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A fourth of U.S. health visits now delivered by non-physicians

hms.harvard.edu

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Re: A fourth of U.S. health visits now delivered by non-physicians

#61

Post by FireBeyond »

enragedcacti wrote: post #49
pen2l wrote: post #18

In a very meaningful way the line between physician and non-physician had been blurring anyway. There's a software called Epic which is used by virtually all large healthcare centers, and while most know it as a database system to store patient history and health records (problems and conditions they've been diagnosed for, lab work results, medicine they're currently taking or have taken in the past), it also has a l…

Only planning for the common case is an insane thing to do in healthcare. We don't train doctors for 12 years so that they are faster or more efficient at diagnosing the common cold, we train them so that they have a wide breadth of knowledge, experience, and skills. People already have difficulty getting satisfying diagnoses from MDs with 12 years of training + Epic, imagine how much worse it would be if the person…

Exactly. Not everything is a zebra, plenty of horses, but...

When I teach new EMTs, there's a common topic that comes up. For clarity, EMTs undergo about 200 hours of training, for what is called BLS (basic life support) - essentially non-invasive processes. Generally they can only administer about 5 medicines (oxygen, aspirin, epinephrine, glucose, nitroglycerin). Paramedics undergo up to 1600 hours of training, for ALS (advanced life support), and can start IVs, administer ~40 medications, and do a variety of invasive procedures.

So our local EMS protocols say that if you administer a caloric supplement (i.e. glucose) for someone with hypoglycemia, you must "upgrade" that call to ALS and have a paramedic respond.

"But what if the patient is getting better?" As expected, as hoped. And if the hypoglycemia is really just that, then 99% of those patients won't need, or want, further care/transport. And for 99% of that 99% (arbitrary, but very high, percentages), it's probably entirely reasonable. "So if they're getting better, why do we want a higher level of care?"

For the zebras. For the person with endocrine issues, or for whom hypoglycemia isn't a simple diabetes-related thing, but actually symptomatic of early organ failure, or other things, to get a deeper review to make sure we don't say "Sure thing, Mrs Smith, just stay home and have your husband make you a PB&J or two for some complex carbs" to the patient who has something more serious going on.

Re: A fourth of U.S. health visits now delivered by non-physicians

#62

Post by FireBeyond »

fnfjfkdngh wrote: post #5

Because PA time is cheaper to the provider than MD time. Give it a few years and a trip to the doctor's office will mean using a touch screen a-la-mcdonalds to describe your symptoms and then the first-line medication pops out of a drawer. I'm pretty jaded with our (US) healthcare system. As long as you stay on the happy path it's fine, but if you stray from that, good luck. Over the last few years I was given antibi…

> Similar for SSRIs. Asked the shrink why SSRIs versus something else - 'got to start somewhere'. Asked them why one SSRI over another, same answer.

At the risk of over-simplifying - and certainly not justifying blasé, ambivalent answers... the brain is a very complex organism. And we have barely scratched the surface of how it actually works. Most of it, we just don't know.

So, from this to psychiatric drugs - SSRIs, MAOIs, SNRIs. Read the drug information sheet in the packet. Not just the "standard" paragraphs on side effects and warnings. All prescription drugs are required to specify "how" the drug works.

For a startlingly high number of these drugs, this paragraph starts with the words:

> It is not understood precisely how [drug] works. It is believed that it does X, Y and Z...

(emphasis mine).

We know that they can work for some people and not others. But while we can perhaps make decent educated guesses, a lot of the time, we can't, because, hell, we don't really know how it even actually works, so we can't know it will work for you.

Disclaimer: while I am medically educated and work as a prehospital provider, I'm not a MHP, despite my use of 'we' in the previous para.

