physasst

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I have to start this with a bit of a sigh. I was just reading in another post about how "midlevels" (a term I despise), are "not a solution".

NOW, if this was a practicing physician with years upon years of experience who has had multiple interactions with PA's and NP's, and has either employed their own "midlevel" in the past, or has worked very closely with them, it would be one thing.

Unfortunately, it is coming from a medical student, who likely has had little, if any interactions with PA's and/or NP's and is making a determination or judgement based on nothing but fear, misinformation or jealousy.

I don't like writing posts like this, but I am always, first and foremost, an advocate for my profession. It is interesting that in my travels, and experience, that physicians who have extensive experience with PA's at least, have nothing but positive comments.

We provide HIGH quality, low cost care. It's that simple. Can we see and manage everything....NO. We are not physicians, and I, at least for one, have never claimed to be. After close to 15 years in practice however, I can safely and comfortably see about 90% or more what comes through an ED's doors on my own. That is experience.

Now, onto the DNP. I have been asked on multiple occasions, including by someone at the WH office for health reform my opinion on the DNP. I will share the same opinion that I gave the president of the AANC 2 months ago. From a PA perspective, I could really care less about the DNP degree, and what the NP profession is doing. This is their move, however, from a health policy perspective, I have significant workforce supply concerns.

Primarily, and regardless of whatever your personal opinion of NP's might be, they have provided an incredibly valuable service by staffing and working in inner city and rural primary clinics, working and providing primary care in areas that physicians have for the most part eschewed. I have concerns that by mandating the entry level degree to the doctoral level, that fewer graduates will practice in these typically lower paying areas. Also, historically, the most likely candidates to practice in rural or underserved areas, are people FROM those areas. They also are usually financially disadvantaged, and may not have the time or resources to complete a doctoral degree. I am concerned that the implementation of this will have serious negative effects on the supply and deployment of NP's, particularly in these areas in which they have been so valuable.

Lastly, PA's and NP's are not going anywhere. IN FACT, the AAMC and other physician groups are providing strong support for additional training of PA's

WHY, you might ask? Because, there is a projected shortage of 124,000 physicians by 2025. Even the current 30% expansion in medical school enrollment will only MODERATE this, not even come close to eliminating it, according to the AAMC. And this doesn't take into account the scores of physicians who work part time, are in administrative positions, research, etc.

It's simple math. Their won't be enough physicians, so you will need us. I would suggest, that rather than disparage us, you learn more about our respective professions, and when you are an attending, you attempt to teach and ensure that the PA's and NP's you work with and come in contact with, are well educated, and can take excellent care of patients.
 
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RGMSU

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You know as well as I do that the primary argument medical students have against the DNP movement is that these people want to be called "Doctor" indistinguishably in a medical environment. The term "Doctor" in this setting has historically designated someone who attended medical school, so the use of the term is confusing to patients who do not always know the difference between various healthcare workers. Our objection is not one of disparagement. You say you want to protect your profession. Well, so do we. It is not proper for a patient to be referring to a nurse practitioner or a PA as "Doctor So and So," but that's exactly what will be the case under the DNP situation. Are you going to tell me that you believe DNP training is the same as MD training? If not, then there should be a distinction in titles so patients know who they're receiving advice from. Not everybody with a white coat and a stethoscope is equally qualified to give advice on every topic. My argument against all the non-physician workers constantly calling for expanded rights is that there is seemingly no end to it. If we allow psychologists to have prescription rights, what's the point in going to medical school to become a psychiatrist? If we allow DNPs to practice cardiology as a pseudo-physician, what is the point of going to medical school to become a cardiologist? It up-ends the entire system and the people who get squeezed out are the best and brightest who made the sacrifices in time and money to complete the most rigorous training. How can we justify the most rigorous training if we are constantly replacing it with shorter and cheaper substitutions? Then, what do we do with the people, such as myself, who have already committed to the more rigorous training and find themselves in indistinguishable competition with people who, by virtue of the lower cost and shorter length of their training, are able to charge half as much? What happened to valuing the expertise of a physician instead of routinely attempting to undercut them at every level of the American medical environment?
 
