AAN Video: Extenders are Doctors, "We’re the Same"

[neglect]

BLUF: The AAN lost it's way, a neurologist interviewed a NP, identified her as doctor, and told us physicians and NPs do "the exact same stuff."

As you know, there's a push for extenders to practice without supervision. This is seriously misguided. It is thought that many routine medical appointments could be handled by an extender. I think this is fair, but medicine very quickly gets complicated, so it is a very modest recommendation to have physician oversight. The NP's think this is just a game to prevent them from making big bucks (not realizing that they will be employed then used and abused by huge medical systems), having had no physician-level responsibility and facing no consequences.

Surprisingly this has carried weight. Many states have now legislated extenders as able to practice without physician oversight. Catch that? They didn't go to med school, so they get the position through legislation, not education and ability. Now many nurses want to be NPs and the educational market is happy to oblige, offering diploma mills that seem more akin to Trump University (some are 15 months, online, 100% acceptance rates) than legit med school and residency. Another obvious event, COVID19, makes them able to use fear and political need to do something, so legislate even more independence.

And now the AAN betrays us. In a video produced by the AAN and still on their website, Dr. Isaacson (more on him later) introduces a NP on his podcast as "Dr." He states, for those who don't know what NPs do, “we’re the same, do the same thing” as a physician. She also displays an interesting example of Orwellian language, making the point that PAs are "not a physician's assistant they're physician assistants. Yes that's an important distinction." Welcome to mission creep.

Isaacson is a dude with a book. The book is titled "The Alzheimer's Prevention and Treatment Diet." He directs a clinic to prevent AD (some might call this a primary care office, right, encouraging people to exercise, take things like statins and BP meds). He's been on The Dr. Oz Show (they appear to be kindred spirits). No RCT trials I could find.

TLDR: Here's the video:

No comments allowed. But plenty on Facebook, if you're still on that miserable platform.

I encourage you to tell the AAN what you think, unless you support the erosion of our profession by legislating short-cuts to practice medicine. Then I can only hope you get exactly the sort of care you advocate for others.

---

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[Surgeonvivor]

Yikes, there was so much propaganda in that video I had to shut it off early. The midlevel kept talking about all of her "wins" of getting more unrestricted practice during the pandemic, and that was particularly disgusting.

 

[Splenda88]

Can not stand academia...

 

[Splenda88]

BLUF: The AAN lost it's way, a neurologist interviewed a NP, identified her as doctor, and told us physicians and NPs do "the exact same stuff."

As you know, there's a push for extenders to practice without supervision. This is seriously misguided. It is thought that many routine medical appointments could be handled by an extender. I think this is fair, but medicine very quickly gets complicated, so it is a very modest recommendation to have physician oversight. The NP's think this is just a game to prevent them from making big bucks (not realizing that they will be employed then used and abused by huge medical systems), having had no physician-level responsibility and facing no consequences.

Surprisingly this has carried weight. Many states have now legislated extenders as able to practice without physician oversight. Catch that? They didn't go to med school, so they get the position through legislation, not education and ability. Now many nurses want to be NPs and the educational market is happy to oblige, offering diploma mills that seem more akin to Trump University (some are 15 months, online, 100% acceptance rates) than legit med school and residency. Another obvious event, COVID19, makes them able to use fear and political need to do something, so legislate even more independence.

And now the AAN betrays us. In a video produced by the AAN and still on their website, Dr. Isaacson (more on him later) introduces a NP on his podcast as "Dr." He states, for those who don't know what NPs do, “we’re the same, do the same thing” as a physician. She also displays an interesting example of Orwellian language, making the point that PAs are "not a physician's assistant they're physician assistants. Yes that's an important distinction." Welcome to mission creep.

Isaacson is a dude with a book. The book is titled "The Alzheimer's Prevention and Treatment Diet." He directs a clinic to prevent AD (some might call this a primary care office, right, encouraging people to exercise, take things like statins and BP meds). He's been on The Dr. Oz Show (they appear to be kindred spirits). No RCT trials I could find.

TLDR: Here's the video:

No comments allowed. But plenty on Facebook, if you're still on that miserable platform.

I encourage you to tell the AAN what you think, unless you support the erosion of our profession by legislating short-cuts to practice medicine. Then I can only hope you get exactly the sort of care you advocate for others.

