PA granted independent practice right in North Dakota

[MedicineZ0Z]

This was already addressed in this thread.


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...

Well ms4s and beginner interns aren't sent out solo to the boonies. Not sure how a few months of glorified shadowing (PA school) prepares you to function as a jack-of-all trades doctor. The EM forums flip **** over the idea of an FM working in a urban ED that has a ton of back up, let alone somewhere with help.

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[jw3600]

This was already addressed in this thread.


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...

But no one is saying fresh interns should be practicing independently.

Not saying they aren’t more capable than some (absolutely not all of or even majority of) midlevels. But that’s not what’s being discussed.

 

[jdh71]

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....

FPs aren't going out there either.

If most of what comes into an ED even by your own admission isn't that serious then it can be dealt with by an APP either managed on site or triaged and shipped out. They can't or don't do what they can't or won't. It's a tautology but not an argument against letting them do what they CAN when no physician will. And the only thing between them and placing chest tube (which is often unnecessary in a good portion of PTX cases) is wslking through a few with a physician who cares to teach them. It's not a microsurgical bypass or anything.

 

[Onewhen]

IMGs on J1 visa are required to works for 3 years in underserved areas post residency in order to get a waiver and be able to continue working in the US. Increasing the numbers might be a part of the solution along with opening up more residency spots and offering incentives to American Students (for example removing tuition fees in exchange for working in ND or any other area of shortage for a set number of years).

 

[Matthew9Thirtyfive]

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.

No, it's just English. He could have written, "But much of what needs to be managed and taken care of by a PCP can be managed by APPs, and much of what needs to be managed by a rural "ED" (best thought of as urgent care+) can be triaged by APPs," but that would be clunky even if it is correct. Including the word "respectively" eliminates the need to repeat phrases, making the sentence more concise while maintaining correctness and clarity. It's standard English.

 

[MedicineZ0Z]

But no one is saying fresh interns should be practicing independently.

Not saying they aren’t more capable than some (absolutely not all of or even majority of) midlevels. But that’s not what’s being discussed.

Strongly disagree. Most interns by spring are absolutely better than the majority of midlevels.
A fresh midlevel with <1 year experience is as good as a ms3 whereas 1-2 years exp = ms4 level. That's largely in terms of practical knowledge. Breadth of total knowledge of any midlevel is drastically lower than ms4 level.

Any decent intern knows more stuff than a midlevel does. It's just a matter of months before the real life applications come into play. Again, PAs do a very light version of ms2 and ms3. Not sure how they're magically more competent than an intern when they not only skipped ms1 and ms4, but didn't even do 3/4 of ms2 and ms4 nor (most important of all) take the steps (aka the prep that comes with it).
Do they magically quadruple their knowledge? or.. ??

FPs aren't going out there either.

If most of what comes into an ED even by your own admission isn't that serious then it can be dealt with by an APP either managed on site or triaged and shipped out. They can't or don't do what they can't or won't. It's a tautology but not an argument against letting them do what they CAN when no physician will. And the only thing between them and placing chest tube (which is often unnecessary in a good portion of PTX cases) is wslking through a few with a physician who cares to teach them. It's not a microsurgical bypass or anything.

Lol you should see the EM forums where they brutally rip apart the idea of an FM (with additional EM training!!) practicing solo in a rural ED. You should post about (essentially a ms3) PAs practicing solo in those settings.

One thing you don't factor into this equation is how much harm will be done. What actually happens in real life is poorly trained FMs perform unnecessary procedures in those settings, get complications and **** happens.
If you're saying we need someone to cast and suture, sure. But I would leave the medical decision making to telemedicine.


Also, you realize the NP/PA camp would literally go to the moon to defend their own kind. And they lead a very strong anti-physician agenda. Nursing school spends half the time bashing physicians. PA students make fun of med school/med students in private literally all the time.
Yet doctors are the only ones who will bash their own, in favor of another profession.

 

[jdh71]

Lol you should see the EM forums where they brutally rip apart the idea of an FM (with additional EM training!!) practicing solo in a rural ED. You should post about (essentially a ms3) PAs practicing solo in those settings.

One thing you don't factor into this equation is how much harm will be done. What actually happens in real life is poorly trained FMs perform unnecessary procedures in those settings, get complications and **** happens.
If you're saying we need someone to cast and suture, sure. But I would leave the medical decision making to telemedicine.


Also, you realize the NP/PA camp would literally go to the moon to defend their own kind. And they lead a very strong anti-physician agenda. Nursing school spends half the time bashing physicians. PA students make fun of med school/med students in private literally all the time.
Yet doctors are the only ones who will bash their own, in favor of another profession.

You simply cannot replace a fully emergency trained physicians with anyone else and get the same thing. This isn't an argument that is being made. It's knocking over straw men. I mean it's literally not even relevant what the guys in the EM forum say about FM's per this discussion.

