Dirty Little Secret of PA/Physician Drama

[Birdstrike]

As physicians, the training road is long and arduous. We often find ourselves cursing it’s seemingly unnecessary length, inefficiency, and scut-work devoid of learning value. We often commiserate that we could have become just as effective at doing our jobs with a shorter, more efficient, fast-tracked education.

Could it be that PAs found a way to do exactly that, to cut the unnecessary waste out of their educational process?

If so, shouldn’t they be praised and their more efficient method of education modeled, rather than derided and devalued?

Who’s smarter, the one who spent over a decade training to be $350,000 in debt and finds their job threatened for being too expensive, over-trained and over qualified?

Or the one who took a training fast track and enjoys most, if not all, of the benefits of being a physician, possibly including taking the actual physician’s job?

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[bravotwozero]

I don't think PAs are as effective as us in doing our jobs. @RustedFox will gladly list examples to the contrary, if you need proof.

 

[Birdstrike]

I don't think PAs are as effective as us in doing our jobs. @RustedFox will gladly list examples to the contrary, if you need proof.

That depends how you define “effective at doing the job.” Does it matter how you and I as physicians define job “effectiveness”?

I say no. I say that our employers define how effective we are at our jobs. They want a certain service, for a certain price. They don’t seem to care much about your or my definition of “effective.” They don’t seem to care about your, my or @RustedFox ‘s examples of PA’s doing, or not doing, their jobs. If they continue to employ them, then they are by definition considering them as doing their job adequately.

Employers of physicians and PAs don’t seem to care about a lawsuit here, or a lawsuit there, against a doctor or a PA.

In fact, in your example, I suspect the hospital CEO would conclude, “I don’t know care who ays they did better or who didn’t. You both got sued.”

Our employers simply don’t care how you and I define “quality” of care. They don’t care who we think is “better qualified.” They have their own definition of quality and job effectiveness. And it’s not the same as ours.

 

[Birdstrike]

Hospital/CMG CEO Viewpoint:

A) PA #1: Will see lots of patients, mostly not get sued, occasionally will. Costs me: X dollars per year.

B) Physician #1: Will see lots of patients, mostly not get sued, occasionally will. Costs me: 2X dollars per year.

Spot the difference?

“A” looks a lot sexier than “B” on the employee selection shelf to the CEO, every time.

That is literally how they see it. It’s literally that simple to them. Especially if they can keep a token doc around to be the fall guy, and create their desired illusion of him or her waving a magic wand of “supervision” over their shop ensuring perfect outcomes by an army of PAs, however impossible.

This ain’t my viewpoint. That’s the viewpoint of those that employ doctors currently.

 

[Birdstrike]

If you don’t understand how your hospital and CMG CEOs view your employment, you’re in for a world of hurt.

They don’t care how much training you and I did, only how you can convert that training to a dollar for dollar return to them, in exchange for your salary.

 

[bronx43]

I don't think PAs are as effective as us in doing our jobs. @RustedFox will gladly list examples to the contrary, if you need proof.

Ok, but the problem is "listing examples" and "proof" are not the same thing...

 

[southerndoc]

If you don’t understand how your hospital and CMG CEOs view your employment, you’re in for a world of hurt.

They don’t care how much training you and I did, only how you can convert that training to a dollar for dollar return to them, in exchange for your salary.

That's not true. Maybe at some places, but if they didn't care they wouldn't care to have board-certified EP's staffing their ER. Some hospitals may be like this, but not the majority.

 

[Tipsy McStagger]

Let us turn to the gospel of Durden for perhaps an apt analogy:

 

[Birdstrike]

That's not true. Maybe at some places, but if they didn't care they wouldn't care to have board-certified EP's staffing their ER. Some hospitals may be like this, but not the majority.

Your ED has no PAs?

 

[Tenk]

Let us turn to the gospel of Durden for perhaps an apt analogy:

God this movie is so damn good. Saw it in the theater as a teenager because my mom is dope af.

 

[Tenk]

Most PAs know that they are betas. I feel like the ones who pretend they are alphas are a very small minority they are just loud and obnoxious af. Almost all the ones I have met and known don’t want to be independent.

 

[TheComebacKid]

I strongly believe that the thousands of hours of additional training you get as a physician makes a difference in how well you can take care of patients. Maybe to a hospital CEO it's basically diminishing returns i.e. "okay, so what, we catch one more MI, or miss one less ectopic" and the cost doesn't justify the benefit in the whole scheme of things.

