CA wants to increase midlevel's scope of practice

[duckie99]

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http://www.latimes.com/health/la-me-doctors-20130210,0,1509396.story

Has anyone else heard of this story?

To give my 2 cents:
1. The article is pretty ridiculously biased and obviously written by a person who has no idea about physician and other provider's training. The writer makes it sound like an optometrist can treat diabetes!

2. I have worked directly with NP students (online classes, setting up her individual "clinical rotations") and PA students (from a "great" PA program) and have seen their deficiencies in knowledge. There is no comparison between their training and a physician's. IMO the med student then residency>>>>>>>>>>>>>>>>PA student>>NP student.

3. To quickly review the scope of practice any PA or NP has... it is directly related to their very specific on the job training done by a physician over several years. A PA can work in the ICU and be fairly competent in the common aspects of vent management, pressor management, abx for certain conditions, who to consult, etc. But that PA cannot go out into the pulm clinic and do bronchs, diagnose different diseases, etc. It really is not comparable at all. In fact I would argue the pulm doc should be able to do IM primary care outpatient or hospitalist work as well based on the training he/she has gone through. Obviously a PA or NP will not be able to.

4. I do think a primary care trained (over years) NP or PA can likely be sufficient for basic primary care after the patient has been seen by the physician. I do not think it is extraordinary difficult to see how a patient is doing with his/her diabetes control and perhaps the next steps one would take (based on the physician's algorithms).

5. Also gotta remember that it has been shown that dedicated clinics (physician lead with heavy NP and PA support) for certain conditions result in better outcomes than physician alone (e.g. heart failure clinic). The reason for this being that there are set algorithms for these issues and NPs/PAs that are only doing this one disease over and over for years on end. So there is a role for NP/PA that I do not discount.



Physicians in the real world don't seem to express any "worry" because it is evident to them that midlevels cannot be a substitute for physicians. However, the problem is that physicians are the few people with the knowledge to be able to see that. It is simply impossible for lawmakers and even patients to see that. All they see is that "oh diabetes is very easy to diagnose and treat so anyone should be able to do it, even optometrists, and there won't be any problems..." IMO the optometrist referenced in the article likely wasn't implying that he wanted to treat the patient's diabetes but I would hope he would direct the patient to someone who could...

Anyway you don't know what you don't know. If something like this goes through then the poorer outcomes from NP or PA only will be very evident. And don't discount that these lawmakers and rich people will be seeing physicians and therefore directing the poor to see midlevels. Yeah that's a "fair" society.

 

[notbobtrustme]

The US is a textbook example of what happens when you don't invest in your citizenry.

 

[FrkyBgStok]

A professor of ours put it very nicely. He drew it out, but in words, if a doctor's skill range is from 1-10, a PA/NP is 1-6, an optometrist from 3-7, etc., doctor's need to stop doing most of their work in the 3-4 skill range and start doing the bulk of it in the 7-8 range. Then the PA/NPs can do the work in the 3-4 range without physicians worrying about stepping on their toes because a physician would consistently work above what they are trained to do. And in a perfect system, the PA/NP would see that physicians are doing things they aren't trained to do and say, "i can't do that, so I am not going to fight for practice rights."

 

[IntelInside]

A professor of ours put it very nicely. He drew it out, but in words, if a doctor's skill range is from 1-10, a PA/NP is 1-6, an optometrist from 3-7, etc., doctor's need to stop doing most of their work in the 3-4 skill range and start doing the bulk of it in the 7-8 range. Then the PA/NPs can do the work in the 3-4 range without physicians worrying about stepping on their toes because a physician would consistently work above what they are trained to do. And in a perfect system, the PA/NP would see that physicians are doing things they aren't trained to do and say, "i can't do that, so I am not going to fight for practice rights."

I actually do agree with this sentiment only if a portion of the money they save by using these "less skilled" professionals were to be used to give physicians a pay increase.

 

[Textbookversion]

A professor of ours put it very nicely. He drew it out, but in words, if a doctor's skill range is from 1-10, a PA/NP is 1-6, an optometrist from 3-7, etc., doctor's need to stop doing most of their work in the 3-4 skill range and start doing the bulk of it in the 7-8 range. Then the PA/NPs can do the work in the 3-4 range without physicians worrying about stepping on their toes because a physician would consistently work above what they are trained to do. And in a perfect system, the PA/NP would see that physicians are doing things they aren't trained to do and say, "i can't do that, so I am not going to fight for practice rights."

The problem with this attitude is that patients don't come labeled with a "3" or "4" over their heads.

Also PA's and NP's practicing independently is inordinately expensive. Why? Consults, imaging, and labs galore.

Primary care and EM are the gateway to the rest of medicine, and the better those providers are the cheaper healthcare is as a whole (dramatically so).

The problem is that specialists are seen as more prestigious, and paid that way, so primary care is seen as the easy thing. It's funny how different other countries are from us. Way more primary care doctors who take care of a wider scope of sick patients.

 

[xenotype]

There needs to be an actual large scale physician PR campaign to stop this nonsense before a lot of patients get hurt.

 

[FSU2013]

The problem with this attitude is that patients don't come labeled with a "3" or "4" over their heads.

Also PA's and NP's practicing independently is inordinately expensive. Why? Consults, imaging, and labs galore.

Primary care and EM are the gateway to the rest of medicine, and the better those providers are the cheaper healthcare is as a whole (dramatically so).

The problem is that specialists are seen as more prestigious, and paid that way, so primary care is seen as the easy thing. It's funny how different other countries are from us. Way more primary care doctors who take care of a wider scope of sick patients.