I can factor fine. The sky simply doesn't fall. Someone willing to stand in the gap when no one else will and do the best they can to the level of their training isn't "doing harm" they are one piece, a cog, in the bigger machine. Complications and **** happens everywhere including with those same emergency trained physicians.

I worked with many many many APPs and I've NEVER once head any "strong anti-physician agenda". It stupid, silly, ludicrous, and paranoid. I promise you aren't being persecuted.

 

[NicMouse64]

You simply cannot replace a fully emergency trained physicians with anyone else and get the same thing. This isn't an argument that is being made. It's knocking over straw men. I mean it's literally not even relevant what the guys in the EM forum say about FM's per this discussion.

I can factor fine. The sky simply doesn't fall. Someone willing to stand in the gap when no one else will and do the best they can to the level of their training isn't "doing harm" they are one piece, a cog, in the bigger machine. Complications and **** happens everywhere including with those same emergency trained physicians.

I worked with many many many APPs and I've NEVER once head any "strong anti-physician agenda". It stupid, silly, ludicrous, and paranoid. I promise you aren't being persecuted.

You must be lucky to be spared. Maybe it is the new generation of MLPs. I have multiple friends in PA school and they talk to me all the time about how much of a waste it was for me to go to medical school when they can do the same thing in 2 years just as well. They also tell me how much more competitive MLP admissions are and how they have to study more to get the same amount of material that we learn. I understand that you have less skin in the game than we do as you probably have a cozy path towards retirement in the next 20 years.

I also understand that it used to be different. It used to not be on the current trajectory, so your biases may be clouding your judgement of the current situation. Or our lack of experience is clouding our judgement. I really don't know which is which.

 

[jdh71]

You must be lucky to be spared. Maybe it is the new generation of MLPs. I have multiple friends in PA school and they talk to me all the time about how much of a waste it was for me to go to medical school when they can do the same thing in 2 years just as well. They also tell me how much more competitive MLP admissions are and how they have to study more to get the same amount of material that we learn. I understand that you have less skin in the game than we do as you probably have a cozy path towards retirement in the next 20 years.

I also understand that it used to be different. It used to not be on the current trajectory, so your biases may be clouding your judgement of the current situation. Or our lack of experience is clouding our judgement. I really don't know which is which.

I might suggest that when one has to separate the trash talk from the real world, that APPs realize what their limitations are quite quickly when they are done. They are essentially mostly physician extenders in almost all circumstances and occasionally do primary care by themselves. That's it.

 

[MedicineZ0Z]

You simply cannot replace a fully emergency trained physicians with anyone else and get the same thing. This isn't an argument that is being made. It's knocking over straw men. I mean it's literally not even relevant what the guys in the EM forum say about FM's per this discussion.

I can factor fine. The sky simply doesn't fall. Someone willing to stand in the gap when no one else will and do the best they can to the level of their training isn't "doing harm" they are one piece, a cog, in the bigger machine. Complications and **** happens everywhere including with those same emergency trained physicians.

I worked with many many many APPs and I've NEVER once head any "strong anti-physician agenda". It stupid, silly, ludicrous, and paranoid. I promise you aren't being persecuted.

I might suggest that when one has to separate the trash talk from the real world, that APPs realize what their limitations are quite quickly when they are done. They are essentially mostly physician extenders in almost all circumstances and occasionally do primary care by themselves. That's it.

Why don't you actually listen to those of who experience the mindsets of the new generation? This isn't a 60 year old PA, it's a 28 year old fresh one we're talking about. And there's a tonnnn more of the latter.

Also, I highly doubt you even have the opportunity to be exposed to the behind the scenes talk of PA students/new grads (or NPs).
Almost all of the new ones or current students think they're doing med school in 2 years.

And this isn't even about their capability. It's the mindset.

 

[jdh71]

Why don't you actually listen to those of who experience the mindsets of the new generation? This isn't a 60 year old PA, it's a 28 year old fresh one we're talking about. And there's a tonnnn more of the latter.

Also, I highly doubt you even have the opportunity to be exposed to the behind the scenes talk of PA students/new grads (or NPs).
Almost all of the new ones or current students think they're doing med school in 2 years.

And this isn't even about their capability. It's the mindset.

They'll learn quickly. The sky can't and won't fall.

 

[nimbus]

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....

What percent of FM docs have ever placed a chest tube?

 

[235009]

You must be lucky to be spared. Maybe it is the new generation of MLPs. I have multiple friends in PA school and they talk to me all the time about how much of a waste it was for me to go to medical school when they can do the same thing in 2 years just as well. They also tell me how much more competitive MLP admissions are and how they have to study more to get the same amount of material that we learn. I understand that you have less skin in the game than we do as you probably have a cozy path towards retirement in the next 20 years.