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physasst

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You know as well as I do that the primary argument medical students have against the DNP movement is that these people want to be called "Doctor" indistinguishably in a medical environment. The term "Doctor" in this setting has historically designated someone who attended medical school, so the use of the term is confusing to patients who do not always know the difference between various healthcare workers. Our objection is not one of disparagement. You say you want to protect your profession. Well, so do we. It is not proper for a patient to be referring to a nurse practitioner or a PA as "Doctor So and So," but that's exactly what will be the case under the DNP situation. Are you going to tell me that you believe DNP training is the same as MD training? If not, then there should be a distinction in titles so patients know who they're receiving advice from. Not everybody with a white coat and a stethoscope is equally qualified to give advice on every topic. My argument against all the non-physician workers constantly calling for expanded rights is that there is seemingly no end to it. If we allow psychologists to have prescription rights, what's the point in going to medical school to become a psychiatrist? If we allow DNPs to practice cardiology as a pseudo-physician, what is the point of going to medical school to become a cardiologist? It up-ends the entire system and the people who get squeezed out are the best and brightest who made the sacrifices in time and money to complete the most rigorous training. How can we justify the most rigorous training if we are constantly replacing it with shorter and cheaper substitutions? Then, what do we do with the people, such as myself, who have already committed to the more rigorous training and find themselves in indistinguishable competition with people who, by virtue of the lower cost and shorter length of their training, are able to charge half as much? What happened to valuing the expertise of a physician instead of routinely attempting to undercut them at every level of the American medical environment?

that is a valid argument. The fact is, I would probably still have a problem with a DNP calling themselves Doctor, but as long as they qualify WHAT they are a doctor of, I am less concerned about that, than I am workforce supply issues. To be honest, physicians should do the same. I am not overly crazy about calling yourself doctor in the clinical setting because, for right or wrong, patients interpret it to mean "MD".

NOW, we can have a great argument about whether that title was usurped from the PhD crowd, because historically, the term has referred to teaching.
 

edmadison

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NOW, we can have a great argument about whether that title was usurped from the PhD crowd, because historically, the term has referred to teaching.[/QUOTE]

Shakespeare referred to physicians as "doctor" so that use is at lease four centuries old. Further, in the United States it is clearly an appropriate term. Until recently, Ph.D holders were rarely referred to as doctor outside the ivy walls. I have yet to hear a non-science/math, liberal arts Ph.D holder referred to as "doctor" anywhere. Typically, they are addressed as "professor". In any event this discussion is somewhat silly in the first place.

The bigger picture is this. Overall, the average NP or PA will provide less-expert care than the average FP doc. The question is: In light of our shortage of people willing to provide care for the small reimbursement offered by insurance companies and the government, is this "less-expert" care good enough?

Ed
 

RGMSU

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You know, it just struck me today how irrelevant turf warfare is at the moment - and perhaps at any moment. I was reading about the possibility of capitation pay schedules and thought about a patient who is not given the care they need because their physician is trying to save money and make a profit. Those of us who really understand what it is like to work in healthcare should really band together regardless of what letters we have behind our names to insure that we continue to be able to offer high quality healthcare to our patients rather than standing by helplessly as businessmen, lawyers, and government bureaucrats are empowered to determine who receives what care based on a formula. If we don't start realizing that we are all on the same ship here, we will find that our entire industry has been taken over by outsiders while we were fighting amongst ourselves. In fact, my fear is it may be too late already to stop that eventuality.
 