Spot on. Also, I'm hard pressed to believe NPs will have the restraint/insight to say "that is something I can't do."

Also agree with the PR thing. If the public believed they were getting inadequate care, there would be a change.

 

[IlDestriero]

I actually do agree with this sentiment only if a portion of the money they save by using these "less skilled" professionals were to be used to give physicians a pay increase.

Once they start working independently, they'll demand equal pay. Bet the house, farm, boat and retirement account on it.
Those dummies will give it to them too.
F CA.

 

[JShephard]

Once they start working independently, they'll demand equal pay. Bet the house, farm, boat and retirement account on it.
Those dummies will give it to them too.
F CA.

I agree.

And I think this battle is inevitable. The government has poorly managed healthcare and all types of spending, now they will look for ways to save money (e.g. midlevels) without addressing the actual cause - gratuitous unrestrained spending and an aversion to cutting anything that would jeopardize political capital or electability.

Our nation needs some real leadership to get us out of this mess.

My guess? The midlevels will gain more and more autonomy until bad outcomes start occurring regularly - until then, expect a steady rise in scope of practice - IMO.

 

[Smokemont]

pharmacists licensed to perform physicals.....wow

 

[JourneyAgent]

It's the 10th round in the PR match. We've been getting out boxed. We're sluggish, out of shape, and gassed out. We didn't train for ****. Thought these nurses weren't even in our league. But with both of our eyes are closing up from the pattering of incessant jabs we're startin to wise up. To how we ended up with a drunk for a corner man, 3 sheets to the wind, and how sleek and fiery and quick our opponent is. And we still can't figure out why the crowd is booing. Weren't we god's gifts to the ill and indigent?

Look. By the time we realize this thing is for real it's already gonna be over. We're fixin to be stuck holding our d!cks when the bills come due on our loans and the bossmen got a long line of people who are less trained, less invested, and will work for a fraction of what we will. Joey Public don't give no 2 f@cks aboutit neither. All he wants is his pain pills and a sandwich.

We got no organization. We're self reliant, independent, aggressive minded and Balkanized. We don't move in herds. We don't cooperate like stealthy meerkats. We've been moseying along at the top of the food chain too long.

It's not gonna happen.

It's gonna be a crowded, competitive field for provider gigs. I'm looking to get specialized, and am planning on studying up on lighter faster models of expert practice. We're not gonna be able to keep up in the PR war. It will be expert niches. And the ability to access an educated patient base who have income and discernment. If I fail at this. I'll think I'll take my archaic education to a behemoth federal job that will be decades behind the economic curve.

That's my fight plan.

 

[Smokemont]

It's the 10th round in the PR match. We've been getting out boxed. We're sluggish, out of shape, and gassed out. We didn't train for ****. Thought these nurses weren't even in our league. But with both of our eyes are closing up from the pattering of incessant jabs we're startin to wise up. To how we ended up with a drunk for a corner man, 3 sheets to the wind, and how sleek and fiery and quick our opponent is. And we still can't figure out why the crowd is booing. Weren't we god's gifts to the ill and indigent?

Look. By the time we realize this thing is for real it's already gonna be over. We're fixin to be stuck holding our d!cks when the bills come due on our loans and the bossmen got a long line of people who are less trained, less invested, and will work for a fraction of what we will. Joey Public don't give no 2 f@cks aboutit neither. All he wants is his pain pills and a sandwich.

We got no organization. We're self reliant, independent, aggressive minded and Balkanized. We don't move in herds. We don't cooperate like stealthy meerkats. We've been moseying along at the top of the food chain too long.

It's not gonna happen.

It's gonna be a crowded, competitive field for provider gigs. I'm looking to get specialized, and am planning on studying up on lighter faster models of expert practice. We're not gonna be able to keep up in the PR war. It will be expert niches. And the ability to access an educated patient base who have income and discernment. If I fail at this. I'll think I'll take my archaic education to a behemoth federal job that will be decades behind the economic curve.

That's my fight plan.

or you could just go into neurosurgery

 

[SpecterGT260]

pharmacists licensed to perform physicals.....wow

Let's hope they put the stethoscope in right....

Sent from my DROID RAZR using SDN Mobile

 

[PrideNeverDie]

or you could just go into neurosurgery

this is the beta attitude that let this happen in the first place

 

[zenman]

1. New Mexico just celebrated 20 years of independant NP practice.
2. Distance education has a lot of evidence behind it...which will only mean something if you believe in EBM.😀

 

[RadOnc04]

1. New Mexico just celebrated 20 years of independant NP practice.
2. Distance education has a lot of evidence behind it...which will only mean something if you believe in EBM.😀

Yet with "NP independent psych practice" in New Mexico, you still rate at <50% of states in mental health

http://www.americashealthrankings.org/NM/MentalHealth

And as far as distance education... it's only worthwhile if you have the right student population... as been shown by the abysmal graduation rates of places like DeVry.

 

[Textbookversion]

1. New Mexico just celebrated 20 years of independant NP practice.
2. Distance education has a lot of evidence behind it...which will only mean something if you believe in EBM.😀

There is a difference between independent practice being legal, and it being widespread. How many NP only practices are there in New Mexico that treat actual sick people (not aesthetics or alt. med.)?

 

[DreamingTheLive]

It's the 10th round in the PR match. We've been getting out boxed. We're sluggish, out of shape, and gassed out. We didn't train for ****. Thought these nurses weren't even in our league. But with both of our eyes are closing up from the pattering of incessant jabs we're startin to wise up. To how we ended up with a drunk for a corner man, 3 sheets to the wind, and how sleek and fiery and quick our opponent is. And we still can't figure out why the crowd is booing. Weren't we god's gifts to the ill and indigent?

