For those of you that work with PAs/NPs

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Yadster101

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So I am a student that is considering FM. The thing I am curious about is, what do the PAs/NPs you all work with do? Before med school I shadowed a PA in a rural town that had her own patient panel, and she did things like abscess drainage, physical exams for school, and saw patients with complaints like dizziness, erectile dysfunction, and knee pain. She was really smart, had like 15+ years of experience, seemed to have a strong relationship with her supervising physician, and completely agreed that she did NOT have the extensive knowledge that her SP had.

I only shadowed her once but it seemed to me like she was doing >70% of the stuff an FM doc would do. IIRC she also told me that she made like ~90k/yr working 3days/wk.

So what do the PAs/NPs you all work with do? What percentage of your job would you say they are able to do? And if I end up doing an FM residency, is there anything I should do to differentiate myself from PAs/NPs to make sure that I have a strong foundation of knowledge?

Also, jc but approximately what percentage of your income do your PAs/NPs (working similar hours) make?

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So I am a student that is considering FM. The thing I am curious about is, what do the PAs/NPs you all work with do? Before med school I shadowed a PA in a rural town that had her own patient panel, and she did things like abscess drainage, physical exams for school, and saw patients with complaints like dizziness, erectile dysfunction, and knee pain. She was really smart, had like 15+ years of experience, seemed to have a strong relationship with her supervising physician, and completely agreed that she did NOT have the extensive knowledge that her SP had.

I only shadowed her once but it seemed to me like she was doing >70% of the stuff an FM doc would do. IIRC she also told me that she made like ~90k/yr working 3days/wk.

So what do the PAs/NPs you all work with do? What percentage of your job would you say they are able to do? And if I end up doing an FM residency, is there anything I should do to differentiate myself from PAs/NPs to make sure that I have a strong foundation of knowledge?

Also, jc but approximately what percentage of your income do your PAs/NPs (working similar hours) make?

Well, to be honest, about 70-80% of medicine, in general, is pretty routine and rote. So, yes, I would expect a reasonably experienced and competent NP/PA to handle that 70% without me. This is true of all fields, by the way - you do things often enough, and you start to be able to do the basic stuff without thinking too hard about it.

The other 20-30%, however, is NOT routine, and a large chunk of the difficulty lies in recognizing when something is unusual, because sometimes it is a subtle difference.

You also have to realize that the PA that you worked with became that good because she had a good supervising physician who taught her that. I have worked with PAs who were terrible, and that is partly because they were poorly trained when they left PA school. They don't get the extensive teaching that the average residency program will give you.

Where I previously worked, NPs and PAs made about 70% of physician salary. They were expected to see fewer patients and had no supervisory duties (obviously). I thought that this was kind of unfair, because there were a couple of kick-ass NPs who saw super sick patients (and did a great job with them!), and there were a couple of physicians who were clearly a few fries short of a Happy Meal. These were not the rule, however.
 
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Well, to be honest, about 70-80% of medicine, in general, is pretty routine and rote. So, yes, I would expect a reasonably experienced and competent NP/PA to handle that 70% without me. This is true of all fields, by the way - you do things often enough, and you start to be able to do the basic stuff without thinking too hard about it.

The other 20-30%, however, is NOT routine, and a large chunk of the difficulty lies in recognizing when something is unusual, because sometimes it is a subtle difference.

You also have to realize that the PA that you worked with became that good because she had a good supervising physician who taught her that. I have worked with PAs who were terrible, and that is partly because they were poorly trained when they left PA school. They don't get the extensive teaching that the average residency program will give you.

Where I previously worked, NPs and PAs made about 70% of physician salary. They were expected to see fewer patients and had no supervisory duties (obviously). I thought that this was kind of unfair, because there were a couple of kick-ass NPs who saw super sick patients (and did a great job with them!), and there were a couple of physicians who were clearly a few fries short of a Happy Meal. These were not the rule, however.

So you think 70% is an accurate number for how much of a physician's job a good PA can do? I was estimating that based on just that one shadowing experience but it's interesting to see your views. Could you give me a few examples of what the other "20-30%" of stuff is? Does that 20-30% include any procedures or is it mostly knowledge? I know in EM that 20-30% includes procedures like intubations, chest tubes, central lines, etc. (I know that pays can do this stuff but its pretty rare).

"Where I previously worked, NPs and PAs made about 70% of physician salary. They were expected to see fewer patients and had no supervisory duties (obviously). I thought that this was kind of unfair, because there were a couple of kick-ass NPs who saw super sick patients (and did a great job with them!), and there were a couple of physicians who were clearly a few fries short of a Happy Meal. These were not the rule, however."

What do you mean by it was unfair? Do you think that they were getting paid too much or too little? Is it common for FM PAs/NPs to make 70% of a physician salary? From job postings I've seen it seems like the bulk of FM mid-levels make between 80-120k depending on experience while the bulk of FM MDs/DOs make 170-220k...so I would've thought that FM docs only making 30% more would be on the low end. Were the PAs making 100k and the MDs making 130k?

Once again very interesting to hear your opinions since your actually a doc. It would be awesome if additional attendings could share their opinion of what % of their jobs their mid-levels do and what % of their salary they make.

Also I totally realize that mid-level salary typically isn't calculated by taking some random % of an MD/DOs income but I still think it interesting to see the numbers.

Edit: Also I am not trying to start a flame war about how if PAs can do x% of a FM doc's job than that means they have x amount of a physicians knowledge. I agree that that is not true.
 
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So you think 70% is an accurate number for how much of a physician's job a good PA can do? I was estimating that based on just that one shadowing experience but it's interesting to see your views. Could you give me a few examples of what the other "20-30%" of stuff is? Does that 20-30% include any procedures or is it mostly knowledge? I know in EM that 20-30% includes procedures like intubations, chest tubes, central lines, etc. (I know that pays can do this stuff but its pretty rare).

