alert the Public, protect our field from the impending deception

This has been addressed multiple times in the forum (different sections) and multiple organizations like AMA and ACP are on board. I agree with you in that we have to be more united to fight this. It scary when you look at the DNP curriculum and think that this people are going to have autonomy after 1-2 years of ridiculous classes that nothing have to do with patient care.

We need to get together on this one or our jobs are going to take a serious hit economically and the government is not going to bail us out of our medical students loans!!!

I think with our current depression, the transition to the Obama administration, the financial meltdown, and with the Big 3 Auto on the verge of collapse, politicians have other things to worry about.

I think the medical profession brought this upon themselves by not having enough supply to meet the demands of the market. Medical residencies have been stagnant and will not meet this nation's demand for physicians in the future. Midlevels and the advent of the DNP will proliferate simply because the market can bear them. Why would the government stop them? They provide much needed healthcare coverage and in eyes of the government, lower quality healthcare is better for Americans than no healthcare at all.

If you want to protect your field, rather than attacking another profession, I think you should advocate strengthening your own. Personally, I think the AMA can stop hemmoraging power if they did the following:

1. Increase medical school seats to increase the proportion of doctors that are American (and will be more likely to defend the profession vocally).

or

2. Increase the amount of residencies. This would be tough to do because government funding for new slots has been stagnant. What I don't understand however, is why the ACGME doesn't allow the possibility of unfunded residencies like the AOA, where a graduate could do their training for free or pay for the training. You don't even have to open up this possibility in the specialties, just primary care.

By doing this, you allow the system to produce many more primary care MDs; while they're likely to be DO grads, USIMGs, and IMGs, you'll still bolster your ranks.

When the additional MDs and the new DNPs are pitted head to head to meet the demand for PCPs, you can bet that MDs will crush the DNPs.

Option number one is been done. School are increasing their spots and new schools are opening (I think two in FL).
Number two I dont have info on that one. With the economy the way it is rigth now i dont see the government giving more money to increase residency spots.

People, there are already nurses who have PhD's and thus are "doctors" technically. There are also pharm D and doctors of physical therapy now. I don't think this is something we can stop. Also, I have no problem with nurse practitioners per se. I think they can be a valuable part of the health care team. I do think that some of their nursing leadership (i.e. Ms Mundinger who is one of the nursing leaders involved in pushing the DNP concept) are overstating the amount of training the DNP's will get, vs. what a primary care physician gets (in terms of hours and complexity of the cases seen). I think that PA and NP's, including the DNP's, are here to stay. We physicians are going to have to prove that we have value, otherwise we might get pushed aside.

I wouldn't want to be a primary care physician right now. I'm afraid that we will see continued stagnation of reimbursement while the cost of medical school and thus the required student loans/debt keeps going up. I do, however, think that some policy makers are starting to "get it" about the importance of primary care, and some people in the general public also understand that, or at least are annoyed they can't seem to find and keep a primary physician. Whether or not these folks (policy makers and public) will value physicians vs. just using another paraprofessional to provide this care I think is an open question. I do think many patients value us (physicians) and know that we have more extensive training and they do value our judgment. They don't really have a concept of the reimbursement issues, etc. going on in medicine because most physicians right now still make a decent living, and some are quite rich (not the primary care docs, but the public still sees the derm and ortho folks driving around in their luxury cars and living in big houses, so what are they going to think but that we are all 'rich doctors'?).

There is no need for FPs and IMs to worry about DNPs. When push comes to shove and FP/IM drops out of the insurance game who do you think cash paying patients that are trying to flee the impending Obama system are going to go see? That's right, the gold standard, Physician. We are approaching the precipice of a two tiered system.

FP/IMs only need to muster up the courage to run a business like a dentist.

Has there been any studies to address the quality of care given by Physician's versus Midlevels. If the quality of care is no different than I don't see anything stopping the trend towards increasing the amount of physician assistants and nurse practicitions.

However, correct me if I am wrong, but midlevels must work underneath a physician and can't practice on their own. So, whether or not they are "Dr" they still will never be treated equal to physicians, atleast in a legal sense. Right?

Spleen said:

There is no need for FPs and IMs to worry about DNPs. When push comes to shove and FP/IM drops out of the insurance game who do you think cash paying patients that are trying to flee the impending Obama system are going to go see? That's right, the gold standard, Physician. We are approaching the precipice of a two tiered system.

FP/IMs only need to muster up the courage to run a business like a dentist.

Click to expand...

With all due respect, I don't think cash practices will make it. People don't care who they see as long as it does not cost them very much.

1. The majority of middle class medicare group can't afford cash doctors.
2. Since a at least 30% of visits can be seen by NPs or PAs (I hate to say it but it's true) most people are ok with seeing them for a large chunk of their visits.
3. That leaves the rest of the visits and the more affluent individuals. The former will see specialists or the remaining primary care docs who are happy with what they are getting (according to he merritt hawkins report at least 40% are ok with what they are getting) and the latter will go to cash doctors some of the time.

So the fantasy of a cash practice is just talk.
Come back in here and tell us how your cash practice goes when you actually DO IT.

One thing I see in here are many medical students and residents living a hope that they can do better than most attending that have been practicing for years.

Don't you think if there was a real way to go about making a 100% cash practice all the primary care docs would jump on it? Why deal with insurance if people were knocking their door down to see you for cash.

We are not that important. We are important, but that big screen TV, the new car, the mortgage and the school tuition wins.

In a bunch of states (20+?) NPs don't require supervision.

I have heard that Kaiser Permanente has decreased their hiring of NPs because the utilize too many exams when compared to FP/IM and have made themselves too expensive in that regard. I don't have a source to back this up.

If you were on an IRB would you let such a study happen? I wouldn't because the anectdotal evidence of our training is sufficient.

WnderWmn10 said:

Has there been any studies to address the quality of care given by Physician's versus Midlevels. If the quality of care is no different than I don't see anything stopping the trend towards increasing the amount of physician assistants and nurse practicitions.

