Future of Team-Based Healthcare and Degree Dilution

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Walter Lance said:
This already exists - DMA, PsyD, EdD, etc.
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DMA's are meant for people planning on composing or performing, not people hoping to teach or study music theory. They're not the same thing and is like comparing someone with a PhD in microbiology to a physician who specializes in ID. They're in the same general field of study, but traditionally have two completely different implications. Same thing with your EdD example, that's like comparing physicians to hospital administrators. Your PsyD example is more apt, though the few people I know with PhDs in Psychology don't give much credence to the Psy D degree outside of the realm of treating patients and have said they wouldn't hire a Psy D for a research position.

Goro said:
If they're turning out good Science, it doesn't matter.
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The point @ChrisMack390 was making is that they're not turning out science themselves. They're piggy-backing off the knowledge and skills of others then claiming the work as their own. We're also not talking about someone doing 5 or 10 years of research as an assistant. We're talking about someone working in a lab for a semester or a year, being 4th or 5th author on 1 or 2 papers, then claiming that their credentials are equal to that of a PhD. It's not "good science", it's fraud.
 
Walter Lance said:
One can get a DMA in (insert instrument here), which can take less time than say a PhD in music theory or musicology and doesn't really require any research, and go on to teach music theory, conducting, musicology courses etc., and become tenured. One can get a PsyD, which is easier than getting a PhD in clinical psychology and often doesn't require any original research and can be obtained in less time. PsyDs have the same practice privileges as clinical psychologists with a PhD, can teach, run labs, and become tenured in what previously used to be PhD only positions... I could go on with other examples, but the point should be clear.

This is exactly what you described in the post of yours to which I first responded.
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Those people are not supplanting PhDs for a lower salary as part of a corporate cost saving policy. This also explains in part why the job market is crap for PhDs outside of the hard sciences, and it is unfortunate that people with less knowledge of a field are educating the next generation rather than those with more knowledge.
 
Stagg737 said:
DMA's are meant for people planning on composing or performing, not people hoping to teach or study music theory. They're not the same thing and is like comparing someone with a PhD in microbiology to a physician who specializes in ID. They're in the same general field of study, but traditionally have two completely different implications. Same thing with your EdD example, that's like comparing physicians to hospital administrators. Your PsyD example is more apt, though the few people I know with PhDs in Psychology don't give much credence to the Psy D degree outside of the realm of treating patients and have said they wouldn't hire a Psy D for a research position.



The point @ChrisMack390 was making is that they're not turning out science themselves. They're piggy-backing off the knowledge and skills of others then claiming the work as their own. We're also not talking about someone doing 5 or 10 years of research as an assistant. We're talking about someone working in a lab for a semester or a year, being 4th or 5th author on 1 or 2 papers, then claiming that their credentials are equal to that of a PhD. It's not "good science", it's fraud.
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It's more like having a freshman who got a C- in online Biology 101 and lab becoming a full professor as a sophomore
 
W19 said:
You have been a big defender of the degree creep in our higher education system... hence I thought someone in your close circle is a NP...
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A lot of the public support for NPs is based on the archaic conception that nurses are God's servants and doctors are money-Grubbing devils. It also has to do with the fact that since any ***** can become a nurse, that many people have a family member who is a nurse and have discussed the idea of becoming an NP with their loved ones or have become one.
 
Question for you physicians and med students. When an NP practices autonomously, do they assume full medical liability and are they required to carry the same malpractice insurance as any MD with similar scope of practice?
 
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When a nurse performs surgery autonomously there will be no such thing as medical liability, insurance will no longer exist, and every physician and medical student will have immigrated to another more developed country that isn't devolving into an unemployed obese, diabetic, foot ulcer with five dependents.
 
SansaStarkMD said:
When a nurse performs surgery autonomously there will be no such thing as medical liability, insurance will no longer exist, and every physician and medical student will have immigrated to another more developed country that isn't devolving into an unemployed obese, diabetic, foot ulcer with five dependents.
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I didn't literally mean "operates", I edited and changed to "practices" instead.
 
