Maybe PA's and NP's should be allowed to do residency

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deleted128562

Stick with me here.

I have recently been involved in a few debates on these forums, mostly with fellow physicians. What I have discovered, shockingly, is that the majority of our colleagues truly believe that residents lose hospitals a lot of money, and also believe that midlevels can do 80-90% of a physician's job. I have argued vehemently against both of these assertions, but have been beat down by several people and must now consider the real possibility that I am wrong. But if that is the case, then I must conclude that the medical school training model is not only inefficient - it is actually, apples to apples - INFERIOR to the mid-level training product while taking twice the time. Again, stick with me here. Holding that the above claims made by our colleagues are in fact true:

1) A new physician is a net drain on a hospital system in excess of $120,000 per year (the money Uncle Sam forks out for training). Conversely, a new mid-level is worth in excess of $80,000 per year in salary and benefits paid directly by the hospital (otherwise they wouldn't be hired). Therefore, a new mid-level is worth at least $200,000 a year more to the hospital than a resident. And this isn't even taking into account that the resident probably works twice as much. So it may be more like a 300-400K disparity.

2) The above demonstrates that the new mid-level is a much more competent clinician out of the gate than the new resident. Therefore, if you put them both into a residency, wouldn't it stand to reason that the mid-level would actually do better?

3) If mid-levels can do 80-90% of our job already, then can you tell me with a straight face that they couldn't pick up the other measly 10-20% during a brutal 3-7 year residency? If the knowledge and ability gap is really that small, then doing a residency which is LONGER than the schooling that gave them the 80-90% in the first place, should be beyond adequate. 3 years is plenty of time to shore up a little knowledge gap, don't you think? And they can do this while being profitable for the hospital! Holy crap!

So how can I now, with a straight face, tell my PA and NP friends they shouldn't be able to do an ACGME residency? And how can I argue that 4 years of medical school is superior to 2 years of PA school of 1 day a week of NP school for 3 years?

And perhaps it's time to change "medical school" to 2 years following the PA model, with the option for residency afterwards to become a supervising provider. If my 4 years of education makes a me a worthless ***** out of the gate compared to the person who went to half the years of school I did, then it's time to acknowledge I have been royally ripped off and that the whole system needs to change.
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Mr. Hat said:
Stick with me here.

I have recently been involved in a few debates on these forums, mostly with fellow physicians. What I have discovered, shockingly, is that the majority of our colleagues truly believe that residents lose hospitals a lot of money, and also believe that midlevels can do 80-90% of a physician's job. I have argued vehemently against both of these assertions, but have been beat down by several people and must now consider the real possibility that I am wrong. But if that is the case, then I must conclude that the medical school training model is not only inefficient - it is actually, apples to apples - INFERIOR to the mid-level training product while taking twice the time. Again, stick with me here. Holding that the above claims made by our colleagues are in fact true:

1) A new physician is a net drain on a hospital system in excess of $120,000 per year (the money Uncle Sam forks out for training). Conversely, a new mid-level is worth in excess of $80,000 per year in salary and benefits paid directly by the hospital (otherwise they wouldn't be hired). Therefore, a new mid-level is worth at least $200,000 a year more to the hospital than a resident. And this isn't even taking into account that the resident probably works twice as much. So it may be more like a 300-400K disparity.

2) The above demonstrates that the new mid-level is a much more competent clinician out of the gate than the new resident. Therefore, if you put them both into a residency, wouldn't it stand to reason that the mid-level would actually do better?

3) If mid-levels can do 80-90% of our job already, then can you tell me with a straight face that they couldn't pick up the other measly 10-20% during a brutal 3-7 year residency? If the knowledge and ability gap is really that small, then doing a residency which is LONGER than the schooling that gave them the 80-90% in the first place, should be beyond adequate. 3 years is plenty of time to shore up a little knowledge gap, don't you think? And they can do this while being profitable for the hospital! Holy crap!

So how can I now, with a straight face, tell my PA and NP friends they shouldn't be able to do an ACGME residency? And how can I argue that 4 years of medical school is superior to 2 years of PA school of 1 day a week of NP school for 3 years?

And perhaps it's time to change "medical school" to 2 years following the PA model, with the option for residency afterwards to become a supervising provider. If my 4 years of education makes a me a worthless ***** out of the gate compared to the person who went to half the years of school I did, then it's time to acknowledge I have been royally ripped off and that the whole system needs to change.
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I agree that medical education is very, very inefficient compared to PA education. There is too much crap we are made to learn and do (not to mention that year of waste that is 4th year). With that said, we do emerge much better trained. To address your points:

1) Your logic is wrong. Resident salary is paid by medicare, and hospitals usually get some amount of money on top of that. So, we are theoretically FREE labor at worst (not sure how you assume we are costing the hospital system 120k/year).