Some of it is procedures, although there are some NPs and PAs who also did procedures. Mostly it was just more complicated patients - poorly controlled diabetics, poorly controlled HIV patients, patients who have multiple chronic conditions, patients who have had pretty severe chronic problems (like a liver transplant, Hepatitis C, etc.).

Physicians, in general, have a better idea of what to do with difficult, complicated patients when a specialist is not available - I have noticed that many NPs/PAs struggle with this. For instance - how do we help the patient with rheumatoid arthritis before they can see the rheumatologist? How do we help the patient without insurance, but has angina pectoris? How do we help the schizophrenic, floridly psychotic patient while they wait to get in with psych? (And, no, the answer is not always "send them to the ER.") Does this ankle fracture truly need an x-ray? Etc.

What do you mean by it was unfair? Do you think that they were getting paid too much or too little? Is it common for FM PAs/NPs to make 70% of a physician salary? From job postings I've seen it seems like the bulk of FM mid-levels make between 80-120k depending on experience while the bulk of FM MDs/DOs make 170-220k...so I would've thought that FM docs only making 30% more would be on the low end. Were the PAs making 100k and the MDs making 130k?

I thought it was unfair in this one particular case - I thought that the NP was getting paid far too little for the amount of effort she was putting in. She was seeing very difficult, complicated patients (almost none of whom had insurance) and doing a great job. She probably deserved an additional $30K based on the complexity of the patients that she was seeing. She was an exception, though.

I have no idea if it is common for PAs/NPs to make 70%. I'm sure it varies widely by practice setting, specialty, geographic location, etc. I can send you more specific numbers by PM if you like.
 
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So you think 70% is an accurate number for how much of a physician's job a good PA can do? I was estimating that based on just that one shadowing experience but it's interesting to see your views. Could you give me a few examples of what the other "20-30%" of stuff is? Does that 20-30% include any procedures or is it mostly knowledge? I know in EM that 20-30% includes procedures like intubations, chest tubes, central lines, etc. (I know that pays can do this stuff but its pretty rare).

"Where I previously worked, NPs and PAs made about 70% of physician salary. They were expected to see fewer patients and had no supervisory duties (obviously). I thought that this was kind of unfair, because there were a couple of kick-ass NPs who saw super sick patients (and did a great job with them!), and there were a couple of physicians who were clearly a few fries short of a Happy Meal. These were not the rule, however."

What do you mean by it was unfair? Do you think that they were getting paid too much or too little? Is it common for FM PAs/NPs to make 70% of a physician salary? From job postings I've seen it seems like the bulk of FM mid-levels make between 80-120k depending on experience while the bulk of FM MDs/DOs make 170-220k...so I would've thought that FM docs only making 30% more would be on the low end. Were the PAs making 100k and the MDs making 130k?

Once again very interesting to hear your opinions since your actually a doc. It would be awesome if additional attendings could share their opinion of what % of their jobs their mid-levels do and what % of their salary they make.

Also I totally realize that mid-level salary typically isn't calculated by taking some random % of an MD/DOs income but I still think it interesting to see the numbers.

Edit: Also I am not trying to start a flame war about how if PAs can do x% of a FM doc's job than that means they have x amount of a physicians knowledge. I agree that that is not true.
The 30% the physicians do is often more complex and higher paying. Additionally, physicians tend to put in more hours- most of the FM docs around here do 44-48, plus time afterward for charting, while the NPs and PAs are doing 36-40.
 
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The 30% the physicians do is often more complex and higher paying. Additionally, physicians tend to put in more hours- most of the FM docs around here do 44-48, plus time afterward for charting, while the NPs and PAs are doing 36-40.

So that's like a 20% increase in hours. So does that mean if mid-levels simply worked as many hours as physicians there salary would be nearly identical?
 
Some of it is procedures, although there are some NPs and PAs who also did procedures. Mostly it was just more complicated patients - poorly controlled diabetics, poorly controlled HIV patients, patients who have multiple chronic conditions, patients who have had pretty severe chronic problems (like a liver transplant, Hepatitis C, etc.).

Physicians, in general, have a better idea of what to do with difficult, complicated patients when a specialist is not available.

What about for healthcare providers working in large hospitals that do have specialists available? Correct me if I am wrong, but in that situation aren't primary care physicians expected to send them to a specialist? Like if you were working in a large University hospital and a poorly controlled HIV patient came to you wouldn't you have to send him to a specialist? If that's the case then what separates an FM doc from PAs/NPs working in large academic medical centers?

If I go FM I am thinking about working either as a hospitalist or as an outpt primary care doc possibly at an academic medical center. If I were to do this, then why types of things would I be doing daily that a FM PA or NP would not do?
 
So that's like a 20% increase in hours. So does that mean if mid-levels simply worked as many hours as physicians there salary would be nearly identical?
Did you miss the other half of my post? A PA/NP might have a ratio of level 2/3/4 visits that is something like 8/4/1, while a physician will have something more like 4/5/4. The physicians also tend to do more procedures, which pay more. So you're working 8-12 hours more and billing a greater number of patients that pay 25-50% more and doing procedures that pay more than most visits. Physicians also tend to be more productive- the last study I saw on workforce productivity pegged midlevels at around 20% less productive than physicians per hour. This isn't because they're working less hard or anything, they do their best, but the extra training physicians posses gives them some advantage in making faster, more efficient diagnoses. So add it all up: physicians work 20% more, are 20% more productive, bill for procedures that make more money, and handle more complex patients that allow for substantially higher billing. At the end of the day, this all adds up to physicians being much more valuable to most organizations, hence the enormous pay gap between physicians and midlevels. And, let's not forget, many states also require physicians to oversee midlevels, so they are required for the midlevels to even function and allow clinics to remain open (for PAs more often than NPs, but even in the case of NPs, independent practice is not yet universal).
 
