Future of FM

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Doublj01

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Im a 3rd yr med student interested in family medicine, but there's alot of talk about ARNPs/NPs/PAs/DNPs will soon, in the near future, will have the same rights and privileges that most FM physicians have now and will do it for less pay. So, what would be the incentive for medical students to go into FM?How will those that do choose FM be affected in the next 5-10yrs? It sucks because I really enjoy FM, but feel like someone with less training and experience can open up a clinic and do what FM does. Insights?
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I'm just an MS1 but I can tell you that midlevels are entering all specialities. The times are changing, but I'm personally not gonna let fear steer me away from something I enthusiasm and drive for. I'll let the more experienced chime in.
 
This is a very sensitive topic for me, as it caused a big fight with my husband. He is a psychiatrist who has a busy practice,and had a FM working with him, he was paying him fair, but the guy retired.
Somebody recommended this nurse practitioner to him that is just a recent graduate, that has changed jobs already like 3 times, looking who pay more, and when I was revising the accounts this past weekend, noticed that he is paying the NP not only the same salary that he was paying the FM doc, but since I am graduating in June, and got a job in urgent care, she is actually making 7 dollars extra an hour than I will make as a physician.
He think I am jeallous, but I am trying to explain to him that he , and others like him is what is causing the NP "problem" , they are inflating themselves with less experience and playing the doctor game.
 
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As a resident now curretly in the middle of all the change, how do you see your future in FM? Do you think NPs like the one York husband hired will be everywhere or is he an exception? What are newly minted FM attendings finding themselves in?
 
It is hard to tell, but nobody is putting them in place, because seriously, They can get degrees faster than we do so they are being produced like an assembly line product, and they will saturate the market.
They have people lobbying for them, and soon I am afraid they can work independently.
What I am getting from my husband is "but why did you go into family medicine, I have hard time explaining to people what is that all about", he wanted me to go into psych, but I do not like psych.
 
microscp2 said:
What I am getting from my husband is "but why did you go into family medicine, I have hard time explaining to people what is that all about", he wanted me to go into psych, but I do not like psych.
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Joke's on him, NPs are taking over psych faster than primary care. Just take a quick glance at the psych forum.
 
^ Nothing has changed. NPs weren't the solution then, and they aren't the solution now.

There is no substitute for a family physician. You will have job security for the rest of your life. Family medicine is the ultimate "lifestyle specialty."

There are a zillion threads in this forum about this stuff. Read 'em.
 
Doublj01 said:
earlier I read this:

http://medicinesocialjustice.blogspot.com/2009/01/ten-biggest-myths-regarding-primary.html

but its from 2009....I'm trying to see how true that article is now since it was first published, since more of the healthcare changes are starting to take place.
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Currently finishing up 4th year at a rural hospital system. Have been here since the beginning of 3rd year. I've rotated at the main hospital (in a town of 28,000) and various satellite sites (3000-4000 people). Worked with and met many physicians (over 150) and maybe 6 midlevels. And only 3 of those midlevels were in primary care.

From what I can see FM pretty much rules here and the docs coming out of residency here are getting offers well, well above average with pretty nice signing bonuses and substantial student loan repayment.

I think much of this midlevel anxiety is overblown. There will always be a need for GOOD family physicians. Do what you enjoy, do it well and you will be fine.
 
I tend to agree with the sentiments expressed above. I personally have seen and worked with just as many NPs (if not more) in various specialties OTHER than primary care...they're everywhere!

In fact, if I were an NP, it would make more sense (at least financially) for me to NOT do primary care, as NPs can make better salaries working under specialists.
 
Psych still has no problem getting jobs, in the foreseeable future. Our average salaries continue to rise. I'm a PGY1 in a competitive region and our grads are getting great offers, can work anywhere in the country, and I personally am getting recruited already by head hunters. Not really concerned about NPs.
 
