Wow, a non-medical person just peeked behind the curtain! This is not just about cookie-cutter medicine to force physicians to practice in a certain ‘evidence-based, best practice’ manner. It is about making medicine cookie-cutter in order to remove the physician from the equation. There is incredible pressure from multiple fronts to ‘simplify’ medicine to algorithm-based practice. Although I know this is going to offend some readers and is not an ad hominem attack, but the biggest push is coming from nursing organizations. There is constant and incredible pressure to have the Internists and Family Medicine physicians replaced with nurse practitioners, Anesthesiologists replaced with certified nurse anesthetists, Obstetricians with nurse midwives and, in general, remove doctors from any role as supervisor and replace them with nurse management. Just a few days ago the Army put a nurse in charge of all Army physicians (and oh boy the Army’s arm is sore from patting themselves on the back for being so ‘progressive’)! There is a struggle to make medicine ‘turn-key’ so that a patient checks boxes as to what is wrong, the ‘provider’ (because everyone: doctors, nurses, techs, janitors, etc. are now called ‘providers’ lest one feel badly about themselves) checks boxes in reaction to the boxes the patient checked, an algorithm is referenced and a suitable ‘treatment’ is selected.

The scary thing is that is usually works!

As I have always said, 90% of medicine is so simple a high-school grad (with a month or two of training) would be able to do it. It does not take effort or intelligence or training to have a patient check boxes (cold-intolerance, weight gain, hair loss, depression), run it through an algorithm (which equals hypothyroid), follow the ‘instructions’ (draw a TSH and T4 levels), and get a response (if TSH is high and T4 is low then start Synthroid at 100 mcg/day, if elderly and/or cardiac problems then start at 50 mcg/day; schedule patient for lab redraw of TSH at 4-6 weeks and change dose up/down/keep constant based on lab value). The algorithm-based practice is being forced down the physician’s throat in order to have it ‘validated’ so that when it is handed over to mid-level providers it can honestly be said that “it worked for the doctors, it will work for us, and look: we have the same outcomes!*”. *Outcomes are the same except for those times when they are not and it is anyone else’s fault than the algorithm.

This is also why there is an internal drive from NPs, CRNAs and midwives to obtain their Internet-based correspondence Ph.D. so that they too can be called ‘doctors’. This is the future of medical care (especially under Obamacare and its drive for cost containment). It is said the most expensive tool in medicine is the physician’s pen. What better way to make medicine more cost effective than get rid of the physicians?

It'll simplify your life if you have a serious illness. You can be lucky or dead. Seriously, when you remove choice from the equation, what else have you got?

An example of this came into effect with the MDS 3.0 implementation on October 1, 2010.

They went from a 7 page to 37 pages of questions.

Many long term care facilities are being screwed by this.

Actually, the Europeans and Canadians, and Israelis, seem to get roughly the same results from their health care systems as we do, but spend half as much of their GDP to do so.

The problem with Obamacare is probably that it is not single payer, Euro-Israeli style care. It is an expensive compromise.

Those Israelis must be a bunch of idiots to go with socialized medicine.

This is representative of our current medical system, not some scary future Obama-care. And frankly, Kaiser defines the "one-size-fits-all" approach and it actually works pretty well for them in managing chronic disease. I love Kaiser and think it's the right approach for a lot of primary care, but to act as though they personalize medicine is ridiculous. They are all about formula.

Doc Jensen - I don't understand your rant above. You complain about mid-level providers replacing MDs in primary care, but then say that most medicine is simple that anyone can practice it. What is the objection then to mid-level providers as primary care practitioners?

Sam, like I said, things are simple until they are not. You pay for having a trained pilot to fly your plane (over 99% of which could be done by a Cessna flyer with some extra teaching) or an experienced air traffic controller who manages said planes (minus the recent sleeping-on-the-job problems). Same for physicians. You pay for someone who has trained for many, many years to pick up that vague and rare complaint that doesn’t fit into algorithm-based medicine. You pay for the top 5% performance and not the bottom 95%. If you are happy with non-physicians directing your medical care, well, you are getting a Faustian deal (and worse, you don’t even know what deal you are getting). You might as well have Dr. Google treat you.

