PA granted independent practice right in North Dakota

[THEBACKANDFORTH]

Can the attendings following this thread explain where PA/NP scope of practice should start and end? Or is it basically they should be allowed to do everything a physician can given the right context. I understand the necessity for the role, but it does appear that they are no longer physician extenders but rather physician fillers for those who either can't afford to demand a physician or don't want to wait a long time.

Some of what irks me about the rural argument is that you can also be a premed that goes to africa and assists in surgery (there was an advertisement for that when I was in undergrad). I know it's a hyperbolic comparison, but just because an area is in need and someone less qualified can go to fill that need when no one else can doesn't necessarily mean it's a good idea or even beneficial for the population.

With my own healthcare I've been to the "doctor" a few times in the past few years. I think 80% of those times I was unknowingly given a MLP despite asking to be seen by a physician. It seems we are already getting a tiered system in the USA.

But it absolutely is within the scope of the MLP to handle your sneezes and sniffles

And nobody should comment on these EXTREMELY rural areas without having lived in them. PAs and NPs can handle 99.9% of what comes through the door, and simply put, we aren't going to get healthcare health care providers within 100 miles of some of these patients without them.

So there is philosophical question here about autonomy and scope, but functionally, this is good for North Dakota. And that is all North Dakota cares about.

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[NicMouse64]

But it absolutely is within the scope of the MLP to handle your sneezes and sniffles

And nobody should comment on these EXTREMELY rural areas without having lived in them. PAs and NPs can handle 99.9% of what comes through the door, and simply put, we aren't going to get healthcare health care providers within 100 miles of some of these patients without them.

So there is philosophical question here about autonomy and scope, but functionally, this is good for North Dakota. And that is all North Dakota cares about.

I've lived in a rural area most of my life. What worries me is my extended family (from a town of 500) wouldn't know any better. They wouldn't know they aren't seeing a doctor. And lemme tell you rural patients have a lot of unresolved issues for precisely the reason that there needs to be more doctors in rural areas. They never see a doctor, or they wait a long time before seeing one, and then the problems are really bad. I see this being a disaster honestly, for precisely the fact that the most vulnerable, sickest, and least educated of our population is being given NP/PAs as the solution.

Edit: also if you knew anything about a rural population you would know that, unlike urban populations, they are very unlikely to go to a physician for minor things such as a cold. They just "stick it out".

 

[THEBACKANDFORTH]

I've lived in a rural area most of my life. What worries me is my extended family (from a town of 500) wouldn't know any better. They wouldn't know they aren't seeing a doctor. And lemme tell you rural patients have a lot of unresolved issues for precisely the reason that there needs to be more doctors in rural areas. They never see a doctor, or they wait a long time before seeing one, and then the problems are really bad. I see this being a disaster honestly, for precisely the fact that the most vulnerable, sickest, and least educated of our population is being given NP/PAs as the solution.

These areas are actually considered "frontier". Most people have a propensity to call their home small or rural--the problem is, access to care is very different in different types of rural, and defining rural is tough. What is the population density of the county you've lived in most of your life?

More doctors isn't an option for ND, and believe me, enough money has been thrown that direction. The medical school there has 80 seats, selects North Dakotans from rural areas, and still produces few rural docs.

So it's either No care or PA/NP care. The choice isn't difficult

 

[THEBACKANDFORTH]

This is why many here don't have a dog in this fight

 

[NicMouse64]

This is why many here don't have a dog in this fight

My hometown is in one of these green areas.....Also no, it's not no care or NP/PA care. It's no care or drive 100 miles to a doctor. While inconvenient, if someone is sick enough, they will do it. I had to drive my grandma an hour and a half to her PCP once a month.....it wasn't convenient but I would much rather have drove her than have her see a NP with an online degree and who knows how much clinical training?

