What specialties can least be done by mid-levels?

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As opposed to the computers discussion, I think this one is even more relevant for us. The writing is on the wall, midlevels can do a lot of the same stuff as certain doctors for a lot less money. Thus, either many physicians will get crowded out or their salaries will have to drop to comparable levels to DNP's (yet another reason not to do med if you will acquire 150k+ in loans). What specialties are gonna be safe from this? Neurosurgery and other advanced surgeries only? Oncology?

Also, not to open a can of worms, but IMO the DNP training is a much more EFFICIENT way to produce health professionals than medical school. How much of the crap you learn in medical school do you actually use in your routine of pattern recognition? Soon enough, many of the people who wasted 200k on it may be seen as too educated to afford, and there are only so many positions in hospitals in rich areas.

Originally Posted by SchroedingrsCat

As opposed to the computers discussion, I think this one is even more relevant for us. The writing is on the wall, midlevels can do a lot of the same stuff as certain doctors for a lot less money. Thus, either many physicians will get crowded out or their salaries will have to drop to comparable levels to DNP's (yet another reason not to do med if you will acquire 150k+ in loans). What specialties are gonna be safe from this? Neurosurgery and other advanced surgeries only? Oncology?

Pretty much anything that isn't primary care.

Originally Posted by SchroedingrsCat

As opposed to the computers discussion, I think this one is even more relevant for us. The writing is on the wall, midlevels can do a lot of the same stuff as certain doctors for a lot less money. Thus, either many physicians will get crowded out or their salaries will have to drop to comparable levels to DNP's (yet another reason not to do med if you will acquire 150k+ in loans). What specialties are gonna be safe from this? Neurosurgery and other advanced surgeries only? Oncology?

First off, I challenge your primary assumption. "midlevels can do a lot of the same stuff as certain doctors for a lot less money." Midlevels tend to see lower patient volumes, simpler cases, and (I know, citation needed) order more tests/referrals, and so a lower salary doesn't mean lower healthcare costs. Furthermore they may have difficulty managing complex cases, while a doc could handle anything coming through the door. Current studies comparing outcomes are inadequate to say the least.

That being said, I'd say surgical and procedural specialties are least vulnerable to encroachment, while outpatient primary care is the most.

Cardiac Electrophysiology

Originally Posted by druggeek

Pretty much anything that isn't primary care.

What about all the fuss already from Anesthesiologists about CRNAs taking their positions?

Originally Posted by SchroedingrsCat

What about all the fuss already from Anesthesiologists about CRNAs taking their positions?

meh, I doubt they will do a full take over anytime soon. I wouldnt ever let a CRNA put anyone in my family/relatives to sleep even for the most basic/easy procedure (serious).

With that being said, I think you gotta go super specialized if you want to be safe from mid levels. Something like a pediatric neuro-deepvascular-spinal-surgeon is pretty safe.

Well, I think specialties with extensive procedural components like many of the surgical specialties are fairly "safe." That being said, midlevel practictioners can be very handy in terms of managing the non-procedural stuff in those specialties (for example, my hospital just hired a few NPs for the neurosurgery department and the residents are loving it because it increases their OR time).

Originally Posted by mmmcdowe

Well, I think specialties with extensive procedural components like many of the surgical specialties are fairly "safe." That being said, midlevel practictioners can be very handy in terms of managing the non-procedural stuff in those specialties (for example, my hospital just hired a few NPs for the neurosurgery department and the residents are loving it because it increases their OR time).

Makes sense anyway. NPs are the ideal people to be asking the patient how they're feeling. Waste of time for a surgeon to be doing that extensively.

Originally Posted by SchroedingrsCat

As opposed to the computers discussion, I think this one is even more relevant for us. The writing is on the wall, midlevels can do a lot of the same stuff as certain doctors for a lot less money. Thus, either many physicians will get crowded out or their salaries will have to drop to comparable levels to DNP's (yet another reason not to do med if you will acquire 150k+ in loans). What specialties are gonna be safe from this? Neurosurgery and other advanced surgeries only? Oncology?

Also, not to open a can of worms, but IMO the DNP training is a much more EFFICIENT way to produce health professionals than medical school. How much of the crap you learn in medical school do you actually use in your routine of pattern recognition? Soon enough, many of the people who wasted 200k on it may be seen as too educated to afford, and there are only so many positions in hospitals in rich areas.

Low paying specialties that require deep knowledge (Rheum, Endo, Nephro, Neuro, etc...).

Originally Posted by Ibn Alnafis MD

Low paying specialties that require deep knowledge (Rheum, Endo, Nephro, Neuro, etc...).

How "low paying" are these specialties exactly?

Originally Posted by SchroedingrsCat

As opposed to the computers discussion, I think this one is even more relevant for us. The writing is on the wall, midlevels can do a lot of the same stuff as certain doctors for a lot less money. Thus, either many physicians will get crowded out or their salaries will have to drop to comparable levels to DNP's (yet another reason not to do med if you will acquire 150k+ in loans). What specialties are gonna be safe from this? Neurosurgery and other advanced surgeries only? Oncology?

Also, not to open a can of worms, but IMO the DNP training is a much more EFFICIENT way to produce health professionals than medical school. How much of the crap you learn in medical school do you actually use in your routine of pattern recognition? Soon enough, many of the people who wasted 200k on it may be seen as too educated to afford, and there are only so many positions in hospitals in rich areas.

Surgery takes a while to learn. Even general surgery, many residents struggle to pass boards after 5 years of residency working 80 hrs/week. I would say surgery will be the last to go. Plus, patients may be ok with their anesthesia being done by a nurse, but they probably want a doctor do that heart surgery or scoping their knee.

Originally Posted by druggeek

How "low paying" are these specialties exactly?

On SDN, 200k is slightly above poverty level.

Originally Posted by SchroedingrsCat

As opposed to the computers discussion, I think this one is even more relevant for us. The writing is on the wall, midlevels can do a lot of the same stuff as certain doctors for a lot less money. Thus, either many physicians will get crowded out or their salaries will have to drop to comparable levels to DNP's (yet another reason not to do med if you will acquire 150k+ in loans). What specialties are gonna be safe from this? Neurosurgery and other advanced surgeries only? Oncology?

Also, not to open a can of worms, but IMO the DNP training is a much more EFFICIENT way to produce health professionals than medical school. How much of the crap you learn in medical school do you actually use in your routine of pattern recognition? Soon enough, many of the people who wasted 200k on it may be seen as too educated to afford, and there are only so many positions in hospitals in rich areas.

