PA granted independent practice right in North Dakota

[W19]

Big News for OTP in North Dakota

And yet physicians need 2-yr post-grad training to practice medicine in some states

---

Members don't see this ad.

 

[Black Coffee 24/7]

Stuff like this is why I'm not going into primary care. I don't know about how things are working on other specialties, but here's my observation with regards to Anesthesiology on my most recent exp:

At a coastal city, all anesthesia procedures are being done by CRNAs unsupervised. At another hospital where the anesthesia service is contracted to an anesthesia group being manned by CRNAs and Anesthesiologists who are being paid the same salary with the same benefits. Of the 6 OR rooms, 4/6 are being manned by a CRNAs while 2/6 are being manned by Anesthesiologists.

In essense, we're talking about CRNAs making 300-400K nowadays and stealing Anesthesia jobs. It's going to happen to all specialties with all of these docs out here busy blaming medical students for their demise without realizing that they're digging their own graves at the moment.

 

[W19]

Stuff like this is why I'm not going into primary care. I don't know about how things are working on other specialties, but here's my observation with regards to Anesthesiology on my most recent exp:

At a coastal city, all anesthesia procedures are being done by CRNAs unsupervised. At another hospital where the anesthesia service is contracted to an anesthesia group being manned by CRNAs and Anesthesiologists who are being paid the same salary with the same benefits. Of the 6 OR rooms, 4/6 are being manned by a CRNAs while 2/6 are being manned by Anesthesiologists.

In essense, we're talking about CRNAs making 300-400K nowadays and stealing Anesthesia jobs. It's going to happen to all specialties with all of these docs out here busy blaming medical students for their demise without realizing that they're digging their own graves at the moment.

Sure until Vandy starts a 2-yr surgical residency for PAs

 

[Lawpy]

See the EM Forums regarding this topic: PAs in North Dakota no longer need physician supervision

 

[DubbiDoctor]

Given the lack of physician advocacy and the appeal to politicians of quick and easy solutions to complex problems (i.e. the healthcare shortage in many parts of the country), without considering the harmful long-term consequences, I would not be surprised if NPs and PAs obtain independent practice in all 50 States within the next 20 years. The trend is certainly toward mid-level autonomy, and I'm not aware of any States that rescinded NP autonomy some time after granting it. All medical students should consider midlevel encroachment, among many other factors, when determining which specialty to pursue. If you would feel unhappy working a job that midlevels are allowed to perform with a fraction of your training and sacrifice, then don't go into primary care. Of course, if you are genuinely passionate about primary care, the longer and more rigorous education and training you go through in med school and residency is valuable and will better prepare you to serve your patients.

In a healthcare system that will be increasingly served by non-physician providers (when traditionally patients expect to see a doctor as their provider), physicians will need to learn how to promote themselves. Physicians will need to use all forms of advertising to inform patients that it is in their best interest to see a physician for their healthcare needs and that midlevels are not equally good substitutes.

 

[nimbus]

Big News for OTP in North Dakota

And yet physicians need 2-yr post-grad training to practice medicine in some states

The link actually says it is not yet a done deal but that they have gained the support of the medical board. The measure still needs to be passed in their legislature.

 

[kb1900]

I get that this is a serious issue worth discussing....

but the amount of times I’ve heard students crack the joke “FM in North Dakota” makes this painfully hilarious

 

[Chibucks15]

^ exactly. If there are no docs that go up there because its below them then these people don't have any access to health care...there's a way to change this without having midlevels take it but unfortunately some of the people on here don't think there's anything outside Cali or NYC

 

[Kuratz]

First they came for FM in North Dakota...

 

[VA Hopeful Dr]

First they came for FM in North Dakota...

So you'll match FM and practice there?

 

[943710]

And this is going to keep happening until we get more physicians going into primary care, and more physicians practicing in rural/underserved areas. Whether or not NPs and PAs are actually going into those fields in higher quantities, the public's perception is that they will and doctors won't. And there's no denying that there's a gap that needs to be filled in rural areas - and there are some midlevels making a big difference in access to care in those regions. So for anybody complaining about this, I better not see you making jokes about any med students getting forced into the worst possible practice setting, FM in North Dakota

There's always FM in rural Alaska.

 

[fldoctorgirl]

So they're PAs who aren't actually assisting physicians...so what does that make them?

This is kind of ridiculous. I get that everything is driven by money...yay, we can pay PAs less and still charge patients the same amount, but this isn't safe for the public. PAs and NPs can manage the sniffles, but people who aren't as educated about medicine don't realize they shouldn't be seeing them as their PCP.

