Happy Hospitalist left this comment yesterday:
I have a better idea. We should train nurse practitioners to be outpatient experts in all fields. Primary care, cardiology, gastroenterology, heme onc. Let them take over outpatient care in general. Since most outpatient care is stable care, we could have vast networks of NP driven communication between each other, each experts in their own right.
When the patient gets admitted, have the MDs take over, since inpatient medicine is where most MDs from most fields shine.
I hope that he wrote this with tongue in cheek. I hope he is not that naive.
I love hospital medicine. We can do a wonderful job caring for serious episodes of illness. We can figure out complex problems. But medicine is so much more than episodic serious illness.
I went to a funeral yesterday of a wonderful man who would have likely died 3 years ago were it not for a great cardiologist. This cardiologist is not a partialist – he is a complete physician. The cardiologist treated this man for severe systolic dysfunction and clearly extended his life. He treated him with full scientific knowledge, but more importantly he provided the doctor patient relationship that allowed him to customize the care that would work for this man. He provided mostly outpatient care, but was also there for the inpatient care.
When I practiced outpatient medicine I know that I could do a good job at preventing many hospitalizations. Outpatient care is not simple, regardless of what some seem to think. Outpatient medicine is complex and nuanced and extremely important.
So Happy might have written tongue in cheek, but if not he is way off base. The best way to improve overall health care quality and decrease health care costs will result from excellent outpatient care, not slick inpatient care. And, oh btw, long term outpatient relationships are great for both physicians and patients. Happy's comment is just wrong.
{ 12 comments… read them below or add one }
Most of outpatient medicine will be sticking to the correct algorithims soon, with most of the benefit being risk reduction from being on correct medication. I just don’t see what’s particularly complicated about outpatient medicine.
Thank you, as a internist who does both outpatient and inpatient care ( although my partners are moving towards hospitalists) I can attest that I find outpatient care more taxing and complex. I am unable to order a shot gun of tests like I do in the inpatient setting,, instead, I have to figure out which test is the singular most appropriate test that has the greatest yield pursuing a diagnosis or treatment. This can make the difference between nailing a diagnosis in a few days or over many weeks. Keeping a patient out of the hospital is more than embarking on evidence based treatments but also the social baggage the patient carries that may nullify any good treatment prescriptions. It is so so much more than “stabilizing”patients in between hospitalizations.
Of course it was tongue in cheek, but the political will of the NP movement is likely not. They believe they are equally qualified to provide outpatient primary care, with no change in outcomes as MD trained physicians. It’s only a matter of time before they make a case for expanding into the independent practice of medical subspecialities and perhaps, even surgical cares as well. I so so what. Let them expand and carry the weight of responsibility for independent care.
I for one would welcome them to the challenge they have to survive in outpatient medicine, independently, on a business model that barely allows primary care MDs to survive. They say they are better and patients like them better because they spend more time. I say great, let them survive the payment model with 1/2 the volume and the same overhead. Let them provide the care they think they can and let them and their patients deal with the consequences of their actions.
A reader sent me this link regarding the NP mantra for equality. I mean, Medicare now recognizes and pays midwives 100% of the MD rate for OB Gyn physicians.
Why would anyone go to medical school anymore when the NP model is seen as equal in the eyes of the third party model.
And the public doesn’t care.
http://news.yahoo.com/s/ap/20100413/ap_on_he_me/us_med_dr_nurse
Which is why I wrote this as tongue in cheek, but it’s not far off base. The NP model will expand without limits. And I personally plan to recertify as an NP once they pay 100% as MDs for all primary are codes.
Wait a minute, do NPs have recertification exams? I guess that means I don’t need to recertify. That’s even better. Save myself several 1000 dollars and provide the same excellent care as NPs do.
I think that this model is long over due. I see outpatient medicine dominated by mid-level providers with physicians functioning as managers and consultants. This would be very efficient and save money.
I am pessimistic that ceding primary care to NPs will save $$$. I think that mid levels are even more prone to refer to expensive specialists than MDs/DOs. HTN that is not controlled with 1-2 drugs goes to nephrology, all chest pain goes to cardiology, any abdominal pain goes to GI, COPD on home 02 goes to pulm, etc. The advantage of having MDs as outpatient docs (the additional training aside)- is that there is no overwhelming professional obligation to refer; you are the expert in outpatient general medicine, your degree gives you some more license to be independent (and wrong, of course).
Secondly, I think hospitalists are deluding themselves if they think that their ability to diagnose something efficiently and effectively wouldn’t be enhanced by a long term knowledge of the patient. As a hospitalist, I am often impressed by the wide variation in symptoms, disease severity and response to medications between patients. When I see a patient in the hospital a 3rd or 4th time, I am much, much better at making a diagnosis and rapidly treating them. Medicine is rarely black/white- its shades of gray- shades that diagnostic testing, algorithms and the initial H and P is only partly helpful with.
Why do hospitalists need so many MRIs? Why do we have to rule out everyone under the sun for an MI? Why do we always need to look for PEs? Partly because we have no prior knowledge of the patient, and we have very without this prior knowledge- our hunches are less certain. And I feel that good medicine is based on a lot of hunches.
Of course I think we are stuck with the outpatient/inpatient split for MDs, and that of course it offers some great advantages to patient care- including being at the bedside at a moment’s notice, a specialized set of inpatient skills, and greater systems approaches to hospital care. I just don’t think it adds a lot to diagnostic accuracy or individualized care; I just can’t imagine that meeting the patient for the first time isn’t some disadvantage in making a diagnosis or selecting a therapy.
