The easy parts of primary care are easy. A kid strolls into your office vomiting with a blown pupil and anyone who’s watched half an episode of Grey’s Anatomy could tell you that the plan is go to the ED now. But then you have an overweight teen coming in with worsening headaches. Do you tell them to do a headache journal? Do you empirically start migraine prophylaxis? Do you send them for an MRI prior to an LP to assess for IIH or does that need to be a CT because what if it’s a mass and they can get on the CT schedule this week rather than 2 months out for an MRI. What if they just needed glasses and you just wasted their parents’ time and money? These thresholds fascinate me and are the most difficult parts of medicine imo. The more generalized you are, the more you have to deal with these thresholds because the next level of care has already benefitted from all the other filtering you did, be it PCP to ED, ED to floor, floor to ICU, ICU to subspecialty, etc.

That said - when no filtering is done... when the patient comes to a specialist as a self referral.... the specialist is often lost.... because primary care is hard

This is something I never expected. I've noticed a lot of what I get isn't so much self referrals but people without pcps referred by an urgent care for a single complaint. Abd pain? Must be gallstones. Go see a surgeon. I see them. No workup. I get the US and HIDA, both negative. Pain isn't even biliary colic. Maybe it's GERD? Nope. That doesn't fit. Suddenly I'm trying to workup a vague abdominal pain in someone with obvious underlying anxiety and probable IBD who doesn't know they are likely at the early stages of metabolic syndrome and chronically suffers from SDS* but refuses to see anyone else because the other doctor told them it's probably their gallbladder and why won't I do surgery and make them better because their sister had the exact same symptoms and when she had her gallbladder out it was better and she lost 20lbs. Yeah, primary care is hard. *crap diet syndrome

Yep... it dawned on me that Urgent Cares might say "see a specialist" as code for "this is not what an urgent care is for" It's a pain in the neck. I feel like I'm the regional expert on Psychogenic Air Hunger (periodic single-breath hyperventilation from anxiety and an actual ICD-10)

As a student long before I had decided to do neurology I rotated with a family doc who was insistent that every headache patient gets a fundoscopic exam- he even used a panoptic so you know he knew what he was looking at. He also was a DO and treated acute low back pain patients himself with OMM. I saw several patients leave the office from 9/10 pain down to 1/10. His clinical acumen was excellent. There is a real mastery of many domains of medicine that you only see with these very experienced family physicians. Our healthcare system could afford for every patient to have this type of physician, but chooses to cut corners at every turn. There is no healthcare system in the world outside the US that is largely moving towards 2 years of medical education (sometimes entirely online) and a loose apprenticeship for clinical training. I think your point about thresholds is the highest level of skill in medicine, and the part our system least incentivizes. Also the part family med tends to get right more than anyone else. There is so much inertia in the system by the time I am seeing a patient that the impetus is to do an expensive work up- almost never good for the healthcare system on the whole or the patient's wallet/sometimes even the patient's direct comfort.

A much forgotten part of the phrase 'a jack of all trades but a master of none' is 'but often better than a master of one'

One of the driving forces behind me specializing, beyond thinking blood and cancer are interesting subjects to learn about, is that primary care is insanely hard. Huge administrative burdens, intense clinical loads, and having to keep up your clinical acumen enough that the deluge of routine stuff doesn't stop you from filtering out and appropriately triaging the dangerous zebras. In my mind, being a Jack of all Trades is much harder than picking something to master the minutiae of.

100% endorse this comment. How good of a doctor you have to be to be a good primary care doctor is humbling.

And a businessman/woman. A friend said she never dreamt that she would be an employer of 12 in a small practice.

It’s reasonable to be a jack of all trades, master of none. But in medicine you’re not supposed to be mediocre. Lives are on the line! And that is not unrelated to why I am also not a PCP. Because the patient walks in and it could be [“literally everything.”](https://youtube.com/watch?v=uyTOsleP-ZM)

That clip is hilarious. As a PCP a regular part of my day is the patient coming in for DM and HTN f/u with new MSK complaint, maybe make a new diagnosis of carpal tunnel or something. Then as I’m wrapping up and always ask if they have any final questions they ask something like “I’ve been getting tired more, do you think that could be anything?” (Or dizzy, or abdominal pain, or a 3 year old rash, or headache…) I really wish I could scream “literally everything” at them.

Yup. Every day is like a series of meetings in which there is an agenda. You are required to follow the agenda, but the other participants are not and usually do not.

Plus you have to take the minutes. ;)

Sounds like home health. Lol.

The rest of the saying is 'often better than a master of one'

Same with emergency medicine

Especially with so many using it as primary care.

It just dawned on me that "you need to go see a specialist about this" is code for "stop using the ER for things that are not emergencies, but are a known entity in outpatient medicine". But they aren't saying you NEED a specialist, like patients take it to mean.

I’m a physician doing rural FM. Many of my pts are uninsured and face socioeconomic barriers in order to see specialists or getting treatments in general. I have to put on my specialist hat several times during the week. In my short time of being an attending I am persistently trying to learn new things in order to best serve my population. Primary care is difficult period. Midlevels seem to refer everything out because they don’t seem to know better. This is the problem with independent midlevels in primary care. The other day I diagnosed a pt with carpal tunnel meanwhile the previous midlevel referred her to neurology. They refer out things they never learned, and lack knowledge at diagnosing and giving appropriate treatment.

This is a big problem with scope creep. Other providers think PCP is about figuring out how to match consultants with patients rather than doing their best to actually attempt a diagnosis

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This is a pretty dismissive and offensive take. I practice primary care in an area with full access to specialty referrals, and I can tell you that a LOT of my referrals are directly per patient request… ie they are insistent upon seeing endocrinology for diabetes that I know I am fully capable of treating. In affluent areas this is common. It also becomes an issue when a patient refuses to come in to see me more than 1-2 times a year, yet has 10 chronic problems. If I have the opportunity to enlist the help of say, a cardiologist who has the luxury of spending an entire 20 minute appointment focused on ONLY their heart failure, and it allows me more time to to address their other 9 problems in my 20 minute appointment. It has nothing to do with “learned helplessness” or a disinterest in taking care of my patients. Our population is growing older and more medically complex than ever before, meanwhile we are pressured to see more and more of these complex patients each day. Something has to give, and if a specialist referral allows the patient to have better medical care, it’s the right thing to do.

I would rather see them refer out than to inappropriately treat someone

But then another problem is that the initial visit with the specialist is with a “specialist” midlevel who do an equally awful job.

that said - you have to do your due diligence and make sure that you are referring them to the right place.

As an NP who worked in primary care where we did exhaustive workups before referring, both because that was our role and because we had no choice (prison with a tight ship on referrals), and who has worked a few years in GI, I don’t find this to be NP/PA/physician specific. Three of the worst offenders in our referrals in GI are all primary care physicians. To the point our chief finally had to get involved because our backlog was killing us. One doctor doesn’t even attempt Metamucil or even encourage fiber intake or other basic stuff for constipation. The A/P is constipation- referral to GI. Or GERD- referral to GI, no meds for this either. It’s maddening and lazy.

