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Should primary care MDs still exist?
It seems like in many places, PAs and NPs can do everything a PCP can (practice independently, prescribe, etc).
NPs practicing independently are scary and dangerous (I see legit malpractice daily) but I think an NP augmented by AI could come close to an average PCP MD.
Would you encourage a friend/relative to who wanted to do primary care to do med school?
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26 Replies
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Theres a lot of business potential for them if they know what they are doing. I know some that are making millions while barely working. They have PAs/NPs running their practices. They do all sorts of things like cosmetic, weight loss, med spa etc.
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Yes, FP is an excellent opportunity for a MD interested in business. Weight loss injections currently lucrative.
I’d switch to FP is Rads went down. I’d get into the business side of things – urgent cares, stand alone ERs, weight loss injections, etc
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Ditto that. I have a friend who is primary care and owns a chain of urgent cares, and also has another practice that has some sort of regenerative medicine angle, I dont even know what the hell that means, but they inject various things that have some limited science backing it, but not enough to be funded by insurance so its all out of pocket cash payments. He still sees patients in clinic at least once a week I think but otherwise he is more of an entrepreneur. Makes way more than me.
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What does it take, to become a FP? Two more years after a transitional internship?
Back in the day old guys they would take the FP boards after 1 year internship and if they passed they were FP. No residency needed.-
I dont doubt that 2% of FP and outpatient IM docs can become wealthy entrepreneurs
But what about the 50th percentile non-specialist IM doc that just wants to see patients in clinic, treat run of the mill HTN and DM, and spend the rest of their time with their family.
Do we still need them?
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I don’t understand.
What stops you from doing this yourself?
Hire some NPs / PAs, in a separate practice. They can own their practice if they want (might even be better).
You own the building they are in and throw in an imaging center.
EVERY patient who has even a minor complaint gets a study.
You don’t own the patients – the NP/PAs are practicing on their own and own their own practice.
Patients are happy, they get scans.
You get a ton of easy scans (mostly negative) and make $$$ as your scanners are whirring constantly.
MONEY PRINTER GO BRRRR
Nothing illegal about this set up.-
There is a growing area of primary care – Direct Primary care. It is an iteration of the concierge medicine idea. They generally do not accept insurance, but the financial model winds up costing the patients not very much (I am tempted to say no more than if they were covered, but I don’t know for sure)
Those who are doing this, having become independent, and caring for patients as they have been trained, are blissfully happy.-
Yes. Some people have complex medical issues that need managed.
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Quote from DICOM_Dan
Yes. Some people have complex medical issues that need managed.
They do.
Those people need “champions” in the ancient connotation of the word – someone who goes into the arena to fight for you.
If you pay a direct primary care person – they are free to give their opinion to you about the best doc for your situation. They are also free to review what is being done and say that it is not good, you need to find someone else.
If you are the patient of an employed physician, they may not be able to send you to the best person, they have to keep it in the system. They also may be told to refer everything to the specialty service to keep those services busy, and also to order more tests. THIS DOES HAPPEN. 60 minutes a few years ago had a story of an ER doc who was fired by a for profit hospital because he didn’t meet quota of numbers of patients admitted per day.You need someone on your side, paid only by you, who can be honest with you. Those employed by the hospital system have strong conflicts of interest.
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There is no doubt primary care is in a bad place, but the hubris to think we as radiologists could do better cracks me up. Sitting in a dark room alone a bit too much I think.
Our view of medicine is so skewed by our back room isolation, we may have lost touch with reality.
If I were on a desert island, a radiologist is not the physician I would pick.
A little more insight and respect for our colleagues would go a long way.
We are becoming like the lonely incel thinking our social media girlfriend is the real deal.
There are real people out there, called patients, who need to be touched, listened to, acted upon and followed. Its an art, which is disappearing, undervalued and even ignored. Abandoning primary care is the last thing we should do, we need to save it. -
Where can I find a social media girlfriend?
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Quote from boomer
There is no doubt primary care is in a bad place, but the hubris to think we as radiologists could do better cracks me up. Sitting in a dark room alone a bit too much I think.
Our view of medicine is so skewed by our back room isolation, we may have lost touch with reality.
If I were on a desert island, a radiologist is not the physician I would pick.
A little more insight and respect for our colleagues would go a long way.
We are becoming like the lonely incel thinking our social media girlfriend is the real deal.
There are real people out there, called patients, who need to be touched, listened to, acted upon and followed. Its an art, which is disappearing, undervalued and even ignored. Abandoning primary care is the last thing we should do, we need to save it.Well said but I would reiterate primary care is not in a good place. Don’t think it can be saved or at least I don’t know how to save it.
What will go extinct first? the general radiologist or the “general” or primary doc? -
General rad definitely not going extinct. In fact, I predict the opposite if AI actually does materialize into something that can impact telerad reads – the on-site Rad who can do a variety of procedures will be even more valuable.
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Kind of a dumb question – that Phil and boomer answer better than I can.
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What an odd question. Noctors are making things worse, not better.
