DNPs will eventually have unlimited SOP

[bala1]

True, but I don't think that was the focal point of what was being discussed. It was said that they will get expanded scope because the training is equivalent. That statement is false. All of that means nothing if people decide for themselves that they want mid-level expansion and legislate it. However, I don't think that can really happen. Americans are arrogant and the only thing they expect over "cheap" is "quality". I don't think medicine can be practiced proficiently at the level of training that DNPs have. The only reason it looks that way currently is because physicians stand as a safety net for them. If they get expanded scope it will be important for physicians to distance themselves from DNP patients, because liability tends to follow he with the largest wallet rather than he with the most blame. Once they are legitimately flying solo..... Ever read the story of Icarus?

you are right in many many ways. If they are cheap they are cheap. i happen to agree with your thinking and i believe you are spot on. People will start dying, misdiagnosis will be rampant, over testing will be the norm, and an outcome quite the opposite of what our government wants will prevail. We have to distance ourselves from this equation. Look at how many years we train and there are still bad outcomes. That number will increase measurably under nurse practicioner care. Guaranteed!! How could it not?

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[alcofribas]

Speaking only from experience of working with excellent MDs and NPs in a FM clinic--

Its closer to vocational training than professional.

That seems fair. I think many NPs would agree. Even if true, it doesn't answer the question of whether or not two different approaches could give similar results.

the dnps dont think their education is sub optimal

Having shadowed NP students on clinical rotations, I would say that their clinical decision-making is more often than not a by-the-book, rote application of EBM guidelines. It is a systematic approach that will produce equivalent results in less complex cases.

In my opinion the biggest threat to FM MDs isn't unlimited SOP for NPs-- it is the fact that MD/DO/NP reimbursements are increasingly tied to paint-by-numbers EBM guidelines. MD loss of autonomy will be felt the most in specialties that can be subsumed into a rigid framework of EBM guidelines and decision-trees.

I think there will be many more issues as certain specialties come to be viewed by the public and by insurance companies alike as little more than paint-by-numbers-- thanks to EBM, iPad apps, etc. This will continue to undermine MDs and give rise to turf wars with mid-levels.

MDs need to work on getting out a pro-MD message to the public...

 

[SpecterGT260]

You shadowed students?

Sent from my DROID RAZR using SDN Mobile

 

[alcofribas]

More of a sitauation where I scribed for MDs/NPs/occasional NP students.

 

[eject]

The clouds continue to gather.

From "America's doctors are overpaid: Time’s long investigation of American health care prices missed one thing: We pay our doctors way too much."

Doctors aren’t as politically attractive a target as insurance companies, hospital administrators, or big pharma, but there’s no rational basis for leaving their interests unscathed when tackling unduly expensive medicine.

Not quite as attractive a target, but a target nonetheless! And in re this thread's original theme:

What’s more, in the 18 states where lesser-paid nurse practitioners are allowed to do primary care without a doctor’s supervision, their treatment is just as good in terms of health outcomes and better in terms of patient satisfaction. Any shortage of primary caregivers, in other words, is about bad rules limiting the number of people who can practice, not a lack of monetary incentives. We need more residencies and more scope for nurses to work unsupervised, not higher-paid doctors.

 

[xenotype]

The clouds continue to gather.

From "America's doctors are overpaid: Time’s long investigation of American health care prices missed one thing: We pay our doctors way too much."



Not quite as attractive a target, but a target nonetheless! And in re this thread's original theme:

That is probably the most trash article I have read this entire month. That guy doesn't have a clue how healthcare works.

 

[badasshairday]

That is probably the most trash article I have read this entire month. That guy doesn't have a clue how healthcare works.

Dude, we are being hung up as the bad guys. We are way too easy of a target. People think it is unfair when someone works hard and gets paid well for there work (re: anyone who makes more than them). They are only ok with entertainers making millions of dollars a year.

 

[eject]

Dude, we are being hung up as the bad guys. We are way too easy of a target. People think it is unfair when someone works hard and gets paid well for there work (re: anyone who makes more than them). They are only ok with entertainers making millions of dollars a year.

Yeah. The article may be trash, but the issue is that Matt Yglesias is (apparently) respected in a lot of policy circles. When people like him start explicitly making doctors "targets" for cuts (with the obligatory caricature of US docs being both under-performers and greedy fat cats), it certainly feels ominous.

 

[Zback]

The clouds continue to gather.

From "America's doctors are overpaid: Time’s long investigation of American health care prices missed one thing: We pay our doctors way too much."



Not quite as attractive a target, but a target nonetheless! And in re this thread's original theme:

What a joke of a article. As usual, the comments about the article are just as good.

 

[JShephard]

What a joke of a article. As usual, the comments about the article are just as good.

The clouds continue to gather.

From "America's doctors are overpaid: Time’s long investigation of American health care prices missed one thing: We pay our doctors way too much."



Not quite as attractive a target, but a target nonetheless! And in re this thread's original theme:

There really is a PR nightmare going on right now for physicians.

Unfortunately we don't have a strong unified group that can deliver a unified message.

