assistant physicians, Missouri, primary care

Never a shortage of bad ideas….

Everyone seems to know that there is a shortage of primary care physicians.  In the next 6 years, there is a predicted shortage of over 20,000 primary care docs.  There are lots of reasons for this- primary care doctors make less money, have more paperwork, have to see more patients…I could go on and on.  Of course, in the United States the prestige of a job is directly proportional to the paycheck received, so…you do the math.  The fact remains that only about 30% of medical school graduates go on to a primary care residency, and even fewer than that actually end up doing primary care, as many people who do an internal medicine residency eventually specialize.

Now, I obviously love doing primary care. I love seeing patients for years and having an ongoing relationship.  But I will admit that I seem to be part of a dying breed, and I would love to see that change.  However, true change will take a whole lot of adjustment in the US medical system.  Since that’s hard to do, Missouri has decided to take another tack.

Missouri has passed a law that creates a new entity- an “assistant physician.”  No, not a “physician assistant”- PA’s have been around for decades.  A PA is a health care provider who has completed a masters degree and is certified by the Board of Medicine.  They work under the direct supervision of a physician.  An “assistant physician” is something else entirely.

First, a quick review of the US medical education system:
1. high school
2. 4 years of college
3. 4 years of medical school
4.  1 year of internship
5. 2-4 years of residency
6. 1-? years of fellowship

Primary care doctors stop after step 5.  For example, after high school I did 4 years of college at the University of Rochester, 4 years of med school at the University of Rochester,  1 year of internship at St. Vincent’s, 2 years of residency at St. Vincent’s, and then I stayed on for an extra year as the Chief Resident.  Specialists go on to step 6.  A cardiologist has a 3 year fellowship.  An endocrinologist has a 2 year fellowship.

Medical students apply to residency during their fourth year of med school.  It’s a very competitive process, because there are only about 29,000 first-year residency spots available for about 40,000 applicants. Now, there are only about 16,000 graduates from US med schools a year, but there are also graduates of international medical school competing for spots, along with those who did not match in a previous year and are trying again.  In 2014, internal medicine filled 99.1% of its spots through the match, and family medicine filled 95%.  The most competitive spots, in specialties like orthopedics, radiation oncology, plastic surgery, etc pretty much fill completely.  The remaining spots go quickly in a process called SOAP.  1,075 positions were filled during SOAP, which leaves about 10,000 medical school graduates without a residency spot.  The vast majority of these are graduates of international schools, but about 500 US students were left without a residency.

Missouri has decided that these unmatched medical school graduates are perfect to fill the primary care void in rural areas.  They’ve decided that if a graduate passes Step 1 and Step 2 of the USMLE, they can work with an established doctor for 30 days and then basically go out on their own.  Forget about the fact that they don’t have to pass Step 3 of the USMLE and obtain an actual license.  They have to be within 50 miles of a designated preceptor and have 10% of their charts reviewed by said preceptor.

This idea is so bad that it really, really blows my mind.  First off, these new graduates are one of two groups: either they are a bottom-of-the-barrel student who truly could not get into any program or they really wanted a competitive specialty and couldn’t get it.  Both are poor candidates for primary care.  One group probably can’t hack the difficulty of it, and the other has no interest in primary care at all.  Add to this the fact that US medical schools are not set up to graduate doctors who are ready for practice. That’s what residency is for.  Med school teaches you the science and the basics.  The true training comes from residency.

Primary care is difficult.  I’m biased, of course, but I think it is one of the hardest specialties.  For many sub-specialists and surgical specialties, the diagnosis is already made by the time the patient reaches the door.  Look at the most competitive specialties that I listed above.  Not as much in the way of cognitive work in those specialties.  Of course, they have amazing other skills, but historically, cognitive work in medicine is incredibly undervalued.  After all, how do you put a price tag on a physician’s thought process and diagnostic acumen?  It’s difficult.  Anyway, what I’m saying is that in primary care a patient doesn’t walk up to you and announce, “Hey, I’m experiencing an occipital lobe infarct!”  They come in and say, “I’m kind of dizzy and not myself.”  And you are left to figure it out.

