Nursing Practitioners capable in primary care?

[Guest Ian Wong]

Here's an interesting article that I dug out of the BMJ. It was published this year in April; I happened to stumble on it while looking for something else. It's a very large retrospective cohort study using a meta-analysis of many previous studies, which concludes that nurse practitioners in developed countries can have the same efficacy as doctors in the primary care setting.

 

<!--EZCODE ITALIC START--> Systematic review of whether nurse practitioners working in primary care can provide equivalent care to doctors<!--EZCODE ITALIC END-->

www.pubmedcentral.gov/articlerender.fcgi?tool=pubmed&pubmedid=11934775

 

Ian

UBC, Med 3

 

 

Edit: Fixing an erroneous statement. -Ian

[Guest cgb]

Just wanted to throw this into the discussion:

 

Nova Scotia is currently conducting a pilot project which incorporates nurse practitioners into the delivery of primary care. I believe it is also true that Ontario's Ministry of Health and Long Term Care is moving towards integrated delivery of primary care which also combines NPs and physicians. In fact, I believe many sites have already been established.

 

I have studied and worked in the health care field in both the US and Canada, and have had the opportunity to work with NPs. I truly believe that the incorporation of NPs will serve to enhance the delivery of primary care in a way that has been long overdue. Complimentary practice involving physicians and NPs has shown great success in the US, and in early Canadian trials. I think that in order to provide patients with high quality, timely patient care, we should begin lifting the monopoly over "physician services" and create a team approach to health care delivery. I really think this team approach could extend beyond NPs as well (We have so many resources that we are not making use of ) In my opinion, it is refreshing to see things moving in this direction.

 

For anyone interested in the Nova Scotia pilot project, it is entitled:

 

"Strengthening Primary Care in Nova Scotia Communities"

 

Bye

[Guest Annon]

I am not connected to health services in any way, but I read these postings for interests sake. Some of them are quite interesting.

 

About nurse practitioners. As a patient, if I have a choice I will definitely go to a doctor. NPs will be my second choice. I know the quality of some of the students go to nursing in our local university. If any of them become NPs, God help us!

[Guest Ian Wong]

Not having seen an NP before, I'd be hard-pressed to make any reliable comments. But, all that extra work we do in medical school and residency has to count for something. If nothing else, the public perception here in Canada would see the licensure of NP's as a cheaper alternative to MD's, and I believe that most patients, if given a choice, would prefer to be seen by a doctor.

 

Also, in Family Med, I appreciated the simple cases a lot of the time (minor musculoskeletal injuries, sore throats, ear infections, annual checkups). It's a chance to get some mental down-time, and these bread-and-butter cases pay the rent. On the other side, dealing with your very chronically sick patients, or your psychiatric patients, or those who need intensive counselling (eg. cancer diagnosis, diagnosis of a chronic condition, addicts, etc) can be very satisfying but also mentally exhausting.

 

I think I'd have a real problem if I was a family doc and my NP got to see all of the "easy" cases, leaving me with all the tough stuff that is out of the NP's element. Getting some straightforward patients into each day would be a requirement to preserve my sanity. Just my opinion.

 

Ian

UBC, Med 3

[Guest Melissa13]

Just for your information Annon, nurse practitioners are not nurses trained in the regular stream from high school straight into undergraduate nursing studies.So the nursing students that you are so worried about having all this extra scope of practice are not the ones that are actually out there practicing. To become a nurse practitioner one must having already been out practicing nursing in some capacity for at least two years before they can even apply to the program...however the vast majority of NPs have had much more than two years under their belts out in practice before they go back to school. These are very well trained, seasoned nurses that you just took a cheap shot at without having the necessary information to make an informed opinion. There are NPs working in several of the hospitals in the Ottawa area and they are well-respected, knowledgeable members of their respective teams. So just a little respect for what they do please.

[Guest Ian Wong]

<!--EZCODE QUOTE START--><blockquote>Quote:<hr> There are NPs working in several of the hospitals in the Ottawa area<hr></blockquote><!--EZCODE QUOTE END--> Really? That's news to me (wouldn't be the first time either). Do you happen to know of any websites that represent NP's in Canada? I'd like to read up more on this.

 

Ian

UBC, Med 3

[Guest Melissa13]

After some quick searching I have found a website for the RNAO (registered nurses association of Ontario) that has an interest group for NPAO. Please feel free to take a look:

 

www.npao.org/

 

It has information on the scope of practice, areas of expertise etc...which make for interesting browsing. My apologies for th abruptness of my last post but I felt that the opinions were somewhat uninformed having had the opportunity to have been educated and instructed by NPs working in Ottawa.

