Holy poo! Hate for midlevels.

[oldManDO2009]

just adding to Taurus - maybe expand the military GMO position to civilian physicians. They could be licensed to practice after a one year rotating internship (like most DO's complete) and could complete a residency if they so desire to specialize. This would take the financial strain off of physicians to complete advanced training for less compensation. Leave some advance track in place for future training.

I am tired of the argument that NP's do not want to expand their scope of practice with the DNP. It is obvious and this war is being wage RIGHT NOW in anesthesiology. The CRNA's are looking to get into pain mgt by stating they need fluoroscopy to insert picc lines and central lines. What a joke - this is an obvious attempt to get licensed to use fluoro and then pain mgt is nothing more than a procedure and the practice of nursing.

So we should not waste any time with polite negotiations with the newly minted "Doctors" via pressure by the AMA and our PAC contributions we need to stop this intrusion right now. Along with educating the public about the differences between the "Doctors" by "who would you want saving grandma's life?" TV spots

The practice of nursing has nothing to do with prescriptions and medical diagnosis so we can stop pretending the ANP act is not the practice of medicine and DNP need to remain supervised. Physician training is superior to DNP training (Just look at the differences in classes posted by zenman http://forums.studentdoctor.net/showthread.php?t=289278&page=10)

If the DNP is not meant to expand the scope of practice then why create this new degree? Because everyone else did is not a convincing argument. It is clear that this is an attempt to increase they reimbursement and scope practice.

This thread is directed toward those militant NP/DNPs that are demanding independent practice. Most the mid-levels that I have worked with are part of a team and understand their limitations as do I. I will not be able to do neurosurgery as a future EM doc and understand the limitation of my training (I have worked in the ER for years as an RN) and have no problem with it.

So before you go defending the poor DNP answer 1 question. What does the new degree bring to the table in terms of training. Since you can get the degree on line while working full time there does not seem to be an improvement in academic standards as compared to the PA degree program (medical model)?

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[foreverLaur]

For the same reason that Physician Assistant programs and Physical Therapy programs are all becoming doctorates as well.

I'm just not sure what that reason is haha

I was thinking about getting my DNP because I want to be a Nurse Practitioner, but I'd also like to teach, but I hate the idea of Ph.D. because I am not interested in heavy research and I like the clinical aspect of things. I have no intention of working independently.

 

[Taurus]

I am tired of the argument that NP's do not want to expand their scope of practice with the DNP. It is obvious and this war is being wage RIGHT NOW in anesthesiology. The CRNA's are looking to get into pain mgt by stating they need fluoroscopy to insert picc lines and central lines. What a joke - this is an obvious attempt to get licensed to use fluoro and then pain mgt is nothing more than a procedure and the practice of nursing.

I am interested to see how this unfolds too. The CRNA's have made the most inroads of any nursing group. The anesthesiologists have done a pathetic job of responding to the CRNA's. If the anesthesiologists had visionaries among their leaders, they would have pushed through AA legislature 20 years ago instead of today when there is great resistance from a very well-funded, well-organized CRNA lobby.

What I hope is that the AMA realizes that the CRNA achievements are not only a threat to anesthesiology but to all of medicine by setting a dangerous precedent: that a fellowship-based medical subspecialty can be invaded by a Master's level nursing group. The AMA needs to use their clout to push through AA legislature in all states and to open more AA schools, similar to how they responded by creating more PA schools in response to the NP attempts at expanded scope more than a decade ago. If any group can do it, it's the AMA.

The way I look at things, you can respond to groups who attempt to expand their scope through many ways. There are political and legislative means. There are also market-based moves, which I favor.

 

[oldManDO2009]

corporate medicine began to grab contracts from EM physician groups and the AAEM began to fight the devaluation of EM physicians. We need a PAC group that has only one purpose - fight the expansion and independent practice "rights" of NP/DNPs and ensure they remain supervised.

I am not sure if this group already exists but it would be a worthy recipient of my hard earned money.

 

[guetzow]

There is some mad midlevel hate on this board...and it scares me, because I may want to be one....and its important for me to work with a doctor. Preferably in a mutually contributing but obviously stratified role...I realize that the push for NPs/PAs to recieve doctoral degrees is making doctors feel like their turf is being invaded, but don't all the people who become midlevels KNOW they will need help/input from a physician? If I become an NP/PA, I won't expect to be autonomous and I won't expect to be completely subservient either.
I just don't want the day to come when I'm an NP or whatever and no doctors will hire me. Lol.

Seinfeld said it best, "The Best Revenge is LIVING WELL". Six figures and NO CALL here. I hope the haters all have MIs and CVAs from all that smouldering. I'll be in my pool...

 

[Jengirl18]

As a new graduate from a PA program, I am also against the DNP program if it is to increase scope of practice and be totally independant from physicians. I have nothing wrong with the degree if it the real reason is to increase the number of nurses teaching at NP programs. There is nothing wrong with increasing one's education to be more knowledgable in research, teaching, etc.

PAs (to my knowledge) have never tried to push for a doctorate degree. We want to work with physicians, not against them. I feel very satisfied in my training as a PA, and would have gone to medical school if I had wanted TOTAL independence. Unfortunately, I do see in the future PA programs becoming doctorate only BECAUSE of the DNP push, if it means that our jobs are threatened.

