Having Second Thoughts about FM

[JohnGrisham]

9 hours ago, Wachaa said:

I don't bill anything for re-referrals, whether I see the patient or not. But the consultants we are talking about would cancel the patient's follow up visit if a new referral is not received. Only very few specialists are seeing the patients for follow ups without requesting a re-referral letter.

This.

and if you try and tell the specialist "feel free to continue seeing for ongoing follow-up care, a re-referral is not required" they essentially tell the patient to keep asking you and blame it on the system. Some cave and just see the patient, but many have their secretaries subtly guide the conversation. Now you have the patient coming back to you to "set up a time to talk, because i need my referral". FM ends up being the bad guy, for not being complicit in the the fraudulent re-referral process.

The college is garbage too, because they say "its within the discretion of the referring provider(FM) to determine if its clinically necesary", when they know very well many FM docs are essentially being forced to re-refer for follow-up care unnecessarily, because if you dont, you risk being put to the bottom of the specialists list when they consider accepting your referrals. Dont play along? "sorry, we have a long waitlist, please consider referring elsewhere". At a point, you give up and let the system suffer so your colleagues can keep billing their cushy follow-ups as re-consults.

I say this as having mostly specialist colleague friends in my social circle, and its openly acknowledged this is a big problem..but now its just apart of the specialist culture for billing purposes, given the cost of overhead has risen overtime etc - so they can maintain their solid incomes to justify lenght of training etc.

 

[JohnGrisham]

13 hours ago, Wachaa said:

All are good points raised by all. In reality I think there are too many issues with the referral system.

There are rheumatologists in the urban cities who will not start treatments for common rheumatological conditions (such as osteoarthritis) or internists who do not see thyroid conditions. Or gastroenterologists who do not see abdominal pain ("OH, I see the patient already had a CT and a scope. Please refer to someone else.")

Many dermatologists will refer to other dermatologists for genital lesions or hair loss.

Many ophthalmologists will refer to their glaucoma colleagues to measure intraocular pressure.

So I don't feel so bad when I refer off proteinuria workups because MSP gets on my case for ordering too many lab tests myself.

Its particularly bad in our centre.  "I dont see general ophthalmology". Then i guess you don't get our Cataract referrals either then, and theyll be sent to someone who will also help triage general opthalmological issues that are redflagged.

[JohnGrisham]

11 hours ago, bearded frog said:

I agree with you that specialists should not game the system, but you're incorrect about what you're citing. The sections you refer to specify that if a specialist sees a patient more than six months from a previous visit, that may or may not be unreasonable, and based on your clinical opinion, you can either refuse to refer, or re-refer. They further say it may be reasonable for you to re-refer without seeing the patient yourself, and hence there is a code for a "no-charge referral".

R2 says that while a new referral is not required if the specialist is content to treat it as a follow-up, but if its been more than 6 months and the specialist requests a new referral, then you can re-refer without seeing the patient as the PCP. R9 says that there is a delay in patient care as the specialist requests a referral every 6 months, the solution specified is that the PCP can re-refer as per the specialist's request without having to see the patient in clinic, and therefore removing the delay. C11 says that to bill for a new consult, it must be more than 6 months since the patient was last seen, and the specialist must have a new referral. The specialist cannot schedule a future visit in 7 months and then bill a new consult, they must either bill it as a follow up, OR request a new consult from the PCP, which leaves it up to the PCP to decide if this is reasonable.

See C10 which explicitly says q7m referrals are valid. Also C14:

Until you work in FM, its difficult to understand the actual way things play out in practice from our side. Theres whats written on paper, and what actually happens in practicality.

In many centres, if you have limited options to refer too, you are stuck as FM in sending an unnecessary re-refeerral to specialists for ongoing care, just so they can fraudulently bill a new consult.  This is not a rare occurrence. And the colleges have written it nicely on paper, and say "no no, FM, YOU can decide if you think its appropriate". But we all know well, that is not the case. It is the specialist that decides in most circumstances, and already communicates with the patient - and if you say no, the patient gets punished or delayed until you cave in. 

