You guys should do DO, NP and PA over Carib MD

[vancouvergeorge]

All physicians are going to get shafted once the health care bill goes into effect in 2014. The winners will be NPs and PAs, who will have half the training and debt, and still do pretty much the same work as primary care physicians do.

IMGs in particular will be doubly shafted. They go through the MD process but have fewer opportunities to enjoy the perks (such as matching into ortho or plastics). At least the DOs have their own exclusive residencies. Furthermore, physician ratings will become more and more central in the future, no one knows how a Caribbean education will factor into the formula. With the Internet generation growing up, patients will also be more savvy in researching your educational background. So all the previous talk about how no one knows or cares where you went to medical school may no longer hold true.

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[vhinrich]

All physicians are going to get shafted once the health care bill goes into effect in 2014. The winners will be NPs and PAs, who will have half the training and debt, and still do pretty much the same work as primary care physicians do.

IMGs in particular will be doubly shafted. They go through the MD process but have fewer opportunities to enjoy the perks (such as matching into ortho or plastics). At least the DOs have their own exclusive residencies. Furthermore, physician ratings will become more and more central in the future, no one knows how a Caribbean education will factor into the formula. With the Internet generation growing up, patients will also be more savvy in researching your educational background. So all the previous talk about how no one knows or cares where you went to medical school may no longer hold true.

I hope you have some proof to back up your claim. Explain to me what provisions of the health care bill can result in the claims you're making?

In my opinion, most people (including the internet generation) don't usually look up where their doctor went to school as long as he is competent, unless of course they are undergoing a major procedure.

 

[badasshairday]

You will be at a disadvantage when it comes to the match, this is no secret.

DO>Carib MD without a doubt, especially these days. Class sizes and the number of new medical schools are on the increase in the USA, while residency positions remain stagnant. If you are an IMG, you better be a superstar, because a blood bath is about to occur in a few years. It is getting tighter and tighter each year.

If you can't get into a DO school, then look at other professions instead. Pharmacy, Dentistry, Physician Assistant, are all great professions and much more secure than going over seas to med school

 

[demayette]

All physicians are going to get shafted once the health care bill goes into effect in 2014. The winners will be NPs and PAs, who will have half the training and debt, and still do pretty much the same work as primary care physicians do.

IMGs in particular will be doubly shafted. They go through the MD process but have fewer opportunities to enjoy the perks (such as matching into ortho or plastics). At least the DOs have their own exclusive residencies. Furthermore, physician ratings will become more and more central in the future, no one knows how a Caribbean education will factor into the formula. With the Internet generation growing up, patients will also be more savvy in researching your educational background. So all the previous talk about how no one knows or cares where you went to medical school may no longer hold true.

As a NP or PA, you will be treated as a second class citizen in health care settings. There will be many times you would say to yourself: I should have gone to medical school (MD or DO). As an RN, I have seen and heard that myself from PA and NP. Also, patients will tell you I dont want an assistant (PA or NP) to treat me; I want to see the doctor (MD or DO). If you can not make it to med school in the US, I think podiatry, dental school , pharmacy school would be a better option. However, if you dont see yourself happy being anything else other than a Physician, I think it worth taking the risk going to the caribbean. I still think for people who want to become primary physicians, the caribbean is good option. Choose only the big 4.

 

[LEVAMISOLE]

I knew I shoulda been a DO!! Damn it take my MD back!! I feel so ashamed......and sad....

 

[Gfliptastic]

Mark my words.

W/ the impending healthcare reforms, the chops will come from at the tops. Just like Wall Street.

You people (which it seems to be everyone on SDN) who expect to live the Dr Christian Troy lifestyle of daily Armani suits in a Lambo are in for a surprise.

Every think tank working on healthcare has acknowledged that reform begins with enticing more people to a Primary Care practice.

Instead of posting on SDN about your desire to make a zillion dollars doing complicated surgery, you should read what is going to happen w/ healthcare.

After all some of us want to be a physician...to heal people.

 

[vancouvergeorge]

I love it when the Caribbean med students go to the orthopedic surgery boards and post "I have a 226 Step 1, how do I make myself competitive for ortho?"

They never bothered to even research NRMP match statistics. If they did, they would have found that only three US IMGs matched into ortho in 2010 and 2009, out of 641 spots. And here they are asking for advice on matching ortho with a below average Step 1 score for even US ortho applicants. Persistence is honorable, but not when it becomes quixotic and self-delusional.

 

[aa62]

yes people the moral of the story is, if you cannot get into medical school in Canada or US, don't bother with pursuing your dream of medicine .

Because no matter how well you do in your basic sciences, in your step exams, in your clinical rotations, or how solid your LORs are, you are destined to go unmatched with hundreds of thousands of dollars in debt .

 

[Gfliptastic]

Thanks troll/vancouvergeorge

Don't you have to be in the FP forum telling them they also need to do NP and PA now?

 

[dragonfly99]

actually, vancouver has some good points...although I think they were a bit overstated.
I would not be surprised if some of what he/she posts does come to pass.
As far as patients wanting to see "the doctor" and not a PA/NP, you will get arrogant egotistical people in any field where you work. As a doc, I get patients who don't want to see me (since I'm still a fellow) or who assume I can't be the cardiologist because I'm a woman, or that I can't be competent because I look too young, or that I can't be competent because I'm not at a famous hospital like Mayo or Harvard. There are people who you will never please no matter how nice or competent you are, or what you do, or how much time you spend with them. There are patients who will think you are great even if you screw up, even if you don't feel you did such a great job...they are just grateful people in general, have a sweet personality, or have a great deal of respect for health care personnel.

As far as PA or NP's grousing that they should have been a doc, I think that if you listen you'll also hear docs, particularly primary care ones, grousing that they should have been a PA or NP or physical therapist or dentist, because they could have worked fewer hours and made almost as much money and spent fewer years in training and paying tuition. The grass is always greener on the other side of the fence.

 

[schandan13]

I love it when the Caribbean med students go to the orthopedic surgery boards and post "I have a 226 Step 1, how do I make myself competitive for ortho?"

They never bothered to even research NRMP match statistics. If they did, they would have found that only three US IMGs matched into ortho in 2010 and 2009, out of 641 spots. And here they are asking for advice on matching ortho with a below average Step 1 score for even US ortho applicants. Persistence is honorable, but not when it becomes quixotic and self-delusional.

That's wisdom right there.

 

[basupran]

I love it when the Caribbean med students go to the orthopedic surgery boards and post "I have a 226 Step 1, how do I make myself competitive for ortho?"

They never bothered to even research NRMP match statistics. If they did, they would have found that only three US IMGs matched into ortho in 2010 and 2009, out of 641 spots. And here they are asking for advice on matching ortho with a below average Step 1 score for even US ortho applicants. Persistence is honorable, but not when it becomes quixotic and self-delusional.

While I do agree that certain things are just not worth the effort, I also realize that there is more to matching. I personally know a Caribbean grad who matched into ortho with an even lower score (215). Exceedingly rare- but possible. Last thing people need is someone telling them that they are being 'quixotic and self-delusional'.

