A thought on solving the PA/DNP & physician autonomy problem

[ijn]

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You seem like a M3 from your posts (maybe M2) so your knowledge base at this point is very very limited. No need for me to write much further.

However I suggest you seek out some 3rd year residents going into a primary care type field (peds, IM, FM, even EM) and ask them if they feel prepared to do all that outpatient primary care entails. Hate to break it to you but patients aren't all 50 yo presenting for 6 month well controlled htn follow-up and that's it... they are 70 yo have htn, ckd stage II, asthma, DM, CAD s/p DES x2, afib, OSA, etc etc etc and they are complaining about SOB, mild pedal edema, and bloody stools and you find their BP to be 145/95 and they insist they are compliant with all their meds... what's the next step? oh yeah well I guess in your mind just increase their HTN meds and they're fine... Suffice to say you simply have no idea what you are talking about.

you can't even see it coming lol. this is why you're going to fail. the united states doesn't need perfect care for some who are able to afford it. we need "good enough" care for everyone. the latter also happens to be much more affordable in the long run. PAs are perfectly able to provide that care.

 

[JShephard]

I think the ones who should be worried about computers are the midlevels and not physicians. Why in the world would you replace the physician before the midlevel? That makes no sense. If a computer increases the productivity of a physician (i.e. the current midlevel's job) then the one who will be replaced is the midlevel.

Only 1 reason.

$

Why do doctors command the salary we do? Training time and cost of replacement. If some midlevels can simpler jobs and get paid half, then less physicians will be needed. It's simple.

If physician salaries are no longer double or triple midlevels, then yes - the physician stays. It's economics.

you can't even see it coming lol. this is why you're going to fail. the united states doesn't need perfect care for some who are able to afford it. we need "good enough" care for everyone. the latter also happens to be much more affordable in the long run. PAs are perfectly able to provide that care.

He gets it.

This is right. Everyone needs to understand that the US just wants good enough care - that's why all these studies about better outcomes doesn't matter much. The gov't just wants to limit terrible outcomes - everything in between terrible and awesome is sufficient. Don't believe it? Look at any government service and tell me if they are exceptional.

In the eyes of the government, cheap good healthcare is better than exceptional expensive healthcare.

 

[duckie99]

Only 1 reason.

$

Why do doctors command the salary we do? Training time and cost of replacement. If some midlevels can simpler jobs and get paid half, then less physicians will be needed. It's simple.

If physician salaries are no longer double or triple midlevels, then yes - the physician stays. It's economics.

the point is that a computer cannot do a physician's job but it can do a midlevel's job. So money would only come into play if a computer could do a physician's job. "Human" jobs are replaced by technology in order of those that require the lesser skills/knowledge. For example, technology has replaced the needs for manual labor in some sectors of farming but the farmer is still necessary. Same analogy can be done for your scenario (one I don't see coming for a very very long time - likely not in any of ours, children's, or even grandchildren's lifetimes). A physician will still be necessary but the midlevel would not.

 

[JShephard]

the point is that a computer cannot do a physician's job but it can do a midlevel's job. So money would only come into play if a computer could do a physician's job. "Human" jobs are replaced by technology in order of those that require the lesser skills/knowledge. For example, technology has replaced the needs for manual labor in some sectors of farming but the farmer is still necessary. Same analogy can be done for your scenario (one I don't see coming for a very very long time - likely not in any of ours, children's, or even grandchildren's lifetimes). A physician will still be necessary but the midlevel would not.

The difference is the computer doesn't see the patient, give the patient drugs, talk to the patient, etc. Then what you're saying would be true. In manufacturing, the computer replaced the entire job of the manufacturer. In this case, the computer is leveraging the knowledge and thinking (diagnostics) of the physician. There are many activities the computer will not be able to do (physical exams, data gathering, etc.) but those aren't really sophisticated jobs - that's why I say the role of the midlevel is yet to increase.

I honestly think the midlevels have a strong position - for 2 years of training, it's a solid deal. Physicians will be fine in MOST fields, but we really need to think ahead and adapt as a team to do well in the future. If physician don't work together, their influence will diminish.

 

[duckie99]

PAs are perfectly able to provide that care.

Have you ever met a PA? seen a PA student? They could not handle the scenario I described like a good physician could and the patient would suffer as a result. Anyway you're just an ignorant M3/M2 and don't know what you are talking about (others who read this note how he did not reply to the scenario -- because he has no idea what he would do).

 

[duckie99]

In this case, the computer is leveraging the knowledge and thinking (diagnostics) of the physician. There are many activities the computer will not be able to do (physical exams, data gathering, etc.) but those aren't really sophisticated jobs - that's why I say the role of the midlevel is yet to increase.

The aspects of patient interaction you dismiss are actually the most sophisticated aspects of the entire process. Then you need to use critical thinking (something that cannot be programed) to figure out the next best step. You aren't the only one to think like you do. It takes a lot of experience to begin to understand what so many new students easily dismiss. I'm not saying I have that experience (M4 with only 1 rotation left) but I do have the know-how to understand it is far more complicated than I gave it credit for initially.

