NP Encroachment

[LoquaciousLoquat]

Most family physicians I know are already very, very hard-working. We just want to be compensated according to our level of investment and training.

[jb24]

8 hours ago, brackenferns said:

Pharmacists have just opened up a walk-in clinic in Edmonton.

To anyone who still wants to go into primary care family medicine... I don't know what to tell you at this point.

Weird how they think pharmacists can do "primary care" without a medical residency. Why even bother having residency? 

But yeah, big pharmacy chains have a lot of lobbying power in Canada. 

[LoquaciousLoquat]

Yet family medicine is increasing residency length to three years...

[Bobthebuilder]

4 hours ago, jb24 said:

Weird how they think pharmacists can do "primary care" without a medical residency. Why even bother having residency? 

But yeah, big pharmacy chains have a lot of lobbying power in Canada. 

It is some form of primary care for sure but it is extremely limited. Pharmacists will mostly do consults for primary care docs and then send recs, med reviews, medication adjustements for common chronic conditions (hypoT4, migraine prophy, HTA, DM2, etc.), treat minor illness such as mild constipation or whatever. There clearly wont be any complete diagnosis made there. Mostly symptomatic and syndromic approaches to clinical presentation. 

Don't know exactly why someone would open-up a new clinic instead of using pharmacy exam/consult room but whatever. As a pharmacist and now med student, I welcome the move from a prescription-based reimbursement to a service-based model that is clear to me. Rest assured pharmacists aint coming for your jobs. It is high quality and complementary to what is offered already. Could give a few examples where pharmacists are working extremely well with new practice rights they have acquired. (such as warfarine adjusments)

[LoquaciousLoquat]

51 minutes ago, Bobthebuilder said:

It is some form of primary care for sure but it is extremely limited. Pharmacists will mostly do consults for primary care docs and then send recs, med reviews, medication adjustements for common chronic conditions (hypoT4, migraine prophy, HTA, DM2, etc.), treat minor illness such as mild constipation or whatever. There clearly wont be any complete diagnosis made there. Mostly symptomatic and syndromic approaches to clinical presentation. 

For the record, it's not a "consult" if the physician did not make an explicit referral. It's the pharmacist making a unilateral decision to practice and treat independently, and making the physician unwittingly responsible for any complications and/or downstream effects. (That "minor ailment" red eye? Actually it's acute angle closure glaucoma)

I'm also not sure how pharmacists are "adjusting medications", so they're independently ordering bloodwork and other tests and prescribing a treatment? If that's the case, I don't see how it's "extremely limited" since that's literally what physicians do, at least in principle. The difference being that physicians are explicitly trained to do this sort of thing. I also don't see how pharmacists treating independently is supposed to work when the patient already has physicians / specialists. 

A bit of a rant here: as a practicing physician, the amount of pharmacists who overstep and start making all sorts of clinical suggestions currently is honestly mind-boggling. I've seen them attempt to diagnose depression, with the suggestion to "please increase the patient's antidepressants or refer to psychiatry". Or another one: "patient reported heartburn, please consider a PPI or refer to gastroenterology." So no, I do not find these suggestions to be helpful. Frankly speaking, I find the majority of pharmacist clinical suggestions to be borderline insulting - "please consider this first-line treatment for a random symptom the patient reported today, and if this does not improve, please refer to a specialist roughly in this body area". I really don't see the "high quality" care from them that you're suggesting.

[Ernest Therriault]

9 hours ago, brackenferns said:

For the record, it's not a "consult" if the physician did not make an explicit referral. It's the pharmacist making a unilateral decision to practice and treat independently, and making the physician unwittingly responsible for any complications and/or downstream effects. (That "minor ailment" red eye? Actually it's acute angle closure glaucoma)

I'm also not sure how pharmacists are "adjusting medications", so they're independently ordering bloodwork and other tests and prescribing a treatment? If that's the case, I don't see how it's "extremely limited" since that's literally what physicians do, at least in principle. The difference being that physicians are explicitly trained to do this sort of thing. I also don't see how pharmacists treating independently is supposed to work when the patient already has physicians / specialists. 