Look. By the time we realize this thing is for real it's already gonna be over. We're fixin to be stuck holding our d!cks when the bills come due on our loans and the bossmen got a long line of people who are less trained, less invested, and will work for a fraction of what we will. Joey Public don't give no 2 f@cks aboutit neither. All he wants is his pain pills and a sandwich.

We got no organization. We're self reliant, independent, aggressive minded and Balkanized. We don't move in herds. We don't cooperate like stealthy meerkats. We've been moseying along at the top of the food chain too long.

It's not gonna happen.

It's gonna be a crowded, competitive field for provider gigs. I'm looking to get specialized, and am planning on studying up on lighter faster models of expert practice. We're not gonna be able to keep up in the PR war. It will be expert niches. And the ability to access an educated patient base who have income and discernment. If I fail at this. I'll think I'll take my archaic education to a behemoth federal job that will be decades behind the economic curve.

That's my fight plan.

While not exactly how I would have put it, I agree. Med students, residents, physicians need to fight the PR battle! Seriously, if the public/government is told enough times that PAs/NPs are somehow equal/superior they'll buy it....in spades.

 

[KnuxNole]

Are clinical rotations for NPs also done online? I can see some school trying to make this happen in the future

 

[JShephard]

While not exactly how I would have put it, I agree. Med students, residents, physicians need to fight the PR battle! Seriously, if the public/government is told enough times that PAs/NPs are somehow equal/superior they'll buy it....in spades.

It's strange that doctors will need to have somewhat of an adversarial relationship to nurses - but nurse organizations are 100% focused on advancing nurse pay and practice rights at the expense of anyone. This is why doctors need to wise up and learn business and politics. Focusing only on science and patient outcomes will not win this battle.

 

[AnnoyedByFreud]

Are clinical rotations for NPs also done online? I can see some school trying to make this happen in the future

... no

 

[zenman]

Yet with "NP independent psych practice" in New Mexico, you still rate at <50% of states in mental health

http://www.americashealthrankings.org/NM/MentalHealth

And as far as distance education... it's only worthwhile if you have the right student population... as been shown by the abysmal graduation rates of places like DeVry.

There are a lot of factors involved in NM, so perhaps there is a need for more providers of every sort. I was treating Texans in NM, who really had a long time to wait for services due to their very restrictive NP policies. One patient even returned from East Texas after being there a year and not being able to see a psychiatrist to get back on her meds.

What does DeVry, a trade school, have to do with anything? I have two masters from traditional programs and a post-master via distance education. Much of our references and coursework was "online" material from where....medical schools.

http://www.forbes.com/sites/realspi...al-care-is-provided-by-those-who-arent-m-d-s/

 

[zenman]

There is a difference between independent practice being legal, and it being widespread. How many NP only practices are there in New Mexico that treat actual sick people (not aesthetics or alt. med.)?

I had many referrals from primary care providers who were NPs. I don't have any figures but never saw any from alternative med or aesthetic providers.

 

[NickNaylor]

Maybe it's a dick move, but whenever I go see a physician I always mention that I would prefer to be seen by a MD rather than a PA and NP - especially when I'm paying the same copay. My hometown PCP practice is actually one MD with two PAs. Every year it seems like you're more and more likely to be seen by a PA/NP rather than a MD. I don't think NP or PAs or incompetent, but when the rubber meets the road I'd much rather be treated my someone with MD/DO training than someone with much more limited training.

 

[Mass Effect]

1. The article is pretty ridiculously biased and obviously written by a person who has no idea about physician and other provider's training. The writer makes it sound like an optometrist can treat diabetes!

The writer didn't make it sound like that. Those representing the state of CA did. They were quoted directly saying that. This is a news story. I didn't see any real bias; just a writer who gathered quotes from those in favor of these proposals.

In fact I would argue the pulm doc should be able to do IM primary care outpatient or hospitalist work as well based on the training he/she has gone through.

That would be an argument not worth having, since pulmonologists are IM doctors. You can't be a pulmonologist unless you did a residency in internal medicine.

 

[EnergyDrink]

While not exactly how I would have put it, I agree. Med students, residents, physicians need to fight the PR battle! Seriously, if the public/government is told enough times that PAs/NPs are somehow equal/superior they'll buy it....in spades.

It's strange that doctors will need to have somewhat of an adversarial relationship to nurses - but nurse organizations are 100% focused on advancing nurse pay and practice rights at the expense of anyone. This is why doctors need to wise up and learn business and politics. Focusing only on science and patient outcomes will not win this battle.

Right on!

Let's post in a medical student forum about it. That'll show them.

I feel better. I did my part.

 

[yehhhboiii]

Right on!

Let's post in a medical student forum about it. That'll show them.

I feel better. I did my part.

Yeah because it's not as if the medical students that are reading these forums are going to be the attendings that will be most affected by decisions made today or anything like that.

 

[Nymphicus]

Are clinical rotations for NPs also done online? I can see some school trying to make this happen in the future

... no

I met at length with an NP student who is doing her program online. For her "clinical rotations," she found an unaffiliated NP locally who was willing to "precept" her for a month or two.

 

[duckie99]

I met at length with an NP student who is doing her program online. For her "clinical rotations," she found an unaffiliated NP locally who was willing to "precept" her for a month or two.

this is the exact same thing the NP student I was with did as well. It is not truly school and this NP student was extremely weak in all aspects of clinical skills and knowledge. A brand new M3 would be far far better simply because he/she took step 1 (almost no matter the score).

