Practicing at the Top of Your License is Not an Option for Primary Care Physicians

Originally posted on my Substack.

You don’t really need a medical degree to know how to follow an immunization schedule, to recommend a colonoscopy, or order a screening mammogram (as long as, in this country, there is a standing order – in some places, mass screenings are done outside the primary care system).

You also don’t really need a medical degree to enter data into an EMR.

And when you decide to order a test, how many of the EMR “workflow” steps really require your expertise? I mean, borrowing from my iPhone, you could say “order a CBC” and facial recognition could document that you are the ordering physician. Really!

And you don’t really need a medical degree to, as I put it, open and sort the (electronic) mail; an eye doctor’s report comes in and if the patient is a diabetic, I have to forward it to my nurse for logging, and if not a diabetic, just sign off on it. And don’t imagine there is time in our day, evening or weekend to actually read the whole report. Patient A saw their eye doctor – check. Next…

Primary care in this country is pathetically arcane and inefficient. And we have a shortage of primary care physicians, they say. If we could all practice at the top of our license, perhaps not. It’s time to reimagine, reinvent, reinvigorate!

14 Responses to “Practicing at the Top of Your License is Not an Option for Primary Care Physicians”

  1. 1 Henry Hochberg March 5, 2023 at 2:24 pm

    Hans, it’s time for you to strike out on your own. If you’re financially comfortable enough just hang out your shingle and let the people who value you for who you are and how you practice come to you. Go back to paper charts. Take a chicken for payment. Start your own subscription service. You probably won’t make enough to live on but you’ll love what you do and it fits you.

    • 2 Medhacker March 17, 2023 at 9:47 am

      This is exactly what I do. You must have the financial means to do it, as most people do not appreciate the value of this type of medical practice

    • 3 Jennifer Allen March 26, 2023 at 8:35 am

      Oh but you can make more in direct pay medicine than any hospital would pay you.

  2. 4 Renae March 5, 2023 at 4:06 pm

    Unfortunately, mental health is going down the same path. I’m providing services to half the number of clients I used to because of the added non-billable, non-clinical “busy work” that I’m required to complete. There’s a growing waitlist for mental health services, so I agree – the system is arcane and inefficient and it’s (past) time to reimagine, reinvent, and reinvigorate!

  3. 5 Lisa Ramey March 5, 2023 at 6:17 pm


  4. 6 Alessandra Chaves March 6, 2023 at 9:37 am

    I have a Ph.D. in biology and 95% of what I do at work does not require my expertise. I have to do things the janitor could do. Go figure. Waste of money and everyone’s time, but workplaces decide to do away with support people and put everything on the back of the scientists.

  5. 7 Brian Gamborg March 6, 2023 at 3:31 pm

    so true, and I am on faculty for family medicine

  6. 8 David Felker March 6, 2023 at 6:22 pm

    It would seem the solution would be to allow Medical Assistants the ability to ‘work’ the EMR. Prior to being acquired by a corporation, my solo practice ran extremely efficiently for 25 years as these tasks were assigned and supervised. This freed up time for me to doctor (verb) the needs of the patients. Alas, corporate primary care will have to re-invent and re-invigorate, as the last of US (the old school primary care) retire in the next 10 years

  7. 9 Medhacker March 17, 2023 at 9:49 am

    Doctor, how do you then define working at the top of your license?

    • 10 acountrydoctorwrites March 17, 2023 at 10:04 am

      Spend all my time on diagnosis and treatment and next to no time on data entry.

      • 11 Jamie Evans March 19, 2023 at 9:27 am

        I have a scribe who essentially transcribes my HPI in the EMR while I gather the information necessary to diagnose, treat and manage my patient’s conditions. My nurses gather social/family surgical history, reconcile meds and enter “standing orders”. My job is to diagnose, treat, make med adjustments, educate, help my patients identify and overcome barriers to treatment and determine what standing orders may/may not be indicated for this individual based on age, condition or personal desires of care. I’m able to individualize my care for each person. That’s what I find as the most valuable use of my licensure. And I believe my patients do too. Continue to step out of the cookie cutter and be the hub of the wheel!

  8. 12 Angela Caffaratti March 18, 2023 at 10:06 pm

    Standing verbal orders coukd cover a lot of this and you can have documentation to guide the MA in those standing orders.

  9. 13 Jennifer Allen March 26, 2023 at 8:33 am

    If you practice outside the beaurocratic, big pharma, big insurance driven, hospital owned system and practice direct primary care- where patients pay you directly- then and only then do you get to use the full extent of your training. The system is otherwise set up for you to feed the money making specialty machine of the hospital. That’s why they think a NP, with a tiny fraction of your training, can do what you do. If you were allowed to use your brain and afforded the time it takes to see someone and hear someone- then you would be more fulfilled and be working at the top of your license. Respectfully- get out! Save yourself.

  1. 1 Practicing at the Top of Your License is Not an Option for Primary Care Physicians – The Health Care Blog – Familyinitiative Trackback on March 12, 2023 at 8:25 am

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