Is an EM physician a replaceable entity?

[CSRA]

I heard an EM physician mention that he had a fear, whether founded or completely ubsurd I am not sure, that EM physicians could be at least partly replaced by Nurse Practitioners or PA's. I believe such is going on in Miss. I have been pondering this for a couple of weeks, and I am not seeing this as a threatening possibility, but I would like more objective opinions please. If this is unclear, let me just make the example of CRNA's starting to replace, or at least serve in place rather than, anesthesiologists in some clinical areas (i.e. low risk plastic surgery at outpatient plastics suites). Do you all see something like this happening in the future to EM docs? Seems like the malpractice to cover an ED run by non-physicians could get astronomically high, but at the same time if malpractice takes on extreme reform, which IMO is a very real possibility in the face of such low healthcare access for many americans, and the solution of a single payer system possibly funded by tax dollars is inacted, then I could see many of the malpractice laws becoming more lax to accomodate the non-physician providers. Heck, I am probably being overly paranoid, but it is in my nature to question everything . . . my wife says I am crazy.

thanks forward to any good responses,

Kendall
www.healthnewsstat.org

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[primadonna22274]

Kendall,

The really excellent, jack-of-all trades, can run a code while managing the GI bleed and ACS and neonatal fevers all at once while keeping one eye on the board, procedurally gifted and critical care-savvy, veteran EM PAs are much less common than the pretty-good at most low-to-moderate acuity, less comfortable with trauma, happy to have my attending there PAs (like me). You'll get a different response from EMEDPA and others like him who have done EM for a long time but IMO, across the board, there will always be a need for EM docs. My ER has such a hard time recruiting EM docs that we have an IM doc (although practiced 15 years in EM) and FPs in fast track (where honestly the PAs could be practicing autonomously but the hospital won't allow it).

My .02

Lisa

 

[EM_Rebuilder]

I heard an EM physician mention that he had a fear, whether founded or completely ubsurd I am not sure, that EM physicians could be at least partly replaced by Nurse Practitioners or PA's. I believe such is going on in Miss. I have been pondering this for a couple of weeks, and I am not seeing this as a threatening possibility, but I would like more objective opinions please. If this is unclear, let me just make the example of CRNA's starting to replace, or at least serve in place rather than, anesthesiologists in some clinical areas (i.e. low risk plastic surgery at outpatient plastics suites). Do you all see something like this happening in the future to EM docs? Seems like the malpractice to cover an ED run by non-physicians could get astronomically high, but at the same time if malpractice takes on extreme reform, which IMO is a very real possibility in the face of such low healthcare access for many americans, and the solution of a single payer system possibly funded by tax dollars is inacted, then I could see many of the malpractice laws becoming more lax to accomodate the non-physician providers. Heck, I am probably being overly paranoid, but it is in my nature to question everything . . . my wife says I am crazy.

thanks forward to any good responses,

Kendall
www.healthnewsstat.org

I think it will happen somewhat to medicine all across the board; esp if MI gets reformed/cheaper. However, I think it will strictly be as you said above 'low risk' positions. I have worked with some PA/NPs in my very limited time. Some of them were AWESOME, but MORE of them left LOTS to be desired. They will certainly never replace physicians completely unless their education means and such was reformed...and thats not going to happen much as more time just means get the MD.

 

[EctopicFetus]

This is an interesting question for a few reasons. Cant this logic be applied to Peds, IM, FP, and almost any other non-surgical field?

I think the truth is that physicians have more of an expertise than a NP or PA. In our EDs here we have these midlevel folks do UC and see some IC type patients.

If my life were on the line I would want a residency trained person there, but of course I am biased. In cases of life and death which is a small percentage of what we see I dont think most NPs or PAs would feel comfortable taking care of those patients.

 

[deleted109597]

...almost any other non-surgical field?...

Someone hasn't seen enough vein harvesting for CABGs by the PA/NP. They're doing a fair bit on some other things. While they aren't doing the whole procedure, I have seen them used like CRNAs, in that the surgeon does the important parts, and the midlevel closes while the surgeon goes to the room next door.

 

[AmoryBlaine]

It's not a question of IF for increased inroads into medicine by midlevels but WHEN. They are coming. We do have some things working in our favor as physicians though.