Someone mentioned the idea of kicking out PAs and putting new physicians (before residency) into their jobs-this idea is rediculous b/c there is a HUGE difference in the ICU (for example) between an experienced critical care PA and a 4th year medical student (which I saw on my trauma rotation). The experienced PAs actually supervised/taught some of the 3rd/4th year surgical residents how to do the procedures, so there's no way that a physician before residency could do this and not compromise patient care since most of this experience is taught in residency.

If you compare the DNP curriculum to the PA curriculum, you would probably see how the DNP is now trying to encorporate classes that the PA curriculum already has at the Master's level-epidemiology, bioethics, etc). I really feel that there only needs to be a revamping of the current NP curriculum to include more of these classes-not to make a 40 credit doctorate level program.

Again, I really dont have a problem with it if it's to make more competent NP educators, but to try and expand the scope of practice with just a 40 credit program is rediculous.

 

[Taurus]

Someone mentioned the idea of kicking out PAs and putting new physicians (before residency) into their jobs-this idea is rediculous b/c there is a HUGE difference in the ICU (for example) between an experienced critical care PA and a 4th year medical student (which I saw on my trauma rotation). The experienced PAs actually supervised/taught some of the 3rd/4th year surgical residents how to do the procedures, so there's no way that a physician before residency could do this and not compromise patient care since most of this experience is taught in residency.

I'll respond to this. Who has more training, a newly minted medical school, NP, or PA grad? Of course a new medical school grad doesn't have much experience as an NP or PA who has been on the job for 20 years. But a medical school graduate can compete pretty well if not better against new NP or PA grads for midlevel jobs. With time and experience, that non-residency physician will know as much and probably more than that PA or NP.

This idea is not new. A Canadian province (I think Mannitoba or Ontario) already allows FMG's to work as midlevels.

This hasn't taken off in this country because we've always had more residency slots than grads. In fact, we've had to import FMG's to fill the gaps. Now with class sizes +20%, more MD and DO schools opening, and unless Congress increase the number of residency slots, that gap is closing. We may see a day when there will be more grads than residencies. If that happens, then the next logical step is to allow them to work as midlevels. Anyone who argues that a non-residency physician isn't qualified to work as midlevels is well naive.

The danger to PA's and NP's isn't that large numbers of these non-residency physicians will start to take their jobs. There will be only several hundred of these people at most I suspect. Instead, the worry should be because it's opening a Pandora's box. You're opening a door to a new pathway that physicians may decide to expand at some later point if they feel threatend by NP's or PA's a la the Canadian province example. Physicians can lay down the time-consuming groundwork now by updating state laws, hospital policies, etc.

 

[Jengirl18]

If the number of medical school graduates keep expanding, we may reach a point where there are more graduates per year than residency positions. The AMA should consider creating a new pathway for these individuals. Since they are already better trained than a DNP or PA, the newly minted MD or DO graduate is more than qualified to function in the midlevel position and can probably edge out any PA or NP for these jobs.

Hi Taurus,

I agree with you that a new grad MD or DO has more training/education than a new grad PA, but you didn't specifcy that in your above quote.

I was talking about a PA who has critical care experience (for example) of even 3 years should be able to function better in that setting than a new MD/DO who has not had residency. It's all about the experience at that point. Beyond residency, that's a different story.

 

[core0]

I'll respond to this. Who has more training, a newly minted medical school, NP, or PA grad? Of course a new medical school grad doesn't have much experience as an NP or PA who has been on the job for 20 years. But a medical school graduate can compete pretty well if not better against new NP or PA grads for midlevel jobs. With time and experience, that non-residency physician will know as much and probably more than that PA or NP.

The difference is primarily in how the training is carried out. I believe it is bandit who stated that medical school produces a physician and residency produces a clinician. PA training is focused on producing practicing clinicians. Could a new grad PA run an ICU, no. But neither could a new med school grad. Now that I am working in academia I am impressed by the strides that interns make in their first year. Most interns that I deal with could easily run an ICU 3-4 months in (and do). I don't think that I can say that about most PAs. However it is also the difference between an educational opportunity and a job.

This idea is not new. A Canadian province (I think Mannitoba or Ontario) already allows FMG's to work as midlevels.

Ontario is allowing a few select FMGs to train as PAs. They have to forfeit the right to apply to residency for four years and most have more than 5 years experience as practicing physicians in their home country. Alberta is also looking at using FMGs for PAs but there the training time is the same (actually a little longer). The difference is that FMGs have less didactic time and more clinical time. The two other "experiments" using FMGs as PAs have occured in the BOP which uses unlicensed FMGs as unlicensed PAs (ie they are not qualified to be licensed in any state as PAs). Florida also attempted license FMGs as PAs but none of them were able to pass the test developed by the state. A number continue to work as PAs since they have a provisional license that does not expire until they fail the test six times (and the test is no longer given). I can also think of at least one state that prohibits a PA from getting a license if they have graduated from medical school. Overall the experience of using FMGs as PAs has not been positive.

This hasn't taken off in this country because we've always had more residency slots than grads. In fact, we've had to import FMG's to fill the gaps. Now with class sizes +20%, more MD and DO schools opening, and unless Congress increase the number of residency slots, that gap is closing. We may see a day when there will be more grads than residencies. If that happens, then the next logical step is to allow them to work as midlevels. Anyone who argues that a non-residency physician isn't qualified to work as midlevels is well naive.

You could also argue as the number of US grads increases the number of FMGs getting residency will decrease.