[JohnGrisham]

9 hours ago, Wachaa said:

For my own workflow/ billings it has minimal impact. It just makes it even harder for patients without a GP, that’s my main concern.

The specialists doing this, are not only wasting system resources by fraudulent billing repeat consults at higher fees, but also actively creating more waste in the system - those unattached patients end up going to walk in clinics or virtual telehealth for primary visit reason "need referral". Now that WIC GP bills a basic visit code for a short visit, and the cycle continues q6months. 

 

[bearded frog]

10 hours ago, JohnGrisham said:

The specialists doing this, are not only wasting system resources by fraudulent billing repeat consults at higher fees, but also actively creating more waste in the system - those unattached patients end up going to walk in clinics or virtual telehealth for primary visit reason "need referral". Now that WIC GP bills a basic visit code for a short visit, and the cycle continues q6months. 

 

Can't speak for other specialties, and I don't do much outpatient, but in peds at least if you haven't seen the patient for 6 months you need the full consult time to assess what's changed in that time. And almost no-one has only one issue, which apparently we should be requesting individual consults for each issue...

[Wachaa]

5 minutes ago, bearded frog said:

Can't speak for other specialties, and I don't do much outpatient, but in peds at least if you haven't seen the patient for 6 months you need the full consult time to assess what's changed in that time. And almost no-one has only one issue, which apparently we should be requesting individual consults for each issue...

I think within reason it's fine to request another referral if it's a different issue.

I was saying when a follow up is booked and it's booked after 6 months. But then requiring the patient to get a repeat referral when they really should not be refusing to see the patient to follow up on changes they initiated 6 months ago. Or to review labs/ tests they did for the initial issue.

[bearded frog]

36 minutes ago, Wachaa said:

I think within reason it's fine to request another referral if it's a different issue.

I was saying when a follow up is booked and it's booked after 6 months. But then requiring the patient to get a repeat referral when they really should not be refusing to see the patient to follow up on changes they initiated 6 months ago. Or to review labs/ tests they did for the initial issue.

I think that's reasonable. I mean a normal peds consult is usually an hour and a true follow up could be a 15 minute visit or phone call. But if it's multiple issues that all need significant reassessments thats going to take the full consult time. The problem is when I rotated through ENT clinic and new consults and followups all were seen in roughly 12 minutes and then they can bill the same as for an hour of time in peds lol

[JohnGrisham]

15 minutes ago, bearded frog said:

I think that's reasonable. I mean a normal peds consult is usually an hour and a true follow up could be a 15 minute visit or phone call. But if it's multiple issues that all need significant reassessments thats going to take the full consult time. The problem is when I rotated through ENT clinic and new consults and followups all were seen in roughly 12 minutes and then they can bill the same as for an hour of time in peds lol

When I was in training, the 4 different outpatient Peds never had consults last more than 30 mins, as that would not be financially sustainable/as lucrative. Im sure theres provincial variation here. They were all quite skilled at cutting off parents who clearly needed longer counselling for benign issues. They had the "specialist mentatlity", and would deflect basic peds stuff back to FM with vigour  

There are many paediatricians in my urban centre that will do 10-20 minute consults like other specialists all the same and see them in repeated follow-ups(lower billing), and get q6month repeat referrals for ongoing routine care. Mind you, their base consult fee is 227$. If they spend almost an hour with patients, their rate 329$. If they spend just over an hour its 391$. If its deemed "complex" and they spent 1.5hr total(60mins with patient and 30mins for file revie)? 450$. As you can see, its more lucrative to see 2 easier consults at 20-30mins each, then a complex one..but even if you do a complex one, you're making good money.

Outpatient peds with a good referral base for consults pays quite well here. Even if you take 20-30 mins for a consult(longer end), they still bill very well. 

Some do primary care, and continue to get q6month re-referrals inappropriately to bill the consults again, despite doing longitudinal care for those patients...and despite already billing very handsomely.

FYI, in our centre, an ENT consult(77$) pays 1/3rd of a base paediatrics consult.  and only just over double a FM office visit. 

The issue now, is you have FM docs who will just send anything not routine to peds, because of this irrational billing system.
 