However, correct me if I am wrong, but midlevels must work underneath a physician and can't practice on their own. So, whether or not they are "Dr" they still will never be treated equal to physicians, atleast in a legal sense. Right?

Click to expand...

Correction.

Many states now allow mid-levels to work independently. More states are about to pass legislation to do the same.

Is the quality the same?

What do you think? your in medical school.

Ok. I stand corrected. I just don't think I have ever seen an outpatient clinic that was completely NP/ PA run. Usually there is atleast a couple docs. Are PA's and NP required to carry the same malpractice insurance that docs do then? I sure hope so.

Quality is good question. I used to see a PA for basic healthcare stuff and she was awesome. However, I can believe the statement that NP would order more tests overall.

Hmmm.. maybe I should have been a midlevel...

Joe Richards,

Cruise these websites: www.simpd.org www.impmo.org
There you will find real examples of primary care docs who are jumping ship and doing just fine. Some are operating within the confines of insurance, others are cash only. It is being done, and physicians are flourishing. There is valid reason for medical student and resident hope. It has been done, it is being done, and will be done.

Many practicing docs haven't made the change because they haven't hit the tipping point. It takes effort to change. Some simply lack the business skills. Others don't see it worth their effort to change before they retire. One FP I've rotated with didn't want to change because he was near retirement and didn't want to fire the office staff he's come to know so well. The issues are indeed complex for why practicing docs haven't made the leap.

In response to your numbers above:
1) No, people can. A retainer physician can function for the exact same price as a pack a day smoking habit. How many poorest of the poor have you seen come up with at least that much money?
2) This argument is applicable to any specialty. A retainer practice can nix these issues. If a patient puts the money down to pay for a physician, you can bet they will use them. But under our existing fee for service it makes sense that people go to a minute clinic in an attempt to mitigate their out of pocket expenses. Existing docs need to simply change their payment methods to account for this.
3) Absolutely, most people are apathetic to who is writing their prescription. However, as more docs shift over to to these models and the tincture of time plays out people will see that their health/issues are better handled by their cohorts utilizing these physicians.

I recognize the value of my services and those of all physicians - you should, too.

Healthcare will become a two-tiered system. Primary care physicians will opt out of insurance plans and accept cash-paying patients only. Those who cannot afford it will be stuck with the doc wannabes.

-The Trifling Jester

dragonfly99 said:

People, there are already nurses who have PhD's and thus are "doctors" technically. There are also pharm D and doctors of physical therapy now. I don't think this is something we can stop.

Click to expand...

This can definitely be stopped, but will involve a lot of effort, money and legal action. In my prior profession, the profession policed its borders carefully and militarily, and the instant a paralegal or realtor or accountant tried to do something which constituted "the unauthorized practice of law" they got haled into court and sued into submission. As a result, lawyers defined their role and locked up all the meaty billing items.

Medicine could totally do the same thing, but chooses not to. It tried once -- had a long and ugly legal battle vs the chiropractors -- and ended up losing. Since then medicine has been quite gun-shy and other ancillary professionals have taken big bites out of the medicine pie. But throwing money at this problem and lawyering up could easilly stop the hemorrhaging. It's all about acting as a group, deciding what is "the practice of medicine" that no other field should be doing, and circling the wagons. If you lobby for a definition of the practice of medicine, sue any person who does something the law defines as a doctor's role, it quickly becomes impractical and unprofitable for others to test these waters, and medicine stays safe. Lobbying to the state as to who can hold themselves out as a doctor in healthcare practice also would be smart (using "doctor" for a PhD credential in the healthcare setting is misleading and technically fraud if the patient is misled to think you are a medical doctor, so this kind of activity could be eliminated with legal action).

Doctors totally have the ability to fix this. But it involves ponying up money, and a concerted action by the profession. The scary thing is that given the current shortage of physicians, and the fact that most of these non-physician healthcare providers work cheap (compared to doctors), makes insurers and politicians like the idea of throwing these nonprofessionals at the healthcare cost issue. If doctors stand quietly, they are going to see these folks rising into the roles of non-specialist physicians pretty rapidly.

Trifling Jester said:

Healthcare will become a two-tiered system. Primary care physicians will opt out of insurance plans and accept cash-paying patients only. Those who cannot afford it will be stuck with the doc wannabes.

-The Trifling Jester

Click to expand...

Nah. This only works when a couple of doctors in a community do this. But if enough doctors try to do this it quickly becomes unprofitable. The folks you read about who offer these concierge services are able to do so because there isn't much competition and so they can snap up the handful of folks willing to pay out of pocket (notwithstanding having insurance through their jobs). But the second a lot of people think this is wise, the cash paying patient base gets too thin and those docs go broke. The market of folks who are willing to pay cash for medical coverage simply isn't big enough to support many physicians in a given community. And you need a lot of patients to make such plans affordable.

Law2Doc said:

This can definitely be stopped, but will involve a lot of effort, money and legal action. In my prior profession, the profession policed its borders carefully and militarily, and the instant a paralegal or realtor or accountant tried to do something which constituted "the unauthorized practice of law" they got haled into court and sued into submission. As a result, lawyers defined their role and locked up all the meaty billing items.

Medicine could totally do the same thing, but chooses not to. It tried once -- had a long and ugly legal battle vs the chiropractors -- and ended up losing. Since then medicine has been quite gun-shy and other ancillary professionals have taken big bites out of the medicine pie. But throwing money at this problem and lawyering up could easilly stop the hemorrhaging. It's all about acting as a group, deciding what is "the practice of medicine" that no other field should be doing, and circling the wagons. If you lobby for a definition of the practice of medicine, sue any person who does something the law defines as a doctor's role, it quickly becomes impractical and unprofitable for others to test these waters, and medicine stays safe. Lobbying to the state as to who can hold themselves out as a doctor in healthcare practice also would be smart (using "doctor" for a PhD credential in the healthcare setting is misleading and technically fraud if the patient is misled to think you are a medical doctor, so this kind of activity could be eliminated with legal action).

