Do we really need that many years of residencies to practice?

[Vacant]

I have not yet done 3rd year rotations, thus this perhaps dumb question.

I am wondering if we really need 3-5 years of residency training to function as physicians. Perhaps more pertinent question is this: is it really necessary to make residencies so grueling? It would be nice to hear from the experienced residents and attendings. Am I wrong to think that our training is unnecessarily difficult to the point of being inhumane? Or are they all necessary part of being an efficient doctor?

Your honest answers would make me feel better and better informed as I prepare to take the next step in this long training path for the rapidly diminishing reward.

Thank you.

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[dragonfly99]

I think 3 years was a good length of time for IM residency training. I think that for general outpatient practice and/or traditional primary care practice, it would have been better if we had more outpatient months and fewer inpatient months. Also, rotating off-service (like through urology and orthopedic clinics) would have been much more helpful vs. doing a couple more medicine ward months during 2nd and 3rd years. However, I do think the overall length of training was correct. I think that it would have been reasonable for those of us specializing (say, GI or cards) to do only 2 years of IM residency, but I cannot say that I didn't learn anything valuable during my 3rd year. Trust me, you're going to feel damn lucky for any and all of your training knowledge at some point...like when you get some patient that you don't know what the hell his diagnosis is...at least for IM you can never know too much.

I actually had (and have) much less of a problem with the "grueling" nature of residency training than I have with the fact that hospitals, attendings and PD's have almost unlimited power over trainees. If it was easier to switch/change residencies, I think that some trainees would get treated better in terms of educational opportunities, because folks would vote with their feet if they were in a bad residency. Currently, once you pick a residency you are kind of married to it and if you don't like your program or find out they aren't teaching you well, you are kind of hosed. I was lucky because I think my residency did train me well, I liked the other residents and most attendings, and the working conditions were generally decent, though the hours were long.

 

[Law2Doc]

I have not yet done 3rd year rotations, thus this perhaps dumb question.

I am wondering if we really need 3-5 years of residency training to function as physicians. Perhaps more pertinent question is this: is it really necessary to make residencies so grueling? It would be nice to hear from the experienced residents and attendings. Am I wrong to think that our training is unnecessarily difficult to the point of being inhumane? Or are they all necessary part of being an efficient doctor?

Your honest answers would make me feel better and better informed as I prepare to take the next step in this long training path for the rapidly diminishing reward.

Thank you.

Medical school gives you foundation, but you really learn how to be a doctor in residency. That is the most crucial part of your training. So yeah, it has to be among the longer and more intense parts of your training because that's where you get all the value. In many other careers you have a number of years right out of school where they work you hard and pay you less -- so too with residency, but a bit more extreme because there is more to know and the stakes are higher.

 

[Vacant]

How is it that DNP, NP, and PA are claiming to be able to do so many things after only 2-3years of learning and training?
It seems they are more "capable" in terms of what they are "allowed" to do after finishing their program than an MD after med school.

Something is not right in this.

 

[Law2Doc]

How is it that DNP, NP, and PA are claiming to be able to do so many things after only 2-3years of learning and training?
It seems they are more "capable" in terms of what they are "allowed" to do after finishing their program than an MD after med school.

Something is not right in this.

Physicians should really be lobbying against this and getting strong distinctions on the books as to what constitutes the practice of medicine (requiring a medical license) and what isn't. Law and other professions have pushed hard to get these kinds of rules in place to fend off interlopers, but medicine seems too lazy or gun-shy, relying instead on tradition. But to a government official who doesn't know any better, a PA or NP who claims they can do the same job as your typical primary care doc, but at a fraction of the price and training, sounds like a great way to cut down on healthcare costs, particularly at a time when there is reportedly a physician shortage. But this shortage will be short lived (the generation behind the baby boomers is considerably smaller), while the encroachment will not be. Once you let the genie out of the bottle it is nearly impossible to get it back in. Once PAs and NPs get to act the same as physicians, you will be hard pressed to force them out of roles they are occupying.

It's a big mistake for medicine to let this kind of erosion and misconception occur. PA and NP can serve important intermediate roles, but until those roles are sharply delineated, they represent a big threat. In law, paralegals, realtors, and accountants all capture various tasks that had generally been done by lawyers, and lawyers attacked full force and repelled the interlopers, hitting them with major lawsuits for engaging in the "unauthorized practice of law". As a result, the "borders" of law have been quite safe for decades. Medicine tried their hand at protective lawsuits against chiropractors some decades ago, fought a lengthy (and poorly engineered) war, but lost big, and since then doctors have seemed afraid to protect their interests. But I think non-doctors practicing medicine is a very different case and one that physicians shouldn't avoid taking on head on before it's too late.

Not that there is anything bad about PAs or NPs -- most are quite good at their jobs and add value to the provision of health care. It's just that they aren't licensed physicians, lack much of the training, and often don't know what they don't know. So to the extent they expand their role without a commensurate expansion of their training, and the fact that now there is a push to give "doctorate"s in nursing and the like so that some of these healthcare professionals will try to hold themselves out as "doctor" should be untenable to the medical profession. Patients and government already don't know the difference between doctors and others who don the white coat. The profession needs to do a better job of protecting their own interests. Or it's almost guaranteed that they will lose out. Enough of my soap box.

 

[colbgw02]

Funny, I would have titled this thread "Do we really need so few years of residency to practice?"

 

[Vacant]

Funny, I would have titled this thread "Do we really need so few years of residency to practice?"

Can you explain yourself?

 

[Winged Scapula]

Can you explain yourself?