[bearded frog]

14 hours ago, JohnGrisham said:

FYI, in our centre, an ENT consult(77$) pays 1/3rd of a base paediatrics consult.  and only just over double a FM office visit. 

Thats much more reasonable.

Regarding output peds, all my experience has been in teaching contexts so maybe the time allotted to see patients with a resident is longer than a standard visit.

[GH0ST]

I am sure this will stir the pot and people will look at me unfavourably but seriously... what is wrong with the concept of a "medical secretary?" I mean there's a lot of practical considerations to any form of medicine and I find trying to help my patients navigate the practical aspects of their care rewarding. 

There's so much important work even if it's more general or "less challenging" (I guess in the academic sense that's true, but I don't think it's always the case with complexity). It's odd that people think of medicine more as the condition or series of diagnosis, rather than the marriage between a clinical condition and the social determinants of health + surroundings that make up their condition. 

I regularly try to help with recruiting physicians in primary care roles or the "less glamorous" aspects of medicine (inner city, addictions, community medicine) but I just think we focus so much on this concept of what it means to be a diagnostician when we should also consider health as a general concept. 

That said ... that's probably why I'm in public health and preventive medicine and only now do clinical work part time. I would in the future love to keep doing clinical work (may or may not specifically be prevention/population health focused), but it's so disheartening to see so many people dislike FM work. 

I apologize if I derailed the thread and if people wish to disagree with my opinion fervently I also understand. I really do hope that those who read this thread aren't turned off by FM because there's really important and amazing work done by GPs regularly. 

- G 

[bellejolie]

2 minutes ago, GH0ST said:

I am sure this will stir the pot and people will look at me unfavourably but seriously... what is wrong with the concept of a "medical secretary?" I mean there's a lot of practical considerations to any form of medicine and I find trying to help my patients navigate the practical aspects of their care rewarding. 

There's so much important work even if it's more general or "less challenging" (I guess in the academic sense that's true, but I don't think it's always the case with complexity). It's odd that people think of medicine more as the condition or series of diagnosis, rather than the marriage between a clinical condition and the social determinants of health + surroundings that make up their condition. 

I regularly try to help with recruiting physicians in primary care roles or the "less glamorous" aspects of medicine (inner city, addictions, community medicine) but I just think we focus so much on this concept of what it means to be a diagnostician when we should also consider health as a general concept. 

That said ... that's probably why I'm in public health and preventive medicine and only now do clinical work part time. I would in the future love to keep doing clinical work (may or may not specifically be prevention/population health focused), but it's so disheartening to see so many people dislike FM work. 

I apologize if I derailed the thread and if people wish to disagree with my opinion fervently I also understand. I really do hope that those who read this thread aren't turned off by FM because there's really important and amazing work done by GPs regularly. 

- G 

Not stirring the pot at all! I do agree some of the realities of FM can be tedious for some and my resident colleagues often complain of these things but I personally am ok with it and enjoy it for the most part. I’ve always been highly organized and good with admin. I love the long term relationship with patients. I enjoy addictions and some of the more challenging cases. I love having a diverse practice. But of course like in any specialty there are things I don’t like - i have patients who can be extremely entitled to my time and think I can just call them back at any point in the day, and specialist colleagues who always refer back to us for things (this whole re consult thing happened to me in peds and I made sure to put in the second consult the doctor specifically required a second consult for a second issue and refused to follow up with the patient on their own even though timing was was less than a few weeks). 
 

i just feel like we need to transition to salary mode and many of the issues we face as doctors would really not be a thing. But I guess we’d risk being “less efficient” by government standards since we’d be less motivated to see more patients? I don’t know but this idea of billing i really am starting to hate it and feel it’s quite a flawed system. 

[JohnGrisham]

59 minutes ago, GH0ST said:

I apologize if I derailed the thread and if people wish to disagree with my opinion fervently I also understand. I really do hope that those who read this thread aren't turned off by FM because there's really important and amazing work done by GPs regularly. 

Agreed completely, as my posts may have been a bit pessimistic!

[medigeek]

1 hour ago, GH0ST said:

I am sure this will stir the pot and people will look at me unfavourably but seriously... what is wrong with the concept of a "medical secretary?" I mean there's a lot of practical considerations to any form of medicine and I find trying to help my patients navigate the practical aspects of their care rewarding. 

