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.

Contact me for a free guide on how to launch your ideal clinic


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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13 comments on “An ingrown toenail is not a lung transplant (how primary care is being held hostage to tertiary care)
  1. Michael H Ballard says:

    Sounds wise to me.

  2. J Timothy Ames, MD says:

    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.

  3. Mark Niedfeldt says:

    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…

  4. 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.

  5. Steve Smith says:

    Diagnosing versus removing metastic lung cancer are not even close to the same thing. And you did neither. You merely took a tissue sample which you could not diagnose yourself. The pathologist did that. The patient then had to go to more specialized centers for treatment such as chemo/radiation/surgery that you could not provide in a primary care setting. You are very irresponsible using the word “removed” implying that you cleared and cured the patient of cancer that had spread to multiple organs. Given what we know about metastic lung cancer the patient is likely terminal or already dead at this point.

    • Pamela Wible MD says:

      I excised a metastatic lung cancer lesion. I actually removed it. Yes. I never stated that I cleared this man’s cancer.

      • Steve Smith says:

        You stated you removed metastic lung cancer. You did not qualify that statement with lesion which makes a huge difference number one. A lesion could be 1 mm in size. Metastic cancer of any kind means tumors all over the body in various sizes from 1 mm to a grapefruit. Secondly, more importantly, you again regurgitate that you “excised a metastic lung cancer lesion”. You did not argue my point that all you really did was take a tissue sample. You did not know it was cancer. You did not know it was metastic. The pathologist and other experts figured that out. You just scraped off part of a lump no more than removing a skin mole. Please stop perpetuating this myth that all we need is to go see a family physician for cancer treatment. We definitely need the hospitals and specialized treatment centers for cancer. The family physician/GP/PCP is a waste of time and money. I went to my PCP for complaint of constipation. She simply said my bowel sounds were good then ordered a STATE abdominal CT scan. The result? Thousands of dollars of out of pocket cost which ultimately showed “idiopathic” left diaphragm paralysis. My initial complaint was never addressed. I made some diet changes based on my own research that seemed to improve it a little, but now I am back at square one. Based on Fiber Menace, I probably have IBD which I will investigate on my own since docs can’t do shit about that either. Thoracic surgeon recommended plication before and after very poor pulmonary function tests which I was not about to do because I researched all this before I saw him the first time. It is irreversible, high complication rate, and doesn’t even fix the problem. But he bragged multiple times about his Youtube videos of the robotic surgery and how he could make my xray “look great”. Fuck what it looks like asshole. I want to breathe. I mentioned multiple possible causes and how the urgent care assholes (I mean doctors) in February misdiagnosed my shoulder pain as bursitis AND failed to tell me of the elevated diaphragm they saw on the xray. They thought heart attack even though I assured them I knew that was not the problem. Over a thousand out of pocket for their incompetence too. He blew off all my research and just said “hindsight is 20/20” That comment is a dead giveaway to someone who knows their cover is blown and is trying desperately to conceal their ignorance. He cemented his stupidity and ineptitude by claiming he “knew docs in Phoenix who do that” when I told him I wanted to pursue a phrenic nerve graft if other possible causes were ruled out. He even said he could refer me to some, but of course he never did because he was full of shit. There are not any other doctors ANYWHERE that do that. Only one. Dr Kaufman in New Jersey. So my point of this diatribe is to sadly point out that you aren’t any different than the rest. Healthcare overall in America completely sucks and doctors themselves are a very big part of the reason. Doctors are the least stressed, best compensated and most protected of just about any class of professionals out there. And for what? You all just do the same stuff patient after patient year after year. You have a standard protocol for every thing you see and do. No research or troubleshooting required. You just do what you were shown 20 years ago in medical school. If I was wrong I would not know what doctors are going to tell me before I even walk in the door. I always know. Thank god there are now sites like so I can do my own diagnosis for a lot less time and money and incompetence than wasting my time with a PCP. My doc didn’t think a CT scan of neck was necessary for phrenic nerve paralysis – how stupid! She doesn’t know basic anatomy obviously. So I insisted which confirmed cervical spondylosis at C3-C5. Obviously a possible cause for phrenic nerve paralysis. Yet she orders a complete blood count? For what? The only thing it showed was low Vitamin D at 6! Talk about an extreme deficiency. But she didn’t bother to check the parathyroid hormone level! How stupid. My calcium level was perfectly fine even with extremely low Vitamin D. So I had to spend more of my own time researching how that could be since all she did was slap me with a potent script for Vitamin D. Turns out my low vitamin D could actually be due to elevated PTH (i.e. parathyroid tumor) but she didn’t bother to check so now I have to figure that out on my own, too. That is proof of my complaint. No research or troubleshooting. She saw I have low vitamin D so she wrote a script for vitamin D. Did she bother to try and understand WHY it is low or even discuss with me why it might be low or what I should do? No. And I live in Phoenix AZ! What the hell? How about just spend 30 minutes a day in the sun for a month then recheck vitamin D? I guess not enough money in that recommendation. So please spare us all on what a great service you are performing and how you have all the answers to not only patient but colleague problems of suicide. As if they are all just over stressed. Sure, not one ever failed a board, lost a malpractice suit or faced an investigation for their incompetence or malfeasance? Right.