Doctors totally have the ability to fix this. But it involves ponying up money, and a concerted action by the profession. The scary thing is that given the current shortage of physicians, and the fact that most of these non-physician healthcare providers work cheap (compared to doctors), makes insurers and politicians like the idea of throwing these nonprofessionals at the healthcare cost issue. If doctors stand quietly, they are going to see these folks rising into the roles of non-specialist physicians pretty rapidly.

Click to expand...

I like your moxie, partner.

Law2Doc said:

Medicine could totally do the same thing, but chooses not to. It tried once -- had a long and ugly legal battle vs the chiropractors -- and ended up losing. Since then medicine has been quite gun-shy and other ancillary professionals have taken big bites out of the medicine pie. But throwing money at this problem and lawyering up could easilly stop the hemorrhaging.

Click to expand...

Wow, its rare I hear from anyone other than a chiropractor who knows about this bit of medicolegal history. I typed up a long post about this and cash practices and then deleted it. I was in my final year of chiropractic school when Wilks versus the AMA was decided and personally knew one of the chiropractors in the lawsuit that was decided at the US dictrict court and upheld at the Supreme court level. I still cannot believe the chiropractors (who won) did not ask for one penny as part of the law suit but only that the AMA allow its members to associate and refer to chiropractors. What is the point of a lawsuit if you do not stand on top of and dig your heel into the financial throat of your opponant? Once again the only people who benefit from a lawsuit are the attorneys.

I also wrote up a piece of cash practices - being someone who in 16 years of owning my own business had much experience both in billing insurance and dropping all insurance literally overnight (from one month to the next) and going 100% to cash, and only seeing business grow (and whose business was already a long and successful one) - but then decided aaahhhhhhhh who cares.

Also knowing personally several independant nurse "doctors" I had a bit to say on that but who cares - they have come, they are here to stay, and most medical doctors are going to resent them, but simply take it on the chin - while wishing they could go all cash. One of the nurse doctors is in youngtown arizona, has an all cash practice dealing mostly with treating endocrine problems with bioindentical hormones and rakes the money in - firing any patient who is late or does not follow her rules.

That is part of the reason one of my classmates in Toronto , who was also a chiropractor prior to med school, dropped out of the whole medical residency game last year and went back to just acupuncture only - and is seeing roughly 50 patient visits a week, at $50 per treatment - all cash.

Regarding business consultants : both dentists and chiropractors have alot of business consultants in their fields. There really are none for medical doctors. And the ones medical doctors have are mostly about insurance billing. I mean for real.... insurance coding.

The ones chiropractors and dentists have are about how to get more cash while working less hours.

And really while the chiropractic ones were the shizznat in the late 80's and early 90's, the dental ones are the best now. Dentists are like the new chiropractors, in their ability to sell you crap you don't really need and unecessary visits/treatments. During medical school I actually saw a patient who was dropping big bucks on cosmetic dental work drop their MD managing their breast cancer care (when they only had something like 3 visits left) because they had changed insurances at the beginning of the year and now they had a $70 co-pay. I mean seriously - they dropped their CANCER doctor over something like $200, when they paid several times that out of pocket cash for elective dental care. They valued dental care more than cancer care - and the MD weakly just said "OK" - but later ranted on and on about it. The MD just took it on the chin, with no idea how to manage the situation.

A good consultant would have the MD trained with what to say in that situation - a good chiropractic consultant would. And I know sure as heck a good dental consultant would have had their clients prepared on what to say when someone wanted to back out of paying for cosmetic dentistry - a successful dentist would not just meekly say "ok". Its one reason I hate to go to dentists now - I was never dentist shy - never feared the drill - what I hate now is all the sales pitches that come with a cleaning - whitening is just the least of it. Dentists are the new chiropractors - bunch of PT Barnum salesman who try to keep you coming back forever for uneeded visits.

I agree with Law2doc. The argument against this is pretty self-evident, and I think it could be an easily made case if the AMA and other advocacy groups decide to take action.

UMED122 said:

I agree with Law2doc. The argument against this is pretty self-evident, and I think it could be an easily made case if the AMA and other advocacy groups decide to take action.

Click to expand...

You never know. the AMA and MD's in general may find their nuts again and do something like that but I think it is doubtful. As law2doc said they got "gunshy" when chiropractors spanked them in 1987, and the chiro's did not even take any money - just sort of asked them to play fairly. If the DC's had done what they should have and hit them where it hurts, I cannot even imagine how weak the AMA would be now.

If the MD's/AMA try something against nurses-and the nurses win-you can bet they will hit the AMA hard financially with a settlement. Certain personalities are drawn to certain professions and the wimpy cerebral nerdy image of MD's is not without merit. I know numerous DC's who participate in MMA (mixed martial arts) , are world class weightlifters and other athletes - but do not know any MD's who are such. Perhaps there are MD's who do such things but I have never met them - if they do "martial arts" its always some ***** martial art like tae kwon do. I doubt you will see an association led by MD's do anything siginificant about this nurse/doctor thing - they just do not have the nuts, the fire-in-the-belly needed to do it. They are not fighters - DC's and fighters, but unfortunately DC's are getting fat and lazy like MD's now.

PTs wanting to be "doctors" is fairly new - and MD's have not opposed it at all. I can remember back in the late 80's when PTs in Arkansas wanted to adjust the spine like chiropractors - the DC's crushed them. Sorry.... MD's do not have the testosterone levels needed to deal with something like this.

I think its inevitable that nurses do this - at best you can forestall them. But in reality you would not care - if you were confident in your game you would let them do it, and then just beat them at the game.

Spleen said:

Joe Richards,

Cruise these websites: www.simpd.org www.impmo.org
There you will find real examples of primary care docs who are jumping ship and doing just fine. Some are operating within the confines of insurance, others are cash only. It is being done, and physicians are flourishing. There is valid reason for medical student and resident hope. It has been done, it is being done, and will be done.

