Your MD degree losing value...

[TysonCook]

Hello,
I'm not much of a rable rouser but this is worth a serious look. Remember, statements from the author consist of DNP being BETTER than the MD, and DNP's in the future competing for residency positions.

Anyway, here is the thread. A good read and for those that sack up and write letters etc, might be a good time to send some emails, letters, and op/ed pieces.

Seriously, when is enough enough....

http://forums.studentdoctor.net/showthread.php?t=473240

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[ForbiddenComma]

Yes, this has been raised in a thread in this forum as well.

Absolutely disgusting. But, it's also refreshing in a way with its honesty. She is quite clear with her agenda of eliminating physicians from clinical practice and replacing them with nurses, and she dispenses with the usual fig leaf of "physician oversight" and whatnot.

I see three objectives for the DNP degree.

1) To funnel more tuition money to nursing programs (of course, it will mean less money to the med schools, but Columbia's administration is nothing if not short-sighted)

2) To reduce the salary of clinicians. NPs make one half to two thirds a physician's salary, which is just ducky in the eyes HMOs, insurance firms, and for-profit hospitals.

3) To reduce the independence of clinicians. It drives some people nuts that doctors think for themselves and that there is variability in between physicians -- NPs generally do not have as much of a problem being completely subserviant to their superiors in their practice, and are therefore more valued. NPs employed in cubicle clinics such as Minute Clinic are required to follow a "cookbook" in their diagnosis and treatment plans, with no deviation from the plan tolerated by the employees, taking "protocol-driven medicine" to a whole new level. This is the wave of the future.

 

[H_Caulfield]

Before reading this article I'd been sure I'd never go into primary care. After reading it? Let's just say that if primary care were my only option...I'd kill myself.

The moral of the story is just to specialize. Ten years from now any primary care M.D.s will have to deal with nurses expecting to be addressed as "doctor" and arguing with their diagnoses and decisions. Not sure who really thinks this would be much of a solution; nurses will simply, eventually, command the same rights and pay as current primary care physicians...and essentially we'll simply have the same program with different terminology.

Laughable part of the article: the section attempting to convince the reader that these nurses are better clinical caregivers AND know as much medically as current physicians. Riiiight...I love the slip-in mention of the "eight years of training." They're actually counting the liberal arts classes they took during college; that world history class they showed up to in their pajamas, hungover and sore from that frat guy who just wanted to chat, upstairs, away from the commotion.

Eight years? If we're playing that game, then doctors have at least 11. 13 for specialists and 15 for subspecialists. With at least 3 years less training, how are they daring to feed anyone this bull about some uber-caregivers with ALL good qualities of both nurses and physicians...? Give me a break.

 

[Proton Dense]

"that world history class they showed up to in their pajamas, hungover and sore from that frat guy who just wanted to chat, upstairs, away from the commotion."

To be fair, he probably had a guitar up there as well as a kick ass CD collection he sensitively wanted to share.

 

[buckley]

i was actually surprised when i first learned about nurse practitioners here in the US. Ive met great nurses and they helped me out a lot as a med student. I also learned from them. but to say they are as good, if not better, in doing a physician's job as a physician, violates basic rules of logic. let a = physician, b = nurses. "a" is an "a" but "b" is a better "a"? weird.

Im sure there are good nurse practitioners out there, but i dont think they should be attacking the MDs. And if naming mistakes is the game, well MDs take in more responsibility, or re they preparing to go into neurosurgery and critical care as well? Oh yeah, my aunt went to a nurse practioner who diagnosed her with 3-day bronchitis and gave her clarithromycin! I auscultated my aunt, those breath sounds were uber clear...i told her to just drink plenty of fluids and rest. But of course, she wont believe me beause the nurse practitioner told her she had bronchitis and needed antibiotics. ??!??! o amount of explanation could dissuade her...and she kept on making statements about how nurses are better doctors...I was like, hell, go waste your copay money...and pray that you're not prt of the antibiotic resistance movement...

 

[TysonCook]

I think that the larger problem is the erroneous thought process of:
"...doctors don't want to do primary care, so MLP's are filling the void..."

This is flawed logic in that you are using the result to justify the problem. The cost to go through medical education is so high that doctors literally CAN'T afford to go into primary care. After someone finishes medschool, making $120k isn't enough to pay off $200k+ in loans. Now the same scenario with RN's (minimal education loans + butloads of scholarships) makes the pathway very very lucrative (and piss-poor for MD's) . I think this is a very high driving factor for people going into subspecialties.

If you look at $/hr pay and lifestyle, PCP have a very very good life compared to NSurg, GSurg, etc.

To compare the educational debt of a physician to that of a nurse is idiotic.

If you wan't to fill the primary care void, start funding medical education, capping tuition for MD degrees (which have seen ~10% increase/year), and giving loan forgiveness for those willing to do primary care.

Physicians as a whole need to be more active and vocal in their political areas, this stuff happens all the time by the joint commission, Govt., State, Attorneys, and the rest.

As I stated on the other thread, being politically active and vocal is the ONLY way that you are going to protect your career, patient care, salary, and future.

 

[TysonCook]

I forgot to post this earlier, but there are great resources at this link. Has forms that can fill out and will automatically go to your designated reps etc.

http://www.ama-assn.org/ama/pub/category/13097.html

you don't have to support the AMA, but this is a great action website.

 

[hatfielj]

Just throwing out a thought here, hopefully this won't cause too much of an uproar, but perhaps doctors are to blame for this sort of thing happening. It even mentions in the article how there is an ever growing trend towards doctors becoming specialists and leaving the primary care field short of good physicians. There is a void that needs to be filled. We can't all be specialists or this is sure to happen. It seems like the only reason PAs and NPs have been able to obtain the kind of independence that they already have (and will apparently get more of) is because there's a shortage of good primary care docs. The shortage is only going to continue to grow as all of the baby boomers get into their elderly years.
I guess I'm just trying to say that this seems like a consequence of everyone's desire for high paying specialty positions with easy hours and no call schedule. Sure its nice to be in that sort of position I'm sure, but be prepared to call your nurses doctor if something doesn't change soon.
We need more GOOD primary care docs!!!

