It's official: Physician Associate (not Assistant).

[emergentmd]

Didn't read all of this but their society screwed up. Took their one shot and went for associate. They should have went for it all and just changed it to Physician ADVISER.

That would sound great. Hi, I am Jane Doe your physician adviser. Oh, you have more than a cough, let me get you a real doctor.

---

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[Lem0nz]

I don’t think the “physical exam is useless” sentiment applies to a lot of the surgical subs. ENT, urology, etc.

Yea I don’t even call what my ENT doc did a physical exam. 80% of it was a video laryngoscopy that just also happened to use a tongue depressor first. The physical is an adjunct to the technology, not the other way around.

Kind of feels the same with uro. The extremely limited physical exam serves as an adjunct to ultrasound and the follow up cysto.

CRS has patients prep with an enema before they even meet them on the first day and does anoscopy and/or flex sig in the office on day one. Not really sure any of that counts as a ‘physical exam’ in the classic sense.

I do a lymph node exam and check surgical scars.

Vascular checks pulses and looks at skin color and maybe listens for a bruit. But they might not and just go straight for the carotid US. Depends on the surgeon. Definitely have attendings who just have their sets of studies that they order on everyone because if you have one vascular problem you’re that much more likely to have more and need objective data.

The classic head to toe exam? Pretty much never. Appropriately so, we’ve simply evolved.

 

[Matthew9Thirtyfive]

Yea I don’t even call what my ENT doc did a physical exam. 80% of it was a video laryngoscopy that just also happened to use a tongue depressor first. The physical is an adjunct to the technology, not the other way around.

Kind of feels the same with uro. The extremely limited physical exam serves as an adjunct to ultrasound and the follow up cysto.

I did an ENT and a uro rotation recently and can think of several specific cases where the physical exam either directly made the diagnosis or sufficiently narrowed it down to where we knew what imaging to get to confirm it.

 

[Lem0nz]

I did an ENT and a uro rotation recently and can think of several specific cases where the physical exam either directly made the diagnosis or sufficiently narrowed it down to where we knew what imaging to get to confirm it.

I can’t honestly remember the last time in general surgery I made an intervention without confirmatory labs *and* imaging with the exception of exsanginuating trauma who had an ED thoracotomy. And I can’t recall a situation where the history would not prompt that objective testing. Even at Temple I watched the attendings CT scan nearly every patient with a gun shot to the belly. That’s gotta be the lowest hanging fruit right? They all get explored?

nah. They wanted to make sure bullets didn’t ricochet off bones and cross other body cavities and didn’t trust the bullet holes on the skin enough.

I don’t know man. It’s not that you can’t diagnose with physical, you can. But there’s so many things with a normal physical that are not ruled out. So many. I guess I would ask that if you had all of those same patients with a history of a thing but a negative physical, would they be getting imaging? And those with the positive physical, are they getting confirmatory imaging?

If so, what did the physical add?

not saying that’s every case. But it’s *nearly* every case. Like you said, a solid 98%.

 

[culturekweenXx]

The AOA just put out a statement against the name change. Will the AMA follow suit?

"This title change could easily create confusion for patients and put their safety at risk. Likewise, there are nurse anesthetists who seek to use the title “nurse anesthesiologist,” and other nurses with academic doctorates in nursing philosophy who use the title “Doctor” in a clinical setting, allowing patients to conflate their doctorates with the rigors of physician-level education and training. Many states have truth in advertising laws in place to protect against these situations, and help ensure that patients know that important medical decisions are being guided by physicians."

AOA statement on physician-led care, Physician Assistant title change and non-physician clinician use of the title 'Doctor'

Position Statement: The American Osteopathic Association calls for truth in advertising, intellectual honesty and transparency with the use of professional designations of non-physician clinicians in service of the public interest. We also call for organized, collaborative discussions among...

osteopathic.org

 

[Neopolymath]

I can diagnose and fix just about any car issue on a car that isn't ultra modern without using an OBDII code reader or more specific brand specific diagnostic service software but I usually use it and the mechanic's version of an HPI instead. I view the physical exam the same way. It's for obvious and very specific stuff. Like you should always literally look at your patient but what good is squeezing some dude's calf when we are just gonna check for DVT the conclusive way???

 

[Steve_Zissou]

The AOA just put out a statement against the name change. Will the AMA follow suit?

