DO or NP/PA??! I need help

[kwinterwinter]

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Hello,
I know there are previous threads discussing the differences, pros and cons but I would love a current perspective now that shifts in the medical world are taking place due to obama care and popularity/autonomy of mid-level providers.

I am 30 years old, and decided to switch from my current career in journalism to medicine through the process of becoming very ill, and recovering over a span of 2 years. I had a mostly negative experience with Physicians, but there were a few stars that stuck with me, and ultimately the kind of provider I would like to become.

I initially decided to aim for NP, as being 29 (at the time of my decision) I felt MD was too long of a road. Moreover I have heard mixed reviews of what it's actually like to be a practicing physician and most of the nurses I know are very happy with their careers. I have just now completed all my pre-reqs for direct entry MSN and accelerated BSN programs (Physio, Anatomy, Chem, Stats, Psych, Micro, Nurtition) and am lined up to apply, however I still feel as though I am trying to convince myself this is the right decision.

My concern about NP and PA are as follows:

*I am afraid I will not have enough scientific/medical knowledge to help others at the level I wish to*

The reason I decided to switch to a medical career is because my personal health was complex, and although it was not enjoyable trying to solve my own medical mystery, I want to be able to take on complex cases and really use the depth of knowledge I have, to help others. I love medical research and am sincerely fascinated by immunology, studies regarding microbiome, infectious disease, physiology in general, autoimmune problems, infectious diseases etc. I think I make my point. I like science.

I do realize that NP's work with doctors in specialty fields now outside of Family Medicine. But Im assuming, if someone is seen with a less common presentation, the NP is not the one to ruminate or help the physician come to a diagnosis. I also felt many doctors wrote me off and refused to brainstorm about my (very serious) symptoms. I don't think I could handle witnessing this, and not being able step in and further explore possibilities, patient history, etc etc. Maybe this is something only possible in private practice though, due to insurance complexities. Im not too knowledgeable in this regard other than knowing at times Doctors hands are tied as well.

I also realize the PA's have the 'medical model' but again, same question as above... Im afraid that I will get stuck with the most basic cases and if I do encounter an individual searching for the root of a problem, it will be beyond my intellectual and legal scope to assist them in their search for an answer.

So I am basically asking if I am wrong in my assumptions. Does anyone work with NP/PA's and can confirm there is room for complex problem solving as an NP/PA?

My concerns about MD:
*If I go the MD route, my career will be spent doing paperwork, at an all time low physician salary, due to pay cuts that some have predicted.*

My concern regarding MD/DO is that the career will be basically flat by the time I am actually practicing, and may not be worth the effort or time (meaning NP's will have such a great level of autonomy it wont really matter either way). Do you think this will actually happen?

And finally considering length of training, I can become an NP by 2019, and a physician by 2025... so this is of concern as well. But if I am never satisfied as an NP, I dont think a few years matters at all in the end. I have read many forums discussing the time commitment and debt that doctors incur, however this confuses me as doctors typically make a decent salary, so the time spent and debt seems to be replaced with a high salary, allowing you to pay off those debts. Am I wrong? I dont have kids yet, but am 99% sure I dont want them, so that is not a deciding factor for me. My undergrad GPA is a 3.2, but my pre-reqs are 3.9 and I plan on maintaining for the next year of prereqs if I choose to continue.... not sure if my undergrad will significantly hold me back at this point.

It is amazing if you have read this far. I so greatly appreciate any advice on any of the above questions. I am obviously struggling to see the reality of both fields and have heard SO many different perspectives, so would love to hear yours! Thank you!!!

 

[Yadster101]

How could you be an NP by 2019? You don't even have a bsn yet. Don't accelerated bsn programs take at least 2 years? Plus NP on top of that is like another 2 years?

 

[acapnial]

Hello,
I know there are previous threads discussing the differences, pros and cons but I would love a current perspective now that shifts in the medical world are taking place due to obama care and popularity/autonomy of mid-level providers.

I am 30 years old, and decided to switch from my current career in journalism to medicine through the process of becoming very ill, and recovering over a span of 2 years. I had a mostly negative experience with Physicians, but there were a few stars that stuck with me, and ultimately the kind of provider I would like to become.

I initially decided to aim for NP, as being 29 (at the time of my decision) I felt MD was too long of a road. Moreover I have heard mixed reviews of what it's actually like to be a practicing physician and most of the nurses I know are very happy with their careers. I have just now completed all my pre-reqs for direct entry MSN and accelerated BSN programs (Physio, Anatomy, Chem, Stats, Psych, Micro, Nurtition) and am lined up to apply, however I still feel as though I am trying to convince myself this is the right decision.

My concern about NP and PA are as follows:

*I am afraid I will not have enough scientific/medical knowledge to help others at the level I wish to*

The reason I decided to switch to a medical career is because my personal health was complex, and although it was not enjoyable trying to solve my own medical mystery, I want to be able to take on complex cases and really use the depth of knowledge I have, to help others. I love medical research and am sincerely fascinated by immunology, studies regarding microbiome, infectious disease, physiology in general, autoimmune problems, infectious diseases etc. I think I make my point. I like science.

I do realize that NP's work with doctors in specialty fields now outside of Family Medicine. But Im assuming, if someone is seen with a less common presentation, the NP is not the one to ruminate or help the physician come to a diagnosis. I also felt many doctors wrote me off and refused to brainstorm about my (very serious) symptoms. I don't think I could handle witnessing this, and not being able step in and further explore possibilities, patient history, etc etc. Maybe this is something only possible in private practice though, due to insurance complexities. Im not too knowledgeable in this regard other than knowing at times Doctors hands are tied as well.

I also realize the PA's have the 'medical model' but again, same question as above... Im afraid that I will get stuck with the most basic cases and if I do encounter an individual searching for the root of a problem, it will be beyond my intellectual and legal scope to assist them in their search for an answer.

So I am basically asking if I am wrong in my assumptions. Does anyone work with NP/PA's and can confirm there is room for complex problem solving as an NP/PA?