 

[Winged Scapula]

Im sure there are good nurse practitioners out there, but i dont think they should be attacking the MDs. And if naming mistakes is the game, well MDs take in more responsibility, or re they preparing to go into neurosurgery and critical care as well? Oh yeah, my aunt went to a nurse practioner who diagnosed her with 3-day bronchitis and gave her clarithromycin! I auscultated my aunt, those breath sounds were uber clear...i told her to just drink plenty of fluids and rest. But of course, she wont believe me beause the nurse practitioner told her she had bronchitis and needed antibiotics. ??!??! o amount of explanation could dissuade her...and she kept on making statements about how nurses are better doctors...I was like, hell, go waste your copay money...and pray that you're not prt of the antibiotic resistance movement...

I had nearly the exact same conversation with my mother this weekend. Since she's had a cold for two weeks she's "going to the doctor on Monday to get some antibiotics". First, I was floored that she would actually go to the doctor but remembered now that she's 65 and has Medicare she doesn't have to pay a co-pay and secondly, that all my talk about antitiotics are not for viruses and antibiotic resistance has been for naught.

But what do I know? My medical knowledge is only useful when its convenient for them (like when they want a script).

 

[Winged Scapula]

Just throwing out a thought here, hopefully this won't cause too much of an uproar, but perhaps doctors are to blame for this sort of thing happening. It even mentions in the article how there is an ever growing trend towards doctors becoming specialists and leaving the primary care field short of good physicians. There is a void that needs to be filled. We can't all be specialists or this is sure to happen. It seems like the only reason PAs and NPs have been able to obtain the kind of independence that they already have (and will apparently get more of) is because there's a shortage of good primary care docs. The shortage is only going to continue to grow as all of the baby boomers get into their elderly years.
I guess I'm just trying to say that this seems like a consequence of everyone's desire for high paying specialty positions with easy hours and no call schedule. Sure its nice to be in that sort of position I'm sure, but be prepared to call your nurses doctor if something doesn't change soon.
We need more GOOD primary care docs!!!

Absolutely they (doctors) are to blame.

No one takes advantage of you without you allowing it. Doctors, for whatever reason - either because they were too arrogant to believe it would happen, too greedy and wanted to see better paying patients, etc. - are if not solely, at least to a great deal to blame for the actions of mid-levels and their striving for independence.

 

[ForbiddenComma]

And part of it is doctors delegating away too many of their duties.

I believe once in the dim, hazy past, doctors would intubate their own patients, run their own vents, handle their own in-patients' diets, and even place their own difficult IVs.

Now, we have RTs to handle those intubations and vents because docs can no longer handle it... dieticians to handle the diets because docs can no longer handle it... and an "IV Team" consisting of nurses to handle difficult sticks because docs can no longer handle it.

My favorite moment last week was when I saw a dietician parading around in his crisp white coat, carrying himself like a doctor and the most important person in the hospital, rounding and charting on a patient... who was NPO.

No doubt, that also resulted in a nice addition to the patient's hospital bill. With armies of allied health people doing various parts of the doctor's job, is it any wonder why healthcare costs are so high? And is it any wonder why some of these allied health types view doctors as obsolete?

 

[deleted6669]

And part of it is doctors delegating away too many of their duties.

I believe once in the dim, hazy past, doctors would intubate their own patients, run their own vents, handle their own in-patients' diets, and even place their own difficult IVs.

Now, we have RTs to handle those intubations and vents because docs can no longer handle it... dieticians to handle the diets because docs can no longer handle it... and an "IV Team" consisting of nurses to handle difficult sticks because docs can no longer handle it.

My favorite moment last week was when I saw a dietician parading around in his crisp white coat, carrying himself like a doctor and the most important person in the hospital, rounding and charting on a patient... who was NPO.

No doubt, that also resulted in a nice addition to the patient's hospital bill. With armies of allied health people doing various parts of the doctor's job, is it any wonder why healthcare costs are so high? And is it any wonder why some of these allied health types view doctors as obsolete?

if they were npo for awhile maybe the dietician was arranging for TPN.....that's what they do, remember....

 

[gclax30]

Absolutely they (doctors) are to blame.

No one takes advantage of you without you allowing it. Doctors, for whatever reason - either because they were too arrogant to believe it would happen, too greedy and wanted to see better paying patients, etc. - are if not solely, at least to a great deal to blame for the actions of mid-levels and their striving for independence.

It seems like a chicken-or-the-egg argument to me. Did these "greedy" doctors start leaving primary care for better paying specialities first, creating a void to be filled by mid-levels? Or did they leave secondary to decreasing reimbursements, increasing cost of education/training and insurance, and just overall getting shafted from every angle so that it wasn't worth going into primary care anymore? I think the later. Believe it or not there are family and internal med docs out there that enjoy the primary care setting and wouldn't give it up for a specialty regardless of pay or lifestyle, but have been forced into considering those options for the reasons above. I really don't think they said "Screw old Ma and Pa Johnson and their blood pressure, let the NPs deal with 'em cuz I got a 7:00 a.m. tee time!" IMHO.

 

[mig26x]

I stopped using my white coat, everybody has one now. Years ago white coats were used to give the patient a better idea of who was the doctor taking care of them, but now a days the pulmonary nurse has one, case manager has one, dietitians have one etc etc.

I was going to go into primary care medicine, but after think that there are people fighting to have the same controlled on a patient care I decided against it.

 

[ForbiddenComma]

if they were npo for awhile maybe the dietician was arranging for TPN.....that's what they do, remember....

The patient was a simple pre-op. And even a lowly med student can probably think up a diet after the procedure. "NPO until flatus, then ad lib as tolerated" doesn't exactly require the patient to be billed by a ridiculously overpaid "dietician."

