AB890 passed - full practice right to FNPs. What is FM MD/DO in California take on this?

[blendermd]

AB890 gave NPs full independent practice rights in California.

I'm wondering to myself why I even went to med school if nurses can do the same job as I can.

What is your take if you are practicing in California as Family Med physician?

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[deleted87716]

I don’t think it’s going to impact most physicians. Some states have allowed NPs to practice unsupervised for years. The patients are the ones who will suffer.

Trust me, they will never do the same job that you can.

 

[AMEHigh]

I don’t let it bother me.
I’ve actually heard multiple NPs talk about how in general the training has gone downhill and they have lots to learn.
I think overall healthcare should be multidisciplinary, but yes patients will likely suffer if NPs (or anyone else) don’t know their limits.
But on an individual basis for myself there are much bigger things I have to worry about and of all the advocacy work I do this definitely is not in the top 10 things I’m worried about or feel the need to advocate about.

 

[hallowmann]

I don’t let it bother me.
I’ve actually heard multiple NPs talk about how in general the training has gone downhill and they have lots to learn.
I think overall healthcare should be multidisciplinary, but yes patients will likely suffer if NPs (or anyone else) don’t know their limits.
But on an individual basis for myself there are much bigger things I have to worry about and of all the advocacy work I do this definitely is not in the top 10 things I’m worried about or feel the need to advocate about.

I've been seeing a lot more talk of diploma mills and poor training from NPs themselves. Saturating markets have also been an issue. The AANP literally has nowhere else but FPA to put the newly minted online NPs being churned out. I think we're going to see a spontaneous adjustment, kind of like with law school, where the good ones will get jobs and the others won't. Practices that hire them and even hospitals are already noticing a difference.

It sucks that patients, especially those with less options and less healthcare knowledge will suffer, but you're right in that they're already suffering in this broken system. There's a lot to fix everywhere.

 

[Reboa]

Look at what happened in the EM job market. Graduating residents can’t even find a job because the market is so saturated with CMGs. If we continue down the path of corporate run medicine I’d imagine something similar is possible although unlikely. At the end of the day we always have the option of opening a private practice.

As has been mentioned previously, the patients will be the ones that truly suffer the consequences.

AAEM/RSA Statement of Concern for Graduating EM Residents and the Current Job Market | AAEM Resident and Student Association

The American Academy of Emergency Medicine Resident and Student Association (AAEM/RSA) is a non-profit professional association for emergency medicine residents and medical students.

www.aaemrsa.org

 

[Fatalis]

The patients are the ones who will suffer.

Trust me, they will never do the same job that you can.

Took the words right out of my mouth!

 

[Matthew9Thirtyfive]

How do they square this with saying residents can’t moonlight by requiring 3 years of GME for an independent license? Someone with a medical degree and an intern year isn’t safe to practice independently, but someone with an online education with little to no medical courses and 500 hours of “shadowing” in a single specialty is safe to practice anywhere?

I just don’t understand how these things keep passing. The only explanation that makes sense is $$$$

 

[SLC]

How do they square this with saying residents can’t moonlight by requiring 3 years of GME for an independent license? Someone with a medical degree and an intern year isn’t safe to practice independently, but someone with an online education with little to no medical courses and 500 hours of “shadowing” in a single specialty is safe to practice anywhere?

I just don’t understand how these things keep passing. The only explanation that makes sense is $$$$

It’s California. Your first problem is asking how things pass and expecting them to make sense.

 

[SLC]

To those of you in California, I will say this. Make 100% certain that you do not curbside consult for any nurse practitioners. Let them use their 100% independent practice rights, independently. And let everyone see just what they are and are not capable of.

Don’t precept NP students either. Let them teach eachother.

 

[simpler2]

Sensing some fragility in responses here. Coming from a state with long standing full practice rights of NPs and working alongside them for more than a decade, the fearmongering strikes me as utter nonsense. I'd happily trust mine and my families care to my system NP colleagues over many area physicians I know. A title doesn't come with guaranteed competence and quality.

 

[Steve_Zissou]

Sensing some fragility in responses here. Coming from a state with long standing full practice rights of NPs and working alongside them for more than a decade, the fearmongering strikes me as utter nonsense. I'd happily trust mine and my families care to my system NP colleagues over many area physicians I know. A title doesn't come with guaranteed competence and quality.

SIMPler indeed.

Has to be a troll though. That or a massive sellout trying to protect his $$$$ that he gets from overseeing midlevels.