The danger to PA's and NP's isn't that large numbers of these non-residency physicians will start to take their jobs. There will be only several hundred of these people at most I suspect. Instead, the worry should be because it's opening a Pandora's box. You're opening a door to a new pathway that physicians may decide to expand at some later point if they feel threatend by NP's or PA's a la the Canadian province example. Physicians can lay down the time-consuming groundwork now by updating state laws, hospital policies, etc.

Right now a physician without a residency could do this. They would still be liable as any other physician. You can also see anecdotal tales here about physicians with only internship training getting in trouble working at the local doc in a box. Also what is the point of racking up the medical school debt if your income is going to be limited to 2/3 the salary of average FP physician at best. Finally, I doubt that practicing physicians would be interested creating a subclass of physicians that needs to be supervised by other physicians.

David Carpenter, PA-C

 

[MedicalMilf]

As a PA it is required, not a matter of wanting....

Ha Ha...not so fast!!! Some PA's actually hire their supervising physicians and because NP's are regulated by a different entity than Physicians and PA's AND have one of the most powerful lobbying groups in this country, they need not have any association with either.

 

[MedicalMilf]

I would not be surprised if it comes true, for many reasons.

1) NPs earn considerably less money than MDs, making them preferable in the eyes of managed care.

2) It is not politically correct to talk about "aptitude" "skill" or "intelligence." NPs (with a few exceptions) do not have the aptitude to make it into med school, but anyone who brings up this fact will be frowned upon for being "elitist" and "mean." (Do not expect any NP "board exams" to be anywhere near the USMLE in terms of content or difficulty.)

3) I could train a high school student to follow a protocol for DM or HTN care. As long as that is the metric by which we measure patient care, of course an NP will be just as good as an MD. An LPN would probably be just as good too.

4) Nurses in are constantly exhorted to double-check MDs, be independent, never settle, always strive to become an NP. In other words, it is no longer acceptable in many circles to "just" be a nurse. I've met plenty of not-too-bright nurses with online degrees, who speak of their plans to become NPs as a matter of fact.


I could go on, but... well, it gets even more depressing from there.

I am so sick of people with this "NP's are people ho couldn't get into med school" egocentric attitude. Educate yourself about the differences and one will quickly see that the models of training and patient-care approach are both very different for the 2 professions. And just to pre-emptively extinguish any burning fires: NO, I am not a nurse, rather a PA student trained in the "medical model" . . . just like the physicians I will work side-by-side with.

 

[foreverLaur]

Why is it that everyone thinks that anyone in the health care profession who is not a doctor is simply in that profession because they weren't smart enough or intelligent enough to hard working enough to survive medical school?

I have not yet met a mid level provider who wanted to go to medical school, couldn't make it, and simply "settled" for their current career.

 

[JRJ26]

Why is it that everyone thinks that anyone in the health care profession who is not a doctor is simply in that profession because they weren't smart enough or intelligent enough to hard working enough to survive medical school?

I have not yet met a mid level provider who wanted to go to medical school, couldn't make it, and simply "settled" for their current career.

One of the nurses I work with actually wanted to go to medical school, took the MCAT, but didn't get a good score and ended up doing nursing. However, he's the exception rather than the rule.

 

[MedicalMilf]

Forever, I think your English skills may have barred you from med school. Just a thought.

 

[foreverLaur]

Forever, I think your English skills may have barred you from med school. Just a thought.

1. I don't think there is anything wrong with my English.
2. You can't judge a person's ability to write English on a forum when people write like how they do on AIM (or at least I do) with no disregard to some punctuation, capitalization, and use of slang.
3. I write for the university newspaper.

 

[foreverLaur]

Yesterday you ripped on me because I didn't spell "sophomore" correctly after 34hrs on-call.

Today it's totally acceptable to screw up your English on SDN.

There is a difference between using Internet slang and not knowing how to spell a very commonly used word. Show me where I misspelled something?

 

[foreverLaur]

Could you be any more desperate to be right all the time?

I am right until proven wrong. I don't go posting false information that will be viewed (and possibly taken as fact) by others.

 

[fab4fan]

1. I don't think there is anything wrong with my English.
2. You can't judge a person's ability to write English on a forum when people write like how they do on AIM (or at least I do) with no disregard to some punctuation, capitalization, and use of slang.
3. I write for the university newspaper.

Are you totally incapable of ever saying "I was wrong"? I'm just wondering, because if you really want to go into the medical field, you'd better be prepared to admit to making mistakes. You have to have some humility. So far, I haven't seen you display either, and it concerns me for the sake of your future patients and co-workers.

 

[Chronic Student]

Not trying to gang up on you, but ditto what fab4fan said.

Its like I try to explain to my mon about going 50 MPH in the fast lane. Her response is always, "Why are all these people going so fast?".

I have tried to explain to her that after the twentieth person has passed you, then maybe its not the other people and you need to consider that it may be you.

Just my opinion.

-Mike

 

[lawguil]

I am right until proven wrong. I don't go posting false information that will be viewed (and possibly taken as fact) by others.

Yes, your writing is often painful to read......

and I do believe you're in your early 20's.

and anybody can write for a university newspaper, but i'm sure you'll tell us that you have to be special to write at your university paper.......

You have a long way to go!

Humility anyone?

 

[oldManDO2009]

I don't seem to be able to learn without making mistakes lately. I gave my attending the wrong labs on a patient today and did not realize it until the words had left my mouth. He laughed and told me to get used to being yelled at...

