PA granted independent practice right in North Dakota

[jdh71]

Such a dearth that the current model of supervision isn't feasible?

Yeah, though because largely unneeded in basic primary care, let them run with the ball.

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[NicMouse64]

We can do all kinds of dueling anecdotes and I won't know who gets to win.

Regardless your grandmother did not get to see a psychiatrist or a cardiologist. Complicated subsiecialty care is handled by physician specialists. Neither of which is prinary care.

You make a good point, however looking back at what they were prescribing, a good family doc could have easily managed her care. I get it is anecdotal and you have every right to attack that. I grew up for half my childhood in a rural area and may even return there, I can tell you the reasons I might go back: better pay, no traffic, cheaper houses, own land, less pollution, more hobbies that I like (water sports, hunting, fishing, etc.). Reasons I may not go back: poor education for kids, wife might go crazy, less "cultural" things to do, hard to get to an airport, want to go into academics.

My anecdotes are merely used as a way to glimpse into why this is happening, not stating the fact that these are the ONLY reasons we have the issue we have. I personally don't think that most people from rural areas will return because honestly rural life is becoming less and less desirable due to infrastructural limitations (you want that 10mb/s internet? In my home city the best you can get is 2 mb/s for $60/month)

 

[hurtem&healem]

(you want that 10mb/s internet? In my home city the best you can get is 2 mb/s for $60/month)

Try living somewhere that the only option is satellite. You don't even have to go very far outside of the city a lot of places. 10gig of data and then you're throttled back to dial-up speeds. You know how fast 10 gigs go in your house? Days!

I had forgotten all about that. It's the absolute worst part of living in the sticks.

 

[nimbus]

Where I did an away, the PA was the first one in the state to use fluro...it's not just PC.

Using fluro to perform various studies themselves with little supervision.

It’s hard to believe a PA was the first to use fluoro in any state since it’s been around since before any of us were born. Surely there must have been an orthopedist who used it in that state to reduce a fracture.

 

[nimbus]

Try living somewhere that the only option is satellite. You don't even have to go very far outside of the city a lot of places. 10gig of data and then you're throttled back to dial-up speeds. You know how fast 10 gigs go in your house? Days!

I had forgotten all about that. It's the absolute worst part of living in the sticks.

The irony is that many 3rd world countries have excellent cheap fast internet.

 

[stayathomemom]

The irony is that many 3rd world countries have excellent cheap fast internet.

Just like physicians, internet service providers are mainly interested in areas where the business is plentiful.

 

[kb1900]

Just like physicians, internet service providers are mainly interested in areas where the business is plentiful.

2019 mid level internet providers you heard it here first

 

[sunshinefl]

Whether physician or midlevel, there have to be enough patients in a given area to support a full panel to justify having either. So how rural are we talking? It’s hard for me to even picture. If there are 500 people within a 200 mile radius, should there really be a PCP there?

Edited to clarify: what I’m asking is have we decided there is some arbitrary maximal distance people should “have” to travel to see the nearest PCP? Or are you guys saying that every single doctor in ND has a full patient panel and is not accepting new patients, leaving residents with zero options no matter the distance?

 

[NicMouse64]

Whether physician or midlevel, there have to be enough patients in a given area to support a full panel to justify having either. So how rural are we talking? It’s hard for me to even picture. If there are 500 people within a 200 mile radius, should there really be a PCP there?

Edited to clarify: what I’m asking is have we decided there is some arbitrary maximal distance people should “have” to travel to see the nearest PCP? Or are you guys saying that every single doctor in ND has a full patient panel and is not accepting new patients, leaving residents with zero options no matter the distance?

The metrics aren't clear on this, and I can't seem to find anything that indicates the people pushing for rural med care. It's not even talked about despite being such an important metric to keep track of. Maybe someone can correct me?

 

[stayathomemom]

Whether physician or midlevel, there have to be enough patients in a given area to support a full panel to justify having either. So how rural are we talking? It’s hard for me to even picture. If there are 500 people within a 200 mile radius, should there really be a PCP there?