I also understand that it used to be different. It used to not be on the current trajectory, so your biases may be clouding your judgement of the current situation. Or our lack of experience is clouding our judgement. I really don't know which is which.

Your insecure friends in PA school trying to protect their egos and justify their life choices don't change reality. This is just like saying that all the OMS2s saying they're going into neurosurgery means there will be as many DOs as MDs in neurosurgery in a few years. It's easy to be shielded from reality when you're in school but it catches up with you real quickly when it's time to step out of the bubble.

 

[jw3600]

Strongly disagree. Most interns by spring are absolutely better than the majority of midlevels.
A fresh midlevel with <1 year experience is as good as a ms3 whereas 1-2 years exp = ms4 level. That's largely in terms of practical knowledge. Breadth of total knowledge of any midlevel is drastically lower than ms4 level.

Any decent intern knows more stuff than a midlevel does. It's just a matter of months before the real life applications come into play. Again, PAs do a very light version of ms2 and ms3. Not sure how they're magically more competent than an intern when they not only skipped ms1 and ms4, but didn't even do 3/4 of ms2 and ms4 nor (most important of all) take the steps (aka the prep that comes with it).
Do they magically quadruple their knowledge? or.. ??



Lol you should see the EM forums where they brutally rip apart the idea of an FM (with additional EM training!!) practicing solo in a rural ED. You should post about (essentially a ms3) PAs practicing solo in those settings.

One thing you don't factor into this equation is how much harm will be done. What actually happens in real life is poorly trained FMs perform unnecessary procedures in those settings, get complications and **** happens.
If you're saying we need someone to cast and suture, sure. But I would leave the medical decision making to telemedicine.


Also, you realize the NP/PA camp would literally go to the moon to defend their own kind. And they lead a very strong anti-physician agenda. Nursing school spends half the time bashing physicians. PA students make fun of med school/med students in private literally all the time.
Yet doctors are the only ones who will bash their own, in favor of another profession.

I just meant I imagine most PAs with 4+ years of experience will be better than an intern on said service. I agree that interns will most likely be more competent and knowledgeable than brand new PAs.
I’m not even acknowledging NPs. Their training is such horse****. The ratio of PAs to NPs in the valuable “APP” category is easily 5:1 or higher in my experience. The lack of knowledge about “why” in NPs has been astounding to me. They just remember what they did as nurses and if it seems like it’s a similar situation, they do it.

 

[NicMouse64]

Your insecure friends in PA school trying to protect their egos and justify their life choices don't change reality. This is just like saying that all the OMS2s saying they're going into neurosurgery means there will be as many DOs as MDs in neurosurgery in a few years. It's easy to be shielded from reality when you're in school but it catches up with you real quickly when it's time to step out of the bubble.

It's good to see the perspectives of practicing physicians and one of the reasons this site is so valuable. My main question is have you been exposed to the new generation of PA/NP graduates, and if so would you describe the mentality as similar or different than the old generation of MLPs? If it's the same then I imagine we as medical students may just have a "the sky is falling attitude".

I'm just trying to identify if I am being cognitively dissonant, stubborn, or just naive in my understanding of the situation.

 

[nimbus]

It's good to see the perspectives of practicing physicians and one of the reasons this site is so valuable. My main question is have you been exposed to the new generation of PA/NP graduates, and if so would you describe the mentality as similar or different than the old generation of MLPs? If it's the same then I imagine we as medical students may just have a "the sky is falling attitude".

I'm just trying to identify if I am being cognitively dissonant, stubborn, or just naive in my understanding of the situation.

I’ve been doing PP MD only anesthesia for over 20 years. 8-10 years ago we had almost no midlevels in the operating rooms. Nowadays we have multiple PAs and 1 or 2 NP’s every day. One of the NP’s has been around for 15 years. All the rest are young people from the new generation. Every single one of them are easy to work with, helpful, cooperative, and don’t display any type of attitude that are described in this thread. Maybe this is unique to surgical PA’s and NP’s or ones who don’t work in academics. Anyway that’s why I defend them in this thread because my personal experience with them has been nothing but positive. I sometimes wish my own partners and surgeons behave as well as they do.

 

[MedicineZ0Z]

What percent of FM docs have ever placed a chest tube?

The ones who work in the ED/ those in unopposed residencies.
A better comparison is what % of PAs or NPs can read a chest xray or EKG properly upon graduation (quite low), before we talk about interventions. I've literally come across one urgent care PA and one ED PA who could not read an EKG with full accuracy. The fact that they exist in those settings is sufficient evidence.

I just meant I imagine most PAs with 4+ years of experience will be better than an intern on said service. I agree that interns will most likely be more competent and knowledgeable than brand new PAs.
I’m not even acknowledging NPs. Their training is such horse****. The ratio of PAs to NPs in the valuable “APP” category is easily 5:1 or higher in my experience. The lack of knowledge about “why” in NPs has been astounding to me. They just remember what they did as nurses and if it seems like it’s a similar situation, they do it.

