Future of medicine cover story; The New Physician magazine

[Pete T]

For our September cover story, The New Physician magazine is putting together the perspectives of physicians-in-training to get a glimpse of the health-care environment you'll be working in 10 to 15 years down the road.

If you'd like to help and perhaps have your name show up next to several health-care leaders and experts, e-mail me a one to two-sentence prediction: the biggest difference or most significant change in health care or medicine you foresee in the next decade and half. We're open to any perspective.

If you'd like, your response can be restricted to a particular field of medicine, a particular technology or an overall change in the way health care is delivered. Or maybe it's about medical education. Whatever you think could be around the corner. The change need not necessarily be positive or negative.

E-mail me with your name, school (if applicable) and what year you'll be in September. If you include a photo of yourself in your reply, we might print that too. Unless otherwise specified, responses will be considered quotable and on the record. We hope to include several responses in our September cover story, but we expect more than we'll be able to fit in. And our apologies in advance if we can't respond to your predictions in a timely fashion.

If you have any comments, questions or suggestions, send them my way.

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[mshheaddoc]

So our users know, this message has been approved by the SDN Administrators.

 

[rmorriso]

Great idea for an article!

 

[Bleurberry]

Can't wait for the Sept. issue. I hope it comes together well.
I've been wondering about this for awhile now.

 

[Taurus]

My prediction: the dumbing down of medicine we provide to patients through the use of more midlevels such as NP's and CRNA's.

 

[cfdavid]

Taurus makes a good point. While mid-level providers are obviously very important to our healthcare system, we as medical students, residents, and physicians need to be aware of CONSTANT attempts at virtually all mid-level provider lobbying groups to fight for equivalency to an MD/DO.

Please do some of your own research on this matter (much is available on SDN). But, suffice it to say that working as a team with other providers is entirely different from legislating away any differences between physician providers and masters level nurses. Also, remember that teams ONLY work when everybody knows their "position" (i.e. place/limitations). This isn't about other providers being "kept in their place" by egotistical doctors, but simply making sure that everyone's role is as well defined as possible.

Much of the lobbying that goes on by mid-level PACs is behind the scenes, and almost always under the guise of acting soley in the interests of patient access/care. But, I've learned over many years that you really do need to follow the money. In other words, what are the other motives for NPs, or CRNAs etc. to lobby the state and federal legislature for full equivalency to an MD/DO? Just think about it, and come to your own conclusion. Comments are welcome, ofcourse.

Again, teams work best when scope of practice (i.e. positions) are well defined and agreed upon by all.....

My prediction: A possible overshoot of physician supply in many primary care specialties. Specializing will be increasingly difficult as more medical schools increase class size and brand new medical schools come into play. Without proportional increases in residency slots, the vast majority of medical students will have no other option than to do primary care as these tend to be most numerous and accessible. These doctors will then find themselves working within some potentially very blurry lines of demarcation b/t themselves and nurses with a masters degree.

 

[deleted87716]

My prediction: A possible overshoot of physician supply in many primary care specialties.

I wish.

Seriously, things would have to turn around in a big way before there's any chance of that happening.

 

[MacGyver]

My prediction: A possible overshoot of physician supply in many primary care specialties. Specializing will be increasingly difficult as more medical schools increase class size and brand new medical schools come into play. Without proportional increases in residency slots, the vast majority of medical students will have no other option than to do primary care as these tend to be most numerous and accessible. These doctors will then find themselves working within some potentially very blurry lines of demarcation b/t themselves and nurses with a masters degree.

This is SPOT ON. IN some ways this cap on residency slots is a good thing. It will force all these new med school grads to confront midlevels directly in primary care. Maybe that will convince all the "live and let live" fools to step up the fight. If not, they can be happy in their HMO practice making the same amount as an NP with half the training.

 

[Its_MurDAH]

Taurus makes a good point. While mid-level providers are obviously very important to our healthcare system, we as medical students, residents, and physicians need to be aware of CONSTANT attempts at virtually all mid-level provider lobbying groups to fight for equivalency to an MD/DO.

Please do some of your own research on this matter (much is available on SDN). But, suffice it to say that working as a team with other providers is entirely different from legislating away any differences between physician providers and masters level nurses. Also, remember that teams ONLY work when everybody knows their "position" (i.e. place/limitations). This isn't about other providers being "kept in their place" by egotistical doctors, but simply making sure that everyone's role is as well defined as possible.

Much of the lobbying that goes on by mid-level PACs is behind the scenes, and almost always under the guise of acting soley in the interests of patient access/care. But, I've learned over many years that you really do need to follow the money. In other words, what are the other motives for NPs, or CRNAs etc. to lobby the state and federal legislature for full equivalency to an MD/DO? Just think about it, and come to your own conclusion. Comments are welcome, ofcourse.