Many practicing docs haven't made the change because they haven't hit the tipping point. It takes effort to change. Some simply lack the business skills. Others don't see it worth their effort to change before they retire. One FP I've rotated with didn't want to change because he was near retirement and didn't want to fire the office staff he's come to know so well. The issues are indeed complex for why practicing docs haven't made the leap.

In response to your numbers above:
1) No, people can. A retainer physician can function for the exact same price as a pack a day smoking habit. How many poorest of the poor have you seen come up with at least that much money?
2) This argument is applicable to any specialty. A retainer practice can nix these issues. If a patient puts the money down to pay for a physician, you can bet they will use them. But under our existing fee for service it makes sense that people go to a minute clinic in an attempt to mitigate their out of pocket expenses. Existing docs need to simply change their payment methods to account for this.
3) Absolutely, most people are apathetic to who is writing their prescription. However, as more docs shift over to to these models and the tincture of time plays out people will see that their health/issues are better handled by their cohorts utilizing these physicians.

I recognize the value of my services and those of all physicians - you should, too.

Click to expand...

You inexperience is showing.

I'll say it again.

When you actually do it then preach to others about it. Until then you are just wishing and hoping it could happen.

Just because a handful of doctors are doing it does not mean it can be done in mass numbers.

By the way I don't even know if I'm talking to a medical student or a resident or some undergrad who thinks he has all the answers.

emedpa said:

a bit of clarification here-around 13 states allow np's to work independently AND rx on their own name, a few more allow independent practice but require a collaborating md to rx..
no states allow pa's to practice independently. pa's must have an association with a physician in all 50 states and territories.

Click to expand...

You're right. It's mostly NP's right now.

Law2Doc said:

This can definitely be stopped, but will involve a lot of effort, money and legal action. In my prior profession, the profession policed its borders carefully and militarily, and the instant a paralegal or realtor or accountant tried to do something which constituted "the unauthorized practice of law" they got haled into court and sued into submission. As a result, lawyers defined their role and locked up all the meaty billing items.

Medicine could totally do the same thing, but chooses not to. It tried once -- had a long and ugly legal battle vs the chiropractors -- and ended up losing. Since then medicine has been quite gun-shy and other ancillary professionals have taken big bites out of the medicine pie. But throwing money at this problem and lawyering up could easilly stop the hemorrhaging. It's all about acting as a group, deciding what is "the practice of medicine" that no other field should be doing, and circling the wagons. If you lobby for a definition of the practice of medicine, sue any person who does something the law defines as a doctor's role, it quickly becomes impractical and unprofitable for others to test these waters, and medicine stays safe. Lobbying to the state as to who can hold themselves out as a doctor in healthcare practice also would be smart (using "doctor" for a PhD credential in the healthcare setting is misleading and technically fraud if the patient is misled to think you are a medical doctor, so this kind of activity could be eliminated with legal action).

Doctors totally have the ability to fix this. But it involves ponying up money, and a concerted action by the profession. The scary thing is that given the current shortage of physicians, and the fact that most of these non-physician healthcare providers work cheap (compared to doctors), makes insurers and politicians like the idea of throwing these nonprofessionals at the healthcare cost issue. If doctors stand quietly, they are going to see these folks rising into the roles of non-specialist physicians pretty rapidly.

Click to expand...

If only the AMA hadn't traded their steel you know what for a pair of joy sticks.

Doowai said:

Regarding business consultants : both dentists and chiropractors have alot of business consultants in their fields. There really are none for medical doctors. And the ones medical doctors have are mostly about insurance billing. I mean for real.... insurance coding.

The ones chiropractors and dentists have are about how to get more cash while working less hours.

And really while the chiropractic ones were the shizznat in the late 80's and early 90's, the dental ones are the best now. Dentists are like the new chiropractors, in their ability to sell you crap you don't really need and unecessary visits/treatments. During medical school I actually saw a patient who was dropping big bucks on cosmetic dental work drop their MD managing their breast cancer care (when they only had something like 3 visits left) because they had changed insurances at the beginning of the year and now they had a $70 co-pay. I mean seriously - they dropped their CANCER doctor over something like $200, when they paid several times that out of pocket cash for elective dental care. They valued dental care more than cancer care - and the MD weakly just said "OK" - but later ranted on and on about it. The MD just took it on the chin, with no idea how to manage the situation.

A good consultant would have the MD trained with what to say in that situation - a good chiropractic consultant would. And I know sure as heck a good dental consultant would have had their clients prepared on what to say when someone wanted to back out of paying for cosmetic dentistry - a successful dentist would not just meekly say "ok". Its one reason I hate to go to dentists now - I was never dentist shy - never feared the drill - what I hate now is all the sales pitches that come with a cleaning - whitening is just the least of it. Dentists are the new chiropractors - bunch of PT Barnum salesman who try to keep you coming back forever for uneeded visits.

Click to expand...

So you are suggesting that doctors start acting like the PT Barnum salesman and car salesman?

Doowai said:

...Certain personalities are drawn to certain professions and the wimpy cerebral nerdy image of MD's is not without merit. I know numerous DC's who participate in MMA (mixed martial arts) , are world class weightlifters and other athletes - but do not know any MD's who are such. Perhaps there are MD's who do such things but I have never met them - if they do "martial arts" its always some ***** martial art like tae kwon do. I doubt you will see an association led by MD's do anything siginificant about this nurse/doctor thing - they just do not have the nuts, the fire-in-the-belly needed to do it.

Click to expand...

Well, there's Dr Rey on "Dr 90210" doing martial arts in the OR each week.

Doctors can be wimpy and cerebral but HIRE folks with some stones to protect their interests. There is no shortage of sharks in the legal and lobbyist community, folks who "play with sharp elbows" and who would be more than happy to step on any encroaching professions throat, for the right fee. All physicians have to do is say, as a group, "yes we want to do this", and up everyone's professional dues a bit to pay for it. If doctors spent the same kind of effort on this as they do on sillier things like keeping pharmaceutical pens out of hospitals, the battle would already be won.