Edited to clarify: what I’m asking is have we decided there is some arbitrary maximal distance people should “have” to travel to see the nearest PCP? Or are you guys saying that every single doctor in ND has a full patient panel and is not accepting new patients, leaving residents with zero options no matter the distance?

Should patients have to drive 200 miles during a ND winter for primary care?

There are people out there. The population density for ND as a whole is 9.7 people per square mile, although in many rural counties it runs from <1 to 5 or so. Some people are elderly. Some are farmers. Some are oil field workers (either directly or indirectly). Some are infrastructure staff. Some are living on reservations. Some are the families of the aforementioned groups. The vast majority have been living out there for generations, and their small communities are all they've ever known, although some oil field workers and families are new in the last decade, trying to make a living. (Western rural ND has exploded in the last 15 years from the oil boom, contributing to the shortage.) Some youth stay to raise their own families and farm or do oil work, etc., because it's all they've ever known and they want to stay with their families. Some of the youth have tasted urban life and get out, often with the help of tertiary education. (Hello, that's me and my husband.) Often, once educated and acclimated to urban life, they don't want to go back. And therein lies the problem--native young MD/DOs would rather stay urban than go back (usually) after they've worked so hard and spent 10+ years away getting trained and educated. And non-native people (presumably MD/DOs in this case) who go visit ND take one look around and nope right the heck out. (It's a lot of this and this and a little bit of this in the corner, the prettiest part of the state.) To add to the problem, old physicians are retiring or dying.

So you have these scattered small communities. There are more than 500 people in a 200 mile radius but they are very spread out, and most MD/DOs don't want to live in the frigid ND boonies. They do have small hospital/nursing home combos in the "larger" towns (I'm using that term "larger" very loosely). But often the town with the specialists can be hundreds of miles away. The problem is that some of these people are impoverished or elderly (or both) and are unable to make that journey easily, and the providers they can access need to be able to handle a wide variety of issues competently. Is a PA without physician supervision able to handle everything from assessing skin lesions to emergencies and everything in between? And do it as well as a physician? The clear vote from the crowd here is a resounding NO, but MD/DOs aren't exactly lining up for the job either.

 

[MedicineZ0Z]

1. Those so pro-midlevel due to rural access, why not fully restrict them to very rural areas for unrestricted practice? No one ever talks about this.

2. Any unrestricted midlevel should absolutely have a telemedicine physician supervising.

3. If you go extremely rural, I mean...what do you expect at that point? Allowing the cities to get filled up with unrestricted PAs so that there's 2 more in the sticks?

BTW, no one ever talks about the extremely higher level of knowledge & skills that is needed for rural medicine. Your typical family doc in the city would be screwed in a very rural area. Bad outcomes are simply accepted to a degree. A PA who has less knowledge than a med student and highly variable skills? oh lord.
There's a good chance there's far more harm done than doing nothing at all.

 

[Taddy Mason]

BTW, no one ever talks about the extremely higher level of knowledge & skills that is needed for rural medicine. Your typical family doc in the city would be screwed in a very rural area.

It tends to be the less competent physicians that end up in rural areas...

 

[operaman]

What are you basing that statement on?

Agreed. That hasn’t been my experience.

The physicians I’ve known who ended up in rural areas are people who grew up in those areas and always wanted to practice in a rural area. That’s really the only reliably predictive thing I’ve seen.

Their competence doesn’t really factor into it. It’s not like big city practices have some magic way of weeding out incompetent physicians and forcing them out into BFE.

 

[Taddy Mason]

What are you basing that statement on?

Having lived in a rural state for almost my entire life, following disciplinary hearings by that state’s board of medicine, rotating at multiple rural sites throughout 3rd and 4th year. I’m not saying rural physicians are de facto less competent, but it is a trend I’ve noticed. Often when physicians are let go from the hospitals in Bismarck, Fargo, or GF over competentcy issues they generally go to rural communities. The point I was getting at it is that rural physicians definitely do not “require an extremely higher level of knowledge and skills” as the person I quoted claimed.