Did you miss the other half of my post? A PA/NP might have a ratio of level 2/3/4 visits that is something like 8/4/1, while a physician will have something more like 4/5/4. The physicians also tend to do more procedures, which pay more. So you're working 8-12 hours more and billing a greater number of patients that pay 25-50% more and doing procedures that pay more than most visits. Physicians also tend to be more productive- the last study I saw on workforce productivity pegged midlevels at around 20% less productive than physicians per hour. This isn't because they're working less hard or anything, they do their best, but the extra training physicians posses gives them some advantage in making faster, more efficient diagnoses. So add it all up: physicians work 20% more, are 20% more productive, bill for procedures that make more money, and handle more complex patients that allow for substantially higher billing. At the end of the day, this all adds up to physicians being much more valuable to most organizations, hence the enormous pay gap between physicians and midlevels. And, let's not forget, many states also require physicians to oversee midlevels, so they are required for the midlevels to even function and allow clinics to remain open (for PAs more often than NPs, but even in the case of NPs, independent practice is not yet universal).

Yea my bad I glossed over that. This explanation definitely taught me some new things though.
 
What about for healthcare providers working in large hospitals that do have specialists available? Correct me if I am wrong, but in that situation aren't primary care physicians expected to send them to a specialist? Like if you were working in a large University hospital and a poorly controlled HIV patient came to you wouldn't you have to send him to a specialist? If that's the case then what separates an FM doc from PAs/NPs working in large academic medical centers?

If I go FM I am thinking about working either as a hospitalist or as an outpt primary care doc possibly at an academic medical center. If I were to do this, then why types of things would I be doing daily that a FM PA or NP would not do?

Just because specialists are nearby in the same health system does not mean that patients have access to them.
1) Pt. does not have insurance. They will often see primary care, but getting them in with the specialist can be harder (if not impossible).

2) Pt. has insurance, but it is crappy insurance. The primary care doctors take it, but the specialists don't.

3) Pt. can get in with the specialist, but the wait is about 3-4 months. Derm and rheumatology can frequently have waiting lists several months long. What will you do for the patient in the meantime?

If you are working as a hospitalist or an outpatient primary care doctor in an academic center, you will probably teaching medical students (which the PA or NP is not going to do as much). If you are a hospitalist, the PA or NP will probably be doing your admission and discharge paperwork; you will be managing the patients. If you are outpatient, you will probably be teaching and, again, seeing the more complicated patients.

Keep in mind that you may not want to work at an academic center. It is what most medical students are most familiar with, but there are real downsides to working at an academic center, particularly if you are in primary care. Money is the biggest one, lack of autonomy is another.
 
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Just because specialists are nearby in the same health system does not mean that patients have access to them.
1) Pt. does not have insurance. They will often see primary care, but getting them in with the specialist can be harder (if not impossible).

2) Pt. has insurance, but it is crappy insurance. The primary care doctors take it, but the specialists don't.

3) Pt. can get in with the specialist, but the wait is about 3-4 months. Derm and rheumatology can frequently have waiting lists several months long. What will you do for the patient in the meantime?

If you are working as a hospitalist or an outpatient primary care doctor in an academic center, you will probably teaching medical students (which the PA or NP is not going to do as much). If you are a hospitalist, the PA or NP will probably be doing your admission and discharge paperwork; you will be managing the patients. If you are outpatient, you will probably be teaching and, again, seeing the more complicated patients.

Keep in mind that you may not want to work at an academic center. It is what most medical students are most familiar with, but there are real downsides to working at an academic center, particularly if you are in primary care. Money is the biggest one, lack of autonomy is another.

I never thought about insurance problems or wait times. Also never considered those downsides of working in an academic center. All very interesting.
 
So that's like a 20% increase in hours. So does that mean if mid-levels simply worked as many hours as physicians there salary would be nearly identical?
No. AFAIK our system has a different RVU value for CRNPs/PA-Cs. In regards to our yearly bonus their pot is only half of what ours is granted you get the full thing.
 
No. AFAIK our system has a different RVU value for CRNPs/PA-Cs. In regards to our yearly bonus their pot is only half of what ours is granted you get the full thing.

So what things would you say you do on a daily basis that FM PAs do not do? Do you do any interesting procedures?

Also would you say that the FM PAs make 70% of FM MD/DO's incomes at your work?
 
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Fallacious logic.

The issue isn't so much whether a midlevel can "do" some portion of what an MD/DO can do, but whether they can appropriately manage multiple complex, inter-related issues or undifferentiated complaints in the typical time allotted for an outpatient office visit (15 minutes).

Good luck with that.

ODNS_primarycare.jpg
 
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Fallacious logic.

The issue isn't so much whether a midlevel can "do" some portion of what an MD/DO can do, but whether they can appropriately manage multiple complex, inter-related issues or undifferentiated complaints in the typical time allotted for an outpatient office visit (15 minutes).

Good luck with that.

ODNS_primarycare.jpg

BD hit on exactly what my thought process was on this one. Our extensive training has us much better suited to seeing, anticipating and managing the complex in an appropriate amount of time. It's sort of difficult to put in to words. Here's an example.