My concerns about MD:
*If I go the MD route, my career will be spent doing paperwork, at an all time low physician salary, due to pay cuts that some have predicted.*

My concern regarding MD/DO is that the career will be basically flat by the time I am actually practicing, and may not be worth the effort or time (meaning NP's will have such a great level of autonomy it wont really matter either way). Do you think this will actually happen?

And finally considering length of training, I can become an NP by 2019, and a physician by 2025... so this is of concern as well. But if I am never satisfied as an NP, I dont think a few years matters at all in the end. I have read many forums discussing the time commitment and debt that doctors incur, however this confuses me as doctors typically make a decent salary, so the time spent and debt seems to be replaced with a high salary, allowing you to pay off those debts. Am I wrong? I dont have kids yet, but am 99% sure I dont want them, so that is not a deciding factor for me. My undergrad GPA is a 3.2, but my pre-reqs are 3.9 and I plan on maintaining for the next year of prereqs if I choose to continue.... not sure if my undergrad will significantly hold me back at this point.

It is amazing if you have read this far. I so greatly appreciate any advice on any of the above questions. I am obviously struggling to see the reality of both fields and have heard SO many different perspectives, so would love to hear yours! Thank you!!!

It sounds like you have a chip on your shoulder about physicians. If you become an NP or PA it would probably be extremely frustrating to you that they both know more about medicine than you and that their word on the patient will outweigh yours. If your attitude about physicians can't change then you might not ever be happy as a midlevel. I would recommend becoming a physician yourself, and be the kind of physician you respect.

 

[dogemeow]

If you are questioning/don't like the length of training for a physician, hands down NP. Becoming a physician is a huge commitment, if you have any doubts about it at all it is not for you.

 

[kwinterwinter]

How could you be an NP by 2019? You don't even have a bsn yet. Don't accelerated bsn programs take at least 2 years? Plus NP on top of that is like another 2 years?

There are a few accelerated programs that are two years for both BSN and MSN, Vanderbilt for example, but youre right depending on where I go, which track I take to get there I think it would likely be closer to 2020 or 2021. Thanks for pointing that out.

 

[kwinterwinter]

It sounds like you have a chip on your shoulder about physicians. If you become an NP or PA it would probably be extremely frustrating to you that they both know more about medicine than you and that their word on the patient will outweigh yours. If your attitude about physicians can't change then you might not ever be happy as a midlevel. I would recommend becoming a physician yourself, and be the kind of physician you respect.

This makes a lot of sense. I hadn't considered my particular frustrations in terms of a deciding factor, as I imagined working with a physician I respected, or working autonomously with a group of likeminded practitioners, at a lower level (if NP). However that may be difficult to find and frustrating in the long run. Thanks for taking the time to reply.

 

[Ho0v-man]

Why not take the MCAT? MD/DO might not even be an option. I have a couple of really smart friends who studied for three months and after bombing a couple of practice tests or even the real deal just went PA. I took it with the mindset that it would kind of decide what route I would follow.

Disclaimer: This is not meant to be an inflammatory post. Trying to be helpful.


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[kwinterwinter]

Why not take the MCAT? MD/DO might not even be an option. I have a couple of really smart friends who studied for three months and after bombing a couple of practice tests or even the real deal just went PA. I took it with the mindset that it would kind of decide what route I would follow.

Disclaimer: This is not meant to be an inflammatory post. Trying to be helpful.


Sent from my iPhone using SDN mobile

That makes sense. If I go the MD route, I have another year + O-chem in pre-reqs, so I was considering finishing those, taking the MCAT, then maybe even applying to both NP and MD... or as you said, maybe the MCAT will rule out MD all together. I think part of the reason I am obsessing so much right now is I have been cramming the NP prereqs this last year, in order to apply this fall.... but if Im not ready to decide I guess Im not ready. Thanks for your input!

 

[theSmurfette]

I was 32 when I matriculated. You're never too old to do what you want.

You have many of the same thoughts I did about NP/PA and why I chose to fight my way to becoming a physician. It took me 4 cycles plus an SMP for my acceptance. Never give up!


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[FourniersGreenGang]

Yeah I would agree that age is not really an issue, especially if you don't want kids. There's a guy in my class who is in his late 40s and just matriculated. I think you need to shadow both professions and see which scope of work and patient population you prefer. I also think that you need to take an accurate self assessment and ask yourself if you want to/can do medical school, as it is very very taxing. Also, take the MCAT as previously mentioned. I know everyone thinks they can be a doctor but it is definitely not an easy path that just anyone can do, and if you are not committed to it fully, you run the risk of burning out and dropping out, if you even get in.

TLDR: it is too early to determine. Explore it more and take stock of your personal abilities/passions to get an accurate idea. Go into NP if you'll be fulfilled in that role.

 

[hallowmann]

I'd recommend PA or MD/DO. PA's in general seem to have a slightly better understanding of pathophysiology than any NP I've met.

That said, MD/DO is a long route. It's not for the easily swayed or faint of heart. Even the most motivated people question their decision multiple times along the way.

It has nothing to do with your age. Average age is 25, with ranges regularly in the early 20s to 40s. It's more about whether you want to go through all of that or whether you'd be just as happy doing something else.

From what you say is important, you're really going to want to go into something that will teach you pathophysiology, and honestly it sounds like MD/DO. You can also do and learn a lot as a PA, and you have lots of options. On top of that, there is a PA to DO bridge that's only 3 years at LECOM, so worst case scenario, you could try for that if you end up not liking it, and you'd only lose a year (and have a backup that could save you in case you don't make it through med school/residency).

Obviously the decision is up to you, but if you really like the science and want to be in a clinical setting (i.e. not do a PhD in science, immunology, etc.), then I think you'd be better served going PA or MD/DO.

 

[nlax30]

There are many PAs/NPs in speciality fields that I respect and interact with daily. Many of them started off in primary care and then transitioned to their current field. While the majority are good and knowledgeable, ultimately the decision rests with the physician.

Many of our sub-specialists have mid-levels to help with the volume though ultimately the physician is the one making the final call in regards to management.