If you're an MD, I dont know what level of training you're at, but I dont think you have any idea of what you're talking about. If you're a DNP, same as above then it makes sense what you're saying.

DNP is any but efficient. They have some of the most useless classes towards clinical medicine there can be. On top of that they've trained as nurses which is absolutely useless in learning how to make decisions as a doctor.

Actually a lot is NOT pattern recognition. Developing a good differential is the key, and that DOES take knowledge from all years of medical school. Residents routinely have to go back to medical school knowledge to develop those. Often those that rely on "pattern recognition" fail to accurately diagnose, stage and/or treat the patient.

Medical school IMO does not teach enough, let alone be inefficient. Yes, there are too many details in certain areas, but often not enough details in other areas, or sometimes topic that extremely important entirely omitted.

Ive been around quite a few NPs and DNPs, and by far they are the most scariest practitioners around. Im not sure about PAs, but these guys routinely hurt people. We get patients who are managed by NPs for simple things like asthma and routinely say WTF are they doing?!

These things are difficult to study, because its not that people die, its just that they get hurt and eventually go to the ER and somebody else figures it out. A lot of the time its chronic disease mismanagement that requires years of many patients to accurately document the mishaps by NPs/DNPs but who has the time/money to ACCURATELY study these things? nobody. But everyone knows it.

We need competent primary care docs. All around the world they have realized that well trained primary care docs cut costs, create a healthier population. Im not going into Primary care and to be honest, if NPs were to come around probably more business for me in the future.

But they're scary and what its going to take is for somebody important to get hurt for things to change and the population to realize that something needs to happen. The problem is that Right now the only people getting hurt by increased scope of practice of midlevels are people in rural areas and inner cities (where im at). So no one cares. If it ever affects someone rich/important, i think the midlevels then better watch out.

Originally Posted by Ibn Alnafis MD

Low paying specialties that require deep knowledge (Rheum, Endo, Nephro, Neuro, etc...).

All doctors who are good at what they do have deep knowledge of their specialty and a solid background in general medicine. Doctors who are bad at what they do don't have deep knowledge or a solid background in general medicine. THis is true of from general surgery to PM&R.

Originally Posted by JackShephard MD

Surgery takes a while to learn. Even general surgery, many residents struggle to pass boards after 5 years of residency working 80 hrs/week. I would say surgery will be the last to go. Plus, patients may be ok with their anesthesia being done by a nurse, but they probably want a doctor do that heart surgery or scoping their knee.




On SDN, 200k is slightly above poverty level.

actually lol'ed at that one. Good show.

Originally Posted by JackShephard MD

Surgery takes a while to learn. Even general surgery, many residents struggle to pass boards after 5 years of residency working 80 hrs/week. I would say surgery will be the last to go. Plus, patients may be ok with their anesthesia being done by a nurse, but they probably want a doctor do that heart surgery or scoping their knee.




On SDN, 200k is slightly above poverty level.

I dont even know how dumb someone can be to let a nurse be in charge of their life..serious (CRNAs).

Originally Posted by todds

If you're an MD, I dont know what level of training you're at, but I dont think you have any idea of what you're talking about. If you're a DNP, same as above then it makes sense what you're saying.

DNP is any but efficient. They have some of the most useless classes towards clinical medicine there can be. On top of that they've trained as nurses which is absolutely useless in learning how to make decisions as a doctor.

Actually a lot is NOT pattern recognition. Developing a good differential is the key, and that DOES take knowledge from all years of medical school. Residents routinely have to go back to medical school knowledge to develop those. Often those that rely on "pattern recognition" fail to accurately diagnose, stage and/or treat the patient.

Medical school IMO does not teach enough, let alone be inefficient. Yes, there are too many details in certain areas, but often not enough details in other areas, or sometimes topic that extremely important entirely omitted.

Ive been around quite a few NPs and DNPs, and by far they are the most scariest practitioners around. Im not sure about PAs, but these guys routinely hurt people. We get patients who are managed by NPs for simple things like asthma and routinely say WTF are they doing?!

These things are difficult to study, because its not that people die, its just that they get hurt and eventually go to the ER and somebody else figures it out. A lot of the time its chronic disease mismanagement that requires years of many patients to accurately document the mishaps by NPs/DNPs but who has the time/money to ACCURATELY study these things? nobody. But everyone knows it.

We need competent primary care docs. All around the world they have realized that well trained primary care docs cut costs, create a healthier population. Im not going into Primary care and to be honest, if NPs were to come around probably more business for me in the future.

But they're scary and what its going to take is for somebody important to get hurt for things to change and the population to realize that something needs to happen. The problem is that Right now the only people getting hurt by increased scope of practice of midlevels are people in rural areas and inner cities (where im at). So no one cares. If it ever affects someone rich/important, i think the midlevels then better watch out.

Said in the best possible way. 5 stars.

I always lol at these "studies" with extreme strong bias towards NPs/DNPs that are done to show that they are as good as family docs or whatever crap they try and say.

The average joe though will get some allergy medicine from some DNP and think "oh theyre good!"

The only specialties "protected" (for the time-being) against mid-level encroachment are surgical specialties.

Otherwise, mid-levels have encroached into nearly every field of medicine. There are already DNP "residencies" (essentially, a couple of months of watered-down focus on one particular field) for specialties like cardiology, dermatology, etc, and these practitioners call themselves "board-certified doctors." Whether you like it or not, whether you personally wouldn't put your health in a mid-level's hands or not, it's too late to stop the encroachment. NPs/DNPs have full independence in most of the states. The nursing organization has an incredibly powerful lobby and will continue to put out flawed studies to sway politicians to give them more independence. All of this comes down to how political-savvy nurses are, not how competent they are at practicing medicine. And physicians are pretty disorganized and politically-unsavvy.

Their next push is for equal pay as physicians, which I think will be the thing that'll hurt them the most. The only thing we can hope for is that they'll start getting equal reimbursements and people will wise up to the fact that they're paying the same amount for someone with a fraction of a physician's training. And we can hope that malpractice lawyers will start targeting independently-practicing NPs/DNPs. Nothing like a high-profile malpractice case to bring their lack of training into the public's focus and scare mid-levels away from the responsibility of independent practice.