[Guest cgb]

Melissa13:

 

I couldn't agree with you more. I have had first hand experience with NPs, and would certainly feel more than confident in approaching them with any sort of complaint. Many people do not realize that to become a NP, a person must first complete a Bachelor of Nursing (usually 4 years in length), accumulate many years of experience, and complete a subsequent NP Masters program in order to graduate and practice as a NP.

 

While I strongly support the inclusion of NPs into the provision of primary care (an other specialties), I am not surprised at the resistance expressed in this forum - although I must say it is pretty disheartening to find in this forum of otherwise seemingly well-informed individuals. One of the early conclusions made in the Nova Scotia NP pilot project is that much education (directed towards the public and physicians alike) is needed to eliminate misunderstanding of the roles of NPs and facilitate the transition towards interdisciplinary provision of primary care. I think that it is easy to devalue the role of NPs when you lack a fundamental understanding of what they actually do, and how competent they actually are. But I would caution any of you against making an uninformed judgment, and in fact urge you, as medical professionals, to become as informed as possible before entering your own practices.

 

I'll be starting medical school next year, and look forward to providing patient care in an interdisciplinary setting including NPs and other allied health providers. I have seen it to be successful in other settings, and look forward to seeing it here in Canada.

 

For anyone interested in the NS pilot project, here is the address:

 

http://www.gov.ns.ca/health/primary-care/pubs/primarycare.pdf

 

Take care

[Guest yeahbut]

I have no problems with NPs but I wonder if they are just a band-aid solution to the trend of physician shortage or the way of the future, where doctors are relieved of minor procedures so they can concentrate on bigger stuff.

[Guest Ian Wong]

Hi cgb, <!--EZCODE QUOTE START--><blockquote>Quote:<hr> I am not surprised at the resistance expressed in this forum.<hr></blockquote><!--EZCODE QUOTE END-->I hope this isn't in reference to myself. There wasn't any intention in my posts to be negative towards NP's; I don't know them at all. I guess what I was trying to say is that with the introduction of NP's, the family doctor's "traditional role" as the person whom you go to for the quick fixes that don't require specialist intervention are really squeezed. On the one hand, the NP is going to take the cases that don't really need an extensive medical consultation (read: the easy stuff), and this leaves the more complicated matters to the family doctor. So does this leave the family doctor with the role of simply deciding which of these remaining patients (the more difficult ones) need a specialist consultation? I just wonder where, with this new variable of another primary care provider entering the mainstream health care team, the family doctor finds his or her niche?

 

Perhaps an even more difficult question, but one that really cuts right to the heart of the matter, is: If we actually had an ample supply of family doctors in a well-distributed manner, aside from potential cost-control reasons, would we need the services of nurse practitioners? Is there something else that they intrinsically do that we currently lack in the system?

 

I don't have any experience in this matter, and would be curious to hear people's opinions.

 

Ian

UBC, Med 3

[Guest cgb]

No Ian, my comment is not directed at you specifically. After re-reading my post and seeing that - at that point you were one of very few people who had posted, I can see how it might have been perceived that way.

 

I am just constantly amazed (on a daily basis) by the ignorance that health care practitioners have of the role and scope of practice of many or even all of their allied health providers (This isn't directed at you, trust me. Its something that I've readily observed amongst many of the health professions). It is concerning to me that this is not incorporated into medical school curriculums in some way. Perhaps doing this would ease much of the animosity that exists between the various health care professions. Maybe I'm being idealistic, but I think the spirit of what I am saying makes sense. What do you think?

 

Preparing for my med school interviews, and out of personal interest, I read a report on health care human resources in Ontario (link below). In one section it specifically addressed the physician shortage and the maldistribution of physicians that has contributed to most rural communities being underserved. It also goes on to discuss how NP's and other allied health providers could be used to alleviate this problem. It also addresses the fact that simply increasing the total number of graduating physicians and providing rural incentives will never alleviate the current primary care practice - even if all those physicians did go into family practise and subsequently into rural areas (which will never happen). Numerically, when considering the current and anticipated increases in the demand for physician services (more advanced treatments, increased survival from chronic diseases which ultimately lead to an increased need for intense continuing care, etc), the ever increasing aged population, the more balanced lifestyles that primary care physicians are choosing to follow (ex. increased family and leisure time) - the numbers just don't work themselves out. Someone mentioned in a previous post that they perceive the NP initiative to be a "band-aid" solution. I simply do not agree. I think that incentive programs are a band-aid solution, not changing the way we deliver primary care. NPs are being introduced with the anticipation that they will become a permanent fixture in primary care - they are not being introduced as a temporary measure.