AOA statement on physician-led care, Physician Assistant title change and non-physician clinician use of the title 'Doctor'

Position Statement: The American Osteopathic Association calls for truth in advertising, intellectual honesty and transparency with the use of professional designations of non-physician clinicians in service of the public interest. We also call for organized, collaborative discussions among...

osteopathic.org

That is surprising, but makes me very happy.

 

[Schwifty]

The AOA just put out a statement against the name change. Will the AMA follow suit?

AOA statement on physician-led care, Physician Assistant title change and non-physician clinician use of the title 'Doctor'

Position Statement: The American Osteopathic Association calls for truth in advertising, intellectual honesty and transparency with the use of professional designations of non-physician clinicians in service of the public interest. We also call for organized, collaborative discussions among...

osteopathic.org

Best line: “Physician-led” does not imply “physician optional.”

 

[Matthew9Thirtyfive]

I can’t honestly remember the last time in general surgery I made an intervention without confirmatory labs *and* imaging with the exception of exsanginuating trauma who had an ED thoracotomy. And I can’t recall a situation where the history would not prompt that objective testing. Even at Temple I watched the attendings CT scan nearly every patient with a gun shot to the belly. That’s gotta be the lowest hanging fruit right? They all get explored?

nah. They wanted to make sure bullets didn’t ricochet off bones and cross other body cavities and didn’t trust the bullet holes on the skin enough.

I don’t know man. It’s not that you can’t diagnose with physical, you can. But there’s so many things with a normal physical that are not ruled out. So many. I guess I would ask that if you had all of those same patients with a history of a thing but a negative physical, would they be getting imaging? And those with the positive physical, are they getting confirmatory imaging?

If so, what did the physical add?

not saying that’s every case. But it’s *nearly* every case. Like you said, a solid 98%.

Gen surg isn’t urology. You usually don’t need confirmatory labs or imaging to diagnose a testicular torsion or Fournier’s gangrene. But that’s sort of my point. It’s only a few fields where the physical exam is useful in more than like 2% of cases.

 

[Lawpy]

The AOA just put out a statement against the name change. Will the AMA follow suit?

AOA statement on physician-led care, Physician Assistant title change and non-physician clinician use of the title 'Doctor'

Position Statement: The American Osteopathic Association calls for truth in advertising, intellectual honesty and transparency with the use of professional designations of non-physician clinicians in service of the public interest. We also call for organized, collaborative discussions among...

osteopathic.org

Unlikely because the AMA has no spine and is probably pro change

 

[thatchemguy]

The AOA just put out a statement against the name change. Will the AMA follow suit?

AOA statement on physician-led care, Physician Assistant title change and non-physician clinician use of the title 'Doctor'

Position Statement: The American Osteopathic Association calls for truth in advertising, intellectual honesty and transparency with the use of professional designations of non-physician clinicians in service of the public interest. We also call for organized, collaborative discussions among...

osteopathic.org

Very strong and well-worded statement. I could never imagine the AMA doing something even half as strong as this, they're incredibly spineless.

 

[Matthew9Thirtyfive]

Very strong and well-worded statement. I could never imagine the AMA doing something even half as strong as this, they're incredibly spineless.

We’ll see. I’m expecting something now because of what the AOA said. But I think it’ll be weak.

 

[Eye-eye]

There's no way this is real, right? I can't imagine any state legislature approving [CRNAs calling themselves nurse anesthesiologists] .

If you think anyone outside medicine (including congressmen at the state or federal level) knows the difference between an anesthesiologist and an anesthetist, I have some news for you...

 

[Eye-eye]

Wow this thread has been derailed to medical be surgical. We should focus at the real problem at hand: midlevels. Lol.

as a surgeon who also works ICU with mostly non-surgeons, I have the perspective of both sides. Somewhat of a hybrid breed.

I think most humans are selfish and just looking out for themselves. This is not unique to surgeons. Yes, surgeons make a lot of revenue for hospitals and often command higher pay or wishlists, but at the end of the day if we are not united as a profession we will all be hurt. No one is truly safe from politics and “market forces”. I think surgeons who think they are too good to help their medical counterparts are somewhat falsely reassured that they’re irreplaceable.

regarding the role of NP/PA in surgical vs non-surgical fields: there is naturally a greater gap in knowledge/skill between the surgeon and NP/PA compared to non-surgeons with their NP/PA. This doesn’t change the fact that we should try to protect our profession and keep roles defined and stop the multitude of reasons that blur the lines including doctors who want to train midlevels to do kind of do exactly what they can do to turn a profit.