You can bet these attacks will keep coming - look @ this comment from the article:

If doctors earned less money, fewer people would want to be doctors. We could offset some of that impact by helping doctors out with medical malpractice reform and more government funding for medical school tuition. But a shortage of people wanting to enter the medical pipeline is the last thing we should be worrying about. As it stands, medical school is getting harder to get into (continuing a longtime trend) even as it gets harder for medical school graduates to find residency slots. What’s more, in the 18 states where lesser-paid nurse practitioners are allowed to do primary care without a doctor’s supervision, their treatment is just as good in terms of health outcomes and better in terms of patient satisfaction. Any shortage of primary caregivers, in other words, is about bad rules limiting the number of people who can practice, not a lack of monetary incentives. We need more residencies and more scope for nurses to work unsupervised, not higher-paid doctors.

This is big trouble. I hope doctors can get away from the BS that is the AMA and create a real professional organization that has physicians and not politicians/leadership as their major interest.

 

[xenotype]

Sure we should cut physician salaries. But I want the MD/PhD stipend and free tuition in school, and I expect never to have to work more than 40 hours a week, and I expect no call. That's what bottom dollar gets you. You want to make physician salaries more like other countries? Make the other factors equivalent as well.

 

[JShephard]

Sure we should cut physician salaries. But I want the MD/PhD stipend and free tuition in school, and I expect never to have to work more than 40 hours a week, and I expect no call. That's what bottom dollar gets you. You want to make physician salaries more like other countries? Make the other factors equivalent as well.

Yeah, honestly I think there will be big changes in the next decade. Physicians are focused enough on these policies - they only focus on the science and Step 1.

We're all amazing at multiple choice exams but completely ignore the entire political system that will determine if you're paid 50% less and nurses are doing 1/2 of your job.

 

[xenotype]

While it does exemplify that we have a serious PR problem, I don't think any policy people seriously buy into what this guy writes. He is definitely not an economist or a groundbreaking journalist. The article appears barely researched, and he seems to have less than a surface understanding of the true costs of healthcare. This would get written off by a real economist instantly for a variety of reasons. I just want this smug journalist to get an opinion piece published against him with wide readership detailing in easy to understand terms why his article is toilet paper. It isn't complicated. Labor costs are not a significant contributer to healthcare costs and cutting physician salaries (ESPECIALLY on the lower end) is a great way to ensure that intelligent people need not apply.

 

[JourneyAgent]

I wouldn't dismiss that article out of hand. It seems pretty reasonable to me. And he did propose making our education cheaper. Truly, if we weren't saddled with so much debt, we could afford to be a lot cheaper.

I think regardless, it's the way we're headed. The thing that I actually disagree with is that we're difficult to target. I think the opposite. But what's worse is our position is impossible to defend. They don't understand our sacrifice. They don't understand our debt. How long it takes laying out loan money before we make a dime or can afford to start paying the debt. They don't have an inkling of what the different degrees are. They just want white coat person to write the scripts and fill out their paperwork.

And our fearless leaders couldn't be more off in how they preach to us our unique special snowflakeness, while we toil away in an aged crumbling castle. Outside, nobody gives a f@ck.

We have shrinking islands of possibility for making a play for an outside angle. Most of us will be stuck humping through jungle in an unpopular war.

I think people talking about political strategy have about as good as a chance as establishing a western style democracy in Afghanistan.

 

[xenotype]

I wouldn't dismiss that article out of hand. It seems pretty reasonable to me. And he did propose making our education cheaper. Truly, if we weren't saddled with so much debt, we could afford to be a lot cheaper.

I would. If 'salaries' were cut as drastically as he wants, you would see market forces responding rapidly. Older docs would retire rather than be paid a pittance for their work. Applicants to med schools would drop in quality significantly as intelligent people switch to engineering and finance. Many docs currently in the business would drop out of the system and require cash payments for services up front. Healthcare may not be a market, but workforces are always markets. I don't know about other people here. I could be making a comfy six figures in engineering or finance, but I chose medicine.

 

[JourneyAgent]

I would. If 'salaries' were cut as drastically as he wants, you would see market forces responding rapidly. Older docs would retire rather than be paid a pittance for their work. Applicants to med schools would drop in quality significantly as intelligent people switch to engineering and finance. Many docs currently in the business would drop out of the system and require cash payments for services up front. Healthcare may not be a market, but workforces are always markets. I don't know about other people here. I could be making a comfy six figures in engineering or finance, but I chose medicine.

Well, I suspect we are going to be squeezed to make over 200 across the board in the ensuing decades. And that while tuitions climb. Interests rates climb. I'm not as confident in there being other, more easily obtainable career options in the future as you.

During the depression the post office in Harlem, just off the top of my head, was a who's who of black American, thinkers writers, artists, and intelligentsia. Like that I think.

Entrepreneurs will always be able to hustle the down side of anything. But they'd rather teach about our moral superiority, god given place in the shepherding of the downtrodden, and all sorts of that kind of bull****.

 

[eject]

I would. If 'salaries' were cut as drastically as he wants, you would see market forces responding rapidly. Older docs would retire rather than be paid a pittance for their work. Applicants to med schools would drop in quality significantly as intelligent people switch to engineering and finance. Many docs currently in the business would drop out of the system and require cash payments for services up front. Healthcare may not be a market, but workforces are always markets. I don't know about other people here. I could be making a comfy six figures in engineering or finance, but I chose medicine.

