Medical graduates moving straight to patient care proposal.

[Per4mer8]

Saw this today, essentially Missouri has a proposal to allow medical school grads to go directly to primary care practice in rural/under served areas without any residency training, including no internship. I find it comical where some of the opposition is coming from....

http://m.stltoday.com/news/special-...5ebf-8247-531129c713a5.html?mobile_touch=true

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[deleted480308]

what they are saying is, "we don't care if the medicaid patients in the woods get good care, we just want them to have care".

 

[Per4mer8]

I understand the thinking from the politicians....

What is hilarious is the PA association in Missouri is upset and thinks it's misleading to patients. Meanwhile in the same state the PA's just got legislature passed to allow independent practice as long as a "supervising physician" is within 50 miles.

I also think it's funny other parties who oppose this proposal argue Doctors need a residency to be appropriately trained (I actually agree of course) but meanwhile it's ok to let PAs and other mid levels do it. So essentially they all argue equivalence and expanding rights of practice with less training, but when the Doctors try it it's crazy and dangerous.

 

[osumd]

How would the proposed scope of practice differ from a PA? In what ways are medical school didactics and clinical rotations different or inferior than PA school (truly, I am ignorant on this)?

 

[nimbus]

This is terrible. It is worse than no care because access to incompetent care will prevent patients from seeking the competent care that they need. And who is going to do this? The bottom of the barrel I imagine. 4th years too dumb to realize they don't know s*** and that they need close supervision.

 

[BuzzPhreed]

I became a doctor in medical school. I learned to be a physician in residency.

Bad idea.

 

[gasdoc1]

Well, thats one way to keep "doctors" in the state of Missouri. Without residency, where else can they go? I'm not sure why anyone with enough intelligence to pass the USMLE would be dumb enough to do this.

 

[urge]

Better an MD than a NP.

I felt competent in outpatient care after med school.

Internship was all hospital based.

 

[Laryngophed]

This isn't being targeted at students who "have their pick" of residency programs, if you'll pardon the turn of phrase. But for students that don't successfully match or SOAP into a position, I could certainly see why this would be attractive. That said, this is perpetual residency. That would be extremely frustrating to me, but if this someone's goal is to work in primary care in rural Missouri and they didn't land a primary care residency, I don't think I'd begrudge their choice.

And just having graduated, I can tell you I don't feel comfortable solo in an outpatient setting. As much as the next 12 months will surely bear down on me, I'm glad the State requires 12 months of supervision before turning docs loose.

 

[Random Anesthesiologist]

I became a doctor in medical school. I learned to be a physician in residency.

Bad idea.

That first year of residency also defines how much you really don't know, and it's frightening.

 

[DermViser]

I became a doctor in medical school. I learned to be a physician in residency.

Bad idea.

It's primary care under a board certified doctor. They act as PAs. Hardly taxing.

 

[nimbus]

It's primary care under a board certified doctor. They act as PAs. Hardly taxing.

This begs the question. Is it necessary to do a 3 year residency to practice primary care? Or can they just go into practice as long as there is a board certified colleague nearby?

 

[DermViser]

This begs the question. Is it necessary to do a 3 year residency to practice primary care? Or can they just go into practice as long as there is a board certified colleague nearby?

Ask the NPs - apparently not. That being said, acting as a PA isn't unreasonable. It makes no sense when PAs are allowed to do so with less training than physicians.

 

[BuzzPhreed]

This begs the question. Is it necessary to do a 3 year residency to practice primary care? Or can they just go into practice as long as there is a board certified colleague nearby?

So you're taking away ACGME oversight? No conferences or scheduled education sessions and lectures? No in-service exams? Board-certification without formalized training?

Is the system so broken right now that this is the fix?

I stand by what I already said.

Ask the NPs - apparently not. That being said, acting as a PA isn't unreasonable. It makes no sense when PAs are allowed to do so with less training than physicians.

PAs are always supervised. At least in theory (and law).