Re: A fourth of U.S. health visits now delivered by non-physicians

#63

Post by syedkarim »

outlace wrote: post #28

MD here. I'm of two minds about this. On the one hand, obviously there's a bit of defensiveness since I went through 12 years of school and training to be an independent physician (4 years college, 4 years medical school, 4 years residency) and I've definitely seen subpar care from other "providers" (not a fan of the term) with less training. The wide variety of different "providers" is also confusing to patients who…

Why do you include your undergraduate degree as part of your medical training? I've asked dozens of doctors (and lawyers) about the relevance of their college/undergraduate education to their day-to-day work and none have said it was critical, most have said it was not relevant, and some have had completely non-medical majors (music and physics). Of course, maybe it's different for you, which is why I ask.

Re: A fourth of U.S. health visits now delivered by non-physicians

#64

Post by ngngngng »

outlace wrote: post #28

MD here. I'm of two minds about this. On the one hand, obviously there's a bit of defensiveness since I went through 12 years of school and training to be an independent physician (4 years college, 4 years medical school, 4 years residency) and I've definitely seen subpar care from other "providers" (not a fan of the term) with less training. The wide variety of different "providers" is also confusing to patients who…

> On the other hand, a lot of what I do doesn't require 12 years of training

What, besides surgery, really requires 12 years of training? I've found I have a greater success rate with self diagnosis and treatment than I have with seeing my physician, and I've found a very good internist. An hour spent with ChatGPT and Google and I always find a couple options that fit what I'm experiencing as well as detailed descriptions on how to narrow it down. And since I'm the one experiencing the symptoms, there's no chance of a communications breakdown between me and the doctor who is trying to diagnose me.

Re: A fourth of U.S. health visits now delivered by non-physicians

#65

Post by bshacklett »

jdsleppy wrote: post #59
hn_throwaway_99 wrote: post #6

Honestly, I don't have any problem with this, and I see it as a great thing. 95% of the time when I go to the doctor it's something routine and basic, e.g. I just need someone to diagnose my cold/flu/infection etc. My question, though, is where are all the "savings" going if so many visits are now seen by lower paid professionals? I was referred to a sleep study, where a PA or nurse practitioner just proceeded to ask…

Why go to the doctor to be told it's a flu or a cold? There's nothing to do but treat yourself well and wait, right? I wonder what portion of visits are for common viruses.

Many jobs require a “doctor’s note” for absences.

Re: A fourth of U.S. health visits now delivered by non-physicians

#66

Post by WirelessGigabit »

syedkarim wrote: post #63
outlace wrote: post #28

MD here. I'm of two minds about this. On the one hand, obviously there's a bit of defensiveness since I went through 12 years of school and training to be an independent physician (4 years college, 4 years medical school, 4 years residency) and I've definitely seen subpar care from other "providers" (not a fan of the term) with less training. The wide variety of different "providers" is also confusing to patients who…

Why do you include your undergraduate degree as part of your medical training? I've asked dozens of doctors (and lawyers) about the relevance of their college/undergraduate education to their day-to-day work and none have said it was critical, most have said it was not relevant, and some have had completely non-medical majors (music and physics). Of course, maybe it's different for you, which is why I ask.

It could be more of explaining the total duration and cost of how long they went to college.

If it's required to have an undergrad I believe one can mention it, even if the undergraduate isn't required.

Like in Belgium you need to have a masters for certain government jobs, but it's not relevant in which field.

Re: A fourth of U.S. health visits now delivered by non-physicians

#67

Post by FireBeyond »

subharmonicon wrote: post #26

Related: I was shocked when I tried to get a COVID booster in NY State and they told me they didn’t have a registered nurse on staff that day so they couldn’t do any vaccinations. In California, all of my vaccinations have come from phlebotomists, and it seems that pharmacists can also do them here. Why does NY State require an RN?

WA state during COVID basically authorized EMTs to administer the vaccine. I mean it's literally "find this landmark on the lateral arm, steadily insert needle into muscle tissue, depress plunger, withdraw needle, massage site, bandaid". They had to do a 30 minute "training" on it.