But when that one patient is your family member, it matters.

We should not be praising those for "being smarter" by taking less time to go through less training and less debt to do a "fine" job. We should be outraged that the standards have fallen in favor of financial profit.

The funniest thing to me about the whole issue with midlevels is that they actually think that they are "valued" in the system beyond the fact that they are cheaper. They think that they bring something clinically to the table in terms of better patient care (mind you with less training and virtually no educational standards and online degrees). They are being played and exploited just as much as we are. The C suite only cares about them because it helps their bottom line, not their patient outcomes. I'm glad I'm not in that category.

Am I disappointed that I put in all this work to get to the point of a collapsing job market, residency expansion etc that likely hurts my financial future? You are damn right I am. But I still sleep well at night knowing I didn't take a short cut. I am confident enough in my ability to make decisions for a patient without the need to ask anyone for help or some supervising physician to cosign my chart and take medicolegal responsibility. I'm pretty proud of that.

You can say employers define the effectiveness of our jobs. And maybe that's true. But there is still a part of me that defines my own personal success and effectiveness, that I value more than whatever my employer thinks. Idealistic? Sure. But I still think there's value in knowing you are the best trained person there is, and the buck stops with you.

 

[southerndoc]

Your ED has no PAs?

That's not my point. You make it sound like the CEO is only concerned about money and not about quality of care, and that is not the truth. Yes, we have PA's in our ER. They handle low acuity stuff primarily. We don't have a CEO/hospital VP that's eager to replace docs with PA's and have them staffing every patient in the ER.

 

[GeneralVeers]

That's not my point. You make it sound like the CEO is only concerned about money and not about quality of care, and that is not the truth. Yes, we have PA's in our ER. They handle low acuity stuff primarily. We don't have a CEO/hospital VP that's eager to replace docs with PA's and have them staffing every patient in the ER.

The primary hospital I work at has an evil CEO. The hospital is part of United Hospital Corporation, which is the largest and second most evil chain. The CEOs in my city compete against each other over profitability numbers. He's more than than glad to make more hallway beds, get us "LVO Stroke Certification" and let us start accepting neurosurgery transfers, despite no available beds, and terrible IUC staffing/care. HIs motto is "Cram them in, as patients = $$$". He'd have no compunction about having my CMG staff all PA/NPs if he could get a piece of the action.

 

[southerndoc]

The primary hospital I work at has an evil CEO. The hospital is part of United Hospital Corporation, which is the largest and second most evil chain. The CEOs in my city compete against each other over profitability numbers. He's more than than glad to make more hallway beds, get us "LVO Stroke Certification" and let us start accepting neurosurgery transfers, despite no available beds, and terrible IUC staffing/care. HIs motto is "Cram them in, as patients = $$$". He'd have no compunction about having my CMG staff all PA/NPs if he could get a piece of the action.

That's terrible. I'd find another place to work.

 

[bronx43]

I strongly believe that the thousands of hours of additional training you get as a physician makes a difference in how well you can take care of patients. Maybe to a hospital CEO it's basically diminishing returns i.e. "okay, so what, we catch one more MI, or miss one less ectopic" and the cost doesn't justify the benefit in the whole scheme of things.

But when that one patient is your family member, it matters.

We should not be praising those for "being smarter" by taking less time to go through less training and less debt to do a "fine" job. We should be outraged that the standards have fallen in favor of financial profit.

The funniest thing to me about the whole issue with midlevels is that they actually think that they are "valued" in the system beyond the fact that they are cheaper. They think that they bring something clinically to the table in terms of better patient care (mind you with less training and virtually no educational standards and online degrees). They are being played and exploited just as much as we are. The C suite only cares about them because it helps their bottom line, not their patient outcomes. I'm glad I'm not in that category.

Am I disappointed that I put in all this work to get to the point of a collapsing job market, residency expansion etc that likely hurts my financial future? You are damn right I am. But I still sleep well at night knowing I didn't take a short cut. I am confident enough in my ability to make decisions for a patient without the need to ask anyone for help or some supervising physician to cosign my chart and take medicolegal responsibility. I'm pretty proud of that.

You can say employers define the effectiveness of our jobs. And maybe that's true. But there is still a part of me that defines my own personal success and effectiveness, that I value more than whatever my employer thinks. Idealistic? Sure. But I still think there's value in knowing you are the best trained person there is, and the buck stops with you.