2) Wrong again. The reason PAs are "worth" 80k+ per year and residents are not has mostly to do with billing. If the system changes where 4th year medical students were able to take an exam and become 'certified' or licensed at the end of medical school, and then be able to bill for services like PAs are able to, we'd earn the hospital system much more than a PA ever could, as we are 'willing' to work as hard as 1.5-2 PAs. Some have suggested different models of making medical graduates "junior" partners with on the job learning where we could bill for our services and not get paid by medicare, but I think this is an academic (i.e. theoretical) discussion at this point.

3) I'd argue that midlevel providers do far less than 80-90% of our job. Sure, they can write orders/notes and follow protocols. Our job is to actually make medically sound decisions in situations that don't fit into a neat little box. With that said, I believe that a PA or NP going through 3-9 years of residency would emerge similarly capable of making medical decisions as physicians. We learn a foundation of knowledge in medical school, but most of what you do on a day-to-day basis as a physician you learn by going through residency (including all the studying that you do as a resident). However, I'd be shocked if any substantial number of NPs/PAs were interested in working twice as a hard to earn half as much for 3-9 years (ie go through residency). There's a reason they chose their career paths. The problem is when a midlevel assumes that by following protocol for 10+ years that they are now of similar knowledge/capability as an attending.
 
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lazymed said:
I agree that medical education is very, very inefficient compared to PA education. There is too much crap we are made to learn and do (not to mention that year of waste that is 4th year). With that said, we do emerge much better trained. To address your points:

1) Your logic is wrong. Resident salary is paid by medicare, and hospitals usually get some amount of money on top of that. So, we are theoretically FREE labor at worst (not sure how you assume we are costing the hospital system 120k/year).

2) Wrong again. The reason PAs are "worth" 80k+ per year and residents are not has mostly to do with billing. If the system changes where 4th year medical students were able to take an exam and become 'certified' or licensed at the end of medical school, and then be able to bill for services like PAs are able to, we'd earn the hospital system much more than a PA ever could, as we are 'willing' to work as hard as 1.5-2 PAs. Some have suggested different models of making medical graduates "junior" partners with on the job learning where we could bill for our services and not get paid by medicare, but I think this is an academic (i.e. theoretical) discussion at this point.

3) I'd argue that midlevel providers do far less than 80-90% of our job. Sure, they can write orders/notes and follow protocols. Our job is to actually make medically sound decisions in situations that don't fit into a neat little box. With that said, I believe that a PA or NP going through 3-9 years of residency would emerge similarly capable of making medical decisions as physicians. We learn a foundation of knowledge in medical school, but most of what you do on a day-to-day basis as a physician you learn by going through residency (including all the studying that you do as a resident). However, I'd be shocked if any substantial number of NPs/PAs were interested in working twice as a hard to earn half as much for 3-9 years (ie go through residency). There's a reason they chose their career paths. The problem is when a midlevel assumes that by following protocol for 10+ years that they are now of similar knowledge/capability as an attending.
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Oh believe me, I get your points. Problem is that they don't seem to be shared by many of your colleagues. Read several recent threads and you will find there are A LOT of residents and attendings who will tell you that even with Uncle Sam paying our salaries + extra, the hospitals are STILL losing a bunch of money on us. Several of my attendings have point-blank told me the same thing. You will also see several of our resident and attending colleagues arguing that midlevels do in fact do 80-90% of our jobs. There was even one recent comment that they work at the level of 3rd year residents. My post essentially addresses the question, "what if they are right?"
 
Idk where you're meeting these brilliant PAs and NPs, but the mid level programs that rotated through my base when I was a medical student churned out scut-monkeys, and not the smart monkeys that use tools and you can take out for a nice dinner. These students were about to graduate and were dead wrong in chronic disease management (aechf, aecopd, dka) when attendings asked them 'what next'. Furthermore, at least half of the PAs in practice that I've worked with didn't even do the scut work well. Sloppy notes, discharges, misordering galore.

I honestly don't know what exactly they did for work. Seems like they just did what our med students did, plus put in simple orders that our attending had to cancel stat because they were often contributing to the reason for the unit transfer.