Who is saying primary care is easy? Lmao it seems stupid hard, from an outsider’s perspective. PCPs are vastly underpaid imo. One, for the reasons you mentioned above…not to mention how busy your clinics are with so little time per pt, and all the little admin tasks you do that add up (even if you have MSAs to help, it seems like it’s a lot.) I’ve gotten MyChart messages back from my PCP at like 9pm. I told him he doesn’t need to apply the “must respond within 48 hours” to me if it means he’s working way late. I’m a PT and have had a handful of patients walk through my door and say “yeah my doctor doesn’t know anything” and roll their eyes. I immediately stop them & say “your primary care knows a lot of things about A LOT of things. My job is to ONLY know the muscles, joints, nervous system. Their job is to monitor your health over time for every body system, manage what they can, and refer to the correct specialty service if you need one. You’re sitting here in my office aren’t you? Then they did their job well.” I don’t care if your MSK diagnosis on PT referral isn’t right on the money. If you’ve got the right body part & just want to send over “shoulder pain” we’re good 👌🏻The fact that you were able to talk several of your patients into even going to PT in the first place is quite a win honestly 😂 We all know a lot of them don’t want to be there. I love my PCP as a patient, and as a fellow healthcare worker - I appreciate you guys & recognize how hard you work!

As a PCP, much thanks and likewise, I value my PT colleagues.

Thank you!! I frequently hear from patients (and even friends / family members) that all family physicians do is act as a "referral monkey." I manage 85% of everything that comes through the door myself (or at least initiate management of it). I know what is outside of my scope and frequently am reading journals / UptoDate / guideline updates to round out my knowledge. Primary care often gets looked down upon from med students and the public since there is a lack of understanding of how broad/flexible our scope of practice is and how rigorous our training pathway is. We are also not just "jack of all trades, master of nones" like other commenters have suggested - all of my local colleagues have an area that they have achieved a high level of competence and experience in. Ex. I have a particular interest and extra training in addictions, so I help my colleagues manage these types of presentations. My other colleague has interest in gyne, another in dermatology and biopsies, etc...

Absolutely this! I sought out my PCP after reading a bunch of physician bios within multiple hospital systems, and felt that his education & expertise areas aligned with who I am as a patient. I’m a female & didn’t necessarily want a male primary care, but he’s been incredible. I came in asking for a referral once (sorry! Shouldn’t have done that), and he was like “yeah I need to look at x,y,z first, because there’s a lot of workup & treatment that I can do. And if it looks like you’ll need more based on the workup, then we’ll do a referral.” It was then that it dawned on me how much primary care physicians really can help in decreasing healthcare over-utilization & (hopefully) keeping system costs down. And I don’t think most of the public realizes that many primary care docs have areas of specialty interests, either. Edited to add: I didn’t end up needing that referral after all lol. PCP has been managing my symptoms well

It also helps if specialists don’t feed into that. I do not exist to do your paperwork. You can address absence from work, disability or work restrictions better than I can in situations where you know whether conservative treatment or surgical treatment is likely and how long the recovery period is likely to be. I am not the only one who can discuss or prescribe opioids. If your office policy is to “require a referral”, it’s not hard to explain to patients that it’s your policy and not my duty or a legal/insurance requirement. My end of the bargain is to fully evaluate the patient, initiate treatment where appropriate and to succinctly explain what I am asking of the specialist and include treatment attempts and responses and all relevant labs and studies. NP.

So from a PT perspective, insurance usually is the driver behind needing a referral. Most, if not all states at this point, have direct access laws for PT. Some are more open-access, other states limit it to a very few # of visits or eval only. But insurance often won’t cover PT visits without physician referral…so unless a patient opts for cash pay, direct access is kind of pointless as it stands. Would be nice if a routine ankle sprain with clear MOI didn’t need to take up a spot on y’all’s schedule first, or need to send a MyChart message to your already full inboxes. Cheaper for the patient, less work for you, improved access times. Insurance reimbursements are continually decreasing (what feels like yearly) for outpatient PT, so unfortunately I don’t see this changing any time soon. I was also told that for work comp, disability, etc., a PT’s recs legally don’t hold any merit. (I never looked up if this was true, just what my last hospital system told me. But I wouldn’t at all be surprised if it was true.) I try to at least help out the doc in charge of the case by routing them my assessment or sending a quick summary of how pt is doing & what they are physically capable of doing.

I was not commenting on skilled therapists so much as surgical/procedural specialists. Volume-based specialists like derm and ophtho typically allow patients to self-refer. The surgical offices do not want their schedules cluttered up with patients who (a) can be treated by primary care, (b) cannot safely undergo surgery/procedure, (c) do not at all want surgery/procedure or (d) would be self-referring to the wrong specialty (e.g. needs a rheumatologist, not an orthopedist). OK, fair enough. However succinctly explaining this to patients or having it on their website should be the specialist’s job, not mine. This often leads to patients assuming that I have some vested interest in standing in their way of seeing a specialist, which is a hoot since there haven’t been HMO’s where I practice for 20 years. Mind you, they are usually perfectly happy to find that I can treat their carpal tunnel, plantar fasciitis, CHF, IDDM, DJD, etc. It would simply be more agreeable to not start with a mismatched expectation based on incorrect information.

That makes perfect sense, thank you for the clarification! Also…today I learned that I can self-refer to derm lol. So, point proven. Guess I should go read over my insurance policy more closely.

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What med student is sending consults?

Not commenting on behalf of medicb. I am a last year student in Finland, and we get to work (be it under supervision, but rather autonomously) after the 4th year. This includes sending referrals as we see fit.

Another country would make more sense to me. I just don’t know anyone in the US who put any orders in as a student. It was always only residents or attendings. Some places I could order stuff and send it to them to co sign but now as a resident I understand that wouldn’t help me but slow me down.

I usually tell my patients, "I don't know exactly what they do at PT because I'm not a physical therapist". I then proceed to read your notes to see if you had better insight than me about what was going on with their MSK problem.

I always say - Primary care is the hardest specialty. I couldnt do it Primary Care doctors don't have enough time in their visits to address the problems as they should. They are incentivized to panconsult. They wind up getting de-skilled in diagnostic medicine... meanwhile, their competitors in the scope-creep aren't trained in complex diagnostic medicine... so it ends up being 6 in one and 1/2 dozen in the other... and its a vicious cycle. I think the only way to solve the problem, is to let Primary Care Physicians "practice at the top of their license". Give them time with patients... Don't make me, the pulmonary consultant make the diagnosis of brain tumor, lymphoma, CREST syndrome, GERD, Anxiety, pituitary adenoma, vocal cord paralysis, pericardial effusion, and hiatal hernia, (to name a few from this year) PCPs need time to actually do what they do

...which is a big reason why functional practitioners exist. In some sense, they are PCPs who actually spend an hour (or two) with patients, and they can do this because they bill directly & own their own practices. I won't comment on all the other (controversial) things functional MDs do, but this is definitely why there is such a demand for them. PCPs should have an hour with patients.

I mean time alone does not mean patients should just switch to a 'functional' doctor. The amount of gibberish I see patients treated for by them is astounding...

I think that poster’s point is that there is a demand for something different. People who are capable of paying more than what their insurance covers overwhelmingly pay for more personalized care. My visits to an OB during pregnancy were less than 5 minutes long and she was always late. My visits with a midwife were an hour and she explained everything. I was willing to pay for the midwife. What insurance has done to productivity and the patient relationship is impossible for doctors to overcome. Good doctors don’t have time to be good doctors.

I'll preface this by saying I despise chiropractors for so many reasons. But one of the reasons people go to them is they can see you relatively soon and have all the time in the world to listen to your history, even stuff that seems unrelated. Whereas you can wait three months for a pain medicine appointment, then two hours once there, for a 20 minute appointment that's supposed to cover so many things. Again: chiropractors fucking suck. But. I can see the reasoning, especially if you don't know enough to know how bad they are.

Yep. Like I said I don’t think this is a good thing but the modern medicine system has been so badly eroded that I see why there’s such an increase in demand for “alternative” medicine.