I’m not sure where to start. Especially in our current mode of mostly employed physicians where we are not part of the chain of command of mid levels or nurses. If anything, there’s often a nurse-administrator who is part of our chain of command. We don’t really hire or fire. We are not really the boss. Sure, we have some say in all these things but ultimately we are “colleagues” of different worth to administration rather than their boss who can dictate terms of engagement.

I 100% agree with everything you said here except that the knowledge/skill gap is inherently greater in surgical specialties. I think it's just a lot easier to see the discrepancies from the outside.

The surgical PA could likely identify a bunch of appendicitis, and though they don't know how to do the surgery, let's be real - they could learn it if taught through some sort of residency (which I sure hope I never see happen IRL). Med school itself doesn't teach you how to do surgery. On the flipside, in a highly intellectual medical field most PAs can probably identify things correctly most of the time and usually provide appropriate treatment... but the intensive knowledge base we get in med school, the foundation, is replaced with a more superficial one in PA or NP training, and that means that the physician should hopefully catch the zebras and know more of the nuances of treatment than PAs.

Now this is just as true in surgery as in medicine - people who think there isn't substantial knowledge needed in surgical fields are deluding themselves - but my point is that if you talk to a member of the public, they might think "of course a PA can treat me for this little cold or upset tummy; they don't need all that basic science you get in med school." But they'll probably have a harder time being okay with the PA doing their surgery. Hell, most patients aren't too pleased with the residents doing their surgery, even if it's a chief, but many will let the urgent care PA diagnose and treat everything that's wrong with them right up to that point. It's all about public perception, and unfortunately, we're not always good at seeing things from that point of view.

 

[Matthew9Thirtyfive]

On the flipside, in a highly intellectual medical field most PAs can probably identify things correctly most of the time and usually provide appropriate treatment...

This hasn’t been my experience. Most of them seem to barely be able to recognize slam dunk things.

 

[jhmmd]

I 100% agree with everything you said here except that the knowledge/skill gap is inherently greater in surgical specialties. I think it's just a lot easier to see the discrepancies from the outside.

The surgical PA could likely identify a bunch of appendicitis, and though they don't know how to do the surgery, let's be real - they could learn it if taught through some sort of residency (which I sure hope I never see happen IRL). Med school itself doesn't teach you how to do surgery. On the flipside, in a highly intellectual medical field most PAs can probably identify things correctly most of the time and usually provide appropriate treatment... but the intensive knowledge base we get in med school, the foundation, is replaced with a more superficial one in PA or NP training, and that means that the physician should hopefully catch the zebras and know more of the nuances of treatment than PAs.

Now this is just as true in surgery as in medicine - people who think there isn't substantial knowledge needed in surgical fields are deluding themselves - but my point is that if you talk to a member of the public, they might think "of course a PA can treat me for this little cold or upset tummy; they don't need all that basic science you get in med school." But they'll probably have a harder time being okay with the PA doing their surgery. Hell, most patients aren't too pleased with the residents doing their surgery, even if it's a chief, but many will let the urgent care PA diagnose and treat everything that's wrong with them right up to that point. It's all about public perception, and unfortunately, we're not always good at seeing things from that point of view.

1. Re: the first bolded point--rotations??
2. Why are so you against surgeons? Surgery is a very competitive field. Surgeons are not idiots.
3. Re: the second bolded point--most pts have no idea

 

[Eye-eye]

1. Re: the first bolded point--rotations??
2. Why are so you against surgeons? Surgery is a very competitive field. Surgeons are not idiots.
3. Re: the second bolded point--most pts have no idea

1. You do learn how to diagnose surgical issues, complications, etc, and some surgical basics, but come on, you don't learn to really do very much surgically in med school. Yes, if you seek out tons of surgical electives and are very proactive, your attendings will let you close and hold a camera for laps - maybe even use some real instruments here and there - but it's mostly retracting, especially if you're not actively trying to get more experience across multiple rotations.

2. I'm not anti-surgeon at all. Want to be one, in fact, and specifically stated that anyone who thinks surgeons aren't very smart and have to do a lot of thinking for their job don't know much about surgery. And I agree - the competitiveness of most surgical specialties implies that on average they are extremely intelligent. My apologies if my wording was confusing.

My point really was that both medical and surgical fields have the same issues - midlevels are theoretically at least capable of handling their field's bread and butter appropriately, but not anything more complicated than that. However, the public often sees more of an issue with midlevels doing surgery than practicing a medical specialty. Heck, several people I know (outside medicine) have recommended me and others to go to a PA instead of a doctor because they spend more time with you, or they listen better, or they're nicer, or more up to date, or whatever other bull**** midlevel propaganda their societies have convinced the nation at large to believe.