Again, teams work best when scope of practice (i.e. positions) are well defined and agreed upon by all.....

My prediction: A possible overshoot of physician supply in many primary care specialties. Specializing will be increasingly difficult as more medical schools increase class size and brand new medical schools come into play. Without proportional increases in residency slots, the vast majority of medical students will have no other option than to do primary care as these tend to be most numerous and accessible. These doctors will then find themselves working within some potentially very blurry lines of demarcation b/t themselves and nurses with a masters degree.

I second this.

All of it.

 

[Corona]

Cant wait till nurses try to take over pharmacy also.

 

[cfdavid]

Cant wait till nurses try to take over pharmacy also.

That seems a bit less likely simply due to the fact that they aren't, in most situations, working directly under the supervision of pharmacists. Whereas in medicine, nurses (and NPs) are all over the place, in the same setting.

Also, considering what many of us feel are the REAL motives, NPs and CRNAs already make the same (or even more) to what PharmDs are making. So, why would they be interested in that. No, they want more money. And the only way to do that is to lobby hard for "equivalency" with MD/DOs. That's why they're coming out with 12 month "doctorate" programs like the DNP and DNAP degree.

So, in the future clinic, or hospital, you'll FOR SURE see nurses walking around calling themselves "doctor" (all but the most ethical might say "Hi I'm Sandy, you're doctorate level nurse"..... Who cares? Think about it. Patient confusion, and overlapping scopes of practice aside (so much for "team work"). What this will do is allow those lobbying groups to go back to YOUR states congress to lobby for full prescription rights (already happening) and then full "equivalency" to MD/DOs.

If this sounds benign to you, try reflecting on this on your 79th hour during PGY3.

I'm interested in hearing other thoughts/perspectives.

 

[soonereng]

I'm interested in hearing other thoughts/perspectives.

I doubt that you are truly open to opposing thoughts and perspectives based upon your comments...

Plus this has been beaten to death already. If you missed out on it, just do some searching.

 

[chef_NU]

That seems a bit less likely simply due to the fact that they aren't, in most situations, working directly under the supervision of pharmacists. Whereas in medicine, nurses (and NPs) are all over the place, in the same setting.

Also, considering what many of us feel are the REAL motives, NPs and CRNAs already make the same (or even more) to what PharmDs are making. So, why would they be interested in that. No, they want more money. And the only way to do that is to lobby hard for "equivalency" with MD/DOs. That's why they're coming out with 12 month "doctorate" programs like the DNP and DNAP degree.

So, in the future clinic, or hospital, you'll FOR SURE see nurses walking around calling themselves "doctor" (all but the most ethical might say "Hi I'm Sandy, you're doctorate level nurse"..... Who cares? Think about it. Patient confusion, and overlapping scopes of practice aside (so much for "team work"). What this will do is allow those lobbying groups to go back to YOUR states congress to lobby for full prescription rights (already happening) and then full "equivalency" to MD/DOs.

If this sounds benign to you, try reflecting on this on your 79th hour during PGY3.

I'm interested in hearing other thoughts/perspectives.

As much as I hate to say it, this is tough medicine that medical students and doctors need to face before they will actually decide to do anything about it. Certainly you can't believe that medical school and residency is the best or most efficient way to train people capable of delivering high quality medical care. I'm a medical student and I'll freely admit that. The fact of the matter is that there are other, faster, and better ways to train people, and mid-level practicioners are a nod in this direction. Medical school and residency is in reality a set of hurdles set up to give people monopoly on the health care market, which is silly. Whine all you want about "safety" of patients, but this is really what doctors' lobbying groups care about (and rightly so, they have invested so much).

Conclusion: mid levels will continue to have a greater and greater influence especially in primary care, and make medical school and residency less desirable fields. Of course, lobbying groups will make an effort to stop this, but it will happen. End result: becomes extremely undesirable to go through the bull**** to get an M.D. and licensing fails because it buckles under its own stupid hurdles. People stop wanting to apply to get an M.D. Yes, this will take a while, but just wait. The nostalgia of the "good doctor" that people respect and sometimes awe will go out the window. Ultimately, this will be good for health care.

 

[cfdavid]

I doubt that you are truly open to opposing thoughts and perspectives based upon your comments...

Plus this has been beaten to death already. If you missed out on it, just do some searching.

That's not true. I respect and am open to other's points of view. My views are not so rigid that I'd be opposed to modifying them based upon different perspectives.

 

[soonereng]

That's not true. I respect and am open to other's points of view. My views are not so rigid that I'd be opposed to modifying them based upon different perspectives.

So did the quote below sway you at all?