I can foresee the market becoming more competitive if/when NPs gain independent practice rights in a majority of states, but if granted the choice, I believe that most patients will always prefer a GOOD medical doctor - why wouldn't you? So we hold a trump card if push comes to shove. Like kdur said, just work hard to become the best family physician that you can be, and the rest should take care of itself.
 
Forgot to mention that when applying to jobs, there was a job in a rehab hospital and was told, also need to let you know that we have a nurse practitioner, and I asked, is he going to work under me? and the recruiter answer was " no she is going to be like another "physician", and of course told her not interested.
 
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Admittedly, I work hard, but my 2012 income was greater than 400K. I have daily job offers. If all I could do was outpatient urgent care, I would be worried. A nurse practitioner cannot do what I do.
 
NP's evolved because we (physicians) failed to provide adequate primary care and general medicine services to communities.

Avoiding primary care and relegating care the NP's will only create more work and chaos for physicians/specialists, because NP just don't know what they're doing (they're figuring it out as they go along, but working under a "mentor"). Their training model is taking medicine back to the apprenticeship days... before GP's.

The only think I'm afraid of is being forced to supervise NP's. It's one thing if they're working on their own, taking responsibility for the care that they render. But it's another for them to do their thing, and then blame it on physician.
 
lowbudget said:
NP's evolved because we (physicians) failed to provide adequate primary care and general medicine services to communities.

Avoiding primary care and relegating care the NP's will only create more work and chaos for physicians/specialists, because NP just don't know what they're doing (they're figuring it out as they go along, but working under a "mentor"). Their training model is taking medicine back to the apprenticeship days... before GP's.

The only think I'm afraid of is being forced to supervise NP's. It's one thing if they're working on their own, taking responsibility for the care that they render. But it's another for them to do their thing, and then blame it on physician.
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It is not just the primary care areas, it is everywhere. The cardiologists have NPs and PAs rounding for them (and your crazy if you think they run everything by the attending before they write orders and schedule caths), the neurologist I rotated with last block has an NP who splits the patient load with him. He does not oversee the patients she saw, just signs her notes I am sure at the end of the day. Midlevels are everywhere. The ED is full of them in community hospitals. The local Pulm group has one that you may or may not see when you go to the office. It is not just the primary care field that is suffering, it is everywhere. My hospitalist group has 14 14 internist's and 2 NPs, those 2 NPs are covering admissions on weekend days for non teaching teams, a slot that should be available for moonlighting residents. Why hire a second cardiologist if I can pay an NP 140k to do all my office work and hospital rounds and then I can just cath and read echos? It is a problem that we collectively need to address as physicians.
 
lowbudget said:
NP's evolved because we (physicians) failed to provide adequate primary care and general medicine services to communities.

Avoiding primary care and relegating care the NP's will only create more work and chaos for physicians/specialists, because NP just don't know what they're doing (they're figuring it out as they go along, but working under a "mentor"). Their training model is taking medicine back to the apprenticeship days... before GP's.

The only think I'm afraid of is being forced to supervise NP's. It's one thing if they're working on their own, taking responsibility for the care that they render. But it's another for them to do their thing, and then blame it on physician.
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While everyone has good and bad stories of NPs/PAs/Physicians -- my interaction with NPs has generally been negative in terms of knowledge base coupled with attitude -- they don't know what they don't know and most are convinced that they are the equivalent of expereinced Family Medicine attendings.....
 
What is the AMA and other medical groups trying to do about it? They don't have much info except that NPs are not supposed to replace physicians and work side by side, but by experience it seems like this is not the trend. Why isn't there a physicians union ?
 
Doublj01 said:
What is the AMA and other medical groups trying to do about it? They don't have much info except that NPs are not supposed to replace physicians and work side by side, but by experience it seems like this is not the trend. Why isn't there a physicians union ?
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same question here. AMA? state representation of some sort? are physicians banding together in some fashion to get in on that power-in-numbers thing? doesn't have to technically be a union, in order to dance around legal issues...
 