 

[narcusprince]

FYI- This has been done for years in the military. For years their have been flight surgeons and general medical officers doing primary care duties with only internship training. I do not see this as far off from that model. I am on the side of fully trained competent(as judged by the ABIM or Family medicine board)physicians taking care of patients. PA's often work their first couple of years as understudies of the physician they are working for so their is a couple years of apprenticeship in getting them up to speed.

 

[pgg]

FYI- This has been done for years in the military. For years their have been flight surgeons and general medical officers doing primary care duties with only internship training. I do not see this as far off from that model.

I think there's a world of difference between a new med school grad and someone with just a year of internship.

Also ... the military GMO model works, mostly, because the patient population is extraordinarily healthy and pre-screened, and there is easy referral (most of the time). Even so, the military gets heavily criticized for sending interns out to practice independently. A growing number of states won't even license physicians with less than two years of GME.

 

[deleted171991]

FYI- This has been done for years in the military. For years their have been flight surgeons and general medical officers doing primary care duties with only internship training. I do not see this as far off from that model. I am on the side of fully trained competent(as judged by the ABIM or Family medicine board)physicians taking care of patients. PA's often work their first couple of years as understudies of the physician they are working for so their is a couple years of apprenticeship in getting them up to speed.

Except that most members of the active military are pretty healthy people, and their problems are minor.

It's the same as saying that because military CRNAs do great on the battlefield we should allow them to anesthetize ASA 4 patients alone.

 

[SinghDoc]

Ideally, everyone who wanted a residency would be able to get one. My wife has passed USMLE Steps I, II, IICS, and III while I did my training, sadly, no interviews for her for 3 application cycles (wife is IMG). I'm from a rural area and I'd rather have her be my primary care doctor than a new PA or NP graduate. The number of US grads not getting a residency position is rising every year--holding these guys back from practicing is unfair in my opinion.

 

[aneftp]

Except that most members of the active military are pretty healthy people, and their problems are minor.

It's the same as saying that because military CRNAs do great on the battlefield we should allow them to anesthetize ASA 4 patients alone.

Don't forget military medical personnel are protected by tort Laws.

It's next to impossible to sue for medical malpractice in the military.

So they can get away with a lot.

 

[deleted171991]

Ideally, everyone who wanted a residency would be able to get one. My wife has passed USMLE Steps I, II, IICS, and III while I did my training, sadly, no interviews for her for 3 application cycles (wife is IMG). I'm from a rural area and I'd rather have her be my primary care doctor than a new PA or NP graduate. The number of US grads not getting a residency position is rising every year--holding these guys back from practicing is unfair in my opinion.

I don't want to be/sound rude, but I honestly don't think that MDs with more than one score under 200-210 should practice medicine. They should be reclassified as PAs, because that's exactly their knowledge level, and that's where it will be even after residency. I have seen people like this, and even the best residency will not teach them the missing fundamentals. (Plus the relatively low IQ can only get lower with age.) I always love how they define themselves as "bad test-takers"; it's never their fault.

Many times, these people end up being trained in intelectually demanding primary-care specialties and bad residency programs, and become the reason why patients cannot see the difference between doctors and midlevels.

Same goes for the ****ty board-certification industry, which allows 80-90% of the candidates to become board-certified. Not everybody should be a "winner"; real life is not the Olympics, and showing up should not be enough to define success.

 

[pgg]

Don't forget military medical personnel are protected by tort Laws.

It's next to impossible to sue for medical malpractice in the military.

So they can get away with a lot.

The large majority of patients treated at military hospitals are family members and retirees. Feres Doctrine doesn't prevent them from suing.

 

[nimbus]

Speaking of military medicine.......

http://mobile.nytimes.com/2014/06/2...-pattern-of-errors-but-not-scrutiny.html?_r=0

 

[aneftp]

The large majority of patients treated at military hospitals are family members and retirees. Feres Doctrine doesn't prevent them from suing.

Still very hard to sue individual providers.

They are entities of the US government.

Like trying to sue VA doctors.

 

[pgg]

Still very hard to sue individual providers.

They are entities of the US government.

Like trying to sue VA doctors.

Can't say I care that it's hard to sue the individuals. It's not a personal vendetta. And the fed goverment has deep pockets, and pays out dollars that spend just as good as if they came from the individual's malpractice carrier.