In my limited experience, a mid level handling a patient that eventually needed, for example, ID management, completely ruined any chance of getting positive cultures in at least 2/3 of patients that they touched by ordering abx all willy nilly. In my experience, they just 'do', they don't think about pphys or the reason why. Maybe it was bias from most of the attendings when they'd complain about their PAs. A pgy3 vs a PA with 3yrs experience? Get out of here. Maybe vs a pgy1 in august, but after that nope nope nope (from my experience)

Except for 1 who was a CT surg subspecialist with 12yrs experience, I wouldn't trust them as far as I can throw them to manage my family, and I put up 245x8 yesterday on incline bench. Ask that PA anything non CT related and you don't get a good answer. Note: these are PAs from 'good' programs like Wayne State.
 
Mr. Hat said:
Stick with me here.

I have recently been involved in a few debates on these forums, mostly with fellow physicians. What I have discovered, shockingly, is that the majority of our colleagues truly believe that residents lose hospitals a lot of money, and also believe that midlevels can do 80-90% of a physician's job. I have argued vehemently against both of these assertions, but have been beat down by several people and must now consider the real possibility that I am wrong. But if that is the case, then I must conclude that the medical school training model is not only inefficient - it is actually, apples to apples - INFERIOR to the mid-level training product while taking twice the time. Again, stick with me here. Holding that the above claims made by our colleagues are in fact true:

1) A new physician is a net drain on a hospital system in excess of $120,000 per year (the money Uncle Sam forks out for training). Conversely, a new mid-level is worth in excess of $80,000 per year in salary and benefits paid directly by the hospital (otherwise they wouldn't be hired). Therefore, a new mid-level is worth at least $200,000 a year more to the hospital than a resident. And this isn't even taking into account that the resident probably works twice as much. So it may be more like a 300-400K disparity.

2) The above demonstrates that the new mid-level is a much more competent clinician out of the gate than the new resident. Therefore, if you put them both into a residency, wouldn't it stand to reason that the mid-level would actually do better?

3) If mid-levels can do 80-90% of our job already, then can you tell me with a straight face that they couldn't pick up the other measly 10-20% during a brutal 3-7 year residency? If the knowledge and ability gap is really that small, then doing a residency which is LONGER than the schooling that gave them the 80-90% in the first place, should be beyond adequate. 3 years is plenty of time to shore up a little knowledge gap, don't you think? And they can do this while being profitable for the hospital! Holy crap!

So how can I now, with a straight face, tell my PA and NP friends they shouldn't be able to do an ACGME residency? And how can I argue that 4 years of medical school is superior to 2 years of PA school of 1 day a week of NP school for 3 years?

And perhaps it's time to change "medical school" to 2 years following the PA model, with the option for residency afterwards to become a supervising provider. If my 4 years of education makes a me a worthless ***** out of the gate compared to the person who went to half the years of school I did, then it's time to acknowledge I have been royally ripped off and that the whole system needs to change.
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1. Nobody anywhere is arguing that mid-levels are cheaper. As you point out, that's the reason they even have jobs.

2. The resident straight out of med school is more competent than the PA straight out of PA school. It makes no sense to compare a PA with years of practice under his belt to someone who was an MS4 6 weeks ago.

3. If you want to see someone who will only know 80-90% about your disease that's your prerogative. While the 4 year medical education is totally wasteful and inefficient (especially the first 2 years), the basic sciences must be taught and there needs to be a strong foundation in them in order to be as proficient as a physician. So, sure if PAs want to quit their $100k+ salaries and go spend 1.5-2 years learning basic sciences, then spend a few more years in clinical rotations they can go right ahead. Oh, but wait, that's just like going to med school.. and for whatever reason (couldn't get in, didn't want to spend the money/time, etc) that PA already chose not to go to med school the first time around.

4. I'd have no problem with PAs going to ACGME residencies if they can pass all the steps, but I doubt any PA could pass step 1.

5. You didn't number this 5, but I want to number it 5. Your 4 years of education makes you a worthless ***** because you are expected to function at a level well above what a PA functions at. Being a worthless ***** is the price you pay for having the opportunity to become the most important part of the healthcare team.
 
Mr. Hat said:
I have recently been involved in a few debates on these forums, mostly with fellow physicians. What I have discovered, shockingly, is that the majority of our colleagues truly believe that residents lose hospitals a lot of money, and also believe that midlevels can do 80-90% of a physician's job.
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The trick, of course, is knowing which 80-90% it is that they know. (Dunning-Kruger anyone?) Not knowing what it is they don't know can be a bit of a problem, no?

I know that sarcasm doesn't always come through in a post, but I think Mr. Hat was being facetious here. Please correct me if I'm wrong.

And if I'm not mistaken, it's been shown that a resident with just a bit of 'seasoning' can be very profitable for their hospital. If not, how can you explain how it is they're worth $200K more the day after completing residency than the day before. Or do hospitals not charge for care provided by residents?
 
