The Death of Primary Care Medicine Is Official

Posted on June 7, 2009
Filed Under Primary Care in America |

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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.

Comments

14 Responses to “The Death of Primary Care Medicine Is Official”

  1. WCS on June 7th, 2009 1:08 pm

    thank you.

    This General Internist agrees wholeheartedly (I’m in the trapped 40-something group), as does my NP wife (who already makes more than I do when considering $/hour of responsibility).

    The saddest part is that not only would the Darvocet-Withdrawaler (my name for the ample-buttocked, pseudo-bureaucrat who has gladly allowed dust to settle on his stethoscope) sell us out, but a majority of practicing physicians will now sell out their own souls, lost in the frenzied, survival mode of one, rather than taking a bigger picture view.

    Indeed, come visit my medical community - it is beginning to resemble our electorate!

  2. Annie on June 7th, 2009 2:03 pm

    Here’s my .02:

    “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.”

    Substitute the word,”nurse”, for PCP, and “professional nursing” for “primary care medicine”, and you describe the drivers of the movement toward NP’s, believe it or not.

    Registered nurses are charged by ethics and statute with safeguarding patients. But because nurses work overwhelmingly as employees, they are placed in a double bind. Employers stuff tasks down the throats of nurses who are also expected to perform flawlessly under incredible and unrelenting time pressures, multiple distractions and unmanageable patient case loads, and nurses respond in passive aggressive ways often suggesting problems but not taking any direct action to halt, prevent or address acts which are unacceptable.

    More than 50% of hospital-based nurses report being threatened, intimidated or assaulted on an annual basis. Having been the target of many over the years, including stalking and physical assaults, I cannot stress to you the importance of creating practice conditions which protect nurses in particular.

    Employers quite effectively retaliate against nurses or other employees who do take action, and so nurses remain inhibited and intimidated. Employers find it less expensive to churn dissatisfied employees than to permit professional nursing self-governance, and physicians who practice as employees are also finding this out the hard way.

    Perhaps a more effective alternative for providing incentives for primary care physicians might include investigating the use of physician/nurse owned and directed professional practice groups, where the structure is such that the PPG performs its own credentialing, chooses/recruits its own members, establishes its own criteria for minimum accepted practice which of course meets or exceeds state board practice requirements, and which provides incentives for members to demand acceptable practice from all of its members.

    This model might also allow for salaries for all licensed providers, in which the playing field might be leveled somewhat between physicians in primary care and those in clinical specialties, as well as to provide a mechanism for more accurately reimbursing nurses with clinical expertise - especially those with a minimum of a baccalaureate level nursing education, which comprises about one third of all licensed registered nurses (about one million of three million total). Nurses with BSN’s have clinical and didactic education to prepare them to serve as patient case managers, chronic disease/illness case managers, and to practice in community, public and home health nursing roles. They serve as the pool for future faculty, advance practice nurses, researchers and administrators.

    PPGs would also provide for clinical career satisfaction and advancement for nurses, which is the major driver of the nursing shortage.

    By practicing in an interdisciplinary group structure, nurses and physicians would be in better positions to collaborate instead of to further competition and resentment.

    I’ve long suspected that the nurse practitioner movement is more a response to unsatisfactory practice conditions for nurses more than a desire to practice in a look alike narrow subset of medicine. And really, there just aren’t that many NPs being prepared that I think would ever meet the US primary healthcare needs, even in the absence of the independent practitioner argument.

    Provide incentives for physicians and nurses to collaborate and use their combined number to influence desired practice conditions instead of pitting their conflicting interests, and I believe that professional autonomy and authority can be returned in some significant degree to them.

    This model would also promote physicians who are already practicing as employees to convert to a peer corporate/professional partnership model, and I believe that physicians would like this for the professional autonomy and authority it preserves without employer loyalty and compliance conflicts.

    But until nurses are added to the physician and patient equation, and incentives to hold clinicians accountable for their patients’ care and outcomes are built in to practice structures, fundamental change will not be achieved in any significant way.