Comparing new PAs to interns is an insane platform of nonequivalency. They shouldn't even ever be in the same sentence.
But sure yes, experience PA will outperform in X specialty vs a new intern. But we're talking more about generalist PAs (FM, IM, ED) rather than specialized ones.

I’ve been doing PP MD only anesthesia for over 20 years. 8-10 years ago we had almost no midlevels in the operating rooms. Nowadays we have multiple PAs and 1 or 2 NP’s every day. One of the NP’s has been around for 15 years. All the rest are young people from the new generation. Every single one of them are easy to work with, helpful, cooperative, and don’t display any type of attitude that are described in this thread. Maybe this is unique to surgical PA’s and NP’s or ones who don’t work in academics. Anyway that’s why I defend them in this thread because my personal experience with them has been nothing but positive. I sometimes wish my own partners and surgeons behave as well as they do.

Oh you should see what they say behind the scenes. It's always funny seeing them go from super nice to the attending to trashing doctors behind the scenes. The new generation carries a very strong "we are equal to doctors" mentality that persists until **** happens.

 

[nimbus]

Oh you should see what they say behind the scenes. It's always funny seeing them go from super nice to the attending to trashing doctors behind the scenes. The new generation carries a very strong "we are equal to doctors" mentality that persists until **** happens.

Perhaps but I don’t have time to worry about stuff I can’t see. I do appreciate that they never throw temper tantrums and hissy fits at the OR control desk when they can’t get their way.

 

[Giovanotto]

Perhaps but I don’t have time to worry about stuff I can’t see. I do appreciate that they never throw temper tantrums and hissy fits at the OR control desk when they can’t get their way.

That's because they can't get away with it.

 

[THEBACKANDFORTH]

Windchill of -60*F is a real thing. And it is brutal.

We hit -34 (real temp, not windchill) my freshman year.

Oh, and my car started.

 

[jdh71]

That's because they can't get away with it.

He's making reference s to every surgeon of every type ever. It's like those is he even your dad jokes. Is he even a surgery if he doesn't lose his **** at the control desk because his case got bumped for something else.

 

[W19]

I’ve been doing PP MD only anesthesia for over 20 years. 8-10 years ago we had almost no midlevels in the operating rooms. Nowadays we have multiple PAs and 1 or 2 NP’s every day. One of the NP’s has been around for 15 years. All the rest are young people from the new generation. Every single one of them are easy to work with, helpful, cooperative, and don’t display any type of attitude that are described in this thread. Maybe this is unique to surgical PA’s and NP’s or ones who don’t work in academics. Anyway that’s why I defend them in this thread because my personal experience with them has been nothing but positive. I sometimes wish my own partners and surgeons behave as well as they do.

Have you ever visited the anesthesia forum? I think sometimes we should look outside of our own circle in order to understand what is really happening to our profession...

Let say that someone graduates from med school in the US and for some reasons do not want to pursue (or can't pursue) a residency, is there a reason why APA is lobbying legislatures to not pass any law that will allow these people to sit for PA boards? Will these people be less qualified than newly minted PA? Yeah, they really care about filling the 'gap'...


I have a feeling we all in here will be fine, but we should think about what the profession will look like for future generation...

 

[MedicineZ0Z]

Have you ever visited the anesthesia forum? I think sometimes we should look outside of our own circle in order to understand what is really happening to our profession...

Let say that someone graduates from med school in the US and for some reasons do not want to pursue (or can't pursue) a residency, is there a reason why APA are lobbying legislatures to not pass any law that will allow these people to sit for PA boards? Will these people be less qualified than newly minted PA? Yeah, they really care about filling the 'gap'...


I have a feeling we all in here will be fine, but we should think about what the profession will look like for future generation...

No surprise, every pro-midlevel doctor on these forums bases their argument on how their specific specialty in their hospital is and entirely ignores other fields/other hospitals. It's insane really.

 

[W19]

No surprise, every pro-midlevel doctor on these forums bases their argument on how their specific specialty in their hospital is and entirely ignores other fields/other hospitals. It's insane really.

Our profession is somewhat fragmented, unfortunately...

 

[MedicineZ0Z]

Every single NP or PA I've encountered so far during third year and in my previous life (hospital admin, so worked with a lot) were absolute gems to docs to their face, and then when the doc wasn't around probably 90% talked **** and complained incessantly. It is incredible to me that you guys don't realize this. Mind blowing really.

And now, as an older MS3, I experience the above every. single. day. They all, ubiquitously, act like you've described to your face but then as soon as you arent around it is an onslaught of jealousy/ malace/ hate. Every NP i know also has a goal of getting a dnp so they can be a "doctor" and they all most definitely plan to practice "advanced nursing" independently.