Originally Posted by Kaushik

And we can hope that malpractice lawyers will start targeting independently-practicing NPs/DNPs. Nothing like a high-profile malpractice case to bring their lack of training into the public's focus and scare mid-levels away from the responsibility of independent practice.

As much as I'm against scare tactics, there is little that would make me happier than a huge malpractice suit against some DNP to alert the public about how little training they are receiving compared to physicians. I've heard too many horror stories of people who saw NPs that missed serious conditions for lack of education and training.

Well here's a newsflash: Medicare and Medicaid can no longer afford however many thousands of dollars are needed for an Anesthesiologist to anesthetize someone. Especially with all you clamoring for tax cuts. Society has reached a point where they will accept marginally lesser quality in return for not being collectively bankrupted by healthcare costs.

Rich people will still demand the highest quality care. But there are far more poor people than rich people, leaving many MD and DO's forced to either work for Nurse wages on these poor people or be left out of a job.

Originally Posted by SchroedingrsCat

Well here's a newsflash: Medicare and Medicaid can no longer afford however many thousands of dollars are needed for an Anesthesiologist to anesthetize someone. Especially with all you clamoring for tax cuts. Society has reached a point where they will accept marginally lesser quality in return for not being collectively bankrupted by healthcare costs.

Rich people will still demand the highest quality care. But there are far more poor people than rich people, leaving many MD and DO's forced to either work for Nurse wages on these poor people or be left out of a job.

Nursing mid-levels are pushing for equal pay as physicians, claiming that they do the same job as physicians. Where's the cost-saving there? The issue of equal reimbursement has already been brought up in one state (and, luckily, shot down, at least for the moment). If you look in the RN/NP/PA forums on SDN (and on a nursing forum elsewhere), someone posted in there that a company recently started paying its physicians and NPs the same amount of money, based only on the number of years of experience.

Originally Posted by Kaushik

Nursing mid-levels are pushing for equal pay as physicians, claiming that they do the same job as physicians. Where's the cost-saving there? The issue of equal reimbursement has already been brought up in one state (and, luckily, shot down, at least for the moment). If you look in the RN/NP/PA forums on SDN (and on a nursing forum elsewhere), someone posted in there that a company recently started paying its physicians and NPs the same amount of money, based only on the number of years of experience.

That is a big mistake on their part as their whole value comes from them being a cheaper alternative. I guess the takeaway is, "Never underestimate the other guy's greed." But, that reach for cash aside, there will continue to be cheaper alternatives popping up that will be preferable due to cost-savings (don't give me some convoluted crap about how it will ultimately be more expensive to have mid-levels providing basic care, you know it's not true). The medical system in the USA is truly broken right now, so I recommend to just try not to be too far in debt yourself when congress finally is forced to deal with the deficit.

I'm going to play devil's advocate here for a minute, and say that physicians have managed to legally secure a monopoly on doing a lot of stuff that it's not clear they deserve. Dermatologists charge many hundreds of dollars to spend a few minutes and tens of cents worth of supplies freezing warts off, a task that requires no particular skill or medical knowledge to do, and which a teenager could probably be trained to safely do in a kiosk at your local mall. If nurses are willing and able to break this monopoly and offer the same service at a cheaper price, I say more power to them.

Originally Posted by JackShephard MD

Surgery takes a while to learn. Even general surgery, many residents struggle to pass boards after 5 years of residency working 80 hrs/week. I would say surgery will be the last to go. Plus, patients may be ok with their anesthesia being done by a nurse, but they probably want a doctor do that heart surgery or scoping their knee.




On SDN, 200k is slightly above poverty level.

I LOL'd

Originally Posted by nburnett3

As much as I'm against scare tactics, there is little that would make me happier than a huge malpractice suit against some DNP to alert the public about how little training they are receiving compared to physicians. I've heard too many horror stories of people who saw NPs that missed serious conditions for lack of education and training.

This. Cant wait for it (serious).

Originally Posted by SchroedingrsCat

Well here's a newsflash: Medicare and Medicaid can no longer afford however many thousands of dollars are needed for an Anesthesiologist to anesthetize someone. Especially with all you clamoring for tax cuts. Society has reached a point where they will accept marginally lesser quality in return for not being collectively bankrupted by healthcare costs.

Rich people will still demand the highest quality care. But there are far more poor people than rich people, leaving many MD and DO's forced to either work for Nurse wages on these poor people or be left out of a job.

Any evidence of them being left out of work? If not, you're just talking random stuff like anyone has about anything. There's a lot more to it than just physician salaries thats screwing up your healthcare costs.

Originally Posted by phltz

I'm going to play devil's advocate here for a minute, and say that physicians have managed to legally secure a monopoly on doing a lot of stuff that it's not clear they deserve. Dermatologists charge many hundreds of dollars to spend a few minutes and tens of cents worth of supplies freezing warts off, a task that requires no particular skill or medical knowledge to do, and which a teenager could probably be trained to safely do in a kiosk at your local mall. If nurses are willing and able to break this monopoly and offer the same service at a cheaper price, I say more power to them.

I completely agree with what you're saying. I've been directed to PA's several times in primary care appt's recently and knew they did 100% the same thing that a FM doc would have and realized it made a lot more sense to pay this guy half of a physicians salary and afford care for more people. Midlevels with much less training (hence less expensive) can do MANY of the tasks of a physician, almost as well, for a fraction of the cost.

This brings us to one of the main problems: the extortion that is medical school. 200k in debt encourages docs to hate midlevels. It encourages docs to try to monopolize simple tasks, overbill, over-perform useless things just to bill. This is at the heart of the broken system.

The medical education system we currently have is simply not sustainable in a country that is 15 trillion dollars in debt. 8 years of expensive schooling (4 of which are mostly useless and just drive up debt) are too much for society to afford to pay back. 50k per year of medical school is a ****ing joke and screws over society when these doctors then (somewhat understandably) bankrupt the rest of the country with their cost.

Originally Posted by druggeek

Any evidence of them being left out of work? If not, you're just talking random stuff like anyone has about anything. There's a lot more to it than just physician salaries thats screwing up your healthcare costs.

Like I said, just wait until after the election when congress will actually have to deal with the deficit. 15 trillion and a trillion dollar (and rising) yearly deficit (with healthcare costs playing a large role) is not something you can just ignore for very long. Baby boomers will get start to get more and more sick. Who is going to pay 50k (each) for mom and dad's hip replacements and PT? The government won't be able to. This is where tough decisions will be made and push will come to shove.

