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How do we stop nurse practitioners?

Discussion in 'Topics in Healthcare' started by libraryismyhome, Nov 20, 2015.

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  1. Chibucks15

    Chibucks15

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    we need all hands on deck at clinics out in the boonies. not in major city centers, which is where many NPs head
     
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  3. Mad Jack

    Mad Jack Critically Caring Gold Donor 2+ Year Member

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    PAs have 2,000-3,000 hours of advanced-level clinical training. APRNs get less than 700. PAs operate under physicians. APRNs often don't. It's apples to oranges.
     
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  4. Mad Jack

    Mad Jack Critically Caring Gold Donor 2+ Year Member

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    Alright, restrict NP licenses to rural practice and primary care in underserved areas. Then we've got a deal.
     
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  5. FNP_Blix

    FNP_Blix Probationary Status Gold Donor

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    You're right, it is apples and oranges. PAs do 2-3 thousand hours because they are being trained as "generalists." They switch specialities at the drop of a hat. They also require more training because you don't know what kind of prior experience they have. A majority of NPs have 10-11 years of RN experience and are far easier to train than PAs. The hospital I currently work in would much rather hire NPs for that reason, because they are far more confident in their skills. The other reason why NPs do not require as many hours is because we specialize only in certain areas of primary care. That is, psych NPs can only work in psych, acute care NPs cannot work in pediatric primary care, etc. RNs typically have thousands of hours of on the job experience in addition to the clinical rotations they fulfilled during their undergrad. NP school is designed as an extension of that education to an "advance practice nurse" level. The model of education is entirely different, and just comparing the number of clinical hours is misleading and a misrepresentation of our education and abilities.
     
  6. FNP_Blix

    FNP_Blix Probationary Status Gold Donor

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    Wrong again. In urban areas, there are access issues too. Populations are larger, and you have more indigent people there that can't get medical services because either they have no insurance, or the doctors in those areas won't take medicare or medicaid. There are other restrictions at the micro level. I used this example earlier, but one example is like the diabetic patient that needs a diabetic shoe. Are you seriously telling me that an NP can't order that shoe because he/she needs a physician signature? These restrictions in some states absolutely need to be lifted because they are ridiculous.
     
    Last edited: Sep 12, 2017
  7. FNP_Blix

    FNP_Blix Probationary Status Gold Donor

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    How insightful.
     
  8. Mad Jack

    Mad Jack Critically Caring Gold Donor 2+ Year Member

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    It'll solve the crisis of the underserved. I thought that was your goal? Or is that bull****?
     
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  9. FNP_Blix

    FNP_Blix Probationary Status Gold Donor

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    MadJack, we've debated extensively before and you already know my position, and I already know yours. What do you want?
     
  10. FNP_Blix

    FNP_Blix Probationary Status Gold Donor

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    And no it wouldn't. Underserved is not just confined to rural areas genius.
     
  11. Chibucks15

    Chibucks15

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    he's got a point...if your arugment is that NPs are needed to fill in where docs arent then all NPs should be required to head out to the country and help in those clinics. That's where its most needed.
     
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  12. Mad Jack

    Mad Jack Critically Caring Gold Donor 2+ Year Member

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    We never addressed that. I proposed an actual way to help the underserved in a substantial way while fulfilling the NP mission. What is wrong with my proposal if the whole impetus for NP independent practice is increased access to care for those that need it?
     
  13. Mad Jack

    Mad Jack Critically Caring Gold Donor 2+ Year Member

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    It was an and statement, meaning rural and underserved. Restrict NPs to federally recognized health care shortage sites. Boom, problem fixed.
     
  14. FNP_Blix

    FNP_Blix Probationary Status Gold Donor

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    A larger proportion of NPs do practice in rural areas and underserved areas than physicians. Access issues go beyond rural America.
     
  15. FNP_Blix

    FNP_Blix Probationary Status Gold Donor

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    I actually agree and wouldn't see anything wrong with restricting Independent NP practice to these areas. However, you will never convince anyone to do away with NPs in team based environments.
     
  16. Chibucks15

    Chibucks15

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    So is your end goal for us to agree that NPs should be fully autonomous everywhere? I mean think about if you had a big legal case...would you want your case handled by a paralegal with hours and hours of experience but nowhere near the education level? Or would you want the guy who went to law school, busted his butt to get through, and knows his stuff?
     
  17. FNP_Blix

    FNP_Blix Probationary Status Gold Donor

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    Read my post to madjack...and I wouldn't mind the paralegal if he/she was darn good and had a reputation. Then sure, bring it on.
     