I think this new growing crop of NPs and their "training" are producing extraordinarily weak health care providers who can at most do straight cook-book medicine. I cannot even fathom this student working on her own in any capacity one day. Even the long time NPs I worked with really only knew the cook-book stuff. Sure they can keep a patient alive on a vent for a time but the attending needs to be there. PAs were a little better than the NPs, but there is just no comparison with the depth of knowledge and training a physician undergoes.

And as I said these concepts are hard for a person with no knowledge of medicine to understand. That's why the nursing lobby works.

 

[JourneyAgent]

this is the exact same thing the NP student I was with did as well. It is not truly school and this NP student was extremely weak in all aspects of clinical skills and knowledge. A brand new M3 would be far far better simply because he/she took step 1 (almost no matter the score).

I think this new growing crop of NPs and their "training" are producing extraordinarily weak health care providers who can at most do straight cook-book medicine. I cannot even fathom this student working on her own in any capacity one day. Even the long time NPs I worked with really only knew the cook-book stuff. Sure they can keep a patient alive on a vent for a time but the attending needs to be there. PAs were a little better than the NPs, but there is just no comparison with the depth of knowledge and training a physician undergoes.

And as I said these concepts are hard for a person with no knowledge of medicine to understand. That's why the nursing lobby works.

The thing that makes it as insidious as it is inevitable is that it they will never be tested independently en masse. They will continue to get a free residency--making twice, working half--for their first years of practice. Rotting barriers to independence from the inside.

Then the journeymen among them will point to the fact that they do the same work--and with the exception of some specialized fields they're right. And so we'll end up looking like crooks for trying to deny the public of a cheaper, teary eyed, lip quivering underdog.

There's no way out of this. The script is too powerful and the public is too dumb.

We simply cannot win.

At best we could do is co-opt their independence movement to achieve some additional options for junior docs. But even that would take way more organization than we possess.

I think we can hold out for long term, let them saturate the market, give them all the stupid people--they're better idiot coaches anyway--and rebrand ourselves on the other end as the Mercedes of medical education.

 

[xenotype]

I think we can hold out for long term, let them saturate the market, give them all the stupid people--they're better idiot coaches anyway--and rebrand ourselves on the other end as the Mercedes of medical education.

They will saturate the market because their leadership was dumb enough to saturate the market for RNs already by lowering standards and accrediting shoddy programs. They are doing the same thing with the DNP, and have no doubt that the minute supply exceeds demand, those NPs will not be able to find jobs. MD jobs will not be replaced, but salaries may be forced down by how cheap the NPs are in comparison. Nobody would hire an NP if they could get an MD in the same price range.

I have a couple good pieces of evidence for this. Look at the lawyers. T14? Six figure job no problem. Not T14? No job at all. Second piece of evidence: physicians subspecialized largely because patients demanded specialist appointments. Insurance companies followed the consumer demand by largely mandating board certification for payment. Patients will pay for perceived higher level care to the extent they can afford it.

The nurses will never be able to shake off the second class citizen connotation and a sizable amount of patients will demand MDs if it is at all possible for them to afford one. The big problem is that there will be lots of downward market pressure on MD salaries at the same time as the loans continue to increase in size.

 

[JourneyAgent]

They will saturate the market because their leadership was dumb enough to saturate the market for RNs already by lowering standards and accrediting shoddy programs. They are doing the same thing with the DNP, and have no doubt that the minute supply exceeds demand, those NPs will not be able to find jobs. MD jobs will not be replaced, but salaries may be forced down by how cheap the NPs are in comparison. Nobody would hire an NP if they could get an MD in the same price range.

I have a couple good pieces of evidence for this. Look at the lawyers. T14? Six figure job no problem. Not T14? No job at all. Second piece of evidence: physicians subspecialized largely because patients demanded specialist appointments. Insurance companies followed the consumer demand by largely mandating board certification for payment. Patients will pay for perceived higher level care to the extent they can afford it.

The nurses will never be able to shake off the second class citizen connotation and a sizable amount of patients will demand MDs if it is at all possible for them to afford one. The big problem is that there will be lots of downward market pressure on MD salaries at the same time as the loans continue to increase in size.

I agree with you that to the extent HMO's and insurance companies can get a better deal they'll take it. And our salary to debt ratio will get really crappy. The only thing that convinces me that medical school systems will continue as they are currently is because the down hill slide of the middle class is so pervasive that even if a medical education equates to a teacher's living standard in the last century a lot of people will still do it. I mean, look at teachers now. I'd still go to medical school with worse financials than do that crap. And so on.

I'm looking for ways out of insurance and HMO ties. I would love to be a physician entrepreneur of some sort. Even if I could do it part time and build it up into my later career. We may just be scarce enough to make our own demands in terms of these burdensome noncompetitive clauses I hear about in the resident forums.

 

[JShephard]

They will saturate the market because their leadership was dumb enough to saturate the market for RNs already by lowering standards and accrediting shoddy programs. They are doing the same thing with the DNP, and have no doubt that the minute supply exceeds demand, those NPs will not be able to find jobs. MD jobs will not be replaced, but salaries may be forced down by how cheap the NPs are in comparison. Nobody would hire an NP if they could get an MD in the same price range.

I have a couple good pieces of evidence for this. Look at the lawyers. T14? Six figure job no problem. Not T14? No job at all. Second piece of evidence: physicians subspecialized largely because patients demanded specialist appointments. Insurance companies followed the consumer demand by largely mandating board certification for payment. Patients will pay for perceived higher level care to the extent they can afford it.

