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physician assistant or direct entry nurse practitioner
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deleted6669
PAs own the midlevel market for emergency medicine. more than 10,000 of us. we have an association with acep and serve on several of their committees, etc
NPs own the market in peds and psych but anything involving procedural medicine or inpt/acute care, go pa.
NPs own the market in peds and psych but anything involving procedural medicine or inpt/acute care, go pa.
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Thank you so much for answering. Would you say this is mainly in NY or everywhere?
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If you're in college now and you want to be a medical "provider" I'd recommend going to medical school and residency. You get better education and training, you get to take care of more interesting cases, you get to be the boss, you have more control over your work environment, and you get to make more money, usually a lot more money. I am a physician partner in a physician group. I employ mid-levels. I make a heckuva lot more money than those mid-levels and have a lot more job security. It is definitely worth the extra 5 years of training, the last 3 of which are paid at about half the salary of a midlevel. The emergency doctors often work 10 or 12 shifts a month. The PAs I know have 2 or 3 different jobs.
It is beyond me why someone who is 22 would choose a mid-level career over just going to medical school. I think the mid-level route is great for someone who has been a nurse or a medic for 5 or 10 years, now has a family, but wants to be a provider. You've got some useful experience that goes a long way, entry requirements are a bit easier and you're back in the workforce in 2 years. Sure, you have to play resident for the rest of your life, but when medical school isn't an option, you get what you get.
But if you're 22 and don't have any experience or career at all? Go to medical school. A PA or NP without significant prior experience is worse than useless, they're dangerous. We don't hire them to work in the ED at all. It isn't PA/NP school that prepares you to a supervised provider. It's too short. Sorry, that's just the way it is. What prepares you to be a supervised provider is PA/NP school plus years of prior experience.
What is the motivation to go straight from college to PA school?
1) Too lazy to train for a little longer for a career you'll have for decades (you definitely shouldn't be a provider at all)
2) Too dumb to get into medical school (maybe you shouldn't be a provider at all)
3) Worried about expense (silly because the difference in pay rapidly makes up for this)
4) Some other life issue that prevents a full 7 years of training
5) Too scared to be in charge of patient care without supervision (again, you definitely shouldn't be a provider at all)
Only # 4 is a reasonable answer, and I think there are few college students who fall into this category.
At any rate, sorry for answering the question you should have asked (maybe not since I'm perhaps mistakenly assuming you're a traditional student). The answer to your question is PA.
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deleted6669
agree with white coat:
MD/DO>PA>NP
MD/DO is the choice I should have made. my personality really suits being a doc> being a pa.
what kept me from medschool was laziness and fear of ochem. stupid reasons in retrospect.
and in answer to your 2nd post, PAs dominate em>nps in the vast majority of locations. there are a few hospitals that like nps but for every one np em job there are 10 for PAs.
MD/DO>PA>NP
MD/DO is the choice I should have made. my personality really suits being a doc> being a pa.
what kept me from medschool was laziness and fear of ochem. stupid reasons in retrospect.
and in answer to your 2nd post, PAs dominate em>nps in the vast majority of locations. there are a few hospitals that like nps but for every one np em job there are 10 for PAs.
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Wow I can not believe how much one person can assume just from me asking a question between two careers. I have 3 years of direct patient care experience and I actually plan to apply to medical schools too. NP and PA is a backup because due to competition I think it is only smart to have a back up. So no it is not because I'm lazy or dumb and I don't believe mid-levels are either
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Counterpoint to the above, as an MD.
1. A little harsh. Makes the assumption that the only valid role is "captain" and supporting roles are less worthy. I disagree.
2. Also, overly harsh. Assumes that the PA profession doesn't need really smart people, and that being a really smart and really good PA would be a waste. I disagree. Don't you want really good and smart midlevels? I do.
3. With insane medical school inflation, cost should be a consideration, especially with future MD salary uncertain under ObamaScare. Too many MDs turn a blind eye to cost and come out of med school $300,000 in debt, and end up in a low paying specialty. Now that's not smart.