 

Ian, I think you are incorrect when you say that the NP is going to take the easier cases. I think that when introducing them into the primary care setting it might be easy for their role to become this if their partner physician doesn't truly understand the extent of their knowledge and/or proficiency. I think that this is were inter-health profession education would be beneficial. In many well established joint practices here in the US, NPs function as an equal partner and/or independently if operating in their own clinic. There is generally not a process in which the clinic receptionist triages all appointments and assigns the less challenging patients to the NP. I think this would be extremely unsatisfying to the NP in this situation. Certainly any NP has the option to seek the advice or consultation of a physician if it is found to be necessary in order to make the differential diagnosis or to prescribe certain medications (ex. narcotics - in certain states). But, they have access to all the same resources and tests.

 

Ian, I think you would find the Ontario report I alluded to above to be pretty interesting. I have linked it below. The section that deals specifically with "making better use of existing resources" is found on page 65. I found the entire report to be really interesting, and I think you would too.

 

www.gov.on.ca/health/engl...kforce.pdf

 

Please don't think I am personally attacking you in any way. That is certainly not my intention. Oh, in case you are wondering - no, I am not a nurse

 

See yah

[Guest Wondering]

So cgb,

 

I am just curious, if a nurse practioner has such a broad scope of practice, why not simply go to medical school instead and become a doctor? What is the difference? Is it just a ploy by governments to get the same care for a cheaper price? Will the NP be paid the same as the doctor or less for the same work? Will that not give rise to a mess of equality issues? If the NP is doing the work of a doctor, why not be a doctor instead? I don't understand the rationale. Please help me.

[Guest cgb]

I think its people might choose to become a NP over a phsyician for various reasons.

 

If a person were already employed and trained as a nurse, it might be more appealing for them to return for a 2 year masters program and become and NP rather than go to medical school for 4 years and subsequently complete another 2 years of residency. Unfortunately, becoming a physician does not coalesce with everyone's life plans, nor is becoming a physician a desire of everyone that works in health care.

 

Some people might might not be interested in being allotted the high degree of autonomy that physicians often possess. I did not claim in any of my my previous posts that NPs have the same autonomy as a physician. While the degree of autonomy they have is often quite high (especially with experience), it is not equivalent to the autonomy afforded to physicians.

 

Why not go to medical school and become a doctor instead? Simple - becoming a physician is not everyone's ambition. Why become a psychologist rather than a psychiatrist? Why become an X-ray technician rather than a radiologist? They are different jobs with different requirements, different roles, and different demands. Becoming a doctor isn't for everyone.

 

Maybe you're right. Maybe it is a ploy by the government, but, I can't say I agree. I support the NP initiative because I think that NPs would be an excellent addition to health care practice - not a phsyician replacement. I know that the nursing profession is extremely happy that governments are finally opening the doors for them to practice. I don't think they see it as a ploy. I come from a rural community where the physician supply is in crisis. I would be more than happy to see a NP if one were available. As I said in my previous post, the physician supply crisis cannot be fixed by simply increasing the number of medical school graduates. I think that diffrentiating the work force and making better use of the resources we have available is a step in the right direction. Just because its different from anything we've ever done in the past doesn't necessarily mean its a ploy or a bad thing in general.

 

Finally, I think you might be misreading, and as a result misrepresenting the things I have written. I never said that NPs are "doing the work of a doctor". Their scopes of practice are different, their training and education is different, and their roles are different. I don't think it is the intent of NPs to ultimately replace physicians. NPs have a defined role in the delivery of health care, as do physicians. I have only claimed that I see NPs as being a great compliment to physician practice in the delivery of primary care. I can't find any good reason we can't change the delivery of primary care such that it becomes a partnership between NPs and physicians rather than one that is physician exclusive. People in rural communities are waiting in excess of 2 weeks to get a 5 minute appointment with their family MD. Something has to be done about that. I have only said that I think they compliment each other well.

 

Hope this helps

[Guest UWOMED2005]

It does help. I'm 4 days a way from finishing 1/4 of my (well, pre-residency) medical training and I've learned more about NPs from reading this site than from all of my lectures combined. Kudos on your point on the need for better training in medical school about the allied health professions.