...until they make medical licensure contingent on accepting medicaid/medicare/whatever-it-becomes-in-the-future...which is something that I heard might happen in MA, but not sure where that stands now. that would be a game-changer.

 

[xenotype]

...until they make medical licensure contingent on accepting medicaid/medicare/whatever-it-becomes-in-the-future...which is something that I heard might happen in MA, but not sure where that stands now. that would be a game-changer.

Okay, then docs unionize and strike. Actions have reactions whether seen or unseen. Don't tell me that docs legally can't do it, because the government legally can't force people to work for free.

 

[SpecterGT260]

Okay, then docs unionize and strike. Actions have reactions whether seen or unseen. Don't tell me that docs legally can't do it, because the government legally can't force people to work for free.

No, but licensure is a state affair. I do believe docs can't legally do it. There may not be criminal charges (although no promises... of that I am not sure) but they can sure as hell pull your license.

 

[xenotype]

No, but licensure is a state affair. I do believe docs can't legally do it. There may not be criminal charges (although no promises... of that I am not sure) but they can sure as hell pull your license.

Miners striking for better pay a century ago faced machinegun bullets. If a significant percentage of docs struck (even 5%), the states could not possibly afford to pull their licenses. Imagine how much damage that would do to the healthcare system; it is mutually assured destruction. You really can only abuse docs so much.

 

[SpecterGT260]

Miners striking for better pay a century ago faced machinegun bullets. If a significant percentage of docs struck (even 5%), the states could not possibly afford to pull their licenses. Imagine how much damage that would do to the healthcare system; it is mutually assured destruction. You really can only abuse docs so much.

I tend to agree with you here. I'm just saying that technically speaking it "isn't allowed". It would take a level of organization and adherence that is unprecedented in medicine, but yes, if doctors went on strike things would have to happen in a hurry. This is pretty ethically difficult, however.....

 

[JourneyAgent]

The problem with the coal miner analogy is we aren't backed into a a corner of starvation and destitution while Peabody coal company store charges our widows exorbitantly for the price of our coffins.

Our old and fattened make money of our future competitors in the provider market. There's no Sandy Hook event to turn the public sympathy and galvanize a physician identity that will address its poor prognosis for future physicians.

No movement. No incentive. No culture of shared identity and concern for a group future. Nothing.

They're gonna run a train on our behinds.

And I have no compunction about cash practice and hustle by any means necessary because of it. Don't trust anyone in practice. We need to get prison body hard and keep our shanks sharp. No way out of this that looks like the fairy take they feed us.

 

[calvnandhobbs68]

Sure we should cut physician salaries. But I want the MD/PhD stipend and free tuition in school, and I expect never to have to work more than 40 hours a week, and I expect no call. That's what bottom dollar gets you. You want to make physician salaries more like other countries? Make the other factors equivalent as well.

Exactly. Give me the 12 hour shift 3 days a week like the nurses and I'll take a pay cut no prob. Oh somebody just went through a plate glass window, is en route to the hospital and everyone else is tied up in other surgeries? Sorry man shift's up in 5 minutes looks like you're outta luck. Hope the next guy comes in on time today or you're not gonna make it.

 

[SpecterGT260]

Exactly. Give me the 12 hour shift 3 days a week like the nurses

You mean emergency med?

 

[Member3]

I agree with the vast majority on this issue - there is no comparison in the knowledge and education that a practicing physician has versus a NP. With that, my wife has been a NP for almost 8 years. We live in MS and she has worked at rural clinics her entire career. She will be the first to tell you this is exactly what a NP is/should be for, not to "take over" an MD's job. She works with two physicians and I'm sure both would say they value having her there and is an asset to their team. And these are old school military docs (not sure if that even makes a difference?). If there is someone too complex or something she is not comfortable doing/doesn't know she'll ask the SP or let him take over. As far as I know there has never been any animosity towards her, but I know she had to earn the respect and trust just like anyone else. Situations like a rural hospital/clinic where most people would dread to work need people to fill the spots and I see nothing wrong with a NP taking this role. I do know she has said most NPs are not ready and shouldn't be practicing solo without a SP with them. I know several NPs and none of them think they are equal to an MD/DO, and they credit their knowledge to their SP. From what I know NPs have a pretty solid education, but I think a lot of it depends on what school they went to. I do think it is ridiculous though that someone could become a NP from an online degree, that's just a damn joke. My wife has actually said she wouldn't feel comfortable working somewhere without a physician on site she could refer to. I think there is definitely a place or NP/PA, but by no means do I think they should have complete autonomy. Their SOP is limited, and honestly they should know what they are capable of. My opinions probably sound biased, but from what I know NPs were meant for rural settings and should probably stay that way.