 

[ijn]

Have you ever met a PA? seen a PA student? They could not handle the scenario I described like a good physician could and the patient would suffer as a result. Anyway you're just an ignorant M3/M2 and don't know what you are talking about (others who read this note how he did not reply to the scenario -- because he has no idea what he would do).

the delusion is great with this one. go look up how many americans who could benefit aren't even on a single blood pressure medicine. or baby aspirin when they need to be on it. simple **** like that will improve national outcomes vastly and can be provided by PAs. ****, in terms of dollar value for outcome diabetic educators are worth twenty MDs. and they didn't waste 7 years of their life in school learning how to click the HA1C check box on the lab request form. family medicine isn't an intellectually challenging field. that's why the kids who barely pass step 1 end up in it (and not by choice). i'd trust a PA as much as the kid who ranked in the bottom 5% of his class and skated past the finish line a 188 after failing once or twice. maybe you haven't spent much time with the 188s of your class. you should try it some time.

 

[notbobtrustme]

Look at any government service and tell me if they are exceptional.

People have no idea of the scale the government works on. Everyone's favorite punching bag, the DMV, handles the registration and licensing of over 150 million drivers and 300 million vehicles. I can't even get the cable guy to show up on time and you expect these kinds of people to handle hundreds of millions of customers? The biggest reason why the government is the punching bag is because everyone has to deal with the government. If I don't want cable, I have alternatives (Hulu/Youtube/cut the cord), but if I want to drive a car legally, I have to deal with the DMV.

 

[duckie99]

the delusion is great with this one. go look up how many americans who could benefit aren't even on a single blood pressure medicine. or baby aspirin when they need to be on it. simple **** like that will improve national outcomes vastly and can be provided by PAs. ****, in terms of dollar value for outcome diabetic educators are worth twenty MDs. and they didn't waste 7 years of their life in school learning how to click the HA1C check box on the lab request form. family medicine isn't an intellectually challenging field. that's why the kids who barely pass step 1 end up in it (and not by choice). i'd trust a PA as much as the kid who ranked in the bottom 5% of his class and skated past the finish line a 188 after failing once or twice. maybe you haven't spent much time with the 188s of your class. you should try it some time.

There's no need to justify you further. Go back to your room and masturbate to thoughts of how great and awesome you are.

But when you do have an answer to my scenario I'd be happy to hear it. Can't wait to have students like you under my control in July. Will hammer your evals very hard (and if you don't send one to me I'll be sure to let the attending know to give you a poor eval). Thing is you think you can hide these thoughts... but you can't. It comes out eventually.

 

[ijn]

There's no need to justify you further. Go back to your room and masturbate to thoughts of how great and awesome you are.

But when you do have an answer to my scenario I'd be happy to hear it. Can't wait to have students like you under my power in July. Will hammer your evals very hard (and if you don't send one to me I'll be sure to let the attending know).

lol what a fail school. interns writing medical student evaluations? talk about the blind leading the blind.

 

[ivfmd]

I'm learning more on this site than I had expected. Pretty fun.

There are a lot of ideas that come up, but if I may, let me offer some food for thought.

Bear in mind that there is relatively little value in convincing each other on this forum. Why? Well, because we each have very little direct effect on the each other's futures. It would be different if we were up here making our case to those who actually can affect our future. For those in the highly bureaucratized fields of medicine, (which is probably >80% of medicine and getting more and more), they would be better served trying to convince the politicians and bureaucrats to value them more and pay more for their services. For those in free market fields of medicine, we would be better served trying to convince potential patients to value us more and pay us more for our services.

Those who are of the opinion that medicine is so complex that doctors in IM will still command a high value in the next few decades have every right to hold that opinion. Whether they succeed or fail in convincing the others on this forum, while fun in a "let's keep score in our debates" sort of way, does little to change the future. The future of medicine will play out based on the whims of a few elite people in the Capitol who have a monopoly on dictating the law of the land. So those of you who believe that IM doctors won't suffer greatly in the future (and yes, I can totally understand why you would WANT to believe that), can hold tightly to that belief. And if your predictions turn out to be accurate, then you have a fun life ahead, earning good money and doing a job that you love. If however, it turns out that the politicians in power make decision based on their own best interests and not on doctors' best interests, and if those decisions end up putting intense price pressure on IM / primary care doctors, then it is what it is, or rather it will be what it will be.

As a med student, it's not too late. There is still time to make decisions. The decision that you make will have a great impact on your future happiness. Do your due diligence. Gather as much information as you can. Keep your mind open to opposing viewpoints and analyze them with the evidence of your eyes and ears and common sense before blindly embracing them nor blindly rejecting them.

I no longer have any personal motive for the rules to change from a professional viewpoint. I'm extremely content with my career choices up to now. By the way, I will confess, they may not so much have been active intelligent choices, so much as randomly being in the right place at the right time and having stumbled down the right path at the right time and chance meeting the right mentors at the right time. But while I am ecstatic with how the state of medicine is for me in the role of a doctor, I am NOT content with how it is for me in the role of a future patient and as someone who has elderly parents who will be future patients. I'm also not content as someone who lives in this country and therefore will be affected greatly by how the economy of this country veers, knowing full well that healthcare policies will greatly affect the economy.

In any case, I thank all of you for your input. I lend as much credence to the opinions of premeds as of attendings and judge more on the content and substance rather than from whom those views came. If you believe something, show based on what we know about the real world, how reality supports your position. Thanks again! This is enlightening.

