Playing Doctor in Michigan by Pat Conrad MD

What to say when the free market conflicts with common sense?  It happens every day, and we should not think that medicine – such as it is – could rise above it.  I’ve written repeatedly here that I think patients should be free to see anyone they want for almost anything, and I should be free to not have to deal with any of the consequences.

We here celebrate Direct Primary Care, as it represents the very best, most effective, and one truly honest way to deliver health care to the individual patient.  But can DPC be delivered by non-physicians?  I guess, yeah, sort of, in the same way that any other health care can be delivered by the Less-Educated, Less-Trained.  On occasion I pop into the Family Dollar General…but I never mistake it for Target.

Stacy Waack and Tara Taylor are both physician assistants at Benessere Wellness Center in Michigan who offer services along the scaffolding of DPC:  “monthly membership fees instead of insurance company reimbursements and co-pays. Adults pay $69 per month and a family of four spends $149 per month for unlimited visits, exams, urgent care and some tests. Families pay $10 per month for each additional child.”  “They can teleconference, send photos via email or use FaceTime or Skype. ‘If you call the office and need to speak with one of us, you’ll speak with us directly.  After hours, you’ll speak with us directly as well.’”  They limit their panel to 500-600.

Aaaand then we take a dirt road right off the reservation…

“John Young, president of the Michigan Academy of Physician Assistants assures us, “PAs are trained in the medical model like physicians.  PAs have partnered with physicians across the state to own medical practices. (Benessere) is the first time we’ve heard of a PA-run or PA-owned direct primary care practice.”

Well, you’re trained in a medical model, but not “the” medical model, otherwise I’d be referring to you as “doctor.”

PA Young:  “Pairing direct primary care — which focuses on high-value services such as disease management, prevention and mental health — with a ‘high-value provider,’ such as a physician assistant, makes a lot of sense.”  Which is to say either that actual physicians are “low-value”, or more accurately, that LELT’s are the bargain option.

And PA Young just had to add, “We are proud of our proven track record of providing high-quality care with our physician colleagues.”  Mr. Young, as “a cardiovascular surgery physician assistant” you could run annuloplasty rings around me on that particular topic.  But you were not there for the never-ending death march of board exams, the long uncompensated hours over a decade of training, the disgusting late night dumps in the ER, the sleep-deprived zombie rounds that followed in the ICU, the never, ever, always more blur of clinic and lecture schedules.  I haven’t seen you in any of the malpractice depositions or subpoenaed “medical expert” court appearances.  Mr. Young, you might be a swell guy, and a pleasure to have a beer with.  But Mr. Young, you are not now, nor will you ever be my colleague until such day as they tattoo that bulls-eye on your back while you are green hooded, and you earn the title “Doctor of Medicine.”  I earned that, along with all the scar tissue and paint knocked off the keel.

I really don’t mind these little PA’s making a buck here or there, any more than I mind anyone else doing whatever they please.  As long as it involves consenting adults, I don’t care if the half-ass tattoo “artist” cons idiots into accepting auto grade silicone injection butt enhancements.  As long as the government stays out, let the educated consumer beware.  But through medical licensing and CME requirements, DEA licensing and surveillance, among others, government still has its thumb on the scale against physicians; if PA’s are allowed to do all that a family doc can, then the worth of the latter is artificially reduced by government restriction.

And these “DPC” PA’s are seeking to play unsupervised family doctor against a backdrop of government, hospital, and Big Insurance opposition, which will become open hostility.  As real DPC takes off, expect the “cost-effectiveness” the PA’s tout to be used to further attempt to restrict real physicians from practicing DPC.

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  15 comments for “Playing Doctor in Michigan by Pat Conrad MD

  1. Spencer Pollok, PA-C
    January 1, 2018 at 7:18 pm

    Wow… just, wow.

    We’re all f@&ked until corporate minded administrators running health care realize that the “business” is about people instead of widgets. Both, patient and provider alike.

    When the money flows in a way that is beneficial to all there won’t be any need for this type of argument. We’ll all be doing the job we were trained to do and getting paid appropriately for that work.

    How’s that going to happen? Hell if I know! I still have planty to learn. What I do know is, if we don’t work on this together the corporate steamroller will continue to show us the way.

  2. Doug Farrago
    December 22, 2017 at 7:07 am

    The militant attacks have started. Don’t even bother trying to post if your theme is “We do the same as doctors do, we are equal in training and experience, I support independent midlevels competing against doctors, etc”. I will just trash your comments and they will never be seen. This is not your blog. Start your own blog. Don’t waste your time posting here.

