Who is your primary care doctor?
A recent Wall Street Journal article – The Doctor Won’t see you Now, highlights the growing trend that fewer and fewer Americans are actually receiving their primary medical care from licensed physicians. Rather, most of their care is coming from members of the healthcare field who have less training than a Medical Doctor. While this may be news to the WSJ, it isn’t news to anyone who has been to the “doctor” in the last ten years.
When we get calls from normal people who have experienced a healthcare crisis, we often ask – “Who is your doctor” and they will tell us – “her name is Shelley, and her office is on Franklin Rd.” We then do a search for Dr. Shelley on Franklin Road and find out Shelly is NOT a doctor, but a physician assistant, or a Nurse Practitioner, or a Doctor, but not one who went to Medical School.* (Yes – they exist. Keep reading).
No surprise as there is a pretty clear movement in primary care provision in the United States – and the movement is from Physician provided care – to Physician “coordinated” care where the actual patient care is given by someone other than an M.D.
I am happy to address the why first. They why this is happening is MONEY. This is happening because Medical Doctors are expensive, and fewer and fewer go into primary care or internal medicine when they could go into a specialty like surgery or cardiology and make four times as much money a year. Also, even if half of medical school graduates wanted to be internal medicine specialists, it is cheaper for the practices to hire one doctor and three physician assistants – than four doctors, so you get a pyramid model of healthcare with few of the highest trained providers, and too many of the lowest trained and lowest paid ones.
Here is a completely unscientific definition of who these providers are:
- Medical Doctor – the highest trained, and likely most capable person in the office. Will have M.D. after their name on the stationary. Actually went to medical school. Ideally, a medical school in the United States.
- Doctor of Osteopathic Medicine – less trained than an MD – but has all the legal rights of an MD. Likely didn’t get into actual medical school (because of less than stellar college grades or tests) and so went the DO route. Will have D.O. after their name on the stationary.
- Nurse Practitioner – someone who has a Masters in Nursing degree essentially – who has the same legal rights to treat, diagnose and prescribe medicine, but cannot work at a medical clinic alone – must work with and under the supervision of a D.O. or M.D. The law says they must consult with the doctor on abnormal findings, and the doctor must review and sign off on their work. **(this rarely happens). *** The laws are changing in many states to expand their powers and lesson the supervision required by doctors.
- Physician Assistant – someone with a Masters Degree, who really should only be the eyes and ears for the doctor and little else.
- Nurse – someone who has an LPN or RN license, and is an actual nurse. Can physically assess patients but cannot ethically diagnose conditions. Must communicate to NP, or DO or MD who is allowed to actually diagnose conditions and treat them.
- Certified Nursing Assistant – someone with 6 weeks of training whose job it is to provide basic care – like assistance with dressing, eating, running errands for nurses. Should not be assessing patients, should not be taking vitals – should really just be getting non-medical tasks done.
- Scribe – no medical training at all, someone who just follows a healthcare provider around and writes things down to get them into the chart quicker, and more accurately – ideally.
Confused yet? This pyramid of care means that doctors either provide hands on care to very few patients in a primary care setting, and most of their time should be spent “supervising” the care provided by their PAs and NPs… In a nursing home, the doctors aren’t even on site – and they do nothing unless called in by the nurses to address a change in condition. In a nursing home – 99% of the care is provided by nurses and CNAs – sometimes less than 1 hour a day of care is provided by an actual nurse.
What this means in our world – is that allot of balls are being dropped in this new model of physician coordinated care. Doctors don’t have time to really supervise their lower level staff, and major medical issues are missed. Patients suffer. Sure, a few dollars are saved – but patient care isn’t maximized.
The take away – if there is one, is the following:
- Try to get your care from an actual Medical Doctor. There are some great DOs out there – but if you can, start with an M.D. ‘
- If you don’t have access to M.D. provided care, and can only get access to M.D. coordinated care (meaning a PA or NP physically see you and treat you) – be more diligent in your recording of problems – and do what you can to ensure the record reflects those – for example, use MyChart or other online communication tools to communicate with the actual doctor. Ask to speak with the doctor. Demand a call – be an advocate for yourself.
- If you don’t feel like the pyramid structure of medical care is working for you – go somewhere else. There are few places in Virginia where you have no choices for primary care – so, be a consumer and take your business elsewhere.
While I personally hate to see us go towards a model of physician “coordinated” care – it’s inevitable. Money talks, and so we as consumers need to know how to best protect ourselves in this changing healthcare world.