If you do GI at Hopkins, you'll be sharing scopes with NP "fellows"

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In the latest issue of Hopkins Medicine magazine, there's a column in there about an NP named Monica VanDongen.

Here are some direct quotes from the article:

"the young woman is unique: VanDongen is a nurse practitioner who completed a one-year, intensive medical fellowship in gastroenterology."

"its reasonable to raise the number of capable providers for the procedure" (quote by Anthony Kalloo, MD, director of GI division.

"departmental reviewers are so pleased with the new venture with Hopkins School of Nursing that two more fellows are in training"



Un****inbelievable. Here's Anthony Kalloo's profile page: http://www.hopkinsmedicine.org/awomansjourney/profiles/kalloobio.html

Email him and ask him how much the school of nursing is paying him to sell out his field. Also ask him to explain how an NP doing scopes in one of the most doctor-concentrated urban centers in the country is really providing a service to "underserved" communities. Its a total crock of ****.

I hope the real MD GI fellows understand that there will be nurses joining their programs as "fellows" too.

what a joke.

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In the latest issue of Hopkins Medicine magazine, there's a column in there about an NP named Monica VanDongen.

Here are some direct quotes from the article:

"the young woman is unique: VanDongen is a nurse practitioner who completed a one-year, intensive medical fellowship in gastroenterology."

"its reasonable to raise the number of capable providers for the procedure" (quote by Anthony Kalloo, MD, director of GI division.

"departmental reviewers are so pleased with the new venture with Hopkins School of Nursing that two more fellows are in training"



Un****inbelievable. Here's Anthony Kalloo's profile page: http://www.hopkinsmedicine.org/awomansjourney/profiles/kalloobio.html

Email him and ask him how much the school of nursing is paying him to sell out his field. Also ask him to explain how an NP doing scopes in one of the most doctor-concentrated urban centers in the country is really providing a service to "underserved" communities. Its a total crock of ****.

I hope the real MD GI fellows understand that there will be nurses joining their programs as "fellows" too.

what a joke.



Wow......Looks like NPs will soon compete MD for most of specialities. They started with primary care, anesthesia, dermatology and now GI. Lets see which field is next...........
 
Apparently whichever field is paying well or has a good lifestyle.
 
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In the latest issue of Hopkins Medicine magazine, there's a column in there about an NP named Monica VanDongen.

Here are some direct quotes from the article:

"the young woman is unique: VanDongen is a nurse practitioner who completed a one-year, intensive medical fellowship in gastroenterology."

"its reasonable to raise the number of capable providers for the procedure" (quote by Anthony Kalloo, MD, director of GI division.

"departmental reviewers are so pleased with the new venture with Hopkins School of Nursing that two more fellows are in training"



Un****inbelievable. Here's Anthony Kalloo's profile page: http://www.hopkinsmedicine.org/awomansjourney/profiles/kalloobio.html

Email him and ask him how much the school of nursing is paying him to sell out his field. Also ask him to explain how an NP doing scopes in one of the most doctor-concentrated urban centers in the country is really providing a service to "underserved" communities. Its a total crock of ****.

I hope the real MD GI fellows understand that there will be nurses joining their programs as "fellows" too.

what a joke.

Have to wonder if he was pissed at the programs that rejected him originally for being a IMG, and thus giving the bird to the established medical community, by starting this bull**** NP fellowship.

I feel sorry for patients, uneducated enough to accept this a medical norm.
Sadly, I bet some insurance companies will pay for the noctor scopes so they only have to pay 75% or so of the usual fee.

I can't imagine how these noctors would get credentialed for GI procedures at any hospital, but I'm sure there are unscrupulous ASCs that would let them scope.
 
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There is nothing new here...NPs have been doing screening colos for years now. A monkey can do a screening colonoscopy. And before you say "well an MD will do it better"...we get obscure GI bleeders transferred all the time where referring docs missed the source and our endoscopists find it.

In the future you will compete directly with NPs for patients in private practice. You will have to show value added for your MD services.
 
In the latest issue of Hopkins Medicine magazine, there's a column in there about an NP named Monica VanDongen.

Here are some direct quotes from the article:

"the young woman is unique: VanDongen is a nurse practitioner who completed a one-year, intensive medical fellowship in gastroenterology."

"its reasonable to raise the number of capable providers for the procedure" (quote by Anthony Kalloo, MD, director of GI division.

"departmental reviewers are so pleased with the new venture with Hopkins School of Nursing that two more fellows are in training"



Un****inbelievable. Here's Anthony Kalloo's profile page: http://www.hopkinsmedicine.org/awomansjourney/profiles/kalloobio.html

Email him and ask him how much the school of nursing is paying him to sell out his field. Also ask him to explain how an NP doing scopes in one of the most doctor-concentrated urban centers in the country is really providing a service to "underserved" communities. Its a total crock of ****.

I hope the real MD GI fellows understand that there will be nurses joining their programs as "fellows" too.

what a joke.

this is unfortunate.. hopefully shd not see such a situation in cardiology. I have heard of NPs getting access for coronary arteriograms; but have not heard of any being allowed to engage coronaries..
 
In the latest issue of Hopkins Medicine magazine, there's a column in there about an NP named Monica VanDongen.

Here are some direct quotes from the article:

"the young woman is unique: VanDongen is a nurse practitioner who completed a one-year, intensive medical fellowship in gastroenterology."

"its reasonable to raise the number of capable providers for the procedure" (quote by Anthony Kalloo, MD, director of GI division.

"departmental reviewers are so pleased with the new venture with Hopkins School of Nursing that two more fellows are in training"



Un****inbelievable. Here's Anthony Kalloo's profile page: http://www.hopkinsmedicine.org/awomansjourney/profiles/kalloobio.html

Email him and ask him how much the school of nursing is paying him to sell out his field. Also ask him to explain how an NP doing scopes in one of the most doctor-concentrated urban centers in the country is really providing a service to "underserved" communities. Its a total crock of ****.

I hope the real MD GI fellows understand that there will be nurses joining their programs as "fellows" too.

what a joke.