The nurses will never be able to shake off the second class citizen connotation and a sizable amount of patients will demand MDs if it is at all possible for them to afford one. The big problem is that there will be lots of downward market pressure on MD salaries at the same time as the loans continue to increase in size.

Good analysis. I agree that there will be downward pressure on physician salaries but the oversaturation by nurses will end up hurting them. Hopefully doctors don't also oversaturate by opening up too many med schools in the next decade.

On second thought, this oversupply of NPs may actually be the best way to deal with the doctor shortage - we will end up managing more + taking care of the difficult problems, and our niche will be more evident as nurse's who call themselves doctors start making errors - followed by public outcry and reform.

Maybe this is the best of all possible worlds.

 

[laconfidential]

I figure there will be continual power grabs by nurses/PAs for more autonomy until something happens so that there's enough public outcry to make congress notice. Just wait for a few Libby Zion-esque deaths and the legislation will change.

Sad to think if it that way, no?

 

[ivfmd]

Whenever the topic of restricting other people's scope of activity comes up, it is important to think about how much of it is intended to protect the interests of the PATIENTS and how much of that is based on motivations to protect the interest of us PROVIDERS?

I am a reproductive endocrinologist and the head of our county's informal professional society (we call it Journal Club). I say informal because it consists simply of 20 or so of us RE's meeting together for a friendly dinner and casual conversation regarding the latest research as well as so-called political issues. This very topic has come up during our meetings because it is relevant for us in many different variations.

- There are many general (non-subspecialist) OB/Gyn's who aggressively advertise themselves to be "INFERTILITY SPECIALISTS". They do not have nearly as much FORMAL training as we do? Do they have the same knowledge and skills? Maybe. Maybe not.

Is it our business to care what they do?

- Even more so, there are chiropractors / acupuncturists / massage therapists and dieticians who aggressively advertise themselves to be "INFERTILITY SPECIALISTS". Particularly extreme is this group of massage therapists who claim they can cure tubal scarring via external massage!

Is it our business to care what they do?

There are arguments from both sides. The selfish view (protecting the provider) states that hey, we spent eleven years in med school, internship, residency and fellowships. We shouldn't have to compete with untrained (lesser-trained) people.

The altruistic view (protecting the patient) states hey, these patients might go to these less-qualified providers thinking they are getting good care with their herbs and adjustments and needles and 12 cycles of Clomid, but what happens if a borderline 37 year old wastes 3 years on ineffective treatment without a successful pregnancy. Then she has been greatly greatly harmed in the permanent loss of 3 very precious reproductive years, because it means the difference between her experiencing motherhood vs not ever experiencing it.

Some of my colleagues want aggressive regulatory actions from the California licensing boards to stop "mid-levels" from competing with us (banning the advertising claim of INFERTILITY SPECIALIST, banning Eastern Medicine folks from ordering lab tests, banning general OB/Gyn's from doing IVF) but my personal approach is very different. I prefer that I will spend my energy in education of the public. I will teach the public as to why my approach, which is an appropriate combination of history-taking and evaluation, paying attention to diet/lifestyle/stress, appropriate use of diagnostic tests, prescribing the right meds, doing low tech insemination procedures, surgery or high tech IVF procedures competes very favorably with what these other people have to offer. However, as long as the patient is not being grossly lied to, then I am happy to let others try their hand at taking care of the patients who voluntarily agree to see them. I will compete by just offering a superior "product" and not try to stifle competition by using state-sanctioned force.

So those are my views specifically as the relate to my field.

As for other fields, I will be consistent and expand on that opinion. I believe that it is the level of training and skill that matters, NOT some piece of parchment or plastic license card.

I'll take the radical view that if I were a dermatologist, for example, I can teach a derm resident to administer Botox. In fact, I can teach a PA/NP to administer botox. In fact, I can teach any reasonably intelligent human being with reasonable manual dexterity and reasonable common sense to administer botox. They may not not necessarily be able to manage the differential diagnosis of a rash nor manage a simple chest pain workup, but I wouldn't then allow them to do that in my practice.

I guess in my field, I would say all those things about intrauterine inseminations. However, by law, it is forbidden to train a non professional to do IUI's no matter how rigorously specific and well-supervised the training is. Is that fair? I don't have a simple answer.

It's an interesting debate. I welcome hearing other people's views. Thanks.

 

[JShephard]

Whenever the topic of restricting other people's scope of activity comes up, it is important to think about how much of it is intended to protect the interests of the PATIENTS and how much of that is based on motivations to protect the interest of us PROVIDERS?

I am a reproductive endocrinologist and the head of our county's informal professional society (we call it Journal Club). I say informal because it consists simply of 20 or so of us RE's meeting together for a friendly dinner and casual conversation regarding the latest research as well as so-called political issues. This very topic has come up during our meetings because it is relevant for us in many different variations.

- There are many general (non-subspecialist) OB/Gyn's who aggressively advertise themselves to be "INFERTILITY SPECIALISTS". They do not have nearly as much FORMAL training as we do? Do they have the same knowledge and skills? Maybe. Maybe not.

Is it our business to care what they do?

- Even more so, there are chiropractors / acupuncturists / massage therapists and dieticians who aggressively advertise themselves to be "INFERTILITY SPECIALISTS". Particularly extreme is this group of massage therapists who claim they can cure tubal scarring via external massage!

Is it our business to care what they do?

