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oops... sorry docgeorge. I meant 'Beastmaster' for the last post...
PACtoDOC said:It will only take one 20/20 propaganda story showing how some NP missed something like nephrotic syndrome and instead sent the poor patient home with a thiazide diuretic to "take care of their fluid retention". Minimal change disease is very common in young adults, and can be easily cured with steroids, not diuretics. I guarantee if you lined up 300 NP's, not a damn one of them could explain the pathophysiology of the epithelial podocyte foot processes and how they get jacked up in this disorder. As a PA, I had never even heard of such a diagnosis. As an almost doctor now, I have already seen it 3 times in 9 months.
Now go ahead NP's run to your little cookbook of medical algorithms and come back knowing all about Lipoid Nephrosis, as I expect you will. But bottom line is that even EMED will hopefully fess up and show that even someone with decades of medical knowledge well superior to an NP, is still not a doctor. Its okay to admit that you don't know what a physician knows. Just don't expect the world to sacrifice their first borns to save a buck. FP will always be dominated by physicians and until I die, I will gladly intend to testify at any state's legislative session about the need to keep physicians as the in-charge. Don't underestimate the damage a former midlevel turned physician can do to a bunch of wannabe NP's trying to get more power. I can happily testify for hours about simple diagnoses I once knew nothing about as a midlevel provider, but now am comfortable treating.
NO NP PCP's on this doc's watch!!!!!
PACtoDOC said:Great Post Windsurf and Emedpa.
But Windsurf, please do not lump all midlevels together. I am only one year behind you in medical school and being a PA, I see that my education as a PA was indeed very disease based and differential based. Med school has simply included more of it. PA's are not like NP's in that we have a unique base of support in the physician population.
CJMPre-Med said:Err, as far as I understand it (admittedly being ignorant of statistics; I don't take it until this coming fall semester), the standard deviation on most IQ tests is roughly 15 points. Is that untrue? I have a 162 verbal IQ, and the average IQ is 100. Do the math. Regardless, this wasn't intended as braggadocio, and was only mentioned because you seem to think that others are "misreading" what you've stated when in fact that is anything but what's happening; I'm merely reading what you wrote as it appears on the screen. But it's interesting to note that you cannot refute any of the points I've raised regarding your manner of expression.
PACtoDOC said:What do you think the healthcare costs will be when the less educated NP has no clue and misses the diagnosis of a very treatable disease pathology, when it was still in the cheap-to-treat stage? And how much do you think it will cost the insurance companies when the NP's triple the number of current referrals to specialists because they are not trained to a level capable of caring for common disease entities? It won't take long for big medicine to realize that these people need to go back to the ward and put on their tight white skirts and paper hats with the red cross on them!! Or maybe that was one of those movies that my Dad used to keep in his underwear drawer!!!
See this is the funny thing about this whole issue.And if they want pay 60% less for care that is 0.1% less perfect, let them see how they like it. But, realistically I don't see this happening any time soon.
Every point of view has studies to back it up. Welcome to the world of science. I'm John, I'll be your guide here.Guess you haven't seen the outcome studies re MDs and NPs??
Award this man his MD. Better yet, give him a DNP! You showed a resident how to do an IV Dig, how very kind of you. I guess medical school is a complete failure, because the student either didn't remember how or the school never taught it. Tisk tisk, he should have gone to nursing school. Maybe tomorrow he'll explain to you the pathophysiology of thrombosis secondary to the lupus anticoagulant to return the favor. You know, it would be interesting to see how many 'corrections' a doctor has made in two days. Because we all know that's how you judge competence, right? I wonder how many times an MD has corrected an NP. I've never heard of it happening, personally. It's not news when that happens.Well, let's see...in the last 2 days I've had to give IV Dig because the resident "didn't know how." Another doc admitted a patient to the ortho floor from ER before getting a Dig level then had to admit the patient to telly unit after the getting the results. Hello, why didn't you wait till you had the results and yes you have to rewrite all your orders again for the telly unit! In ICU a really smart NP working as a staff nurse stood up to an Endocrinologist and won her case because the patient's glucose keep rising when the Endocrinologist swore it wouldn't. I've trained so many doctors...guess I should go to NP school
windsurfr said:Docgeorge:
Think about it.... pick up a medical economics journal or talk to someone who actually knows about medical finace. What percentage of the US health care dollar is spent on MD's. You figure this out... then figure out what 60% of that is. This is what the public would "save" for seeing an NP or PA. (I'll give you a hint: the cost is way below 10%)
So your final cost saved is somewhere in the ballpark of 1.5% On a 150 dollar visit this is about 2-3 bucks. Now lets think about what the costs are for an NP or PA to order even one more MRI a week than an MD. (Hint: Way more than a grand).