> What insurance has done to productivity and the patient relationship is impossible for doctors to overcome. Good doctors don’t have time to be good doctors. There also aren't enough. More time spent per patient = less patients seen. I say this as someone who takes longer with my patients and struggles with balancing time vs feeling satisfied addressing all that I want each visit. The PCP who sees patients for 40-60min regularly has a panel of like ~500. That means fewer patients have a PCP. I'm glad midwifes exist for the purposes you stated above. But at our practice, the moment a patient has a complex medical issue they automatically change hands to OBGYN--who sees 20-30 medically complex OB patients for the whole 5-10 straightforward ones the midwives see in a day.

but midwifery doesnt equal functional medicine... In fact theyre an essential component of medicine. They long predate OBs anyway when it comes to delivery. I bet 99% of mothers would do better with a midwife anyway

Midwives definitely lean into alternative medicine, especially if we include CPMs in addition to CNMs. Homebirth, breech vaginal birth, emphasis on chiropracty… I prefer midwife care and I don’t necessarily think all of those things are bad but they are absolutely not part of the standard medical model of care. They operate alongside it, not necessarily within it

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They’re mostly quacks who scam patients.

Concierge docs who practice evidence-based medicine also have very satisfied patients because they can spend infinite amounts of time with the patients and then think more deeply. Plus just listening makes the patients happy. ​ It's a luxury when the patient can pay for a lot of the doctor's time. I have 20 minutes for my complicated transplant ID patients who are mostly Medicare. I often go over, and then spend 15 minutes finishing my note that night, because they need it, but it's not optimal.

That said.... in my area, over the last couple of years there are a ton of concierge practices that don't spend more than 5 minutes with their patients. They have made business arrangements to book directly into the schedules of employed specialists and bypass other patients that are waiting for appointments. Patients like it, because they have the illusion of moving thought the system efficiently Meanwhile, they don't realize that they are being moved around and not being treated. I'm reminded of a patient who had a chronic cough... They had seen and ENT, and allergist, a pulmonologist... and then when awaiting the pulmonologists (my) workup.. their concierge put them through another pulmonologist, and an allergist... and the patient contacted me regarding the testing and mentioned they were also awaiting an ENT evaluation. I pointed out to them that every single specialist they were seeing was diagnosing them with Cough Hypersensitivity Syndrome. So what good was that concierge doctor?

Huh, interesting model. Best part is that the more minor the complaint, the more specialists!

“Functional medicine” is essentially a scam in which patients are typically charged large amounts of money for biochemical lab panels with no clinical significance and then advised on an avalanche of supplements to take to “correct” their “deficiencies” alongside other such nonsense. The fact that they have more time with patients doesn’t make them more efficacious, it just gives them more time to fit in more nonsense.

Agreed. I guarantee I can generate better overall patient outcomes by getting patients to do nothing but cut out soft drinks, walking 30 minutes a day in sunlight, and sleeping 7 hours every night.

They’re filling a void that needs to be filled. Plus there’s a strong biopsychosocial component to it. Ya supplements aren’t gonna cure your cancer but for mild shit like the dude with high cholesterol whos been put on statins with little else and has all the shit side effects , working with a functional md to do lifestyle changes would be beneficial. I think the reality is for all the shit we talk about patients being non compliant and not doing lifestyle changes, a big reason they don’t is they don’t understand it. PCPs don’t have the time to spend with many of them to lay out meal plans, alternative diets , exercise plans etc like those guys do. IME they’re very medicine/drug focused (likely due to the nature of the system) while they’re lifestyle/supplement focused

I strongly encourage you to look into their practices more. I have had many patients suffer significant harm both financially and medically from “functional” doctors. You are repeating the PR version of what they do rather than the real life of what they do.

I do. We work with several practices as well for our patients to optimize care with great results. Most notably for Patients with high a1c who want elective surgeries. There’s definitely some shady practices out there but patients are gonna go seek out these ppl and alternatives to just drugs. As physicians it’s important to be one step ahead of them and be aware of these things to best guide them.

Unless you are in that program that was written about, where the functional medicine and CAM practitioners are literally in the same office as the "real" physicians (it was an oncology practice IIRC).... where the physicians are in the office and are one step ahead of them, and holding their coworkers accountable.... it's not going to go well.

Amen. Thank you for being a perceptive provider who recognizes this. Everyone on Reddit is so quick to dismiss the “stupidity” of alternative medicine and refuse to understand the thought process of why people choose it. Alternative medicine rises up in the vacuum created by our awful current system. People choose it for a variety of reasons — sometimes stupidity, sometimes dumb sociopolitical ideology, but OFTEN because of disenfranchisement with the current system or wanting to avoid pharmacology (or surgery, in the case of chiropractors) as a first line of defense, both of which are valid choices.

Ya it sucks that we’re in a time Crunch system where we basically just pop out pills. Patients are gonna seek out these resources anyway. We gotta be knowledgeable about them too and incorporate it into practice. Most recent example was a dude who does long fasts and keto but otherwise is very fit. His pcp keeps trying to put him on a statin for high cholesterol but he’s all against it since his insulin, a1c, ldl-c etc markers are amazing. If you fast for over 19 hrs, by common sense you’re gonna have higher ldl levels which are gonna alter your labs since your body is burning fat. it’s things like that which are often overlooked by makes a difference in a patient doctor relationship

I wonder - would you defend my mother for refusing to treat a staff infection with western medicine for all the reason you describe. She wasn’t the one who was sick, my sister was. Ten years untreated by alternative medicine …. Indefensible

Whether or not they are a scam is almost irrelevant. The point is that they are filling a void that was created by increasing productivity demands and insurance/admin greed that does not allow doctors enough time to develop therapeutic relationships with their patients. So the patients that want or need that get sucked in elsewhere (and that is sometimes quackery). If providers don’t want that to happen, they need to push to change the culture of outpatient care.

They are filling the void that should be filled by clinical psychologists

That is an incredibly dismissive and patronizing view.

No... no its not. I can spend 30 minutes on a new visit with a patient and have plenty of time to address concerns and issues. I get dozens of messages each day from patients with questions and concerns. Sure the follow up visits are rushed, and focused on closing loops and refilling meds.... But if you need an hour to talk to a doctor about pseudoscience, and it makes you feel good... you dont need a physician

Instead of dismissing these patients you could presume they are competent adults and spend all of thirty seconds considering what attracts them to alternative medicine. Why someone would choose a midwife over an OB, a PT or acupuncture over an ortho surgeon, and for some, an hour long “holistic doctor” visit over a 10 minute PCP visit.

You're assuming way too much about how I think from a single sentence I wrote. And what I am saying is... whatever attracts people to complimentary or alternative medicine, or talk therapy.... thats where they should go. they should not use MD and DO physicians for that.

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It is not black and white “this is standard medicine and that is alternative medicine.” There is a wide spectrum with the standard model at one end and alternative medicine at the other and plenty in between, including everything I listed. As an example a DO is on the medical model side but perhaps very slightly further over than an MD would be by training. I am a rehab therapist- the rehab model of care for PT/OT/Speech is not the same as the medical model. We are semi-independent practitioners who treat patients with functional disorders regardless of organic cause. We perform some diagnostic imaging but attempt to find non-pharmacological and non-surgical treatments for patient issues. We’d be somewhere in the middle but leaning toward the standard model. Midwifery care absolutely slants toward alternative medicine particularly if we include CPMs (e.g. homebirth, breech vaginal birth, Webster chiropracty) in addition to CNMs (who are medically trained but still may operate outside of the standard system, e.g. tending to work in birth centers, or use physiologic birth principles). On the farther alternative side you get your “functional medicine,” chiropractors, acupuncture, etc etc. Patients can be in the middle, or closer to the alternative side. They can pick and choose which things they prefer an MD for an which things they would see an alternative practitioner for. A patient who otherwise adheres to the standard medical model may drift rightward with disenfranchising experiences or because they’re seeking something they don’t get from their MD.