 

[762513]

1. Those so pro-midlevel due to rural access, why not fully restrict them to very rural areas for unrestricted practice? No one ever talks about this.

2. Any unrestricted midlevel should absolutely have a telemedicine physician supervising.

3. If you go extremely rural, I mean...what do you expect at that point? Allowing the cities to get filled up with unrestricted PAs so that there's 2 more in the sticks?

BTW, no one ever talks about the extremely higher level of knowledge & skills that is needed for rural medicine. Your typical family doc in the city would be screwed in a very rural area. Bad outcomes are simply accepted to a degree. A PA who has less knowledge than a med student and highly variable skills? oh lord.
There's a good chance there's far more harm done than doing nothing at all.

I hope we can have a non toxic conversation here, in the past we have failed that between the two of us. I’m not trying to trigger you, I’m just responding to your posts.

1. The logistical nightmare to create county level APP licenses based on rural or urban areas would be a nightmare. Can you image? On one road it’s considered rural and the next road over that falls into a “city” of 5000 people it’s considered urban? I don’t think the government is capable of getting that right.

2. If a doc tele supervised every midlevel interaction aren’t we doubling the cost of healthcare? Even then, how do we know if the lung sounds are crackles or it’s just ronchi cleared by coughing? That could be the difference between a CAP diagnosis and unneeded antibiotics or not. There’s just too much room room for failure for that to work well in my opinion.

3. Saying rural people should accept the situation that they won’t have access to healthcare because midlevel practice expansion inevitably expands to cities is an ethically problematic statement.

 

[jdh71]

Agreed. That hasn’t been my experience.

The physicians I’ve known who ended up in rural areas are people who grew up in those areas and always wanted to practice in a rural area. That’s really the only reliably predictive thing I’ve seen.

Their competence doesn’t really factor into it. It’s not like big city practices have some magic way of weeding out incompetent physicians and forcing them out into BFE.

I think I can confidently say that there are idiots everywhere. Literally everywhere. I've seen garbage come in from the sticks and garbage from the city. I am no longer surprised by the level of bad care that can happen . . . anywhere.

 

[kb1900]

I think I can confidently say that there are idiots everywhere. Literally everywhere. I've seen garbage come in from the sticks and garbage from the city. I am no longer surprised by the level of bad care that can happen . . . anywhere.

Sad but so true

 

[jdh71]

3. Saying rural people should accept the situation that they won’t have access to healthcare because midlevel practice expansion inevitably expands to cities is an ethically problematic statement.

This is where I am on this. I do have a general positive bias regarding APPs after having worked side by side with them in a state where they have fairly liberal practice allowances and the sky simply doesn't and hasn't fallen. Which makes me think it probably won't fall.

To be clear I'm talking about basic primary care in fairly straight forward patients. For instance, if you are 50 years onld and only have a bit of elevated cholesterol, 30 extra pounds of weight, and need to get yourself a colonoscopy arranged, this does not need the mind and training of a physician. It just doesn't. It needs someone, and a physician can do it, but they are better used elsewhere. Complicated, multiple overlapping, and often conflicting chronic medical illness, especially if regularly exacerbating NEED a physician and usually also regular visits to subspecialists. I have had to tell more than a few of my patients that they simply need to move out of their tiny mountain communities into the major metro area if they really want to get the best medical care. Ultimately it's up to them, but much of what needs to be managed and taken care of by a PCP or rural "ED" (best thought of a urgent care+) can be managed and triaged respectively by APPs. I've seen it occur. I know it's a reality. With very few exceptions APPs are very aware of their limitations and knowledge gaps and refer and ask questions appropriately.

 

[Chibucks15]

I hope we can have a non toxic conversation here, in the past we have failed that between the two of us. I’m not trying to trigger you, I’m just responding to your posts.

1. The logistical nightmare to create county level APP licenses based on rural or urban areas would be a nightmare. Can you image? On one road it’s considered rural and the next road over that falls into a “city” of 5000 people it’s considered urban? I don’t think the government is capable of getting that right.