  18. Chibucks15

    Chibucks15

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    So say your trial is for life in prison...you'd really entrust your life to a paralegal? Not all that dissimilar from our discussion. Whatever floats your boat bud
     
  19. FNP_Blix

    FNP_Blix Probationary Status Gold Donor

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    This. You are a hypocrite. People in general are looking for a good life, good job, with good pay. A place to rear families and be close to their loved ones. You can't expect NPs to be any different. However, be that as it may, NPs are far more likely to practice in rural areas and as I said before, have a larger proportion of them working for the underserved in both rural and urban areas. And the physician shortage issue is multifactorial. There is a maldistribution issue in addition to their simply not being enough physicians. There will not be enough of you guys to fill the gaps NPs are filling for at least two more decades. So I'm not even worried. Job security either way.
     
  20. Chibucks15

    Chibucks15

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    I feel like all the hard work physicians put in is much more deserving of going where they want to honestly...not being a hypocrite whatsoever. Nurses work hard yes, but the floor is nowhere near as tiring as the training doctors have to do. And a lot of the NP programs aren't exactly super scholastic
     
  21. Chibucks15

    Chibucks15

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    Nurses can go wherever they like...just not with the full autonomy they havent earned. These are peoples lives were talking about one mess up and they can die. I'd trust a doc 10/10 in those situations
     
  22. If the physician shortage in underserved areas is the primary reason for becoming an NP, and if NPs are as clinically and academically skilled as physicians, why not just go to medical school and become a primary care physician?


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  23. sb247

    sb247 wait...you mean I got in? 5+ Year Member

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    We already went through that, there is barely a difference at all
     
  24. FNP_Blix

    FNP_Blix Probationary Status Gold Donor

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    Its a big difference. And Yea 11 vs 15%. NPs having 15-18% of us actively practicing out in rural areas. More than 90% of us are credentialed in some form of primary care. And in our debate we talked about the underserved in rural America. That doesn't include and discredits what NPs in urban areas do too to serve the underserved. You just make it sound black and white like the NPs in rural areas are the only ones doing good. The issue of access is epidemic and is not just restricted to farms and valleys.
     
  25. sb247

    sb247 wait...you mean I got in? 5+ Year Member

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    Even if I bought the notion that lack of access is an epidemic, which I don't.....you are making a false claim that somehow this disproportionately large fraction of NPs are taking one for the team and working for the "underserved"...11 vs 15 is not at all a large difference

    And going back to before....will you admit you were wrong and someone with literally no health care background can now earn an MSN in america in 2 yrs?
     
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  26. FNP_Blix

    FNP_Blix Probationary Status Gold Donor

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    First because I love nursing and the lattitude we have. Second, because that doesnt solve the problem right now. Physicians take too long to produce so whats the point of nurses doing that when we can do the NP path and be of service in as short as 6 years, from start to finish. Many of us are already nurses and are just answering the call right now.

    Its not false claims, and no I wouldn't because there is nothing wrong about what we are doing.

    Its a big difference
     
  27. sb247

    sb247 wait...you mean I got in? 5+ Year Member

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    From nothing to NP in 4 yrs as I linked earlier

    From nothing to MSN in 2
     
  28. FNP_Blix

    FNP_Blix Probationary Status Gold Donor

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    Okay go get a life for a few hours sb247. Enjoy the sun or something. Im at work now saving lives right now in MSICU.

    And you linked Columbia. Like one of the best schools. Their programs are shorter but excellent.
     
    Last edited: Sep 13, 2017
  29. FNP_Blix

    FNP_Blix Probationary Status Gold Donor

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    I bet your upset because there are NPs that you probably know that can run circles around you. I get it. You just dont want to admit that nursing has found a way to practice medicine just as good as physicians without going to med school. Tough pill to swallow.
     
  30. sb247

    sb247 wait...you mean I got in? 5+ Year Member

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    So you are claiming the one of the highest quality NP programs....the most credible. Makes independent practicing, equal to physicians, nps in 4 yrs from nothing?

    I'm going to disagree
     
  31. FNP_Blix

    FNP_Blix Probationary Status Gold Donor

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    No, I havent been arguing that NPs right out of school are prepared to practice independently. The studies I referenced take highly experienced NPs and make those comparisons in outcomes, in independent practice, with physicians. Personally, I dont care for those programs. I feel like nursing students should at least get 2-3 years of experience in acute care as an RN before becoming NPs. Unfortunately I dont have any control over that lack of consistency in my profession. Time will only tell how all this turns out. I just would recommend to employers to not hire NPs that dont have RN experience and recommend to nursing students to avoid independent practice right out of school (which I would say nearly all do).
     