Certainly you can't believe that medical school and residency is the best or most efficient way to train people capable of delivering high quality medical care. I'm a medical student and I'll freely admit that. The fact of the matter is that there are other, faster, and better ways to train people, and mid-level practicioners are a nod in this direction. Medical school and residency is in reality a set of hurdles set up to give people monopoly on the health care market, which is silly. Whine all you want about "safety" of patients, but this is really what doctors' lobbying groups care about (and rightly so, they have invested so much).

 

[Taurus]

I think that training physicians can be made more efficient and be done in less time. But no one would agree that midlevels are a wholesale replacement for physicians. There is only so much you can learn in a 2 year program. Furthermore, with medical school, you have the brightest of the brightest going through many grueling years of training. With most midlevel programs, you have much weaker students who want part-time and online programs and be done in 2 years. Honestly, most of these students wouldn't be able to hack it through pre-med classes which is why most don't get into medical school. Please tell me how the quality of care won't be impacted for the worse if we relied more on midlevels. If anything, they will drive up costs by ordering unnecessary tests and physicians fixing their mistakes. If midlevels truly want independence, let them also take full legal responsibility and the consequences that go with it. Insurance carriers and lawyers would have a field day if your vision came true.

 

[soonereng]

Please tell me how the quality of care won't be impacted for the worse if we relied more on midlevels. If midlevels truly want independence, let them also take full legal responsibility and the consequences that go with it. Insurance carriers and lawyers would have a field day if your vision came true.

All preconceptions of the quality of students aside (being a good test taker does not a good healthcare provider make), the government did a study on NPs and PAs and concluded that for the cases studied (primary care), the treatment and outcome was equal to or better than that of physicians (I'm too lazy to get a link but I've posted it on SDN before). There have also been several other studies with the same conclusion.

I don't remember having stated a vision in this thread, but in my state NPs DO practice under their own license, with their own malpractice insurance, and lawyers haven't had a "field day." Not that this is the case everywhere though.

People have the preconceived notion that all the things done in the physician training process are necessary to make truly competent healthcare providers. What if only 1/3 of the basic science material were really necessary to be a good clinician (not a researcher)? You could easily fit this into a 2 year program. Kind of like a PA or NP program. Just food for thought.

In almost every industry employers want people with on the job experience. Why? Because this is where much of the real training is done. PAs, NPs, etc. get out in the field in 1/2 the time as physicians. Giving them more real world experience more quickly. Some of the top medical programs seem to be moving this way by cramming the BS into less time to get into rotations faster (Baylor comes to mind specifically).

I don't think that anyone would argue that midlevels are trained to the same level or content as physicians. The question that remains however, is this: is the physician training duration, content, methodolgy, etc. actually necessary to produce competent healthcare providers. I think that chef_NU hit on some of the real underlying issues as to why we won't be seeing broad physician training changes in the near future.

 

[Taurus]

Let me guess. You're another midlevel, most probably an NP because they seem to have the biggest inferiority complexes, who has come onto a medical board telling us how these great studies paid for by midlevel groups published in midlevel journals are so convincing. Midlevels, by their limited training, do fine when under supervision by a physician. Midlevels do fine in primary care because most the cases are bread and butter. But I don't think that midlevels want just primary care. It's the same reason why the specialties are more attractive to medical students. The money is in the specialties, not primary care. If the midlevels think that the doctors are going to let them into the specialties, they better think again. I honestly think that the nicest people and people who want to just help people in medical school go into primary care. The really competitive people go into the specialties and how do you think they will respond with midlevel groups trying to take a piece of their turf? Turfwar is nothing new. Physician groups take work from each other all the time. All physician groups have been watching what's happening to the CRNA's and NP's. How are the anesthesiologists responding to the CRNA threat? They're getting AA legislation passed in more and more states. How do you neutralize NP's? You replace them with PA's. There are even incipient radiology midlevel groups. The radiologists are already laying down plans to make sure that radiology doesn't become another anesthesiology.

Honestly, I think that it's stupid that the midlevels are agitating the physicians. The physicians have more respect with the public, more political clout, and more sway over hosptial policies. If we truly feel threatened by midlevels, we'll crack down on you guys hard. We have a full arsenal at the ready. The public and lawmakers do not view midlevels as being equivalent to physicians. Most of the public don't even know what a midlevel is! You guys should find a way so that everyone is still happy at the end of the day.

I can already see backlash forming. When I first posted about CRNA's in the anesthesiology forum 3 years ago, I got many responses saying that they weren't a problem and I'm just overstating the problem. Go over there now and it's a total 180. With the DNP, there will be a backlash among other physician groups. The DNP will become a symbol that physicians can all relate to and have a common cause. Just by us having this little discussion is raising awareness. So keep it up.