 

[CaribKid]

Whenever I need motivation during studying (I think we all know that time of day when you have checked Facebook ten times, read the news twice, and are struggling to stay awake), I read this forum. So, let's all try this together:
Relax.
If any anonymous person on SDN tells you to not become an MD because you will should be a PA or NP instead (for no other reason than you didn't get into a US or Canadian school), just laugh. People will tell you this your entire life. Give up. You can't do it. I am better than you. Who cares what they think? Go to medical school for you, and only you. If it is in the Caribbean, so be it. Of course, you should do a lot of homework, but I will get to that.
Relax.
Not everyone wants to do ortho or plastics. Doing something you are not interested in isn't a "perk". It is annoying. Do what you enjoy, whatever it may be. If it is Primary Care, be a GP. If it is ortho, are you at a disadvantage in the Caribbean? Yup. Should you give up? It would be a shame if you did because some guy on a forum told you to. Does this mean you should expect that amazing residency match? Unfortunately, no. Don't EXPECT anything. Work as hard as humanly possible, and do everything you can to get that residency you want. You may not get it. But you didn't give up, either. And, happily, you will still be what you wanted to be: a doctor. Remember why you wanted to be one in the first place?
Relax.
When I read about a patient becoming savvier with the internet, I had to laugh. Patients do not care if you went to the Caribbean. Really. I worked in a hospital for two years before coming to med school in the Caribbean. The chief of emergency medicine? Caribbean. Three GPs? Caribbean. Quite a few surgeons? Caribbean and foreign. They treated patients every day, and I never once, in two years, heard a single word about where they went to med school.
Relax, for the love of God.
I love how Caribbean match numbers get quoted as if they came down from God. We all understand the difference between the Big 4 (3) don't we? (I don't mean to put down Saba, it's just the lack of federal loans can be a deal breaker). However, Caribbean match numbers are not from just those schools. They are ALL Caribbean schools. To be honest, if you go to a Caribbean school which will not let you practice in the US in all 50 states it is a mistake (unless you don't care about being restricted in such a way…..I think you should, but I don't know you and you know about your own life a lot better than me). There are a lot of Caribbean schools which are not schools, and will just take your money. If this is your school, you will have problems with the Step. If you have problems with the Step, you won't match. The match numbers are MUCH MORE FAVORABLE when you exclude all but the Big 4 (3). That 47% goes up quite a bit. AUC (which I attend) reports their number as around 90%. Does this include Transitional Year to General Surgery, etc.? Yeah, probably. But having been here and physically talking to students who match, I can tell you the number isn't 47%. So saying that three guys matched Ortho out of ten million and thus the percentage is 0.0000000000001% isn't completely truthful.
And finally, RELAX!
A "blood bath"? Really? Hyperbole is fun in freshman lit. Will it get tougher? Certainly. Impossible? Far from it. There has been no decision about residency numbers. They may go up. They may stay the same. But the US schools (the vast majority) will not be graduating new medical students until sometime around 2016. Yes, you can do a quick Google search to find this is true. It all comes down to Medicare, which pays for residencies in hospitals. I personally don't think my classmates' body parts will be strewn across me on Match Day. I think some of them will scramble, and some will go unmatched. It won't be the 97% (or 99%?) as in US med schools. But for the next decade or so (yes, decade, again look up when the vast majority of schools are planning on graduating classes) it will be fine. You will most likely not go unmatched (if you are Big 4 (3), anything else is a bit of a gamble, to be fair). You will be ok.
In sum, why take advice about the Caribbean from someone who isn't here? People will tell you that you must have gone to the Caribbean because you are dumb. I, for example, ended up here because I had to work two jobs during undergrad, and come from a rough home. Not as conducive to studying as one may expect. Many of my classmates had similar issues. Are they dumb? Far from it. Work hard, perform well, and you will be fine. Slack off, don't study, and you will do poorly. Period. And if you need motivation when you get a little tired of studying, come read SDN Caribbean. Now, let the hate mail pour in…..

 

[schandan13]

Whenever I need motivation during studying (I think we all know that time of day when you have checked Facebook ten times, read the news twice, and are struggling to stay awake), I read this forum. So, let’s all try this together:
Relax.
If any anonymous person on SDN tells you to not become an MD because you will should be a PA or NP instead (for no other reason than you didn’t get into a US or Canadian school), just laugh. People will tell you this your entire life. Give up. You can’t do it. I am better than you. Who cares what they think? Go to medical school for you, and only you. If it is in the Caribbean, so be it. Of course, you should do a lot of homework, but I will get to that.
Relax.
Not everyone wants to do ortho or plastics. Doing something you are not interested in isn’t a “perk”. It is annoying. Do what you enjoy, whatever it may be. If it is Primary Care, be a GP. If it is ortho, are you at a disadvantage in the Caribbean? Yup. Should you give up? It would be a shame if you did because some guy on a forum told you to. Does this mean you should expect that amazing residency match? Unfortunately, no. Don’t EXPECT anything. Work as hard as humanly possible, and do everything you can to get that residency you want. You may not get it. But you didn’t give up, either. And, happily, you will still be what you wanted to be: a doctor. Remember why you wanted to be one in the first place?
Relax.
When I read about a patient becoming savvier with the internet, I had to laugh. Patients do not care if you went to the Caribbean. Really. I worked in a hospital for two years before coming to med school in the Caribbean. The chief of emergency medicine? Caribbean. Three GPs? Caribbean. Quite a few surgeons? Caribbean and foreign. They treated patients every day, and I never once, in two years, heard a single word about where they went to med school.
Relax, for the love of God.
I love how Caribbean match numbers get quoted as if they came down from God. We all understand the difference between the Big 4 (3) don’t we? (I don’t mean to put down Saba, it’s just the lack of federal loans can be a deal breaker). However, Caribbean match numbers are not from just those schools. They are ALL Caribbean schools. To be honest, if you go to a Caribbean school which will not let you practice in the US in all 50 states it is a mistake (unless you don’t care about being restricted in such a way…..I think you should, but I don’t know you and you know about your own life a lot better than me). There are a lot of Caribbean schools which are not schools, and will just take your money. If this is your school, you will have problems with the Step. If you have problems with the Step, you won’t match. The match numbers are MUCH MORE FAVORABLE when you exclude all but the Big 4 (3). That 47% goes up quite a bit. AUC (which I attend) reports their number as around 90%. Does this include Transitional Year to General Surgery, etc.? Yeah, probably. But having been here and physically talking to students who match, I can tell you the number isn’t 47%. So saying that three guys matched Ortho out of ten million and thus the percentage is 0.0000000000001% isn’t completely truthful.
And finally, RELAX!
A “blood bath”? Really? Hyperbole is fun in freshman lit. Will it get tougher? Certainly. Impossible? Far from it. There has been no decision about residency numbers. They may go up. They may stay the same. But the US schools (the vast majority) will not be graduating new medical students until sometime around 2016. Yes, you can do a quick Google search to find this is true. It all comes down to Medicare, which pays for residencies in hospitals. I personally don’t think my classmates’ body parts will be strewn across me on Match Day. I think some of them will scramble, and some will go unmatched. It won’t be the 97% (or 99%?) as in US med schools. But for the next decade or so (yes, decade, again look up when the vast majority of schools are planning on graduating classes) it will be fine. You will most likely not go unmatched (if you are Big 4 (3), anything else is a bit of a gamble, to be fair). You will be ok.
In sum, why take advice about the Caribbean from someone who isn’t here? People will tell you that you must have gone to the Caribbean because you are dumb. I, for example, ended up here because I had to work two jobs during undergrad, and come from a rough home. Not as conducive to studying as one may expect. Many of my classmates had similar issues. Are they dumb? Far from it. Work hard, perform well, and you will be fine. Slack off, don’t study, and you will do poorly. Period. And if you need motivation when you get a little tired of studying, come read SDN Caribbean. Now, let the hate mail pour in…..

Great post.

Now don't get all riled up when posters start bashing every line in it.

 

[Aphtalyfe]

Great post.

Now don't get all riled up when posters start bashing every line in it.

x2

Pretty hard to bash the stuff he said... since its all true.