 

[DermViser]

I don't want to be/sound rude, but I honestly don't think that MDs with more than one score under 200-210 should practice medicine. They should be reclassified as PAs, because that's exactly their knowledge level, and that's where it will be even after residency. I have seen people like this, and even the best residency will not teach them the missing fundamentals. (Plus the relatively low IQ can only get lower with age.) I always love how they define themselves as "bad test-takers"; it's never their fault.

 

[aneftp]

Can't say I care that it's hard to sue the individuals. It's not a personal vendetta. And the fed goverment has deep pockets, and pays out dollars that spend just as good as if they came from the individual's malpractice carrier.

It's not just the individual. It's the fact the government is involved. Malpractice lawyers hate trying to sue the government.

Ask yourself why VA docs do less procedures. Do less surgery? See less patients. Order less tests?

It's not just laziness on part of the VA doc's part. It's that they also don't practice defensive medicine. Because they know they can't be sued. But the government doesn't push them to order more testing either because the government hospital or clinic is much less likely to be sued than a private hospital or clinic.

You gotta sue the VA at the federal level which is much more cumbersome than dealing at the State level.

Sure sometimes the VA will settle a wrongful death lawsuit for $150-300K. But you aren't going to see many of those mega jackpot lawsuit verdicts against the government

 

[narcusprince]

I don't want to be/sound rude, but I honestly don't think that MDs with more than one score under 200-210 should practice medicine. They should be reclassified as PAs, because that's exactly their knowledge level, and that's where it will be even after residency. I have seen people like this, and even the best residency will not teach them the missing fundamentals. (Plus the relatively low IQ can only get lower with age.) I always love how they define themselves as "bad test-takers"; it's never their fault.

Many times, these people end up being trained in intelectually demanding primary-care specialties and bad residency programs, and become the reason why patients cannot see the difference between doctors and midlevels.

Same goes for the ****ty board-certification industry, which allows 80-90% of the candidates to become board-certified. Not everybody should be a "winner"; real life is not the Olympics, and showing up should not be enough to define success.

I do agree with you my friend about some of the graduates I have met in other specialities having severe patient harming lack of knowledge. I agree with you especially on Step I and II most people blow off step III and take it with a week of studying post internship.
In my former life I dated a family medicine resident and she was one of those people you have discussed nice woman. Terrible I mean terrible board history. Multiple failures on COMLEX I and II and III and failures on exams during medical school. The reality is many of these folks are too far invested in their training financially before the real brick wall comes up board certification. She attended a DO school that did everything to try and make her pass instead of giving her a reality check and letting her find another career. Medical school is expensive and trying to pay back tons of student loans at a greatily reduced salary is difficult. Cost benefit analysis should be made IE How much cost in harm would DR X make vs Loan forgivness to allow medical student X to persue another road. They need to have an effective exit strategy devoid of ridicule and praised for their insight in finding another career.

 

[pgg]

I don't want to be/sound rude, but I honestly don't think that MDs with more than one score under 200-210 should practice medicine. They should be reclassified as PAs, because that's exactly their knowledge level, and that's where it will be even after residency. I have seen people like this, and even the best residency will not teach them the missing fundamentals. (Plus the relatively low IQ can only get lower with age.) I always love how they define themselves as "bad test-takers"; it's never their fault.

I agree with a lot of what you write and your general sentiment towards demanding quality and high standards, but this is nonsense.

Totally bizarre nonsense, at that.

The bar for "allowed to practice medicine" for the USMLE is a passing score. Which IIRC is somewhere in the 170s for each step of the USMLE. Also IIRC the mean is around 210.

You're saying that anyone with a couple scores below the mean shouldn't practice medicine? Really? You think half (or nearly half) of US allopathic medical school graduates are missing the fundamentals to practice medicine? That they have low IQs?

Nonsense.

You should back up even further. The purpose of the USMLE has always been (very explicitly I might add) to verify, via a passing score, a minimum level of knowledge to practice medicine. It was specifically not designed or intended to be used as an aptitude test to stratify test-takers. That residency programs would use the scores in this manner was obviously unavoidable, but that's not the purpose of the exam.