 

[soonereng]

Let me guess. You're another midlevel, most probably an NP because they seem to have the biggest inferiority complexes, who has come onto a medical board telling us how these great studies paid for by midlevel groups published in midlevel journals are so convincing.

Sorry to disappoint you, but I'm a medical student. No inferiority complex stemming from midlevel training for me.

So we shouldn't rely on government or midlevel studies, but we should rely on propaganda from groups with even more financial incentive to keep the status quo? Sounds pretty hypocritical.

Again all you are talking about is the money. You haven't even addressed the training issues that I was talking about. But I tire of these games, both of us sounding like a broken record and all. I will leave you to your propaganda.

 

[LJDHC05]

I'd have to agree with the above statements. With the climate of the private insurance/medicaid/medicare reimbursement system that is currently so firmly in place, I think we're definitely going to see midlevels playing an increasing role in the Primary Care fields, simply as a profit maximization measure. Lets face it, you can squeeze the same amount of money out of a patient for their office visit to a mid-level, but you can reimburse a non-MD at a lower cost because they're not an MD. Unfortunately, this process would happen at an even faster rate if we had a national health care system because the government would be looking for any way to cut costs as much as possible to keep their program afloat...which is why I'm against an entirely governmentalized health care system...but that's another topic for another time.

I think the point that hasn't been mentioned is that they will play an increasing role in the hospital setting as well, again as a hospital cost-saving/ profit-maximizing measure. There are already PA's doing large portions of surgeries in non-academic medical settings (basically playing the role the intern/resident in opening and closing the patient), and there are NP's/PA's running the fast track portions of many trauma centers. Again, with a national health care system this would happen to a further extent.

What does that mean for us? The increasing numbers of physicians trained in the future, with our breadth/depth of training, will be chased into even further specialized fields of medicine to make a living. This will necessitate even longer training times and more basic science material being incorporated into the pre-clinical years. American graduates will begin to push some of the better foreign physicians out of the NRMP, to fill up our residency programs with more of us, therefore increasing the cost of health care due to the astronomical costs of US medical training that need to be repaid. Ultimately, with the further specialization of physicians, we'll end up keeping sicker people alive for even longer periods of time instead of addressing the root causes of the newest scourges of the western heath, thus continuing the upward-spiraling trend of medical costs. I don't predict that there will be a great solution to the American Health Care Crisis in the next 15 years either, and the nightmare of working in American health care will continue.

 

[cfdavid]

All preconceptions of the quality of students aside (being a good test taker does not a good healthcare provider make), the government did a study on NPs and PAs and concluded that for the cases studied (primary care), the treatment and outcome was equal to or better than that of physicians (I'm too lazy to get a link but I've posted it on SDN before). There have also been several other studies with the same conclusion.

I don't remember having stated a vision in this thread, but in my state NPs DO practice under their own license, with their own malpractice insurance, and lawyers haven't had a "field day." Not that this is the case everywhere though.

People have the preconceived notion that all the things done in the physician training process are necessary to make truly competent healthcare providers. What if only 1/3 of the basic science material were really necessary to be a good clinician (not a researcher)? You could easily fit this into a 2 year program. Kind of like a PA or NP program. Just food for thought.

In almost every industry employers want people with on the job experience. Why? Because this is where much of the real training is done. PAs, NPs, etc. get out in the field in 1/2 the time as physicians. Giving them more real world experience more quickly. Some of the top medical programs seem to be moving this way by cramming the BS into less time to get into rotations faster (Baylor comes to mind specifically).

I don't think that anyone would argue that midlevels are trained to the same level or content as physicians. The question that remains however, is this: is the physician training duration, content, methodolgy, etc. actually necessary to produce competent healthcare providers. I think that chef_NU hit on some of the real underlying issues as to why we won't be seeing broad physician training changes in the near future.

F. ck it I agree with you 100%. Let's do away with clinical MD/DO's and have midlevels handle all cases. Let the PhD's in the specific sciences dictate new knowledge and have the DNP/DNAPs impliment it to the clincial setting. Let's eliminate MD/DO programs as clearly thery'er irrelivent. Then, costs will decrease, and all will be good.

 

[gro2001]

I study at Cornell Medical College's Qatar campus. Some of you may have heard of it as the first US med school to opena branch camppus over seas. The medical program is identical to the NY one, but there is an innovation in the premed program: instead of 4 years to complete your degree, you go through two years in which you take all the premed courses with few humanities. You dont get a degree at the end of this premed program, but if you get into med school you get to be a doctor in 6 years. I understand there are obvious advantages to completing a degree before going onto med school, but in light of the economical pressures from the midlevelers, is it possible that more med schools will adopt this approach in the future?

