Lenk

switzerland

I recently returned from a church Men’s Retreat in the resort town of Lenk, Switzerland. This was MY kind of ‘retreat.’ The majority of our two days was spent on the ski slopes, not talking about God and theology and right and wrong.

 

I’ve been a Christian since I was 8, so the pastoral lectures and Bible verses never feel especially new to me.

I routinely enjoy the music, and in our case a great band led those times in the evenings, but I was happy to attend a retreat that was mostly just a cheap ski vacation. I met some cool guys, got a little better on a snowboard, and stood in absolute awe at some of the most beautiful scenery I have ever known.

 

I don’t worship God very well through study, or through listening to lectures from pastors. Lectures, ever, haven’t worked well with my brain. Ask any teacher of mine all the way back to 1st grade and you’ll probably get some version of the same mildly exasperated half-smile, and a reply along the lines of, “he really, really TRIED to give a crap.”

 

Adelboden-Lenk

But when I’m in the shadow of the Swiss Alps, with 1,000 year old glaciers clinging to jagged sawtooth ridges in a 300-degree ring all around me, I pay attention. Somehow, breathing in crystal-pure air, with rolling forests and organic dairy farms dotting the countryside in every direction far below me, I have no problem thinking about God and wondering how I couldn’t possibly be closer to His almighty Spirit for that moment.

So, it was a spiritual time for me, but with very little preaching or Bible-studying. Perfect.

 

I was also struck by the unity and beauty of the towns we passed through on our way to Lenk. Switzerland has been highly resistant to change over the years, from what little I’ve read of the country. It is fairly hard to immigrate there, and once you ARE there, good luck building consensus around any particular idea or religious creed that departs from the time-honored ways of the Swiss. Du willst ein Minaret? Das wird nie passieren!

Deutsch: Chalet in Pöschenried, Gemeinde Lenk,...

These, dotting the countryside as far as you can see. Plus snow when it’s winter.

 

 

In Switzerland, you know you are in Switzerland. Especially in the countryside. The buildings are stirringly beautiful, most made of a light-colored wood sometimes set on dazzling white painted rock or concrete bases. The barns looks related to the houses. Everything is clean, ordered, pristine.

This unity isn’t by accident. But it takes enormous force of will to maintain a cultural identity in an increasingly pluralistic and mobile society. To do so inevitably becomes political, with increasingly volatile arguments on either side.

My homeland, America, has never really had a unity of culture and history to this degree. We’re a nation of very few subjugated natives, and very very many immigrants. To walk through my country – or any large American city – is to walk around the world.

Both have their merits (except for our treatment of the natives). But there’s something so deeply peaceful about meandering through a place that knows itself so well. A place that is OLD, and has not forgotten the value of of old things. King Solomon was rewarded by God with power and money because when God offered to give Solomon anything he wanted, the young man asked for wisdom. Any place that honors age, honors wisdom, and God seems to have blessed the Swiss accordingly.

I’m not saying Switzerland is paradise or utopia. There are problems. But they’re getting lots of things right. Here, walking is revered over driving. Food is valued for quality and purity rather than quick access or cost.The country has some of the best health care access in the world, with 3.6 doctors and 10.7 nurses per 1000 people. Life expectancy is around 73 years old. Obesity is less than 8% (it’s almost 50% in the U.S.), and it is estimated that 100% of the population has access to clean drinking water and sanitation facilities.

As a Caucasian from the American suburbs, with no knowledge of my heritage further back than my grandparents, this place holds an impossible appeal for me. I don’t know my family history, whether a story of thieves or kings. My nation’s history doesn’t even span 300 years.

As our retreat drew to a close, I knew I could never truly be a part of a place like Lenk, Switzerland. I could only marvel and yearn, watching that priceless world slip past my car window, as we hurried home.

 

Bread Between The Legs

English: Candida albicans

We call these ‘branching hyphae’

Yeast infection: Yuck-central to the average vagina owner. Discharge like milk curds, funky smell something akin to old toes floating in rotten vinegar, and an intense itch that you can’t actually itch because if you try, it hurts. Cool, huh?

When you’re talking about this fun experience, what you’re largely talking about is overgrowth of a specific type of yeast called Candida albicans, which is actually a fungus. Pretty gross.

Truth is, there’s probably a few of these little guys hanging around the average human vagina all the time and it’s no big deal, but too many of ‘em and you’ve got a problem.

