DrNP and ND programs

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oops... sorry docgeorge. I meant 'Beastmaster' for the last post...

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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!!!!!

mostly agree with you here matt. I think it is fair to say that the avg physician knows more than the avg midlevel of any type.for this reason there should be a physician in every health care setting running the show. we are years away from this happening though. there are not even enough em and fp docs to cover all the er's in the country so pa's take up the slack or no one would be there at all. there are extraordinary pa's(take mr bob for example) who have run their own practices as pcp's for years with minimal oversight(but always available as needed). there are also some physicians out there who scraped through school, barely passed their boards and if they did a residency didn't impress anyone. I have worked with some of these folks. they haven't cracked a book in 20 years and have forgotten most of the medicine they learned at their bottom tier school. so given the choice between a stellar midlevel who studies every day and aced their program and boards or a bottom of the barrel md who has forgotten that keflex is a cephalosporin, who do you think I would pick to care for my family in a rural setting?
by the way I know what nephrotic syndrome is and have dx and treated it. I'm sure you know the pathophys of it much better than I do but it is always on my differential list for peripheral edema or unexplained weight gain.I'm also sure that your differential list would be a lot longer than mine at this point as well but that is why you are going to be making the big bucks :)
 
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.

Well, yah.... the PA students where I go to med school are essentially trained along a similar model as the med students. They just do it in a very short intense period. In fact some of my physical exam courses were taught to me by PAs who are instructors in the PA school.
 
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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. :thumbup:

Not taking stats until fall semster... take some of your own advice and do not comment on things you don't know. I've done grad school and med school, and very few, less than 10 %, of my med school class would be able to get beyond the abstract of any papers that were involved with my graduate research. Trust me these are smart people, many are smarter than me. It's just that a history degree with a few pre-med courses and an MD degree does not make one a scientist. It makes them an MD.
 
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!! :laugh: Or maybe that was one of those movies that my Dad used to keep in his underwear drawer!!!

Guess you haven't seen the outcome studies re MDs and NPs??

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 :laugh:
 
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.
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. Furthermore, a pimary care NP will be doing a lot more specialist referrals than a primary care physician would. Your insurance companies aren't going to like that. Once the NPs start owning their own offices, paying their own staff, paying full malpractice rates, and getting shafted by insurance companies, we'll see what happens to the low fee.

Guess you haven't seen the outcome studies re MDs and NPs??
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.

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
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.
 
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.

Your points are well taken. My arguments presuppose that a doctorate in nursing would be structure in a certain rigorous way. If it isn't (quite probably), forget about it... They are fantasizing.

I'm also curious about how big pharma would react, as NPs might be more credulous with prescriptions if granted that authority (ie, NPs hesitant to over-prescribe while being over-pimped by the pharma sales teams).
 
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.

NPs can carry their own insurance. Due to their safety record it's only $734 /yr for $1,000,000/$3,000,000.

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.

I can guide myself, thanks. So what about this "evidence-based" medicine?

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.

Funny! I'm just showing that if someone wants to pick on one profession (NPs) I can also do the same to MDs.
 
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.

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?
 
NPs can carry their own insurance. Due to their safety record it's only $734 /yr for $1,000,000/$3,000,000.
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.

Notice that these all rotate around autonomy. If you start practicing like a physician you will start having headaches like a physician.
 
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.
 
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?


While this is one of the most RN friendly posts I have ever seen my a med student, I would like a minor clarification......Where you mentioned two people that went back to med school, you say "NP anesthesiologist". I am wondering if you meant a CRNA because a NP doesn't do anesthesia and an anesthesiologist is already a MD.

Just wondering.
 
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psisci said:
NPs can specialize in anesthesiology doc....

:)
yes, they are called crna's.
to the best of my knowledge there is no anesthesiology np program although I suppose a critical care np could do pre-op anes screening thay could not pass gas. to pass gas you have to be an mda, crna, or aa.
 
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?


I have always had fun teaching everyone, regardless of position. My point is that anyone will make a mistake somewhere along the line...and I've seen everyone, including me do it. The endocrinologist was the attending...I'll bet money she's Bipolar :smuggrin:
 
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.