I think what colgbw is saying, because I agree with him/her, is that the field of medicine is so broad, and most attendings will tell you that they are faced with lots of things they never saw in medicine, is that residency could be/should be longer, or at least more efficient.

Since you haven't done residency, you will come to find that the lack of efficiency, the time spent in non-educational activities, the sheer breadth of what you are expected to know, means that you should savor every minute of your training because its darn scary out here sometimes.

 

[Vacant]

Since you haven't done residency, you will come to find that the lack of efficiency, the time spent in non-educational activities, the sheer breadth of what you are expected to know, means that you should savor every minute of your training because its darn scary out here sometimes.

This is exactly what I wanted to point out. I do not know the extent of this problem, but I do suspect it's pretty significant. Why is this wasteful "tradition" continued? Why are we wasting our time and energy so much on useless stuff when we have so much better things to do with our training time? Aren't the new and young attendings interested in changing this? Who has the power to change this? I thought they were the newly made docs revolting the old and revolutionizing the field for the good of all.

Out of 8-10 years of training and you still feel unsure of what you are doing? We definitely are not using those years effectively. Meanwhile, DNP, NP and PA are claiming to do as well as physicians coming out 2-3 years of training. I bet their trainings are much more practical and focused.

Someone in the right position got to do something about this.

 

[DrMom]

the entire practice of medicine is full of inefficiencies, not just residency

 

[OTD]

Meanwhile, DNP, NP and PA are claiming to do as well as physicians coming out 2-3 years of training. I bet their trainings are much more practical and focused.

Actually NO they are not more practical or focused, they are just lacking so much that they don't realize how much they DON'T know.

It's kinda like the med student that thinks he/she is more sure about the decision to go or not go to the OR than the resident/attending. They don't know enough to know what could go wrong, what to be afraid of, or the gravity of their decision. Their lack of training and lack of knowledge is what makes them so sure they know exactly what is going on, and that's dangerous.

Not meant to offend, but that's just the truth of the situation.

 

[mig26x]

Im with vacant on this one!!! If DNP's are going to have an opportunity to practice medicine on their own with their online classes and 1 visit per semester to campus for classes that nothing have to do with clinical medicine I really think 3 years is an overkill for outpatient medicine, maybe for inpatient medicine 3 years is adequate but for outpatient medicine is an overkill. At leas that's what the DNP's program are making IM residency training look like!!!

 

[Vacant]

Actually NO they are not more practical or focused, they are just lacking so much that they don't realize how much they DON'T know.

This is already a known fact. There is no argument here among us. The point is, rather, whether there is a way to make our own training more time efficient. Intense 80+ hrs of 3-5 years dedicated by a very intelligent person should produce something that no DNP, NP or PA can even dare to claim they can imitate to do. Yet they contend to do so. And even some docs themselves feel, "Yeah, they can do those things on their own." Isn't this why they are not harshly rebuked and put down as they should have been the moment they opened their mouths about it?

 

[Law2Doc]

This is already a known fact. There is no argument here among us. The point is, rather, whether there is a way to make our own training more time efficient. Intense 80+ hrs of 3-5 years dedicated by a very intelligent person should produce something that no DNP, NP or PA can even dare to claim they can imitate to do. Yet they contend to do so. And even some docs themselves feel, "Yeah, they can do those things on their own." Isn't this why they are not harshly rebuked and put down as they should have been the moment they opened their mouths about it?

I think you are missing the point. There are two things residencies provide #1 is training, and #2 is being the workhorse of the hospital. You seem interested in eleiminating all of #2 that doesn't contribute to #1. But the economic drive that makes #1 possible is #2. So yes, you do all the hours of scut and grunt work as a resident to make it affordable to do the training part. This isn't school anymore. They can't just send you a bill and train you. Or I guess they could, but nobody would stand for it. So where the training is inadequate a lot of places add a year -- a number of tracks recently jumped from 3 to 4 years in the last few years -- or tack on a recommended fellowship at the end. More training is going to be the norm.

Comparing to DNP, PA, NP is folly because you are simply comparing trained people to untrained an saying "why can't we be more like them?" Sure you can go out into the jungle unarmed and often come back unscathed. Doesn't mean you aren't taking huge risks or going in oblivious to what might happen and woefully unprepared to deal with it. But hey, without the extra time, cost or training you get out there quick and cheap. Or you can spend the 3-8 years of training necessary to be ready to deal with anything you come across. Medicine does the latter, and it's the right approach. If anything, it should be a bit longer training, but we are cutting that off because it's not as cost effective. But the goal shouldn't be to make medical training shorter, it really should be to limit actions of non-physicians unless they have substantially longer training. You don't give take a path to provide worse quality in order to compete, you make clear that your competitors are not providing equivalent service. In this respect medicine has faltered, but it's not due to the length of training or quality it provides, simply as to how it addresses and deals with the competition.

 

[elresidante]

Actually NO they are not more practical or focused, they are just lacking so much that they don't realize how much they DON'T know.

It's kinda like the med student that thinks he/she is more sure about the decision to go or not go to the OR than the resident/attending. They don't know enough to know what could go wrong, what to be afraid of, or the gravity of their decision. Their lack of training and lack of knowledge is what makes them so sure they know exactly what is going on, and that's dangerous.

Not meant to offend, but that's just the truth of the situation.

This is the best advice I think I have heard on this post. NP's, PA's, and DNP's (or maybe more specifically, the schools they train at), claim to be something on the line of a physician - but this is at its nicest laughable. And OTD is completely right that the lack of their knowledge is what makes them think they no more and/or dangerous. They just don't realize how much they don't know. Oftentimes, what a nurse does know is simply knee jerk - following out a doctor's orders for several problems they have seen managed on several occasions. Forget about pathyphys, pharm, micro, etc. I don't know if they even study that stuff (sarcastic here a little).