You do the math. Now envision when NP's and PA's (with their new independence) finally get slammed with a 3 million dollar lawsuit and the floodgates open. What will happen to their MRI/CT/Cardiolyte/etc ordering practice. Trust me, the powers that be will be watching very closely. NP's and PA's are valuable members of the health-care team, but they are not physicians. Unfortunately medicine is a buisness and people will be scrutinizing these things very closely. As always I am looking foreward to arguements and other points of view... in the end hopefully we all learn from the mess that we are getting into.
JohnDO said:See this is the funny thing about this whole issue.
NP's think that they will be able to maintain their fee while simultaneously obtaining more autonomy. They don't realize that the only reason they can charge this fee is because some physician who has malpractice insurance is taking on the brunt of their liability.
Every point of view has studies to back it up. Welcome to the world of science. I'm John, I'll be your guide here.
Award this man his MD. Better yet, give him a DNP! You showed a resident how to do an IV Dig, how very kind of you. I guess medical school is a complete failure, because the student either didn't remember how or the school never taught it. Tisk tisk, he should have gone to nursing school. Maybe tomorrow he'll explain to you the pathophysiology of thrombosis secondary to the lupus anticoagulant to return the favor.
zenman said:NPs can carry their own insurance. Due to their safety record it's only $734 /yr for $1,000,000/$3,000,000.
I can guide myself, thanks. So what about this "evidence-based" medicine?
Funny! I'm just showing that if someone wants to pick on one profession (NPs) I can also do the same to MDs.
Having a good safety record is a direct reflection of the types of cases NP's handle, not a reflection of how malpractice companies perceive the ability of NPs to handle cases safely. Low malpractice rates are due to a variety of factors. First, you don't provide the scope of practice that physician is able to provide. If all physician's dealt with all day was colds and minor infections then of course their malpractice insurance would be much lower. As your "scope" increases, so will your rates. Second, you aren't held to the same standard of care. That is, the physician on the case is more likely to be held responsible by a court of law than you are, even if his or her involvement was minimal. Eliminate physicians and you become the only target. Third, you are statistically less likely to be involved with a lawsuit because you see less cases and because of the nature of cases you see. Fourth, you pass off anything complicated to a physician.NPs can carry their own insurance. Due to their safety record it's only $734 /yr for $1,000,000/$3,000,000.
Furrball said:In your previos example you chose how you educated a resident. Good, residents are physician-trainees. As a resident a person is there it learn and get training. He or she probably thanked you and even if they didn't they were glad you were there. I only survived my SICU rotation becasue the ICU nurses would pre-pimp me before rounds to make sure I was ready for the attending. BTW in med school we are taught the how's of diagnosis and treatment, or least enough so we can function as a resident where our education really begins. We are not taught how to administer medications, we would only get in the RNs way.
I'm starting residency in a few months and I hope the nurses and NPs will help me, most will have far more experience managing patients than me. It doesn't change the fact that as a newly minted MD, I have had a type of training that the RNs and NPs do not have. I am basing this opinion on two of my classmates. One was a med-surg floor nurse for ten years before med school and the other was a NP anesthesiologist for many years before med school. Like the rest of us there were things in med school they knew and things they had to learn. But their extensive experience as an RN or NP did not automatically give them all the knwoledge and experience they needed to be a physician, it just gave them more experience.
And the endocrinologist, was it a fellow or an attending?
yes, they are called crna's.psisci said:NPs can specialize in anesthesiology doc....
Furrball said:In your previos example you chose how you educated a resident. Good, residents are physician-trainees. As a resident a person is there it learn and get training. He or she probably thanked you and even if they didn't they were glad you were there. I only survived my SICU rotation becasue the ICU nurses would pre-pimp me before rounds to make sure I was ready for the attending. BTW in med school we are taught the how's of diagnosis and treatment, or least enough so we can function as a resident where our education really begins. We are not taught how to administer medications, we would only get in the RNs way.