3. Yup, I know. But those who do notice that there are people who aren't the attending on the surgical team seem very adamant about asking "Dr. [attending's name] is the one doing the actual surgery, though, right?!?"

 

[Eye-eye]

This hasn’t been my experience. Most of them seem to barely be able to recognize slam dunk things.

Fair. I should have said urgent care clinic or something instead of a medical subspecialty. I guess the scenario I think of is, for example, a kid who comes in with a sore throat and has obvious signs of a moderately severe, likely bacterial, infection on exam. For most of those kids, I would expect the PA to be able to treat with some abx, not kill them with an allergy or something, etc. The problem comes when there's a somewhat subtle uvular deviation in an uncooperative kid with the same presentation. If all they get is some abx, that peritonsillar abscess that needed to be drained isn't. And I would absolutely expect any (good) doctor to do a good enough exam to see that and treat appropriately.

On the flipside, I've worked with fantastic midlevels as well (usually the older ones), who have been fantastic precisely by knowing their limitations and calling in a doc just to make sure any time there was anything about the case that was unusual - even if said midlevel was pretty sure they knew the correct answer. I.e., working as the assistant to the physician (though I think the one I'm really thinking about was an NP, lol).

 

[jhmmd]

1. You do learn how to diagnose surgical issues, complications, etc, and some surgical basics, but come on, you don't learn to really do very much surgically in med school. Yes, if you seek out tons of surgical electives and are very proactive, your attendings will let you close and hold a camera for laps - maybe even use some real instruments here and there - but it's mostly retracting, especially if you're not actively trying to get more experience across multiple rotations.

2. I'm not anti-surgeon at all. Want to be one, in fact, and specifically stated that anyone who thinks surgeons aren't very smart and have to do a lot of thinking for their job don't know much about surgery. And I agree - the competitiveness of most surgical specialties implies that on average they are extremely intelligent. My apologies if my wording was confusing.

My point really was that both medical and surgical fields have the same issues - midlevels are theoretically at least capable of handling their field's bread and butter appropriately, but not anything more complicated than that. However, the public often sees more of an issue with midlevels doing surgery than practicing a medical specialty. Heck, several people I know (outside medicine) have recommended me and others to go to a PA instead of a doctor because they spend more time with you, or they listen better, or they're nicer, or more up to date, or whatever other bull**** midlevel propaganda their societies have convinced the nation at large to believe.

3. Yup, I know. But those who do notice that there are people who aren't the attending on the surgical team seem very adamant about asking "Dr. [attending's name] is the one doing the actual surgery, though, right?!?"

1. I am aware of this. Regardless of operating time, med students on surgery rotations learn to operate. See one do one teach one.
2. Regardless of heresay, the fact is that it is harder to get into medical school, so surgeons are more likely to be kind, competent, and know what they're doing. In fact the whole reason that the MCAT was revamped was to promote more humanistic, caring doctors. You really sound like you have a chip on your shoulder. Doctors spend plenty of time listening.
3. Not sure if you are aware--the attending is the person ultimately responsible for each case, regardless if the resident, the fellow, or even the med student is operating.

 

[Matthew9Thirtyfive]

1. You do learn how to diagnose surgical issues, complications, etc, and some surgical basics, but come on, you don't learn to really do very much surgically in med school. Yes, if you seek out tons of surgical electives and are very proactive, your attendings will let you close and hold a camera for laps - maybe even use some real instruments here and there - but it's mostly retracting, especially if you're not actively trying to get more experience across multiple rotations.

Depends on the rotation. The expectation at my gen surg site was to do at least one lipoma excision start to finish, including consenting the patient, positioning, etc all the way to the post op counseling.

 

[Redpancreas]

Depends on the rotation. The expectation at my gen surg site was to do at least one lipoma excision start to finish, including consenting the patient, positioning, etc all the way to the post op counseling.

Yeah, as usually, M9:35's medical school has some amazing thing like this. TBH most medical students could do it, it's just that not many are given the opportunity with residents/attendings around.

 

[ACSurgeon]

I 100% agree with everything you said here except that the knowledge/skill gap is inherently greater in surgical specialties. I think it's just a lot easier to see the discrepancies from the outside.