Also, to the original question, those of you who think 3-5 years is too long will soon learn the reality of medicine - which is by the time you are done with your residency the education is just starting. As a first year resident, you realize you know little more than a med student (and nothing compared to the third years and attendings). As a second year, you realize you know more than a first year. And as a third year, you realize that pretty soon you will be on your own and you better get your stuff together fast. Not that residency is inefficient, it's just way too much information to learn in a couple years (especially if you do a general residency, like surgery, IM, FP, peds, ER - I imagine derm would be easy to grasp after 3 years of training).

That's my opinion.

 

[Doowai]

Wow, the new Cancer Treatment Centers of America western regional hospital is awesome! It is certainly one of the nicest hospitals in the Phoenix area. On staff they have 2 naturopathic physicians (NMD's - naturopathic medical doctors) along with all the oncologists and surgeons.

THe NMD program at Southwest College of Naturopathic Medicine (SCNM) in Scottsdale is a 4 year program that teaches everything an internal or family medicine doctor knows, everything an acupuncturist knows, everything a chiropractor knows, everything a homeopath knows, everything an herbalist or botanical medicine healer knows. They can do oriental/asian medicine, traditional medicine, spinal adjusting, botanical herbal medicine. They can prescribe morphine or moxibustion (look it up), they can adjust your spine and they can set a broken arm. All in 4 years.

Chiropractors hedge at that, since they spend 4 years exclusively learning to adjust the spine. MD's in medicine hedge at that since after 4 years they can do everything a FP or IM doctor can do by law. Acupuncturists hedge since they can do everything an acupuncturist can do. in 4 years they can do everything all these other professions spend 4 years alone learning to do (not even counting residency for the MD's).

It seems wrong - but yet they seem to practice competently. Several specialty hospitals in Phoenix area have NMD's on staff. Beautiful hospitals that make residency program hospitals like Phoenix Baptist Residency Hospital look backwoods. It appears the NMD's did not need 3 years to place an acupuncture needle, or 4 years to adjust the spine or 4 years to prescribe atenolol. NMD's (at SCNM) do something like 2000 total hours of clinical hours to graduate, of which something like a total of 350 hours can be in traditional western medicine and the rest has to be in alternative treatment clinics like naturopathy or acupuncture.

I don't know - I await hearing about a big NMD screw up, but it never seems to happen. Yet regularly I hear and read about MD disasters.

but residency is in large part a money maker for hospitals - providing cheap skilled labor. It would be nice if in return they would let you get board certified sooner, or let IMG's get licensed before 3 years is up (I mean after all they are pretty much practicing full scope before year 3) - but that dangles like a carrot to keep you from quitting early.

On the other hand for some specialties I see longer training as necessary - like surgery and OB. But I have to admit, 4 years for psyche seems a bit crazy. Here is half of psyche residency training : "hmmmmm, and how does that make you feel?"

 

[Vacant]

I think you are missing the point. There are two things residencies provide #1 is training, and #2 is being the workhorse of the hospital. You seem interested in eleiminating all of #2 that doesn't contribute to #1. But the economic drive that makes #1 possible is #2......

Comparing to DNP, PA, NP is folly because you are simply comparing trained people to untrained an saying "why can't we be more like them?" Sure you can go out into the jungle unarmed and often come back unscathed. Doesn't mean you aren't taking huge risks or going in oblivious to what might happen and woefully unprepared to deal with it. But hey, without the extra time, cost or training you get out there quick and cheap. Or you can spend the 3-8 years of training necessary to be ready to deal with anything you come across. Medicine does the latter, and it's the right approach. If anything, it should be a bit longer training, but we are cutting that off because it's not as cost effective. But the goal shouldn't be to make medical training shorter, it really should be to limit actions of non-physicians unless they have substantially longer training. You don't give take a path to provide worse quality in order to compete, you make clear that your competitors are not providing equivalent service. In this respect medicine has faltered, but it's not due to the length of training or quality it provides, simply as to how it addresses and deals with the competition.

Your point is well taken, but you have missed the crux of my argument. Let me spell it out. The import or usefulness of your position, according to those that matter, is expressed by how much you get compensated. In this measure, DNP, NP, and PA coming out of their short trainings are more important and useful than MD graduates or residents with much longer trainings. It doesn't matter how much we medical students and residents argue how much they don't know, how dangerous their practice is, or how much longer clinical training must be. The current hospitals, HMOs, insurance companies and even AMA believe they are more valuable than MD grads and residents. Why do they do this? And why do we put up with this? No matter how much we cry that our training is much more in depth with all of the complexities, they still get paid and treated with far more respect than us. Is it perhaps because they actually can deliver the service well enough with their trainings?

Look at it this way. A resident who quit after 2 years won't get licensed and will be very difficult to get hired. A DNP, NP, and PA with far less trainings have no problem being hired with much higher pay. The economy is simply telling us their knowledge and skills are more valuable, no matter how much we want to disprove.

So what I am saying is if we actually do know more than them finishing our MD schools, we should change the current false milieu where we are told that's far from the reality. If we actually don't have better skills than them, we should change how med schools are run.

Crying among us that we know more and are more skilled have no impact on what's happening.

By the way, who actually control AMA and how are the officers elected? If there is no real leaders in that group, why are they still occupying the pivotal positions so much so that those alert and willing physicians have to brainstorm how to form a separate group to have their voices heard?