So what? I think this is great. It provides the NP with a great training program. This board is very negative towards NPs, not sure why because nobody is saying that NPs are better than docs, and if some NPs are saying this, then they are idiots. I work as a nurse in GI currently and this fellowship looks very appealing to me. I do not have a problem working under docs, that is my purpose, if I wanted to be a doc I would go to medical school. But, can a NP do 85% of what docs do safely? Yes, and for that extra 15% we go to the real experts. Why do you feel threatened when I say that yes you are above NPs and have more training and make $400k per year as a GI doc, why cant I be a partner at your practice and make $120k and work as a team and let you make the end decisions? Here is a thought, start your own GI center and hire NPs to do all the work for you, use them, thats what I would do.
 
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Definitely it is horrible for the field.
Some past experiences with mid levels:
1- Optometrists and Ophthalmologists: They have started working with ophthalmologists. Later they became independent. Many started their own office. A few years ago they tried to do LASIK and cataract. Although they were stopped, still the fight is out there.
2- CRNAs and Anesthesiologists: No need to say that CRNAs have reached a point that many feel their serious threaten to the field of anesthesiology. They started working with Anesthesiologist. Now they try and are signing independent contracts with the hospitals.
3- PAs and NPs: They started as assistant to doctors for H&P. Now a lot of them try to gain in dependency and in fact have been successful. In a lot of places they are pushing for working as a family doctor equivalent with prescription privileges.
4- Derm PAs: They started as assistant to dermatologists. Now they have shifted into independent practice. Many are injecting BOTOX.
5- Neurosurgery and ortho PAs are trying to manage back pain themselves independently. It includes medical management and spinal injections.

So if you'd like to screw you specialty and like to devalue it hire some mid level providers. They are a great help for short time, but in long run they will become independent and claim/take a piece of your pie, which is already getting smaller day after day by decreased specialist's reimbursements by the government.
 
So what? I think this is great. It provides the NP with a great training program. This board is very negative towards NPs, not sure why because nobody is saying that NPs are better than docs, and if some NPs are saying this, then they are idiots. I work as a nurse in GI currently and this fellowship looks very appealing to me. I do not have a problem working under docs, that is my purpose, if I wanted to be a doc I would go to medical school. But, can a NP do 85% of what docs do safely? Yes, and for that extra 15% we go to the real experts. Why do you feel threatened when I say that yes you are above NPs and have more training and make $400k per year as a GI doc, why cant I be a partner at your practice and make $120k and work as a team and let you make the end decisions? Here is a thought, start your own GI center and hire NPs to do all the work for you, use them, thats what I would do.

The whole argument for having mid level providers is that they're supposed to fill an unfilled need or provide service to underserved areas. In reality, this rarely happens. An NP in a GI fellowship is not filling an unmet need. There is absolutely no shortage of GI doctors or internal medicine residents who want to go into GI. GI is one of the most competitive specialties out of internal medicine.

And if they're paying NPs $120K to work for them they might as well just hire the poor family practitioner or pediatrician down the street who is far more qualified and trained and give him or her the job. I'm sure he'd appreciate the pay raise and the better working hours.
 
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The whole argument for having mid level providers is that they're supposed to fill an unfilled need or provide service to underserved areas. In reality, this rarely happens. An NP in a GI fellowship is not filling an unmet need. There is absolutely no shortage of GI doctors or internal medicine residents who want to go into GI. GI is one of the most competitive specialties out of internal medicine.

And if they're paying NPs $120K to work for them they might as well just hire the poor family practitioner or pediatrician down the street who is far more qualified and trained and give him or her the job. I'm sure he'd appreciate the pay raise and the better working hours.

Actually, these days a typical family practitioner makes about $177K, but I agree that they'd be much better qualified.
 
Seeing that these comments are about me, I thought I should respond to my anonymous critics.
First there are definitely not enough gastroenterologists to meet the demand for screening colonoscopy. An Agency for Health Research and Quality report commissioned for the 2010 National Institutes of Health State-of-the Science Conference on Colorectal Cancer Screening found that the colonoscopy capacity would need to be substantially increased to continue to perform screening colonoscopies at the current rate after screening the 40% of the eligible population that has not yet been screened (Allen JD, Barlow WE, Duncan RP, et al. NIH state-of-the-science conference statement: Enhancing use and quality of colorectal cancer screening. NIH Consens State Sci Statements. 2010;27(1))
The State-of-the-Science Conference recommended that an increase in the endoscopic screening capacity is needed and recommended that expanding high-quality endoscopy training to non-physicians, such as nurse practitioners, may be warranted. Several studies have estimated the number of additional colonoscopists needed to meet the demand for screening colonoscopy. A 2004 study estimated that 1,000 additional colonoscopists were needed if 70% of the 2004 population was screened. At that time there were only 59 million Americans ages 50 to 74 years old that needed screening as compared to 80.5 million in 2010. Gastroenterologists are unlikely to meet the demand as the number of gastroenterology fellowship positions increased by only 50 between 2004 and 2009. Similarly, a report prepared on behalf of the colonoscope industry estimated an additional 1,000 colonoscopists were needed by 2020 to meet the rising demand for colorectal cancer screening.(The Lewin Group Inc. The impact of improved colorectal cancer screening on adequacy of future supply of gastroenterologists. 2009. Available from: http://www.crcawareness.com/files/Lewin-Gastroenterologist-Report.pdf. Accessed August 30, 2012)
These estimates do not account for the growing number of gastroenterologists working fewer hours due to changes in lifestyle and the increasing number of female gastroenterologists who tend to work fewer hours than their male counterparts.(Elta GH. GI training: Where are we headed? Am J Gastroenterol. 2011;106(3):395-397)
Secondly I am an International Medical Graduate and I care deeply for my patients and love the field of gastroenterology. I am a pioneer of Natural Orifice Translumenal Endoscopuc Surgery (NOTES) an emerging endoscopic field designed to empower gastroenterologists to perform more endoscopic procedures as an alternative to surgery. (Kalloo AN, Singh VK, Jagannath SB, Niiyama H, Hill SL, Vaughn CA, Magee CA, Kantsevoy SV. Flexible Transgastric Peritoneoscopy: A Novel Approach to Diagnostic and Therapeutic Interventions in the Peritoneal Cavity. Gastrointestinal Endoscopy 2004 July; 60(1):114-117) (NOTES: current status and new horizons; Khashab MA, Kalloo AN.Gastroenterology. 2012 Apr;142(4):704-710.e1. Epub 2012 Feb 17)

It appears many of the commenters on this forum are more concerned with their own financial gain as opposed to seeking cost effective care for patients. If you are willing to engage in a meaningful discussion about the training of NPs to perform colonoscopy, I would be happy to do so...just own up to your opinions and identify yourselves.
Anthony Kalloo
[email protected]
 
Dr. Kalloo,

No one needs to identify themselves to share their opinion on this site.