I agree that physician salaries are only one part of the equation. Malpractice lawyers will get the short end as well as more malpractice caps are enabled. All I am saying is it's obvious that midlevels will be a big part of an attempted solution and doctors need to try to minimize their debts and be ready for competition.

Don't be greedy and bitter and you will be ok. I take comfort in all the studies that have shown that income above 80k a year does not increase happiness. All I want is 80k and an interesting/rewarding job and I will be fine - I just hope tons of my peers aren't full of angst once they realize they can't buy that McMansion. You really should try to enjoy your time in medical school - only do it if you love learning about medicine - if you are just grudgingly waiting for the payoff you will end up hating your decision.

Originally Posted by SchroedingrsCat

Don't be greedy and bitter and you will be ok. I take comfort in all the studies that have shown that income above 80k a year does not increase happiness. All I want is 80k and an interesting/rewarding job and I will be fine - I just hope tons of my peers aren't full of angst once they realize they can't buy that McMansion. You really should try to enjoy your time in medical school - only do it if you love learning about medicine - if you are just grudgingly waiting for the payoff you will end up hating your decision.

I'm sorry, but this is just naïve. If I'm spending upwards of $200,000 on my postgraduate education (not counting my undergrad), then I damn well better be compensated more than $80,000/year if nothing else than so I can pay off my student loans. That's not even considering the near minimum wage that we will be paid as residents for 3-7 years while our loans keep accruing interest.

I'm not saying that I went into medicine for the money - I didn't. But if I'm going to have this much education and be specialized in such an important field, then you're goddamn right that I'm waiting for the payoff. If I found out that I'd only make 80 grand coming out of med school, I'd drop out in a heartbeat and quit while I was ahead.

Sorry if I wasn't clear, I meant 80k as to what the study makers meant - after paying off a percentage student loans but before taxes. Basically it's the "magic number' where you don't have to worry about paying your bills and can afford a few luxuries and vacations (bills here do not mean Porsche payments). So 90-100k as a base income, with 10-20k per year going to student loans, is something I would be content with. If you have to accumulate 200k+ in student loans, this will be a good deal harder to pay off and I seriously suggest not attending medical school if you cannot get into a cheaper one.

Originally Posted by nburnett3

I' But if I'm going to have this much education and be specialized in such an important field, then you're goddamn right that I'm waiting for the payoff.

Here is the fallacy. You know well that it is likely that physician reimbursements will decrease given the state of the budget. Anyone going into this based on cost/benefit analysis should become a DNP or PA instead - you can still become specialized and you get much more fiscal benefit for the cost (opportunity and tuition). Go for an MD if you truly enjoy learning about medicine and value becoming an expert in the field. Just don't get spiteful against the mid-levels when you can't demonstrate how superior you are economically.

Originally Posted by SchroedingrsCat

Like I said, just wait until after the election when congress will actually have to deal with the deficit. 15 trillion and a trillion dollar (and rising) yearly deficit (with healthcare costs playing a large role) is not something you can just ignore for very long. Baby boomers will get start to get more and more sick. Who is going to pay 50k (each) for mom and dad's hip replacements and PT? The government won't be able to. This is where tough decisions will be made and push will come to shove.

I agree that physician salaries are only one part of the equation. Malpractice lawyers will get the short end as well as more malpractice caps are enabled. All I am saying is it's obvious that midlevels will be a big part of an attempted solution and doctors need to try to minimize their debts and be ready for competition.

Don't be greedy and bitter and you will be ok. I take comfort in all the studies that have shown that income above 80k a year does not increase happiness. All I want is 80k and an interesting/rewarding job and I will be fine - I just hope tons of my peers aren't full of angst once they realize they can't buy that McMansion. You really should try to enjoy your time in medical school - only do it if you love learning about medicine - if you are just grudgingly waiting for the payoff you will end up hating your decision.

clearly you're a midlevel of some sort. That's fine. They can provide a good cheap service to patients known to not be complicated at all. However it's hilarious to think midlevels can take over any field. There's absolutely no way. They neither have the knowledge nor the training to do so. Midlevels are trained to do one specific task and recognize only what they are specifically trained to recognize. For simple cases it works fine. But if anything at all is remotely complicated in the least their training breaks down. They don't have a critical thinking ability which is key. Thus midlevels will always be deemed to tasks such as taking care of pre/post op patients, seeing healthy clinic visits, etc. If DNPs think they can do primary care just as well as a fully trained doctor let them do it. They'll soon realize the difficulty involved and the trouble they can get in to and so even now they still work for a doctor. Most simply aren't that stupid not to.


regarding the topic at hand the fields least likely to be encroached on at the least are pathology and diagnostic radiology both of which require extensive knowledge and training. Simple procedures in rads such as biopsy's, incisions/drainage, etc are actually already done on large scale by midlevels but they are still supervised by radiologist. Any subspeciality is safe. No way a patient will exclusively see a DNP cardiologist with absolutely no oversight. No way. Not ever.

With respect to cyrotreatment, true it is not technically difficult to perform but the decision to treat should be made by a person with training who will know the lesion. This could be MD or midlevel in certain cases. If it's so easy why doesn't your local nephrologist do them? Because those guys know they don't have the extensive knowledge of derm necessary to feel comfortable to make a decision like that. Midlevels who practice for years and years in derm I would hope do have such knowledge for easier cases.

This whole situation will eventually be sorted out. Laws will be passed that require certain training, degrees, certification, etc for pretty much any procedure or field of medicine. Midlevels will lose. These laws will be passed because of cases with bad outcomes managed exclusively by a midlevel. That's how all laws eventually come to be and this case will be no different. And so midlevels will never function at a level beyond a resident.

Druggeeks post was closed in the NP/PA forum so it looks like he's going to troll elsewhere.

Look, I get where you guys are coming from nurses are NOT doctors. The education and training are just not there. However as a pre-med coming from a nursing background mid-levels are not bad clinicians contrary to what SDN says. I am sure some of you guys are MS1/2s, when you get around some attendings in the hospital you will not see this animosity that is so insidiously present on here. Random anecdotes presented as this NP messed up here or there happens with physicians as well. Anecdote for the day: Friend presented to ER with stabbing upper epigastric pain and a distended abdomen made worse by food and laying down. The ED doc ordered a IV morphine bolus, some fluids and told him all he needed was a bowel movement and sent him on his way. Turns out he got a second opinion a week later with another doc and tested positive for H.pylori and a scope confirmed gastritis and ulcers. Anecdotes, we all got em'

The military has some of the finest medicine in the US with premiere hospitals and physicians alike. CRNAs were pretty much pioneered in military hospitals and continue to provide a large portion of the anesthesia during surgeries. When I did my rotations/clinicals at.mil hospitals a lot of the docs (surgeons and anesthesiologists) sang praises for their CRNAs.