 

[Vacant]

Comparing to DNP, PA, NP is folly because you are simply comparing trained people to untrained an saying "why can't we be more like them?"

Why do they pay so much for the "untrained"? Why do they trust the "untrained" so much so that they are able to practice on their own? Are people crazy? Or is it because they can actually deliver the adequate service with their "inadequate" training?

Who's calling them "untrained" besides us? HMO's? Hospitals? Insurance companies? government? or AMA? I think it's just us, unfortunately.

This most ridiculous myth that training physicians is a huge investment by the nation is perpetuated by medical students and residents themselves. If our nation has invested so much for us, why do most of us end up with such a large dept, lost earning years and still inadequate training with abundant abuse, thus perpetuating the group of docs who are readily abused by anyone and everyone.

 

[Law2Doc]

Your point is well taken, but you have missed the crux of my argument. Let me spell it out. The import or usefulness of your position, according to those that matter, is expressed by how much you get compensated. In this measure, DNP, NP, and PA coming out of their short trainings are more important and useful than MD graduates or residents with much longer trainings. It doesn't matter how much we medical students and residents argue how much they don't know, how dangerous their practice is, or how much longer clinical training must be. The current hospitals, HMOs, insurance companies and even AMA believe they are more valuable than MD grads and residents. Why do they do this? And why do we put up with this? No matter how much we cry that our training is much more in depth with all of the complexities, they still get paid and treated with far more respect than us. Is it perhaps because they actually can deliver the service well enough with their trainings?

Look at it this way. A resident who quit after 2 years won't get licensed and will be very difficult to get hired. A DNP, NP, and PA with far less trainings have no problem being hired with much higher pay. The economy is simply telling us their knowledge and skills are more valuable, no matter how much we want to disprove.

So what I am saying is if we actually do know more than them finishing our MD schools, we should change the current false milieu where we are told that's far from the reality. If we actually don't have better skills than them, we should change how med schools are run.

Crying among us that we know more and are more skilled have no impact on what's happening.

By the way, who actually control AMA and how are the officers elected? If there is no real leaders in that group, why are they still occupying the pivotal positions so much so that those alert and willing physicians have to brainstorm how to form a separate group to have their voices heard?

I haven't missed the crux of your argument, you just still aren't getting why I think you are missing the boat. NO, the import and value of your position isn't dictated by your salary -- I don't get why you think that but it is a flawed assumption. Folks aren't paid based on how important they are, they are paid based on how much money they can generate vs how much expenses they have to incur. And FWIW, NP, PA earn less than physicians, not more -- I don't quite see how you are coming to the opposite conclusion. The whole benefit of these ancillary professionals and why they are so competitive is that they are CHEAPER, not better paid.

The way to address the competition issues isn't to shorten medical residencies in a race to the bottom, an attempt to be the lowest common denominator, and see who can provide medical care cheaper. The goal is to fight the misperceptions that anyone else is providing equivalent care, and force everyone else to increase their training if they want to "compete". When someone provides services that constitute the practice of medicine without a medical license, or holds themselves out in a healthcare setting as a doctor, you need to go to court and fight it. So in fact "crying among us that we know more and are more skilled" CAN have an impact if it wakes up the profession to do what most other professions do -- protect its borders. In law the lawyers organized and thwarted paralegals, accountants, realtors and scores of others who tried to impinge on legal work. Medicine ought to do the same. It doesn't have to be through the AMA, but some form of organization and fund raising needs to happen. By not doing so, physicians tacitly concede that what other ancillary paths are providing are acceptable, and the erosion will continue.

Your suggestion -- to abandon the real value in the profession (superior training) in favor of something more competitive is the exact wrong approach. The goal should never be to beat them on cheapness/lack of training. HMOs and insurance companies don't believe that these groups are "more valuable" than physicians. But their goal isn't to provide the best service. Their goal is to provide the CHEAPEST service that the public will stomach. So yeah, if an NP is willing to provide an office visit for half the price of an MD and the public is willing to go to an NP, then sure the HMO loves this model. They only make money when the premiums plus investments outweigh what they pay out to providers. So if the public would accept it, they would provide horrible cheap care. You don't look to them as an indication as to what is "more valuable" -- you look to them as an indication as to what is dirt cheap.

But I would hope folks on the medicine path realize that there is something of value coming out of medical training. Part of the problem with the lay person's vantage point of medicine is that they only see the horses but not the zebras, only see the typical outcomes, not the awful complications. So the average member of the public or typical congressman might say -- "Gee, I don't see any reason why an NP can't examine a patient, give a routine vaccination, and only cost healthcare a fraction of the cost". But what if that person has an unusual condition, has an unusual reaction, has subtle symptoms someone without more training wouldn't recognize, starts to code, etc. There is good reason to have someone with more training in some of these routine settings. But unless you explain and sell it, nobody thinks of this. And the insurers and HMOs aren't going to mention it because, as mentioned, their goal isn't to provide you the care you need, their goal is to cut costs.

 

[colbgw02]

Can you explain yourself?

My post didn't have very much to do with mid-level providers and it certainly didn't have much to do with the non-academic energy spent in residency. I chose my specialty, in part, because it eliminates so much of the non-academic BS that goes on in medicine. Others have a much bigger bone to pick with GME about that particular nugget than I do.

I made that statement because the overarching trend in medicine is toward specialization and sub-specialization. Part of that is because of the litigious side of medicine; i.e., physicians are hesitant to take on an issue in which they are not specialized.