The worst part is, nobody called this dietician. They tend to just show up on their own.

I stopped using my white coat, everybody has one now.

On many services, I've noted that the only people not wearing a white coat these days... are the doctors.

I wouldn't wear my Short Coat of Shame if it weren't required.

 

[MacGyver]

And part of it is doctors delegating away too many of their duties.

I believe once in the dim, hazy past, doctors would intubate their own patients, run their own vents, handle their own in-patients' diets, and even place their own difficult IVs.

Now, we have RTs to handle those intubations and vents because docs can no longer handle it... dieticians to handle the diets because docs can no longer handle it... and an "IV Team" consisting of nurses to handle difficult sticks because docs can no longer handle it.

My favorite moment last week was when I saw a dietician parading around in his crisp white coat, carrying himself like a doctor and the most important person in the hospital, rounding and charting on a patient... who was NPO.

No doubt, that also resulted in a nice addition to the patient's hospital bill. With armies of allied health people doing various parts of the doctor's job, is it any wonder why healthcare costs are so high? And is it any wonder why some of these allied health types view doctors as obsolete?

Spot-on. I read something that did a study on this and showed that the number of healthcare workers assigned to each patient in 1975 was 4. In 2005, that number was 15.

As for dieticians not getting called and just showing up on patients, thats a ploy by the hospitals to defraud Medicare and insurance companies in general. They assign these cadres of ancillary healthcare workers to every patient admitted to the floor. That way they can submit a bunch of BS charges. So how does Medicare and the insurance companies respond to this: they cut doctor reimbursement.

And just think now all of the ancillary helathcare workers (dietiticians included) want their own provider numbers so they can bill Medicare directly. What a ****ing joke.

There's a lot of greedy hands who want a piece of the healthcare pie, and more "providers" means less money for doctors.

 

[MacGyver]

Another ploy that hospitals like to use is the "diabetes nurse"

Every time the computer records that there's a new patient coming to the floor with a diagnosis of DM, they get automatically assigned. No consults, they just show up automatically and put in their 2 cents about the "optimal" insulin regimen your pt should be on.

They bill for about a 30 min time block figuring out an insulin regimen thats only about 2% different from mine that I came up with in about 3 mins.

Yet another way for hospitals to defraud Medicare.

 

[Tired]

Let me offer a counter-thought:

With the rise of evidence-based medicine, especially in the outpatient management of chronic medical conditions, we don't really need doctors. It actually is cookbook medicine. If you have diabetes, you get these medicines in this order until your A1c is under this number. Ditto for high blood pressure. If you have a sore throat, the MA swabs your throat without an order. If you have back pain you get Motrin, and on your second visit, PT.

It's just a bunch of algorithms anyway.

The situation is even worse in "health surveillance" where prev med has defined what you get at every visit based on age/gender/race/comorbidities. Same for antenatal visits.

Hell, we don't even need NPs for this. Give a tech a book of flowcharts, and let them order what is needed. Once a week an RN can stop by, review the results, and send anyway with a critical value to a doctor.

We could eliminate the need for 75% of clinic-based physicians and nurses. The whole thing could be run by an office manager and three minimum-wage technicians.

 

[PharmD2MD]

Im sure there are good nurse practitioners out there, but i dont think they should be attacking the MDs. And if naming mistakes is the game, well MDs take in more responsibility, or re they preparing to go into neurosurgery and critical care as well? Oh yeah, my aunt went to a nurse practioner who diagnosed her with 3-day bronchitis and gave her clarithromycin! I auscultated my aunt, those breath sounds were uber clear...i told her to just drink plenty of fluids and rest. But of course, she wont believe me beause the nurse practitioner told her she had bronchitis and needed antibiotics. ??!??! o amount of explanation could dissuade her...and she kept on making statements about how nurses are better doctors...I was like, hell, go waste your copay money...and pray that you're not prt of the antibiotic resistance movement...

Similar story here...my mom went to a NP last year around this time because she was short of breath and was having to sleep in chair so she could breath easier. NP "diagnosed" her with community acquired pneumonia. Well, as you might guess, the antibiotic did nothing. She never had pneumonia. She had heart failure due to rheumatic heart disease. She's lost faith in the NP's and now sees a cardiologist at the Cleveland Clinic.

 

[mdjobexchange]

This country really faces a dilemma in its attitude towards healthcare. Patients keep getting sicker, fatter, more complex, and more demanding, while doctors keep losing ground to managed care, Medicare, and Medicaid. Most of us are too busy and too in debt to make much of a stand.

Physicians are facing pressure from many different directions and it really amazes me. I don't know how we got to be such as target, but we have. It is interesting that people have not put together the facts that healthcare costs keep going up, but doctors' incomes slowly decline.

Mid-level providers are making their inroads just like drug-eluting stents. It will be interesting to see if they make the difference, both in terms of quality and cost savings that people think they will over the long-term. I think mid-level providers serve an important role in healthcare, but I rarely hear an overhead page for "Mid-level provider to the ICU stat." Or when somebody has cancer, do you hear, "I have this terrible cancer growing in my brain, I better call the nurse practitioner." The question is not whether four years of medical school and another 3 to 9 years of additional training make a difference, but whether or not America values that training.

As far as the future value of an MD degree, medical students and residents need to take a careful look at the market and talk to many people about different specialties. Unless you have low student debt, I really don't see how you can make it in this country as a primary care doctor. The cost of living is just through the roof here.

At the same time, other specialties have their issues. I keep hearing people at my hospital talking about outsourcing radiology and even sending patients to India for elective total joints. The problem is that India has a booming population and are there enough doctors in India to handle extra volume from the US? With the falling dollar, is it still economically advantageous to send patients overseas?

Pick a good specialty like heme/onc, orthopedics, general surgery, pediatric anesthesia, gastroenterology, or invasive cardiology. They are good bets to retain the value of your MD degree. Also, take on as little debt as possible and think about business issues. Strongly consider the fact that you will change jobs within 2 years of finishing training, so use that time to pay off debt, not accumulate huge mortgages and trinkets.