The surgical PA could likely identify a bunch of appendicitis, and though they don't know how to do the surgery, let's be real - they could learn it if taught through some sort of residency (which I sure hope I never see happen IRL). Med school itself doesn't teach you how to do surgery. On the flipside, in a highly intellectual medical field most PAs can probably identify things correctly most of the time and usually provide appropriate treatment... but the intensive knowledge base we get in med school, the foundation, is replaced with a more superficial one in PA or NP training, and that means that the physician should hopefully catch the zebras and know more of the nuances of treatment than PAs.

Now this is just as true in surgery as in medicine - people who think there isn't substantial knowledge needed in surgical fields are deluding themselves - but my point is that if you talk to a member of the public, they might think "of course a PA can treat me for this little cold or upset tummy; they don't need all that basic science you get in med school." But they'll probably have a harder time being okay with the PA doing their surgery. Hell, most patients aren't too pleased with the residents doing their surgery, even if it's a chief, but many will let the urgent care PA diagnose and treat everything that's wrong with them right up to that point. It's all about public perception, and unfortunately, we're not always good at seeing things from that point of view.

My point was most PAs/NPs will learn enough on the job to mimic their medical attendings and the day to day diagnosis and management becomes “similar”. Not identical and obviously no where near the knowledge equivalent. in surgery, the PAs/NPs will never learn “on the job” to operate even if they first assist that’s all they do. First asssit. An no, opening/closing or even harvesting a vein for CABG is not the first step towards becoming a full surgeon. Your statement that a residency could open is not contrary to my point. It reinforces that in today’s practice model, there is a larger difference in day-day work that a surgeon does compared to a non-surgeon with their mid levels. This gap would require a huge initiative such as a full blown residency to narrow that gap. The same cannot be said about non-surgical disciplines where midlevels can narrow the gap by paying attention and working on the same service for 5-10 years.

 

[Matthew9Thirtyfive]

Yeah, as usually, M9:35's medical school has some amazing thing like this. TBH most medical students could do it, it's just that not many are given the opportunity with residents/attendings around.

We have residents too. They just created a lipoma day that med students are given priority for, and then on Fridays the residents have didactics and they send the med students to the OR so we can get to do a ton.

 

[Redpancreas]

We have residents too. They just created a lipoma day that med students are given priority for, and then on Fridays the residents have didactics and they send the med students to the OR so we can get to do a ton.

Hmmm. Yeah I'm not sure what it is about your medical school that allows it to do this but it probably has something to do with the 1000 other things you say happens at your medical school that doesn't seem to happen elsewhere.

 

[jhmmd]

Yeah, as usually, M9:35's medical school has some amazing thing like this. TBH most medical students could do it, it's just that not many are given the opportunity with residents/attendings around.

But they're always around!

 

[Matthew9Thirtyfive]

Hmmm. Yeah I'm not sure what it is about your medical school that allows it to do this but it probably has something to do with the 1000 other things you say happens at your medical school that doesn't seem to happen elsewhere.

I mean they could do it at other places. They just don’t. My school takes this weird stance that med students should actually learn things on rotations.

 

[Lem0nz]

We have residents too. They just created a lipoma day that med students are given priority for, and then on Fridays the residents have didactics and they send the med students to the OR so we can get to do a ton.

Your school is an absolute outlier for medical education and not reflective of 99% of medical school elsewhere.

 

[Matthew9Thirtyfive]

Your school is an absolute outlier for medical education and not reflective of 99% of medical school elsewhere.

That’s really sad actually.

 

[Splenda88]

We were first assists when one of my classmates and I rotated in surgery together. He was interested in GS and I was not. The attending let my classmate do some cutting. I did not since I did not care about surgery. The attending gave me a B (HP) and still blasted me on the comment section of my eval by saying something of that sort: 'medicine is a team, and even a career in surgery was not in my radar, I shouldn't make it so obvious'.

 

[Lem0nz]

We were first assists when one of my classmates and I rotated in surgery together. He was interested in GS and I was not. The attending let my classmate do some cutting. I did not since I did not care about surgery. The attending gave me a B (HP) and still blasted me on the comment section of my eval by saying something of that sort: 'medicine is a team, and even a career in surgery was not in my radar, I shouldn't make it so obvious'.

Sounds like you got off easy...? Is there some behavior in there that sounds worthy of honors?

 

[Splenda88]

Sounds like you got off easy...? Is there some behavior in there that sounds worthy of honors?

None. Just could not stand surgery.