4. Agree
5. Just a rehash of 1 & 2. Assumes that a midlevel by definition, is a "failed wanna-be MD" by default. Sort of like saying, "If you're a co-pilot, you must be afraid to fly, so don't bother to watch the controls at all, just get off the plane." I disagree. In fact, I really should write and entire 2,000 word post on this #5 alone, and put it on Whitecoat's call room, or KevinMD, because I'm sure it would go viral. It's a hot button issue, and I'm willing to passionately defend top notch midlevels, and midlevel education. Why? Because I appreciate a great level provider. I think MDs crapping on mid-levels is completely unacceptable, and it completely pisses me off when I see a doc do it. The expectation is that you should be as good as a doc, and if you are, you are flawed for some reason in that you didn't become one, and if not, you're a crappy PA. That's a no win situation.
I think there's lots of good reasons to become a midlevel. Less liability, shorter training, always having "backup" from an MD (or at least their license and med mal policy as back up). With all the crap we deal with as docs, sometimes I wish I became one. I call bull**** on the attitude of "You're a nobody if you didn't become and MD." Bull****.
Personally, I'm bullish on the mid level pathway. There are pro's to the con's. Don't anyone, ever feel bad for becoming an awesome midlevel. This Bird's got yo' back.
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deleted6669
Thanks Bird. I wish more docs shared your sentiments. There are still lots of docs who crap on PAs just because of the initials after our name, won't talk to a pa on the phone, etc.
To all the haters out there I would say this-
If I do something stupid, call me on it and I will own it. Don't disrespect me just because I'm not a member of your MD/DO club without knowing who I am and how I practice.
To all the haters out there I would say this-
If I do something stupid, call me on it and I will own it. Don't disrespect me just because I'm not a member of your MD/DO club without knowing who I am and how I practice.
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I don't think I "crapped on" mid-levels. Like I said, I work with good mid-levels every day. I hire them. I fire them. I've worked with great ones. I've worked with not-so-great ones. I appreciate the good ones.
Fact: It is harder to get into medical school than mid-level school. It requires better grades, higher scores, and more impressive extracurricular stuff.
Fact: You make more as a doctor than as a mid-level.
Fact: Mid-levels straight out of PA school with no prior experience require far too much supervision in the ED to be worth the effort.
Fact: You have more control over your job in emergency medicine as a doctor than as a mid-level.
Fact: A "really smart" doctor can do a lot more good than a "really smart" mid-level in the ED.
Fact: A residency-trained emergency physician, on average, provides better emergency care than a mid-level, even with a one year PA residency.
I don't really see any of those as arguable. Harsh? Perhaps. Just calling it as I see it. If you think I'm harsh on mid-levels, stop by Sermo sometime. You'd think mid-levels were the devil.
Fact: It is harder to get into medical school than mid-level school. It requires better grades, higher scores, and more impressive extracurricular stuff.
Fact: You make more as a doctor than as a mid-level.
Fact: Mid-levels straight out of PA school with no prior experience require far too much supervision in the ED to be worth the effort.
Fact: You have more control over your job in emergency medicine as a doctor than as a mid-level.
Fact: A "really smart" doctor can do a lot more good than a "really smart" mid-level in the ED.
Fact: A residency-trained emergency physician, on average, provides better emergency care than a mid-level, even with a one year PA residency.
I don't really see any of those as arguable. Harsh? Perhaps. Just calling it as I see it. If you think I'm harsh on mid-levels, stop by Sermo sometime. You'd think mid-levels were the devil.
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nvm
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The hostility comes from 2 sources:
1) Med school is brutal and so is residency. Given the amount of trauma inflicted, we psychologically need to believe that it was worth it.
2) "You don't know what you don't know" - It's easy to think that you could have been a doctor but x,y,z things made it more practical to go down another path. But you don't know what you didn't learn because you didn't do med school + residency. In areas where we aren't skilled, we vastly overestimate our performance. It's human nature and the consequence of this flaw in our perception has a far reaching impact on medical care. Nobody thinks they're bad at their job until they get good enough to realize there's another level that they're just getting glimpses of. Most APCs (95%) understand that next level exists and are fine to work with. Some don't and they're dangerous.
