Family medicine — something I devoted my life to and believe in — is being undermined by local doctors and hospital administrators. And I would move, but it seems to be a national trend as well. It’s more cost-effective to hire NPs and turn a blind eye to the difference in education and training … you get what you pay for. So after 13 years of college and 25 years of private practice, I am obsolete — a dinosaur. My skills feel like they are diminishing. And my needs are lessening as the demands on me are decreasing. When I first moved to town, this was an underserved area for obstetrics as well as general medicine, when we were called doctors — not PCPs. I was in my glory — and so were my patients. We were free to do OB, peds, IM, critical care, central lines, ICU, high-risk deliveries. And of my patient panel, only a 15 percent admit rate, less than 20 percent Cesarean rate. Lots of hugs, tears, laughter, and great numbers. So much greater than when the government intervened and brought an anagram of words: MIPS, MU, PQRST, etc. At this point, I was winning! I got all the goals because this is the type of medicine I was always doing anyway. Then somewhere, in the past few years, we lost the forest for the trees. I found that young medical students didn’t have the idealism anymore. They didn’t have the passion or drive to pursue a calling. The advance practice practitioners (APPs) had definitely leveled the playing field. The nursing profession introduced shift work, quality of life, and time off — more than we could do ourselves, the medical profession was introduced to a different style of practice. We could slow down. No, we had to slow down. We couldn’t see as many patients and chart on them with onerous EMRs. So, the bean counters of the profession, in flogging us to be efficient, actually made us more inefficient. And the specialists tapped into this. They figured out they could be specialists as well as generalists if they hired a bunch of APPs and “oversaw” them. Then they could self-refer legally and make a cut of the profit from each primary care visit. Cut out the family doctor. They didn’t realize in time the APPs would grow up and decide to cut out the specialists and, in effect, cutting out doctors as a viable profession in America. The hospitals bought into this plan. They could hire the APPs, and control them, they thought, and make money from them. They didn’t realize in time they would alienate the doctors who initially kept them in business. Older doctors would retire, and younger ones would move to cities and shift work and quality of life. So the rural hospitals would suffer — no doctors, less quality. But the American population had been brainwashed to think that getting all of their care from an APP was appropriate and fine. Half of the time, they didn’t know when someone came at them with a long white coat if they were seeing a doctor or a nurse anyway. So, they stopped protesting and started embracing the model. Many of them had nurses in the family anyway — so it was an easier way for them to get prescriptions. And still, the doctors went away. Should they have unionized and nipped it in the bud? Or was their personal greed too great 25 years ago to ward this off- and now, as they themselves age, they find they are taken care of more and more by nurses, and not by doctors themselves? I am a patient now. I have had to have serious procedures done by nurses with a fraction of the education I have — and a fraction of the hard-won skillset. I didn’t have a choice. Anesthesia, biopsies, all previously done by doctors, are now done by nurses and PAs. Are they done appropriately? Who knows. I am asleep most of the time, and the profession will never confess until a very bad adverse event happens. I have mixed emotions. If they can do these things, why can I not any longer? Why every time I go for my two-year reappointment at the hospital, do I fight so hard for privileges for things I have done for a quarter of a century, with no malpractice or adverse effect? Yet people younger than my children are doing these same procedures semi-independently — and lobbying hard for full independence? If they can’t do them successfully, why are there no governing bodies regulating them? Urgent care clinics are popping up everywhere, doing shoddy care often, and supposed to have physician oversight and signing off on charts. Yet I don’t see it happening. They are supposed to bill only 80 percent if the physician isn’t in house, yet I don’t see it. If they can do it successfully, why do we have doctors at all? And why is it so hard to get into medicine and so expensive? Are we weeding out to the worst geekiest population of patients in the world? What are doctors of the future going to look like? Doctors of the future should note that at the end of the day, the patient just wants to be listened to, loved, cared for, and diagnosed. Patients don’t really care if we meet government-mandated and regulated goals, or how many hoops they jump through. We need to remember that and spend more time marketing our caring personalities, and not our star rating scores. That’s how the APPs won in the marketing game. Doctors of the future need to learn from the APPs that slowing down and shift work isn’t a bad thing. But we also need to remember why this is a calling and a profession and not just a job — and never let it be just a job. Attention to detail, staying up to be sure all the labs got bad and signed off, and remembering patients are humans with complex human needs goes a long way to keep people alive and keep lawsuits at bay. Doctors of the future need to fight for their profession — it is a worthy one. Medicine was shaped by both William Osler and Florence Nightingale. There is a place for both. And hospitals of the future need to know their client is the doctor, not the nurse or patient. If we don’t support doctors, especially in rural areas, they will go away. Doctors are extremely mobile professionals. And they are what attract the patient into the hospital system. As more and more rural hospitals are folding and running into financial trouble, hospitals need to be cognizant of this fact. Still, to this day, patients travel to doctors — not to APPs. They will drive hours and wait half a day to see a good physician. They will not do this for APPs. There is still an underlying reason for this. Don’t undermine it, or make it go away. Sigrid Johnson is a family physician. Source