The comparisons to PhD are getting off topic, as the "gap" is much larger.
4 Undergraduate--> 4 Medical school --> 3-7 residency = Physician
4 BSN (I'm assuming it's not just RN) --> 2 DNP (apparently it can be done in 12 months) = gap bridged
4 Undergraduate --> 2 PA --> 2 (part time) DMS = gap bridged

If one calculated hours, let alone hours and level of rigor, rather than calendar years it would be much more startling.
 
wxman393 said:
Where are NP's allowed to intubate? I'm not talking about the CRNA that has a DNP or what not. Are there NP's in emergency departments that have privileges for advanced airway management?

I will say that while I was working as a medic in NY, we had an NP as med control (not the only one but when he/she was on, we got orders directly from him/her). This was the same NP that attended one of my ACLS refresher classes and kept defibrillating asystole.




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Not sure if it is the norm but I work in an ICU with only NPs at night. They intubate, place lines, run codes, etc. During codes a hospitalist will typically stick their head in for a minute and make sure nothing is needed and leave.
 
Yet when push comes to shove, the NPs call the doctors.

More than once, while on call, I've fielded pages from the NPs who work in the hospital; they page me to their home phone number, because they can, and describe their relative/friends post op condition over the phone so we can "check on them" because they don't trust their own judgement.

But you know, NPs can do the same things Drs. can.
 
Mad Jack said:
America is the only nation in which we believe that patients do not deserve the treatment of a fully-trained physician. Other nations find ways to train more doctors, while in America we say, "oh, someone with adequate training is just too much for you to need."
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Off the top of my head the following nations use PAs, NPs, or their equivalent: Canada, UK, Australia, New Zealand, Israel, India, Liberia, South Africa, China, Japan, Malaysia, Holland,
also see this: https://en.wikipedia.org/wiki/Clinical_officer (22 nations , mostly in Africa that use non-physician providers).
 
Mad Jack said:
America is the only nation in which we believe that patients do not deserve the treatment of a fully-trained physician. Other nations find ways to train more doctors, while in America we say, "oh, someone with adequate training is just too much for you to need."
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This is truth.

If someone thinks NPs or PAs can provide the same quality care as MD/DO then either the training of physicians is completely unnecessary in length and intensity or they're wrong. It is either our training is over kill or NPs/PAs can not deliver the same level of care to the patients and you are just ok with "good enough". Mid-levels have their place in a healthcare team and can be very valuable, but the notion that they can do the same things as an attending is wrong. Referring to themselves "doctor" in a setting where they are administering care is highly misleading to the patient and is wrong.
 
kamakazi5 said:
Not sure if it is the norm but I work in an ICU with only NPs at night. They intubate, place lines, run codes, etc. .
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not that uncommon. PAs and NPs solo staff many rural emergency depts. without a physician on site. I have 2 such jobs. Recently I have intubated 18 times, run 3 codes, cardioverted 3 times, etc
 
emedpa said:
Off the top of my head the following nations use PAs, NPs, or their equivalent: Canada, UK, Australia, New Zealand, Israel, India, Liberia, South Africa, China, Japan, Malaysia, Holland,
also see this: https://en.wikipedia.org/wiki/Clinical_officer (22 nations , mostly in Africa that use non-physician providers).
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Alright, so we've got Commonwealth countries, Africa, and Japan. Few first world nations engage in the practice, and most that do engage in it on a much more limited basis than the United States.

I'm not against PAs or NPs, but it would be preferable to have physicians if we could afford to do so.
 
emedpa said:
I have a doctorate and I agree with you on this point. I'm only Dr Emedpa when I teach or write articles, never in a clinical situation.
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But what if you say: 'I am Dr. emedpa, and I am your Physician Assistant'. What's wrong with that?
 
W19 said:
But what if you say: 'I am Dr. emedpa, and I am your Physician Assistant'. What's wrong with that?
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it would confuse folks. you don't need to be confused when you come to the hospital. My name tag says PA, DHSc. if someone asks what DHSc is I explain I have an academic doctorate in global health.
 
emedpa said:
not that uncommon. PAs and NPs solo staff many rural emergency depts. without a physician on site. I have 2 such jobs. Recently I have intubated 18 times, run 3 codes, cardioverted 3 times, etc
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And there's the key word. I don't have a problem allowing NPs or PAs full autonomous practice if there aren't physicians readily available, but putting someone with inferior training in charge when there are better options is just silly (especially when we're talking about something as important as a person's well-being).
 
