Should physicians let NP/PA take over primary care and anesthesia?

[NickNaylor]

Generalizations are generalizations, but I've noticed a few things just during the course of the third year:

-Midlevel providers are attractive to hospital systems for obvious reasons. Advantages or disadvantages aside, as @Tired mentions, there are strong forces at work which oppose the "longer training = better results" argument, irrespective of whether it's true or not.

-PAs, in general, tend to recognize their scope of practice and when they get into hot water. They tend to rely more on physicians when necessary while practicing independently when able. They tend to be knowledgable and well-trained, and I've worked with several PAs that have been excellent teachers on rotations.

-APNs, on the other hand, seem to be more variable in quality. Some, obviously, are very good and indistinguishable from a PA or possibly even an MD/DO. Others, though, are clearly unimpressive, and it's somewhat concerning that they're able to see patients somewhat independently. They seem less accepting of the "hierarchy" and more likely to do their own thing. While certainly not always true, I've found that, in general, their knowledge base tends to be weaker than those of PAs and MDs/DOs as they seem to rely more on experience than theory, if that makes sense.

-CRNAs are much the same. Some are very good, others not so much. I think there's no doubt that there's a difference between CRNAs and anesthesiologists. CRNAs tend to be more reactive and mechanistic, while anesthesiologists, again, tend to be more theoretical.

The real problem MDs/DOs have is that the reality is that an overall majority of care can likely be provided by midlevels with an efficacy equivalent to that of physicians in 95% of cases. This is because common things being common and zebras being just that, diagnostic skill not withstanding you're likely to get a basic diagnosis right if only because of epidemiological realities. Where I think physicians can make their value known is in their ability to detect those other 5% of cases - the things that are imitators or complicated or less obvious. That's when the lack of in-depth training becomes obvious. The real question is whether policy makers, who ultimately hold the money, will buy into that argument. I think it's particularly strong in the realm of primary care; as someone else mentioned, I have no doubt that high-quality chronic care no doubt has a significant impact on overall patient health, even if those distinctions might be difficult or impossible to demonstrate quantitatively. There's also the problem of non-medical people reading medical literature and not interpreting it correctly. This is how studies by the AANP demonstrating equivalent SBPs and blood glucose levels between NPs and MDs/DOs are convincing to policy makers. We know that those findings are absolutely useless and don't demonstrate anything about the actual quality of care being provided, but if you're a layman, how are you supposed to know that?

Ultimately I do think patients stand the risk of being harmed should they be managed by less well-trained providers, but the difficulty is 1) quantifying that distinction and 2) making that argument without coming across as elitist or "protecting your turf." In both cases physicians lose from the outset.

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[PL198]

Nick you make good points but another thing to consider is that with something like medicine you have to have a little "overkill" in terms of knowledge relative to your scope, to prevent catastrophic events. I'd rather have a provider have " too much" knowledge on average(MD seeing avg patient) than someone having "too little" (NP) seeing a complex patient that they don't recognize as being complex. Physicians are like insurance in my opinion, you don't want to have to use them, but when you use them, you want your a** covered. If you start cutting corners and going with a cheaper policy, yeah it might not hurt you, but there's also going to be people that do that which end up completely screwed because of it(these people would absolutely be in the minority, just recognizing that fact).

Part of treating the common stuff in my opinion is knowing that if it ever becomes uncommon, the same person is ready to treat it and good to go. I also kinda compare it to like having a good mechanic change the oil in your car vs jiffylube(if you don't do it yourself). Yeah changing someone's oil isn't a big deal and I doubt they're going to do any worse than a good mechanic, but the good mechanic might notice other things going on that aren't even being addressed which could save me a lot of hassle down the road(no pun intended).

It seems everyone is so quick to cut costs and have every patient see someone with knowledge relative to the severity of their illness and I agree that's 1 way of increasing efficiency, but I don't think health care is an industry where people strive for efficiency. It seems ironic to me that the same people that say being a doc is a calling and physicians have some special duty to their patients are the same ones that want to bring mid-levels in to increase efficiency. On one hand those people are arguing where it's some special industry and shouldn't be run like a typical business and another they're trying to do so and lower costs. That paradox is what in my opinion leaves physicians to be blamed in the event where mid-levels mess up. If they're adequate enough to treat the common problems, then they're adequate enough to take full responsibility of the potential negatives as well.