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physasst

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You know, it just struck me today how irrelevant turf warfare is at the moment - and perhaps at any moment. I was reading about the possibility of capitation pay schedules and thought about a patient who is not given the care they need because their physician is trying to save money and make a profit. Those of us who really understand what it is like to work in healthcare should really band together regardless of what letters we have behind our names to insure that we continue to be able to offer high quality healthcare to our patients rather than standing by helplessly as businessmen, lawyers, and government bureaucrats are empowered to determine who receives what care based on a formula. If we don't start realizing that we are all on the same ship here, we will find that our entire industry has been taken over by outsiders while we were fighting amongst ourselves. In fact, my fear is it may be too late already to stop that eventuality.
is the bast damn post I have ever read here on SDN. Bravissimo.

Look, it's simple, there will not be enough doctors. It's that easy. So, don't worry. YOU will still have a job, and perhaps, you can utilize one of us to provide even more care at a lower cost.

Utilization of PA's all comes down to trust. When I saw a 20 month old with a febrile seizure, and a temp of 106, I did the workup, and noted a right lower lobe infiltrate, exam and workup otherwise benign. I gave Rocephin, and called the covering doc, who said, sounds good, and if they can't control the fever, or if more seizure symptoms, return immediately, NOW, I already knew this, and had it on the discharge instructions, but I have earned that level of trust and respect.

WHY, cause there have been other times, like working in critical, and seeing a guy with the WORST case of ACE inhibitor induced angioedema of the tongue that I have ever seen. He needed an advanced airway, and needed more than a simple intubation. The consultant on, said "Mike, can it wait", I said "NO, I need you OVER HERE NOW!". He came, and we did a fiberoptic nasotrachial intubation. The consultants, and attendings I work with trust me, cause they know that I am experienced, smart, and will not hesitate to call for help if I need.
 

MOHS_01

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Like all professions, there are good and bad in all fields and walks of life. On Friday I had a "walk in" who had seen a local NP earlier in the day. She was diagnosed with an allergic reaction, given 50mg of Benadryl IM, 80mg of Kenalog IM, Rocephin IM, and told that she needs to see a dermatologist. She had orbital cellulitis and was in pretty bad shape. She ended up getting admitted for IV antibiotics after I sent her to the ED (I had to argue with her for a long time just to get her to go). A couple of months ago I had another NP call me to ask what she should do with verrucous carcinoma on the scalp. She attempted to excise it and could not get it to come back together, so she put a bandage on it and called me to ask if I would help her out.

There are both good -- and bad -- ones out there.
 
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physasst

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Like all professions, there are good and bad in all fields and walks of life. On Friday I had a "walk in" who had seen a local NP earlier in the day. She was diagnosed with an allergic reaction, given 50mg of Benadryl IM, 80mg of Kenalog IM, Rocephin IM, and told that she needs to see a dermatologist. She had orbital cellulitis and was in pretty bad shape. She ended up getting admitted for IV antibiotics after I sent her to the ED (I had to argue with her for a long time just to get her to go). A couple of months ago I had another NP call me to ask what she should do with verrucous carcinoma on the scalp. She attempted to excise it and could not get it to come back together, so she put a bandage on it and called me to ask if I would help her out.

There are both good -- and bad -- ones out there.

Exactly, and I have never claimed otherwise. There are good and bad physicians too. I know docs that I think the world of, and would entrust my daughters life to. I also know docs that I wouldn't let treat my dog.
 
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Either on the Federal Level or the State Levels we need to set up an interdisciplinary board that regulates scope of practice rights, and has procedures for implementing changes in each professions scope, and issues. This BOHC would have legal authority to oversee scope of practice issues, regulate insurance bodies and oversee legal issues that accumulate between competing professions. This board would not be staffed by lawyers or politicians, but instead be staffed primarily with representatives from every licensed profession that currently exists with a few lawyers and cabinet members or congressmen, and PhD level health researchers.

There are alot of issues that could be solved if we as the healthcare professionals had control over these problems, since we are the ones who have to tell the patient what can and can't be done because some BA business administrator or worse a High school graduate insurence representative tells us what we can do or what diagnostic tests need to be performed before they cover a patient's tests or treatment.
 