It seems the argument is that we must keep things convenient so that those in rural areas can get their medical care FAST (just like why we need CVS and walmart minute clinics). What many people don't understand is that the people in these areas are used to not having....a grocery store, a gas station (sometimes), a mall, a place to buy clothes, etc. etc. They choose to live here because it is in their blood and heritage. They are stubborn and have pride in their land or their familial lineage. Why does the medical community decide that we must provide them with medical care that's close to them? They have chosen a life where they are far from basic necessities, and that is fine.

I'm also certain the health disparity in rural areas has nothing to do with access to medical care. It's absurdly high amounts of drug, gun, alcohol, and tobacco useage compared to the general populations.

 

[Brawndo2016]

So an official board prep site for NPs is not valid for some reason, because it was posted on an online forum?

It's funny cause in the NP/PA circles they constantly go on about how they learn everything medical students learn in a fraction of the time frame & how they can pass our exams with ease. On physician boards, apparently some doctors like to bash the med students also in favor of midlevels.

PA with 20 years experience here. I literally know hundreds of PAs and have never once heard any of them “go on” with such ignorant statements. I don’t know how big your sample size is, but you’re invalidating your original argument with this one.

 

[THEBACKANDFORTH]

It seems the argument is that we must keep things convenient so that those in rural areas can get their medical care FAST (just like why we need CVS and walmart minute clinics). What many people don't understand is that the people in these areas are used to not having....a grocery store, a gas station (sometimes), a mall, a place to buy clothes, etc. etc. They choose to live here because it is in their blood and heritage. They are stubborn and have pride in their land or their familial lineage. Why does the medical community decide that we must provide them with medical care that's close to them? They have chosen a life where they are far from basic necessities, and that is fine.

This is stupid. Grandma shouldn't have to drive 100 miles every 3x months to talk about her A1C and discuss why potatoes are a bad diabetic food. Show somebody that weird mole on her back she can't reach, and then get an SK frozen. Get that possible UTI treated. Change her asthma inhaler. Discuss smoking cessation. The list is endless

 

[NicMouse64]

This is stupid. Grandma shouldn't have to drive 100 miles every 3x months to talk about her A1C and discuss why potatoes are a bad diabetic food. Show somebody that weird mole on her back she can't reach, and then get an SK frozen. Get that possible UTI treated. Change her asthma inhaler. Discuss smoking cessation. The list is endless

She had the option to move closer to a doctor. She and my grandpa wanted to stay where the farm was. She decided the farm was more important. Tell me again why the medical establishment needs to baby rural populations when no other industry or government faction does? Is it for $$$? That's what they would think.

Also you don't think you should drive an hour and a half to have someone take a look at a weird mole? really?!? That's one of the reasons I took her to a PCP, where they found a mole that had melanoma! Again, with our fair skin and amount of freckles, not sure I would have trusted the opinion of a NP/PA in that context.

 

[jdh71]

But it absolutely is within the scope of the MLP to handle your sneezes and sniffles

And nobody should comment on these EXTREMELY rural areas without having lived in them. PAs and NPs can handle 99.9% of what comes through the door, and simply put, we aren't going to get healthcare health care providers within 100 miles of some of these patients without them.

So there is philosophical question here about autonomy and scope, but functionally, this is good for North Dakota. And that is all North Dakota cares about.

99.9 is an oversell

 

[jdh71]

Can the attendings following this thread explain where PA/NP scope of practice should start and end? Or is it basically they should be allowed to do everything a physician can given the right context. I understand the necessity for the role, but it does appear that they are no longer physician extenders but rather physician fillers for those who either can't afford to demand a physician or don't want to wait a long time.

Some of what irks me about the rural argument is that you can also be a premed that goes to africa and assists in surgery (there was an advertisement for that when I was in undergrad). I know it's a hyperbolic comparison, but just because an area is in need and someone less qualified can go to fill that need when no one else can doesn't necessarily mean it's a good idea or even beneficial for the population.