Just saying many here fear NPs and mid levels are taking over medicine is not true. If it was why would I be trying for med school and not NP school. Mid levels do have their place (under supervision_)whether you like it or not. Don't worry your 200k+ jobs will still be around when you graduate, no need to worry....

EDIT: The DNP doesn't add much clinical knowledge over the masters right now so there will need to be some serious overhaul for it to be considered a "clinical" doctorate. I am not completely for it until they add more relevant courses.

Originally Posted by SchroedingrsCat

Sorry if I wasn't clear, I meant 80k as to what the study makers meant - after paying off a percentage student loans but before taxes. Basically it's the "magic number' where you don't have to worry about paying your bills and can afford a few luxuries and vacations (bills here do not mean Porsche payments). So 90-100k as a base income, with 10-20k per year going to student loans, is something I would be content with. If you have to accumulate 200k+ in student loans, this will be a good deal harder to pay off and I seriously suggest not attending medical school if you cannot get into a cheaper one.

I can promise you 10000% of people would be MUCH happier making 500k as opposed to 80k. But I'm glad you'd be content with 90-100k. Leaves more money to be made for everyone else. When you apply for a job you know on average makes somewhere around 200k I would expect you to say "no, no I don't want that much. I will take 95k because studies show that's all I need to be happy."

Originally Posted by Dranger

Druggeeks post was closed in the NP/PA forum so it looks like he's going to troll elsewhere.

Look, I get where you guys are coming from nurses are NOT doctors. The education and training are just not there. However as a pre-med coming from a nursing background mid-levels are not bad clinicians contrary to what SDN says. I am sure some of you guys are MS1/2s, when you get around some attendings in the hospital you will not see this animosity that is so insidiously present on here. Random anecdotes presented as this NP messed up here or there happens with physicians as well. Anecdote for the day: Friend presented to ER with stabbing upper epigastric pain and a distended abdomen made worse by food and laying down. The ED doc ordered a IV morphine bolus, some fluids and told him all he needed was a bowel movement and sent him on his way. Turns out he got a second opinion a week later with another doc and tested positive for H.pylori and a scope confirmed gastritis and ulcers. Anecdotes, we all got em'

The military has some of the finest medicine in the US with premiere hospitals and physicians alike. CRNAs were pretty much pioneered in military hospitals and continue to provide a large portion of the anesthesia during surgeries. When I did my rotations/clinicals at.mil hospitals a lot of the docs (surgeons and anesthesiologists) sang praises for their CRNAs.

Just saying many here fear NPs and mid levels are taking over medicine is not true. If it was why would I be trying for med school and not NP school. Mid levels do have their place (under supervision_)whether you like it or not. Don't worry your 200k+ jobs will still be around when you graduate, no need to worry....

EDIT: The DNP doesn't add much clinical knowledge over the masters right now so there will need to be some serious overhaul for it to be considered a "clinical" doctorate. I am not completely for it until they add more relevant courses.

I'm MS4 and I agree I see no sign anywhere midlevels are taking over (except maybe in primary care peds). But when you say you don't see any animosity that's because you were on the nurse's side of things and polite people don't go around bashing others for no reason. But when you're around other physicians at their level (even as a med student) it's blatantly clear they do not respect a DNP/PA beyond how any boss respects an employee and if you ever talk to them candidly they say the same things as SDN about midlevels not having the critical thinking ability necessary to be an independent physician and do not support any DNP trying to do so. Once you get to the level of even M4 you'll see that they don't. It's complicated to explain in writing why that is but no MD/DO will disagree with me.

Physicians hire a midlevel so that they can make more money. That is how every single PA/DNP is seen.

Haha, the sad truth is that this is the point of medical school (and college for that matter):

http://books.google.com/books?id=nZE...ed=0CDYQ6AEwAw

The point of college is to prove you could get into college and graduate.

The point of medical school is to prove you could get into medical school and graduate.

You then learn your actual profession during your residency.

It isn't all signaling, some of the stuff from medical school is relevant, but you could argue the most important part of medical school is getting admitted.

Originally Posted by docshop12

I'm MS4 and I agree I see no sign anywhere midlevels are taking over (except maybe in primary care peds). But when you say you don't see any animosity that's because you were on the nurse's side of things and polite people don't go around bashing others for no reason. But when you're around other physicians at their level (even as a med student) it's blatantly clear they do not respect a DNP/PA beyond how any boss respects an employee and if you ever talk to them candidly they say the same things as SDN about midlevels not having the critical thinking ability necessary to be an independent physician and do not support any DNP trying to do so. Once you get to the level of even M4 you'll see that they don't. It's complicated to explain in writing why that is but no MD/DO will disagree with me.

Physicians hire a midlevel so that they can make more money. That is how every single PA/DNP is seen.

I have spoken candidly to quite a few physicians outside of the work setting regarding my career path. Almost unanimously they all urged me to go NP since I already had 4.5 years into a BSN. I even talked down NPs (education, pay, prestige etc) and discussed its drawbacks until one MD said "if you ever wake up at night regretting not going to med school, don't". Against their better wishes I decided on med school.

I never said independent but I think a physician supervised NP/PA practice in a variety of settings could be beneficial to the health care system.

Originally Posted by Dranger

Look, I get where you guys are coming from nurses are NOT doctors. The education and training are just not there. However as a pre-med coming from a nursing background mid-levels are not bad clinicians contrary to what SDN says.

The military has some of the finest medicine in the US with premiere hospitals and physicians alike. CRNAs were pretty much pioneered in military hospitals and continue to provide a large portion of the anesthesia during surgeries. When I did my rotations/clinicals at.mil hospitals a lot of the docs (surgeons and anesthesiologists) sang praises for their CRNAs.
.

Wanted to comment on the two bolded sentences.

1. If you're a premed, then how do you know they are not "bad" clinicians. Its because you havent seen any animosity? Once/if you're through with medical school and onto residency, then you will know enough to see the ridiculousness that NPs do routinely, for simple things like HTN, asthma, diabetes, im not talking about complex medical care. Im not going into primary care, but its outrageous. I agree that ER docs can be terrible as well, but at least the MD route gives you the best shot as a competent clinician.