More importantly, I think, is that the science demands it. The bulk of information is such that it practically demands sub-specialization to maintain the standard of care. My wife is finishing her family medicine residency, and - despite the fact that she is very intelligent and has done well in her training - the idea that she should be able to handle everything from prenatal care to geriatrics is laughable. I'm halfway through my 5 year residency, and the idea that I'm supposed to have accumulated half of the knowledge and experience to be a board-certified specialist is similarly laughable.

Residents have implicitly recognized this shift by doing more and more fellowships, but the world still needs generalists. Despite more sub-specialists, these generalists still need intense training - at the very least - to be able to recognize when a patient needs sub-specialty care.

Combine all of that with the very real likelihood of further work hour restrictions coming, and I don't see how we have any choice but to extend the number of years required for residency.

Edit: Oops, I split an infinitive.

 

[Vacant]

I haven't missed the crux of your argument, you just still aren't getting why I think you are missing the boat. NO, the import and value of your position isn't dictated by your salary -- I don't get why you think that but it is a flawed assumption. Folks aren't paid based on how important they are, they are paid based on how much money they can generate vs how much expenses they have to incur..

I think you should learn to be humble a little, friend. Also it's interesting how you studied law and yet keep missing the important point in a sentence. Always remember that you are not the most intelligent or that you have the best opinions. This will make your life smoother as you move on to residency.

I repeat one more time for your sake what my point is. Read it carefully word by word.

You argue repeatedly MD training is far more important. Am I disagreeing with it? No. You argue repeatedly MDs need more training to be really effective. Am I disagreeing with it? No. You argue repeatedly residency should not be shortened. I argued the training can be done more effectively. Do you disagree with this? Haven't read differing arguments from the current residents above? Or is your argument still the only valid one?

Now back to the crux: I said, "The import or usefulness of your position, according to those that matter, is expressed by how much you get compensated."

And who are those that matter? HMOs, hospitals, insurance companies, government, and public. Why? because they are the ones that pay us. And why is "payment" the measure of one's import? Not in moral perspective, but in that of economy. This is too obvious to even be discussed. Now don't tell me you are willing to work as physician with the earning of an RN. Why you wouldn't? Because you feel you are more important than an RN and should therefore be compensated more. Plus you would point out extra investment you've put into becoming a physician to demand more. My point is taken from that perspective.

Why it doesn't matter how much MDs talk among themselves how valuable they are? Because no one else is listening.

Now, who get paid higher? MD grads and residents or DNP, NP, PA grads? My comparison was not between physicians and the midlevels. By the way, there is still not much difference between what some PA and NP make and what PCPs make, yet we argue there is a significant difference in knowledge skill. The payment value says otherwise.

Who know more? MDs want to argue that we know more. Everyone else, including AMA (ironically), believes otherwise. Proof? MD grads and terminated residents cannot get a job that DNP, NP, and PA get with their "inferior" skills.

Does this make sense to you?

That's why I am saying MDs telling each other how they know more and are more important in patient care is totally irrelevant until those that matter start to listen and be convinced as well. Until then nothing will change.

Again, I hear you and I agree with your points. Now spend your energy to convince other non-MDs instead of wasting your time convincing who are already convinced.

 

[UMED122]

Who know more? MDs want to argue that we know more. Everyone else, including AMA (ironically), believes otherwise. Proof? MD grads and terminated residents cannot get a job that DNP, NP, and PA get with their "inferior" skills.

Those are midlevel jobs though, they are not board certified physicians. If you were arguing that md grads w/out residency should be able to work as midlevels, then your point has more relevance.

 

[Law2Doc]

I think you should learn to be humble a little, friend. Also it's interesting how you studied law and yet keep missing the important point in a sentence. Always remember that you are not the most intelligent or that you have the best opinions. This will make your life smoother as you move on to residency.

I repeat one more time for your sake what my point is. Read it carefully word by word.

You argue repeatedly MD training is far more important. Am I disagreeing with it? No. You argue repeatedly MDs need more training to be really effective. Am I disagreeing with it? No. You argue repeatedly residency should not be shortened. I argued the training can be done more effectively. Do you disagree with this? Haven't read differing arguments from the current residents above? Or is your argument still the only valid one?

Now back to the crux: I said, "The import or usefulness of your position, according to those that matter, is expressed by how much you get compensated."

And who are those that matter? HMOs, hospitals, insurance companies, government, and public. Why? because they are the ones that pay us. And why is "payment" the measure of one's import? Not in moral perspective, but in that of economy. This is too obvious to even be discussed. Now don't tell me you are willing to work as physician with the earning of an RN. Why you wouldn't? Because you feel you are more important than an RN and should therefore be compensated more. Plus you would point out extra investment you've put into becoming a physician to demand more. My point is taken from that perspective.

Why it doesn't matter how much MDs talk among themselves how valuable they are? Because no one else is listening.

Now, who get paid higher? MD grads and residents or DNP, NP, PA grads? My comparison was not between physicians and the midlevels. By the way, there is still not much difference between what some PA and NP make and what PCPs make, yet we argue there is a significant difference in knowledge skill. The payment value says otherwise.

Who know more? MDs want to argue that we know more. Everyone else, including AMA (ironically), believes otherwise. Proof? MD grads and terminated residents cannot get a job that DNP, NP, and PA get with their "inferior" skills.

Does this make sense to you?

That's why I am saying MDs telling each other how they know more and are more important in patient care is totally irrelevant until those that matter start to listen and be convinced as well. Until then nothing will change.

Again, I hear you and I agree with your points. Now spend your energy to convince other non-MDs instead of wasting your time convincing who are already convinced.