I think the only reason the NP's are wanting to do this is because at the present time they are NOT allowed to call themselves doctor in a clinical setting due to their Phd not being medical.

They want this so they can call themselves doctor and elevate their status in the clinical setting because they don't like to admit that they are not doctors, and it helps them when they try to explain to patients that they really really really are just like doctors.

If they could call themselves doctors in the clinical setting they wouldn't go through this right now. That's all they want, they could care less about the degree or training, they just want to be able to legally call themselves doctors.

Dr. V said:

If they could call themselves doctors in the clinical setting they wouldn't go through this right now. That's all they want, they could care less about the degree or training, they just want to be able to legally call themselves doctors.

Click to expand...

You say "that's all they want" as if it's not a big deal. But that's exactly what physicians should fight. Once ancillary professionals can call themselves doctors and provide medical care, the public doesn't know the difference. Which means this is money right out of physicians pockets. This is a group of people holding themselves out as doctor, providing medical care, and for a lot less because they don't have the tuition debt, the years of training investment, etc to cover. So insurers will love it, and the public will be unaware of the distinction. The public thinks they are getting the same educated and trained "doctor" that the folks who previously called themselves doctors had, so they are really being defrauded. As I mentioned, in law there were a variety of groups trying to provide legal services over the years -- ranging from paralegals working on their own doing forms, to realtors wanting to do title documents, to accountants wanting to do a variety of tax driven legal actions. The lawyers saw this as encroachment, and sued them into submission. And it worked -- the scope of what constitutes "the practice of law" has been relatively unchanged for decades. Medicine cannot make the same statement -- there are very real encroachments going on. And it is costing people money. You might say -- no big deal, there is a shortage of doctors anyhow, or we can keep the interesting stuff and let these ancillary groups have the boring and routine office visits. But there are two problems with that. One, the shortage is currently being caused by an aging baby boomer generation, but the generation behind that one is substantially smaller and the shortage is going to rapidly disappear in not that many years. And two, erosion is a progressive thing. Today these groups want to handle routine stuff and call themselves doctors. Tomorrow, they will want to do somewhat less routine stuff. And they can do it cheaper because they don't have to go through the training and don't have some of the restrictions that physicians, rightly, have on them. It's a mistake not to fight this -- to specify that which is "the practice of medicine" and who can call themselves "doctor" in a healthcare setting. It is a big deal. If you don't head this off at the pass, it becomes very hard to put the genie back into the bottle later.

No, that's not what I am saying when I say that. Take the context of my entire post into consideration.

What I am saying is that they don't care about the patient, they don't care about their abilities or education, they don't want to be better able to care for patients. ALL they care about is being able to call themselves something they DID NOT EARN. All they want is to be called doctor, without the education, work, or professionalism that comes with it.

Yes we should fight this because they are NOT doctors and are NOT qualified to call themselves such. They want to blur the lines and convince people that they really, really, really are as good as docs. If they could call themselves doctor it would be easier for them to perpetuate this fraud on the general public.

If they want to be called doctors let them go to medical school.

Dr. V said:

No, that's not what I am saying when I say that. Take the context of my entire post into consideration.

What I am saying is that they don't care about the patient, they don't care about their abilities or education, they don't want to be better able to care for patients. ALL they care about is being able to call themselves something they DID NOT EARN. All they want is to be called doctor, without the education, work, or professionalism that comes with it.

Yes we should fight this because they are NOT doctors and are NOT qualified to call themselves such. They want to blur the lines and convince people that they really, really, really are as good as docs. If they could call themselves doctor it would be easier for them to perpetuate this fraud on the general public.

If they want to be called doctors let them go to medical school.

Click to expand...

We are in agreement. sorry I misunderstood your prior post.

As someone contemplating going into primary care to the OP for starting this thread. I am going to check out the status of DNPs in my state and see what i can do to stop this before it gets too far.

I agree with most of what has been said, and I have hard time understanding how the NPs are justifying their title of "doctor." I mean, the term doctor was, by default, reserved for medical doctorate. Now when they are coming up with the new term-doctorate of NP, what are they trying to say? The nurse doctors have equal knowledge base and competence as other "doctors?" If those few individuals that make it to DNP are so smart and hard working, why not just let them get through medical doctorate instead from the first place?

Now, what catches my interest was this statement posted by OP.

TecmoBowl said:

The reason Medicine is always "whipped" by Politicians and Lawyers is because we don't stick together.

Click to expand...

I agree with the sentiment completely. Even with the feeling I just expressed, I really don't see physicians acting strongly against this problem. I think most of medical students don't even know about this. The thing about being in medicine is that many people think they are above the political changes or are shielded from atmosphere. I guess some are thinking that they can always opt to derm/plastics. Some just don't care. Some are actually fighting among themselves within the turf of medicine (cardiothoracic surgeons vs. cardio interventionlists, anyone?). And then, lastly, but with a serious relavance, there will BE some people with MDs that will say, well, if it helps patients, why not???

Although this may be a bit exaggerated, I always felt that people in medicine are generally the more hardworking and more brilliant that other professions, generally (yes, that "generally" is an important disclaimer). However, we are always low-balled and always spanked by some extra groups, and I always thought this was because we don't stick together when someone is pushing us. Yes, I guess it is awkward to "fight back" when 99% of people repeat (truthfull or untruthfully) that they are doing this because they want to help others. Maybe we have too many elites in our groups, and everyone wants to be leaders. So no one end up being leader and everyone does his or her own thing.

I really hope this does not go unchecked. I am not interested in anestheology, but I was honestly disturbed enough as I heard things about CRNAs encroaching into the medical field already.