 

[SpecterGT260]

I agree with the vast majority on this issue - there is no comparison in the knowledge and education that a practicing physician has versus a NP. With that, my wife has been a NP for almost 8 years. We live in MS and she has worked at rural clinics her entire career. She will be the first to tell you this is exactly what a NP is/should be for, not to "take over" an MD's job. She works with two physicians and I'm sure both would say they value having her there and is an asset to their team. And these are old school military docs (not sure if that even makes a difference?). If there is someone too complex or something she is not comfortable doing/doesn't know she'll ask the SP or let him take over. As far as I know there has never been any animosity towards her, but I know she had to earn the respect and trust just like anyone else. Situations like a rural hospital/clinic where most people would dread to work need people to fill the spots and I see nothing wrong with a NP taking this role. I do know she has said most NPs are not ready and shouldn't be practicing solo without a SP with them. I know several NPs and none of them think they are equal to an MD/DO, and they credit their knowledge to their SP. From what I know NPs have a pretty solid education, but I think a lot of it depends on what school they went to. I do think it is ridiculous though that someone could become a NP from an online degree, that's just a damn joke. My wife has actually said she wouldn't feel comfortable working somewhere without a physician on site she could refer to. I think there is definitely a place or NP/PA, but by no means do I think they should have complete autonomy. Their SOP is limited, and honestly they should know what they are capable of. My opinions probably sound biased, but from what I know NPs were meant for rural settings and should probably stay that way.

Unfortunately there are those on both sides that polarize this issue. If more people were like your wife I think it would be a non-issue. However there are NPs who publicly claim that their clinical experience is a proper substitute for the training an MD receives and push such claims in order to pass favorable legislation. Those docs and medical students who feel (rightfully) threatened by this make counter arguments which are received by the more moderate NPs as insults and..... It's pretty much the problem with any online debate. I can't say "no you're wrong" without it being heard with a silent "and go f*** yourself with a claw hammer" strung along at the end.

I'm not even in the clinic yet and already have a healthy understanding of what nurses and other midlevels can do for healthcare and how valuable they are. I think it starts to look like midlevel bashing in these threads and what gets forgotten or lost is that it starts with a midlevel practitioner essentially trashing and undermining the hard work that physicians have gone through.

 

[JourneyAgent]

Unfortunately there are those on both sides that polarize this issue. If more people were like your wife I think it would be a non-issue. However there are NPs who publicly claim that their clinical experience is a proper substitute for the training an MD receives and push such claims in order to pass favorable legislation. Those docs and medical students who feel (rightfully) threatened by this make counter arguments which are received by the more moderate NPs as insults and..... It's pretty much the problem with any online debate. I can't say "no you're wrong" without it being heard with a silent "and go f*** yourself with a claw hammer" strung along at the end.

I'm not even in the clinic yet and already have a healthy understanding of what nurses and other midlevels can do for healthcare and how valuable they are. I think it starts to look like midlevel bashing in these threads and what gets forgotten or lost is that it starts with a midlevel practitioner essentially trashing and undermining the hard work that physicians have gone through.

Perhaps for some. Myself, I don't feel personally insulted by the NP movement. Although I take your point that that is often how it is interpreted.

To me it's a simple matter of workplace mechanics. Set the bar here for X. There for Y. Start the game. Players train. Make the sacrafice to learn. And then change the rules as the players are midstream, about to take the field.

The NP's aren't personally offensive for being cheaper labor offered up to my bosses for what in many cases is equal work. They just are.

What offends me is the epically slow gears of our own system. Replete with clerics preaching something alien to what occurs and will occur in the future of the real workplace. All the while ever inflating the cost of their own bureaucratic apparatus.

If we were just 2 labor contractors with the same piss test and job application competitng to fill the same spots it would be one thing. But our system acts if it it can make us go A to Z and pay dearly for it, just to accept their forthcoming decree of how special we are.

At this point. One of the only reassuring things about our training is that I can get clear or at least not under the @ss of our own kind to a greater extent and ease than NP's can currently.

When they get that they win. And they don't insult me, I insult myself for being a sucker.

 

[Siggy]

No, but licensure is a state affair. I do believe docs can't legally do it. There may not be criminal charges (although no promises... of that I am not sure) but they can sure as hell pull your license.

It's not a medical board issue... it's an anti-trust issue. Physicians, by and large, are not employees, but independent contractors. If a town has 5 independent practices of ____ specialty, then those 5 practices are seen as independent competitors. If they join together to "negotiate" for better rates from insurance companies, it becomes a very fine line before it's "collusion" and "price fixing."

PHYSICIAN UNIONS

The antitrust laws have long exempted from scrutiny the collective bargaining activities of employees with employers. This labor exemption from the antitrust laws, however, applies only to employees, not to independent economic actors such as self-employed physicians in independent practice. Recently, an increasing number of physicians have been joining unions and other organizations hoping to increase their bargaining leverage with health plans.

Competitive concern: Unions can provide various useful services that are valuable to their members, and may collectively bargain for employed physicians. However, antitrust issues arise when a union (or any other organization) attempts to negotiate on behalf of otherwise competing, non-employee physicians.

Delaware Case

On August 12, 1998, the Division filed a civil case in U.S. District Court in Wilmington, Delaware against the Federation of Physicians and Dentists, a physician union, for orchestrating a boycott to extract artificially high fees for independent competing orthopedic surgeons in Delaware. The complaint alleges that in 1996 and 1997 nearly all of the orthopedic surgeons in Delaware joined the Federation, and thereafter acted in concert through the Federation to resist the efforts of Blue Cross of Delaware to reduce the fees Blue Cross paid to them. By the end of 1997, nearly all of the members of the Federation rejected a Blue Cross fee proposal and terminated their contracts with Blue Cross.

