The Decline of Physicians: Do we really need them anymore in Primary Care?

[AAC.271]

Legislature Votes to Make NP Payment Parity Law Permanent - Nurse Practitioners of Oregon

Oregon equal pay for equal work law has been signed into law in an independent practice state with NP's and PA's getting paid FULL amount from private insurance. This means that a new grad NP's will be paid the same amount as an attending family physician and psychiatrist and also have the same rights and scope of practice as a family physician and psychiatrist.

With the tremendous push for equal pay and for autonomy for PA and NP, is there any reason for medical students to want to go into primary care anymore? I guess my question is, it seems so bizarre that someone would put themselves through hell when they could become a competent provider through the NP route or PA route.

So do you think with these new laws, PA's and NP's will ultimately lead primary care? will these laws drive away medical students from primary care? Is it financially reasonable for a medical student to become a family physician in an equal pay state?

As an sNP, I'm incredibly thrilled and happy at how much progress our profession has made. However, I also understand how some medical students hoping to go into family medicine can feel cheated and grumpy about it. What are ya'll thoughts?

[BostonFNP, APRN]

I cannot remember hardly any of them but neither can my MD colleagues and truth be known - it does not matter! We can look it up!

My partner, a physician of more than 40 years, just called the orthopedic about a patient that had trauma to her hand and said "the x-ray looks like she has a fracture" and of course the orthopod says "which bone" and he responds "I don't know, one of her hand bones, something about lovers and positions". They laughed and laughed. But it's true, he had no clue what the bones of the hand are other than there was a mildly crude mnemonic.

[offlabel]

My partner, a physician of more than 40 years, just called the orthopedic about a patient that had trauma to her hand and said "the x-ray looks like she has a fracture" and of course the orthopod says "which bone" and he responds "I don't know, one of her hand bones, something about lovers and positions". They laughed and laughed. But it's true, he had no clue what the bones of the hand are other than there was a mildly crude mnemonic.

Makes me wonder what the orthopedic surgeon would have said if the NP had said the very same thing.

[core0]

General family practice physicians will complete 4 yrs of medical school then a 2 yr residency program. They do not usually touch a patient until their 4th year of med school.

A fellowship is not necessary for the family physician as fellowships will lead to specialization. That being said, some GPs do go through fellowships. Most of the GPs I've worked with began right after residency. I am not disputing the difference between med school and NP education here, for the record. I am simply pointing out that family practice physicians may have the bare minimum in education, same as FNP, before entering the paid workforce. FNP clinical rotations focus on primary care, not every specialty like medical residency. The clinical hours vary depending on the program, but typically require 500-1000 hours (mine was 750) or minimum 12 weeks, max 25 weeks in family practice.

Not sure where you work or what general family practice physician is. It sounds like you are combing general practitioner and family practice. For the record a family medicine is a three year residency according to ACGME. Also the med students we work with are third year. Fourth year is for preparatory rotations interviews. Many med schools are now starting clinical rotations in the second year to help med students get the all important letters for residency apps so most med students have 2 years of full time clinical experience before residency. As far as family medicine residents, their rotations are pretty specific to family medicine and usually total around 7500 hours.

[AAC.271]

Some lovers try positions they can't handle.

Scaphoid, lunate, triquetrium, pistiform, trapezium//trapezoid capitate hamate.

[AAC.271]

General family practice physicians will complete 4 yrs of medical school then a 2 yr residency program. They do not usually touch a patient until their 4th year of med school.

A fellowship is not necessary for the family physician as fellowships will lead to specialization. That being said, some GPs do go through fellowships. Most of the GPs I've worked with began right after residency. I am not disputing the difference between med school and NP education here, for the record. I am simply pointing out that family practice physicians may have the bare minimum in education, same as FNP, before entering the paid workforce. FNP clinical rotations focus on primary care, not every specialty like medical residency. The clinical hours vary depending on the program, but typically require 500-1000 hours (mine was 750) or minimum 12 weeks, max 25 weeks in family practice.

As much as i appreciate your enthusiasm for the NP political movement, your assessment is actually wrong. Many medcial schools nowadays are doing some level of clinicals even in the firsst year. At one of my friend's medical school, they run health clinics and have a physician-patient course where they go into hospitals and practice taking histories of patients, all while in their first year. At hofstra, all medical students are required to become trained EMT's by first year.

Also, to be fair, there are just as many medical students who went above and beyond the minimum requirements with many holding Ph.D's , PharmD, NP, RN, PT, DMD degrees and former paramedics/PJ's/EMT's.