I agree that MDs needs to stick together as a group to fight midlevel encroahment. We need to help the PCPs in this issue, as well as the anesthesiologists/CRNAs, ophthalmologists/optometrists, psychiatrists/psychologists, PMR/PTs, OBs/midwifes, ortho/podiatrists, etc. We need a united front, enough said...especially with the upcoming administration.

With all due respect to many of the above posters:

1. Who is the "we" that should get together? Med students? Residents? Attendings? Everyone?

2. Perhaps a plan of some sort from those in the know - i.e., the attorneys and the bigwigs at the AMA, AMSA, etc.

3. If, as someone mentioned, med students really aren't aware of this - perhaps the place to begin is with med school administrations?

4. What can the average MD or MD-in-training do to fight this? Perhaps every med school specialty club should have an "anti-DNP" officer of some sort - then they can all get together and begin a lobby from the ground up.

Finally, as Law2Doc and others mentioned, the legal profession zealously guards its borders - however, I would bet most doctors, not to mention medical students, don't even realize what their borders are, since many of them don't really know what PA's/NP's do that is encroaching on their territory.

Sorry for the ramble . . . just the mind working late.

zoondel said:

Finally, as Law2Doc and others mentioned, the legal profession zealously guards its borders - however, I would bet most doctors, not to mention medical students, don't even realize what their borders are, since many of them don't really know what PA's/NP's do that is encroaching on their territory.

.

Click to expand...

I think this is a good point. I'd suspect that there is something in the law books that defines what constitutes the "practice of medicine", since there is a law against "practicing medicine without a license".

This is something that we can do, and other healthcare fields do it. As previous posters have said, Chiro does it.

In fact, nursing does it very well... and that is why they are kicking our butts.

They have recently decided that obtaining a manual blood pressure is a nursing procedure, and they no longer allow certified nursing assistants to learn how, or to take them.

There is a "Nursing Clause" in some lawbooks which makes a blanket statement that A Paramedic shall never be permitted to perfom a duty that has been traditionally performed by a nurse. And so, in those states, paramedics can not work in an emergency room, and are consistently pushed out of the interfacilty transport realm of EMS.

Nursing as also halted the Paramedic Practitioner curriculum and program, which was proposed to the governmental powers that be. Paramedic Practitioners have existed for many years in the countries that follow the British system... England, Australia...Canada? But, in the US....nurses have managed to keep them down.
Heres an article from BMJ about paramedic practitioners, just to give you an idea of what they do. http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=2048868

So, once we define what our borders are, we can police them. And, we have to stick to our guns. Weve already decided long ago that we want nothing to do with teeth, or feet... and so theres a specialty that knows, and can do just as much for the foot as a hand fellowship trained orthopedic surgeon can do for the hand. We didnt want to field calls at night, round all over the place, and do minor suturing and ortho stuff in the ED, AND hire another MD... so we have NPs and PAs.

Physician shortage? These midlevels fill the need? They dont have to. All we need to do is have more residency spots. I understand that this costs money, but look at the alternative... I would think it works itself out after a while. In the last Match, there were 25,066 seats, and 35,956 applicants. That means that 10,890 people who passed Step1 and Step2, and have an MD from someplace, were waiting in the wings. But we turned them away, because we want to hire an NP.
What happens to these 10,890 people? I know some of them, have gone to community college, and they become nurses aids, medical assistants, EKG techs, telemetry monitor techs, two of the more motivated ones I know became an RN, and an respiratory therapist. The guy who I chatted with every day as I was buying coffee from him every day before work... physician in his country. Theres a guy who owns a chinese restaurant down the block from a large teaching hospital... dermatologist. 10,890 of these people passed the USMLE Step 1 and 2, and applied for the match this year... and we gave their jobs to an NP.

It might just be me... But I think that any of them would rather do primary care in the middle of nowhere in the US, than sell coffee, or give sponge baths.

So.... there is something we can do. We just dont do it.

Those who have posted here so far seem to be ignorant of the fact that there is a massive primary care gap in this country. Health care costs are higher and higher for the consumer (otherwise known as "ill person"). Only 7% of med school grads are going into primary care, prefering to work in less demanding and higher paying fields. I am going into FM personally, and am totally unconcerned by the competition. There is a place for midlevels in primary care, and until "we" take this place for ourselves there is no sense in complaining. Most mid-levels do a great job. There are those who don't, but there are plenty of MD's who are crappy, too. Get off your high horses, stop resenting those with less debt, and do your job.

yumita said:

Those who have posted here so far seem to be ignorant of the fact that there is a massive primary care gap in this country. Health care costs are higher and higher for the consumer (otherwise known as "ill person"). Only 7% of med school grads are going into primary care, prefering to work in less demanding and higher paying fields. I am going into FM personally, and am totally unconcerned by the competition. There is a place for midlevels in primary care, and until "we" take this place for ourselves there is no sense in complaining. Most mid-levels do a great job. There are those who don't, but there are plenty of MD's who are crappy, too. Get off your high horses, stop resenting those with less debt, and do your job.

Click to expand...

Or make it possible for the 10,890 "qualified" MDs to fill the gap.

From my perspective, this isn't about MD's whining that we're the real doctors, and that DNP's are just playing make-believe and getting paid for it (despite the fact that it seems to be true.)

This is simply about taking care of ourselves. I'm not a history buff, but my sense of things is that since time immemorial, physicians have never had to worry about "defining" their profession because it was, well, pretty obvious what it was. Even when the mid-levels starting chewing at the edges, we tended not to notice because it didn't affect our income, prestige, etc. . . In addition, physicians, especially those in clinical practice, have trained far longer than mid-levels by orders of magnitude, and odds are, most work harder once in practice than the mid-levels do. It's natural that we would feel "entitled" to our title. (The lawyers, who often have worse hours than docs, deal more effectively with this because they deal with defining things every day. Most docs aren't so-minded.)