 

[ijn]

Thing is you think you can hide these thoughts... but you can't. It comes out eventually.

bro, i gots honors in fm, im, surg, peds. just psych and ob to go, which are jokes. i can hide these thoughts just fine. my evals are great. even from the former 188s who ended up doing primary care because they had to. 😉

 

[xenotype]

Those who are of the opinion that medicine is so complex that doctors in IM will still command a high value in the next few decades have every right to hold that opinion. Whether they succeed or fail in convincing the others on this forum, while fun in a "let's keep score in our debates" sort of way, does little to change the future. The future of medicine will play out based on the whims of a few elite people in the Capitol who have a monopoly on dictating the law of the land. So those of you who believe that IM doctors won't suffer greatly in the future (and yes, I can totally understand why you would WANT to believe that), can hold tightly to that belief. And if your predictions turn out to be accurate, then you have a fun life ahead, earning good money and doing a job that you love. If however, it turns out that the politicians in power make decision based on their own best interests and not on doctors' best interests, and if those decisions end up putting intense price pressure on IM / primary care doctors, then it is what it is, or rather it will be what it will be.

The battle will be fought in state legislatures and in courtrooms, not in the capital. It will also be fought between and within individual hospital systems. Federal politics does not have a lot to do with the expansion of midlevels now that the ACA is passed and judged. For the record, I think you are right. It'll be intense price pressure, but MDs will still be preferred as the market gradually becomes saturated. The key is to figure out how to dump student loans as quickly as possible, and be prepared for lots of political infighting soon to come in hospital medical staff.

 

[JShephard]

People have no idea of the scale the government works on. Everyone's favorite punching bag, the DMV, handles the registration and licensing of over 150 million drivers and 300 million vehicles. I can't even get the cable guy to show up on time and you expect these kinds of people to handle hundreds of millions of customers? The biggest reason why the government is the punching bag is because everyone has to deal with the government. If I don't want cable, I have alternatives (Hulu/Youtube/cut the cord), but if I want to drive a car legally, I have to deal with the DMV.

I like the post office example. Because both the government and UPS or Fed Ex offer similar services. The private market is much better. We've never seen a private industry that competes against the government's DMV backed with the finances of the government. Back to the post office, they are losing TONS of money. Google it.

 

[xenotype]

I like the post office example. Because both the government and UPS or Fed Ex offer similar services. The private market is much better. We've never seen a private industry that competes against the government's DMV backed with the finances of the government. Back to the post office, they are losing TONS of money. Google it.

They are losing TONS of money because the government has forced them to fully fund pensions ahead of time in a manner that no other government entity or even corporate entity is required to do.

 

[Kaputt]

bro, i gots honors in fm, im, surg, peds. just psych and ob to go, which are jokes. i can hide these thoughts just fine. my evals are great. even from the former 188s who ended up doing primary care because they had to. 😉

Hello Britta Perry, nice explanabrag.

 

[Wilf]

That last line of your argument is a serious insult to many professions, as well as a condescending and ignorant remark. That fallacy in itself should make others question your entire response...

Please get over yourself.

 

[yehhhboiii]

I like the post office example. Because both the government and UPS or Fed Ex offer similar services. The private market is much better. We've never seen a private industry that competes against the government's DMV backed with the finances of the government. Back to the post office, they are losing TONS of money. Google it.

UPS and Fedex aren't comparable to the USPS. It's easy to be profitable when you only transport packages and don't have to provide service to Kotzebue, Alaska.

 

[ivfmd]

They are losing TONS of money because the government has forced them to fully fund pensions ahead of time in a manner that no other government entity or even corporate entity is required to do.

I know this is getting off topic, but this fallacy (or truth?) sounds fascinating.

In your opinion, if this prepayment of pensions were completely eliminated and the post office received no taxpayer subsidies at all, how profitable do you think they would be? In the black? Or would they only be running a small deficit? Or would they still be running a huge deficit, as they currently are?

 

[notbobtrustme]

I know this is getting off topic, but this fallacy (or truth?) sounds fascinating.

In your opinion, if this prepayment of pensions were completely eliminated and the post office received no taxpayer subsidies at all, how profitable do you think they would be? In the black? Or would they only be running a small deficit? Or would they still be running a huge deficit, as they currently are?

Is the Post Office comparable to a private entity? If a private entity doesn't want to provide service to Podunk, Alaska, they can cut that route and say "**** you" to those residents. The Post Office doesn't have that luxury. The Post Office is a service, not a business. It shouldn't be run like a business because that would entail disenfranchisement of hundreds, if not thousands, of counties. Delivering mail to a small town of 100 people is in no way feasible, but does perform a vital, necessary service to those 100 people. If FedEx/UPS had to deliver to that same town, the rates would be extraordinarily high to the point where it would be out of reach for most people.


And yes, the Post Office has been forced to overpay into it's pension as per Congressional Acts.

I like the post office example. Because both the government and UPS or Fed Ex offer similar services. The private market is much better. We've never seen a private industry that competes against the government's DMV backed with the finances of the government. Back to the post office, they are losing TONS of money. Google it.

Do we want the private sector to handle the DMV? I mean, set aside the logistical difficulties of setting up a free market, the private sector has shown itself to be pretty incompetent when it comes to matters of personal data. Just about every other week there's a release saying that such and such thousands of accounts have been compromised.

Secondly, the private sector isn't required, by law, to service every single township, county and village in the country while the DMV has some pretty strict requirements to be readily accessibly by most persons. Again, the private sector has no incentive to establish a reachable DMV for that town of 100, and if left to their own devices, that small town has a significant hurdle to register their vehicle.