Dude, I read your post and continue to believe that it is as flawed as the prior one -- all you really did was add a dig at me in the first paragraph and essentially restate the things I don't agree with from your prior post. And no, you aren't agreeing with my points based on your initial post in this thread -- the notion of cutting back years of residency is exactly what I think is wrong wrong wrong. Addressing the onslaught of ancillaries in other ways is what I think might be appropriate, but not attempting to compete with them at their training level, which I continue to maintain your first post on this thread suggests. So no you can't say you are on the same page as me unless you are renouncing the suggestion that residencies are too long. I haven't heard you say that yet.

And no, the organizations that you say "matter" are not "measuring the import" or value of physicians based on compensation. They are going for cheap. They are very intentionally sacrificing quality for price. The HMOs and insurance companies KNOW that the quality is inferior from midlevels with less training. Nobody in these organizations denies this. What they are doing is basically saying screw you to their customers and saying hey, we can take your premiums and give you inferior care for less money. That's not a measure of physician value -- it's more like serving up a patron hot dogs because the filet mignon costs too much to make. Nobody denies that the filet mignon has more value or is of higher quality. Certainly the insurance companies don't question this. They simply are in a business where their bottom line is better if they DON'T provide the best quality or value. So they don't. But don't kid yourselves into thinking that because HMOs prefer someone who works cheap that the HMO is saying that this is a better person to be providing care. They would grab someone off the street to provide the same care if they thought the public would buy it. They make money by giving less value, less quality. So almost by definition if the HMOs and insurance companies back them, it's not of as much value as the consumer is paying for. Because if it were, then those companies wouldn't make as much money. It's a warped system, but one in which you cannot glean value/quality based on what the payor wants to pay for -- you actually can assume the opposite.

 

[Law2Doc]

Proof? MD grads and terminated residents cannot get a job that DNP, NP, and PA get with their "inferior" skills.

Does this make sense to you?

Um no. They are separate fields. You can't get terminated as a doctor and so just come back as a nurse practitioner. They are separate -- not steps on the same path. For the same reason an NP can never become a doctor merely by adding a few more years of training, a med student can't fall back on another field. They are different paths with different training, schooling. They aren't part of the same path, they just happen to work in the same arena. So I don't see how that is proof at all, It's a totally different job -- you don't get to jump from one to the other just because the skillsets overlap. It is flawed logic. You are trying to say one group has skillset a and another has a+b, so the latter person could put aside the b and be equivalent to a. But the world doesn't work that way, and professions definitely don't. For instance, as a lawyer I probably did a lot of what many other jobs did. But that doesn't mean I could jump right into those jobs without the appropriate training, licensure, etc. That is simply faulty logic, not "proof".

 

[Vacant]

Those are midlevel jobs though, they are not board certified physicians. If you were arguing that md grads w/out residency should be able to work as midlevels, then your point has more relevance.

That is exactly my point.

 

[Vacant]

Law2doc, I repeat again. Spend your energy, valuable time, and verbal skill to convince the government and patients regarding this issue, instead of spending so much time here where the readers are mostly med students and residents. They need to be aware of this "warped" situation.

Also, as I mentioned in my original post, I prefer to hear the experienced views from the actual residents and attendings regarding this issue. But I still appreciate and feel good that we are all thinking about this situation that needs to be addressed.

There were some attendings and residents in other threads that pushed for residents who didn't finish being able to function at the level of DNP or PA. I agree.

Your distinction of professionals in medical fields sounds good but flawed. Nurses and Physician Assistants are originally established to facilitate the function of physicians. They cover what they can do with their limited trainings so that the physicians can work more efficiently with more complex duties. What they can do, any physician-in-training should be able to do as well with little extra training if anything at all. Can you tell me one thing NPs do that an Internal residents simply cannot do?

Starting tomorrow I must hit the books. I will check back here after my first midterm.

Thank you. I learned a good deal with all of your inputs.

 

[lisichka]

may be MDs need to suffer more...than others
i see no other reason


for example i think that 3 years of internal med/ +3 years RIGOROUS cardio fellowship/+1-2 years interv/ep training is an overkill

 

[Law2Doc]

Your distinction of professionals in medical fields sounds good but flawed. Nurses and Physician Assistants are originally established to facilitate the function of physicians. They cover what they can do with their limited trainings so that the physicians can work more efficiently with more complex duties. What they can do, any physician-in-training should be able to do as well with little extra training if anything at all. Can you tell me one thing NPs do that an Internal residents simply cannot do?

You don't get to jump from one licensed career to another seamlessly just because you are capable of doing the tasks. As a lawyer, I sometimes did things accountants, CFPs etc did, but I sure couldn't just step into their jobs without the requisite licensing/coursework. As a physician you aren't a "PA plus" or a "nurse plus". You are in a totally different field. There are resemblances but that's it -- it is not a lesser included job on the same path. So the point isn't that a resident could do someone else's job -- it's that they aren't in the same fields as the NP, they just deal with similar patients and settings. And that's really the crux of the problem. If a physician were a "PA plus" there would be better understanding by the midlevel of what that "plus" was. As a separate career they are free to try to push and define their borders until somebody pushes back.

 

[8744]

Actually NO they are not more practical or focused, they are just lacking so much that they don't realize how much they DON'T know.

It's kinda like the med student that thinks he/she is more sure about the decision to go or not go to the OR than the resident/attending. They don't know enough to know what could go wrong, what to be afraid of, or the gravity of their decision. Their lack of training and lack of knowledge is what makes them so sure they know exactly what is going on, and that's dangerous.

Not meant to offend, but that's just the truth of the situation.