I am just glad I am in a learning environment were mistakes are possible and learning is expected. I have no illusions of perfection.

Then again welcome to healthcare...

 

[PSYCHARNPTOMD]

I am new and see there are several NP/ PAs considering Med school. I am wondering why. Oh I am one of them

 

[zenman]

I am new and see there are several NP/ PAs considering Med school. I am wondering why. Oh I am one of them

How long you been wondering?

After talking with a married couple (MD) who are triple certified, I've decided to go do the post-masters psych NP program I've been thinking about for a while. But no way I'll be even thinking about MD; too old anyway.

 

[Taurus]

Finally, I doubt that practicing physicians would be interested creating a subclass of physicians that needs to be supervised by other physicians.

What do you call residents being supervised by an attending? Those residents are doctors. What's the difference then between supervising residents and a doctor who is not on a residency track?

If there is a new pathway, most people would use it as a way to buff up their resume, not as a career. Like how some people now spend years working in a research lab before applying med school to buff up their med school application or how some people spend 1 year doing research while in med school to buff up their residency application. FMG's could definitely use it to prove to residency directors that they're capable. This will become more and more important as the competition for residency heats up and there is no longer a guarantee of a residency position.

I like the idea because I think it's wrong to lock someone into at minimum a 7 year path that they may or may not like. Some people become disenfranchised with medicine after going through 3rd and 4th years. If they have no desire to work as an attending, they should have the option of working immediately after med school in a role that's below an attending but above NP or PA midlevels. Right now, if a medical school grad decides not to pursue residency, he/she has to find another career and basically waste their 4 years of training. Isn't that ridiculous when you think about NP's and PA's who go for just 2 years and can find a job? I don't think that your argument about med school grads not being able to fill such a role holds much water. I think that they are more than capable, especially when you compare new med school grads with new PA or NP grads.

Look at it this way. The medical establishment a few years ago unilaterally decided without any promises by Congress of more residency positions to increase enrollment by +20%. Does anybody really know what the true motive was? Was it a countermove in response to a power grab by the nurses? Was it a preemptive move to try to pressure Congress to increase residency numbers? Why such a dramatic increase of 20% versus a more conservative 5% even when they knew that more MD and DO med schools were opening? Who knows.

No matter what the motive is, this is how it could eventually play out. If Congress does nothing, then it's quite possible that med school graduates may not get a guaranteed residency position anymore and my prediction of a new pathway comes true. If Congress does increase caps, that means more residents, which would be disfavorable for midlevels who were greatly benefited by the 80 hour work rule. Either way, it's a win-win for those of us in medicine.

 

[lawguil]

What do you call residents being supervised by an attending? Those residents are doctors. What's the difference then between supervising residents and a doctor who is not on a residency track?

If there is a new pathway, most people would use it as a way to buff up their resume, not as a career. Like how some people now spend years working in a research lab before applying med school to buff up their med school application or how some people spend 1 year doing research while in med school to buff up their residency application. FMG's could definitely use it to prove to residency directors that they're capable. This will become more and more important as the competition for residency heats up and there is no longer a guarantee of a residency position.

I like the idea because I think it's wrong to lock someone into at minimum a 7 year path that they may or may not like. Some people become disenfranchised with medicine after going through 3rd and 4th years. If they have no desire to work as an attending, they should have the option of working immediately after med school in a role that's below an attending but above NP or PA midlevels. Right now, if a medical school grad decides not to pursue residency, he/she has to find another career and basically waste their 4 years of training. Isn't that ridiculous when you think about NP's and PA's who go for just 2 years and can find a job? I don't think that your argument about med school grads not being able to fill such a role holds much water. I think that they are more than capable, especially when you compare new med school grads with new PA or NP grads.

Look at it this way. The medical establishment a few years ago unilaterally decided without any promises by Congress of more residency positions to increase enrollment by +20%. Does anybody really know what the true motive was? Was it a countermove in response to a power grab by the nurses? Was it a preemptive move to try to pressure Congress to increase residency numbers? Why such a dramatic increase of 20% versus a more conservative 5% even when they knew that more MD and DO med schools were opening? Who knows.

No matter what the motive is, this is how it could eventually play out. If Congress does nothing, then it's quite possible that med school graduates may not get a guaranteed residency position anymore and my prediction of a new pathway comes true. If Congress does increase caps, that means more residents, which would be disfavorable for midlevels who were greatly benefited by the 80 hour work rule. Either way, it's a win-win for those of us in medicine.

You can't argue that it's an interesting idea to have a sub-class of non-residency trained physicians, but a lot of questions would have to be answered. Not having a background in medicine, I would have these questions:

1. I was under the impression that many residencies go unfilled every year due to the lack of graduating physicians, exspecially in primary care.

2. Would an non-residency trained MD be comparable to a PA. As mentioned before, PA education (similar to PT, DDS....) is tailored in such a way that the student is prepared to practice when they graduate. My understanding is that an MD isn't prepared the same way, but I guess you could argue that the clinical training is greater than that of a PA.

3. How would these physicians be paid and how would they be reimbursed?

4. The big question for me is: why would you create a longer, more expensive path of education in this dang age. non-residency trained MD = more money, more dept, and similar ability to that of a PA with less dept, and potentially similar pay, and less time in school (although, if you look at it in number of months, it isn't terribly different). What would an MD student who wasn't interested in med school do their last year in med school?