 

[padfoot777]

Sounds like you want to be a physician just from the original post. But know the road is very long, and the road feels even longer if you have your heart set on something very competitive such as dermatology. PA's have a lot more flexibility when it comes to the type of specialty they would like to practice. In the end only you can decide what you want to do ultimately and I hope you figure out what works for you. Good luck

 

[Dreamislandcaptive]

Medicine

 

[drklouds]

I think the real question is what do you want the most out of your life.

If it is to be the most fulfilled/proud of yourself you can be at work-then perhaps medicine is for you. However, keep in mind that you will not be receiving a paid physician salary until you are 40+ if you need to do more medicine prereqs/MCAT/multiple attempts at applying etc no to mention you will have to pay the $300-400k of debt you have racked up.

If you are ready to put in 16-18 hours a day for 7 years and do little else, all in the name of practicing medicine- go for it.
You can still see and work with interesting pathology as a PA (all very dependent on what you go into and who you work for) and make a livable salary-with the bonus being that you leave it at work when you walk out of the door.

If I could do it all over, I would definitely go the PA route (current MSIII), but I think we are coming from very different perspectives. I definitely want a family. The farther I have come, the more I feel like I wouldn't mind someone else to go to to double check my decisions (but that may just be because I am still not confident in my medical knowledge.) At the end of the day I think being a PA carries a lot less stress and allows more of a life outside of medicine.

 

[hckyplyr]

I was a PA, now starting MSII. I matriculated at age 32, and there are plenty of people (and PA's) older than me in my class. Just reading your posts now, you won't be satisfied as a PA/NP. You can try to justify all the reasons why you might, but you won't. You will be envious of medical students, residents, and attendings all throughout your PA schooling, and PA career, especially when you realize you are likely smarter/better clinically/better surgically/etc than many of them. I had a laundry list of reasons why I wanted to go back to be a physician, only two reasons to stay a PA. Would you rather be a 40yr old PA hating your life and career choice, or be a physician? Even if you're a fresh attending in your early 40's, you still have a long career ahead of you (>25yrs). Just make the necessary moves and go all the way, you won't regret it in the long run.

 

[shadowlightfox]

I was a PA, now starting MSII. I matriculated at age 32, and there are plenty of people (and PA's) older than me in my class. Just reading your posts now, you won't be satisfied as a PA/NP. You can try to justify all the reasons why you might, but you won't. You will be envious of medical students, residents, and attendings all throughout your PA schooling, and PA career, especially when you realize you are likely smarter/better clinically/better surgically/etc than many of them. I had a laundry list of reasons why I wanted to go back to be a physician, only two reasons to stay a PA. Would you rather be a 40yr old PA hating your life and career choice, or be a physician? Even if you're a fresh attending in your early 40's, you still have a long career ahead of you (>25yrs). Just make the necessary moves and go all the way, you won't regret it in the long run.

Don't a lot of people want to be a PA because it's not physician (i.e. it's less intensive than a physician, but you still enjoy the similar benefits of a physician like good pay, etc)? I've had a lot of people in my college want to go to PA route over MD/DO, explaining that it's a safer route and you don't have to spend as many years in school.

 

[hckyplyr]

Yes, people do that for those reasons. After having done both, I think those reasons are a cop out. Based on the OP's post, they want to possibly do research, and seemingly want to know all the intricate, minute detail of his courses, medicine and disease states. That's all they had to say, go MD/DO. People always make this argument "PA school is cheaper, I'll have less debt." Yea, you'll also have a salary that is 1/2-1/4 of a physician too. They also say it takes much longer. What does it matter if you're a PA working 40-70hrs a week, or in a residency working 80hrs a week to become a physician. You're still ultimately practicing medicine, just with much more respect, knowledge and opportunities at your end goal as a resident. I would write a million reasons for going MD/DO, because I've had the unfortunate opportunity to experience both sides of the fence. I don't want to write a book, so I'll just say again OP, go to med school.

 

[W19]

Don't a lot of people want to be a PA because it's not physician (i.e. it's less intensive than a physician, but you still enjoy the similar benefits of a physician like good pay, etc)? I've had a lot of people in my college want to go to PA route over MD/DO, explaining that it's a safer route and you don't have to spend as many years in school.

A lot of them do until they start working and see the treatment they receive from staff/patients ect... is different from that of physicians. I have met so many (NP/PA) wanna be physician as a RN, hence I did not even consider them as career when I decided to go back to school.

I would do pharmacy before doing NP/PA even if their roles are different... Being a second class 'provider' is not fun...

 

[Ho0v-man]

A lot of them do until they start working and see the treatment they receive from staff/patients ect... is different from that of physicians. I have met so many (NP/PA) wanna be physician as a RN, hence I did not even consider them as career when I decided to go back to school.

I would do pharmacy before doing NP/PA even if their roles are different... Being a second class 'provider' is not fun...

Yeah but it's still pretty cool for someone who's older, has a thick skin, a just wants to practice medicine and doesn't give AF how.

OP, maybe you could post your question on the PA forum. Most people on a doctor forum are going to say go to med school. Might be nice for a different perspective.


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[edgerock24]

A lot of them do until they start working and see the treatment they receive from staff/patients ect... is different from that of physicians. I have met so many (NP/PA) wanna be physician as a RN, hence I did not even consider them as career when I decided to go back to school.

I would do pharmacy before doing NP/PA even if their roles are different... Being a second class 'provider' is not fun...

Some people could care less about what other people think of their status in the hospital, and just want a job that is stable & pays good money.

I get what you are saying, though. I think NP's seem to have issues with their role more than PA's for the most part. The PA's that I've come into contact with, and from reading MD's/DO's/medical students' opinions of them from here, seem to be content with their responsibilities.

 

[scpod]

The NP's that work for my own group really don't make all that much more than when they were nurses, but they have a lot more debt. They provide a great service to me because they do a lot of the stuff that I don't really want to waste my time on as a physician. On many of the specialist services they pretty much just provide note writing services. That said, I know some well-respected PA's and NP's. They have generally been practicing more than 10 or 15 years and I listen to what they have to say. But there aren't many of them.