That is exactly it, except in general mid-levels (especially those who vist my blog to leave irate comments) can't really make up their minds if they should claim their training is more or less intensive than phyisicians, their current mantra being that they learn everything (or almost everything) medical students learn just in a more intensive format as befits their superior intelligence and drive. On the other hand they are quick to point out that they don't learn any of that "useless stuff" which most medical students don't remember after the exam anyway; of course implying that those red-hot gunner PA students never forget anything.

Not to mention the typical mid-level who comments on my blog something to the effect of "I've been a PA for 25 years and I know more about Emergency Medicine (or surgery or family practice) than most of the interns who I precept."

 

[8744]

THe NMD program at Southwest College of Naturopathic Medicine (SCNM) in Scottsdale is a 4 year program that teaches everything an internal or family medicine doctor knows, everything an acupuncturist knows, everything a chiropractor knows, everything a homeopath knows, everything an herbalist or botanical medicine healer knows. They can do oriental/asian medicine, traditional medicine, spinal adjusting, botanical herbal medicine. They can prescribe morphine or moxibustion (look it up), they can adjust your spine and they can set a broken arm. All in 4 years...

...I don't know - I await hearing about a big NMD screw up, but it never seems to happen. Yet regularly I hear and read about MD disasters...

You cannot teach everything an internist or a family physician knows in four years, especially if to it you add all of that CAM knowledge, all of which is bunk but intricate bunk that does require effort to learn. Don't believe the propaganda. Four years of real medical school and three years of internal medicine is barely enough time to learn what you need to know to be a good internist.

As for not hearing about screwups of our friends in the snake oil side of medicine, it is hard to screw something up if your therapies are mostly placebos. I "screw things up" occasionally because I receive into my trauma/critical care bay patients who are horrifically sick, unconscious or altered, with no medical records, no family nearby, and thus no knowledge of the patient except what I can gather from the physical exam, some quick lab tests and a portable chest film before I have to start making decisions. Since some of these decision involve dangerous procedures and medications the risk of making a mistake is always there...although you have to understand that not every bad outcome is necessarily the result of a mistake.

As for the rest of it, I'm going to start sending my elderly multiply comorbid patients to naturopaths and chiropractors. They can send me all of their vague back pains or psychosomatic complaints and let's see who kills more patients. In other words, it's easy to brag about how great a doctor you are if you never see patients who are really sick.

 

[8744]

I have not yet done 3rd year rotations, thus this perhaps dumb question.

I am wondering if we really need 3-5 years of residency training to function as physicians. Perhaps more pertinent question is this: is it really necessary to make residencies so grueling? It would be nice to hear from the experienced residents and attendings. Am I wrong to think that our training is unnecessarily difficult to the point of being inhumane? Or are they all necessary part of being an efficient doctor?

Your honest answers would make me feel better and better informed as I prepare to take the next step in this long training path for the rapidly diminishing reward.

Thank you.

It is not a dumb question. The answer is, "Yes, you do need residency training to function as a physician." The residency training system is not perfect but didactic and practical training beyond medical school is required.

On your first day of intern year you will realize this and will laugh, yes laugh, to think you ever thought you could be a doctor without more training. And on that day you will give thanks that you are not expected to function like a fully trained doctor.

 

[Winged Scapula]

It is not a dumb question. The answer is, "Yes, you do need residency training to function as a physician." The residency training system is not perfect but didactic and practical training beyond medical school is required.

On your first day of intern year you will realize this and will laugh, yes laugh, to think you ever thought you could be a doctor without more training. And on that day you will give thanks that you are not expected to function like a fully trained doctor.

Or she/he could wait until the last day of their residency and think, "oh ^&%^, am I really supposed to be able to do all of this stuff without more training?"

BTW Doowai, I can show you several pictures of patients with fungating masses treated by our local naturopaths with some sort of "salve". So just beacuse you don't hear about the failures doesn't mean they aren't out there (and PB has an excellent point that we see sicker patients and do more risky interventions so there are going to be complications).

Guess what? Their cancer didn't get better with the salve. At least one of the naturopaths told the patient that he agreed that she needed surgery and sent her back to me.

 

[Doowai]

At least one of the naturopaths told the patient that he agreed that she needed surgery and sent her back to me.

And you are complaining about that becaaaauuusseeee..........

As for the rest of it, I'm going to start sending my elderly multiply comorbid patients to naturopaths ....... In other words, it's easy to brag about how great a doctor you are if you never see patients who are really sick.

So you are saying the patients the NMD's are seeing at Cancer Treatment Centers of America are not really sick?

 

[Doowai]

Cancer Treatment Centers of America : where smart MD's and NMD's work side by side on really sick patients

 

[Winged Scapula]

And you are complaining about that becaaaauuusseeee..........

I wasn't complaining about him specifically because he did finally realize that her problem was not going to be helped by natural methods. But since you asked...because it took him 3 months of putting "salve" on her "abscess" before deciding that it was actually a fungating cancer and that no amount of natural medicine or salve was going to fix that.

So you are saying the patients the NMD's are seeing at Cancer Treatment Centers of America are not really sick?

I never said that.

BUT, there is a difference btwn a multidisciplinary approach like the CTCA where MDs/DOs and NMDs work "side by side" and private practice NMDs who eschew Western Medicine and advise their patients to. The availability of CAM at places like CTCA is solely for the benefit of the patient's mental status and attracts lots of people in a state like Arizona what with its vortex and crystal believing populace.

I am all for CAM and encourage my patients, for whom it is important, to continue with what ever alternate treatments they like as long as the continue to pursue proven Western treatments as well.

And when we speak of "really sick", we are saying that you don't see critically ill patients at the NMD. The patients at CTCA are ill, but they are not critical. Its the MDs and DOs who are really taking care of the sick patients.

