Cut-Rate in Podunk by Pat Conrad MD

“We’ve been trying for years to address our maldistribution <sic> of physicians in the country. We have all sorts of incentive programs and all sorts of ways to try to get them to go out to Podunk, but a lot of them just don’t want to go to Podunk.”

So a fix is proposed by orthopedist and Missouri Rep. Keith Frederick, in a plan “to treat patients in Missouri’s underserved areas as a result of a planned expansion of a first-in-the-nation law aimed at addressing a pervasive doctor shortage.”

Hey, cool, they’re going to actually pay doctors extra to go … to … aw hell.  First we had PA’s and NP’s evolving from “extenders” to solo practitioners, pharmacists providing primary care, and more recently, the world-changing innovation of “nurse doctors.”  It may be that the logical gymnastics are nearing full circle.  Missouri wants a new category of providers for people “who graduate from medical school and pass key medical exams but aren’t placed in residency programs needed for certification.”

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This amazing new category is called – drum rolllllllll, please – “assistant physicians.”  The AP’s are to give primary care in “medically underserved” areas with the supervision of another physician, and can work as assistant physicians indefinitely, “essentially sidestepping traditional residency requirements.”  Well that’s just fan- (insert copious profanity here) -tastic.    The AP applicants are those who didn’t pass their board exams, or did not pass subsequent tests within the time limit, or for whatever reason did not actually finish a residency.  So they are sort of non-physician doctors, with all the expertise I had on my first day of residency, which is to say, almost none.  And for these sub-substantially trained that fail to “match” there will now be the opportunity for politicians, themselves eager to expand state compassion, to match them with second-class patients.

How dare I refer to patients as “second-class”?  I didn’t.  Their political caregivers did by pushing cut-rate, pre-physicians on them as though that were a fix to bad economic policy (which is of course, the same thing they did with solo flying PA’s and NP’s).  The rhetoric is out that a new crop of AP’s will “save lives” in Missouri, and it’s being considered in several other states.  And they won’t have the worry of those extra years of lost income that we post-residency saps had to incur.

For years the ABFM has worked diligently to make primary care as unpleasant as possible, even as they extolled the excellence that only they through their extorted certifications can provide.  Ditto the ABIM.  Can we expect these two cash pig rip-off groups to issue emergency statements condemning assistant physicians as dangerous to patients?  Will the American Board of Medical Specialties sound the alarm that pre-boarded, MOC-ineligible doctors will not have the confidence expected by such discerning patients who demand more?  No, I’m not holding my breath either.  Will separate modifiers be issued by Medicare/’caid to pay AP’s less, given the lesser degree of – ahem – “quality” that they would be expected to render?

This is yet another demonstration of how our society is willing to devalue those who have achieved more and worked harder.  And Missouri has the language wrong.  The term “assistant physician” could be to easily confused with another, similar professional title, many members of which would have superior expertise.  For the sake of precision, I propose “LELT doctor.”*  Catchy, huh?

* Less Educated, Less Trained

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  10 comments for “Cut-Rate in Podunk by Pat Conrad MD

  1. Connie S
    June 4, 2017 at 6:51 pm

    In the combination of the dumbing down of the population and the PC culture of adding more and more “sensitivity” requirements to the average degree, the degrees required for providers become higher and higher. Steve O addressed the same phenomenon when it comes to nursing. When I took my BS in PT there were only one or two masters-level programs out there. Now all PTs routinely graduate as DPTs, spend their day filling out check-box forms on new patients, while the aides and the assistants do all the work. The same appears to be happening with physicians. The specialists learn more and more about less and less, and there aren’t enough little guys to triage to the big guys. Wish I had the solution… especially since the general populace seems to be demanding single payer these days.

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  2. Bill Ameen MD
    June 1, 2017 at 8:24 am

    Anybody remember Chairman Mao’s “barefoot doctors” from the Cultural Revolution of the late 1960’s?
    Whatever happened to the thought of forgiving debt to young doctors to attract them to opiate-ridden Podunk? Or stopping the MOC crap for family physicians?