DokterMom said:
I know that sarcasm doesn't always come through in a post, but I think Mr. Hat was being facetious here. Please correct me if I'm wrong.
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Sarcastiball isn't my favorite sport for nothing.... (South Park reference).... 🙂
 
Interesting proposition. Some thoughts as someone who is a PA (14 yr overemployment), taught and precepted PAs, and will graduate med school in 3 weeks, soon to be PGY1:
I think what looks like more efficient training to you is what we in the PA world call "clinical competence". Since the very early days (70s) of the profession PA education has focused on meeting clinical competency. Physician education didn't focus on that until the past decade or so. So now you're seeing more medical schools teaching basic procedural skills and emphasizing physical exam and history gathering. Now you have the CS and PE exams to prove the student doctor is competent to see a patient, conduct an exam and formulate a plan. Interestingly, the PAs dropped this part of certification exam somewhere in the late 90s (there is talk of bringing it back).
So while a new grad PA sans residency (there are many optional one-year PA residencies in many specialties) looks ready, they need a lot of mentoring. My first year out of school my supervising physician (FM) spent teaching time with me every single day for 30 minutes. By the end of that year I was highly competent. It was invaluable. But MOST PAs and NPs don't get that in our productivity-driven world.
What do seasoned physicians, PAs and NPs do really well? What enables them to make a doorway diagnosis? PATTERN RECOGNITION. We all (or at least the vast majority) get there, but it takes time to hone that skill. At least 3 years of broad experience, full time I would say.
But what happens when the pattern doesn't fit? The newbie PA or NP stumbles. The PA more than the NP has some fundamental knowledge of basic sciences to fall back on and hypothesize, come up with a differential diagnosis and whittle down, but may take more twists and turns (and order more tests and invasive studies that add expense and may or may not harm the patient and may or may not be necessary or indicated) to get to the right diagnosis...and I can say this because I have done all of those things!
Then there's the management--a totally new skill to master. Physicians spend 3 years of residency mastering this. PAs and NPs learn the very basics but the subtleties and nuances are learned along the way, on the job. We get better and smarter and eventually clinically practice similarly to physicians. The very smart folks read constantly and widely and learn as much as they can on their own. But physicians have the advantage of a highly structured clinical curriculum during residency that is far superior to any on-the-job learning or self-study.
There is a difference in both education and product. I've learned both ways and done both. I was taught quite well as a PA student and I've had good mentors, but I knew there was so much I didn't know. I couldn't stand that and went back to med school to learn it deeper and better. I agree there are HUGE inefficiencies in traditional medical education right now--there was so much redundancy in my preclinical curriculum I couldn't believe it. That should be trimmed. In PA school it goes so fast that if you didn't learn the first time, you'd better learn it on your own because it won't be re-taught.
I think there is less re-teaching in PA school because 1) there's no time and 2) there is no step 1 exam at the end of didactic year to pass. The PA certification exam (PANCE) focuses almost entirely on diagnosis and management. Very little basic sciences are tested. I've said on this forum and on the PA forum that I'm confident any licensed and certified PA could pass step 2 and probably step 3 (though I haven't taken that one yet so I reserve my opinion here) but would be very challenged by step 1 because that stuff is just not taught in PA school. And the 10% of the time you might need to know the stuff the PAs never learned is the difference that makes you the PHYSICIAN, the team leader, the guide and check system of the team. Used to be we worked as PA-physician TEAMS. Since that's largely fallen away, there's more room for errors and well-meaning but uninformed mistakes. A mandatory residency could help address that and may well be something we see evolve for new PAs (and maybe NPs) in the future.
 
dyspareunia said:
2. The resident straight out of med school is more competent than the PA straight out of PA school. It makes no sense to compare a PA with years of practice under his belt to someone who was an MS4 6 weeks ago.
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It makes perfect sense if you're pushing an agenda. I see this all the time on EMS forums where someone claims to have more faith in the EMT with 10 years experience (or is it 1 year experience repeated 9 times) than a paramedic fresh out of school.
 