    Last edited: Sep 13, 2017
  32. MBVT

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    As someone who lives in rural Vermont which urbanites that come here from Metro NYC/CT/NJ consider the boonies, I am taken aback by the thinking that we somehow are not as deserving of Primary Care MD's to the same extent as urban/suburban folks are. The NP's should be made to come to rural places and all that. Maybe that's not what has been meant but it is what it sounds like. I would throw in the comment I saw that MD's prefer to be in "good" areas (which I took to mean doesn't include rural areas) is part of my interpretation. Personally I think I live in paradise but that's just me. More importantly any Internist MD, NP, or PA that comes here would have as many patients as they can handle and would earn a good living. The quality of life would be quite high, but again maybe that's just me. As it stands there are no Internist MD's within a 1.5+ hour circle from where I live that are taking new patients. The NP's and PA's are almost all maxed out as well.

    It seems that if medical schools aren't going to churn out enough primary care MD's that there is no choice but for NP's and PA's to pick up the slack. MD's, NP's, and PA's need to figure out how to co-exist. Our Family and Internal Medicine practices all seem to have some of each.
     
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  33. FNP_Blix

    FNP_Blix Probationary Status Gold Donor

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    They already do 99.9% of the time. Don't let this debate we are having worry you all that much, because in reality, outside of this blog and the internet, physicians and NPs mostly work in team based environments and get along just fine.
     
  34. MBVT

    MBVT

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    Thanks FNP_Blix, it was sounding like NP's vs MD's rather than NP's and MD's. I have learned a lot following the discussion however.
     
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  35. Actually, some of us have argued that what you deserve -are- MDs, and not substandard care provided by unsupervised midlevels. The solution to a physician shortage is more physicians, not more nurses.


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  36. MBVT

    MBVT

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    Cigar, so how do we get more primary care physicians? Note that this region is not experiencing a population explosion that is creating shortages. The population is flat, but it is aging which increases demand I suppose.
     
  37. FNP_Blix

    FNP_Blix Probationary Status Gold Donor

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    Well why dont you go out there and be of service then? Until physicians reach a point where they can meet the needs of the whole population (maybe 2 decades minimum), NPs will remain the solution for millions of people.
     
  38. As it has been pointed out several times here, the proportion of NPs who practice in underserved areas is similarly low when compared to doctors who serve in underserved areas.

    It's also irrelevant to this discussion where each of us in this thread intends to practice.

    The solution for a shortage of primary care physicians is to produce more primary care physicians. There are new medical schools emerging with a focus on primary care in their states who recruit students with a commitment to primary care or family medicine . Midlevel providers who are not under the supervision of a physician may provide "access to care," but 1) most of them aren't practicing where care is needed the most, and 2) that care is lower quality than what people in well-serviced areas receive. The goal should be that everyone has access to the same thing, not just that everyone has access to something.


    Sent from my iPhone using SDN mobile
     
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  39. Create more accredited medical schools whose mission is to train primary care physicians in underserved areas. In my home state of GA, two of the four medical schools serve this purpose, and then our state school recruits a certain portion of its class for this purpose.


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  40. FNP_Blix

    FNP_Blix Probationary Status Gold Donor

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    The difference is not really marginal when you consider that 15%-18% (depending on source of data you look at) of NPs (when there are only 250,000 us) work in rural areas. That is compared to maybe 9%-11% of all physicians practicing in rural communities. And while this number may not seem significant, it makes the difference of tens of thousands of patients served each year. And as I mentioned earlier, more than 90% of NPs are credentialed to practice in primary care areas, making us much more likely (and able) to practice in those areas. That doesn't only include rural areas. That includes poor and underserved urban communities as well.

    While I agree that we need more physicians, NPs are the solution we have right now in front of us. That shouldn't be diminished or under appreciated. We are (and have been for over 5 decades) making a large contribution while having quality of care rival that of a physicians (despite what you believe, yet are unable to prove). Almost by definition, NPs practice wherever there is a need. Just because an NP is working with an intensivist group in Chicago doesn't render him/ her not needed in that population they serve. Likely that group and the population they serve would be strained without that NP functioning as their extender. That said, most FNPs (which constitutes the majority of us) work in areas of primary care and our numbers are growing faster than physicians. In the hospital, FNPs are being phased out (leaving more NPs to serve in primary care areas), and more now, are acute care NPs (different set of credentials and more suitable for the hospital setting) working in hospitals. This reality, at least for right now, points to NPs being a quicker and less-expensive solution in delivering care wherever there are needs in both urban and rural areas, and in various settings; all this while maintaining quality at the same time. They alleviate pressures to both society, the medical community, and healthcare as a whole by serving as independent providers in primary care settings (less frequently) and as part of a team in various specialties (more frequently).