 

[pgg]

It's not just the individual. It's the fact the government is involved. Malpractice lawyers hate trying to sue the government.

Ask yourself why VA docs do less procedures. Do less surgery? See less patients. Order less tests?

It's not just laziness on part of the VA doc's part. It's that they also don't practice defensive medicine. Because they know they can't be sued. But the government doesn't push them to order more testing either because the government hospital or clinic is much less likely to be sued than a private hospital or clinic.

You gotta sue the VA at the federal level which is much more cumbersome than dealing at the State level.

Sure sometimes the VA will settle a wrongful death lawsuit for $150-300K. But you aren't going to see many of those mega jackpot lawsuit verdicts against the government

I don't agree with any of this.

Malpractice lawyers don't like suing the government because we have an infinite supply of lawyers on salary, and we'll defend just about everything ... even stuff that maybe oughtn't be defended. We have a tendency to NOT just settle to get the ankle-biting ambulance-chaser to go away. One of the great silver linings to government waste and inefficiency is that we'll happily blow $200K of lawyer time to avoid paying out a $100K bull**** settlement.

And you seem to be confusing the military system with the VA system. VA doctors don't enjoy any of the Feres Doctrine protection. They don't see active duty patients. (And again, 80%+ of military patients are dependents and retirees, also not subject to Feres Doctrine protection.)

We in the military looooove our malpractice situation, but not because we're "immune" to being sued. We love it because we don't pay a $premium for it and because we have that aforementioned army of lawyers on our side, and because the risk of getting tossed into the national provider database over some BS lawsuit is greatly diminished.

The VA docs do less procedures because they're non-defensive? What? That's a new interpretation of why salaried workers with no production incentive don't grind out cases. "Half the work for half the pay."

Mega jackpot lawsuit verdicts are an evil abomination by definition; again I don't see a problem with there not being very many.

 

[narcusprince]

The major issue with the VA are simple at least in my eyes. Not enough providers in key facilities a crumbiling infrastructure failing to keep up with the retirees being added to the system. The VA should farm out patients to private practice clinics if they cannot meet the need. At the one VA facility I rotated as a medical student the Anesthesia model was MD only. Plenty of great cases to go around and plenty of sick folks in the system. I would definetly work at the VA once out of the .mil.

 

[aneftp]

I don't agree with any of this.

Malpractice lawyers don't like suing the government because we have an infinite supply of lawyers on salary, and we'll defend just about everything ... even stuff that maybe oughtn't be defended. We have a tendency to NOT just settle to get the ankle-biting ambulance-chaser to go away. One of the great silver linings to government waste and inefficiency is that we'll happily blow $200K of lawyer time to avoid paying out a $100K bull**** settlement.

And you seem to be confusing the military system with the VA system. VA doctors don't enjoy any of the Feres Doctrine protection. They don't see active duty patients. (And again, 80%+ of military patients are dependents and retirees, also not subject to Feres Doctrine protection.)

We in the military looooove our malpractice situation, but not because we're "immune" to being sued. We love it because we don't pay a $premium for it and because we have that aforementioned army of lawyers on our side, and because the risk of getting tossed into the national provider database over some BS lawsuit is greatly diminished.

The VA docs do less procedures because they're non-defensive? What? That's a new interpretation of why salaried workers with no production incentive don't grind out cases. "Half the work for half the pay."

Mega jackpot lawsuit verdicts are an evil abomination by definition; again I don't see a problem with there not being very many.

Show me a mega jackpot that specifically mentions either the VA or the individual VA doctor?

There simple are not many directed at the VA. And certainly none at the VA doc. Usually the docs are dropped from lawsuit altogether unless criminal activity occurred (sexual assault being one example)

 

[deleted171991]

I agree with a lot of what you write and your general sentiment towards demanding quality and high standards, but this is nonsense.

Totally bizarre nonsense, at that.

The bar for "allowed to practice medicine" for the USMLE is a passing score. Which IIRC is somewhere in the 170s for each step of the USMLE. Also IIRC the mean is around 210.