There are arguments from both sides. The selfish view (protecting the provider) states that hey, we spent eleven years in med school, internship, residency and fellowships. We shouldn't have to compete with untrained (lesser-trained) people.

The altruistic view (protecting the patient) states hey, these patients might go to these less-qualified providers thinking they are getting good care with their herbs and adjustments and needles and 12 cycles of Clomid, but what happens if a borderline 37 year old wastes 3 years on ineffective treatment without a successful pregnancy. Then she has been greatly greatly harmed in the permanent loss of 3 very precious reproductive years, because it means the difference between her experiencing motherhood vs not ever experiencing it.

Some of my colleagues want aggressive regulatory actions from the California licensing boards to stop "mid-levels" from competing with us (banning the advertising claim of INFERTILITY SPECIALIST, banning Eastern Medicine folks from ordering lab tests, banning general OB/Gyn's from doing IVF) but my personal approach is very different. I prefer that I will spend my energy in education of the public. I will teach the public as to why my approach, which is an appropriate combination of history-taking and evaluation, paying attention to diet/lifestyle/stress, appropriate use of diagnostic tests, prescribing the right meds, doing low tech insemination procedures, surgery or high tech IVF procedures competes very favorably with what these other people have to offer. However, as long as the patient is not being grossly lied to, then I am happy to let others try their hand at taking care of the patients who voluntarily agree to see them. I will compete by just offering a superior "product" and not try to stifle competition by using state-sanctioned force.

So those are my views specifically as the relate to my field.

As for other fields, I will be consistent and expand on that opinion. I believe that it is the level of training and skill that matters, NOT some piece of parchment or plastic license card.

I'll take the radical view that if I were a dermatologist, for example, I can teach a derm resident to administer Botox. In fact, I can teach a PA/NP to administer botox. In fact, I can teach any reasonably intelligent human being with reasonable manual dexterity and reasonable common sense to administer botox. They may not not necessarily be able to manage the differential diagnosis of a rash nor manage a simple chest pain workup, but I wouldn't then allow them to do that in my practice.

I guess in my field, I would say all those things about intrauterine inseminations. However, by law, it is forbidden to train a non professional to do IUI's no matter how rigorously specific and well-supervised the training is. Is that fair? I don't have a simple answer.

It's an interesting debate. I welcome hearing other people's views. Thanks.

I like the idea of your approach, I think the flaw is that single physicians will have a difficult time educating the masses. Which goes to what I mentioned earlier, that we need a singular clear message that can show the public the difference. If only some doctors are highlighting the differences, while others just work really hard on patient care and ignore public relations while the midlevels have a singular large organization attempting to educate the public of the exact opposite - "there is no difference in outcomes" "we provide more patient centered care" or the deceptive: "I'm a doctor" - yet they are a DNP etc.

This is an important debate. As medical students, we can't just focus on grades, boards, research, etc. while neglecting the public relations and business side of medicine.

Thanks for the input ivfmd. I hope future physicians can find a way to work as a team to educate the public about what we do. The government is going to open up regulations to save money, so we need to work together or our training will become less important.

In essence, we have a great product but no marketing. While they have a inferior product and incredible marketing + governmental support.

 

[ivfmd]

Agreed.

You say "physicians will have a difficult time educating the masses". I agree.

But it's far from impossible. There are many many doctors who are providing superior product. Some of it might be beyond what others are willing to do (giving out their cell phone #'s to patients, seeing patients in the evenings and on weekends, spending extra time talking with patients), but those who deliver on their promises have been greatly rewarded. This is the actually the entire foundation of CONCIERGE MEDICINE.

If an MD's product to a patient is a 5 minute rushed conversation, ordering an UA and writing a prescription to treat a UTI, who would blame a patient for preferring that same experience with a PA/NP for half the price or less.

If however, the MD spends an hour exploring the underlying reasons for this patient's frequent recurrent UTI's especially as how it related to his/her quality of life and other health issues so that the patient walks away feeling very well-cared for, then (some) patients would be willing to pay what it is worth to them. Those who value it would compensate the doctor accordingly. Those who don't value it will stick with the NP/PA's that their managed care plans give to them for free.

I cite this story as a general example. It is not meant to be an exact scenario, but you get the point.

I will also agree there are many underlying forces working (intentionally or indirectly) to undermine this concept of free-market medical services, but that just means it's more challenging to achieve, not impossible to achieve.

Just the very fact that you are thinking about it at this stage in your career bodes well for your future. Best of luck.

 

[munchymanRX]

If you're californian, or plan on practicing in the state, WRITE YOUR CONGRESSPEOPLE. Internet discussion on a forum where most of us share opinions to begin with on NPs having expanded practice rights is largely fruitless.

 

[JShephard]

If you're californian, or plan on practicing in the state, WRITE YOUR CONGRESSPEOPLE. Internet discussion on a forum where most of us share opinions to begin with on NPs having expanded practice rights is largely fruitless.

Right on!

Let's post in a medical student forum about it. That'll show them.

I feel better. I did my part.

Discussions are productive because they can help generate ideas.

I agree that just complaining is of no use, but I think if you look at the attending who just posted - we're trying to define a problem and think of solutions.

Thanks for the comments though, it reminds us that ideas need to be followed by action and leadership.

 

[JourneyAgent]

Discussions are productive because they can help generate ideas.

I agree that just complaining is of no use, but I think if you look at the attending who just posted - we're trying to define a problem and think of solutions.

Thanks for the comments though, it reminds us that ideas need to be followed by action and leadership.

