Future of Fam Med- How will NPs and PA affect salary?

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AI is not a serious threat to physician livelihood even for the youngest among these forums (speaking as an MS4). Other occupations will experience AI takeover long before medicine ever will, if only for liability and legal reasons.

We are absolutely the most insulated industry. And after seeing what NPs and PAs consult for, I think we are very safe.

I spent 30 minutes talking to a patient about her referral to heme/once before determining that they were consulted for iron deficiency anemia secondary to metromenorrhagia. I couldn't believe this happened. I must have asked her ten different ways which cancer she had.


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Atlas Shrugged said:
AI is not a serious threat to physician livelihood even for the youngest among these forums (speaking as an MS4). Other occupations will experience AI takeover long before medicine ever will, if only for liability and legal reasons.

We are absolutely the most insulated industry. And after seeing what NPs and PAs consult for, I think we are very safe.

I spent 30 minutes talking to a patient about her referral to heme/once before determining that they were consulted for iron deficiency anemia secondary to metromenorrhagia. I couldn't believe this happened. I must have asked her ten different ways which cancer she had.


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I was just floating the possibility out there but as a M3 interested in FM, the opinions I'm seeing here from current providers makes me much more optimistic about the future of the field.

BTW, good time to say thanks to @Blue Dog, @cabinbuilder, @VA Hopeful Dr and others that frequent the FM sub-forum and always add valuable posts. The mods seem to be running off a lot of long time members recently and I hope this trend doesn't impact anyone I tagged above.
 
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F1rstGen said:
I was just floating the possibility out there but as a M3 interested in FM, the opinions I'm seeing here from current providers makes me much more optimistic about the future of the field.

BTW, good time to say thanks to @Blue Dog, @cabinbuilder, @VA Hopeful Dr and others that frequent the FM sub-forum and always add valuable posts. The mods seem to be running off a lot of long time members recently and I hope this trend doesn't impact anyone I tagged above.
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SDN truly values its members.

However, "long term" members are subject to the Terms of Service just like others; in fact, given the length of their association with SDN, they should be more familiar with the TOS and the culture of the forums as far as what's allowable.

There is no plot to "run off" long term members. Undoubtedly you are speaking of 3 recent events where long term members received administrative action in response to a long term pattern of behavior; all 3 members were well aware that their accounts were in jeopardy and had been warned on many occasions. In fact, one had double digit number of warnings. You could even claim that these long term members have been treated more favorably over the years and given multiple second, third and tenth chances, whereas newer members would not have.

Given that @Blue Dog @VA Hopeful Dr and @cabinbuilder have never received any serious action against their accounts, its unlikely we will be "running them off".
 
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JustPlainBill said:
Yikes! Oh, this could get interesting in a hurry.....
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We all met for drinks when my wife and I were in the area a few months ago. Second time we've met IRL, actually. Nobody thought to take a picture either time, though! :(
 
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Just a lowly pre-med hoping to be accepted this cycle, but I just wanted to add this little anecdote:

My grandmother and aunt were talking the other day and trying to make dinner plans. My aunt was saying she wouldn't be available on so-and-so date because she had an appointment with her cardiologist and that she had been waiting for this particular appointment almost 4 months. Her exact words: "they tried to get me to see the PA, but I refused. If I'm going to be paying $30 I want to see a real doctor. That's why I had to wait so long."

My aunt is about 75, on a fixed income and has the most basic/cheapest medicare plan so she has to pay more out of pocket compared to those with private insurance.

"Doctor" still means something you guys. :p
 
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iqe2010 said:
Just a lowly pre-med hoping to be accepted this cycle, but I just wanted to add this little anecdote:

My grandmother and aunt were talking the other day and trying to make dinner plans. My aunt was saying she wouldn't be available on so-and-so date because she had an appointment with her cardiologist and that she had been waiting for this particular appointment almost 4 months. Her exact words: "they tried to get me to see the PA, but I refused. If I'm going to be paying $30 I want to see a real doctor. That's why I had to wait so long."

My aunt is about 75, on a fixed income and has the most basic/cheapest medicare plan so she has to pay more out of pocket compared to those with private insurance.