The passing scores, in my time, used to be around 188. Now they are 192 for Step 1 and 209(!) for Step 2 CK. So the NBME felt exactly the same as I did, and raised the bar significantly for Step 2. For Step 3 it's still 190.

You're saying that anyone with a couple scores below the mean shouldn't practice medicine? Really? You think half (or nearly half) of US allopathic medical school graduates are missing the fundamentals to practice medicine? That they have low IQs?

No offense, but somebody who scores 199/199 on Steps 1 and 2 CK does not have a huge amount of knowledge. That's only about 60% of questions answered correctly. And Step 2 CK is very much a matter of logic, too, not only of pure knowledge, so IQ does matter. Also, the national mean for Step 1 is 227, with a SD of 22, meaning that 84% of the test-takers will have a score higher than 205. For Step 2 CK, the numbers are 238, and 19, meaning that 97.5% of the test-takers are above 200.

Anyway, the idea was that people who have trouble covering large amounts of material for these exams end up practicing IM, FP, Peds and other primary care specialties, where they will need an even more encyclopedic knowledge. This while the high scorers end up in many procedural "non-brainer" specialties. Isn't it ironic?

Nonsense.

You should back up even further. The purpose of the USMLE has always been (very explicitly I might add) to verify, via a passing score, a minimum level of knowledge to practice medicine. It was specifically not designed or intended to be used as an aptitude test to stratify test-takers. That residency programs would use the scores in this manner was obviously unavoidable, but that's not the purpose of the exam.

Sorry, I will not back up. See why above. Not only that, but I think that the USMLE, and similar anonymous objective national exams, should become the standard of admission to residency/fellowship etc. Not interviews, "research", CV, and other BS that was invented to make sure that certain people will get accepted in certain places. See the South Korean, the Chinese or the Soviet model. It's not surprising that all those systems excel(led) at science- and knowledge-based jobs.

 

[pgg]

The passing scores, in my time, used to be around 188. Now they are 192 for Step 1 and 209(!) for Step 2 CK. So the NBME felt exactly the same as I did, and raised the bar significantly for Step 2. For Step 3 it's still 190.

Did they really "raise the bar" or just recalibrate the numbers?

If the passing score is now 209 when it used to be 174, but the same percentage of takers fail, then the bar hasn't been raised.

No offense, but somebody who scores 199/199 on Steps 1 and 2 CK does not have a huge amount of knowledge. That's only about 60% of questions answered correctly. And Step 2 CK is very much a matter of logic, too, not only of pure knowledge, so IQ does matter. Also, the national mean for Step 1 is 227, with a SD of 22, meaning that 84% of the test-takers will have a score higher than 205. For Step 2 CK, the numbers are 238, and 19, meaning that 97.5% of the test-takers are above 200.

So what's your argument? That the USMLE should fail more people?

Anyway, the idea was that people who have trouble covering large amounts of material for these exams end up practicing IM, FP, Peds and other primary care specialties, where they will need an even more encyclopedic knowledge. This while the high scorers end up in many procedural "non-brainer" specialties. Isn't it ironic?

It is kind of ironic. But that's an indictment of a culture / healthcare system (that value$ procedures over primary care), not the examination and licensing system.

Maybe, just maybe, the USMLE is exactly what it is designed to be, and what its makers claim it is: a test to ascertain whether or not takers possess the minimum knowledge level to obtain a license to practice medicine, and not a tool to be used to stratify new grads into "smart enough for ENT" vs "too dumb for pediatrics" ...

Sorry, I will not back up. See why above. Not only that, but I think that the USMLE, and similar anonymous objective national exams, should become the standard of admission to residency/fellowship etc. Not interviews, "research", CV, and other BS that was invented to make sure that certain people will get accepted in certain places. See the South Korean, the Chinese or the Soviet model. It's not surprising that all those systems excel(led) at science- and knowledge-based jobs.

Why don't we just let the individual programs decide what they want to use as metrics? They'll get who they get, and their programs will flourish or flounder based on who they recruit and who they admit. USMLE scores weigh heavily in that process already.