2. If a doc tele supervised every midlevel interaction aren’t we doubling the cost of healthcare? Even then, how do we know if the lung sounds are crackles or it’s just ronchi cleared by coughing? That could be the difference between a CAP diagnosis and unneeded antibiotics or not. There’s just too much room room for failure for that to work well in my opinion.

3. Saying rural people should accept the situation that they won’t have access to healthcare because midlevel practice expansion inevitably expands to cities is an ethically problematic statement.

The first point wouldn't be THAT complicated. If the surrounding x miles contains under x number of people, you're rural. Geographically it wouldn't work but per capita it would theoretically. And surprisingly I agree with the other two points.

If there are no other providers than give the midlevels who are willin to go there more leeway. And if you are found to be practicing in the wrong area, its viewed similar to malpractice. I'm sure there's legal jargon that could make that work. The issue that everyone has is that NPs congregate to the same urban and suburban areas as the docs do so full independence is just not a good idea

 

[NicMouse64]

I hope we can have a non toxic conversation here, in the past we have failed that between the two of us. I’m not trying to trigger you, I’m just responding to your posts.

1. The logistical nightmare to create county level APP licenses based on rural or urban areas would be a nightmare. Can you image? On one road it’s considered rural and the next road over that falls into a “city” of 5000 people it’s considered urban? I don’t think the government is capable of getting that right.

2. If a doc tele supervised every midlevel interaction aren’t we doubling the cost of healthcare? Even then, how do we know if the lung sounds are crackles or it’s just ronchi cleared by coughing? That could be the difference between a CAP diagnosis and unneeded antibiotics or not. There’s just too much room room for failure for that to work well in my opinion.

3. Saying rural people should accept the situation that they won’t have access to healthcare because midlevel practice expansion inevitably expands to cities is an ethically problematic statement.

My problem can be summed up with this: Imagine we have a dartboard where the bullseye is a major metro area. Most providers (MLPs and Doctors) are aiming for the bullseye. If you add more darts eventually the bullseye is going to get so crowded that you will have to aim outside of the bullseye. Some providers won't be aiming for the bullseye but that's just because they don't care to "play the game" that everyone else is playing. Then those bullseye areas will get saturated and people will be forced to move more rural to find jobs. The MLP lobby would have you believe that most MLPs are actually aiming outside of the bullseye. This is simply not true unless I am misinterpreting the data. The way we are moving in healthcare is that as the bullseye gets more crowded, in order to accomodate all these extra providers we have minute clinics in walmart and CVS opening up. These MLPs would obviously be much more useful and have a greater scope of practice in rural areas. They just don't want to go to these areas.

So eventually the MLP lobby will probably be right. The major metro areas are going to get SO saturated that people will have to move away to find better jobs. This is exactly what Corporate administrators want. They want providers to not have any better options. This is why scope of practice and more MLPs flooding the market is not good for either profession. IF there were some self policing on both ends we could continue to hold some leverage in the conversation. Unfortunately they don't realize their goals are very shortsighted.

 

[762513]

The first point wouldn't be THAT complicated. If the surrounding x miles contains under x number of people, you're rural. Geographically it wouldn't work but per capita it would theoretically. And surprisingly I agree with the other two points.

If there are no other providers than give the midlevels who are willin to go there more leeway. And if you are found to be practicing in the wrong area, its viewed similar to malpractice. I'm sure there's legal jargon that could make that work. The issue that everyone has is that NPs congregate to the same urban and suburban areas as the docs do so full independence is just not a good idea

I'm taking a screen shot here as the first moment we've ever agreed on anything.

 

[nimbus]

I do agree with the other posters that midlevels are no more likely to practice in rural areas than doctors. The carrot of independent practice may not be enough to draw them out there. The ones I know don’t even want to be independent.

 

[operaman]

In think midlevels will ultimately fill into many of these rural positions.

