Wednesday, September 25, 2013

Can retired specialists be retrained to ease the shortage of family doctors? No



Last week there was some buzz on Twitter about a proposal from a retired plastic surgeon in San Diego who has developed a plan to retrain retired specialists as family practitioners. The idea is that this could alleviate the shortage of primary care physicians that exists now and is predicted to worsen as more people become insured.

The 15-module course created by some faculty at the University of California at San Diego involves 100 hours of online study with patient simulator testing on the campus for tuition of $7,500.

According to an article in U-T San Diego, at least one doctor, also a retired plastic surgeon, has completed the course and seven more have enrolled.

Is this a possible answer to the shortage of primary care physicians?

I think not.

Take the course—100 hours of online learning. Does that sound like enough to you? It takes three-years to complete a family medicine residency. Most plastic surgeons I know haven't touched a stethoscope since medical school, don't know the names of any drugs, and couldn't recognize a sick patient under any circumstances.

I rarely look at the comments for online articles, but I read a few family medicine physicians' comments on this. They were highly indignant at the mere mention of training anyone to do what they do for only 100 hours. I would have to agree.

As one commenter said, there must be quite a few lawyers in California salivating over this scheme. Maybe it was even cooked up by a committee of the plaintiffs' bar.

Another small flaw in this plan is just how many retired specialists would even want to do this?

With all due respect [this is what someone usually says to preface a disrespectful comment], I couldn't do it.

We all considered primary care when we were in medical school, but we did not do so for one reason or another. I'm glad some people did. Bless their hearts.

For me to become a family practitioner at this or any other stage of my life would be tantamount to going straight to hell without passing "Go" and without collecting $200.00.

The primary care shortage is going to have to be solved without me and, I suspect, most of my specialist colleagues.

31 comments:

Anonymous said...

"Take the course—100 hours of online learning. Does that sound like enough to you? It takes three-years to complete a family medicine residency. Most plastic surgeons I know haven't touched a stethoscope since medical school, don't know the names of any drugs, and couldn't recognize a sick patient under any circumstances."

I will comment (or maybe not) when I've stopped laughing and agreeing with this comment. There is *one* plastic surgeon I know who has a clue on nutrition, etc. but that's it. I have another subspecialist surgeon that hasn't used a stethoscope in years either, and recommended a plastic surgeon who got sued successfully for 1.9 mil for sending an extensively operated on patient home who died.

No offense to surgeons, but yes, I totally agree, some docs should stick to what they went into.

Can you imagine what the PA's and NP's are going to say? We had more training than the MD's. Oh boy ... WWIII ... the impaction material will hit the fan then.

Skeptical Scalpel said...

Thanks for commenting. That's a very good point about the NPs and PAs.

Anonymous said...

I inadvertently have used my oncologist as my primary care provider. When I see him, his stock greeting is to ask how I'm doing, any aches or pains, lumps or bumbs? To me that is an invitation to unload. And he kindly addresses most of my concerns, even though non-cancer. One big one was diagnosing my mild abdominal pain, which ended up being accute appendicitis. The first imaging he ordered, a CT, revealed nothing, also my blood work was normal, but mild pain continued. He then ordered an MRI which revealed the problem advising urgent care. As I wasn't in terrible pain I opted out of the ER for scheduled surgery with a surgeon he recommended down the hall. Saw her that afternoon, and surgery was scheduled a few days later. I was so appreciative he took the reins and smoothly saw me through this with such speed. The operation was open due to 2 previous open procedures for ovarian cancer and resultant adhesions.

I wonder if he regrets using the catch-all greeting, but so far he hasn't. I'm thankful for that. And if he ever considered going into primary care after he retires, (which is a pipedream), I would grab him in a heartbeat.

Emily

Anonymous said...

I want to see some retired orthopods enter this program.

Anonymous said...

Anon, with all due respect to you and your oncologist, you didn't have acute appendicitis. Which kinda prove the point of SS's post.

Anonymous said...

With all due respect Anon (6:52), I am scratching my head over your presumptuous comment.

My appendicitis history copied from my medical records:

MRI abdomen/pelvis impression: acute appendicitis

Operation:

1. exploratory laparotomy, ileocecectomy, with ileo-ascending anastomosis
2. Small-bowel resection with primary anastomosis
3. Enterolysis of dense adhesions

Operative findings: Cecal mass with gangrenous appendix; no evidence of tumor implants.

Surgical Pathology report:

xanthogranulomatous appendicitis and periappendicitis, involving cecum

Emily

Anonymous2 said...

"I inadvertently have used my oncologist as my primary care provider. "

Is this why America spends so much more on healthcare than any other country?