I am a hospitalist, I love my job- I just think we are crazy if we don’t think high level outpatient medicine is really, really important. A great primary care doc keeps many, many patients out of the hospital- which is probably the safest place to be.
Funny how many of the people writing about how outpatient medicine is so simple and can be done equally well by mid-levels are people who have never done outpatient medicine. I currently do both outpatient and inpatient medicine and have done a lot of ER work in the past. ER and inpatient medicine are easier than outpatient medicine intellectually, but the ER and inpatient medicine problems are often more urgent so they get more attention (and money). If you are a Steven Covey fan, much of primary care is in that non-urgent but important category, so it’s easy short change (and expensive in the long run if its short changed).
Also, most of academic medicine is in the inpatient environment. Many in academia don’t really know much about real world outpatient medicine outside of their ivory towers. If they did, they wouldn’t be pushing this mid-levels for all outpatient/primary care agenda. It’s not their turf, so they don’t care much about it.
I am currently a hospitalist but did primary care for 12 years before joining the ranks of hospitalists. Although hospitalized patients are sicker, I found outpatient medicine to be much harder and more challenging. It also didn’t last for a shift – someone has to cover the practice at night and it usually isn’t an NP. Whoever out there thinks that outpatient care can be reduced to plugging people into algorithms is ignorant of the nuances of humanity and our varying responses to diseases and treatment.
The system I am in uses NP’s heavily. They have a definite role and generally do a good job but they are NOT physicians. It is hard for me to believe they are less expensive in the long run. The “provider’s” visit is the least cost of medical care these days. If a person is paid half the amount for seeing half the number patients, but ends up referring more to subspecialists and obtains more radiologic studies and tests, I fail to see how that saves money.
Having said that, with only 2% of the graduating medical school class going into primary care, and with the current low value that society sets on primary care MD’s (as evidenced by NP’s who think they can do a better job with much less training as an example), in the future we will not have the doctors who will be willing to do the job. I unfortunately see future outpatient medicine as being run by NP’s and PA’s with anything complicated getting shunted to subspecialists.
I read ‘Happy’s’ piece, which wasn’t that happy. Many of his points are valid. Try to replace trained professionals with folks with less training and pay them less. In the hospitals I work in, you need to hire private investigators to try to find an RN on the wards. We now have LPNs, nurses’ aides, etc, If you want to prescribe medicine, consider differential diagnosis, devise a diagnostic and treatment algorithm – to be a physician – then you should have the training to do so. We should resist the movement for various professions from reaching beyond what they are properly trained to do, who then claim expertise in a new frontier. Of course, this is true for our profession as well.
It’s a done deal at this point. Med students know enough not to go into a field where those in charge would rather pay midlevels to do the work. Additionally, being a midlevel supervisor is not what most go to med school for. It’s usually not a realization of the dreams that push one down the physician path.
So whether or not we want a midlevel driven model in primary is a moot point. No doctors are choosing to do the job anymore, and someone needs to do it.
There has been a lot of talk about the value of primary care and the current plight of the outpatient primary care physician trying to stay afloat with rising costs and declining reimbursments in real terms. But nothing, absolutely nothing, has been done or proposed that would make the practice of outpatient primary care as an attractive carrer path again. And no one seems to notice that declining payments for cognitive services (now estimated at 30-50% of 1990 inflation adjusted payments) seem to correlate directly with increasing, often excessive, use of expensive technology, with little to no improvement in health outcomes.
At this time, I feel that it is irresponsible for those in academic medicine to counsel residents and medical students that outpatient primary care medicine is a viable career path for a physician. It is not. Most of us who took this path years ago told our residency interviewers that we enjoyed internal medicine because of the long term relationships formed with patients. Thanks to Medicare and insurance company payment schemes and the rise of hospitalists, that relationship lasts right up until the employeer purchases a new insurance plan or the patient is hospitalized. Last week, I received a letter from a hospice informing me that one of my long term patients had died at home and the hospitalist was signing the death certificate. At least the hospice notified me! Otherwise, I wouldn’t have known at all. So much for long term relationships. As far as I’m concerned, the NPs
can have it if they will take it.
There is an opportunity to accomplish with primary care what Emergency Medicine did 30 years ago. That is, create a specialty de novo. I would like to see FP and IM merged into one new specialty: Primary Care Medicine. PCM would be a 4 year residency with training in business management, finance, and systems/organizational science. Graduates would be expected to have supervisory responsibility over PA’s and NP’s in the outpatient setting or function as hospitalists and organizational leaders in the inpatient setting. Fellowships would be available in pediatrics, geriatrics, sports medicine, occupational medicine, or women’s health extending training to 5 years.
Pediatrics would be retained as a formal specialty, but it would be anticipated that those completing peds would do so as a foundation for a pediatric specialty not direct service. Ditto OB/GYN. Training preparation for the traditional internal medicine sub-specialties (GI, Cards, Neph, etc) would be accomplished by 3 years of training in academic PCM departments followed by sub-specialty training in their chosen field. They would not receive certification in PCM and would be ineligible for the opportunities that certification would eventually bring. Emergency medicine went from being a mish-mash of a specialty to a highly sought after field after solidifying to a unified specialty.
Completely restructuring training in primary care medicine is the only way to restore credibility to this beleagured field.
Rainbow, stop dreaming. All that will do is make trainees one year further in debt. Until someone wants to step up and PAY what you think it’s worth, more training is futile. There is an analogy to the ER though – Hospital Medicine becomes a speciality and outpatient IM/FP fades away.