Let’s rememebr that they are putting out grads at an incredible rate and at some point will outpace the jobs available. When we’ve posted for NPs at my institution those jobs are getting hundreds of applications so they are facing saturation in some areas like anyone else. That’s far more submissions than I’ve heard some of our physician faculty positions getting.

They don’t have the relative bottleneck of med school and residency to protect their job market and will probably find it harder and harder to land good positions. Not being able to find ANY good position in a big city will drive people into more rural positions.

My sense is that we are living in what for midlevels is a golden age with many good paying jobs and seemingly unlimited prospects. I just don’t see how long that will be sustainable with so many thousands of midlevels coming out of training each year.

 

[NicMouse64]

In think midlevels will ultimately fill into many of these rural positions.

Let’s rememebr that they are putting out grads at an incredible rate and at some point will outpace the jobs available. When we’ve posted for NPs at my institution those jobs are getting hundreds of applications so they are facing saturation in some areas like anyone else. That’s far more submissions than I’ve heard some of our physician faculty positions getting.

They don’t have the relative bottleneck of med school and residency to protect their job market and will probably find it harder and harder to land good positions. Not being able to find ANY good position in a big city will drive people into more rural positions.

My sense is that we are living in what for midlevels is a golden age with many good paying jobs and seemingly unlimited prospects. I just don’t see how long that will be sustainable with so many thousands of midlevels coming out of training each year.

It's not sustainable. And it's also why all those ppl at the AMA shouting residency expansion need to shut their F***ing mouths.

 

[hurtem&healem]

In think midlevels will ultimately fill into many of these rural positions.

Let’s rememebr that they are putting out grads at an incredible rate and at some point will outpace the jobs available. When we’ve posted for NPs at my institution those jobs are getting hundreds of applications so they are facing saturation in some areas like anyone else. That’s far more submissions than I’ve heard some of our physician faculty positions getting.

They don’t have the relative bottleneck of med school and residency to protect their job market and will probably find it harder and harder to land good positions. Not being able to find ANY good position in a big city will drive people into more rural positions.

My sense is that we are living in what for midlevels is a golden age with many good paying jobs and seemingly unlimited prospects. I just don’t see how long that will be sustainable with so many thousands of midlevels coming out of training each year.

Take a stroll through the Pharm board to get an idea of what they'll be facing in a few years.

 

[MedicineZ0Z]

I hope we can have a non toxic conversation here, in the past we have failed that between the two of us. I’m not trying to trigger you, I’m just responding to your posts.

1. The logistical nightmare to create county level APP licenses based on rural or urban areas would be a nightmare. Can you image? On one road it’s considered rural and the next road over that falls into a “city” of 5000 people it’s considered urban? I don’t think the government is capable of getting that right.

2. If a doc tele supervised every midlevel interaction aren’t we doubling the cost of healthcare? Even then, how do we know if the lung sounds are crackles or it’s just ronchi cleared by coughing? That could be the difference between a CAP diagnosis and unneeded antibiotics or not. There’s just too much room room for failure for that to work well in my opinion.

3. Saying rural people should accept the situation that they won’t have access to healthcare because midlevel practice expansion inevitably expands to cities is an ethically problematic statement.

1. It happens in other countries so I'm certain you can impose regional restrictions. You can have a community and/or practice that must qualify instead of the other way around.

2. Telemedicine is used for many things and providing medical input to a midlevel is probably as useful as it gets.

3. I'm saying there's reality that comes with geography. I can't expect perfect road maintenance in the jungle either....

It tends to be the less competent physicians that end up in rural areas...

Or extremely competent. There are guys who have done actual surgeries (more than just c sections) along with literally everything else (running vents, prescribing biologics, placing lines/tubes, delivering babies, colonoscopies, etc.) for years.

This is where I am on this. I do have a general positive bias regarding APPs after having worked side by side with them in a state where they have fairly liberal practice allowances and the sky simply doesn't and hasn't fallen. Which makes me think it probably won't fall.