The last place in the world that a new grad with no residency training should be is in a rural area taking care of patients who have not had adequate primary care in ages.  Those patients are likely to be sick, sick, sick.  They need and deserve real health care, not some new grad who has no training and doesn’t really want to be there in the first place.  Missouri seems to be operating under the delusion that some care is better than no care at all.  They forget that poor care can do actual harm to a patient, and someone who doesn’t know what he’s doing can be a true danger to others with a prescription pad in his hand.

I also want to know what sucker physicians are going to agree to be preceptors for these assistant physicians.  The liability implications of this make my head spin.  No way would I agree to be responsible for the actions of some wet-behind-the-ears new grad who is 50 miles away from me.  No way.

Look, there are always going to be difficulties in getting physicians to practice in rural, remote areas.  That’s why the areas are rural and remote.  No one else wants to live there, either.  But this is the wrong way to go about solving this problem.

biking, running, triathlon, Wallis Sands triathlon

Race Report- Wallis Sands Triathlon

Well, I lived to tell the tale.  No shark encounters.

The day started off with the alarm going off at the ungodly Sunday hour of 5:40.  The next thing I noticed was the sound of rain.  Pouring rain.  A look out of the window confirmed it- there was a downpour.  A quick check of the weather forecast was useless- according to Accuweather and, it was just cloudy with a chance of a shower.  Ha.

I spent the next half hour drinking my coffee and playing a mental game of “Will I or Won’t I?”.  In the “Won’t I” column was the fact that I’d be standing around in the rain for at least an hour or more before the race, all my stuff would get wet, including my socks (I HATE running in wet socks), the ocean was probably going to be rough, road bikes tend to skid a lot on wet roads, and my bed was looking really, really cozy.

In the “Will I” column was the fact that I had trained for this damn thing.  And spent the money on the damn wetsuit.

So I went.

It was still pouring when I got to the race site.  It finally let up enough for me to get out and pick up my race packet.  I brought my bike and stuff over to the transition area, at which time it started pouring again.  Luckily I had put everything in a big garbage bag.  I left it there and went and hid in my car, hoping that no one would think my stuff was actual garbage and throw it away.

About a half hour before race time, the rain finally let up.  I finally went and got my stuff all set up.  Right about this time, my friend Sarah showed up to cheer me on.  And good thing she did, because it was time to get on the wetsuit.

So, it was hard to do this while sitting on a bench with nice, dry skin and feet.  Doing this while standing in a puddle with very damp skin and soaking wet feet really made for a great time.  If Sarah hadn’t been there for me to hang on to, there’s a good chance my race would have been over before it started, the damn wetsuit abandoned.

Then it was down to the beach for the start.  I was in the third wave to start, otherwise known as over-40-old-fogeys.  I was getting nervous…the water was nowhere as rough as my disastrous swim last Saturday, but it certainly wasn’t calm, either.

Man, I’m short.

That first buoy was looking really far away.  No time for further panic, we were off.  I ran in and started dolphin diving, and then started swimming.  And started panicking.  There were big waves.  And choppiness.  And water was going up my nose.  And…I seemed to literally forget how to swim for a second.  Like, I bobbed there in the water and started doggy-paddling.  Then I mentally screamed to myself, “WHAT ARE YOU DOING???”  So I started swimming again.  No good.  I was really freaked out.  So, I flipped onto my back and started doing the backstroke.  And at one point laughed out loud, because I was actually passing other swimmers while doing the backstroke.  It was so ridiculous.  Here I was, doing the backstroke because I was too freaked out to put my face in the water, and I was doing it fast!  Finally, I touched bottom and ran out.  My swim time was a minute faster than my swim last year, for a swim that was farther.  

The transition was a lot slower.  In addition to getting out of the damn wetsuit, I was trying to get most of the sand off of my feet.

The bike ride was great.  I had practiced the route several times, since the race was in my town.  No wind, very flat course, and a nice surprise- many freshly paved roads!  My ride time was 5 minutes faster than last year’s same length ride.