5. If your idea were to happen, once a base of non-residency trained MD's were established (= dependent practitioner similar to a mid-level), you can anticipate an entirely new political movement......non-residency trained MD's who lobby to be independant practitioners (hey they're already 'doctors' who went to med school.....we're giving it to NP's, why not MD's). Also, how does a non-residency trained (dependant pratitioner) introduce themselves to patients?.........Similar to when I'm being seen by an NP or PA, I definately want to know when I'm seeing the Real "doctor" and in my eyes, a non-residency trained MD must be supervised. When I've been seen by a resident at a hospital, they always say....."I'm Dr. XYZ, a resident".......
It just seems like you would be marginalizing the education of a physician.

I'm sure folks trained in medicine can think of many more than I can.

Interesting nonetheless and obviously possible.

 

[Taurus]

The details of any new pathway will get hashed out later so I won't attempt to come up with them. There will be some common ground that every can live with.

Can you imagine the PR nightmare that the medical establishment would have if it became common knowledge that people may spend 200k and 4 rigorous years and may have to look for new careers because they couldn't get a residency? If you read some of the threads on this board, what are common themes for why people go into medicine (besides of course helping people)? Good job prospects, good job security, guaranteed high pay compared to law or business, etc. Basically, it's because medicine is as close to a sure thing as you can get -- once you survive the training. People put up with the high tuition and long hours of studying and being on the wards because they think that they will be rewarded for their efforts, even if it's with a FP residency. If you tell them that they may not be able to obtain a residency and that they may need to look for another career, that's going to send a huge chill through the application pool. That's why the medical establishment will create some new pathway if suddenly 5-10% of grads can't get residencies initially.

I say 5-10% because I don't believe that being an American MD or DO grad will guarantee you a spot over FMG's or IMG's. Residency directors I believe will select a foreigner with 99% percentile board scores, 5 first authored papers, and strong letters over an American who barely passed med school. Many of the IMG's I've met in fact have already completed residencies in their home countries. It will be tough for a slacker or someone graduating from a lower tier school to compete against them. The top 5%-10% of people around the world will be competing against the bottom 5%-10% of American med schools. I don't like those odds.

A positive thing about this new pathway is that they are fellow physicians, not NP's or PA's who are set on trying to expand their scope and autonomy. Honestly, I think that the medical establishment should never have created the NP or PA roles and should instead have used this type of provider. A common complaint I hear a lot from NP's and PA's is that they have no way to progress in their careers except to go back to medical school. They're stuck in this second fiddle role even though they may have 20 years of experience. While I don't think that they're equivalent to physicians even after that much time and that these people should have thought it more before they chose the midlevel route instead of the medical one, I can empathize with them for feeling stuck career-wise. These groups will never be happy or rest until they get equivalency.

Remember that technically, a physician who has completed internship and passed Step 3 can practice as a general practitioner, but residency training is becoming the standard, which can be imposed by the reimbursement practices of Medicare and insurance companies. With this new pathway, these individuals have the ability to progress in their careers because all they need to do is a residency and they could become an attending. So I don't see any effort by this new group to organize and lobby.

 

[lawguil]

The details of any new pathway will get hashed out later so I won't attempt to come up with them. There will be some common ground that every can live with.

Can you imagine the PR nightmare that the medical establishment would have if it became common knowledge that people may spend 200k and 4 rigorous years and may have to look for new careers because they couldn't get a residency? If you read some of the threads on this board, what are common themes for why people go into medicine (besides of course helping people)? Good job prospects, good job security, guaranteed high pay compared to law or business, etc. Basically, it's because medicine is as close to a sure thing as you can get -- once you survive the training. People put up with the high tuition and long hours of studying and being on the wards because they think that they will be rewarded for their efforts, even if it's with a FP residency. If you tell them that they may not be able to obtain a residency and that they may need to look for another career, that's going to send a huge chill through the application pool. That's why the medical establishment will create some new pathway if suddenly 5-10% of grads can't get residencies initially.

I say 5-10% because I don't believe that being an American MD or DO grad will guarantee you a spot over FMG's or IMG's. Residency directors I believe will select a foreigner with 99% percentile board scores, 5 first authored papers, and strong letters over an American who barely passed med school. Many of the IMG's I've met in fact have already completed residencies in their home countries. It will be tough for a slacker or someone graduating from a lower tier school to compete against them. The top 5%-10% of people around the world will be competing against the bottom 5%-10% of American med schools. I don't like those odds.

A positive thing about this new pathway is that they are fellow physicians, not NP's or PA's who are set on trying to expand their scope and autonomy. Honestly, I think that the medical establishment should never have created the NP or PA roles and should instead have used this type of provider. A common complaint I hear a lot from NP's and PA's is that they have no way to progress in their careers except to go back to medical school. They're stuck in this second fiddle role even though they may have 20 years of experience. While I don't think that they're equivalent to physicians even after that much time and that these people should have thought it more before they chose the midlevel route instead of the medical one, I can empathize with them for feeling stuck career-wise. These groups will never be happy or rest until they get equivalency.

Remember that technically, a physician who has completed internship and passed Step 3 can practice as a general practitioner, but residency training is becoming the standard, which can be imposed by the reimbursement practices of Medicare and insurance companies. With this new pathway, these individuals have the ability to progress in their careers because all they need to do is a residency and they could become an attending. So I don't see any effort by this new group to organize and lobby.

Interesting!

Do you know the percentage of physicians that choose to complete internship and step 3 every year?