"Doctor" still means something you guys. :p
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What if she could see a DNP, APRN, NP, RN, BSN that referred to his/herself as a "doctor of clinical practice"?

I think the title of doctor is under attack but we can still reserve the title of "physician" for only those completing a MD/DO degree. It's foolish but because of some recent trends I've started telling people outside the medical community that I'm in school to become a physician rather than a doctor if they ask :/
 
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Nobody should be referring themselves as "doctor" but the physician. I know NPs can somehow get away with calling themselves "doctor" but I've personally never experienced that.

I was in the ER with my grandmother not too long ago, the ER doctor simply said "the admitting doctor, Dr. X and his assistant will be in to see you shortly." The NP came in first, then the doctor came.

A friend of mine said that a NP referred to herself as "doctor" during a clinic visit, but the doctor simply said "she isn't a doctor." I'd have paid to see the NP's face after that.
 
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bronx43 said:
Where are you located? I have never seen a private practice PCP office that was mostly midlevels. Around my area, the private practice (AKA those with insurance) population KNOW if their provider is a MD or midlevel. They would not tolerate having a NP primary care provider.
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This is true in my area too. At many PCPs offices, there are patients that ask specifically to see only the doctor. Also, I have relatives and friends that state that they had no choice but to see a Nurse Practioner. It was too much of a hassle to look for another physician.
 
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northernpsy said:
Here is a video that the TX NP organization made to campaign for full practice rights in Texas:



Notice that the commercial is telling people that NPs provide the same level of care and have equal patient outcomes.
They don't want to work under you. They want to replace you. If you want to keep pretending this isn't happening until it's too late, well, then I guess our profession deserves what is about to happen to it.

Yes, you can say I am melodramatic, because this issue does work me up. However, I don't see anyone actually providing data to tell me why we shouldn't be worried about the fact that 20,000+ new NPs are graduating every year and that an increasing number of states are letting them do more and more without any physician oversight. Things aren't too bad yet - for now, there are still enough patients to go around that most docs can still find jobs easily - but to me it is clear things are heading in a direction that is very worrying. I think we all should be fighting this.
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I think there are doctors that are happy with midlevels gaining independent practice rights: They don't have to supervise them; if the midlevel effs up, the midlevel takes the hit, not the doctor; practices make revenue off of midlevels because it is cheaper to hire them.
 
northernpsy said:
It looks like they are still at it. Better join now so you too can have 24/7 access to a "practitioner" :

A Heartbeat Away... - HOME:

The movement to allow NPs to practice independently is scary as hell. There are a number of subpar online training programs cranking out thousands of new DNPs who then go on to lobby for full rights to practice as "doctors". No, a DNP who completed an online class is not as qualified as a board certified FM doc, but the people who write the laws allowing them to practice as doctors don't understand or care about that. We need to start organizing to fight this and pouring money into lobbying against the Noctors. If we don't, early career doctors WILL get screwed over.

I also strongly recommend refusing to train NP students or give curbside help to NPs. You're training your replacement if you do.
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I will include PAs too. But, sadly so many doctors want midlevels around because it is cheaper to hire them. It will get worse when PAs gain independent practice rights.
 
F1rstGen said:
What we should all actually be scared of is the advances being made in neural networks and AI. It's worth giving Elon Musk a follow on twitter. He is obviously invested in tech but he projects that by 2030 that AI will be able to match or surpass human reasoning in any area. It's very possible that in the future we simply take histories, for a very modest salary, and input them into a computer that does the diagnostic reasoning. Surgeons may be the only ones immune but even then, their replacements will come with increasing advancement of robotics.

^That's the real worst case scenario for future docs. Based on how awesome EMRs have been though, I'm still not losing any sleep from worry.
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This isn't just an issue for doctors though. I'm new to clinical practice in the US so I won't comment on midlevel encroachment but AI is an area that I'm quite knowledgeable about. The optimistic AI scientists like to say that they expect to develop artificial intelligence equal to that of human intelligence between 2045-65. Theoretically, AI could significantly outpace all human endeavors after that point, not just medicine. If development of an artificial superintellgence actually ever occurs, you're looking at an extinction level event at worst and a complete social and technological transformation at best. Whether or not we can practice family medicine would be the least of your worries at that point.
 