Yes, there are mid-levels who do great work. There are also incompetent physicians. That's irrelevant. The key here is that if we physicians can hang up our white coats for a minute, get our hands dirty and put up a solid fence, we'll feel more secure in the present and for the future, and we'll still have good neighborly relations with the mid-levels.

yumita said:

Those who have posted here so far seem to be ignorant of the fact that there is a massive primary care gap in this country.

Click to expand...

I think it's at least as much of a distribution problem as an actual shortage. Most doctors cluster around the nicer areas of big cities. Nurse practitioners have the same tendencies, which is one reason why this argument for allowing them free reign to practice medicine isn't very sound. I think there are some pretty obvious things we/the government can do to help alleviate the distribution problem...one of them would be to adequately fund the national health service scholarships, which pays for medical school tuition in exchange for commitment to practice primary care in an underserved area. I think there's also a place for skilled and very experienced nurse practitioners willing to practice in such areas with minimal supervision, but it should be done on a case by case basis at the discretion of the board of medicine, so that US medicine doesn't turn into the wild wild west.

agree with yumed
the primary care shortage really isn't just a "pipeline" problem. Even giving more scholarships is not going to fix the problem IMHO, because primary care is hard work and ill compensated and they have to see many, many patients/day to make ends meet in their offices in many cases. Also, they have to deal with endless reams of paperwork and hassles from insurers, and don't necessarily get respect from other docs or from some patients. also, when practicing in a rural area one tends to have little backup from specialists and other docs, so one ends up taking more call with less backup/help to deal with some of the sickest patients. Many PA's and NP's do the same thing as a lot of docs...stay in some underserved area or clinic for 2-3 years to get the loan repayment, then quit for a job with a better lifestyle and less of a hassle factor.

Ya'll know it's not truly a DNP thread until Taurus adds his two cents, right?

For those who need some background on DNP's, read my signature and follow the links.

I agree whole-heartedly with Law2Doc, Doowai, and others. For whatever reason, whether being burned by the courts a few times, our profession is eroding. We are allowing non-physicians to introduce themselves as "doctors" and letting them examine, diagnose, treat, prescribe meds to patients without any physician supervision. That's incredible. If we as a profession do not do something about it, in a few decades, the public will assume that their "doctor" could be a physician, nurse, physical therapist, pharmacist, chiroprictor, naturalist, etc. Even the title "physician" is not safe anymore. The optometrists, podiatrists, naturopathic doctors, etc want to incorporate "physician" in their titles. I agree with Law2Doc that we need to defend our professional borders zealously but smartly. We need to get involved, donate to our medical organizations, get elected into Congress (currently has 14 physicians), file lawsuits, etc.

Don't be fooled by the statements from DNP's about how they would go to the underserved areas. The NP's used the same arguments to gain prescribing powers and become autonomous. Once they achieved those things, the NP's were no more likely to move to the boonies than physicians.
Until the nurses have the same scope, pay, privileges, recognition, etc as physicians, they will never stop because we have been letting them walk all of us. First, the nurses will claim to want to do primary care only. It's foolish to think that it will stop there. Primary care is a way for them to get their foot in the door. After firmly establishing themselves in primary care, the nurses will set their sights on fields like derm, cards, GI, etc. While the health clinics have had some hiccups, they're spreading. 3.4 million American families, or 2.3%, had used a retail clinic as of 2007. That's why every physician in every specialty needs to pay attention to this problem.

If you've been reading my posts, you'll know I favor revamping the entire midlevel model. With NP's going to the DNP and even the PA's are considering a doctorate now, I think it's time for the AMA to consider changing the midlevel model from using non-physicians such as NP's and PA's to one using physicians who have not completed a residency. If a physician who hasn't completed a residency can't even get privileges at a hospital or be reimbursed by insurance carriers, then it makes sense to allow such individuals to function as midlevels. These non-residency physicians are more trained and more qualified than any DNP or PA. Furthermore, these physicians can pursue residency in the future to further their careers and become independent attendings. I think a lot of the problems we see today in medicine can be addressed by taking medicine back from non-physicians and returning it to people who actually went to medical school. I believe that expanding class sizes and opening more medical schools will create a situation where there will more med grads than residency positions. At that point, Congress will either be forced to create more residency positions or states will begin to recognize that they have a new source of medical manpower.

The AMA is responding to the DNP, but more has to be done. We need to all spread the message and make the commitment to not sell out our profession.

yumita said:

I am going into FM personally, and am totally unconcerned by the competition. There is a place for midlevels in primary care, and until "we" take this place for ourselves there is no sense in complaining. Most mid-levels do a great job. There are those who don't, but there are plenty of MD's who are crappy, too. Get off your high horses, stop resenting those with less debt, and do your job.

Click to expand...

It's this kind of thinking that drives me nuts...

Just look at how far CRNAs have gone. Seriously, take a look at this job advertisement below

http://www.merritthawkins.com/job-search/job-details.aspx?job=7583&contract=15731

The other day while i was in my ccu rotation i had a family member come an talk to me about his family member (pt hospitalized). He told me about how the "dr." did this and that about X condition been treated. At first the name of the doctor didnt sound familiar. I had to call the operator from the hospital to help me with finding who this "dr" was. After a few minutes talking to the operator from the hospital I found out that this "dr" was a PA from one of our clinics. I went back to the patient family member and explained (very politely) that this "Dr" that they talked to me about was a PA and went ahead and told them that he/she didnt go to med school and in fact didnt go through residency. The family member was confused, I think he really thought he's family member was seen a doctor because they kept calling her/him "dr". And I really think this PA doesnt introduce him/herself as a "dr" but people see the whitecoat, stethoscope and quickly think "dr".

This is just one example of many were I have encounter people calling "dr" PA's that they see in cardiology clinics etc etc.

And as Taurus says, its going to be primary care first and then they are going to reach with their tentacles into other specialties, you have already seen it with cardiologist working with PA's and different surgical specialties.

Is just a matter of time. And who has the 150K-200K student loans? is not the PA's, NP's!!! Its the freaking MD's, THATS WHY WE SHOULD FIGHT UNTIL THE END!!!