Basically, it sounds like a non-residency option already exists! You're saying to create an option that even eliminates the internship......not being in medicine, I don't understand why that would make sense. I believe medical internships are basically 1 year = general practitioner and physician pay and autonomy.......do you think there would be a lot of physicians who would opt for the non-internship path for mid-level pay and autonomy (but I do get the point about having the ability to compete for residency later on....an option PA/NP don't have).

I'm assuming this is somewhat hypothetical on your part.

It is my understanding that there is a shortage of physicians both currently and future, especially primary care because most MD/DO specialize. Wouldn't increasing enrollment by 20% force med grads to take primary care paths.

Why exactly do you think this could happen......do you really think it's realistic?

I only ask because more than ever, I've been thinking about going back to school, either MD or PA and I've been leaning towards PA.

If this is actually realistic........I might lean MD (assuming I could get into either).

Good stuff

L.

 

[Taurus]

At this point, it's all speculation. You have to look at the facts to help you divine what the future may look like.

1) +20% increases for MD schools already in effect.
2) More MD and DO schools opening.

It's quite possible that existing residencies soak up the increased number of grads. But if you have hundreds of people every year with no residencies, I expect some kind of action by the medical leaders. It's very bad PR if med grads with 200k in debt have to go to work at Wal-Mart because they couldn't get a residency.

Either more residencies will be created by Congress or funded by states or hospitals themselves or some kind of new pathway is created that is inbetween an attending/resident and NP and PA midlevels or possibly both. Either way, it's a win-win for physicians.

 

[primadonna22274]

Taurus, do you really think a "new pathway" is in the works? I've been keeping my ears open for such a thing for years but have never heard more than conjecture. Interesting idea, although I'm not sure that skipping residency would be enticing to me at all--isn't that where the real learning happens?
Huh. Now I'm confused again.

 

[The Janitor]

It's very bad PR if med grads with 200k in debt have to go to work at Wal-Mart because they couldn't get a residency.

Maybe they should've studied harder.

The world does not owe you a living simply because you graduated from medical school. If you have poor grades or board scores, are difficult to work with, etc., don't expect to be welcomed with open arms. Even FM residencies want the best they can get, and rightfully so.

We already have enough mediocre doctors. Inventing a new "pathway" to keep them viable makes no sense. Some people probably should change careers.

 

[Jawbone]

I'm not sure that skipping residency would be enticing to me at all--isn't that where the real learning happens?
Huh. Now I'm confused again.

Exactly. I see doctors go from bumbling (read: teachable) 1st years to excellent (read: independent) 4th years. I can't imagine you could graduate from medical school and swing right into full-fledged practice.

Taurus, what year are you in medical school?

Graduate, go through the hell, humiliation, and learning experience (residency) I observe at work EVERY DAY, and then tell us how you feel about non-residency trained physicians being competent.

Yes, you graduate with a wealth of book and general clinical knowledge. Much more than a midlevel.

Yes, physicians should get to sit on the top rung of the medical ladder.

Midlevels are not out to steal your job.

I don't see any practical use for the DNP either. That being said, I'll be grandfathered in by 2015.

There's a place for MDs and a place for midlevels, and hopefully when we ALL finish our respective educations we can all appreciate that.

Tired, you're awesome.

Peace.

 

[Taurus]

I can't imagine you could graduate from medical school and swing right into full-fledged practice.

Why don't you reread my posts more carefully? I didn't say full-fledged independent practice. I said they would function pretty much as an intern or resident under attending supervision, but they wouldn't be officially in a residency.

It would be a way for people to get experience and buff up their resume before they apply to residency or for FMG's or IMG's to show off what they can do to help their applications. For some, they can make it as a career.

Their role is higher than NP or PA but below a resident. A significant benefit of an MD is that it has fewer legal loops to jump through than either NP or PA. The laws don't differentiate between a residency and non-residency trained MD, but they do for NP or PA. So in states that are more restrictive, it would be advantageous to hire non-residency MD's as assistants because they could get more done with less supervision.

In most places, a physician can practice independently after finishing internship and getting their license. Whether they get reimbursed for it is a different matter. That's why most do a residency.

No one can predict what the future will bring, but one can make some educational guesses. The trend is that there will be more med grads in the future. Something like ~30% increase. If there's no increase in residencies, you're cutting it really close when it comes to displacing the ~30% of residencies that FMG's and IMG's get now. I've worked with many excellent IMG's. Remember, these are folks who may be in the top 5% of their class and many have already completed residencies in their home countries. I really doubt that all IMG's and FMG's will be locked out so that only American med grads will get residencies. If grads can't be guaranteed residencies anymore, it's not hard to imagine that something will change. Maybe it will be more residencies or maybe it will be the creation of a new role. Either way, it's all good.

Physicians are the masters when it comes to limiting supply to drive up demand and hence salaries. For practicing physicians, which scenario do you think they would they prefer? Increasing residencies which leads to increased supply and hence lower salaries? Or, creating a new role that is not a competitive threat?

 

[primadonna22274]

This is my pipe dream: I would love to see a system in the next decade where my experience as a PA is valued as a strong foundation to build upon to create a physician. How to do that? I don't know. It would be a hybrid that cuts out some of the time and expense of the current traditional 4-year med school + 3 year minimum residency. If something like that develops I will most likely partake, but until then I just don't think it's worth it.