As for training nurses to do endoscopy, that's your business but don't pretend like its all about getting people screened. Those percentages don't reflect the number of people who need CRC screening but just can't find a gastroenterologist to do their scope. As you know, the problem is far more complex (insurance/cost, desire to undergo a bowel prep/procedure, quality in endoscopy, etc). As for cost, your nurses are going to charge just as much. Since you're in the northeast, I bet you use propofol for sedation so your nurses are more expensive than a staff physician out west.

Also, 1000 more colonoscopists in 10 years time? We've increased the number of fellows trained per year each of the last 10 years and have already met that demand.

GI fellowship is highly competitive. If you think we need more gastroenterologists, you should train more. We know the impact of bad colonoscopy on the protective effect of screening so why choose to train a nurse over a highly qualified IM physician?

I'm sure you've benefited by training nurses. The administration at your institution probably loves it. Why don't you talk about it at DDW next year and see how your colleagues respond. As for your comment about NOTES, I fail to see how that is relevant to this discussion. NOTES hasn't translated any meaningful technology into the general gastroenterology practice in at least 10 years. Your "new horizons" are the same horizons that seemed so exciting back when I started fellowship. Its just not going to change the practice of the vast majority of us.

BTW, bumping this thread only serves to ensure that it will remain easy to google. oops.
-G
 
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Seeing that these comments are about me, I thought I should respond to my anonymous critics.
First there are definitely not enough gastroenterologists to meet the demand for screening colonoscopy. An Agency for Health Research and Quality report commissioned for the 2010 National Institutes of Health State-of-the Science Conference on Colorectal Cancer Screening found that the colonoscopy capacity would need to be substantially increased to continue to perform screening colonoscopies at the current rate after screening the 40% of the eligible population that has not yet been screened (Allen JD, Barlow WE, Duncan RP, et al. NIH state-of-the-science conference statement: Enhancing use and quality of colorectal cancer screening. NIH Consens State Sci Statements. 2010;27(1))
The State-of-the-Science Conference recommended that an increase in the endoscopic screening capacity is needed and recommended that expanding high-quality endoscopy training to non-physicians, such as nurse practitioners, may be warranted. Several studies have estimated the number of additional colonoscopists needed to meet the demand for screening colonoscopy. A 2004 study estimated that 1,000 additional colonoscopists were needed if 70% of the 2004 population was screened. At that time there were only 59 million Americans ages 50 to 74 years old that needed screening as compared to 80.5 million in 2010. Gastroenterologists are unlikely to meet the demand as the number of gastroenterology fellowship positions increased by only 50 between 2004 and 2009. Similarly, a report prepared on behalf of the colonoscope industry estimated an additional 1,000 colonoscopists were needed by 2020 to meet the rising demand for colorectal cancer screening.(The Lewin Group Inc. The impact of improved colorectal cancer screening on adequacy of future supply of gastroenterologists. 2009. Available from: http://www.crcawareness.com/files/Lewin-Gastroenterologist-Report.pdf. Accessed August 30, 2012)
These estimates do not account for the growing number of gastroenterologists working fewer hours due to changes in lifestyle and the increasing number of female gastroenterologists who tend to work fewer hours than their male counterparts.(Elta GH. GI training: Where are we headed? Am J Gastroenterol. 2011;106(3):395-397)
Secondly I am an International Medical Graduate and I care deeply for my patients and love the field of gastroenterology. I am a pioneer of Natural Orifice Translumenal Endoscopuc Surgery (NOTES) an emerging endoscopic field designed to empower gastroenterologists to perform more endoscopic procedures as an alternative to surgery. (Kalloo AN, Singh VK, Jagannath SB, Niiyama H, Hill SL, Vaughn CA, Magee CA, Kantsevoy SV. Flexible Transgastric Peritoneoscopy: A Novel Approach to Diagnostic and Therapeutic Interventions in the Peritoneal Cavity. Gastrointestinal Endoscopy 2004 July; 60(1):114-117) (NOTES: current status and new horizons; Khashab MA, Kalloo AN.Gastroenterology. 2012 Apr;142(4):704-710.e1. Epub 2012 Feb 17)

It appears many of the commenters on this forum are more concerned with their own financial gain as opposed to seeking cost effective care for patients. If you are willing to engage in a meaningful discussion about the training of NPs to perform colonoscopy, I would be happy to do so...just own up to your opinions and identify yourselves.
Anthony Kalloo
[email protected]

Stop acting like colonoscopies are simply looking to find just polyps. You know that they are not, and can be used to identify other conditions that patients may have. A nurse goes through only a couple of years of training. A GI goes through 4 years of med school, 4 years of int med residency, and 3 years of fellowship. You cannot possibly think that nurses who have a lot less training could match the knowledge of a GI. If there aren't enough GIs, then you train PCPs to do to the job. They have far more experience than a nurse.

It appears you are more concerned with your own financial payout from the nursing industry as opposed to seeking safe, high quality care for patients. If you are willing to disclose your financial payout from the nursing lobby, we would be happy to hear that...just own up as to who your financial donors are and identify how much they gave to you.

Barack Obama,
President of the United States
 
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Stop acting like colonoscopies are simply looking to find just polyps. You know that they are not, and can be used to identify other conditions that patients may have. A nurse goes through only a couple of years of training. A GI goes through 4 years of med school, 4 years of int med residency, and 3 years of fellowship. You cannot possibly think that nurses who have a lot less training could match the knowledge of a GI. If there aren't enough GIs, then you train PCPs to do to the job. They have far more experience than a nurse.

It appears you are more concerned with your own financial payout from the nursing industry as opposed to seeking safe, high quality care for patients. If you are willing to disclose your financial payout from the nursing lobby, we would be happy to hear that...just own up as to who your financial donors are and identify how much they gave to you.