Screw the old titles. I will be referred to as grand master stark, after I complete some unaccredited coursework of course. I'm not trying to be phony.
 
For the record, I'm not degrading those who practice in healthcare and also have achieved an academic doctorate like @emedpa but rather degrees that are masters level achievement being renamed a doctorate for superfluous or malicious reasons.
 
Re. foreign physicians:


Nominally, but the training is not nearly as long or intense nor are salaries as high. So by those standards they could be viewed like our midlevels. So that's how they do it.
 
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Stagg737 said:
And there's the key word. I don't have a problem allowing NPs or PAs full autonomous practice if there aren't physicians readily available, but putting someone with inferior training in charge when there are better options is just silly (especially when we're talking about something as important as a person's well-being).
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No. The standard of care is the standard if care and a midlevels solo staffing an ED should always be illegal.

Something that I think people don't get is that there are always physicians available... for the right price. That rural ED could easily pull in an ED doc, or at least an FP, with a high enough salary. However when you let them recruit inadequately trained providers they will keep the money and do that instead.
 
wxman393 said:
Where are NP's allowed to intubate? I'm not talking about the CRNA that has a DNP or what not. Are there NP's in emergency departments that have privileges for advanced airway management?

I will say that while I was working as a medic in NY, we had an NP as med control (not the only one but when he/she was on, we got orders directly from him/her). This was the same NP that attended one of my ACLS refresher classes and kept defibrillating asystole.




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NPs and RTs regularly intubate in some places. I had interviewed as an attending in one of these places where the NP had 10 years experience and had done "hundreds" of intubations. He was taught by the big boss of this particular PP group (who has since retired) so that the fat cats could round in other hospitals/do clinics and bill, while this fellow went about managing the ICU. All these intubations were billed as under direct supervision of critical care consultant.

Being in tort reform states sometimes encourages these practices.


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Perrotfish said:
No. The standard of care is the standard if care and a midlevels solo staffing an ED should always be illegal.

Something that I think people don't get is that there are always physicians available... for the right price. That rural ED could easily pull in an ED doc, or at least an FP, with a high enough salary. However when you let them recruit inadequately trained providers they will keep the money and do that instead.
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Couldn't agree more. Midlevels running codes, placing lines and intubating is the stuff nightmares are made of. It's just a matter of time before they create a midlevel film reader because of a 'radiologist shortage' and before midlevels are doing solo appys.
 
Perrotfish said:
That rural ED could easily pull in an ED doc, or at least an FP, with a high enough salary. However when you let them recruit inadequately trained providers they will keep the money and do that instead.
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these places staff an FP doc or a PA interchangeably. they can not afford boarded ER docs and it would be hard to find one willing to hang out to see only 12-14 pts in 24 hrs. truth be told, the PAs at my solo jobs are more skilled at EM than the FP docs. If we walk into badness at shift change the FP docs want us to run the codes, do the scary procedures, etc as we have an avg of 25+ years of em experience and most of us were previously medics in busy systems. some of the fp guys are 1-2 yrs out of residency in primary care. I have tons of respect for docs and some fp docs in the ER are great, but a new fp grad , except in rare instances, is not a replacement for a skilled em pa with > 100,000 pt care encounters over 20+ years.
 
emedpa said:
these places staff an FP doc or a PA interchangeably. they can not afford boarded ER docs and it would be hard to find one willing to hang out to see only 12-14 pts in 24 hrs. truth be told, the PAs at my solo jobs are more skilled at EM than the FP docs. If we walk into badness at shift change the FP docs want us to run the codes, do the scary procedures, etc as we have an avg of 25+ years of em experience and most of us were previously medics in busy systems. some of the fp guys are 1-2 yrs out of residency in primary care. I have tons of respect for docs and some fp docs in the ER are great, but a new fp grad , except in rare instances, is not a replacement for a skilled em pa with > 100,000 pt care encounters over 20+ years.
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I respectfully disagree. Depends on the FM's training. Many at the programs in my state have as much ER experience (as an attending) as the residency trained guys. All depends on electives and how much you moonlight. A mommy track clinic attending is very different than someone who planned on doing some EM.
 
