FM vs mid level provider?

[deleted6669]

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You're right...there are no rural practices anywhere in the country that do not have a physician immediately available....midlevels are completely redundant as the current supply of physicians is, and will continue to be , adequate to see every pt who needs to be seen regardless of complaint or location within a reasonable period of time.....right......

 

[erichaj]

Sorry your info is mistaken.

Oregon state medical board lists multiple doctors in surrounding towns.

Here's one:

Timothy Herrick, family practice, Antelope OR (about 20 miles from Fossil)

Also, the oregon state medical board states that Dr. Boss is currently active license and registered at Boardman, OR, which is only about 40 miles away from Fossil.

There are obviously many doctors within an hour's radius of Fossil.

Shall we continue this charade?

I would say that the charade is now over. I still don't understand why anyone would want to go to a Pa or NP if they had the choice of an MD. Regardless of specialty.

Lets look at the training for PAs.

Its an undergraduate degree. During that time they do clinical rotations.
I say so what. I don't know a single doctor that graduated medical school (which also does clinical rotations) and felt ready to treat patients.

But there are PAs that get out school and go to work in clinics treating patients. I call that false security.

There needs to be a residency period for PAs and NPs.

WAIT. THAT WOULD BE LIKE MEDICAL SCHOOL.😱

 

[8744]

I would say that the charade is now over. I still don't understand why anyone would want to go to a Pa or NP if they had the choice of an MD. Regardless of specialty.

Lets look at the training for PAs.

Its an undergraduate degree. During that time they do clinical rotations.
I say so what. I don't know a single doctor that graduated medical school (which also does clinical rotations) and felt ready to treat patients.

But there are PAs that get out school and go to work in clinics treating patients. I call that false security.

Huh? PAs can make 70 to 90K right out of school and depending on their area of expertise, can make as much if not more than an FP on the low end of the pay scale. I know a PA who works for an ENT group who makes 110K with decent benefits for about sixty hours of work a week. Not bad for a 27-month undergraduate degree which involved only about a year of clinical rotations, almost no call, and rational hours.

You and I, on the other hand, will need anywhere from seven to ten years of training before we can make decent money, not to mention that 80 hour work week or not, residency pretty much blows from the standpoint of work hours.

Do I think PAs are interchangeble with physicians? Of course not. On the other hand it's no mystery why intelligent, rational people would choose the PA path over medical school.

 

[secretwave101]

it's no mystery why intelligent, rational people would choose the PA path over medical school.

Ugh. No kidding. I've certainly re-thought the wisdom of my chosen career.

And re-thought and re-thought and re-thought.

Yeah, I'm supposed to be better-trained than the average PA. And by time-expenditure alone, this is a defensible point. But I'll conceed to any PA who claims that I'm over-educated that they also have a defensible point.

 

[erichaj]

Ah, I'm glad you said it.

Now, I can say that physicians sold out.

Yes, it is a logical choice. 40K in debt and making 90K.

We should not have allowed this to happen.

But now that it has, it's not going to stop, is it?

So, I will use the PAs like my cheap labor and work less hours and make a **** load more.

 

[deleted6669]

So, I will use the PAs like my cheap labor and work less hours and make a **** load more.

AND THAT'S FINE. IF YOU WANT TO PAY SOMEONE 80K TO DO ALL YOUR WORK FOR YOU THEY WILL. IF YOU OFFER LESS THAN THAT NO ONE WILL WORK FOR YOU....and then they will quit after a month or two because your attitude about midlevels sucks....

on the educational issue...most pa programs are taught at the masters level now and require prior experience and a bs degree to get in. my path to pa was 9 yrs of school and 10 yrs of work experience:
bs=4
(insert 5 yrs as an er tech here)
paramedic school=1
(insert 5 yrs in a busy 911 system here)
pa=3(masters in pa)
1 yr post grad training in em=1

for pa's of my age this is a typical progression.
for the younguns it's less time than this as programs are deemphasizing prior experience.
employers know the difference. that's why I get a salary higher than most in my area.