Doublj01 said:
What is the AMA and other medical groups trying to do about it?
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Scope of practice legislation typically gets passed at the state level. The AMA works mostly at the federal level. That's why it's important to be involved in your state medical society (which is the state chapter of the AMA) and state specialty society, or at the very least contribute to their PACs. You can do this even as a student. You're either at the table, or you're on the menu.

That being said, the number of physicians who contribute to PACs and get involved in politics is shockingly low, considering what a bunch of whiners we are. Put your money where your mouth is.

Your question about unions would be best discussed in the Topics In Healthcare forum (as it has been a thousand times before).
 
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I have mixed feelings about mid-levels. On the one hand, my interactions with them have given me the impression that their background knowledge base of physiology/pathology/basic sciences is basically non-existent. On the other hand, they are generally smart people and plenty capable of learning to imitate their attending/supervising physician's practice patterns. Coming up with their own practices seems to be something that would be totally out of range for them, as does evaluating studies and adapting to new evidence. I think they can serve a good role in terms of basically functioning as a permanent "resident" for a non-academic attending. That said, we have three times cancelled our appointments with practices when they schedule someone in our family with an NP/PA... it's pretty easy to find a practice without them, and I have to pay the same to see a physician or NP/PA anyhow. And I don't know if I can see how they would realistically serve much of a role in my future practice... I think they are much better suited for inpatient/specialty work.
 
agree that NP's are no substitute for a FP in a primary care practice.

As a specialist, I do supervise an NP who helps out in clinic so I can get the sleep studies interpreted.
Regulations and laws make it difficult for me to hire a GP or internist/FP to do the same function. The NP can (and does) tell patients and and sometimes writes in her notes that she is working under my supervision. Doctors can not do the same thing. If I hire a GP who flunked out of residency, he can't say that he is working under my direct supervision- he would be held to a higher standard and the cost of his malpractice insurance would be much higher than an NP's (and my malpractice rates would go up in if I working in such a situation).

I guess I could hire another sleep doc but that would be expensive and even then that doctor couldn't really function as my assistant. Agree with ztaw15: " I think they can serve a good role in terms of basically functioning as a permanent "resident" for a non-academic attending."

I guess what I am trying to say is that for a doc who wants to hire a clinician as an assistant, a NP/PA is the best option.
 
As a student all I hear are rumors. Which is one reason why I wanted some clarification. I agree that an NP/PA won't replace physicians, but what about ARNP/DNP? I constantly hear from nurses, " Don't do primary care, that's what we're going to be doing in the future! you should specialize!"....um seriously?
 
xenotype said:
Joke's on him, NPs are taking over psych faster than primary care. .
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yep....except for anesthesia, nps are going to put a hurting on psychiatrists more than any other field.
 
Doublj01 said:
As a student all I hear are rumors. Which is one reason why I wanted some clarification. I agree that an NP/PA won't replace physicians, but what about ARNP/DNP? I constantly hear from nurses, " Don't do primary care, that's what we're going to be doing in the future! you should specialize!"....um seriously?
Click to expand...

The DNP is an academic degree filled with courses in nursing research. They are not any better than your standard issue NP except now they get to call themselves "doctor".

I remember reading somewhere that a NP is required to do 800 clinical hours. A FM doc has something like 17000 clinical hours. Huge difference.
 
psych nps are not a threat to psych...I have seen no evidence of this...don't listen to vistaril..he's a troll
 
kdur said:
The DNP is an academic degree filled with courses in nursing research. They are not any better than your standard issue NP except now they get to call themselves "doctor".

I remember reading somewhere that a NP is required to do 800 clinical hours. A FM doc has something like 17000 clinical hours. Huge difference.
Click to expand...

And that's part of the problem --- I have been in situations in an ER Obs unit where a DNP came in with the team, wearing a white lab coat and trying really hard to look "official" - i.e. like they knew WTF they were doing - and the physician introduced them as 'Dr. SoandSo'....Did the NP clarify that to the patient? No and it probably wasn't appropriate....