The Federation purported to be operating as a third-party messenger. If properly implemented, with adequate safeguards against collusion, a third-party messenger system should not lead to a messenger negotiating on behalf of competing independent physicians or enhancing the bargaining leverage of such physicians. When properly implemented, third-party messenger arrangements may facilitate the contracting process, reduce transaction costs, and thus, ultimately benefit consumers.

Here, however, the Federation's messenger system facilitated, rather than safeguarded against, collusion. The Federation encouraged the physicians to refuse to negotiate with Blue Cross except through the Federation, and ultimately nearly all of the physicians terminated their contracts with Blue Cross. U.S. v. Federation of Physicians and Dentists, Inc., 98-475 (D.Del. 8/12/98).

http://www.justice.gov/atr/public/health_care/2044.htm

 

[SpecterGT260]

Perhaps for some. Myself, I don't feel personally insulted by the NP movement. Although I take your point that that is often how it is interpreted.

To me it's a simple matter of workplace mechanics. Set the bar here for X. There for Y. Start the game. Players train. Make the sacrafice to learn. And then change the rules as the players are midstream, about to take the field.

The NP's aren't personally offensive for being cheaper labor offered up to my bosses for what in many cases is equal work. They just are.

What offends me is the epically slow gears of our own system. Replete with clerics preaching something alien to what occurs and will occur in the future of the real workplace. All the while ever inflating the cost of their own bureaucratic apparatus.

If we were just 2 labor contractors with the same piss test and job application competitng to fill the same spots it would be one thing. But our system acts if it it can make us go A to Z and pay dearly for it, just to accept their forthcoming decree of how special we are.

At this point. One of the only reassuring things about our training is that I can get clear or at least not under the @ss of our own kind to a greater extent and ease than NP's can currently.

When they get that they win. And they don't insult me, I insult myself for being a sucker.

I'm not sure if I am following, but you appear to be citing the argument that "NPs have found a more efficient way to achieve the same thing and doctors are just pissed about it".

I certainly hope not. I have no idea where you are in your training, but if one of the first things you learn in medical school isn't the awareness of how little you truly know I'd say we have identified the problem. Being cheaper is fine, and nobody is arguing that (yet... although true autonomous care may very well cost more in the long run). The thing that is offensive is the suggestion they provide the same product at lower cost. They don't. The fact that their clinical outcomes are currently similar to that of docs is not a function of their training (or lack there of) but a function of patient demographics and their current restricted scope. I've dissected their "publications" many times of these forums and highlighted the logical and unacceptable mathematical errors in their models... but that is a side point that we can get to later or in another thread.

If we are lucky, mid-level practitioners will know when to bail. If we are realistic, this will happen slowly as they screw up and learn where the end of that comfort zone lays. I just consider this to be unacceptable. I consider many of the things in medical education to be responsible for conveying this sense of "knowing what you don't know" because that is where I gained that sense. I can say with a fair amount of certainty that if I had gone through a nursing curriculum (which is largely clinic based, protocol driven, and in the case of the DNP, consumed with things more appropriate for MHA or MPH students than clinicians) I would be uncomfortably comfortable doing the things that I had done many times before and blissfully unaware of any number of things that should send of flares that something isn't right.

The tragic thing is that we really can't test this (IMO) certainty without giving some slack to the leash and giving them the opportunity to do damage. Their current scope prevents it. or... rather, prevented. They are getting pain Rx rights in some states now so, I predict new data within a couple of years.

 

[JourneyAgent]

I'm not sure if I am following, but you appear to be citing the argument that "NPs have found a more efficient way to achieve the same thing and doctors are just pissed about it".

I certainly hope not. I have no idea where you are in your training, but if one of the first things you learn in medical school isn't the awareness of how little you truly know I'd say we have identified the problem. Being cheaper is fine, and nobody is arguing that (yet... although true autonomous care may very well cost more in the long run). The thing that is offensive is the suggestion they provide the same product at lower cost. They don't. The fact that their clinical outcomes are currently similar to that of docs is not a function of their training (or lack there of) but a function of patient demographics and their current restricted scope. I've dissected their "publications" many times of these forums and highlighted the logical and unacceptable mathematical errors in their models... but that is a side point that we can get to later or in another thread.

If we are lucky, mid-level practitioners will know when to bail. If we are realistic, this will happen slowly as they screw up and learn where the end of that comfort zone lays. I just consider this to be unacceptable. I consider many of the things in medical education to be responsible for conveying this sense of "knowing what you don't know" because that is where I gained that sense. I can say with a fair amount of certainty that if I had gone through a nursing curriculum (which is largely clinic based, protocol driven, and in the case of the DNP, consumed with things more appropriate for MHA or MPH students than clinicians) I would be uncomfortably comfortable doing the things that I had done many times before and blissfully unaware of any number of things that should send of flares that something isn't right.

The tragic thing is that we really can't test this (IMO) certainty without giving some slack to the leash and giving them the opportunity to do damage. Their current scope prevents it. or... rather, prevented. They are getting pain Rx rights in some states now so, I predict new data within a couple of years.