  3. Matt on June 9th, 2009 12:04 am

    “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.”

    As a long-term reader of your blog and newly minted MD beginning his family medicine residency one week from today, your comment above surprises, terrifies, angers, and offends me all at once. Were you to point out that this decision is a difficult one for medical students to make, and one that for many of us requires drawing on admittedly non-rational, non-quantifiable motivators such as passion, optimism, idealism, altruism, and (heaven forbid) hope, would be one thing. But for you, as a physician, to advise your readers that simply because we have chosen this noble profession, we are not fit to take care of seriously ill patients is not only offensive, it is a dangerous, irresponsible, and deeply hurtful insult to us, our teachers, and the institutions who have trained us. My decision to pursue a primary care specialty was not an easy one, especially as my grades, test scores, and academic accolades could have taken me into any specialty I would have chosen (I say this not to boast, but to reassure your readers and defend against the notion that those of us who willingly choose primary care are intellectual duds, insane, or unfit to make serious medical decisions for our patients). I chose this path in spite of the adversity associated with it because, to me, being a physician means taking care of individuals and not just a particular disease or organ system. I have faced down many teachers and mentors who told me that I was “too smart to do family practice” and that I would be much better suited to their particular partialist sub-specialty, and this I have tolerated with some understanding of their own perspective and bias. But never have I been told (until today) that choosing a primary care specialty would make me unfit to care for patients. That is simply absurd.

    Addressing your main point, that NPs are equivalent to general internists, I have to ask, do you actually believe that this is true? I understand your argument that, by engaging the NPs in a head-to-head competition, the ACP may have functionally made this the case. But, do you, in reality believe that an NP with 2 years of post-college medical training can in fact provide the same level of care as a physician with 8-10 years? Because if the NP really can, then medical school and residency are the most inefficient, bloated, unimaginable wastes of time of in all of existence and we MDs are all on the laughing end of a cruel and unusual joke. We were all fooled into thinking that to do the things that doctors do we had to bust our rears through undergrad to have the grades and scores needed to get into medical school so that we could shell out hundreds of thousands in tuition, waste away our twenties and early thirties memorizing endless lists of facts, enduring demeaning, patronizing, and often demoralizing clinical rotations, only for the “privilege” of working ungodly hours for barely minimum wage, when all we had to do was work half as hard in college to get our BSN and spend 2 years on an MSN.

    This simply cannot be the case (can it?). Of course a physician with 8-10 years of training must bring something to patient care that an NP simply cannot (mustn’t he?). I believe that these are important questions that the entire profession (not just PCPs) is going to have to face head on. If NP PCPs really are as effective as MD PCPs (as the NPs assert), then it’s only a matter of time until NPs demonstrate that they can also provide subspecialty care at the same level as MDs. This is almost certain as, with a few exceptions, the total volume of knowledge, degree of expertise, and skill required to do any one medical specialty is similar to any other. For example, while you have to score higher on your boards to get a dermatology residency, you don’t really need to be any smarter than an internist or a pediatrician to actually do the job (derm is more competitive only because it’s more lucrative). Nurses have already demonstrated procedural skills that are equal to MDs with advanced specialty procedures like endoscopy (http://www.bmj.com/cgi/content/short/338/feb10_1/b231?rss=1). If these facts seem untrue, it’s probably because the financial de-valuation of primary care has tried to convince us that being a PCP must be fundamentally easier than being a specialist. If NPs can successfully demonstrate (or convince) that they are functionally equivalent to ANY MD, it will represent not just the death of primary care, but the death of the doctor.

  4. DrRich on June 9th, 2009 11:44 am

    Matt,

    I can understand your being angered, terrified and offended by my post, and I am sincerely sorry for having caused this reaction.

    I hope to elaborate much more on the following point in my next post, but to say a little about it here:

    Physicians who choose to train as generalists remain (in my estimation) the heroes of medicine. They are performing an essential and indispensable (through grossly under appreciated) service; they are the “real” doctors. Their years of training are absolutely necessary, and they cannot be replaced by nurses.