    Some interesting sources that highlights some of the points I've been making:
    1) MMS: Error <--by NEJM and written by MD
    2) Primary Care Workforce: The Need To Remove Barriers For Nurse Practitioners And Physicians

    Sent from my iPhone using SDN mobile[/QUOTE]
     
    Last edited: Sep 14, 2017
  41. MBVT

    MBVT

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    If I might add a thought on how to get more physicians into rural areas, it is perhaps to ease the ability for students from those areas to go to medical school. These are people more apt to "go home" and practice after residency but the barriers to entry can be insurmountable no matter how smart they may be. Those who come from families with means or who have friends or relatives that are physicians have certain advantages over those who do not. Large urban/suburban high schools give ambitious kids advantages towards getting into the right programs and schools that kids in many rural high schools just don't have. If your graduating class is 25 kids and there are no AP or honors courses and only very limited math and science offerings, it is just harder to compete when applying no matter how smart you may be.

    I didn't pursue medical school but by way of example to make my point, growing up I did not know a single person in my extended family or in my neighborhood that had gone to college. Few had graduated from high school. I didn't know anybody I could talk to about what my options were let alone how to achieve them. The day after turning 15 I took a job scrubbing pots in a cafeteria after school and on non-school days to start saving money to go to college. That precluded any after-school extracurriculars or volunteer work that might have made me look well rounded, and when the time came to pay for my college applications even that expense was entirely on me which tells you where I was coming from financially. Visiting schools I applied to was an impossible luxury in travel expense and time off from work. Fortunately where I went didn't require an interview. The 1st time I saw the college I went to was when I moved into the dorm. Hard work and much sacrifice paid off handsomely and I am quite well off now but rest assured there are very smart kids out in the rural areas who might like to become a physician but just can't see how to overcome the barriers to entry for people like them and from where they are. Many would go home again to practice if somehow they could find the path to medical school.
     
  42. FNP_Blix

    FNP_Blix Probationary Status Gold Donor

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    The funny thing is a nurse was surgeon general for about 5 months this year lol

    Nurse Replaces Surgeon General After Obama Appointee Resigns
     
    Last edited: Sep 15, 2017
  43. atomheart

    atomheart

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    So the problem is that physician specialties are so specific that actual services are spread thin, requiring that expensive and complicated tertiary care services be centered in large hospital institutions or areas with high catchment. That is the maldistribution issue that has allowed midlevel growth. There are definitely plenty of physicians graduating with new schools being opened all the time, so shortage issues are rapidly disappearing. The maldistribution issue is not.

    Though many could live and practice primary care in rural areas, NP and PAs are not trained to practice full scope medicine as an FM graduate theoretically could (many PCPs do not for reasons I mentioned in previous posts). This frequently requires midlevels to refer out for tertiary services (Ob, radiology, ENT, Cardiology, etc). It simply does not make sense for midlevels to practice in rural areas, though it is nice that midlevels are moving there, and I'm sure that many appreciate what they can offer. You are propagating an illusion that full care access is being provided when it is certainly not. It is not that physicians are refusing to answer the call, but that full access to medicine is more complicated than people believe; almost everybody will require tertiary services at some point in their life, and the belief that primary care access alone solves the care issue is just flat out wrong. The trend over the next 50 years will be midlevels going into tertiary care services in larger cities and bulking up "access" there. Private specialized training centers (e.g, CRNA schools) will proliferate for this purpose. It just so happens that the lowest hanging fruit is ambulatory services that do not require intensive training.

    Medical services are changing which makes people uneasy, esp when tuition plus other training fees can exceed half a million USD per physician. There will be physician pushback with definite consequences that some midlevels will not appreciate if this trend continues. One thing that certainly needs to happen by physicians (rather than nurses) is operationally defining professional differences in scope of practice and responsibility, which could restrict midlevel income and opportunities. I agree with your sentiment that most people are looking for a good life, but all must pay the tollkeeper to find reward in this crappy US healthcare system. Believe that the crappiness will be distributed equitably by your physician peers.
     