 

[JustPlainBill]

<snip>
My concern about NP and PA are as follows:

*I am afraid I will not have enough scientific/medical knowledge to help others at the level I wish to*

The reason I decided to switch to a medical career is because my personal health was complex, and although it was not enjoyable trying to solve my own medical mystery, I want to be able to take on complex cases and really use the depth of knowledge I have, to help others. I love medical research and am sincerely fascinated by immunology, studies regarding microbiome, infectious disease, physiology in general, autoimmune problems, infectious diseases etc. I think I make my point. I like science.

I do realize that NP's work with doctors in specialty fields now outside of Family Medicine. But Im assuming, if someone is seen with a less common presentation, the NP is not the one to ruminate or help the physician come to a diagnosis. I also felt many doctors wrote me off and refused to brainstorm about my (very serious) symptoms. I don't think I could handle witnessing this, and not being able step in and further explore possibilities, patient history, etc etc. Maybe this is something only possible in private practice though, due to insurance complexities. Im not too knowledgeable in this regard other than knowing at times Doctors hands are tied as well.

I also realize the PA's have the 'medical model' but again, same question as above... Im afraid that I will get stuck with the most basic cases and if I do encounter an individual searching for the root of a problem, it will be beyond my intellectual and legal scope to assist them in their search for an answer.

So I am basically asking if I am wrong in my assumptions. Does anyone work with NP/PA's and can confirm there is room for complex problem solving as an NP/PA?

Thank you!!!

So -- I read this and felt compelled to respond -- a few things --

1) I get that you want to be able to take on complex cases and use the depth of knowledge to help others --- recognize that you most likely won't be able to have the time to do that unless you open a cash only practice -- that's assuming you want to use medicine as a profession, are not independently wealthy or have a spouse that's willing to support you while you spend hours with each patient "getting to the root" of the problem. Not the way it works in modern medicine -- we can gripe and moan all day long about that but it's the truth. Why? well, for a large part of it, people refuse to accept that fact that physicians don't know why their 3rd toe tingles whenever they turn their head to the right and cough after drinking cold water or some other such nonsense -- there's a phrase -- idiopathic -- meaning "we don't know what's causing it" and we treat the symptoms -- this isn't like fixing a washing machine or desktop -- a very complex and dynamic organism that changes from second to second. There are quite a few cases that mystify physicians and we do all we can but to take the time to sit with everyone on my panel and discuss everything that's perceived to be wrong and run it to ground -- ain't gonna happen and I doubt you'll find anyone in the medical field that can/will do this -- my truly complex cases have been referred to colleagues at research hospitals and about 10-20% of those come back as "idiopathic" and the symptoms are treated and followed.... my first patient I pronounced was likely medication induced from a treatment for prostate cancer but the actual causative agent in his death? No freakin' idea.

2) NPs typically have a knowledge base on par with a weak 3rd year medical student -- witnessed by the watered down Step 2 exams that 50% of them failed in an experiment done a while back. No, they're not going to "ruminate". At times, I may spend 5 or 10 minutes with my physician colleagues with unusual cases but there's not a lot of "rumination" that goes on. And while I can learn or get ideas from anyone -- typically NPs don't help me "come to a diagnosis" --- not trying to be condescending and they have their place on the team but just stating facts.

3) Most physicians will not "brainstorm" with patients -- because we're not trained to -- that's typically software development/engineering/business type of thinking -- we're trained to walk into a room with a basic differential depending on stated chief complaint -- ask pertinent questions to move things up or down the differential, do a physical exam that helps with confirmation and then either diagnose and treat or order tests to confirm suspicions and treat symptoms while we're waiting. Brainstorming -- not so much. And you probably felt like you were written off because the physician already had a plan of action and wasn't good at hiding their disdain at the time constraints you were ignoring -- not meaning to do so as you probably legitimately had concerns but all of us are under time pressure in clinic.

4) Don't know that I've ever had one of my midlevels in the room with me seeing patients -- usually they have their own panel and are busy also. Yes, it would not be good to be in the room with a physician and then step in and muck about with the physician's plan -- it would undermine patient confidence and likely be viewed in a dim light -- not being arrogant but there is a hierarchy in medicine.

5) You will encounter people searching for the root of the problem -- always -- the problem is making them realize that 1) we may not know the root of the problem, ever. 2) Unless they have really deep pockets, insurance companies will not pay for the $1million dollar workup that their presenting condition likely doesn't need 3) No, everything you read on the internet is not true 4) A google search does not count as research 5) if you can't tell me the evidence hierarchy, I'm not likely to view your evidence with any great interest other than to amuse you. 6) I'm more than willing to go the extra mile with my patients and some of them have my cellphone number -- I spend the time where it's needed and typically run an hour behind because I take the time to explain the physiology, microbiology, etc. to my patients as it helps them understand why I'm doing what I'm doing -- but I don't have time to explain to a patient that no, your fatigue isn't likely from a CoQ10 deficiency that you read about on the internet, it's most likely from whatever's causing this ST segment elevation and you need to get to the ER right freakin' now (turned out to be a 90% occluded LAD and 80% occluded right circumflex) ----

Anyway, good luck to you -- again, this is just my experience -- and recall that I have had multiple bad experiences with NPs and really don't trust them as a group -- but that's just me -- there are a few in my practice that I've come to trust over a period of time....

 

[cbrons]

I would not ever consider N.P. though it is extremely easy to get into those programs from what I understand.

PA is not a bad option, but like NP (or DNP, exact same thing) you won't be handling the seriously ill or really doing much outside the routine stuff that basically an R.N. could and should in some cases be able to do following an algorithm.

 

[WeeBay]

The length of training argument is really stupid.

Doctor = 4 years + 3-5 of residency
PA\NP = 2 years + an entire career of doing resident work

If "residency length" is a real factor, why not choose the path that has an ending.