 

[GoldenFish]

And this is going to keep happening until we get more physicians going into primary care, and more physicians practicing in rural/underserved areas. Whether or not NPs and PAs are actually going into those fields in higher quantities, the public's perception is that they will and doctors won't. And there's no denying that there's a gap that needs to be filled in rural areas - and there are some midlevels making a big difference in access to care in those regions. So for anybody complaining about this, I better not see you making jokes about any med students getting forced into the worst possible practice setting, FM in North Dakota

Midlevels are concentrating where everyone else is concentrating - the populated, nice areas to live. Solving the rural healthcare shortage is going to be a big problem.

 

[VA Hopeful Dr]

The point of that poem is to stand up for those groups of which you are not a part so they may return the favor. Will be practicing radiology in the upper Midwest. But if you don't want me to give a damn as a rad so be it. Why so many primary care physicians are apathetic toward the issue or even pro-midlevel autonomy is mindnunbing.

Because as a practicing primary care physician, I'm not that worried about it. As I grow weary of explaining, most places are going for physicians over mid-levels for primary care.

The hospital system I work for currently has 5 job listings for primary care physicians, and zero for nurse practitioners or physician assistants.

Same thing for the 2 hospitals one town over - multiple physician job openings zero mid-level openings.

 

[Black Coffee 24/7]

Oh, I don't disagree. Like I said: "Whether or not NPs and PAs are actually going into those fields in higher quantities, the public's perception is that they will and doctors won't." Also, just from my personal experience living in a rural area, doing some rural primary care rotations, and talking with rural FM docs I know, there are some PAs and NPs working in rural areas where they are very sorely needed, and rural practices and hospitals have a very hard time recruiting physicians. Some faculty members at residencies I've spoken to left their rural practices 10+ years ago and have not been replaced, and the practices hired midlevels because it's just what they could get.


You missed the point. We know that there is a shortage of certain specialties in certain regions where they are sorely needed. Midlevels market themselves as filling those gaps in care. And many are providing essential services to folks who otherwise would not have access to care. Meanwhile, physicians/med students are plenty willing to complain about the expanding scope of practice, but few are willing to actually do the work it takes to reduce the need for midlevels to expand their scope. So yes, we'd love it if you give a damn. But please actually do something about it instead of just anonymously whining about midlevels on an internet forum. Advocate for recruitment of students from rural and underserved communities who are statistically more likely to go back to practice in them. Advocate for your school to have more exposure to primary care and other shortage specialties. Quit telling people that a match list full of primary care programs in the middle part of the country is a bad match list. Quit telling students who messed something up that their only choice is rural FM in ND like it's the worst thing in the world. Don't be like the attending who told me I was "too smart for that" when I said I was applying to FM. Not saying you specifically do these things, obviously I wouldn't know - but these are not uncommon sentiments I see around SDN and in real life from other med students and physicians.

The only reason why places like ND have a provider shortage bc they don’t pay adequately enough to lure docs into that tundra region. There’s always a price for everything.

It first starts with cheap PA labor in underserved areas. Then, it will be soon more PA providers in desirable cities in order for hospital management to cut cost and make more money.

After reading some of these posts, it’s not astonishing to see the majority of docs living paycheck by paycheck bc the economic and financial common sense shown by the majority of posters here are close to nil.

 

[VA Hopeful Dr]

The only reason why places like ND have a provider shortage bc they don’t pay adequately enough to lure docs into that tundra region. There’s always a price for everything.

It first starts with cheap PA labor in underserved areas. Then, it will be soon more PA providers in desirable cities in order for hospital management to cut cost and make more money.

After reading some of these posts, it’s not astonishing to see the majority of docs living paycheck by paycheck bc the economic and financial common sense shown by the majority of posters here are close to nil.

Right, but do you know how much it would take to lure a doctor to rural North Dakota? Because I promise you the hospitals and recruiters do and I suspect the numbers aren't pretty.

 

[Black Coffee 24/7]

Right, but do you know how much it would take to lure a doctor to rural North Dakota? Because I promise you the hospitals and recruiters do and I suspect the numbers aren't pretty.

I do. But that’s the price in a free market. They need to either step up their recruiting incentives or gtfo.

That means total loan forgiveness in 4 years, a compensation of 50-80% above the national baseline, and 8-10 weeks of paid vacation.