 

[XORD]

Hello, first i want to thank you guys for such a awsome post.i have very important question for .i someoen who did both PA and MD .want ask which field basic science classes are more difficult P.A or Med . I can do pa in usa , but for med school i have to go to carribean and im just scared with science curriculum . Can u please rate basic science classes of pa vs med from 1-10 scale , for each .and i would also like to know about ur experiance with usmle vs pance which was more difficult. Im 22years old last year of my under graduate. and really stuck at this point, im the only one pursuing education in my family and i want to know where im getting myself into.i need your opinion on this. If basic science classes are easier on pa than med , it will less riskier for me and my family to pursue pa.so do usmle 1 vs pance. I love health care and im not trying to get a easy route , its just all my family hopes are on me i just waana make a safer decision career wise .please help me .if im ready to commit everything.just want to know your insight and experiance while preparion for classes and test
Thank you very much.

 

[NotAProgDirector]

Although I can't really answer your primary question (which basic sci classes are harder), you did mention that you're looking for an answer that is "less risky" and "safer". There is no question that doing PA school here in the US is much safer than doing a carib MD. If a low risk, stable, well paying career in healthacre is what you're looking for, then you should be a PA. If you absolutely want to be an MD and are willing to accept higher risk, then the carib is a reasonable option.

 

[Skip Intro]

I work with a lot of PAs, NPs, CRNAs and a whole host of other practitioners who are not MD/DOs.

Bottom line is all that anyone cares about is competence. There are a lot of paths out of the forest. Choose the one that gives you the highest chances of success.

I will say this, though: no one has to co-sign my orders.

-Skip
Ross Grad
Board-Certified

 

[LoudBark]

Legally doctors don't have to co-sign orders of NP's and PA's.....just med students.
NP's and PA's can and do write orders on their own and although they may work under a doctor, they can write their own orders independently.

 

[Skip Intro]

Legally doctors don't have to co-sign orders of NP's and PA's.....just med students.
NP's and PA's can and do write orders on their own and although they may work under a doctor, they can write their own orders independently.

Wrong.

Yes, a PA/NP can write a prescription or order. But, that is under the authority of a supervising physician. I work with many CRNAs, and they draw-up and give drugs all the time... under my supervision. And, depending on individual hospital bylaws those orders may have to be co-signed. Or, as in the case at my hospital, always.

But, don't take "co-signing orders" too literally. When you are a mid-level, you always answer to someone higher in the patient-caregiver relationship . And, trust me, most of the time that is a good thing.

-Skip

 

[Skip Intro]

All physicians are going to get shafted once the health care bill goes into effect in 2014. The winners will be NPs and PAs, who will have half the training and debt, and still do pretty much the same work as primary care physicians do.

IMGs in particular will be doubly shafted. They go through the MD process but have fewer opportunities to enjoy the perks (such as matching into ortho or plastics). At least the DOs have their own exclusive residencies. Furthermore, physician ratings will become more and more central in the future, no one knows how a Caribbean education will factor into the formula. With the Internet generation growing up, patients will also be more savvy in researching your educational background. So all the previous talk about how no one knows or cares where you went to medical school may no longer hold true.

This type of scaremongering has been recycled, literally, for the past twenty plus years. It came into full effect when Clinton took office. It just doesn't seem to go away. And, I just don't believe that the public is as willing to allow this type of grandiose social experimentation as you assert.

Me? I'm still waiting for the sky to fall... In the meantime, I can tell you firsthand that if you think that hospital administrators are desperate to rid the halls of their institutions of doctors and replace them with inferior-trained mid-levels, you'd be wrong. Very, VERY wrong.

We are actually trying to replace our CRNAs with doctors right now, not the other way around. And, that, my friends, is an equally vexing challenge. Tell an advanced-practice nurse that makes $180K+ a year and who doesn't directly report to your group that you think they're overpaid and don't provide a value-added service to the organization for a variety of reasons... and you have a pack of fun times on your hands.

I happen to work at a hospital that has turned around their surgical services and increased the caseload, in large part by hiring the group I'm working for over 6 years ago (just renewed our hospital three-year contract, and I've been there coincidentally for the past three years). The quality improvement in peri-operative care, although often difficult to quantify, is noticed by those steering the ship. It's noticed by the surgeons. It's noticed by the community. A large part of that has been reining in the out-of-control hospital-employed CRNAs, many of whom have been there for 25 years or more. Prior to our group coming, they chased out three different groups prior to ours. Too much to go into here, but basically they bullied those prior groups into doing things "their" way, and the hospital flounder throughout the 1990's and early 2000's like a fish flopping on the counter top, barely alive.

Fortunately, since our group took over, I have a very strong chief who has not been afraid to say "no", and runs a tight ship. The volume difference, which is quantifiable, has been noticed. And, the care is substantially better. Two of the CRNAs left when our group took over. They weren't missed. They weren't re-hired or replaced. And, that (again trust me) was noticed by the others.

So, no, vancouvergeorge. Your future is not a course that this country is destined to chart. What we need is strong physician leaders and the willingness to stand-up and say we're not going to accept inferior care. And, when we do this, the results are tangible. My experience is living proof of that. The people in charge at my hospital have our back 100%.

Don't accept a mid-level degree in lieu of becoming a physician. The extra time, training, blood, sweat, and tears is worth it in the long run. It always will be. Shortcuts are just that. And, everyone knows what they say about people who take shortcuts. You will meet many PA/CRNP/CRNA who, although they may not admit it directly to your face, will say they wish they'd gone to medical school. You will meet few, if any, physicians who will say the reverse.

-Skip

 

[LoudBark]

Wrong.

When you are a mid-level, you always answer to someone higher in the patient-caregiver relationship .
-Skip

There are actually a number of states where nurse practitioners can work independently........and that is without working directly under a doctor...Washington State for one among others.

 

[Denatured]

Also, most states only require chart review (usually 10%) for PAs. Washington state require only sponsorship and has no supervision requirement for PAs. NC only requires a 30 minute meeting every six months. This can all be superseded by hospital policy to be more strict, but not less strict. Some PAs own there own practice and enjoy much more autonomy.

CRNAs are not required to be supervised by an anesthesiologist in any state, and most require no supervision at all. What actually happens depends on the group or hospital. From no anesthesiologist at all to tight control, like the above. The most common practice is usually in the middle.

Independent NP practice has already been mentioned, but again, usually there are stricter standards at the hospital. Though they have even less difficult time opening their own practice.

 

[Skip Intro]

In no state are mid-levels able to be licensed to practice independently. Period. Even in so-called "opt-out" states, where CRNAs can bill independently, they still have to operate under medical direction.

Now, you can argue that what often happens is de facto rubber-stamping of charts... but that becomes legal and not-so-technical fraud where the supervision is lax, and it exposes the "stamper" to serious liability. Likewise, as you also state, hospital by-laws are often much stricter on who can practice what with whichever credentials even in those states.

Of course, if you are a hospital administrator out in the middle of BFE, I guess you take what you can get. That's not where I practice, not where I want to practice, and certainly never where I want myself or anyone I care about to be treated.

Again these instances represent essentially a public health experiment based upon, in no small part, the now and further looming doctor shortage that I've talked about on other threads. It does not ultimately represent the best interest of the public. And, like my hospital, administrators (who have been burned in the past) are desperate to hire doctors whenever possible, not mid-levels, to run the show. There is no real cost differential when it comes down to it, especially if they're doing the hiring. There is a hard-to-quantify-but-tangible quality difference, though. And, as such, mid-levels will never be able to compete as independents in those markets where most of us choose to live... unless they are willing to work in a situation where they are heavily supervised.