Indeed. And I like his/her approach also. Personally that is, because I think psych--my field of interest--has potential for this kind of approach. However, I think REI is not typical. And lends itself, almost exclusively, to patients with disposable income that want good, personalized service.

Are we to presume the general pediatrician whose parents just need their kid's shots and paperwork in order to go to kindergarten has the same options?

In their case, yours and the other protest oriented poster points are more poignant. But poignance applies to tragic plays, and I think that's really what we're looking at for the rank and file primary care fields. Tuition will continue to climb steeply. The financiers will continue to net good returns, the faster degrees with less cumbersome training will arrive as nearly equal players in the provider market place with much less debt overhead. So the big squeeze will hit them the hardest. I mean look at peds in some places. Board certified pediatricians starting at less than 100,000. Significantly less I've heard. I like kids, but there's no way I'm going to try to tackle my debt at those market rates. And this category of opportunities for us will just expand.

Protests won't change the economic pressures. Which in turn fuel the deceptive political narratives of any group that want to seize more license while offering the public cheaper service.

I don't mind sounding pessimistic on this one. Realism is your best ally in this case. And opportunities for entrepreneurial activities in and related to medicine will be key in the future in my opinion.

So with regards to your perspective on how we need to learn more business related stuff: part of that has to do with looking at potential careers with this in mind.

I know from battling insurance companies for my own work injury and subsequent problems that I will try anything I can to not spend the rest of my career wrangling money for my services out these deliberately bureaucratic swamps. They just try suck the will out of you so you just give up. I hate them. I want free of them. If not in PP then for a federal agency one of the systems that combine coverage with the medical care.

But being an entrepreneur is my dream at this point.

REI lends itself to this. Child Psych lends itself to this. We should think of some others....

 

[xenotype]

I think if the government is going to pay hundreds of billions of dollars for healthcare, then minimum standards of competence of the providers receiving the funds would be an important regulatory check. REI is a niche and probably wouldn't even be covered in an NHS type system providing a basic level of healthcare. Quality primary, acute, and inpatient care is not a niche that should be left to the absolute free market (read: bill medicare with no credentials) when taxpayer funds are significantly used to pay for them, nor should patients receiving this substantial support be able to spend it in any way they please. I do not agree with ivfmd. There has to be standards when public money is involved, and that set of standards needs to be universal instead of two tiered (NP and MD) as it currently is.

 

[ivfmd]

If you're californian, or plan on practicing in the state, WRITE YOUR CONGRESSPEOPLE. Internet discussion on a forum where most of us share opinions to begin with on NPs having expanded practice rights is largely fruitless.

Interesting discussion here. Coincidentally, I was just discussing these very topics with my med students (MS3's) in clinic.

I invite you all to take a minute to think outside the box. Ask yourself these questions. By the way, I'm not asking for an answer like Yes or No or 3.0578. Rather I'm inviting you to look at the big picture and think a bit differently.

I'm going to use the world "political" for lack of a better word, but first, I'll define the way I'm using it here.

Imaging two extreme worlds, one that is 0% "political" and another that is 100% "political". By the way, our real world is somewhere in between.

In a 0% political world, ones success is determined solely by our own hard work - hard work spent on making other people happy. So, using medicine, as an example, since we're doctors (and future doctors) here, in a 0% political world, you would open an office and spread the word that you are going to spend your time/energy doing surgery and giving advice and suggesting medications etc to help solve other people's medical problems. People then come in and you negotiate terms. "You give me $200 and I'll spend 30 minutes talking with you in hopes of figuring out your best treatment strategy." "You pay me $400 and I'll perform an office procedure to remove your mole" "You pay me $1000 and I'll perform a C-Section when the time comes to help your breech-position baby be born safely"

Make people happier, give them more value and they are willing to pay you more.



In a 100% political world, ones "success", (this time I put it in quotes because it's arguable whether success within this paradigm, is truly success from a moral perspective) is determined solely by how one games the system to placate the "powers that be". For examples, for many doctors, their financial "success" is not determined by the extent they please the patient. Believe it or not, it is really determined by how many encounters they generate and how many of each specific CPT code they submit to the insurance company or to the government and what kind of contracts they sign. Now, some of you immediately are shouting "that's ludicrous". That's not how medicine works! I invite you to ask a doctor whose practice is heavily weighted towards managed care and ask what determines whether his revenues go up or down in a given quarter.

So back to the question. Do we live in a system that is closer to 0% political or 100% political? The more that it is 0%, the better we would be served becoming a better doctor, giving more value to our patients and doing what it takes customer-service-wise to make our patients happy so that we can earn, deserve and command a higher price scale. The more we live in a 100% political world, the better we would be served "writing congressmen", paying lobbyists to "influence" congressmen, sending your billers to coding camp to learn coding tricks etc.

munchymanRX, I respect your right to have an opinion. You say that talking on a forum is not that useful. Fine, I'll neither disagree nor agree with that. But then you go on to tell people to write their congressmen. Ask yourself how truly useful that tactic is or isn't?

So in one scenario, if 100 medical students write their congressmen 10 times a year and in another scenario 0 medical students write their congressman, what do you think is the difference in % chance that the laws will be changed to limit PA/NP's scope of activity? In your worldview, that's one of the thing that makes the most difference?

Why should I believe or not believe that based on evidence of the real world as we see it?

I appreciate your feedback and your understanding that my goal is for us to educate each other.

 

[ivfmd]

when taxpayer funds are significantly used to pay for them, nor should patients receiving this substantial support be able to spend it in any way they please. I do not agree with ivfmd. There has to be standards when public money is involved.