A few points (in my patented numbered style -- that means the rest of you cretins aren't allowed to use it):

1. Supervision - technically PA/NP in the non-fast track ED are working under the supervision of a physician. As long as mid-levels require supervision they will need docs.

2. Litigation - a subheading of supervision really. Let's just play the thought experiment that the ED at a particular hospital figures out a way to let a PA (or NP, or DNP) work completely independantly. Let's even say that PA Smith is at the top 99th percentile in skill. One of these days Smith is going to make a mistake (malpractice) and there's going to be a really bad outcome. In the ensuing lawsuit against Smith and the hospital the prosecutor is going to say, "don't you think, MR. Smith, that this case would have been better handled by a physician?" Then the lawyer is going to painstakingly point out all the ways in which PA education is not equal to MD education. A hypothetical hospital could not be expected to make that mistake a great many times.

3. Patient satisfaction - a subheading of litigation really. As I have said before with the popularity of House/Scrubs/GA/ER (RIP) I think the general population is becoming marginally more savvy about who is providing their care. I bet every PA in the room can tell you stories of a patient who said, "thanks, but I want to see a doctor." If you think patient complaints don't register, ask your friendly neighborhood community emergency physicians about them.

4. Mid-level fear - I think the mids will clamor for more autonomy/power/whatev to a certain point and then the good ones will realize that they are a) not trained to be docs and b) unwilling to assume liability. It is one thing for a PA to make broad statements about their skill, it is quite another for them to work with no physician back-up. At the end of the day all of the tough stuff gets run by the doc.


As an aside, on one of my aways the PAs were my favorite people. If they knew there were EM-bound students in the room they would usually cherry pick all the really painful cases and let us do our durrty thang.

 

[hyperbaric]

2. Litigation - a subheading of supervision really. Let's just play the thought experiment that the ED at a particular hospital figures out a way to let a PA (or NP, or DNP) work completely independantly. Let's even say that PA Smith is at the top 99th percentile in skill. One of these days Smith is going to make a mistake (malpractice) and there's going to be a really bad outcome. In the ensuing lawsuit against Smith and the hospital the prosecutor is going to say, "don't you think, MR. Smith, that this case would have been better handled by a physician?" Then the lawyer is going to painstakingly point out all the ways in which PA education is not equal to MD education. A hypothetical hospital could not be expected to make that mistake a great many times.

The lawyers will find a way to manipulate the system and I have long held that they will use mid-level care to get into pocketbooks. With tort reform in Texas, I am worry this will be sooner than later.

 

[Chronic Student]

I am a PA and can tell you unequivocally that we will never replace physicians for a number of reasons.

The first has already been mentioned and that is that as a PA, I work under the supervision of a physician and hence cannot replace him or her. I can't tell you about the NP side. I really think they are conflicted about independent practice. I can't see how the really smart NP's would think that its a good idea for any number of reasons.

The second thing is that as a PA I am regulated by the BOM and they have the final say.

The third is that I am not arrogant enough to think that I know as much as a doctor. In my field I may know more than docs who are not in my field. However, there are so many things that I don't know and so many different situations that there are nuances that any doc may pick up on that I may miss. Hence, if I have something out of the ordinary or something that does not fit or a red flag than I can kick it up to my boss.

In the end, I am a physician extender not a replacement.

 

[Perrin]

I believe such is going on in Miss.

I think this has less to do with a paradigm shift in the field as it does with resource allocation. We only have one medical school and it graduates 6-8 (not sure) EM physicians a year. Meanwhile, we have an abundance of tiny communities with po-dunk ERs that need staff. We have a telemedicine program that allows EM physicians at UMC to work with nurses and PAs at remote sites around the state to manage care at these locations. I know a few residents who help ease the burdon (for $ reasons) by moonlighting through "Keystone" at rural communities.

We are a resource poor state and as a few residents and faculty have said to me, "If you ain't from Mississippi, you aren't going to want to stay here."

 

[Old_Mil]

In the end, money makes the world go round, and health care in America today isn't a non-profit institution that's being run by a bunch of nuns. In the event that MBAs and MHAs can make the risk/reward equation balance in such a way that ALL primary care physicians can be replaced by PAs and NPs, it'll happen. It won't happen to EM docs exclusively - and likely not first - with FPs and Peds being the first victims. EM docs and IM docs (as hospitalists) will be able to hide behind the fortified walls of inpatient medicine for a longer period of time.