Look. I understand where your coming from. I don't disagree with you. I just don't think we're every likely to see proof of our theory of superior quality. Even though it is a matter of some common sense and a simple summation of our clinical training. But the satisfaction of a here look see! on the inside and a cool calculated stride in front of the jury with head cocked high ready to unleash exhibit A. None of this will transpire. Our patients don't care. The bill payers don't care. We're talking to ourselves. No matter how satisfying our arguments, they are bouncing lonely around our own halls. We are an amorphous crowd of white coat people.

Some of the only narratives likely to escape the simplicity of our surrounding dullness are those that say to the mouth breathing idiots in front of their TV's: [Ms. Doctor Nursey Lady talk nice to me. Spend time esplaining why butthole itch. Write me pill. How come bad doctor rich man want her be slave. He bad.].

They've been adroitly throwing softballs of feel good stories to the public as we've been sliding into a frame of criminal collusion with big pharma and The Man.

Studies and their quality make no more difference than a fart in the wind. Because the evil genius of the NP comeuppance is that they are never isolated on their own. They use our training and our slavish servitude to the hospitals of America to train them to do our jobs. They never venture out on their own without getting paid fat salaries while we train them and get them ready for clinical I dependence first. Physicians who are clever can hustle their services to make money. And they're always cautious enough such that the thing works. And they truly do not have any worse outcomes than us. They have a culture of mutual dependence instead of laconic independence that wards against clinical mistakes.

So that they are equal in safety. But much, much more masterful in strategy.

What pisses me off is that we get taught nay brainwashed into being slaves such that hustle and entrepreneurship and creativity gets squashed in us. And we will not have the skills and worse the illusion that we are special and that everyone thinks we're special too.

Basically we're getting bred to be the type that gets raped when things rough. Which is where we're headed soon enough.

 

[SpecterGT260]

I can agree with that.

 

[zenman]

I agree with the vast majority on this issue - there is no comparison in the knowledge and education that a practicing physician has versus a NP. With that, my wife has been a NP for almost 8 years. We live in MS and she has worked at rural clinics her entire career. She will be the first to tell you this is exactly what a NP is/should be for, not to "take over" an MD's job. She works with two physicians and I'm sure both would say they value having her there and is an asset to their team. And these are old school military docs (not sure if that even makes a difference?). If there is someone too complex or something she is not comfortable doing/doesn't know she'll ask the SP or let him take over. As far as I know there has never been any animosity towards her, but I know she had to earn the respect and trust just like anyone else. Situations like a rural hospital/clinic where most people would dread to work need people to fill the spots and I see nothing wrong with a NP taking this role. I do know she has said most NPs are not ready and shouldn't be practicing solo without a SP with them. I know several NPs and none of them think they are equal to an MD/DO, and they credit their knowledge to their SP. From what I know NPs have a pretty solid education, but I think a lot of it depends on what school they went to. I do think it is ridiculous though that someone could become a NP from an online degree, that's just a damn joke. My wife has actually said she wouldn't feel comfortable working somewhere without a physician on site she could refer to. I think there is definitely a place or NP/PA, but by no means do I think they should have complete autonomy. Their SOP is limited, and honestly they should know what they are capable of. My opinions probably sound biased, but from what I know NPs were meant for rural settings and should probably stay that way.

I agree except for the online comment, which is correctly called distance education. I have masters in both brick and mortar and distance education schools. I've also been an assistant professor and have a teacher wife so I kinda keep up with educational trends. I went through a top NP program for my post-masters NP certificate. A lot of our references material was distance education material put out by medical schools. Check out the evidence based studies in distance educational journals. Much of what you learn in medical school could be done more efficiently and cheaper than actually sitting in class. And I'm hoping you know clinical is actually just that.

 

[JourneyAgent]

I agree except for the online comment, which is correctly called distance education. I have masters in both brick and mortar and distance education schools. I've also been an assistant professor and have a teacher wife so I kinda keep up with educational trends. I went through a top NP program for my post-masters NP certificate. A lot of our references material was distance education material put out by medical schools. Check out the evidence based studies in distance educational journals. Much of what you learn in medical school could be done more efficiently and cheaper than actually sitting in class. And I'm hoping you know clinical is actually just that.

Yep. If ivy covered halls are the bees knees then why are Sattar and Fischer and others able to catch fire on the free market side of our education.

Pull back the ivy for a minute and read the graffiti of revolution. Our days in traditional primary care roles are numbered. We are most certainly replaceable. All the tenured f@cks and all he horses and men are fattened liars at the table of a drunken king. Our enemies surround us stealthily and yet we prefer bedtime stories or how special and cute we are.

Sleep cherubs.

Me, I'm getting my **** together. I gonna figure out a way outta here.

 

[tobi44]

I agree except for the online comment, which is correctly called distance education. I have masters in both brick and mortar and distance education schools. I've also been an assistant professor and have a teacher wife so I kinda keep up with educational trends. I went through a top NP program for my post-masters NP certificate. A lot of our references material was distance education material put out by medical schools. Check out the evidence based studies in distance educational journals. Much of what you learn in medical school could be done more efficiently and cheaper than actually sitting in class. And I'm hoping you know clinical is actually just that.

