Highest Paid Specialty, Historically, and for the future...

[womansurg]

Originally posted by dcw135
If there are anatomical variations or complications, just HOW exactly is a PA worse off than a recent graduate of an academic surgical residency where she did more Whipples than lap choles? What would the PA do - well, if well trained he would do EXACTLY what an MD would do.

What would the PA do with bleeding - make it stop.

I'm sorry dcw135, these silly statements of yours are clear demonstration of exactly how little you understand about surgery.

A Whipple procedure includes cholecystectomy, and is one of the few operations where a surgeon consistenly encounters and deals with variations in hepatobiliary anatomy.

When surgical bleeding occurs during laparoscopic cholecystectomy, it is torrential. The subhepatic space pools up with blood faster than you can suck it out. When you have your suction instrument in, then you don't have your clip applier in. In the time it takes to exchange instruments, your visability is lost to bleeding again. That's why bleeding commonly results in need for conversion to open approach. Here is where the inexperienced operator would try to blindly throw clips - injuring the CBD, tearing the hepatic artery. Here is where the staff surgeon calmly walks the terrified third year surgery resident through the steps needed to regain control. Is a novice going to have a friggin' clue how to set up the Bookwalter retractor, atraumatically pack the bowel away, isolate the portal triad and perform Pringle maneuver while identifying and appropriately controlling the source of bleeding? (*sigh* Here is where your astonishing ignorance will again reveal itself...I'm certain that your initial response is, "why sure! What in the heck is so tough about that?")

Honey, you are exactly right -IF THE PA WERE AS WELL TRAINED AS THE MD they would be equally competent in handling these situations. That is precisely what they are NOT.

I said it before, if a PA can arrange to undergo the equivilent of a surgical residency, I would not object to their acting as surgeons. BUT THEY DON'T. PAs go to PA school primarily because of lifestyle issues. They don't want to devote their lives to their craft. This level of commitment is truly what is required for surgical excellence - which is the same thing as COMPETENCE.

Surgery can never be a part time or an amateur level endevour.

-ws

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[Andrew_Doan]

Originally posted by womansurg

Honey, you are exactly right -"IF THE PA WERE AS WELL TRAINED AS THE MD they would be equally competent in handling these situations. That is precisely what they are NOT.

I said if before, if a PA can arrange to undergo the equivilent of a surgical residency, I would not object to their acting as surgeons. BUT THEY DON'T. PAs go to PA school primarily because of lifestyle issues. They don't want to devote their lives to their craft. This level of commitment is truly what is required for surgical excellence - which is the same thing as COMPETENCE.

-ws

Well said Doctor. I think the ignorant posts in this thread is due to lack of experience and in depth knowledge of medicine. PAs are trained to assist, and they were never meant to be independent surgeons. PAs and NPs serve a specific role in the delivery of health care. Why even argue that PAs can assume the role of an independent surgeon?

Furthermore, patients will not want to go to a PA for surgical evaluation. If I'm sick and need surgery, then I'll want an MD involved in my medical care. Wouldn't you?

 

[yaoming]

i hope you can read my comment on page 3 about my and most ppl's perspective about PA/RN and MDs.

 

[yaoming]

and also, if you had a brain tumor or some pox that no one you know has ever seen before or u want lasik or plastic surgery for you ears, would you pay more for the MD to get it done for you, or the RN/PA for a lower price? MD is the obvious choice for me.

 

[Andrew_Doan]

Originally posted by yaoming
and also, if you had a brain tumor or some pox that no one you know has ever seen before or u want lasik or plastic surgery for you ears, would you pay more for the MD to get it done for you, or the RN/PA for a lower price? MD is the obvious choice for me.

And is the obvious choice for 95% of the patients out there. No one wants to bargain hunt at the Wal-Mart of Medicine for their medical care.

 

[dcw135]

OK, I have to admit, you guys are really wearing me down here. I don't know how long I can go about saying the same things and hearing the same things: what MDs do is so special that no-one can replace us despite that most of our so called training is nonsense and so on.

So here we go again, and then perhaps I'll quit unless someone tells me why exactly someone with 2 years less of useless med school memorization than an MD/DO (or not, you never know what goes on in those freaky Carribean, Chinese, or Russian med schools) is incapable of doing the same job. The sometimes good and sometimes bad job that doctors do. If putting the trocar into some vessel seems an important objection, why can't the answer be stop it and call vascular like the MD surgeon. If telling me my "ignorant posts" are due to my "lack of experience and in depth knowledge of medicine" (from a PGY2 - OPHTHO!?) is the answer, why can't the answer be: 1. That its good training if you recognize how simple our jobs actually are? 2. It needs no anwer because it is a shameful example of how stupid people who argue by insults can get MDs.

Yao:
i hope you can read my comment on page 3 about my and most ppl's perspective about PA/RN and MDs.

And I didn't reply because this is off topic. My position isn't that PAs will hurt quality, although I personally don't think they will.

And I'll even give you a good analogy. I would like to have tailored shirts. Instead, because I'm a resident, I deal with off the rack mass produced shirts. Not out of preference. So why do I buy them? Because they'll do the job and I really don't have a choice given market conditions.

THe market will affect medicine in the same way. We are entering an age where medicine is becoming standardized, so that 99% of presentations can be worked up in a standardized manner and the treatments - with their trials and interpretations (and note that I don't think PAs are going to be doing this - this is for the smart stats people) - will also come standard. Who can do this? Answer: anyone. And by anyone I mean doctors and PAs and NPs.

And my entire argument is that they will start competing with MDs and drive prices down by offering the same services for cheaper. So if a PA offers lasik for much less, I'm there - but more importantly - I can then choose an MD, if I choose to, because his prices have to compete with the PA so will have to go down. Too bad the MD has all those loans.

If you'd like to respond, please do so against this idea.

People probably said there's no way shirts could be mass produced - no way people would buy them over tailored shirts. And then along came ACF.