From what I've witnessed, I actually don't think the externality here is missing one more MI or missing one more ectopic... not missing isn't the problem. You can get a monkey to not miss ANY diseases. How? Over-test. Over-consult. Over-everything. That's what midlevels do from what I have seen. X complaint? Forget diving through clinical history and finding the pre-test probability. Just order the f'ing test. Test came back borderline abnormal? Call the on-call consultant.

The actual externality here is much more insidious. One that will never actually be picked up from within the system. It's that health care costs are untenable. Will that ever change? Probably? But we've been saying that for decades now.

 

[Birdstrike]

That's not my point. You make it sound like the CEO is only concerned about money and not about quality of care, and that is not the truth. Yes, we have PA's in our ER. They handle low acuity stuff primarily. We don't have a CEO/hospital VP that's eager to replace docs with PA's and have them staffing every patient in the ER.

I think hospital CEOs only care about healthcare because they have to. I truly believe, the minute they can find a way to replace doctors with cheaper mid-levels, they will. If they can find a way to replace mid-levels with even cheaper AI or computers, they will.

If hospital CEOs could make money in another without providing healthcare, I think they would. But if they could provide health care without making money, do you think they would?

 

[GeneralVeers]

That's terrible. I'd find another place to work.

Agreed. If the pay wasn't good I'd quit entirely. Nowhere better to work without moving cities unfortuantely.

 

[Kuratz]

Politicians and by proxy society betrayed physicians by making it so they couldn’t own hospitals. So now instead we get corporations whose main concern is profits and the shareholder. Brilliant. They don’t give a damn about patients. They’ve also stacked the deck against solo/small group practice. US healthcare from the patient side of things is an albatross of a ****ing scam and physicians stand no chance against mega-corps in the long run.

So on one hand socialized medicine sounds alright because **** it, let’s just see if it’s better than this nonsense. But on the other I can definitely see the government going with a PA/NP heavy model and low-salary take-it-or-leave it mentality with docs. Sucks really. I’m just glad my debt is reasonable and I’ll be able to pay it off if salaries in another field hold for a few more years.

What’s the solution? I don’t see one

 

[aafisahar]

I strongly believe that the thousands of hours of additional training you get as a physician makes a difference in how well you can take care of patients. Maybe to a hospital CEO it's basically diminishing returns i.e. "okay, so what, we catch one more MI, or miss one less ectopic" and the cost doesn't justify the benefit in the whole scheme of things.

But when that one patient is your family member, it matters.

We should not be praising those for "being smarter" by taking less time to go through less training and less debt to do a "fine" job. We should be outraged that the standards have fallen in favor of financial profit.

The funniest thing to me about the whole issue with midlevels is that they actually think that they are "valued" in the system beyond the fact that they are cheaper. They think that they bring something clinically to the table in terms of better patient care (mind you with less training and virtually no educational standards and online degrees). They are being played and exploited just as much as we are. The C suite only cares about them because it helps their bottom line, not their patient outcomes. I'm glad I'm not in that category.

Am I disappointed that I put in all this work to get to the point of a collapsing job market, residency expansion etc that likely hurts my financial future? You are damn right I am. But I still sleep well at night knowing I didn't take a short cut. I am confident enough in my ability to make decisions for a patient without the need to ask anyone for help or some supervising physician to cosign my chart and take medicolegal responsibility. I'm pretty proud of that.

You can say employers define the effectiveness of our jobs. And maybe that's true. But there is still a part of me that defines my own personal success and effectiveness, that I value more than whatever my employer thinks. Idealistic? Sure. But I still think there's value in knowing you are the best trained person there is, and the buck stops with you.

if our only argument is that it benefits patients and families, we are ****ed. patients and families haven't won a battle in healthcare since the 60s.

 

[namethatsmell]

It's not like this everywhere. I've been on staff for years at a place that doesn't have NP/PAs in the ED and there are no plans to bring on any them anytime soon. Quadruple physician coverage at peak levels. Non-profit health system that's physician-led at the highest levels, which really does make a difference in my experience.

 

[namethatsmell]

if our only argument is that it benefits patients and families, we are ****ed. patients and families haven't won a battle in healthcare since the 60s.

It's not the only argument. If you find your way into a hospital that actually cares about and feels responsible for patient care, outcomes, and costs, then you'll find yourself at a place that understands the value of physicians. These places are usually non-profit, physician-led, and have bland marketing.