He probably let me off the hook because I was the first person to show up and the last one to leave. And I sometimes answer his pimping questions.

He slapped my classmate in the hand once because my classmate was not doing the cutting properly.

 

[NicMouse64]

The educational experience at my school is widely variable even from rotation to rotation. For the most part the clinical years are good and we get good guidance on HPI, A+Ps, and lectures. We also get a good amount of hands on experience. Low ranked MD school but I definitely feel the educational experience is quality. The main thing I've noticed rotating with PAs is they learn cookie cutter medicine, not pathophysiology. Attendings pimp us on pathophys, and I have yet to see a PA answer these questions well. The PA students do often know the management of various conditions but fail to know the why most of the time. Also if you rotate with PA students you'll notice there is a difference in caliber and attitude. I am always impressed with the intelligence and knowledge of my classmates. PA students, eh, not so much.

 

[Matthew9Thirtyfive]

The educational experience at my school is widely variable even from rotation to rotation. For the most part the clinical years are good and we get good guidance on HPI, A+Ps, and lectures. We also get a good amount of hands on experience. Low ranked MD school but I definitely feel the educational experience is quality. The main thing I've noticed rotating with PAs is they learn cookie cutter medicine, not pathophysiology. Attendings pimp us on pathophys, and I have yet to see a PA answer these questions well. The PA students do often know the management of various conditions but fail to know the why most of the time. Also if you rotate with PA students you'll notice there is a difference in caliber and attitude. I am always impressed with the intelligence and knowledge of my classmates. PA students, eh, not so much.

This has generally been my experience. The PA students are much less likely to know the why or be able to put together more than one or two things on a differential, and then their work up is usually not appropriate.

 

[sunshinefl]

1. You do learn how to diagnose surgical issues, complications, etc, and some surgical basics, but come on, you don't learn to really do very much surgically in med school. Yes, if you seek out tons of surgical electives and are very proactive, your attendings will let you close and hold a camera for laps - maybe even use some real instruments here and there - but it's mostly retracting, especially if you're not actively trying to get more experience across multiple rotations.

I did way more than this despite not wanting to do surgery as my career (though I thought it was cool for 8 weeks) starting from day 1. And that was with residents being on the service too.

 

[Splenda88]

This has generally been my experience. The PA students are much less likely to know the why or be able to put together more than one or two things on a differential, and then their work up is usually not appropriate.

That is what I hate about the system. A med school graduate can't practice medicine w/o residency while a PA with less medical knowledge can.

AP license should be in every state for people who cant match. That will put NP/PA out of business.

 

[Lem0nz]

That is what I hate about the system. A med school graduate can't practice medicine w/o residency while a PA with less medical knowledge can.

AP license should be in every state for people who cant match. That will put NP/PA out of business.

I'm not claiming that there are not NPs and PAs who go straight out of school and just start slinging drugs and doing medicine with zero oversight, because I'm sure there are. But I'm pretty comfortable in saying that most of them don't do that for their first job. Pretty much every new midlevel I've ever met goes through on the job training for another year. Including veteran PAs who are in a new discipline.

So expecting them to be comparable to a resident in any flavor given that limitation is kind of silly. They essentially get at minimum six, but often times closer to 9-12 months of 'being on one rotation'. If you or any medical student/resident sat on a single service for a year you'd have more of a claim to make those sweeping statements provided you then practiced only that thing. But we don't. On purpose.

Equating medical student education to PA school is just not worth while.

 

[Splenda88]

I'm not claiming that there are not NPs and PAs who go straight out of school and just start slinging drugs and doing medicine with zero oversight, because I'm sure there are. But I'm pretty comfortable in saying that most of them don't do that for their first job. Pretty much every new midlevel I've ever met goes through on the job training for another year. Including veteran PAs who are in a new discipline.

So expecting them to be comparable to a resident in any flavor given that limitation is kind of silly. They essentially get at minimum six, but often times closer to 9-12 months of 'being on one rotation'. If you or any medical student/resident sat on a single service for a year you'd have more of a claim to make those sweeping statements provided you then practiced only that thing. But we don't. On purpose.

Equating medical student education to PA school is just not worth while.

That has not been my experience. 2-3 months is more like it.

We can let unmatched IMGs/FMGs go through some job training as well. Not advocating for them to come out practicing w/o residency. Just make them equivalent to PA so they can make a living.

 

[Lem0nz]

That has not been my experience. 2-3 months is more like it.