You say:
if you have... some pox that no one you know has ever seen before u want lasik or plastic surgery for you ears...would you want MD or PA?

This is really desparation. To posit something horribly wrong with me and ask what I'd want. Of course you even had to go all the way to brain tumor.

Some pox? Which pox: small or large? What are you talking about? If I had a bad brain tumor I think I'd go somewhere warm instead of sitting around the hospital getting a well intentioned dvt. Would I want an MD or PA? Well, how about a resident or an intern? How about a toxic resident? How about a senior resident? And although there's nothing wrong with my ears (can the surgeon perf the aorta from there?), if I were told to go to a PA by my insurance plan, then the shirt fits, doesn't it?

 

[womansurg]

Originally posted by dcw135
perhaps I'll quit unless someone tells me why exactly someone with 2 years less of useless med school memorization than an MD/DO is incapable of doing the same job.

If putting the trocar into some vessel seems an important objection, why can't the answer be stop it and call vascular like the MD surgeon. :

Talk about having to say the same thing over and over again..... Geez, I could just excerpt from my previous posts here instead of generating new script.

It is not the additional two years (U of Iowa's PA program is 4 years anyway...) that makes the major difference - although it does make a difference. I use my 'useless' ob/gyn, neurology, pediatric, so forth, training all the time as a general surgeon.

It's the part where you learn how to be a surgeon that the PAs are missing. If they fulfilled that part, they would - like any other human being - be safe and competent to practice surgery.

You think a podunk town that would be having a PA do surgery is going to have a vascular surgeon available? Give me a break.

So, after you put a trocar into the iliac vein, just "stop it", eh? You freakin' *****. My classmate BROKE DOWN AND WEPT during a Morbidity and Mortality conference presentation when he described how a woman in her 40s bled out perilously close to death on the table after the gynecologist/oncologist tore the vein, couldn't get control, stat paged the general surgery team, who then struggled madly to control the bleeding over the next hour while the anesthesia team poured blood products into her. The pelvis fills with blood faster than 2 dedicated suction catheters can evacuate it. The vein is extremely fragile, tears with every manipulation, and lies in the deep/posteror aspect of the pelvis. You work with foot long instruments at the bottom of a hole, which everytime your assistent releases pressure, fill instantly with blood, obscuring your field.

You have no idea the sheer terror of having someone dying in your hands, while you frantically try to perform technical feats which rival using one hand in your back pocket to tie a strand of hair into a french knot.

You are an insult to the dedicated people who sacrifice so incredibly much to achieve a baseline level of skill and knowlege, which qualifies them for the ENORMOUS RESPONSIBILITY, the HONOR and the PRIVILEGE of providing surgical services to the members of their community.

Maybe a PA can follow your neurology algorithms for diagnosis and treatment as well as you can...I'll leave you to wonder about that. But no one can practice surgery safely and effectively without DEDICATED, FOCUSED, ORGANIZED, SUPERVISED, LENGTHY training - the type received in residency and fellowship programs. To suggest otherwise is ignorant, irresponsible, and if conveyed to patients, borders on malpractice.

 

[Andrew_Doan]

Originally posted by dcw135

So here we go again, and then perhaps I'll quit unless someone tells me why exactly someone with 2 years less of useless med school memorization than an MD/DO (or not, you never know what goes on in those freaky Carribean, Chinese, or Russian med schools) is incapable of doing the same job.

This is where your arguement is primarily flawed. It's not just 2 YEARS LESS of useless med school memorization. A PA does not go through a formal residency training program. It's the difference of 5 years for a corneal surgeon who does LASIK, 6 years for a retinal surgeon, 7 years for a neurosurgeon, 4 years for a neurologist, 5+ years for a cardiologist, etc... This doesn't even include the 2 useless years you mentioned. Until PAs go through the same formal training as MDs, they will never replace our jobs and will never be able to offer the same services.

 

[Voxel]

Why are you guys getting all worked up about a senseless troll who really does not understand politicolegal environment in which medicine is practiced in this country. His/her statements are of course obsurd. Remember it is lack of knowledge of what one doesn't know that makes him/her dangerous to the patients. It's a good thing the people still have the common sense to damand doctors (assuming they live in your non-rural area) and that the malpractice lawyers exist (as bad as they seem) . Malpractice lawyers would have their way with the so called PA everytime a PA made a mistake, the insurance companies would probably just settle or worse yet, the all those cases would go to trial, insurance companies would loose tons of money and PAs could not afford the coverage anymore. Just remember to pay your dues to the AMA and your local medicalty specialty board because there are PAs who think like this and would love nothing more than to have the ability to practice medicine without going through the training necessary to practice it well.

 

[womansurg]

Originally posted by Voxel
Why are you guys getting all worked up about a senseless troll who really does not understand politicolegal environment in which medicine is practiced in this country. His/her statements are of course obsurd.

You're right, Voxel, good advice. I apologize for getting so outraged. (Did I really call him a "freakin' *****"?)

A PA espousing such nonsense is easy to dismiss. This person represents himself as a neurologist in training. What that really means we have no idea, of course. The thought that someone could have passed through accredited medical training in this country and be so clueless is alarming.

What is it that they say about neurologists, 'they don't treat disease, they admire it'? Well, this guy's chosen the right field then, because he has no idea of the awesome burden of the accurate identification and responsible intervention of disease in the practice of medicine.

 

[Ernest T. Bass]

You guys ever stop to think that in a capitalistic society (which we supposedly live in, but not really), anybody could practice any kind of medicine they want. Of course they have to be up front about what sort of degree they have, etc. If patients want to go to PA's or nurse practitioners or LPN's for that matter, let them. They will die soon enough from inadequate care and others will quickly realize that they should go to a real doctor if they expect real treatment.