It's not likely to happen through executive fiat unless we end up with nationalized health care. Rather, it will probably happen through continued reimbursement cuts which result in equal reimbursement for all PCPs, regardless of the degree they hold making it impossible for actual Physicians to afford to practice outpatient primary care.

The loss of efficacy of medical care will merely be an acceptable by product of the new system (just like the 5% are who don't make it in all those EBM studies claiming 95% success).

Again - the risks of all this happening are exponentially higher with any sort of nationalized/single payer federal health care system.

 

[Apollyon]

We are a resource poor state and as a few residents and faculty have said to me, "If you ain't from Mississippi, you aren't going to want to stay here."

I absolutely love it here, but I've said that South Carolina needs a "Go Mississippi!" license plate, because, if it wasn't for MS, SC would be #50.

 

[AmoryBlaine]

In the end, money makes the world go round, and health care in America today isn't a non-profit institution that's being run by a bunch of nuns. In the event that MBAs and MHAs can make the risk/reward equation balance in such a way that ALL primary care physicians can be replaced by PAs and NPs, it'll happen. It won't happen to EM docs exclusively - and likely not first - with FPs and Peds being the first victims. EM docs and IM docs (as hospitalists) will be able to hide behind the fortified walls of inpatient medicine for a longer period of time.

It's not likely to happen through executive fiat unless we end up with nationalized health care. Rather, it will probably happen through continued reimbursement cuts which result in equal reimbursement for all PCPs, regardless of the degree they hold making it impossible for actual Physicians to afford to practice outpatient primary care.

The loss of efficacy of medical care will merely be an acceptable by product of the new system (just like the 5% are who don't make it in all those EBM studies claiming 95% success).

Again - the risks of all this happening are exponentially higher with any sort of nationalized/single payer federal health care system.

I'm not at all sure that's true. Can you provide data to suggest that mid-levels do more of the care in Can/Fr/UK/Ger?

 

[Pterion]

I heard an EM physician mention that he had a fear, whether founded or completely ubsurd I am not sure, that EM physicians could be at least partly replaced by Nurse Practitioners or PA's. www.healthnewsstat.org

At least partly. As Chronic points out, there is a clear role for PAs in most settings; that of physician extender. I think the "replacement" issue has more to do with the overtaxing of ERs with nonemergent complaints. In the state where I currently reside (southeast), many of our ERs are hiring NPs and PAs to attempt to scurry these nonemergent complaints through and free up the MDs for the more critical cases. As long as the public and the legislature continue to believe in the "extender" model, this will not change.

In med school I definitely watched NPs and some PAs in the OR do things that I never would have dreamed they would be allowed to do. There are certainly several sides to this issue....

 

[docB]

I think this could be a real problem in the future. I don't see midlevels opening up EDs on their own or taking over contracts but I do see them replacing physicians in terms of hours worked. I think the most likely senario is one where more and more EDs use midlevels supervised by physicians. There will then be fewer physicians needed in the ED. I can easily imagine EDs that have traditionally had double or triple physician coverage dropping to single coverage with multiple midlevels.

If we go to socialized healthcare several of the roadblocks to this will be removed. Med mal will likely be greatly reduced as a barrier. Patient satisfaction won't matter (eg. post office and DMV). Cost will become the absolute paramount issue and midlevels may be seen as the way to reduce those costs.

Remember that the driving force behind American healthcare that that people want the absolute best care they can get without ever paying anything out of pocket.

 

[jbar]

Another way to look at it is that given the increasing number of people using the ED, mid levels could see many more ED patients without needing reduce the number of ED docs. Furthermore, I think that is you have a good Fast Track and get people through quickly, more people would be coming to the ED to be seen (as word gets out that for a UTI you only have to wait an hour instead of 12). So more midlevels in the ED may also lead to more patient visits, though not changing the number of high acuity patients who still need the same number of EM docs.
This is my impression, I'm sure there is some research out there on what increasing numbers of midlevels do to ED visits, utilizations etc. I'd look but the boards are in 7 days, so.....