We can let unmatched IMGs/FMGs go through some job training as well. Not advocating for them to come out practicing w/o residency. Just make them equivalent to PA so they can make a living.

I'm not being a jerk when I ask this. Why would you want to advocate for more midlevels, albeit physician midlevels, if you're already against midlevels? I'm genuinely curious.

 

[Splenda88]

I'm not being a jerk when I ask this. Why would you want to advocate for more midlevels, albeit physician midlevels, if you're already against midlevels? I'm genuinely curious.

I want qualified midlevels... Not what are being produced (hello NP) these days. It will a plus if they are all under the BOM in every state.

 

[Matthew9Thirtyfive]

That has not been my experience. 2-3 months is more like it.

We can let unmatched IMGs/FMGs go through some job training as well. Not advocating for them to come out practicing w/o residency. Just make them equivalent to PA so they can make a living.

Yeah I’d like to see actual data on how many go right into practicing independently after graduating.

 

[Lem0nz]

I want qualified midlevels... Not what are being produced (hello NP) these days. It will a plus if they are all under the BOM in every state.

So... PAs?

 

[Matthew9Thirtyfive]

So... PAs?

Meh. PAs are about as close as you can get, but ideally every state would have an associate physician program so that unmatched physicians can practice under supervision.

 

[Redpancreas]

I'm not being a jerk when I ask this. Why would you want to advocate for more midlevels, albeit physician midlevels, if you're already against midlevels? I'm genuinely curious.

I agree with his take.

1.) It gives students/residents who failed to match or left their program a lifeline. Right now if you fail to match or have to leave your program, the only choice is to find a residency program. Even if you do, you wait it out for the year.

2.) While I think SDN MD/Reddit Medical Student are too anti-midlevel because they ignore the benefits they provide, that doesn't mean I don't resent the fact that the field was essentially designed for one thing and now a bunch of people are trying to turn it into something it's not for the sake of their selfish interests. If they want to play that game, let's go to point #3.

3.) Implementing the above should decrease the cost (they'd be paid resident salary) and increase the quality of medicine (they're better trained) effectively saturating the service (undercutting physicians) midlevels (NPs/PAs) provide.
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The only critique voiced I agree with is by Lawpy who noted that career midlevels (PAs/NPs) would have continuity making them more desirable. The only thing I'd say to that is that I think resident physicians and medical students would be pretty quick on the uptake. It only takes me 3-4 weeks to get in the groove of a specialty service. Imagine @Lawpy if you were on Cardiology consults for a year. Me thinks you'd outperform any midlevel.

 

[Lem0nz]

I agree with his take.

1.) It gives residents who failed to match clinical experience. Right now if you fail to match or have to leave your program, the only choice is to find a residency program. Even if you do, you wait it out for the year.

2.) While I think SDN MD/Reddit Medical Student are too anti-midlevel because they ignore the benefits they provide, that doesn't mean I don't resent the fact that the field was essentially designed for one thing and now a bunch of people are trying to turn it into something it's not for the sake of their selfish interests. If they want to play that game, let's go to point #3.

3.) Implementing the above should decrease the cost (they'd be paid resident salary) and increase the quality of medicine (they're better trained).
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The only critique voiced I agree with is by Lawpy who noted that career midlevels (PAs/NPs) would have continuity making them more desirable.

Continuity isn't part of the argument though, its almost all of it. I presume, and perhaps I'm wrong, but the vast majority of those associate physicians would be some combination of IMGs, people who failed to match, or both who would be trying to get back into the match and a residency at their first chance as that would dramatically increase their income and autonomy which are two primary drivers for getting your MD.

Why would you hire an AP over a PA if there is a massive chance that within a year they will be leaving and you'll have a revolving door of trainees? There is no value to that over a resident. At that point it makes far more sense to just hire a resident because at least residents will train themselves as they progress in the years assuming you're truly looking for an assistant and that you aren't in it for the altruism or the educational aspect.

 

[Redpancreas]

Continuity isn't part of the argument though, its almost all of it. I presume, and perhaps I'm wrong, but the vast majority of those associate physicians would be some combination of IMGs, people who failed to match, or both who would be trying to get back into the match and a residency at their first chance as that would dramatically increase their income and autonomy which are two primary drivers for getting your MD.

Why would you hire an AP over a PA if there is a massive chance that within a year they will be leaving and you'll have a revolving door of trainees? There is no value to that over a resident. At that point it makes far more sense to just hire a resident because at least residents will train themselves as they progress in the years assuming you're truly looking for an assistant and that you aren't in it for the altruism or the educational aspect.