 

[Voxel]

This "capitalistic society" does have laws that govern the practice of medicine (the business of medicine whatever you want to call it) and who is "allowed" to practice it and call themselves a "physician". While these laws vary by state there are some common themes. These laws also empower patients with the ability to sue for malpractice for those who make mistakes or in cases where the outcome is bad. These laws would be difficult to change. And would of course be fought tooth and nail by the "establishment". It's not quite the wild jungle a purely capitalistic society would have it be, but a jungle non-the-less with a strict hierarchy. ROAR.

 

[Ernest T. Bass]

I'm not suggesting that there is even the slimmest chance of achieving a purely free market as far as health care is concerned (due to the socialistic nature of most of the electorate in this country.
I'm just saying that is the way it should be. Of course people would be free to sue for malpractice. However, if you go to an LPN for treatment of an MI, this would be viewed as stupidity on your part, not malpractice on the LPN's part, unless she misrepresented herself as being a physician or actually did harm to you.
Restrictions in health care invariably hurt both patient and provider.

 

[futuremd45]

PBA,

You are a breath of fresh air! I have been reading the previous msgs and what I have been surprised with is how defensive everyone is about how the business of medicine will not change.

I am the "wallstreet washout" and I am sure I know a "little" bit more about business than everyone else on this board. However, what is amazing to me is how everyone assumes knowledge about medical procedures implies knowledge of medical economics. I would wager that not a single person on this thread has taken more than a single economics course in their entire lives and has never held more than a summer job. God, the arrogance on this thread is astounding.

However, I do admit, I do not have a clue what will happen when it comes to RNs or PAs or whatever. But I do know that the health industry is swimming in money and everyone is out to get a piece.

The easiest place to funnel the money is from doctors. Why? because doctors, judging by the stereotype, which by the way is aptly demonstrated on this thread, are so unbeliavably naive when it comes to financial dealings and arrogant when it comes to learning about even basic financial truths that they are sitting ducks (as history has proven).

Luckily, for the people who went into medicine for the purpose of providing a service to their fellow men, this all means very little. Because when the industry does change and reimbursements shrink even more and doctors make a good living, rather than a great living, they still will be helping people.

To everyone else, cling to your fantasies and hopefully, the truth will not hurt too much.

 

[orthoguy]

Random thoughts..........

1)How do you judge a person's economic naivet? based upon a post on a webpage and how then do you further extrapolate that to a profession in general??truly wall street and medicine are synchronous to the extent that you must be extremely well prepared for a career in managing your medicine network??.I hope your ?clients? appreciate this.

2) The logic that anyone can be trained to do anything cannot be argued with???Complex surgery with unforeseeable complications?train a PA to do it/ Neurosurgery?Train PAs to do it/Hitting a 95 mph fastball?Train a PA to do it/NASA flight director?train a PA to do it???clearly the only career that this logic might work against is an artist??.by allowing this slippery slope to continue PA?s can be trained to do anything that can be done?other than Picasso

3) Have none of you read the earlier post by Yasergale one of the few individuals with some actual EXPERIENCE with acting as a medical administrator??I suggest most of you go back and read it and understand the difference between the real world and the ones invented by a 3rd year neurology resident and a wall street individual who has not even started medical school yet???

4) Rash predictions based upon na?ve assumptions and inexperience should not be fodder for concern or debate???.it is only the uneducated OPINION of a random individual on a webpage

5) I firmly believe that monkeys will eventually overtake mankind??although pba has the right idea of using them in the stead of beepers we will find that the monkeys will grow stronger than we have ever imagined and enslave all of mankind??their reign will be fierce and merciless??but there will be hope?..at man?s darkest hour a PA sshall rise up and lead us all to salvation (while simultaneously driving down reimbursements)

 

[womansurg]

Originally posted by orthoguy
The logic that anyone can be trained to do anything cannot be argued with???Complex surgery with unforeseeable complications?train a PA to do it/ Neurosurgery?Train PAs to do it/Hitting a 95 mph fastball?Train a PA to do it/NASA flight director?train a PA to do it???clearly the only career that this logic might work against is an artist??.by allowing this slippery slope to continue PA?s can be trained to do anything that can be done

Sure, PAs are people - usually pretty bright people - so they can be trained to do things that other people are trained to do.

My strenuous objection is that no one, including PAs, can safely perform the task of surgery WITHOUT adequate training - which is by necessity the situation they are always in. It's like someone wanting to be NASA flight director after watching Apollo 13 on video a few hundred times.

Or someone who insists on walking onto a major league baseball diamond to swing at 95 mph pitches when they've played a few games of softball at the local YMCA.

There's a solution to PAs wanting to do surgery. It's called medical school followed by surgery residency.

 

[The Pill Counter]

Forget surgery, I wouldn't want anyone without an MD looking at my sore throat.

 

[Andrew_Doan]

Originally posted by futuremd45
PBA,

You are a breath of fresh air! I have been reading the previous msgs and what I have been surprised with is how defensive everyone is about how the business of medicine will not change.

I was not objecting to how the business of medicine will change due to competition and reimbursements. I'm not not saying that MDs are Gods. We're arguing that PAs will need to have more formal training in order to do the jobs that MDs are trained to do. They don't do a residency/fellowship program which trains them how to do their job and be a primary care giver or specialist.

Until they do this formal training, they will NEVER REPLACE THE ROLE OF MDs. This is why they work under the guidance of a licensed physician.

Your post on how ignorant doctors are about finances are so wrong. The successful physicians in private practice are extremely good business managers, otherwise their practices fail. The physicians I work with at U of Iowa are very health-cost conscious too. New residents may be clueless on business, but they learn fast if they want to survive.

One last note, reimbursements for physicians' services have changed. Few doctors are making millions or even a fraction of that. I've had a medical economic course, and surprisingly, the portion of the pie that we assign to "physicians' fees" are a small fraction. Here's is a breakdown of where we spend our health care dollar:

http://www.publicagenda.org/issues/factfiles_detail.cfm?issue_type=healthcare&list=5

Of that 25% of the pie that is spent for physician and clinical services, less than half of it go directly to physicians for compensation. Thus, less than 10-15% of the total health care dollar goes directly to the physicians. In order to reduce your cost of health care, there's more to address than simply physician compensation.