 

[docB]

Another way to look at it is that given the increasing number of people using the ED, mid levels could see many more ED patients without needing reduce the number of ED docs. Furthermore, I think that is you have a good Fast Track and get people through quickly, more people would be coming to the ED to be seen (as word gets out that for a UTI you only have to wait an hour instead of 12). So more midlevels in the ED may also lead to more patient visits, though not changing the number of high acuity patients who still need the same number of EM docs.
This is my impression, I'm sure there is some research out there on what increasing numbers of midlevels do to ED visits, utilizations etc. I'd look but the boards are in 7 days, so.....

That's true but I expect that with socialism would come the end of ED visits for primary care. It will be all about cost so your sore throat can wait until you go see your PMD (who will definitely be a midlevel or maybe a tech or possibly an interactive computer program) at the central health complex. Once there's no more liability and no incentive to see patients in the ED we'll be defering everything out.

 

[bulgethetwine]

I'm not at all sure that's true. Can you provide data to suggest that mid-levels do more of the care in Can/Fr/UK/Ger?

Actually, there is almost no mid-level care in Canada, U.K. and Ireland.

It is true that it is almost uniquely American that the NPs and PAs do as much as they do. A nationalized health care system has nothing to do with this issue.

Nice try in yet another attempt at fear mongering against such a system though, dude.

The reason why NPs and PAs even exist at all is because it is a way to cut costs by the bean counters.

 

[ForbiddenComma]

I think this could be a real problem in the future. I don't see midlevels opening up EDs on their own or taking over contracts but I do see them replacing physicians in terms of hours worked. I think the most likely senario is one where more and more EDs use midlevels supervised by physicians. There will then be fewer physicians needed in the ED. I can easily imagine EDs that have traditionally had double or triple physician coverage dropping to single coverage with multiple midlevels.

This has already happened with anesthesia. At our hospital, anesthesia staff docs pretty much never sit on a case. They supervise CRNAs and residents, and pop in once or maybe twice a case.

Really, the only reason why these "supervisor" anesthesia MDs exist is to satisfy an artificial legal requirement. And as we all know, artificial legal requirements are no match to the combined lobbies of the insurance companies, the for-profit hospital chains, and the nursing lobbies, all of which have a vested interest in reducing or eliminating high-priced MD/DOs from practice and replacing them with midlevels.

Idiot anesthesiologists decided to grab up the easy life short-term with their "supervisory" positions, ignoring the fact that they are also making themselves obsolete.

 

[RxnMan]

But socialized care will just generate a 2-tier system in the US. Sure, some gov't clinics will be like the DMV, where there may be a PA + MD model, but then you'll have the shining new private hospital out in the 'burbs, where you pay for time with the doc. Docs will just shift to the private sector.

 

[deleted109597]

Docs will just shift to the private sector.

I have a feeling that with our government, they won't allow that.
They already tried in Tennessee to prevent docs from not taking medicaid by threatening a $500,000 fine if you left the state after graduation (ie, didn't come back after residency). They blatantly said during the house discussion "Yeah, this bill won't work as written, but we will find a way to word it so that it will." Thankfully, I've already left, but lawyers frighten me.

 

[AmoryBlaine]

Actually, there is almost no mid-level care in Canada, U.K. and Ireland.

It is true that it is almost uniquely American that the NPs and PAs do as much as they do. A nationalized health care system has nothing to do with this issue.

Nice try in yet another attempt at fear mongering against such a system though, dude.
The reason why NPs and PAs even exist at all is because it is a way to cut costs by the bean counters.

Uh, what?

I think we kind of are agreeing with each other despite your hostile tone. Here is what happened.

1. Old Mil made the point that PA/NP takeover was more likely in a socialized system.
2. I asked if PA/NP was actually a more popular option in socialized system. This was driven by genuine curiosty...
3. You indicated that they were not.

No fear-mongering here. I actually try not to monger anything if I can help it -- it gives me heartburn.

 

[AmoryBlaine]

But socialized care will just generate a 2-tier system in the US. Sure, some gov't clinics will be like the DMV, where there may be a PA + MD model, but then you'll have the shining new private hospital out in the 'burbs, where you pay for time with the doc. Docs will just shift to the private sector.

Yes, they will. Whether there would be any large-scale role for emergency physicians in this second tier is questionable.

The Derms, Orthos, PCPs etc could set up the "shining new" place but would such a place really have an ED? Would it be a cash and carry joint? Would it have any trauma designation?