Candida albicans

Same as the above pic, just the DANCE version.

Of interest, Candida is kept at bay by another creature that you want hanging around in your vagina called, as a group, the lactobacilli. These guys don’t fight candida, they’re much more suave. They simply produce an acid (“lactic” acid…get it?) as part of their normal life cycle that subsequently keeps the vagina acidic. This makes things real tough for most other creatures, except for the odd Bear Grylls of the Candida world who eat acid for breakfast.

Yeast infections result when the acidity levels in the vagina drop. It’s hard to predict when and how the pH will change in that region of the world, but often it does.

Historically, yeast infections were easily treated with anti-fungal creams or a single pill of the drug fluconazole. But the “easy” part is going away. Increasingly, I’m seeing patients who have recurrent yeast infections despite the usual treatment.

Often, these patients have a history of heading to the doc for “that pill.” And often, docs (or the “provider”) just fire the pill at them and everyone calls it a visit. It’s quick for the patient, saves the doc time, everyone’s happy. Unfortunately, the happiest of all in this equation is the yeast.

Fluconazole

Fluconazole

Fluconazole works by blocking an enzyme. That enzyme facilitates reactions that create the yeast’s cell wall. With the drug around, their cell walls get floppy(er) and don’t hold together as well.

But that doesn’t mean the bug is dead. Fluconazole isn’t some flaming thunderbolt from Mt. Olympus that blasts yeasts back to the Elysian (bread) Fields. The drug is fungastatic, not fungicidal. The weakened yeast is then susceptible to other bugs our our immune systems. Like a mob boss of the pharmaceutical world. It doesn’t do the killing, it just arranges, eehh, ‘tings.

These days, fluconazole isn’t as tough as it used to be. It doesn’t work like it did, often not with the strength it had. So tossing this pill at a yeast infection is a bad idea. Real bad.

Certain types of yeasts make poofy bread and good beer and they keep Jewish people busy (some would say crazy) during Passover. So they’re not all bad. But it’s an organism that we could do without. Fungal infections, when they become systemic, have always been tough to treat; more so than bacterial. And systemic anti-fungals have always been tougher on the body than antibiotics.

Under these circumstances, the best approach to recurrent yeast infection is NEVER to just go get another pill. You should firmly request that your doctor not only get a wet prep (which is merely looking for the presence of yeasts on microscope slide), but also order a culture of the yeast should any grow on the prep. From that culture, not only can the species of yeast be determined, but it can also be tested for sensitivity to fluconazole and other anti-fungals to see if the right drug has been chosen.

Recurrent yeast infections are beatable, but not if you’re lazy about it. For reasons that most men can understand, yeasts really, really like the vagina. If you don’t like ‘em there, you’ve got to put more than just a little effort into getting ‘em out.

Reader Q: Why Did You Sign with the Army?

Hi Dr. SW101,

Enjoyed reading some of your blog posts both older and the newer army related ones today. Lots of smiles and chuckles, Thanks.

Laughter? In response to this blog? That’s TERRIBLE. This was supposed to be serious stuff. Like taxes. This is information. Data. Recommend re-read.

I’m curious to know why you signed up?

I signed up for the Army for one major reason and one minor reason.

The major reason was the craven want of money. I wish it was something more patriotic, but the primary motivation was an offer of a loan repayment grant and monthly stipend during my years in residency. The Army required nothing in return during my training years. Faced with sneaking my 6-member family into a 2-bd apartment that allows only 4 people, I took the money. Instead of the apartment, I was able to put my family in a cute 3-bd home on a quiet corner two blocks away from my training hospital.

The second reason was patriotic. Despite my vehement opposition to the war in Iraq, and moderate opposition to the war in Afghanastan, I was fully aware that primary care was severely lacking in the U.S. Army at a time when young Americans were throwing themselves into war. Irrespective of how I felt about those conflicts, I remain an American. News of my countrymen dying or suffering partially due to lack of good medical care was something I couldn’t tolerate.

I have always been taken with depictions of how our nation pulled together and sacrificed during the second world war. Back then, those war efforts were truly a national affair. Virtually everyone gave to the effort in some fashion. And, I think a huge reason for the wealth and power we have enjoyed for the past 60 years are a direct result of those sacrifices made by our Greatest Generation.