There's so much important work even if it's more general or "less challenging" (I guess in the academic sense that's true, but I don't think it's always the case with complexity). It's odd that people think of medicine more as the condition or series of diagnosis, rather than the marriage between a clinical condition and the social determinants of health + surroundings that make up their condition. 

I regularly try to help with recruiting physicians in primary care roles or the "less glamorous" aspects of medicine (inner city, addictions, community medicine) but I just think we focus so much on this concept of what it means to be a diagnostician when we should also consider health as a general concept. 

That said ... that's probably why I'm in public health and preventive medicine and only now do clinical work part time. I would in the future love to keep doing clinical work (may or may not specifically be prevention/population health focused), but it's so disheartening to see so many people dislike FM work. 

I apologize if I derailed the thread and if people wish to disagree with my opinion fervently I also understand. I really do hope that those who read this thread aren't turned off by FM because there's really important and amazing work done by GPs regularly. 

- G 

Cause why do you need years of intensive training to be a medical secretary? A regular nurse can do that easily. You literally don't even need an NP or PA, an RN can do it just fine. 

There's a unique physician role for public health because it's a connection between physician clinical care to public health parameters. But you don't need doctors in every corner who are medical secretaries. Again, that job doesn't even need an NP. Now if you add basic easy medicine complaints to it, why exactly can't an NP do 100% of the work? 

The answer is that we justify doctors practicing medicine only because our training is supposed to allow us to not miss less common conditions or atypical presentations AND to manage the vast majority of conditions. 

[medigeek]

2 hours ago, bellejolie said:

Not stirring the pot at all! I do agree some of the realities of FM can be tedious for some and my resident colleagues often complain of these things but I personally am ok with it and enjoy it for the most part. I’ve always been highly organized and good with admin. I love the long term relationship with patients. I enjoy addictions and some of the more challenging cases. I love having a diverse practice. But of course like in any specialty there are things I don’t like - i have patients who can be extremely entitled to my time and think I can just call them back at any point in the day, and specialist colleagues who always refer back to us for things (this whole re consult thing happened to me in peds and I made sure to put in the second consult the doctor specifically required a second consult for a second issue and refused to follow up with the patient on their own even though timing was was less than a few weeks). 
 

i just feel like we need to transition to salary mode and many of the issues we face as doctors would really not be a thing. But I guess we’d risk being “less efficient” by government standards since we’d be less motivated to see more patients? I don’t know but this idea of billing i really am starting to hate it and feel it’s quite a flawed system. 

I think the important part is that we're practicing to the extent of our training and license. Hence, the only point of even having a doctor. 

[1D7]

2 hours ago, bellejolie said:

i just feel like we need to transition to salary mode and many of the issues we face as doctors would really not be a thing. But I guess we’d risk being “less efficient” by government standards since we’d be less motivated to see more patients? I don’t know but this idea of billing i really am starting to hate it and feel it’s quite a flawed system. 

Salary = death of our healthcare system.

The FFS psych practice around me sees 2-3x (literally) the volume of patients the salaried one does. I have no doubt this effect would be seen in more or less any specialty.

Working fast is unpleasant and incurs increased medicolegal risk. Unless it is incentivized, basically everyone will work at a "comfortable" speed which in my experience is 40-50% of their maximum speed.

[GH0ST]

1 hour ago, medigeek said:

Cause why do you need years of intensive training to be a medical secretary? A regular nurse can do that easily. You literally don't even need an NP or PA, an RN can do it just fine. 

There's a unique physician role for public health because it's a connection between physician clinical care to public health parameters. But you don't need doctors in every corner who are medical secretaries. Again, that job doesn't even need an NP. Now if you add basic easy medicine complaints to it, why exactly can't an NP do 100% of the work? 

The answer is that we justify doctors practicing medicine only because our training is supposed to allow us to not miss less common conditions or atypical presentations AND to manage the vast majority of conditions. 