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northernpsy said:
Hey, look, it's a direct primary care where all the primary care is being done by NPs. You don't need a physician as long as you have your own personal "provider". :rolleyes:
About | What is primary care at Celebrate Primary Care compared to a traditional doctor's office
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Lol, I would actually love to see the end game on this. Their prices are not actually lower than traditional concierge or DPC practices run by physicians. In a free market, I would be curious to see how they would fare when people with the means of paying these prices can pick between an NP or a MD.
 
bronx43 said:
Lol, I would actually love to see the end game on this. Their prices are not actually lower than traditional concierge or DPC practices run by physicians. In a free market, I would be curious to see how they would fare when people with the means of paying these prices can pick between an NP or a MD.
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Yeah that's more expensive than my prices.

But, NPs are more likely to give you whatever you want...
 
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My personal belief is that the people who hold the purse strings are planning to flood the market with NPs so that patients get used to the idea that you see an NP instead of a doctor, and within a generation or two doctors will be pretty much obsolete.

Here's a place in AZ that has independent NPs doing house calls! What could possibly go wrong having poorly trained "providers" seeing patients at home for conditions like CHF, COPD, or DM without any of the backup of a traditional hospital setting?
Healthy Tomorrows offer advanced Nurse Practitioner house calls to treat chronic medical conditions such as heart failure, emphysema, diabetes, high blood pressure, paralysis and many others. A member of our medical staff will drive to your house or adult care facility and treat you with patience and in the familiar surroundings of your living area.
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Concierge and House Call Medicine, Nurse Practitioner, Home Care, House Calls, Healthy Tomorrows

Oh wait, never mind. The NP doing your house call can always fall back on her training in using Essential Oils (the below quote was followed by a link to her Doterra site, which is a multi level marketing company that sells essential oils)
I am trained in modern Western medicine through Arizona State Nurse Practitioner program. However, I was introduced to alternative medicine through Essential Oils in 2015. At first, my team only used them on our families and we still do. We found such great benefits from them. We also use them when cooking and cleaning in our home. We have found many positive results from these naturally derived sources.

Now please do not get me wrong, for traditional care of ailments I will use modern Western medicine.

Some may not believe, but I do. Nevertheless, I tried and was so surprised on how well they work. If I found the benefits, maybe others will too. I am now sharing my knowledge of these oils with others. I hope I can help others on their journey to a more natural and chemical free way of living.
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Concierge and House Call Medicine, Nurse Practitioner, Home Care, House Calls, Healthy Tomorrows

Medicine is in DEEP trouble, friends. I am not saying this because I like it or want to scare you. Unfortunately, it's just the truth of what's going on. The dumbing down of medicine is happening right now.
 
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VA Hopeful Dr said:
Yeah that's more expensive than my prices.

But, NPs are more likely to give you whatever you want...
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Maybe you should increase your prices. If you're charging less than $900 a year for a 64 year old, I think you're short selling yourself.
 
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northernpsy said:
My personal belief is that the people who hold the purse strings are planning to flood the market with NPs so that patients get used to the idea that you see an NP instead of a doctor, and within a generation or two doctors will be pretty much obsolete.
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As much as I hate having midlevels pretend to be doctors, I think this is a bit of a hyperbole. The only thing that I truly fear in terms of replacement of MDs is AI.
 
Right now, there is still a place for physicians in our system, but I don't see that lasting at the rate that NPs are taking over the work of physicians. What exactly is the point of having two different levels of "providers" who both do the same things if they supposedly have equal outcomes? (You and I know they aren't equal, but the NPs are the ones who have poorly designed studies to back up their claims they are our equals and the legislators seem to believe them).
Why would anyone bother to take on the debt and stress of med school when an online NP degree from University of Phoenix will get you the same kind of job opportunities much faster, more easily, and with no debt? I really don't see the best and brightest of the next generation wanting to be doctors when doctors are rapidly losing ground to NPs. For our generation, there's still time to get while the getting's good, but for those who come after us, unfortunately I think it's just not worth it anymore to become a physician. :(

For anyone keeping track, it looks like the efforts to allow NPs to do vasectomies in OR went through. I as a psychiatrist would never try to argue that I can do a vasectomy just as well as an FM doc or urologist, but NPs with a fraction of MY training are going to be able to do it:

“If something happens, you can lose a testicle or you can get a bad infection,” he said. “There are bad things that can happen, and I think you’d want a urologist to be able to help out with whatever that is.”

