Mayo Clinic Symposium on Health Education Reform

[physasst]

As a member of the Mayo Clinic Health Policy Center, I wanted to drop an update on the just held Symposium on Health Education Reform...

From my blog:

http://physasst.blogspot.com

WOW....surrounded by heavyweights...all of them.

Had breakfast with Polly Bednash, who is the Executive Director of the AACN, Darrell Kirch, the current president and CEO of the AAMC, and my friend, and colleague, VP of the AAPA Bill Fenn.

Attendees include:

President Emeritus AAMC
Chancellor Emory University
Director, Division of Undergraduate Medical Education, AMA
President and CEO of the Institute for Healthcare Improvement
Professor and Dean of Vanderbilt School of Nursing
CEO Henry Ford Medical Group
Senior VP of the American Board of Medical Specialties
CEO and Executive VP, American Colleges of Pharmacy
CEO Accreditation Council for CME
CEO National League Nursing
President and CEO ACGME
President American Association of Colleges of Osteopathic Medicine
Coordinating Producer ABC News Health Care Task Force

as well as NUMEROUS other deans and presidents of various medical schools.

It was a good day.

First session started with a review of the four cornerstones of health reform for the Mayo Clinic.

Discussion also focused around reforming medical student education to NOT teach disease treatment, but to teach healthcare delivery. There was a lot of focus on integrated classes for medical students, WITH MANY classes being taken with other health professionals. For example. Anatomy. There was discussion that medical students, nursing students, PT students, and PA students ALL TAKE THE SAME ANATOMY COURSES TOGETHER. There was talk about incorporating a course that would solely teach and focus on teamwork, and (sorry Happy) teaching the physician that they are an EQUAL with other members on the team, and not always in charge.

There was a LOT of very pro PA and NP and "nonphysician provider" discussion.

There was a lot of discussion about the Intermountain group, that manages 30,000 diabetic patients with only FOUR endocrinologists. HOW? They use non physician providers.

The next session was about Licensure, Accreditation, and Certification. There was a lot of debate about having a SOLITARY interdisciplinary certifcation process.

There was a talk about Professionalism, and having medical students NOT graded on individual exams to test medical knowledge that they won't remember, but to test them on the concepts, and the ability to find the answers when they need them. ALSO, to test them on HOW WELL THEY FUNCTION IN THE TEAM MODEL.

The next session included Realigning the Health Care Training System Toward Coordinated Patient Centered Care, again discussing the team model, and dramatically changing the current medical school structure.

Finally, we were asked to submit a singular answer from EVERY table as to HOW to best reform the health care system.

Then, we had dinner, and a discussion on Driving Change in Academic Medicine.

I'm tired now. A lot of information, a lot of very intense discussion amongst a group of highly accomplished and intelligent folks.

I will update you tomorrow with the findings at that time.

Here's some more information:

After the introduction, Denis Cortese, M.D., presented an overview of the Mayo Clinic Health Policy Center’s consensus-driven cornerstones for health care reform in America: create value, coordinate care, reform the payment system and insure everyone. He noted that medical education must play a crucial role in preparing individuals to provide high-value, coordinated care and introduced several issues for education professionals to consider, including specific curriculum designed to increase value, student selection criteria, instruction methods, assessment and financing.

Zoë Baird then introduced the panel and framed the discussion around how to train students to create a healthier America. All panelists agreed that the educational system must be redesigned to break down professional silos, creating an educational environment in which physicians, nurses, other allied health professionals, community health workers and family caregivers learn to work together on behalf of the patient.

“There is concern about a shortage of physicians today,” said Michael Johns, M.D. “I think if we gave allied health staff the ability to practice to the full extent of their skills, that shortage would be a lot smaller.

“We need the right person at the right time to provide leadership to the care team,” he continued. “Physicians need to be comfortable not being at point all the time. Every person is important.”

Panel members also noted that the curriculum must incorporate elements of engineering and health delivery science in addition to biological science.

Dr. Cortese commented that the current education system encourages learners to focus on accumulation of knowledge rather than innovative ways to deliver health care to individuals.

The group also called for the development of novel assessments – including measurement based upon patient outcomes, teamwork and individual performance.

“We need to move away from GPA and standard examinations as our primary or sole assessment tools,” said Jack Stobo, M.D. “There is no correlation between these tools and how students perform in practice.”

“We are in control of health professional education… it’s ours to win or lose,” he emphasized. “There currently is a mismatch with how we’re educating professionals and what society needs.”