Where I come from, residents, particularly surgical residents, do a lot of lines, intubation, spinals, etc., so I just have to use "techniques" as "one" measure of capability. Granted, they have to learn and get a few under their belt. Which is why I didn't make a resident feel bad a few night ago when he hit the femoral artery inserting a line and he had this rather large pool of blood and swelling. It was a code anyway and the patient wasn't gonna make it. But it hasn't all been technical questions; we get med questions all the time, or "what fluids should I use." But that's ok; makes us stay sharp. :idea:
 
psisci said:
NPs can specialize in anesthesiology doc....

:)





NP and CRNA are entirely different nursing tracks and their education focus and clinical preparation are as different as well.
While it is true that a NP could possibly work for an anesthesia group doing pre-ops, testing, and post-op rounds, this NP could never deliver anesthesia, hence a NP working for anesthesia is not the same as a CNRA. What spurred my question was the fact the words "NP anesthesiologist" was used when describing someone who went to med school.
 
windsurfr said:
oops... sorry docgeorge. I meant 'Beastmaster' for the last post...


You stand forgiven, now go forth and sin no more. :D
 
I love the people who love make ridiculous statements like, “I can’t 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!!!
 
ether_screen said:
I love the people who love make ridiculous statements like, “I can’t 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!!!

Yes, because the rigorousness and length of training has absolutely no bearing on the incidence of medical errors. :laugh: :thumbup:


The "ether_screen" syllogism:

Major premise: Physicians make mistakes
Minor premise: NP's make mistakes

Ergo, physicians are equivalent to NP's in terms of the incidence of medical errors.


Yeah, you sound really bright. :thumbup:
 
While there are a whole host of issues here, the one that resonated with me was the lack of knowledge that the general public has about medical education.

I like to study at starbucks, every so often someone approaches me, looks at my books, and asks me if I am pre-med. When I explain that I am a medical student they usually reply something like: "yeah, i know, pre-med, you're not a doctor right?"

The sequence of pre-med, medical school, residency, fellowship, etc. is not well known or appreciated; while in the medical world each of the above denotes a clear level of education, and mastery of knowledge.

This then get compounded with the term doctor being used by nurses with advanced degrees. At the same time I do believe that nurses (who I have nothing but the uttmost respect for) who undergo more advanced training do deserve to have it recognized, I am just not sure this is the best way.
 
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.
 
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.
:thumbup:
 
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.

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.
 
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?

It isn't just knowledge, it is experience and pattern recognition based on a foundation of basic science knowledge and training in clinical reasoning. The actual knowledge changes. I think it is this type of training that separates physicians from others in health care. Also it is the willingness to be the person who takes responsibility if something goes wrong. Even if you rely upon AI software in the end you have to make a decision and sometimes those decisions hurt or even kill people.
 
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?

Actually this has already been done. There are programs designed for reading EKGs; apparently if you train them on enough traces they do better than the cardiologists.
 
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.


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.
 
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.

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.
 
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.

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.
 
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.

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.
 
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.

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.
 
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.

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.
 
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.

I believe that their are surgeons that are demoted, but tell me who's more qualified than a physician to become a surgeon? And clearly, the system that is in place for physicians to perform competently is working; right. I really don't think we're getting the full story here. I've never heard of a surgeon who was an under-achiever who insisted on poor and careless technique. I understand what you’re saying, but it doesn't sound like a problem of somebody becoming a physician that shouldn't have become one. I've met some young surgeons who are extremely cautious about what they do. You don't become a surgeon without understanding the risks or because you have poor judgment.
 
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......
 
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......

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?
 
"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 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?

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. :mad:
 
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. :mad:

Sorry jwk - I don't mean to come across as stubborn or with arrogance. I actually agree with you in many respects. I think I acknowledged that to a certain point, a PA's autonomy should be the judgment of the physician. You make the case that experienced physicians make stupid mistakes and I am not disagreeing, I just think that the issue is a little deeper than we are able to discuss on this forum for the sake of time. Despite how I have come across, I think I agree with you more than I disagree, but at this point I don't even remember what we're arguing about.
 