 

[dadaddadaBATMAN]

It's not that simple. If we're going to claim that we are physician scientists, we have an obligation to address things scientifically. You wouldn't argue that diabetics don't need close blood glucose monitoring because "you can make a study say anything" so you shouldn't do it here either.

Take a look at this article if you get bored. Health Affairs is a serious, respected journal. They reviewed 500,000 cases and found no significant difference in patient outcomes. I have never seen a study with this many data points.

No Harm Found When Nurse Anesthetists
Work Without Supervision by Physicians
Health Affairs, Brian Dulisse and Jerry Cromwell,
2010(29):1469-1475.

I read your other posts, but this one seemed most relevant for a reply.

I agree that we need more directed studies carried out by physicians. The debate has progressed far passed the point where we can simply say "more education = superior treatment."

However, I think it's important to acknowledge the numerous obstacles to such a study.

1.) An anesthesiologist is only one component of many affecting hard data, like mortality/complications. The patient base, skill of the surgeon, time of diagnosis, multitude of different diseases, etc. all dilute any benefit from an anesthesiologist.

2.) CRNAs may have back-up, even when practicing independently. They do not practice in a vacuum.

3.) Large population based studies dilute the pool of patients who truly need an anestheiologist

4.) We need to demonstrate more than mere equivalence, we need to demonstrate superiority. This is more difficult to obtain than non-inferiority or equivalence from a statistical standpoint.

5.)Studying the question gives it more legitimacy: I would argue this is no longer a practical reason.

6.) Anesthesiologists in practice maintain a relatively good lifestyle/income. There is not necessarily strong incentive to study this question yet.

Even a perfect study which factored in all of these considerations would not address cost, or risk-benefit. Nor would it test the more common model of a team of CRNAs headed by a MD.

I am a little leery of the specific study you mentioned for a number of reasons, some of which have been covered already. It may have been biased by funding, the records they used may not take into account all complications, they did not explore specific patient populations, they only looked at state-wide differences, the term "complications" is somewhat nebulous (I may have missed a specific definition that they used: I skimmed the paper), etc.

In short, I don't know if it is completely fair to blame Gas for its woes. There are real obstacles to a good study showing their worth.

Just my two cents.

 

[Taurus]

Oh where do I even begin with this thread.

After I became an attending, my thoughts and feelings have not changed at all on this topic. I first began discussing this topic 10 years ago and many of my predictions are becoming reality.

It would be absolutely foolish for physicians to simply "give up" primary care and let NP's have it. That's what the NP's want. Why? Because it doesn't stop there. If you think that physicians are safe in the specialties, then you're naive. NP's are not happy with just primary care. They want to create residencies for NP's in different specialties as well. If the NP's have it their way, they will essentially create a shadow medical training system like the one for physicians. Think of how the DO's have essentially the same but oftentimes inferior residencies as the MD's. There will be nursing versions of essentially all MD residencies. Every nursing school is essentially producing DNP's, something like 20,000 or more per year.

If the NP's control primary care, then they control patient flow. They will control what services are consulted and oftentimes by which group. Why must they send a consult to a physician cardiology group when they can send it to an NP cardiology group? Do you want your specialty being flooded by these nurse specialists? Do you understand what will happen to your income level and job prospects when the supply far exceeds the demand? What will happen to "low hanging fruit" specialties like derm and ED? Derm has been successful in attracting the best medical school applicants because it maintains high income and good lifestyle. What do you think will happen to derm when the nursing derm specialists start to flood the market? Pathology and radiology job markets are bad because we now have an oversupply of them. Back in 2002, radiology was the hottest specialty for jobs. Beginning around 2008, the radiology job market began to cool off because people delayed retirement, reimbursements dropped so groups refused to hire, teleradiology became more popular, and imaging volume stagnated. Many radiologists today complain that we need to reduce the number of graduating residents to improve the job market. This is what you can expect as the nurses infiltrate the specialties. Another example, look at what has happened to the lawyer job market. Lawyers are getting offers $10-$20/hour at lots of places.

CRNA's are the most militant of the nurses and a good preview of what's to come. They purposely confuse the public and lawmakers that they are no different in ability and knowledge to anesthesiologists. You already see that with NP's and primary care and ED. If the NP's have it their way, there should be no difference between an NP and physician in responsibility and authority and most important no difference between an NP and physician in salary. It's not 16 states that have approved independent practice for CRNA's. It's 23 states now. California and Colorado are the most recent states. It's just a matter of time before all 50 states approve independent practice for CRNA's and NP's. That's a reasonable assumption to make over the next 10-20 years. If that happens, imagine how the healthcare landscape for physicians will change. Choosing your specialty is very critical

Unfortunately, physicians have created this monster because we keep employing these NP's. Physicians are looking for short-term gain by increasing their salaries at the cost of the profession. Remember that you wouldn't have 120,000 NP's in this country if there were no jobs for them.