 

[simpler2]

SIMPler indeed.

Has to be a troll though. That or a massive sellout trying to protect his $$$$ that he gets from overseeing midlevels.

No need for direct name calling. I work at an FQHC and receive no additional compensation for supervision of my NP colleagues. After about 1 year, being independently licensed, they generally need little, if any scheduled direct supervision. Without NPs serving our state, there would simply be large swaths of our population without access to primary care. The negative attitudes towards NPs cropping up here and on this forum baffle me. There is a clear need and place for NPs and PAs in US healthcare. Maybe it has less of a roll in past fee for service and private practice models being transitioned out. I have little interest in working in the old models and don't see that outcomes support a need to continue to defend them with fervor.

 

[Steve_Zissou]

No need for direct name calling. I work at an FQHC and receive no additional compensation for supervision of my NP colleagues. After about 1 year, being independently licensed, they generally need little, if any scheduled direct supervision. Without NPs serving our state, there would simply be large swaths of our population without access to primary care. The negative attitudes towards NPs cropping up here and on this forum baffle me. There is a clear need and place for NPs and PAs in US healthcare. Maybe it has less of a roll in past fee for service and private practice models being transitioned out. I have little interest in working in the old models and don't see that outcomes support a need to continue to defend them with fervor.

Alternatively, we could allow more medical students to matriculate at more schools with a required primary care pathway.

My understanding is that it is a myth that we have a true shortage of physicians. We have a localization shortage because it’s not appealing enough to many physicians (and NPs/PAs) to go to rural areas.

 

[Leonthemedico]

I have yet to see the midlevel that can provide the appropriate care to a patient with an undifferentiated problems who has HrfEF, EF 35%, Afib, asthma, diabetes and a knee pain. Unsupervised all while optimising 15 different medications! And this is not an exaggeration this is the typical PCP patient these days.

 

[deleted941485]

No need for direct name calling. I work at an FQHC and receive no additional compensation for supervision of my NP colleagues. After about 1 year, being independently licensed, they generally need little, if any scheduled direct supervision. Without NPs serving our state, there would simply be large swaths of our population without access to primary care. The negative attitudes towards NPs cropping up here and on this forum baffle me. There is a clear need and place for NPs and PAs in US healthcare. Maybe it has less of a roll in past fee for service and private practice models being transitioned out. I have little interest in working in the old models and don't see that outcomes support a need to continue to defend them with fervor.

This is laughable on so many levels. Yeah that antiquated FFS model where you were paid to see patients. You sound like a corporate shill just riding out the rest of your career. Maybe its being pounded into the ground with the relentless nursing propaganda NP = MD that has gotten to you.

Not like it matters because pretty soon your patients, if you actually still see any, will trust your NP more than they ever trusted you. But don't worry! by the time your overlords realize that you are just an overpaid middle manager you'll be moving on to retirement where you can look back on a life of selling out youre own profession and dabbling in patient care.

Yeah there's a clear need for NP/PA's and corporate medicine has spoken: its EVERYWHERE they can save money!

Is there a roll on NP cannot fill? or is that question just as baffling to you?

 

[Consigliere]

....my NP colleagues.

They have never been, nor will they ever be, my colleagues you ball-less, sycophantic, soy boy sell out.

 

[hallowmann]

 

[Sardonix]

 

[deleted87716]

They have never been, nor will they ever be, my colleagues you ball-less, sycophantic, soy boy sell out.

 

[FrustratedFamDoc]

This is getting good. Things have been pretty boring on the FM boards for a bit so this is nice. Hope the mods allow it to stay open for a while.

This is an issue where there is little to no middle ground.

You either be like

Or you be all like:

Is there a middle ground? Perhaps. There have always been mid-level providers but the rules across the land have changed drastically. Most physicians are now employed by MBAs.

 

[chocomorsel]

I just googled soy boy.

 

[nimbus]

I have yet to see the midlevel that can provide the appropriate care to a patient with an undifferentiated problems who has HrfEF, EF 35%, Afib, asthma, diabetes and a knee pain. Unsupervised all while optimising 15 different medications! And this is not an exaggeration this is the typical PCP patient these days.

Is anybody capable of optimizing 15 different medications? Can any patients keep them straight?

 

[topraman]

Support it fully. If you're threatened by it then you need to up your skills to the point where you're simply not doing the same things. And if that's the case already your work should speak for itself. FM of all specialties should understand the tenuous link between formal qualification and competency.