It drives me ape**** sometimes.... especially when I had an NP/CNM try to pimp me on OB....she was trying to frame a leading question to get to the difference between early, late and variable decels but couldn't figure out how to put it into a clinical context....I finally figured out what she wanted and where she was going with her line of questioning and told her that our thinking patterns as physicians are different from theirs.....

But to them, that's the problem...as we all know, according to these NP/CNMs I've been exposed to (and not in the good sense), NPs are more caring and consider the whole patient, much moreso than physicians ever could and therefore are better practitioners of the healing arts....we're just mean and want to do surgery or procedures on all our patients when we should just "assist the natural process".....

Anyway, I'm ranting....for me, an NP is an extender to handle simple, cookbook stuff, same day appointments for med refills, BP checks, DM f/u and fielding patient calls....maybe.

Just my $0.02, YMMV, no warranties expressed or implied....
 
EdibleEgg said:
Admittedly, I work hard, but my 2012 income was greater than 400K. I have daily job offers. If all I could do was outpatient urgent care, I would be worried. A nurse practitioner cannot do what I do.
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How in the world do you manage to pull this off? Do you cover both outpatient and inpatient? OB? Moonlight in an ER/UC? Or just never sleep?
 
kdur said:
The DNP is an academic degree filled with courses in nursing research. They are not any better than your standard issue NP except now they get to call themselves "doctor".

I remember reading somewhere that a NP is required to do 800 clinical hours. A FM doc has something like 17000 clinical hours. Huge difference.
Click to expand...

I believe NP's can earn a doctorate certification by doing it online? Don't even need to attend classes. :rolleyes:

Although as one of the attendings pointed out that there were tons of threads about this topic and reassured its not that bigga deal, I feel the current attending are addressing the point from an experienced practitioner who I don't feel have the same challenges ahead of them.

Starting a 3 year residency in july and coming out 3 years down the line who knows what it would be like for the fresh graduate?
 
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Exactly my thoughts, those of us starting residency soon have no idea how things will change in the next 3-4yrs in terms of the autonomy and practice regulations an NP can have. Not just in primary care but in all fields.
 
Doublj01 said:
Exactly my thoughts, those of us starting residency soon have no idea how things will change in the next 3-4yrs in terms of the autonomy and practice regulations an NP can have. Not just in primary care but in all fields.
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and some of us have a couple years before we even start residency...should be an interesting ride
 
Nurses Spar With Doctors as 30 Million Insured Seek Care

Nurse practitioners say they can do their jobs just fine without doctors and they’re lobbying lawmakers to end restrictions in more than a dozen of the 34 states that require physician oversight. Despite the need for increased care, doctors are pushing back, fighting for restrictions with their own lobbying efforts as well as with lawsuits across the country, arguing that patients’ basic care is at risk.
 
Future of medicine? :scared:
1) Do true NP outcome studies
2) Pass institutional policies restricting 'Dr' title
3) Hire PA's & AA's not DNP's or CRNA's

4) Come up with plan to make sure all those people who don't have good access to doctors get that access.

Come on, guys. Let's lead from the front for a change, eh?
 
Blue Dog said:
^ Nothing has changed. NPs weren't the solution then, and they aren't the solution now.

There is no substitute for a family physician. You will have job security for the rest of your life. Family medicine is the ultimate "lifestyle specialty."

There are a zillion threads in this forum about this stuff. Read 'em.
Click to expand...

Blue Dog, I enjoy your posts b/c they give me hope. You have to admit that people do hear a lot of crap about FM. I mean I have had patients and families comment that FM is the low end of the income scale for docs, and people would have to be foolish to go into it. I mean you do hear it everywhere, and at least where I am (Northeast), you see a lot of NP movement and six figure incomes for them.
 
jl lin said:
You have to admit that people do hear a lot of crap about FM.
Click to expand...