 

[deleted6669]

"I would say that the charade is now over. I still don't understand why anyone would want to go to a Pa or NP if they had the choice of an MD. Regardless of specialty."

( you do realize that you just quoted the individual widely regarded as sdn's longest standing chief of trolls, right? he is either a 3rd yr medstudent or a frustrated high school kid and is on the ignore list of most on this board. he's not on mine just because of comic value)

I make > 125k/yr consistently(highest yr so far=146k) and have no school debt.I work 18 days/month.
starting fp docs right out of residency in my area make 90-110k/yr and work more hrs and take call.(why do fp docs sell out so cheaply when there are plenty of 140k fp jobs out there? is it the security of working for a big group in ones home town?)
I drive a nicer car and live in a bigger house than the fp docs I work with. my kids are in private schools while theirs go to public schools. I vacation in mexico. they vacation in las vegas.
yes, they know more primary care medicine than I do. I enjoy my life more.

 

[erichaj]

There are plummer and general contractors making way more than doctors.

As far as selling out , you would have to ask that question from the aafp and
the others who have done that.

 

[deleted6669]

"Er tech does not mean much."
agree- it made paramedic school much easier though.
also means I knew more when I started the process than the vast majority of medical students who are completely clueless clinically until the end of their internship year. sure, they know the 4th line medication to treat peripheral neuropathy in someone who is allergic to gabapentin, elavil, etc but they don't know how to perform even the most basic of procedures. medschool spends 4 yrs creating an acadmic medical scholar and then 3+ yrs to create a clinician in residency. pa school takes folks who already have a clue( rn, emt-p, r.t., etc) and hones them into competent clinicians(not medical scholars) in 2 yrs. remember I precept fp residents at 2 well regarded programs and have for > 10 yrs....this has been really nice because when they become attendings I call them, they know me and don't give me any guff about admissions, next day f/u's in clinic, etc. if I say " you need to come in and see this guy" or " he needs to see you 1st thing in clinic tomorrow" they make it happen because they remember that I know what I am talking about.

 

[MacGyver]

I precept fp residents at 2 well regarded programs and have for > 10 yrs...

I doubt they are "well regarded" programs but by all means tell us which programs they are. I doubt you would do that because I think you are trying to pull a fast one on us. But by all means make these programs public and prove me wrong. I'd like to email the program director and ask about this directly.

Its already bad enough at my clinic with the residents recieving way more supervision than PAs/NPs. But I have NEVER seen a PA/NP precept a resident here. As bad as things are here, they arent THAT bad.

Precepting = authorizing and approving of a diagnosis/treatment plan by a resident. A PA/NP has NO BUSINESS doing this with residents.

 

[MacGyver]

"( you do realize that you just quoted the individual widely regarded as sdn's longest standing chief of trolls, right? he is either a 3rd yr medstudent or a frustrated high school kid and is on the ignore list of most on this board. he's not on mine just because of comic value)

How many logical fallacies are there in this diatribe? You made a claim that was easily refutable by a simple internet search. So then you lash out in anger with insults that have nothing to do with the matter at hand.

You know that you have won an argument when the opposing side shifts away from the topic and towards ad hominem fallacies.

 

[deleted87716]

Final warning, folks.

The next ad hominem attack closes the thread. 😡

 

[deleted6669]

"Precepting = authorizing and approving of a diagnosis/treatment plan by a resident"

I am well aware of that. let me be clear. I am the precptor of record for a required pgy 1 fp rotation. the residents run cases by me, I instruct them in procedural skills and I write their final evaluation for the rotation. it is a must pass rotation just like any other. thankfully I have never had to fail anyone.
I am not about to disclose these residency programs(2). that would result in directly identifying me. this is an anonymous forum for the most part and I intend to keep it that way. I don't see you coming out with your actual name, position, medical school, and current rotation site mac so don't expect me to do the same.
ps the residency director at one of these sites is a friend of mine and also happens to be my sponsoring physician of record.my 1st few yrs there he treated me like a resident. after that I trained residents.

