Primary Care – Drinking the Coolaid
There has been alot of talk in the twitter universe and bloggosphere lately about primary care: how to deliver it, who should deliver it, how to get more people to do it, etc. There’s alot of vitriol about “physician extenders”. There’s alot of strum und drang about the cost of medical school. The death of primary care has been announced and renounced.
I hate to say it, but I’m afraid primary care physicians might have drunk the coolaid. Think about this: what is a medical student qualified to do the minute he graduates with his MD? Nothing. Nada. He/she has to do a residency in something first. The only thing the MD gets you is a really crappy job with really crappy hours and crappy pay for 3-8 years. Why? Because you don’t learn how to be a doctor in medical school. You learn it in residency.
Medical school doesn’t really teach you anything. Much of the curriculum is tradition, an exercise in rote memorization in an age when such knowledge can be found in you pocket. Even the clinical years don’t really instruct much, except how to look enthusiastic 4 hours into a robotic prostatectomy. All medical school gets you is the degree.
Now think about this: if I graduate from college with a degree in, say, journalism, what does that qualify me to do? Nothing. It’s my first job that teaches me how to do the job. The degree is only the entry point, something I can put on a resume so people won’t throw it in the trash. An MD is just a very expensive and time-consuming entry point.
With me so far? So to be able to take care of patients you really need practical experience, an apprenticeship, an internship, a residency, or some kind of structured training. You need to see and treat a whole bunch of people. You need to know your anatomy and physiology and disease processes etc. but you probably don’t need to know where the nucleus ceruleus is. Who knows anatomy and physiology? Any motivated college student might. Doctors do. Nurses do. So if I can take a nurse, who has a college degree and maybe a masters and knows her anatomy and physiology, and give her a residency, how is her ability to diagnose and treat any less valid than the doctors? If I take a guy with a college degree, teach him anatomy and physiology in a physicians assistant program, and give him a whole bunch of experience treating patients with brain tumors, why is he less qualified to first- or second-assist on a surgery than the intern? If I do a residency in anesthesia (my own field) I become the “supervisor” to my certified nurse anesthetist who has been doing anesthesia for 30 years. Not because I know more or am more skilled. Because I have a piece of paper that says I spent $100,000 and 4 years of my life in medical school. That’s it.
I’m going to dare to suggest here that some of the anger about using nurse practitioners to give primary care is that the doctors suspect they’ve been duped. No one wants to hear that the same work can be safely and effectively done by someone who hasn’t “paid” in time and money the same as they have. Do you need 4 years of school and 3 years of residency to be a primary care doctor? I would suggest NO. Do you need 4 years of school and 3 years of residency to be an anesthesiologist? I would suggest NO. Do you need a couple of years to learn how the human body works and 3 years to actually treat a whole bunch of people to be a good healthcare provider? Why not?