Barack Obama,
President of the United States


How much endoscopy/colonoscopy exposure do you think anyone gets in 4 years of med school and 3 (not 4) years of internal medicine residency? Practically none. First-year GI fellows walk into their first case learning from scratch, both in terms of operating the scope and identifying findings. The technical skills of scoping have nothing to do with the other non-endoscopy-related training. The same goes for identification and removal of polyps. I agree that colonoscopy is used for more than just screening for polyps. However, screening cases can be easily separated from diagnostic cases during scheduling based on referral information, so that only screening cases are scheduled with NPs. Suggesting that there would be any significant decrease in quality of care with the use of fellowship-trained NP in screening colonoscopy would be a stretch.

The suggestion that PCPs can be trained to do these procedures to fill the need does not make sense for several reasons: (1) as mentioned above, a PCP would have no more exposure/training in colonoscopy in their "years of medical training" than an NP, (2) a specialized NP/PA would likely possess more GI knowledge than a generalist MD (we have a few PA/NPs in our group handling patient calls and other issues in clinic. I would definitely rate their knowledge in diagnosis/management of GI diseases higher than most generalist MDs, probably due to the fact that they are specialized and work with complex GI patients with us daily), and (3) together with the very real shortage of colonoscopists for CRC screening, there is an even greater shortage of PCPs in the country -- taking away more PCP to do specialist work does not make sense.

Everyone here talks about how NPs getting trained in colonoscopy would eventually lead to the downfall/demise/killing of GI as a specialty. However, people seem to forget that colonoscopy does NOT define GI as a specialty. It is only a part of GI, and screening colonoscopy is probably one of the most mindless things performed by a gastroenterologist. The specialty of GI existed before we started doing screening colonoscopy and there would still be more than enough for gastroenterologists to do even if we stop doing colonoscopies altogether.

Finally, I respect Dr. Kalloo for standing up and defending his position, using actual published data to support his argument rather than just sensationalism demonstrated by some here. I don't think that anyone needs to identify himself/herself to share opinions on the topic on here. However, if they are going to descend to the level of personal attacks, like some have done here, they should own up to their comments.
 
How much endoscopy/colonoscopy exposure do you think anyone gets in 4 years of med school and 3 (not 4) years of internal medicine residency? Practically none. First-year GI fellows walk into their first case learning from scratch, both in terms of operating the scope and identifying findings. The technical skills of scoping have nothing to do with the other non-endoscopy-related training. The same goes for identification and removal of polyps. I agree that colonoscopy is used for more than just screening for polyps. However, screening cases can be easily separated from diagnostic cases during scheduling based on referral information, so that only screening cases are scheduled with NPs. Suggesting that there would be any significant decrease in quality of care with the use of fellowship-trained NP in screening colonoscopy would be a stretch.

How often is referral information actually correct? More often than not, one has to dig a little deeper to ensure that a simple case is indeed simple. Futhermore, who determines when a patient is screened? What about the patient who is high risk? What about the patient who has PSC? To answer your question - I would much prefer to have my case reviewed by a trained PHYSICIAN as opposed to a NP. A PCP has learned the foundations of medicine to build his or her knowledge of GI - an NP does NOT have this foundation - not matter how many years the NP spent in the endoscopy unit or in the GI department. There are major gaps in their knowledge.

As for actually performing a simple screening procedure - anyone can actually learning the technical skills of endoscopy. What separates a physician from an NP is to interpret the histopathologic findings in the broader context. Futhermore - most gastroenterologists I know are better able to understand and manage their patients when they performed the endoscopic procedure themselves - to delegate the task to someone else to an NP is to relinquish a significant a major portion of the patient care.

The suggestion that PCPs can be trained to do these procedures to fill the need does not make sense for several reasons: (1) as mentioned above, a PCP would have no more exposure/training in colonoscopy in their "years of medical training" than an NP, (2) a specialized NP/PA would likely possess more GI knowledge than a generalist MD (we have a few PA/NPs in our group handling patient calls and other issues in clinic. I would definitely rate their knowledge in diagnosis/management of GI diseases higher than most generalist MDs, probably due to the fact that they are specialized and work with complex GI patients with us daily), and (3) together with the very real shortage of colonoscopists for CRC screening, there is an even greater shortage of PCPs in the country -- taking away more PCP to do specialist work does not make sense.

Everyone here talks about how NPs getting trained in colonoscopy would eventually lead to the downfall/demise/killing of GI as a specialty. However, people seem to forget that colonoscopy does NOT define GI as a specialty. It is only a part of GI, and screening colonoscopy is probably one of the most mindless things performed by a gastroenterologist. The specialty of GI existed before we started doing screening colonoscopy and there would still be more than enough for gastroenterologists to do even if we stop doing colonoscopies altogether.

If a lay person on the street spent 5 years in a GI clinic they would know more than a PCP about GI disease - that certainly does not make them competent or capable or qualified of taking care of a GI patient. What you fail to understand is that the delegation of "simple" clinical cases is an egregious error in delegation of tasks as it creates opportunities for patients to fall through the cracks - as a physician, you are not defined by the number of successfully managed cases - you are defined by your rates of morbidity. There are not studies comparing the ability of an NP to manage IBD vs a gastroenterologist - it makes no intuitive sense to make such a comparison - so why open the door the dangerous idea of delegating what we do as a living as a mid-level provider - and at the same time accept at the risk - and obtain non of the benefit?
 
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I am responding as an EM attending, not as a GI physician.

Given that, I find it disheartening that we have to go through as much training as we do, jump through many hoops - yet it is ok for similar, parallel fields to do the same with less training. It's not fair and while life isn't fair - it's STILL not fair. If this was the case, then they should cut down reisdency and fellowship lengths since the powers that be are saying that you can adequately practice your field with less training than you were forced to endure.

Oh wait, they don't want to do that - who will staff hospitals for minimum wage?
 
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I am responding as an EM attending, not as a GI physician.

Given that, I find it disheartening that we have to go through as much training as we do, jump through many hoops - yet it is ok for similar, parallel fields to do the same with less training. It's not fair and while life isn't fair - it's STILL not fair. If this was the case, then they should cut down reisdency and fellowship lengths since the powers that be are saying that you can adequately practice your field with less training than you were forced to endure.

Oh wait, they don't want to do that - who will staff hospitals for minimum wage?

I couldn't agree more!
 