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".

This is what my Hapkido teacher also said, that he would be judged by the performance of his worst black belt. If you earned one you knew what you were doing. He also insisted on continual performance and you must attend his twice yearly seminars (no matter how far away you live) in order for him to see your progress. He has also been known to strip a 4th degree of his rank.

Our hospital has just started a policy which helps identify impaired physicians. I think this may be a JCAHO thing but I'm not sure. Anyone can "write up" a physicians's behavior and he will be checked out and counseled by his peers.

I've turned in a surgical resident because he is just dumb. He parked in an attendings parking spot, got a ticket, did it again and got his car towed. He asked the nursing supervisor for a ride to the tow lot and she informed him that she could not leave the hospital. He had a patient who's blood sugar had been running in the 40s for hours and was on hourly checks. The floor nurse called me (supervisor) wanting to get the patient into ICU. I asked her what IV the doc had ordered and she said "normal saline." I told her to forget the resident and call the attending stat. The attending blew a gasket because he had written orders for D5W/NS and the idiot resident had cancelled them. This is just a few of his antics including not being able to remember where he leaves his coat and pager. I don't know how he made it this far. He will not be here long!!

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.

There are already national certifying exams in place for NPs. None for clinical that I know of except for the clinical preceptor. Were you not the "quality control" for these student...if you were their preceptor?

I've considered going the post-masters route for NP but have dropped that idea because my salary would actually drop. I know other NPs who also work as staff nurses due to being able to make more money. The only way I would consider NP would be just for the additional training and knowledge. But acupuncture school looks more to my liking.
 
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.......


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. I fully understand the intensity of what it takes to become a PA, but if you compare what a resident has to go through to have the same autonomy as a PA, it's a fair amount more. My understanding is a resident would require more oversight than a practicing PA fresh out of school (again, just my understanding - you might be able to give a little more insight). How you define a PA's autonomy should be comprehensive as well and should look out for the safety of the patient. How exactly do you do this?
An attending physician has gone through a very comprehensive process to get where he is at. A resident is still learning his trade and will make errors in a variety of ways, including parking in the wrong parking spots (I admit, the guy zenman talked about sounds like an idiot, but who knows what I would be doing on my 80th hour of a hard and busy week - hopefully not parking in an attending parking spot).

I am not degrading a particular profession because I think that just about everybody who makes it to fruitation in their particular discipline is probably competent at what they do. I get annoyed when people loosely define a physician, PA, PT ect as an idiot or incompetent when everybody has probably shared a similar status sometime in his/her career. To give an example, I use to work with a PT who was dismissed as a horrible practitioner or sometimes stupid, mostly by the secretarial staff or the PTA's because he use to leave patients in rooms for long periods of time simply because he forgot they were in there. The stenographers hated him because he was always behind on his notes. At times he seemed like he was clueless about what was going on around him. However, he was brilliant at what he did. If you weren’t having any success with a patient, he was the guy to go talk to about what to try and strangely enough had one of the highest patient satisfaction rates of all the PT's probably because he had great character. Granted, he wasn't the guy you would put in charge of a clinic, but he was the best at getting a patient better. He just didn't do it in the orthodox way that everybody else did. Importunely, in my experience, most accusations about practitioners don't usually have a lot of depth to them or it's about one error out of hundreds of things they do extremely well everyday. I suspect that if we all had a more global understanding of what a physician is doing or thinking we just might have a different perspective of how we measure them.
 
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.

I totally agree that there MUST be more supervision for new grads than with those with tenure as a PA. Currently, that is up to the employing physician. Some take this responsibility lightly, some do not. My first job was in Occ Med. I was in a clinic, solo, just an MA and front desk person with me, after two weeks. Was I prepared for that? Hell no! But I got by without killing anybody, thank God.

Minimum requirements for education for NP's and PA's would assist the physician in determining the minimum they should expect from a new grad. Then, treat everyone like that for a little while, until the "individual" PA or NP comes out and they become more comfortable.

Thanks,

Pat
 
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.