[Guest Wondering]

Thanks cgb, your comments are intelligent and well thought out. It does help me too.

 

However, as far as "doing the work of a doctor", is that not what they will be doing? They wouldn't have as wide a scope of course, but as Ian pointed out, they would be handling the "bread and butter" of general practice. There is obviously overlap between the two's roles, or am I mistaken about this?

 

I suppose I'm trying to predict the future. Will NP's devalue the work of doctors? Some comments from politicians already point to this. To me, it still seems that the solution to physician shortage is to train more physicians, unless we really agree that physicians should be a "limited commodity" (and thereby be able to command a certain price for services). The NP solution in this case does seem stop gap (or "band-aid" as someone else put it) to address immediate physician shortage concerns (which there are).

 

If you've got the time, I would love to hear more of your thoughts.

[Guest Ian Wong]

Just as an additional comment; I have no axe to grind with NP's, or any other allied-health professions. If NP's did have equivalent practice rights throughout each area of the province, then I can virtually guarantee that the majority of these individuals will be localised to the major cities, and not in the rural towns and communities where they are most sorely needed.

 

Just like doctors, NP's are humans too, and if the majority of NP's originally came from larger cities (and most nurses do), then, like doctors, they are equally unlikely to seek out those rural communities to work in, as that is an unfamiliar environment to them.

 

In my class, the people who intend to practice in rural settings almost invariably came from those locales before med school. The people who were city folks first and foremost seem to have the goals of staying in cities once they start practicing. Therefore, producing more NP's may not do much to alleviate the disproportionment between the numbers of health care providers in the rural and urban setting, as they'll just do what the doctors, physio's, pharmacists, and all the rest do: head for the city.

 

As a second comment, given what I've heard above, I still don't see what niche an NP will fill that a family doctor can't already occupy.

 

This is all just my opinion; I don't have any stats to back up a word of what I'm saying above.

 

Ian

UBC, Med 3

[Guest bluesky125]

I think one of the problem with just training more doctors is currently medical schools do not have the resource to train the number of doctors needed for the next 10 years. I think using NP is used as an supplementary way to help solve the problem with physician shortage. However, what I am concern about is the nursing shortage? Will training NPs diminish our limited pool of nurses?

[Guest UWOMED2005]

That's an excellent point Ian. The greatest shortage of Family Physicians is in rural setting. . . and beyond the issue of whether Nurse Practioners would want to practice in a small community, is whether they could fulfill the role of the small community (aka rural) doc. While, as previously stated, my understanding of Nurse Practioners is rather limited (I do understand that they have advanced training compared to other nurses, and I've heard they've been given some prescription priveleges) my understanding of rural medicine is a fair bit better (and will be better this time two weeks - I'm off to do a one week mini-clerkship in Newbury, Ontario as of next Sunday!) In many smaller communities, the family physician is practically it when it comes to health care. . . that rural family docs have to provide a much wider range of services (ie obstetrics, some surgical scrub-ins, etc.) as they are in some cases the only health care available.

 

Just adding some fuel to the debate. . .

[Guest MarmotYVR]

When I worked in Nunavut, the remote health stations were staffed completely with nurses. Family docs visited about once a month to follow-up with more complex cases, and were available for phone consults. The nurses, however, ran the show - literally. They did their own labs, took their own xrays, diagnosed, prescribed, ran public health initiatives, preventative care programs etc etc. They were VERY impressive - and NONE of them even had the extra training of an NP! These nurses worked in such remote locations because it afforded them the opportunity to work to the fullest capacity of their training.

 

I think the "fear" of NPs is financial - yep, they may take over the "bread & butter" cases that pull up a family docs income - but do we really need all of the expertise of a family doctor for simple blood pressure checks, once the initial diagnosis has been made? It may be in the best interests of an MDs bank account, but I don't see any added benefit for the patient OR for taxpayers!

 

I think we, as MDs-to-be, need to look at this with an eye to health economics. What is the most cost-effective way of delivering primary care? Most certainly, NPs, and other allied health should be involved. In fact, studies have shown that patients with HTN, CHF, and those who take coumadin have better outcomes when followed by a pharmacist rather than an MD (I had to throw that one in for my profession!)

 

Yep, NPs would be doing the "job" of a physician - but the question is, what SHOULD be the job of a physician? If a job can be done equally well, if not better, by another health professional, shouldn't we offer them the opportunity? And, if the role of a nurse expanded, maybe more people would be interested in becoming a nurse, as well as contiuing in the profession, cutting down on the shortage. Plus, it would leave docs more time to work on the more complex and interesting cases - also increasing job satisfaction.