-Skip

 

[Denatured]

In no state are mid-levels able to be licensed to practice independently. Period. Even in so-called "opt-out" states, where CRNAs can bill independently, they still have to operate under medical direction.

Now, you can argue that what often happens is de facto rubber-stamping of charts... but that becomes legal and not-so-technical fraud where the supervision is lax, and it exposes the "stamper" to serious liability. Likewise, as you also state, hospital by-laws are often much stricter on who can practice what with whichever credentials even in those states.

Of course, if you are a hospital administrator out in the middle of BFE, I guess you take what you can get. That's not where I practice, not where I want to practice, and certainly never where I want myself or anyone I care about to be treated.

Again these instances represent essentially a public health experiment based upon, in no small part, the now and further looming doctor shortage that I've talked about on other threads. It does not ultimately represent the best interest of the public. And, like my hospital, administrators (who have been burned in the past) are desperate to hire doctors whenever possible, not mid-levels, to run the show. There is no real cost differential when it comes down to it, especially if they're doing the hiring. There is a hard-to-quantify-but-tangible quality difference, though. And, as such, mid-levels will never be able to compete as independents in those markets where most of us choose to live... unless they are willing to work in a situation where they are heavily supervised.

-Skip

It is debatable whether they should be independent or not, but the fact that some advance practice nurses are independent isn't really debatable. NPs are, by law, independent in several states. They are in mine and a NP across town has his own FP clinic.

CRNAs in a handful of states are required to be supervised by a physician, but that can be the surgeon which is often how rural hospitals get by. CRNAs are able to bill independently to Medicare part B in all states, the opt out states are so that the hospital may bill for them as well. My state is not an opt out state, but their is no supervision requirement in our state or our hospital. We have no anesthesiologist with completely independent CRNAs.

As for PAs, no, they are not independent anywhere.

 

[Nymphicus]

In no state are mid-levels able to be licensed to practice independently. Period. Even in so-called "opt-out" states, where CRNAs can bill independently, they still have to operate under medical direction.

-Skip

According to the most recent Pearson Report published in 2007 (available at http://www.webnp.net/images/ajnp_feb07.pdf), 23 states require no physician involvement for the licensed NP to diagnose and treat

http://www.medscape.org/viewarticle/506277_5

And that's an old article, it's closer to 30 states now.

 

[Skip Intro]

Well, I have to admit that it appears I was wrong at least with regards to CRNPs. More pressingly, I am tremendously dismayed and dumbfounded.

http://www.rwjf.org/pr/product.jsp?id=61808

The above article shows where CRNPs apparently can practice completely independently. It is only 15 (including D.C.), and most of those are out west where I never have even visited, let alone practiced or did any of my training.

Everything else regarding CRNAs I said is correct, though. You may not see an anesthesiologist in the hospital in some places (New Mexico come to mind), but physician supervision is still a requirement. I am aware of one practice I was looking at for an unrelated reason in the Albuquerque area some time back, and was surprised to find a CRNA-only practice where their "medical director" was a FP-trained doctor that had absolutely no anesthesia training. Scary. And, that's a relatively large metropolitan area.

-Skip

 

[Denatured]

Well, I have to admit that it appears I was wrong at least with regards to CRNPs. More pressingly, I am tremendously dismayed and dumbfounded.

http://www.rwjf.org/pr/product.jsp?id=61808

The above article shows where CRNPs apparently can practice completely independently. It is only 15 (including D.C.), and most of those are out west where I never have even visited, let alone practiced or did any of my training.

Everything else regarding CRNAs I said is correct, though. You may not see an anesthesiologist in the hospital in some places (New Mexico come to mind), but physician supervision is still a requirement. I am aware of one practice I was looking at for an unrelated reason in the Albuquerque area some time back, and was surprised to find a CRNA-only practice where their "medical director" was a FP-trained doctor that had absolutely no anesthesia training. Scary. And, that's a relatively large metropolitan area.

-Skip

I'm sorry, sir, but there are many hospitals with completely independent CRNAs. While I won't reveal my own hospital, I will tell you places I've been.

Check out Minden Medical Center in Minden, LA. It's 30 miles outside Shreveport, it's an anesthesia group owned by a CRNA and operates at other outlying centers, and 100% CRNA with no medical director. They do everything but spines and hearts.

You can also check Monroe County Hospital in Monroeville, AL. It's 100 miles north of Mobile, CRNA owned with 3 CRNAs, and they pretty much only do general and OB. No medical director at either.

Lastly, the entire US army. Read the regulations. CRNAs are 100% independent. They do not distinguish, at least clinically, between a CRNA and an Anesthesiologist. This isn't just on deployment. Many bases have CRNAs only.

You are misinformed, unfortunately. You can hate it and fight it, won't affect me, but you cannot argue with its existence.

 

[LoudBark]

I'm sorry, sir, but there are many hospitals with completely independent CRNAs. While I won't reveal my own hospital, I will tell you places I've been.

Check out Minden Medical Center in Minden, LA. It's 30 miles outside Shreveport, it's an anesthesia group owned by a CRNA and operates at other outlying centers, and 100% CRNA with no medical director. They do everything but spines and hearts.

You can also check Monroe County Hospital in Monroeville, AL. It's 100 miles north of Mobile, CRNA owned with 3 CRNAs, and they pretty much only do general and OB. No medical director at either.

Lastly, the entire US army. Read the regulations. CRNAs are 100% independent. They do not distinguish, at least clinically, between a CRNA and an Anesthesiologist. This isn't just on deployment. Many bases have CRNAs only.

You are misinformed, unfortunately. You can hate it and fight it, won't affect me, but you cannot argue with its existence.

What you said is correct. Not just CRNA's, but in certain states (Washington for example, but many others), NP's frequently run urgent care centers without ANY doctor supervision (and it is 100% legal in these states).

Skip, just because you have never practiced (or stepped foot in) those states, doesn't mean it is not a reality. Not only is it a reality, but pretty soon it will be legal for them to practice independently in your state and all others. The CRNA's and NP's have extremely strong unions and lobbying for more and more independence. It is only a matter of time.

 

[Skip Intro]

I'm sorry, sir, but there are many hospitals with completely independent CRNAs. While I won't reveal my own hospital, I will tell you places I've been.

Check out Minden Medical Center in Minden, LA. It's 30 miles outside Shreveport, it's an anesthesia group owned by a CRNA and operates at other outlying centers, and 100% CRNA with no medical director. They do everything but spines and hearts.

You can also check Monroe County Hospital in Monroeville, AL. It's 100 miles north of Mobile, CRNA owned with 3 CRNAs, and they pretty much only do general and OB. No medical director at either.

Lastly, the entire US army. Read the regulations. CRNAs are 100% independent. They do not distinguish, at least clinically, between a CRNA and an Anesthesiologist. This isn't just on deployment. Many bases have CRNAs only.

You are misinformed, unfortunately. You can hate it and fight it, won't affect me, but you cannot argue with its existence.

Please try to better understand the law.

As a CRNA, you cannot practice "independently" - even in opt-out states. You can bill independently. A physician must always sign-off on the anesthestic (or dentist or podiatrist, etc.) and is legally responsible for the medical aspects of the patient's care.

Many states - not just opt-out states - only require a physician (any physician) to sign-off on the anesthesia care, and do not require an anesthesiologist.

This is a CMS ruling from the federal government (regarding the opt-out of the CMS requirements for billing anesthesia services) and requires the governor of each state requesting opt-out for billing purposes in order that an anesthesiologist does not have to supervise the case to bill Medicare/Medicaid. It has nothing to do with "independent" practice other than for billing purposes. All 50 states require some physician (surgeon, dentist, podiatrist, etc.) to sign-off on the patient's anesthetic care that that CRNA provided, regardless as to whether or not the choose to bill for it or not. And, they are legally responsible if that CRNA fails to provide "standard of care" and something goes wrong.