 

[futuremd45]

mud-phud,

Looking at your pie chart only confirms my belief that physicians' compensation will further shrink. My reasoning is that every other group on the chart has an extremely strong business mentality and political lobby. Doctors on the other hand do not have any strong political lobbying body and have already demonstrated poor business skills.

For example, after speaking to my close friend who is currently starting a retina fellowship in optho, I was told optometrists with their extremely powerful lobby are fighting, seemingly successfully, for greater inroads into opthamology. I think this is a case in point how medical economics rule the day.

And again to womansurg, I have no opinions on what exactly will happen however I do know something will happen. I am sure you all know that two macroeconomic factors are at work here currently: 1. Health costs are already rising at an unsustainable rate, 2. the Social security/Medicare funds/funding are quickly dwindling. Now no matter what you guys wish, you can not get something out of nothing so what happens when there are fewer dollars to go around.

 

[Andrew_Doan]

Originally posted by futuremd45
mud-phud,

Looking at your pie chart only confirms my belief that physicians' compensation will further shrink. My reasoning is that every other group on the chart has an extremely strong business mentality and political lobby. Doctors on the other hand do not have any strong political lobbying body and have already demonstrated poor business skills.

I think you missed my point. The problem we face today is not primarily physician compensation. If you shrink the physician compensation to say 50% right now, then there will be less than a 10% decrease in overal health care costs (about 1/2 of the current physician fees go into fixed costs like insurance and business costs). This will do nothing to correct the current problem. Current physician salaries are not the main problem. We have to address the many other inefficiencies in our current system in order to achieve more economical health care for our country.

You are correct that optometrists are lobbying for more share, particularly in the area of LASIK. But ophthalmology has equally a strong lobby too and it will be a tough battle. However, in the end, I think that it will come down to the fact that if optometrists want to do some surgical procedures, then they will have to compete for residency/fellowship positions. At this current time, most optometrists do not complete residency and fellowship training. If people are properly trained, then I have no objections for optometrists to do surgery.

My problem lies in the fact that people want to do more without the proper medical training. Until optometrist do retinal or corneal fellowships or even a general ophthalmology residency, I doubt they will touch the retina, cataract surgeries, or do corneal transplants. Likewise, until PAs complete residencies in surgery, they will never be the primary surgeon.

 

[futuremd45]

mud-phud,

I hope you are right. Check out the other thread "surgery -- - the final realm" and read ESU's reply. It is interesting.

HG

 

[Andrew_Doan]

I read ESU's reply, and I have observed similar surgeries too. There is, however, a HUGE DIFFERENCE between nurses and PAs doing surgeries by themselves versus doing surgeries under the supervision of experienced CT surgeons. In ESU's example, although the nurses have quite a bit of autonomy, they are still working under the supervision of the CT surgeon. He/she may be in a different OR but is available if needed. If some thing goes wrong, then it is the CT surgeon who will sit on the stand defending his practice.

I don't think they (PAs and nurses) will ever break away and do surgeries independently. This will not happen without further training that is involved in becoming a CT surgeon, i.e. 8+ years of surgical residency and fellowship. BTW, these nurses are making good money. Probably near $80,000 per year; but the average CT surgeon makes $500,000+ per year. Is this too much money? I think not because there aren't many CT surgeons out there in the first place, and the fee the CT surgeon collects is very small in comparison to the other costs involved with CABG.

Furthermore, ESU asks why anyone would want to be a CT surgeon if nurses and PAs are doing surgery and making decent money. The answer is simple. If you want autonomy and the ability to be the lead surgeon, then go to medical school, residency, and fellowship.

 

[womansurg]

Originally posted by Ophtho_MudPhud
the average CT surgeon makes $500,000+ per year. Is this too much money?

I think so. Half a million per year is probably excessive.

Financial compensation should never be a driving force for entering the field of medicine. It is a service and an honored role that we are entrusted with. Compensations should be commiserate with our difficult lifestyles, long years of sacrifice and valuable skill/knowledge sets, but should never be a driving force for us, or even a temptation.

Just my humble opinion.

 

[Andrew_Doan]

Originally posted by womansurg
I think so. Half a million per year is probably excessive.

Financial compensation should never be a driving force for entering the field of medicine. It is a service and an honored role that we are entrusted with. Compensations should be commiserate with our difficult lifestyles, long years of sacrifice and valuable skill/knowledge sets, but should never be a driving force for us, or even a temptation.

Just my humble opinion.

I agree here too, but this is the reason why I think CT surgeons deserve a big salary. They are on call for their whole career (and probably more than any speciality) and it takes over 12 years of training, including medical school, to become one. For what CT surgeons do, I truly believe they should be paid well.

This being said, don't take me for a physician who is out to make big money. I plan to serve our country as a Navy Physician, and I aim to serve my full 20 years or more.

However, if CT surgeons are saving lives performing heart transplants, valvular repairs, and CABGs, then they deserve every dollar they get.

 

[Voxel]

I think what the market will bear in terms of supply and demand and in terms of what insurance (private or public)/ private payers are willing to pay for a service is what should determine what is the appropriate compensation. Monetory compensation should never be confused or equated with nobility of one's profession/career. To do so sets one up for disappointment. Financial considerations are among other things what attracts the best and the brightest to the field of medicine. To deny this is to ignore reality. There are a multitude of factors which attract individuals to the field of medicine. However I believe everyone should be grounded in financial reality given the financial liability incurred in medical school these days along with the long training and sacrafice required by medicine. To make decisions soley based upon money can of course have devastating consequences for all parties involved. However to ignore financial issues can also have devastating consequences. I believe in life their should be a balance of factors with each individual person assigning a weight of relative importance each factor important in the decision making process.