The problem is that the narrative that the government has to be run like a business has taken a stranglehold of America. The government is nothing like the private market because it has to provide service to hundreds of millions of citizens and do so in an equitable manner.

 

[ivfmd]

Again, the private sector has no incentive to establish a reachable DMV for that town of 100, and if left to their own devices, that small town has a significant hurdle to register their vehicle.

Let's think outside the box again. Imagine a friendly town of let's say 1000 people doing their own thing. There are 1000 cars being driven by the residents there. They are 50 miles from the nearest DMV.

So my first question would be "So what?"

To which you would reply, "They have a hurdle to register their vehicle"

In the absence of an artificially-created bureaucracy, would their natural lives be any worse by not being able to go somewhere and pay a fee to get a colorful flat piece of metal to adorn their car with?

 

[JShephard]

UPS and Fedex aren't comparable to the USPS. It's easy to be profitable when you only transport packages and don't have to provide service to Kotzebue, Alaska.

They are losing TONS of money because the government has forced them to fully fund pensions ahead of time in a manner that no other government entity or even corporate entity is required to do.

So how would you rate the post office on a scale of 1-10 on being profitable and achieving excpetional level of service and quality. Let's say a company like Google or Apple or whoever you think is doing very well, is a 10 or a 9 on profitability / efficiency / level of excellence... where is the post office?

Pensions is an excuse. I've walked into a grumpy, slow, inefficient, unhappy, rude post office many times in my life. It's amazing what you can get away with when there are no alternatives. Which goes back to medical educaiton - it's slow because it's there are no other options - no one can sit Step 1 and apply for residency unless they go through one of the approved schools.

the delusion is great with this one. go look up how many americans who could benefit aren't even on a single blood pressure medicine. or baby aspirin when they need to be on it. simple **** like that will improve national outcomes vastly and can be provided by PAs. ****, in terms of dollar value for outcome diabetic educators are worth twenty MDs. and they didn't waste 7 years of their life in school learning how to click the HA1C check box on the lab request form. family medicine isn't an intellectually challenging field. that's why the kids who barely pass step 1 end up in it (and not by choice). i'd trust a PA as much as the kid who ranked in the bottom 5% of his class and skated past the finish line a 188 after failing once or twice. maybe you haven't spent much time with the 188s of your class. you should try it some time.

+1 - There are plenty of people with MDs who are less competent than some PAs. We have more education, and many MDs are smarter - but I wouldn't go around saying every MD is superior at primary care than every PA. There are some really great PAs and some terrible MDs. Experience, passion, and life long learning all play a big role and have little to do with your degree.

Is the Post Office comparable to a private entity? If a private entity doesn't want to provide service to Podunk, Alaska, they can cut that route and say "**** you" to those residents. The Post Office doesn't have that luxury. The Post Office is a service, not a business. It shouldn't be run like a business because that would entail disenfranchisement of hundreds, if not thousands, of counties. Delivering mail to a small town of 100 people is in no way feasible, but does perform a vital, necessary service to those 100 people. If FedEx/UPS had to deliver to that same town, the rates would be extraordinarily high to the point where it would be out of reach for most people.


And yes, the Post Office has been forced to overpay into it's pension as per Congressional Acts.



Do we want the private sector to handle the DMV? I mean, set aside the logistical difficulties of setting up a free market, the private sector has shown itself to be pretty incompetent when it comes to matters of personal data. Just about every other week there's a release saying that such and such thousands of accounts have been compromised.

Secondly, the private sector isn't required, by law, to service every single township, county and village in the country while the DMV has some pretty strict requirements to be readily accessibly by most persons. Again, the private sector has no incentive to establish a reachable DMV for that town of 100, and if left to their own devices, that small town has a significant hurdle to register their vehicle.

The problem is that the narrative that the government has to be run like a business has taken a stranglehold of America. The government is nothing like the private market because it has to provide service to hundreds of millions of citizens and do so in an equitable manner.

So basically the argument is that - the government is at a huge disadvantage because they are required to do X,Y, and Z - but they are still exceptionally run and incredibly efficient?

To my question above, how would you rate the post office on a scale of 1-10? 10 being exceptional, among the greatest ran organizations on the planet.

I'm not arguing that private sector should take over anything. I'm just asking how well the government runs its organizations, how efficient they are.

I don't think this discussion is going anywhere, because the idea is that the governmental organizations are handicaped - and this isn't even where I'm meaning to have the discussion - I'm just comparing the attitudes, efficiency, competence, customer service, capability, and professionalism in general that I've seen at great companies and @ local *whatever* (post office, DMV, court house to pay fines, etc).

 

[duckie99]

+1 - There are plenty of people with MDs who are less competent than some PAs. We have more education, and many MDs are smarter - but I wouldn't go around saying every MD is superior at primary care than every PA. There are some really great PAs and some terrible MDs. Experience, passion, and life long learning all play a big role and have little to do with your degree.

dude don't "+1" that guy. What you said and what he said are completely different. His point is that primary care is just checking off boxes and is very easy (even when his lack of knowledge is very evident because he cannot answer my simple question I posed earlier lol).

 

[JShephard]

Let's think outside the box again. Imagine a friendly town of let's say 1000 people doing their own thing. There are 1000 cars being driven by the residents there. They are 50 miles from the nearest DMV.

So my first question would be "So what?"