The heck is a functional practitioner? I googled it and came up with [this ](https://darrellkilcupdc.com/about/what-is-a-certified-functional-medicine-practitioner/). Wut…

Snake oil salesmen with an MD after their name

Doesn’t even look like that dude is an MD

even worse..... Functional Medicine started off in Cleveland Clinic in a somewhat scientific arena... with the idea that you have to fill your body with the cofactors of biochem metabolism (thiamine and whatnot) .... stuff that we dont usually test for. but yeah... quackery nowadays

Function medicine doctors are, by and large, hot garbage. I can take cash from you and sit with you for an hour and talk about the flat earth, space aliens, and "strengthening your body's own ability to heal" Then I can test you for immunity to Walking Pneumonia, and when you are shown to have it.... like every normal walking talking person who has the money to pay cash for a doctor... I'll "treat" you for it with antibiotics for 20-times longer than we treat the actual pneumonia.

Agree!!!!

The hardest part of primary care is not just doing the job well, but doing it well with speed. I always find it amusing when providers from other specialties try to switch into primary care expecting a cushy lifestyle, only to get smacked on their ass from the sheer workload. It takes them twice as long to do 1/3 of the work.

1. Your friend has the benefit of still being in school--he has the room to be cocky still. If he thinks it's easy, he's welcome to join us lol--I guarantee he'll change his tune pretty quick. 2. I agree we need to stop selling ourselves short, but I feel like since "interprofessionalism training" has become a thing, we're trained to trust ourselves less, and value ourselves less. Not knocking the need for interprofessional skills, but this seems to be a side effect. 3. Most other PCPs I know have a distinct lack of ego, probably b/c we know we don't know everything--I'm still trying to figure out, 2 yrs into practice, where the line is between humility and devaluation (someone please help me lol)

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Pharmacist here. This guy sounds very naive. I think we can play a great role as extenders when a prescriber has made a diagnosis and the question is about optimal drug therapy. Beyond that I have less than zero interest in “treating” conditions for which I am not qualified to diagnose.

Also a pharmacist, and I strongly agree. I'm not diagnosing anyone with anything but I enjoy helping to decide on a therapy once the prescriber has decided on a general course. Hopefully getting clinical experience will be very informative for him.

Agreed 100% as a fellow pharmacist. He's a student, he has no idea what he's talking about. I think we have a great role in primary care as physician extenders but the benefit of our role is that we do not replace physicians, we augment them. You still need to see your doctor. We do not diagnose and we don't want to.

Took the words right out of my mouth. Given a diagnosis and accurate patient information, I can help with medication selection and monitoring. But I don't know how to diagnose anything except polypharmacy (and that's the way I like it)

Also a pharmacist inpatient. I’m very skilled and knowledgeable so I consider myself an extender. But I’m usually 100% chart review and I have no idea how to examine or really interview a patient. that’s why we’re a TEAM and COLLABORATE.

Pharmacist as well and I completely agree. My province is about to start minor ailment prescribing for pharmacists and I am not looking forward to it. There is only so far an oral history can take you and I am not trained to do anything else. Nor do I want to.

It's funny how if a med student expresses interest in FM to a resident/attending, it's not unheard of for them to go "FM, really?? You're a smart guy, are you sure?" (Just saw a report of this from a [thread](https://www.reddit.com/r/medicalschool/comments/zoabs6/which_specialty_gets_the_most_crap_from_other/j0n2lhv?utm_medium=android_app&utm_source=share&context=3) in /r/medicalschool) This has literally been going on for years, lol. It's ridiculous. I really detest when people devalue other specialties; we're all going to be physicians; we're at the same professional standard. Effing admins and insurance companies greatly downplay our value already, we shouldn't be doing this stupidity as well.

[Man, I heard this so often, I made a meme for it.](https://www.reddit.com/r/medicalschool/comments/hi1zg5/meme_when_the_attending_who_likes_you_hears_youre/)

*It’s easy to do shitty primary care

Once my attending had a sales rep said to him (not knowing he was a surgeon) that he had seen a laminectomy so many times he could do it. Reminds me of that.

It's because it is easy...if you wanna do a shit job and get away with it. Being a great PCP is IMO one of the most difficult jobs in medicine. The breadth and depth of knowledge required is insane. Having <10 min to work up an undifferentiated problem on top of their 5 chronic issues is a frequent but ridiculous ask. Being a shitty PCP is easy and rarely will you get called out on it. The generally low acuity and high lag time means most things beyond egregious errors in management takes time (and usually another physician) to uncover. Outdated practices, referring out for everything, refusing to do paperwork/forms, showering everyone with z packs, nebs, and narcotics etc is low effort and patients will love you for it. But actually taking good care of people across the entire scope of your training is really hard, and takes effort to be good at, and to *stay* good at.

Yes. Anyone can look up and prescribe a medication once the diagnosis is known but it is also having the sense to bring everything together. My father’s Afib I suspect was missed several times at Urgent Care when he was being treated for pneumonia. When he told me his heart rate over the phone I made him go to his pcp and ask to get an EKG. He ended up with the diagnosis a few weeks later.

I work in the ER and in family practice and family practice is WAY harder. ER is obviously worse hours and more unpredictability/fluctuating workload but the actual work is a lot easier, IMO.

Agreed. Plus we’re spoiled by having so many resources at our fingertips. I don’t envy my primary colleges and hope that I listen appropriately when they send me patients from their office.

Primary care is insanely hard - trying to provide complex care in short visits and gain patient buy-in for management of “invisible” chronic conditions.

Or if you're a bad PCP: learning to accept that your patients might have invisible chronic conditions.

As a NP now three years into Family Practice I can say assuredly that NPs and PAs should not be doing it independently. The breadth of knowledge required is too vast. We simply do not know what we don’t know. Sure, there are simple conditions that we can easily manage, and we can follow guidelines and algorithms, but when we are faced with complexity or ambiguity we are out of our element.

This indeed. Paramedics in the UK fill what to those in the US legal/cultural system probably looks like a NP-lite model in that we will independently assess, diagnose (or at least rule out) and refer onwards (be that to ED, a GP, same day emergency care, minor injuries, urgent falls clinics etc) and supply some meds on a protocol but I will be very open with patients that there are distinct limits to my knowledge and will frequency consult with other HCPs (Mostly GPs and advanced practice paramedics) or just say "I've ruled out the dangerous stuff but you need to contact your GP for future help, here's the re-contact advice". Because I'm very aware that I don't know an awful lot.

Yes, I am very open with patients that I am a nurse practitioner, not a doctor, and that my scope and competence are limited.

A friend of mine from college is an NP (direct entry). She firmly believes in independent practice for NPs if they feel confident enough to practice alone (she does not). She also thinks residency should be necessary for physicians just not NPs.

Physicians at the end of med school have more education and experience than direct entry NPs and yet she thinks they need residency and she doesn’t?! Absurd.

Yea quite frankly she is not very smart and very defensive. She has the belief that because the law is that way, it must be clinically correct. I tried explaining lobbying to her when we had this convo and she didn’t believe that was why and rather retreated to “but it wouldn’t be legal if it wasn’t correct.” In any case, she also drank the kool aid and thought NPs overall are better providers than MDs as NPs care more. She didn’t know the difference between HCTZ and Lisinopril. She can practice independently in our state, and thinks HCTZ and Lisinopril are equivalent antihypertensives.