I was all set to disagree with this when I realized the majority of my lectures (US allopathic medical school) are webcasted, so I view and learn from home. And for the classes that have required attendance I don't think that anything would be lost if they were webcasted too. Except maybe for anatomy lab. So I guess I shouldn't throw stones.

 

[rog411]

I was all set to disagree with this when I realized the majority of my lectures (US allopathic medical school) are webcasted, so I view and learn from home. And for the classes that have required attendance I don't think that anything would be lost if they were webcasted too. Except maybe for anatomy lab. So I guess I shouldn't throw stones.

The problem is that historically schools that offered online courses have not been of the highest quality when compared to the brick and mortar schools and thus online classes as a whole developed a bad reputation. Nowadays even the best schools are webcasting, so that perception will begin to change.

Of course there are many benefits that in-person courses have over online ones such as hands on labs (anatomy, histology, etc), group sessions, ability to interact with your classmates and teachers in person, use of your school's resources and facilities, etc.

 

[calvnandhobbs68]

The problem is that historically schools that offered online courses have not been of the highest quality when compared to the brick and mortar schools and thus online classes as a whole developed a bad reputation. Nowadays even the best schools are webcasting, so that perception will begin to change.

Of course there are many benefits that in-person courses have over online ones such as hands on labs (anatomy, histology, etc), group sessions, ability to interact with your classmates and teachers in person, use of your school's resources and facilities, etc.

Way overrated

 

[rog411]

Way overrated

Maybe so for you, but I don't like the idea of sitting in my room staring at videos on a screen for hours upon hours with no human interaction at all.

 

[calvnandhobbs68]

Maybe so for you, but I don't like the idea of sitting in my room staring at videos on a screen for hours upon hours with no human interaction at all.

Well then I'm glad you feel like you're getting your money's worth by paying for the privilege of classmate interaction

 

[SpecterGT260]

I was all set to disagree with this when I realized the majority of my lectures (US allopathic medical school) are webcasted, so I view and learn from home. And for the classes that have required attendance I don't think that anything would be lost if they were webcasted too. Except maybe for anatomy lab. So I guess I shouldn't throw stones.

I tend to do all of my studying either on campus privately or at home. I have maybe attended 1/6th of lectures.

The idea that medical education can be boiled down to the 3-4 didactic semesters is pretty absurd. You learn a lot. You also have to re-learn it over and over and over. It astounds me that people can make this argument. We are talking about a group of people who have consistently not met the performance standards of another group (physicians) academically, and claim to be able to achieve an equivalent level of understanding in less time. Go ask a resident about the case they had today and ask how many times they had seen the concepts discussed prior. Most will tell you "many" and "had to re-learn it again". And this is only really concerning the ground work. The first two years do not teach you to be a doctor at all. If anyone thinks they can do that and then "well I know how to be a doctor" they are insane. The first two years lay down a theoretical understanding upon which the next 2 years builds in order to get you to a level where you can become a resident and THEN start actually training. A point where, before which, we were too incompetent to perform at the minimum necessary level.

As for NP clinical training -
http://nursing.uw.edu/academic-services/degree-programs/dnp/dnp-curriculum-components.html

So requirements are 90 credits in "Advanced practice, leadership, and practice inquiry", 1/3 of which can be cut if you have a masters. So Washington state is producing DNPs which are basically RNs + team building with 1000 hours of clinical experience in nursing. (for perspective, most of us will have hit 1000 hours in the clinic by or near the end of the first semester 3rd year, in medicine... not nursing which is fundamentally different in its scope and approach)

https://www.chatham.edu/ccps/dnp/curriculum.cfm

This one is worse... "Communication for Collaboration for Health Care Leadership" oh well why didn't you say so.. of course your can manage my care. You took a class in leadership!

I come across as pretty condescending here, I know... but my point is that this is the groundwork they are using to argue that they should get an expanded scope of practice. There is very very little guided clinical training (where one really learns medicine) and the fact that is overlooked is that unguided clinical experience does nothing other than to cement the bad habits one has formed. It is a bad model for providing quality care. It may work wonders for making happy patients (until they die prematurely from improperly managed illness), but I kinda thought that wasn't the goal here... If I just wanted happy patients I'd strap a stethoscope to a puppy and send him into the room rigged to shoot pain pills out whenever he sits to kick/scratch his ear.

 

[SpecterGT260]

Well then I'm glad you feel like you're getting your money's worth by paying for the privilege of classmate interaction

I would be interested to know where most of the tuition money goes...

From what I understand, a good many lecture halls are donated (funds... anyways) or shared with the UG. Most professors have it in their contracts that they have to teach anyways and teaching medical students is way better than undergrads.... I really wouldn't be too surprised if going entirely online with the didactic courses had a negligible impact on cost of operations.

 

[calvnandhobbs68]

lol hey I'm glad they take such essential courses as Scholarship and Grant writing, I'll ask my NP to help me write up my next grant when I'm in the hospital. Information Technology and Data Driven decision making also sounds like a pretty clinically useful class. 500 whole clinic hours too!