Taurus

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Like all professions, there are good and bad in all fields and walks of life. On Friday I had a "walk in" who had seen a local NP earlier in the day. She was diagnosed with an allergic reaction, given 50mg of Benadryl IM, 80mg of Kenalog IM, Rocephin IM, and told that she needs to see a dermatologist. She had orbital cellulitis and was in pretty bad shape. She ended up getting admitted for IV antibiotics after I sent her to the ED (I had to argue with her for a long time just to get her to go). A couple of months ago I had another NP call me to ask what she should do with verrucous carcinoma on the scalp. She attempted to excise it and could not get it to come back together, so she put a bandage on it and called me to ask if I would help her out.

There are both good -- and bad -- ones out there.
After treating them, I would have given the patients the names of some good lawyers.
 

RGMSU

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I probably will employ mid-levels in my practice when I get to that level. I actually would favor PAs over NPs because I think their training is much better. I have never had a problem with physician extenders. I think they are quite useful. I do have a problem with physician extenders who want to function as physician replacements. I find that a little irritating. I also find it irritating when someone thinks that being an MD makes them better than everybody else. When MDs and PAs can work with each other, I do think that is a very healthy and profitable arrangement. I think it works to the advantage of PAs that they train with MDs in actual medical schools, whereas nursing folks tend to segregate themselves a little more. I also think it is to the advantage of an MD to be friendly with nurses because it makes life for the MD much easier. Nurses who dislike you can make life as an MD much more difficult.
 

platon20

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Atul Gawande wrote an article in the New Yorker about McAllen Texas and the overutilization of health resources. Apparently there are thousands and thousands of doctors in McAllen running up healthcare bills by scoping everybody and everything that comes into their practice.

This is McAllen, bumblestick, Texas ya'll. This isnt New York, or Los Angeles, or Chicago. Before Gawande wrote that article, nobody had ever heard of McAllen before.

If there are that many doctors running around McAllen doing scores of CABGs and colonoscopies, how many more of them are there in the major metro areas?

My point about all this is that there is NO doctor shortage. There's certainly no shortage in McAllen, which means that there's likely no shortage in 95% of the areas of the United States.

The doctor shortage is a HUGE myth, and you guys have bitten it hook, line, and sinker.
 

Sol Rosenberg

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Atul Gawande wrote an article in the New Yorker about McAllen Texas and the overutilization of health resources. Apparently there are thousands and thousands of doctors in McAllen running up healthcare bills by scoping everybody and everything that comes into their practice.
Thousands and thousands? In a city with a population of ~100k?

:rolleyes:
 

Dr Oops

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Atul Gawande wrote an article in the New Yorker about McAllen Texas and the overutilization of health resources. Apparently there are thousands and thousands of doctors in McAllen running up healthcare bills by scoping everybody and everything that comes into their practice.

This is McAllen, bumblestick, Texas ya'll. This isnt New York, or Los Angeles, or Chicago. Before Gawande wrote that article, nobody had ever heard of McAllen before.

If there are that many doctors running around McAllen doing scores of CABGs and colonoscopies, how many more of them are there in the major metro areas?

My point about all this is that there is NO doctor shortage. There's certainly no shortage in McAllen, which means that there's likely no shortage in 95% of the areas of the United States.

The doctor shortage is a HUGE myth, and you guys have bitten it hook, line, and sinker.
So if McAllen is twice the nation average, than that must mean there are places that spend half as much as McAllen! Hmmm and places like florida spend much more through medicare/aid and they also have higher malpractice rates dont they?
 

MOHS_01

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The doctor shortage IS a huge myth. From a physician workforce standpoint, what we have is a distribution and utilization problem. From a societal standpoint we have an already too large and increasing number of lazy fatties who smoke and think of Mt Dew and Krispy Kremes as breakfast.