 

[womansurg]

Originally posted by Ophtho_MudPhud
However, if CT surgeons are saving lives performing heart transplants, valvular repairs, and CABGs, then they deserve every dollar they get.

Silly, I save lives every day performing colon resections, breast cancer operations, gallbladder surgeries...
Cardiologists save lives performing PTCAs, managing dangerous heart rhythms...
ER docs save lives diagnosing and managing myocardial infarction, respiratory failure, trauma...

And no one has harder call than a general surgeon.

CT surgeons pull their pants on one leg at a time, just like the rest of us.

 

[Sandpaper]

A generous response offered by womansurg: "I think so. Half a million per year is probably excessive."

This statement is absurd. How do you determine what is and isn't excessive? What pay scale are you using to judge? Would it make you feel better if CT surgeons make half as much, a quarter as much? And please tell us whether a CEO or a CFO of a Fortune 500 company making $50 million/year and then defrauding the company landing it in Chapter 11 bankruptcy court is excessively rewarded. This type of inane statement reeks of self-righteousness that is befuddling.

 

[dcw135]

WS:
(Did I really call him a "freakin' *****"?)

Yes you did.

WS:
A PA espousing such nonsense is easy to dismiss. This person represents himself as a neurologist in training. What that really means we have no idea, of course.

It probably means what I said. I am an MD. I went to school in the US. I learned the Kreb cycle. I know that Tach Sachs matches with the one that starts hexos...ase.

WS:
The thought that someone could have passed through accredited medical training in this country and be so clueless is alarming.

You should listen in to some surgeons here as they call in a consult - then you'll really be alarmed.

But seriously, you make some of my points for me. Point: there is nothing special with what doctors do. And I am clueless. Yet I went through med school. I could have become a surgeon if I didn't hate it so entirely. Instead I manage stroke patients and I do try to appreciate them and their diseases, something which you indicate does not offer you any gratification. I do all this and remain, in your terms, "clueless." I am a living example to you that anyone can do the work of an MD, aren't I?

And let's talk about you. You are a highly trained person, but you can't discuss an idea without throwing around insults and questioning credentials - you need your self rightousness and authority. But really, there are bright 10 year olds you can put together a more cogent post than what you appear capable. That is, WITHOUT calling the other person names or dismissing what they say as "nonsense" and WITH giving arguments to the contrary. See, what you've done is WITH the former (that's the first) and WITHOUT the latter (that's the second).

Thus I believe that YOUR posts, in this manner, are *****ic and, perhaps, come from a *****. Yet you can do surgery. If you do surgery and you are a *****, then a ***** can do surgery.

OK. I'm done. I'll try to restrain myself and not repeat what I've said before in future posts. We will see what the future holds. I think I've laid out what I think (as well as why). And here's another prediction: unless you and others like you start THINKING, break out of your self-promtional and very pleasing fantasies ("just my humble opinion"), and stop arrogantly insulting (what am I saying - that's highly unlikely), then life will continue like it is for you.

Enjoy.

 

[Voxel]

dcw, how about rebuttals to my arguements? Let's get some constructive replies. While I did in fact call some statements obsurd, I did state my opinions on why things mentioned would be very unlikely to occur.

 

[MustafaMond]

Originally posted by The Pill Counter
Forget surgery, I wouldn't want anyone without an MD looking at my sore throat.

Well, I wouldn't want to waste my damn time, as an MD, taking care of your straight-up-and-down sore throat.
Here's my nurse practitioner- let her see it.
Your complaint wouldn't even buy you a visit w/ a PA in a lot of ED's.
I dont know how it is in Australia, but here in the US, in an HMO (and in most private settings too), you wouldnt be seen by an MD.

If you want to be seen by an MD so bad, then dish up the cash, and go see a private GP.

 

[womansurg]

dcw, how about rebuttals to my arguements? Let's get some constructive replies. While I did in fact call some statements obsurd, I did state my opinions on why things mentioned would be very unlikely to occur.

Ditto.

dcw, I've written pages of replies to you, exactly one line of which was an insult - for which I immediately apologized.

'a neurologist in training' could mean anything from a naive premed student who thought neuro was cool, to a second year Fellow working as a physician. That's all that refers to - my inability to judge your level of real life medical experience based on that descriptor.

I do - continue - to find you to be frighteningly unaware. dcw, I don't deal primarily with patients who are irreparably damaged by disease, who are marginally affected by my interventions. I have essentially healthy people who walk into my office, sit down face to face with me, listen to my recommendations, and then literally place their lives in my hands. Before every surgery I always take my patient's hand, look them straight in the eye, and tell them, "I'm going to take very good care of you today." They know that I mean it, absolutely and with everything that I am. It's emotional -- they tear up; I tear up. My responsibility to them is enormous, and I feel it greatly.

I can tell you, it's a mighty long walk down that hallway after a surgery to talk to family members about a case that didn't turn out well.

I have worked greater than 120 hours per week during my training. I've gone days without leaving the hospital. I've scrubbed on cases after being awake and on my feet for more than 40 hours. I've read countless medical journals and texts. The sacrifices of my education have been profound.

Now, at the conclusion of my long years of formal training, it is apparent to me how all of this enormous effort is only a first step in the process of becoming a surgeon. All of this concerted learning, these years of compressed experiences - these are what are necessary - the minimum of what is necessary - in order to be responsible and capable in this role.

I apologize for my frustration in trying to convey this important concept to you. It was inappropriate to call you a *****. I do despair at your ability to comprehend the unique trust relationship between a surgeon and his or her patient - and how vitally important it remains that surgeons strive to honor that trust.

Regards,
-ws

 

[MustafaMond]

I do despair at your ability to comprehend the unique trust relationship between a surgeon and his or her patient

Yes...the bond that only a butcher and his cow can feel.

 

[Ponyboy]

A little off topic:
We've been talking about how a PA can do almost 90% of what a primary care doc does and, given the right amount of training, could probably perform the same duties as an MD.
Why can't the reverse be possible?