There’s no reason for docs to be fine with an assault on medical education and profession due to some state with barely any pt not having adequate access to available care. I would rather have telecom care by a physician for these pts rather than the current assault that’s being camouflaged as ready unsupervised care by middle providers.

 

[DubbiDoctor]

I do. But that’s the price in a free market. They need to either step up their recruiting incentives or gtfo.

That means total loan forgiveness in 4 years, a compensation of 50-80% above the national baseline, and 8-10 weeks of paid vacation.

There’s no reason for docs to be fine with an assault on medical education and profession due to some state with barely any pt not having adequate access to available care. I would rather have telecom care by a physician for these pts rather than the current assault that’s being camouflaged as ready unsupervised care by middle providers.

But if we're talking about the free market, don't they have the right to hire providers with less training for cheaper, if the cost of hiring a physician is too high? Just as consumers may purchase USDA choice beef if the price of prime beef is too high. If midlevel independent expansion continues, I wonder if a two-tiered healthcare system could develop, where poor and/or underinsured people seek care primarily from less-trained midlevels and people with more ability to pay seek care primarily from physicians.

 

[Black Coffee 24/7]

But if we're talking about the free market, don't they have the right to hire providers with less training for cheaper, if the cost of hiring a physician is too high? Just as consumers may purchase USDA choice beef if the price of prime beef is too high. If midlevel independent expansion continues, I wonder if a two-tiered healthcare system could develop, where poor and/or underinsured people seek care primarily from less-trained midlevels and people with more ability to pay seek care primarily from physicians.

Yeah but it’s not happening like that. CRNAs in Anesthesiology who are doing unsupervised cases are using the same billing codes and are making the same amount of compensation as some Anesthesiologists in some places.

Your thoughts make sense but that’s not the reality right now. I expect the same results for other specialties if they continue to let the assaults on their professions to be sustained without litigation.

 

[VA Hopeful Dr]

I do. But that’s the price in a free market. They need to either step up their recruiting incentives or gtfo.

That means total loan forgiveness in 4 years, a compensation of 50-80% above the national baseline, and 8-10 weeks of paid vacation.

There’s no reason for docs to be fine with an assault on medical education and profession due to some state with barely any pt not having adequate access to available care. I would rather have telecom care by a physician for these pts rather than the current assault that’s being camouflaged as ready unsupervised care by middle providers.

And has it occurred to you that rural hospitals, which are almost universally struggling these days, can't afford the type of incentives necessary to get doctors out there?

 

[nimbus]

Many rural practices and hospitals already offer significantly better pay and benefits than more suburban or urban practices, including the things you mentioned - higher base salary, loan repayment, sign on and relocation bonuses, etc. - not to mention the much lower cost of living. And as others have pointed out, rural hospitals are already financially struggling and can't usually afford to pay enough to convince people who aren't originally from rural areas to stay. Ask somebody from LA, NYC, or really any urban or suburban area who doesn't already have an interest in rural practice what it would take to move to a town with a 20k population and no major cities within a 4 hour drive and let me know what they say. I'm guessing the answer would be that no amount of money would be worth it for them, or it would be well above what rural practices and hospitals can reasonably afford.

Seriously. I don’t want to live without Whole Foods or opera. I didn’t go to medical school so I can live somewhere 30miles from the nearest Walmart.

 

[kb1900]

Seriously. I don’t want to live without Whole Foods or opera. I didn’t go to medical school so I can live somewhere 30miles from the nearest Walmart.

Maybe when I near retirement I can see the appeal of a rural area

 

[nimbus]

I do. But that’s the price in a free market. They need to either step up their recruiting incentives or gtfo.

That means total loan forgiveness in 4 years, a compensation of 50-80% above the national baseline, and 8-10 weeks of paid vacation.

There’s no reason for docs to be fine with an assault on medical education and profession due to some state with barely any pt not having adequate access to available care. I would rather have telecom care by a physician for these pts rather than the current assault that’s being camouflaged as ready unsupervised care by middle providers.

Rural hospitals tend to be both low volume and serve an impoverished population. Their patients are not highly paid tech workers and managers with good insurance. Those jobs aren’t there. Where do you propose they get the money to pay for this?

And it’s not just the money. Spouses have limited employment and social options in these areas and schools tend to be bad.

No amount of money will get the vast majority of doctors to move to these areas.

 

[Ho0v-man]

This should only be allowed for primary care and only select counties. Now North Dakota will be the place to be for dermatology “providers.”