Then onto the run.  I was actually a bit nervous for the run, because running seems to make my back flare up more than any other activity.  I haven’t really done much running lately, but luckily my back held out.  Just a bit of cramping in the last mile, but nothing I couldn’t run through.  My time was 5 minutes fast than last year’s.  It helped that there were no trees or boulders to scramble over.

So there you have it!  It was a really well-organized race and the scenery of Rye can’t be beat.  I was glad to have improved my time.  Next year- more practice swims in open water!

biking, running, swimming, triathlon, Wallis Sands triathlon

The Sun’ll Come Out, Tomorrow…

I am happy to report that both Scarlett O’Hara and Annie are right- tomorrow is another day, and the sun did come out!  My swim today went much better.  The weather was chilly, but beautiful and sunny.  The water was nice and calm.
I was able to practice running into the water and “dolphin-diving,” along with practicing sighting, which is the only way to swim in a reasonably straight line in open water.  It was also nice to just kind of bob around in the ocean and get a bit more comfortable.  The wetsuit really does help you float, by the way.  But it wasn’t any easier to get on.
Can I just say what a gorgeous day it was today?  I can’t imagine living anywhere else.  I also did a bike ride and a run today, and how amazing is it to see this kind of scenery on a daily basis?!

I hope everyone had a wonderful weekend!

triathlon, Wallis Sands triathlon

A bit scary…

When I blogged about my triathlon experience last year, I mentioned how crummy the swim portion was for me.  I’m not a particularly strong swimmer, a fact that was made painfully clear as I brought up the rear of the race.  So this year I decided that I’d actually train a bit, and I’ve been swimming about a half a mile twice a week (the swim portion of this race is 1/3 of a mile).  I’ve been feeling better about my swim prospects.

Until today.

You see, there’s just one problem…this swim is in the ocean.  I’ve been paddling around in the nice warm, calm lap pool at the gym.  That’s juuuuuuust a bit different than swimming in the Atlantic.

Now, last year I didn’t use a wetsuit for the swim, something I lamented after the fact, since wetsuits add some buoyancy.  Since this swim is in the Atlantic at the end of September, you’d have to be an idiot not to wear one.  So, I bought a wetsuit, which has been sitting, still with the tags on, in my closet.  I’ve been hesitant to take the tags off in case I either a) chicken out, or b) have my back injury from last fall flare up again.  Since I’m now a week out from the race and my back is doing pretty well, I decided to take the tags off and give it a whirl today.  It would have been nice to have done it on a warm day with calm water, kind of like this…

Aren’t they cute?  But no, I had to wait until today.  Overcast, windy as hell, with lots of waves and a cross-current.  And nary a soul to be seen on the beach.

Hardheaded and stubborn as always, I pulled on the wetsuit.  And pulled.  And pulled.  And tugged.  And then contorted myself into this weird pretzel to get it zipped up.  By the time I was done, I was sweating.  That thing is TIGHT!  I mean, I know it’s supposed to be tight, but…wow.

I was still pretty nervous about getting in the water, but now I was sweating so I was at least ready to cool off.
Of course, it was also low tide.  For those of you that have not experienced our New England low tides…they’re low.  It added a nice, long walk in my very tight suit.  I finally reached the water and ran in.  I hadn’t even hit knee deep water before I got knocked over by a wave and carried several feet south.  I came up and gamely tried to dive under the next one.  That went a bit better, but the waves were basically on top of each other.
Now, I’ve said it before and I’ll say it again…I’m stubborn, but I’m not stupid.  And I was not staying out there any longer.  It was too rough and certainly too dangerous for me to play around out there by myself.  So, I called it a day.
The good news- the wetsuit seems to work fine.  I was warm and once I was in the water it didn’t seem so tight.
The bad news- I’m now fairly terrified about this swim.  I hope things are a bit calmer tomorrow and I can give it another try.
behind the scenes, humor


When I dictate my office visit notes, I use a voice-recognition system called Dragon Naturally Speaking.  It’s pretty amazing.  I talk pretty fast, and for the most part it keeps up with me.  Because I have the medical version, it’s also pretty good at picking up medical terms and drug names.  I mean, who would expect it to accurately pick up the word “hydrochlorothiazide?”  But it does!