Another other "arrangements" is simply skirting the law. Hope that clears up any confusion. I don't care about care in the Armed Forces, Canada, or Timbuktu.

-Skip

 

[Skip Intro]

More info:

http://www.asahq.org/For-Members/Pr...Supervision-Rules-for-Nurse-Anesthetists.aspx

(NB: It says "physician", not anesthesiologist necessarily).

-Skip

 

[Denatured]

I see the link you posted is about CMS and is related to the opt out issue, but it doesn't prove your point.

Read the first paragraph under Physician Supervision of this PDF file
http://www.aana.com/aboutus/documents/legalissuesnap.pdf

That is the reality. 33 states that do not require any supervision.

 

[Denatured]

Also, as to the "being legal responsible for the CRNA" or commonly called "captain of the ship doctrine," I ask that you show concrete evidence, not anecdote, of one incidence of a physician being held liable for the actions of a CRNA. It has never happened.

 

[Skip Intro]

You are referring to the "captain of the ship" doctrine. The legal term is vicarious liability. It is real. Surgeons get sued for it. And they can't always get out of it. Yes, there are a lot of opinions flying around the Intrawebs about this topic, mostly from CRNAs... and many of them are just plain wrong.

http://www.vawd.uscourts.gov/OPINIONS/JONES/202CV00043OPN.PDF

This is at least one example (with another referenced in the proceedings) where a surgeon was denied from getting himself removed (i.e., summary judgment) from a lawsuit because it was felt by this judge that a jury should determine whether he was "vicariously liable" for the actions of this CRNA. (Whether or not he ultimately lost the case, I'm not sure. Getting sued is bad enough.)

CRNAs cannot practice medicine. Therefore, the bottom line is that they cannot practice the full scope of anesthesia care. A physician is required and must in effect order anesthesia, thus "signing off" on that anesthetic, whether or not they are actually legally required to sign the chart for billing purposes per the CMS opt-out ruling. While allowing for billing, nowhere does it completely remove the supervision requirement (or co-requisite legal responsibility on part of the physician ordering their medical/surgical care... at least one example of which I provided above). Remember, we are only talking about billing for services here.

Let me frame this another way... Say, for example, the nursing board in a particular state successfully petitions the legislature to change the nursing regulations to allow dialysis nurses to be "bill independently" when they provide dialysis for a patient (i.e., that they can get paid for their services separate from an arrangement at an approved hospital or dialysis center). A physician still has to order dialysis. Sure, that physician may or may not understand the exact technical nature of hooking up the dialysis machine, priming the dialysate bags, and actually administering the dialysis, but it is a medical diagnosis and determination that this particular patient needed dialysis. If that nurse screws up while administering the dialysis and gets sued, the doctor may not necessarily be liable if a technical error occurred by that nurse. But, they can be liable if they ordered the wrong dialysis or too much dialysis (or the like) on that patient and the patient had a bad outcome. The nurse, after all, was following that medical order.

Yet framed still another way that also poses a dilemma for CRNAs (and a real one)... Suppose a medical doctor says a patient isn't "cleared" for surgery. What does that CRNA (or the patient) then do? Waste time and try to get a second opinion? I, as a physician, am the second opinion. That is, in my medical determination I can make an overriding decision about whether nor not it is safe to proceed. A CRNA cannot legally do this. That's why it's called practicing medicine, and a CRNAs don't practice medicine. This type of scenario happens more frequently than you may realize. Sure, they can refuse to give anesthesia if they feel it isn't safe, but that's not what I'm talking about. (And see how long a solo CRNA practice lasts if that becomes a routine thing.)

As an example, I took care of a patient not that long ago where an internal medicine doctor wrote in the chart, "Patient has critical aortic stenosis and therefore must avoid general anesthesia. Spinal anesthesia indicated or postpone procedure." He was dead wrong, and the patient would have been dead as well if that plan had been followed. Now, if an "independently" practicing CRNA in an opt-out state had followed that recommendation and killed the patient, you can bet that this particular medicine doctor would have been sued, probably successfully, under the "vicarious liability" provision because they had made recommendations outside their scope of expertise which were subsequently followed. (But, hopefully a CRNA would have had enough good sense to refuse to do it as ordered... although based on some of the ones I've worked with, I'm not so sure.)

So, putting aside the admission that I was not until recently fully abreast of how certain cohorts of patients seek healthcare in rural Idaho, perhaps at strip malls or shopping centers, suffice it to say that I work in a hospital in the mid-Atlantic and (fortunately) don't have to deal with that particular scenario anyway. However, I know a lot about the subtleties of this particular topic, aside from the rhetoric and propaganda from the AANA, because I live it everyday. Still, if you haven't had enough of this discussion, I suggest you take it to the Anesthesia sub-forum. I'm sure people over there will be more than helpful and willing to discuss.

-Skip

 

[Denatured]

No, I'm done. I have no dog in the fight, just trying to be the bearer of truths and have interest is healthcare law. I and another physician have disagreed with you. You have given no facts contrary to my points. As a matter of fact, you helped prove it because the opt out rules specifically spell out that a state cannot opt out if there is a law stating there must be physician supervision in that state. So, while there are states that have not opted out and have independent practice, all states that have opted out do not have any law requiring supervision. Also, if you read that article I posted, you would see that prior case rulings have determined that anesthesia is the practice of nursing and medicine. Again, you don't have to like it or believe it is best for patients, but that is what has happened.

Either way, good luck in your future endeavors!

 

[Skip Intro]

I have no dog in the fight, just trying to be the bearer of truths and have interest is healthcare law.

Well, if you are indeed a practicing physician, I'm more than a little disappointed to hear you say that.

First off, there is a lot more opinion than there is truth in much of this debate, much of which is promulgated by whichever side the interested party happens to align themselves.

Secondly, I'm equally concerned about matters outside of my own field of practice, such as dental assistants lobbying to be able to do routine fillings, optometrists trying to get Lasik approved within their scope of practice, psychologists wanting to prescribed anti-depressants... and the list goes on and on.

The fact is, the physician as the pinnacle of healthcare decision making is crumbling. This is born out of lack of access to care and, make no mistake, an equally important factor: money. Mid-levels, quite simply, want a bigger piece of the pie, and are willing to sacrifice what is, in my opinion, what's likely best for the patients under their care.

Mid-levels claim parity to physicians in many venues and, the simple truth is, they just don't always know what they don't know. I have innumerable anecdotes of what-would-have-been bad patient care decisions had I not been there to intervene. We just have a damn-near-impossible time of being able to cogently collect and report "near misses" in those cases, though. It does make a difference.

I've said before, and I'll say again (without trying to beat a dead horse), that the regulations are clear - at least with CRNAs - that billing independently for services is not the same as practicing independently. I just have much more power and decision making ability regarding what I feel is the most safe and effective clinical course for patients under my care than a CRNA.

Now, lobbying and fighting in the courts about legislative issues is the only recourse our field currently has. CRNAs have, in effect, stood on the shoulders of physician giants, and we've all reaped the benefit of safer care. But, this does not mean that they should (or, in fact, do) have carte blanche to do whatever they want. Lawsuits are rare in this era of ultra-safe anesthesia. However, this does not relieve those physicians responsible for medical direction of that patient's care from vicarious liability (as I hopefully at least in part have successfully argued on this thread).