I believe only 4 months would be needed to get a resident/medical student up to speed at where a PA is after a few years. Remember in med school or residency where you got used to a rotation for 2 weeks and suddenly they shuttled you off? Imagine if you were on it for 16 additional weeks. By that time I would start automating the processes. The AP population comes with far more motivation/intelligence overall than the PA/NP population. The APs will be making 60K with non-gradual increase in salary per year they stay incentivizing continuity with a cap at where PA/NP salaries are (i.e. after 3 years, the salary jumps to PA/NP level).

 

[jhmmd]

I agree with his take.

1.) It gives students/residents who failed to match or left their program a lifeline. Right now if you fail to match or have to leave your program, the only choice is to find a residency program. Even if you do, you wait it out for the year.

2.) While I think SDN MD/Reddit Medical Student are too anti-midlevel because they ignore the benefits they provide, that doesn't mean I don't resent the fact that the field was essentially designed for one thing and now a bunch of people are trying to turn it into something it's not for the sake of their selfish interests. If they want to play that game, let's go to point #3.

3.) Implementing the above should decrease the cost (they'd be paid resident salary) and increase the quality of medicine (they're better trained) effectively saturating the service midlevels (NPs/PAs provide).
---

The only critique voiced I agree with is by Lawpy who noted that career midlevels (PAs/NPs) would have continuity making them more desirable. The only thing I'd say to that is that I think resident physicians and medical students would be pretty quick on the uptake. It only takes me 3-4 weeks to get in the groove of a specialty service. Imagine @Lawpy if you were on Cardiology consults for a year. Me thinks you'd outperform any midlevel.

1. What exactly was medicine designed for if not to heal people? What are people trying to turn medicine into? Where are you getting this stuff?
2. Again, it is not about comparing ourselves to midlevels. It is about working together. Medicine is TEAMWORK.

 

[Matthew9Thirtyfive]

Why would you hire an AP over a PA if there is a massive chance that within a year they will be leaving and you'll have a revolving door of trainees?

Because not all of us are just in it for maximizing revenue?

 

[Lem0nz]

I postulate only 2 months would be needed to get a resident/medical student up to speed at where a PA is after a few years. These APs will be making 60K with gradual increase in salary per year they stay incentivizing continuity with a cap at where PA/NP salaries are.

Resident salaries are woefully inadequate so we're going to make a pseudo incomplete training path that continues to pay garbage and probably will cap at whatever PGY-10 is, which is like 80k at best? I can definitely see them also having 80 hour work weeks if used ubiquitously. They're physicians after all, so they should take call like physicians.

And what are we going to do with them in five or ten years when they're telling us they've been doing the same job as an MD, *with* an MD, for 5+ years - why can't they bill and function as an independent MD? They've essentially 'done' residency right? As long as they just do the job they were trained?

Why would we not give them the same independent practice as we already have to NPs and PAs (and by we I mean the country, not doctors. Because we're already against independent practice, but we obviously do not control all the levers of power). Here is an ultra cheap solution to the 'doctor shortage'. But they take call.

I'm imaging some worst case scenarios, sure. But independent practice of NPs and PAs directly out of school is a worst case scenario and that's what we're talking about. So it CAN happen.

 

[Lem0nz]

Because not all of us are just in it for maximizing revenue?

Thank you captain obvious, proceed to the next two sentences and explain why you would hire this person and not simply start a residency or host residents for rotations.

 

[Redpancreas]

1. What exactly was medicine designed for if not to heal people? What are people trying to turn medicine into? Where are you getting this stuff?
2. Again, it is not about comparing ourselves to midlevels. It is about working together. Medicine is TEAMWORK.

1. The PA/NP was never meant to replace physicians, but they are gradually attempting to out of regret that at some point there is a cap to their privileges/ability as there should be. They have created these shortpaths, etc. without even basic understanding of what medical training should entail. Medicine is learning the evidence based mechanisms which dictate the human body and applying those mechanisms and insights to treating humans in the most effective way. Physicians go to medical school knowing the committment at hand. Wanna hear the most common argument you get out of college students planning to go the NP/PA route? "It's shorter"...that has real life consequences. Is a patient in trouble, but it's 4:58 PM on a Friday? Guess who wants to sign out per hospital policy?

2. Yes it is. A PAs job is to assist a physician. Not replace one. If we have 3 fields trying to do the same thing, it's inefficient. Let's divide the labor appropriately.