 

[soonereng]

F. ck it I agree with you 100%. Let's do away with clinical MD/DO's and have midlevels handle all cases. Let the PhD's in the specific sciences dictate new knowledge and have the DNP/DNAPs impliment it to the clincial setting. Let's eliminate MD/DO programs as clearly thery'er irrelivent. Then, costs will decrease, and all will be good.

See I told you I didn't think you were really open to opposing views....

 

[cfdavid]

See I told you I didn't think you were really open to opposing views....

I'm not going to get into a b..tch fest with you on the internet. Clearly you have some time on your hands to go back to one of my OTHER posts and take one sentence (of which you clearly missed the sarcasm) out of many as a weak attempt at taking things out of context.

But, wait, soonereng, you still haven't answered the OP's question. What's YOUR prediction? What do YOU think? Don't continue taking the easy way out by not making a statement of your own, but rather critiquing those of others. Stop being a weak "passive observer" and step up to the plate. What are your thoughts on this? Please enlighten us all.

 

[gro2001]

In any case, the market will eventually decide.

Adam Smith and the Invisible Hand are DEAD I tell you!

 

[cfdavid]

I am a graduated doctor. I often laugh at the indignation of MDs who wring their hands about midlevels invading their territory. "How can they do this when they only go to school for 2 years?" Perhaps the question is better reframed as, "Why do they present on so much crap in medical school that it takes 4 years?" In any case, the market will eventually decide.

Hey, great idea. The volume of medical information has increased almost exponentially over the past decade. So, let's dilute medical training!! Great idea. I understand you may be a bit embittered, but that doesn't make it the correct thing to implement. There are already diluted/expedited forms of clinical training. They're called PA and NP.

Also, getting back on topic. The original article posted had much to say about teamwork. And, I stand behind my statement that teams only work when all members know their role (and limitations in training). So, perhaps the doctors you mention whom "wring their hands" are doing so out of frustration, as part of a team whos members DON'T know their role, thereby leading to a disintegration of the team.

 

[soonereng]

I'm not going to get into a b..tch fest with you on the internet. Clearly you have some time on your hands to go back to one of my OTHER posts and take one sentence (of which you clearly missed the sarcasm) out of many as a weak attempt at taking things out of context.

Not trying to get into a b!tchfest with you. I got the sarcasm in the post I quoted...it was exactly this sarcasm that proved my original statement regarding your open-mindedness, but whatever.

But, wait, soonereng, you still haven't answered the OP's question. What's YOUR prediction? What do YOU think? Don't continue taking the easy way out by not making a statement of your own, but rather critiquing those of others. Stop being a weak "passive observer" and step up to the plate. What are your thoughts on this? Please enlighten us all.

I actually did make a prediction of my own (see below), just not in your format; so, to appease you, here goes: In the area of physician training we won't see any significant changes even though they are definitely needed. This lack of change will be truly shocking to future generations in retrospect as access to healthcare by physicians diminishes and costs continue to skyrocket to cover the inefficiencies and needless expense of the physician training system.

I think that chef_NU hit on some of the real underlying issues as to why we won't be seeing broad physician training changes in the near future.

 

[cfdavid]

Medical school is an extreme of sorts. I'm just about to enter my 2nd year. We've had 10 weeks total off this summer. That's ridiculous, and yes, inefficient. You could argue that 4th year could be more productive as well, from what I'm told. So, yeah, perhaps med school could be more efficient.

As for residency, regardless of the scutwork of varying degrees, I think it's imperitive for freshly minted MD/DOs to learn on the job, under the direction of an attending. We'd all want that for our family members (and hopefully, patients at large).

So, it is perfect? No. But, I stand behind what I consider a fact that mid-level training in no way compares to the training of a physician. There's a big difference. And, let's not forget that they have inefficiencies of their own.

Ever see the required courses to obtain a DNAP?? A joke, really.

 

[PriorityMed]

Medical school is an extreme of sorts. I'm just about to enter my 2nd year. We've had 10 weeks total off this summer. That's ridiculous, and yes, inefficient. You could argue that 4th year could be more productive as well, from what I'm told. So, yeah, perhaps med school could be more efficient.

As for residency, regardless of the scutwork of varying degrees, I think it's imperitive for freshly minted MD/DOs to learn on the job, under the direction of an attending. We'd all want that for our family members (and hopefully, patients at large).

So, it is perfect? No. But, I stand behind what I consider a fact that mid-level training in no way compares to the training of a physician. There's a big difference. And, let's not forget that they have inefficiencies of their own.

Ever see the required courses to obtain a DNAP?? A joke, really.