Thank you for your thoughts and to some extent I agree... in a conventional sense a physician is mainly involved in the diagnosis of conditions, though I think that scope doesn't acknowledge the importance and nuances of management. Having the right diagnosis doesn't change the difficulty in trying to get the patient the right management and balance their situation as well. Just using a basic example, we make adjustments in our prescribing to accommodate for insurance/costs, or find alternative means for patients to access medications. I even do home visits to my patients that I know have significant health care access issues, mainly because I think it's important regardless of how inconvenient it is for myself. 

Now the argument there can be made that someone else could also do that or to delegate the work, but as we all know that doesn't always work out either because delays can hinder prognosis. Another public health example that I still continue to advocate for are paid sick days to allow patients who are sick with COVID to have more flexibility to follow public health guidance without worrying about losing their income to pay rent. We know that COVID disproportionately affects lower income communities, especially given the fact the nature of their work (combined with lower wages) makes it so that their exposure risk is higher than others who can work from home. I am continuing to work on advocating for increased paid sick leave for struggling individuals so that the community can be more safe. None of those things are diagnosis related at all and yet are also equally important, especially helpful with the perspective the MD can bring. 

That said, my point wasn't meant to diminish your own ideas, and I'm sure in other specialties this nuance is less important but I'm just trying to share the perspective that management is also something that MDs are uniquely qualified to do and the experience over time is important to navigate these difficult challenges for patients. 

Take care and I hope you have a wonderful day. 

- G 

[medigeek]

1 minute ago, GH0ST said:

Thank you for your thoughts and to some extent I agree... in a conventional sense a physician is mainly involved in the diagnosis of conditions, though I think that scope doesn't acknowledge the importance and nuances of management. Having the right diagnosis doesn't change the difficulty in trying to get the patient the right management and balance their situation as well. Just using a basic example, we make adjustments in our prescribing to accommodate for insurance/costs, or find alternative means for patients to access medications. I even do home visits to my patients that I know have significant health care access issues, mainly because I think it's important regardless of how inconvenient it is for myself. 

Now the argument there can be made that someone else could also do that or to delegate the work, but as we all know that doesn't always work out either because delays can hinder prognosis. Another public health example that I still continue to advocate for are paid sick days to allow patients who are sick with COVID to have more flexibility to follow public health guidance without worrying about losing their income to pay rent. We know that COVID disproportionately affects lower income communities, especially given the fact the nature of their work (combined with lower wages) makes it so that their exposure risk is higher than others who can work from home. I am continuing to work on advocating for increased paid sick leave for struggling individuals so that the community can be more safe. None of those things are diagnosis related at all and yet are also equally important, especially helpful with the perspective the MD can bring. 

That said, my point wasn't meant to diminish your own ideas, and I'm sure in other specialties this nuance is less important but I'm just trying to share the perspective that management is also something that MDs are uniquely qualified to do and the experience over time is important to navigate these difficult challenges for patients. 

Take care and I hope you have a wonderful day. 

- G 

I don't disagree. I just mean those are things to acknowledge and consider but a lot of that doesn't affect the plan of action in the clinic or hospital. Certainly in your job, you take more direct action. But daily clinical practice probably factors those things in, but doesn't necessarily change the final action plan. We all have to consider the patient's social situation for their treatment plan and hence do the best we can. 

I guess I mean does it really affect the whole scope of practice discussion?

[LoquaciousLoquat]

On 2/19/2022 at 8:20 PM, medigeek said:

The answer is that we justify doctors practicing medicine only because our training is supposed to allow us to not miss less common conditions or atypical presentations AND to manage the vast majority of conditions. 

The issue is that primary care, in practice, has no filter on what constitutes as an acceptable consult from the public. Anyone can book an appointment with you for any reason. This reality is what completely makes primary care different from every other specialty.

Most of your work as a family physician will be practicing "shallow" medicine, because by and large, the public will bring to you "shallow" presentations, which you have no choice but to accept. Specialists mostly do not have this problem, since they have far greater control over what they see (and what they don't!).

The argument about "not missing atypical conditions" works better in specialist settings, because it's nigh impossible for midlevels to approach the knowledge / expertise of a specialist. Sure, midlevels can follow algorithms or do an initial consult (which is largely formulaic anyway, a clerk / early resident could do it), but the huge range in disease complications and the medicolegal risk of missing something important will deter midlevels from ever replacing specialists.