So did I, and I graduated from medical school in 1998, historically the peak period of interest in family medicine.

match2011.jpg
 
jl lin said:
Nurse Practitioner Scope of Practice Authority 2012:


http://www.healthaffairs.org/healthpolicybriefs/brief.php?brief_id=79

Scroll down to the Ppt slide of the USA to see all the areas where no physician involvement is needed. Yes, a lot of those states are those with a major shortage and remote places where many don't want to go.
Click to expand...

This state-level map is misleading. The Rocky Mountain region and the Pacific Northwest are highly desirable states where it is relatively easier to recruit MD or DO physicians overall, so long as you're talking about urban areas.

The real divergence is between urban and rural areas. The urban areas in all states are well-supplied with physicians and the rural areas aren't.

We need a more helpful story that explains why NPs can practice independently in Colorado, but not in Tennessee.
 
jl lin said:
Scroll down to the Ppt slide of the USA to see all the areas where no physician involvement is needed. Yes, a lot of those states are those with a major shortage and remote places where many don't want to go.
Click to expand...

Nurses don't want to go there, either. NP "independence" has never solved the primary care crisis anywhere.
 
Doublj01 said:
So blue dog, would you recommend FM to any aspiring medical student with all these changes coming along?
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I've never told anyone that they should go into family medicine. That's a decision that everyone needs to make for themselves. Personally, I think it's the best job in the world.

The "changes coming along" are generally positive for family medicine.
 
BlueDog: you and I have spoken before. I am a long-time PA who has worked in FM and EM. My first love is rural FM.
Please tell us more about the positive changes you see in your crystal ball.
Thanks :)
 
You know you have a great job when everybody else wants to do it. :)
 
Blue Dog said:
You know you have a great job when everybody else wants to do it. :)
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Thanks, but specifics? I'm still a little nervous about committing to any one specialty...the best part about being a PA was that I could change.
 
Pretty broad subject. Feel free to browse through previous threads (there are many).
 
Im sorry but the local mental health hospital affiliated with my hospital is ABSOLUTELY run by NPs; anytime we want to transfer a psych patient to their facility a "Crisis response" member comes over and evaluates the patient. If there is any "medical issues" and this includes dx like ETOH withdrawal, or this was the most ridiculous, the patient required arm restraints, the NPs wont accept them because they are not medically stable. I even talked to a Psych resident about this because it seemed ludicrous that they would not accept the patients - he just shrugged and said, "thats their policy". It seems to me, just what everyone else has mentioned, NPs or "APN"s are in every single field of medicine, and making inroads significantly with their watered down degrees. Oh well, may the best "doctor" win!
 
I always joked that the psych patients, aside from their minds, were the most healthy people I saw during third year...HTN not under perfect control? Medically unstable...
 
Blue Dog said:
^ Nothing has changed. NPs weren't the solution then, and they aren't the solution now.

There is no substitute for a family physician. You will have job security for the rest of your life. Family medicine is the ultimate "lifestyle specialty."

There are a zillion threads in this forum about this stuff. Read 'em.
Click to expand...

I am a FM doc who retrained in anesthesia. Guess what? We are competing against CRNAs. This issue is here and is not going away. As physicians we have to work hard to show the value that we bring. It is no longer enoughto be a physician. We have to bring something substancial to the table. We will survive, but we need to be prepared to work hard.

Find a specialty that you love and throw yourself into it. Do not let the threat of mid levels dictate your choice of specialty.

Cambie
 
CambieMD said:
I am a FM doc who retrained in anesthesia. Guess what? We are competing against CRNAs. This issue is here and is not going away. As physicians we have to work hard to show the value that we bring. It is no longer enoughto be a physician. We have to bring something substancial to the table.
Click to expand...

As I've said before, if you worried that you could be replaced by a mid-level, maybe you should be.
 
One of my attendings said this- at 4:30PM, midlevels will go home even if they screwed up a case and patient needs to be seen immediately in the ER. It is us, physicians who will end up holding the hand of the patient and having to fix the mess into the wee hours. Everyone wants to play doctor wihtout the real responsibility.
 
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