This argument reminds me of plumbers getting angry at unlicensed drain cleaners running scopes down a sewer." What could some hack know about plumbing, I went through a four year apprenticeship...yada yada"
Change is inevitable, but expertise, education, and experience will always be as valuable as it is rare. You guys have nothing to worry about. Think how bad ass you'll feel when some overly confident NP perforates someones colon and they call in the big guns to fix it up.
I'm visiting from the plumbers forum. I thought THOSE guys were grouchy and overly concerned with money, but wow, this forum is a hoot.
 
i am responding as an em attending, not as a gi physician.

Given that, i find it disheartening that we have to go through as much training as we do, jump through many hoops - yet it is ok for similar, parallel fields to do the same with less training. It's not fair and while life isn't fair - it's still not fair. If this was the case, then they should cut down residency and fellowship lengths since the powers that be are saying that you can adequately practice your field with less training than you were forced to endure.

Oh wait, they don't want to do that - who will staff hospitals for minimum wage?

Everyone wants MD pay but without assuming any of the risk and we have to blame ourselves for it.
 
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There is no intellectual honesty if one things that a NP trained in a one year "fellowship" will be able to give the same standard of care as a fellowship trained gastroenterologist. Before I felt competent at completing a colonoscopy I was in the three hundred range. My first 80-100 colonoscopies I maybe got into the cecum 40-60% of the time.

Being a gastroenterologist is much more about just being able to perform a colonoscopy. I would not put my license on the line for a NP who has a higher chance of missing a flat right sided lesion. Will they next start managing crohn's and ulcerative colitis? Why not let them start doing liver biopsies? EGDs with dilations? These are all procedures that can be learned right? There is a reason why we go to school for 4 years, residency for 3 and fellowship for three. Many do subspecialization ERCP, hepatology or IBD. I would rather my loved one go to a fellowship trained ERCP gastroenerologist than a generalist if they needed one.
 
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Definitely it is horrible for the field.
Some past experiences with mid levels:
1- Optometrists and Ophthalmologists: They have started working with ophthalmologists. Later they became independent. Many started their own office. A few years ago they tried to do LASIK and cataract. Although they were stopped, still the fight is out there.
2- CRNAs and Anesthesiologists: No need to say that CRNAs have reached a point that many feel their serious threaten to the field of anesthesiology. They started working with Anesthesiologist. Now they try and are signing independent contracts with the hospitals.
3- PAs and NPs: They started as assistant to doctors for H&P. Now a lot of them try to gain in dependency and in fact have been successful. In a lot of places they are pushing for working as a family doctor equivalent with prescription privileges.
4- Derm PAs: They started as assistant to dermatologists. Now they have shifted into independent practice. Many are injecting BOTOX.
5- Neurosurgery and ortho PAs are trying to manage back pain themselves independently. It includes medical management and spinal injections.

So if you'd like to screw you specialty and like to devalue it hire some mid level providers. They are a great help for short time, but in long run they will become independent and claim/take a piece of your pie, which is already getting smaller day after day by decreased specialist's reimbursements by the government.

I completely agree with the above post. I don't understand why as doctors we don't push harder to put an end to this and not be so amenable to hiring midlevels and hence going down the slippery slope as mentioned above. PAs/NPs should not be working independently, that is absolutely crazy. They did not go through the selection process/years of training etc that mds have gone through and hence should not even be considered to be working independently. I think we have had way too much infiltration and while it may make sense in the short term financially to hire help, in the long run it is horrible for healthcare.
 
Will there be an Endoscopic Ultrasound fellowship at Johns Hopkins for NP's in the near future?
 
I completely agree with the above post. I don't understand why as doctors we don't push harder to put an end to this and not be so amenable to hiring midlevels and hence going down the slippery slope as mentioned above. PAs/NPs should not be working independently, that is absolutely crazy. They did not go through the selection process/years of training etc that mds have gone through and hence should not even be considered to be working independently. I think we have had way too much infiltration and while it may make sense in the short term financially to hire help, in the long run it is horrible for healthcare.

I refuse to collaborate with NP's. Why take on the vicarious liability of a person who DOES NOT KNOW WHAT THEY DONT KNOW.

They have infiltrated psychiatry with APNP (advanced practice nurse practitioners) and some with PHd's, so they are called DOCTOR which thoroughly confuses the patients.

Now, they have some nursing board certification so they are BOARD CERTIFIED DOCTORS. They work for 1/3rd the price of a psychiatrist, and do whatever administration asks of them, ethical or not.

:eek:

But when they make wrong decisions its "Im just a nurse..I didn't know...." and the collaborating doc gets sued for failure to collaborate. Nurses will always say they are not SUPERVISED until they get in trouble.

They are EVERYWHERE.
 
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I refuse to collaborate with NP's. Why take on the vicarious liability of a person who DOES NOT KNOW WHAT THEY DONT KNOW.

They have infiltrated psychiatry with APNP (advanced practice nurse practitioners) and some with PHd's, so they are called DOCTOR which thoroughly confuses the patients.

Now, they have some nursing board certification so they are BOARD CERTIFIED DOCTORS. They work for 1/3rd the price of a psychiatrist, and do whatever administration asks of them, ethical or not.

:eek:

But when they make wrong decisions its "Im just a nurse..I didn't know...." and the collaborating doc gets sued for failure to collaborate. Nurses will always say they are not SUPERVISED until they get in trouble.

They are EVERYWHERE.

Oh brother! The situation is un believably awful for us.
 
I heard about this too!! Now they have come up with a clever trick where as nps they have to get a doctorate in nursing -> hence will technically be called doctor. Basically tricking the public into not differentiating them with real doctors. This is just crazy. Why don't we stick together as doctors and try to fight this nonsense. Thats what they do and the reason why they are succesful.
 
I am a pioneer of Natural Orifice Translumenal Endoscopuc Surgery (NOTES) an emerging endoscopic field designed to empower gastroenterologists to perform more endoscopic procedures as an alternative to surgery. (Kalloo AN, Singh VK, Jagannath SB, Niiyama H, Hill SL, Vaughn CA, Magee CA, Kantsevoy SV. Flexible Transgastric Peritoneoscopy: A Novel Approach to Diagnostic and Therapeutic Interventions in the Peritoneal Cavity. Gastrointestinal Endoscopy 2004 July; 60(1):114-117)


You obviously love training NPs, so give me one good reason why we should let you do this when a nurse can do it at 1/4th the cost and do it JUST AS WELL AS YOU CAN.