To which you would reply, "They have a hurdle to register their vehicle"

In the absence of an artificially-created bureaucracy, would their natural lives be any worse by not being able to go somewhere and pay a fee to get a colorful flat piece of metal to adorn their car with?

Which is a great point - a lot of the handicaps that people are mentioning are SELF IMPOSED.

We will all be complaining or not happy with all the government hoops and bureaucracy involved in medicine, it's in fact many physicians #1 problem with healthcare - government getting overly involved... well, that's self imposed - the government creates the hoops.

How about our tax code. Someone please explain how this is efficient, exceptional or based anyway in common sense... it's not. It's built to be difficult, create winners and losers, and to allow the informed to find loopholes. Our tax code is a big joke. And it's self imposed.

dude don't "+1" that guy. What you said and what he said are completely different. His point is that primary care is just checking off boxes and is very easy (even when his lack of knowledge is very evident because he cannot answer my simple question I posed earlier lol).

I didn't read it carefully - My post displays my opinion on the topic.

Anyway, great discussion and great points by everyone.

Edit: My purpose here was to think about solutions and maybe others can think of creative ideas that can help our future and our profession. Some people on SDN are tomorrow's leaders in healthcare. So we may disagree on things like government this or that, but I hope we can focus on ideas and solutions on how to approach the future challenges. So while this is a discussion, I hope we don't get into a useless internet argument. Let's focus on solutions to the problems. Good luck.

 

[ivfmd]

JShephard is correct. He said in a slightly different way, but essentially people are driven by incentive and accountability.

When there is more accountability, people do a better job. The principle of government is that of forced involuntary interactions between people rather than consensual voluntary interactions. And as such, the incentive to go above and beyond are just not there. Over time, this accumulates. The evidence is all around us if we just open our eyes.

 

[45408]

A very unpopular opinion, I'm sure.

Why not just shut down 70-80% of medical schools? Seriously. Dead serious.

Socialized healthcare is going to go for cost-effective savings. There isn't a lot of evidence that there is a HUGE danger in using PA's/Noctors, at least in comparison to the amount of money saved with an NP serving in a primary care capacity.

So, because not too many patients will die or be harmed, we should get rid of 80% of physicians, even though we already have shortages?

With all that power they're getting--and continue to get--soon there will be too many chiefs (MD's) and not enough indians. By shutting down a lot of the med schools/converting them to nursing/PA schools we can just feed nurses/PA's into their primary care role and divorce from it entirely, then consolidate power in specialized fields that they've barely touched. It also decreases competition among MD's since the field will, over time, become less saturated.

Because it shouldn't be about power and turf, it should be about providing good care for patients.

Ask yourself this. Who is actively blocking this from happening? Who is blocking competition in the medical education sector and preserving the old school monopoly? What is their motivation for maintaining their monopoly?

I believe Perrotfish alluded to the answer.

But that's a conversation for another day.

CMS, because they're the gateway to residency funding.

 

[45408]

Lets be honest, we don't want to work that hard either. And almost no one does, when they have any choice about it: attendings are no less (or more) greedy/lazy than NPs. And there's no real evidence that we're doing ourselves or our patients any favors by working this hard accumulating a 'broad base' of knowledge. Our system of 80 hours/week residency training was created on the basis of no evidence to replace a system of practical apprenticeship (newly graduated doctors gained experience by working for senior doctors) that was working perfectly well and continues to work perfectly well in every other industry on the planet.

I enjoy time off like everyone else, but I am willing to work hard, because I think it is necessary in order to become even a halfway competent surgeon, let alone an excellent one. I would say that I'm "less lazy" than the many people who tell me "I could never do that," or "Better you than me," because they don't want to work this much. Does that make me a better person? No, that's not what I'm saying at all. We need people at every level for all kinds of jobs, including people who work very hard to become skilled at something difficult. Someone who is willing (and does) put in the work to become a surgeon is "less lazy" than someone who gets half of the education and works half of the hours.

Reasons why I don't believe that we should be working 80 hours a week for all those years:

1) I think that medical knowledge is more specific to your ultimate professional goal than most people believe. While everything helps a little, a lot of the hours that we put in as residents are designed to cram in low yield activities. For example in Peds we work 80 hours a week on the ward for six months so that future hospitalists can also cram 6 months of NICU into their residency, and so that future neonatologists can cram 6 months of hospital medicine into residency. Very few residents will actually need both skillsets to be that well developed, and they're mostly Navy physicians working on very small islands where neonates need to be airlifted to a tertiary care center with a neonatologist. I don't think that there are enough patient care benifits in accumulating a broad base of knowledge to justify the cost and sacrifice. If residency training were more specific to how we actually chose to practice we could get the necessary knowledge base in much less time. Medical school is even broader and the yield is even lower.

2) I think it perpetuates an unhealthy dichotmy between 'ready to practice' and 'not ready'. In most professions, even professions with formal licensing processes, there is a middle ground between needing to still be in school and being ready to be in charge, and in that middle ground you work as a normal salaried employee for more experienced people. A licensed professional engineer (a guy who can can legally sign off on plans for large structures, certifying that they won't collapse and kill everyone inside) graduates as an engineer from undergrad and then just works as an engineer for a decade, all while filing regular evaluations and taking occasional standardized tests, before he gets his license. If we could negotiate our salaries in the free market, and move easily between employers, I think a much better system would be for us to work 40 hour supervised weeks for 6 years than to work 80 hour supervised weeks for 3 years.