If you think about it:
PA school = 1 year basic science, 1 year clinical rotations (ie. MS3)

Med school = 2 years basic science, 1 year clinical rotations and 1 additional year of subI's and electives.

Sooo, why can't newly minted (no residency) MD's get jobs as PA's? Why can't MS4's write the Physician Assistant National Certifying Examination (PANCE) and moonlight as PA's? Why can't I have the priviledges of a PA during my fourth year? i have the same education as a PA (if not more). Why can't I work as a PA?

Here's another thought: How comfortable would you feel being the sole medical care provider in a rural town after completing MS3? How comfortable do you think your patients would be?

 

[The Pill Counter]

Well Mustafa, Western Europe or US, what is it? You should know majority of Western Countries don't give the type of privileges granted to non-MD's in the States. The whole PA/RNP is a purely US creation. I would be weary of any non-medics eroding the professional domain of the doctor. The term PA itself implies assisting a medic in his/her professional practice. Since when did that extend to PA's practicing on their own? I'm not too familiar with the primary care set-up in the States, but I did have a friend doing Oral Surgery in NY tell me he had patients come in whose primary care provider was not an MD. That may be the norm in the US, but I hope it's a trend you guys keep to yourself. A doctor is a doctor is a doctor. I was (am?) a pharmacist, and I find it laughable the PharmD's in the States call themselves Dr. So and So. I would never have had the gall to do that. The overuse of the title by ancillary professionals in the States erodes it value. Here in Aus, the only non-medic that can use Dr. are dentists, not optometrists, not podiatrists, and definitely not pharmacists.
The sentiment on this thread appears to be that market-economy forces will eventually erode the doctor's position in society to a level on par with ancillary professionals with sub-par training, and that the public will go along with it. (hence the subliminal use of the title Dr. for every tom-dick-and-harry job in the health field.
I'm writing my first year medical exams in a few days, and it feels like I've gone to hell and back already. Something tells me a lot more of it is to come in the coming years. This year already has been more challenging than all five of my previous years in university. How that can equate to inferior training in ancillary fields is beyond me.
In relation to surgery, that claim is even more outlandish than the claim that PA's will over-run primary care. I challenge a PA to tell his patient that he is so and so, has trained for such and such a period and will now operate on you. No one would accept it, society wouldn't accept it. It's to one's benefit, except territory hungry ancillary professionals.
I've been told Florida and California pharmacists have limited prescribing and substitution rights. Even as a pharmacist, I find that to be ridiculous. My training as a pharmacist was sufficient to be a pharmacist, not to be making therapeutic decisions.
All in all, if the public was truthfully told what was going on, they would invariably choose a member of the medical profession to be their care provider. Ancillary providers are for ancillary needs.

 

[orthoguy]

More random thoughts (Note: please refer back to my previoud random thoughts post for more insights)


1)Dcw must have not studied anything but the Kreb cycle during medical school based upon all posts referring to the content of a medical school curriculum

2)One CANNOT make broad generalizations about anyone based upon posts on internet chat boards........this cannot be stressed enough people

3) Hail monkeys

4) I like this particular angry animation for no real reason

 

[MustafaMond]

1)Dcw must have not studied anything but the Kreb cycle during medical school based upon all posts referring to the content of a medical school curriculum

2)One CANNOT make broad generalizations about anyone based upon posts on internet chat boards........this cannot be stressed enough people

PLease tell me that you are intentionally being sarcastic. Please tell me that you do see the contradiction there.

 

[Thewonderer]

It is hard to keep track of all the posts that have been posted between dcw135 and womansurgeon. But from my impression, it seems that in the beginning, dcw135 was thinking about PA/NP's replacing surgeons but then I think he backed down a bit later and said that PA/NP's are just as capable if not more capable than residents and even fresh attendings IF they get to do a lot of cases (under some supervision of course) However, in order to be THAT experienced, they have to do a lot of surgeries (i.e. isn't that equivalent of a training program???). On the other hand, Womansurgeon has been talking about the SAME thing.... PA/NP's cannot be that good at surgery unless there is a special training problem established for them.

So perhaps in the end you two are arguing past each other even though you agree on the same thing?? But then, maybe I am wrong so you two can start your argument again....

Ultimately, I don't see a problem where surgery will evolve to where anesthesia is at right now. CRNA are "specially trained" (they are not just any PA or NP's, but they are CRNA's) to do anesthetic procedures, and can do a lot WITH the supervision of an attending that covers 3 OR cases at the same time. I don't see why there won't be a CRNA-equivalent surgery personnel in the future who can cut general surgery cases and when in trouble, they can turn to an attending surgeon who also covers 2 other OR rooms. What do you think?

 

[Voxel]

What happens if the S**t hits the fan in two rooms at the same time cause by these NP/PA/Whatever you want to call them? How are you going to have that surgeon be in the same room at the same time. I would never accept this arrangement for my family going under the knife. And the surgeon would have to face the families afterwards. Boy I sure would hate to be in his shoes and the malpractice lawyer will have a field day with his sorry ass.

 

[Thewonderer]

Originally posted by Voxel
What happens if the S**t hits the fan in two rooms at the same time cause by these NP/PA/Whatever you want to call them? How are you going to have that surgeon be in the same room at the same time. I would never accept this arrangement for my family going under the knife. And the surgeon would have to face the families afterwards. Boy I sure would hate to be in his shoes and the malpractice lawyer will have a field day with his sorry ass.

Well, same thing as what happens when S**t hits the fan in two separate OR's with CRNA and/or Anesthesia resident.... i.e. you get another back-up attending who has the pager to come in.

The system has already subject your family to this type of anesthesia arrangement. I don't see why surgery can't do the same in the future.