That guy is a fool...

 

[Postictal Raiden]

BLUF: The AAN lost it's way, a neurologist interviewed a NP, identified her as doctor, and told us physicians and NPs do "the exact same stuff."

As you know, there's a push for extenders to practice without supervision. This is seriously misguided. It is thought that many routine medical appointments could be handled by an extender. I think this is fair, but medicine very quickly gets complicated, so it is a very modest recommendation to have physician oversight. The NP's think this is just a game to prevent them from making big bucks (not realizing that they will be employed then used and abused by huge medical systems), having had no physician-level responsibility and facing no consequences.

Surprisingly this has carried weight. Many states have now legislated extenders as able to practice without physician oversight. Catch that? They didn't go to med school, so they get the position through legislation, not education and ability. Now many nurses want to be NPs and the educational market is happy to oblige, offering diploma mills that seem more akin to Trump University (some are 15 months, online, 100% acceptance rates) than legit med school and residency. Another obvious event, COVID19, makes them able to use fear and political need to do something, so legislate even more independence.

And now the AAN betrays us. In a video produced by the AAN and still on their website, Dr. Isaacson (more on him later) introduces a NP on his podcast as "Dr." He states, for those who don't know what NPs do, “we’re the same, do the same thing” as a physician. She also displays an interesting example of Orwellian language, making the point that PAs are "not a physician's assistant they're physician assistants. Yes that's an important distinction." Welcome to mission creep.

Isaacson is a dude with a book. The book is titled "The Alzheimer's Prevention and Treatment Diet." He directs a clinic to prevent AD (some might call this a primary care office, right, encouraging people to exercise, take things like statins and BP meds). He's been on The Dr. Oz Show (they appear to be kindred spirits). No RCT trials I could find.

TLDR: Here's the video:

No comments allowed. But plenty on Facebook, if you're still on that miserable platform.

I encourage you to tell the AAN what you think, unless you support the erosion of our profession by legislating short-cuts to practice medicine. Then I can only hope you get exactly the sort of care you advocate for others.

**** like this makes me question my desire to pursue a fellowship. Really. What's the point of overtraining if the job can be done by someone who didn't even go to med school, let alone completing a rigorous 4-year residency?

Very disappointing. Medicine, as a whole, is beyond saving imo. Let's count our blessings and make hay while sun still shines.

 

[Splenda88]

**** like this makes me question my desire to pursue a fellowship. Really. What's the point of overtraining if the job can be done by someone who didn't even go to med school, let alone completing a rigorous 4-year residency?

Very disappointing. Medicine, as a whole, is beyond saving imo. Let's count our blessings and make hay while sun still shines.

I look him up into CMS open payment systems. He got over 70k in 2014 in speaking and consulting fees from Novartis... These are the king of people that should not speak for us.

I was thinking about an ID fellowship as well... Seeing where medicine is heading, I can use that 2-yr of attending salary to pay a substantial amount of my student loan.

Search Physicians - Open Payments Data - CMS | CMS Open Payments Data

openpaymentsdata.cms.gov

 

[Postictal Raiden]

I look him up into CMS open payment system. He got over 70k in 2016 in speaking and consulting fees from Novartis... These are the king of people that should not speak for us.

I was thinking about an ID fellowship as well... Seeing where medicine is heading, I can use that 2-yr of attending salary to pay a substantial amount of my student loan

The profession is changing and so should we. For us with astronomical amounts of loans, there's very little incentive for fellowship training, specially in a system that continues to punish the overtrained and reward those who take shortcuts.

I'm a little bitter today after a long tiring shift.

 

[bronx43]

**** like this makes me question my desire to pursue a fellowship. Really. What's the point of overtraining if the job can be done by someone who didn't even go to med school, let alone completing a rigorous 4-year residency?

Very disappointing. Medicine, as a whole, is beyond saving imo. Let's count our blessings and make hay while sun still shines.

The other side of this argument is that this should make you want to do a fellowship MORE. The more specialized one is, the more that patients will look for real and perceived expertise. The most vulnerable fields are the ones where these midlevels have backup... that they can just punt to a real doctor. This is why so many feel comfortable in primary care. Don't know the answer? Just refer to whichever MD sounds appropriate. Not the right MD? No problem, let's try a different one. Because that's what a primary care physician does anyway, right?