Pretty Sure I Woulda Deserted

“Earn this,” CPT John Miller, dying from a mortal wound during the Battle of Ramelle, implored Private Ryan in the Spielberg movie. The message, as I took it, was our generation (and the Boomers before us) must understand that great sacrifices were made to allow us to live on the top of the world as we have as Americans. It remains our mandate to earn that sacrifice; it was made before we even deserved it.

So I signed.

I saw posts about officer training and an earlier one about trying to figure out the military scheme as a civilian. What got you in? 

I think you’re referring to how I got into the Army as a civilian. If so, the answer is website: http://www.usajobs.com. Everything runs through this site. I applied to this site in the winter of my senior year of residency, and forgot about it. Literally. When I was called by the clinic here in Germany for an interview in MARCH the following year, I had no idea why.
If you want to get a job overseas, however, this is one of THE best routes. You can’t work for the State Dept as a doctor until you’ve been in practice out of residency for 5 years. You can’t get a job with any of the aid organizations unless you know someone AND don’t need money. So, this is a good option because the pay is steady, only slightly beneath the national average, and comes with perks that don’t usually accompany private-sector jobs.
There’s lots of archane goofiness that come with Army medicine. There’s lots of unusual quirks that are a result of non-medical “commanders” decreeing all kinds of demands from on-high.
But, in reality, every managed care organization functions like this these days. I wouldn’t put Army medicine behind or beneath any of the major HMO’s (in principle, I haven’t worked with any of them). I think Army Med is about on-par with most of American medicine…approximately 18th best in the world.
Also wondering why Olympia was your first choice? You’ve said elsewhere that Ventura is probably the best FM program in the US. I’ve heard of a number of graduates going to Tacoma Family Medicine and lots of interest in Alaska, too. Can you comment on them?
I am very proud of my FP training program, and maintain the belief that it is one of the best programs on Earth, and THE best on all outlying planets. I firmly believe that Providence is one greatest healthcare organizations anywhere.
But in all honesty, I have to say that Olympia is not the best. Just MY best.
English: Statue of Father Junípero Serra. Vent...

Father Ventura, surely a surfer

Ventura is better. Better than anywhere else I know of (and I practically got a PhD in FP residency research during med school). The hands-on experience they allow there, assuming times haven’t changed, is second to none. The faculty are top-notch; some are dual-certified, etc. Facilities suck, too, which is great. I can think of no better means of preparing an FP to deal with a crappy, under-funded, under-supplied environment where the only thing you have to give to patients is your training.
I was told I had a shot there. What they told me likely sounded MUCH like what they tell EVERY short-white coat wearing minion worshipping at the altar of VCMC during their exit interview. But I still like believing I coulda made it in there. I never ranked them, however, because my large family would have needed to live in a box on the beach to afford the cost of living in Ventura. And, truth be told, since I could have reasonably placed that box at the point at Fairgrounds (read: KILLER surf spot), residency would have been AWESOME for me. Just not for my kids waking up with sand fleas in their eyes and facing yet another breakfast of seaweed and/or Wonderbread bologna plus peanut butter sandwiches at the local Rescue Mission.
One nuance Ventura is the dual FP/MPH program at Dartmouth which is as good as it gets if policy and health system design is your calling. Love it or hate it, the Obama Health Care plan wisely referred to the health resources utility research out of Dartmouth. Although barely ranked, I am of the opinion that Dartmouth is actually one of the best – if not THE best – MPH program in the country because the research and work they do is prescient, unassailable, repeatable, tested and longstanding.
Tacoma is a great program, but they have nothing on Olympia. Their city smells weird, their facilities aren’t any better than ours, and we do rotations at the Peds ER up there anyway. So I recommend ranking them 1/2 with the top choice going to the town you like best.
Alaska is probably a lot like Ventura. Sans wicked right point-break and unfortunate box.

Yesterday O’Clock

Special Forces Sniper
This guy was dead asleep in his underwear exactly 33 seconds ago.

Doing Army stuff is awesome.  Except that it starts so early, the time is best described as “yesterday.” 

It’s not uncommon to hear (through my ears), something along the lines of “Formation at Yesterday O’Clock, soldiers!  Then we head to the range for M-16 qualifying.” 

I assume he means we will be qualifying with the rifles by the light of Orion’s belt, since that will be the major source of target illumination for the next 5 hours.

My particular training class has a group of Army Rangers in it, along with some Special Forces guys too.  They all decided to hang up the guns and take up stethoscopes as P.A.’s and pursue things in life, like hobbies and families.  As you might expect, these guys can handle Yesterday O’Clock better than anyone. 