I’d counter that we are in desperate need of more capable PMDs, at least of the dinosaur variety: >130 IQ men able to do more than copy-pasta, shotgun tests and refer out. It was a joy to watch them work, even with the egos.
It’s outright criminal that so many resort to becoming the charlatans and snake oil salesmen described above. Less dirty is concierge medicine, if only as to why it is so in demand.
Get off my lawn. -
Agree, definitely need MDS/DOs as primary care.
BTW, I have heard the generalist radiologist would be extinct since about 1995. They are still here in full force and needed as much as ever outside of the University IVY Towers. Don’t believe everything your radiology professors at the residency tell you. -
Two clarifying points:
1) Primary care/FP are very needed and important parts of the system. They and their efforts ARE needed to properly care for patients.
2) notwithstanding #1, the question as to whether a new doc goes into one of these areas is not so much are they needed, but “will the system allow them to exist?” That is very uncertain. They are being pushed out of the system, because those holding the reins business-wise can make much more money by replacing them. The midlevels replacing them are without any question not capable of doing this, but the business entities do not care.
I saw yesterday that now 74% of physicians are employed. That number will likely be much higher for primary care. Every one of these docs is much more expensive to the employer than is his/her replacement. At the same time, the employer can bill the same or nearly the same for midlevel work as for physician work.
One reason to employ a physician is purely to absorb the malpractice liability for a stable of midlevels. I have even seen this in radiology. See the appended screen capture for a job listing for IR. No procedures required of an IR. What will this person do? Absorb malpractice risk, apparently.
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Quote from Phil Shaffer
There is a growing area of primary care – Direct Primary care. It is an iteration of the concierge medicine idea. They generally do not accept insurance, but the financial model winds up costing the patients not very much (I am tempted to say no more than if they were covered, but I don’t know for sure)
Those who are doing this, having become independent, and caring for patients as they have been trained, are blissfully happy.It used to be called fee for service private practice.
I have tried to convince some IM and FP to go that route but it’s like they are abused spouses or something. The admins have beaten and abused them for so long that they think they can’t survive without HMO contracts, a hospital provided EMR and administrators who give them permission when to poop.
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One of my NPs makes more from her side gig weight loss injections then she does during her full time (4 day/wk) job with me.
She works hard, but has also made quite the name for herself in the well off population here. -
Quote from fw
Quote from Phil Shaffer
There is a growing area of primary care – Direct Primary care. It is an iteration of the concierge medicine idea. They generally do not accept insurance, but the financial model winds up costing the patients not very much (I am tempted to say no more than if they were covered, but I don’t know for sure)
Those who are doing this, having become independent, and caring for patients as they have been trained, are blissfully happy.It used to be called fee for service private practice.
I have tried to convince some IM and FP to go that route but it’s like they are abused spouses or something. The admins have beaten and abused them for so long that they think they can’t survive without HMO contracts, a hospital provided EMR and administrators who give them permission when to poop.
I think you know there is more to it than that fw. A lone FP or IM against a giant insurance company or hospital? Comical. In the real world David doesn’t take down Goliath.
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Quote from drad123
I think you know there is more to it than that fw. A lone FP or IM against a giant insurance company or hospital? Comical. In the real world David doesn’t take down Goliath.
You simply dont deal with insurance. Fee for service, direct care. Patient gets a printed CMS-1500 with the patient as the pay-to address. You take your money up front, if the patient gets money back from the insurance, great, if not you dont care. You are medicare opt-out and non-par with medicaid. If you see a medicare patient you execute a private contract.
You can’t do this everywhere. You need a good sized population who isn’t bothered by paying you a fee that isn’t much different from what they pay at the Lexus dealership. -
Yes because then who else would be blame bad ordering on. I bet it was family med doc
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Quote from knightrider
I don’t understand.
What stops you from doing this yourself?
Hire some NPs / PAs, in a separate practice. They can own their practice if they want (might even be better).You own the building they are in and throw in an imaging center.
EVERY patient who has even a minor complaint gets a study.
You don’t own the patients – the NP/PAs are practicing on their own and own their own practice.
Patients are happy, they get scans.
You get a ton of easy scans (mostly negative) and make $$$ as your scanners are whirring constantly.
MONEY PRINTER GO BRRRRNothing illegal about this set up.
Pretty sure that would be considered a kickback.
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Yeah….NP / PA’s are a nightmare in general based on how many unnecessary tests they order and what they cost our healthcare system and patients. Somebody with common sense needs to keep practicing primary care.
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2 year residency post internship. If at large community hospital deliver babies, take care of nicu, icu, inpatients, rotate under friendly surgeons and gynes again? Overnights 80 hour workweeks, etc. A few of us did family med prior to radiologytotally different than radiology. But then some of us trained prior to 80 hour workweek limits too.
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Yes they should. They play a value in medicine just like we do and just like any other specialty. They are our colleagues and we shouldnt throw them under the bus. Just like we shouldnt expect certain doctors say there needs to be less radiologists or anesthesiologists. Or say that AI is going to replace us.
Divide and conquer. Only in medicine do different areas try to cannibalize each other.
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