 

[bronx43]

One other thing...

How is a neurology NP even a thing? The subtleties of physical exam findings, requirement of understanding of neuro pathways/pathophysiology, utility and limitations of testing makes neurology one of the last fields I would ever consider for a midlevel.

 

[neglect]

All great points, thanks for all comments.

Yikes, there was so much propaganda in that video I had to shut it off early. The midlevel kept talking about all of her "wins" of getting more unrestricted practice during the pandemic, and that was particularly disgusting.

I was going to discuss this in my OP, but because she wasn't entirely explicit about it, I deleted a section. Here's one of the relevant sections: "we want folks to get the care they need in an efficient way, so that's been a win for us. So there have been some positives."

This is a thinly veiled play to use the COVID crisis to get more independence. Good for you for picking that out.

Can not stand academia...

Like anything else, some are good, some bad. What's tragic is that he's using residents to do inpatient service stuff for him (assuming he takes call in the hospital), but then is not loyal to their work. Residency created some of the darkest hours of my life. But I got better and made it. Now Isaacson tells me that an NP/PA is basically the same as me, and an NP is a doctor. Furthermore, the moral hazard here is insane. This guy gets grants to pretend he's preventing and slowing down AD (without RCT we'd never know). He's in this rarefied academic tower. He has no clue that NPs are seeing our patients and ordering 10,000 dollar workups for fatigue, including crazy consults to rheum, neuro, and endocrine.

**** like this makes me question my desire to pursue a fellowship. Really. What's the point of overtraining if the job can be done by someone who didn't even go to med school, let alone completing a rigorous 4-year residency?

Very disappointing. Medicine, as a whole, is beyond saving imo. Let's count our blessings and make hay while sun still shines.

Because quality will ALWAYS matter in medicine. We're not digging ditches. The actual quality, not what insurance companies and Medicare try to measure, matters. You can make a gold standard diagnosis, use treatments appropriately, know the anatomy, physiology, and pharmacology in a deep manner that others can only parrot.

I look him up into CMS open payment systems. He got over 70k in 2014 in speaking and consulting fees from Novartis... These are the king of people that should not speak for us.

I was thinking about an ID fellowship as well... Seeing where medicine is heading, I can use that 2-yr of attending salary to pay a substantial amount of my student loan.

Search Physicians - Open Payments Data - CMS | CMS Open Payments Data

openpaymentsdata.cms.gov

Interesting, his papers disclose advisory boards with Neurotrak, Lilly and 23andMe. Getting into bed with 23andMe says it all to me. That company is pure evil and makes Facebook look like Gandhi.

One other thing...

How is a neurology NP even a thing? The subtleties of physical exam findings, requirement of understanding of neuro pathways/pathophysiology, utility and limitations of testing makes neurology one of the last fields I would ever consider for a midlevel.

Extenders are best in situations that have low consequences and 'shake-and-bake' protocols. Headache can be catastrophic, but those typically go to the ER. "Dr." Cook practices at Emory, so has attending backup. That said, these patients can quickly get WAY out of hand. I've seen some managed so inappropriately that I don't even gently say "I recommend de-escalation of therapy," I use a heading of polypharmacy, and literally d/c 2/3 meds with SSRI properties (like zoloft, cymbalta, AND amytriptyline).

 

[Telamir]

I agree but that won't stop someone trying. I work with 2 NPs in the hospital setting. One of them has 10+ yrs of neuro only exeprience. I'd put that one at a late PGY-2 level. The other one is straight out of training and honestly is at an MS4 level if that. They tend to see the more "formulaic" stuff like stroke/metabolic encephalopathies and I still catch relatively obvious/basic mistakes.

The outpatient ones handling headache/epilepsy are not much better. While I agree that there is a bit of "art" to managing antiseizure drugs I've seen them take a patient on Depakote + Lamictal, remove the Depakote without an increase in Lamictal dose, replace it for Keppra 500 BID (guy was pretty large) and call it a day only for the guy to show up with a breakthrough seizure in 3-5 days after the appointment.

Again...still won't stop them from trying.