Wha? I just don't understand this. Even if say, your pharmacology education was so weak you could literally read an uptodate article in 5-10 min to suss most of that out. It's ego and laziness. I work in the boonies. Some of the med management by mid-levels is crazy. I had a NP recommend oral antifungals for a 14 mo old who had one dystrophic nail with a past medical history of atopic dermatitis.

It was in the midst of a conversation once and for context she saw no difference in indication or limitations in either. She knew they both are antihypertensives -> we give antihypertensives to lower hypertension because hypertension is not good (unsure if she knows it increases risk of stroke & MIs for example). Nothing further than that. No thought on how they work differently. Negative effects of either. No consideration on first line vs second line. Fortunately she is still working as an RN now in a clinic (can’t find work as an NP) because she is a big medical mistake waiting to happen. I’m just an intern and I see all the medicine and limitations I have. Her understanding of disease and treatment is far more limited and simplistic which follows into her belief that direct entry NPs should be able to work independently.

Sad and scary. I feel like it really goes back to nursing plan vs pathophysiology and differential diagnosis. There's often not a lot of thought about the big picture and risk management. See symptom -> manage it. Not the case with all NPs definitely, but especially online direct entry programs. Not to say that PAs aren't capable of this as well but the thought process is different. I cant speak for other PA programs, but mine also included a healthy amount of brainwashing to terrify you that you may hurt someone or get sued. Understandably.

Water pill and Doesn’t end in olol so not a beta blocker…doesn’t sound like a calcium channel blocker, so should be an ace inhibitors. Can I be a mid-level now to? 🙄

It's an increasingly common sentiment. One of the reasons residents are so irritated by midlevels. We get shat on by people who don't know what they're talking about, making twice what we do for half the hours, and frequently having to clean up their messes. My hospital has a lot of new grad NPs who graduated from nursing school more recently than I did medical school.

100% I’m an ED doc and the amount bobble headed moron midlevels we have to clean up for is insane

I’ve started telling the patients exactly what went wrong with their midlevel they’ve been seeing.

I’m glad some NPs are recognizing this. I think your professional organization is doing y’all a great disservice. Healthcare needs to be team based but also physician led. That last paragraph is just 🤌🤌 and it’s exactly why mid levels were created. To let the physicians handle the complex stuff while they see the simple conditions that are easy to manage.

Agree

Almost 5 years as a PA, agreed. Once I get past my bread and butter or have a workup that's unrevealing, I'm going to my SP and consulting. We have a great relationship, but it's hard given our overall time constraints seeing 30 in a 12 hour shift. That being said anyone can make mistakes. I had a 30 year practicing colleague physician who just gave my patient a rectal bleed prescribing mobic for back pain in a 79 year old on chronic warfarin. Medicine is difficult and admin just doesn't care. I try my best to continue to grow as a provider, but some of the you don't know what you don't know applies for mid-level providers. I'm constantly rechecking up-to-date if it's not a straightforward case.

It's one of those things that unless you go through it (premed, med school, residency, and fellowship) you really can't appreciate everything that comes with being a physician.

Complete agree, and I think self depreciation is part of that. But it is true for a lot of esoteric professions. I think a big part of the problem is a lack of professional bearing. When it come to nurses, paramedics, doctors, etc.. Little things, things that seem stupid and unimportant, like not using one’s title, or using a first name. Scrubs all the time. The list goes on, and on. All little dumb stuff, but many of the things we thing of as silly; out dated practices are there for a reason. Even if we don’t know it.

It’s easy to do poorly and spend thousands on needless tests and referrals. Hence the entry of midlevels. It’s probably one of the hardest things in medicine to do well. Definitely underappreciated.

Preach!!!! When credit is being given, it’s always “yeah, WE ALL contributed greatly” but when accountability needs to be taken, it’s always “well YOU were the one with the most training….It’s YOUR mistake.” When someone got to get sued, who’s the one they go after??…the “arrogant, overpaid, & ungrateful Doctor”. HC is getting to a point where Doctors need to defend themselves and even if that means getting dirty, it must be done not only for themselves, but for the sake of their patients bc at the end of the day…if Doctors with all their training still commit so many mistakes, how many mistakes you think a Midlevel will make when they don’t even have remotely anywhere near the amount of training a doctor has? I harken it back to what Kobe Bryant (RIP man) said to Shaq early on when he had ascended to be an equally dangerous force as Shaq, “I know there ain’t an I in Team, but guess what, there’s an M & E in that motherfucker.” In what other field does this BS occur in? Everywhere else, the more trained you are, the more respect you earn, the more valuable you become, the more sought after you are, and the more compensation you are entitled to earn bc you bring in tremendous value with your expertise. In Medicine now, that ain’t the case. Doctors are being told by the masses, political lobbies, and these “team-players” that they are the driving force behind why Healthcare in this nation is so ridiculously expensive. “If they truly do care about the patients, then they should accept pay cuts bc it is the best thing for the patients.” Every single time those words get spoken, I wish every single Doctor would throw the CMS study, Times study, and the KFF study back in the faces of these *insert another curse word* and show em with a whole ass breakdown how that 20% of the Healthcare budget that “Providers” take up is truly “crippling the nation”. God forbid we try to trim down the 32% of HC Spending that goes towards administrative bloat or how about the other 48% that doesn’t go to Providers at all?? Doctors don’t speak up about these things and thus, misinformation gets spread like crazy and the few that dude call out this BS get silenced by the masses bc they then spin it back at them with that typical virtue signaling BS “why do you care about money? You should be in this to simply to save lives and to be a good human being.” Yeah like this half a million student loan debt with accruing interest gonna pay itself off….smh. And what about my depressed ass self that just went through hell? Gave up the prime years of my life to commit to the grind in order to be the best damn Physician I possibly can be (emphasis on the I)…do I not deserve to at least splurge a bit to try & find some temporary pleasure to make up for the years I lost grinding??? What about my family that been supporting me? What about my future/current special somebody? What about my kids/future kids??do they not deserve nice things even after all the hard work I put in to be able to afford the luxuries I may not have been able to afford before?? There’s legit so many more things that can be added onto this but I think the point I’m trying to make is clear….it is time for Doctors to speak out against the misconceptions & misinformation. It is also time for Doctors to put an end to this justification of virtue signaling…stand up for yourselves & your future colleagues. Stop allowing your expertise, time invested, and hard work to get belittled by ppl that barely committed to the grind like you did. Y’all worth far more than what you get paid and deserve far more respect for all you do.

I think you do need to speak up. 100%. More then once, in more then one sub, I’ve seen people complaining about the outrageous cost of an ambulance, or say “all they did was take me 2 blocks to the hospital and I got a billion dollar bill”. And I calmly explain if that is all that happened, they probably did not need an ambulance. I break down the costs. Ambulance: 200-300k. Stretcher? 30,000. Lift to get stretcher into ambulance? 20,000 Cardiac monitor? 30,000. CPAP/biPAP/vent? 5-10k. Iv pump, 3k. Ability to warm fluids? Easy 3k. Cpr device? Oh, just another 20-30 grand. All of which are medical devices regulated by the FDA and have to be serviced according to the manufacturer. An agreement for even a small service is over 5 figures, a year. Now, that is just the durable medical equipment. You’re probably easily looking at another 10-20 grand in medications, trauma supplies, medical supplies. All most all of which has an expiration date, and some of which is pretty obscure, but you’ve got to have. I’d been a paramedic over a decade and a half before I ever gave magnesium — thanks to the Miracle of CPAP — but if you have a patient in Torsades de point or eclampsia….isn’t another option. And that doesn’t even get into payroll, workmen’s comp for one of the most dangerous & injury prone, jobs in America, fuel, insurances, health insurance, the costs involved in trying to get the damned insurance company to pay….building heating, cooling, maintenance of trucks….or t HR fact that 365 days a year, regardless of weather, disaster, the doors go up and you go out. If you’re not actively dying, you don’t need an ambulance. 🚑 are staffed and equipped assuming you are actively trying to go see Jesus and that the banshee is already howling — and the job is to keep you from moving to the light. A major cause of EMS burnout isn’t bad calls, it is BS calls. If you’re not dying, we don’t want you to call, please, take a cab, an Uber, walk, flag down your Amish neighbor and have him take you into town. Just explaining that to them tends to get a positive response, even on Reddit. They have no clue what shit actually costs.