To be clear I'm talking about basic primary care in fairly straight forward patients. For instance, if you are 50 years onld and only have a bit of elevated cholesterol, 30 extra pounds of weight, and need to get yourself a colonoscopy arranged, this does not need the mind and training of a physician. It just doesn't. It needs someone, and a physician can do it, but they are better used elsewhere. Complicated, multiple overlapping, and often conflicting chronic medical illness, especially if regularly exacerbating NEED a physician and usually also regular visits to subspecialists. I have had to tell more than a few of my patients that they simply need to move out of their tiny mountain communities into the major metro area if they really want to get the best medical care. Ultimately it's up to them, but much of what needs to be managed and taken care of by a PCP or rural "ED" (best thought of a urgent care+) can be managed and triaged respectively by APPs. I've seen it occur. I know it's a reality. With very few exceptions APPs are very aware of their limitations and knowledge gaps and refer and ask questions appropriately.

uh... You know those rural eds get difficult airways, pneumothorax, stemis, shock needing a line, trauma, fractures etc. right? I've rotated through a rural ED in the past and placed a chest tube, intubated, placed a central line and did way more ortho cast/splinting than I ever did in the urban ED setting. The attendings were also far more skilled than an urban setting doc (em board certified) and had 2 nurses to help. (they were family med docs too)

Key difference? There's no anesthesia or surgeon back up. Can't get an airway, you're screwed. There was a thread on here last month about some PA solo staffing a ED or some urgent care who didn't know how to intubate and they were calling begging someone to come do it.
So I think a PA/NP should be kept as far away as possible from a rural ED given that your skillset literally has to be triple than of a board certified urban ED doc. A better solution for those EDs is just paying a lot more $$ to bring the physician in.



disclaimer: I'm looking to practice in a suburban setting so I have zero bias towards/against urban/rural settings. Just laying out the facts since I've rotated through all three settings in different states.

 

[jdh71]

1. It happens in other countries so I'm certain you can impose regional restrictions. You can have a community and/or practice that must qualify instead of the other way around.

2. Telemedicine is used for many things and providing medical input to a midlevel is probably as useful as it gets.

3. I'm saying there's reality that comes with geography. I can't expect perfect road maintenance in the jungle either....

Or extremely competent. There are guys who have done actual surgeries (more than just c sections) along with literally everything else (running vents, prescribing biologics, placing lines/tubes, delivering babies, colonoscopies, etc.) for years.


uh... You know those rural eds get difficult airways, pneumothorax, stemis, shock needing a line, trauma, fractures etc. right? I've rotated through a rural ED in the past and placed a chest tube, intubated, placed a central line and did way more ortho cast/splinting than I ever did in the urban ED setting. The attendings were also far more skilled than an urban setting doc (em board certified) and had 2 nurses to help. (they were family med docs too)

Key difference? There's no anesthesia or surgeon back up. Can't get an airway, you're screwed. There was a thread on here last month about some PA solo staffing a ED or some urgent care who didn't know how to intubate and they were calling begging someone to come do it.
So I think a PA/NP should be kept as far away as possible from a rural ED given that your skillset literally has to be triple than of a board certified urban ED doc. A better solution for those EDs is just paying a lot more $$ to bring the physician in.



disclaimer: I'm looking to practice in a suburban setting so I have zero bias towards/against urban/rural settings. Just laying out the facts since I've rotated through all three settings in different states.

Wow. Really? I had no idea those kinds of things could go through a rural ED. I was this many days old when I learned it.

 

[MedicineZ0Z]

Wow. Really? I had no idea those kinds of things could go through a rural ED. I was this many days old when I learned it.

You said a midlevel is well equipped to handle rural ED. Me as a ms4 am more well equipped to handle it than all but very experienced ED midlevels, aka nearly every midlevel out there. Your average run of the mill PA has no clue how to even hold the ultrasound probe properly, what the indications for a central line are, has never intubated let alone knows which drug are to be used when, never even seen a chest tube placed, wouldn't know how to read any sort of imaging with proficiency and the list goes on.

 

[jdh71]

You said a midlevel is well equipped to handle rural ED.

That isn't what I said, actually.