For any NPs who might be offended reading these posts, understand that these types of classes are like side classes in medical school or something we pick up on our own time. I took a class in quality improvement as an ELECTIVE while taking microbiology and pathology at the same time. Not to mention we don't come straight out of preclinical years with a license to practice medicine anyway...

 

[rog411]

Well then I'm glad you feel like you're getting your money's worth by paying for the privilege of classmate interaction

Well since I'm not getting a discount by staying home and streaming the stuff online, I might as well enjoy the extras.

 

[calvnandhobbs68]

Well since I'm not getting a discount by staying home and streaming the stuff online, I might as well enjoy the extras.

True true I should try to negotiate a discount

 

[ivfmd]

It's not a medical board issue... it's an anti-trust issue. Physicians, by and large, are not employees, but independent contractors. If a town has 5 independent practices of ____ specialty, then those 5 practices are seen as independent competitors. If they join together to "negotiate" for better rates from insurance companies, it becomes a very fine line before it's "collusion" and "price fixing."

There is that classic joke.

Three businessmen are sitting in jail.

One said, "I charged more than everybody else". So I was convicted of PRICE GOUGING.

The second one said, "I charged less than everybody else". So I was convicted of PREDATORY PRICING.

The last one said, "I charged the same as everybody else" So I was convicted of COLLUSION.

----------------------------------------------

It's even worse than that for doctors. Doctors are not legally allowed to talk to "competing" practices about each other's pricing. Technically, I'm not even sure if I am allowed to look at another practice's website if they were to mention their pricing on there.

There is a benefit to having order and laws, but is it possible there comes a point where the lawyers and lawmakers have run amok and start doing things that don't make common sense?

 

[SpecterGT260]

lol hey I'm glad they take such essential courses as Scholarship and Grant writing, I'll ask my NP to help me write up my next grant when I'm in the hospital. Information Technology and Data Driven decision making also sounds like a pretty clinically useful class. 500 whole clinic hours too!

For any NPs who might be offended reading these posts, understand that these types of classes are like side classes in medical school or something we pick up on our own time. I took a class in quality improvement as an ELECTIVE while taking microbiology and pathology at the same time. Not to mention we don't come straight out of preclinical years with a license to practice medicine anyway...

Yeah, I would also expand this point to say that it isn't directed at NPs in general. Just those who try to equate the training and argue for expanded scope.

 

[rog411]

Yeah, I would also expand this point to say that it isn't directed at NPs in general. Just those who try to equate the training and argue for expanded scope.

As much as I hate people who do this, I feel like if I was on their side I would probably do it. It's a pretty crazy competitive world out there and you got to do whatever it takes sometimes.

 

[SpecterGT260]

As much as I hate people who do this, I feel like if I was on their side I would probably do it. It's a pretty crazy competitive world out there and you got to do whatever it takes sometimes.

yeah. I'm not saying it isn't in their best interest to do so. I'm saying I can see through their BS My biggest fear is actually that the people making these arguments lack the cortical power to even understand why the argument is such BS. I would actually have more faith in them if they knew they were full of it and were just spinning a self-benefiting story.

 

[rog411]

yeah. I'm not saying it isn't in their best interest to do so. I'm saying I can see through their BS My biggest fear is actually that the people making these arguments lack the cortical power to even understand why the argument is such BS. I would actually have more faith in them if they knew they were full of it and were just spinning a self-benefiting story.

Yeah, you're right. I think the people who created these myths of equality knew that they were BS. However, these myths have become so prevalent that many are starting to actually believe they are true and that will only increase with time, unless we can "bust" them.

I think what we need is a marketing campaign to expose the differences in training between midlevels and physicians. It can't just be on medical websites and journals, it has to be everywhere. It has to be on TV, on news sites, on Youtube videos, on twitter, on hulu, basically everywhere. There have got to be physician groups out there that have the money to launch marketing campaigns like this.

If they won't do it, maybe we should do it ourselves. We have people with experience in marketing, graphics design, video editing, etc among us. And if we each pitch in a bit, we can raise enough money to buy a lot of ad space. Instead of preaching to the choir here, why don't we take this information to the public??

 

[SpecterGT260]

one of issues is that "team based medicine" is becoming the expectation. Not that it wasn't already the norm, but now that we are labeling it as such, those with "team building" experience demand leadership positions and bigger cuts because they bring something of no tangible value to the process. A solution would be for physicians to completely cut off DNPs from our training processes and leave them to train themselves. It would quickly flounder. But between outward pressure, docs who just dont give a damn, and those who have the "happy golden retriever complex" (the mindset that everyone is good at whatever and we should just trust whatever and bleh....) actually believe this to be a good idea.

 

[rog411]

one of issues is that "team based medicine" is becoming the expectation. Not that it wasn't already the norm, but now that we are labeling it as such, those with "team building" experience demand leadership positions and bigger cuts because they bring something of no tangible value to the process. A solution would be for physicians to completely cut off DNPs from our training processes and leave them to train themselves. It would quickly flounder. But between outward pressure, docs who just dont give a damn, and those who have the "happy golden retriever complex" (the mindset that everyone is good at whatever and we should just trust whatever and bleh....) actually believe this to be a good idea.

where is the outward pressure coming from? and what can we do to change the mindset of these docs who just don't care? we've been talking about it forever.. but what action can we actually take now??