They aren't the common shop these days, but they still exist.

 

[Sushirolls]

That's not my point. You make it sound like the CEO is only concerned about money and not about quality of care, and that is not the truth. Yes, we have PA's in our ER. They handle low acuity stuff primarily. We don't have a CEO/hospital VP that's eager to replace docs with PA's and have them staffing every patient in the ER.

Give it time, that CEO will be replaced and then you will get the reductionist version.

 

[Sushirolls]

It's not the only argument. If you find your way into a hospital that actually cares about and feels responsible for patient care, outcomes, and costs, then you'll find yourself at a place that understands the value of physicians. These places are usually non-profit, physician-led, and have bland marketing.

They aren't the common shop these days, but they still exist.

And with each passing day they will fold into the main stream, new leadership emerges and things turn to scat.

As a Psychiatrist I have worked at a for profit psych hospital and non-profit "christian" based health system and both we're equally scat but in slightly different ways.

 

[Sushirolls]

Politicians and by proxy society betrayed physicians by making it so they couldn’t own hospitals. So now instead we get corporations whose main concern is profits and the shareholder. Brilliant. They don’t give a damn about patients. They’ve also stacked the deck against solo/small group practice. US healthcare from the patient side of things is an albatross of a ****ing scam and physicians stand no chance against mega-corps in the long run.

So on one hand socialized medicine sounds alright because **** it, let’s just see if it’s better than this nonsense. But on the other I can definitely see the government going with a PA/NP heavy model and low-salary take-it-or-leave it mentality with docs. Sucks really. I’m just glad my debt is reasonable and I’ll be able to pay it off if salaries in another field hold for a few more years.

What’s the solution? I don’t see one

Legislatively fixing this, so Certificate of Need disappears and all the Stark laws gone is the only chance of putting healthcare back in the hands of physicians. Granted there will be some that emerge that are the exact same as the current model corporations, but to have any fighting chance this is the only way.

If I could I would strongly consider opening my own 8 or 10 bed psych unit with an ECT service I run, attached TMS, and outpatient clinic I run. Attached CLIA lab for providing injectable Suboxone for OUD services, ketamine infusions for refractory depression. But I can't.

 

[namethatsmell]

And with each passing day they will fold into the main stream, new leadership emerges and things turn to scat.

As a Psychiatrist I have worked at a for profit psych hospital and non-profit "christian" based health system and both we're equally scat but in slightly different ways.

Incorrect. I'm very familiar with two systems with the qualities I mentioned that have been continuing to expand and grow for the last 15 years. All the while taking market share from their local the HCA and UHS outfits. And I'm only an n of 1.

Look around and network--there are still some decent places to land.

The entire house of medicine is not currently a complete dumpster fire. Just most of it.

 

[Birdstrike]

And with each passing day they will fold into the main stream, new leadership emerges and things turn to scat.

As a Psychiatrist I have worked at a for profit psych hospital and non-profit "christian" based health system and both we're equally scat but in slightly different ways.

"Non-profit" is a myth. Do you know any hospitals that are "for losses"?

They all want profit. The for-profits send the excess money to themselves and shareholders and call it "profit." The non-profits will send the excess money back to themselves and call it "reinvestment in the hospital system." But when you check the balance sheet, the bulk of it is in salary increases for themselves.

Hospitals that don't have excess revenue, or at least break even, cease to exist. It's called bankruptcy.

 

[docB]

"Non-profit" is a myth. Do you know any hospitals that are "for losses"?

They all want profit. The for-profits send the excess money to themselves and shareholders and call it "profit." The non-profits will send the excess money back to themselves and call it "reinvestment in the hospital system." But when you check the balance sheet, the bulk of it is in salary increases for themselves.

Hospitals that don't have excess revenue, or at least break even, cease to exist. It's called bankruptcy.

I agree with this. There are some public sector hospitals, we used to call them "county hospitals," that can run at a loss and get tax money to cover the shortfall. But if they fall too far behind and the drain on the politician's pork projects goes up the admin heads roll. So it's not like there's carte blanche to worry about patient care.

 

[Matthew9Thirtyfive]

So a PA with PA school and a single rotation in EM is just as effective and educated in EM as a physician with med school and a 3 year EM residency? Is that what you’re suggesting? Just trying to clarify.