 

[Taurus]

This is my pipe dream: I would love to see a system in the next decade where my experience as a PA is valued as a strong foundation to build upon to create a physician. How to do that? I don't know. It would be a hybrid that cuts out some of the time and expense of the current traditional 4-year med school + 3 year minimum residency. If something like that develops I will most likely partake, but until then I just don't think it's worth it.

I don't think that the physician groups are blind. When they see that times are changing, they adapt as well. For example, CT surgery used to take 4 years med school + 5 years gen surg residency + 3 years CT fellowship. CT surgery used to be one of the most sought after residency because attendings were making nearly a million a year. CT surgery has fallen on hard times due to competition from cardiologists. Salaries are like 40% of their peak in the 80's. How did CT surgery respond? By recognizing that the status quo was not acceptable anymore (albiet kinda too late). They've now created a new direct pathway that combines gen surg and CT fellowship into a single 6 year CT residency.

When the physician groups are seeing the NP's coming out with the DNP and pushing for more, they recognize that the status quo is no longer acceptable. They will adapt so that they can keep their field on top. That's why I believe they pushed for more PA schools to open as direct competition with NP's in the 90's and why they increased enrollment by 20% today. Maybe they will see that locking people into a minimum of 7 years of rigorous training is no longer the only way. Today's generation of doctors want more flexibility, more choices.

 

[primadonna22274]

I agree the next decade will be interesting to see how it unfolds.
Can I join you on that cruise ship?

I don't think that the physician groups are blind. When they see that times are changing, they adapt as well. For example, CT surgery used to take 4 years med school + 5 years gen surg residency + 3 years CT fellowship. CT surgery used to be one of the most sought after residency because attendings were making nearly a million a year. CT surgery has fallen on hard times due to competition from cardiologists. Salaries are like 40% of their peak in the 80's. How did CT surgery respond? By recognizing that the status quo was not acceptable anymore (albiet kinda too late). They've now created a new direct pathway that combines gen surg and CT fellowship into a single 6 year CT residency.

When the physician groups are seeing the NP's coming out with the DNP and pushing for more, they recognize that the status quo is no longer acceptable. They will adapt so that they can keep their field on top. That's why I believe they pushed for more PA schools to open as direct competition with NP's in the 90's and why they increased enrollment by 20% today. Maybe they will see that locking people into a minimum of 7 years of rigorous training is no longer the only way. Today's generation of doctors want more flexibility, more choices.

 

[deleted6669]

I agree the next decade will be interesting to see how it unfolds.
Can I join you on that cruise ship?

TAURUS- she's a hottie......but married.....

 

[primadonna22274]

Ha, thanks, I needed that....

TAURUS- she's a hottie......but married.....

 

[Jawbone]

Why don't you reread my posts more carefully? I didn't say full-fledged independent practice. I said they would function pretty much as an intern or resident under attending supervision, but they wouldn't be officially in a residency.

You're right... sorry. Being the subpar researcher that I am, and given my instinctive avoidance for anything involving statistics and research outside of school, I felt if I quoted your statement verbatim I'd have to cite the source, as well as put it in APA format

You make an excellent point.

 

[timerick]

You may find that the folks who "hate midlevels" also look down on other classes of people. Don't let them determine your goals.

 

[Moniker]

This is my pipe dream: I would love to see a system in the next decade where my experience as a PA is valued as a strong foundation to build upon to create a physician. How to do that? I don't know. It would be a hybrid that cuts out some of the time and expense of the current traditional 4-year med school + 3 year minimum residency. If something like that develops I will most likely partake, but until then I just don't think it's worth it.

why? so you can tell people "yeah, the option was given to me to become a doctor (I mean obviously I'm above going through all that silly medical school, as I'm basically a doctor now), but I decided not to"? bullcrap. no. your oh-so-valuable PA experience doesn't qualify you to "pass out" of any med school classes any more than an M1 with a PhD in biochemistry can pass out of M1 biochem.

heck no. you want to be a doctor, then start studying for the MCAT. period.

 

[deleted6669]

many med schools allow individuals with a phd in a basic sciences area or a pharmd to skip or only audit a course as they could teach it.....

 

[RAMPA]

why? so you can tell people "yeah, the option was given to me to become a doctor (I mean obviously I'm above going through all that silly medical school, as I'm basically a doctor now), but I decided not to"? bullcrap. no. your oh-so-valuable PA experience doesn't qualify you to "pass out" of any med school classes any more than an M1 with a PhD in biochemistry can pass out of M1 biochem.

heck no. you want to be a doctor, then start studying for the MCAT. period.

..........................

 

[Moniker]

many med schools allow individuals with a phd in a basic sciences area or a pharmd to skip or only audit a course as they could teach it.....

hey at least in that instance they'd have the highest degree possible in the subject, arguably superior to an MD. no one would argue the same for a PA degree.

by the way, is it really true that PA's are pushing for a "doctorate" of PA? is it just me, or is this getting pretty fricking ridiculous? A doctorate in assisting doctors? Is that a joke?

 

[deleted6669]

Hmm, mine didn't.

my understanding is that duke(and other programs) will give adv. standing on a case by case basis for individual courses.
duke (specifically) has been known to waive courses for pa's who went to duke(and only to duke) and took certain courses along with the medstudents. same course, same instructors, same tests, passing score=adv. standing.

 

[Tired Pigeon]

my understanding is that duke(and other programs) will give adv. standing on a case by case basis for individual courses.
duke (specifically) has been known to waive courses for pa's who went to duke(and only to duke) and took certain courses along with the medstudents. same course, same instructors, same tests, passing score=adv. standing.