A bit of a rant here: as a practicing physician, the amount of pharmacists who overstep and start making all sorts of clinical suggestions currently is honestly mind-boggling. I've seen them attempt to diagnose depression, with the suggestion to "please increase the patient's antidepressants or refer to psychiatry". Or another one: "patient reported heartburn, please consider a PPI or refer to gastroenterology." So no, I do not find these suggestions to be helpful. Frankly speaking, I find the majority of pharmacist clinical suggestions to be borderline insulting - "please consider this first-line treatment for a random symptom the patient reported today, and if this does not improve, please refer to a specialist roughly in this body area". I really don't see the "high quality" care from them that you're suggesting.

I am sorry you've had this experience and that you didn't find their input valuable. You have your opinion. I respect that. I have a different view and my physician colleagues do too. (And The college of physicians apparently)

I'd gladly invite you to come and see what we do. I'm sure you'd be surprised. 

I do not know where you practice but here pharmacists have been ordering lab tests independently for the last 7 years.

[LoquaciousLoquat]

What I and many other physicians find difficult is the rise of non-MD providers independently performing services for our patients without our prior knowledge. It's especially problematic when said services overlap with what we do... except we ultimately are obligated to take full responsibility if something goes wrong.

My tone was probably more pessimistic than warranted. I do value my pharmacist colleagues and find their advice very helpful within the realm of pharmacology. However, what I find problematic is the unwarranted clinical management advice, or trying to take over as the first point-of-access for care (I've had pharmacists tell my patients to go to them first for any issues, and they'll decide it's worth seeing me), or diagnosing the so-called minor ailments but ultimately all misdiagnoses ends up being the responsibility of the family physician anyway. Many other of my physician colleagues have noticed the same patterns, so I doubt it's just me or where I practice.

[GH0ST]

18 minutes ago, brackenferns said:

What I and many other physicians find difficult is the rise of non-MD providers independently performing services for our patients without our prior knowledge. It's especially problematic when said services overlap with what we do... except we ultimately are obligated to take full responsibility if something goes wrong.

My tone was probably more pessimistic than warranted. I do value my pharmacist colleagues and find their advice very helpful within the realm of pharmacology. However, what I find problematic is the unwarranted clinical management advice, or trying to take over as the first point-of-access for care (I've had pharmacists tell my patients to go to them first for any issues, and they'll decide it's worth seeing me), or diagnosing the so-called minor ailments but ultimately all misdiagnoses ends up being the responsibility of the family physician anyway. Many other of my physician colleagues have noticed the same patterns, so I doubt it's just me or where I practice.

This is what I find most bothersome... I also see many situations where the pharmacist attempts to override my management with their suggestions without any understanding of the context, let alone the clinical acumen. 

- G 

[shikimate]

Well for FM to work well, there should be 1 central coordinator who has a grasp of the entire patient's chart. If the patient sees pharmacy for ABC, NP for DEF and specialists for XYZ but nobody takes the leadership role, eventually something will fall through the cracks. 

Btw I've seen this on the autopsy table a few times whereby long time ago, somebody told the patient/family about some abnormal thing that might require future check, but obviously was forgotten...

[indefatigable]

On 12/12/2022 at 1:23 PM, Edict said:

Although this seems mind boggling, the real reason of course for this is that this contract is a get out of jail free card for whatever government which enacted it since 5 years is just about the time that a government serves in office for. Its a temporary solution to a problem that is much more complex to deal with. For example, raising the fees for family doctors would be a permanent thing not temporary, it would probably involve negotiation with other specialists who would want increases etc etc. This is a quick and easy way to solve a problem that the government can't easily fix and a nice easy way to make a profit for this company. 

The key thing about Fonemed is that they have to hire NPs who are licensed in NFLD and live there, so that in itself forces them to charge a premium. 