 

[alphaholic06]

Let me offer a counter-thought:

With the rise of evidence-based medicine, especially in the outpatient management of chronic medical conditions, we don't really need doctors. It actually is cookbook medicine. If you have diabetes, you get these medicines in this order until your A1c is under this number. Ditto for high blood pressure. If you have a sore throat, the MA swabs your throat without an order. If you have back pain you get Motrin, and on your second visit, PT.

It's just a bunch of algorithms anyway.

The situation is even worse in "health surveillance" where prev med has defined what you get at every visit based on age/gender/race/comorbidities. Same for antenatal visits.

Hell, we don't even need NPs for this. Give a tech a book of flowcharts, and let them order what is needed. Once a week an RN can stop by, review the results, and send anyway with a critical value to a doctor.

We could eliminate the need for 75% of clinic-based physicians and nurses. The whole thing could be run by an office manager and three minimum-wage technicians.

Interesting concept. But the question is would the techs eventually want to have PhDs?

 

[Tired]

Interesting concept. But the question is would the techs eventually want to have PhDs?

One of the many lessons we should learn from the NP/CRNA push is this: You can always farm out work to someone with a lower-level of education and training.

If they want a PhD, let them have one; we can always just fire the lot of them (or move them into "Healthcare Administration"), hire undocumented farm workers from Mexico, and translate the books into Spanish.

 

[Coastie]

Primary care physicians can BANK.

When will physicians realize this? Buck medicare/medicaid, take cash only/high insurance only, and help more people out while helping yourself out at the same time.

Computerize your practice. Have low overhead. Destroy the mid-level competition by advertising as a DOCTOR.

 

[Tired]

Primary care physicians can BANK.

When will physicians realize this? Buck medicare/medicaid, take cash only/high insurance only, and help more people out while helping yourself out at the same time.

Computerize your practice. Have low overhead. Destroy the mid-level competition by advertising as a DOCTOR.

Gotta have a high-income population, which tends to have a wealth of PCPs there already. Hard to get established in an area like that unless you have a practice you can buy into.

How about boutique medicine? Low-number panel, but available 24/7 and you have to do home visits. Be curious to know how those guys make out.

 

[deleted6669]

Mid-level providers are making their inroads just like drug-eluting stents. It will be interesting to see if they make the difference, both in terms of quality and cost savings that people think they will over the long-term. I think mid-level providers serve an important role in healthcare, but I rarely hear an overhead page for "Mid-level provider to the ICU stat." .

GUESS AGAIN:
http://www.connapa.org/jobbank/Surgical%20ICU PA.pdf

Also see links to pa residencies in hospital medicine, trauma, burns, and critical care....
www.appap.org

keep in mind that these pa's do have medical supervision and were hired by and work for physician groups, not as cowboy intenivists.

 

[Annette]

Let me offer a counter-thought:

. . .
We could eliminate the need for 75% of clinic-based physicians and nurses. The whole thing could be run by an office manager and three minimum-wage technicians.

I hate to say it, Tired, but you are right. Unfortunate for the complex patients who fall out of the algorythm.

Renal a. stenosis, CHF, HTN, COPD and DM?
"Sorry, sir, I can't treat you because my books don't have a pathway for all of your diseases."

 

[mig26x]

GUESS AGAIN:
http://www.connapa.org/jobbank/Surgical ICU PA.pdf

Also see links to pa residencies in hospital medicine, trauma, burns, and critical care....
www.appap.org

keep in mind that these pa's do have medical supervision and were hired by and work for physician groups, not as cowboy intenivists.

that's very scary!!!

 

[parvas24]

Let me offer a counter-thought:

With the rise of evidence-based medicine, especially in the outpatient management of chronic medical conditions, we don't really need doctors. It actually is cookbook medicine. If you have diabetes, you get these medicines in this order until your A1c is under this number. Ditto for high blood pressure. If you have a sore throat, the MA swabs your throat without an order. If you have back pain you get Motrin, and on your second visit, PT.

It's just a bunch of algorithms anyway.

The situation is even worse in "health surveillance" where prev med has defined what you get at every visit based on age/gender/race/comorbidities. Same for antenatal visits.

Hell, we don't even need NPs for this. Give a tech a book of flowcharts, and let them order what is needed. Once a week an RN can stop by, review the results, and send anyway with a critical value to a doctor.

We could eliminate the need for 75% of clinic-based physicians and nurses. The whole thing could be run by an office manager and three minimum-wage technicians.

I see in the not too distant future there would be huge computer machines interactive with patients in Outpatients ..... following basic protocols and treating patients .... complicated cases made easy by TELEMEDICINE

I feel that only doctors allowed to manage their patients and prescibe treatments ....the nurses should do their Nursing part only ... Unfortunately they seem to step on Doctor's toes all the time here

 

[deleted6669]

that's very scary!!!

no more scary than having a resident from another service do it...these folks only do ICU so they are good at it. most of them teach md residents as a regular part of their jobs. I have worked at 3 facilities where I have( and currently do) precept residents who know a lot less em than I do. I currently am precepting a pgy-1 fp resident. in the last week I have taught him how to suture, staple, treat an ingrown toenail, do a digital block, perform anoscopy, use a slit lamp, I+D an abscess, work up a kid with fever, etc he had done all these things before"once or twice" as an ms-3 but forgot how to perform these skills.
folks are good at what they do every day, regardless of the initials after their names. do I get consults on difficult pts? sure, all the time. do my md colleagues?, of course. do they get fewer than I do? probably. most of the time when I am puzzled by something going on with a pt the docs in my group don't know the answer either and I end up calling a subspecialist. after doing this for 20 yrs I have learned a few things about em.
do I think I know more em than an em trained doc? nope. do I know more em than most(read the vast majority) non-em physicians? yup( for purposes of arguement an fm doc who has worked em his whole career is an em doc as far as I am concerned).