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OTR trucker? It's an important job, but it doesn't require too much brain power. Also, you literally get to sit on your butt all day. And if you're married but don't like your spouse, you might even enjoy the work.
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All right, lazy and dumb are loaded words I shouldn't have used. I apologize. But, let's come at this from another angle.
Let's say your goal is to work in an emergency department as a diagnostician. You want to walk into a room, take a history and examine a patient, order some tests, interpret those tests, do procedures, and arrange an appropriate disposition. What is the best way to get really good at those things? What is the best training available? Without a doubt, it is to go to medical school and residency. So if you're young, and aspire to do those things, go to medical school and residency. Is it hard? Yeah it's hard. Does it take a long time? Yea, it takes a long time. Is there some way to get that same ability with just 2 years of education taught at a lower level? No, there isn't. So if someone with their whole career ahead of them is asking me if they should go to PA/NP school or med school then I say go to medical school.
More so than most specialties, I'm not a huge fan of mid-levels in the ED. Think about it, do patients come to the ED because they want to be evaluated by a mid-level? I have yet to meet one who came asking for or expecting to be evaluated by one. Some don't mind, no doubt, but given the choice of being evaluated by someone with 2 years of training vs 7, nearly everyone will choose the physician. Especially since they're paying the same price.
So, why are there mid-levels evaluating patients in the ED (often completely independently and usually mostly independently)? There are two reasons.
1) Doctors won't come there for financial or other reasons.
2) Someone wants to make more money. It might be the hospital, it might be the physician group. They justify that a PA is "good enough for the fast track patients" or "they're being supervised" and I hope that is true, but in the end, it's all about the bottom line.
There is the opposite view, espoused by Birdstrike that mid-levels are "part of the team." The argument is basically that you just have that expensive doctor do only the things she can do. "You wouldn't use a doctor where you can use a tech or a triage nurse." And that's a valid argument. I just disagree that diagnosing and treating undifferentiated complaints is something where costs should be cut, especially when you're charging the customer several thousand dollars for a 2-4 hour visit.
Let's say your goal is to work in an emergency department as a diagnostician. You want to walk into a room, take a history and examine a patient, order some tests, interpret those tests, do procedures, and arrange an appropriate disposition. What is the best way to get really good at those things? What is the best training available? Without a doubt, it is to go to medical school and residency. So if you're young, and aspire to do those things, go to medical school and residency. Is it hard? Yeah it's hard. Does it take a long time? Yea, it takes a long time. Is there some way to get that same ability with just 2 years of education taught at a lower level? No, there isn't. So if someone with their whole career ahead of them is asking me if they should go to PA/NP school or med school then I say go to medical school.
More so than most specialties, I'm not a huge fan of mid-levels in the ED. Think about it, do patients come to the ED because they want to be evaluated by a mid-level? I have yet to meet one who came asking for or expecting to be evaluated by one. Some don't mind, no doubt, but given the choice of being evaluated by someone with 2 years of training vs 7, nearly everyone will choose the physician. Especially since they're paying the same price.
So, why are there mid-levels evaluating patients in the ED (often completely independently and usually mostly independently)? There are two reasons.
1) Doctors won't come there for financial or other reasons.
2) Someone wants to make more money. It might be the hospital, it might be the physician group. They justify that a PA is "good enough for the fast track patients" or "they're being supervised" and I hope that is true, but in the end, it's all about the bottom line.
There is the opposite view, espoused by Birdstrike that mid-levels are "part of the team." The argument is basically that you just have that expensive doctor do only the things she can do. "You wouldn't use a doctor where you can use a tech or a triage nurse." And that's a valid argument. I just disagree that diagnosing and treating undifferentiated complaints is something where costs should be cut, especially when you're charging the customer several thousand dollars for a 2-4 hour visit.