I'm starting residency in a few months and I hope the nurses and NPs will help me, most will have far more experience managing patients than me. It doesn't change the fact that as a newly minted MD, I have had a type of training that the RNs and NPs do not have. I am basing this opinion on two of my classmates. One was a med-surg floor nurse for ten years before med school and the other was a NP anesthesiologist for many years before med school. Like the rest of us there were things in med school they knew and things they had to learn. But their extensive experience as an RN or NP did not automatically give them all the knwoledge and experience they needed to be a physician, it just gave them more experience.
And the endocrinologist, was it a fellow or an attending?
windsurfr said:I hear frequently "med students and residents dont know anything" because we are not good at starting lines, etc. That is not what we learn in medical school. Our first year is learning the normal, second year is all the pathology, pharm etc. Third year is coming up with a differential diagnosis. Fourth year is principles and basics of management. It does not incorporate IV's, vent settings, charting, etc... these are all things we learn on the fly as we go. It is very difficult to come up with a good DDx and treatment plan. That is why school is so difficult. So please quit using the "IV" examples as a measure of capability. That is not what we go to school for, however most of us are willing to learn if people take the time to teach us a dig, start, etc.
psisci said:NPs can specialize in anesthesiology doc....
windsurfr said:oops... sorry docgeorge. I meant 'Beastmaster' for the last post...
ether_screen said:I love the people who love make ridiculous statements like, I cant wait until the NP does (insert something bad here) and all hell will break loose, without realizing that physicians make equally as disastrous decisions on a daily basis.
To think that an MD can do no wrong is as ignorant as thinking an NP can do nothing right.
Advanced practice nurses CRNAs, NPs, and soon DNPs will continue to prove their worth in this dynamic health care environment and are here to stay!!!
DocWagner said:We should not judge based upon the upper crust of the profession , but rather the bottom level, for they will be treating as well.
DocWagner said:We should not judge based upon the upper crust of the profession , but rather the bottom level, for they will be treating as well.
I have personally trained and lectured some extremely poor NP students.
paddyboy777 said:I wonder whether a super handheld computer with all the knowledge of medicine in the world with an Artificial Intelligence software would not be better at diagnostics than any doc on a good day. After all, all the knowledge in doctor's heads' is memorized from experience. Why cant all the knowledge be put on a chip?
paddyboy777 said:I wonder whether a super handheld computer with all the knowledge of medicine in the world with an Artificial Intelligence software would not be better at diagnostics than any doc on a good day. After all, all the knowledge in doctor's heads' is memorized from experience. Why cant all the knowledge be put on a chip?
jwk said:As long as that statement applies to MD's as well, I'd have no argument.
Let's not pretend that all MD's are perfect - they're not. We're all human, regardless of the letters after our name.
There are crappy students in all professions as well. Again, let's not pretend that med students are always superb while NP students universally suck, which is exactly what you're implying.
lawguil said:The point was that MD/DO are already measured this way. Medical training already have the checks and balances in place and working. NP's have nothing of the sort in place. Why is it hard to understand that it is about changing the training, not changing the name of the training that already exists.
jwk said:Please - there are plenty of crappy MD's coming out of med school and making it out of residency. The checks and balances don't always work.
Again - my point was that there are good and bad in all professions. Doc Wagner implies that non-physicians should be "measured" by the worst of those in their profession, while physicians somehow should not. If I measured MD's by the worst in the profession, I'd have a pretty low opinion overall, because I've seen some lousy ones.
And it's a whole lot harder to get rid of a lousy MD than it is a lousy PA or NP. They usually just get fired. Ever seen a hospital go through the motions to get rid of a bad MD? You can't imagine the hurdles involved.
lawguil said:I guess that you should define what a "bad MD" is? Is it a reflection of his knowledge, skills, bedside manner, and socialization amongst other professionals? What exactly are you talking about? My guess is that far fewer medical students slip through the cracks when you consider the obstacles of MCATs, GPA's, Interviews, rigors of medical school, COMPLEX/USMLE, residency, fellowship, and finally practicing. I find it hard to believe that the final product is a complete ***** or an under-achiever. Now, consider the alternative. It really doesn't compare. I wouldn't under estimate the filtration system at a medical school. I would be concerned of the matriculation standards at a nursing practitioner program. Tell me about the rigors of acceptance and success there.
jwk said:You're still convinced that docs are perfect. It just ain't so. The vast majority of MD's, PA's, and NP's that I work with do excellent work every day. There are always a few that slip through the cracks, including MD's. You may find it hard to believe, but maybe you haven't been out in the real world yet, or at least not long enough to see it.
lawguil said:Apparently you have crossed a few MD/DO's that have slipped through the cracks, but you still havn't explained why you think they suck. Is it because you think you know better than you do, or because they don't respect what you do and you think they are ignorent about your training and abilities. What exactly is that has convinced you. Is it because they made a mistake or because you have actually learned that they are human.