Re: A fourth of U.S. health visits now delivered by non-physicians

#68

Post by nharada »

ngngngng wrote: post #64
outlace wrote: post #28

MD here. I'm of two minds about this. On the one hand, obviously there's a bit of defensiveness since I went through 12 years of school and training to be an independent physician (4 years college, 4 years medical school, 4 years residency) and I've definitely seen subpar care from other "providers" (not a fan of the term) with less training. The wide variety of different "providers" is also confusing to patients who…

> On the other hand, a lot of what I do doesn't require 12 years of training What, besides surgery, really requires 12 years of training? I've found I have a greater success rate with self diagnosis and treatment than I have with seeing my physician, and I've found a very good internist. An hour spent with ChatGPT and Google and I always find a couple options that fit what I'm experiencing as well as detailed descrip…

I think where this breaks down is when you have something rare that requires immediate attention. My impression is that a lot of that medical training is being able to say "oh that's unusual, you need to see a specialist".

Re: A fourth of U.S. health visits now delivered by non-physicians

#69

Post by sys_64738 »

diogenescynic wrote: post #25

If you go to urgent care, you most likely won't get a physician. 9/10 visits are urgent care you only see a PA or NP and they can't even really do much. Urgent care seems to also provide really poor results--every time I've gone it's a long wait, the workers seem over-stressed, you barely get any time with the doctor, and usually they just do a strep test or give you a Zithromax pack and hope you'll go away.

> If you go to urgent care, you most likely won't get a physician.

Not my experience. Every time I've gone to urgent care I am always seen by a MD.

Re: A fourth of U.S. health visits now delivered by non-physicians

#70

Post by SOLAR_FIELDS »

ngngngng wrote: post #64
outlace wrote: post #28

MD here. I'm of two minds about this. On the one hand, obviously there's a bit of defensiveness since I went through 12 years of school and training to be an independent physician (4 years college, 4 years medical school, 4 years residency) and I've definitely seen subpar care from other "providers" (not a fan of the term) with less training. The wide variety of different "providers" is also confusing to patients who…

> On the other hand, a lot of what I do doesn't require 12 years of training What, besides surgery, really requires 12 years of training? I've found I have a greater success rate with self diagnosis and treatment than I have with seeing my physician, and I've found a very good internist. An hour spent with ChatGPT and Google and I always find a couple options that fit what I'm experiencing as well as detailed descrip…

A recent occurrence I will share related to this was having to convince my doctor that I had Lyme disease. I Googled the symptoms, saw the trademark bullseye, and of course concluded that I had Lyme disease. It was right where I got the tick bite, 8 weeks later.

My doctor refused to believe me. He told me to see a dermatologist about it, thinking it was some skin rash, even though it was exactly where the tick had bit me and it was a bullseye. I shortly thereafter went to an urgent care center where fortunately an RN happened to be from Maryland (I live in the South, where Lyme disease is not really a thing) and she immediately saw my rash and prescribed me the appropriate antibiotics.

The reason my doctor did not believe me? It took 8 weeks for the bullseye to develop. I had gotten the tick bite in Europe (which of course I informed the doctor of very first thing). Typically American Lyme disease displays symptoms much faster (days instead of weeks). The doctor did not bother to do any research to discover what I had found in a few minutes of Googling: that European Lyme disease takes much longer to display symptoms (and I had told him as such as well). He was happy to simply assume that all Lyme disease takes only days to display symptoms instead of weeks, because that's what he knew of, and since mine had taken weeks, well, I just must simply be wrong.

My doctor did have a small redemption: once he was confronted with evidence and did the research himself on what I was saying (after the RN had already treated me), he did call me and apologize. But still. This is a daily occurrence, especially for people that are of underserved genders and races.

I realize this turned into a bit of a rant, but in essence I just want to affirm what you're saying. A lot of doctors, especially PCP, are often not much more than glorified technicians. Combine that with the ego problems that typically accompany being an MD and you get a recipe for people getting subpar care, especially women and minorities.

In the end, unfortunately, only you are responsible for your own medical care and getting the best outcome. It is not sufficient to just trust someone else because they have the words MD after their name.

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