Also, I'd like you to explain your hypocrisy -- you wont expand the GI fellowship for MDs even though there's a "shortage of providers" according to you. Instead of dong the RIGHT THING by expanding the Hopkins GI program, you cook up some crazy scheme to let nurses shortcut the training. Explain yourself, sir.
 
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who are the idiots who are training them? why not just make a family medicine fellowship to learn how to do screening colonoscopies? why the hell are we training these fraud dnp's? it just makes no sense.
 
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Let it be known that I will never, ever supervisor a NP endoscopist - nor should any of you Staff/Fellow GIs out there reading this. As a GI fellow, I will make it my business for the rest of my professional career to eliminate, once and for all, the threat that these mid-level providers pose to our profession.
 
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Let it be known that I will never, ever supervisor a NP endoscopist - nor should any of you Staff/Fellow GIs out there reading this. As a GI fellow, I will make it my business for the rest of my professional career to eliminate, once and for all, the threat that these mid-level providers pose to our profession.

Amen. Im totally with you on this.
 
ITT, Dr. Anthony Kalloo is an obvious sellout to the nursing lobby. It truly is sad. I hope one day the public can differentiate between a glorified DPN and a doc who has far more knowledge. Still waiting on the answer, Dr. Kalloo. Why won't you expand the GI program there? Just how much did they pay you ? =) It's a free country...Im not judging; you do what you want. But, in your mind, who is more qualified?
 
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Let it be known that I will never, ever supervisor a NP endoscopist - nor should any of you Staff/Fellow GIs out there reading this. As a GI fellow, I will make it my business for the rest of my professional career to eliminate, once and for all, the threat that these mid-level providers pose to our profession.

good luck....it's like trying to spray raid to eliminate roaches after the infestations
 
Curious, though. What if there was evidence supporting their use? I.e. - rates of complications, false negative studies, and outcomes were equivalent or non-inferior. Then what? Is it still 'destroy' them or is it our duty to promote cost effective solutions.

I don't know, I'm from rad-onc, just trolling, but in my field, someone lower level could contour the prostate just as well as me. The issue is deciding who gets treatment and what volumes to treat and to what dose. In medicine fee-schedules, the bureaucrats (and because of them, the physician) are more interested in the procedure itself then the clinical decision-making involved and the analysis of the data from a study. If the payment was associated with the decision, then perhaps it would be good to have a scope monkey do the procedure. You could turn it around the other way - say in an alternate world, the clinical decision making was paid for. Maybe the comments on the forum would be: "Why would I have trained so long to have to actually do the colonoscopy? That's the easy part and my nurse does it." I don't know...

There is so much butthurt in medicine. CRNAs have very good outcomes (evidence based), and it's a money issue not a patient care issue. It hasn't destroyed anesthesia - it just means the docs do the hard cases and are on back up for complications when CRNAs need help. NPs and PAs are doing fine in Minute Clinics and fill a void. If their results stink and something blows up, their will be backlash. I suspect it won't, because they stick to the easy stuff. I'm feeling sort of libertarian about this stuff. If someone can do an equivalent job for less, I just don't think fighting them is smart. Just got to add value to your own services somehow.

Finally, insinuating that this GI at Hopkins is getting paid off by the nurses lobby is a really juvenile and not necessarily thoughtful response. JHH's GI department is world class, my close friend is a fellow there and they are on the cutting edge of medicine. If they think this is possible solution, I'm certain they have thought through it and won't risk their legacy for it. I practice in a rural area, and there is most definitely a wait to get a screening colonoscopy. They could stand to have a few more endoscopists here, but not too many people want to live/work in Southern Maryland.
 
There is so much butthurt in medicine. CRNAs have very good outcomes (evidence based), and it's a money issue not a patient care issue. It hasn't destroyed anesthesia - it just means the docs do the hard cases and are on back up for complications when CRNAs need help. NPs and PAs are doing fine in Minute Clinics and fill a void. If their results stink and something blows up, their will be backlash. I suspect it won't, because they stick to the easy stuff. I'm feeling sort of libertarian about this stuff. If someone can do an equivalent job for less, I just don't think fighting them is smart. Just got to add value to your own services somehow.

I think you're underestimating how the CRNA issue has changed anesthesia. I believe 17 states are opt out states in which CRNAs can practice independently.

CRNAs can be reimbursed for pain procedures without any specific training
http://forums.studentdoctor.net/showthread.php?t=961402

http://forums.studentdoctor.net/showthread.php?t=840632

Anesthesia may not be "destroyed" but it is ignorant to think that it isn't having a very strong effect on the nature of the practice. Unfortunately, the genie is out of the bottle relating to this and anesthesia has shot themselves in the foot with this.

Finally, insinuating that this GI at Hopkins is getting paid off by the nurses lobby is a really juvenile and not necessarily thoughtful response. JHH's GI department is world class, my close friend is a fellow there and they are on the cutting edge of medicine. If they think this is possible solution, I'm certain they have thought through it and won't risk their legacy for it. I practice in a rural area, and there is most definitely a wait to get a screening colonoscopy. They could stand to have a few more endoscopists here, but not too many people want to live/work in Southern Maryland.

The Hopkins GI department is selling out. The fact that they are cutting edge is irrelevant. Instead of training more gastroenterologists to fill a void, they would rather introduce nurses to fill this role. How does this make sense.

Also, the comment that not many people want to work/live in rural areas is true. But what makes you think that mid levels will be content with that piece of the pie. I guarantee you that they may start out in the rural regions but will quickly move to different regions competing with physicians. It's evident in anesthesia that this is going on as well.

But I think some specialties are certainly insulated from the mid level threat, rad onc probably being one of them. But if a bread and butter procedure that has risk and is one of the main cornerstones of compensation for a rad onc is being taught to mid levels under the guise of increasing access, you can guarantee that radiation oncologists would be up in arms about this as well.

Honestly, what it comes down to is that more and more people in the medical profession want the compensation/prestige/skill set of a physician without actually going to medical school and residency. But when $hit hits the fan, MDs/DOs are the ones cleaning up the mess.
 