    Last edited: Sep 16, 2017
  44. Gastrapathy

    Gastrapathy no longer apathetic Lifetime Donor 10+ Year Member

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    The midlevel threat in primary care is overrated. They just don't work hard enough and aren't a good deal for the pay they want. That's why you won't find midlevels in primary care in my large multispecialty group. That, and the overconsulting and lack of ownership. You have to pay them for every minute, make sure they get breaks, etc (docs will chart/call patients on their own time). Overall, we are hiring fewer across all specialties, even anesthesia, and have none left in PC.

    Your training is better. Your culture is better. Even big bureaucracies are starting to see that.
     
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  45. atomheart

    atomheart

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    Is this a medical school admissions personal statement? Cringeworthy. Needs editing.
     
  46. SterlingMaloryArcher

    SterlingMaloryArcher

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    By learning more than they do about how their role is created and defined
     
  47. aformerstudent

    aformerstudent probationary status 4life

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    NP's and PA's do not have the training needed to practice full-scope medicine. Then again you could say that some general practitioners are not as skilled as others.

    Who am I to judge someone who became an NP or a PA. I know good ones and I know some terrible ones.

    My argument is that in medicine, you should have the right as to who you want to see. And that doesn't mean pick the MD/DO over the PA or NP all the time. If I had a minor condition, I would probably want to be seen by the PA or NP. If I had what I felt was a more complex issue, I would certainly want to be seen by an MD.

    If you truly relegated PA's and NP's to "easy medicine" then I think you'd make medicine more efficient but then again why would you pay PA's and NP's that kind of money to practice "easy medicine" to begin with.
     
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  48. FNP_Blix

    FNP_Blix Probationary Status Gold Donor

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    Your statements are inaccurate on multiple accounts. Thats why you should provide citations to corroborate your claims or do more research on industry... Shortage issues absolutely do exist and are actually getting worse. I invite you to look at the NRMP data to understand how many med students are actually getting placed into primary care residency.

    And if anything physicians, patients, and overall, society appreciates the contributions midlevels have made in mitigating the shortage issue. So pushback will not occur as you state at all.

    The pay we earn is fair considering how much revenue we produce for a practice and the services we provide.
     
    Last edited: Sep 16, 2017
  49. atomheart

    atomheart

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    There's actually no proof that a physician shortage exists. The "proof" is dependent on the model you use. The NRMP data is separate from population demand and doesn't mention shortages. Various partisan organizations instead use this data to declare a physician shortage using their own models.

    The rest of your post is opinion based, and similarly has no factual basis. Also, pushback already occurs at state and federal levels for scope of practice, so there's evidence against you there.
     
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  50. FNP_Blix

    FNP_Blix Probationary Status Gold Donor

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    The only opinion stated so far today was your notion that NPs earn too much money. What is factual is that there is a shortage. No matter what political paradigm you align yourself with, the data outthere is overwhelmingly clear atomheart. And no matter how you want to spin your argument, there is nothing partisan about NRMP data. Its pretty obvious that demand for primary care services will only increase with the aging population and the next wave of retiring physicians on the horizon. Creation of primary care doctors is at the very least plateuing and thats being generous.

    Furthermore, you can open up as many FM focused med schools as you want, but if there is a lack of residencys or preceptor, then those med school graduates are rendered basically useless. This is so true to the extent that I've seen 3rd and 4th year medical school students following NPs here where I live.

    Also, I would like to see what data you have on "pushback" because as far as I can tell, our scope and practice authority is only increasing by the state.
     
  51. atomheart

    atomheart

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    Then prove it with studies that don't use any modeling. What is factual is that definitions of physician shortage vary. What is factual is that Nursing Practitioners do not ameliorate physician shortages because by definition they are not physicians.

    Data? Here is a random article from 2014 from my state Anesthesiologist society on Pain Clinics:

    "At the request of House Speaker David Ralston, the GCMB included language to clarify that CRNAs are not prohibited from working in pain clinics within CRNA scope of practice as defined by Georgia Code. This language was initially crafted by GSA and submitted to the Board in February in response to the Speaker’s request so that the language could be inserted into the proposed rule rather than the legislature re-opening the pain clinic licensure act. GSA successfully fought an attempt by the GA Association of Nurse Anesthetists to amend the definition of “Medical treatment or services” to exclude administration of anesthesia by a CRNA acting within scope of practice as defined in code. The GSA Government Affairs Committee and the American Society of Anesthesiologists determined that the GANA amendment would, were it adopted by the Medical Board, later be used by the GANA to seek expanded CRNA scope through Nursing Board rulemaking."

    source: https://gesa.memberclicks.net/assets/gsa scope summer 2014.pdf

    In other words, physician societies have long been calling out midlevels on their scope of practice bull****.
     

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