Even so, I do pick up some pretty funny transcriptions at times.  Here are some of my favorites:

1. “The patient is a 53-year-old woman who presents for the above reason. She was using a Q-tip to clean her uterus on Saturday. She states that somehow it slipped and she felt it puncture her eardrum.”

Wow, that’s one long Q-tip!  Now, I’m really not sure how I said “ear” and it heard “uterus”…

2.  She also saw Dr. cystoscopy for a skin check.” 

This one is where having the medical version of the program got me in trouble.  A “cystoscopy” is a type of procedure done in the office, and people often say “cysto” for short.  Unfortunately, a local dermatologist is named “Dr. Sisto.”  Dragon thought it was being helpful…not so much.

3.  “Since her discharge, Mrs. X has basically 24-hour a day help with shopping, cleaning and cocaine and she is doing quite well.”

I’m not even sure what this was supposed to be.  I think it was “cooking,” but I can virtually guarantee that Mrs. X does not have 24 hour a day help doing cocaine.

4.  “MEDICATIONS: Penthouse, Avodart, Pradaxa, Lyrica, tramadol”  

Now, I said that it was pretty good at picking up medication names, but clearly it isn’t perfect.  Unless “Penthouse” is the new substitute for Viagra.

5.  “allergic rhinitis: Restart her on Aricept and patent anus”

Another medication problem.  This should have been “Allegra and Patanase.”  But it’s always good if an anus is patent.

6.  “Examination of the face reveals prominent feces”


7.  “Here for preoperative evaluation at the request of Dr. pelican running”  

You can add people’s name to Dragon and it learns to recognize them, but clearly it needs to practice a bit more with Dr. Pallatroni.

8. “She is continuing to have chronic dry, tight cough. She SpaghettiOs intermittently for the past several years.”

No idea what this was supposed to be, but I have never, ever had the occasion to dictate the word “SpagettiOs”.

9.  “Examination of the ear showed a sperm impaction.”

Er.  No.  That was supposed to be “cerumen impaction” (otherwise known as ear wax).

10.  “He also tells me that he accidentally was using the wrong size noodles instead of the longer ones that I had prescribed.”

Well, no wonder his diabetes wasn’t controlled!  You can’t inject insulin using noodles!  

running, triathlon, Wallis Sands triathlon

Swim, Bike, Run…Part Deux

I apologize for yet another long blogging absence.  Against my better judgment, I registered for another triathlon.  This year, it’s going to be the Wallis Sands Tri, scheduled for September 21.  After my pitiful swim performance last year, I vowed to actually practice swimming a bit this time around. So, I’ve been swimming for a half hour twice a week.  I’ve also been biking about 40 miles a week and running 3 times a week.  Hopefully, this will be enough so that I don’t embarrass myself.

Ironically, of all the three legs that I have to do, running is the one I am most worried about.  I’ve honestly had trouble running every since my stupid back injury last year.  It still hurts me on a daily basis, and running certainly seems to aggravate it.  It actually flared up so much this spring that I wasn’t able to run the Red Hook 5K with the rest of Marni’s Army, which was a disappointment.  But, I’m nothing if not stubborn (sometimes to the point of stupidity), so I continue to run.  And damn it, even if I have to stop to stretch every 2 minutes, I’m going to run this race!

Of course, I am still worried about the swim leg, too.  Unlike last year’s race, this one is in the ocean. With waves.  And seaweed.  And possibly sharks.  I’m just hoping for a relatively calm day, surf-wise.  Or maybe a lot of surf, so I can ride a wave in for the last third of the swim.

Anyway, if you want to come out and cheer me on, or you just want to point and laugh at me in a wetsuit, come on out to Wallis Sands on September 21!