10-11:30 a.m. – Licensure, Accreditation and Certification: Achieving Harmonic Resonance

Moderator:
Susan Wagner, Producer, Dr. Oz Show

Panelists:
Geraldine Bednash, Ph.D., Executive Director, American Association of Colleges
of Nursing
Claire Bender, M.D., Director for Education, Mayo Clinic in Minnesota
Richard Hawkins, M.D., Senior Vice President for Professional and
Scientific Affairs, American Board of Medical Specialties
Thomas Nasca, M.D., CEO, Accreditation Council for Graduate Medical Education


Moderator Susan Wagner provided introductions and began the discussion by asking the panelists to define licensure, accreditation and certification. Then, discussion revolved around identifying steps to change licensure, accreditation and certification standards/processes without a clear sense of what reforms will shape the care delivery system.

Geraldine Bednash, Ph.D., R.N., discussed efforts in advanced practice nursing to bring together the different standard-setting groups to agree on a common set of standards for certification and accreditation. Dr. Bednash noted that licensing occurs at the state level by government and is influenced more by political considerations instead of evidence of capability of providers.

Expanding sharing opportunities is an area that can be explored immediately, according to Claire Bender, M.D. Dr. Bender described new efforts at Mayo Clinic to bring different providers together in the same class when curriculum is applicable to both. It has been successful in demonstrating that different providers have and need different skills. The model also provides an environment that allows different health care professionals to become familiar with each other and respect the abilities of each type of provider.

Thomas Nasca, M.D., pointed out that it will be difficult to get hundreds of professional societies, accrediting bodies and licensure boards around the table, but that it may be possible to begin agreeing on unifying themes that move across discipline boundaries. It will be important to make sure that licensure, accreditation and certification standards don’t prohibit change, and reinforce core competencies that learners can carry forward as health care delivery systems evolve.

Richard Hawkins, M.D., discussed how assessments can be redefined to reinforce the principles of teamwork in a reformed health care environment. He suggested creating a feedback cycle from clinical care into the education and certification process.

Participants spent a portion of the session submitting ideas for changes in licensure, certification and accreditation to aid in transforming the educational system to support patient-centered, coordinated health care reform. The following actions received the highest endorsement.

Introduce team-based minimum standards for training and care models for both certification and accreditation.

Introduce team-based exercises as part of individual certification.

Certification should more closely mirror real-life clinical situations.

Consider use of a public/private entity, independent of Congress, to bring societies and professions together and adopt more common standards for training, certification and accreditation.


Noon-1:30 p.m. – Professionalism - The Critical Element in Health Care Education


If doctors falter in their professionalism, health care reform efforts will come up short, said Jordan Cohen, M.D., president emeritus of the Association of the American Medical Colleges and professor of medicine and public health at George Washington University.

“Professionalism is when physicians know the right thing to do and then do it,” he remarked in his keynote luncheon address. “It’s the behavior required of doctors in fulfilling their compact with society. They are honor bound on their own volition to work in patients’ best interest and use their knowledge and expertise to that end.”

Dr. Cohen said that nurturing professionalism is one way to advance needed changes in U.S. health care, and he recommended six ways for educators to promote professionalism:

Adopt and approve admission criteria. Few medical students fail to graduate and fewer still fail to get licensed. Educators have a fundamental role as gatekeepers to the profession.
Establish explicit learning objectives. Adults learn best when they have prospective understanding of what they are going to learn.
Address the rationale for adhering to the precepts of professionalism in the formal curriculum. Future physicians need to be mindful of temptations and ways to withstand conflicts of interest.
Be proactive and intentional in the informal curriculum. Educators need to model behaviors emblematic of professionalism. Informal curriculum is one of the most powerful influences on adopting the norms of the profession.
Articulate institutional expectations. “We need to be unabashed about communicating these expectations,” says Dr. Cohen.
Evaluate and reward behaviors that are emblematic of professionalism. Sanction and call out those who are not professional.

Americans long to trust their physicians and polls show that they largely do, Dr. Cohen added. And, trusting doctors is good for patients. “It increasing compliance and improves outcomes,” he remarked. “But that trust is earned, not owed. The surest way to lose that trust is to abandon professionalism.”



1:30-3 p.m. – Realigning the Health Care Training System for Coordinated Patient- Centered Care

Moderator:
Maggie Mahar, Ph.D., health care fellow, Century Foundation

Panelists:
Mark Kelly, M.D., Henry Ford Medical Group
Lindsey Henson, M.D., University of Minnesota
William Hersh, M.D., Oregon Health and Science University
Beverly Malone, PhD, RN, FAAN, National League of Nursing
Alyce Schultz, RN, PhD, FAAN, EBP Concepts



Today’s medical education system has holes that prevent the next generation of doctors, nurses and allied health professionals from learning how to provide patient-centered care.

That was the premise of moderator Maggie Mahar, Ph.D., health care fellow, Century Foundation, as she opened the session titled “Realigning the Health Care Training System for Coordinated Patient-Centered Care.”