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I'm not saying people would not be up in arms. Just saying if someone could do what I do for cheaper, it would make me rethink what value I have. Nation going broke. If mid levels are equivalent, than they are equivalent. The market balances out. For example, chiropractors claim they can do what a doctor does. And insurers pay for them. But they have screwed up so much that the average person will only see them for minor neck and back pain. The market corrects, in my opinion. Endless regulations, restrictions, turf wars increase costs not quality, unless the disruptive party is worse. When they are worse, people vote with their feet. The moment scopes done by a nurse have a higher perf rate and they are missing cancers, PCPs will stop referring and public health is benefited. I just think the endless restrictions and rules stifle any opportunity to lower health care costs. Look at general peds- we train people for 3 years in this specialty and when they come out, FPs can do what they do for most things. No one is fighting the fact that someone with less than one year of pediatric training is allowed to do what someone with 3 years of training can do. Heck, NPs do that kind of stuff, too, and the apocalypse is not upon us.

I say lets review the results and then see if a policy is necessary. We de-escalate treatments in cancer medicine all the time (from ABVD x 4 + 36 Gy to ABVD x 2 and 20 Gy for Hodgkins). We know less is more. It's more scientific to debate efficacy and outcomes rather than have these battles preemptively.

Sorry to be a dissenter. I just don't know why debate is about protecting financial security rather than what's best for patients. If the NPs suck, they suck.

I think you're underestimating how the CRNA issue has changed anesthesia. I believe 17 states are opt out states in which CRNAs can practice independently.

CRNAs can be reimbursed for pain procedures without any specific training
http://forums.studentdoctor.net/showthread.php?t=961402

http://forums.studentdoctor.net/showthread.php?t=840632

Anesthesia may not be "destroyed" but it is ignorant to think that it isn't having a very strong effect on the nature of the practice. Unfortunately, the genie is out of the bottle relating to this and anesthesia has shot themselves in the foot with this.



The Hopkins GI department is selling out. The fact that they are cutting edge is irrelevant. Instead of training more gastroenterologists to fill a void, they would rather introduce nurses to fill this role. How does this make sense.

Also, the comment that not many people want to work/live in rural areas is true. But what makes you think that mid levels will be content with that piece of the pie. I guarantee you that they may start out in the rural regions but will quickly move to different regions competing with physicians. It's evident in anesthesia that this is going on as well.

But I think some specialties are certainly insulated from the mid level threat, rad onc probably being one of them. But if a bread and butter procedure that has risk and is one of the main cornerstones of compensation for a rad onc is being taught to mid levels under the guise of increasing access, you can guarantee that radiation oncologists would be up in arms about this as well.

Honestly, what it comes down to is that more and more people in the medical profession want the compensation/prestige/skill set of a physician without actually going to medical school and residency. But when $hit hits the fan, MDs/DOs are the ones cleaning up the mess.
 
http://www.asge.org/uploadedFiles/P...ractice_Guidelines/endo non physicians(1).pdf

Guideline-based medical recommendations note that a Flex Sig is reasonable to perform by appropriately trained non-physicians; however, screening colonoscopies aren't supported by these recommendations. Sure maybe you'll find some article in a Nursing Journal that supports NPs doing colonoscopies, but until these reach guideline based recommendations, the widespread adoption of this practice is NOT supported by the currently available medical literature.
 
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I'm not saying people would not be up in arms. Just saying if someone could do what I do for cheaper, it would make me rethink what value I have. Nation going broke. If mid levels are equivalent, than they are equivalent. The market balances out. For example, chiropractors claim they can do what a doctor does. And insurers pay for them. But they have screwed up so much that the average person will only see them for minor neck and back pain. The market corrects, in my opinion. Endless regulations, restrictions, turf wars increase costs not quality, unless the disruptive party is worse. When they are worse, people vote with their feet. The moment scopes done by a nurse have a higher perf rate and they are missing cancers, PCPs will stop referring and public health is benefited. I just think the endless restrictions and rules stifle any opportunity to lower health care costs. Look at general peds- we train people for 3 years in this specialty and when they come out, FPs can do what they do for most things. No one is fighting the fact that someone with less than one year of pediatric training is allowed to do what someone with 3 years of training can do. Heck, NPs do that kind of stuff, too, and the apocalypse is not upon us.

I say lets review the results and then see if a policy is necessary. We de-escalate treatments in cancer medicine all the time (from ABVD x 4 + 36 Gy to ABVD x 2 and 20 Gy for Hodgkins). We know less is more. It's more scientific to debate efficacy and outcomes rather than have these battles preemptively.

Sorry to be a dissenter. I just don't know why debate is about protecting financial security rather than what's best for patients. If the NPs suck, they suck.

so why become an MD at all...why dont you go become a SW or nurse and do whats best for patients without taking up govt funding for your residency?

And if the NPs suck, they are still working under YOUR license and YOUR malpractice..So it effects YOU...the chiro does not hop on your license..

Good luck to you all!
 
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There is so much butthurt in medicine. CRNAs have very good outcomes (evidence based), and it's a money issue not a patient care issue. It hasn't destroyed anesthesia - it just means the docs do the hard cases and are on back up for complications when CRNAs need help. NPs and PAs are doing fine in Minute Clinics and fill a void. If their results stink and something blows up, their will be backlash. I suspect it won't, because they stick to the easy stuff. I'm feeling sort of libertarian about this stuff. If someone can do an equivalent job for less, I just don't think fighting them is smart. Just got to add value to your own services somehow.

Look closely at this 'research'. Most of it is questionable at best - the studies often use metrics like 'patient satisfaction' as surrogates for real outcomes measurement. They're also usually administered by nurses themselves, so there are many conflicts of interest built into the system.

I also contest the notion that NPs and PAs are 'doing fine' in Minute Clinics etc. In my own (and my family's) experience, I've only dealt with a couple NPs that really had a feel for what they were doing even as a PCP. The ones that don't do a lot of truly cockamamie stuff.
 
Look closely at this 'research'. Most of it is questionable at best - the studies often use metrics like 'patient satisfaction' as surrogates for real outcomes measurement. They're also usually administered by nurses themselves, so there are many conflicts of interest built into the system.

I also contest the notion that NPs and PAs are 'doing fine' in Minute Clinics etc. In my own (and my family's) experience, I've only dealt with a couple NPs that really had a feel for what they were doing even as a PCP. The ones that don't do a lot of truly cockamamie stuff.

the longer you do this, the longer you'll realize a lot of doctors do a lot of cockamamie stuff as well. medical school/residency didnt seem to help them.
 