 

[Postictal Raiden]

I agree but that won't stop someone trying. I work with 2 NPs in the hospital setting. One of them has 10+ yrs of neuro only exeprience. I'd put that one at a late PGY-2 level. The other one is straight out of training and honestly is at an MS4 level if that. They tend to see the more "formulaic" stuff like stroke/metabolic encephalopathies and I still catch relatively obvious/basic mistakes.

The outpatient ones handling headache/epilepsy are not much better. While I agree that there is a bit of "art" to managing antiseizure drugs I've seen them take a patient on Depakote + Lamictal, remove the Depakote without an increase in Lamictal dose, replace it for Keppra 500 BID (guy was pretty large) and call it a day only for the guy to show up with a breakthrough seizure in 3-5 days after the appointment.

Again...still won't stop them from trying.

Recently had a pt admitted for recurrent breakthrough seizures. Review of home meds reveals leviteracetam 100mg bid. Not a typo. 100 bid. Might as well just have the pt stare at Keppra bottle for 5 mins BID and call it therapeutic dose.

 

[Splenda88]

Recently had a pt admitted for recurrent breakthrough seizures. Review of home meds reveals leviteracetam 100mg bid. Not a typo. 100 bid. Might as well just have the pt stare at Keppra bottle for 5 mins BID and call it therapeutic dose.

Lol...

 

[Telamir]

I prefer giving them a pill and say "Lick it once in the morning and once before bed. No more". You can make a 60 pill supply last you a lifetime. Who said I wasn't saving money? I mean, maybe who knows he/she just missed a 0. She was one order of magnitude away from a decent dose.

 

[neglect]

Update. I just got a very disturbing link to the AAN APP guidelines. Link: https://www.aan.com/policy-and-guid...ements/neurology-advanced-practice-providers/

From the source: "Advanced practice providers can conduct evaluations, prescribe medications, order and interpret testing, and perform some procedures independent of direct physician supervision" (My highlight). This is the only mention of "supervision" in the entire passage.

So the AAN essentially backs up Dr. Isaacson. And if you think I'm reading that wrong (like the can give botox independent of direct physician supervision), the article also states, "APPs may assume the leadership of straightforward cases."

I've been in practice for over a decade. I'm a leader in my office. I direct a trial center. But I do not "assume the leadership" of any patient. What does this even mean? I'm the doctor, the patient has other doctors. But how does one use language to make an extender into a doctor? You use words like 'leader.'

I used to think that the AAN is generally useless, good for a conference (kinda junky, doesn't know what it is trying to be), but now I think they are harmful. They have sold out and now think the extenders are the same as doctors. I hope they all get the care they clearly advocate.

 

[neglect]

Recently had a pt admitted for recurrent breakthrough seizures. Review of home meds reveals leviteracetam 100mg bid. Not a typo. 100 bid. Might as well just have the pt stare at Keppra bottle for 5 mins BID and call it therapeutic dose.

I didn't know it came in 100 mg doses. Pediatric?

But per the AAN "APPs may be able to assist in patient education which may also decrease the overutilization of the medical system." So what you witnessed is obviously impossible.

 

[Postictal Raiden]

I didn't know it came in 100 mg doses. Pediatric?

But per the AAN "APPs may be able to assist in patient education which may also decrease the overutilization of the medical system." So what you witnessed is obviously impossible.

No, adult. It was a liquid form.

 

[neurochica]

I have supervised many outstanding NPs. What I have experienced is that they lack the deep medical thinking when the going gets tough.

I don’t think an NP can be inserted into a 4th year resident program and be expected to succeed. This is the type of responsibility they are seeking....and In my experience, not ready.

If you really think about it, NPs can jump from a Neurology gig to a dermatology clinic with no residency or fellowship required.

 

[deathmerchant]

BLUF: The AAN lost it's way, a neurologist interviewed a NP, identified her as doctor, and told us physicians and NPs do "the exact same stuff."

As you know, there's a push for extenders to practice without supervision. This is seriously misguided. It is thought that many routine medical appointments could be handled by an extender. I think this is fair, but medicine very quickly gets complicated, so it is a very modest recommendation to have physician oversight. The NP's think this is just a game to prevent them from making big bucks (not realizing that they will be employed then used and abused by huge medical systems), having had no physician-level responsibility and facing no consequences.