  3. Jesse Belville,PA-C
    December 21, 2017 at 3:00 pm

    Dr. Conrad;

    Thank you. I am a PA-C in primary care/Family Practice with experience in Emergency medicine, Cardiology, Internal medicine and Chronic pain Medicine.
    I graduated From George Washington University PA Program in 1076 passed the national certifying exam in 1077 and have retaken that exam every 6 years since then to maintain my C in PA-C.
    PA-C were designed to handle routine medical issues 70 to 80 percent of what primary care physician’s do daily. This was supposed to be so the expensive to train MD or DO had more time for their sicker patients. Lower cost primary care provider to supplement MD or DO’s and perhaps give them more time for Family, research, better quality of life. maybe even improve patient care and detect developing problems sooner. That was the model
    Before PA school I was an Army medic with 19 months in Vietnam. some in combat,some working ER in field hospital doing “sick call” ,suturing minor lacerations, wound care and burn care. Good times cause I was learning and helping. Came home learned more about PA school, polished up my study skill and got accepted to PA school in 1974, graduated in 1976. Worked nights and went to school during day. Only owed 1800 bucks when I graduated.
    I am still a PA-C who writes my PA leaders to protest trying to cast us as being able to hang out our own shingle and practice independently. We and NP’s should NOT. We should practice with an MD or DO supervising us. I have not had a lot of supervision over the last 41 years of active practice. My physician supervisors watch me and review a chart as required and then just go their merry ways confident I am not going to kill anyone. So far I have not killed or injured anyone. Everything is competition and as more people crowd into the Primary care field more pushback will come. So keep pushing back and encourage your fellow MD’s or DO’s to do the same. Shape the future of medicine, don’t just let it happen. .
    Thank you

  4. Patrick
    December 20, 2017 at 1:27 pm

    First I wanted to thank you for taking a dump all over my career path. Very thought provoking condescension. Why would I ever want to consider being your colleague?
    I’ve been a PA for the past 16 years. I haven’t played doctor, well, except when the employer I work for wants to collect 100% physician fee for every patient I see. Its been a career of observing physician employers collect (legally) 100% physician fee for my services. They pocket 35-45% of each of my billing collected. Only a colleague when you’re getting paid of my back, right? Isn’t this what your argument is all about, someone potentially taking away from your revenue stream?
    Core quality measures from the federal government (yes, I know the VA is not the best place to use for data) regarding PA, NP, and Physician primary care has been equivocal in the primary care setting for core disease states i.e DM, HTN, etc. Does data matter or is this all just more of a pissing match…..”But I went to school 4 semesters longer and was paid poorly for 3-4 more years in residency, before I could actually make good money!” You think over the past 16 years I haven’t learned anything about caring for people? The books, lectures, clinical time, and testing didn’t come from magical source. Medical school wasn’t a mystical magical place where only you had access to learning medicine.

    I enjoy all the condescending commentary about PA’s, but physicians will hire an on-line trained NP in 30 seconds if given the chance. Talk about making easy money off the back of the willing. On-line trained while they work as a full time floor nurse. Write a tons of on-line papers, take on-line tests, log 250 hours of clinical time with a buddy who works in an office and poof…..ready to practice. Totally the same as medical school, right? I think you might have more colleague competition from this group than ours in the near future.

    At least PA school follows medical school’s model for system based learning. You’d think that would earn a little respect, but nope. You have no concept of the PA school experience. It’s a full time job, non-stop, for 2 years. No summers off (medical school). Employment is impossible during the training. It is full emersion for 2 straight years. I often wonder how some of the physicians I’ve met along the way would have done cramming 2 years of core medicine into their heads before starting to practice with supervision.

    I enjoyed reading about long nights in the ER, ICU, or being an expert witness. I’m so happy I’ve never had to study/worked long hours, take care of a disaster patient in the ER, taken board exams, or been an expert witness in a deposition. Of course, that’s not true because, I’ve had to do all of those things. But, you never saw it, so it must not have happened. With regard to supervision, I totally agree I should always have a physician of record available to me in collaboration. I’ve never had this “practice alone” issue that all the younger PA’s and NP’s want. It all comes down to money, because none of us have an amazing hypertension treatment plan that differs from each other. If you don’t want to see yourself as a colleague, that’s more your own insecurity than a problem for me. Either way you and your “colleagues”, whoever they are, will profit from my work and I will continue to provide excellent patient care.