When we look at this problem closely though, as physicians we created this problem as well. The new generation of physicians doesn't want to work the same hours, doesn't want to live in rural areas and this is what government's have been left with. The government is getting less ROI for every physician they train compared to before. The government can't make us work there, but the government also can't afford to pay doctors twice as much to convince people to work there. They are increasingly being forced to rely on NPs. 

I have no idea of what the NL government is thinking -I have a feeling the whole system is more politically motivated -e.g. greedy doctors etc.  NP from NL may tick the right checkmarks.  Also an "always on" 811 service is convenient.  I suspect having enough calls to show it's useful but not too many is the key point.  I don't see why GP call groups couldn't directly handle the calls.     

I listened to this situation recently in NL 1) patient phones 811; 2) NP directs them to go to their family or other doctor; 3) patient tries to get FP assesment; 4) FP is not available goes to ER.  So step 2) is a consult/triage with a NP that directs the patient to GP.  The consult/triage costs twice as much as an FP consult would have cost.  FP is capped in terms of number of telephone consults they can do (which actually cost half as much as 811).  Patient ends up in ER anyways.  

In terms of work a big study just came out saying that FPs work just as hard (at least in terms of patients) than in the past.  I suspect they are doing less however (e.g. less anesthesia, obstetrics, ER..).  

https://www.cbc.ca/news/canada/nova-scotia/study-dalhousie-family-doctors-1.6682845

 

[Edict]

11 hours ago, indefatigable said:

I have no idea of what the NL government is thinking -I have a feeling the whole system is more politically motivated -e.g. greedy doctors etc.  NP from NL may tick the right checkmarks.  Also an "always on" 811 service is convenient.  I suspect having enough calls to show it's useful but not too many is the key point.  I don't see why GP call groups couldn't directly handle the calls.     

I listened to this situation recently in NL 1) patient phones 811; 2) NP directs them to go to their family or other doctor; 3) patient tries to get FP assesment; 4) FP is not available goes to ER.  So step 2) is a consult/triage with a NP that directs the patient to GP.  The consult/triage costs twice as much as an FP consult would have cost.  FP is capped in terms of number of telephone consults they can do (which actually cost half as much as 811).  Patient ends up in ER anyways.  

In terms of work a big study just came out saying that FPs work just as hard (at least in terms of patients) than in the past.  I suspect they are doing less however (e.g. less anesthesia, obstetrics, ER..).  

https://www.cbc.ca/news/canada/nova-scotia/study-dalhousie-family-doctors-1.6682845

 

I took a look at the study and it is interesting, there appears to be a non-significant trend down overall in terms of patient contacts. People overall are working less, its not just new grads. 

Results: Between 1997/98 and 2017/18, the median number of patient contacts per provider per year fell by between 515 and 1736 contacts in the 4 provinces examined. Median contacts peaked at 27–29 years in practice in all provinces, and median physician-level continuity of care increased until 30 or more years in practice. We found no association between graduation cohort and patient contacts or physician-level continuity of care. 

[1D7]

The rural physicians I worked with agreed that newer generations did not work the same kind of hours. I don't think it's controversial to say that our generations expect a better work-life balance than our predecessors (who were treated better & relatively paid much better compared to COL).

Regardless, I believe the demand/supply mismatch of physician care has been inevitable due to changes in patient demographics (i.e. large number of baby boomers relative to everyone else) and increasing complexity/cost of care.

The change will have to be political, otherwise we will have to continue to quietly accept lower quality of care.

[Edict]

4 hours ago, 1D7 said:

The rural physicians I worked with agreed that newer generations did not work the same kind of hours. I don't think it's controversial to say that our generations expect a better work-life balance than our predecessors (who were treated better & relatively paid much better compared to COL).

Regardless, I believe the demand/supply mismatch of physician care has been inevitable due to changes in patient demographics (i.e. large number of baby boomers relative to everyone else) and increasing complexity/cost of care.

The change will have to be political, otherwise we will have to continue to quietly accept lower quality of care.

I agree, we are going to have to increase family medicine residency spots, train more doctors and likely accept that NPs will have a role as well.  