3) Finally, maybe most importantly, I think that while the long hours in residency might mike for better attendings in the short term, they make for worse doctors in the long run. The years upon years without weekends or free time at night during medical school and residency gives most attending physicians a sense of entitlement that, in the long term, means they study less, work less, and still feel less satisfied with their lives and salaries than they should. Medical education is a life long process, but when we treat the first three years as a sprint no one has the energy left to run the rest of the marathon.

1. Your examples may be relevant to pediatrics, but I do not feel that they are applicable to surgery. Could we toss a few rotations? Yes, of course, but you'd be saving a few months out of 5 years. Many surgical subspecialties practice nearly every kind of thing they do during residency. In a mega-center, you might have a shoulder orthopedic surgeon, but in many places, these guys are generalists. Their residencies were entirely relevant to their practices.

2. I see your point, but how would you really implement this in medicine? I've attended several talks and read many articles about how most surgical practices or academic centers try to mentor the junior partners and the importance of doing so. No one thinks that you come right out of residency/fellowship ready to start cranking out Whipples and esophagectomies with aplomb.

3. Seems awfully subjective. Not sure how to quantify any of that.

 

[AlmostAnMD]

So, because not too many patients will die or be harmed, we should get rid of 80% of physicians, even though we already have shortages?

I still haven't seen any hard evidence that PA/NP's in primary care can't manage patients. Everyone--yourself included--keeps blowing that "too many patients will die" horn. But here's a thought: that hasn't happened yet. In places where they have more autonomy, you haven't seen published reports of them inducing hundreds of needless deaths. That's wishful thinking. You and many others are content to sit and wait for midlevels to take more power and just keep telling yourself "Wait until they harm/kill X # of patients, then people will care". But what if that doesn't happen? Where will you be, then?

Physician shortage? That's laughable. There isn't a shortage of plastic surgeons or dermatologists or interventional cardiologists, the kinds of specialties people want to go into.

Family medicine. general internal medicine. pediatrics. Here's where there's a shortage, and 1) PA/NPs can probably do most of this with supervision (ie, you can't show me anything published that suggests otherwise) and 2) Most graduating medical students don't WANT to do FM. How many unfilled spots are there each year? That's not a "shortage", medical students don't want to do it. Close most of the med schools and let midlevels practice under an expanded scope in primary care and see what happens to your "shortage".

I don't think it's best really, myself...I think the most qualified people should be in charge of patient care. But again politicians care about saving money, and I don't think the costs are as melodramatic as you make it out to be.

 

[Perrotfish]

Nvm

 

[duckie99]

I still haven't seen any hard evidence that PA/NP's in primary care can't manage patients. Everyone--yourself included--keeps blowing that "too many patients will die" horn. But here's a thought: that hasn't happened yet. In places where they have more autonomy, you haven't seen published reports of them inducing hundreds of needless deaths. That's wishful thinking. You and many others are content to sit and wait for midlevels to take more power and just keep telling yourself "Wait until they harm/kill X # of patients, then people will care". But what if that doesn't happen? Where will you be, then?

Physician shortage? That's laughable. There isn't a shortage of plastic surgeons or dermatologists or interventional cardiologists, the kinds of specialties people want to go into.

Family medicine. general internal medicine. pediatrics. Here's where there's a shortage, and 1) PA/NPs can probably do most of this with supervision (ie, you can't show me anything published that suggests otherwise) and 2) Most graduating medical students don't WANT to do FM. How many unfilled spots are there each year? That's not a "shortage", medical students don't want to do it. Close most of the med schools and let midlevels practice under an expanded scope in primary care and see what happens to your "shortage".

1. There are not enough interventional cardiologists. There are tons and tons of places that need them. Plastics and derm are a little different because they are not "necessary" at many institutions like cardiologists are. However I assure you that wait times are extremely long for these physicians which therefore indicates there is a "shortage" of them as well.

2. There's a reason there's no "good" research comparing midlevels to physicians... because people who actually know something (real physicians who run these trials and studies and not dumb med students) understand midlevels cannot do their job. Period.

However there is also the case of getting studies like this approved. How would you structure it? Have a PA/NP vs MD in a general outpatient setting with patients totally randomized with absolutely no physician oversight of midlevel activity to even the slightest degree? And then follow multiple parameters of patient outcomes as well as economic ones? Well the problem is that this would not get through an IRB approval. You'd also have the issue of enrolling a large number of patients to see midlevels knowing that there will be absolutely no oversight to what is done. The only way to "prove" what you ask is to have it done prospectively in a manner such as this.

3. This is the last time I will say this... primary care and general medicine/peds/whatever is not easy. This sentiment is only held among med students who don't know what they don't know. There are aspects of it that are not "challenging" and can be performed by midlevels but you literally have these issues in every single field (midlevels gain access to [name that body part] on their own in surgery, harvest svg on their own in CABG, see consults on their own for surgery, see post op patients on their own for surgery, etc etc etc). Midlevels are employed for all fields and all subspecialities and they can perform adequately if well trained. Primary care is not the only field... jeez you med students here are like a freaking broken record.

4. I understand that many people here (myself included) are not pursuing primary care. That's fine. But you all need to get a reality check and start to have a healthy respect for things you do not fully understand. Point being that a trained neurosurgeon cannot do primary care. I don't care what your freaking step 1 score was or how many honors you got M3 year.