 

[MedicineZ0Z]

That isn't what I said, actually.

"but much of what needs to be managed and taken care of by a PCP or rural "ED" (best thought of a urgent care+) can be managed and triaged respectively by APPs."

 

[jdh71]

"but much of what needs to be managed and taken care of by a PCP or rural "ED" (best thought of a urgent care+) can be managed and triaged respectively by APPs."

What part of "triaged" was hard for you to understand?

 

[MedicineZ0Z]

What part of "triaged" was hard for you to understand?

oh semantics.

 

[hurtem&healem]

"but much of what needs to be managed and taken care of by a PCP or rural "ED" (best thought of a urgent care+) can be managed and triaged respectively by APPs."

Triaged, stabilized, and shipped the f out. Again, the question comes down to is having someone who can maybe buy the patient some time better than having no one?

 

[jdh71]

oh semantics.

What "semantics"? Does triage mean something different to me than you? Enlighten me.

 

[MedicineZ0Z]

What "semantics"? Does triage mean something different to me than you? Enlighten me.

And you said manage....

 

[jdh71]

And you said manage....

You clearly don't read well.

Look at the statement. Manage is referring to primary care. Triage is referring to emergency care. The word "respectively" should have helped you out. That's not "semantics". It's simply your poor understanding and grasp of grammar.

But I think you just wanted to try to be offended and pick a fight. Do you feel better?

 

[MedicineZ0Z]

Triaged, stabilized, and shipped the f out. Again, the question comes down to is having someone who can maybe buy the patient some time better than having no one?

And how are you stabilizing a crashing patient who needs an airway?

 

[MedicineZ0Z]

You clearly don't read well.

Look at the statement. Manage is referring to primary care. Triage is referring to emergency care. The word "respectively" should have helped you out. That's not "semantics". It's simply your poor understanding and grasp of grammar.

But I think you just wanted to try to be offended and pick a fight. Do you feel better?

No I'd argue that it's poor sentence structure. You're grouping in two completely different things (which do significantly overlap, yes) into one sentence.

 

[jdh71]

No I'd argue that it's poor sentence structure. You're grouping in two completely different things (which do significantly overlap, yes) into one sentence.

Even if I simply beg the question on that point it's STILL not "semantics".

 

[MedicineZ0Z]

Even if I simply beg the question on that point it's STILL not "semantics".

The main point that you hopefully agree on? = PAs are not capable of stabilizing whatever comes through the door.

 

[jdh71]

The main point that you hopefully agree on? = PAs are not capable of stabilizing whatever comes through the door.

If the point is that APPs are not physicians, then that is a big "no duh". Don't hurt your shoulder patting yourself on the back for genius level observation.

Most of what comes into any ED isn't cardiac arrest, respiratory arrest, or major trauma the types of things that really require a physician to get correct. The APP is perfectly fine triaging and even *gasp* "managing" much of what will come in. Cough. Stubbed toe. Non cardiac chest pain. Vaginal discharge. Blah. Blah. Blah. It matters very little that APPs are not physicians.

If we want to play dueling anecdotes I've seen plenty of horse**** come up from the ED or into my unit from outside ED that was seen by a physician who completely **** the bed on management and diagnosis, rural or metro. I don't know whose anecdote gets to win?

The bottom line is that people regardless of level of training will do their best they can at that level. And if all the APP does is look at a case and arrange for transfer that is better than nothing and needed in locales that have to do
what they can because they can't get an ED physicians to work there. It may not be a perfect situation but it's a better situation.

Nowhere did I say an APP replaces a trained EP in all situations. So try not spending so much energy knocking over strawmen. It's kind of funny to watch but you need to ask yourself: "what am I getting out of this anyway??"

 

[RNthenDoc]

Y’all realize that even in Big Metro City a ton of the ED patients are only seen by mid levels, right?