It’s a bit mystical, really.  In our tent of 30 men, someone starts to stir at the ungodly prescribed hour, and everyone just organically follows suit.  Soon every guy in the tent is methodically working step-wise to primp themselves (Army-style, more on that later) for another dimly lit Army morning. 

Everyone except the 4 Rangers.  They stay there, still as statues, enshrouded in their sleeping bags while the tent becomes a kicked anthill of activity.  The minutes tick by, the spectre of arriving to formation suffusing the humid tent’s air. 

Maybe these Ranger guys so easily stare down scary things like being late to formation because they’ve stared down much scarier things, like death via hot shrapnel.  Whatever.  Fine. But here in our little AMEDD training world, being late to formation is scary.  And being late is easy, because it’s scheduled so freaking early, it’s yesterday o’clock.

As the appointed “time” (more of a philosophical concept, this early in the morning) approaches, a frantic rush ensues.  In desperation, we huff out to stand in our little box of humans, also called “formation.”  And guess who’s standing there, looking sharp and ready to plant a spear in a saber-tooth bear? 

The Rangers.  2 minutes ago these guys were lined up on their cots like 3-toed sloths on an ativan drip.  The rest of us have been running around for 45 minutes. 

“Where you guys been?”  One of them asks, as I run up, wild-eyed and still priffing with my uniform.  “We’ve been here since yesterday.”

Smarching

Sprinkler03

Me, spinning in formation

“1st Platoon!  Atten-SHUN!”

We all throw our shoulders back and stare straight ahead into nothing.  And we don’t move.  Leaders mill about, thinking about things, looking over their retirement accounts, playing Tetris on their phones. 

But we, the little people, just stand there.  Sweating.  Sweat runs in what feels like lightning patterns down my face.  Down my neck.  My back.  My rear…and down my legs.  I stand there taking a sweat-shower.  Spin me around fast enough and I’d fling so much water in every direction I think I could personally ease the drought problem in Texas.

“SMAAAARCH!”

Well, he actually say ‘march,’ but, really, you just can’t call it that.  No nuance.  We aren’t marching.  We’re walking around in 104 degree F heat, with sweat pouring from our bodies on par with your average Bangladeshi monsoon.  So we’re sweating.  With a little marching thrown in. 

It’s smarching.

Officer Basic Training – Day 1 (or, The Subjugation of Befuddlement)

I have left my family in Germany and successfully arrived in tepid San Antonio, TX for 28 days of training to become an officer in the U.S. Army Medical Corps (pronounced ‘core’ not ‘corpse,’ though both work pretty well).

On my flight over here, I called some in-charge guy from Oh-Hare airport in Chicago to ask him where to go when I arrived last night because I was a day early.
 
***note to friends and family who know anything about me…I showed up EARLY for something I regard as totally stupid.  Note that. Somewhere.  Just get it down for posterity somehwere.  Not just on-time.  Early.  Me.***
 
A guy actually picked up his phone when I called and told me to go to building #596, which is an Army hotel on Ft. Sam Houston. 
 
“Nice,”  I think.  “I’ll be staying there for a month.”  I take a cab from the airport to the hotel.  The cab driver drives away.  I walk up to the counter, am asked for a copy of my orders, then am told that my room is at the Holiday Inn next to the airport.
 
“I was just at the airport.”
 
“Yep.”
 
“I just paid a cab guy to get me out here.”
 
“Yep.”
 
“Thank you, so much, ma’am, for your help.  Can I have my orders back?  And, could you call me a cab…maybe even THAT GUY driving away over there who just dropped me off?”
 
She calls a cab, but not that guy.  It will be a half-hour, she says, until a cab can get here. 
 
Hmmm.  K.
 
Then, feeling Army-saavy, I ask her to COPY the copy of my orders she asked me for, and make me a few extra, AND SHE DOES!  
 
We’ve been told to come here, inexplicably, with 10 copies of the orders telling us to come here.  The need for a billion copies of paper orders is one of the many stipulations that totally befuddles me.  I am actively in the process of subjugating all sense of confusion, befuddlement, and mystification, with mixed results. 
 
But with respect to my orders, I’m making it my personal goal to leave this course with MORE copies of my orders than I arrived with.  If I get back home with more than 10 copies of my orders…I’m taking my wife to dinner or something.
 