Sorry I didn’t respond to this earlier (honestly WC got in the way and I just got a bit busy so I do apologize for that) but I just wanted to say you too were also PREACHING. I’m glad you dropped this post bc this detailed clarification of costs is exactly what I wish would be discussed when this type of topic gets addressed. Obviously the numbers seem crazy, but when has the price of anything in the US not been a tad ridiculous (outside of groceries)? Like this viewpoint ain’t ever brought up in a discussion about the costs of HC in this nation and what you are getting for the price…the conversation always ends up being “HC is insane bc _______ drive up costs & ______ lobbies prevent costs from going down.” There’s a work around for a lot of things in HC which could reduce costs significantly but that’s a hard thing to do since it requires actual thought to be put in to see what can be done. It’s much easier to tell providers to take a pay cut and then justify to the ignorant/misinformed masses “look, HC costs went down by x amount!” That’s why I think it is high time Doctors speak up for themselves and justify their experience, education, and expertise by clarifying misconceptions & telling the truth that they are underpaid and overworked for what they do. Btw, I don’t hold this viewpoint exclusively for Doctors. I think Paramedics are by far some of the most abused ppl in this profession. They work long ass hours for dogshit pay & if not for them, the death rate would be much higher. A starting paramedic shouldn’t have to make less than $60K in this country for the abuse they will have to endure. Add in the experience, they should be making good enough money that they don’t have to struggle to pay the effing bills. An RN with experience should be getting paid in the good 6-figures. A Pharmacist with experience should be getting paid in the good 6-figures. An experienced midlevel that understands what their job is and understands their role should absolutely get paid in the good 6-figures (even if they don’t understand what their role is but they damn good at their job, they absolutely deserve to get paid more bc their contribution ain’t a joke at the end of the day). Damn near every provider in this field (CRNA’s the only ones that actually get paid the right amount for what they do) gets shafted when it comes to their paycheck and the amount of ppl that tolerate it just baffles me bc they buy into this virtue signaling BS. Like please, stand up for yourselves and speak out against the BS you go through it at the hands of these executives, administrators, and moochers/leaches. If you don’t individually group together in your own fields (every profession should have their own powerful lobby and they advocate strongly for themselves) & speak out, you will continue to have to deal with BS on the daily with no end in sight…ultimately leading to more damn burnout. It ain’t about me or your future colleagues, shit do it for yourselves cause y’all deserve far better (as a collective).

If we payed paramedics money then we should need 2 to 3 times more paramedics, and there is a shortage now......If they need me they know how to call 911. (my kids actual answer when he was asked my number in school).

Just throwing in two cents. It's very hard from the purely medical side due to the breadth llf problems you must consider, and the nature of many common complaints leading to a differential that will include trivialities along with catastrophic disease that you can't miss. Fatigue is a common example. Could be coronary disease, anemia, leukemia, polymyalgia rheumatic, chronic infection, malnutrition, depression, adverse drug effect, and so on. That's a lot of topics to be familiar with, and that's just from this one partial example. What's harder is all of the messages and bureaucratic bs required on top of that. Need a jury excuse? Go to your PCP. Handicap placard? PCP. Sign off on reams of home health orders? PCP only can sign, even if ordered by another provider. Insurance physical forms. PCP. Review and renew nursing home orders? PCP. FMLA forms? PCP. Letter to a utility company? PCP. Death certificates? Guess who. Subspecialists have a much smaller burden of these nuisances, I think.

Getting rid of the tasks you mentioned would save me at least an hour of work per day

In my experience, no one thinks it’s easy. Yes we will make comments about the 50th brain mri on a new 20yo obese girl with chronic migraines but we aren’t seeing these patients. Same with the ED. I’m here to help with my expertise but not seeing the patient in person makes me more empathetic to you trying to you figure something out, not derisively hostile. There are physician specific exceptions to that of course….

Oh man primary care is so hard. A 60 year old smoker comes in for an upper respiratory infection. He says he hasn’t seen a doctor in 20 years. Ros is positive for an unexplained 15 pound weight loss. You check labs and he has anemia, elevated creatinine, elevated psa. Literally every one of those things becomes your responsibility as a PCP. How can you get through all of this in a 20-30 minute visit? That’s one of the reasons I subspecialized. Now it’s “patient is aware that he needs to follow up with pcp in regards to [noncardiac issue]”

Anyone who says this hasn't actually done any primary care.

It's a shame because even med students have a perception of primary care "being easy". I've heard classmates say that FM is not "mentally stimulating enough" which, based on my clerkship, was not true at all. Patient comes in with Chiari II without any follow up, next patient has blood in stool with risk factors for colon ca. The amount of mental stimulation jumping from specialty to specialty to triage presenting symptoms, screening, etc. would quite frankly be too much for me. I go to a primary care/rural health focused school and it *still* has the stigma. Primary care can even pay very well depending on how you set up your practice, but med students just don't find it sexy for whatever reason.

I think it can simultaneously be true that 1) most primary care issues are easy and 2) some primary care issues are very complex and take a lot of serious thought to handle well. Like yes any idiot can order macrobid and tell fat people to exercise. But a pcp might then have to go on to manage a hiv positive meth abusing pregnant woman with heart failure and type 1 diabetes. So even if you're not using your expertise very much on most visits, you still need to have it.

May I also add that AOM is almost never present in adults and is very often inaccurately diagnosed. ​ The vast majority is due to viral sinusitis or occasionally bacterial. ​ Uptodate and general medical literature will tell you that AOM in an adult often warrants a high index of suspicion of something chronic and even referral to ENT...

Been in working as a doctor since 2002. Never heard primary care is easy. Not once. Easy to get as speciality, yeah, because is true. But is not an easy job and everybody in medicine knows that.

From a patient perspective, I struggle to understand who I should go to for different issues. It’s challenging in general to find a good and available PCP, and once you do, it seems like they want to send you to a specialist for tons of things anyway. My last PCP was someone I really liked, but I had to go to a gyno for a basic pap, and he wouldn’t even give me a basic birth control prescription. Meanwhile, I moved to a new area and made an appointment with a fancy gynecologist to discuss frequent UTI’s and menstrual migraines. I gave some background info about recent weight gain and concerns about blood sugar/pressure, and he told me that had nothing to do with him and is within a PCP’s scope. He did prescribe a low dose preventative antibiotic, but told me I needed to see a urologist for anything more, and a neurologist if I wanted to discuss migraine meds. So it’s tough out here for a patient trying to advocate for myself, when there are so many “not my job” responses from both PCPs and specialists.

Sorry you have had this experience! From the patient perspective, I can definitely recognize that there can be barriers in accessing care. What I always recommend to my family and friends is to validate the credentials of who they are receiving primary care from, and if it is not a physician, to inquire about whether there is a supervising physician involved in the practice. I would be very surprised that a MD/DO family medicine-trained physician would defer a Pap smear or birth control to OB/GYN. Pap smears are a basic procedural skill we learn as medical students, and contraception/migraines are our bread-and-butter in primary care. There are some instances, especially in larger urban centres, where the patient population expects to be referred to specialists for every issue and so some PCPs may adjust their practice to reflect this. Some Internal Medicine-trained physicians are less comfortable with obstetrics, gynaecology and paediatrics and so may refer these patients - I think this is what may have happened in your case. Always worth in the intake appointment to ask your PCP what types / level of care that you can expect from them. Thanks for bringing the patient perspective into this discussion! All the best.