 

[Faebinder]

no more scary than having a resident from another service do it...these folks only do ICU so they are good at it. most of them teach md residents as a regular part of their jobs. I have worked at 3 facilities where I have( and currently do) precept residents who know a lot less em than I do. I currently am precepting a pgy-1 fp resident. in the last week I have taught him how to suture, staple, treat an ingrown toenail, do a digital block, perform anoscopy, use a slit lamp, I+D an abscess, work up a kid with fever, etc he had done all these things before"once or twice" as an ms-3 but forgot how to perform these skills.
folks are good at what they do every day, regardless of the initials after their names. do I get consults on difficult pts? sure, all the time. do my md colleagues?, of course. do they get fewer than I do? probably. most of the time when I am puzzled by something going on with a pt the docs in my group don't know the answer either and I end up calling a subspecialist. after doing this for 20 yrs I have learned a few things about em.
do I think I know more em than an em trained doc? nope. do I know more em than most(read the vast majority) non-em physicians? yup( for purposes of arguement an fm doc who has worked em his whole career is an em doc as far as I am concerned).

The ICU, the land of Zebras and home of the near-dead. It's not like the ER where you just need to know if a) admit and let them deal with it or b) treat and send them home.

Residents in the ICU are necessary evil so they can learn (otherwise you will have no more attendings). They don't usually even use the 1st year residents, usually it's a second year resident. PAs in the ICU? Unncessary risk that the hospital takes probably to save money and the attendings are okay with it so they dont get called as much. That's my take. There are way too many factors involved.

 

[Coastie]

Not as high as you may think, man.

I know of docs who make ALOT has PCP (>300k), with reasonable hours in a middle income type of area. It's all about how you do things...You think middle class people can afford a $50-75 doc visit? Heck yeah..

Gotta have a high-income population, which tends to have a wealth of PCPs there already. Hard to get established in an area like that unless you have a practice you can buy into.

How about boutique medicine? Low-number panel, but available 24/7 and you have to do home visits. Be curious to know how those guys make out.

 

[mig26x]

moral of the story? SPECIALIZE!!!

 

[mig26x]

no more scary than having a resident from another service do it...these folks only do ICU so they are good at it. most of them teach md residents as a regular part of their jobs. I have worked at 3 facilities where I have( and currently do) precept residents who know a lot less em than I do. I currently am precepting a pgy-1 fp resident. in the last week I have taught him how to suture, staple, treat an ingrown toenail, do a digital block, perform anoscopy, use a slit lamp, I+D an abscess, work up a kid with fever, etc he had done all these things before"once or twice" as an ms-3 but forgot how to perform these skills.
folks are good at what they do every day, regardless of the initials after their names. do I get consults on difficult pts? sure, all the time. do my md colleagues?, of course. do they get fewer than I do? probably. most of the time when I am puzzled by something going on with a pt the docs in my group don't know the answer either and I end up calling a subspecialist. after doing this for 20 yrs I have learned a few things about em.
do I think I know more em than an em trained doc? nope. do I know more em than most(read the vast majority) non-em physicians? yup( for purposes of arguement an fm doc who has worked em his whole career is an em doc as far as I am concerned).

nope, because thats their JOB to be physicians, PA are assistants. That simple!!

You want to be a physician go to med school.

 

[deleted6669]

nope, because thats their JOB to be physicians, PA are assistants. That simple!!

You want to be a physician go to med school.

sorry, cat's out of the bag, dude. we are working in every setting now...don't like it , don't hire us. someone else will.

 

[Tired]

sorry, cat's out of the bag, dude. we are working in every setting now...don't like it , don't hire us. someone else will.

I know that you know the stats on this way better than I do, but I can't help but wonder if your analysis of the PA/NP situation is somewhat colored by the fact that you are a PA.

I have worked in/trained in over a dozen hospitals (in three different states) in the last eight years. In that time, I have met two PAs in an ER, and a PA who did preops for a Neurosurgery group. I have met one NP, in a Peds Ortho clinic. Other than that, I have never worked with or seen mid-levels in tertiary care facilities.

For all our worries about the rise of mid-level independence, I really haven't seen them working hardly at all, much less independently.

 

[deleted6669]

I know that you know the stats on this way better than I do, but I can't help but wonder if your analysis of the PA/NP situation is somewhat colored by the fact that you are a PA.

I have worked in/trained in over a dozen hospitals (in three different states) in the last eight years. In that time, I have met two PAs in an ER, and a PA who did preops for a Neurosurgery group. I have met one NP, in a Peds Ortho clinic. Other than that, I have never worked with or seen mid-levels in tertiary care facilities.

For all our worries about the rise of mid-level independence, I really haven't seen them working hardly at all, much less independently.

There are 60,000+ working pa's now. they are all working somewhere and >50% now work in specialties.chances are you have seen pa's and not known that they are pa's. some random guy in a white coat rounding with the xyz team was probably a pa. we aren't trying to take over. we are trying to blend in on physician led teams and make a contribution.
it's likely that at this point in your education you have been mostly at large acaemic medical ctrs with tons of residents(cheap labor). out in the community(non-teaching facilities) pa's fill a lot of these roles. at my facility( a major trauma ctr with 118k visits/yr) pa's work on almost every service in the hospital except for ob.
if you call for an ortho or ct surg consult you get a pa.if they can't solve the problem they call their attending. there are pa's on the hospitalist team. inpt psych evals are done by an np. our satelite em facility is staffed 24/7 by pa's with a doc on days only.
we are not trying to replace you guys...really.....do you see DNP in my signature?....

 

[Tired]

we are not trying to replace you guys...really.....do you see DNP in my signature?....

Don't worry, I'm not threatened by PAs. In truth, I'm not threatened by any of the NP stuff either, because I find it highly unlikely anyone in nursing will put in the time necessary to do surgical procedures.