 

[MedicineZ0Z]

So a PA with PA school and a single rotation in EM is just as effective and educated in EM as a physician with med school and a 3 year EM residency? Is that what you’re suggesting? Just trying to clarify.

I think OP is maybe very partially correct. We can filter out some of the material (ends up being a minority) such as more nuanced biochem/genetics, extremely detailed anatomy and niche topics phds like to get into. Stuff that no one remotely remembers basically.

The reality is, almost all doctors would autoconsult if faced with something even suggestive of a metabolic disorder. Niche topics are also better learnt from a clinical perspective (step 2 material) and in residency. Same goes for very detailed anatomy.
You can apply this to some other med school topic categories as well.

 

[Birdstrike]

So a PA with PA school and a single rotation in EM is just as effective and educated in EM as a physician with med school and a 3 year EM residency? Is that what you’re suggesting?

I’m not saying that, at all. PA education does not produce a higher level clinician. Medical school does. That’s not my point.

What I’m saying is, from the viewpoint of your bosses (hospital and CMG administrators) the PA educational pathway is shorter and therefore more efficient. It doesn’t take more than a decade, or typically leave its students $350,000 in debt. It produces a less expensive product (PA salary) which is more attractive to them.

PA school is the assembly line producing the Camry: Plentiful, affordable and practical. These sell well for a reason.

MD school is the assembly line producing the Aston Martin. It’s product is in short supply, impractical and building it by hand takes forever. It’s expensive as hell, but it performs well on the track, off the line and at top speed.

You want at least one Aston Martin out up front to show you’re serious and to pace the Camry’s drafting behind. But if you can get away with it, you want your fleet full of as many Camrys as possible, because although they can’t do everything the Aston Martin can, they do most things well, they’re cheaper and easier to make.

And the best thing about the Camry, is with the right paint job, surface treatment and racing package you can make it look enough like the Aston Martin a lot of customers might not know the difference or care.

 

[HoosierdaddyO]

Just saying... every single chest pain patient I’ve ever staffed with a PA, their diagnosis is god damn costo/MSK. I’ll walk into the room after they present with a hypotensive patient with back and chest pain... I’m like “Yep, totally costo/MSK🙄”!!! They don’t know what they don’t know, that’s what separates us from them!!!

 

[turkeyjerky]

I’m not saying that, at all. PA education does not produce a higher level clinician. Medical school does. That’s not my point.

What I’m saying is, from the viewpoint of your bosses (hospital and CMG administrators) the PA educational pathway is shorter and therefore more efficient. It doesn’t take more than a decade, or typically leave its students $350,000 in debt. It produces a less expensive product (PA salary) which is more attractive to them.

PA school is the assembly line producing the Camry: Plentiful, affordable and practical. These sell well for a reason.

MD school is the assembly line producing the Aston Martin. It’s in short supply, cost-prohibitive, impractical and building it by hand takes forever. But it performs well on the track, off the line and at top speed.

You want at least one Aston Martin out up front to show you’re serious and to pace the Camry’s drafting behind. But if you can get away with it, you want your fleet full of as many Camrys as possible, because although they can’t do everything the Aston Martin can, they do most things well, they’re cheaper and easier to make.

Except midlevels are more like Chevy corvairs...

 

[Matthew9Thirtyfive]

I’m not saying that, at all. PA education does not produce a higher level clinician. Medical school does. That’s not my point.

What I’m saying is, from the viewpoint of your bosses (hospital and CMG administrators) the PA educational pathway is shorter and therefore more efficient. It doesn’t take more than a decade, or typically leave its students $350,000 in debt. It produces a less expensive product (PA salary) which is more attractive to them.

PA school is the assembly line producing the Camry: Plentiful, affordable and practical. These sell well for a reason.

MD school is the assembly line producing the Aston Martin. It’s product is in short supply, impractical and building it by hand takes forever. It’s expensive as hell, but it performs well on the track, off the line and at top speed.

You want at least one Aston Martin out up front to show you’re serious and to pace the Camry’s drafting behind. But if you can get away with it, you want your fleet full of as many Camrys as possible, because although they can’t do everything the Aston Martin can, they do most things well, they’re cheaper and easier to make.

And the best thing about the Camry, is with the right paint job, surface treatment and racing package you can make it look enough like the Aston Martin a lot of customers might not know the difference or care.

Ah okay. I see where you’re coming from now.