Anyway, it’s a nice hotel, and I have to keep reminding myself that I am NOT here for the usual blah-blah conference.  For example, our day starts tomorrow at oh-430…well before the “free” breakfast I’m entitled to.  And some of the classes we’re supposed to take start at 6pm or later.  So, it ain’t a cardiology meeting in Oahu.
 
I’m in SanAntonio, in August, in a heat-wave that is about to break historic records.  So yes, it is butt-hot outside.  And I’m the kind of person who thinks PERFECT weather is overcast, rainy and 65 degrees F.  Seriously.
 
But it turns out that the heat actually doesn’t bother me, so far.  Mostly just feel like I’m back in Beer Sheva, Israel where I went to medical school.  I haven’t been running around in it yet, but so far it hasn’t really phased me.  It’s hot.  Like med school.  Who cares.
 
I met a guy at breakfast this morning who is also in the class.  Cool.  Older.  Knows stuff, like what he “makes” per day and that it’s good to bring a roll of toilet paper when we go “to the field.” 
 
As he sits there describing Army stuff, I wonder what my problem is with details and why I’m so averse to them.  He’s talking about tax-deductions for military pay or something and I’m thinking…”Kyle Orton, he’s really the guy who needs to play for Denver this year”…and…”At some point, this guy is gonna tell me how to get out of deployment AND monthly drilling and when he does, boy, I’ll be RIGHT HERE ready to pay attention…but he just said ‘requisition’ so no need to tune in yet.”
 
His name’s “Ray” and I’m extremely proud of myself that I remembered it.  I came up with “First-day Ray” and now it’s in my head forever. 
 
Ray assures me that since we’re off-post, I won’t be given a roommate.  That was an “on-post” stipulation because it was a barracks environment.  The hotel lady yesterday told me otherwise, saying that I would be getting a roommate and I had not choice in the matter and would not be allowed to pay extra for my own room. 
 
So, the jury’s out on “Ray.”  If my single room survives today…he wins.  Stud.  Fount of knowledge.  I’ll actually like him at that point.  And he won’t be placed in my category of people who talk like they know stuff but who I ignore for your own safety.
 
Having my own room is pretty cool.  I can sit here, for example, completely naked and type my little blog.  I’m NOT, actually.  It’s just that I COULD if I wanted to…which is the whole point. 
 
It’s the Manhattan Effect…the desire of millions of people to live in Manhattan so they can be near museums, shows, galleries and restaruants and theaters even though they won’t patronize even 5% of what’s available to them for the entirety of time they actually there.  It’s just that the CAN go if they want to.
 
‘s called freedom, and I’m rather partial to it. 
 
So, my own room is nice in that way.  Doesn’t sound like I’ll be in it much, though.  Class starts at 430 in the morning, and the last class starts at 7pm.  So it doesn’t really matter who’s in here.
 
And I suppose I won’t type naked anyway. I’m afraid that as the hard drive warms up, a film of sweat will form between the laptop and the actual “lap”, as it were, and the machine will short itself out in an explosion of wicked-blue electricity bolts right into an area that really should have been covered out of respect for my readers, for God’s sake, if not for my own sense of Fallen-Man shame.
 
I do have a sense of pleasant anticipation as the day gets started.  I’m like any average boy who grew up crawling around fields and forests “fighting” Nazi’s and aliens and dragons.  Already I was “ordered” to buy a pocket knife, which definitively makes this better than your average medical seminar. 
 
So as I enter day 1, I can say that if over the next 28 days there’s firing of weapons – of any kind – any choppers, night-vision goggles, topo maps, compasses, smoke, explosions, crawling on elbows and knees, face paint, knives, matches, tents, or at least 11 copies of my orders…this little month away from my family might just be worth it. 

‘Concierge’ Medicine – A De Facto Manifesto

My blogging output has been at an all-time low since moving to Europe.  Who knows why…this place is such a bore.  I continue to hack away at my book, which never seems to get close to done – the literary equivalent of Sisyphus’ ever-rolling stone.

The other day a reporter contacted me to hear my thoughts on so-called “concierge” medicine.  It was a timely query, since I’m considering a loose offer to join a concierge practice back in the States.  In my email reply to him, I found myself writing my own little manifesto on the subject.  A treatise, if you will.  A declaration.  A primer? A resolution, a promulgation…

William Osler (1849 - 1919), Professor of Clin...