 

[nimbus]

This should only be allowed for primary care and only select counties. Now North Dakota will be the place to be for dermatology “providers.”

https://www.aamc.org/download/447214/data/northdakotaprofile.pdf

There are 23 dermatologists in the state of North Dakota so they need some.

 

[Ho0v-man]

And if 10,000 PAs open up dermatology offices in North Dakota tomorrow, they will still only have 23 dermatologists.

 

[alprazoslam]

Yeah it should only be PCP. You know there will be a huge boom of glamour chick PAs reading to open med spas and such.

 

[alprazoslam]

Rural hospitals tend to be both low volume and serve an impoverished population. Their patients are not highly paid tech workers and managers with good insurance. Those jobs aren’t there. Where do you propose they get the money to pay for this?

And it’s not just the money. Spouses have limited employment and social options in these areas and schools tend to be bad.

No amount of money will get the vast majority of doctors to move to these areas.

I’d go I love rural. Buy a giant limited 250 and put some decent tires on that sucker and off-road all day.


Won’t reiterate how I love the fact nobody likes rural.


Get away frum muh jerbs

 

[Black Coffee 24/7]

Rural hospitals tend to be both low volume and serve an impoverished population. Their patients are not highly paid tech workers and managers with good insurance. Those jobs aren’t there. Where do you propose they get the money to pay for this?

And it’s not just the money. Spouses have limited employment and social options in these areas and schools tend to be bad.

No amount of money will get the vast majority of doctors to move to these areas.

Why do we need a vast majority of docs to the North Dakota region? We just need 2-3% of graduating medical students to go to these regions considering the low # of pt volume. So, the answer is to pay up to attract these docs to the regions.

Allowing PAs/NPs into the field and letting them bill insurances with the same billing codes aren't the answers. It's really common sense.

As a medical students during my first two years, I'm always astounded as to how the big moneymakers aren't the revenue bringers but rather the general managers. It defies common sense across sports and in all fields. However, after talking to a bunch of physicians during my third year, I now know the answer. It's because attending physicians are just clueless in business management and financial common sense.

 

[Ho0v-man]

Why do we need a vast majority of docs to the North Dakota region? We just need 2-3% of graduating medical students to go to these regions considering the low # of pt volume. So, the answer is to pay up to attract these docs to the regions.

Allowing PAs/NPs into the field and letting them bill insurances with the same billing codes aren't the answers. It's really common sense.

As a medical students during my first two years, I'm always astounded as to how the big moneymakers aren't the revenue bringers but rather the general managers. It defies common sense across sports and in all fields. However, after talking to a bunch of physicians during my third year, I now know the answer. It's because attending physicians are just clueless in business management and financial common sense.

Hey I’m anti mid level and everything, but I thought they only got 85% reimbursement, which makes them appealing to insurance as well.

 

[Black Coffee 24/7]

Hey I’m anti mid level and everything, but I thought they only got 85% reimbursement, which makes them appealing to insurance as well.

Nah, hell no. Same billing codes with same revenue, bro. That's why we have some CRNAs in places 1.5 hrs away from a major metropolitan areas making 300 K a year. I was flabbergasted when I heard these quotes from actual practicing Anesthesiologists and CRNAs from my rotating hospital.

 

[Ho0v-man]

Nah, hell no. Same billing codes with same revenue, bro. That's why we have some CRNAs in places 1.5 hrs away from a major metropolitan areas making 300 K a year. I was flabbergasted when I heard these quotes from actual practicing Anesthesiologists and CRNAs from my rotating hospital.

Maybe it’s different for CRNAs?

Nurse Practitioner Reimbursement Gap Remains Among Public, Third-Party Health Insurance Payers | National Association of Pediatric Nurse Practitioners

But don’t worry, they’re lobbying hard to make it more “fair.”

 

[Dr. Doctor MD]

https://www.aamc.org/download/447214/data/northdakotaprofile.pdf

There are 23 dermatologists in the state of North Dakota so they need some.

Do they though?

Population 750,000

Each dermatologist can have 10,000 patient visits per year (40 patients per day times 250 days)

Multiple by 23 dermatologists = 230,000 appointment spots per year, maybe call it 200,000 including part time and extra vacation.

Considering not every or even most patients need to see a dermatologist each year, it seems like they aren't that bad off with just 23 derms.

The real problem is that 10-15 dermatologists are probably in 2-3 big cities, leaving the rest of the state with an multiple hour drive to see a dermatologist.

Also these numbers assume not a single midlevel in the state, which isn't true.