 

[3dtp]

Or she/he could wait until the last day of their residency and think, "oh ^&%^, am I really supposed to be able to do all of this stuff without more training?"

Amen! and again I say AMEN!

BTW Doowai, I can show you several pictures of patients with fungating masses treated by our local naturopaths with some sort of "salve". So just beacuse you don't hear about the failures doesn't mean they aren't out there (and PB has an excellent point that we see sicker patients and do more risky interventions so there are going to be complications).

Guess what? Their cancer didn't get better with the salve. At least one of the naturopaths told the patient that he agreed that she needed surgery and sent her back to me.

I've had a couple of cases like this too. One was a young patient with brain mets from a breast primary who wanted to do the naturopathic cure rather than appropriate neurosurgery followed by brain radiation. I ended up sending her to a CTCC type place for a second opinion by the naturopath and she came back got her tumor excised and radiation. Now NED.

I had another with a large neck mass treated for a year by the solo naturopath who ended up in ED, and now after magic rays and a little magic potions is now NED.

Morals: You can never know too much, you will never know enoug, what you don't know can hurt you and others and sometimes, dag nabbit, placebos just don't work.

 

[Faebinder]

Wow, the new Cancer Treatment Centers of America western regional hospital is awesome! It is certainly one of the nicest hospitals in the Phoenix area. On staff they have 2 naturopathic physicians (NMD's - naturopathic medical doctors) along with all the oncologists and surgeons.

THe NMD program at Southwest College of Naturopathic Medicine (SCNM) in Scottsdale is a 4 year program that teaches everything an internal or family medicine doctor knows, everything an acupuncturist knows, everything a chiropractor knows, everything a homeopath knows, everything an herbalist or botanical medicine healer knows. They can do oriental/asian medicine, traditional medicine, spinal adjusting, botanical herbal medicine. They can prescribe morphine or moxibustion (look it up), they can adjust your spine and they can set a broken arm. All in 4 years.

Chiropractors hedge at that, since they spend 4 years exclusively learning to adjust the spine. MD's in medicine hedge at that since after 4 years they can do everything a FP or IM doctor can do by law. Acupuncturists hedge since they can do everything an acupuncturist can do. in 4 years they can do everything all these other professions spend 4 years alone learning to do (not even counting residency for the MD's).

It seems wrong - but yet they seem to practice competently. Several specialty hospitals in Phoenix area have NMD's on staff. Beautiful hospitals that make residency program hospitals like Phoenix Baptist Residency Hospital look backwoods. It appears the NMD's did not need 3 years to place an acupuncture needle, or 4 years to adjust the spine or 4 years to prescribe atenolol. NMD's (at SCNM) do something like 2000 total hours of clinical hours to graduate, of which something like a total of 350 hours can be in traditional western medicine and the rest has to be in alternative treatment clinics like naturopathy or acupuncture.

I don't know - I await hearing about a big NMD screw up, but it never seems to happen. Yet regularly I hear and read about MD disasters.

but residency is in large part a money maker for hospitals - providing cheap skilled labor. It would be nice if in return they would let you get board certified sooner, or let IMG's get licensed before 3 years is up (I mean after all they are pretty much practicing full scope before year 3) - but that dangles like a carrot to keep you from quitting early.

On the other hand for some specialties I see longer training as necessary - like surgery and OB. But I have to admit, 4 years for psyche seems a bit crazy. Here is half of psyche residency training : "hmmmmm, and how does that make you feel?"

And yet I don't see you or NDs or any of the primary cares for that matter managing your own psychotic or manic patients.. telling the malingerers they are full of s**t and the borderlines that it's all in their thinking that they are not truly psychotic.....or better yet...taking capacity away from a patient with some level of dementia on board... what's the matter? Too afraid to defend yourself in court? hmmmmm, and how does that make you feel?

Stop judging specialties when you barely scratched the surface of their training.

 

[8744]

...So you are saying the patients the NMD's are seeing at Cancer Treatment Centers of America are not really sick?

No. They're sick. But the Naturopaths add nothing to their care but a little bit of entertainment masquerading as medical care. CAM is a marketing gimmick to attract paying customers. It is not generally offered at charity hospitals because when it is time to cut budgets, one would like to think that we cut out the fluff first.

How about I send my cancer patients to a Naturopathic hospital and call for an occasional Oncology Consult? You'd have a hospital full of dead patients.

 

[CambieMD]

I have not yet done 3rd year rotations, thus this perhaps dumb question.

I am wondering if we really need 3-5 years of residency training to function as physicians. Perhaps more pertinent question is this: is it really necessary to make residencies so grueling? It would be nice to hear from the experienced residents and attendings. Am I wrong to think that our training is unnecessarily difficult to the point of being inhumane? Or are they all necessary part of being an efficient doctor?

Your honest answers would make me feel better and better informed as I prepare to take the next step in this long training path for the rapidly diminishing reward.

Thank you.

Residencies will probably need to be lengthened because of the 80 hr rule and the desire to cut down even further on work hours. Someone did a study to determine what it took to make a world class classical musician. The one common denominator in all of the elite classical musicians was the time spent in practice. It takes 10,000 hrs to really master a particular disipline. We have an attending who can place a mac cordis in three minutes. This is from the time that he touches the neck to palpate landmarks to when he sews that puppy in. This man has his 10k hrs and then some.

Do not use the 80 hr/week to calculate the total # of hrs work. Think about the actual time that you spend in your specific specialty. Off service rotations other fluff decrease the actual time spent in your chosen disipline during training.

Residencies should be longer.

Cambie