However, this argument doesn't really work in family medicine: where a "typical case" either means some form of non-medical secretarial work, or a benign self-limiting condition (that would've improved without ever seeing an MD). An "atypical case" in family medicine means the patient actually has some real organic illness, and in such a situation, it's really not that complicated to follow algorithms and/or start first-line treatment... which the midlevels are already capable of doing. 

Again, this "shallowness" in family medicine has nothing to do with a lack of physician expertise or proper training - it all comes down to a practice environment that allows patients to see a family physician for anything and everything. 

On 2/19/2022 at 8:20 PM, medigeek said:

Cause why do you need years of intensive training to be a medical secretary? A regular nurse can do that easily. You literally don't even need an NP or PA, an RN can do it just fine. 

I think the intensive training for family physicians is from an age before the Internet and the widespread accessibility of information. Without the Internet, you would have to keep more knowledge in your head. You can no longer look up an algorithm or read about the first-line treatment of a less common disease. Hence, it makes sense to go through extensive training even to do "superficial" medicine, because you need to select for smarter people who have the mental horsepower to keep that breadth of information in their heads.

However, with the advent of the digital / Internet age, this intensive training is largely redundant. Breadth of knowledge is no longer a valuable commodity... because you can mentally offload the more algorithmic / formulaic parts of medicine to online references and access them in a matter of seconds.

Instead, depth of expertise (i.e. specialization) has become far more valuable, because 1 - There is less consensus on what is an acceptable course of management, 2 - The information is always evolving, and 3 - Atypical cases / medico-legal risk increases significantly as you dive deeper into a specialty. These are the reasons why specialists are not being replaced (and in my estimation, won't ever be replaced) by digitization +/- mid-levels.

So basically, the rise of the midlevel encroaching on primary care is not just due to politics. It's also that technology has enabled midlevels to become competitors to family physicians in the domain of generalist medicine, whereby the physician's extensive training for breadth of knowledge is nullified by the widespread accessibility of generalist knowledge on established online medical platforms (i.e. UpTodate, DynaMed, etc...)

[medigeek]

6 hours ago, brackenferns said:

The issue is that primary care, in practice, has no filter on what constitutes as an acceptable consult from the public. Anyone can book an appointment with you for any reason. This reality is what completely makes primary care different from every other specialty.

Most of your work as a family physician will be practicing "shallow" medicine, because by and large, the public will bring to you "shallow" presentations, which you have no choice but to accept. Specialists mostly do not have this problem, since they have far greater control over what they see (and what they don't!).

The argument about "not missing atypical conditions" works better in specialist settings, because it's nigh impossible for midlevels to approach the knowledge / expertise of a specialist. Sure, midlevels can follow algorithms or do an initial consult (which is largely formulaic anyway, a clerk / early resident could do it), but the huge range in disease complications and the medicolegal risk of missing something important will deter midlevels from ever replacing specialists.

However, this argument doesn't really work in family medicine: where a "typical case" either means some form of non-medical secretarial work, or a benign self-limiting condition (that would've improved without ever seeing an MD). An "atypical case" in family medicine means the patient actually has some real organic illness, and in such a situation, it's really not that complicated to follow algorithms and/or start first-line treatment... which the midlevels are already capable of doing. 

Again, this "shallowness" in family medicine has nothing to do with a lack of physician expertise or proper training - it all comes down to a practice environment that allows patients to see a family physician for anything and everything. 

I think the intensive training for family physicians is from an age before the Internet and the widespread accessibility of information. Without the Internet, you would have to keep more knowledge in your head. You can no longer look up an algorithm or read about the first-line treatment of a less common disease. Hence, it makes sense to go through extensive training even to do "superficial" medicine, because you need to select for smarter people who have the mental horsepower to keep that breadth of information in their heads.

However, with the advent of the digital / Internet age, this intensive training is largely redundant. Breadth of knowledge is no longer a valuable commodity... because you can mentally offload the more algorithmic / formulaic parts of medicine to online references and access them in a matter of seconds.