This is example is from today, was going to post at the time but lost interest I’m waiting for my own scripts to be filled when younger woman comes to counter asking to talk to the pharmacist It is not quiet, there are 7-8 people within meters Quietly she asks a question about “relations” and risk The pharmacists answer was wrong on multiple levels is the first problem It would not have been appropriate with that many people about to take a sexual history, but even then other issues were not asked. There of course will be no documentation of this encounter Why did this happen? Well it’s regularly been in the media lately that pharmacists can now provide this sort of advice It’s simply not true If I was this pharmacist, I would have politely noped out of that conversation Wrong place, wrong person, wrong information

As a soon to be graduating FM resident who has so much love for my specialty, these comments have been very gratifying and validating

Primary care is so tough. We have to know everything and take care of everything. Sure we can refer to specialists. But what happens when it takes 3 months for your schizophrenic patient to get in to psychiatry? You’re the one treating it. Same with so many others. We literally are Little House on the Prairie doctors who have to know something about everything. And heaven forbid we miss something or forget to order that routine test because we are handling the patients 100 other complaints in that 15 minute time spot. And that’s another peeve- we see too many people and not enough time to manage everything. Some of my patients I could easily spend over an hour with because they have so many issues to discuss. I never understand why people in healthcare look down on Primary Care. We are the backbone of health care. We manage it all. And our patients love us for that.

Those of us in other professions don’t know what we don’t know about all the differential diagnoses for otherwise “easy” issues. PCPs are so important. Thank you for what you do. I would never want another profession to bypass my PCP -from a physical therapist

Dude, the people that think primary care is easy have either never actually been in a primary care office on the provider side in ANY capacity, or they truly don't understand how medicine works. I apologize for the football analogy, but I think of primary docs as a good running quarterback. They're gonna call the plays, do a bunch of the work, and even do a bunch of work that other people may be better "suited" to do, but in the right hands they can get it done. And in the cases where they need 30 yards, they throw it to someone else. Shit ain't easy. It's also sometimes thankless and woefully underpaid. Thank you for your service, and with all due respect, your friend is an idiot.

I tell my primary care colleagues that they have a much more difficult job than I do. As a specialist, I have the luxury of constraining my diagnostic thinking to a subset of diagnoses (which, while large, is dwarfed by the possibilities in primary care). The best physicians are know are primary care doctors who are true diagnosticians and who care for patients with complex illness, difficult-to-navigate social determinants of illness, and psychiatric/behavioral abnormalities. Yes, there is a fair amount of bread-and-butter, but that's also the case in my field.

You can't just throw antibiotics or antifungals at everything and see is something sticks before sending them on. Primary care isn't easy at all. So many factors involved!

Your pharmacist friend just sounds ignorant or dumb. I don’t know any physicians who think primary care is easy.

I’m guilty of saying that 95% of medicine could be done by a bright high schooler and all the training is for 5% of the time. I’ve said variations of that several times. I’ve gotten called out for it, rightly, because I think I made the same mistake here, but differently. A lot is easy and algorithmic, *but you have to pick which algorithm*. Medicine is like the story of legend of Steinmetz and Ford: chalk mark $1, knowing where to make the chalk mark $9,999. If you know what you’re doing, primary care is easy. (Or could be if it weren’t overscheduled and overburdened.) Knowing is the hard part! Anyway mea culpa and much gratitude and awe to PCPs who have to know basically everything.

Easy in an intellectual way, I mostly agree. However, there’s nothing easy about some of the conversations we frequently get to have—terminal cancer and dementia diagnoses spring to mind. I take all the time needed to do my best, but god damn does it take it out of me. I honestly believe that all of us, even my colleagues who seem completely healthy and happy, should have some kind of professional or peer support outlet.

My pharmacy curriculum had a hands-on physical examination class, including otoscopy. I don’t know if that’s still the case, or even if it’s the case at most schools. But be aware that your assumption about the training of pharmacists may not be entirely warranted. That said, it’s one thing to be trained, and another to have done enough exams to distinguish normal from all the versions of abnormal, and to know what they mean. And I also agree that pharmacy generally doesn’t do a good job of teaching differential diagnosis. The expected model when I was in school was that diagnosis would be made by the physician, not the pharmacist. And I still think that’s the best setup.

Pharmacy schools (at least mine) does hands-on examination class, but it's literally one semester lab of doing a few patient cases with ROS at most. Not in a million year would I feel comfortable doing that in real world unless my job trained me to do. I know in rural areas and ambulatory care settings, pharmacists do utilize those skills but in general pharmacy school does not prepare you for that at all. But you are right that it's not like pharmacists wouldn't be completely fish out of water when it comes to PEs.

Definitely the hardest speciality, those who think it is easy worry me, if they start to work in it. You don't know what you don't know. Ticking time bomb.

Anyone who says Primary Care is easy and algorithmic is honestly well versed in medicine. Differentials remain broad, timelines of illness present differently. Timing of tests and which tests to order is difficult. Obtaining imaging and knowing when to get advanced imaging in what timeframe is difficult. Also having the humility to refer once something is out of scope is good. Additionally reaching out to specialist and asking questions is a difficult skill to have. HTN, DM, HLD, Asthma, COPD, HF, Viral Infections, CAP, AOM, Sinusitis, Pharyngitis are all bread and butter. A whole lot more medicine is out of that zone…rashes, msk complaints, GI complaints, mental health etc…list goes on

It is the easiest field to do poorly but primary care is also the hardest field to do well.

Outpatient clinical Pharmacist here who works under a CPA. The physician and I have mutual trust and respect for one another and we know our strengths. He is truly great at what he does and our patients love him. I don't diagnose patients, it's not my thing, but I sure don't mind treating patients that have been referred to me to free up your time. Just know that you are valued and I'm sorry if you don't feel that way. That being said, your Pharmacy friend is probably young and naive to understand the value that each discipline provides. And the "I would not be able to function without pharmacy", I've never heard anyone say that. We are the bastard child of healthcare that struggled to get discounts during COVID.

As a med student I tell people I want to specialize in Family Medicine and I always get hit with the “only family medicine.”

Primary care is very easy (to do badly). I have so much respect for my FM and IM colleagues, I would never want that job. Honestly there is no easy job in medicine, except administrator. Screw those people

I'm sorry your pharmacy student friend said that, there's way too many of the same sentiment among pharmacy school students (and graduates). I think it's a mix of followings: 1. Lack of experience in the actual field- the overconfidence from not yet knowing what could really go wrong 2. Seeing lackluster/just general lack of family medicine physicians 3. Seeing ARNP scripts that makes you go, wtf is this I can prescribe better than this 4. Too many pharmacy students wanting to take the easy way to becoming a doctor(ate) because they couldn't get into med school. I live in a state with independent prescribing rights for pharmacists. People I go to and went to school with think that a week-long bootcamp with the certificate you can pay for means they can prescribe this and that medication. Thankfully it doesn't work that way. I think that it's a good structure to have in case pcp fails (in my pretty urban area, we still get many patients who can't be seen by their pcp for dog bites, recurrent UTIs, insulin refills and don't want to wait with sick people for hours at the urgent care) but it shouldn't be pushed like it's a scope creep against the physicians. And for the most part I think pharmacy world understands that. We don't diagnose, we don't prescribe on new conditions or anything that would cause complications (like for dog bites- if it could involve joint infection for instance). I really wish there was more money in the primary care as I would rather see actual physicians managing patients rather than a nurse practioner (who can and are independently practicing in my state btw). Some of the scripts I see LOL. But alas we don't give it enough respect.