I think this may be the exception rather than the rule. At my school, anyway, PA's don't take the same courses as we do. The former PA's who are now med students have to take the same courses as everyone else. Hell, even people coming in with PhD's in biochem, neuroanatomy, immunology etc. were required to take every course. For sure they might have had an easier time, but bottom line they still had to jump through the same hoops as everyone else.

 

[deleted6669]

there are several models for pa education:
pa's take classes with pa's only taught by pa, md, phd, and pharmd instructors
pa's take courses with pa's and some with other non-physican clinicians and allied health
pa's take classes with pa's and medstudents(mostly pa programs at schools that also have a medschool affilated with a major academic medical ctr-texas for example)

bottom line- any kind of transfer applicant has to be looked at specifically to see if their course is equivalent. that is why this is the exception not the rule. for what it is worth I have heard temple has also given certain pa's advanced standing for a course or 2 in the past

 

[Moniker]

there are several models for pa education:
pa's take classes with pa's only taught by pa, md, phd, and pharmd instructors
pa's take courses with pa's and some with other non-physican clinicians and allied health
pa's take classes with pa's and medstudents(mostly pa programs at schools that also have a medschool affilated with a major academic medical ctr-texas for example)

bottom line- any kind of transfer applicant has to be looked at specifically to see if their course is equivalent. that is why this is the exception not the rule. for what it is worth I have heard temple has also given certain pa's advanced standing for a course or 2 in the past

My medical school doesn't either. Yeah I think the sentiment that it is the exception, rather than the rule is pretty accurate. sure, there may be medical schools that allow it in rare circumstances (i.e. same course, same institution, same exams, same grading, recently completed), but it's pretty well established that PA curriculum is not at all equivalent to a medical school curriculum. therefore I'd say it'd be pretty tough to argue that PA's wishing to enter medical school should be able to have advanced standing in the absence of such rare circumstances. It's a little insulting that people suggest any component of a degree should be disregarded. If I dropped out of medical school and enrolled in PA school, I'd expect to take all the PA courses. Not only that, but I'd be concerned if they did excuse me from any coursework that I would be lacking knowledge and training that would eventually be a disservice to me, my patients, and the profession (on a large enough scale). Likewise, I'd have serious concerns about any school's curriculum that allowed other health professions to ditch the class. Look at what a fuss was made over that breast-feeding chick who wanted an extra few minutes of break time for the USMLE step 2. She wanted an unfair accommodation and was met with massive resistance...and she was graduating from Harvard as an MD. Why would someone want to be the driving force behind compromised educational standards?

Most PA's in med school are more than happy to go through all the necessary steps along the way. The fact that there is a vocal PA contingent determined to get some sort of credit from the medical profession (and try to publicly edge themselves that much closer to our degree) by these "bridge" programs is disturbing. It'll never happen. we'll fight it tooth and nail because it's stupid and unnecessary and is another degrading force upon the medical profession.

 

[Taurus]

many med schools allow individuals with a phd in a basic sciences area or a pharmd to skip or only audit a course as they could teach it.....

My school doesn't either. Whether you have a masters or a phd, you have to take the same course as everyone else does.

There's even a guy in my class who came straight from phd in biochem. I asked him if at the very least having that phd in biochem made taking the med school biochem a breeze. You know what his answer was? It helped a little, but he still had to work hard to learn the material because there is not as much overlap as you would think. You know why? It's because when you're doing a phd you're focused on very narrow area. Maybe you become an expert on reaction A + B --> C and you learn all the chemistry and physics about it. But biochem, like any branch of science, is so broad that you will never know all of it to get your phd. Med school requires that you take its course because it has a slant toward pathways that are medically relevant. When you take biochem, anatomy, physiology, microbiology, genetics, etc as a general course, it's not the same as if you take it in medical school because they don't have that medical slant. Makes sense, eh?

 

[primadonna22274]

Makes a lot of sense. These are the things I want to learn because I'm uncomfortable with not knowing them well enough. But please, there are things like medical interviewing and physical exam/diagnosis courses that I did as a PA student and have been doing for 8 years...to have to repeat those is just an exercise in frustration.

My school doesn't either. Whether you have a masters or a phd, you have to take the same course as everyone else does.

There's even a guy in my class who came straight from phd in biochem. I asked him if at the very least having that phd in biochem made taking the med school biochem a breeze. You know what his answer was? It helped a little, but he still had to work hard to learn the material because there is not as much overlap as you would think. You know why? It's because when you're doing a phd you're focused on very narrow area. Maybe you become an expert on reaction A + B --> C and you learn all the chemistry and physics about it. But biochem, like any branch of science, is so broad that you will never know all of it to get your phd. Med school requires that you take its course because it has a slant toward pathways that are medically relevant. When you take biochem, anatomy, physiology, microbiology, genetics, etc as a general course, it's not the same as if you take it in medical school because they don't have that medical slant. Makes sense, eh?

 

[deleted6669]

Makes a lot of sense. These are the things I want to learn because I'm uncomfortable with not knowing them well enough. But please, there are things like medical interviewing and physical exam/diagnosis courses that I did as a PA student and have been doing for 8 years...to have to repeat those is just an exercise in frustration.

agree- I would need to take antidepressant meds to repeat biopsychosocial issues in pt care, history taking, or medical ethics....