 

[nimbus]

The real problem is that 10-15 dermatologists are probably in 2-3 big cities, leaving the rest of the state with an multiple hour drive to see a dermatologist.

I agree. You’ve nailed it.

 

[Black Coffee 24/7]

More like 20% of graduating medical students assuming it needs to be proportional to the 20% of the population living in rural areas.

Ugh, no. Having done 2 of my clinical rotations already in areas considered rural, I would say that only about 5-10% of the US population truly live in bfe places. This 20% number is straight up wrong.

And as multiple people have told you, which I didn't notice that you actually responded to...they are already paying up as much as they can afford to. Check out some rural job offers and compare them to suburban/urban. I've already said this above, but the salaries and benefits are already significantly better in rural areas - including all the things you mentioned like loan repayment, paid vacation, etc. - and the cost of living is SO much lower. Read some articles about what's happening to rural hospitals and tell me if it sounds like they can afford to increase their operating expenses. They're already folding financially as it is. What you're saying is great in theory but it doesn't work in the real world.

15-20% above the national baseline isn't significantly better for bfe places. Apparently, that's why they're having trouble recruiting docs there.

ETA: And let me ask you this - if you're not from a rural area, how much would it take for you to move to an area like where my family is from? Population <10k, ~4 hours from a major city. 95% white and Christian. The "mall" has a JC Penny and a thrift shop and that's about it. Maybe a couple dozen bars and restaurants. No museums, concerts, operas or musicals, and the big cultural event of the year is the fishing competition. Public schools won't prep your kids well for college and there are no private options unless you want to send your kid to boarding school. What salary would you expect to do family practice there?

To answer your question, it would take about 500-700K a year, about 10 weeks of paid vacation, and complete student loan forgiveness after 4 years if I'm a family medicine doc, which is approximately 50-100% above the national baseline for me to practice in the above place. I don't see this number being available at any truly bfe places on Practice Link and other job search sites. However, for rural communities that are 1.5-2 hr away from a major metropolitan area, it would take 300-350K as a FM doc, which is about 10-15% above the national baseline. I see these numbers quite often for these areas.

The thing is that this kind of legislation would only help the 4-5% of pts in bfe places while screwing up the job market for all future docs who are considering mildly rural communities. Mildly rural communities make up about 20-40% of the US population.

This will be the reality for you as a family med doctor if you support this kind of crap:
1) Your so called 250-300K salary for mildly rural areas will sink to 200K a year
2) Fam docs in urban areas will now have to settle for 150-180K a year
3) BFE fam docs will earn 300-350K a year

In essence, you're screwing over 80-90% of your family med colleagues by supporting this nonsense especially when the average med ed debt is about 300-350K nowadays. Regardless of the legislation or political forces, only about 2-3% of a medical school class will want to practice in bfe places in your description. Real smart thinking there to appease only a small minority of the population.

Lastly, it's foolish to think that there will be a stratification in term of billing codes for NP/PA vs MD/DO. The future for this scenario has already been shown in Anesthesia, in which both CRNAs and Anesthesiologist are using the same billing codes and making the same money especially if both groups are doing unsupervised cases.

 

[VA Hopeful Dr]

Ugh, no. Having done 2 of my clinical rotations already in areas considered rural, I would say that only about 5-10% of the US population truly live in bfe places. This 20% number is straight up wrong.




15-20% above the national baseline isn't significantly better for bfe places. Apparently, that's why they're having trouble recruiting docs there.



To answer your question, it would take about 500-700K a year, about 10 weeks of paid vacation, and complete student loan forgiveness after 4 years if I'm a family medicine doc, which is approximately 50-100% above the national baseline for me to practice in the above place. I don't see this number being available at any truly bfe places on Practice Link and other job search sites. However, for rural communities that are 1.5-2 hr away from a major metropolitan area, it would take 300-350K as a FM doc, which is about 10-15% above the national baseline. I see these numbers quite often for these areas.

The thing is that this kind of legislation would only help the 4-5% of pts in bfe places while screwing up the job market for all future docs who are considering mildly rural communities. Mildly rural communities make up about 20-40% of the US population.

This will be the reality for you as a family med doctor if you support this kind of crap:
1) Your so called 250-300K salary for mildly rural areas will sink to 200K a year
2) Fam docs in urban areas will now have to settle for 150-180K a year
3) BFE fam docs will earn 300-350K a year

In essence, you're screwing over 80-90% of your family med colleagues by supporting this nonsense especially when the average med ed debt is about 300-350K nowadays. Regardless of the legislation or political forces, only about 2-3% of a medical school class will want to practice in bfe places in your description. Real smart thinking there to appease only a small minority of the population.