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P.S. PA/NP school isn't a "back-up." It's a completely different career. DO school, Caribbean schools, applying to 60 schools, going foreign is a back-up. You're just undecided on what you want to do as a career. I think you ought to consider medicine. You're young and motivated and apparently want to be a provider. Those are the people who should go to medical school. If you can't get in to any medical school despite doing all the prerequisites and applying broadly, I would argue you shouldn't be able to get into a mid-level school either, but perhaps that's not the case.
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As a counterpoint, I just had a chat with the PA I'm working with tonight. She also feels that PA>>NP for working in the ED, but admits she definitely wasn't ready to be in the ED after coming out of PA school (she went straight through) and had diarrhea the entire first year from the stress. She's a great PA now, but we wouldn't have hired her right out of school. She loves her career but admits she isn't the primary wage earner for her family which might have swayed things for her. She hates that the patients are always asking when the doctor is coming in, but that's probably more because she's female than that she's a PA, since my female partners all get the same thing all day long.
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Very profound, especially #1. There's so much truth there. I agree completely. I wonder myself sometimes, too: was it worth it?
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As far as White Coat Investor's viewpoint, I understand the frustration. Part of it is the lack of control many in the ED feel due to their pseudo-employee or employee status. Though WC Investor seems to have the control to hire and fire, most ER docs have little choice in these matters. You're told you have to work with certain staff, mid-levels, etc. If there is one you do not feel comfortable with, you are only one voice out of X docs, if that. The others may not want to increase their workload until a new PA is hired. One doc may not want mid-level help at all, others may want to add as many as possible.
On the other hand, if you are a solo doc or in a small group (2-3) in an outpatient practice, I think there's less frustration on this issue. If you're not happy with a mid-level, medical assistant or nurse, a pink slip is given and the 90 day termination clock starts counting down. There's less chance of being forced to put your license on the line for someone you're not comfortable with, didn't choose and cannot let go. Often, the frustration gets directed at the mid-level, if there's a sense of a lack of control.
More and more as time goes on, we as physicians are losing control over our professions and practice lives, in all specialties, though it came first and fastest to EM. This influence comes from hospital administrators, government policy makers, insurance companies, or demands from do-no-wrong "customers". It's a trend that shows no sign of slowing down.
On the other hand, if you are a solo doc or in a small group (2-3) in an outpatient practice, I think there's less frustration on this issue. If you're not happy with a mid-level, medical assistant or nurse, a pink slip is given and the 90 day termination clock starts counting down. There's less chance of being forced to put your license on the line for someone you're not comfortable with, didn't choose and cannot let go. Often, the frustration gets directed at the mid-level, if there's a sense of a lack of control.
More and more as time goes on, we as physicians are losing control over our professions and practice lives, in all specialties, though it came first and fastest to EM. This influence comes from hospital administrators, government policy makers, insurance companies, or demands from do-no-wrong "customers". It's a trend that shows no sign of slowing down.
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You quoted me, then...nvm
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What does this mean. I am confused and I am not drunk.
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Let's not forget our own greed and lack of pride in our own profession. We allowed this.
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Agree completely.
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Hey guys! i been reading this post nad i am annoyed and ashamed how high level practioners are talking bad about midlevel. i been in the military since '97 and i can say that i hold the title of "doc". why because it is the immediate care pereson that is next to the infantryman who is shot up, blown up, crying for medical care. no physician is out there no PA no one but the combat medic. and funny how the high level providers ask the low and mid level providers about the patient. moving from the battle field to the hospital the same things apply why cuz as a nurse aide i am with the patient more than the nurse and the Dr. and i am asked the question of the patient. some drs cant operate equipment that i can operate, intubate a patient, draw blood advance a catheter. i seen this. as an army medic i can do the job of a nurse and a doctor but i dont brag i observe and keep it moving. i see that high level providers are concerned about how much they can show off about how much they know instead of taking care of the patient. consumed in their degree or title. i seen it with experience. mid level providers dont do that. i seen it with my experience. and many mid level providers have bedside manners because they probably cleaned a patient's butt full of poop. i only seen one dr in my life time do that cuz he didnt forget where he came from. so this goes beyond the scope of the classroom
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Missed this initially. What part was confusing?
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I'm mixed on this.
Medical school is very hard and it's not for everyone.