All I can do is warn my fellow physicians and physicians-in-training as I have for the past 10 years. I do my part by refusing to train or hire NP's. If given the choice, I choose to hire a fellow physician or at least a PA.

 

[Tired]

In short, I don't know if it is completely fair to blame Gas for its woes. There are real obstacles to a good study showing their worth.

You make great points, but I would argue two things:

(1) The obstacles to a good study that you mention are all real. And all can be overcome. If a private research service could cull a half-million records to come up with that study, the ASA could fund the same. Start with all ASA 3s and go from there.

(2) More importantly, as I've argued earlier, they don't even need a damn study. There is a lot more to anesthesiology than passing gas on routine elective cases. Unfortunately their professional organization has all the tact and charm of their posters on SDN - zero. If you compare the PR of my professional organization (AAOS) to the ASA, it's almost comedic at how poor anesthesiology manages their public image. They aren't engaging the public, they aren't engaging their colleagues, and then they expect everyone to recognize how great they are. As I've mentioned before, nothing substantitive has changed in the eight years I've been on this board, so they must be pretty happy being isolated and grumpy, so whatever.

 

[dadaddadaBATMAN]

You make great points, but I would argue two things:

(1) The obstacles to a good study that you mention are all real. And all can be overcome. If a private research service could cull a half-million records to come up with that study, the ASA could fund the same. Start with all ASA 3s and go from there.

(2) More importantly, as I've argued earlier, they don't even need a damn study. There is a lot more to anesthesiology than passing gas on routine elective cases. Unfortunately their professional organization has all the tact and charm of their posters on SDN - zero. If you compare the PR of my professional organization (AAOS) to the ASA, it's almost comedic at how poor anesthesiology manages their public image. They aren't engaging the public, they aren't engaging their colleagues, and then they expect everyone to recognize how great they are. As I've mentioned before, nothing substantitive has changed in the eight years I've been on this board, so they must be pretty happy being isolated and grumpy, so whatever.

For 2 at least, maybe it's more that SDN does not represent the overall feelings of the profession. Or that as long as they make money, they won't feel much incentive to change things.

 

[NickNaylor]

Nick you make good points but another thing to consider is that with something like medicine you have to have a little "overkill" in terms of knowledge relative to your scope, to prevent catastrophic events. I'd rather have a provider have " too much" knowledge on average(MD seeing avg patient) than someone having "too little" (NP) seeing a complex patient that they don't recognize as being complex. Physicians are like insurance in my opinion, you don't want to have to use them, but when you use them, you want your a** covered. If you start cutting corners and going with a cheaper policy, yeah it might not hurt you, but there's also going to be people that do that which end up completely screwed because of it(these people would absolutely be in the minority, just recognizing that fact).

Part of treating the common stuff in my opinion is knowing that if it ever becomes uncommon, the same person is ready to treat it and good to go. I also kinda compare it to like having a good mechanic change the oil in your car vs jiffylube(if you don't do it yourself). Yeah changing someone's oil isn't a big deal and I doubt they're going to do any worse than a good mechanic, but the good mechanic might notice other things going on that aren't even being addressed which could save me a lot of hassle down the road(no pun intended).

It seems everyone is so quick to cut costs and have every patient see someone with knowledge relative to the severity of their illness and I agree that's 1 way of increasing efficiency, but I don't think health care is an industry where people strive for efficiency. It seems ironic to me that the same people that say being a doc is a calling and physicians have some special duty to their patients are the same ones that want to bring mid-levels in to increase efficiency. On one hand those people are arguing where it's some special industry and shouldn't be run like a typical business and another they're trying to do so and lower costs. That paradox is what in my opinion leaves physicians to be blamed in the event where mid-levels mess up. If they're adequate enough to treat the common problems, then they're adequate enough to take full responsibility of the potential negatives as well.

I completely agree, and your points are what I weakly implied in my post. It would be great if we could easily distinguish the GERD pain vs. MI and the back pain vs. aortic dissection and triage patients to appropriate providers quickly, but we can't. And, of course, there are even more subtle cases than that. You never know if the person coming in for whatever complaint is a slam-dunk bread-and-butter case or something a little more elusive.