[indefatigable]

11 hours ago, 1D7 said:

Regardless, I believe the demand/supply mismatch of physician care has been inevitable due to changes in patient demographics (i.e. large number of baby boomers relative to everyone else) and increasing complexity/cost of care.

7 hours ago, Edict said:

I agree, we are going to have to increase family medicine residency spots, train more doctors and likely accept that NPs will have a role as well.  

More family doctors can help, but unfortunately it's not going to fix to health care or even family medicine.  I think the most acute crisis is in the short-staffed and overcrowded ERs/limited hospital capacity/long term care homes,..  Very many ill patients are already followed by family doctors, nurse practitioners,.., We are an older and sicker population that's more difficult and expensive to care for.  Age is a risk factor for almost every single condition.  

The biggest demand/supply mismatch of health and physician care is in rural areas.  Geography is really one of the biggest challenges.  We know that family doctors are essential in those communities.  We also know that they need to practice broad scope medicine because specialist care is much more difficult and it's where family doc can make the biggest impact.  Unfortunately, most CMGs and IMGs don't want to work in those regions - either financial incentives ("carrots") or ROS ("sticks") are often used to bring more physicians into those communities.  The NOSM model seems to have worked the best so far.   

Just adding more family physicians won't solve the rural problem at all - it's much easier for docs to roster healthy urban patients than to go rural.  In fact, patients without a family doc in Ontario tended to be healthier and younger (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3016634/).  I can see a future Ontario government showing improved graphs of rostered patients through increased use of IMGs though as an easy way of showing health care improvements.  It's an easy target.  

I believe that the BC government has realized that it's not so much the number of family doctors as what the family doctors are doing.  An older, complex patient takes more time and work. FFS dis-incentivizes caring for such a patient.  So family docs have chosen to do other things like hospitalist work.  So their new fee structure might really help encourage family docs to do comprehensive care.  

There's actually now even roughly twice the number of FPs per capita than there were 50 years ago - that's not even including other primary care providers.  

[Supervenience]

52 minutes ago, indefatigable said:

More family doctors can help, but unfortunately it's not going to fix to health care or even family medicine.  I think the most acute crisis is in the short-staffed and overcrowded ERs/limited hospital capacity/long term care homes,..  Very many ill patients are already followed by family doctors, nurse practitioners,.., We are an older and sicker population that's more difficult and expensive to care for.  Age is a risk factor for almost every single condition.  

The biggest demand/supply mismatch of health and physician care is in rural areas.  Geography is really one of the biggest challenges.  We know that family doctors are essential in those communities.  We also know that they need to practice broad scope medicine because specialist care is much more difficult and it's where family doc can make the biggest impact.  Unfortunately, most CMGs and IMGs don't want to work in those regions - either financial incentives ("carrots") or ROS ("sticks") are often used to bring more physicians into those communities.  The NOSM model seems to have worked the best so far.   

Just adding more family physicians won't solve the rural problem at all - it's much easier for docs to roster healthy urban patients than to go rural.  In fact, patients without a family doc in Ontario tended to be healthier and younger (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3016634/).  I can see a future Ontario government showing improved graphs of rostered patients through increased use of IMGs though as an easy way of showing health care improvements.  It's an easy target.  

I believe that the BC government has realized that it's not so much the number of family doctors as what the family doctors are doing.  An older, complex patient takes more time and work. FFS dis-incentivizes caring for such a patient.  So family docs have chosen to do other things like hospitalist work.  So their new fee structure might really help encourage family docs to do comprehensive care.  

There's actually now even roughly twice the number of FPs per capita than there were 50 years ago - that's not even including other primary care providers.  

I agree that complexity has become a huge barrier within family practice. Seeing 30-40 patients a day q10-15 minutes for 1 issue visits can feel pretty breezy. Seeing even a single complex geri or psych patient with 9 active issues and a page long problem list for a 45 minute visit can ruin your entire clinic day, and these patients are more and more common and are also less and less likely to be receiving consistent specialist follow up as many specialists are transitioning to consult + short term follow up models.