CF, I think that you might have hit on something quite interesting. It seems that many midlevels (CRNAs especially) are arguing that they've had enough "real world" or "in the field" experience to make them as good or better in some instances than their MD/DO counterparts. I have a feeling that if this type of situation continues and socialized medicine is enacted in some form or another we may be seeing medical education modeled after the pre-Flexner report medical schools of old which were essentially apprenticeships. This would alleviate the "on the job" training requirements, and hopefully but not definitely the training requirements from practitioner to practitioner, program to program, would be the same.

As for the training under an attending, I'm certain there would be financial incentives in place for attending physicians, NPs, PAs, etc. to train these new healthcare providers under a government system. Those that didn't train the new providers would be at a significant financial disadvantage is my gut feeling.

At the beginning of the summer I would have wrung your neck for suggesting 10 weeks was too much of a break, but now I'm chomping at the bit to get back in class. See you in two weeks dude!

 

[Taurus]

Anyone who thinks that the physicians are going to just welcome midlevels as one of their own is simply naive. The battles are going on right now and I don't see physicians raising the white flag. Somes battles we win, some we lose. At the end of the day, you have to ask yourself what the public and lawmakers want: more midlevels or more physicians. It's more physicians. I read those studies comparing MD vs midlevel care. Sure, the care is equivalent when it is subacute and straight-forward. What happens if the case is more complex? Sure, the patient is more satisfied because the midlevel spends more time with them. If an NP is busy operating a clinic, they won't have any more time than a physician to spend with the patient. I've also heard of lots of anecdotes where the NP just doesn't know what they're doing. With just 2 years of training and then throwing them into the trenches, is anyone really surprised? So you want midlevels to gain experience by on-the-job training. You better hope you're not a training case for the midlevel. That's why midlevels need to be supervised.

Here's a trick question: why are CRNA malpractice premiums 1/10th of an anesthesiologists? If CRNA's claim to provide the same level of care as physicians, why shouldn't the premiums be at least equal? Maybe it's because the insurance carriers are still assuming that CRNA's work under the supervision of an anesthesiologists? When something goes wrong, who does the midlevel try to point to for responsiblity? It's the physician. Why do you think that lawyers go after the physician? Because they think we have deeper pockets.

If midlevels truly want independence and function like a physician, the free market will shake things out. Insurance carriers and lawyers will wake up to the new reality and things will readjust accordingly. The consumer will decide how they want to spend their healthcare dollars. If you're paying the same copay, would you want a midlevel or a physician?

And no, socialized medicine isn't coming to this country any time soon, even with Hilary. We will simply expand Medicare.

After a while, this gets a little repetitive and I get tired of having to rehash my arguments.

 

[soonereng]

So you want midlevels to gain experience by on-the-job training. You better hope you're not a training case for the midlevel.

Umm...the same could be said for any PGY1. Having an attending overseeing training is the same in either case. Again, in most industries the more experienced people train the less experienced, but in medicine this process is highly institutionalized in order to keep the labor force numbers down intentionally, thereby artificially controlling the supply regardless of demand. Just think about the rediculousness of the whole process: 2 yr of basic sciences, 2 yrs of rotations, 3-7 yrs of residency. It's all about keeping the dollars in the fewest hands possible. Even your own arguments are financially based rather than productivity based.

The problem is that the supply has been kept down for so long, the market is finding other ways to supply a sufficient (even if it is inferior) product. That's really what this all boils down to. The physician training process is screwing itself.

After a while, this gets a little repetitive and I get tired of having to rehash my arguments.

I already said we were sounding like broken records.

 

[cfdavid]

CF, I think that you might have hit on something quite interesting. It seems that many midlevels (CRNAs especially) are arguing that they've had enough "real world" or "in the field" experience to make them as good or better in some instances than their MD/DO counterparts. I have a feeling that if this type of situation continues and socialized medicine is enacted in some form or another we may be seeing medical education modeled after the pre-Flexner report medical schools of old which were essentially apprenticeships. This would alleviate the "on the job" training requirements, and hopefully but not definitely the training requirements from practitioner to practitioner, program to program, would be the same.

As for the training under an attending, I'm certain there would be financial incentives in place for attending physicians, NPs, PAs, etc. to train these new healthcare providers under a government system. Those that didn't train the new providers would be at a significant financial disadvantage is my gut feeling.

At the beginning of the summer I would have wrung your neck for suggesting 10 weeks was too much of a break, but now I'm chomping at the bit to get back in class. See you in two weeks dude!

First, good points on the above PriorityMed. One of the recent posters here seems to think the institutional changes of the Flexnor report were for naught...... Well, I think they're important!

Second, I TOO would have considered myself crazy thinking 10 weeks was too much. Especially as I walked out of that last Neuro exam....lol

I just may make an appearance on the 25th as well. I'll call you.