    Lastly, there are plenty of physicians “playing physicians” out there. Have the degree, but lack the basic people skills to be an effective care giver or revenue generator. Some are down right terrifying. One of the comments to this article said something about “not spending all that time, money, and emotional pain to become a physician? Might want to talk to a physician, but maybe consider a new career. Just some advice from a friendly PA.

    • Doug Farrago
      December 21, 2017 at 6:50 am

      I will let Pat Conrad respond on his own to this. Be warned, however, that this blog has been around as long as you have been a PA. Your response is typical and not my first rodeo with this. Here is how it usually plays out. Other militant midlevels will try to jump in and bash doctors (“we’re the same, look at the studies, etc.”). The point of this piece was not to bash PAs but to bash the concept of PAs, or NPs, going out on their own to compete with doctors. Not collaboration but competition. To that end, I will leave your comment up. If the parade of critics pile on then I block them all.

      • Patrick Dougherty
        December 21, 2017 at 12:05 pm

        Fair enough. I’ve put in my time. I’m far more concerned about NP expansion than PA militancy. I guess I came off as us against them in my writing. I’m not a wannabe physician or “I’m better than a doc” PA. I can get absolutely get behind the concern over the autonomy concept. I always have! I’m a firm believer in the law, as a PA, I practice medicine WITH a collaborative physician, not in spite of…. I’ve worked with many great people and avoided self congratulating jackasses who need to be thanked for making through medical school. P. S. Many people are ecstatic to just have the opportunity to become a physician. Anyway, 2 decades in medicine starting as a medic, just sick of all the belittling. Especially watching the overall “expertise” of the medical community decline into a battle over who can generate the most revenue for the least amount of work, while engaging in the great American past time of passing the buck until its time to collect all whike expecting a pat on the back. Times are forever changing I guess.
        Appreciate the feed back. I’ll tone it down. This article tickled my angry bone…..

      • ed mathes
        December 21, 2017 at 1:21 pm

        I’ve been a PA for 37 years. Surgery, Internal Medicine, Interventional Radiology.
        I’ve followed you for a while. Interesting, fun writing. You make your points in creative ways.
        Stroking done….
        Most PAs won’t “bash” doctors.
        Most of us appreciate the guidance provided by the physicians we work WITH.
        Most recognize their limitations and work within those.
        The frustration comes when we try to expand our knowledge, skills, push our limits, and a physician, typically worried about liability (which is OK) hinders progress.
        Most PAs do not want to “compete” with physicians. We, since the beginning of our profession, have embraced the concept of team practice, in a collaborative rather than authoritarian model.

    • Steve O'
      December 21, 2017 at 11:17 am

      Stray dogs fight over a bag of trash. PharmD’s and medics are the next in the lineup to do independent primary care. So nobody bitch when THEY see patients. The factory model says that anyone can check a box. Wait until Prison Voke gives clinician courses in primary care! No controlled substance license for them.
      They are using PAs as the meat puppets today. In 2020 it will be EMT’s. (They can save your life, why can’t they prescribe, huh?). Usw.

      • Patrick Dougherty
        December 21, 2017 at 12:15 pm

        Can’t say I disagree. The DNP is the next in line. PA’s have been pretty consistent over the past 50 years. With a lobby like nursing is it any wonder NP’s practice solo and DNP ‘S are out countries new “doctors”. When nursing runs most of the hospital systems from floor nurse to the executive level is it any wonder that this is happening? Meat puppet or not, the push for autonomy didn’t have any teeth until the entire career path was threatened by the nursing community and appears to be welcomed with open arms by the physician community (OK, more like hospital nursing run administrative community) . All because they can “practice alone” and that give the hiring physician group a false sense of reduced liability.

        • Steve O'
          December 21, 2017 at 1:41 pm

          The corporate goal is to keep the dogs fighting. It worked with unions, didn’t it?

    • Pat
      December 21, 2017 at 12:23 pm

      Patrick, thanks for reading and for your comments.

      To start, I am not bashing PA training or abilities, or PA’s as individuals trying to do the best job they can, when viewed in a factual context. I am absolutely attacking a mid-level industry that is constantly trying to lessen the value of physicians in the eyes of the idiot, corrupt politicians, unscrupulous Big Insurance and Big Hospital CEO’s, and the general public.