We should be worried about the factors in medicine that limit our patients access and outcomes and our relationship with them and those that limit our ability to address these.

 

[trapperjohn4077]

Support it fully. If you're threatened by it then you need to up your skills to the point where you're simply not doing the same things.

Have you no empathy for the patients who are currently being hurt by under-educated midlevels? We are not fighting this because we feel "threatened". We fight this because these folks are actively hurting patients!!!

 

[deleted87716]

FM of all specialties should understand the tenuous link between formal qualification and competency.

That's B.S., and FM of all specialties should know it.

 

[topraman]

Blue dog. Could you expand? Curious why you say so.

What I mean is that we should not extend the specialist argument that family medicine should not conduct deliveries or manage heart failure or whatever because of our generalist training, aka absence of formal qualification in the domain specific to the problem being managed. Obviously in some cases that's true and recognizing where that limit lies is both important but also dynamic and highly variable between different doctors. Should we not extend the same reasoning? If we're concerned about patient safety, shouldn't we focus on how to better assess or demonstrate competency and not limits of license?

 

[deleted87716]

Blue dog. Could you expand? Curious why you say so.

A specialty of breadth treating patients presenting with undifferentiated complaints is the least appropriate field for someone to attempt with inadequate training.

 

[topraman]

Agree to not minimize the challenge of quality primary/generalist care. I'd just say, not all are inadequately trained, that it is possible to learn on the job and train with time, that the counterfactual in many areas is not quality physician care but often no care, etc. We are in sync on the challenge but perhaps not on the solution.

 

[Angus Avagadro]

In my entire career, I have never asked a midlevel what they think I should do in a given situation. I have been asked that question by them hundreds of times. This I think is the salient point and why supervision is required. I don't consider a business card with my phone number on it as supervision.

 

[topraman]

Would the same logic not apply to our specialist consults? The need to consult for X% of cases doesn't negate the ability to manage the remainder right? Asking and learning is a good sign, I'd be more worried about independent practice if someone didn't do that.

 

[hallowmann]

Agree to not minimize the challenge of quality primary/generalist care. I'd just say, not all are inadequately trained, that it is possible to learn on the job and train with time, that the counterfactual in many areas is not quality physician care but often no care, etc. We are in sync on the challenge but perhaps not on the solution.

I think one of the issues is that there is literally no quality control, and the governing organizations, specifically the AANP, is diametrically opposed to methods of competency or formal qualification.

To give you an idea, they abandoned attempts at a higher level of standardized examination (i.e. the simplified and abridged Step 3 developed by the NBME that only about 30-50% of the highest trained NPs could pass), they actively oppose requirements for "residencies" or advanced training for FPA, they actively oppose more stringent standardization of NP training - leaving room for literally hundreds of online NP schools partly why graduates have quadrupled in the last decade, and as pointed out in their lunch talks and lectures many high-level NPs in the AANP essentially believe that the argument for FPA is completely unrelated to standardization of training. With that kind of representation and lobbying, do you truly not see the issue?

On top of that, state nursing boards are simply incapable of effectively taking action against dangerous NPs due likely to underfunding and the sheer amount of nurses they govern over. This is typically rarely an issue, because most nurses have oversight, but in the case of FPA, many NPs will not.

When training standardization and oversight is not possible and opposed, supervision becomes even more important.

There absolutely are excellent NPs and PAs, and crappy physicians. Physicians aren't saying midlevels shouldn't exist, they are saying there should be supervision.

 

[bronx43]

Agree to not minimize the challenge of quality primary/generalist care. I'd just say, not all are inadequately trained, that it is possible to learn on the job and train with time, that the counterfactual in many areas is not quality physician care but often no care, etc. We are in sync on the challenge but perhaps not on the solution.

Do you have data showing midlevels disproportionately going to areas without any healthcare service?

 

[Angus Avagadro]

Would the same logic not apply to our specialist consults? The need to consult for X% of cases doesn't negate the ability to manage the remainder right? Asking and learning is a good sign, I'd be more worried about independent practice if someone didn't do that.

I assume you are replying to me, so here goes. Would the same logic not apply to having RTs making all the ventilator adjustments on icu patients? Asking and learning is a good sign , no? They could just ask for help if they need it. Supervision is not a business card with the pulmonologists phone number on it. Just because a patient survives sub standard care, doesn't mean the right things were done, it just means someone got away with providing substandard care. I would be more worried about a midlevel practicing unsupervised with list of approved meds to trial and error, as in a psych NP.