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  3. Maria Elayne DeSimone
    May 31, 2017 at 7:13 pm

    This isn’t yet one more example of legislators overstepping their expertise. I agree that there is a significant problem of access, especially in rural areas of the country. I also think that it is unlikely that physicians will suddenly flock to primary care. That being said, there is already a cadre of well educated, high quality people who can meet the current and future health care needs. PAs and NPs like primary care and decades of study have demonstrated that patient are outcomes are good to great! NPs and PAs work well with physicians and function well in teams and as individuals.
    Should we create yet one more health care profession? I think not.

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    • RSW
      June 1, 2017 at 4:32 pm

      PAs and NPs DON’T like primary care – they’re fleeing it for other specialties and/or early retirement.

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  4. Tad Hominem
    May 31, 2017 at 6:05 pm

    I agree this is crazy, but what is the solution?? $$$? who pays the extra $$ to make annual earnings attractive? Feds?? lmao!!!! Evil State?? maybe BUT u know there will be strings and regs!!
    AND $$$ may not be enough!!! I live in rural upstate NY, about 1 hour from major city!! Same problem with docs as with business execs, WIVES, HUSBANDS, SIGNIF OTHERS / PARTNERS don’t wanna live here!! None of the allure and attractions of modern life!! Even though it is only 1 hour away!!

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  5. G. D. Jacobs, M.D.
    May 31, 2017 at 5:25 pm

    Obviously LELT: the chest x-ray is upside down.

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  6. tom walsh
    May 31, 2017 at 11:43 am

    This is being implemented in Highlands County, Florida by Florida Hospital Heartland.

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    • Pat
      May 31, 2017 at 3:47 pm

      Damn. I practice in FL, had not heard this.

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  7. Steve O'
    May 31, 2017 at 8:31 am

    Jacqueline M. McGrath, PhD, RN, FNAP, FAAN wrote an interesting article regarding the targeted role of the Nurse Doctor. The AACN stated that a PhD in nursing was an academic opportunity, not a new role in healthcare. She asked, wisely, that if there is no difference in capacity to do nursing, what is the purpose of the Nurse Doctor intended to be? She seems genuinely worried that the nursing PhD is to be unproductive low-paid research churning in the Ivory Tower, with no benefit to the student in graduate nursing. A very good question.

    It seems to be like the University’s football team and rock-climbing wall for the students – a bonus that tempts alumni cash.

    The Brits, a different topic, write about the negative correlation between physician age and patient survival in the hospital.

    The findings of Tsugawa and colleagues lead inevitably to a re-evaluation of requirements for continuing education for physicians. Besides this study, 74% of studies evaluated in a systematic review found a partially or consistently negative association between physician age and adherence to recommended treatment, leading to a conclusion that quality improvement interventions in the form of continuing education should be explored…
    Tsugawa and colleagues showed that patients of older hospitalists had higher odds of 30 day in hospital mortality than patients of younger hospitalists.

    Experience kills, it seems to warn. Lectures, memorization and study skills outweigh the actual doing of the job, as any obstetrician can tell you.(not) The IOM study of ’99 is being used as an excuse for a medical pogrom against the resistance. The BMJ adds an opinion to the rather orthodox article, obviously written by a revolutionary and slipped into the publication before the censors caught it:

    But missing from the discussion on physician age and quality of care is consideration of the importance of the organizational context of clinical care. Arguably, the single most important contribution of the Institute of Medicine’s landmark quality and patient safety reports was the conclusion that quality and safety are properties of institutions. The IOM reports cite evidence that institutional resource priorities, processes, and culture create the possibility of good patient outcomes despite variation in education, training, and clinical performance of the individuals who comprise the hospital workforce.

    That was the original intent of the terms quality and safety, before these concepts were turned into factory-floor Press Gainey ratings. Counterrevolutionary. And what institution still has a culture of good primary care? The institution of one – DPC.

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  8. Steve O'
    May 31, 2017 at 7:50 am

    You can see perfectly clearly now how this “shortage” that they have been publishing about and warning everyone about, fits into an insidious plan. If you don’t want to pay for qualified services, make a “tragic shortage” and throw any willing body into the gap.
    Our state also has a “tragic shortage” of dentists. The legislature is mulling over licensing dental assistants to perform independent dentistry “for the sake of the children.” Fortunately, there is no “tragic shortage” of bureaucrats.

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