 

I look forward to working in a clinic that incorporates NPs, PTs, OTs, dieticians, pharmacists, midwives etc - patients would have better health outcomes at lower cost - shouldn't that be our goal?

[Guest cgb]

MarmotYVR,

 

It seems like you are reading my mind I couldn't agree with you more about an interdisciplinary approach to health care. AND, I completely agree with your point regarding pharmacists. I have a family member that just completed her pharmacy degree and we have talked extensively about the disparity that exists between physicians and pharmacists. She tells me about instances when she has contacted family MD's with suggestions regarding prescriptions (ex. an antibiotic that was prescribed for a pregnant patient that was in fact contraindicated because of her pregnancy), only to be snubbed or belittled by the physician or even worse, by the receptionist at the physicians office after the physician refused to take the call. She has told me about physicians refusing to call in prescriptions to the pharmacy after such instances. And please trust me, the pharmacists of whom I speak display a high degree of professionalism in all their interactions, especially when handling these delicate matters. Medicine is about serving patients in the best way possible. It seems like common sense to me that the best way to optimize a patient's pharmacological regimen and minimize drug interactions along with their subsequent complications would be by working collaboratively with a pharmacist. I think that a collaborative approach to patient care is the best way to serve patients best. My family member and I frequently jokingly talk about the group practice we will set up together when I finish school. Who knows, maybe it will happen. I sure hope so. I think that these combined forces are ideal, along with PTs, OTs, NPs, RN's, midwives, etc.....exactly as you have indicated. Oh, I've added a link below which I think you will find very interesting. It talks about the pharmacist issue exactly as you have addressed.

 

www.cma.ca/cmaj/cmaj_toda.../06_20.htm

 

I mentioned in previous posts that there is mounting evidence that simply increasing the number of medical school graduates will have little effect on alleviating the current and growing future physician crisis. I don't share the view that NPs are a bandaid solution to the health care crisis. How can a complete reform to the way we deliver primary care be a bandaid solution? Could someone address this question? NPs are being introduced as a permanent, not a temporary fixture. The most recent updates from the Nova Scotia pilot project show that NPs have alleviated the burden on physicians such that some physicians have been able to see 40% more patients in the run of a day. To me, that is very encouraging. Nova Scotia has recently passed legislation to allow the permanent introduction to NP into practice. This is a direct result of having observed the positive outcomes that have surfaced out of the 2 year pilot project. If interested see the link below and the one listed in one of my previous posts.

 

www.cma.ca/cmaj/cmaj_toda.../04_15.htm

 

Regarding the recruitment of NPs into rural areas, I'm not really too sure how to respond. It is my understanding that NPs are more or less trained with a focus on rural or remote care. I have no doubt that many NPs will choose not to practice in rural areas as someone has indicated (Ian I think). I also think its possible that many NPs will indeed choose to go into rural practice. It seems as if it would be in these rural areas that they would really be able to function at their fullest capacity. Imagine the satisfaction you would feel functioning at the capacity described in MarmotYVR's Nunavut example.

 

Many provinces are considering a move towards alternative payment plans for physicians to replace the antiquated "fee for service" approach. If this happens, perhaps the looming threat of NPs would become less aversive.

 

I don't think NPs will ever replace family MDs. I think that they function well together. This has been demonstrated for some time in the US, and in parts of Canada already.

 

I'm sure I neglected to address some questions. I'm really interested in this issue and I will try to post at another time.

 

Good luck to everyone on the Friday mail-out

[Guest cgb]

Hey Wondering:

 

I just wanted to address the "bread and butter" issue in your post. I believe this idea is incorrect. In my experience, NPs are not routinely assigned the "bread and butter" cases. In my experience, NPs function as "equal" partners in the primary care setting. Equal partner meaning that NPs see and follow their own regular patients, or other patients as necessary. Let me qualify this by saying that NPs are not allotted the same degree of autonomy as a physician. As a result, NPs regularly review cases with their partner MD, seek MD consultation on certain issues or when prescribing certain medications. In remote settings, NPs often function independently with "on-line" MD consults when necessary (phone, teleconference, etc). Here in the US, NPs operate their own clinics. I am certain that the belief that NPs are routinely assigned the easier cases is incorrect.

[Guest Ian Wong]

It's threads like this that make me realise just how cool this forum is. Nothing like good, clean, informative discussions.