Neeb is among many physicians who disagree with a new law championed by Planned Parenthood and the Oregon Nurses Association that makes Oregon the third state in the country to allow nurse practitioners to perform vasectomies. The doctors argue nurse practitioners don’t have enough training, especially when it comes to performing such a complicated surgical procedure, to ensure patient safety.

Proponents of the measure counter that with the right education and certification, nurse practitioners are just as capable as doctors of performing the procedure — which they describe as simple — safely.

But it’s still unclear what training will be required, who will provide it and how nurse practitioners will demonstrate aptitude. Those details are not in the law.
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Oregon nurse practitioners can now perform vasectomies
 
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northernpsy said:
Right now, there is still a place for physicians in our system, but I don't see that lasting at the rate that NPs are taking over the work of physicians. What exactly is the point of having two different levels of "providers" who both do the same things if they supposedly have equal outcomes? (You and I know they aren't equal, but the NPs are the ones who have poorly designed studies to back up their claims they are our equals and the legislators seem to believe them).
Why would anyone bother to take on the debt and stress of med school when an online NP degree from University of Phoenix will get you the same kind of job opportunities much faster, more easily, and with no debt? I really don't see the best and brightest of the next generation wanting to be doctors when doctors are rapidly losing ground to NPs. For our generation, there's still time to get while the getting's good, but for those who come after us, unfortunately I think it's just not worth it anymore to become a physician. :(

For anyone keeping track, it looks like the efforts to allow NPs to do vasectomies in OR went through. I as a psychiatrist would never try to argue that I can do a vasectomy just as well as an FM doc or urologist, but NPs with a fraction of MY training are going to be able to do it:


Oregon nurse practitioners can now perform vasectomies
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Yeah --- I think if I'm going to let someone in that area with a sharp instrument, and that's a big, big, IF -- it'll be someone who's a physician with a specialty residency and lots and lots of years of practice and procedures behind them with the ability to take me to the OR if things go south....
 
In case you guys are not keeping score at home, there are now 23,000 NPs graduating annually. Assuming an average career length of 30 years, that represents an NP workforce of ~700,000 compared to today's 130,000. Their numbers are expected to double within just the next 8 years. Obviously the job market cannot absorb so many additional midlevels if they're only going to staff the types of roles they've traditionally staffed, so if you think you're seeing "militant" midlevels encroaching on your turf you ain't seen nothing yet. They will have to come gunning for your jobs simply because there won't be enough of "their" jobs for their teeming masses, and you can bet your bottom dollar that corporate med will be happy to enable this process to depress wages all around and increase the bottom line.

I'm just glad I'm still in med school and neurotic enough to see this trainwreck coming. The last thing I wanted to do was a surgery residency but at the end of the day 4 years + 5 for something safe is better than 4+3 that are gonna go to waste.
 
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Brahnold Bloodaxe said:
In case you guys are not keeping score at home, there are now 23,000 NPs graduating annually. Assuming an average career length of 30 years, that represents an NP workforce of ~700,000 compared to today's 130,000. Their numbers are expected to double within just the next 8 years. Obviously the job market cannot absorb so many additional midlevels if they're only going to staff the types of roles they've traditionally staffed, so if you think you're seeing "militant" midlevels encroaching on your turf you ain't seen nothing yet. They will have to come gunning for your jobs simply because there won't be enough of "their" jobs for their teeming masses, and you can bet your bottom dollar that corporate med will be happy to enable this process to depress wages all around and increase the bottom line.