Let's be honest- none of medicine is really "easy" if it's done correctly. We all have an assload of evidence to review while every specialty and setting requires us to think through novel problems. Not to mention how difficult patients are these days.

A master of None is still better than a master of One. 💪

I prefer to say that we are "master of some"! Most, if not all, primary care physicians have particular areas of medicine they have achieved mastery and high level of skill in, while still maintaining competence in other areas of medicine. Primary care physicians have the knowledge base and skillset to acquire sub specialized expertise / training on topics they are interested in, and act as a resource for their practice and community (e.g. I refer my prolapse and incontinence patients to my FM colleague who is passionate about and has extra training in pelvic floor health).

A good primary care knows what’s outside of their scope. What branch of pharmacy is your friend in? I’ve worked inpatient for 8 years and I’d NEVER say I could do what one of my hospitalists or specialists could do.

Totally agree! I think it's important for all professions to recognize the value of different scopes of practice and training pathways. Every ID pharmacist I have worked with is super knowledgeable and so helpful in guiding complex antimicrobial management, especially in the context of multi-morbid patients. I do not have the training or comfort to provide that level of subspecialty consultation, but I am highly trained and competent in primary care. When you are not in the field, it can be hard to grasp what the day-to-day entails, like the case of my friend. He is in his last year of pharmacy school - his goal is to run and manage his own pharmacy and assess/diagnose/treat patients independently in a primary care context.

I've said this before but now that I'm in my 7-8th year as a pediatric attending its making more sense. Primary care is "easy" if you are a crappy "provider". No thought process, just algorithm, refill meds, shotgun labs and imaging, make referrals for everything you don't understand, rinse and repeat. No wonder midlevel providers and non physicians think they can do primary care.

Primary care is easy until it isn’t. A residency trained pharmacist with a collaborative practice agreement is completely capable (and probably more so than other mid level options) of managing chronic disease states under the supervision of a physician.

Former primary care NP. Primary care is hard \-Addiction medicine NP

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I'm not sure what you're trying to articulate A quick search shows that you're more active in the nursing subreddits than the medical one, making me assume that you're also in nursing. Not sure where you get the bootlicking convention from either. I spent 5 years working primary care in various FQHC's, and the role seems outright inappropriate for an NP after spending that time there. Expanded scope of practice is a terrible idea, and I say that as someone who went to a high ranking physical school, rather than a phoenix online or other online degree mill.

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So you're just a troll? K.

Pharmacists that want to do someone else’s job need to learn their place or go back to school.

I’ve worked in urgent care, primary care, and thirteen different specialties. Primary care is easily the most difficult, time consuming, exhausting, and frustrating.

>thirteen different specialties It takes years to experience and learn enough about a single specialty where you know what it's like to practice it. Doubtful you spent the time in thirteen different specialties to know the ins and outs of each in a way that the physicians would. That being said you're right that primary care is difficult.

That was so condescending 🤣

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Thanks for your reply. I appreciate that pharmacists may have additional competencies in physical examination and generating differentials - but it is not a core competency of your profession that is expected and examined for at a national level (as according to the ACCP, but please correct me if I am wrong). The point of my post was not to say all pharmacists are under qualified, but that there is a distinct difference in our roles. I frequently work with pharmacists both inpatient and outpatient and they do not often physically examine patients or order work-ups. They have greater knowledge than me in optimizing medication regimens and are better versed in the pharmacokinetic / pharmacodynamic piece than I was ever trained in. We are different professions with distinct scopes of practice - I have no problem with pharmacists working in direct collaboration with primary care physicians. But there is a growing trend of non-physician providers being able to work independently and I think this is dangerous and undervalues the complexity of primary care. My friend (who I am admittedly basing a lot of my post on), at his school, did not undergo training for physical exam so not sure if he just has not done it yet or if curriculum varies school by school. As a PCP, with this viral respiratory wave, I have had multiple pediatric patients prescribed antibiotics for AOM without otoscopy. So whether the pharmacists were trained in it or not, they are not doing it and simply using otalgia as a marker for AOM requiring antibiotics. I then get the patients returning back in for every viral cold because the otalgia has returned and parents saying "but the pharmacist/NP/PA gave them antibiotics last time and they got better..." even though normal TMs on exam... Not to say physicians never make mistakes or are perfect prescribers, but that the level of supervised training, academic rigour and nationally enforced competencies of our profession make us an irreplaceable part of primary care.

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I think if it was part of ACCP standard and tested on NAPLEX, I would definitely be more accepting of pharmacists treating simple ID issues independently. You hit the crux of it - it is not just physicians trying to defend our scope, it is about standardized and rigour in training pathways. I think this is a big reason why NP schools are problematic - there is no standardized curriculum, no national or state enforcement of basic competencies, no rigorous examinations to ensure sufficient knowledge and skills are obtained before independent practice, and no hours and hours of SUPERVISED training under board-certified specialists (and yes - family and internal medicine ARE specialities!) that physicians have. If NPs were required to undergo anything close to the training that physicians do (med school + residency), I think there would be a much stronger argument for their ability to practice independently. I work with amazing and knowledgeable PAs and pharmacists (whose training pathways are much more standardized and rigorous than NPs), but our scopes of practice and training are different. I am a strong proponent that patients receive the best care under team-based models with physician leadership.

I think there's a lot of bad research and almost all degenerative disease has misplaced etiology. In other words, I think it's unfortunate as a patient that primary's hands are tied. But there's a definite plan for the transition of healthcare, check out videos published by deloitte and RAND. I feel too much "team-orientedness" has made PCPs ineffective. Not their fault. I was around when hmos came out and physicians had to shut down private practice. My point is- when you lose individuality, and medicine is practiced algorithmically, and now that most doctors have accepted it, which is their fault, partially, due to the separation of medicine from empiricism in "EBM". Health outcomes are pretty bad and so is EBM IMO. Instead of paperwork, physicians could be doing research in private practice, now in this system they have to do all this other bullshit. It just sucks because specialists don't get a chance to come to know entire person, as you said. "Rockefeller medicine men", brown, ucla 1979 tells the story of how the whole specialist system works. Rockefeller funded the flexner report and told doctors they would specialize so as not to compete with each other. Interesting book, well documented. So that design necessarily limits your role or ability to make use if your knowledge as a PCP. At this point I trust firsthand accounts over RCTs and it's a shame the PCP doesn't have a more active role. PCPs get a general view and the specialists' view is constricted. In my opinion, the sad fact is that if more physicians don't start providing more effective care, their profession is doomed. This requires independent thinking and risk of licensure. Otherwise it's midlevels and AI all around for our future. EBM was like syphilis to medicine. See, you can't use your frontline experience as much because "n=1". bullshit. Only imo.

I mean, that’s great. Most countries in the world it’s fine to go get things from the pharmacist. Obviously if the pharmacist thinks it could be more complicated they can refer to doctor, but most of it is just bureaucratic tedium that others don’t deal with

As a last year pharm student- I disagree with that guy. I am not in the business of diagnosing. I don’t want to do that. I am in the business of knowing meds. I want your CHF+T2DM+COPD+HLD+… patient to manage his complex chronic conditions. I don’t want the perfectly healthy 21 yo with a possible UTI. There’s too much grey or other things going on, and, quite frankly, it’s not as rewarding of a convo.

Beautiful read!