With my own healthcare I've been to the "doctor" a few times in the past few years. I think 80% of those times I was unknowingly given a MLP despite asking to be seen by a physician. It seems we are already getting a tiered system in the USA.

Primary care and urgent care.

Otherwise they are working under a doc.

 

[VA Hopeful Dr]

Primary care and urgent care.

Otherwise they are working under a doc.

And even then unless no doctors are available (like in rural ND), they should be working under one of us.

In my state, for example, its basically impossible to be more than 30 minutes away from a good sized hospital. Are there counties without a physician? Sure. Is it more than 30 minutes to the nearest physician? Nope.

 

[alprazoslam]

But it absolutely is within the scope of the MLP to handle your sneezes and sniffles

And nobody should comment on these EXTREMELY rural areas without having lived in them. PAs and NPs can handle 99.9% of what comes through the door, and simply put, we aren't going to get healthcare health care providers within 100 miles of some of these patients without them.

So there is philosophical question here about autonomy and scope, but functionally, this is good for North Dakota. And that is all North Dakota cares about.

99.9 I don’t think any one person can handle that even if a doc lol

 

[NicMouse64]

Yeah, some of your other points about the nuances of rural care are solid but this is just not correct. While it's true that the risk factors you listed likely contribute to rural-urban health disparities, it's pretty well-established in the literature that lack of access to adequate primary and acute care is a significant predictor for morbidity and mortality.

links? I admit I am basing this on my own biases and anecdotes.

 

[NicMouse64]

And even then unless no doctors are available (like in rural ND), they should be working under one of us.

In my state, for example, its basically impossible to be more than 30 minutes away from a good sized hospital. Are there counties without a physician? Sure. Is it more than 30 minutes to the nearest physician? Nope.

*GASP*. 30 minutes away from the nearest physician? That's unacceptable as rural patients don't have cars so we must flood the market with NP/PAs so that those poor rural patients don't have to drive more than 5 minutes to the nearest "provider".

/s

 

[jdh71]

And even then unless no doctors are available (like in rural ND), they should be working under one of us.

In my state, for example, its basically impossible to be more than 30 minutes away from a good sized hospital. Are there counties without a physician? Sure. Is it more than 30 minutes to the nearest physician? Nope.

I don't know if I'm completely convinced they need to be under a doc if a doc is around in primary care, but I also don't have strong opinions against that. Seems reasonable.

 

[NicMouse64]

I don't know if I'm completely convinced they need to be under a doc if a doc is around in primary care, but I also don't have strong opinions against that. Seems reasonable.

To me, it seems reasonable to say then, that the 7 years of training to become a PCP is unnecessary and we should eliminate residencies in primary care residencies.

 

[jdh71]

To me, it seems reasonable to say then, that the 7 years of training to become a PCP is unnecessary and we should eliminate residencies in primary care residencies.

The training for physicians isn't for the easy cases it's for the hard. We have been over this more than once in this discussion, the APP can handle most things, the physicians will need to handle what they can't. This isn't hard, nor does it require catastrophizing.

 

[NicMouse64]

The training for physicians isn't for the easy cases it's for the hard. We have been over this more than once in this discussion, the APP can handle most things, the physicians will need to handle what they can't. This isn't hard, nor does it require catastrophizing.

In your experience is it fairly simple to determine what is complex not? Also where's the gray line between what is too complex for a PA/NP and whether to refer to a specialist or just the PCP. I guess if it's too complex the PA/NP could just refer out to a specialist. Boom no need for primary care docs.

 

[VA Hopeful Dr]

I don't know if I'm completely convinced they need to be under a doc if a doc is around in primary care, but I also don't have strong opinions against that. Seems reasonable.

Around v. supervised with... one is merely a more formal arrangement compared to the other.

I know without a formal agreement, I wouldn't be OK with being curbsided by a mid-level in my office.

 

[jdh71]

In your experience is it fairly simple to determine what is complex not? Also where's the gray line between what is too complex for a PA/NP and whether to refer to a specialist or just the PCP. I guess if it's too complex the PA/NP could just refer out to a specialist. Boom no need for primary care docs.