I'm just glad I'm still in med school and neurotic enough to see this trainwreck coming. The last thing I wanted to do was a surgery residency but at the end of the day 4 years + 5 for something safe is better than 4+3 that are gonna go to waste.
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You're being ridiculous. Despite an ever increasing number of midlevels, few primary care practices in my state are hiring them. Of the 3 hospital systems that I've worked for in 3 different cities, only one of them hires midlevels for primary care and they limit that to one per practice to help cover same day stuff only.

There is even good evidence that midlevels are avoiding primary care in favor of specialty practices which should surprise no one.

Go into surgery if that's what you actually want to do, but choosing a career based on what you think the midlevels want to do is foolish.
 
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VA Hopeful Dr said:
You're being ridiculous. Despite an ever increasing number of midlevels, few primary care practices in my state are hiring them. Of the 3 hospital systems that I've worked for in 3 different cities, only one of them hires midlevels for primary care and they limit that to one per practice to help cover same day stuff only.

There is even good evidence that midlevels are avoiding primary care in favor of specialty practices which should surprise no one.

Go into surgery if that's what you actually want to do, but choosing a career based on what you think the midlevels want to do is foolish.
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Everything you said may very well be true and it still doesn't affect the reality of the thing: at the current rate of 23,000 NPs graduating a year, their numbers will swell from 130k to 700k in the next 20-30 years and double in the next 8. I'm sure they'd all like to do outpatient derm and colonoscopies and a lot of them very well might, but the specialties cannot absorb 23,000 (and growing!) NPs a year. Are you really trying to argue that the NP workforce is going to increase by 600,000 but somehow only the specialties will be affected while family med goes on its merry way? C'mon now.
 
Brahnold Bloodaxe said:
Everything you said may very well be true and it still doesn't affect the reality of the thing: at the current rate of 23,000 NPs graduating a year, their numbers will swell from 130k to 700k in the next 20-30 years and double in the next 8. I'm sure they'd all like to do outpatient derm and colonoscopies and a lot of them very well might, but the specialties cannot absorb 23,000 (and growing!) NPs a year. Are you really trying to argue that the NP workforce is going to increase by 600,000 but somehow only the specialties will be affected while family med goes on its merry way? C'mon now.
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You mean with the shortage/maldistribution of pretty much every specialty?

Yeah, still not worries
 
northernpsy said:
To me, the problem is that I don't see much of a sense of urgency in fighting back from most doctors.

Here's what one NP leader has to say about their fight to gain more independence in Illinois as we speak - emphasis added by me:

Let the Celebration Begin - IL Society for Advanced Practice Nursing

They're assuming that they will win with very little opposition - and they're probably right, because how many doctors in Illinois are paying attention to this? How many docs will work on fighting it even if they do know what's going on and disagree with what the NPs want?
Just from what I have seen of these fights over NP scope of practice, it seems like the NPs willing to lobby for independent practice are far more numerous, better organized, and more passionate about the issue compared to doctors who disagree with NPs going independent. I think that is a HUGE problem for us.

Yes, right now we can all still find jobs pretty easily - but I for one do not feel confident that will remain the case throughout the rest of my career as NPs gain independent practice in all 50 states, keep growing in numbers, and confuse people into thinking they are physicians by calling themselves "Dr.".
I think this is a very serious threat to the survival of our profession and we need to act like it. I hear the large healthcare organization I work for talk about hiring an army of NPs but not about bringing in more doctors. That looks like it is going to be the way of the future - why on earth would any healthcare employer want to spend the money on hiring physicians if they can get by using NPs? This is going to become a major problem soon for physicians in general. I don't think it is realistic to think that every physician in the country will be able to have a successful concierge practice if NPs push us out of employed positions.
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This is so true. Doctors keep hiring these NPs. I am looking for a PCP, and I can't find a clinic in my area without an NP.
 
IzumioH20 said:
DPC is very expensive because one needs to pay for health insurance coverage in addition to this.
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Except it isn't....often 50-100 month with now less need for the more expensive "copay" style plans, some states even have specific plans designed to cost less with dpc customers
 
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So for you DPC or concierge folks out there. Do you actually provide basic medications that the patients can buy from you? If so, who are your suppliers?
 
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