Actually the ER doc anecdote is a good one. Despite 4 years of medical school, 3 years of an intense residency, a doc can still make mental mistakes. Thats because medicine is not easy and you always have to be careful. Thats why it takes so many years to train and despite that people still make lots of mistakes for "simple" things. What makes anyone think that NPs will significantly less years of book studying, significantly less years of training as an independent clinician can even come close to the ER doc you mentioned.

2. I just loled at the second bolded comment. I dont want to start a flame war, but i think if you hang around SDN enough, you'll know why its not "premier" in any sense as you mention. The fact that surgeons/anesthesiologist sing praises has less to do with competence and more to do with general niceness of the person. As a med student in private, if you ask them, they will make fun of their aptitude, but comment on how nice they are. I hope you get into medical school to see this in person to see how dramatic it is.

Originally Posted by Dranger

I have spoken candidly to quite a few physicians outside of the work setting regarding my career path. Almost unanimously they all urged me to go NP since I already had 4.5 years into a BSN. I even talked down NPs (education, pay, prestige etc) and discussed its drawbacks until one MD said "if you ever wake up at night regretting not going to med school, don't". Against their better wishes I decided on med school.

I never said independent but I think a physician supervised NP/PA practice in a variety of settings could be beneficial to the health care system.

You had already spent 5 years outside nursing school which I think is 4 years of education after high school so I'd guess you'd be about 28 when you decided you wanted to do medical school. As a result in order to go to med school you would have to complete a full undergraduate degree and get the necessary requirements (2 years), complete medical school (4 years), and do at the very least 3 years of residency which would result in essentially you doing primary care - a field DNPs often do largely unsupervised but still employed by a physician. That would make you around 37-38 at the absolute earliest that you could start practicing. If you choose a fellowship or depending on the residency field you choose it could make you well over 40.

My point is I completely disagree with pursing medicine more than 1-2 years outside of a college degree and that's assuming you don't have to go back to college to fulfill requirements. It ends up taking far too long and you likely can get equal satisfaction from DNP and won't spend sooo much of your life in school/training. I would have suggested DNP for your situation as well.

on a related note:
http://www.dailymail.co.uk/news/arti...new-light.html

Originally Posted by docshop12

I'm MS4 and I agree I see no sign anywhere midlevels are taking over (except maybe in primary care peds). But when you say you don't see any animosity that's because you were on the nurse's side of things and polite people don't go around bashing others for no reason. But when you're around other physicians at their level (even as a med student) it's blatantly clear they do not respect a DNP/PA beyond how any boss respects an employee and if you ever talk to them candidly they say the same things as SDN about midlevels not having the critical thinking ability necessary to be an independent physician and do not support any DNP trying to do so. Once you get to the level of even M4 you'll see that they don't. It's complicated to explain in writing why that is but no MD/DO will disagree with me.

Physicians hire a midlevel so that they can make more money. That is how every single PA/DNP is seen.

I got a ped on his soapbox while shadowing...totally agree with that statement.

Plus, I work at a mental hospital with a DNP as the admin...needless to say the majority of the MDs don't give a darn what he says.

On a side note, sorry for thinking you were a split personality of one of the omnipresent 'mid-level' students. I was in a bad mood last night and your posts are obviously individual and informed. Appreciate your input.

Originally Posted by thecgrblue

On a side note, sorry for thinking you were a split personality of one of the omnipresent 'mid-level' students. I was in a bad mood last night and your posts are obviously individual and informed. Appreciate your input.

lol no prob. I'm staying away from that thread because some of those guys just got so upset for no real reason.

but hey now that you mention it I will quickly point out why a OD is not a midlevel. They train completely separately. It's that simple. They do a field completely separate from all other aspects of health care aside from ophtho. They also practice totally independently. Thus they aren't midlevels in the same sense.

The scope of practice of ODs is far more limited that the MD ophtho. ODs all know that and they know their scope. They prescribe abx for limited eye diseases such as conjuctivitis (things they have trained for throughout school) because often times when a patient has a problem with their eyes they will first go to the OD if they don't see their PCP (ODs are a lot cheaper and know more about the eye than the PCP usually). But there are plenty of ODs who also don't want to see medical conditions. The vast majority of their scope is eyeglass prescriptions with occasional foreign body and conjuctivitis/keratitis/etc. If something is complicated they know right away and area always more than willing to send the patient to the ED or ophtho. MD ophtho does diabetic retinopathy, complex prescriptions, surgery, etc.

And if people have a problem with an OD prescribing a zpac (largely harmless abx) then where is the outrage with the dentist doing anesthesia or prescribing abx? What about the DDS in OMFS doing full blown surgery in the hospital? So dumb. The fear of takeover is only in their head and is not happening in the real world.

Originally Posted by todds

Wanted to comment on the two bolded sentences.

1. If you're a premed, then how do you know they are not "bad" clinicians. Its because you havent seen any animosity? Once/if you're through with medical school and onto residency, then you will know enough to see the ridiculousness that NPs do routinely, for simple things like HTN, asthma, diabetes, im not talking about complex medical care. Im not going into primary care, but its outrageous. I agree that ER docs can be terrible as well, but at least the MD route gives you the best shot as a competent clinician.

Actually the ER doc anecdote is a good one. Despite 4 years of medical school, 3 years of an intense residency, a doc can still make mental mistakes. Thats because medicine is not easy and you always have to be careful. Thats why it takes so many years to train and despite that people still make lots of mistakes for "simple" things. What makes anyone think that NPs will significantly less years of book studying, significantly less years of training as an independent clinician can even come close to the ER doc you mentioned.

2. I just loled at the second bolded comment. I dont want to start a flame war, but i think if you hang around SDN enough, you'll know why its not "premier" in any sense as you mention. The fact that surgeons/anesthesiologist sing praises has less to do with competence and more to do with general niceness of the person. As a med student in private, if you ask them, they will make fun of their aptitude, but comment on how nice they are. I hope you get into medical school to see this in person to see how dramatic it is.