      I have worked with some very fine PA’s over the past 20 years, and on average much prefer them to ARNP’s; they are generally far more skilled, and far more respectful of the training and expertise differences with physicians. A good friend of mine in med school was a very experienced PA who seemed to think there was a great deal of difference in training; of course that’s a N=1, but more useful to me than any core measures justifications you want to wave. So you did this for 16 years and have learned a thing or two “about caring for people”? Good for you. And yes, I have known some excellent PA’s who indeed performed with more skill and caring than some truly half-ass docs. So what? Do these little anecdotes make our career paths equal? According to the presumptuous ass I quoted in the article, PA’s are actually the better-value choice. So it is the organized PA industry that devalued physicians by implication – they dumped first.

      PA school may follow a medical school model, but is it medical school? If not, what is the difference? Should medical schools only graduate specialists, since you middies can cover the rest? Your argument is that they are so similar, that with enough practical experience, you are the equivalent of a primary care physician. And if you are more cost-effective, with all of my skills, then why shouldn’t the world flock to your shingle? Aren’t you arguing that “real” doctors are specialists, and that those of us who went into primary care are just bitchy types who can’t provide any better than a sharp PA with a few years under his belt?

      Your reply began and ended with economics, slapping at docs who make money “off the backs” of the LELT’s. And I agree, why would docs hire one except to improve their own bottom line? Or would you rather do away with ALL physician oversight and work as a truly solo flier? Is that what you want, but can’t quite say it? If you don’t want to be truly independent, then why not? What can a physician possibly offer that you don’t already provide? By pushing for independence, LELT’s have trapped themselves into this question that they are too cowardly to answer forthrightly.

      If my time machine weren’t busted, I would zoom back to the 1970’s and do away with the PA/ARNP industry in its infancy, along with most of what has become accepted medical economics. Not because they are bad people or not dedicated, but like hospitalists, the LELT industry is an economic response to the traditional physician model being artificially devalued. Your side will hide behind the “shortage and underserved areas” rationalizations; my answer is to produce real doctors, and pay them what they are worth. No, scratch that – let them deal directly with their customers and charge what they believe they are worth.

  5. mamadoc
    December 20, 2017 at 11:37 am

    Bout time somebody said this. Colleague my left foot.

  6. Perry
    December 20, 2017 at 9:05 am

    More incentive not to spend the time, money and emotional pain to become a physician, especially Primary Care.

    • Kurt
      December 20, 2017 at 2:25 pm

      Ditto, May any ivory tower academic spend time in purgatory or eternity in Hades for duping
      a med student to go into primary care. It’s not going to get better, it’s getting worse.

      And once there are no MD’s left doing it. The world will be stuck with the LELT’s. It’s just that simple!!

  7. Steve O'
    December 20, 2017 at 8:39 am

    One of the problems is that the entirety of the outpatient visit is analyzed by the business community familiar with the factory model. Imagine a ten-year-old trying to describe an office visit – a nasty, arrogant little ten-year-old who knows that you are doing everything WRONG!

    You ask questions (because you’re too lazy to look in the chart!), you examine the offending part, you order tests – because tests will show what’s wrong; and you prescribe medicines. Nice to see you again! The drug company gives you money to prescribe their product.

    If that’s an office visit, really anyone can do it. They just need to google whatever they want, which takes zippo minutes, and bazzzing!

    That’s also incompetent, inefficient, cost-no-object medicine. I do not image joints unless I plan to send them for orthopedic repair. I hate the concept of “routine labs.” There is no such thing as a “routine EKG.”

    I find some colleagues will order an EKG and put it in the chart, as though that worshipful sacrifice is all that is needed for good care. What does it say? Well, the machine prints out a little thing that says “Normal EKG” or “HEART ATTACK!!” Isn’t that good enough?

    The more the business people try to squeeze profits from the assembly line by cutting down on experience and decreasing visit length, the more MRI’s and CT’s and what-have-yous get ordered. Sometimes I sit in the office and count up how much unnecessary testing I’ve avoided. But I rarely have the time.

    The commodification approach to medicine says that less and less experience is needed, the more technology advances. Maybe you don’t need a human at all – just google it. The VA has experimented with bringing medics – enlisted persons trained for emergency and other medical care at the VA – on board as the equivalent of residents. Surely they can write prescriptions, some even are skilled at surgery! And the PA’s will be distressed. Medics have no medical degree – but so what! And why should veterans get the practice spots – there’s lots of good EMT’s out in the field! and so on.

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