I am not bashing midlevels here, but have you seen what most of them do for a living? they are residents just make *slightly more* money and work better hours

 

[dozitgetchahi]

So -- I read this and felt compelled to respond -- a few things --

1) I get that you want to be able to take on complex cases and use the depth of knowledge to help others --- recognize that you most likely won't be able to have the time to do that unless you open a cash only practice -- that's assuming you want to use medicine as a profession, are not independently wealthy or have a spouse that's willing to support you while you spend hours with each patient "getting to the root" of the problem. Not the way it works in modern medicine -- we can gripe and moan all day long about that but it's the truth. Why? well, for a large part of it, people refuse to accept that fact that physicians don't know why their 3rd toe tingles whenever they turn their head to the right and cough after drinking cold water or some other such nonsense -- there's a phrase -- idiopathic -- meaning "we don't know what's causing it" and we treat the symptoms -- this isn't like fixing a washing machine or desktop -- a very complex and dynamic organism that changes from second to second. There are quite a few cases that mystify physicians and we do all we can but to take the time to sit with everyone on my panel and discuss everything that's perceived to be wrong and run it to ground -- ain't gonna happen and I doubt you'll find anyone in the medical field that can/will do this -- my truly complex cases have been referred to colleagues at research hospitals and about 10-20% of those come back as "idiopathic" and the symptoms are treated and followed.... my first patient I pronounced was likely medication induced from a treatment for prostate cancer but the actual causative agent in his death? No freakin' idea.

2) NPs typically have a knowledge base on par with a weak 3rd year medical student -- witnessed by the watered down Step 2 exams that 50% of them failed in an experiment done a while back. No, they're not going to "ruminate". At times, I may spend 5 or 10 minutes with my physician colleagues with unusual cases but there's not a lot of "rumination" that goes on. And while I can learn or get ideas from anyone -- typically NPs don't help me "come to a diagnosis" --- not trying to be condescending and they have their place on the team but just stating facts.

3) Most physicians will not "brainstorm" with patients -- because we're not trained to -- that's typically software development/engineering/business type of thinking -- we're trained to walk into a room with a basic differential depending on stated chief complaint -- ask pertinent questions to move things up or down the differential, do a physical exam that helps with confirmation and then either diagnose and treat or order tests to confirm suspicions and treat symptoms while we're waiting. Brainstorming -- not so much. And you probably felt like you were written off because the physician already had a plan of action and wasn't good at hiding their disdain at the time constraints you were ignoring -- not meaning to do so as you probably legitimately had concerns but all of us are under time pressure in clinic.

4) Don't know that I've ever had one of my midlevels in the room with me seeing patients -- usually they have their own panel and are busy also. Yes, it would not be good to be in the room with a physician and then step in and muck about with the physician's plan -- it would undermine patient confidence and likely be viewed in a dim light -- not being arrogant but there is a hierarchy in medicine.

5) You will encounter people searching for the root of the problem -- always -- the problem is making them realize that 1) we may not know the root of the problem, ever. 2) Unless they have really deep pockets, insurance companies will not pay for the $1million dollar workup that their presenting condition likely doesn't need 3) No, everything you read on the internet is not true 4) A google search does not count as research 5) if you can't tell me the evidence hierarchy, I'm not likely to view your evidence with any great interest other than to amuse you. 6) I'm more than willing to go the extra mile with my patients and some of them have my cellphone number -- I spend the time where it's needed and typically run an hour behind because I take the time to explain the physiology, microbiology, etc. to my patients as it helps them understand why I'm doing what I'm doing -- but I don't have time to explain to a patient that no, your fatigue isn't likely from a CoQ10 deficiency that you read about on the internet, it's most likely from whatever's causing this ST segment elevation and you need to get to the ER right freakin' now (turned out to be a 90% occluded LAD and 80% occluded right circumflex) ----

Anyway, good luck to you -- again, this is just my experience -- and recall that I have had multiple bad experiences with NPs and really don't trust them as a group -- but that's just me -- there are a few in my practice that I've come to trust over a period of time....

This is one view. My experience has been a bit different.

There are plenty of occasions in medicine where having the right depth of knowledge at the right time makes all the difference in the world - sometimes life vs death. The ICU is a classic example. Yes, there are plenty of people who enter the ICU who even Dr Osler, Dr House and (pick your other medical idol) combined weren't going to save - but there are people who were definitely brought back from the brink when sharp residents/fellows/staff made a judgement call and figured something out.

It's not always about ordering endless tests either. Sometimes it's about realizing that the dude who has been bridging to warfarin from Lovenox for the last 8 months (because he's mysteriously not theraputic yet) is having an interaction with his azathioprene (I spotted this in clinic once after it had been missed by several other residents and others who had seen the pt previously). Etc etc etc.

Yes, there's a lot of idiopathic stuff in medicine. There's also a lot of 'idiotpathic' (as both a previous staff and Dr Goljan called it) stuff, where a real diagnosis has been missed because nobody thought of diagnosis xyz. Surprisingly, spotting this stuff often doesn't require the million dollar workup (in my experience). You are a hell of a lot better equipped to anticipate and deal with these issues as an MD/DO than as a midlevel.

 

[W19]

Yeah but it's still pretty cool for someone who's older, has a thick skin, a just wants to practice medicine and doesn't give AF how.

OP, maybe you could post your question on the PA forum. Most people on a doctor forum are going to say go to med school. Might be nice for a different perspective.


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After hearing the same thing 100x, one will feel bothered by it even if you have a thick skin... I have seen it, trust me. Then again, I used to work in a hospital that is in an upper middle class and rich neighborhood. Even physicians would put in their consult orders: 'Not to be seen by NP/PA' or something similar. Or some stupid cardiologist throw a fit in front of everyone when a NP/PA writes a stupid order in one of his patients.

 

[Mad Jack]

Some people could care less about what other people think of their status in the hospital, and just want a job that is stable & pays good money.

I get what you are saying, though. I think NP's seem to have issues with their role more than PA's for the most part. The PA's that I've come into contact with, and from reading MD's/DO's/medical students' opinions of them from here, seem to be content with their responsibilities.