Physicians have value exactly because their training gives them a greater chance of distinguishing between imitators and similar conditions and recognizing when something "isn't right" and should be worked up more thoroughly. The NP argument that they can treat most cases "equivalent to physicians" is somewhat convincing, but who wants to be the 5% that they miss? No one. That's exactly why I refuse to see APNs when I go to the student health clinic - even if it means a longer wait. Frankly I don't trust them as a general rule to provide care equivalent to an MD, and dammit if I'm going to pay the same in tuition bucks for access to the student clinic, then I'm going to be seen by a MD or DO and not an APN.

Unfortunately the nuances of medicine are lost on anyone that hasn't been through medical training or provided medical care. This is why patients think their 20 minutes of research on WebMD is equivalent to being seen by the physician and they get frustrated when the physician wants to do a full H&P despite the patient telling you what they think is going on. Laymen don't get it. Unfortunately, many midlevel providers also don't seem to get it, as their ignorance consequent to their reduced training provides a misplaced confidence.

None of this is to say that midlevels are competent or important pieces of providing healthcare. They absolutely are. I'm just strongly opposed to their independent practice unless they can demonstrate equal competency to that of physicians. You wanna practice independently? Fine, pass step 2 and step 3, do some broad-based clinical training, and go at it. Don't do some nonsense 600-hour clinical program and then claim equivalence to physicians. That doesn't even pass the common sense test.

 

[PL198]

I completely agree, and your points are what I weakly implied in my post. It would be great if we could easily distinguish the GERD pain vs. MI and the back pain vs. aortic dissection and triage patients to appropriate providers quickly, but we can't. And, of course, there are even more subtle cases than that. You never know if the person coming in for whatever complaint is a slam-dunk bread-and-butter case or something a little more elusive.

Physicians have value exactly because their training gives them a greater chance of distinguishing between imitators and similar conditions and recognizing when something "isn't right" and should be worked up more thoroughly. The NP argument that they can treat most cases "equivalent to physicians" is somewhat convincing, but who wants to be the 5% that they miss? No one. That's exactly why I refuse to see APNs when I go to the student health clinic - even if it means a longer wait. Frankly I don't trust them as a general rule to provide care equivalent to an MD, and dammit if I'm going to pay the same in tuition bucks for access to the student clinic, then I'm going to be seen by a MD or DO and not an APN.

Unfortunately the nuances of medicine are lost on anyone that hasn't been through medical training or provided medical care. This is why patients think their 20 minutes of research on WebMD is equivalent to being seen by the physician and they get frustrated when the physician wants to do a full H&P despite the patient telling you what they think is going on. Laymen don't get it. Unfortunately, many midlevel providers also don't seem to get it, as their ignorance consequent to their reduced training provides a misplaced confidence.

None of this is to say that midlevels are competent or important pieces of providing healthcare. They absolutely are. I'm just strongly opposed to their independent practice unless they can demonstrate equal competency to that of physicians. You wanna practice independently? Fine, pass step 2 and step 3, do some broad-based clinical training, and go at it. Don't do some nonsense 600-hour clinical program and then claim equivalence to physicians. That doesn't even pass the common sense test.

I'd just love to ask a NP leader that question : " So if you're telling me you get equal outcomes to MDs, what exactly is the purpose of medical school and residency?"

 

[NickNaylor]

I'd just love to ask a NP leader that question : " So if you're telling me you get equal outcomes to MDs, what exactly is the purpose of medical school and residency?"

Yeah, that's just great. I posted this in another thread on a similar topic but the AANP released a statement regarding residencies (oh, I'm sorry, "fellowships") for NPs that essentially stated that requiring additional training is 1) unnecessary since NP training as it currently is is complete, 2) a waste if taxpayer dollars, and 3) would delay much needed providers from getting out there and providing healthcare.

It would be hilarious if it weren't so infuriating.

 

[PL198]

Yeah, that's just great. I posted this in another thread on a similar topic but the AANP released a statement regarding residencies (oh, I'm sorry, "fellowships") for NPs that essentially stated that requiring additional training is 1) unnecessary since NP training as it currently is is complete, 2) a waste if taxpayer dollars, and 3) would delay much needed providers from getting out there and providing healthcare.