 

[topraman]

Just from my own experience in rural areas of the West Coast where they make up a higher proportion of the providers.

@hallowmann many thanks for the regulatory background. I was only vaguely aware of those issues. I would agree that in the absence of standardization, resistance to competency based exit exams, and an ineffective supervising board, independent practice makes little sense. There has to be give and take and if there is resistance to those reasonable quality controls I change my stance - my support for their independent practice would be contingent on having those measures in place.

 

[bronx43]

Just from my own experience in rural areas of the West Coast where they make up a higher proportion of the providers.

@hallowmann many thanks for the regulatory background. I was only vaguely aware of those issues. I would agree that in the absence of standardization, resistance to competency based exit exams, and an ineffective supervising board, independent practice makes little sense. There has to be give and take and if there is resistance to those reasonable quality controls I change my stance - my support for their independent practice would be contingent on having those measures in place.

I have practiced in more rural locations as well as urban and currently academia. I have noticed no difference in midlevel prevalence between any of those practice environments. Unless you have data showing disproportionately more midlevels going to underserved areas, then the “all we need is someone to provide care” argument holds no water. If we truly want to solve the maldistribution problem with sheer supply, then may as well open the floodgates for residency spots.

 

[Sardonix]

I have practiced in more rural locations as well as urban and currently academia. I have noticed no difference in midlevel prevalence between any of those practice environments. Unless you have data showing disproportionately more midlevels going to underserved areas, then the “all we need is someone to provide care” argument holds no water. If we truly want to solve the maldistribution problem with sheer supply, then may as well open the floodgates for residency spots.

I forget where I've seen it but I'm pretty sure they've done some studies that show NPs are not proportionately practicing in rural areas like their national organizations like to claim. I'm too lazy to find the study right now, but basic human behavior would tell me they're subject to the same parameters that make most physicians gravitate to cities as well... the difference being physician groups don't argue they're somehow the only one filling the rural primary care gap as a means of increasing their autonomy.

 

[deleted87716]

I forget where I've seen it but I'm pretty sure they've done some studies that show NPs are not proportionately practicing in rural areas like their national organizations like to claim. I'm too lazy to find the study right now, but basic human behavior would tell me they're subject to the same parameters that make most physicians gravitate to cities as well... the difference being physician groups don't argue they're somehow the only one filling the rural primary care gap as a means of increasing their autonomy.

For Our Patients and Families: The NP Independent Practice Problem, Why You Should Care, and What You Can Do - Physicians for Patient Protection

In speaking with our family and friends, we have found that the vast […]

www.physiciansforpatientprotection.org

 

[deleted941485]

Do you have data showing midlevels disproportionately going to areas without any healthcare service?

That was just to get their foot in the door...clearly. Well healed hospitals in suburban hospitals in major metros are using them too. what a lie that was.

 

[SXMMD]

Agree to not minimize the challenge of quality primary/generalist care. I'd just say, not all are inadequately trained, that it is possible to learn on the job and train with time, that the counterfactual in many areas is not quality physician care but often no care, etc. We are in sync on the challenge but perhaps not on the solution.

Are we now saying that nursing is a reasonable back door to becoming a doctor if you have enough “on the job” training? How do you standardize competency with that nebulous requirement? We don’t even let physicians from other countries practice here without at least going through residency, but a nurse practitioner without the basic science or clinical foundation of a medical student should somehow be allowed to practice medicine independently if they’ve put in enough time into... nursing?

If you’re advocating on the job learning as an adequate replacement for med school and residency, then we have to acknowledge that medical school is a sham, and the difficulty in getting into medical school is a sham, and the hours of training for residents and fellows is a sham. How can all that **** have any real educational value if all we needed to do is be nurses for a few years for “on the job training” to be adequately trained independent practitioners? That proposition is absurd on its face and when you examine it in any depth.

midlevels have a place in medicine. Independent practice isn’t it. The solution to access issues isn’t giving people crappy care by perhaps well intentioned substandard practitioners. It’s finding ways to get properly trained doctors out there.

 

[topraman]

Agree that mid-levels are a part of system and not physician replacements by any means. We just draw the line differently. I wonder for how many of us, our professional identity is defined by the ability to independently practice? For me it's not, it's the skill, breadth, depth, and leadership I know I bring. As Blue Dog said well "Trust me, they will never do the same job that you can."

