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Now browsing: Hometown News > Columnist Archives > Counseling - R.J. Oenbrink

Family doctors versus primary care providers
Rating: 1.86 / 5 (311 votes)  
Posted: 2007 Oct 19 - 02:55

There's a lot of confusion as to what's what and who to go to regarding medical care.

Primary care provider is a somewhat misleading and vague term. There are "physician extenders," such as certified physician assistants and registered nurse practitioners.

Physician extenders typically have up to four years of college, which may or may not include a bachelor's degree. There will be training in how to take care of patients under a physician's supervision.

Certified PAs have a licensing exam that they must take in order to practice. Once they pass that exam, they practice under direct supervision from a physician.

RNPs don't have quite the same restrictions. The biggest shortfall of these providers is that while they can do some more straightforward things in the clinic, both lack the depth of training required of physicians.

This means that while the correct drug can be prescribed, it's not always fully understood how and why this is the correct medication. It can also lead to mis-prescribing medications and over-prescribing at other times.

To their credit, "mid-level" providers are frequently applauded for taking a lot more time with patients and patients appreciate this immensely. They are also better able to provide a lot more patient education.

One common complaint about physicians is that they seem aloof and distant. This complaint seems to be less commonly made against mid-level providers.

Levels of supervision vary depending on the extenders' experience skill and training.

A recent trend is to have these providers, especially RNPs working in drugstore clinics, more commonly among the larger chain drugstores. Supervision doesn't imply that the supervisor is in the building. In some areas, RNPs can practice independently without much supervision at all, even writing prescriptions for a variety of medications as would traditionally be done by a physician.

The supervision they get may be in the form of written protocols. This can lead to a "cookbook" medical practice, which can be inadequate, because patients don't always present straightforward problems "by the book." After all, that's what makes this the practice of medicine.

Difficulties arise when these providers get in "over their heads" or more worrisome, when they don't recognize that they've exceeded the limits of their training. This is when the supervisor is supposed to be able to step in and take over. While this can happen easily in a physician's office, it's not always so easy with an independently practicing "provider."

When multiple simultaneous problems/diseases are ongoing, things can become quite challenging. One condition may alter the presentation and treatment of another. Having four to five simultaneous ongoing problems that require different treatment strategies will challenge the most skilled and experienced doctor.

There is a lot to be said, however, for having a deep understanding of disease processes, why they appears and understanding how therapies will act to lessen the impact of conditions. This understanding is obtained more readily by physicians, who typically have a four-year college degree, with at least a bachelor's degree, prior to going on to another four years of medical school.

Once this eight-year stint has concluded it's time to start the internship and/or residency training. In bygone years, many generalist physicians would practice after a single year of internship, earning the title of "GP" or general practitioner. Probably the most comprehensive of the specialties involves family practice.

Specialists have training beyond the first post-graduate or internship year. Family physicians and general internal medicine specialists (internists) have at least three years of training beyond the eight years of college and medical school. After completion of all of this training, they're qualified to take a specialty examination for their specialty. If they pass this examination they are called board certified.

There are two certifying boards for family physicians: the American Board of Family Medicine certifies MDs, while the American Board of Osteopathic Family Physicians certifies the DOs. A few of us have passed examinations given by both boards.

Family practice was the first specialty to require periodic re-certification. We need to repeat the examination and do other work every seven to eight years to maintain our certification credentials.

Other specialties are following our lead. Most of these specialties are "partialists," who choose to specialize in a given organ system; neurologists for the brain, ophthalmologists for the eyes, etc.

There seems to be a general increase in the number of physician extenders being used in all specialties. This may have to do with simple economics. It's cheaper to provide care with less educated providers. The big managed care insurance companies, and even the government, are always looking for ways to keep costs down while publicly talking about how important quality is.

Unfortunately, incomes for physicians have declined steadily over the past five years. Even more unfortunate to those of us who have taken the time to specialize in the primary care areas, we've been hit the hardest. Before the reader thinks the above sentence is an indication of simple greed by the writer, please consider the future of medical care in our country.

Currently, fewer numbers of medical students than ever are choosing to enter the primary care specialties, choosing the much more lucrative partialist specialties. We need to change health care delivery in our country; few if any will argue this. The only way to get qualified primary care doctors is to pay adequately to help make up for 12 or more years of training after high-school followed by 50-60 hours of work weekly, and the necessity of maintaining board-certification and all of the other responsibilities that we have.

Another couple of unfortunate facts: there is a large group of primary care doctors who are now retiring from their practices, taking their accumulated wisdom with them; fewer numbers of doctors are entering these specialties and we're losing a wealth of knowledge. There is a predicted shortage of physicians in the next several years as our population ages. Primary care will be the hardest hit if things don't change in terms of how healthcare for our country is planned and reimbursed.

Our primary care sector needs to be empowered and revitalized to make it attractive to bright young people willing to spend four years in college, then four more in medical school while amassing great debt, to be followed by more years of training before they have the opportunity to try to go out and earn a living while paying off their educational debt.

We need to be permitted to provide the care that we're trained to provide, not limited by capricious policies of hospitals, governments and insurance companies.

We are highly-trained specialists who have been roped in by inadequate reimbursements and policies at all levels that stifle growth and professional development.

Institutions are committed to maintaining the status quo: partialist and institution-driven health care that will drive our great nation to the poorhouse while allowing many innocents to die.

R.J. Oenbrink of Tequesta Family Practice is a board certified doctor of osteopathy. His offices are located at 395 Tequesta Drive, Suite B. Send your questions to: pbnews@hometownnewsol.com. He is available to speak to groups on this or a variety of other topics. Please call his office, if interested, at (561) 746-4333.





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