1. I'm not going into primary care a commonly echoed statement among med students here eh?

2.Military hospitals are well regarded in terms of staffing, training, experience (i.e.trauma) and latest equipment. I am not going to go into a discussion about it though, you can sift into the .mil forum for that. I see enough pre meds critiquing other professions than to care what others think of military medicine. The CRNAs were praised because they were competent anesthesia providers and had vastly more hours and training than their civvy counterparts. I would think "nice" would go away if patient's were dropping dead or having bad outcomes. I have another anecdote about ketamine and PTSD but I am tired haha

Originally Posted by docshop12

You had already spent 5 years outside nursing school which I think is 4 years of education after high school so I'd guess you'd be about 28 when you decided you wanted to do medical school. As a result in order to go to med school you would have to complete a full undergraduate degree and get the necessary requirements (2 years), complete medical school (4 years), and do at the very least 3 years of residency which would result in essentially you doing primary care - a field DNPs often do largely unsupervised but still employed by a physician. That would make you around 37-38 at the absolute earliest that you could start practicing. If you choose a fellowship or depending on the residency field you choose it could make you well over 40.

My point is I completely disagree with pursing medicine more than 1-2 years outside of a college degree and that's assuming you don't have to go back to college to fulfill requirements. It ends up taking far too long and you likely can get equal satisfaction from DNP and won't spend sooo much of your life in school/training. I would have suggested DNP for your situation as well.

on a related note:
http://www.dailymail.co.uk/news/arti...new-light.html

I am still in my early 20's, perhaps I poorly worded it but I my nursing school was 4.5 years long. What's a full undergrad degree? I did my nursing program (BS Nursing) at a liberal arts university not a CC and did all the gen eds like every other student.

Most of my pre reqs are done now I just plan to work for clinical experience and take my MCAT. No clue why you guys are getting on me for my experiences in a variety of hospitals and settings (just like you guys have your experiences), I am on your side :/..to pursue medicine.

Originally Posted by Kaushik

The only specialties "protected" (for the time-being) against mid-level encroachment are surgical specialties.

Otherwise, mid-levels have encroached into nearly every field of medicine. There are already DNP "residencies" (essentially, a couple of months of watered-down focus on one particular field) for specialties like cardiology, dermatology, etc, and these practitioners call themselves "board-certified doctors." Whether you like it or not, whether you personally wouldn't put your health in a mid-level's hands or not, it's too late to stop the encroachment. NPs/DNPs have full independence in most of the states. The nursing organization has an incredibly powerful lobby and will continue to put out flawed studies to sway politicians to give them more independence. All of this comes down to how political-savvy nurses are, not how competent they are at practicing medicine. And physicians are pretty disorganized and politically-unsavvy.

Their next push is for equal pay as physicians, which I think will be the thing that'll hurt them the most. The only thing we can hope for is that they'll start getting equal reimbursements and people will wise up to the fact that they're paying the same amount for someone with a fraction of a physician's training. And we can hope that malpractice lawyers will start targeting independently-practicing NPs/DNPs. Nothing like a high-profile malpractice case to bring their lack of training into the public's focus and scare mid-levels away from the responsibility of independent practice.

This is true. PA's are great in an ASSISTING role, I even considered being one at first. They are even great at handling low to medium acuity cases in primary care. The clinic I work at has used them as extenders for years; however, we recently brought in an NP. She seemed great at first, but I can think of at least two times the medical director saved her from a lawsuit by catching a potential mistake. He told me that it was something he'd expect any MS3 to MS4 to know and was shocked that she was unaware.

The law suit is coming, I don't wish it on anyone ever-but it's coming. While the general public may not care to know the difference, you better believe the lawyers do.

Also what's with the massive migration of NPs into private practice Derm, I thought they were supposed to be helping fill the "primary care shortage."

Originally Posted by Kaushik

Nursing mid-levels are pushing for equal pay as physicians, claiming that they do the same job as physicians. Where's the cost-saving there? The issue of equal reimbursement has already been brought up in one state (and, luckily, shot down, at least for the moment). If you look in the RN/NP/PA forums on SDN (and on a nursing forum elsewhere), someone posted in there that a company recently started paying its physicians and NPs the same amount of money, based only on the number of years of experience.

I find this absolutely fascinating. I don't blame them, but I also wonder what effect it will have if somewhere like Oregon ends up passing a bill in favor of it. It could shoot their movement in the foot (but then again the people who are already DNPs will have it made).

A NP case I found interesting:

Suit claims clinic failed to properly treat woman for thyroid condition
http://thegazette.com/2012/03/13/nor...wifes-suicide/

The husband of a North Liberty woman who committed suicide on April 3, 2010, is suing the Coralville Healthcare Clinic and a nurse practitioner there on allegations they failed to properly diagnose the woman with Hashimoto’s disease and treat her for the condition.

Kathleen Ropp became a patient at the Coralville Healthcare Clinic, 2180 Norcor Ave., on June 2, 2008, according to the lawsuit filed by her husband, Kevin Ropp, last week in Johnson County District Court. She met with nurse practitioner Jennifer Swearingen, who ordered a variety of laboratory tests, according to the lawsuit.

Swearingen told Ropp she would inform her of the test results when they came back, the lawsuit alleges. On June 11, 2008, the labs returned showing high thyroid antibodies but, according to the lawsuit, Swearingen didn’t tell Ropp or treat her for the abnormal thyroid levels.

On Oct. 7, 2008, Ropp filled out a questionnaire at the Coralville clinic indicating she was experiencing “moderately-severe depression,” the lawsuit states. Swearingen diagnosed Ropp with situational adjustment reaction and treated her for that condition, according to the suit.

Ropp returned to the clinic on March 24, 2010, complaining of feelings of anxiety, depression, sleeplessness and forgetfulness. On March 31, according to the lawsuit, Swearingen spoke with Ropp about her symptoms, which were severe enough to take time off work.

Ropp killed herself April 3, 2010, at age 32, according to the lawsuit. The Johnson County Medical Examiner performed an autopsy on Ropp and found she had Hashimoto’s disease, a treatable thyroid condition that has been linked to severe depression and suicide, the lawsuit states.

Kevin Ropp is accusing the Coralville clinic and Swearingen of failing to appropriately evaluate, test and treat Kathleen Ropp, constituting “medical negligence.”

Their “conduct was a cause of a loss of chance of survival and of Kathleen Ropp’s untimely death,” the lawsuit states.

Kevin Ropp is seeking damages for his wife’s pre-death injuries as well as pain and suffering, interest on premature funeral expenses and loss of value to the estate.

Definitely an interesting case JS, but in defense of both parties I'm sure there's a lot more to the story than we see.