You've got your 5'3", 230 lb patient coming in talking about some new onset back pain issues +/- mild radicular symptoms, no inciting injury, no obvious badness going on. How do you best spend the 15 minute window you're confronted with? Do you see the overall picture? Do you see a back pain pt and offer/discuss NSAIDs, Gabapentin, PT, Stretching, XR lumbar, etc? I see that this is just the tip of the iceberg. For the most part, heavy people hurt more than their less heavy counterparts. He/she will likely be able to CURE her/his back pain with some changes in how she/he lives her life. I don't want to start new chronic medicines unless I really have to. I don't want this patient to accept that back pain is something they will have to just live with. I don't want them to accept that just because they have "always been this way" that it has to continue. We discuss how this is only the physical toll that weight takes but there is also an emotional one as well as an internal health one. This is one of those wakeup calls that God likes to throw our way once in a while. The back is not the problem. The back usually is a byproduct of excessive weight. The weight itself is usually not the problem either. Weight is largely a byproduct of poor eating habits. What is it that's contributing to the poor eating habits? Poor planning? Depression? Thyroid? Life stress? Etc? All the while going over all of this in verbage the particular pt can understand, walking that fine line between pep talk and scare tactic to hopefully see them down a couple pounds when you see them back in 3-4 weeks. Even my routine stuff is rarely routine. A poorly managed middle aged patient can be a damn disaster 20 years.

So there is a hell of a whole lot that goes in to the way an adequately trained FM doc practices medicine that an EMR and some ICD codes will never capture. What am I going to do, write a manifesto for every pt note that day? Don't have the time. I'm already 25 minutes behind after discussing the chronic cough my 52 y/o smoker has had for the past 6 mos.
 
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Because the gist of the responses to the OP suggest midlevels can do much of what FM docs can do, and even the parts they can't do they actually can, at least "well enough for government work."

They already have independent practice rights in almost half the states and will have just about all the states within the next 10 years. Also within the next 10 years their numbers will roughly double, which means there are two possible outcomes: you will either have a bunch of unemployed midlevels on the streets (unlikely), or the midlevel infestation of medicine will be dramatically worse than it is today.
 
Because the gist of the responses to the OP suggest midlevels can do much of what FM docs can do, and even the parts they can't do they actually can, at least "well enough for government work."

They already have independent practice rights in almost half the states and will have just about all the states within the next 10 years. Also within the next 10 years their numbers will roughly double, which means there are two possible outcomes: you will either have a bunch of unemployed midlevels on the streets (unlikely), or the midlevel infestation of medicine will be dramatically worse than it is today.

As I have said, most of clinical medicine is routine. This is true of any specialty, from pathology, to surgery, to oncology, to radiology, to primary care. And thank god that it is, to be honest - if every day was a series of super complicated patients after another, you would burn out of clinical medicine in less than 3 years. Think about it - if your drive home was a crazy, unpredictable obstacle course that changed every day, you would eventually never leave the house.

The parts that they aren't trained to do, they CAN'T do "well enough for government work." That is the point of what we have been trying to say.
 
<snip> Mostly it was just more complicated patients - poorly controlled diabetics, poorly controlled HIV patients, patients who have multiple chronic conditions, patients who have had pretty severe chronic problems (like a liver transplant, Hepatitis C, etc.).

Physicians, in general, have a better idea of what to do with difficult, complicated patients when a specialist is not available - <snip>

Agreed -- one example I use -- a pretty well trained PA who is a production God, knows her stuff and if my colleague ever didn't need them, I'd snap them up in a minute --- I was trying to figure out logistics for a pretty sick patient (new to the practice/system) so I walked over to their pod, looking for the physician who happened to be out that day. I talked with the PA and as a result, had to briefly discuss the case. PA states, "Wow, they sound pretty sick". To which I responded, "Well, they obviously meet SIRS criteria and depending on XRay results they may be septic." PA replies,"SIRS? What's that?" -- took it as a teaching moment and used it.

Don't make the mistake of watching an attending casually discuss a therapeutic plan and assume it's boilerplate easy. There are so many unspoken considerations that go into each patient encounter that we never talk about because they just happen in our train of thought. Quite often, when I meet Dr. Google in my patient encounter, I'll start verbalizing my "physician's inner monologue" while I'm establishing my differential and prioritizing it and planning my workup/treatment plan -- usually by the 3rd evil thing I've ruled out, Dr. Google asks me to shut up. Same thing here.

Believe me -- there's a reason why you had to learn the difference between a macrolide, cephalosporin, fluoroquinolone, non-dihydropyridine CCB, etc. -- there's a reason why you had to read Robbins/Cecil's/spent all those nights on wards and days in clinic ---

I don't particularly care how many years of nursing/non-doctoral experience people have -- nothing counts and you're not my peer until you've finished med school, residency and are board certified -- sorry, just the way it is...
 
Because the gist of the responses to the OP suggest midlevels can do much of what FM docs can do, and even the parts they can't do they actually can, at least "well enough for government work."

I don't see how you're getting that out of the responses. You must be getting that from the OP. This has been the #1 trolling question in this forum for years.
 
Because the gist of the responses to the OP suggest midlevels can do much of what FM docs can do, and even the parts they can't do they actually can, at least "well enough for government work."

They already have independent practice rights in almost half the states and will have just about all the states within the next 10 years. Also within the next 10 years their numbers will roughly double, which means there are two possible outcomes: you will either have a bunch of unemployed midlevels on the streets (unlikely), or the midlevel infestation of medicine will be dramatically worse than it is today.

I agree with you in that I thought we would get more specifics from the docs. I expected them to list things like procedures, types of pts, and maybe job opportunities that mid-levels don't have like hospitalist. So far they have all pretty much stated that physicians can manage more complex cases in a short amount of time. I agree with this but I expected a lot more specifics like, "yesterday I saw 25 pts, 12 of those pts the PA could have seen but the other 13 had to be seen by a physician cuz of reason x,y,z.".
 