 

[Birdstrike]

Just saying... every single chest pain patient I’ve ever staffed with a PA, their diagnosis is god damn costo/MSK. I’ll walk into the room after they present with a hypotensive patient with back and chest pain... I’m like “Yep, totally costo/MSK🙄”!!! They don’t know what they don’t know, that’s what separates us from them!!!

True. And that’s the system working exactly how the bosses want it to. Their only question is, “What’s the right ratio PA’s to doctors? How far can I push the ratio and get away with it?”

 

[Birdstrike]

A major lie we’re all told in Medical training so frequently we accept it as unquestionable truth: “Doctors are the leaders of the Medical team.”

WRONG

Your hospital CEO is. The administrators are. They may not show their face, you may not know their name and they may not be in the room. But they’re in charge.

This is a cause of tremendous cognitive dissonance, and therefore burnout, among physicians: “I’m in charge, but it feels like I control almost nothing.”

We’re told this lie from our doctoral infancy.

 

[Matthew9Thirtyfive]

True. And that’s the system working exactly how the bosses want it to. Their only question is, “What’s the right ratio PA’s to doctors? How far can I push the ratio and get away with it?”

That and how many midlevel lawsuits can I eat before it becomes more expensive than hiring physicians?

 

[Birdstrike]

That and how many midlevel lawsuits can I eat before it becomes more expensive than hiring physicians?

Exactly. But since the docs and the PAs usually both get named together, the administrators can’t ever really cleanly sort out who’s to blame. “Did this happen because a PA messed up or because a doc messed up by supervising badly? Whatevs...Cost of doin’ business, I guess. Renew that insurance and let’s cut some more costs.”

 

[southerndoc]

I’m not saying that, at all. PA education does not produce a higher level clinician. Medical school does. That’s not my point.

What I’m saying is, from the viewpoint of your bosses (hospital and CMG administrators) the PA educational pathway is shorter and therefore more efficient. It doesn’t take more than a decade, or typically leave its students $350,000 in debt. It produces a less expensive product (PA salary) which is more attractive to them.

PA school is the assembly line producing the Camry: Plentiful, affordable and practical. These sell well for a reason.

MD school is the assembly line producing the Aston Martin. It’s product is in short supply, impractical and building it by hand takes forever. It’s expensive as hell, but it performs well on the track, off the line and at top speed.

You want at least one Aston Martin out up front to show you’re serious and to pace the Camry’s drafting behind. But if you can get away with it, you want your fleet full of as many Camrys as possible, because although they can’t do everything the Aston Martin can, they do most things well, they’re cheaper and easier to make.

And the best thing about the Camry, is with the right paint job, surface treatment and racing package you can make it look enough like the Aston Martin a lot of customers might not know the difference or care.

Aston... now you're speaking my language. Totally makes sense now.

 

[Kryptocoin]

Medicine and its lengthy training was great and justified when physicians controlled the market and legislations. 2020 cracked that fissure wide open. It has shown several groups with competing agendas are vying for a cut--politicians, midlevels, hospitals, CMGs. CMGs need us because we train midlevels and assume liability coverage. Hospitals need us due to state bylaws. Politicians don't seem to care about our training. They are drinking the midlevel koolaid (" physician shortage").

 

[Apollyon]

Except midlevels are more like Chevy corvairs...

Good one! "Unsafe At Any Speed"!

 

[dantt]

As physicians, the training road is long and arduous. We often find ourselves cursing it’s seemingly unnecessary length, inefficiency, and scut-work devoid of learning value. We often commiserate that we could have become just as effective at doing our jobs with a shorter, more efficient, fast-tracked education.

Could it be that PAs found a way to do exactly that, to cut the unnecessary waste out of their educational process?

If so, shouldn’t they be praised and their more efficient method of education modeled, rather than derided and devalued?

Who’s smarter, the one who spent over a decade training to be $350,000 in debt and finds their job threatened for being too expensive, over-trained and over qualified?

Or the one who took a training fast track and enjoys most, if not all, of the benefits of being a physician, possibly including taking the actual physician’s job?

Sad but I think there is some truth to this. Don't forget, your patient is not the customer. The customer (payer) is the government, insurance company, medicare, medicaid, etc. Now if you're cash pay, your patient is the customer and if they want to see a physician, they'll pay and go see a physician.

 

[Oligodinero]

Just saying... every single chest pain patient I’ve ever staffed with a PA, their diagnosis is god damn costo/MSK. I’ll walk into the room after they present with a hypotensive patient with back and chest pain... I’m like “Yep, totally costo/MSK🙄”!!! They don’t know what they don’t know, that’s what separates us from them!!!