I'm not saying that physicians are perfect. What I am saying is I havn't met a physician that was stupid or didn't know what he was doing. I may not like her/him, or disagree with a decision, but it's not because he/she is useless or poorly trained.
jwk said:In my case, I'm talking mainly about surgeons who really have no business operating because of their poor or careless technique. It's not just my opinion - sooner or later most of these docs will get kicked off the medical staff for their incompetence. We just see their problems and complications first-hand because we're in the OR with them. I've seen even board-certified surgeons lose their privileges because of their unacceptably high morbidity and mortality rates. All ya gotta do is look through a few legitimate malpractice cases - you'd be shocked.
emedpa said:I think what jwk is saying is that anybody can be out of their depth in a certain area. most fp docs are great when they are in clinic and some could work in an er without too many problems but when inexperienced docs (or anyone else for that matter) are working beyond their competency range it is a problem. I have seen it many times when internists or fp docs think they can just walk in and be er docs and they can't and the er md and pa staff have to bail them out. I had to walk an fp doc through an acute mi the other day because at some point he had forgotten(or never learned?) how to manage one appropriately.....he would have sent the guy across town to the cath lab without an iv, o2, ntg, morphine, asa, etc....he just freaked and wanted to send the guy without stabilizing him 1st.....
there comes a time when health care providers need to retire and many older docs don't realize when they have crossed that line. I work with a 72 yr old ortho doc who is still sharp and I have no doubts about his competency. I also work with a 70 yr old fp doc who should have retired 20 yrs ago becasue they have no concept of modern technology.also work with a few 65+ yr old er nurses who still just put pts in rooms , take their vitals, and put the chart in the rack regardless of complaint. no iv, no heads up to the staff if someone is really sick. they don't want to do ANYTHING without a written order.should have retired when florence nightingale hung up her little white hat......
lawguil said:I can agree with what your saying if a physician oversteps their ability or is working outside the boundaries of what they are trained. However, with the examples listed above, we're still not talking about a physician who slipped through the cracks and should have never become a physician. Perhaps some physicians should retire, but they certainly served a population well and competently at some point in their career.
I suspect when you helped the inexperienced physician navigate through the ER situation that you described above, he learned something. The more time he spends working in the environment, the better physician he is going to become. This is how competence develops. I understand that he may have been acting like he new what he was doing at the beginning, but sometimes we are all fooled. I wouldn't dismiss this guy as some smuck who finished at the bottom of his class in medical school or an incompetent physician (and the same can be said about many healthcare providers).
JWK wrote "Please - there are plenty of crappy MD's coming out of med school and making it out of residency.
JWK also wrote "Doc Wagner implies that non-physicians should be "measured" by the worst of those in their profession, while physicians somehow should not."
This is what I was responding too. My point is that I don't believe that medical schools are producing "plenty of crappy MD's". I agree with Doc Wagner that we should measure NP's, PA's by the worst in the class because they will have the autonomy of the best. I also understand that some of the responsibility rests with the supervising physician and it is ultimately up to the MD/DO to make sure proper patient care is provided with proper oversight based on the PA/NPs experience. I also understand that a poor PA or NP student doesn't translate into an incompetent PA or NP 10 years down the road. I believe that medical school is an entirely different situation, simply because to successfully become an attending physician, you have to complete post-doctorate training and one should be completely competent in that particular setting. Does this mean that there will be better physicians within the same setting - of course, but they will still be competent in that they have entry level standards?
jwk said:Geez, you just don't get it. Maybe you're just a med student with delusions of grandeur - I don't know since your profile is empty. Let me say this clearly for you, and then I'm dropping this discussion. There are MD's - including board certified ones - and granted, not many - who are clearly incompetent. They make mistakes that 1st year residents usually don't make. They make errors in judgment that med students usually don't make.
For whatever reason, you refuse to even consider the possibility that this could happen. Do you think that ALL medical malpractice claims are baseless? No, they're not. Some actually have merit due to egregious mistakes made by what you would call "competent" physicians.