It's just hard to imagine it working with EM. If it did it might be a shockingly bad practice environment despite higher reimbursements. Just think -- a room full of wealth suburbanites paying out of pocket for your time. If they want those abx for their kids cough they are going to get them by hook or by crook.

 

[jbar]

such a place would almost certainly have to have an ED. Cardiac cath patients, ICU patients, ortho trauma patients etc who have insurance represent a lot of money for the hospital, and they'd be missing out if they couldn't take those patients in via an ED.

 

[pseudoknot]

Dare I to point out that no presidential candidate with any chance of being elected has proposed any sort of "socialized medicine," nor is either of the major parties in favor of such a thing, nor any other major political force of which I'm aware.

"Socialized medicine" is a straw man.

 

[EctopicFetus]

Well another term for socialized medicine is single payor and other code words for the same thing in effect.

Now you know there is a difference between communism and socialism.. My parents and I left one and we werent planning on going into another system like that.

Bottom line like one of those SAT questions

Socialism:Communism as Single payor is to?
a) socialized medicine
b) socialized medicine
c) socialized medicine
d) socialized medicine

A-D your choice.

 

[pseudoknot]

Nobody's proposing single payer either. I wish they were, but that's just another straw man at this point.

 

[RxnMan]

...The Derms, Orthos, PCPs etc could set up the "shining new" place but would such a place really have an ED? Would it be a cash and carry joint? Would it have any trauma designation?...

Why wouldn't it have a place for EPs? The rich-er will have accidents. They will just go to the hospital where they have coverage. The UK has a similar system already.

To my understanding, many hospitals were cash and carry joints of some sort or another prior to WWII and Medicare.

I get your point about the working environment. Here's another thing - if a patient had private insurance, and they showed up at their private hospital, would you have to see them, regardless of complaint?

 

[bulgethetwine]

Uh, what?

I think we kind of are agreeing with each other despite your hostile tone. Here is what happened.

1. Old Mil made the point that PA/NP takeover was more likely in a socialized system.
2. I asked if PA/NP was actually a more popular option in socialized system. This was driven by genuine curiosty...
3. You indicated that they were not.

No fear-mongering here. I actually try not to monger anything if I can help it -- it gives me heartburn..

Sorry, I included the wrong message in the quotes. We ARE arguing the same point -- I should have highlighted Old Mil's message.

 

[Drawing Dead]

I get your point about the working environment. Here's another thing - if a patient had private insurance, and they showed up at their private hospital, would you have to see them, regardless of complaint?

Been watching this post, just wanted to put in my thoughts on this comment.

If the richer with their private insurance came in, I would WANT to see them, even if they stubbed their toe. Why, because, and I'm only assuming here, that their insurance pays well. It's the medicaid/"self-pay" (should be a better term for that since they don't pay usually) that come in at 4 a.m. with their chronic back pain for 4 years that piss me off.

Now, I'm a long way away from that ever affecting me directly as an attending, and I know there are many ways of getting reimbursed as an EP (Hosp. employee vs. third party group vs. private entity with different variations) so I'm sure there are different ways of private insurance reimbursing. I would be interested in seeing what current attendings have to say on that, and if they notice a large difference in how they are reimbursed according to how the patient is insured.

 

[Old_Mil]

I'm not at all sure that's true. Can you provide data to suggest that mid-levels do more of the care in Can/Fr/UK/Ger?

They don't. However, there are fundamental differences between Europe and the United States. One is:

"American CEO's are notoriously overpaid in comparison to their international counterparts. A ceiling of 40 times the pay of the lowest paid corporate employee seems to be the norm in many western European countries and Japan."

"When I was a lad, the chief executive of a major public company was paid about 30 or 40 times what a line worker was paid. Now the multiple is about 180." (...in the US, and the multiple is likely higher today).

That has to come out of someone's hide. Europe has a strong tradition of protecting European jobs for European workers. We have a strong tradition of doing anything and everything to bolster the bottom line, including throwing our own citizens under the bus. With these fundamental differences in administrative compensation - and with the "lawyers gone wild" culture that exists here - single payer health care will not work as well as it does elsewhere (and it doesn't work all that well elsewhere, necessarily).