With that being said, I strongly feel as though physicians are overtrained in primary care. In the few months that i've been in clinicals, it is quite clear to me that rare diseases are in fact incredibly rare and the vast majority of patients come in with simple ailments and more complex patients are appropriately referred to specialists. Don't expect the family doctor to feel comfortable diagnosing bacterial endocarditis secondary to Strep. Viridans infection from a dental procedure resulting in mitral valve regurgitation. It ain't happening and any mitral valve regurg will be appropriate referred to the cardiologist.

[Jules A, MSN]

With that being said, I strongly feel as though physicians are overtrained in primary care. In the few months that i've been in clinicals, it is quite clear to me that rare diseases are in fact incredibly rare and the vast majority of patients come in with simple ailments and more complex patients are appropriately referred to specialists. Don't expect the family doctor to feel comfortable diagnosing bacterial endocarditis secondary to Strep. Viridans infection from a dental procedure resulting in mitral valve regurgitation. It ain't happening and any mitral valve regurg will be appropriate referred to the cardiologist.

I agree that for the routine patients in GP physicians might be considered overtrained however the concern for me with the brief NP education is not the 1,000 patients who present with uncomplicated issues but the 1 in that thousand who is actually trying to die and that is when a physician's additional education is beneficial. Your example above is exactly why I'm not comfortable with our limited NP education sans RN experience because how is the referral for mitral valve regurg even going to take place if it is missed by an undereducated provider?

[SummitRN, BSN, RN]

General family practice physicians will complete 4 yrs of medical school then a 2 yr residency program.

Most FP residencies are 3 years.

They do not usually touch a patient until their 4th year of med school.

Most med schools have MS3 spending about half their time in clerkships (what they call clinicals) and most of the MS4 time is in clinicals.

FNP clinical rotations focus on primary care, not every specialty like medical residency. The clinical hours vary depending on the program, but typically require 500-1000 hours (mine was 750) or minimum 12 weeks, max 25 weeks in family practice.

PGY1 or internship year is focused on all areas of care, the next two years are in specialty.

Guess what, that intern spent as many hours in family practice in their PGY1 year as you spent in your entire DNP program clinicals, plus another 3,000 or so hours getting a broad overview of medicine including OBGYN, oncology, surgery, emergency, and hospital medicine. Then they spent two more residency years (~6,000 additional hours) exclusively in family practice.

You will only end up looking the fool if you try to minimize medical education. I suggest you stick to claiming it is overboard.

[BostonFNP, APRN]

Your example above is exactly why I'm not comfortable with our limited NP education sans RN experience because how is the referral for mitral valve regurg even going to take place if it is missed by an undereducated provider?

If I had to choose a provider, I would gladly take an NP with 3 years of NP experience over a novice NP with 30 years of RN experience. From my experience, most even experienced nurses have difficulty detecting and identifying murmurs.

[OllieW, DNP, PhD, NP]

If I had to choose a provider, I would gladly take an NP with 3 years of NP experience over a novice NP with 30 years of RN experience. From my experience, most even experienced nurses have difficulty detecting and identifying murmurs.

I so would not! I have seen over and over again NPs and PA without that background do scary stuff.

[Jules A, MSN]

If I had to choose a provider, I would gladly take an NP with 3 years of NP experience over a novice NP with 30 years of RN experience. From my experience, most even experienced nurses have difficulty detecting and identifying murmurs.

I don't utilize NPs for either myself or my family although I do know a few NPs and a few PAs who I think are excellent. That said I'm extremely picky about the MDs we see also and am thankful I'm in this industry so I have a better chance of sifting out the kitty from the litter.

[BostonFNP, APRN]

I so would not! I have seen over and over again NPs and PA without that background do scary stuff.

I bet you have never seen RNs or MDs or DOs (especially interns) or PharmDs or any other medical profession "do scary stuff"!

I have been involved with the didactic and clinical education of both NPs and MDs for many years, a few years of in-the-trenches practice experience (physician residency, NP collaborative practice) develops a clinical knowledge base that far exceeds any amount of schooling, or RN experience for that matter.

[offlabel]

With all due respect, all of that experience having that effect depends entirely on the intellect and work ethic of the provider. I say this as an advanced practice nurse. While there are plenty of aprn's that easily rival their physician counterparts, the fact is that, as it stands right now, medical school weeds out those with inferior work ethic and intellectual ability far better than any NP program as a general rule.

That "experience" phenomena has exactly the same effect on new physicians as well.