 

[Voxel]

Unfortunately, in any one town there maybe 4 general surgeons/hospital, and it may be the day that all but one general surgeon is in clinic, the other is in the OR supervising NP/PAs who make a critical mistake and unfortunately the S**t hits the fan and your family member dies. I don't want a healthcare system that exposes my family to those kinds of risks. Maybe you are ok with it, but I am not. In fact I'd rather have the surgeon (and the anesthesiologist) to be in the room with my family throughout the entire operation. And, here's the clincher, I'd be willing to pay for it in terms of higher premiums or co-pays or extra fee-for service dough.

Lastly, I'd rather not put my family in a situation where there are residents or CRNAs unless they must have a procedure done at place X which has CRNAs and Resident Anesthesiologists.. I would go to a private hospital without residents if I could help it. Otherwise, I'd ask Dr. Anesthesiologist for a favor and then hand him some bills to be in the room from start to finish.

Unfortunately back up attendings on beeper call for elective/non-emergency procedures may not make it in time to save grandma.

 

[AviatorDoc]

Speaking on the topic of allied health professionals, I'd like to share a little experience of mine.

In between 1st & 2nd years (during that one month "vacation" we get), KCOM sends students out to do a two-week rotation in a primary care setting... sort of whetting the whistle to get us through the second year. I was in a very small town in Missouri shadowing a couple of family practice docs. It was a really great experience, especially so early on in our training. I even got to scrub in on a few surgeries. I actually got to assist on a C-section. Not just "hold", but actually stitch!

Anyway, here's the interesting part. The only physician in the entire room was the family practice doc. No OB/Gyn, no anesthesiologist, no pediatrician. The rest of the room was full of nurses, and a lowly quasi-2nd yr med student. So I was curious as to how common an event this was. Turns out this happens all the time in small towns. They've been doing it for years. And they've been doing fine at it.

If I have a point here, its this: the trend right now is for NPs/PAs and the like to continue to make gains in the fields that were once solely that of the physician. And the trend doesn't look to be slowing, like it or not.

If you don't like it, stand up and be heard. Work for public policy against it. Work to fix this insane medical insurance mess we're in. Otherwise, don't start crying when your neighborhood NP/PA starts making as much money as you, doing the same job as you.

 

[womansurg]

Originally posted by Thewonderer
Well, same thing as what happens when S**t hits the fan in two separate OR's with CRNA and/or Anesthesia resident.... i.e. you get another back-up attending who has the pager to come in.

When I was at Ohio State, one of the surgeons was simultaneously staffing three ORs at the same time. He'd have three senior residents working at once, and go from room to room for the difficult portions of the case.

He was indicted for Medicare fraud.

The ACGME mandates - and correspondingly the standard of care to which the medicolegal community holds surgeons acting as teachers - is for graduated responsibility throughout the five years of training. Senior residents operate independently on select cases, during which staff must be 'immediately available'. Most people interpret this is being, at the very least in the hospital, and more commonly, coming down to look in during the case and make certain things are going well.

I suppose a similar arrangement could exist with ancillary personnel (PAs, RNs) in theory. I think that a jury and the licensing boards would be tremendously less understanding of a complication which occurred while a surgeon was available but just choosing not to operate while his PA worked, than they would if a surgeon was making a responsible decision to be absent but available in the normal course of teaching a surgeon-in-training to work independently and autonomously. And no one would be at all understanding if a PA or a surgeon-in-training operated while no one was available.

In general, patients fare better in teaching hospitals than they do in nonteaching hospitals. Probably there are just that many more minds applying themselves to the problem, so that correct diagnosis and treatment are arrived at sooner. The exception is surgery patients. Experienced private surgeons have better outcomes overall than the collective outcomes of teaching surgeons and their proteges.

As to C-sections, it's pretty common for FPs to do them. There is a nationwide shortage of OB/Gyns, and somebody's got to deliver the babies. Even here in the heart of metropolitan Des Moines, we've got an FP who does sections on a regular basis. I don't think the OB/Gyn community likes it, but it's a fiscal and physical reality.

 

[droliver]

Originally posted by womansurg

.Experienced private surgeons have better outcomes overall than the collective outcomes of teaching surgeons and their proteges.

Is this published? I've seen the whole outcome comparisons of teaching vs. private hospitals (in which teaching hospitals overall fare better), but I've never seen a breakdown of surgical procedures as such. Was it comparing specific high-risk ones (AAA's, pneumonectomy, or valves/CABG's) or common procedures like hernias,etc....?

 

[womansurg]

It's been a couple/few years. I read it in one of my (many) journals I take, so couldn't tell you offhand where I saw it, or any of the particulars. Would have to do a lit search .

 

[Andrew_Doan]

There's been a big discussion on how physicians get paid too much and that their incomes will drastically decline due to supply/demand, competition, and economic forces. I've made the point that the portion of the health dollar that physicians receive is less than 10-15% of the pie.

Interestingly, I was reading the business section of the NY Times, and the sector in health care that has demonstrated the most increase in profits were the HMO. Yes, hospital and health care organizations made an average of 40% gains in profit while the economy has tanked. These organizations are purely for profit and only care about returns to their stock holders. The second sector to make the most gains were the nurses due to the great shortage of nursing. Nurses can make about $80,000 per year now through agency work. The third sector are device manufacturers. An example they gave in the article is cardiac intervention. Cards used to balloon everyone at $300 cost for the balloon; however, post-procedure occlusion is very high. They started stenting at $1000 per device. Stenting also resulted in high rates of re-stenosis; so now there is the coated stent that costs $2000-$3000 per stent! Stents will cost an estimated 1.5 Billion dollars next year for all the new interventional cases.

Many here have argued that physician's salaries are the reasons for high health care costs and should be and will be the target for future cuts. While the above three sectors have increased profits and reimbursement several fold, physicians salaries have only increased 2% per year for the last decade! Clearly, what doctor's make is trivial in the whole scheme that demand how much our society must pay for health care. Thus, if we are to reduce health care costs, we must do more than simply reduce physicians' reimbursement, which is already at a historical low.