We don't need further dumbing-down of the healthcare system in this country. Figuring out a way to allow all patients to have access to the best possible care should be paramount. And, that doesn't, in my humble opinion, mean allowing greater practice rights for those who have a small fraction of our formal training. And, I think that, barring the decisions of those who aren't on the front lines doing what we do everyday, will only ultimately be meted out in the tort system of our local, state, and federal judicial branches.

-Skip

 

[debthasnumbedme]

all physicians are going to get shafted once the health care bill goes into effect in 2014. The winners will be nps and pas, who will have half the training and debt, and still do pretty much the same work as primary care physicians do.

Imgs in particular will be doubly shafted. They go through the md process but have fewer opportunities to enjoy the perks (such as matching into ortho or plastics). At least the dos have their own exclusive residencies. Furthermore, physician ratings will become more and more central in the future, no one knows how a caribbean education will factor into the formula. With the internet generation growing up, patients will also be more savvy in researching your educational background. So all the previous talk about how no one knows or cares where you went to medical school may no longer hold true.

i also heard the world was coming to an end in 2012....

 

[Unzbuzzled]

Schematic for success:

1. Do not, under any circumstance, go offshore for medical school unless you're 100% certain that medicine is the only career option for you and you've exhausted all other options (SMP, DO, Post-Bacc, ect.).
2. If you're thinking about going to the Caribbean, you should only be considering the "top 4" schools. If you can get into a top 4 Caribb school, you are therefore competitive enough to get into an SMP linkage program into a US MD school. Review point #1 and apply to an SMP program.
3. If you can't get into a top 4 school, you are not ready for medical school. Either improve your file or choose a different career.
4. If you are thinking about going to a Caribbean school that isn't in the top 4, you are setting yourself up for disaster. Do any amount of research and you'll see what a horrible, horrible idea it is.
5. If you try an SMP and still fail to get into medical school, then and only then should you consider going to one of the top 4 schools. But before you do, look once again at other career options and review point #1.

Keep in mind a huge part of being a doctor is your reputation and the reputation of your academic institution. That might not be fair, but that's the way it is. If you head to the Caribbean, you are accepting a lower quality of education and the negative perception of that education. Your patients, your patients' families, your family, your superiors, your residents, your nurses, and your community will all judge you accordingly, fair or not. Only go to the Caribbean if you are willing to carry the label of a "Caribbean doc," with all the associated ups and downs of that title.

 

[miguelito88]

Whenever I need motivation during studying (I think we all know that time of day when you have checked Facebook ten times, read the news twice, and are struggling to stay awake), I read this forum. So, let's all try this together:
Relax.
If any anonymous person on SDN tells you to not become an MD because you will should be a PA or NP instead (for no other reason than you didn't get into a US or Canadian school), just laugh. People will tell you this your entire life. Give up. You can't do it. I am better than you. Who cares what they think? Go to medical school for you, and only you. If it is in the Caribbean, so be it. Of course, you should do a lot of homework, but I will get to that.
Relax.
Not everyone wants to do ortho or plastics. Doing something you are not interested in isn't a "perk". It is annoying. Do what you enjoy, whatever it may be. If it is Primary Care, be a GP. If it is ortho, are you at a disadvantage in the Caribbean? Yup. Should you give up? It would be a shame if you did because some guy on a forum told you to. Does this mean you should expect that amazing residency match? Unfortunately, no. Don't EXPECT anything. Work as hard as humanly possible, and do everything you can to get that residency you want. You may not get it. But you didn't give up, either. And, happily, you will still be what you wanted to be: a doctor. Remember why you wanted to be one in the first place?
Relax.
When I read about a patient becoming savvier with the internet, I had to laugh. Patients do not care if you went to the Caribbean. Really. I worked in a hospital for two years before coming to med school in the Caribbean. The chief of emergency medicine? Caribbean. Three GPs? Caribbean. Quite a few surgeons? Caribbean and foreign. They treated patients every day, and I never once, in two years, heard a single word about where they went to med school.
Relax, for the love of God.
I love how Caribbean match numbers get quoted as if they came down from God. We all understand the difference between the Big 4 (3) don't we? (I don't mean to put down Saba, it's just the lack of federal loans can be a deal breaker). However, Caribbean match numbers are not from just those schools. They are ALL Caribbean schools. To be honest, if you go to a Caribbean school which will not let you practice in the US in all 50 states it is a mistake (unless you don't care about being restricted in such a way…..I think you should, but I don't know you and you know about your own life a lot better than me). There are a lot of Caribbean schools which are not schools, and will just take your money. If this is your school, you will have problems with the Step. If you have problems with the Step, you won't match. The match numbers are MUCH MORE FAVORABLE when you exclude all but the Big 4 (3). That 47% goes up quite a bit. AUC (which I attend) reports their number as around 90%. Does this include Transitional Year to General Surgery, etc.? Yeah, probably. But having been here and physically talking to students who match, I can tell you the number isn't 47%. So saying that three guys matched Ortho out of ten million and thus the percentage is 0.0000000000001% isn't completely truthful.
And finally, RELAX!
A "blood bath"? Really? Hyperbole is fun in freshman lit. Will it get tougher? Certainly. Impossible? Far from it. There has been no decision about residency numbers. They may go up. They may stay the same. But the US schools (the vast majority) will not be graduating new medical students until sometime around 2016. Yes, you can do a quick Google search to find this is true. It all comes down to Medicare, which pays for residencies in hospitals. I personally don't think my classmates' body parts will be strewn across me on Match Day. I think some of them will scramble, and some will go unmatched. It won't be the 97% (or 99%?) as in US med schools. But for the next decade or so (yes, decade, again look up when the vast majority of schools are planning on graduating classes) it will be fine. You will most likely not go unmatched (if you are Big 4 (3), anything else is a bit of a gamble, to be fair). You will be ok.
In sum, why take advice about the Caribbean from someone who isn't here? People will tell you that you must have gone to the Caribbean because you are dumb. I, for example, ended up here because I had to work two jobs during undergrad, and come from a rough home. Not as conducive to studying as one may expect. Many of my classmates had similar issues. Are they dumb? Far from it. Work hard, perform well, and you will be fine. Slack off, don't study, and you will do poorly. Period. And if you need motivation when you get a little tired of studying, come read SDN Caribbean. Now, let the hate mail pour in…..

You don't know how badly I needed to read what you wrote right at this moment. Thank you for posting that.

 

[Uzr]

Thing is that it's possible to get into a carribean medical school with a bad GPA and a good MCAT. I can't do that with dentistry or pharmacy even though I'm a fan of the professions (well dentistry at least, volunteered and didn't like it at a pharmacy).

Also PA's in Canada....not such a great match. If you're an MD then okay maybe you can't get into the US but you still have tonnes of options open to you and if someone is willing to go study in a country abroad then they're probably willing to work abroad. I don't personally care if I make more or less as an MD from the Caribbean compared to a dentist here as long as it's a decent wage. Doctors are paid way too much in much of Canada anyways.

 

[Skip Intro]

Schematic for success:

1. Do not, under any circumstance, go offshore for medical school unless you’re 100% certain that medicine is the only career option for you and you’ve exhausted all other options (SMP, DO, Post-Bacc, ect.).
2. If you’re thinking about going to the Caribbean, you should only be considering the “top 4” schools. If you can get into a top 4 Caribb school, you are therefore competitive enough to get into an SMP linkage program into a US MD school. Review point #1 and apply to an SMP program.
3. If you can’t get into a top 4 school, you are not ready for medical school. Either improve your file or choose a different career.
4. If you are thinking about going to a Caribbean school that isn’t in the top 4, you are setting yourself up for disaster. Do any amount of research and you’ll see what a horrible, horrible idea it is.
5. If you try an SMP and still fail to get into medical school, then and only then should you consider going to one of the top 4 schools. But before you do, look once again at other career options and review point #1.