 

[deleted6669]

http://www.rhpp.vt.edu/pasurvey/sld003.htm

 

[flighterdoc]

http://www.rhpp.vt.edu/pasurvey/sld003.htm

Yeah, in an area with <10K census, it'd be hard to support an MD.

 

[lowbudget]

Precepting: Learn learn learn. As an FM resident, you stand to learn the most when you shut your trap and allow yourself to be taught by those around you. I don't care if it's wound care nurses, athletic trainers, physical therapists, L&D nurses, ER midlevels, casting techs. They're trained to know/do a very narrow field and they do it well. So I don't mind learning from them, checking cases out to them but only within their field. L&D nurses are good at vag exams but bad at running the first 5 minutes of a code compared to ICU nurses. Trainers and PT do awesome musculoskeletal exams but I wouldn't take pointers from them on working up SOB. You just have to learn the right things from the right people. I think one key difference between FP's and midlevels is that midlevels don't train well in EBM. And so sometimes, they practice the way that they were trained, or follow protocols that may be outdated.

Midlevels vs Physicians: I see midlevels as Well-Paid Lifelong Senior Residents. Personally, that would suck. I'm happy I chose med school and FP for that matter and I don't feel threatened one bit from midlevels, insurance companies, specialists or whoever. If anything, it's just more motivation to re-think what you can offer as bigger and better, then go out there and sell it. And if you can't, just let others do it, who cares? Everything's gonna be alright.

 

[delicatefade]

Curiously, FP seems to be the only field where this anxiety about being replaced by mid-level providers exists. I've never heard a GI doc or Endocrine doc concerned about the presence of PA's in their field. Come to think of it, I've never heard any FP's too worried about it, either, except here on SDN.

Ever been to the anesthesia forum???

 

[Faebinder]

Ever been to the anesthesia forum???

Well FP reimbursement and Anesthesiologists reimbursements are no where near each other.

Anyhow... I forsee number of FP programs dropping in the future and a steady amount of FP and indeed PA/NP taking over.... This is for truly... truly... for the goodness of the FPs and sadly ... for the bad for the general population.

Why good for the FP?
It will become truly botique medicine and urgent care centers pretty much and to top that.. less supply.. more demand...

Why bad for the population?
An FP with X amount of years of experience is a better clinician than a PA or NP with X amount of years of experience. Not to mention FP are the best scientests when it comes down to research on studies that combine mass population and basic science.... they would be the ones with the highest n and the most varied n and the best insight on why things happen the way they happen in primary care. Unfortunately, studies that perfect medicine in large populations are not that sought after by the two major funding sources: NIH which focuses a lot more on basic science and pharm companies.

 

[8744]

...Unfortunately, studies that perfect medicine in large populations are not that sought after by the two major funding sources: INH which focuses a lot more on basic science and pharm companies...

That's because those kinds of studies are so gosh-darned fuzzy, prone to be manipulated for political ends, and hard to design because of confounding factors.

Then, once you discover something, what do you do with it? It's one thing to discover, as if it wasn't obvious, that obesity is running rampant, it's another thing to propose a realistic solution.

 

[MacGyver]

I am well aware of that. let me be clear. I am the precptor of record for a required pgy 1 fp rotation. the residents run cases by me, I instruct them in procedural skills and I write their final evaluation for the rotation.

ps the residency director at one of these sites is a friend of mine and also happens to be my sponsoring physician of record.my 1st few yrs there he treated me like a resident. after that I trained residents.

that sounds EXACTLY like the Duke FP program that was recently shut down.

 

[deleted6669]

that sounds EXACTLY like the Duke FP program that was recently shut down.

PANDA- correct me if I am wrong here....duke had many issues, yes? it was not closed down because midlevels were involved in teaching, correct?
if that is the case MANY other residencies would be closed down as well

 

[primadonna22274]

Very well said. You appear to be one of the enlightened ones. 😍
This is exactly why I'm leaving the PA profession. I cannot be the senior resident for the rest of my life. I've learned a lot and been happy in my work more often than not, but I've never been content.
As an MD, you bet I'll support PAs--I know where we come from. It is hard though to overcome the preconceptions of so many younger docs who don't have a clue about our training or skill set.
Here's an interesting tidbit: I have never in six+ years of PA practice had a problem with a mature, well-seasoned doc (in practice a good ten years or more). The only ones I butt heads with are the ones who've been in practice a shorter time than me. They seem to be the ones who are threatened. What on earth happened to progress?