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I agree with you in that I thought we would get more specifics from the docs. I expected them to list things like procedures, types of pts, and maybe job opportunities that mid-levels don't have like hospitalist. So far they have all pretty much stated that physicians can manage more complex cases in a short amount of time. I agree with this but I expected a lot more specifics like, "yesterday I saw 25 pts, 12 of those pts the PA could have seen but the other 13 had to be seen by a physician cuz of reason x,y,z.".

You have articulated precisely the reason this thread has fueled my already considerable neuroticism. To use a sports analogy, you either can dunk a basketball, or you can't. So far I haven't seen anyone present a convincing case that in the practice of medicine, doctors can dunk and midlevels can't. Maybe if I'm a beneficent ruler of the world with bottomless pockets, looking out for the absolute best interests of my subjects, this thread would convince me that objectively, physicians will provide better care for my subjects than midlevels.

But if I'm a healthcare executive looking to maximize profits and pad my annual bonus (ie, the actual reality of the world)? The responses in this thread leave me completely unconvinced that hiring physicians over midlevels is the way I maximize that annual bonus. Maybe physicians will deliver better care or make the right decision more often than the midlevels, but who is to judge? The patients? Ha. If I was putting on a slam dunk contest, I'd have no choice but to hire only people who can dunk or no one would buy tickets. If I'm a healthcare executive, the notion I'm getting from this thread is that there isn't any particular thing that a family doc can do that a midlevel unambiguously just can't in a way that would drive away business. It would be hard for me to justify paying a doc $250k to do something that a midlevel could do, however sub-optimally, for $130k. Yes, I know that a doctor would do the job "better," but why do I care as long as the midlevel can do that job well enough to get that reimbursement paycheck?

I don't see how you're getting that out of the responses. You must be getting that from the OP. This has been the #1 trolling question in this forum for years.

I think I addressed that just above. I don't think it's a trolling question, I think it's just about THE question in medicine right now. Anyone who's still in school and years away from earning his first attending paycheck and not worried about midlevels is either oblivious or not the sharpest tool in the box.
 
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My mom is a legit NP, who practiced independently before retiring. She is the reason I went to medical school and became a family doctor. I asked her about becoming an NP instead (due to cost, hassle of career change and starting from scratch, time, etc. She was adamant that I would be better off going to medical school, despite her extensive professional successes and joy of being a nurse.

I have zero doubt about the skills I obtained in residency. My mother did a great deal of good in an underserved community, but I don't see high level NPs (decade(+) of legit nursing before NP at a good program) replacing me. The ones that go straight through, without the value of nursing experience are not to be worried about either.

I think we should push back, but I don't see Family Med docs being placed out of business. I do see a rise in NP use with specialists that might hurt the specialist job market, because the narrow focus might help them make up for shorter training duration, i.e. 2 cardiologists + 1 NP vs 3 cardiologists. Who knows.

As for job opportunities, I will give you my email and password and you can delete the 50+ emails a DAY I get for jobs....
 
You have articulated precisely the reason this thread has fueled my already considerable neuroticism. To use a sports analogy, you either can dunk a basketball, or you can't.

Good analogy, because there's a hell of a lot more to being a good basketball player than just being able to dunk a basketball.
 
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You have articulated precisely the reason this thread has fueled my already considerable neuroticism. To use a sports analogy, you either can dunk a basketball, or you can't. So far I haven't seen anyone present a convincing case that in the practice of medicine, doctors can dunk and midlevels can't. Maybe if I'm a beneficent ruler of the world with bottomless pockets, looking out for the absolute best interests of my subjects, this thread would convince me that objectively, physicians will provide better care for my subjects than midlevels.

But if I'm a healthcare executive looking to maximize profits and pad my annual bonus (ie, the actual reality of the world)? The responses in this thread leave me completely unconvinced that hiring physicians over midlevels is the way I maximize that annual bonus. Maybe physicians will deliver better care or make the right decision more often than the midlevels, but who is to judge? The patients? Ha. If I was putting on a slam dunk contest, I'd have no choice but to hire only people who can dunk or no one would buy tickets. If I'm a healthcare executive, the notion I'm getting from this thread is that there isn't any particular thing that a family doc can do that a midlevel unambiguously just can't in a way that would drive away business. It would be hard for me to justify paying a doc $250k to do something that a midlevel could do, however sub-optimally, for $130k. Yes, I know that a doctor would do the job "better," but why do I care as long as the midlevel can do that job well enough to get that reimbursement paycheck?

I think I addressed that just above. I don't think it's a trolling question, I think it's just about THE question in medicine right now. Anyone who's still in school and years away from earning his first attending paycheck and not worried about midlevels is either oblivious or not the sharpest tool in the box.

I'm not sure what to tell you. Midlevels are a fact of life in almost every specialty. If you're concerned about midlevels taking over family medicine, then don't go into the specialty. I'm not worried, and I don't think that you should be either, but I also don't particularly care if you go into primary care or not.

As more health plans switch to a capitated model, I think that NPs and PAs will be increasingly squeezed out unless they drastically change their curriculums. There are a few private practices that refuse to hire PAs/NPs because they accept a lot of capitated plans.
 
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Good analogy, because there's a hell of a lot more to being a good basketball player than just being able to dunk a basketball.

The thing is that me (and I believe @Brahnold Bloodaxe) are students. We aren't asking this stuff to criticize FM. Like I said, I think there's a chance that I decide to go FM. @Brahnold Bloodaxe even straight up said that he was neurotic. I think part of the reason we are asking stuff is to feel reassured by attendings that the field we have an interest in is strong and they can back that up by providing us evidence of things they do on a daily basis.

Also, I have nothing against NPs/PAs. I think that they do have a rigorous curriculum and many of them are well trained. I just wanted to get any idea of the things that differentiate an FM MD/DO from an FM NP/PA. I know you guys have given us a few examples, like managing more complex patients. So maybe its my fault for not better understanding that "more complex pts" is a very good response that comprehensively answers what the difference between the two jobs is.