In any other sane country, as long as someone else (insurance company, government) is picking up the tab, you don't GET to use incredibly expensive specialists as general practitioners. I know that a lot of American women say that they use their OB/GYN as their primary care physician, and that just floors me. YOU DON'T NEED A SPECIALIST SURGEON TO LOOK AT YOUR RASH (or to check your blood pressure, or treat your cold, or to do your pap smear, etc etc etc.).

And you don't need a specialist oncologist to be doing routine GP care.

In most countries, you are only referred to specialist for specialist skills which a GP cannot provide. If your referral is approved, you see him or her FOR THAT ONE BIT OF CARE, which is all coordinated through your GP, and you still see your GP for all the routine stuff that you don't need a specialist for.

How many American healthcare dollars are wasted by patients improperly using the expensive resources of specialists when there's no clinical need for them to do so?

P.S. And to top it off, the high-priced specialist who told you that you had "acute appendicitis"? Yeah, no. From your account, notsomuch. If you had had acute appendicitis you wouldn't have opted out of emergency surgery (ooooh, is the ER /too common/ for Emilys who get their GP care from /specialists/?) and been faffing about for several days in only "mild pain" waiting for the special surgeon of your choice.

Gah. Spoilt children.

Anonymous said...

Skeptical, my story above about my oncologist and appedicitis was just an anecdotal story of what happened to me. It was not a challenge to the findings in your post. I'm still bristling that somene here just pulls out of his hat that I'm mistaken or even made up my diagnosis.

And btw, I'm not anonymous, I sign my name, Emily, at the end of my posts because I don't know how to get it on at the beginning.
Thanks.

Emily

Skeptical Scalpel said...

Anon2, you are coming close to the edge here. I don't allow personal attacks on this blog. I think her path report is pretty clear. Also, one could argue that since she is seeing her oncologist anyway and he is willing to do some primary care, it might be cheaper and more efficient for the oncologist to deal with many of her issues.

Anonymous said...

Just one last comment, and I won't take it further. But I have ovarian cancer, and my abdominal pain could have been a sign of another recurrence. That's why I mentioned it to him when he asked any "aches or pains". No way would I have taken advantage of him for a dermatological or any other problem like that. And that he took the reins heading me in the right direction with an introduction to the surgeon, I'm so appreciative and consider myself very lucky to be his patient. And yes,it was my decision not to go to the ER as my pain was never worse than 5/10. And the surgeon seemed OK with it.
Thanks again,

Emily




Henna said...

Anon2, you are being ridonkulous. And ooh, the heavy heavy sarcasm! Because otherwise no one would have understood your point, right?
It was clear from Emily's story that because she had OVARIAN CANCER, that's why she was seeing an oncologist. Of course he would ask about aches and pains. She has explained why very reasonably (although I was able to infer that without her explanation).
In the United States, as in any other country, a person who needs to see a specialist regularly often sees that doctor more than they do their GP. I think of a close friend in Australia whose daughter has a chronic condition--they see her GP once a year for a perfunctory referral to a paediatrician, who then co-ordinates all of her daughter's care.
Specialist visits in the United States are not significantly more expensive than seeing a GP. Emily did not stay away from the ER because it was "too common" for her. She very sensibly stayed away to SAVE health care dollars. ER visits are hugely expensive, as you probably know, in the US *and in other countries*, even though in other countries the patient does not always see the cost since it may be "free" to walk in.
Emily's appendix could have become acutely painful at any time after she walked down the hall and saw the surgeon. If it had, the surgeon would have removed it on an emergent basis. She was lucky. Congratulations, Emily. I'm glad you have such a sensible oncologist.

Skeptical Scalpel said...

Due to a misplaced click, I accidentally deleted this comment from my most loyal follower, Artiger. I recovered it from the email that notified me of it.

artiger has left a new comment on your post "Can retired specialists be retrained to ease the s...":

I would certainly think that a cancer patient could, and possibly should, turn to his/her oncologist with a vague issue such as abdominal pain, especially as in Emily's case where the previous problem was ovarian CA. Now, some of the above discussion might have been quibbling over acute versus perforated appendicitis, but I would say hats off to the onc for keeping after it until the problem was resolved.

Back to the original topic, I would agree that this is not going to make a dent in the primary care shortage, and even if retired surgeons came out from all corners of the country, this is not the way to do it. Nothing would terrify me more than having to deal with medical issues on a daily basis, and I've only been out of residency for 16 years. I can see, MAYBE, that medical specialists who did an internal medicine residency prior to a fellowship might do OK with this (e.g., a pulmonologist or nephrologist), but I doubt there would be a lot of takers.