I don't know if I'm more sad or shocked by your stance.

Exactly this. It's incredibly rampant. Those same docs will then defend these midlevels... it's comical. And like we saw in the other thread, favor them over residents/med students!

 

[nimbus]

One of the NP’s I work is a DNP. I knew her since she came to my hospital as a young traveling OR circulator. Then she became permanent staff and eventually she became our weekend OR charge nurse which is not an easy job at my hospital. She worked almost every single weekend for 2years while she did an online DNP. She was working full time the entire time she was working on her degree. She had to piece together her own clinical rotations because her school in the Midwest was no help to her on the west coast. After she earned her degree, she joined our urology group, a fantastic group of surgeons. She has no desire to work independently. She’s plenty busy seeing patients in the office and assisting in the OR. She’s a smart, humble, respectful person and will do anything to make people laugh. She’ll put on funny costumes, never forgets a birthday and goes out of her way to make people feel better about themselves. A truly nice human being.

I’ve had the pleasure of working daily with others like her. They just want to do some good and make a living like the rest of us. They don’t want my job and they don’t want the surgeons jobs either. We have a close knit OR. Everyone (doctors, nurses, techs, and aids) socializes with everyone. If the midlevels hated us, I doubt they’d invite us to their parties or hang out at the beach or run races together.

Seems like some medical students like to see all midlevels as evil doctor wannabes. That is emotionally immature splitting. Children do that.

I can believe my own firsthand experience or I can believe an online message board full of insecure, angry medical students. Anyone notice the pro-midlevel doctors here are the people who actually work with them in real life? It pains me to watch the bashing of decent people.

These boards definitely bring out the worst in people.

 

[nimbus]

No surprise, every pro-midlevel doctor on these forums bases their argument on how their specific specialty in their hospital is and entirely ignores other fields/other hospitals. It's insane really.

I have no other basis to make a judgement except my firsthand experience. Should I give more weight to an anonymous internet board?

 

[nimbus]

Have you ever visited the anesthesia forum? I think sometimes we should look outside of our own circle in order to understand what is really happening to our profession...

Let say that someone graduates from med school in the US and for some reasons do not want to pursue (or can't pursue) a residency, is there a reason why APA is lobbying legislatures to not pass any law that will allow these people to sit for PA boards? Will these people be less qualified than newly minted PA? Yeah, they really care about filling the 'gap'...


I have a feeling we all in here will be fine, but we should think about what the profession will look like for future generation...

I’m there a lot.

 

[MedicineZ0Z]

I have no other basis to make a judgement except my firsthand experience. Should I give more weight to an anonymous internet board?

Once again, isolating n=1 anecdotes. The country of this population size doesn't run on your anecdotes. We're not complaining about midlevels specifically just for the sake of complaining when we could complain about any other group.
Also, it blows my mind that you don't feel obligated to defend your field at all costs against others. Shows your lack of respect for the profession.

 

[nimbus]

Once again, isolating n=1 anecdotes. The country of this population size doesn't run on your anecdotes. We're not complaining about midlevels specifically just for the sake of complaining when we could complain about any other group.
Also, it blows my mind that you don't feel obligated to defend your field at all costs against others. Shows your lack of respect for the profession.

It does not run on your n=1 anecdotes either.

I refuse to fight some imaginary war. The only evidence of war that I have ever seen is on SDN. The NP’s and PA’s that I see in the operating room are invited by the surgeons. They help. What am I defending my field against?? Should I agree with you and start ranting on SDN against midlevels that I don’t actually hate in real life? Some of them are my friends. What purpose would that serve?


If your medical school is not providing adequate clinical experiences, it’s on them. Don’t blame midlevel students who are also paying a lot of money for their education. They are just as powerless as you.


But if you feel that strongly, perhaps you can get involved in organized medicine and rally against midlevels. That’ll be very constructive.

 

[BidingMyTime]

The key issue is increasing provider care to rural communities, but there is little reason to think that increasing scope of practice to midlevel's will do that.

Pretty much everyone agrees that there are areas where very few professionals want to live and work. And there is reason to think that even paying a $500,000/yr salary wouldn't change that. So instead of trying to find people to make a year or longer commitment, why don't hospitals finance a clinic, and fly in a different MD/DO for a 1 - 3 week period? Give the MD/DO above average pay and provide at least room (if not room and board) while they are there. I would think there would be many doctors willing to use their 1 - 3 weeks vacation from their regular practice, to get a nice "bonus" paycheck. Especially if this program was advertised positively that doctors would be doing a tremendous service by helping provide medical care to people who otherwise would be seeing a mid-level. The only minus I see is that people would always be seeing a different doctor, but I think that would be offset by their seeing an actual doctor, rather than a mid-level. Plus doctors would probably be coming in from out-of-state, so they would have to maintain 2 state licenses. I'm not a MD/DO nor a mid-level, so maybe I'm missing an obvious reason why this wouldn't work.