W19 said:
But what if you say: 'I am Dr. emedpa, and I am your Physician Assistant'. What's wrong with that?
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This would be so confusing to patients. Many don't even know what physician assistants even are and add on Dr. to that, its a nightmare.
 
SansaStarkMD said:
I respectfully disagree. Depends on the FM's training. Many at the programs in my state have as much ER experience (as an attending) as the residency trained guys. All depends on electives and how much you moonlight. A mommy track clinic attending is very different than someone who planned on doing some EM.
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AGREE. some FPs are rock stars in the ER. most of the guys I work with at my solo gig are full time in primary care clinics, have no desire to do EM, and only cover the ER 1-2 shifts/mo because the hospital requires them to do so to keep admitting privileges. apparently that is not uncommon at rural critical access hospitals, which by federal definition have an FP focus with primary staffing done by FP for hospitalist, ob, etc services.
 
deafdealer said:
Couldn't agree more. Midlevels running codes, placing lines and intubating is the stuff nightmares are made of. It's just a matter of time before they create a midlevel film reader because of a 'radiologist shortage' and before midlevels are doing solo appys.
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Do NPs and PAs steal procedures in residency? I.e. if you are a medicine resident doing ICU? I've tried to factor this possibility into my program choices, in that I'd want to avoid places that heavily utilize MLPs.

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cbrons said:
Do NPs and PAs steal procedures in residency? I.e. if you are a medicine resident doing ICU? I've tried to factor this possibility into my program choices, in that I'd want to avoid places that heavily utilize MLPs.

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I also have this question.
 
the teaching hospitals that I have worked at that use PA/NP folks in the icu typically have teams composed of attendings + either PA/NP or residents so on any given team you typically don't have a PA/NP and a resident. The PA/NP teams usually cover nights and the resident teams cover days or they cover completely different patients, so there are plenty of procedures to go around. Most of my friends who work icu are involved in the teaching of residents, especially interns. A PA who has started 1000 central lines, etc is certainly capable of teaching the procedure to others.
 
Perrotfish said:
No. The standard of care is the standard if care and a midlevels solo staffing an ED should always be illegal.

Something that I think people don't get is that there are always physicians available... for the right price. That rural ED could easily pull in an ED doc, or at least an FP, with a high enough salary. However when you let them recruit inadequately trained providers they will keep the money and do that instead.
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I agree it is often more or less a given that they will do it if it is allowed bc. they can pay $150/ hr less and cost is always a concern. Its not soo much they are just "keeping" the money as redeploying resources. The added cost of the MD is very steep but there are reasonable arguments that it is justified. During the day shift the PA and the MD might be splitting the patients with the MDs name being prefilled on the forms the PA uses. The PA may have 15 years more experience than the MD and it is possible that he is a better provider. Still, there are valid arguments for requiring the MD but they are often not obvious in practice and this makes it easier to justify indirect oversight.
 
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Perrotfish said:
No. The standard of care is the standard if care and a midlevels solo staffing an ED should always be illegal.

Something that I think people don't get is that there are always physicians available... for the right price. That rural ED could easily pull in an ED doc, or at least an FP, with a high enough salary. However when you let them recruit inadequately trained providers they will keep the money and do that instead.
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And that's the catch. How much would you have to pay to pull physicians into a full-time gig in bumblef***, Idaho? I rotated with an OB attending earlier this year who turned down a 500k/year salary in a rural area b/c he'd rather raise his family near a city with more resources even though was offered less than 200k. Hell, I've got classmates that have said they'd rather switch careers than practice outside of a major city. Sure, there are those who want to practice in the rural setting, but there are also plenty of rural areas that can't attract physicians. Plus, how many of those rural hospitals can financially afford to fully staff physicians at "the right price".