I think it is pretty straight forward to know what is too complex. And much of what is complex doesn't need a specialist and that would also be inappropriate. Specialists will manage their single organ issues and will not be holding all of the complicated pieces together, this is where the physician trained primary care provider comes in.

 

[VincentAdultman]

LOL when the f#@$ did reddit gain this much weight in medical circles?

 

[THEBACKANDFORTH]

99.9 is an oversell

i prefer hyperbole

 

[jdh71]

i prefer hyperbole

me too

it's why I recognize it so easy

 

[AnatomyGrey12]

I literally know hundreds of PAs and have never once heard any of them “go on” with such ignorant statements.

Not really jumping into the discussion but saw this and just wanted to say that I have seen it quite a bit actually, but only in the PA/NP student or incoming PA student population. I've never heard a practicing mid-level say this except the ones in the media. Unfortunately in my experience the next generation of mid-levels include a lot of people who genuinely think they are somehow circumventing the system and will get the career/skill set of a physician without having to go to medical school.

This doesn't really apply to this scenario though. I am undecided on how I feel about PAs in rural ND being able to practice without supervision. I think there are pros and cons to both sides and it isn't as black and white as some people want it to be.

 

[MedicineZ0Z]

But it absolutely is within the scope of the MLP to handle your sneezes and sniffles

And nobody should comment on these EXTREMELY rural areas without having lived in them. PAs and NPs can handle 99.9% of what comes through the door, and simply put, we aren't going to get healthcare health care providers within 100 miles of some of these patients without them.

So there is philosophical question here about autonomy and scope, but functionally, this is good for North Dakota. And that is all North Dakota cares about.

99.9%? Either you've been rotating through with dr joe the med refill specialist or you're an ms1 who has 0 exposure to clinical settings. You realize even a top notch ED or IM or FM doc isn't handling anything close to 99% with competency right?

I would put the number at 50% (max) for those with experience and well below that for inexperienced ones. Handling something and doing a good job are two completely different things as well.

Again, this is why people defending midlevels lose credibility...

 

[MedicineZ0Z]

Can the attendings following this thread explain where PA/NP scope of practice should start and end? Or is it basically they should be allowed to do everything a physician can given the right context. I understand the necessity for the role, but it does appear that they are no longer physician extenders but rather physician fillers for those who either can't afford to demand a physician or don't want to wait a long time.

Some of what irks me about the rural argument is that you can also be a premed that goes to africa and assists in surgery (there was an advertisement for that when I was in undergrad). I know it's a hyperbolic comparison, but just because an area is in need and someone less qualified can go to fill that need when no one else can doesn't necessarily mean it's a good idea or even beneficial for the population.

With my own healthcare I've been to the "doctor" a few times in the past few years. I think 80% of those times I was unknowingly given a MLP despite asking to be seen by a physician. It seems we are already getting a tiered system in the USA.

PAs NPs should be considered equals to doctors, do the same tasks and be paid the exact same too. Our job should be to absorb all the litigation, ideally in a 10 to 1 supervision ratio.



(sounds funny till you realize it's true)

 

[NicMouse64]

99.9%? Either you've been rotating through with dr joe the med refill specialist or you're an ms1 who has 0 exposure to clinical settings. You realize even a top notch ED or IM or FM doc isn't handling anything close to 99% with competency right?

I would put the number at 50% (max) for those with experience and well below that for inexperienced ones. Handling something and doing a good job are two completely different things as well.

Again, this is why people defending midlevels lose credibility...

To some extent I agree with the senior and physician posters here. When it comes down to it if the complexity can easily be discerned and the need for a PCP isn't necessary then let PA/NP handle those patients. There are too many patients in the system with medicaid expansion and medicare for physician only care. This is probably part of the reason why some physicians harp on the ACA as being bad. In a perfect world we would expand residencies and keep the PA/NP levels at 90's levels. But we don't live in a perfect world, and this is the USA, where what's best for the consumer/patient doesn't determine policy.