Keep in mind a huge part of being a doctor is your reputation and the reputation of your academic institution. That might not be fair, but that’s the way it is. If you head to the Caribbean, you are accepting a lower quality of education and the negative perception of that education.

I fully agree with you... up to this point, that is...

Your patients, your patients’ families, your family, your superiors, your residents, your nurses, and your community will all judge you accordingly, fair or not. Only go to the Caribbean if you are willing to carry the label of a “Caribbean doc,” with all the associated ups and downs of that title.

I have no sense of this. I have been asked, maybe, once a year on average (if that) where I went to medical school by a patient or colleague (i.e., less than three times since being in private practice). I sense absolutely zero opprobrium from my physician colleagues. And, believe me when I tell you that my lab coat simply says "Skip Intro, MD" - there is no indelible reference to the fact that a very small fraction of my formal education occurred in the Caribbean.

-Skip

 

[laricb]

And a DO doctor will constantly be asked what does DO stand for.....

 

[Bancrofti]

Whenever I need motivation during studying (I think we all know that time of day when you have checked Facebook ten times, read the news twice, and are struggling to stay awake), I read this forum. So, let’s all try this together:
Relax.
If any anonymous person on SDN tells you to not become an MD because you will should be a PA or NP instead (for no other reason than you didn’t get into a US or Canadian school), just laugh. People will tell you this your entire life. Give up. You can’t do it. I am better than you. Who cares what they think? Go to medical school for you, and only you. If it is in the Caribbean, so be it. Of course, you should do a lot of homework, but I will get to that.
Relax.
Not everyone wants to do ortho or plastics. Doing something you are not interested in isn’t a “perk”. It is annoying. Do what you enjoy, whatever it may be. If it is Primary Care, be a GP. If it is ortho, are you at a disadvantage in the Caribbean? Yup. Should you give up? It would be a shame if you did because some guy on a forum told you to. Does this mean you should expect that amazing residency match? Unfortunately, no. Don’t EXPECT anything. Work as hard as humanly possible, and do everything you can to get that residency you want. You may not get it. But you didn’t give up, either. And, happily, you will still be what you wanted to be: a doctor. Remember why you wanted to be one in the first place?
Relax.
When I read about a patient becoming savvier with the internet, I had to laugh. Patients do not care if you went to the Caribbean. Really. I worked in a hospital for two years before coming to med school in the Caribbean. The chief of emergency medicine? Caribbean. Three GPs? Caribbean. Quite a few surgeons? Caribbean and foreign. They treated patients every day, and I never once, in two years, heard a single word about where they went to med school.
Relax, for the love of God.
I love how Caribbean match numbers get quoted as if they came down from God. We all understand the difference between the Big 4 (3) don’t we? (I don’t mean to put down Saba, it’s just the lack of federal loans can be a deal breaker). However, Caribbean match numbers are not from just those schools. They are ALL Caribbean schools. To be honest, if you go to a Caribbean school which will not let you practice in the US in all 50 states it is a mistake (unless you don’t care about being restricted in such a way…..I think you should, but I don’t know you and you know about your own life a lot better than me). There are a lot of Caribbean schools which are not schools, and will just take your money. If this is your school, you will have problems with the Step. If you have problems with the Step, you won’t match. The match numbers are MUCH MORE FAVORABLE when you exclude all but the Big 4 (3). That 47% goes up quite a bit. AUC (which I attend) reports their number as around 90%. Does this include Transitional Year to General Surgery, etc.? Yeah, probably. But having been here and physically talking to students who match, I can tell you the number isn’t 47%. So saying that three guys matched Ortho out of ten million and thus the percentage is 0.0000000000001% isn’t completely truthful.
And finally, RELAX!
A “blood bath”? Really? Hyperbole is fun in freshman lit. Will it get tougher? Certainly. Impossible? Far from it. There has been no decision about residency numbers. They may go up. They may stay the same. But the US schools (the vast majority) will not be graduating new medical students until sometime around 2016. Yes, you can do a quick Google search to find this is true. It all comes down to Medicare, which pays for residencies in hospitals. I personally don’t think my classmates’ body parts will be strewn across me on Match Day. I think some of them will scramble, and some will go unmatched. It won’t be the 97% (or 99%?) as in US med schools. But for the next decade or so (yes, decade, again look up when the vast majority of schools are planning on graduating classes) it will be fine. You will most likely not go unmatched (if you are Big 4 (3), anything else is a bit of a gamble, to be fair). You will be ok.
In sum, why take advice about the Caribbean from someone who isn’t here? People will tell you that you must have gone to the Caribbean because you are dumb. I, for example, ended up here because I had to work two jobs during undergrad, and come from a rough home. Not as conducive to studying as one may expect. Many of my classmates had similar issues. Are they dumb? Far from it. Work hard, perform well, and you will be fine. Slack off, don’t study, and you will do poorly. Period. And if you need motivation when you get a little tired of studying, come read SDN Caribbean. Now, let the hate mail pour in…..

I typically only speak about SGU, so It's good to see someone from another of the large schools speak up. It gets annoying on the allo forum when they attempt to lump the big 3/4 in with the statistics that include all of the other schools. I agree with the message also. If you genuinely had a desire to be an MD, why give up on your hopes because you hit one stumbling block?

 

[Unzbuzzled]

I fully agree with you... up to this point, that is...

I have no sense of this. I have been asked, maybe, once a year on average (if that) where I went to medical school by a patient or colleague (i.e., less than three times since being in private practice). I sense absolutely zero opprobrium from my physician colleagues. And, believe me when I tell you that my lab coat simply says "Skip Intro, MD" - there is no indelible reference to the fact that a very small fraction of my formal education occurred in the Caribbean.

-Skip

I think it also depends on your specialty and the environment in which you practice. It could be worse in academics, research, and specialities where you have a closer relationship with your patients. Most of my experience is in Cardio and EM. In the ED, I have seen residents scoff at other caribb residents and interns behind their backs, not once but several times. Attendings themselves have talked down caribbean schools several times, often not politely, back when I was a premed and inquiring about them. If they think that way about caribbean schools, then they must judge caribbean graduates similarly. I've even seen this same thing with DOs. The scoffers are usually giant tools in their own right, but acting like educational reputation doesn't matter is misleading. Any good physician knows that it's competence, not credentials, that makes a great clinician. But the hospital is a place full of scholars and egos, and sometimes the caribbean stigma comes out. I'm not defending this behavior, but I think you'd be remiss to assume it doesn't exist in certain areas.

For the record, I respect you Skip and I value your opinion, which I've always found to be insightful and honest. I don't share the views of the aforementioned egotistical physicians because I've also worked alongside very capable Caribbean graduates who are excellent, compassionate clinicians. I just think that it's a tough road for Caribb grads, both academically and socially, and it's therefore a better idea to avoid going offshore.

 

[lobelsteve]

I think it also depends on your specialty and the environment in which you practice. It could be worse in academics, research, and specialities where you have a closer relationship with your patients. Most of my experience is in Cardio and EM. In the ED, I have seen residents scoff at other caribb residents and interns behind their backs, not once but several times. Attendings themselves have talked down caribbean schools several times, often not politely, back when I was a premed and inquiring about them. If they think that way about caribbean schools, then they must judge caribbean graduates similarly. I've even seen this same thing with DOs. The scoffers are usually giant tools in their own right, but acting like educational reputation doesn't matter is misleading. Any good physician knows that it's competence, not credentials, that makes a great clinician. But the hospital is a place full of scholars and egos, and sometimes the caribbean stigma comes out. I'm not defending this behavior, but I think you'd be remiss to assume it doesn't exist in certain areas.