It sounds like the doc who developed this (isn't he a retired surgeon?) was looking for a way to supplement his retirement income, at $7500 a pop. Did he take the course?

Anonymous said...

The best (?only) way to significantly increase the number of primary-care docs is to increase their pay compared to specialists. We can either go up on PCP income, go down on specialist pay, or both.

Much of reimbursement for specialist intervention is divorced from outcome. Examples: spinal fusion for back pain; coronary stents for stable angina. Yet these are among the top paid procedures. (Last year spinal surgeons were the top paid docs.)

Skeptical Scalpel said...

Anon, you are absolutely right. One problem I see is that it is very hard to quantify what primary care docs do. Time is not a good metric [I hate that word]. Here is something I wrote last year. http://skepticalscalpel.blogspot.com/2012/12/electronic-medical-records.html

artiger said...

Scalpel, thanks, I was worried for a moment that I had been blacklisted.

I don't mean to denigrate primary care, but I just got finished spending several hours of an evening (that otherwise would have been free) with a postop patient with a nonsurgical issue, and unfortunately, a lot of that time was spent handholding with a sizable family. Primary care doctor was nowhere to be found. I know I shouldn't generalize, but it's times like this that make me think that the pay scales aren't so out of whack after all. Then again, I certainly don't think ortho and some of the other superdocs would have lowered themselves to such matters either.

Is primary care being taught to do anything more than triage these days? I can think of some training programs in family medicine (John Peter Smith, and some that are in more rural states, for example) that actually get residents some all around experience. But those are not the majority. I'll just go ahead and spot the ugly elephant in the room...Should docs be paid more if they are just a consult and triage service? Would they do more if they were paid more? Kind of a chicken and egg thing.

Food for thought, and speaking of that, I'm hungry. Hope I didn't tick anyone off with that rant which was admittedly a bit biased.

Skeptical Scalpel said...

Good points. It's not politically correct to point these things out.

Anonymous said...

Should primary care be given by docs? If so, then the best way to increase their numbers is to pay them a lot more.

I know that in urban areas PCP's do mostly triage and referrals, but these are not trivial skills. I remember as an intern how stressful it was deciding whether or not to send a patient home from the ER.

I suspect that in small towns and rural areas primary care docs do a lot of actual medical care.

How should we value medical care anyways? Spinal fusion requires extensive training and good visual-spatial skills, and its practitioners are the highest paid docs. Yet the literature says the efficacy for back pain (the most common indication) is iffy. Is a spinal surgeon worth 4 times that of a family doc?

Another example: numerous studies say that coronary stents for stable angina do not much affect mortality or even symptoms compared to the ASA, beta blockers, etc. given by PCP's, but the relative value units are 25 for the interventional cardiologist and 0.5 for the PCP (AFAIR).

(I am not a primary care doc).

Skeptical Scalpel said...

Anon, sorry for the delayed response. I think you are correct that PCPs in small towns do more medical care and less mere triage.

That's a good point about spine surgery and stents. it could be valid for procedures like colonoscopy too.

Vamsi Aribindi said...

I actually see a role for this.

One of my mentors in medical school is a general surgeon who had to retire 14 years ago in his early 60s. A spinal fusion surgery (for a crushed vertebrae) gone wrong destroyed his ability to withstand the physical rigors of surgery. He told me once he is most troubled by the thought that if he had done a non-surgical specialty, he might still be seeing patients.

Another wonderful ENT surgeon recently retired in his late 50s, as he found his vision to be slowly declining. He could still operate with loops, but decided that loops decreased his view of the operative field to the point where he may not notice blood or other problems. He decided to stop now before he started hurting his patients.

There are a great many surgeons and specialists who would love to continue practicing medicine after they are no longer physically able to do surgery. And I see this program as a great way to harness that talent. The human body hasn't changed all that much. And while there is certainly an incredible amount to learn, family practice has increasingly become "recognize when a problem is bigger than me and pass it on". Instead, what has come to the fore are the human aspects- dealing with a patients' fears and concerns, the parts of medicine that can never be taken over by a computer- that is something elderly surgeons can and should be perfectly able to learn to deal with, no? Someone has HTN, Hypercholesterolemia, T2DM, CHF, and now has a UTI? Refer them to the nearest board-certified internist.

Finally, there is great heterogeneity in medicine. An academic radiation-oncologist may not be the best candidate for this program. A rural general surgeon who deals with everything from boils to broken bones to the occasional heart attack while he or she covers the local ER? They should be able to take advantage of this program and get some formal cover for the work they've done their entire career.