 

[cfdavid]

So do you propose that the length of training explode exponentially to keep pace with the explosion of information? Obviously, this is untenable because nobody will be able to be proficient at everything. At some point you have to divide the work.

And, since when are roles written in stone? It seems that many of these questions could be tested empirically (e.g. can nurses competently perform task X that was previously performed only be doctors) rather than resorting to fossilized notions of roles and job boundaries. Perhaps this should be decided by competence rather than degrees.

No, but it shouldn't be SHORTENED for physicians. The two years of basic and pathologic sciences only serve to provide us with a strong foundation. Sure, science with evolve. That's part of the challenge of medicine. But, in order to properly interpret new science or research, you NEED the foundation.

And it's exactly that foundation in the sciences that most mid-levels lack. Sure, they get some, but it's not comparable. As for separation of duties, we have that already it seems.

Again, don't be fooled by the real motives of NPs and CRNAs striving to create "doctoral" level candidates within their own ranks. And, like a broken record, I'll restate that their drive for near equivalency is already happening (like Taurus said as well). It's not about patient care, but rather greed, and in some cases an inferiority complex.

 

[Taurus]

Umm...the same could be said for any PGY1. Having an attending overseeing training is the same in either case.

It's not the same. A PGY1 is supervised by an attending and there is a whole team. In some states, an NP with just 2 years of training can go out and practice without supervision or remote supervision. What is even scarier that for some midlevel groups (CRNA's) more than 50% of their members don't even have college degrees because they were grandfathered in. You will meet many NP's who don't have one either. Midlevels are told to know their limitations and the idea is that they can do 80% of what a physician can do. But quite a few, I suspect, like to think of themselves as being equivalent to physicians and don't know their limitations. We're letting midlevels do their training on the unsuspecting public without proper supervision.

Everytime I tell people the differences between midlevel and physician training (assuming they even know what a midlevel is), they're shocked and swear they will in the future make sure the provider has an MD or DO behind their names. If you're paying the same amount of money, which one would you choose? The free market will determine the outcome and I wouldn't underestimate the average consumer. The only time I hear people wanting a midlevel is because they're faster with appointments for simple things (annual physical, ear ache, common cold). That's why you see NP's staffing the clinics at Wal-Mart, CVS, etc. Anything more serious, the consumer demands a physician. Midlevels can compete with physicians if they offer faster appointments or lower prices. But if the midlevel and physician charge the same prices, the consumer isn't stupid.

Have more confidence in the medical establishment. Our arsenal is far bigger and deeper than any midlevel's. We have the respect and support of the public and policymakers. Sure, there's a medical crisis looming. I predict that will mean salary cuts across the board for all healthcare professionals, but not huge scope expansion of midlevels so that they gain equivalence with physicians. The AMA has asked schools to increase class sizes by 20%. This will help with the physician shortage problem.

To prevent midlevels from expanding their scope, physicians should be aware of their attempts. The advanced nursing groups such as the NP's and CRNA's are the most active. The CRNA's national organization comes out and says they're just as competent as anesthesiologists. The nurses have created a doctorate for themselves called the DNP. How soon will have a nurse in a long white coat going around introducing themselves as "doctor" to patients? Sooner than you think. We can thwart these attempts by supporting midlevels who fall under the board of medicines of each state such as AA's and PA's. It is dangerous to give monopoly power to any one midlevel group as we have see what can happen with anesthesiology. They will abuse that power to gain more scope for themselves. What's the motive? It's pretty much human nature to want to make more money and "be your own boss". Having multiple groups who occupy the same role will serve to act as counterbalances to each other. If one group acts up, we replace them with another group.

 

[MeowMix]

I wish the New Physician would do more substantive research than post on SDN every time it wants material for stories.

I've pretty much stopped reading the feature articles because they lack substance. There's usually plenty of real data and info that could be incorporated, but that would definitely take more time and effort. I'd challenge the NP writers and editors to actually do some research, instead of churning out another mediocre, unbalanced article featuring a tiny sample of the med student/resident/physician population.

And, having our quotes next to those of the "experts" also does not constitute meaningful investigative research or a balanced perspective.

 

[Sir Buckethead]

what are you talking about meowmix? this thread is about MD vs NP!

 

[Nodelphi]

I wish the New Physician would do more substantive research than post on SDN every time it wants material for stories.

I've pretty much stopped reading the feature articles because they lack substance. There's usually plenty of real data and info that could be incorporated, but that would definitely take more time and effort. I'd challenge the NP writers and editors to actually do some research, instead of churning out another mediocre, unbalanced article featuring a tiny sample of the med student/resident/physician population.

And, having our quotes next to those of the "experts" also does not constitute meaningful investigative research or a balanced perspective.

I totally agree with this.