primadonna22274 said:
Interesting proposition. Some thoughts as someone who is a PA (14 yr overemployment), taught and precepted PAs, and will graduate med school in 3 weeks, soon to be PGY1:
I think what looks like more efficient training to you is what we in the PA world call "clinical competence". Since the very early days (70s) of the profession PA education has focused on meeting clinical competency. Physician education didn't focus on that until the past decade or so. So now you're seeing more medical schools teaching basic procedural skills and emphasizing physical exam and history gathering. Now you have the CS and PE exams to prove the student doctor is competent to see a patient, conduct an exam and formulate a plan. Interestingly, the PAs dropped this part of certification exam somewhere in the late 90s (there is talk of bringing it back).
So while a new grad PA sans residency (there are many optional one-year PA residencies in many specialties) looks ready, they need a lot of mentoring. My first year out of school my supervising physician (FM) spent teaching time with me every single day for 30 minutes. By the end of that year I was highly competent. It was invaluable. But MOST PAs and NPs don't get that in our productivity-driven world.
What do seasoned physicians, PAs and NPs do really well? What enables them to make a doorway diagnosis? PATTERN RECOGNITION. We all (or at least the vast majority) get there, but it takes time to hone that skill. At least 3 years of broad experience, full time I would say.
But what happens when the pattern doesn't fit? The newbie PA or NP stumbles. The PA more than the NP has some fundamental knowledge of basic sciences to fall back on and hypothesize, come up with a differential diagnosis and whittle down, but may take more twists and turns (and order more tests and invasive studies that add expense and may or may not harm the patient and may or may not be necessary or indicated) to get to the right diagnosis...and I can say this because I have done all of those things!
Then there's the management--a totally new skill to master. Physicians spend 3 years of residency mastering this. PAs and NPs learn the very basics but the subtleties and nuances are learned along the way, on the job. We get better and smarter and eventually clinically practice similarly to physicians. The very smart folks read constantly and widely and learn as much as they can on their own. But physicians have the advantage of a highly structured clinical curriculum during residency that is far superior to any on-the-job learning or self-study.
There is a difference in both education and product. I've learned both ways and done both. I was taught quite well as a PA student and I've had good mentors, but I knew there was so much I didn't know. I couldn't stand that and went back to med school to learn it deeper and better. I agree there are HUGE inefficiencies in traditional medical education right now--there was so much redundancy in my preclinical curriculum I couldn't believe it. That should be trimmed. In PA school it goes so fast that if you didn't learn the first time, you'd better learn it on your own because it won't be re-taught.
I think there is less re-teaching in PA school because 1) there's no time and 2) there is no step 1 exam at the end of didactic year to pass. The PA certification exam (PANCE) focuses almost entirely on diagnosis and management. Very little basic sciences are tested. I've said on this forum and on the PA forum that I'm confident any licensed and certified PA could pass step 2 and probably step 3 (though I haven't taken that one yet so I reserve my opinion here) but would be very challenged by step 1 because that stuff is just not taught in PA school. And the 10% of the time you might need to know the stuff the PAs never learned is the difference that makes you the PHYSICIAN, the team leader, the guide and check system of the team. Used to be we worked as PA-physician TEAMS. Since that's largely fallen away, there's more room for errors and well-meaning but uninformed mistakes. A mandatory residency could help address that and may well be something we see evolve for new PAs (and maybe NPs) in the future.
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So, how come you didn't want to be a Physician's Assistant anymore?
 
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primadonna22274 said:
Thanks Fab
And duh, I was never a Physician'S Assistant. I am not, never was and never will be the property of a physician.
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You sound upset. Did your physician mistreat you?

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Mr. Hat said:
Oh believe me, I get your points. Problem is that they don't seem to be shared by many of your colleagues. Read several recent threads and you will find there are A LOT of residents and attendings who will tell you that even with Uncle Sam paying our salaries + extra, the hospitals are STILL losing a bunch of money on us. Several of my attendings have point-blank told me the same thing. You will also see several of our resident and attending colleagues arguing that midlevels do in fact do 80-90% of our jobs. There was even one recent comment that they work at the level of 3rd year residents. My post essentially addresses the question, "what if they are right?"
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You misunderstood the entire arguments of everyone else in that thread.

The claim is not that the work that residents do loses money for the hospital. The claim is that the work residents do does not outweigh the resources spent on training the residents and helping them grow as providers. Those are very, very different points.

When you hire a PA, you don't have to use your most valuable staff members (the attendings) to give them lectures 10-15 hours a week. You don't have to put together an entire administrative infrastructure, with at least one attending working half-time in administration and at least one secretary/coordinator in order to coordinate your PAs work. You don't have to slow down your own procedures so that the PA can better understand how they're going to do it themselves later, because they won't be doing it themselves later.

I didn't see the post that said a PA is on the level of a 3rd year resident, but I've worked with PA's in a number of rotations and I'd say that a good one with some experience is easily at the level of an intern 6-8 months into their residency. That's fine. But the thing is, they stay there. They don't get comprehensive education in how to do everything on their own, and their lack of such attention means the other members of the team are freed up to be more efficient. On the other thing, residents frequently slow things down when they're learning. But we accept that slow down because otherwise we won't end up with any new competent, independent providers.