Instead, depth of expertise (i.e. specialization) has become far more valuable, because 1 - There is less consensus on what is an acceptable course of management, 2 - The information is always evolving, and 3 - Atypical cases / medico-legal risk increases significantly as you dive deeper into a specialty. These are the reasons why specialists are not being replaced (and in my estimation, won't ever be replaced) by digitization +/- mid-levels.

So basically, the rise of the midlevel encroaching on primary care is not just due to politics. It's also that technology has enabled midlevels to become competitors to family physicians in the domain of generalist medicine, whereby the physician's extensive training for breadth of knowledge is nullified by the widespread accessibility of generalist knowledge on established online medical platforms (i.e. UpTodate, DynaMed, etc...)

 

Superficial and shallow medicine is the patient's first visit with you. But what about follow up visits? I can continue the workup and eventually finalize a diagnosis over several visits. Often significantly quicker than their first specialist appointment (if referred). That diagnosis may or may not need specialist involvement for treatment. But again, "in depth" medical practice is something a family doctor would do on subsequent visits. The shallow aspect only applies to the initial visit. Keep in mind though I'm USA trained where you do (3 years) tons of hours of inpatient medicine and see all sorts of atypical presentations of uncommon illnesses. May not apply to others, but I personally found it helpful when it comes to solo managing super complex patients. 

On the note of PAs/NPs, they already are heavily involved in all specialties in USA. Many have their own niches and practice independently as specialists basically, in USA. This happens in many states, in community and academic centers. And it has been happening for years, with a continued growth every year. They are definitely not practicing just primary care. It's common to refer a patient to a specialist in USA, and they will only ever see a PA or NP. This includes very complex issues, and again includes many settings (this is not just an isolated occurrence). One example I saw was a difficult liver patient who potentially had small duct AMA-negative PSC but they could not finalize a diagnosis. There was no physician involved in this patient's care, even as a curbside. 

Anyway I get what you're saying but i think some of it is different in practice. 

[LoquaciousLoquat]

1 hour ago, medigeek said:

Superficial and shallow medicine is the patient's first visit with you. But what about follow up visits? I can continue the workup and eventually finalize a diagnosis over several visits. Often significantly quicker than their first specialist appointment (if referred).

The issue is that you will see far more patients with self-limiting issues (i.e. viral URIs, contact dermatitis, UTIs, etc...) or secretarial issues (i.e. MD letters, insurance forms, prescription renewals, etc...), than patients with actual medical problems requiring multiple visits for diagnostic or management clarification.

So the question of followup visits doesn't really apply because most patients only need to see you once. Once they get their treatment prescribed or paperwork filled out there's no more "digging" to be done. 

Also, don't forget the issue of volume. Sometimes you can't afford to bring a patient back multiple times and it's better to refer to free up your schedule (i.e. so you can see more superficial medicine that you cannot refer to specialists).

It might be where you practice, but you seem to be seeing far sicker patients than the average. Generally, I would say that "finalizing a diagnosis over several visits" is not something that a family physician would routinely do. 

1 hour ago, medigeek said:

It's common to refer a patient to a specialist in USA, and they will only ever see a PA or NP. This includes very complex issues, and again includes many settings (this is not just an isolated occurrence). One example I saw was a difficult liver patient who potentially had small duct AMA-negative PSC but they could not finalize a diagnosis. There was no physician involved in this patient's care, even as a curbside. 

As a non-traditional applicant, I will come out and say that at the end of day, there is really nothing special about physicians. We are on average, smarter, more hardworking, and better trained, but the bulk of our learning will always be on the job (i.e. when you become staff). The midlevels have long since figured out that they can do the same work we do... by getting the same work experience. 

I saw the writing on the wall. But I decided to go into medicine anyway (and especially family medicine), because as it stands I can still make a fair amount of money (especially in a FHO) and reach my financial goals at an earlier age. I don't think I will do family medicine forever, though. 

[lovemedicinesomuch]

25 minutes ago, brackenferns said:

 

I saw the writing on the wall. But I decided to go into medicine anyway (and especially family medicine), because as it stands I can still make a fair amount of money (especially in a FHO) and reach my financial goals at an earlier age. I don't think I will do family medicine forever, though. 