 

[AmoryBlaine]

such a place would almost certainly have to have an ED. Cardiac cath patients, ICU patients, ortho trauma patients etc who have insurance represent a lot of money for the hospital, and they'd be missing out if they couldn't take those patients in via an ED.

Absolutely true, but then comes the issue of other people who show up. Say that an indigent person stumbles up to triage with crushing SSCP. Is this hypothetical institution going to ask for a Visa before he gets an EKG?

There are alot of ethical issues here and while the "cash and carry" model sounds pretty good it might involve some pretty cold decisions at the gate...

Furthermore, one could argue that such a practice environment would be antithetical to the practice of emergency medicine -- "anyone, anywhere, anytime." How much you care about that metaphysical idea is an argument for another thread...

 

[RxnMan]

Drawing Dead - I agree with any encounter with a paying customer is probably a good one. I want to float out the idea that their insurance may force you to see them.

Absolutely true, but then comes the issue of other people who show up. Say that an indigent person stumbles up to triage with crushing SSCP. Is this hypothetical institution going to ask for a Visa before he gets an EKG?

There are alot of ethical issues here and while the "cash and carry" model sounds pretty good it might involve some pretty cold decisions at the gate...

Furthermore, one could argue that such a practice environment would be antithetical to the practice of emergency medicine -- "anyone, anywhere, anytime." How much you care about that metaphysical idea is an argument for another thread...

I disagree. Medicine (and emergency rooms) existed during the fee for service era. Note that charity care and sliding scales were also part of any doc's practice.

EMTALA was enacted to prevent these situations, and the result is a health policy of "just go to the ED."

 

[deleted6669]

"EMTALA was enacted to prevent these situations, and the result is a health policy of "just go to the ED." "

this is why > 80% of ed care can be provided by competent midlevels...it's really just same day clinic/ambulatory primary care clinic or urgent care stuff.
I work in an e.d. that sees around 250 pts/day. of those maybe 25-40 really need the services of a residency trained/board certified em doc while the rest are handled very well by the multiple midlevels working in various areas of the dept(fast track, medium acuity care areas that see belly pain, pelvic pain, h/a's, minor trauma,etc, peds, and the chest pain obs unit where pa's do all treadmills/stress echos).
docs work in the main area seeing unstable elderly pts., many of whom are handed off to the cath lab team or stroke teams.
trauma is handled by a trauma team of which the first page goes to the trauma pa who evals all trauma pts and calls the docs as needed.
psych pts are managed by a psych np who (rarely) consults a staff psychiatrist.

 

[deleted87716]

80% of ed care can be provided by competent midlevels

So, which patients should the incompetent midlevels see?

Just curious.

 

[deleted6669]

So, which patients should the incompetent midlevels see?

Just curious.

as discussed earlier in the thread dnp's have their own panels....

 

[AmoryBlaine]

as discussed earlier in the thread dnp's have their own panels....

Hey! They are doctors just like the rest of us!

 

[danzman]

I’m curious to see if anyone else thinks this will solve itself? As NPs take on more and more responsibility they will lobby to be paid more. Eventually their salaries will approach physicians pay and their will be no more incentive to hire them. I imagine this will reach a plateau where NP’s make say 75% of ED physician salaries, and can do 75% of their jobs, yet they will be required to have more education. When this takes effect, it will be more difficult to become an NP and thus people who were on the cusp of deciding will choose medical school over nursing school. I could even see a time when they are granted equal practice rights (think MD/DO) but would have to complete the same level of training. I for one would have no problem with this as long as the training requirements were the same. Again everything would balance itself out in the end; you would just have another type of physician in America. Even this has to reach a saturation point, however, as we now have DC’s DNP’s DPA’s ND’s, and MD/DO’s all trying to find a spot. In any system, (other than complete socialization) basic economics principles still hold. Any thoughts??

 

[jbar]

the problem with "having to complete the same level of training" is how do you have people go back and make up the difference once they are on a different track? My roomate is a PA student, I'm a medical student. A few months ago we were talking about our neuroanatomy classes. My class was something like 50 hours of lecture, his about half of that (sorry I don't remember exact numbers). So if ten years down the line he was told that he could get an MD but had to complete the same amount of training. How would he go back and do the other 25 hours of neuro? If we had an hour on Huntingtons and they had half you can't just go take a half hour make up on Huntingtons because that missing half hour was integrated into a larger lecture.