So yes, if our programs didn't give a rats ass about educating us and just used us for scutwork while the attendings were off earning maximal money, a resident could easily earn his entire salary and more. But that would be a piss-poor educational experience, and one that isn't (or shouldn't be at least) the case in any program that's actually ACGME accredited. Our attendings accept the inefficiency of the residents and everything that entails (extra supervision in some cases, extra autonomy in others) and try to maximize our educational potential.
 
Brain Bucket said:
You sound upset. Did your physician mistreat you?
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tRCcX.gif
 
Sorry if this was already posted but I just cant sift through these posts. Correction for the OP - hospitals make an absolute killing by having residents. I don't know who told you otherwise, but they bill insurance companies for 100% of the resident's patient care, and pay 0% of the residents salary. The gov pays for the residents salary, and kicks a little extra to the hospital for having them.

Hospitals can bill insurance companies for 85% of a midlevel's patient care, and must pay 100% of their salary.

The government pays for residency training... But they aren't getting burned throughout the process. Despite the cost of residency training, they make money off the loan interest that (most) residents accrue.
 
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ChrisGriffen said:
Sorry if this was already posted but I just cant sift through these posts. Correction for the OP - hospitals make an absolute killing by having residents. I don't know who told you otherwise, but they bill insurance companies for 100% of the resident's patient care, and pay 0% of the residents salary. The gov pays for the residents salary, and kicks a little extra to the hospital for having them.

Hospitals can bill insurance companies for 85% of a midlevel's patient care, and must pay 100% of their salary.

The government pays for residency training... But they aren't getting burned throughout the process. Despite the cost of residency training, they make money off the loan interest that (most) residents accrue.
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Actually, go over to the General Residency forum and read the "Why Aren't Residents Paid More?" thread. You'll find that many, probably even the majority, of your colleagues disagree with you and believe quite strongly that hospitals lose money overall by having residents. That, plus some recent midlevel threads, is what got me on this rant in the first place. Which obviously was not sarcastic enough.
 
Mr. Hat said:
Actually, go over to the General Residency forum and read the "Why Aren't Residents Paid More?" thread. You'll find that many, probably even the majority, of your colleagues disagree with you and believe quite strongly that hospitals lose money overall by having residents. That, plus some recent midlevel threads, is what got me on this rant in the first place. Which obviously was not sarcastic enough.
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Sorry but there are quite a few hospitals that would CRASH TO THE GROUND, if residents tomorrow were to stop working and attendings did all the work. You're really going to make the argument that a PA/NP on Day 1, is worth more money than an MD on Day 1? Nice to see Stockholm Syndrome is quite prevalent.
 
A 6th or 7th year neurosurgery resident is worth his/her weight in gold: doing surgeries worth millions, getting paid 55K flat. Some departments keep the entire hospital afloat. And who are the worker bees? Residents. There's a reason residency years are increasing.
 
DokterMom said:
The trick, of course, is knowing which 80-90% it is that they know. (Dunning-Kruger anyone?) Not knowing what it is they don't know can be a bit of a problem, no?

I know that sarcasm doesn't always come through in a post, but I think Mr. Hat was being facetious here. Please correct me if I'm wrong.

And if I'm not mistaken, it's been shown that a resident with just a bit of 'seasoning' can be very profitable for their hospital. If not, how can you explain how it is they're worth $200K more the day after completing residency than the day before. Or do hospitals not charge for care provided by residents?
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This reminds me of the labels on Lysol bottles: "Kills 99.99% of germs! Guaranteed!" Except, when you do contract a little bugger, it'll be in the .01% no doubt. CYA at its best.
 
BurghStudent said:
This reminds me of the labels on Lysol bottles: "Kills 99.99% of germs! Guaranteed!" Except, when you do contract a little bugger, it'll be in the .01% no doubt. CYA at its best.
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It actually just has to do with numbers. That .01% isn't a small number, so it really isn't surprising.

WhippleWhileWeWork said:
The memes are losing me. Rebutting memes with more memes....
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They'll get no more until they prove they're capable of intelligent discourse. The fact that they think ravel and unravel are antonyms isn't doing them any favors.
 
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Raryn said:
You misunderstood the entire arguments of everyone else in that thread.

The claim is not that the work that residents do loses money for the hospital. The claim is that the work residents do does not outweigh the resources spent on training the residents and helping them grow as providers. Those are very, very different points.