        • Pamela Wible MD says:

          I knew it was cancer. I knew it was metastatic. I did not know the primary source which is why I sent the entire metastatic lesion to the pathologist. obviously cancer treatment (depending on what patient wants) is done by the physicians who specialize in the organ/condition being treated.

          Assembly-line medicine fails everyone—doctors and patients including you it seems.

          “Doctors are the least stressed, best compensated and most protected of just about any class of professionals out there.” Absolutely not the case. Doctors have zero protection from inhuman working conditions and have the highest suicide rate of any profession. Here’s a letter I just received from a radiologist that will help you understand working conditions in US hospitals:

          Dr Wible,

          I just finished reading your book on physician suicide from the disgustingly inhuman working conditions for physicians in the US. It certainly rings true. I lost many physician schoolmates and friends to suicide. There is however a relatively new phenomenon in my medical field that you need to be aware of: non-suicidal death or permanent physical disability from exhaustion due to disgustingly inhuman working conditions. Here is my story.

          I am an academic radiologist at a top program on the West Coast. Over the past few years, our work conditions have significantly deteriorated. Typical day involves working non-stop from 7am to as late as 3am, with no possible breaks for eating or going to the bathroom (although we do go to the bathroom before we explode). When I finish late at 3am, I have to sleep on the floor of my office until the next shift at 7am. We have to interpret up to a quarter of a million images per day, are required to work up to 120h per week and up to 7 days per week.

          In the past two years, our radiologists have been dropping left and right. In my small division, almost all of our senior radiologists have taken early retirement out of total disgust. Some of our mid career radiologists have simply dropped out of medicine out of total disgust. And of the young radiologists who stayed to provide the necessary care to our massively ungrateful patients (who are suing the hospital left and right), 25% of our young radiologists have either died (from exhaustion) or suffered strokes leading to permanent lifetime physical disability. I myself am the latest of our young radiologists to fall. Last month I suffered a hypertensive stroke leading to almost complete blindness. I permanently lost vision in one eye and have three feet of vision left in the other eye, just enough to still function as a radiologist. They gave me a few days to recover from the stroke and put me back to work.

          At this point, I still need an income but feel that I will likely die or become completely blind in a few weeks or months in such working conditions. It’s like that at other US institutions so moving is not an option. I have started to look at opportunities in other countries, that are less cruel to their physicians. In the meantime, I have taken a good life insurance policy to benefit my wife and kids in case I die, and I have a bullet I keep at an accessible location in case I become completely blind.

          I hope you can see that it’s reached a point where not only do physicians die by suicide, but physicians also die from exhaustion or have their health destroyed with permanent resulting handicaps due to the disgustingly inhuman working conditions for physicians in the US.

          George B. Anonymous

          P.S. No imminent plans to use that bullet. I just like to plan ahead. Will only use it if I eventually become completely blind.

          • Lyn Trosper says:

            To George B. Anonymous,
            I was appalled at the conditions of you work environment and am sorry to hear of your illness. I’m sure, though, that you know that most life insurance policies do not pay in cases of suicide. Take care of your family by taking care and loving yourself.

  6. Lola says:

    Can a primary doctor remove an entire toenail due to it coming off of nail bed, and therefore bleeding profusely and that blood drying underneath? A specialist would cost me $200.00 to remove entire toenail (to grow back) while GP visit would cost me only $15.

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