I agree that many midlevels can do 75% of what physicans do just as well. But to get that last 25% isn't simply a matter of taking an extra class or doing an internship. During the four years of medical school and 3-9 years of residency/training physicans are expected to learn, think, and practice dealing with that last 25%.

 

[AmoryBlaine]

the problem with "having to complete the same level of training" is how do you have people go back and make up the difference once they are on a different track? My roomate is a PA student, I'm a medical student. A few months ago we were talking about our neuroanatomy classes. My class was something like 50 hours of lecture, his about half of that (sorry I don't remember exact numbers). So if ten years down the line he was told that he could get an MD but had to complete the same amount of training. How would he go back and do the other 25 hours of neuro? If we had an hour on Huntingtons and they had half you can't just go take a half hour make up on Huntingtons because that missing half hour was integrated into a larger lecture.

I agree that many midlevels can do 75% of what physicans do just as well. But to get that last 25% isn't simply a matter of taking an extra class or doing an internship. During the four years of medical school and 3-9 years of residency/training physicans are expected to learn, think, and practice dealing with that last 25%.

You are right about that last 25% concept. The thing is that I suspect alot of PAs have the attitude that they could have gone to med school. To which I would reply, "yes, but you didnt."

So we really could never know if they would have been able to hack M1/2, pass Step1, succeed in clinical rotations, Match, get through internship, get through residency, pass medical boards, and get licensed.

Actually having gone through the crucible is, to me, worth alot more than saying that you could have. My point (and I do have one) is that the difference between a midlevel and a physician is not just a quantifiable amount of knowledge. Doctors are doctors.

 

[danzman]

I agree completely with the above two posts. To Jbar, I agree that you can’t make up the difference and you never will. All you could ever hope for is to adjust the coursework so that in the future they will be the same, rather than forcing them to remediate. Again, this is why they could only do 75% of the job and thus get 75% of the reimbursements. I am not so worried about the PA, but the quality of the DNP degrees that I have seen are laughable. That’s not to say that some of them could not be great physicians, it’s just that their level of science based education is absolutely not even close to that of a physicians, in my experience. This brings me to why I agree with ArmoryBlaine. In this country one of the ways that we distinguish between positions is based around certifications. There are certain requirements that a person must complete in order to become “certified.” Look at engineers; I imagine that most automotive mechanics could do about 75% of what an automotive engineer could do. However, in order to be an engineer, you have to jump through all of the hoops to become one. Medicine is the same way. If you want to be a nurse, go to nursing school, if you want to be a physician, jump through that hoop. The beauty of America is that at the end of the day, you get to (for the most part) decide what you want to do with your life; you just have to be willing to work for it. And for the record, I can’t understand at all why nurses want to become NP’s. My friend is an RN and was looking at becoming an NP or getting his MBA and going into nursing admin. There was absolutely no comparison to the job opportunities. Nurse admins have a WAY better gig, and the earning potential is significantly higher than the NP route. He found that the only reason to be an NP was if you had an intense desire to do what a MD/DO does. So I ask, why not just go to medical school?

 

[Red Beard]

In the end, money makes the world go round, and health care in America today isn't a non-profit institution...

This is the crux of it, and the only real deciding factor that will determine what happens long-term.

Under a purely capitalist system, hospitals and physician groups will choose to utilize cheaper providers to the greatest extent they can get away with in order to increase profits.

Under a purely socialist/single payor system, the government will use the same approach to limit expenditures to the greatest degree it can get away with.

As a side note, I sure as hell didn't go to medical school to be a manager, I went to practice medicine. I sincerely hope that being a manager to a pack of NPs and PAs isn't the only career option I end up with.

 

[dilated]

Actually, there is almost no mid-level care in Canada, U.K. and Ireland.

WTF are you talking about? Mid level care is exploding in the UK. The government is constantly pushing to lower levels of qualification to save money. Because specialists are expensive, they now encourage "general practitioners with special interests" as a replacement (no, that's not a joke). Because general practictioners are expensive, they now encourage people to go to NP-run FP clinics. They're even getting into the idea of the "nurse consultant" (which would be saying "nurse attending" here).

Not sure why it hasn't caught on in Canada. I suspect they just haven't gotten training programs rolling yet.