I've heard a few PAs who felt like they were being boned in primary care and EM. Most of them are happy with their role though.

 

[cbrons]

After hearing the same thing 100x, one will feel bothered by it even if you have a thick skin... I have seen it, trust me. Then again, I used to work in a hospital that was in an upper middle class and rich neighborhood. Even physicians would put in their consult orders: 'Not to be seen by NP/PA' or something similar. Or some stupid cardiologist throw a fit in front of everyone when a NP/PA writes a stupid order in one of his patients.

Why is he "stupid" for that? His customers pay a lot for his services and expect physician only treatment. If he wants to provide that, he is the one in charge.

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[W19]

Why is he "stupid" for that? His customers pay a lot for his services and expect physician only treatment. If he wants to provide that, he is the one in charge.

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Undermining other healthcare professionals in front of other staff members is not cool...

 

[cbrons]

Undermining other healthcare professionals in front of other staff members is not cool...

How is it undermining them? Some physicians tell med students not to see a certain patient bc said patient wants only wants to see a physician. How is that any different?

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[Ho0v-man]

How is it undermining them? Some physicians tell med students not to see a certain patient bc said patient wants only wants to see a physician. How is that any different?

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It's probably that doctors childish unprofessional attitude.


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[cbrons]

It's probably that doctors childish unprofessional attitude.


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Throwing a fit is unprofessional, but simlly saying that medlevels are not to see or write orders on a patient is perfectly reasonable.

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[W19]

How is it undermining them? Some physicians tell med students not to see a certain patient bc said patient wants only wants to see a physician. How is that any different?

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It's ok to write in your consult orders that you don't want PA/NP to see your patient, but it's not ok to berate PA/NP in front of other staff. I had problem with the way he did that on multiple occasions.

 

[WeeBay]

After hearing the same thing 100x, one will feel bothered by it even if you have a thick skin... I have seen it, trust me. Then again, I used to work in a hospital that was in an upper middle class and rich neighborhood. Even physicians would put in their consult orders: 'Not to be seen by NP/PA' or something similar. Or some stupid cardiologist throw a fit in front of everyone when a NP/PA writes a stupid order in one of his patients.

I once put in a consult for heme/onc on a Friday afternoon on a patient. Dont really remember the exact circumstances of the patient, but she was sick as hell and had 11 kids who stayed with her over the weekend... that i remember vividly. Heme/onc had their PA see the patient over the weekend who wrote basically nothing in his note. Something to the effect of "patient's condition is multifactorial due to sepsis/vdrf/anemia".

Monday rolls around, we get the attending who immediately recognizes that the patient is acute HLH......which the PA has never even heard of before. Its too late, we start steroids but the patient crashes and dies Monday afternoon.

Im really not saying that PAs and NPs aren't great at what they do, but it is absolute bull**** when you consult a service and then get stuck with recommendations from someone with less training and experience than most ICU nurses

 

[shadowlightfox]

I once put in a consult for heme/onc on a Friday afternoon on a patient. Dont really remember the exact circumstances of the patient, but she was sick as hell and had 11 kids who stayed with her over the weekend... that i remember vividly. Heme/onc had their PA see the patient over the weekend who wrote basically nothing in his note. Something to the effect of "patient's condition is multifactorial due to sepsis/vdrf/anemia".

Monday rolls around, we get the attending who immediately recognizes that the patient is acute HLH......which the PA has never even heard of before. Its too late, we start steroids but the patient crashes and dies Monday afternoon.

Im really not saying that PAs and NPs aren't great at what they do, but it is absolute bull**** when you consult a service and then get stuck with recommendations from someone with less training and experience than most ICU nurses

How is that even legal? I think from that it's pretty clear the PA didn't have qualifications to see that patient. Whoever allowed that should get fired.

 

[dozitgetchahi]

I once put in a consult for heme/onc on a Friday afternoon on a patient. Dont really remember the exact circumstances of the patient, but she was sick as hell and had 11 kids who stayed with her over the weekend... that i remember vividly. Heme/onc had their PA see the patient over the weekend who wrote basically nothing in his note. Something to the effect of "patient's condition is multifactorial due to sepsis/vdrf/anemia".

Monday rolls around, we get the attending who immediately recognizes that the patient is acute HLH......which the PA has never even heard of before. Its too late, we start steroids but the patient crashes and dies Monday afternoon.

Im really not saying that PAs and NPs aren't great at what they do, but it is absolute bull**** when you consult a service and then get stuck with recommendations from someone with less training and experience than most ICU nurses

Totally agree.

At my fellowship program, midlevels are only allowed to see a certain range of clinic followups - they don't see new referrals and they don't do hospital consults. This is why.

 

[scpod]

How is that even legal? I think from that it's pretty clear the PA didn't have qualifications to see that patient. Whoever allowed that should get fired.

Its perfectly legal for the PA to see the patient. The problem comes in billing. If you bill under the PA then no one else ever need see the patient and the group will get paid at the reduced PA rate. If, however, they bill under the physician, with most payors, there is a requirement that the physician see the patient themselves on the same calendar day and document that fact. Some payors require documentation of a second physical exam before they will pay. Some payors, like AL Medicaid for instance, do not recognize and PA or NP consults at all and the physician has to do the entire thing... including the dictation.

The real question is: is it ethical? A consult should never be done by a PA or NP without discussing it with an attending on the same day. That's too much of a liability because it will lead to a lot of missed diagnoses and potentially poor outcomes.

 

[W19]

Totally agree.

At my fellowship program, midlevels are only allowed to see a certain range of clinic followups - they don't see new referrals and they don't do hospital consults. This is why.

That's how it's supposed to be... I still don't get how some hospitals and physicians can get away with something so unethical like that. Having midlevels taking care of consults make no sense at all.

 

[cbrons]

I once put in a consult for heme/onc on a Friday afternoon on a patient. Dont really remember the exact circumstances of the patient, but she was sick as hell and had 11 kids who stayed with her over the weekend... that i remember vividly. Heme/onc had their PA see the patient over the weekend who wrote basically nothing in his note. Something to the effect of "patient's condition is multifactorial due to sepsis/vdrf/anemia".