I'm still against the idea of PA/NP in a rural area unsupervised. Rural patients from my own experience are the most complex and would benefit most from a physician. you can send a premed to africa to do surgery that doesn't mean it's a good idea.

 

[THEBACKANDFORTH]

99.9%? Either you've been rotating through with dr joe the med refill specialist or you're an ms1 who has 0 exposure to clinical settings. You realize even a top notch ED or IM or FM doc isn't handling anything close to 99% with competency right?

I would put the number at 50% (max) for those with experience and well below that for inexperienced ones. Handling something and doing a good job are two completely different things as well.

Again, this is why people defending midlevels lose credibility...

You're acting like ben shapiro. And while a little careless with my language, i was referring to the fact that an NP or PA can handle almost all of the same things in a primary care setting (this law is addressing primary family med) as well as a family med doctor. Context, of course, made that clear.

 

[MedicineZ0Z]

You're acting like ben shapiro. And while a little careless with my language, i was referring to the fact that an NP or PA can handle almost all of the same things in a primary care setting (this law is addressing primary family med) as well as a family med doctor. Context, of course, made that clear.

Cmon dude, that's a ridiculous statement to make.
You're saying midlevels (2 years of training) are equivalent to a family doctor (7 years). And if we break down the hours & rigor, it's more like 2 years vs 12 years. I'm not sure how they're making up such a large gap of knowledge.

Who do you want treating your mother's pneumonia? Or managing your dad's copd/chf? Someone who had a brief lecture on it and watched a doctor do it a few times, or someone who's done it 100x already and seen it from every angle + knows the in-depth science behind every move.

Yes I'm a ms4, but I suspect you're an ms1-ms2 aka zero true clinical exposure. Family medicine isn't just medication renewal and URIs.

 

[NicMouse64]

Cmon dude, that's a ridiculous statement to make.
You're saying midlevels (2 years of training) are equivalent to a family doctor (7 years). And if we break down the hours & rigor, it's more like 2 years vs 12 years. I'm not sure how they're making up such a large gap of knowledge.

Who do you want treating your mother's pneumonia? Or managing your dad's copd/chf? Someone who had a brief lecture on it and watched a doctor do it a few times, or someone who's done it 100x already and seen it from every angle + knows the in-depth science behind every move.

Yes I'm a ms4, but I suspect you're an ms1-ms2 aka zero true clinical exposure. Family medicine isn't just medication renewal and URIs.

I think the argument though is that there aren't enough doctors around to have doctors do these things and everything else. Therefore give someone with minimal training the easy stuff and accept the light risk of less education and missing a few zebras here and there.

 

[MedicineZ0Z]

I think the argument though is that there aren't enough doctors around to have doctors do these things and everything else. Therefore give someone with minimal training the easy stuff and accept the light risk of less education and missing a few zebras here and there.

That's a different argument though. For him/her to say midlevels are as good as family doctors is pretty ignorant.

 

[THEBACKANDFORTH]

I think the argument though is that there aren't enough doctors around to have doctors do these things and everything else. Therefore give someone with minimal training the easy stuff and accept the light risk of less education and missing a few zebras here and there.

exactly.

 

[THEBACKANDFORTH]

That's a different argument though. For him/her to say midlevels are as good as family doctors is pretty ignorant.

I never said that, nor implied that, nor is "as good" an okay descriptor in the insulting way you meant it.

 

[Goro]

I never said that, nor implied that, nor is "as good" an okay descriptor in the insulting way you meant it.

Don't bother anymore, TBF, he's unteachable.

At this point, I have throw up my hands and tell y'all:
:troll::troll::troll::troll::troll::troll::troll::troll::troll::troll::troll::troll::troll::troll::troll::troll::troll::troll::troll::troll: