Creation of "associate physician" in VA

[mvenus929]

It's interesting that you say that - most of the senior residents that I've worked with on medicine rotations feel the third year is a complete waste of time and think they are more than adequately trained after PGY-2. Would you agree or do you think you still have much to gain from your final year?

Well, I can't speak to the training of an IM residency, since I'm in peds, but most all of the third year residents I've spoken to in my program are terrified of being out on their own, even though we generally train our residents very well. And those who are completely confident about going out on their own scare me. That might have something to do with the structure of most peds programs--we do some intern work and some senior work as second years, but we really learn how to hone our senior skills in third year when we are running the wards teams. We also don't have as much independence through residency as I hear IM does--we do NICU our first year, but not PICU at the vast majority of places, and there are fewer and fewer programs where the NICU and PICU attendings are not in house 24/7. So while an IM intern may be managing sick ICU patients alone 2 months into intern year, we manage sorta sick kids with attendings very close at hand for most of our residency.

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[deleted547631]

https://legiscan.com/VA/bill/HB900/2016

Thoughts? Seems to be a way to avoid expanding GME funding. (And more confusion over physician assistants, "physician associates", etc.) Any other states that have this?

So, how is exploring use of and implementing 'associate physicians' (aka the Missouri model) not preferable to the VA (Veterans Affairs, not Virginia) proposing to allow NPs full autonomy as has been the latest proposal here: http://www.va.gov/opa/pressrel/pressrelease.cfm?id=2793

 

[W19]

@OutRun We are diluting our brand , so it's better to let NP get rid of that brand altogether...

 

[deleted547631]

@OutRun We are diluting our brand , so let NP get rid of that brand altogether...

Exactly.

http://www.jgme.org/doi/full/10.4300/JGME-D-15-00341.1

"Accumulating evidence suggests that midlevel providers deliver high-quality, cost-effective care. Thus, while an assistant physician license might be granted to inadequately trained individuals to practice in settings in which they have little expertise, midlevel providers are specifically educated and credentialed in a narrowly defined focus."

I can't help but be annoyed at the comment above by its physician author. So, a PA that spent an average of 54 weeks total mostly shadowing a physician or another PA, is adequately trained whereas a medical school graduate that completed two years of a more rigorous clinical education and passed USMLE Step 1, 2CK, 2CS, and 3 is not only inadequate but can't somehow be expected to function at or above the level of a PA from day one?

Why does 'organized' medicine hate itself so much?

 

[Setto]

Exactly.

http://www.jgme.org/doi/full/10.4300/JGME-D-15-00341.1

"Accumulating evidence suggests that midlevel providers deliver high-quality, cost-effective care. Thus, while an assistant physician license might be granted to inadequately trained individuals to practice in settings in which they have little expertise, midlevel providers are specifically educated and credentialed in a narrowly defined focus."

I can't help but be annoyed at the comment above by its physician author. So, a PA that spent an average of 54 weeks total mostly shadowing a physician or another PA, is adequately trained whereas a medical school graduate that completed two years of a more rigorous clinical education and passed USMLE Step 1, 2CK, 2CS, and 3 is not only inadequate but can't somehow be expected to function at or above the level of a PA from day one?

Why does 'organized' medicine hate itself so much?

But what if we compare these two candidates:

Med student - Always wanted ENT, did all sorts of ENT research, rotations, shadowing etc. and scores 222 on their Step 1. Applied only to ENT, didn't get into anything and decide that they will celebrate their life being over by going into the AP program.

PA - Everything they did was aimed towards primary care.

Who do you think would be a better candidate to work in primary care?

 

[Taddy Mason]

But what if we compare these two candidates:

Med student - Always wanted ENT, did all sorts of ENT research, rotations, shadowing etc. and scores 222 on their Step 1. Applied only to ENT, didn't get into anything and decide that they will celebrate their life being over by going into the AP program.

PA - Everything they did was aimed towards primary care.

Who do you think would be a better candidate to work in primary care?

The one that didn't disgrace his/her parents, school, and the field of ENT.

 

[Lee Ik-jun MD]

not to pile on PA and NP

ok, so this just happened a few minutes ago..
i'm covering the whole hospital and i got paged for an abnormal EKG from a neonate
i look at kiddo and assess him and made the call of sending him to NICU for further observation.

The NICU, since it's the weekend has an NP instead of the Peds intensivist.
SHE completely rejected my order , without even seeing the patient
she said, baby is not having fever .. just do a septic work up and observe on the floor.

WTF!

i'm sorry but i can't have a higher level of conversation with mid level providers sometimes
which i can DO with a medical student anytime

 

[wizzed101]

not to pile on PA and NP

ok, so this just happened a few minutes ago..
i'm covering the whole hospital and i got paged for an abnormal EKG from a neonate
i look at kiddo and assess him and made the call of sending him to NICU for further observation.

The NICU, since it's the weekend has an NP instead of the Peds intensivist.
SHE completely rejected my order , without even seeing the patient
she said, baby is not having fever .. just do a septic work up and observe on the floor.

WTF!

i'm sorry but i can't have a higher level of conversation with mid level providers sometimes
which i can DO with a medical student anytime

What courses of action, if any, can be taken against that NP in such situation?

 

[Crayola227]

.

 

[Psai]

not to pile on PA and NP

ok, so this just happened a few minutes ago..
i'm covering the whole hospital and i got paged for an abnormal EKG from a neonate
i look at kiddo and assess him and made the call of sending him to NICU for further observation.

The NICU, since it's the weekend has an NP instead of the Peds intensivist.
SHE completely rejected my order , without even seeing the patient
she said, baby is not having fever .. just do a septic work up and observe on the floor.

WTF!

i'm sorry but i can't have a higher level of conversation with mid level providers sometimes
which i can DO with a medical student anytime

wtf? Do a septic workup for not a fever...does not compute

 

[Crayola227]

not to pile on PA and NP

ok, so this just happened a few minutes ago..
i'm covering the whole hospital and i got paged for an abnormal EKG from a neonate
i look at kiddo and assess him and made the call of sending him to NICU for further observation.

The NICU, since it's the weekend has an NP instead of the Peds intensivist.
SHE completely rejected my order , without even seeing the patient
she said, baby is not having fever .. just do a septic work up and observe on the floor.

WTF!

i'm sorry but i can't have a higher level of conversation with mid level providers sometimes
which i can DO with a medical student anytime

Exactly. I've said it before, it takes an MD to understand why these other providers without one just don't totally get it. Their ed doesn't prepare them to *totally get it*.

 

[ACSurgeon]

But what if we compare these two candidates:

Med student - Always wanted ENT, did all sorts of ENT research, rotations, shadowing etc. and scores 222 on their Step 1. Applied only to ENT, didn't get into anything and decide that they will celebrate their life being over by going into the AP program.

PA - Everything they did was aimed towards primary care.

Who do you think would be a better candidate to work in primary care?

You realize the ENT applicant probably did well on their IM/FM/Peds/OB/surgery rotations, right? It's not like someone who's interested in ENT spends most of their clinical rotations "focused on ENT".

So yes, any medical student who graduates should be able to perform better than a fresh PA. Don't forget that PAs also do a variety of rotations and aren't allowed to "take an interest" in primary care and do nothing else. Also, new PAs get extensive on the job training before they can function well. An AP physician with half the amount of on the job training should be able to catch on and do fine.

 

[ACSurgeon]

not to pile on PA and NP

ok, so this just happened a few minutes ago..
i'm covering the whole hospital and i got paged for an abnormal EKG from a neonate
i look at kiddo and assess him and made the call of sending him to NICU for further observation.

The NICU, since it's the weekend has an NP instead of the Peds intensivist.
SHE completely rejected my order , without even seeing the patient
she said, baby is not having fever .. just do a septic work up and observe on the floor.

WTF!

i'm sorry but i can't have a higher level of conversation with mid level providers sometimes
which i can DO with a medical student anytime

- you said kiddo so I had a hard time reading the rest of the post seriously
- you never told us what your indication for icu transfer. "Abnormal EKG" can be something serious or nothing at all
- just the other day I got consulted for "sepsis of unknown origin" by the medicine team. Patient had no fever, normal HR and BP, and had an elevated WBC as his only SIRS criteria.
- why couldn't you call the intensivist responsible for the unit? Just because the NP is in house doesn't mean there's no intensivist on call from home, correct? Ultimately, doing the right thing for the patient is what matters.

Not a great example of MD vs APP. Im also not sure why sdn keeps having those discussions. It's evident to all of us that we have far more advanced education and training. Venting on sdn isn't the answer. We need to do something at a national level through existing or new lobby efforts.

 

[ACSurgeon]

What courses of action, if any, can be taken against that NP in such situation?

You can call the MD that is ultimately responsible. Don't be afraid to go up the chain of command if patient care depends on it. Now, if you don't have a medically sound reason, you'll probably get chewed out for calling an attending at home to complain about the NP if the NP was actually doing the right thing (or even an acceptable thing). You should never get in a pissing match, but also don't let anyone other than the highest person on the team make a decision that you truly believe hurts the patient.

 

[Psai]

But what if we compare these two candidates:

Med student - Always wanted ENT, did all sorts of ENT research, rotations, shadowing etc. and scores 222 on their Step 1. Applied only to ENT, didn't get into anything and decide that they will celebrate their life being over by going into the AP program.

PA - Everything they did was aimed towards primary care.

Who do you think would be a better candidate to work in primary care?

ENT guy easily. It's not even close and the fact that you think that this is a valid question makes me wonder about you.

- you said kiddo so I had a hard time reading the rest of the post seriously
- you never told us what your indication for icu transfer. "Abnormal EKG" can be something serious or nothing at all
- just the other day I got consulted for "sepsis of unknown origin" by the medicine team. Patient bad no fever, normal HR and BP, and had an elevated WBC as his only SIRS criteria.
- why couldn't you call the intensivist responsible for the unit? Just because the NP is in house doesn't mean there's no intensivist on call from home, correct? Ultimately, doing the right thing for the patient is what matters.

Not a great example of MD vs APP. Im also not sure why sdn keeps having those discussions. It's evident to all of us that we have far more advanced education and training. Venting on sdn isn't the answer. We need to do something at a national level through existing or no lobby efforts.

Seems like everyone even tangentially related to peds says kiddo. I've heard grizzled 60 year old pediatric surgeons use that word.

 

[ACSurgeon]

Seems like everyone even tangentially related to peds says kiddo. I've heard grizzled 60 year old pediatric surgeons use that word.

I know... It doesn't make it any easier to take seriously

 

[Law2Doc]

ENT guy easily. It's not even close ...

ENT is a very competitive field. If you aspire to that you are going to need to have solid evaluations in all your primary care rotations, not just surgical ones. This isn't like college where you get to major in something and take mostly those courses. And med school is not very ENT oriented -- you'd at best do a few away rotations in ENT compared to many more months of rotations in primary care fields. By contrast someone else in med school could do significantly worse in his desired field than the ENT guy and still end up in one of the less competitive primary care fields. So yes the ENT guy or anyone bent on a competitive field would do better, because he already had to do well in those rotations, he'd just enjoy it less.

But neither med student nor PA would be ready to function independently after school.

 

[Lee Ik-jun MD]

You can call the MD that is ultimately responsible. Don't be afraid to go up the chain of command if patient care depends on it. Now, if you don't have a medically sound reason, you'll probably get chewed out for calling an attending at home to complain about the NP if the NP was actually doing the right thing (or even an acceptable thing). You should never get in a pissing match, but also don't let anyone other than the highest person on the team make a decision that you truly believe hurts the patient.

i was trying to be vague so as to comply with HIPAA.
anyway the 14 hr old neonate was having episodes of bradycardia 70's and tachycardia 200
hypoglycemia in the 30 even after breast feeding.
on a spot EKG it says abnormal
i read it as ventricular tachycardia but still sinus rhythm

i just want the baby to be monitored on teli.
anyway, the ward attending agreed with my decision to send the "kiddo" to NICU
however, it all depends if the NICU will accept the patient.

i can't call the Peds Intensivist directly.. he will just say talk to the NP on duty and hang up.
and whatever the NP decides, he rubber stamps it.

 

[Crayola227]

i was trying to be vague so as to comply with HIPAA.
anyway the 14 hr old neonate was having episodes of bradycardia 70's and tachycardia 200
hypoglycemia in the 30 even after breast feeding.
on a spot EKG it says abnormal
i read it as ventricular tachycardia but still sinus rhythm

i just want the baby to be monitored on teli.
anyway, the ward attending agreed with my decision to send the "kiddo" to NICU
however, it all depends if the NICU will accept the patient.

i can't call the Peds Intensivist directly.. he will just say talk to the NP on duty and hang up.
and whatever the NP decides, he rubber stamps it.

yes, I have seen a patient die from a turf war

that's what you're describing

 

[Psai]

i was trying to be vague so as to comply with HIPAA.
anyway the 14 hr old neonate was having episodes of bradycardia 70's and tachycardia 200
hypoglycemia in the 30 even after breast feeding.
on a spot EKG it says abnormal
i read it as ventricular tachycardia but still sinus rhythm

i just want the baby to be monitored on teli.
anyway, the ward attending agreed with my decision to send the "kiddo" to NICU
however, it all depends if the NICU will accept the patient.

i can't call the Peds Intensivist directly.. he will just say talk to the NP on duty and hang up.
and whatever the NP decides, he rubber stamps it.

You know if something bad happens, he will deny talking to you and throw you under the bus. If it's not in the chart it didn't happen. I would call and document your conversation.

 

[ACSurgeon]

i was trying to be vague so as to comply with HIPAA.
anyway the 14 hr old neonate was having episodes of bradycardia 70's and tachycardia 200
hypoglycemia in the 30 even after breast feeding.
on a spot EKG it says abnormal
i read it as ventricular tachycardia but still sinus rhythm

i just want the baby to be monitored on teli.
anyway, the ward attending agreed with my decision to send the "kiddo" to NICU
however, it all depends if the NICU will accept the patient.

i can't call the Peds Intensivist directly.. he will just say talk to the NP on duty and hang up.
and whatever the NP decides, he rubber stamps it.

That's when a staff to staff discussion needs to happen.

 

[deleted547631]

But what if we compare these two candidates:

Med student - Always wanted ENT, did all sorts of ENT research, rotations, shadowing etc. and scores 222 on their Step 1. Applied only to ENT, didn't get into anything and decide that they will celebrate their life being over by going into the AP program.

PA - Everything they did was aimed towards primary care.

Who do you think would be a better candidate to work in primary care?

Jokes about Mr or Ms 222 Step 1-'My Life is Ruined' aside, the AP route is for doctors whom couldn't get a residency for whatever reason. Let's utilize their training and certification and put them in these roles so that they can fulfill a need. Perhaps, limit it to US citizens and PR green card holders if there's a legitimate worry about a flood of FMGs 'braindraining' the countries they're emigrating from.

I'd like to think that such applicants applying to these AP programs most likely are: 1) seeking eventual residency, 2) happy to able to put their education to use and earn a living, and 3) serving a public need. Remember, before the family medicine specialty was created there were general practitioners who need only complete an intern year and were ready for practice. Aren't general medical officers (GMOs) in the Navy and Army essentially acting as 'associate physicians' after just completing intern year?

 

[Brahnold Bloodaxe]

Jokes about Mr or Ms 222 Step 1-'My Life is Ruined' aside, the AP route is for doctors whom couldn't get a residency for whatever reason. Let's utilize their training and certification and put them in these roles so that they can fulfill a need. Perhaps, limit it to US citizens and PR green card holders if there's a legitimate worry about a flood of FMGs 'braindraining' the countries they're emigrating from.

Couldn't care less about the bolded. The much more powerful reason to worry about a flood of FMGs practicing in the US without doing residency is the legitimate worry about what that would do to our salaries.

 

[Crayola227]

I think we're jumping the gun. If I recall the MO law, you have to be US accredited medical school.

There's another law in another state that ONLY applies to graduates of the school in that state, or maybe those with strong ties to the state.

I don't think these laws have opened the floodgates for FMGs.

 

[W19]

We are 'ceding' primary care to NP anyway, so I would ok if some states are opening the floodgate for FMG to become PCP... There is a reason why NP organizations are fiercely fighting these laws.

 

[Brahnold Bloodaxe]

I think we're jumping the gun. If I recall the MO law, you have to be US accredited medical school.

There's another law in another state that ONLY applies to graduates of the school in that state, or maybe those with strong ties to the state.

I don't think these laws have opened the floodgates for FMGs.

I hope you are right. Do you by any chance have a link that specifies the details of these laws?

 

[Crayola227]

Nope:





http://www.pr.mo.gov/boards/healingarts/AP Rules.pdf

http://www.jgme.org/doi/pdf/10.4300/JGME-D-15-00341.1

One of the states that has made one of these laws it is restricted to grads in that state. Maybe those with ties I can't remember.

I'm not sure how many schools are in the World Directory. I'm still not convinced that this throws the doors wide open to FMGs.

In any case, thank you for clarifying my error.

 

[Setto]

ENT guy easily. It's not even close and the fact that you think that this is a valid question makes me wonder about you.



Seems like everyone even tangentially related to peds says kiddo. I've heard grizzled 60 year old pediatric surgeons use that word.

I know right? It's almost like I was referencing a post on this board and being tongue in cheek about the fact that some students sell their skills and abilities short because they under perform on a single test.

http://forums.studentdoctor.net/threads/well-i-just-ruined-my-life.1212463/

 

[deleted547631]

It's interesting that you say that - most of the senior residents that I've worked with on medicine rotations feel the third year is a complete waste of time and think they are more than adequately trained after PGY-2. Would you agree or do you think you still have much to gain from your final year?

In Canada, their FM residencies are two years in length. I'd consider their training as equivalent. I also see shortening FM in the US to two years as a way to alleviate the primary care shortage but that's a different discussion than this.

Example: https://familymedicine.queensu.ca/education/prospective/overview

 

[W19]

In Canada, their FM residencies are two years in length. I'd consider their training as equivalent. I also see shortening FM in the US to two years as a way to alleviate the primary care shortage but that's a different discussion than this.

Example: https://familymedicine.queensu.ca/education/prospective/overview

There was talk underway about making FM a 4-year residency... There was a thread about it in SDN... Our hospitals want free labor!

http://www.annfammed.org/content/10/1/84.full

A lot of these stuff seem to be arbitrary... i.e EM 4-year vs. 3-year

 

[GypsyHummus]

One thing schools could do is a fast track program like what LECOM does. You pledge to be in either family medicine or general internal medicine before medical school and the training is only 3 years not 4, cutting out the surgical requirements (pun not intended).

I say Go a step further. Have special MD/DO programs for pumping out GP grads that is 3 years of Med school and a 2 or even 1 year general practice residency. Make becoming a doctor 5 years and people might actually go into primary care in rural and underserved areas. Dental school takes 4 years for you are a fully fledged Doctor who can independently preform procedures on people, literally surgery. Optometry school takes 4 years too and they are allowed to do laser surgeries in select states. Why not medicine?

 

[Crayola227]

One thing schools could do is a fast track program like what LECOM does. You pledge to be in either family medicine or general internal medicine before medical school and the training is only 3 years not 4, cutting out the surgical requirements (pun not intended).

I say Go a step further. Have special MD/DO programs for pumping out GP grads that is 3 years of Med school and a 2 or even 1 year general practice residency. Make becoming a doctor 5 years and people might actually go into primary care in rural and underserved areas. Dental school takes 4 years for you are a fully fledged Doctor who can independently preform procedures on people, literally surgery. Optometry school takes 4 years too and they are allowed to do laser surgeries in select states. Why not medicine?

No. You are pre-health. You have no idea.

In my post history is an impassioned defense of why those not going into surgery still need surgical exposure.

 

[GypsyHummus]

No. You are pre-health. You have no idea.

In my post history is an impassioned defense of why those not going into surgery still need surgical exposure.

I agree that some surgical exposure would be beneficial to General Practice Docs. Thats what the GP residency would do. 2 year residency seems fine.

 

[Mansamusa]

No. You are pre-health. You have no idea.

In my post history is an impassioned defense of why those not going into surgery still need surgical exposure.

Exposure in residency or med school? Because the 3 yrs programs still do all the normal clinical rotations

 

[deleted547631]

The Missouri 'Associate Physician' program is moving forward, albeit slowly. It will be now forwarded to Missouri Secretary of State before promulgating: http://www.pr.mo.gov/boards/healingarts/RulemakingFlowSheet.pdf