Perhaps this is the wrong place to post this question, but if I can do the same things as a doctor does, with less time in school and consequently less debt, why shouldn't I become a NP rather than going to med school? Right now, I'm looking at half a million dollars of med school debt, and am slightly terrified. if I can do the same job, albeit for a smaller salary, why shouldn't I choose to become an NP? It appears that they are gaining independence and may not be working under a physician in the future.
 
Perhaps this is the wrong place to post this question, but if I can do the same things as a doctor does, with less time in school and consequently less debt, why shouldn't I become a NP rather than going to med school? Right now, I'm looking at half a million dollars of med school debt, and am slightly terrified. if I can do the same job, albeit for a smaller salary, why shouldn't I choose to become an NP? It appears that they are gaining independence and may not be working under a physician in the future.

You should go NP. Unless you are female and attractive in which case you should be a Cook Endoscopy rep.
 
Perhaps this is the wrong place to post this question, but if I can do the same things as a doctor does, with less time in school and consequently less debt, why shouldn't I become a NP rather than going to med school? Right now, I'm looking at half a million dollars of med school debt, and am slightly terrified. if I can do the same job, albeit for a smaller salary, why shouldn't I choose to become an NP? It appears that they are gaining independence and may not be working under a physician in the future.

if you dont want to be a doctor....dont be a doctor. it's pretty simple.
 
This dr kalloo has clearly spent too much time in *******s-he has turned into one!! Who in their right mind would let a nurse do a procedure on them?
And yes, what data is there to say that there is a shortage of GI docs? You can get booked in a day anywhere for a screening colo!! I don't understand doctors like him-maybe he is boffing that nurse he is teaching. What a sellout. What he doesn't understand or has forgotten is that it is a privilege to learn and be able to do duh procedures for a patient. A privilege that is earned by long years of hard work and sacrifice in MEDICAL SCHOOL and RESIDENCY. Taking a 10 month shortcut via online NP school does not give you the rights to that privilege.
 
This dr kalloo has clearly spent too much time in *******s-he has turned into one!! Who in their right mind would let a nurse do a procedure on them?
And yes, what data is there to say that there is a shortage of GI docs? You can get booked in a day anywhere for a screening colo!! I don't understand doctors like him-maybe he is boffing that nurse he is teaching. What a sellout. What he doesn't understand or has forgotten is that it is a privilege to learn and be able to do duh procedures for a patient. A privilege that is earned by long years of hard work and sacrifice in MEDICAL SCHOOL and RESIDENCY. Taking a 10 month shortcut via online NP school does not give you the rights to that privilege.

I hate NPs and other midlevels that think they're equivalent to MDs when in fact they're not, but this is just a laughable mindset to have. There is no such thing as privilege. Whatever "privilege" you think you earned with length of education isn't real - it's made up. The only thing that matters is the end result and the efficiency/cost-effectiveness.

The funny thing here is that if scopes reimbursed like complete **** and office visits reimbursed a boatload, there wouldn't be a peep from us physicians. None. We would gladly hand over keys to the endoscopy and colonscopy suites and we would be chatting up patients all day in clinic. In fact, specialty trained midlevels would be the only ones doing scopes and it would have been like that since day one. And the kicker is that this business model would be totally okay. In fact, it would be the smart thing to do. But, it's simply pathetic to hide behind the ruse of some abstract and artificial construct of privilege when financial incentives are the main driver.
 
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Wow......Looks like NPs will soon compete MD for most of specialities. They started with primary care, anesthesia, dermatology and now GI. Lets see which field is next...........

Interventional cardiology? Teach NP or even high school studunt how to do angioplasty. Why spend 14 years studying to get oppotunity to learn this procedure?:rolleyes:
 
Interventional cardiology? Teach NP or even high school studunt how to do angioplasty. Why spend 14 years studying to get oppotunity to learn this procedure?:rolleyes:

If a non-MD can do a procedure as effectively as an MD, then that's what should happen (unless the MD is willing to take as little money as the non-MD would). Whether or not a non-MD CAN do the procedure as effectively is a different argument altogether, and it is the one that we should be having. Studying and training for 14 years means nothing more than studying and training for 14 years. It grants you no divine right independent of your abilities.
 
Look no one should teach an NP to do anything of the sort. Only physicians should be granted such privileges. Nps dont know what they dont know. They THINK they know everything but it is actually laughable the lack of knowledge that is there. And hiding under a doctors license is pathetic. No one in their right mind would let a nurse do procedures on them.
Further, Bronx you are clearly an NP troll.
 
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I think that most of the people engaged on this post are just upset with the amount of time, energy, money, and loss of their own lives they have spent to become physicians when they could have had a well rounded path as an advanced provider!
 
If a non-MD can do a procedure as effectively as an MD, then that's what should happen (unless the MD is willing to take as little money as the non-MD would). Whether or not a non-MD CAN do the procedure as effectively is a different argument altogether, and it is the one that we should be having. Studying and training for 14 years means nothing more than studying and training for 14 years. It grants you no divine right independent of your abilities.

So I take it you believe that there should be no barriers on scope of practice to anyone then?

What if I proposed a training program to take motivated high school students, put them in the cath lab with an intervent cardiologist for a year, and see if they can do procedures with the same outcomes as a fellow/attending. I'm not talking about some half ass deal where they do 2 procedures a week. I'm talking about 8 hours 5 days a week doing NOTHING but cath procedures.

You OK with me trying that?
 
I hate NPs and other midlevels that think they're equivalent to MDs when in fact they're not, but this is just a laughable mindset to have. There is no such thing as privilege. Whatever "privilege" you think you earned with length of education isn't real - it's made up. The only thing that matters is the end result and the efficiency/cost-effectiveness.

The funny thing here is that if scopes reimbursed like complete **** and office visits reimbursed a boatload, there wouldn't be a peep from us physicians. None. We would gladly hand over keys to the endoscopy and colonscopy suites and we would be chatting up patients all day in clinic. In fact, specialty trained midlevels would be the only ones doing scopes and it would have been like that since day one. And the kicker is that this business model would be totally okay. In fact, it would be the smart thing to do. But, it's simply pathetic to hide behind the ruse of some abstract and artificial construct of privilege when financial incentives are the main driver.

Yeah then nobody in his/her right mind would go into GI :laugh:
 
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