Sure, the nurses can skate by in the medicine world, writing prescriptions and ordering tests, with very rare complications. But in surgery the complications are imminent and come up on a regular basis, and not knowing the anatomy/complications/treatments of complications will kill patients with alarming regularity. I just don't see NPs learning anatomy.

So for me, what do I care?

Your point about academic centers is well-taken. All my work and school experience has been in centers with multiple residency programs. I will be curious to see, after I get out of the major military hospitals, how much we are utilizing PAs in other areas.

I also appreciate the fact that I have yet to meet an active duty NP.

 

[PharmD2MD]

I also appreciate the fact that I have yet to meet an active duty NP.

They're out there- little commands, overseas bases.

 

[OTD]

I have worked with many, many NP and PA's. The only threat from them is due to ignorance of congress/public when they start believing they are "as good as a doctor". That's just dangerous.

NP's are great for what they do (glorified triage nurse), they have very little in depth knowledge, they just know you treat a UTI with Bactrim, can give flagyl for vaginosis etc. Very little in depth but fairly broad, they can also half way diagnose bronchitis etc.

PA's are just the opposite, the Neurosurgery PA will be spot on with everything Neuro, very in depth, knows most of the complications etc. Just don't ask him to know anything about the medications (other than mannitol LOL), the belly, leg or any other thing. He is not very broad based, but he knows his **** in his little defined category very, very well.

For me, I will likely end up hiring a couple of PA's as they would be very helpful and I would trust them due to their in depth understanding of their narrow scope. They are good at what they do. Never met one that wanted to be a doctor or thought they were even close in knowledge to the attending. The ones I met considered themselves as something like a Trade, such as Heating/Air Conditioning etc. Very very good at what they do and that's enough for them.

 

[Mephisto]

My one beef with PAs and Nurses is this:

I do not believe they will have the time or desire to do what doctors do. I have worked at 6 hospitals now and I always see the interns and residents and attendings staying later than they have to, truly showing dedication. I have never met a nurse who doesn't punch her time card AS SOON as her shift ends, no matter what her patient is doing. She is signed out and gone! I was actually semi-floored by this.

At one of the hospitals, there was a brief 3 day nursing strike after long contract negotiations with the union failed. The strike was pending and the hospital had hired scab traveling nurses, but those nurses hadn't arrived yet. Needless to say, the nurses went on strike as scheduled (the buses with the scabs were due to arrive an hour and a half later). EVERY freakin' nurse just left her patients and the interns and residents and attendings (WHO HAVE NOTHING TO DO WITH THEIR CONTRACT DISPUTE) were scrambling to take care of all the patients. We're talking ICU nurses too. Just up and left the floor at the scheduled time. No concern for collegues or patients. I understand there's a contract dispute, but if doctors did this, people would be outraged (and that's why it's illegal for docs to unionize).

So yeah, if nurses want to be doctors, I say let them, and let them take all the crap that comes with it. If they want to practice independently, make them disband their unions and make them buy malpractice insurance (i'd like to see what their premiums would be).

 

[Therapist4Chnge]

That is a scary article. I respect the training of each profession, but if you are going to spout off things like what was in that article, you better have hard data (peer reviewed) to back it up. Without data it is just an agenda, and there are too many examples of how agendas can really undermine what is best for patients.

-t

 

[Tired]

That is a scary article. I respect the training of each profession, but if you are going to spout off things like what was in that article, you better have hard data (peer reviewed) to back it up. Without data it is just an agenda, and there are too many examples of how agendas can really undermine what is best for patients.

That's the point though, there are studies that show equivalence between physicians and NPs. She wasn't just blowing smoke there.

 

[Doowai]

So yeah, if nurses want to be doctors, I say let them, and let them take all the crap that comes with it.

I agree. In the article it says she wants to give the DNP's "similar tests" as those given MD's to prove they are just as good. I read this to mean, "similar but way easier" so that every DNP looks super smart. If they want to be doctors then they ought to take the USMLE's - and afterwards they can be awarded the DNP (not MD, since they are not - but nurse doctors) - but they ought to take the USMLE step 1-3.

 

[Therapist4Chnge]

That's the point though, there are studies that show equivalence between physicians and NPs. She wasn't just blowing smoke there.

Hmmm....anyone have a link to that? I've only heard reference to it (in JAMA?) though I haven't had a chance to read it yet. What area does it assess...PCP? FP?

-t

 

[Tired]

Hmmm....anyone have a link to that? I've only heard reference to it (in JAMA?) though I haven't had a chance to read it yet. What area does it assess...PCP? FP?

-t

Here's the one I was thinking of:

---------------------------------------------------------------------------------------------
Randomised controlled trial of nurse practitioner versus general practitioner care for patients requesting "same day" consultations in primary care
British Medical Journal, April 15, 2000 by Paul Kinnersley, Elizabeth Anderson, Kate Parry, John Clement, Luke Archard, Pat Turton, Andrew Stainthorpe, Aileen Fraser, Chris C Butler, Chris Rogers
Abstract

Objective To ascertain any differences between care from nurse practitioners and that from general practitioners for patients seeking "same day" consultations in primary care.

Design Randomised controlled trial with patients allocated by one of two randomisation schemes (by day or within day).

Setting 10 general practices in south Wales and south west England.

Subjects 1368 patients requesting same day consultations.

Main outcome measures Patient satisfaction, resolution of symptoms and concerns, care provided (prescriptions, investigations, referrals, recall, and length of consultation), information provided to patients, and patients' intentions for seeking care in the future.

Results Generally patients consulting nurse practitioners were significantly more satisfied with their care, although for adults this difference was not observed in all practices. For children, the mean difference between general and nurse practitioner in percentage satisfaction score was -4.8 (95% confidence interval -6.8 to -2.8), and for adults the differences ranged from -8.8 (-13.6 to -3.9) to 3.8 (-3.3 to 10.8) across the practices. Resolution of symptoms and concerns did not differ between the two groups (odds ratio 1.2 (95% confidence interval 0.8 to 1.8) for symptoms and 1.03 (0.8 to 1.4) for concerns). The number of prescriptions issued, investigations ordered, referrals to secondary care, and reattendances were similar between the two groups. However, patients managed by nurse practitioners reported receiving significantly more information about their illnesses and, in all but one practice, their consultations were significantly longer.