 

What do you plan to do once you are done with FM?

[frenchpress]

1 hour ago, brackenferns said:

It might be where you practice, but you seem to be seeing far sicker patients than the average. Generally, I would say that "finalizing a diagnosis over several visits" is not something that a family physician would routinely do. 

Disagree. I do this routinely, as do most of the family docs I have worked with. I think part of it is that I am training primarily in rural / suburban centres, but most of the docs I work with a comfortable with complexity and train for complexity. The other big part of it is how you run your practice and what your patient population looks like, which to some extent you can influence. If you have a panel of 1000 patients and it’s easy to get in to see you, your patients will come for routine visits and when weird things happen to them and you get to be the one to work them up. 

[medigeek]

1 hour ago, brackenferns said:

The issue is that you will see far more patients with self-limiting issues (i.e. viral URIs, contact dermatitis, UTIs, etc...) or secretarial issues (i.e. MD letters, insurance forms, prescription renewals, etc...), than patients with actual medical problems requiring multiple visits for diagnostic or management clarification.

Of course, 100% true.

1 hour ago, brackenferns said:

So the question of followup visits doesn't really apply because most patients only need to see you once. Once they get their treatment prescribed or paperwork filled out there's no more "digging" to be done. 

Also, don't forget the issue of volume. Sometimes you can't afford to bring a patient back multiple times and it's better to refer to free up your schedule (i.e. so you can see more superficial medicine that you cannot refer to specialists).

I'm not sure how it frees up time though. The "vast majority of less common things" (if that makes sense) should not take a long time to investigate on a follow up visit. Can you name some examples of things that take up a long time? I asked others for examples and never got any. 

1 hour ago, brackenferns said:

It might be where you practice, but you seem to be seeing far sicker patients than the average. Generally, I would say that "finalizing a diagnosis over several visits" is not something that a family physician would routinely do. 

There's really no reason not to though. The patient gets a quicker diagnosis that way. And I don't agree with the argument that it's a slot taken away from someone else. Those of us who practice hospital medicine or emerg are by default going to be away from the clinic many days as it is. 

1 hour ago, brackenferns said:

As a non-traditional applicant, I will come out and say that at the end of day, there is really nothing special about physicians. We are on average, smarter, more hardworking, and better trained, but the bulk of our learning will always be on the job (i.e. when you become staff). The midlevels have long since figured out that they can do the same work we do... by getting the same work experience. 

I saw the writing on the wall. But I decided to go into medicine anyway (and especially family medicine), because as it stands I can still make a fair amount of money (especially in a FHO) and reach my financial goals at an earlier age. I don't think I will do family medicine forever, though. 

Yeah basically

[LoquaciousLoquat]

1 minute ago, frenchpress said:

Disagree. I do this routinely, as do most of the family docs I have worked with. I think part of it is that I am training primarily in rural / suburban centres. But a big part of it is how you run your practice and what your patient population looks like, which to some extent you can influence. If you have a panel of 1000 patients and it’s easy to get in to see you, your patients will come for routine visits and when weird things happen to them and you get to be the one to work them up.

I think we're on the same page still; I was imagining "several visits" as bringing the patient back for >3 appointments for multiple rounds of investigations while still not having a clear diagnosis. For me at least, that doesn't often happen.

What is more routine is a patient coming in with an undifferentiated complaint, and then I can narrow it down with either 1-2 rounds of investigations, or 1-2 rounds of a medication / treatment / lifestyle intervention that ends up making them better (hence confirming the working diagnosis). 

[medigeek]

8 minutes ago, frenchpress said:

Disagree. I do this routinely, as do most of the family docs I have worked with. I think part of it is that I am training primarily in rural / suburban centres. But a big part of it is how you run your practice and what your patient population looks like, which to some extent you can influence. If you have a panel of 1000 patients and it’s easy to get in to see you, your patients will come for routine visits and when weird things happen to them and you get to be the one to work them up. 

Yeah I mean I'm not going to be working up the super nuanced pediatric immunologic conditions. But I can definitely treat HepC or workup nephrotic syndrome or do rheum workups.