When you hire a PA, you don't have to use your most valuable staff members (the attendings) to give them lectures 10-15 hours a week. You don't have to put together an entire administrative infrastructure, with at least one attending working half-time in administration and at least one secretary/coordinator in order to coordinate your PAs work. You don't have to slow down your own procedures so that the PA can better understand how they're going to do it themselves later, because they won't be doing it themselves later.

I didn't see the post that said a PA is on the level of a 3rd year resident, but I've worked with PA's in a number of rotations and I'd say that a good one with some experience is easily at the level of an intern 6-8 months into their residency. That's fine. But the thing is, they stay there. They don't get comprehensive education in how to do everything on their own, and their lack of such attention means the other members of the team are freed up to be more efficient. On the other thing, residents frequently slow things down when they're learning. But we accept that slow down because otherwise we won't end up with any new competent, independent providers.

So yes, if our programs didn't give a rats ass about educating us and just used us for scutwork while the attendings were off earning maximal money, a resident could easily earn his entire salary and more. But that would be a piss-poor educational experience, and one that isn't (or shouldn't be at least) the case in any program that's actually ACGME accredited. Our attendings accept the inefficiency of the residents and everything that entails (extra supervision in some cases, extra autonomy in others) and try to maximize our educational potential.
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That said, it would be interesting to see the performance of a PA if he/she took a 3-7 year residency after doing a number of years work.

Brain Bucket said:
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Mr. Hat said:
Actually, go over to the General Residency forum and read the "Why Aren't Residents Paid More?" thread. You'll find that many, probably even the majority, of your colleagues disagree with you and believe quite strongly that hospitals lose money overall by having residents. That, plus some recent midlevel threads, is what got me on this rant in the first place. Which obviously was not sarcastic enough.
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To be completely honest, its really hard to tell who is being sarcastic and who is just incredibly uninformed when it comes to the $ involved with GME. I didn't really read any of the posts in here to try to differentiate the two. I have never ventured into the resident's pay thread, but that thread should be one post long, and it should say "balanced budget act of 1997"
 
primadonna22274 said:
Interesting proposition. Some thoughts as someone who is a PA (14 yr overemployment), taught and precepted PAs, and will graduate med school in 3 weeks, soon to be PGY1:
I think what looks like more efficient training to you is what we in the PA world call "clinical competence". Since the very early days (70s) of the profession PA education has focused on meeting clinical competency. Physician education didn't focus on that until the past decade or so. So now you're seeing more medical schools teaching basic procedural skills and emphasizing physical exam and history gathering. Now you have the CS and PE exams to prove the student doctor is competent to see a patient, conduct an exam and formulate a plan. Interestingly, the PAs dropped this part of certification exam somewhere in the late 90s (there is talk of bringing it back).
So while a new grad PA sans residency (there are many optional one-year PA residencies in many specialties) looks ready, they need a lot of mentoring. My first year out of school my supervising physician (FM) spent teaching time with me every single day for 30 minutes. By the end of that year I was highly competent. It was invaluable. But MOST PAs and NPs don't get that in our productivity-driven world.
What do seasoned physicians, PAs and NPs do really well? What enables them to make a doorway diagnosis? PATTERN RECOGNITION. We all (or at least the vast majority) get there, but it takes time to hone that skill. At least 3 years of broad experience, full time I would say.
But what happens when the pattern doesn't fit? The newbie PA or NP stumbles. The PA more than the NP has some fundamental knowledge of basic sciences to fall back on and hypothesize, come up with a differential diagnosis and whittle down, but may take more twists and turns (and order more tests and invasive studies that add expense and may or may not harm the patient and may or may not be necessary or indicated) to get to the right diagnosis...and I can say this because I have done all of those things!
Then there's the management--a totally new skill to master. Physicians spend 3 years of residency mastering this. PAs and NPs learn the very basics but the subtleties and nuances are learned along the way, on the job. We get better and smarter and eventually clinically practice similarly to physicians. The very smart folks read constantly and widely and learn as much as they can on their own. But physicians have the advantage of a highly structured clinical curriculum during residency that is far superior to any on-the-job learning or self-study.
There is a difference in both education and product. I've learned both ways and done both. I was taught quite well as a PA student and I've had good mentors, but I knew there was so much I didn't know. I couldn't stand that and went back to med school to learn it deeper and better. I agree there are HUGE inefficiencies in traditional medical education right now--there was so much redundancy in my preclinical curriculum I couldn't believe it. That should be trimmed. In PA school it goes so fast that if you didn't learn the first time, you'd better learn it on your own because it won't be re-taught.
I think there is less re-teaching in PA school because 1) there's no time and 2) there is no step 1 exam at the end of didactic year to pass. The PA certification exam (PANCE) focuses almost entirely on diagnosis and management. Very little basic sciences are tested. I've said on this forum and on the PA forum that I'm confident any licensed and certified PA could pass step 2 and probably step 3 (though I haven't taken that one yet so I reserve my opinion here) but would be very challenged by step 1 because that stuff is just not taught in PA school. And the 10% of the time you might need to know the stuff the PAs never learned is the difference that makes you the PHYSICIAN, the team leader, the guide and check system of the team. Used to be we worked as PA-physician TEAMS. Since that's largely fallen away, there's more room for errors and well-meaning but uninformed mistakes. A mandatory residency could help address that and may well be something we see evolve for new PAs (and maybe NPs) in the future.
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So basically what you're saying is that you don't have any experience as an NP so you have no idea about how awesome their clinically oriented education and how they're just as smart and safe, if not more, as physicians while being much more holistic and caring for the patient through the amazing nursing model of knowing less medicine than physicians but being better in practice, especially when unsupervised and by the way, I'm not trying to be a doctor but I do have a doctorate so please address me as Dr. Sands from anesthesia.
 