Surprisingly this has carried weight. Many states have now legislated extenders as able to practice without physician oversight. Catch that? They didn't go to med school, so they get the position through legislation, not education and ability. Now many nurses want to be NPs and the educational market is happy to oblige, offering diploma mills that seem more akin to Trump University (some are 15 months, online, 100% acceptance rates) than legit med school and residency. Another obvious event, COVID19, makes them able to use fear and political need to do something, so legislate even more independence.

And now the AAN betrays us. In a video produced by the AAN and still on their website, Dr. Isaacson (more on him later) introduces a NP on his podcast as "Dr." He states, for those who don't know what NPs do, “we’re the same, do the same thing” as a physician. She also displays an interesting example of Orwellian language, making the point that PAs are "not a physician's assistant they're physician assistants. Yes that's an important distinction." Welcome to mission creep.

Isaacson is a dude with a book. The book is titled "The Alzheimer's Prevention and Treatment Diet." He directs a clinic to prevent AD (some might call this a primary care office, right, encouraging people to exercise, take things like statins and BP meds). He's been on The Dr. Oz Show (they appear to be kindred spirits). No RCT trials I could find.

TLDR: Here's the video:

No comments allowed. But plenty on Facebook, if you're still on that miserable platform.

I encourage you to tell the AAN what you think, unless you support the erosion of our profession by legislating short-cuts to practice medicine. Then I can only hope you get exactly the sort of care you advocate for others.

What a joke! One thing I have noticed that physicians/neurologists' who do not have a good grasp on the complexity/nuances of medicine/Neuro are the ones supporting midlevels to be able to work independently.
I have been studying the brain/neuro for about 15 years now and still question my decision making on a regular basis. Every day there is a challenging situation that requires critical thinking with roots in basic sciences and accumulated experience of clinical medicine over the years.

I think, either some of these physicians lack deep understanding of these complexities or have a secondary gain by promoting this travesty.

 

[neglect]

What a joke! One thing I have noticed that physicians/neurologists' who do not have a good grasp on the complexity/nuances of medicine/Neuro are the ones supporting midlevels to be able to work independently.
I have been studying the brain/neuro for about 15 years now and still question my decision making on a regular basis. Every day there is a challenging situation that requires critical thinking with roots in basic sciences and accumulated experience of clinical medicine over the years.

I think, either some of these physicians lack deep understanding of these complexities or have a secondary gain by promoting this travesty.

RIght on, headache is one of those things that takes a few months to learn and a lifetime to master. You can build a basic level of competence very quickly for migraines, tension, cluster and oddball HA's. You can seek out help for the rare things that'll kill and maim while hiding behind a headache. In short, this is a good fit for a NP or PA role. Another factor is that the patient volumes are huge, HA specialists are rare, so extenders make good business sense.

The problem is that if an extender feels like they get headache, then the next thought is that they can get MS, stroke, epilepsy, movement, peripheral, dementia, other pain, etc.

We really are in for it. The AAN still has the video up, with their logo and approval. To them we really are the same: as long as we pay the dues, we're just part of the flock.

 

[Splenda88]

Someone needs to reach out to the AAN and tell them to take down that video...

 

[neglect]

Someone needs to reach out to the AAN and tell them to take down that video...

But then they’d lose all the NP’s who join the AAN in order to boost their legitimacy.

 

[Postictal Raiden]

@neglect

I came across a post of yours on the socioeconomic forum regarding the PA emergency medicine residency at UNC. Another member responded to you that they canceled the program after they observed an increased rage among students/residents/attendings, specially on sites such as SDN.

This is true. UNC is no longer harboring such a program.

Correction of misinformation online regarding APPs | Emergency Medicine

Dear Residents & Prospective Residents, As you may know, there was a very premature release of information this week announcing the introduction of a proposed new advance practice provider (APP) Emergency Medicine (EM) education pathway. To be clear: UNC does not have an APP EM education...

www.med.unc.edu

Perhaps we should do the same. Complain and verbalize concerns. This irresponsible behavior by AAN and prominent figures in the fields shouldn't go unnoticed.

 

[neglect]

@neglect

I came across a post of yours on the socioeconomic forum regarding the PA emergency medicine residency at UNC. Another member responded to you that they canceled the program after they observed an increased rage among students/residents/attendings, specially on sites such as SDN.

This is true. UNC is no longer harboring such a program.