The problem is that I see how this process really works. Simply put, military medicine is a socialistic system that has all these parts already in place: mid-level providers delivering a significant portion of care, nurse managers in charge, etc. What I live is what you all are going to get, sans unquestioned, unlimited taxpayer funding; however, with/without complete legal protection for liability (al a Feres v. the United States: basically you can’t sue military medicine for malpractice regardless of how egregious—please look it up!). I see all the near misses of things that were ‘overlooked’, I see the complications of inappropriate care from untrained and inexperienced ‘providers’, and I have seen deaths, f*cking clean-kills, f*cking children, infants and otherwise healthy people basically manslaughtered, directly attributable to substandard care delivered by those who should never have been in a position to deliver it. As a physician and professional I am distraught and infuriated that this is allowed to happen. No patient who enters the hospital should ever be exposed to increased morbidity or mortality just so someone else can ‘play doctor’. Medicine is dangerous enough even with highly trained, motivated and caring physicians trying to manage the insanity. And yet it is all swept under the rug because of Feres v. United States and the ‘progressive’ nature of military medicine. You truly place you and your family’s lives in danger in a military medical facility since you are de facto accepting substandard medical care.

So yes Sam, I do rant and rave over what I see as substandard, bordering on buffoonery, medical care that is delivered by my military system. The only reason that Kaiser-care works is that it is still largely controlled by physicians (who review and call the shots of all mid-level providers). Don’t get me wrong: Kaiser is a system that recognizes a distribution of labor: you don’t need a physician to see a viral cold. As such, it saves money and allows the physician to treat the 5% that needs their level of training. However, a distinction in shades of gray is not in the United States’ future. When Obamacare goes into full force my world will become yours. I wonder if the standard or Feres v. United States will be extended to the masses when people start dying? Citizens of the United States: this is you, your parent’s and children’s future of medical care.

I forwarded it to mys sister who had her thyroid fried. And a friend whose a liberal (not diehard) and believes in obamacare.

I am perfectly happy taking myself or the kids to NP's for most of what we need care for (ear infections, strep, etc). But I damn well want an experienced, actual Dr around when we have something not blatantly obvious that needs investigation.

"I am perfectly happy taking myself or the kids to NP's for most of what we need care for (ear infections, strep, etc). But I damn well want an experienced, actual Dr around when we have something not blatantly obvious that needs investigation"

This is actually why I think mid-levels work well in primary care - because most health conditions encountered in primary care don't need more than that. Mid-levels can bill for their time, which means you can staff a clinic with NPs and PAs in a way you can't do with nurses, but they must work under the supervision of a physician. (Did you know that Doc Jensen? That mid-levels cannot work independently?)

When momof4's kids come in with something more complex than an ear infection, they can see the MD (especially since you are a well-informed parent who advocates for their kids) but the clinic isn't going broke because it's staffed entirely with people who have 200K in med school debt to pay off.

And medical errors are a systemic problem, not specific to mid-level providers.

This isn't really about government medicine. It's about a) liability issues and b) poor understanding of statistics on the part of doctors.

Doctors learn in med school about the dangers of excess thyroid production so they are incredibly cautious about increasing corrective medicine for hypothyroidism once a patient reaches the nominal lab test values. Worries about being sued if a patient has liver damage is probably a large part of it.

In my experience, doctors don't tend to understand much about statistics. Presumably, the correct TSH level has some sort of statistical distribution but to try to convince a doctor that you might need to sit about the average value will get you nowhere. This is why it took 3 years after I first complained about fatigue to be diagnosed with hypothyroidism. I was in the normal range at first so therefore I was not hypothyroid. Wait a couple of years and suddenly I am. Amazing!

As a side note, if you ever are diagnosed as hypothyroid, get a referral to an endocrinologist! Mine got my Synthroid level right from the start while my father's general physician took a year of achingly slow increases in dosage to creep him up to the right level.