Psai said:
So basically what you're saying is that you don't have any experience as an NP so you have no idea about how awesome their clinically oriented education and how they're just as smart and safe, if not more, as physicians while being much more holistic and caring for the patient through the amazing nursing model of knowing less medicine than physicians but being better in practice, especially when unsupervised and by the way, I'm not trying to be a doctor but I do have a doctorate so please address me as Dr. Sands from anesthesia.
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Lolz what?!
I'm not a nurse. Not an NP. Have worked with a few fantastic and some scary NPs. In fact I see a (very smart) NP for most of my primary care needs now, which are minor as I am healthy and don't go in much. She happens to be a former colleague that I trust and a dear friend. What I do know is their didactic and clinical curriculum is widely variable and wayyyyy different than PAs and physicians.
I'm not interested in debating the qualifications and credentials of NPs as I'm not one. I'm sure someone else will weigh in here.
 
primadonna22274 said:
Lolz what?!
I'm not a nurse. Not an NP. Have worked with a few fantastic and some scary NPs. In fact I see a (very smart) NP for most of my primary care needs now, which are minor as I am healthy and don't go in much. She happens to be a former colleague that I trust and a dear friend. What I do know is their didactic and clinical curriculum is widely variable and wayyyyy different than PAs and physicians.
I'm not interested in debating the qualifications and credentials of NPs as I'm not one. I'm sure someone else will weigh in here.
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I think you missed the sarcasm there...
 
No they definitely shouldn't. Imagine if they did. Primary care and derm would definitely be out of a job. It'll never happen though. Doesn't matter.
 
vasca said:
Strange indeed. While everyone agrees the fresh out of med school MD is a liability for a hospital, that is why they have senior residents and attendings supervising them so that no document is valid unless it is signed and approved by a senior employee. The hospital is also getting very, very, very cheap labor. When you calculate the hours earned by a resident's monthly salary, many of them are earning less than minimum wage. Their wages are also paid by a subsidy of the US government. The hospital obtains fresh easily moldable labor not only cheaply but for free!

If an attending thinks an experienced midlevel is more valuable, I don't say they are wrong because an employee doing the same job for 20 years will do it better than a PGY in their first week, but a resident earns only a small fraction of cash without as many job benefits as a unionized worker that can claim sick days and training days and freebie days and extra vacation days, etc... If a resident is making a lot of mistakes, it may be because the resident isn't studying as hard, or is very tired from lack of sleep or perhaps the attending is sadly not supervising and teaching as well as they should. That is why many residency programs have self assessment anonymous surverys to see where can the teaching improve and give suggestions to improve the program.
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Actually, they don't. Again, you continue to give bad and wrong advice.
 
There are no such thing as an anonymous survey. Only surveys where I don't give a flip if the requesting organization cares who I am... like those "you're graduating in a week... here's 10,000 surveys to complete" times.
 
futurepsych0 said:
I assume you're talking about residencies that are equivalent to that of a physician? Because they already have quite a bit of residencies and fellowships in almost every specialty. For example, http://www.lahey.org/Departments_an...e_Practitioner_Fellowship_in_Dermatology.aspx for derm or http://www.cumc.columbia.edu/pulmonary/clinical-centers/critical-care-np-pa-program for critical care. They learn from other NPs, PAs and physicians.
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So dermatological NPs huh. Why is Harvard/MGH promoting this?
 
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