The vast majority of MD's are perfectly competent, albeit some are obviously better or more talented than others. The same is true of PA's and NP's. All of us have great anecdotes about the screw-ups we've seen at the hands of any number of providers bearing many variations of letters after their names. But for you or anyone to consider every PA and NP to be no better than the absolute worst PA or NP you can think of is really just the height of arrogance. But hey, I guess arrogance is fine if you're perfect otherwise.
DocWagner said:We should not judge based upon the upper crust of the profession , but rather the bottom level, for they will be treating as well. One does not judge the ability of an fantastic medical student and place that judgement on all medical students do we? No, all must earn their stripes...because even the bottom 10th of the class are still called "doctors".
I have personally trained and lectured some extremely poor NP students. The quality control for their rotations is nonexistant. If they disliked the rotation, they simply "dropped out" ...I had 3 do this.
What we need to do is create a national standard of testing (like the USMLE) including written and clinical. FORCE all NPs to be under the direction of state medical boards and insist they be recertified in a similar fashion to physicians.
emedpa said:"Does this mean that there will be better physicians within the same setting - of course, but they will still be competent in that they have entry level standards?"
while I can't speak to np standards I can tell you about standards at my pa program. every student had to pass every didactic class. if you failed 1 you had to repeat the entire year and graduate a yr later. you had to pass every rotation the 1st time. failing a rotation got you kicked out of the program. the last month of the program we had a mock boards week with 3 written exams( primary care, surgery, core knowledge) and 3 practical exams. failure of any one of these and you had to do an entire summer of remedial work in that subject then retest on all components. if you failed again you were kicked out of the program. then after graduation we had to pass a week long board exam similar to that described above with written exams in surgery, primary care and core knowledge plus 3 practicals. you had to pass this exam in order to get a license. pa's have to retake boards every 6 yrs to show continued competence in addition to 100 hrs of cme every 2 years. failure to do this and you lose your cert and any state licenses you hold.
so....we have a minimum standard as you can see from the above.
there are lots of ways to fail out of a pa program.....I know several people who flunked out along the way at different points and they are currently not seeing pts in any capacity.......
lawguil said:I think that PA's are very well trained and suspect that most professions have entry level standards, some with more rigor than others. I think the PA profession is right up there with some of the more credible programs/professions. I guess the question I would pose is how you acknowledge a PA's skills appropriately. Do you base it on the entry level standards or by the abilities of a PA with 10 years of experience in practice? My hope is that there are some checks and balances for the new graduate who has minimal experience. I don't think that chart review a couple times a year is adequate for a new graduate.
DocWagner said:Let me make something ABSOLUTELY CLEAR...it is not important that a fantastic NP or PA can work well independently or has a great understanding of procedures or medicine...but because this is a political issue for every good/fantastic/independent NP that says "I can run a line in...I can mix this...I know how to treat that" there is a hapless one that will be awarded the exact same rights. We should not judge based upon the upper crust of the profession , but rather the bottom level, for they will be treating as well. One does not judge the ability of an fantastic medical student and place that judgement on all medical students do we? No, all must earn their stripes...because even the bottom 10th of the class are still called "doctors". So don't tell me what YOU can do, tell me how the worst in your class are, because they will have the same rights as you...and I will judge all NPs based upon their performance.
I have personally trained and lectured some extremely poor NP students. The quality control for their rotations is nonexistant. If they disliked the rotation, they simply "dropped out" ...I had 3 do this.
What we need to do is create a national standard of testing (like the USMLE) including written and clinical. FORCE all NPs to be under the direction of state medical boards and insist they be recertified in a similar fashion to physicians.
hospPA said:What about PA's and NP's taking USMLE step 2 and 3? I am willing to do it. As of now, the PANCE is too easy. I cannot speak for the NP exam. Just a thought.
It still would not address the "Is PA X or NP Y worth their weight....." I don't think their's any way you can ensure that. You can't even do it with docs.
Pat
emedpa said:if you allowed that you would have to let folks challenge step 1 also. most seasoned pa's could pass step 2 and 3 easily and probably could pass step 1 after a year of directed study in the basic sciences if done in a kaplan style format(study for the test, not to learn the material....) so it would be the end of the med school monopoly as it currently exists.docs would be throwing themselves out of high windows in protest. dogs and cats would lie down together. there would be a plague of frogs and locusts. you get the idea. not going to happen.......
emedpa said:SERIOUSLY, if even 1 pa or np passed step 1-3 of usmle without attending med school what message would that send to the medical education community at large?
you don't need to do 4 yrs of med school and a residency to practice medicine at the highest level......