It would be hilarious if it weren't so infuriating.

honestly residency is unnecessary, medicine should just be a layperson seeing patients, phoning the results into a 20 yr old that memorizes some book and then recites the book back to the layperson who carries out the needed treatment

 

[DermViser]

Yeah, that's just great. I posted this in another thread on a similar topic but the AANP released a statement regarding residencies (oh, I'm sorry, "fellowships") for NPs that essentially stated that requiring additional training is 1) unnecessary since NP training as it currently is is complete, 2) a waste if taxpayer dollars, and 3) would delay much needed providers from getting out there and providing healthcare.

It would be hilarious if it weren't so infuriating.

Yeah they deem it "unnecessary". Not surprised there. After all they're practicing nursing, not medicine.

Not at all surprised they use the financial angle, bc that appeals the most to politicians, and that apparently it delays providers out to the public -- forget if it's safe or not - as long as the public gets its providers.

Meanwhile the medical education establishment is turning the screws on med students, residents, and attendings when it comes to licensure and certification, while NPs don't do jack squat. Apparently MDs can't be trusted around Pharma at all, but for NPs it's a-ok and even encouraged. Ridiculous.

 

[DermViser]

honestly residency is unnecessary, medicine should just be a layperson seeing patients, phoning the results into a 20 yr old that memorizes some book and then recites the book back to the layperson who carries out the needed treatment

What I think is sad that it takes the govt. for med schools to change their education rather than med schools changing their education on their own. Now med schools are playing catch up instead of trimming inefficiencies within the system.

 

[PL198]

What I think is sad that it takes the govt. for med schools to change their education rather than med schools changing their education on their own. Now med schools are playing catch up instead of trimming inefficiencies within the system.

they'll never trim, medical administrators have the smallest amount of common sense and business sense of any group of people in the world. honestly I believe that. I mean the whole profession basically sucks common sense out of you, so it's no surprise, same with anything involving money. I mention compensation in class and I'll end up with "professionalism concerns" or something like that.

 

[DermViser]

they'll never trim, medical administrators have the smallest amount of common sense and business sense of any group of people in the world. honestly I believe that. I mean the whole profession basically sucks common sense out of you, so it's no surprise, same with anything involving money. I mention compensation in class and I'll end up with "professionalism concerns" or something like that.

It's bc medical administrators, many of them MDs, PhDs, M.Eds, etc. benefit from the system as it is now. Being a Dean of Student Affairs where you sit on your *** pays more than being a doctor who actually sees patients full-time.

 

[PL198]

It's bc medical administrators, many of them MDs, PhDs, M.Eds, etc. benefit from the system as it is now. Being a Dean of Student Affairs where you sit on your *** pays more than being a doctor who actually sees patients full-time.

yes but you're forced to sit around other *****s all day. I'd rather not do that

 

[DermViser]

yes but you're forced to sit around other *****s all day. I'd rather not do that

You would if it was double your salary busting your balls as a clinician.

 

[KnuxNole]

yes but you're forced to sit around other *****s all day. I'd rather not do that

Thats no different than most jobs in the US

 

[PL198]

Thats no different than most jobs in the US

true but the people in academia think they're gods even though they're *****s, that's what annoys me

 

[oldbearprofessor]

true but the people in academia think they're gods even though they're *****s, that's what annoys me

I'm curious if you've ever met an "academic" whom you thought was at least reasonably humble and wise and to whom you were grateful for the time and effort they spent teaching you?

 

[PL198]

I'm curious if you've ever met an "academic" whom you thought was at least reasonably humble and wise and to whom you were grateful for the time and effort they spent teaching you?

in 1.1 years of med school and undergrad? twice. one in undergrad, one in medical school.

 

[Psai]

I'm curious if you've ever met an "academic" whom you thought was at least reasonably humble and wise and to whom you were grateful for the time and effort they spent teaching you?

I've met five. All awesome people and really great teachers

 

[DermViser]

I'm curious if you've ever met an "academic" whom you thought was at least reasonably humble and wise and to whom you were grateful for the time and effort they spent teaching you?

 

[oldbearprofessor]

You've never met an "academic" (meaning med school faculty in this context) whom you thought was at least reasonably humble? Well, that certainly isn't me, but I think they might exist. Regardless, if any of you who did meet profs to whom you were grateful for their teaching, did you tell them? And I don't mean did you give ritual applause at the end of a lecture, but did you personally thank them?

 

[DermViser]

You've never met an "academic" (meaning med school faculty in this context) whom you thought was at least reasonably humble? Well, that certainly isn't me, but I think they might exist. Regardless, if any of you who did meet profs to whom you were grateful for their teaching, did you tell them? And I don't mean did you give ritual applause at the end of a lecture, but did you personally thank them?