Frumps said:

It's this kind of thinking that drives me nuts...

Just look at how far CRNAs have gone. Seriously, take a look at this job advertisement below

http://www.merritthawkins.com/job-search/job-details.aspx?job=7583&contract=15731

Click to expand...

This why we need to have more states pass AA legislation and build more AA schools. CRNA's have a monopoly on the anesthesia midlevel market and they're leveraging it to increase scope and pay. CRNA's are the most militant of nursing groups with the most blatant propaganda and lies.

I am going into FM (yeah! I think ... ) and I have alot of respect for the AAFP. Now that I am reading their website and really trying to learn as much as I can about them, I realize that this 'unglamorous' area of medicine is pretty darn hardworking. "Strong Medicine for America," indeed.

Anyway. this whole NP -->"doctor" thing is ridiculous. One or two years of fluffy academic chit-chat is not the same as the seven years of rigorous training that a FM doc goes through. No flipping way. The PA's and NP's I have met who want all the glory of being a physician without the hard work it really takes are the ones who do not know their limitations and who are frankly dangerous. Mostly, because they insist they know best when in fact they know least.

The smartest ones I have met are the ones who know their limitations and are able to effectively work within the guidelines of the medical system. A nurse is not a physician. Period. I have seen (or been told of) many many situations where the nurse insisted that her/his mud puddle shallow knowledge was all that was necessary to make a diagnosis. Never mind that they did not understand the presenting symptoms or what it could be other that their very limited algorithms. Example: 52 yo M with increasing onset of lower back/hip pain, some LE neuropathy and normal labs except for increasing foaming urine at every urination. Urine dipstick is negative for protein. Otherwise healthy. NP? "I don't know what the foaming urine means, and I am sure it is nothing. The lower back pain is probably arthritis and I will refer to a PT for stretching exercises but we will do no imaging or no further evaluation of the 'foaming urine' because the dipstick was negative."

Hello? MM anyone?

NP's and PA's are good for simple things but can never replace a physician when it comes to the complexities of many patient encounters.

CRNAs are the worse of the worse, agreed there.

I think we absolutely should allow graduates of med school without residency to do midlevel work. The problem is they dont have advocates and are pressured down by the local state medical licencing boards, which is an old set of local groups to kill the competition. They have no power over the nursing boards and thus unable to control the NPs.

I predict we in the future will see a big final show down in court between physicians and nurses for the scope of practice. Bound to happen.

TecmoBowl said:

Hi,

To all Medical Students, Physicians (Residents/Attendings/Fellows), please note that the "Doctorate in Nursing" programs are forging ahead. What does this mean to you?

Basically, a nurse will be able to introduce himself/herself as "Doctor". When is the last time your patient asked you whether you were really a Doctor (unless you were a Medical Student)?

This is an impending deception, and we have to alert the public. I've emailed ABC News, and plan on e-mailing the other major News networks.

Most importantly, we need to do this in unison and en masse. The implications of this are profound if you think about it.

The reason Medicine is always "whipped" by Politicians and Lawyers is because we don't stick together. This is another assault on our field, and take the small amount of time to e-mail someone, somebody. Just make your voice be heard, that's all. You pay your taxes, make sure the Politicians earn their pay.

Click to expand...

If we had more doctors like you, the field wouldn't be in the state that it is in now. It seems that the best doctors can do these days is post complaints in anonymous forums and grieve about how bad they have it. Very few suggest solutions and even fewer take actions like you did. I am not far along my path yet, but I just wanted to thank you for being proactive. If I was a doctor, I'd try to get a bunch of my colleagues together and draft a detailed letter about the possible problems that the new system might cause and then have it signed by the best doctors in every field, as many as possible. Isn't there a non-anonymous serve list or e-mail group where you can directly address many doctors at a time? Lawyers are pretty good at having organizations like this. I hope SDN is not the best that's out there.

This is the curriculum of the DNP from Columbia Univ.:

Curriculum
Support Core 19
Translation and Synthesis of Evidence for Optimal Outcomes
Quantitative Research Methods
Epidemiology and Environmental Health
Legal and Ethical Issues
Clinical Genomics Advanced Seminar
Practice Management
Informatics
Clinical Core 11
Doctor of Nursing Practice I and II
Didactic
Clinical
Didactic and Clinical
Chronic Illness Management
Residency/Seminar 10
Total credits 40

Upon completion of all course work and field experiences (the first year), the student enters the Residency. In this mentored experience, the student assumes a mentored and supervised full time position where DNP competencies can be mastered. The DNP Residency must provide access to and authority for expanded scope practice. Students are encouraged to negotiate a paid position. The Residency must be in an approved setting which may or may not be in the New York metropolitan area. However attendance at scheduled seminars at Columbia is required during the Residency year. During the Residency year, the portfolio is developed and submitted as a required criterion for degree completion.


On a side note: there are already 50 schools that offer the DNP, and this started 4-5 years ago. How many med schools are there in the USA? So how many DNP's are we going to have in 10 years? More DNP's than MD's??

Excelsius said:

If we had more doctors like you, the field wouldn't be in the state that it is in now. It seems that the best doctors can do these days is post complaints in anonymous forums and grieve about how bad they have it. Very few suggest solutions and even fewer take actions like you did. I am not far along my path yet, but I just wanted to thank you for being proactive. If I was a doctor, I'd try to get a bunch of my colleagues together and draft a detailed letter about the possible problems that the new system might cause and then have it signed by the best doctors in every field, as many as possible. Isn't there a non-anonymous serve list or e-mail group where you can directly address many doctors at a time? Lawyers are pretty good at having organizations like this. I hope SDN is not the best that's out there.

Click to expand...

A couple of months ago in the General residency section there was a sticky that someone started that had the websites to AMA, ACP, congress etc for which we could send emails etc about this topic. I dont know where that topic is rigth now. But things have been done in the past.