Lastly, it's foolish to think that there will be a stratification in term of billing codes for NP/PA vs MD/DO. The future for this scenario has already been shown in Anesthesia, in which both CRNAs and Anesthesiologist are using the same billing codes and making the same money especially if both groups are doing unsupervised cases.

And where is the money going to come from to pay a family doctor 500k/year with 2.5 months vacation and 50-75k/year in addition for student loan repayment? That salary alone is 100% above national average/median with roughly twice the time off - and that's ignoring the loan repayment part of that.

Where do you think rural hospitals are going to get this money?

 

[VA Hopeful Dr]

Yeah it should only be PCP. You know there will be a huge boom of glamour chick PAs reading to open med spas and such.

That seems ideal to me. It lets them have their long-desired "independence" while keeping them away from actual sick patients.

Its win-win.

 

[VA Hopeful Dr]

Why do we need a vast majority of docs to the North Dakota region? We just need 2-3% of graduating medical students to go to these regions considering the low # of pt volume. So, the answer is to pay up to attract these docs to the regions.

Allowing PAs/NPs into the field and letting them bill insurances with the same billing codes aren't the answers. It's really common sense.

As a medical students during my first two years, I'm always astounded as to how the big moneymakers aren't the revenue bringers but rather the general managers. It defies common sense across sports and in all fields. However, after talking to a bunch of physicians during my third year, I now know the answer. It's because attending physicians are just clueless in business management and financial common sense.

Your ignorance is startling.

I'm one of the lowest paid physicians out there (FM), but I still earn more than every non-clinical person at my hospital except for the top 2 levels (one level is the CEO, the other level is stuff like the CFO, COO, you get the idea).

 

[alprazoslam]

More like 20% of graduating medical students assuming it needs to be proportional to the 20% of the population living in rural areas.

And as multiple people have told you, which I didn't notice that you actually responded to...they are already paying up as much as they can afford to. Check out some rural job offers and compare them to suburban/urban. I've already said this above, but the salaries and benefits are already significantly better in rural areas - including all the things you mentioned like loan repayment, paid vacation, etc. - and the cost of living is SO much lower. Read some articles about what's happening to rural hospitals and tell me if it sounds like they can afford to increase their operating expenses. They're already folding financially as it is. What you're saying is great in theory but it doesn't work in the real world.

ETA: And let me ask you this - if you're not from a rural area, how much would it take for you to move to an area like where my family is from? Population <10k, ~4 hours from a major city. 95% white and Christian. The "mall" has a JC Penny and a thrift shop and that's about it. Maybe a couple dozen bars and restaurants. No museums, concerts, operas or musicals, and the big cultural event of the year is the fishing competition. Public schools won't prep your kids well for college and there are no private options unless you want to send your kid to boarding school. What salary would you expect to do family practice there?

That seems ideal to me. It lets them have their long-desired "independence" while keeping them away from actual sick patients.

Its win-win.

Good point. Wonder if the diet pill clinics will explode

 

[alprazoslam]

Your ignorance is startling.

I'm one of the lowest paid physicians out there (FM), but I still earn more than every non-clinical person at my hospital except for the top 2 levels (one level is the CEO, the other level is stuff like the CFO, COO, you get the idea).

But this is sdn and anything sub 400 is poverty

 

[NITRAS]

Debt loads are very school dependent, and you actually have more control over your debt load than you think (despite what is posted on SDN).

As to the original topic, physicians will always have an advantage compared to PA's. We are the default leaders in medicine. We have a broader and deeper knowledge base, and will always have a market advantage. My hospitalist department has about 50 physicians and probably 20 PA's. Many of them started as new grads. Trust me. A brand new PA gets lots of on the job training because they really need it.

Times are changing. Midlevels are here to stay. Smart physician will find out ways to treat their patients better and gain financially.

Again, times always change. Things just change faster now.

 

[evilbooyaa]

Ugh, no. Having done 2 of my clinical rotations already in areas considered rural, I would say that only about 5-10% of the US population truly live in bfe places. This 20% number is straight up wrong.




15-20% above the national baseline isn't significantly better for bfe places. Apparently, that's why they're having trouble recruiting docs there.