I was hoping that you guys could be a bit more specific with the amount of work you do that the mid-levels you work with don't do. Smq123 did describe that about 20-30% of the work she does is not routine and probably could not be done by most mid-levels. It would be nice if you all could have given us a better understanding of what that 20-30% is even if it just involved anecdotes from your most recent work day. Once again maybe it's just my fault for not better understanding the differences you have provided.
 
As more health plans switch to a capitated model, I think that NPs and PAs will be increasingly squeezed out unless they drastically change their curriculums. There are a few private practices that refuse to hire PAs/NPs because they accept a lot of capitated plans.

I just quickly googled what a "capitated model" is (sounds like DPC). How would that squeeze out NPs/PAs unless they change their curriculum? Once again I am genuinely asking...not criticizing. It's difficult to convey tone on the internet which is maybe why it sounds like every question is actually criticism.
 
I think part of the reason we are asking stuff is to feel reassured by attendings that the field we have an interest in is strong and they can back that up by providing us evidence of things they do on a daily basis.

I don't work with midlevels (by choice).
 
I just quickly googled what a "capitated model" is (sounds like DPC).

Not even close. DPC is like garlic to the capitation/ACO vampire.

In the latter, you have to achieve the correct balance between "quality" (based on metrics) and cost in order to maximize your reimbursement and minimize your downside risk (if any). This doesn't happen by accident, and it won't likely happen if you have midlevels who over-test and over-refer to make up for a lack of knowledge and/or skill.

My group is one of the top-performing Medicare ACOs in the country, FWIW. That being said, some of our offices employ midlevels, but they're all generating a profit for the physicians who hired them.
 
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I was hoping that you guys could be a bit more specific with the amount of work you do that the mid-levels you work with don't do. Smq123 did describe that about 20-30% of the work she does is not routine and probably could not be done by most mid-levels. It would be nice if you all could have given us a better understanding of what that 20-30% is even if it just involved anecdotes from your most recent work day. Once again maybe it's just my fault for not better understanding the differences you have provided.

I just quickly googled what a "capitated model" is (sounds like DPC). How would that squeeze out NPs/PAs unless they change their curriculum? Once again I am genuinely asking...not criticizing. It's difficult to convey tone on the internet which is maybe why it sounds like every question is actually criticism.

It's ok....it's hard to remember that stuff that is now habitual to us as a practicing physician was once new and foreign. :)

So, to answer your questions in reverse order...DPC is not at all like a capitated model.

DPC is literally like joining a country club. You pay a set amount of money per year (let's say $10,000 for the sake of argument). As a result, you now have open access to the amenities that the country club offers - you can play golf whenever you like, or use the swimming pool whenever you like, or bring your family for brunch or dinner whenever you want.

A capitated model is where the insurance company guarantees a certain set amount of money per patient per year - again, let's say $10,000 for the sake of argument. If the patient never uses any resources (never goes to the ER, never gets a CT scan or an MRI, never goes to urgent care), then the primary care doctor will be paid the full $10,000 at the end of the year. Great!

However, if that same patient, the following year, has a bad year and has to go to the ER for an emergent hernia repair, and then 6 months later needs an MRI for a torn meniscus, and then needs to see ortho after that - all those visits to the ER, the MRI center, and the ortho get taken out of that $10,000. And those are all expensive things; it is possible that the primary care doctor will not see any money from that pt.'s account at all.

So, obviously, if you have a physician who can take care of most things in the office without having to rely on a referral or expensive imaging test is more beneficial for the practice than a physician (or an NP/PA) who refers absolutely everything out. However, it is hard to find an NP/PA who can do that.

Keeping the above in mind...

- A patient comes in complaining of daily migraines.

I have seen inexperienced NPs/PAs either a) send the patient to neurology, or b) order an expensive MRI (because all migraines need an MRI, right?) or c) send the patient out on daily Imitrex or Fioricet and then wonder why the patient's insurance company refuses to pay for any of this.

If you have a pretty compliant patient population with great insurance, this might be ok. That is becoming increasingly rare. A patient might never go to the neurologist because "I can't take time off of work," or "I can't afford the copay right now," and then be dismissed as "noncompliant" while still suffering from daily migraines. Or the insurance company will refuse to pay for the MRI because you can't document that it is clinically necessary, so the patient never gets it done, and leaves that clinic to find another doctor who can help her. Option C is definitely a no-go because there are precious few insurance companies willing to pay for daily Imitrex. Daily Fioricet just makes the problem worse. Options a and b are also frowned upon in this capitated world because, again - cost.

Most good physicians that I know, even those relatively fresh out of residency, would approach the patient differently. They evaluate the patient for red flags, and finding no evidence of these, decide that CT or MRI is not necessary at this time. They would usually counsel the patient on the importance of avoiding caffeine, staying hydrated, getting adequate sleep, and not relying heavily on Excedrin, because of the risk of rebound. They would then start the patient on migraine prophylaxis (beta-blocker, Topamax, Gabapentin), and only send to neurology if pt. has failed everything.

Are there NPs/PAs who would know enough to do the second track? Sure, although they are not in the majority and worth their weight in gold. Are there MDs who would do the first track? Sure....lazy people are found in all disciplines. But, for the most part, that is the difference in approach.
 
I just wanted to get any idea of the things that differentiate an FM MD/DO from an FM NP/PA. I know you guys have given us a few examples, like managing more complex patients.

Hmmm. Well, for instance...

- I would expect a reasonably competent, reasonably experienced NP/PA to handle a stable diabetic who is coming in just for refills. I would expect them to know when to check their feet, check their eyes, give them their vaccines (and which vaccines), etc.