---------------------------------------------------------------------------------------------

And here's a few more:

Mundinger, M.O., Kane, R. L., Lenz, E.R., Totten, A.M., Wei-Yann, T., Cleary, P.D., Friedewald, W. T., Siu, A. L., Shelanski, M.L. (2000) Primary care outcomes in patients treated by nurse practitioners or physicians. JAMA. 283(1): 59-68.

Rudy, E.B., Davidson, L.J., Daly, B., Clochesy, J.M., Sereika, S., Baldisseri, M., Hravnak, M., Ross, T. & Ryan, C. (1998). Care activities and outcomes of patients cared for by acute care nurse practitioners, physician assistants, and resident physicians: a comparison. Am J. Crit Care. 7(4):267-281.

Sox, H.C. (1979). Quality of patient care by nurse practitioners and physician assistants': a ten year perspective. Ann Intern Med. 91:459-468.

Spitzer, W.O., Sackett, D.L., Sibley J.C., et al. (1974). The Burlington randomized trial of the nurse practitioners. New England J. Med. 290:251-256.

 

[Tired]

Physicians are approaching this topic all wrong. The issue is not whether NPs can provide the same quality of routine care as physicians. Of course they can. Hell, I'll go a step further and argue that an experienced nurse can adequately manage 95% of the average patients seen in a primary care clinic. It's really not that complex.

We don't make a nice salary for providing routine care. We get paid to pick up the small proportion of patients who come in with a minor complaint but end up having something life-threatening. Any monkey can hand out Nexium to every patient with GERD, but picking up the one patient whose nausea is actually an MI is what we're really here for.

Our expertise comes from (a) managing critical patients with complex acute and chronic medical conditions, and (b) picking up on the profoundly ill patient before they end up dying. Trying to compare us to NPs by tracking adherence to well-publicized, easy-to-follow clinical practice guidelines is just stupid.

 

[Faebinder]

Here's the one I was thinking of:

---------------------------------------------------------------------------------------------
Randomised controlled trial of nurse practitioner versus general practitioner care for patients requesting "same day" consultations in primary care
British Medical Journal, April 15, 2000 by Paul Kinnersley, Elizabeth Anderson, Kate Parry, John Clement, Luke Archard, Pat Turton, Andrew Stainthorpe, Aileen Fraser, Chris C Butler, Chris Rogers
Abstract

Objective To ascertain any differences between care from nurse practitioners and that from general practitioners for patients seeking "same day" consultations in primary care.

Design Randomised controlled trial with patients allocated by one of two randomisation schemes (by day or within day).

Setting 10 general practices in south Wales and south west England.

Subjects 1368 patients requesting same day consultations.

Main outcome measures Patient satisfaction, resolution of symptoms and concerns, care provided (prescriptions, investigations, referrals, recall, and length of consultation), information provided to patients, and patients' intentions for seeking care in the future.

Results Generally patients consulting nurse practitioners were significantly more satisfied with their care, although for adults this difference was not observed in all practices. For children, the mean difference between general and nurse practitioner in percentage satisfaction score was -4.8 (95% confidence interval -6.8 to -2.8), and for adults the differences ranged from -8.8 (-13.6 to -3.9) to 3.8 (-3.3 to 10.8) across the practices. Resolution of symptoms and concerns did not differ between the two groups (odds ratio 1.2 (95% confidence interval 0.8 to 1.8) for symptoms and 1.03 (0.8 to 1.4) for concerns). The number of prescriptions issued, investigations ordered, referrals to secondary care, and reattendances were similar between the two groups. However, patients managed by nurse practitioners reported receiving significantly more information about their illnesses and, in all but one practice, their consultations were significantly longer.

---------------------------------------------------------------------------------------------

And here's a few more:

Mundinger, M.O., Kane, R. L., Lenz, E.R., Totten, A.M., Wei-Yann, T., Cleary, P.D., Friedewald, W. T., Siu, A. L., Shelanski, M.L. (2000) Primary care outcomes in patients treated by nurse practitioners or physicians. JAMA. 283(1): 59-68.

Rudy, E.B., Davidson, L.J., Daly, B., Clochesy, J.M., Sereika, S., Baldisseri, M., Hravnak, M., Ross, T. & Ryan, C. (1998). Care activities and outcomes of patients cared for by acute care nurse practitioners, physician assistants, and resident physicians: a comparison. Am J. Crit Care. 7(4):267-281.

Sox, H.C. (1979). Quality of patient care by nurse practitioners and physician assistants': a ten year perspective. Ann Intern Med. 91:459-468.

Spitzer, W.O., Sackett, D.L., Sibley J.C., et al. (1974). The Burlington randomized trial of the nurse practitioners. New England J. Med. 290:251-256.

There is no way we can compare that to the US unfortunately. We are way more complicated in management in the US. More CT scans are due, more MRIs are due, more Angiography, more Biopsies.

General practice in the UK is a total different game. They don't do defensive medicine and don't have as many test follow-ups not to mention as much garden variety as we do in the US.

Further, zebras don't show up in a 1000 people. Come on, I once looked at the list of 20 year practicing Family Physician. His clinic only included 2 patients that were primarily diagnosed with MS by him in those 20 years. A delay in diagnosis means a delay in treatment resulting in earlier complications and morbidity. You might think (oh yeah it's a joke to pick MS in the ER). Yes it is because the MS is not masquerading amongst 5000 normal blurry vision cases spread over 20 years.