Doing this same thing rurally doesn’t seem that scary. Obviously they need to know when to emergently transport, but I’ve recieved plenty of those patients and I’ve always been glad that they’ve had access to a rural care ED to get things rolling early. For example, when they sensed sepsis they sent them my way, but first doses of ABX were already complete/pt had good access prior to EMS arrival/patient got fixed-wing transport instead of private vehicle that could have cost them their life.

Obviously having a physician present would be better, but I don’t think it’s an all-or-nothing situation. Personally, I’d be more scared of the lack of service lines present than anything else. ACS rolls in with no cath lab in hospital? Yikes

 

[Taddy Mason]

....and just got done perusing MedicineZ0Z’s post history....

 

[nimbus]

In many European countries, physicians ride in ambulances to deliver prehospital care to patients. They show better outcomes when physicians are on the ambulance. They must the we are crazy to staff ours with paramedics and EMTs.

 

[nimbus]

The main point that you hopefully agree on? = PAs are not capable of stabilizing whatever comes through the door.

That’s not universal. It depends on the PA, their experience and training background. A fresh grad won’t be prepared but those with experience and on the job training could take of many problems on their own.

 

[jdh71]

In many European countries, physicians ride in ambulances to deliver prehospital care to patients. They show better outcomes when physicians are on the ambulance. They must the we are crazy to staff ours with paramedics and EMTs.

I'd be interested to see if those results could/would be replicated in this country.

 

[FiremedicMike]

I'd be interested to see if those results could/would be replicated this country.

There are EMS systems in the US where docs respond on incidents. I think these are primarily medical directors who choose to be active with their agencies and/or EMS fellows and not necessarily a designed staffing model for these agencies.

That said, there should be some US data on the impact of having physicians on EMS runs.

 

[NicMouse64]

Gasp, why do you hate paramedics so much. Are you scared to Lose r jobs? You mean to tell me that someone with more training and expertise has better outcomes than someone with less training? Why are you so close minded and why can't you just accept NP/PA/RN/Paramedics as your equal?




/s

on a tangential note in the UK where I used to live paramedics and EMTs are usually the first on scene, but for serious trauma and cardiac issues a physician is called to scene to give more advanced care.

In many European countries, physicians ride in ambulances to deliver prehospital care to patients. They show better outcomes when physicians are on the ambulance. They must the we are crazy to staff ours with paramedics and EMTs.

 

[MedicineZ0Z]

If the point is that APPs are not physicians, then that is a big "no duh". Don't hurt your shoulder patting yourself on the back for genius level observation.

Most of what comes into any ED isn't cardiac arrest, respiratory arrest, or major trauma the types of things that really require a physician to get correct. The APP is perfectly fine triaging and even *gasp* "managing" much of what will come in. Cough. Stubbed toe. Non cardiac chest pain. Vaginal discharge. Blah. Blah. Blah. It matters very little that APPs are not physicians.

If we want to play dueling anecdotes I've seen plenty of horse**** come up from the ED or into my unit from outside ED that was seen by a physician who completely **** the bed on management and diagnosis, rural or metro. I don't know whose anecdote gets to win?

The bottom line is that people regardless of level of training will do their best they can at that level. And if all the APP does is look at a case and arrange for transfer that is better than nothing and needed in locales that have to do
what they can because they can't get an ED physicians to work there. It may not be a perfect situation but it's a better situation.

Nowhere did I say an APP replaces a trained EP in all situations. So try not spending so much energy knocking over strawmen. It's kind of funny to watch but you need to ask yourself: "what am I getting out of this anyway??"

My argument is you're far better off getting a family doc drawn out to those areas via high pay than a midlevel. Most of what comes into the ED isn't that serious, but at least docs working in the ED know how to place a chest tube on a pneumothorax or manage a serious hypotensive afib patient. If I had a dollar for every midlevel who didn't even know how to read chest xrays let alone place a tube....

 

[Taddy Mason]

...family doc drawn out to those areas via high pay...

This was already addressed in this thread.

If I had a dollar for every midlevel who didn't even know how to read chest xrays let alone place a tube....

If I had a dollar for every MS4 or beginning intern who didn’t know how to read a CXR or place a chest tube...