Monday rolls around, we get the attending who immediately recognizes that the patient is acute HLH......which the PA has never even heard of before. Its too late, we start steroids but the patient crashes and dies Monday afternoon.

Im really not saying that PAs and NPs aren't great at what they do, but it is absolute bull**** when you consult a service and then get stuck with recommendations from someone with less training and experience than most ICU nurses

Dont think for 1 second that an NP providing the consult wouldve changed the outcome. Get ready for much, much more of these situations as NPs are increasingly "independent."

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[cbrons]

I once put in a consult for heme/onc on a Friday afternoon on a patient. Dont really remember the exact circumstances of the patient, but she was sick as hell and had 11 kids who stayed with her over the weekend... that i remember vividly. Heme/onc had their PA see the patient over the weekend who wrote basically nothing in his note. Something to the effect of "patient's condition is multifactorial due to sepsis/vdrf/anemia".

Monday rolls around, we get the attending who immediately recognizes that the patient is acute HLH......which the PA has never even heard of before. Its too late, we start steroids but the patient crashes and dies Monday afternoon.

Im really not saying that PAs and NPs aren't great at what they do, but it is absolute bull**** when you consult a service and then get stuck with recommendations from someone with less training and experience than most ICU nurses

Piggybacking off this, I know of a case where a "Neurology" NP was sent to consult on an inpatient with infectious enterocolitis who developed new-onset bilateral weakness of the distal LE. She ordered an MRI which was normal and chalked up to stress. Patient was paralyzed and a vent shortly thereafter.



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[kwinterwinter]

Thank you for your replies. Your input was helpful and Ive decided to move forward with premed courses and hope to apply next Summer, or possibly the following. Then, when all is said and done I will have been a student for 12 years not including residency. Fortunately, I like school...

 

[kwinterwinter]

This is one view. My experience has been a bit different.

There are plenty of occasions in medicine where having the right depth of knowledge at the right time makes all the difference in the world - sometimes life vs death. The ICU is a classic example. Yes, there are plenty of people who enter the ICU who even Dr Osler, Dr House and (pick your other medical idol) combined weren't going to save - but there are people who were definitely brought back from the brink when sharp residents/fellows/staff made a judgement call and figured something out.

It's not always about ordering endless tests either. Sometimes it's about realizing that the dude who has been bridging to warfarin from Lovenox for the last 8 months (because he's mysteriously not theraputic yet) is having an interaction with his azathioprene (I spotted this in clinic once after it had been missed by several other residents and others who had seen the pt previously). Etc etc etc.

Yes, there's a lot of idiopathic stuff in medicine. There's also a lot of 'idiotpathic' (as both a previous staff and Dr Goljan called it) stuff, where a real diagnosis has been missed because nobody thought of diagnosis xyz. Surprisingly, spotting this stuff often doesn't require the million dollar workup (in my experience). You are a hell of a lot better equipped to anticipate and deal with these issues as an MD/DO than as a midlevel.

Thank you for this perspective. This 'depth of knowledge' is what I was attempting to relay in my original post. I have seen many physicians due to my own health issues and regardless of the system, some are interested in digging deeper and others are completely uninterested. A midlevel doesn't really have the choice to care either way, beyond a certain point. Thanks again.

 

[kwinterwinter]

So -- I read this and felt compelled to respond -- a few things --

1) I get that you want to be able to take on complex cases and use the depth of knowledge to help others --- recognize that you most likely won't be able to have the time to do that unless you open a cash only practice -- that's assuming you want to use medicine as a profession, are not independently wealthy or have a spouse that's willing to support you while you spend hours with each patient "getting to the root" of the problem. Not the way it works in modern medicine -- we can gripe and moan all day long about that but it's the truth. Why? well, for a large part of it, people refuse to accept that fact that physicians don't know why their 3rd toe tingles whenever they turn their head to the right and cough after drinking cold water or some other such nonsense -- there's a phrase -- idiopathic -- meaning "we don't know what's causing it" and we treat the symptoms -- this isn't like fixing a washing machine or desktop -- a very complex and dynamic organism that changes from second to second. There are quite a few cases that mystify physicians and we do all we can but to take the time to sit with everyone on my panel and discuss everything that's perceived to be wrong and run it to ground -- ain't gonna happen and I doubt you'll find anyone in the medical field that can/will do this -- my truly complex cases have been referred to colleagues at research hospitals and about 10-20% of those come back as "idiopathic" and the symptoms are treated and followed.... my first patient I pronounced was likely medication induced from a treatment for prostate cancer but the actual causative agent in his death? No freakin' idea.

2) NPs typically have a knowledge base on par with a weak 3rd year medical student -- witnessed by the watered down Step 2 exams that 50% of them failed in an experiment done a while back. No, they're not going to "ruminate". At times, I may spend 5 or 10 minutes with my physician colleagues with unusual cases but there's not a lot of "rumination" that goes on. And while I can learn or get ideas from anyone -- typically NPs don't help me "come to a diagnosis" --- not trying to be condescending and they have their place on the team but just stating facts.

3) Most physicians will not "brainstorm" with patients -- because we're not trained to -- that's typically software development/engineering/business type of thinking -- we're trained to walk into a room with a basic differential depending on stated chief complaint -- ask pertinent questions to move things up or down the differential, do a physical exam that helps with confirmation and then either diagnose and treat or order tests to confirm suspicions and treat symptoms while we're waiting. Brainstorming -- not so much. And you probably felt like you were written off because the physician already had a plan of action and wasn't good at hiding their disdain at the time constraints you were ignoring -- not meaning to do so as you probably legitimately had concerns but all of us are under time pressure in clinic.

4) Don't know that I've ever had one of my midlevels in the room with me seeing patients -- usually they have their own panel and are busy also. Yes, it would not be good to be in the room with a physician and then step in and muck about with the physician's plan -- it would undermine patient confidence and likely be viewed in a dim light -- not being arrogant but there is a hierarchy in medicine.