 

With that said, looking at things from the MD point of view, I'm totally happy to concede that my pharm knowledge base stinks compared to a pharmacist. I would certainly hope it does! Just this week I talked to our hospital pharmacist regarding a medication that I'd never heard of before, but that a staff doctor uses regularly. Turns out it's not yet been released in Canada, although it's used all the time in Europe, and has been for the last 20 years.

 

I think one problem with the multidisciplinary approach is the adage that too many cooks spoil the broth. Continuity of care, and having a cohesive and unified management plan can really get hosed to heck if each person brings in their own area of expertise, but forgets or neglects to consider each other's points of view.

 

You see that all the time with complex medical patients, where a psychiatrist may be handling the mental illness, a cardiologist could be tampering with the heart problems, and the family doctor is left to sort out the mess. A recent case that was presented in our psychiatry block concerned an individual with low sexual drive that was alleviated by testosterone, and testosterone alone, but who also had cardiac problems. The cardiologist to the man to stop taking the testosterone, and here's the poor patient stuck between a psychiatrist's recommendations, a cardiologist's advice, and the family doctor stuck in the middle trying to balance the man's failing relationship with his wife while handling the health issues too!

 

All this happened because the cardiologist was only approaching the problem from the heart point of view, while the psychiatrist wasn't considering any adverse physiological problems. I could totally see this scenario occurring in a multi-disciplinary clinic, where a dietician really only knows about nutrition, the pharmacist won't step on the physio's toes when it comes to managing something like low back pain, the occupational therapist needs to co-ordinate with the social worker, etc. You can set up a cycle where there's an awful lot of team meetings, and not a lot of action.

 

I do think that the vision of future health care sees a lot more interaction between the different health sciences. However, as medicine continues to get more and more specialized, I think we'll continue to see more sub-divisions of expertise from each health care profession, which all contributes to lowering the continuity and coordination of care for each patient.<!--EZCODE QUOTE START--><blockquote>Quote:<hr> I also think its possible that many NPs will indeed choose to go into rural practice. It seems as if it would be in these rural areas that they would really be able to function at their fullest capacity. Imagine the satisfaction you would feel functioning at the capacity described in MarmotYVR's Nunavut example.<hr></blockquote><!--EZCODE QUOTE END-->As far as this statement goes, I have to disagree. If this were the case, you would see many family docs pursuing this career as well, because instead of seeing only the urban standard of seeing only office-treatable conditions and referring everything else away, family docs would be out en masse in rural communities delivering babies, administering anesthesia, scrubbing as surgical assists, and working in rural ER's.

 

A lot of my classmates (and I would include myself here), think that being a rural family doctor who was a true generalist and was capable in all of the above would be an amazing career. It's the rural isolation, the crummy lifestyle of being perpetually overworked and on call, and the lack of ready specialist backup that scares most of us away from this path.

 

Ian

UBC, Med 3

[Guest mtws]

Great discussion.

Wish I had have read this when I originally saw it. My wife is a nurse and is seriously considering the NP route in the future. If I get in (knocking wood) our dream is to one day retire to a small practice in cottage country (she could take some of the call - run clinics, etc.). (She's a great nurse and so easy to talk to - perfect for this sort of thing - BUT she doesn't want to be a doctor? Likes to be in the trenches so to speak.)

 

There is an example like this in Sharbot lake (North of Kingston) where a practice (running on capitation) has two doctors and a NP. (I had my poison Ivy checked out there last year - nice place - nice people).

 

Matt

 

P.S. I'm fairly new to these discussion boards and have a tendency to chime-in near the end of discussions. I would like to hear what some of you think of my posts??

 

P.P.S. When someone responds to something you've posted, it's like getting presents.

 

Mattism - "email is like presents".

[Guest marmotYVR]

Your plan sounds great. I would love to work in a clinic like the one you described.

 

Just watch out for the hazards of working with your spouse... It may become difficult to separate your home life from your work life. Plus, if your practice is small, it may be virtually impossible for you to both take holidays at the same time without leaving your patients stranded. Plus, there is the issue that, at some point, the 2 of you will have differing opinions on treatment - this is inevitable between any 2 colleagues. But, b/c you are "the doc", you may (depending on the situation) be in a position to overrule her opinion - which might not make for a pleasant evening after work, ya know? (As a pharmacist who used to work & live with a family doc, trust me, it can get messy!)

 

Good luck!

 

Marmot

[Guest mtws]

...and she's a firecracker too!!