To answer your question, it would take about 500-700K a year, about 10 weeks of paid vacation, and complete student loan forgiveness after 4 years if I'm a family medicine doc, which is approximately 50-100% above the national baseline for me to practice in the above place. I don't see this number being available at any truly bfe places on Practice Link and other job search sites. However, for rural communities that are 1.5-2 hr away from a major metropolitan area, it would take 300-350K as a FM doc, which is about 10-15% above the national baseline. I see these numbers quite often for these areas.

The thing is that this kind of legislation would only help the 4-5% of pts in bfe places while screwing up the job market for all future docs who are considering mildly rural communities. Mildly rural communities make up about 20-40% of the US population.

This will be the reality for you as a family med doctor if you support this kind of crap:
1) Your so called 250-300K salary for mildly rural areas will sink to 200K a year
2) Fam docs in urban areas will now have to settle for 150-180K a year
3) BFE fam docs will earn 300-350K a year

In essence, you're screwing over 80-90% of your family med colleagues by supporting this nonsense especially when the average med ed debt is about 300-350K nowadays. Regardless of the legislation or political forces, only about 2-3% of a medical school class will want to practice in bfe places in your description. Real smart thinking there to appease only a small minority of the population.

Lastly, it's foolish to think that there will be a stratification in term of billing codes for NP/PA vs MD/DO. The future for this scenario has already been shown in Anesthesia, in which both CRNAs and Anesthesiologist are using the same billing codes and making the same money especially if both groups are doing unsupervised cases.

You are very strongly opinionated on things you think have a mastery of, but, in reality, don't have any appreciable amount of knowledge about, as multiple others have noted in this (and other) thread(s). Your personal anecdotes does not mean that census data is incorrect (as you claim in the bolded). I encourage you to re-consider whether you are truly a savant and everybody else is wrong about everything, or if it's possible that all the people disagreeing with you might be correct.

Given that you're a current medical student, I don't think arguing with a practicing FM doctor about the realities of FM is a winning move.

 

[hurtem&healem]

Seriously. I don’t want to live without Whole Foods or opera. I didn’t go to medical school so I can live somewhere 30miles from the nearest Walmart.

Funny, I'm going to medical school precisely because I want to live 30 miles from the closest Walmart. Not in ND, though. Spent 5 years of my life there... never again.

As to the larger discussion, one of the big arguments for midlevel autonomy is their ability to fill some of this need in rural areas. But we all know they are still concentrating in the same overpopulated spots. In an ideal world, why not limit their ability to practice independently to underserved locations? Of course this assumes the belief that somebody is better than nobody.

 

[alprazoslam]

I’m pretty sure more than 4% are over 300. If you go to any school in my state you’ll have 250+ with living expenses and interest. Even the cheapest MD

 

[stayathomemom]

I grew up in North Dakota and did my undergrad there.

Rural hospitals tend to be both low volume and serve an impoverished population. Their patients are not highly paid tech workers and managers with good insurance. Those jobs aren’t there. Where do you propose they get the money to pay for this?

To add to this, rural hospitals have been closing in the state. There just aren't the resources to keep them afloat.

And it’s not just the money. Spouses have limited employment and social options in these areas and schools tend to be bad.

No amount of money will get the vast majority of doctors to move to these areas.

All of this is true. Even if you did give them an insane salary, there's nothing out there to spend it on. The priciest house might be $500,000-700,000 in a rural area. It's no gated mansion, either (although you could get a ton of very boring land for a song!). When I was growing up, there were no Mercedes, Jaguars, or sports cars of any notable brand. The schools were really, really limited in their offerings and there was zilch in the way of non-school-sponsored extracurriculars (for instance, now my family lives in a city with a science museum that offers camps and classes my kids can take; this wasn't an option for me, and I even lived in a larger town). Even procuring groceries can be a mission when living in a rural area; the nearest grocery store could be 30 minutes away or more. This is to say nothing of the killer winters (literally) and hot, muggy summers. You want to give them a huge amount of vacation time? Who's going to cover for them?

Look, I'm not defending midlevels as a blanket statement. But there is a provider shortage in these deeply rural areas that won't be rectified by pulling in out-of-staters. That just won't work very well. By allowing midlevels to practice without immediate oversight, local nurses can be trained to provide primary care to the places they already live.

I know, I know, slippery slope, blah blah blah. Do you have any better ideas? Let these rural farmers, oil field workers, and Native Americans on reservations go without medical care? I mean, seriously, if you have a solution that helps both docs keep their business and the people get quality care, I'm sure the rural hospitals of ND would like to know.

