An ingrown toenail is not a lung transplant (how primary care is being held hostage to tertiary care)


Here’s a quick review of health care delivery basics:

Primary care – Stuff you can get handled with your primary care doctor in your neighborhood. Example: ingrown toenail.

Secondary care – Stuff your primary care doctor refers to a secondary specialist down the road. Example: colonoscopy.

Tertiary care – Complex stuff you need to deal with at a big-city hospital. Example: lung transplant.

Simple. Right?

Here’s the problem: In modern medicine we’re holding primary care hostage to a tertiary care delivery model. 

If you’re getting a lung transplant you need a 5-story hospital with helipad, medical team, insurance coding/billing software (you actually need insurance to cover the $500,000+ bill) and all sorts of special machines and complicated equipment. If you’re getting a colonoscopy, you need one person to shove a tube up your butt in a simple office with a few staff. If you’ve got an ingrown toenail you need one primary care doc in one tiny exam room with a pair of scissors. 

When we force ingrown toenails and buttholes to subsidize 5-story hospitals, helipads, medical teams, and insurance systems, we create incredible inefficiency and expense. In fact, all that crap is not only unnecessary, it just gets in the way and makes your $100 toenail or $1000 colonoscopy cost hundreds and thousands more! 

When we force primary care to pay for the infrastructure of tertiary care medicine, we end up with  assembly-line medicine in which patients are forced through 7-minute visits. Both high volume and price gouging are required to pay for the unnecessary helipads and hospitals for your ingrown toenail.

I’m a family doctor and I’ve been delivering primary care to my community for decades. I’ve removed ingrown toenails and metastatic lung cancer. I’ve cared for psychiatric patients and complex neurologic conditions. In fact, I can deliver care for 99% of what ails my patients right in the comfort of my 280-square-foot office. Just two chairs. One exam table. And no staff.

All I really need is my brain. And my brain tells me we must stop allowing buttholes to design primary care delivery in America.

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Pamela Wible, M.D., is founder of the Ideal Medical Care Movement and author of Physician Suicide Letters—Answered.  Jorge Muniz, PA-C, is an internal medicine physician assistant, illustrator, and author of Medcomic: The Most Entertaining Way to Study Medicine. Image credit:

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8 comments on “An ingrown toenail is not a lung transplant (how primary care is being held hostage to tertiary care)
  1. You’ve removed metastatic lung cancer? Or has the word “diagnosed” escaped from that sentence? Other than that editing question, I agree with your article. Relief will come in the form of a major contraction of the number, and influence, of hospitals in this country. Many of them are losing money, despite the preposterous subsidies that have been granted them in the form of facility fees and the like. Their overhead structure has doomed them.

  2. So true! I am solo sports MD and I do advanced joint injections (SI joint, hip joint, etc) in my office with ultrasound guidance. Patients who have had injections done at the hospital are amazed. It’s just me in the room and we are done in 5 minutes. The response is always, “wait, that’s it?”. Yep, simple. No fluoro suite, no 6 people in the room, and most importantly, no big bill. The only issue is getting the insurance companies to reimburse me appropriately. They seem to be happy to pay the big hospitals $$$$ for the procedure, but only want to pay me $. But that’s another article…

  3. Kathleen MD says:

    This system is broken and is breaking young physicians along with it. Erin, your story is awe inspiring. To survive having a brain tumor and to endure medical school is incredible in and of itself. Then, to have a residency program that fell blind to your gifts is gut-wrenching. You were an asset to what seems to be a very malignant program. UVA has and will continue to suffer a great loss with your absence.

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