To clarify, I'm not talking about the ethical standards we should be striving for. I'm talking about the feasibility of creating a system in which every hospital is able to be staffed by physicians without forcing physicians to practice in regions they don't want to be in that is financially realistic. It's the same reason the "physician shortage" exists.
 
YUP, at one of my rural hospitals they had to guarantee the only OB doc in town a 10k raise every year(on top of a top 5% salary) to keep him around. that worked for 5 years before he went back to the big city. same facility has zero MD anesthesiologists and to keep CRNAs they have to pay them their full (top) salary just to be on call and extra for each and every case they are called in for.
 
Stagg737 said:
And that's the catch. How much would you have to pay to pull physicians into a full-time gig in bumblef***, Idaho? I rotated with an OB attending earlier this year who turned down a 500k/year salary in a rural area b/c he'd rather raise his family near a city with more resources even though was offered less than 200k. Hell, I've got classmates that have said they'd rather switch careers than practice outside of a major city. Sure, there are those who want to practice in the rural setting, but there are also plenty of rural areas that can't attract physicians. Plus, how many of those rural hospitals can financially afford to fully staff physicians at "the right price".

To clarify, I'm not talking about the ethical standards we should be striving for. I'm talking about the feasibility of creating a system in which every hospital is able to be staffed by physicians without forcing physicians to practice in regions they don't want to be in that is financially realistic. It's the same reason the "physician shortage" exists.
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Right and the examples you give highlight why the greater use of PAs has not driven down physician salaries nearly as much as many expected. I would argue that just as operative is the fact that the ability of hospitals to use midlevels for many functions blunts the impact of the high wages of the physicians they do have and allows them to be less price conscious in this regard. If hospitals were indifferent to employing physicians they wouldn't plaster them all over their billboards and promotional literature.
 
FBurnaby said:
The comparisons to PhD are getting off topic, as the "gap" is much larger.
4 Undergraduate--> 4 Medical school --> 3-7 residency = Physician
4 BSN (I'm assuming it's not just RN) --> 2 DNP (apparently it can be done in 12 months) = gap bridged
4 Undergraduate --> 2 PA --> 2 (part time) DMS = gap bridged

If one calculated hours, let alone hours and level of rigor, rather than calendar years it would be much more startling.
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Our didactic period was 1.25 which is pretty typical. 1.5 is more common than 1.0, which is getting rare. One of my classmates got cancer and dropped out of Georgetown U Med after 3rd yer. He says the pace is the same ie a slightly transitional summer and then balls to the wall till the end ( I calculated the actual credit equivalent using CUNY credit metrics for one term and it was like 22-23). Cadaver was a little short ( 1 month) but servicable and we we did a few other things like tubes, lumbar, lines, joints with them later. Other than that as others have said histo and embriology are left out and there is less detail ie . we would learn that the rods and cones were deep to the choroid but wouldn't expect to be tested on the relative position of features and physiology of every layer. But niether do we just learn to ID the gallbladder as some green thing; needed to know where it lay in relation to the 4 segments of duodenum, that it was in a fossa in the liver, its basic physiology, pathology, ducts etc. No citric acid cycle or the like. Physiology, body chem, labs, drugs are covered well. Full term patho class and inflammation, coag, cancer are covered in depth. So a decent amount of material is triaged out, but in a very deliberate way. The devt. of clinical reasoning is relentlessly pursued and from Jan to Aug it is the whole game; I think most of our preceptors are impressed with the product. Then a full year of clinicals 9x 5 weeks ea. Can double for your spec. Ob/gyn and couple others are 2.5 ea. So yeah, its a little broader than it is deep but my ER rotation was with a really squared away group and I learned and did a ton ( we were always the only student at the site we were at so only were pissing off the RNs by getting in the way). We do a thesis which is mostly just a lot of BS work and reading although these is some good contextual review of stats with an emphasis on learning to deconstruct and critique papers; but we do them ourselves--no piggybacking

I guess I would argue that while your time comps are fairly accurate your level of rigor multiplier would not be very significant for our program. And of course I need to mention that while residency is cearly optimized for honing clinical skills the PA student is already working as a PA by then and its not like learning stops ( i think our PBL format format served us particularly well in teaching us to be effective lifelong learners).