Originally Posted by SchroedingrsCat

Like I said, just wait until after the election when congress will actually have to deal with the deficit. 15 trillion and a trillion dollar (and rising) yearly deficit (with healthcare costs playing a large role) is not something you can just ignore for very long. Baby boomers will get start to get more and more sick. Who is going to pay 50k (each) for mom and dad's hip replacements and PT? The government won't be able to. This is where tough decisions will be made and push will come to shove.

I agree that physician salaries are only one part of the equation. Malpractice lawyers will get the short end as well as more malpractice caps are enabled. All I am saying is it's obvious that midlevels will be a big part of an attempted solution and doctors need to try to minimize their debts and be ready for competition.

Don't be greedy and bitter and you will be ok. I take comfort in all the studies that have shown that income above 80k a year does not increase happiness. All I want is 80k and an interesting/rewarding job and I will be fine - I just hope tons of my peers aren't full of angst once they realize they can't buy that McMansion. You really should try to enjoy your time in medical school - only do it if you love learning about medicine - if you are just grudgingly waiting for the payoff you will end up hating your decision.

Originally Posted by SchroedingrsCat

Sorry if I wasn't clear, I meant 80k as to what the study makers meant - after paying off a percentage student loans but before taxes. Basically it's the "magic number' where you don't have to worry about paying your bills and can afford a few luxuries and vacations (bills here do not mean Porsche payments). So 90-100k as a base income, with 10-20k per year going to student loans, is something I would be content with. If you have to accumulate 200k+ in student loans, this will be a good deal harder to pay off and I seriously suggest not attending medical school if you cannot get into a cheaper one.



Here is the fallacy. You know well that it is likely that physician reimbursements will decrease given the state of the budget. Anyone going into this based on cost/benefit analysis should become a DNP or PA instead - you can still become specialized and you get much more fiscal benefit for the cost (opportunity and tuition). Go for an MD if you truly enjoy learning about medicine and value becoming an expert in the field. Just don't get spiteful against the mid-levels when you can't demonstrate how superior you are economically.

cool man. enjoy your 80k a year for telling patients to get some rest when they have a cold.

Originally Posted by docshop12

I can promise you 10000% of people would be MUCH happier making 500k as opposed to 80k. But I'm glad you'd be content with 90-100k. Leaves more money to be made for everyone else. When you apply for a job you know on average makes somewhere around 200k I would expect you to say "no, no I don't want that much. I will take 95k because studies show that's all I need to be happy."

lol the major problem with that study was that it was done on the average person. The average person does not even attend university, let alone medical school... They usually struggle to make more than 50-60k so obviously by the time they're making 70-80k they're going to be very happy.

Originally Posted by docshop12

lol no prob. I'm staying away from that thread because some of those guys just got so upset for no real reason.

but hey now that you mention it I will quickly point out why a OD is not a midlevel. They train completely separately. It's that simple. They do a field completely separate from all other aspects of health care aside from ophtho. They also practice totally independently. Thus they aren't midlevels in the same sense.

The scope of practice of ODs is far more limited that the MD ophtho. ODs all know that and they know their scope. They prescribe abx for limited eye diseases such as conjuctivitis (things they have trained for throughout school) because often times when a patient has a problem with their eyes they will first go to the OD if they don't see their PCP (ODs are a lot cheaper and know more about the eye than the PCP usually). But there are plenty of ODs who also don't want to see medical conditions. The vast majority of their scope is eyeglass prescriptions with occasional foreign body and conjuctivitis/keratitis/etc. If something is complicated they know right away and area always more than willing to send the patient to the ED or ophtho. MD ophtho does diabetic retinopathy, complex prescriptions, surgery, etc.

And if people have a problem with an OD prescribing a zpac (largely harmless abx) then where is the outrage with the dentist doing anesthesia or prescribing abx? What about the DDS in OMFS doing full blown surgery in the hospital? So dumb. The fear of takeover is only in their head and is not happening in the real world.

Umm, you are aware OMFS docs go to both dental AND medical school, right? Based on your dumb comment, I'm taking no...

Originally Posted by Slack3r

Umm, you are aware OMFS docs go to both dental AND medical school, right? Based on your dumb comment, I'm taking no...

Not necessarily. Many OMFS docs just earn a DDS or DMD and complete a OMFS residency.

Originally Posted by KinasePro

Not necessarily. Many OMFS docs just earn a DDS or DMD and complete a OMFS residency.

Most OMFS residencies give you an MD and require you to attend medical school courses.

Originally Posted by Slack3r

Umm, you are aware OMFS docs go to both dental AND medical school, right? Based on your dumb comment, I'm taking no...

That wasn't my point. I'll let you figure it out since it should be obvious.

Originally Posted by KinasePro

Not necessarily. Many OMFS docs just earn a DDS or DMD and complete a OMFS residency.

Correct. This is true for a large majority. You can get the MD if you want.

Originally Posted by johnnydrama

Most OMFS residencies give you an MD and require you to attend medical school courses.

"Most"? Totally false. Just look at program lists like UCSF and you'll see most residents are DDS or DMD.

Originally Posted by docshop12

"Most"? Totally false. Just look at program lists like UCSF and you'll see most residents are DDS or DMD.

Exactly. According to the AAOMS, 57 of 102 accredited programs (56%) offer 4-year residencies without the MD component. It's a popular option and many OMFS docs prefer it for obvious reasons.

http://www.aaoms.org/docs/residency/program_list.pdf

Note to the OMS ignorant in this thread: 1 year of "barely more than shadowing" clerkships, and a slightly more complex path and micro class don't make you competent to perform surgery on hospitalized patients.

DDS only OMS (Who are, in fact, the majority of OMS due it most older OMS not having MD's and the balance in current graduating residents mentioned above) gain experience managing surgical patients by TAKING CARE OF THEM IN RESIDENCY, the same way every resident physician does.

An MD does not qualify you to perform surgery, or manage surgical patients, surgical skill and medical knowledge does. This is why oral surgeons easily gain hospital privileges, and take care of more acute facial trauma per capita than any other specialty.

Originally Posted by docshop12

"Most"? Totally false. Just look at program lists like UCSF and you'll see most residents are DDS or DMD.

UCSF is a mandatory, 6 year, MD-required OMS residency. You have it completely backwards. In fact, UCSF medical school is so anal, it used to be 7 years, and they required the OMS residents to attend all 4 years of med school.