Correction of misinformation online regarding APPs | Emergency Medicine

Dear Residents & Prospective Residents, As you may know, there was a very premature release of information this week announcing the introduction of a proposed new advance practice provider (APP) Emergency Medicine (EM) education pathway. To be clear: UNC does not have an APP EM education...

www.med.unc.edu

Perhaps we should do the same. Complain and verbalize concerns. This irresponsible behavior by AAN and prominent figures in the fields shouldn't go unnoticed.

YES! I think we should all complain and if its in you, quit. The AAN does very little anyway. THey have a great racket going - money for nothing.

 

[Staphylococcus Aureus]

Anyone who is a member of AAN needs to individually voice concern unless you want your training to be so blurred into false equivalency that administrators will use terms like nurse neurologist or neurology providers (be it interchangeably NP/PA/MD) and be treated/compensated accordingly.

 

[neglect]

Anyone who is a member of AAN needs to individually voice concern unless you want your training to be so blurred into false equivalency that administrators will use terms like nurse neurologist or neurology providers (be it interchangeably NP/PA/MD) and be treated/compensated accordingly.

This guy gets it.

I'd only add that when your parents, cousins, friends go see a "provider" they see a licensed physician or someone overseen by a physician.

 

[neglect]

Someone started a petition. Not sure if the AAN cares, but good to see this issue is getting traction. Please sign it and tell your friends.

Tagging folks in thread who expressed similar horror, hope you don't mind: @Surgeonvivor @Splenda88 @Staphylococcus Aureus @Ibn Alnafis MD @Telamir @neurochica @deathmerchant

 

[Splenda88]

Signed...

 

[Postictal Raiden]

@neglect

seems that the video was taken down by AAN. I can't find it anymore. If so, means they listened.

 

[neglect]

@neglect

seems that the video was taken down by AAN. I can't find it anymore. If so, means they listened.

Let’s not give a prize to a kid for only tearing one ear off the kitten before getting caught and stopping.

How long has it been before they took it down? How about leaving it up, apologizing, and changing their policy.

From above, check out their current APP guidelines. Link: https://www.aan.com/policy-and-guid...ements/neurology-advanced-practice-providers/

"Advanced practice providers can conduct evaluations, prescribe medications, order and interpret testing, and perform some procedures independent of direct physician supervision" (My highlight). Also, "APPs may assume the leadership of straightforward cases."

Screw the AAN.

 

[Staphylococcus Aureus]

@neglect What is the point of fellowships if they have this view? One would assume they hold the same view for a physician who only did an internship seeing neuro patients.

 

[Postictal Raiden]

@neglect What is the point of fellowships if they have this view? One would assume they hold the same view for a physician who only did an internship seeing neuro patients.

Exactly my thoughts. Why should I slave away 1-2 more years on top of my already excessive training so I can be viewed “equivalent” to someone who has no real medical education or even a rigorous science-based undergrad degree?

I’m very, very disappointed

 

[neglect]

@neglect What is the point of fellowships if they have this view? One would assume they hold the same view for a physician who only did an internship seeing neuro patients.

Exactly my thoughts. Why should I slave away 1-2 more years on top of my already excessive training so I can be viewed “equivalent” to someone who has no real medical education or even a rigorous science-based undergrad degree?

I’m very, very disappointed

Have a pulse, pay dues, pay for CME, pay for conference, that’s all they care about. Prove me wrong.

 

[deathmerchant]

There is one good thing about AAN: continuum. But the most recent Stroke edition now has an NP as one of the authors. Look at her degree list. Looks better than MD

 

[Postictal Raiden]

There is one good thing about AAN: continuum. But the most recent Stroke edition now has an NP as one of the authors. Look at her degree list. Looks better than MD
[/]

Alphabet soup behind your name can only tell me one thing about you. Insecure.

 

[neglect]

There is one good thing about AAN: continuum. But the most recent Stroke edition now has an NP as one of the authors. Look at her degree list. Looks better than MD

She's never independently diagnosed or treated stroke. But she is an expert in stroke. Makes sense.


Totally agree on that. Remember the Wizard of Oz, they give the idiot character a diploma to make him feel smart.

 

[Staphylococcus Aureus]

We need an American Academy of Neurologists apparently

 

[NOSfan]

 

[Mad Jack]

The hubris is off the charts