I have a idea...how 'bout I actually know who you are, AND care about your medical issues?

 

I’m a big believer in concierge medical practice, although I use the term “concierge” only as a nod to already-established norms.  Really ‘concierge’ medicine is a throw-back to true primary care medicine before it was ruled by other industries.  So the idea isn’t new.  It’s old – old as William Osler and Johns Hopkins and William Carlos Williams.
This industrial “take-over” I mention isn’t entirely due to craven insurance businessmen.  It’s also due to the allure of “Wal-Mart” pricing that so captivates Americans.  I suppose you’ve heard the adage that as a consumer, you can only have 2 out of 3 options in the market: Fast, Good and Cheap.  If you want something fast (hamburger), you can get it cheap (McDonald’s) but it won’t be good.  Or, you can have it fast and “good” (quality, taste, etc), but it won’t be cheap (maybe, Red Robin?).
This principle is true in medicine too.  Americans, over the past 20 years, have been trending toward Fast and Cheap medicine, just like they want clothes, household goods, food, etc. quickly and cheaply.  Hence, the rise of WalMart, which provides easily acquired things of questionable quality.
Concierge medicine isn’t “cheap,” by WalMart standards.  It requires real cash investment.  But it IS better.  And, while there is little problem with wearing nondescript, zero-style golf shirts to work every day, primary care is different.  We’re talking about your life, here.  Not only are you likely to live longer and healthier with good primary care, but it really is cheaper over time because it is so effective in offsetting gigantic medical calamities later.
I dispute the notion that no one can afford concierge medicine, by the way.  Most people in the richest nation on earth perceive they can’t afford it, but really can.  I blame this perception on the invention of the 10-dollar co-pay.  This idea was such poison in American medicine.  It made medical care seem like the equivalent of a few iTunes, or sunglasses from a roadside gas station – just another in the ocean of cheap, disposable and generally worthless products. Yet so many Americans shell out enormous amounts of money on alcohol, cigarettes and fast food.  They don’t think twice about coming up with over a thousand dollars to fix the clutch on their car, or to trick it out with lights and racing wheels.  But when it comes to good, relationship-based primary care, they resent anything more than “10 bucks.”
I’m currently in a line of work that provides “free” care to everyone (the military), so at the moment I have no vested interest in the above comments.  But I continue to feel strongly that it is not immoral to require a reasonable, even significant, amount of money for true primary care, especially when obtaining that care may require cutting out things that are terrible for your health.  I see major problems with a medical system that tries to provide unlimited access, especially when coupled with zero perceived cost for that access and care.
More health care is not better health care; worse, it can be dangerous.  On a daily basis, people needlessly lose breasts, prostates (read: sex life), resistance to microbes, and countless other quality of life measures in the process of hunting down phantom maladies or responding to false-positive tests.  High-quality primary care offers good, analytically based work ups of genuine symptoms that justify that work up.  NOT investigating something further can often be the best medical care available.
I mention ‘analytically based’ decisions because most mid-levels (a cost-cutting invention in American medicine) are trained to provide algorithmic decision-making:  that is, if X symptom, then Y action with little analysis involved.  recipe medicine.
Often algorithmic medical decision-making is just fine, but it easily leads to over-testing and over-treatment.  When it comes to possibly dying from cancer, for example, most of us want someone who knows us, knows how we communicate, and what is important to us (e.g. dignity vs. “full court press”). Further, we want that same person to be well-trained in weighing the risks vs. the benefits of treatment vs. non-treatment, based on the latest available medical knowledge.
Doctors seeing 20 patients a day can’t provide this adequately.  Mid-levels are not trained to provide this type of risk-benefit analysis, and don’t have the hours of training experience even if they wanted to.
Disclaimer:  I’m speaking in generalities here; there are fantastic PA’s and NP’s out there, many of whom are compassionate and professional; better than many physicians.  Most I’ve met are smarter than me.  But in general, the care from a mid-level is fundamentally of less quality because the training of a doctor is an average of 3 times more than any mid-level (roughly 3,000 hrs vs. 12,000).  This differential limits mid-levels to algorithmic, rather than analytical, decision-making.  When it comes to your health care, the mantra should be “reason, not recipes.”
These days, you can’t get this care from HMO’s (Group Health in Seattle is getting very close), you can’t get it from mid-levels.  The only place I know where you can get this level of care, is in a ‘concierge’ practice, where the benefits of the increased cost are immeasurable.