PS Shout out to all the FM docs in ND, thanks for doing what you do. Eat some fleischkuekle for me.

 

[Black Coffee 24/7]

Did you notice that I linked to the US Census Bureau website to support that 20% figure? Are you suggesting that the census is wrong? Would you like to share some other data you've found that perhaps I'm not aware of, or is your estimate of how many rural people live in the entire United States just based on the fact that you have personally visited two rural communities?

Here's the link again in case you missed it: New Census Data Show Differences Between Urban and Rural Populations

I have talked to physicians that practiced at my clinical sites and my local communities. Almost all of them received BFE loan forgiveness and other benefits. Almost all of them don't believe that they live in BFE places. I also don't believe so. Lastly, I have travelled and lived across at least 20 states in this country. I'm talking about actually living at each location for at least 1 month, and not driving through towns. I personally don't believe that 20% of Americans live in BFE places. However, I continue to hope for this misconception to continue for future wage negotiation when I become an attending down the road.

 

[alprazoslam]

The 4% figure I'm citing comes from a 2017 study in JAMA Internal Medicine which looked at data from the AAMC Graduation Questionnaire. It included debt accumulated before medical school. The response rate was about 80% and it is based on self-reported debt, so it's certainly possible that it's not quite accurate. I'd be happy to consider other data if you have any suggesting it's higher than 4%.

Link: Distribution of Medical Education Debt by Specialty, 2010-2016

EDIT: I did find some more recent data from the AAMC stating that 14% of the class of 2017 was >300k in debt which is not insignificant. However, the mean and median debt of those who were not debt-free was still ~190k.

Link: https://members.aamc.org/iweb/upload/2017 Debt Fact Card.pdf

But again...regardless of the indebtedness of medical grads, which I absolutely agree is an issue, it's still true that:
- rural hospitals and practices already have significantly higher salaries/benefits compared to urban/suburban
- rural hospitals do not have money to pay their physicians half a million dollars a year to not even be available in the community for 20% of that time, as some in this thread have suggested they ought to
- even if they did, there are still plenty of people who would not accept any amount of money to be away from the city amenities to which they are accustomed
So just saying "well rural jobs should pay more" isn't a solution to the bigger problem of a lack of access to care we're discussing.

With median pub being 33k and priv being like 58 not including fees or living expenses one can assume it’s common for people to have parental help. Doesn’t include undergrad fees either. So something still doesn’t add up.

Unless they got scholarships at certain schools. I know my crappy DO school sure doesn’t not even with a 4.0 or 99th boards. Dumb do schools /endrant

Unless you are “underrepresented”

 

[VA Hopeful Dr]

I have talked to physicians that practiced at my clinical sites and my local communities. Almost all of them received BFE loan forgiveness and other benefits. Almost all of them don't believe that they live in BFE places. I also don't believe so. Lastly, I have travelled and lived across at least 20 states in this country. I'm talking about actually living at each location for at least 1 month, and not driving through towns. I personally don't believe that 20% of Americans live in BFE places. However, I continue to hope for this misconception to continue for future wage negotiation when I become an attending down the road.

Well there is truth in that. I was offered a rural 6 figure signing bonus for a job that's 10 miles from my house in the center of my 50k town in the largest MSA in SC.

 

[RNthenDoc]

Also don’t discount hard-working blue-collar folks who payed as they went through undergrad by pursuing degrees that came with jobs.

I’m a nurse, I have classmates who are engineers, school teachers, etc. We payed off our undergrad the old-fashioned way.

Please note: I’m not saying we are superior or smarter for having done that (lots of lost $$$ in future earnings as a doc), but not everybody gets into medical school. The majority try and fail. I didn’t want to be one of those who tried and failed and had no fallback.

But anyway, I didn’t mean to derail the convo, I just wanted to say it’s not as uncommon as you think to have no UG debt or some money saved up prior to Med school. That trend will probably continue as even more nontrads enroll.

 

[Ho0v-man]

So in the meantime, are people in North Dakota just supposed to go without any care whatsoever?

Yes.

I don’t think anyone wants the people of North Dakota to go without primary care. But these people aren’t qualified to deliver it without supervision. There’s no system in place to verify that they are qualified to do so. Their entire education revolves around doing their job with a doc acting as a safety net. There’s no check in place to verify that they’re qualified to work alone. FFS, assisting a physician is in the title of the frickin’ degree!

If they can practice without supervision, then what’s the point of med school?