    And as an old guy who did both general internal medicine for a few years, then super-sub specialized in cardiac electrophysiology, I completely agree with you that being a good generalist is far more difficult and more challenging than being a good specialist. And most procedures that specialists do could be taught in 6 - 12 months to any literate high school graduate with reasonably good hands.

    However, “Primary Care Practice” has now been formally defined downward, to rote activities, to merely following handed-down guidelines, and to being evaluated based on how well they follow them. This is not how real doctors ought to practice, and (I argue) doctors who accede to such a thing are indeed functionally equivalent to nurse practitioners (who in theory will follow guidelines every bit as well as doctors, and maybe better).

    General physicians need to clearly define what it is they provide that nurse practitioners following guidelines cannot provide, then market themselves accordingly. Whatever that is, it will not be “Primary Care,” because Primary Care has now been entirely re-defined, and the ACP has made the re-definition official.

    So I commend you on your choice of career - as long as your training program teaches you complex diagnosis, management of complex muti-organ disease, and does not focus entirely on the rote stuff that nurse practitioners can do. In your training you need to clearly differentiate your skills from the rote stuff, so that later on you can differentiate yourself from what now passes as Primary Care. Because like it or not, primary care is now going to be done by nurses.

    Unfortunately, judging from the actions of the ACP, such differentiation will have to come from the grassroots, and not from the top leadership of the physicians’ own organizations.

    Rich

  5. pcb on June 9th, 2009 1:29 pm

    matt:

    yes, there are those who feel MDs are overtrained to deliver the overwhelming majority of primary care. Which would explicitly mean it is a bloated, expensive, and unnecessary route to becoming a “provider” of such services. And it seems those who believe this are growing in number.

    Of course, the definition of what primary care is to those who hold such an opinion is much different than yours. But you will be called a “marcus welby” dinosaur, not fit for the new era of team based, evidence based, algorithm driven, perfomance measured, primary care. If your training is good, you may someday believe something like “a wise physician knows when not to follow the guidelines.” Following such wisdom in today’s world gets you labeled a low quality physician. Go figure.

    It may just be all about the money. Those paying the bills would rather pay a midlevel for services more expensively delivered by a physician. That used to not be an option, but it is now. Most med students see the writing on the wall, despite the lofty rhetoric and idealism that those training future generalists still cling to.

    Usually, when there’s a shortage in a given specialty, salaries go up, some prestige returns, and med students flock back. Isn’t going to happen this time. The PCP shortage is just another ‘good reason’ to move midlevels into primary care. Undercuts the whole supply/demand effect, and salaries could actually fall (closer to midlevel range) as shortages worsen and midlevels increase their influence.

    I agree with your idealism in theory, but it’s completely failing in practice. And many (most?) think there is no hope for vision you hold in mainstream medicine.

    now retainer medicine, on the other hand……..

  6. Sandra Brown MD on June 9th, 2009 4:13 pm

    Dear Matt:

    I thought your post was terrific. The elegance of your syntax supports your description of your intellectual credentials. So I want you to survive.

    Listen to these guys (above). Throughout your training, look for opportunities to become “the internist’s internist”. Fight back against EMR systems that promote rote data entry, and therefore rote thinking. I’m not saying bomb the server, just remember that your job is to learn how to think like an artist of medicine, not how to navigate screens.

    Pay careful attention to any overheard ‘business tips’ or straight out advice from faculty you admire. Cultivate, in particular, relationships with volunteer or part-time faculty who are in private group or solo practice much of the time.

    Be smart. This is different from being intelligent. Learn everything you can about retainer medicine. Carve 30 minutes a week to reach Small Business for Dummies. Take advantage of practice management seminars even when it’s your only weekend off. After you graduate, you pay the big bucks to attend.

    Very best wishes from a sympathetic sub-specialist.