A physician who is a faculty member of the medical school and works for an academic medical center who is humble? No. They were quite happy and full of themselves , unlike physicians in private practice. And I agree with you, I would never accuse you of being humble.

 

[oldbearprofessor]

A physician who is a faculty member of the medical school and works for an academic medical center who is humble? No. They were quite happy and full of themselves , unlike physicians in private practice. And I agree with you, I would never accuse you of being humble.

Is it necessarily the case that "being full of themselves", and "happy" is problematic for you as a learner? Are confident academic attendings always bad teachers? I can see that an attending that was so egotistical that they couldn't accept any other perspectives would be problematic as a teaching physician, but is it possible to be confident and a good teacher? Have you met such people that you respected as educators?

 

[Kahreek]

I would choose a physician just because it makes everything more glamorous, tbh.

 

[DermViser]

I would choose a physician just because it makes everything more glamorous, tbh.

I love your contributions to the conversation.

 

[fancypantsdance]

my dads friend hurt his knee and went into an ER one night, a PA evaluated him, check out the imaging studies, and diagnosed it as a sprain, gave him some meds and sent him home. Turns out, he had fractured his tibial plateau. Because of the wrong diagnosis, his conditioned worsened and he had to have surgery done a week later that could have otherwise been avoided.

No, I don't think primary care should be turned over to PA's or NP's. They will miss things that will cost the patient time, money, and maybe their life. I don't think they should be in charge of anything. There is stark contrast between the knowledge of a physician and a mid level provider. The only reason they are around is because they save certain people money.

 

[DermViser]

my dads friend hurt his knee and went into an ER one night, a PA evaluated him, check out the imaging studies, and diagnosed it as a sprain, gave him some meds and sent him home. Turns out, he had fractured his tibial plateau. Because of the wrong diagnosis, his conditioned worsened and he had to have surgery done a week later that could have otherwise been avoided.

No, I don't think primary care should be turned over to PA's or NP's. They will miss things that will cost the patient time, money, and maybe their life. I don't think they should be in charge of anything. There is stark contrast between the knowledge of a physician and a mid level provider. The only reason they are around is because they save certain people money.

PAs are the worst, esp. in acute/emergency settings. I would have sued if I was your Dad's friend.

 

[NontradCA]

Have any of you guys ever seen an NP for care and noticed a gap in knowledge between yourself and them? I'm curious since we are all med students or physicians on here.

Yes. Everytime I've ever seen an NP. Despite what you read on SDN NPs and physicians usually work collaboratively and NPs understand their role. The last two times I've seen a NP they both referred me to a physician. The time before that I was thrown antibiotics during a 2 minute visit.

This is obviously from a patients perspective but it's in plain view. I wouldn't worry too much about CRNAs, NPs.

 

[calvnandhobbs68]

There are a lot of great reasons to prefer anesthesia-supervised care over CRNA independent practice. Anesthesiology offers a range of services that CRNAs are not capable of, including ICU-level medical care, superior preoperative evaluation, improved ability to diagnose/manage/treat medical diseases, and significant dilution of the medicolegal liabilities inherrent in surgical care. If I were an anesthesiologist, these are the thing that I would be emphasizing to hospitals and surgeons. I don't think this is even a discussion that needs to be had with the general public, since ultimately it is hospitals and surgeons who will make the call on the desirability of independent CRNA practices.

FWIW - as an eventual attending surgeon, I find it highly unlikely I would ever utilize the services of an independent CRNA.

lol

you know who does the pre-op evals for our pre-op clinic? Guess who?
PAs

 

[Psai]

So I just had a family come in for an initial visit because the other doctors office they were going to had them seeing NPs and PAs all the time. They were dissatisfied at not being able to see the doctor and said that the midlevels didn't really know them, didn't really listen to them and just looked at the computer the whole time. They said that they felt like they were being rushed in and out of the office. Just wondering if other people have had the same experience because I have heard this many times, especially about specialty offices. Which doesn't make much sense to me because you send someone to a specialist to get the specialist's opinion, not a midlevel

 

[zeppelinpage4]

As a med student currently interested in primary care, I certainly hope not. I think NP/PAs are very helpful and have an important role in it. But, I'd like to have my place in the field too if I pursued it.