I would actually agree with this statement.
It goes in line with: What do you call a physician who's graduated at the top of her class? Physician. What do you call a physician who's graduated at the bottom of her class? Physician.

Having a national accrediting exam for nursing and medicine is great. It sets a minimum standard. I also believe that there should be a national accreditation exam for advanced practice for any health care profession which does not require a doctorate to practice.
Therefore, if I'm to be a CRNA/CNM/NP/PA, etc ad nauseum, I should have taken and passed an exam which unifies all who fall in that category and says that I have met the minimum practice standard.

It is my opinion that having such unification would end (somewhat) the bickering that exists about "who knows what".

Now whether Ed the PA is worth his salt as a PA would be a different issue, as would questioning whether Steve the CNM knows what he should. Having obtained those degrees of recognition and education and passed such a standard test would put that issue to moot.
 
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
 
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

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:
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.......

lol
 
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......
 
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......

I really do need to consolidate my loans. :)

Also, I do not plan on jumping out of windows should PAs pass the USMLE. Just a couple of observations. First of all, there's no question that seasoned health care providers could pass the USMLE steps 2 and 3. Nobody should argue that those tests are the gold standard for today's physicians. Rather, they function to "gauge" an individual student's competence. They are MINIMUM standards that graduating students must meet to be considered for licensure. It is up to residency program directors and staff to seek out the higher scores and investigate individual merit. While experienced PAs might not bat an eyebrow at Steps 2 and 3, I'd be willing to bet that the ABEM/AOBEM (board examinations in emergency medicine) would be considerably harder. It is not unheard of for unprepared board eligible physicians to fail one of two parts of their specialty certifying examinations. What I'm getting at is the following: the question of whether PAs could pass the USMLE is unimportant. It is not even relevant to the existence of a medical school monopoly. Again, the exams enforce minimum standards required for eventual graduate training.... To focus on the examination does little to acknowledge the student's particular background. The USMLE is designed to assess the student who has completed two years of training in the basic medical sciences. Nurse practitioners, on the other hand, do not undertake a comprehensive study of biochemistry and are therefore not prepared for the USMLE. Similarly, physicians know little of the process-based approach to health maintenance and care. NPs, PAs, and docs serve different yet complementary roles... the training is necessarily tailored to the needs of each profession.

Emedpa makes several salient points and I do not want to detract from his contribution to the forum. Rather, I'm just trying to move away from equating good medical practice with some standardized test. Good NPs and PAs will most probably practice, "better" medicine than their unseasoned and naive medical student/resident counterparts. That is undisputed. To function as a specialist and to have ultimate responsibility for patient care, on the other hand, requires more investment in training. That is why physicians must complete residency training and choose to focus on a specialty track. Notice the elimination of the general practitioner. Today's GPs are not really generalists in the strictest interpretation of the word. Family practice physicians have to complete 3 years of post graduate education to be board eligible. I cannot argue that board certified family practitioners are far and away the best arbiters of primary care. What is clear, however, is that the family medicine specialist will:
1. get 100% reimbursement from medicare/medicaid
2. be ultimately responsible for patient care
3. pay higher malpractice premiums
4. dictate their own scope of practice
5. Have narcotic prescriptive privileges in all 50 states
6. Have the opportunity for further sub-specialization

Is that worth the three years? That, I think, is the important question.

Hmmmm...
 
I posted previously my concerns about PA/NP's that go directly into training. They do so instead of medical for one of four reasons:

1. They dont want to go to school as long (hours,debt, etc)
2. They dont want the legal responsibilities
3. They want more predictable hours than physicians
4. They couldn't get into medical school

If I a am wrong in this statement, please tell me otherwise.

The problem that I have with the above is that it SELF SELECTS those who are less willing to work hard and learn at a deeper level. They want to know the basics, learn treatment algorithms.... and thats it. They have selected to undergo 5-8 years less training in hopes to attain the same privaleges / title / etc. You may not need molecular genetics or neurophysiology to practice primary care... but the in depth scientific background is important to fundamental understanding of pathophysiology. This is not learned in PA or nursing school.
Again: those of you who went into NP/PA programs did so for one of the above four reasons... therefore in what position are you to demand more?
 
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