 

[RxnMan]

WTF are you talking about? Mid level care is exploding in the UK...They're even getting into the idea of the "nurse consultant" (which would be saying "nurse attending" here)...

This is more in-line with what I've heard. There's a whole movement that opposes the dumbing-down of the NHS.

 

[allendo]

I was in the fast track last week and a NP student approached me and asked if I knew how to suture lacs. I told her I did and to my surprise she tells me she doesn't know how. So I asked when she graduates and she tells me next week. It makes me sick to think these individuals could practice on the same level with us one day.

 

[EM2BE]

I was in the fast track last week and a NP student approached me and asked if I knew how to suture lacs. I told her I did and to my surprise she tells me she doesn't know how. So I asked when she graduates and she tells me next week. It makes me sick to think these individuals could practice on the same level with us one day.

That reminds me...I had talked to a NP (licensed and not in the ED) who said she had never given injections. I'm hoping she just meant that type of injection and not NONE. I didn't even think to ask that part because I was absolutely in shock at the time (and was the patient).

 

[bulgethetwine]

That reminds me...I had talked to a NP (licensed and not in the ED) who said she had never given injections. I'm hoping she just meant that type of injection and not NONE. I didn't even think to ask that part because I was absolutely in shock at the time (and was the patient).

This brings up a good point, too -- when they do get their training, be it lac repair, injections, etc. who suffers as a result of the loss of the training opportunity? The explosion of PA and NP programs across the country is making this an emerging issue.

When I was on an off-service rotation as a 2nd year EM resident in the PICU (a notoriously ****e rotation at my institution for precisely the following reason) I wasn't allowed to intubate sick kids -- the NP got to do it?!?! WTF? First off, NPs wouldn't be intubating without a physician present, so why should it be part of their training at all? But it illustrates how the NP/PA "creep" is not just an issue going forward with regard to who might take jobs, but is also impacting the training of residents.

 

[docB]

But it illustrates how the NP/PA "creep" is not just an issue going forward with regard to who might take jobs, but is also impacting the training of residents.

Interestingly while we would argue this is evidence of the problem with midlevel creep they will argue that it means they are better trained than docs. Just watch.

 

[allendo]

I have more examples! I'm on medicine rounds and the attending slaps the lab report in front of me and it reads calcium pyrophosphate crystals. He turns to the NP student and asks what the patient has?? She has no idea....How do you not know what Pseudogout is?
We're on medicine rounds again and the attending playfully asks what's the problem when a patient on long term steroids is abruptly taken off and what blood chemistry abnormalities might be seen...Again NP student doesn't know. Attending walks off and she whispers to me that she doesn't understand and has not heard of adrenal crisis. These are basic concepts that they are missing!

 

[MacGyver]

Idiot anesthesiologists decided to grab up the easy life short-term with their "supervisory" positions, ignoring the fact that they are also making themselves obsolete.

Anesthesiologists as a group are the greediest and most short-sighted docs of all. They were making 300k before CRNAs came along, but they decided that wasnt good enough and they wanted to make 450k, so they started "supervising" these CRNAs and billing for them. 30 years later, the joke is on them as they are being shoved out for more CRNAs.

Contrast MDAs with general surgeons. General surg makes about 100k less per year than anesthesiologists, but they control their field and havent allowed interlopers to break in.

What a foolish group the MDAs turned out to be.

 

[MacGyver]

I have more examples! I'm on medicine rounds and the attending slaps the lab report in front of me and it reads calcium pyrophosphate crystals. He turns to the NP student and asks what the patient has?? She has no idea....How do you not know what Pseudogout is?
We're on medicine rounds again and the attending playfully asks what's the problem when a patient on long term steroids is abruptly taken off and what blood chemistry abnormalities might be seen...Again NP student doesn't know. Attending walks off and she whispers to me that she doesn't understand and has not heard of adrenal crisis. These are basic concepts that they are missing!

First things first. You need to ask your attending why he's selling out the field to NPs. You need to ask the dept of medicine chair the same question.

As long as MDs continue to train and hire these interlopers they will not go away, they will only get stronger. The decision to insert NP students into a medicine team is NOT a nursing decision. Nurse managers dont have the clout to make those decisions. Those decisions come from idiot MDs (either at the dept chair or attending level).