Midlevels vs Physicians: I see midlevels as Well-Paid Lifelong Senior Residents. Personally, that would suck.

 

[8744]

PANDA- correct me if I am wrong here....duke had many issues, yes? it was not closed down because midlevels were involved in teaching, correct?
if that is the case MANY other residencies would be closed down as well

I was never precepted by a PA or a midlevel at Duke except on my OB rotation where my primary preceptors where the exceptionally talented Nurse-midwives. These ladies know a lot about pregnancy and childbirth and it was my privelege to be instructed and guided by them.

But the Family medicine clinic had a lot of very competent mid-levels seeing their own panel of patients and more-or-less functioning as family physicians. They did precept medical students but never the residents as I suppose this would have caused a riot. It is fashionable to pretend that prestige is not important to physicians but, to paraphrase Dr. Evil, a lot of people, "didn't go to four years of evil medical school to work under PAs."

I am a big fan of PAs. I think it's a perfectly reasonable career choice and if they can do the work, then they should. This includes work in Family Medicine, Emergency Medicine, and other specialties. I also don't believe that PAs should be limited because they are encroaching on doctor's turf. I've been against that kind of protectionism in every aspect of economics and I'd be a hypocrite to all of sudden cry "foul" when it's my ox being gored.

On the other hand it is also fashionable for mid-levels to believe that they know as much as physicians which is not the case. Clearly a PA who has been in practice for ten years knows more about practical patient care than a newly minted intern. That's just experience. But there is no comparrison to the level of knowledge between a physicians who has just finished his training (from seven to ten years worth of it) and a PA who has has just finished his.

The fear for young medical students and residents is that they have wasted their time struggling through their training when somebody with a third as much of it can do their job as well...and more importantly that the bargain hunting public and the government sees it like this as well.

The Duke model of family medicine, by the way, embraces the mid-level providor at the expense of most of the physicians. Please read the article on my humble blog on this subject.

 

[deleted6669]

I was never precepted by a PA or a midlevel at Duke except on my OB rotation where my primary preceptors where the exceptionally talented Nurse-midwives. These ladies know a lot about pregnancy and childbirth and it was my privelege to be instructed and guided by them.

But the Family medicine clinic had a lot of very competent mid-levels seeing their own panel of patients and more-or-less functioning as family physicians. They did precept medical students but never the residents as I suppose this would have caused a riot. It is fashionable to pretend that prestige is not important to physicians but, to paraphrase Dr. Evil, a lot of people, "didn't go to four years of evil medical school to work under PAs."

I am a big fan of PAs. I think it's a perfectly reasonable career choice and if they can do the work, then they should. This includes work in Family Medicine, Emergency Medicine, and other specialties. I also don't believe that PAs should be limited because they are encroaching on doctor's turf. I've been against that kind of protectionism in every aspect of economics and I'd be a hypocrite to all of sudden cry "foul" when it's my ox being gored.

On the other hand it is also fashionable for mid-levels to believe that they know as much as physicians which is not the case. Clearly a PA who has been in practice for ten years knows more about practical patient care than a newly minted intern. That's just experience. But there is no comparrison to the level of knowledge between a physicians who has just finished his training (from seven to ten years worth of it) and a PA who has has just finished his.

The fear for young medical students and residents is that they have wasted their time struggling through their training when somebody with a third as much of it can do their job as well...and more importantly that the bargain hunting public and the government sees it like this as well.

The Duke model of family medicine, by the way, embraces the mid-level providor at the expense of most of the physicians. Please read the article on my humble blog on this subject.

thanks for your input. I do appreciate it-e

 

[deleted87716]

I've moved the posts related to a "fat tax" into a new thread, located here.