I would expect the physician in that office to be able to dedicate their time to treating the poorly controlled diabetic who is homeless and floridly schizophrenic.

- I would expect a reasonably good NP/PA to see a routine pediatric or adult physical, know which screening tests are indicated, etc.

I would expect the physician in that office to see the pediatric patient who is there for shots, but has had a liver transplant a few years ago. Or the adult physical who has a history of BRCA or Lynch Syndrome, and has very specific screening needs.

- I would expect a reasonably good NP/PA to see a patient with mild psoriasis and know how to treat that. I would be really disappointed if they did not.

I would expect the physician in that office to see the patient with severe psoriasis with psoriatic arthritis, who doesn't have insurance and can't get in to see derm.

(These are all real life examples.)

To be honest, most NPs/PAs that I know and trust wouldn't want to see those complicated patients. I have had NPs/PAs actually tell me, "I don't want to see this type of complex patient, this is not what midlevels were designed for." There are a few NPs/PAs who think that they can "handle it all," but I have not met any of them.
 
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Hmmm. Well, for instance...

I would expect the physician in that office to be able to dedicate their time to treating the poorly controlled diabetic who is homeless and floridly schizophrenic.

I would expect the physician in that office to see the pediatric patient who is there for shots, but has had a liver transplant a few years ago. Or the adult physical who has a history of BRCA or Lynch Syndrome, and has very specific screening needs.

I would expect the physician in that office to see the patient with severe psoriasis with psoriatic arthritis, who doesn't have insurance and can't get in to see derm.

Maybe I am wrong, but I think that in all three of the cases you mentioned, an FM doc at the hospital I worked at would send those pts to a specialist. What about being an FM hospitalist? I know there are mid-levels hospitalists, but from my understanding the work the do is very different from that of the attending.

Also would you agree with what @Mad Jack said, "A PA/NP might have a ratio of level 2/3/4 visits that is something like 8/4/1, while a physician will have something more like 4/5/4. The physicians also tend to do more procedures, which pay more."

Is that the ratio that you see at your work when you compare physicians vs mid-levels? Also if you agree with his remark about procedures, could you list the ones that you commonly do?
 
Maybe I am wrong, but I think that in all three of the cases you mentioned, an FM doc at the hospital I worked at would send those pts to a specialist. What about being an FM hospitalist? I know there are mid-levels hospitalists, but from my understanding the work the do is very different from that of the attending.

Also would you agree with what @Mad Jack said, "A PA/NP might have a ratio of level 2/3/4 visits that is something like 8/4/1, while a physician will have something more like 4/5/4. The physicians also tend to do more procedures, which pay more."

Is that the ratio that you see at your work when you compare physicians vs mid-levels? Also if you agree with his remark about procedures, could you list the ones that you commonly do?
A good PCP doesn't need to send everyone to specialists. Hell, a good PCP can take care of the vast majority of a patient's needs if they're so inclined.
 
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A good PCP doesn't need to send everyone to specialists. Hell, a good PCP can take care of the vast majority of a patient's needs if they're so inclined.

Definitely. Referrals for things that are routinely managed in primary care are viewed with contempt by most specialists. Sometimes, they're even blocked (none of the rheumatologists in my area will see fibromyalgia, for example). You don't want to be that guy.

I recently had a newly-diagnosed diabetic self-refer to endocrinology after I started her on metformin (HgbA1c still <7.0%). I was pissed when I found out, and made sure the endocrinologist know that it wasn't my idea.
 
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I would expect the physician in that office to be able to dedicate their time to treating the poorly controlled diabetic who is homeless and floridly schizophrenic.

I would expect the physician in that office to see the pediatric patient who is there for shots, but has had a liver transplant a few years ago. Or the adult physical who has a history of BRCA or Lynch Syndrome, and has very specific screening needs.

I would expect the physician in that office to see the patient with severe psoriasis with psoriatic arthritis, who doesn't have insurance and can't get in to see derm.

Maybe I am wrong, but I think that in all three of the cases you mentioned, an FM doc at the hospital I worked at would send those pts to a specialist.

If that is true, then you should request another FM rotation. Because that's practicing lazy medicine.

Where would you even refer these people? You're really going to send a homeless, schizophrenic patient to BOTH endocrine and psych? The average wait time to get into psych for a patient like that can be 3-6 months. Endocrine isn't going to be able to offer much more to that patient than you can, until the schizophrenia is better controlled. So you just let the patient sit there and wait 4 months to be seen by psych before you act on their diabetes?

(On a side note, there was an NP at the local mental health center who was notorious for putting EVERYONE on Paxil. Literally, everyone. That was the only medication she ever seemed to use. Do the med students in the audience know why this is a bad idea?)

Where do you send the patient with known BRCA or Lynch? They don't have cancer, so are you really just going to send them to an oncologist? And even if you do, so what? Is the oncologist going to do their pap and manage their HTN?

Good luck getting an uninsured patient in to derm. Heck, good luck getting an INSURED patient in to derm. It takes months.

I don't know what to tell you guys. There isn't a field of medicine where midlevels aren't seeing patients. But as long as there are complicated patients, you will always need physicians.
 
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If that is true, then you should request another FM rotation. Because that's practicing lazy medicine.

Where would you even refer these people? You're really going to send a homeless, schizophrenic patient to BOTH endocrine and psych? The average wait time to get into psych for a patient like that can be 3-6 months. Endocrine isn't going to be able to offer much more to that patient than you can, until the schizophrenia is better controlled. So you just let the patient sit there and wait 4 months to be seen by psych before you act on their diabetes?

(On a side note, there was an NP at the local mental health center who was notorious for putting EVERYONE on Paxil. Literally, everyone. That was the only medication she ever seemed to use. Do the med students in the audience know why this is a bad idea?)