 

[sazerac]

Family medicine. general internal medicine. pediatrics. Here's where there's a shortage, and 1) PA/NPs can probably do most of this with supervision (ie, you can't show me anything published that suggests otherwise) and 2) Most graduating medical students don't WANT to do FM. How many unfilled spots are there each year? That's not a "shortage", medical students don't want to do it. Close most of the med schools and let midlevels practice under an expanded scope in primary care and see what happens to your "shortage".

What makes you think PA's and NP's want to do primary care either? Today more than half of NP's are specialized, because that is where the money is. They also prefer to work in urban environments, just like the doctors.

Closing medical schools and/or opening up more positions to midlevels will solve none of the imbalance of healthcare availability.

 

[JShephard]

1. There are not enough interventional cardiologists. There are tons and tons of places that need them. Plastics and derm are a little different because they are not "necessary" at many institutions like cardiologists are. However I assure you that wait times are extremely long for these physicians which therefore indicates there is a "shortage" of them as well.

2. There's a reason there's no "good" research comparing midlevels to physicians... because people who actually know something (real physicians who run these trials and studies and not dumb med students) understand midlevels cannot do their job. Period.

However there is also the case of getting studies like this approved. How would you structure it? Have a PA/NP vs MD in a general outpatient setting with patients totally randomized with absolutely no physician oversight of midlevel activity to even the slightest degree? And then follow multiple parameters of patient outcomes as well as economic ones? Well the problem is that this would not get through an IRB approval. You'd also have the issue of enrolling a large number of patients to see midlevels knowing that there will be absolutely no oversight to what is done. The only way to "prove" what you ask is to have it done prospectively in a manner such as this.

3. This is the last time I will say this... primary care and general medicine/peds/whatever is not easy. This sentiment is only held among med students who don't know what they don't know. There are aspects of it that are not "challenging" and can be performed by midlevels but you literally have these issues in every single field (midlevels gain access to [name that body part] on their own in surgery, harvest svg on their own in CABG, see consults on their own for surgery, see post op patients on their own for surgery, etc etc etc). Midlevels are employed for all fields and all subspecialities and they can perform adequately if well trained. Primary care is not the only field... jeez you med students here are like a freaking broken record.

4. I understand that many people here (myself included) are not pursuing primary care. That's fine. But you all need to get a reality check and start to have a healthy respect for things you do not fully understand. Point being that a trained neurosurgeon cannot do primary care. I don't care what your freaking step 1 score was or how many honors you got M3 year.

One thing to keep in mind is this is not an all or none discussion. 100% of primary care is not easy? 90%? It's not that high. To be honest, maybe 20% or even 40% is pretty easy. The same goes with Emergency medicine - is everything an emergency? No. There are 20% of cases that could easily be handled by midlevels. And that is the point - there will ALWAYS be physicians there, but we are asking how many - and whether or not the midlevels will have an increasing role. Those are big questions.

So I wouldn't brush off the idea and think, "oh, they can't do this." Instead we need to work as a team to make sure the public is educated on what is going on - and possibly leverage midlevels to help take care of more patients. What we don't want to do is what the midlevels are marketing - blurring the lines between a physician and midlevel.

The idea that we can just laugh off that they can't do our job won't be beneficial. Look at anesthesia... again, a question of "how many cases can midlevels do (what %)?" It's not about replacing the physician entirely.

 

[45408]

I still haven't seen any hard evidence that PA/NP's in primary care can't manage patients. Everyone--yourself included--keeps blowing that "too many patients will die" horn. But here's a thought: that hasn't happened yet.

Did I say too many patients will die? No.

Physician shortage? That's laughable. There isn't a shortage of plastic surgeons or dermatologists or interventional cardiologists, the kinds of specialties people want to go into.

This statement is absurd. There are shortages of quite a few necessary specialties (including my own - general surgery), and there IS a shortage of dermatologists. It takes months to get in to see one. They just happen to like it that way.

And guess what specialties the NPs and PAs want to go into? It's often the same ones that med students want to do.

That's not a "shortage", medical students don't want to do it.

Yeah, that's called a shortage...

 

[barkatthemoon]

lower labor costs is the dumbest way to lower medical costs, espically coming from medical people that i can imagine. Health care costs typically go up quite a bit annually like 7% and this is driven by technology and innovation. Over the last 15 years physicians haven't seen much increase in pay, most have seen decreases. This hasnt done anything regarding health care costs. Labor is a base cost but not playing significantly into the rate of increase.

So we get cheaper labor, costs continue rise too quickley then we don't have enough money and we make nurse aids into nurses, nurses into NP and NPs into MDs all not making any money.

 

[KnuxNole]

I still haven't seen any hard evidence that PA/NP's in primary care can't manage patients. Everyone--yourself included--keeps blowing that "too many patients will die" horn. But here's a thought: that hasn't happened yet. In places where they have more autonomy, you haven't seen published reports of them inducing hundreds of needless deaths. That's wishful thinking. You and many others are content to sit and wait for midlevels to take more power and just keep telling yourself "Wait until they harm/kill X # of patients, then people will care". But what if that doesn't happen? Where will you be, then?

Physician shortage? That's laughable. There isn't a shortage of plastic surgeons or dermatologists or interventional cardiologists, the kinds of specialties people want to go into.

Family medicine. general internal medicine. pediatrics. Here's where there's a shortage, and 1) PA/NPs can probably do most of this with supervision (ie, you can't show me anything published that suggests otherwise) and 2) Most graduating medical students don't WANT to do FM. How many unfilled spots are there each year? That's not a "shortage", medical students don't want to do it. Close most of the med schools and let midlevels practice under an expanded scope in primary care and see what happens to your "shortage".