 

[VA Hopeful Dr]

The key issue is increasing provider care to rural communities, but there is little reason to think that increasing scope of practice to midlevel's will do that.

Pretty much everyone agrees that there are areas where very few professionals want to live and work. And there is reason to think that even paying a $500,000/yr salary wouldn't change that. So instead of trying to find people to make a year or longer commitment, why don't hospitals finance a clinic, and fly in a different MD/DO for a 1 - 3 week period? Give the MD/DO above average pay and provide at least room (if not room and board) while they are there. I would think there would be many doctors willing to use their 1 - 3 weeks vacation from their regular practice, to get a nice "bonus" paycheck. Especially if this program was advertised positively that doctors would be doing a tremendous service by helping provide medical care to people who otherwise would be seeing a mid-level. The only minus I see is that people would always be seeing a different doctor, but I think that would be offset by their seeing an actual doctor, rather than a mid-level. Plus doctors would probably be coming in from out-of-state, so they would have to maintain 2 state licenses. I'm not a MD/DO nor a mid-level, so maybe I'm missing an obvious reason why this wouldn't work.

That's called locum tenens. Its already a thing and obviously not sufficient.

 

[VA Hopeful Dr]

No surprise, every pro-midlevel doctor on these forums bases their argument on how their specific specialty in their hospital is and entirely ignores other fields/other hospitals. It's insane really.

You realize that your "sufficient evidence" from earlier was you having met 2 midlevels who had trouble with ECGs, right?

 

[MedicineZ0Z]

The key issue is increasing provider care to rural communities, but there is little reason to think that increasing scope of practice to midlevel's will do that.

Pretty much everyone agrees that there are areas where very few professionals want to live and work. And there is reason to think that even paying a $500,000/yr salary wouldn't change that. So instead of trying to find people to make a year or longer commitment, why don't hospitals finance a clinic, and fly in a different MD/DO for a 1 - 3 week period? Give the MD/DO above average pay and provide at least room (if not room and board) while they are there. I would think there would be many doctors willing to use their 1 - 3 weeks vacation from their regular practice, to get a nice "bonus" paycheck. Especially if this program was advertised positively that doctors would be doing a tremendous service by helping provide medical care to people who otherwise would be seeing a mid-level. The only minus I see is that people would always be seeing a different doctor, but I think that would be offset by their seeing an actual doctor, rather than a mid-level. Plus doctors would probably be coming in from out-of-state, so they would have to maintain 2 state licenses. I'm not a MD/DO nor a mid-level, so maybe I'm missing an obvious reason why this wouldn't work.

Great idea.

That's called locum tenens. Its already a thing and obviously not sufficient.

This would work if it paid even more and was marketed properly.

You realize that your "sufficient evidence" from earlier was you having met 2 midlevels who had trouble with ECGs, right?

I've also seen ones who didn't know the difference between ACE and ARBs, thought statin doses were in the hundred mg ranges, had 0 approach to reading a chest xray let alone reading it, had to google what a chole was, thought a Na of 132 was "very low", gave a patient on 3 QT prolonging meds a 4th one and didn't even know the significance of it and... I can literally go on all day.
Best part? These are all different midlevels, in different hospital/clinics, in different states with different training backgrounds. You'd have to look hard to even find an ms3 who would make those errors/not know those things, let alone a resident.

 

[Iz_FtB]

When the national lobbying groups for midlevels are motivated by independent practice, anecdotal evidence means jack. Because the NP trucking away in the OR is happy with their lot in life doesn't mean her peers feel similarly. It's a fight for hearts and minds right now, and we've got doctors not even willing to bring a knife to this gun fight.

 

[VA Hopeful Dr]

Great idea.

This would work if it paid even more and was marketed properly.

I've also seen ones who didn't know the difference between ACE and ARBs, thought statin doses were in the hundred mg ranges, had 0 approach to reading a chest xray let alone reading it, had to google what a chole was, thought a Na of 132 was "very low", gave a patient on 3 QT prolonging meds a 4th one and didn't even know the significance of it and... I can literally go on all day.
Best part? These are all different midlevels, in different hospital/clinics, in different states with different training backgrounds. You'd have to look hard to even find an ms3 who would make those errors/not know those things, let alone a resident.

You are astoundingly ignorant.

Locums couldn't be marketed more. I get literally a dozen emails and 2-3 calls PER DAY from locums recruiters.

Where is the money supposed to come from. I know what it would take to get me out to rural ND for a week and it's not a low number. Multiply that by 52 weeks and most places can't afford that.