 

[VA Hopeful Dr]

Agree that mid-levels are a part of system and not physician replacements by any means. We just draw the line differently. I wonder for how many of us, our professional identity is defined by the ability to independently practice? For me it's not, it's the skill, breadth, depth, and leadership I know I bring. As Blue Dog said well "Trust me, they will never do the same job that you can."

My dad and both of his parents were optometrists and I considered doing that myself, but I didn't really like the idea of having to go to the state legislature to gain privileges every time a new medication came out.

So yes, being able to fully independently practice was a part of my decision making.

 

[Sardonix]

My dad and both of his parents were optometrists and I considered doing that myself, but I didn't really like the idea of having to go to the state legislature to gain privileges every time a new medication came out.

So yes, being able to fully independently practice was a part of my decision making.

Family get togethers must have been something to see.

"Hey little VA, would you like some ice cream? Or would you like some pie? Ice cream you say? Which flavor would you like? Chocolate or vanilla? Number 1? Or Number 2? Can you read that smallest line on the box to see how many servings it has? Why don't you read it out to me. Does it say three scoops? Or four scoops?"

 

[smq123]

Family get togethers must have been something to see.

"Hey little VA, would you like some ice cream? Or would you like some pie? Ice cream you say? Which flavor would you like? Chocolate or vanilla? Number 1? Or Number 2? Can you read that smallest line on the box to see how many servings it has? Why don't you read it out for me."

Which is better, 1 or 2? How about if I add some sprinkles, now which is better, 1 or 2? How about if we switch to you chewing on the other side of your mouth?

 

[Sardonix]

Which is better, 1 or 2? How about if I add some sprinkles, now which is better, 1 or 2? How about if we switch to you chewing on the other side of your mouth?

Either way we better check the diameter of the ice cream cups just to be safe.

 

[Sushirolls]

1) Don't supervise or train ARNP
2) End CMS funding for GME - this reliance on funds is choking our GME system with the concept of 'golden handcuffs', a greater equilibrium will arise once programs lose the short sighted nature of having only 'funded' GME slots
3) Petition states to reduce licensure requirements from PGY 1 (or 2), to that of Medical school graduates, and to drop step/level III exams in their entirety and on state statutes for licensure requirement
4) Ramp up MD/DO schools and/or class sizes, flood the market with newly minted MD/DO grads who then become the new mid levels
5) Join the only organization that actually gives a darn: Home - Physicians for Patient Protection
6) Create medical groups or private practices that advertise they are physician only

 

[VA Hopeful Dr]

Family get togethers must have been something to see.

"Hey little VA, would you like some ice cream? Or would you like some pie? Ice cream you say? Which flavor would you like? Chocolate or vanilla? Number 1? Or Number 2? Can you read that smallest line on the box to see how many servings it has? Why don't you read it out to me. Does it say three scoops? Or four scoops?"

God help you if you ever squint at anything

 

[Matthew9Thirtyfive]

Just from my own experience in rural areas of the West Coast where they make up a higher proportion of the providers.

There are data that refute this. Your anecdote experience doesn’t trump the studies showing they don’t practice in rural areas any more than physicians do.

 

[Matthew9Thirtyfive]

Agree to not minimize the challenge of quality primary/generalist care. I'd just say, not all are inadequately trained, that it is possible to learn on the job and train with time, that the counterfactual in many areas is not quality physician care but often no care, etc. We are in sync on the challenge but perhaps not on the solution.

Bad care causing harm is worse than no care in many instances.

 

[Mad Jack]

I dunno, in psych we have plenty of NPs and they all send the cases they can't solve to physicians because they seem to recognize the limits of their abilities. Most often, anyway. When they don't it doesn't go well, but thankfully most of the ones I've worked with know when to ask for help.

Pandora's box has already been opened; we need to learn to differentiate ourselves based on the quality of service provided and our outcomes if we intend to thrive into the future

 

[Matthew9Thirtyfive]

I dunno, in psych we have plenty of NPs and they all send the cases they can't solve to physicians because they seem to recognize the limits of their abilities. Most often, anyway. When they don't it doesn't go well, but thankfully most of the ones I've worked with know when to ask for help.

Pandora's box has already been opened; we need to learn to differentiate ourselves based on the quality of service provided and our outcomes if we intend to thrive into the future

I see literally endless posts on Reddit about inappropriate management by psych NPs.

There is an NP in the gen surgery department where I’m doing my surgery rotation. She is amazing. She knows her role and does it very well. That’s what an NP is supposed to be. Not practicing the broadest fields of medicine with effectively or literally no oversight.