Then you need to have a talk to your department chief and the midlevel supervisor because your PAs are crap. Someone also needs to be holding compulsory didactics regularly with the MLPs on the various high risk complaints seen in the ED.

 

[d2305]

Corvairs were dependable and fun to drive. Vegas were undependable.

 

[docB]

Except midlevels are more like Chevy corvairs...

Good one! "Unsafe At Any Speed"!

You guys are really dating yourselves by remembering Corvairs.

Corvairs were dependable and fun to drive. Vegas were undependable.

Interesting point but I disagree on a metaphorical level. They aren't undependable like Vegas. They do what they do pretty well if what you want done is moving the low acuity meat and "satisfying" patients while doing it. So they're dependable and in terms of fun to drive they address a lot of the problems created by poor administration like understaffing, stacking patients in waiting rooms, and poor ancillary services so there's that. The problem, like with the Corvair, is that they can fail spectacularly causing a fiery explosion that burns everyone in the car. That seems pretty apt.

 

[Oligodinero]

The deal with MLPs in the ER is that you have to remember that they have very limited didactic and clinical training. They need to be vetted clinically by each supervising physician they'll staff with so that the doctors get a feel for how much they trust the MLP's judgement. They also need regular didactic instruction. They need their charts reviewed....not just signed off on. Not just rubber stamped with a disclaimer that the SP did no evaluation and is being forced by admin to sign the chart. If you do the above you can get a good MLP who will help move the sore throat, poison ivy, ankle sprain, scabies cases out of the department and help your group meet the metrics admin is hounding you to meet like turn around time to discharge, MSE time, etc. It also makes the patients happy when they're seen and discharged quickly for their ingrown toenail complaint.....and happy patients don't tend to send back crappy Press Gainey surveys.
Also realize that like any profession, there are some firecracker MLPs and there are some duds who only want to punch the clock and see 1 ESI 5 patient per hour all shift long. The latter are the ones you want to purge from your group. The former are the ones to keep.

 

[Splenda88]

I have been saying that for 100 yrs in SDN. There is no practical reason for the system to take 11 yrs to produce a PCP. Again, the whole thing should be 2 yrs prereqs, 3 yrs med school and 2-6 years residency. Medical education in the US needs a major overhaul.

 

[Kuratz]

There is too much money for the system to ever be practical. Colleges want their $, med schools want their $ and hospitals want their $ in the form of cheap labor. As a bonus ERAS siphons its share, as does the USMLE and all the test prep material companies. It’s a huge racket.

There is a defined pathway in medicine and once on the path, the trainee has zero leverage. If you ever want to practice medicine and pay off those loans then you will do/pay what is required of you. The fundamental purpose of my 80-100 hours a week as an intern was to provide labor for the hospital, not to be an effective educational use of my time as a future freaking radiologist.

We get taken for a ride and the whole system is nonsense but you don’t realize it until you’ve already had your pants pulled down. The profession is screwed if the compensation drops to the point where FI/RE just isn’t attainable.

 

[thegenius]

Your ED has no PAs?

I work at an ER (a Kaiser one) that has no PAs.

 

[thegenius]

So a PA with PA school and a single rotation in EM is just as effective and educated in EM as a physician with med school and a 3 year EM residency? Is that what you’re suggesting? Just trying to clarify.

No....but the real issue here is that the ER is not used for emergencies, or potential emergencies anymore. Maybe in the 70's and early 80's when most patients were trauma or having massive bleeding or MI's.

These days, ER's are just glorified primary care clinics with an open door, immediate access 24-7. People coming in for any reason, and most are just nonsense reasons. That's why we can have PA's and NPs see probably 1/3 of all ER patients with no drop-off in care, or if there is it's negligible.
I only agree with Birdstrike a little bit.

I think there needs to be a rethinking about medical school education, perhaps it should only be 3 years and not 4. The most bang for the buck is during residency though.

Remember we used to do things like CENTOR criteria and make clinical decisions about whether someone has pneumonia or worsening heart failure. You know, we use to be good at doing physical exams. Now we just swab the back of the throat, order a CXR, or get a Cr / BNP / CXR to see if someone is in worsening HF. More and more medicine (e.g. emergency medicine) is interpreting numbers and less critical thinking.