I don't think it's best really, myself...I think the most qualified people should be in charge of patient care. But again politicians care about saving money, and I don't think the costs are as melodramatic as you make it out to be.

Just cause there isn't a shortage of those specialties doesn't mean there isn't a physician shortage. Those 3 specialties are also a TINY proportion of doctors out there anyway haha. A lot of people want to go into them, but only a small amount will actually succeed. People are correct in that NPs/PAs want to specialize too. Just cause residents and med students don't want them too doesn't mean they are gonna listen.

 

[88845]

JShephard is correct. He said in a slightly different way, but essentially people are driven by incentive and accountability.

When there is more accountability, people do a better job. The principle of government is that of forced involuntary interactions between people rather than consensual voluntary interactions. And as such, the incentive to go above and beyond are just not there. Over time, this accumulates. The evidence is all around us if we just open our eyes.

Well said.

 

[xenotype]

lower labor costs is the dumbest way to lower medical costs, espically coming from medical people that i can imagine. Health care costs typically go up quite a bit annually like 7% and this is driven by technology and innovation. Over the last 15 years physicians haven't seen much increase in pay, most have seen decreases. This hasnt done anything regarding health care costs. Labor is a base cost but not playing significantly into the rate of increase.

So we get cheaper labor, costs continue rise too quickley then we don't have enough money and we make nurse aids into nurses, nurses into NP and NPs into MDs all not making any money.

Exactly right. Physician salaries are 8.6% of healthcare spending. Replace all the MDs and you save maybe 3-4% with a huge uncertainty of increasing costs due to the inexperience of many of the midlevels. On some levels it only appears to be cheaper to use NPs, but it isn't actually cheaper. There is no substitute for residency. When they are new, they will almost certainly be ordering too many tests/referrals, and potentially harming patients. They also get paid more than residents as they start out even though their productivity is probably worse than most residents and the lack of supervision leads to more costly care.

 

[DreamingTheLive]

a very unpopular opinion, i'm sure.

Why not just shut down 70-80% of medical schools? Seriously. Dead serious.

Socialized healthcare is going to go for cost-effective savings. There isn't a lot of evidence that there is a huge danger in using pa's/noctors, at least in comparison to the amount of money saved with an np serving in a primary care capacity.

I mean, it's already happening. They're encroaching more and more, and soon they'll have quite a bit of the primary care field/anesthesiology/and probably a few other fields.

So my question is...why not give it to them?

With all that power they're getting--and continue to get--soon there will be too many chiefs (md's) and not enough indians. By shutting down a lot of the med schools/converting them to nursing/pa schools we can just feed nurses/pa's into their primary care role and divorce from it entirely, then consolidate power in specialized fields that they've barely touched. It also decreases competition among md's since the field will, over time, become less saturated.

With such a dramatic downturn in physician output, physicians that still want to pursue primary care can just manage large practices run by nurses since there won't be enough doctors to actually provide the service themselves. It puts doctors back into a supervisory role and saves the advanced specialties for just md's.

Really though. Reading all of these topics, looking about on the interwebs, i don't think we can obstruct nurses/pas from taking more power, but if we become proactive we can carve out a role for ourselves in the future rather than just be hit by it.

I mean, admissions to medical school will get even more competitive but with a smaller field of medical schools you'll have better chosen students and tuition may actually go down. We'll be encouraged to go into a subspecialty field or manage mid levels as they practice.


I was just thinking about this as i finished up a pbl class that we take with pa students. They're learning quite a bit. Not everything i am, but they're still quite knowledgeable and i feel that with basic care they'll probably do ok, especially if someone is just watching distantly. Of course there will be mistakes, but with the way the economy is going i can't see anyone overlooking the cost savings here, and this would probably save the most.

Am i really crazy? Completely alone in thinking this? Maybe. I'm just curious what other medical students/residents think.

s.t.f.u.

 

[notbobtrustme]

JShephard is correct. He said in a slightly different way, but essentially people are driven by incentive and accountability.

When there is more accountability, people do a better job. The principle of government is that of forced involuntary interactions between people rather than consensual voluntary interactions. And as such, the incentive to go above and beyond are just not there. Over time, this accumulates. The evidence is all around us if we just open our eyes.

Really? The private sector has been pretty awful at accountability. I'd rate my cable/phone/internet service just as favorably as the DMV, if not worse. Anytime I have a question on my bill, it takes anywhere from 1 hour to days to figure out. At least when I go to the Post Office, I can be in and out in less than an hour and they'll deliver my package across the US in a couple days for relatively no cost.

 

[JShephard]

Really? The private sector has been pretty awful at accountability. I'd rate my cable/phone/internet service just as favorably as the DMV, if not worse. Anytime I have a question on my bill, it takes anywhere from 1 hour to days to figure out. At least when I go to the Post Office, I can be in and out in less than an hour and they'll deliver my package across the US in a couple days for relatively no cost.

There are arguments both sides. It just comes down to personal experience - most of us that have had thorough experience with the government (i.e. worked full time jobs that have daily interaction with the gov't) could tell you that there is a BIG difference.

I'd be interested to see how you feel about gov't efficiency, excellence, thrift and "going above and beyond" type of service - after working in healthcare for 5 years.