Perhaps the answer is somewhere in between: can this certificate allow these doctors to practice in a group while supervised by board-certified family practitioners?

Respectfully,
Vamsi Aribindi

Skeptical Scalpel said...

Vamsi, you are right. There may be a few specialists out there who would become PCPs. I doubt there are many. This doesn't address the training period of only 100 hours. If all PCPs do is triage (and that's not really true), then anyone could do it. Why would you need a doctor?

Anonymous said...

I think several issues are commingled here.

Should primary care be provided by doctors? Or by nurses?

Urgent Care is not Primary Care. A general surgeon can work in a DOc-in-a-Box setting but not know how to keep up with vaccinations, screening recommendations, and preventive medications.

Do we really want a 60-year old guy to pick up new skills in 2 weeks and go at it on unsuspecting patients? Here is the politically-incorrect data on aging. Cognitive skills peak in the late 20's, are stable to age 40, suffer a slow decline to mid-60's, and then dramatically decline. Those of us past age 40 *know* this to be true.

The whole thing is just a terrible idea on so many levels.


Anonymous said...

The best, gentle exit for a surgeon is to first-assist. You will still be called "doctor", get paid well per case, socialize, get free food, and occasionally make valuable suggestions to the primary surgeon.

Getting into primary care in your doddering days seems delusional.

Vamsi Aribindi said...

Hmm- the decline of cognitive skills during aging is only partially true:

http://med.emory.edu/ADRC/healthy_aging/healthy_aging/

In fact, broadly most skills stay intact- and many "declines" are more than compensated for by experience.

Dr. Scalpel, you are correct that I over-generalized: PCPs are of course not merely triage specialists, and I was certainly wrong to imply that these retrained specialists could do all of primary care after 100 hours. And you are certainly right that not many will take up this offer. When I think of this program, I suppose I am thinking of my mother, a pediatric anesthesiologist, and others like her for whom doctoring is in their bones. She told me she'd rather die than retire, and I imagine that should she lose the ability to perform intubations and put in lines, she'd jump at the chance to keep seeing patients. (For that matter, she loves learning new things even after decades in practice, and she told me she's interested in apprenticing with a family practitioner before getting some variety and cover an Urgent Care clinic once in a while).

The point I should have made but didn't was this: triage is all that these retired and retrained surgeons have to be able to do at minimum: as long as they can recognize a serious problem and triage it they aren't compromising patient safety. Anything more is a bonus to the system: If they're comfortable managing isolated essential hypertension after screening for secondary hypertension, if they're comfortable managing diabetes, all the better. If they re-learn the vaccination/child development schedule and take care of URIs, UTIs, and other isolated complaints- they're only adding value. Should they be able to hang up a shingle and practice independently? Probably not- and I doubt any malpractice insurer will let them get away with that. But in a supervised setting, in a role akin to NPs and PAs? I hope the few who do take this up will help patients.

Respectfully,
Vamsi Aribindi

Anonymous said...

I would really like to see a role for docs of all persuasions who can no longer practice their specialties, but I do not believe it is in primary care, with or without a 100-hour course. Primary care is not just a fall-into or backup specialty. Just because all docs have gone to medical school and, at some point in their career, have examined a naked body, it does not mean that s/he can practice Primary Care. Even if a doc can learn current standards for HBP, vaccinations, high lipids, asthma, etc., etc., you cannot teach experience. You have to examine a lot of patients to recognize the difference between back strain and a dissecting aneurysm, between the little old lady "tea-and-toast" anemic from the little old lady who is losing blood from a silent GI bleed. I could go on and on, but I think that Primary Care physicians go into their specialty for a reason - one might say that they are born and bred as such, not created for a retiree's dabbling pleasure.

This reminds me of a situation many years ago when I was an ICU nurse and the stupidvisor pulled me to take charge on a 40-bed medical surgical floor. Are you kidding? All of my clinical experience had been ICU or ED experience; I had NEVER - in school or after graduation - worked on or been in charge of a med-surg floor where (glory be!) they let patients get out of bed and walk around and even breathe on their own! I refused. She countered with the argument that as an ICU nurse, "You know everything." Huh? No, I don't know everything, I just know different things than your average bear in scrubs, but what I do not know how to do is manage 40 patients who run the gamut from fresh post-op, to going home post-op, to pre-op (maybe), to we-are-not-sure what is going on, to waiting for a nursing home bed. I had no skill, knowledge, or desire for this assignment and it scared the hell out of me. I did poorly enough on the assignment, including making 3(!!!) med errors, (which thankfully were not dangerous or harmful to the patient). They never asked again. Go figure. I spent the rest of my clinical experience back in ICUs (and EDs when I needed a break) where people breathe through tubes (as God meant, or why would he have made those fantastic breathing machines?) and where I can watch exactly what the heart is doing and how well it is doing it. And I felt safe. Tricia

Skeptical Scalpel said...