She was joined by representatives from, nursing, medical education and medical center leadership to discuss how the core competencies identified in the Institute of Medicine’s 2003 report “Bridge to Quality” might fill those gaps.

Panel discussion centered on the core competencies, most taken from the IOM report, including:

Providing patient-centered care
Working in interdisciplinary teams
Using evidence-based practice
Applying quality improvement
Using informatics
Shifting culture toward professionalism

The discussion sparked more than 30 recommendations to keep patients at the center of coordinated care. The top-ranked recommendations encompassed common themes of teaching future providers how to work in teams and across disciplines. The recommendations challenged educators to find ways to increase learning opportunities in real world settings.

Participants ranked these recommendations as most important:

Introduce (early in training programs) team-based and reality-based standards and experiences that reflect all health care team members contributing at their highest level of training.

Establish an institutional/unit commitment to patient-centered collaborative care.

To understand patients, students should interface with the patients in their communities experiencing medical care through their patients eyes and experiences

Incentives for students (i.e. evaluation) must be aligned with team learning.

Health education schools need to work across disciplines to develop areas of shared curriculum to teach students team care delivery

Create a non-punitive culture for understanding and learning from mistakes and inefficiency


3:30-5 p.m. – Your Views Concerning Change – What is Required to Create the Health Care Workforce of the Future?

Event co-hosts Pat Mitchell and Dr. Cascino challenged participants to brainstorm ideas to answer the same question posed to MD Connector Competition participants:

“In order to create a health care workforce equipped to provide a high-value team approach to coordinated, patient-centered health care, what is the most important change required of the health care education system?”

The group spent an hour discussing potential changes, and submitted their consensus responses. Responses will be compiled during the evening, and participants will review and prioritize the recommendations during the opening session on Tuesday morning.



7-8 p.m. – Driving Change in Academic Medicine

Darrell Kirch, M.D., president and CEO, Association of American Medical Colleges provided perspective on the need for change in academic medicine.

Dr. Kirch emphasized the importance of focusing medical and health care education reform on the training of all professionals who work in the delivery of health care. Individuals who practice in any portion of care delivery are a vital part of the team approach to medicine and need to have a voice in the evolution of training.

Dr. Kirch noted that many buzzwords are associated with health care reform. One of these words is “change.” He focused on two degrees of change:

Incremental, which is usually considered good in academic settings, and
Revolutionary, which encompasses broad change

Dr. Kirch proposed the need for a middle ground in education: transformational change. This involves sweeping, fundamental change that recognizes the tremendous good in the current system – especially the dedicated people.

A primary barrier to change, he noted, is true culture shift in medical and health care education. Dr. Kirch cited the 1910 Flexner Report as the last true culture shift in medical and health care education. Flexner emphasized an academic culture which has medical research at its core. While this is a valid foundation, Dr. Kirsh said that this focus has led to competition among individuals in research and practice.

A New Culture
Dr. Kirch discussed that today’s patient expects teamwork in medicine. The current health care practice – which emphasizes individualism – is unsustainable, and there is broad recognition that teaching and learning have to be different. Health care professionals need to use information rather than retain information.

Dr. Kirch concluded his presentation by outlining five items for medical and health care education reform:

First, health care systems and educational systems need to be partners. This involves training organizations that are accountable for developing value in the health care system.

Second, the medical and health care training system needs to put aside culture and focus on training that meets the needs of patients.

Third, medical and health care education schools must be increasingly transparent with financial and tuition information.

Fourth, medical education must develop future leaders, building a bottom-up approach that focuses on teamwork and consensus.

Fifth, the health care system must examine the factors that drive medical and health care education training. This must include the concept of justice in the health care system. Dr. Kirch emphasized that the current health care system is unjust or fundamentally unfair, which is not a political issue but a core ethical issue.


AND this was just the first day. I will update on todays events later.

Thought you might enjoy to hear what the leaders in Healthcare education are discussing.

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Members don't see this ad.

 

[chessknt]

There was talk about incorporating a course that would solely teach and focus on teamwork, and (sorry Happy) teaching the physician that they are an EQUAL with other members on the team, and not always in charge.

Sorry if I am being ignorant, but in what case would a nurse or PA need to be in charge of a physician? This seems like it might cause confusion/undermine delivery of healthcare. Just look at the military (which I think is the best example of a team effort)--there is a very clear line of command which is (usually) correlated with experience/leadership ability.

 

[physasst]

Sorry if I am being ignorant, but in what case would a nurse or PA need to be in charge of a physician? This seems like it might cause confusion/undermine delivery of healthcare. Just look at the military (which I think is the best example of a team effort)--there is a very clear line of command which is (usually) correlated with experience/leadership ability.