  7. annie on June 10th, 2009 5:53 am

    I can well understand why even advanced practice nursing is described as merely just a lot of “rote stuff”. Nursing is overly externally controlled and its legitimate practice autonomy and authority undermined and usurped by non-nurse entities including employers (sound familiar, hospitalists, emergency medicine docs, etc?), regulators and legislation (nurse patient ratios). But nursing practiced professionally is no more rote stuff than is any clinical practice specialty in medicine. Both professions require astute assessment and professional judgment applied rigorously and intended to serve the patient’s best interests (yes, I know, DrRich - only in theory and in the golden nostalgic glow of misted memories).

    Nurses failed to claim and hold their professional territory, and I see identical forces and disincentives at work with the primary care problems and trends. Advanced practice nursing grew out of a response to woeful workplace conditions, unmanageable patient case loads, employers who defined nursing practice as endless tasks which included everything from telephone operator to maid functions and with the desire to be able to provide direct care to patients and to advocate more effectively for them. It also grew out of the perennial disregard medicine displays toward professional nursing.

    All the more reason to understand the characteristics of the nursing workforce, beyond advanced practice nurses, and to identify common interests and opportunities for interprofessional collaboration so that the power of numbers and breadth and depth of professional expertise and resources can be brought to bear.

    ftp://ftp.hrsa.gov/bhpr/nursing/rnpopulation/theregisterednursepopulation.pdf

    (The American Association of Colleges of Nursing is the go-to site for professional nursing statistics and white papers. The American Nurses Association,like its AMA counterpart, has failed to represent its profession’s interests, and it no longer has much influence in any arena, unlike its AMA cousin.)

    http://www.aacn.nche.edu/Media/FactSheets/NursingWrkf.htm

    Nurses have long failed to work across education, clinical practice, education and research interest silos, and an argument can be made that nursing as a nascent profession is catastrophically failing. I believe (and DrRich so eloquently and ironically posits) that medicine is on a similar, if more gradual, trajectory.

    I have no dog in this hunt. Doctorally educated in nursing, but not an advanced practice nurse, I was wrongfully terminated after uncovering illegal and unethical patient practices at a “leading” academic medical center. I made the fatal mistake of acting as a patient, physician (especially for emergency medicine and the lower reimbursed medical services - you know who you are, med. onc, gen. med., and Medicaid heavy folks), nurse and healthcare worker advocate, and the swift retaliation, blacklisting, defamation and career ruin was total.

    I would no more voluntarily work within the healthcare system as they would hire me - not gonna happen. And my experience is the norm in nursing. Most nurses who practiced as I did were chased out of the field. Nursing routinely cannibalizes is own. That’s a key reason why the American Organization of Nurse Executives exists as a subsidiary of the American Hospital Association and has no alliance with,no oversight by and no accountability to the American Nurses Association. The physicians for whom I advocated all promised to support me, but then they, too, magically disappeared into the woodwork.

    Complain and lament, but understand that unless there is a fundamental consensus on professional autonomy with concomitant support of members who speak up and act accordingly, the lamenting will be impotent,and non-professionals will regulate your profession and usurp your practice autonomy.

    A take on the still relevant-

    First they came for the nurses, but I was not a nurse.

    Then they came for the primary care physicians, but I was not a primary care physician.

    Then they came for the hospitalists and emergency medicine physicians, but I did not practice in those specialties.

    Then they came for (your clinical specialty here), and there was no one left….

  8. drRon on June 11th, 2009 9:01 pm

    Matt

    I am sincerely sorry that you have invested your youth,talent and creditworthiness in a system that values you not at all and in fact is planning on using you to control its population

    There is a way our, however.

    Live as cheaply as possible.

    Pay down your debt as soon as you can.

    It will take intention on your part but learn medicine from those who will teach it and limit your exposure to the check box approach that passes for medicine

    Do not put down roots, keep your options open. When you feel comfortable doing so, leave the country and practice medicine…..real medicine where nothing gets between you and your patient. Honduras, Peru, Ghana, Singapore. Leave and never come back.

    If you invest in US healthcare you will look back at the comment you posted above 20 years from now and hate what you have become.