Anon, good stuff. Lots of common sense. Thank you for giving us your thoughts.

Dr. G said...

Very interesting blog.
Thank you for the open dialogue.
I am a Board Certified Family Physician. An MD. I am not a refer-ologist. I am not a triage center. I am a Physician.
I could have been a surgeon, an orthopod, an OB/GYN -- many things-- as is true for the great majority of us. I chose Family Medicine because I am passionate about education, patient advocacy and helping people look at the big picture towards living better. I'm good with uncertainty and enjoy the surprises that come with the whole gamut of patient care.

If I were to take a 100 hour course and market myself as having the skill equivalent of a plastic surgeon I would lose my license. I appreciate the respect presented in this blog toward capable, well-trained primary care physicians.

Skeptical Scalpel said...

Dr. G, thanks for commenting. We're on the same page on this issue.

Chris said...

2 thoughts:

1) as mentioned by an anon commenter above, the only way we'll get more PCPs is by paying them more (and in all likelihood, paying specialists less--political napalm). Does anyone think it's merely coincidence that the most highly paid specialties also happen to be the ones that are hardest to match into residency? How popular would dermatology be if it paid the same as family practice?

2) regarding the commentary above about oncologists etc serving the role of PCP, this often happens in the real world. As a rheumatologist I often end up as a de facto PCP for many of my patients with chronic diseases such as lupus or RA. A rule of thumb I sometimes apply: is it likely that this patient's "real" PCP will attribute any major new issues to the condition I am treating them for, and as a result direct them to seek evaluation by me before they do anything? If so, it's probably best that I just address it in the first place. As a result, if a lupus patient (or for an oncologist, a recently treated cancer patient as in the example above) presents with new onset abdominal pain, it's often most expedient for me to begin the workup. Similarly, when I have RA patients on biologic agents, they often call me rather than their PCP if they have a respiratory infection, cellulitis, etc, because they want to know if they should stop or continue their medication, if the medication could've contributed to their new issue, and if they need antibiotics due to their immunosuppressed status. Even a good PCP may not know the answer to these questions depending on the condition or the drug in question. That said, I do still ask most of my patients to have a PCP they check in with once or twice a year to make sure they are following the most current recommendations about blood pressure and lipid targets, cancer screening, routine vaccination, etc.

Skeptical Scalpel said...

Chris, I doubt you'll see a time when derms make less money than PCPs. Derms can always go off insurance panels and they'll still get plenty of work. Your system of dealing with primary care issues seems quite reasonable to me.

Chris said...

I agree it's unlikely that pay will ever be equivalent between family doctors and dermatologists (or plastic surgeons, orthopedists, cardiologists, neurosurgeons, radiologists), and perhaps it shouldn't be. But I'm not convinced that the magnitude of the difference as it stands is justified.

My point was not to single out a particular field as overpaid, but rather to point out that these highly paid specialties are also highly competitive for entry. Perhaps there is a direct correlation between compensation and the factors required for entry into a field, but I suspect the relationship between compensation and competitiveness is much more bidirectional than many would like to admit. My strong suspicion is that many fewer medical students would voice a strong passion for dermatology or radiology if the pay was commensurate with other fields with a similar length of training but significantly lower income potential.

The broader point I was trying to illustrate is that medical specialization is but one example of the illusion of a "free market" in our healthcare system. If physician reimbursement was determined by availability of services, underserved services like primary care would be paid much more (have you tried to get in to see an internist as a new patient recently?) and highly served services like dermatology and interventional cardiology would be paid much less. As it is, reimbursement for services is determined much more by specialty society lobbying and regulatory capture than it is by the balance of supply and demand for services.

Administrative burden and other "hassles" are frequently cited as a reason that medical students do not pursue primary care, but these are present in virtually every medical practice, so I don't buy that as the real reason for the shortage. Perceived lack of prestige is probably a more important factor, but that is much more closely tied to compensation--compare your local spine surgeon's house/car/office facility to those of your family doc.

Since the "market" does not set these prices, the only way that I can see that the supply of primary care services will expand is by increasing the set price of them and making them more attractive to medical students considering their choice of specialty. Another alternative is to give up on the idea of MD's as PCPs altogether.

Skeptical Scalpel said...

I understand your points. I believe the alternative in your last line is already starting to occur. I think MDs as PCPs will gradually wither, and APRNs and/or PAs will take over.

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