I've seen practicing physicians make similar errors. Why don't you ask the EM folks about the stupid **** that they see doctors send to them "because it's an emergency"?

 

[MedicineZ0Z]

You are astoundingly ignorant.

Locums couldn't be marketed more. I get literally a dozen emails and 2-3 calls PER DAY from locums recruiters.

Where is the money supposed to come from. I know what it would take to get me out to rural ND for a week and it's not a low number. Multiply that by 52 weeks and most places can't afford that.

I've seen practicing physicians make similar errors. Why don't you ask the EM folks about the stupid **** that they see doctors send to them "because it's an emergency"?

Oh cold emails are effective marketing?? You clearly have a strong business background.

I did say effective marketing, not just the money alone.

And no, doctors, residents and even med students would not make those elementary mistakes I listed. Your idea of what is considered dumb is still multiple levels above the stuff I listed. Did you even read them?

 

[235009]

Oh cold emails are effective marketing?? You clearly have a strong business background.

I did say effective marketing, not just the money alone.

Maybe you should quit med school and do marketing for a locums agency then? I'm sure they'd love to hear your brilliant ideas. In fact I'm dying to hear one right now.

I think the fundamental misunderstanding here is that med students, usually because of their financial circumstance and the fact that they've usually never had a real job, overvalue money over all else. Convincing someone to leave their home and family for a week or two at a time and travel across the country is incredibly difficult regardless of how much money or marketing you use. Essentially starting a new job for a week or two would be beyond frustrating. After doing primary care for 3 years in residency I was just getting a handle on our clinic's resources and state's rules. When you're inpatient there is an EMR you have to become facile with, social services following discharge, insurance issues, consults, who to call to get something done. I'm not surprised your thought process is extremely superficial but would recommend you pipe down until you've at least been around the block once.

 

[KeikoTanaka]

Why not just have tele-medicine IM/FM doctors who monitor electronically certain counties and they review notes for the independent NPs/PAs in really rural areas? If the NP practicing alone in the middle of no where thinks a certain medication could work for a patient, they queue it up, the IM doc responsible for that NP reviews the chart and either A.) Verifies the medication B.) Asks for more testing to be done or C.) Changes the plan completely based on the notes/labs they've reviewed? This way you can have 1 IM doctor in lets say San Francisco responsible for various NPs/PAs in North Dakota. They get their ability to physically be there providing for patients, but they're still "on a leash" so they can be monitored. It may be hard to do this in real time in a setting like an emergency department, but, I guess you could do the same thing, have a "GoPro" or something like that on the PAs head with an EM doc in Austin, TX monitoring a really difficult patient that needs stabilization and can walk them through something.

Just spit-balling ideas, don't hate me, you're all extremely opinionated and can become very toxic quickly. Lol...

 

[VA Hopeful Dr]

Why not just have tele-medicine IM/FM doctors who monitor electronically certain counties and they review notes for the independent NPs/PAs in really rural areas? If the NP practicing alone in the middle of no where thinks a certain medication could work for a patient, they queue it up, the IM doc responsible for that NP reviews the chart and either A.) Verifies the medication B.) Asks for more testing to be done or C.) Changes the plan completely based on the notes/labs they've reviewed? This way you can have 1 IM doctor in lets say San Francisco responsible for various NPs/PAs in North Dakota. They get their ability to physically be there providing for patients, but they're still "on a leash" so they can be monitored. It may be hard to do this in real time in a setting like an emergency department, but, I guess you could do the same thing, have a "GoPro" or something like that on the PAs head with an EM doc in Austin, TX monitoring a really difficult patient that needs stabilization and can walk them through something.

Just spit-balling ideas, don't hate me, you're all extremely opinionated and can become very toxic quickly. Lol...

It's not a bad idea, but you'd have to find doctors willing to get a ND license and supervise midlevels they've never met. I wouldn't take that risk.

 

[VA Hopeful Dr]

Oh cold emails are effective marketing?? You clearly have a strong business background.

I did say effective marketing, not just the money alone.

And no, doctors, residents and even med students would not make those elementary mistakes I listed. Your idea of what is considered dumb is still multiple levels above the stuff I listed. Did you even read them?

I have literally seen med students make those mistakes. Even seen an intern make a few of them. And I've absolutely seen attendings have patients on multiple QT prolonging meds with no ECGs on file.

Never underestimate stupidity.

Oh, and tell me then what incentives besides money you'd use to get people to do rural ND locums.

 

[Matthew9Thirtyfive]

I have literally seen med students make those mistakes. Even seen an intern make a few of them. And I've absolutely seen attendings have patients on multiple QT prolonging meds with no ECGs on file.

Never underestimate stupidity.

Oh, and tell me then what incentives besides money you'd use to get people to do rural ND locums.

Right but med students and interns don’t practice independently.

 

[VA Hopeful Dr]

Right but med students and interns don’t practice independently.