    Best Regards and good luck

  9. donutdoc on June 11th, 2009 9:08 pm

    One trend that DRRICH misses is that the cost of becoming an NP is skyrocketing, now nearing 80K in private and 40K in public schools. If this trend continues, fewer nurses will forgo rising nursing salaries to become indebted indentured servents, especially once the word of mouth spreads regarding how limited the scope of practice will become. Physicians Assistants will be the next NP.

  10. Drew on June 14th, 2009 11:31 pm

    This is absolutely frightening.

    I thought drRon was going to be recruiting Matt for some kind of Atlantis village from Atlas Shrugged. It seems like the only place for the (valuable) general medicine doc is in retainer/concierge medicine.

    If I were four years older, I’d like to think I’d be right there with Matt. But the way it is, I may not make it. I have no interest in working as a proceduralist, and I’m slowly coming to terms with the fact that the career I want for myself in medicine just isn’t there.

  11. owen linder on June 15th, 2009 4:09 pm

    Your home work includes reading about alternate paradigms; for the main - Medicare Advantage severity adjusted full risk systems. Pile on integrated practice units bundling the payments.
    the future will be different than fee for service.
    Instead of eloquently described defeatism it would be great if we simply demanded new systems included specialist pay parity for primary care.

  12. Don Klinestiver on June 30th, 2009 9:24 am

    Rich,
    I want to respond but I am too demorilzed. Also I am busy trying to make sure my patient isn’t discharged early from the hospital, because a nurse with a checklist has decided they are ready to go….

    For nearly fifteen years I tried my absolute best to convince every resident I taught that they should practice Internal Medicine. I believed with all my heart that it would provide the best life experience for those young people. I publicly apologize. I wouldn’t recommend the field to anyone now for many of the reasons you outline. I have managed to have fun, and still do love taking care of my patients but the beurocracy is frightening.

    My last patient of the day a week ago was an elderly man dying of cancer. We spent time talking about his life and how we could control his pain as well as many other concerns. Back on my desk at the end of his visit waited a dreaded checklist to determine if I know how to manage my patients with diabetes. I was incensed. The form will indicate that my 87 year old diabetic with lung cancer hasn’t had a Hemoglobin A1C in 6 months and that he lacks a retinal exam. Some beaurocrat will actually take the time and energy required to enter this worthless info in a database. Their wages undoubtably directly or indirectly come from my patient, who unfortunately might have the gaul to die before his next blood test. In return, we will not learn that my patient and I are the best judges of the priorities in his health care, but that I really don’t know much about diabetes.

    Thanks for letting me rant, and I miss you!
    Don

  13. DrRich on July 1st, 2009 6:27 am

    Don,

    I am truly sorry that my analysis of the state of American primary care medicine seems to be so accurate.

    That those who run the healthcare system have been so successful in engendering (intentionally and systematically, in my estimation) the level of utter frustration which you so eloquently express, in an internist as superb and dedicated and passionate as you are, is a crime against humanity. Unfortunately, it is a necessary step in creating the centralized, bureaucratized, rules-based, top-down, population-focused instead of individual-focused, species of primary care so fervently desired by our overseers.

    Rich

  14. DrMark on July 2nd, 2009 9:53 pm

    Matt,
    Unfortunately, what others are saying about the sad state of affairs for doctors in this country is true. Like a fly in a plastic bag, they are suffocating us slowly. Those who are one decade older than I am are planning exit strategies because they can. Myself and my contemporaries are praying that the current, inpalatable systems lasts a few more years. It is like hanging on to the last piece of debris from a sinking ship. The salt water tastes terrible.
    In between the nurse and the patient are computers. In between the doctor and the patient, paperwork, hospitals and insurance. The patient doesn’t even imagine where his dollar in spent.
    Those who are ten years younger only two words of advice: DON’T ENTER.
    You will be controlled by a system that does not care for your work. You will be watched, punished, demeaned and regulated in a way that all the love, compassion and affection that you wanted to give will taste bitter.
    Switch now while you can, get a JD go into health care law, pharmaceuticals, research, you decide.
    Heed my words Matt

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