5) You will encounter people searching for the root of the problem -- always -- the problem is making them realize that 1) we may not know the root of the problem, ever. 2) Unless they have really deep pockets, insurance companies will not pay for the $1million dollar workup that their presenting condition likely doesn't need 3) No, everything you read on the internet is not true 4) A google search does not count as research 5) if you can't tell me the evidence hierarchy, I'm not likely to view your evidence with any great interest other than to amuse you. 6) I'm more than willing to go the extra mile with my patients and some of them have my cellphone number -- I spend the time where it's needed and typically run an hour behind because I take the time to explain the physiology, microbiology, etc. to my patients as it helps them understand why I'm doing what I'm doing -- but I don't have time to explain to a patient that no, your fatigue isn't likely from a CoQ10 deficiency that you read about on the internet, it's most likely from whatever's causing this ST segment elevation and you need to get to the ER right freakin' now (turned out to be a 90% occluded LAD and 80% occluded right circumflex) ----

Anyway, good luck to you -- again, this is just my experience -- and recall that I have had multiple bad experiences with NPs and really don't trust them as a group -- but that's just me -- there are a few in my practice that I've come to trust over a period of time....

Thank you for taking the time to reply, I appreciated your perspective. I do understand it is often difficult/impossible to know the root of a problem, however, I have encountered physicians that seemed to completely shut down once confronted with complexities, while others have taken a few minutes to ask questions and I can see they are actively thinking. Ultimately, I at least want the option to think, whereas the NP route would leave me slightly disabled in this regard. Also, maybe my end goal should be a research hospital 😉 Thanks again!

 

[JustPlainBill]

Thank you for taking the time to reply, I appreciated your perspective. I do understand it is often difficult/impossible to know the root of a problem, however, I have encountered physicians that seemed to completely shut down once confronted with complexities, while others have taken a few minutes to ask questions and I can see they are actively thinking. Ultimately, I at least want the option to think, whereas the NP route would leave me slightly disabled in this regard. Also, maybe my end goal should be a research hospital 😉 Thanks again!

No worries -- you also have to take a few things into account with the physicians that seemingly "shut down" -- and I'll give you an example ---

I had a 25 y/o HM present AFTER being seen/treated for viral syndrome and then pharyngitis with rocephin and steroids with a standard lab workup (CBC/CMP/rapid strep) for the presentation --- seen by a PA both times and signed off by oversight physician (not me) -- this guy shows up with diffuse joint aches, obviously toxic/sick, febrile and in some pain --- the differential is long and extensive in this one --- I've got 15 minutes to try to figure out what path I want to go down -- so I start labs on him looking for various viral etiologies and some zebras but there was something in the presentation that made me want to tap this guy --- and I've got no tap kits in the office and it's been about 3 years since I've done one --- I contact my local research hospital's ER and do a doc to doc with the ER physician --- they agree to see him and possibly admit given presentation and labs -- he goes immediately and winds up getting admitted that night -- isolated, on contact precautions and they called in rheum, ID, neuro --- neuro signs off, rheum stays on board, ID stays on board but eventually signs off -- treatment includes very high dose steroids, broad spectrum ABX that were d/c'd after a day or so --- eventual diagnosis was adult onset Still's dz and he was d/c'd home to f/u with me and rheum --- was something wrong? Yes. Was it a complex case? yes. Could I figure it out in my office -- No -- did he really need to be admitted and worked up -- yes ---

if you're going to try to do that kind of case in your office, you're treading on some thin ice ----

Now, contrast that with the -- I have a burning sensation in my lower legs and palms that's been happening for the last 3 weeks and feel like my legs are heavier than they usually are - both of these come and go by the way with no known alleviators/aggravators -- so we begin a basic workup and go from there -- labs reveal no abnormalities, no abnormalities on PE -- so is it worth the referral to neuro for nerve conduction studies, etc or rheum or whatever to satisfy this patient with something that's most likely a normal part of daily living?

A lot of times, at least in my experience, people want to feel like they're 20 when they're in their 50s -- and while modern medicine is good, don't know that we can do that yet ----

Anyway, I now return you back to your regularly scheduled programming....

 

[RichterBelmont]

Do you want to feel confident in your abilities, and have the training to back that confidence up? Go MD/DO. The difference in training between NP/PA and MD/DO is absurd.

 

[shadowlightfox]

Do you want to feel confident in your abilities, and have the training to back that confidence up? Go MD/DO. The difference in training between NP/PA and MD/DO is absurd.

No way! Another fellow Castlevania fan!? Word! That's awesome!

 

[Psai]

I once put in a consult for heme/onc on a Friday afternoon on a patient. Dont really remember the exact circumstances of the patient, but she was sick as hell and had 11 kids who stayed with her over the weekend... that i remember vividly. Heme/onc had their PA see the patient over the weekend who wrote basically nothing in his note. Something to the effect of "patient's condition is multifactorial due to sepsis/vdrf/anemia".

Monday rolls around, we get the attending who immediately recognizes that the patient is acute HLH......which the PA has never even heard of before. Its too late, we start steroids but the patient crashes and dies Monday afternoon.

Im really not saying that PAs and NPs aren't great at what they do, but it is absolute bull**** when you consult a service and then get stuck with recommendations from someone with less training and experience than most ICU nurses

I hate on midlevels with the best of them but I've never heard of HLH either

 

[hallowmann]

I hate on midlevels with the best of them but I've never heard of HLH either

Literally heard about HLH for the first time a few months ago. I was never big on heme/onc, but wondered how I got through 3 years of med school not hearing about this thing that apparently everyone around me has heard of already.

 

[WeeBay]

Literally heard about HLH for the first time a few months ago. I was never big on heme/onc, but wondered how I got through 3 years of med school not hearing about this thing that apparently everyone around me has heard of already.

thats the kicker though, because if you had went to PA/NP school you would already be "qualified" to walk around with "heme/onc" on your white coat and take consults.