 

[Thewonderer]

Originally posted by womansurg

The ACGME mandates - and correspondingly the standard of care to which the medicolegal community holds surgeons acting as teachers - is for graduated responsibility throughout the five years of training. Senior residents operate independently on select cases, during which staff must be 'immediately available'.

It is interesting that you brought this up, because my friend has told me cases in the VA where the chief resident is the "man" in the OR. Horror story happens when chief resident has trouble control bleeding during the surgery and thus a med student has to stick around for a 12-hour lap chole while an attending is tied up at the main hospital and cannot come to the VA to help out.

How can the VA system work like this?

 

[chessgirl]

I have been reading these, rather heated, arguments over the past day or so and found them facinating and frustrating. Before I throw in my 2 cents, I will explain my position and limitations. I currently working as a research tech in a teaching hospital (6yr) and plan to go into the PA profession as soon as I can. I know that I don't fully understand some limitations until I experience them, but here are my opinions from my perspective.

The future that I see from medicine in an increase in fragmenting duties. Midlevel practioners are showing signs of being here to stay because they can, and do, effeciently and effectively extend care to patients in a variety of capacities. Unfortunately, this is the time that we are stuck in where there is a lot of grey area where duties/responsibilities/education overlap. One point that was mentioned earlier was that medicine was, at one time, limited to physicians only and that every proceedure was their responsiblity. This is an important point to consider when projecting into the future.

Progress has pushed medicine along and now we have nurses, PCTs, PA, NP, and others who perform these and other responsibilities. What no one has addressed is why this was allowed to happen. It happens because we have a greater expanse of knowlege about the human body and its functions, mostly in a very short period of time. This expanse has caused the fragmentation of medicine into very select and concise specialties. Doctors of various degrees no longer oversee every little proceedure because it is no longer necessary and the risk involved to the patient has dramatically decreased with education and research. Doctors forge that way and others fill in from behind. Does that mean that doctors are less then they were? Of course not, it means that doctors and their jobs have evolved. This will happen with the midlevel practioners as well, but we will always be following from behind.

If you carry this trend into the future, what does that mean for medicine? Well let me whip out my crystal ball and give you a divinely inspired answer (note sarcasm)...I believe that midlevel practioners will be seeing more opportunity to expand their services. Already the education for intermediates is beginning to fractionate. There is "residency" training for midlevels, although in its infancy (I use the term 'residency' since there is no appropriate word coined yet), and services are in high demand because of the spiralling costs of care. Does this mean that PAs will be able to perform surgury? A very cautioned 'perhaps'. I say this because at the rate of medical knowledge expansion, it could happen. But only if proper training was in place to teach and supervise it. Midlevel practioners are not meant to replace doctors in the sense that they are no longer needed, but to free them and enrich their care to others.

I am concerned about the sentiments floating around about the character and quality regarding midlevels. The general population of midlevels is made of other healthcare workers (EMT, nurses, paramedic, etc) who want to go into the field because the want to do more then they are currently doing. Not because they want to get by doing less. It is probably true that the decision is heavily weighted by lifestyle considerations; however, that does not make them second rate health providers. Their care and committment to patients is just as deep, and shallow, as doctors. It just manifests itself in a position that has limitations. Like every profession there will be those who abuse it and those who are not in it for the "right" reasons. Unfortunately, the grey area is fogging all of our perceptions of how far all healthcare professionals will mesh.

I think that my 2 cents has turned into a dime. Sorry!

 

[AviatorDoc]

Thanks, chessgirl, for the perspective.

There's way too much "everybody-but-me" bashing that goes on here. Many physicians justify the hell they go through by believing they are superior people, when in fact, most of the business world laughs at how doctors handle money. Investment managers know a good thing when they see a physician with lots of money and no time to watch it closely.

Doctors are sometimes known as the worst pilots. This is because many physicians will purchase an airplane, believing that learning to fly couldnt be half as hard as learning to be a physician. They don't put the time & effort into learning, and thus run into big trouble.

Within the practice of medicine, you have all sorts of specialties vying for "whos the best." Everybody says "It really depends on you" but deep down, we're rationalizing how our chosen specialty really is the best. Here on this network, the MD forums are full of "what's yer stats" and the DO forums are full of "why we're superior."

Having said all that, how about getting back to the original topic?

Predictions for the future:

Medicare will go broke. It will plunge us into a recession and a health care crisis/emergency.
HMOs will begin to break apart once physicians & patients get wise & get politically active.
Procedures will always pay more. PAs & NPs will be doing more of them.
Surgery specialties will continue to pay more than medical specialties.
"Income" and "Lifestyle" will become much less synonymous.

 

[orthoman5000]

This whole argument of if NP's/PA's had the same training as a surgeon (minus a few years of memorizing basic science) they could do surgery reminds me of one of my favorite sayings: "If my aunt had a dick she'd be my uncle." If NP's/PA's had the same training as a Doctor we'd call them MD's!

I'll relay a story that an MD told us during my first lecture of my first day of medical school (O.K. I'm an MS1 so it wasn't very long ago). He was talking about the albumin levels of a patient that they were prepping for surgery. The blood levels just would not go up to an adequate level. Anyway the intern did the math again and determined the patient hadn't been recieving a high enough protein intake. Seems the the first diet was figured by a "paraprofessional" as the MD put it. He then said rather firmly "Never let a paraprofessional make important clinical decisions for you. The burden is on your shoulders, and unless you have the utmost trust in their judgement you make the decision."

Remember this is Day 1, Lecture 1 of medical school so they obviously though it was pretty important.

 

[orthoman5000]

Ah yes, one more thing.

My father earned his pilots liscense years ago and what his instructor told him was that physicians and ministers make the worst pilots. Why? Not because of lack of skill. It's just that those two professions are more willing to take risks while flying because they often deal with life or death on a daily basis and it's practically routine for them to be staring death in the face.

So it's not a skill thing (but sort of an arrogance thing).

BTW my Dad is a Minister.