Your MD degree losing value...

[badasshairday]

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.

This is a good post. We need active lobbying to get things like this done. Nurses do this like crazy and they are getting everything they want.

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[badasshairday]

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).

That is ridiculous! What did the patients and families have to say about the strike.

 

[core0]

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.

There are a lot of bad studies published. There are studies published in Nature and Science that have been withdrawn because they were fraudulent. Just because it is published doesn't mean it has validity.

The onus is one the NPs if they wish to claim that they are equivalent to MDs. The standard of medical care in the US is a board certified MD. That is the standard that you will be held to. For that matter that is the standard that I will be held to. If the NPs want to claim independent status then they need to show that they can preform at that level. If they want to continue (as most NPs currently are doing) in a supervised status then there is no need to show equivalence. The claim has been made that the NP is not only equivalent to the MD but superior. This is simply not supported by the facts and needs to be challenged. If the NPs want to show equivalence let them demonstrate it if they can.

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.

Nurse run all of the clinics that you mention above (an some without advanced degrees). However, they are supervised by physicians when they do this. It would be relatively easy to design a study similar to the JAMA study with proper power. However, the issue is finding true independent NP practice and patients willing to participate in the test. While patient satisfaction is not a valid metric adherence to clinical practice guidelines does have a meaningful outcome on patient morbidity and mortality.

David Carpenter, PA-C

 

[OTD]

The scariest part is now thanks to Billary the requirements for actual experience for entrance in to NP school have mostly fallen by the wayside.

Now you have new FNP's that have NEVER taken care of a patient, they went through their nursing school then 18 months of "Nursing Theory" in Nurse Practitioner school and are starting out "in my own practice."

I am very close to a NP school and it is indeed very scary to see graduating NP with the knowledge base of a good Biology undergrad or maybe a first year med student between first and second semester and realize that this person is going out "in private practice". They usually end up handing out candy.

Of course I have seen the other side too, 20 years ICU nurse making a very good competent NP but that is getting rare now. When these schools were set up the requirements weren't that tough because EXPERIENCE was required and they had lots of on the job training, therefore the schools didn't need to retrain them and waste time. The requirements for experience have been dropped but the training continues as if they are still teaching experienced students. Thats the dirty little secret that the majority of the public doesn't know.

The level of incompetence that is "graduating" from NP school now is overwhelming since the experience requirements have been lifted.

 

[fab4fan]

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.

In my area, NPs don't work independently at all. Perhaps in metro areas there's more interest in independence, but it seems like a lot of the push for it comes from the heads of academic institutions, not from the NPs who are out there working.

At this point I'm on the NP path, but not DNP. If that becomes mandatory, then I'm dropping my plans for something else--who knows what. I have no need or desire for a DNP. I don't want to practice independently; I just want to do more than I can as a staff nurse.

 

[fab4fan]

The scariest part is now thanks to Billary the requirements for actual experience for entrance in to NP school have mostly fallen by the wayside.

Now you have new FNP's that have NEVER taken care of a patient, they went through their nursing school then 18 months of "Nursing Theory" in Nurse Practitioner school and are starting out "in my own practice."

I am very close to a NP school and it is indeed very scary to see graduating NP with the knowledge base of a good Biology undergrad or maybe a first year med student between first and second semester and realize that this person is going out "in private practice". They usually end up handing out candy.

Of course I have seen the other side too, 20 years ICU nurse making a very good competent NP but that is getting rare now. When these schools were set up the requirements weren't that tough because EXPERIENCE was required and they had lots of on the job training, therefore the schools didn't need to retrain them and waste time. The requirements for experience have been dropped but the training continues as if they are still teaching experienced students. Thats the dirty little secret that the majority of the public doesn't know.

The level of incompetence that is "graduating" from NP school now is overwhelming since the experience requirements have been lifted.

But they will be very quick to tell you that experience is totally "irrelevant." Trust me--I've had that conversation on more than one occasion. It's not even worth getting into anymore.

 

[Tired]

Nurse run all of the clinics that you mention above (an some without advanced degrees). However, they are supervised by physicians when they do this. It would be relatively easy to design a study similar to the JAMA study with proper power. However, the issue is finding true independent NP practice and patients willing to participate in the test. While patient satisfaction is not a valid metric adherence to clinical practice guidelines does have a meaningful outcome on patient morbidity and mortality.

The current standard for evidence-based medicine is analysis of available data. Peer-reviewed studies in respected journals cannot be dismissed over issues of methodology, unless you correct the methodology in a subsequent study.

We have this fight over and over again with stents, BP meds, diabetes management etc, but we never look at a medical study in NEJM and go, "Oh, I'm going to ignore that study because the methodology bothers me." We say, "Man, that method sucked, but until I see something better I guess I'll just have to go with its conclusions." I mean, look at the WHI study on HRT. Everyone new it was horribly flawed and drew impropoper conclusions, but clinical practice changed almost overnight anyway.

As NP practice becomes more independent (which of course it will), these studies will be easier to design and carry out. I doubt finding patients will be difficult, because people don't know much about medical care, and already they are getting used to the idea of an NP being "just like a doctor". Probably the harder part will be finding NPs to participate . . .

 

[OTD]

We have this fight over and over again with stents, BP meds, diabetes management etc, but we never look at a medical study in NEJM and go, "Oh, I'm going to ignore that study because the methodology bothers me." We say, "Man, that method sucked, but until I see something better I guess I'll just have to go with its conclusions."

Really cause we do it all the time. "I can't believe this crap got published, this does't mean anything except they want to sell more of X" or "they just want insurance to pay for Y" and toss it in the trash. That's what Journal Club is for at our institution, to critically read the journals to see what the study REALLY means.

Unless it passes our judgement it doesn't change how we practice regardless of which journal it came from. IMO If it's crap, it's crap no matter who published it.