Not the argument I'm rebutting

 

[Matthew9Thirtyfive]

Not the argument I'm rebutting

Right, but it's part of the argument. If you just want to take it out of context and say med students and physicians make those errors, then yes you are right. But the context of the argument is that MLPs are getting independent practice despite not having the education and training to not make those errors. Med students and interns don't practice independently. They are under supervision because they aren't ready to practice independently, and making those errors is part of the reason why. MLPs are making those types of errors as well, and yet we're saying it's okay to let them just go make them on patients because there's a provider shortage?

 

[Matthew9Thirtyfive]

Not the argument I'm rebutting

I will say I have also seen attendings make stupid errors like that. I've posted about them before. But I've also seen them much less frequently than the sorts of errors I've seen midlevels make. It's anecdotal, but all of this is since we don't actually have a robust study (for reasons we've discussed before).

 

[KeikoTanaka]

It's not a bad idea, but you'd have to find doctors willing to get a ND license and supervise midlevels they've never met. I wouldn't take that risk.

I assume that you would find like one doctor specifically for one region who would monitor ..idk, 3-5 of them? You would probably be nervous I guess at first, but once you've been doing it for a while, I assume you would even do video-skype calls to them on occasion to educate/discuss/or to catch up on certain patients. So I'd think you would develop a relationship with them and understand their style and how their charts flow, it would get faster / more comfortable with the process.

Edit: I didn't think about the need for the ND licensure. That's an interesting thing. How do locums go about different state licensures?

 

[jdh71]

I have literally seen med students make those mistakes. Even seen an intern make a few of them. And I've absolutely seen attendings have patients on multiple QT prolonging meds with no ECGs on file.

Never underestimate stupidity.

Oh, and tell me then what incentives besides money you'd use to get people to do rural ND locums.

I regularly have patients on multiple qt prolonging medications all at once. They are in an ICU and on a monitor though.

 

[VA Hopeful Dr]

Right, but it's part of the argument. If you just want to take it out of context and say med students and physicians make those errors, then yes you are right. But the context of the argument is that MLPs are getting independent practice despite not having the education and training to not make those errors. Med students and interns don't practice independently. They are under supervision because they aren't ready to practice independently, and making those errors is part of the reason why. MLPs are making those types of errors as well, and yet we're saying it's okay to let them just go make them on patients because there's a provider shortage?

Again, not the argument I'm working with

 

[KeikoTanaka]

This has nothing to do with doctors making mistakes, or interns or medical students making mistakes. We're all human, it's going to happen. The difference is, like in ANY form of business, you do things to LIMIT the propensity for mistakes, AKA in our situation: Medical School, Board Examinations, Residency, CMEs, and more board exams. This is why people have a problem with MLPs having independent rights in the first place because why would you hold physicians to these standards to limit error, but then give other people who are not held to the same standard the ability to practice? It's not about 1 NP killing a patient or 100000 MDs killing patients, it's about the fact if an MD (or DO) did it, you have very specific ways of going back through their methodology because you know what they SHOULD know and therefore what they SHOULD have done. If a NP kills a patient, there's not as comprehensive of a way to correct their methodology, did they just blatantly miss it or were they actually never trained and tested on it? If you're going to offer independence, you need to have a schooling set up by them that is very specific in their scope of practice ACROSS THE BOARD, and allow them limited scopes with the ability to consult someone higher up when their scope of practice is being breached. Otherwise, just combine all the schooling and eliminate the profession entirely because its pointless to have 2 tiers of doctors independently working.

 

[Taddy Mason]

This has nothing to do with doctors making mistakes, or interns or medical students making mistakes. We're all human, it's going to happen. The difference is, like in ANY form of business, you do things to LIMIT the propensity for mistakes, AKA in our situation: Medical School, Board Examinations, Residency, CMEs, and more board exams. This is why people have a problem with MLPs having independent rights in the first place because why would you hold physicians to these standards to limit error, but then give other people who are not held to the same standard the ability to practice? It's not about 1 NP killing a patient or 100000 MDs killing patients, it's about the fact if an MD (or DO) did it, you have very specific ways of going back through their methodology because you know what they SHOULD know and therefore what they SHOULD have done. If a NP kills a patient, there's not as comprehensive of a way to correct their methodology, did they just blatantly miss it or were they actually never trained and tested on it? If you're going to offer independence, you need to have a schooling set up by them that is very specific in their scope of practice ACROSS THE BOARD, and allow them limited scopes with the ability to consult someone higher up when their scope of practice is being breached. Otherwise, just combine all the schooling and eliminate the profession entirely because its pointless to have 2 tiers of doctors independently working.

APPs also have board exams that they have to retake every X number of years, maintain CME credits, and can be reported to their respective state licensing boards just like physicians, dentists, pharmacists, etc.