 

[cbrons]

There have been many debates about NP/PA encroaching into primary care and anesthesia and I have heard that physicians are often the ones who carry the malpractice burden because most of the time these people (NP/PA) are working 'under the supervision' (whatever that means) of a physician... Also, I think that when **** hit the fan, most people won't go after the NP/PA; they most likely will go after the MD/DO because that where they think the money is... Why would physicians take such big risk for other health care professionals? Should the system phase out PCP/(maybe)Anesthesia MD/DO where people don't have to go to med school to become a full scope provider and let them have all the BS that comes with that... Do you think these NP/PA will they try to encroach further if physician let them?

NPs will be doing surgery autonomously in a few years. Peeps who said to let them have XYZ primary care specialty because you are ABC specialist may be surprised, but that's the nature of "give an inch, lose a mile." First they came for the family practitioners, and I didn't speak out because I wasn't an FP. Then they came for the anesthesiologists, and I didn't speak out because I wasn't an anesthesiologist. Then they came for the derms and I didn't speak out because I wasn't a derm. Etc. etc. etc.

but all of that is just my prediction, I'm still a student and I don't know how much I care about the issue truthfully, just making an observation based on human nature

 

[W19]

I would say let them take over...

 

[BestDoctorEver]

NPs will be doing surgery autonomously in a few years. Peeps who said to let them have XYZ primary care specialty because you are ABC specialist may be surprised, but that's the nature of "give an inch, lose a mile." First they came for the family practitioners, and I didn't speak out because I wasn't an FP. Then they came for the anesthesiologists, and I didn't speak out because I wasn't an anesthesiologist. Then they came for the derms and I didn't speak out because I wasn't a derm. Etc. etc. etc.

but all of that is just my prediction, I'm still a student and I don't know how much I care about the issue truthfully, just making an observation based on human nature

I was reading a nursing blog where some of them were saying nursing organizations should advocate for them to get 1-2 year surgical training so they can do 'minor' surgeries because NP do that in some place in Europe (I think in England) . I read somewhere here that some hospitals are teaching them to do scopes. Watch out GI docs! So it is not impossible to start hearing these nursing organizations start saying that they is some shortage and they can be trained to do minor surgeries and let surgeons take on the big cases...

http://www.nursingtimes.net/developing-the-nurse-practitioners-role-in-minor-surgery/206424.article

 

[PL198]

what is the point at being called a nurse then

 

[67552931811]

I would say let them take over...

Wtf? Let's "let them take over" EM, psych, and peds too.

Or, do you object to that since you want psych atm?

 

[W19]

Wtf? Let's "let them take over" EM, psych, and peds too.

Or, do you object to that since you want psych atm?

If they are providing equal or better care that is cheaper, why not... Most NP are 'prestige-seeking ....' , so I doubt they will go into psych.

 

[Carbocation1]

My friend at a top school said that his school's dean gave a dinner lecture talking about how midlevels are negatively impacting opportunities for physcians. He singled out anesthesia specifically. I was shocked to hear this. When academia admits it's a problem, you know it has gotten really bad.

 

[67552931811]

If they are providing equal or better care that is cheaper, why not... Most NP are 'prestige-seeking ....' , so I doubt they will go into psych.

Ah, yes, the equal or better care comment. Let's be real, effectively no one actually believes that. Cheaper for...? Who, exactly?

So much prestige in FM, so much...

 

[W19]

Ah, yes, the equal or better care comment. Let's be real, effectively no one actually believes that. Cheaper for...? Who, exactly?

So much prestige in FM, so much...

While FM does not have that much prestige among physicians, it is, however, a big thing for NP. You can't deny that most people don't consider psychiatrist as doctors...

 

[Pasmal]

Ah, yes, the equal or better care comment. Let's be real, effectively no one actually believes that.

What's your definition of "better care"? In terms of managing chronic conditions and meeting target levels, NPs do fairly well. In terms of patient satisfaction, preventative medicine, I see no reason to expect a lower standard of care from NPs.

Ask any family physician who oversees NPs though, and they'll tell you that the supervision is definitely needed because they need someone to turn to when they run into "weird" stuff. For an experienced NP, however, I'd imagine that support becomes less frequent. That is to say, in 199/200 visits the NP knows exactly what to do. What, then, prevents them from performing in a manner clinically comparable to a trained physician?

 

[PL198]

What's your definition of "better care"? In terms of managing chronic conditions and meeting target levels, NPs do fairly well. In terms of patient satisfaction, preventative medicine, I see no reason to expect a lower standard of care from NPs.