For the record, I respect you Skip and I value your opinion, which I've always found to be insightful and honest. I don't share the views of the aforementioned egotistical physicians because I've also worked alongside very capable Caribbean graduates who are excellent, compassionate clinicians. I just think that it's a tough road for Caribb grads, both academically and socially, and it's therefore a better idea to avoid going offshore.

Your N is too small. My N, my local hospital, has an ER doc that graduated SGU. I graduated SGU. My Rheum friend went to Ross, his friend in ID and another in IM went to Ross. Carib trained doss are everywhere. Nobody knows and nobody cares once you've got paper on the wall.

 

[Unzbuzzled]

Your N is too small. My N, my local hospital, has an ER doc that graduated SGU. I graduated SGU. My Rheum friend went to Ross, his friend in ID and another in IM went to Ross. Carib trained doss are everywhere. Nobody knows and nobody cares once you've got paper on the wall.

Some people know and some people care. If not, why would there be a stigma in the first place? And isn't it more alarming that my sample size is small? I've only shadowed in a few EDs and in a few ICUs and the subject of Caribbean education has come up more than once. I'll also point out that when I was debating whether or not to head to the Caribbean for medical school, several people, most of whom were not in the medical field, thought it was a bad idea. Nowadays, people google their doctors before scheduling an appointment, and if their doc's education doesn't meet their expectations, they'll choose someone else. This behavior is becoming more common, and it has to be expected when the quality of a physician's education could be the difference between life and death. The bottom line is that Caribbean matriculants perform less successfully their US counterparts, evidenced by the low average matriculant statistics, high attrition rates, and low USMLE scores of Caribbean medical students. Usually, only the best and most competent Caribbean students land a residency, so they usually measure up when scrutinized. Surely you do or you would be shown the door very quickly. But for people who don't know you, including superiors and colleagues at a new hospital, residency selection boards, and new patients, the Caribbean title is still a red flag. It is mostly for this reason that I say you should try as many options as possible to get admitted to a US school before you head offshore. There's just too much working against you.

 

[mrjbb]

Some people know and some people care. If not, why would there be a stigma in the first place?

Nowadays, people google their doctors before scheduling an appointment, and if their doc's education doesn't meet their expectations, they'll choose someone else. This behavior is becoming more common, and it has to be expected when the quality of a physician's education could be the difference between life and death.

There's a stigma because people (mostly those in our proffesion) look at carribean students as second rate medical students that couldn't cut it in US med schools. Although this may be the case for a majority of the matriculated students in Carib med schools, what should even out the playing field on some level is step scores. But that's not always the case I'm sure.

I HIGHlY doubt a physician in private practice is going to starve because a few people decided to google him/her. Even though a doctors degree was from the Caribbean, his/her residency training will be from the US.

Personally I don't care if I get looked down upon by a small group of judgemental individuals, I'm a minority and depending on where I travel to or where I pass through on my travels I might get treated differently anyhow. These people that judge carib grads aren't going anywhere, but you can expect that of a society that has the will to form personal opinions.

 

[Skip Intro]

But the hospital is a place full of scholars and egos, and sometimes the caribbean stigma comes out. I'm not defending this behavior, but I think you'd be remiss to assume it doesn't exist in certain areas.

Again, I can only speak from my own experience and tell you that I have experienced none of this. And, I am only one (of two) Carib grads who work in my current environment among a vast majority of U.S. med school graduates from Harvard, Hopkins, Penn (among others). I am treated with respect and deference, and am even on several hospital-wide committees where my opinion not only wanted but valued.

The same does not hold true for the PAs/CRNAs/CRNPs with whom I work, most of whom are seen merely as order-takers and grunts.

The main forewarning I've said over and over again, yet I'll say again, is this: (1) know what you're getting yourself into, and (2) choose wisely.

-Skip

 

[Skip Intro]

But for people who don't know you, including superiors and colleagues at a new hospital, residency selection boards, and new patients, the Caribbean title is still a red flag.

You seem to know a lot about this topic. It has even apparently come up a lot on rounds (although my experience as a student and resident was to talk about patients on the wards... go figga.)

So, what about when patients Google their doctor and find out they went to Meharry or Howard or Morehouse? Is the stigma the same?

Just curious to hear your thoughts on that too, since you seem so informed.

-Skip

 

[Unzbuzzled]

You seem to know a lot about this topic. It has even apparently come up a lot on rounds (although my experience as a student and resident was to talk about patients on the wards... go figga.)

So, what about when patients Google their doctor and find out they went to Meharry or Howard or Morehouse? Is the stigma the same?

Just curious to hear your thoughts on that too, since you seem so informed.

-Skip

Come on now, don't be coy. There's plenty of time for casual conversation in the ED when this topic could come up, especially when a student shadow is asking about the pros and cons of heading to the Caribbean for med school.

I don't think the stigma of attending a lower-tier US school is nearly as dramatic as for the caribbean. For one thing, few US medical schools get bad press, while many Caribbean medical schools seem to attract it. I just googled "Caribbean Med School News" and the things that jump out at you are the skirmishes about residency placement and the plethora of scam schools advertising "No MCAT Required!" and 72%* Pass Rates. The average patient probably has heard very little about Caribbean medical education. But if they have heard anything about it, chances are that bit of press was bad. That's enough for a patient to form an opinion, and it's enough for that person to overlook you, as unfair and shallow as that might seem. And it stinks if you went to SGU or Ross, because the press often does not discriminate between the “good” Caribbean schools and the “bad” ones.

There will always be snobs who google their doctor's medical school rank and judge them, but that's probably not normal practice for most laypeople. The reason for that is that there are no bad US medical schools. All US medical schools have high USMLE pass rates and low attrition rates. All have solid match lists, and all are standardized by the LCME, which has extremely high standards. The same thing goes for DO schools. There are some people who might be biased against DOs, but at the end of the day, their bias is unwarranted because all DO schools have excellent curricula and high performance standards. The Caribbean however, is full of schools with dismal USMLE pass rates, high attrition rates, low admissions standards, and shoddy residency placement, among other things. Even the best Caribbean schools have low admissions standards, low USMLE pass rates, and high attrition when compared to even the lowest ranked US schools. Even though the average patient might not know all these stats, you can bet that program directors do, which is why it’s harder for Caribb students to get clerkships and residencies in the US, even if they do well on the Steps.

So I'll reiterate my stance on this whole thing. I don't believe all Caribbean schools are bad. The top 4 have historically done a good job at landing their graduates US residency spots for students willing to work hard. Furthermore, the US has high enough standards that if you can gain a residency position in the US, you almost certainly possess the ability to become a competent clinician. After all, clerkships and residency are where you learn most of your chops, not sitting in a classroom learning basic science. The perception of Caribbean schools as a whole, however, is tarnished in no small part because of the majority of Caribbean schools with shoddy curricula, shady faculty, low success rates, and countless horror stories. Additionally, I doubt you could find any US medical school that does not significantly outshine even the best Caribbean schools as far as curricula, faculty, resources, networking, ect. Nonetheless, you could be a hardworking student from Windsor or SMU and become a better physician than a Hopkins grad; it’s just that this will certainly not be the case for the vast majority of students. So even though you can potentially become a competent physician through the Caribbean, I advise people not to go, because the chances of success are generally small and getting smaller. There are safer, more conservative options that should be exhausted first, before risking it all on such an unreliable path.