No fundamental disagreement, just a little pushback

An individual with an existing BA /BS can add on a BSN in 12 months via an accelerated program (they are very full time) or 2 years PT. OW its 4 years but incorporates a regular bachelor's degree with all the electives.

Matt
 
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A traditional PA applicant will also have some type of training before PA school for 1-2 years. My path:
EMT in high school
ER tech 24 hrs/week through college(60 hrs/week summers)
BS medical anthro from University of CA
1 year paramedic program
5 yrs as a medic
3 yr PA program
1 Yr postgrad MS in clinical emergency medicine
20 yrs practice as an EM PA
4 yrs for Doctorate in global health including 3 months spent in a developing nation doing research and leading teams.
along the way also picked up all the typical EM certs, the EM CAQ, and a few 1 yr graduate certificates( Family medicine, emergency medicine, global health). also am currently rostered on state, federal, and international disaster medical teams.
I like being a student, what can I say?
 
The rigor was more aimed at NP route, again the PA is a great degree. Residency is always written off as "we'll were working during that time" which is not a fair comparison, if so you can compare a PA with 3 years experience and a board certified physician with 3 years experience. Residency is not just a job with learning opportunities but a structured training program. Given same rigor, it's still 7-11 years of 80hr weeks verses 2-2.5 excluding undergrad, I'm not versed on PA exams so I won't compare MCAT, boards, etc. I did not mention experience before professional education because that is highly variable and not related to competency standards in our fields once graduated. Yes some PAs have years if not a decade of experience in fields but so do some doctors before medical school. Probably the majority of my classmates worked as a EMT or tech type position before school.
 
Being a nurse going to med school soon, I truly believe that all nursing professions, minus professor level teaching, should be limited to masters level degrees. NP training is so sub-par to PA training it's scary (i looked into all my options before applying to med school). All you need is ONE YEAR of RN experience. Some programs don't differentiate that experience, like 1 year of clinic nursing vs 1 year of level 1 ER experience. And... and... it can be done online, mostly.

I actually go see an NP for my endocrinology issues, but she was a nurse for 12 years prior to going to NP school. The standards for admissions for NP programs needs to be standardized and made harder.

And the ANA is pushing for all RN's to have BSNs and MSNs (completely useless) - some of the best nurses I know are diploma and associate degree nurses. It's all about money for colleges and cheaper employees for hospitals, which will not equal good care.



p.s. not burning NPs, there are some crazy good NPs out there. But making everything a Doctorate doesn't make people any smarter.
 
degree inflation will stop soon when tuition gets so high it doesn't make practical sense
 
SansaStarkMD said:
degree inflation will stop soon when tuition gets so high it doesn't make practical sense
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The tuition bubble is coming. That and when people realize that doubling down on degrees won't translate into the career you want (not healthcare specific). The bachelors degree, once an unquestioned seal of knowledge, is so diluted that employers now have to screen applicants with basic competency tests. What is the point of a bachelors if employers don't trust that you've mastered high school level algebra and freshmen linguistics? Just a matter of time until billy and his parents realize a BA from NYU isn't worth $256,000
 
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BehindBlueEyes said:
Not exactly relevant, but DMA is a doctoral degree in composition or performance (of an entire group of instruments, i.e. woodwinds, percussion, brass), not one instrument. As @ChrisMack390 responded with, professors with DMA degrees are not supplanting professors with PhDs for lower salaries. Furthermore, they are teaching students who want to be proficient in things like performance and composition... A DMA is who you want to teach these students music theory. There is no controversy over this and is not a relevant example.
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The example is very relevant to the post to which I was responding. It obviously wasn't the best choice because apparently most on here don't know what most DMAs entail (e.g., your description in the quoted post, along with what was posted by @Stagg737 and @ChrisMack390 clearly demonstrates you have little insight to what you are talking about...) or the difference between a PhD in a music field v. a DMA. Also, PhDs in higher ed music departments are regularly being supplanted by individuals with less training, or less "qualified" training simply for the sake of saving money on salary. So, I still stand behind this example given the context of the conversation. Regardless, this is kind off topic.

Edit - you should also change your status beings you aren't a med student.
 
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