 

[core0]

Here's the one I was thinking of:

---------------------------------------------------------------------------------------------
Randomised controlled trial of nurse practitioner versus general practitioner care for patients requesting "same day" consultations in primary care
British Medical Journal, April 15, 2000 by Paul Kinnersley, Elizabeth Anderson, Kate Parry, John Clement, Luke Archard, Pat Turton, Andrew Stainthorpe, Aileen Fraser, Chris C Butler, Chris Rogers
Abstract

Objective To ascertain any differences between care from nurse practitioners and that from general practitioners for patients seeking "same day" consultations in primary care.

Design Randomised controlled trial with patients allocated by one of two randomisation schemes (by day or within day).

Setting 10 general practices in south Wales and south west England.

Subjects 1368 patients requesting same day consultations.

Main outcome measures Patient satisfaction, resolution of symptoms and concerns, care provided (prescriptions, investigations, referrals, recall, and length of consultation), information provided to patients, and patients' intentions for seeking care in the future.

Results Generally patients consulting nurse practitioners were significantly more satisfied with their care, although for adults this difference was not observed in all practices. For children, the mean difference between general and nurse practitioner in percentage satisfaction score was -4.8 (95% confidence interval -6.8 to -2.8), and for adults the differences ranged from -8.8 (-13.6 to -3.9) to 3.8 (-3.3 to 10.8) across the practices. Resolution of symptoms and concerns did not differ between the two groups (odds ratio 1.2 (95% confidence interval 0.8 to 1.8) for symptoms and 1.03 (0.8 to 1.4) for concerns). The number of prescriptions issued, investigations ordered, referrals to secondary care, and reattendances were similar between the two groups. However, patients managed by nurse practitioners reported receiving significantly more information about their illnesses and, in all but one practice, their consultations were significantly longer.

---------------------------------------------------------------------------------------------

And here's a few more:

Mundinger, M.O., Kane, R. L., Lenz, E.R., Totten, A.M., Wei-Yann, T., Cleary, P.D., Friedewald, W. T., Siu, A. L., Shelanski, M.L. (2000) Primary care outcomes in patients treated by nurse practitioners or physicians. JAMA. 283(1): 59-68.

Rudy, E.B., Davidson, L.J., Daly, B., Clochesy, J.M., Sereika, S., Baldisseri, M., Hravnak, M., Ross, T. & Ryan, C. (1998). Care activities and outcomes of patients cared for by acute care nurse practitioners, physician assistants, and resident physicians: a comparison. Am J. Crit Care. 7(4):267-281.

Sox, H.C. (1979). Quality of patient care by nurse practitioners and physician assistants’: a ten year perspective. Ann Intern Med. 91:459-468.

Spitzer, W.O., Sackett, D.L., Sibley J.C., et al. (1974). The Burlington randomized trial of the nurse practitioners. New England J. Med. 290:251-256.

Not a particularly good one. The NP in the UK is significantly different than the NP role in the US. The NPs in the UK do walk in clinics for minor illness in this case. We are not talking about managing diabetes or HTN. This is the same job that the Army uses medics for. Not particularly different from the local minute clinics. Also patient satisfaction is a better outcome.

The study everyone talks about is this one (which was done by the author of the article):
http://jama.ama-assn.org/cgi/content/full/283/1/59

Numerous faults including single center,sample size etc. Interestingly the physicians were thought to be better listeners and had higher patient satisfaction than the NPs (who would have thunk it).

However the real follow up at two years which should have shown equivalence in measurable rates like HTN or A1C foundered on lack of continuity and was published in a third (4th?) tier journal (abstract):
http://www.rwjf.org/pr/product.jsp?id=14785&topicid=1395

So there has never been a study that was properly done and shown even equivalence much less superiority of NPs over BC/BE MDs. There have been a few studies that showed NP superiority in NICUs and renal clinics over residents, but in both cases the NPs and the residents were supervised by BC/BE physicians making it more likely the effect was from continuity not training.

Mundinger knows that this evidence she talks about does not exist. It is simply propaganda that tries to espouse here extreme brand of nursing. As far as success of the "NP clinic" that she is so proud of. In the first study there were seven NPs, two years later there were four NPs, currently there are three NPs. If the NPs truly had a better product, I would expect them to have numerous clinics all over Manhattan instead of fading into obscurity.

David Carpenter, PA-C

 

[core0]

I agree. In the article it says she wants to give the DNP's "similar tests" as those given MD's to prove they are just as good. I read this to mean, "similar but way easier" so that every DNP looks super smart. If they want to be doctors then they ought to take the USMLE's - and afterwards they can be awarded the DNP (not MD, since they are not - but nurse doctors) - but they ought to take the USMLE step 1-3.

Never happen. I would like to see the NPs pass step I much less any of the others. To prove this won't happen you just have to look at the state of current nursing certification. There are five different certifying organizations that offer certification. At least four specialties have two organizations that certify NPs in that specialty. Can you say race to the bottom.

David Carpenter, PA-C

 

[Tired]

So there has never been a study that was properly done and shown even equivalence much less superiority of NPs over BC/BE MDs. There have been a few studies that showed NP superiority in NICUs and renal clinics over residents, but in both cases the NPs and the residents were supervised by BC/BE physicians making it more likely the effect was from continuity not training.

We can argue all day about methodology, but when peer-reviewed studies appears in jounals like JAMA and NEJM, you no longer get to say things like "there has never been a study that was properly done". In general, I agree with your assessment of these studies (the few I have read, anyway), but the appropriate way to refute studies whose design we take issue with, is to design better studies and hope they show the opposite. To the best of my knowledge, this has not been done, nor is it being attempted.

But again, I argue that this is a futile road to travel. Most routine primary care does not require a physician's expertise, which is why nurses run diabetes care centers, coumadin clinics, and hypertension clinics. However, picking out the patients who need further workup does. Outcomes like "patient satisfaction" and adherence to clinical practice guidelines are poor metrics to judge physicians.

We shouldn't be playing this game at all, and shame on the docs who participated in the studies I cited above.