In any case to contribute: I predict that in the next decade or so Physician salaries will decline, the cost of medical school will rise, and enrollment in medical schools will eventually suffer as it will make less and less sense to go to medical school. We'll start importing more and more doctors from overseas.

The media will catch on and hype up the fact that fewer and fewer people want to become doctors but tout the heroic efforts of midlevels trying to fill the deficit.

 

[cfdavid]

I totally agree with this.

In any case to contribute: I predict that in the next decade or so Physician salaries will decline, the cost of medical school will rise, and enrollment in medical schools will eventually suffer as it will make less and less sense to go to medical school. We'll start importing more and more doctors from overseas.

The media will catch on and hype up the fact that fewer and fewer people want to become doctors but tout the heroic efforts of midlevels trying to fill the deficit.

Agreed. I remember reading an article (can't remember where, but it was "mainstream" ) that stated how with increasing costs of medical education, we may well go back to the days where only the truly privilidged could afford to attend. We don't want that.

If the public signs on to massive tax increases necessary to offer "free" medical coverage for 300 million Americans, hopefully (at the very least) we'd see federal (through those taxes) subsidies of medical education costs and/or debt relief. But, that seems like a pipe dream....

 

[mshheaddoc]

Just got this on my AMSA listserve:
********************************************************
We're wrapping up our future of medicine cover story for TNP's September issue, so if you'd like to make a prediction, now's the time!

By 5 p.m. Sunday (July 15), e-mail us a one to two-sentence prediction: the biggest difference or most significant change in health care or medicine you foresee in the next decade and a half. Please include your full name, school (if applicable) and what year you'll be in September. And, if you can, include a photo of yourself. It might end up on the cover!

Unless otherwise specified, responses will be considered quotable and on the record. We hope to include several responses in our September cover story, but we expect more than we'll be able to fit in. And our apologies in advance if we can't respond to your predictions in a timely fashion.

Thanks!

Pete Thomson
associate editor, The New Physician magazine

 

[Coastie]

I hope to see less government regulation, intervention, and overall control in the next 10 to 15 years.

I hope to see a decrease in the "universal health care" schemes currently being thrown onto medicine by underqualified and over-hyped public health and political types who know as much about medicine as my gastric bypass cousin knows about working out.

I hope to see free market solutions injected into the equation, and I certainly hope to see less commie/hippie training amongst medical schools which is nothing more than an excuse for half the faculty to draw a paycheck.

 

[banana5]

-

 

[Taurus]

Basically, if NPs/CNAs/whatever are such a panacea, why haven't they been implemented to a large degree elsewhere?

To understand the midlevel issue, you have to understand how medicine is regulated in this country. Medicine is regulated by each state by their Board of Medicine. That's why you have to be licensed in the state you work in. Each state defines the scope of its practitioners. If a midlevel group organizes, creates a PAC, and hires lobbyists, they can expand what they can do, not by their training, but by legislative changes. How do you think CRNA's and NP's got the right to basically practice medicine independently without a medical license in certain states? Politicians are not healthcare experts and if you can make a reasonable argument and donate to their reelection funds you can usually get your way. Furthermore, NP's and CRNA's are regulated by the state's Board of Nursing. The nurses are actively trying to invade the physician's role and gain equivalence. That's why I support midlevel groups which fall under the Board of Medicine. Physicians are still in control of their future by whom they choose to hire as assistants. In the future, I will have a hiring preference for PA's, AA's, etc. The AMA is taking the issue of the DNP very seriously.

Many groups have been inspired by their examples and many want in on the action too. What is the most absurd group I've heard? Ultrasound techs, the vast majority of whom have associate's degrees, want the right to diagnose (yes, diagnose) medical conditions and then bill for them independently like NP's. Read all about it:

http://www.sdms.org/career/upinfo.asp

In socialized medicine Canada, why aren't CRNA's allowed to practice independently? Because their healthcare system is organized at the federal level so it's much harder to change laws by lobbying politicians. The govt there understands that it is unsafe to unleash an unsupervised group on the public who have minimal training.

 

[Coastie]

Ultrasound Practioner?

That's so laughable I don't know where to start.

I guess it's not surprising given the recent trend of everyone and their mother trying to be doctors without going to medical school.

But, in the end, it's really the oldest trend of all: jealously, greed, and pride.

 

[stunna8]

I hope to see less government regulation, intervention, and overall control in the next 10 to 15 years.

I hope to see a decrease in the "universal health care" schemes currently being thrown onto medicine by underqualified and over-hyped public health and political types who know as much about medicine as my gastric bypass cousin knows about working out.

I hope to see free market solutions injected into the equation, and I certainly hope to see less commie/hippie training amongst medical schools which is nothing more than an excuse for half the faculty to draw a paycheck.

Could not agree with this more.