I will concede to you on this.

It's a different matter when third party payment is involved.

From a moral perspective, the person who is paying the money should have the say on how that money is spent.

With regards to the classic free-market model of person A and person B coming to an agreement, then they should be the sole decision-makers. (I guess you could make an exception if it is a 7 year old child).

So how do we address this if A (payor) is paying B (provider) to render medical care to C (patient). Then this longer becomes an interaction between B and C. It really becomes fundamentally a deal between A and B. C is just the bystander. This is one of the reasons medicine has become the way it is today. To complicate it further, what if A is not an individual but a nation of taxpayers or a body of insurance company customers.

So xenotype if you are focusing the discussion on a model where the patient is just the recipient of the services, but the payment is primarily coming from a third source, then one could say that the decision is up to the payor if he wants it to go to an MD or a NP/PA. Isn't that the crux of this discussion originally? Whether politicians want to hire NP/PA's for a particular scope of service or hire MD/DO's only?

Now to further further complicate this, one could argue that C does have a say because in an indirect way, he is paying as well, because C (patient) pays A (politician or insurance company) who then keep some of the money for themselves and allocate the rest to B.

And THIS is exactly why healthcare is such a complex topic.

This makes a small argument towards taking into consideration just how much of your future chosen specialty is bureaucratized/politicized and how much of it is free-market. That's certainly not the only consideration in your future happiness, but it's not entirely insignificant neither. 🙂

 

[ManaPool]

tl;dr

 

[xenotype]

So xenotype if you are focusing the discussion on a model where the patient is just the recipient of the services, but the payment is primarily coming from a third source, then one could say that the decision is up to the payor if he wants it to go to an MD or a NP/PA. Isn't that the crux of this discussion originally? Whether politicians want to hire NP/PA's for a particular scope of service or hire MD/DO's only?

Now to further further complicate this, one could argue that C does have a say because in an indirect way, he is paying as well, because C (patient) pays A (politician or insurance company) who then keep some of the money for themselves and allocate the rest to B.

And THIS is exactly why healthcare is such a complex topic.

This makes a small argument towards taking into consideration just how much of your future chosen specialty is bureaucratized/politicized and how much of it is free-market. That's certainly not the only consideration in your future happiness, but it's not entirely insignificant neither. 🙂

Patients at large do not pay politicians. That really isn't the flow of money in the political game. Most of the money comes from business interests, which is used by politicians to influence how patients vote. The payer has most of the power provided they don't make a decision so radically unacceptable to patients that it drastically changes the way they vote in elections. My contention is that the payer needs to decide what its definition of competence is.

 

[ivfmd]

The payer has most of the power provided they don't make a decision so radically unacceptable to patients that it drastically changes the way they vote in elections. My contention is that the payer needs to decide what its definition of competence is.

My apologies, but I am not clear on what you mean. When you refer to the payer, are you referring to the government or to insurance companies? I tried to analyze your comments either way, but it's still not clear. Unfortunately, such is the limitation of discussion via back and forth messages on the internet. I'm guessing if we were having an actual live conversation, it would be easier.

In any case, I wish you and your classmates the best in your selection of your future specialties. Would you agree that medicine in the next 10 years will be very different from medicine 10 years ago with respect to the level of bureaucracy that most doctors will have to face?

The original topic of this thread (future impact of PA/NPs) is relevant as there will be greater pressure than ever to cut costs, and as such, the choice of specialty can make a tremendous difference as to ones vulnerability to politically motivated price controls on doctors.

 

[xenotype]

My apologies, but I am not clear on what you mean. When you refer to the payer, are you referring to the government or to insurance companies? I tried to analyze your comments either way, but it's still not clear. Unfortunately, such is the limitation of discussion via back and forth messages on the internet. I'm guessing if we were having an actual live conversation, it would be easier.

In any case, I wish you and your classmates the best in your selection of your future specialties. Would you agree that medicine in the next 10 years will be very different from medicine 10 years ago with respect to the level of bureaucracy that most doctors will have to face?

The original topic of this thread (future impact of PA/NPs) is relevant as there will be greater pressure than ever to cut costs, and as such, the choice of specialty can make a tremendous difference as to ones vulnerability to politically motivated price controls on doctors.

Medicare largely sets the reimbursement rates that insurance companies use, and insurance companies really only compete with each other in the sense that your power company 'competes' with the one serving the next county over. So I mean both when I say payer.

 

[The kitchen sink]

A physician with good business savvy that does not compromise the quality of care delivered will be immune to the increases in scope of practice of midlevel providers imo.

 

[ivfmd]

A physician with good business savvy that does not compromise the quality of care delivered will be immune to the increases in scope of practice of midlevel providers imo.

Well-said. Relatively-immune at least, although the particular specialty and type of services will have an influence on just HOW MUCH more desirable your brand of care is than the MD/NP/PA down the street.


----------------------------------------
Edit:
That should have read " Relatively-immune at least, although the particular specialty and type of services will have an influence on just HOW MUCH more desirable your brand of care WILL NEED TO BE than the MD/NP/PA down the street, in order to command a higher fee.

 

[JourneyAgent]

Well-said. Relatively-immune at least, although the particular specialty and type of services will have an influence on just HOW MUCH more desirable your brand of care is than the MD/NP/PA down the street.

Yeah, demand, scarcity, and a more unique product would give you the necessary leverage. I would extend your ideas, though, to say it isn't that feasible in some field and almost a requirement on the extreme end in your case. I mean, are there any public service REI outfits. It's not reimbursed by any of the public payors right?