Midlevel can be an excellent career for some. NPs are moving up in the world also, Psych NPs are out there earning 120k in some states (increasing too) and nurse anesthetists are earning 150k.
MD = more challenge, more rewards, more ups, more downs, more $
Midlevel = less stress, less challenge, less money, less commitment, less headaches, less thrills
Obviously, if you talk to enough people in each field they will say the opposite, but in general I think the above is true. For some people midlevel will be enough, others will want to push for the doctorate.
Medical school is very hard and it's not for everyone.
Midlevel can be an excellent career for some. NPs are moving up in the world also, Psych NPs are out there earning 120k in some states (increasing too) and nurse anesthetists are earning 150k.
MD = more challenge, more rewards, more ups, more downs, more $
Midlevel = less stress, less challenge, less money, less commitment, less headaches, less thrills
Obviously, if you talk to enough people in each field they will say the opposite, but in general I think the above is true. For some people midlevel will be enough, others will want to push for the doctorate.
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This is more of a political arena.
Your trying to look at midlevels as individual people with character traits, who laugh and cry and serve, etc.
On this forum, people speak about midlevels from a distant view, as their role in the healthcare system. No one is disparaging midlevels as people. Their role is completely different in healthcare than a physician. And NPs specifically are vying for independent practice rights in fields like anesthesia, psych, FM, derm, etc. while claiming to be the same as physicians with much less training. It's very annoying, especially when medical school is so challenging.
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I think I was drunk.
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We have midlevels. I love working with most of them. Lets be honest, brutally so.. An ED has midlevels for 1 of 2 reasons ONLY.
1) They make us money
2) We cant hire docs
I am ultra bullish on midlevels. I think their $$$ wil continue to rise. Here in AZ midlevels in the ED make more than peds and some PCPs.
Our groups uses them for #1.
Honestly, some are as smart as doctors. FWIW PA>>> NP.. NP school is like some part time bs. At least PA school is focused and IMO and experience they tend to be better providers in the ED.
1) They make us money
2) We cant hire docs
I am ultra bullish on midlevels. I think their $$$ wil continue to rise. Here in AZ midlevels in the ED make more than peds and some PCPs.
Our groups uses them for #1.
Honestly, some are as smart as doctors. FWIW PA>>> NP.. NP school is like some part time bs. At least PA school is focused and IMO and experience they tend to be better providers in the ED.
D
deleted6669
ACEP likes PAs more as well. according to a recent president of ACEP PAs are the "non-physician provider of choice in emergency medicine". (and yes, we make the docs a boatload of money-where I work the docs get 50% of the RVUs on each PA chart they sign-our joke is we buy each MD partner a BMW each and every year, because that is how much they each get as pure profit after paying all our overhead for using us instead of more md partners).
ACEP helped us design our new CAQ EM specialty exam, appoints PAs to several of their committees, and sits down with our national organization (SEMPA) on a regular basis to discuss issues of mutual interest. Their are places that use NPs in EM, but you will mostly find those are places full of docs who THINK that using NPs means no liability. Think again.
ACEP helped us design our new CAQ EM specialty exam, appoints PAs to several of their committees, and sits down with our national organization (SEMPA) on a regular basis to discuss issues of mutual interest. Their are places that use NPs in EM, but you will mostly find those are places full of docs who THINK that using NPs means no liability. Think again.
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Do PA for NY. I went to residency in NY and there was some insurance rule about billing that made PA's more financially attractive than NP's. Our group wouldn't even hire NP's as a result. As mentioned above about experience: our group required either a PA residency or work experience elsewhere prior to working in the ED.
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I also was "in the military from 1999 to 2010" and trained both PAs and independent duty corpsman. Even in the military, PAs aren't docs. IDCs aren't even close. And the person standing next to the guy getting blown up...placing tourniquets and pouring in coagulants does not a doctor make. They might call you "doc," but they don't want you managing their grandma's heart failure, removing their appendix, delivering their baby etc.
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deleted6669
Pretty sure "robomedic" is a med student who opened up a new account to troll on this forum.