Where do you send the patient with known BRCA or Lynch? They don't have cancer, so are you really just going to send them to an oncologist? And even if you do, so what? Is the oncologist going to do their pap and manage their HTN?

Good luck getting an uninsured patient in to derm. Heck, good luck getting an INSURED patient in to derm. It takes months.

I don't know what to tell you guys. There isn't a field of medicine where midlevels aren't seeing patients. But as long as there are complicated patients, you will always need physicians.

Well from my understanding, sometimes it's not even up to the physician. The hospital that they work at just makes everyone refer a lot of things out.
 
If that is true, then you should request another FM rotation. Because that's practicing lazy medicine.

(On a side note, there was an NP at the local mental health center who was notorious for putting EVERYONE on Paxil. Literally, everyone. That was the only medication she ever seemed to use. Do the med students in the audience know why this is a bad idea?)

SIADH would be my biggest concern for the patient.

If I was taking the drug myself? Decreased libido/ED
 
Well from my understanding, sometimes it's not even up to the physician. The hospital that they work at just makes everyone refer a lot of things out.

7838d0f32bd50b6727adcffa38403c35ecf64795db85764c5830634b73800c6c.jpg


No way. Especially not in today's environment.
 
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7838d0f32bd50b6727adcffa38403c35ecf64795db85764c5830634b73800c6c.jpg


No way. Especially not in today's environment.

You could just tell me that i am wrong. It took me like 30 seconds to find the following quote from an old thread on this topic which you were actually a part of.

"Why don't they just hire a bunch of NP/PA's? Honestly, what are the KP docs in FM doing that a midlevel can't at that point?"


uh, they do....kp has pcp's who are midlevels in fp, im, peds, and gyn.
it's not that the docs don't know more(they do) but the fact is that anything the avg md would do that the avg midlevel wouldn't is something that kp encourages pcp's to refer to specialists. for example, vasectomies. many fp docs can do them right out of residency but they are all done by urology at kp. ditto colposcopy. ditto treadmills. ditto endometrial biopsy.
ditto sigs and colonoscopies. they are all refered to gi(although at kp many of the scopes are done by pa's with extra training).
kp is not the place to work as an fp doc if you want a broad scope of practice. your scope will be EXACTLY the same as the midlevels you supervise. if you want to do all the fun procedures you learned in residency, do your own treadmills, do ob, etc, kp is not the place for you. it is a cush m-f 9-5 outpt only setting with no nights/ weekends/holidays/call/inpatients where you are using about 50% of your training. that is why a pa or np in the same setting has the same pt load and responsibilities.
I have worked for kp in the past as a pa for > 10 yrs. I would never work there as an md in primary care if I went back to school because I would want to do procedures, round on my own pts in the hospital, and have a scope of practice different than the pa or np in the next office.
 
Kaiser is a closed system. They're pretty much an anomaly (unless you want to count the VA, which isn't really comparable, as they're spending other people's money). Kaiser also moved away from midlevels as PCPs after they figured out how much it was costing them in over-testing and over-referral.

So...
tb08QvV-.jpg


Happy now? ;)
 
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Kaiser is a closed system. They're pretty much an anomaly (unless you want to count the VA, which isn't really comparable, as they're spending other people's money). Kaiser also moved away from midlevels as PCPs after they figured out how much it was costing them in over-testing and over-referral.

So...
tb08QvV-.jpg


Happy now? ;)

I think the quote i posted was from 2006. So ru saying that in the last 10 years Kaiser has moved away from using mid levels as PCPs?
 
I think the quote i posted was from 2006. So ru saying that in the last 10 years Kaiser has moved away from using mid levels as PCPs?

It isn't widely publicized, as it was based on internal data (so, good luck Googling it...I've tried), but...yep.
 
It isn't widely publicized, as it was based on internal data (so, good luck Googling it...I've tried), but...yep.

Well then I guess I was wrong and you win blue dog. But I just want you to know that in some systems the students actually grade the teachers. And if you were my preceptor in such a system I would remember this conversation and quite possibly adjust your grade based on this thread!
 
Well then I guess I was wrong and you win blue dog. But I just want you to know that in some systems the students actually grade the teachers. And if you were my preceptor in such a system I would remember this conversation and quite possibly adjust your grade based on this thread!

1461364895-muchtolearn.gif
 
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Well then I guess I was wrong and you win blue dog. But I just want you to know that in some systems the students actually grade the teachers. And if you were my preceptor in such a system I would remember this conversation and quite possibly adjust your grade based on this thread!
So you don't like the free information you are getting here that you specifically asked for, and so now you're going to throw in a bitchy comment like that?

And the medical students wonder why so few attendings actually stick around here for long.
 
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So you don't like the free information you are getting here that you specifically asked for, and so now you're going to throw in a bitchy comment like that?

And the medical students wonder why so few attendings actually stick around here for long.

I am sorry but I was kidding. I swear I thought that that was obvious because the "threat" I came up with was possibly adjusting his grade if he were my preceptor. I genuinely appreciate the help you all provide and once again apologies.
 
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I am sorry but I was kidding. I swear I thought that that was obvious because the "threat" I came up with was possibly adjusting his grade if he were my preceptor. I genuinely appreciate the help you all provide and once again apologies.

You should totally use memes. It would clear up the confusion.

Plus, I would respect the fact that you either have Ninja-level Google skills (like me), or you've invested time and effort in your response. Bonus points either way. ;)
 
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I am sorry but I was kidding. I swear I thought that that was obvious because the "threat" I came up with was possibly adjusting his grade if he were my preceptor. I genuinely appreciate the help you all provide and once again apologies.
Fair enough, sarcasm definitely doesn't translate well through the written word so that's my bad.
 
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