Ask any family physician who oversees NPs though, and they'll tell you that the supervision is definitely needed because they need someone to turn to when they run into "weird" stuff. For an experienced NP, however, I'd imagine that support becomes less frequent. That is to say, in 199/200 visits the NP knows exactly what to do. What, then, prevents them from performing in a manner clinically comparable to a trained physician?

Because what makes a physician isn't how you handle 199/200, it's how you handle the 1 with unusual stuff. Most residents can treat colds, diabetes and smoking cessation counseling sessions pretty easily, yet they're still learning for a reason. The whole point is that you don't see adverse outcomes from NPs because the supervising physician catches them. As you continue to say NPs are valid, either a) you put more of them under the watch of one physician, making them more prone to miss things that the NPs screw up b) they truly practice on their own and screw up that 1/200.

Common is common. It's not difficult to treat common. You don't go to med school for 4 years and then residency to be an expert for common.

I've said this so many times before. So if you think NPs get equal outcomes and that there's no statistical confounding or bias there, then what is the point of medical school?

 

[Pasmal]

I was responding to your claim that care is unequal with the idea that the care may be equal in certain areas, and that as a NP's develops his/her clinical reasoning, his/her clinical efficacy approaches that of a physician in the majority of cases, . Statements like "everyone agrees they're not equal" oversimplify the issue and discourage further inquiry IMO.

 

[NickNaylor]

What's your definition of "better care"? In terms of managing chronic conditions and meeting target levels, NPs do fairly well. In terms of patient satisfaction, preventative medicine, I see no reason to expect a lower standard of care from NPs.

Ask any family physician who oversees NPs though, and they'll tell you that the supervision is definitely needed because they need someone to turn to when they run into "weird" stuff. For an experienced NP, however, I'd imagine that support becomes less frequent. That is to say, in 199/200 visits the NP knows exactly what to do. What, then, prevents them from performing in a manner clinically comparable to a trained physician?

As @PL198 says above, that's because these things are, on their face, simple to treat. By the time you're an M4, you will very likely be able to successfully diagnose and treat things like UTIs, HTN, DM, and other "chronic" diseases. Yet, you are forbidden by law to practice immediately after graduating from medical school. So what gives?

The true competency is being able to generate a differential that is more than two diagnoses long and, when treatment failure occurs, being able to rethink your diagnosis and come up with an alternate cause.

Also, having looked at the studies used by the AANP to advocate for equal NP practice rights, I would be giving them credit by saying that the studies are weak at best. The largely consist of either 1) comparing BP after x amount of time for patients with HTN treated by NPs and physicians or 2) average blood glucose in patients with DM treated by NPs and physicians. How on earth does that even come close to measuring competency or quality?

 

[Pasmal]

Agreed, to clarify I don't think NPs will ever be able to replace physicians, I just wanted to state that saying "nobody really believes x" doesn't really do anything for the discussion at hand, a discussion that has significant numbers of administrators who do make these decisions on both sides of the table.

 

[KnuxNole]

I'd puke in their mouth if a NP thinks s/he can replace a MD

 

[Psai]

If they are providing equal or better care that is cheaper, why not... Most NP are 'prestige-seeking ....' , so I doubt they will go into psych.

That's a bs statement. They provide inferior care. You take a lesser product and give it much less training and less experience, how can it possibly match up? Spend some time doing clinical medicine and the gap will be very obvious. There are also nps in psych, it has little to do with prestige

And cheaper? Who says? Who benefits? Sure as hell ain't patients

 

[Psai]

What's your definition of "better care"? In terms of managing chronic conditions and meeting target levels, NPs do fairly well. In terms of patient satisfaction, preventative medicine, I see no reason to expect a lower standard of care from NPs.

Ask any family physician who oversees NPs though, and they'll tell you that the supervision is definitely needed because they need someone to turn to when they run into "weird" stuff. For an experienced NP, however, I'd imagine that support becomes less frequent. That is to say, in 199/200 visits the NP knows exactly what to do. What, then, prevents them from performing in a manner clinically comparable to a trained physician?

You can't just make up a bs number like that. Experience counts for a lot but it doesn't replace formal training. And there are plenty of times where the pcp doesn't know what to do so they refer out

In the second year of medical school, they tell you that you see this this and this then it's this disease. In real life you get this maybe this another random thing out of left field and you also have this weird thing on their eye. Ten things on the differential, you get a consult and you still have no idea what is going on.

I can meet measures and manage chronic diseases right now. But I'm nowhere close to my attendings