatened by the FSMB if they provided "misinformation" regarding Covid "vaccines". My PCP who initially wanted to help me admitted to me in a phone call: "It's a very strange time. The medical board is breathing down our necks".
I do wonder: Are there long-term studies to prove that mRNA technology is safe or effective for infants and children? Is the author concerned about possible adverse reactions her patients may risk? Or, as you said, is she and other M.D.'s simply following orders and carrying water for governing medical bodies and Big Pharma.
There’s so much going on with the medical profession. We have for decades believed in our professional and academic organizations—it was Covid that opened my eyes fully to their conflicts of interest and agendas—power, money etc. Also in the US at least a religious, fanatical belief in vaccines as some sort of miraculous intervention—it’s a dogma we are not supposed to question. Finally, we are not listening to patients—this started before Covid but Covid made it quite clear to me how much it is happening—it’s really the great tragedy of current medical practice to me because that is where the satisfaction can come from—the doctor truly connecting with a patient in a human way. I bet a lot of young docs have never heard a story from a patient about a vaccine-related adverse event, and if they had they may not have taken it seriously. I believe there are No long term data on the safety of modified RNA products like what’s in the Pfizer and Moderna products. But there are data on the lipid-nano proteins (LNPs that are in those vaccines)—they have been known for years to travel all over the body.
Couldn't agree more. Preventive medicine is wishful thinking. Doctors are trained to diagnose and treat disease. I don't like the term "healthcare". Health doesn't need care---illness does. I spent years in medical practice telling patients to avoid the medical system if they feel well. If you have a problem, see a doctor and get a diagnosis along with options and recommendations for treatment, if necessary. Doctors can't tell you how to "maintain health" or avoid disease. Their recommendations on lifestyle modifications have no real evidence to back them and probably don't differ much from what you hear from the average layman with common sense.
Most preventive counseling is highly ineffective. The number needed to counsel for clinically meaningful weight loss is probably 500. Meanwhile when I am sick I am forced to go to urgent care and see a stranger, rather than a doctor who knows me.
I love the NNC but it should be number of attempts to counsel. How may times is each patient counseled? Side effect in most is a glazing over of the eyes.
500 is optimistic...
Medicine 2.0, as someone else called it, is pharmaceutical-based and profit driven. The incentives and structure are perverse.
In ancient China, doctors were paid when their patients were healthy -- not when they were sick. How's that for a proper incentive?
One of my nursing instructors summarized the difference between medicine and nursing this way: "Doctors treat diseases; nurses treat patients." Why should doctors be primary care providers, then, if they're not going to spend time with their patients? If healthcare is to be patient-driven, then patients should be able to choose their primary care provider and preferred treatment methods. Primary care providers can refer as needed and desired.
Why blow off all the disciplines that would be perfect for primary care -- the ones that focus on prevention and health, the ones whose practitioners enjoy spending time with patients? You know, the ones that so many doctors roll their eyes at: chiropractors, naturopaths, nurse practitioners, acupuncturists...
These practitioners should be taught what's needed for proper referrals, e.g. red flags and such. (Keep licensing frameworks intact.) Doctors should learn to play well with these other disciplines -- not because they like them or agree with them, but because they respect a patient's right to choose them. The creation of the AMA in the mid-1800s (for the purpose of elevating doctors' position, power, and wealth) is a significant factor in how we got to where we are now because its members stigmatized everything but the "doctor" as they defined it. Dissenters either shut up and played along or were kicked out. The increasing interest in holistic and natural medicines is just a natural re-emergence of what was suppressed ~175 years ago. (A drop in the bucket of human history, mind you.)
The doctors-and-drugs-as gods model is so young, and, as Vinay points out frequently, gets more things wrong than right for decades before making corrections. Besides paying attention to patient preference, evidence-based medicine can only be good and useful if it's based on a correct understanding of physiology, not just information that someone has spent enough money to pay for its creation and publication.
So, When I get up at 2am and drive 20 miles over snowy roads to take care of a sick child you don't think I should be paid? Will YOU do it ??
I understand your point. Of course on an individual person or event basis my reference doesn't seem logical.
I am not in any way versed in economics, and don't pretend to have an answer on how to structure details. But it seems to me that, at a philosophical level, if hospitals were paid a bonus on how few re-admissions they had, that would incentivize more cautious and thorough care. (I recall coming across some data showing that nurse practitioners, for example, tend to have fewer re-admissions than doctors.) Or, if providers were paid a bonus based on how few of their patients developed chronic diseases, or how few medications their patients needed...
And that doesn't exclude the possibility of getting extra pay to go the extra mile -- literally and figuratively -- to help someone at home and, hopefully, prevent them from needing to go to the hospital in the first place.
Does that make more sense?
From what I can tell, the hospital that I am at now incentivizes the hospitalists to discharge patients as quickly as possible. This creates unhappy patients who don't feel seen, tended do, or cared for. It creates conflicts between doctors and nurses, who aren't only looking at the patient from the point of view of "medical stability". This results in an often-antagonistic situation between doctors and nurses.
Wouldn't it be better to have an environment where the goals -- good patient care and outcomes -- are shared and everyone is on the same team?
This article is spot on.
It’s not that “lifestyle modifications” are not worth doing, per se. It’s that they are, generally, not based on high quality evidence AND their absolute benefit generally tends to be small. So they are LESS worth doing than many other things a primary care doctor could be doing, per unit time.
The key question remains, of “if not the PCP, then who?” And I don’t think that will be a one size fits all scenario. But I think taking things off a PCP’s plate is the functional first step….with the next steps being finding an alternate place for all those things to be addressed, by someone other than physicians.
Also appreciate the reference to EBM. Always good to remind people that “the evidence” is only 1 part of the 3 part Sackett framework. Too often, pt preferences and clinical experience (comorbidities) are given short shrift. Not that those other 2 spheres alter the evidence itself; but they certainly impact the relevance of the evidence, and how that should be applied (or how applicable it is) to the patient at hand.