GOOD question, it's not about a nurse or PA being in "charge" of a physician, although several PA's are now executive board members of large institutions, and one Bill Hunt is the COO/EVP of the eighth largest healthcare system in the country, but I digress. IT'S ABOUT EVERYONE on the team having EQUAL input. It's about changing the physician education model, and culture, from one of autonomy and isolation to some degree, to one of integration, and collaboration. Maybe the PA IS better suited then the MD to take care of THAT patient. Maybe the MD is. Maybe the nurse knows more about what is going on than anyone else, and instead of giving orders, the physician should ask for suggestions and/or input.

Our CEO,and my colleague, Denis Cortese, MD, has a saying he uses frequently when discussing this...."The patient needs the RIGHT provider, with the RIGHT training, for the RIGHT condition, in the RIGHT place, at the RIGHT time, AND, we need to realize that that might not be a physician".

Basically, the symposium was about breaking down long held beliefs, and breaking down the siloed system that we currently have.

WE can, and have to do, much better.

BTW- AFAIK, almost every attendee there was very much in agreement with this.

 

[Danbo1957]

"IT'S ABOUT EVERYONE on the team having EQUAL input."

"Our CEO, and my colleague, Denis Cortese, MD, has a saying he uses frequently when discussing this...."The patient needs the RIGHT provider, with the RIGHT training, for the RIGHT condition, in the RIGHT place, at the RIGHT time, AND, we need to realize that that might not be a physician".

As well as Mayo Clinic works, it does so in its own self-made, bubbled, environment. In the real world...

 

[chessknt]

So you are saying PAs and nurses have training that is equivalent to an MD/DO? Isnt that shorting the # of hours of training med students and residents get?

There is an educational inequality at play here that is not merely a 'cultural' issue, but a realistic one. Letting a nurse or PA take charge is great in theory, but who gets the blame if the nurse/PA is wrong? What if the nurse/PA think he/she knows better but really doesnt?

 

[UCFMOP]

Everyone is equal in mother russia. Doctor = premed all the same training.

 

[efex101]

Mayo *is* very unique and not sure if things that would work there will work in other healthcare environments...this is from personal experience.

 

[physasst]

"IT'S ABOUT EVERYONE on the team having EQUAL input."

"Our CEO, and my colleague, Denis Cortese, MD, has a saying he uses frequently when discussing this...."The patient needs the RIGHT provider, with the RIGHT training, for the RIGHT condition, in the RIGHT place, at the RIGHT time, AND, we need to realize that that might not be a physician".

As well as Mayo Clinic works, it does so in its own self-made, bubbled, environment. In the real world...

Yes, but these decisions were NOT made by Mayo.

Michael Johns, the Chancellor of Emory University made the point about increased reliance on allied health staff, and also:

“We need the right person at the right time to provide leadership to the care team,” he continued. “Physicians need to be comfortable not being at point all the time. Every person is important.”

In fact, many of us that were at the Symposium FROM Mayo, were non voting participants. In other words, we participated in, and sometimes kept the discussion on track in our various work groups, but did not vote on the end result. We are trying to be very careful about limiting the "mayo influence" on the results.

 

[physasst]

So you are saying PAs and nurses have training that is equivalent to an MD/DO? Isnt that shorting the # of hours of training med students and residents get?

There is an educational inequality at play here that is not merely a 'cultural' issue, but a realistic one. Letting a nurse or PA take charge is great in theory, but who gets the blame if the nurse/PA is wrong? What if the nurse/PA think he/she knows better but really doesnt?

Well, there was discussion on Day two ABOUT shortening and condensing medical school.

The point is, we need to work as a team. I have physicians often ask my opinion about certain conditions, and treatments for them, as they might have a question. I ask them at times with my own patients. Many, if not most of my patients don't need to see a physician, but some do. Sometimes a physician has a question that I might or might not know the answer too.

The point is, the entire educational system needs to change. Dramatically. We need to break down the current siloed environment. We need to educate medical students and nursing students, and PA students TOGETHER.

There was discussion about not only grading you on tests, but grading medical students on TEAMWORK, by giving them real patient scenarios, and then grading the WHOLE team. NOT the individuals.

We need to think outside the box.

 

[UCFMOP]

Well, there was discussion on Day two ABOUT shortening and condensing medical school.

The point is, we need to work as a team. I have physicians often ask my opinion about certain conditions, and treatments for them, as they might have a question. I ask them at times with my own patients. Many, if not most of my patients don't need to see a physician, but some do. Sometimes a physician has a question that I might or might not know the answer too.

The point is, the entire educational system needs to change. Dramatically. We need to break down the current siloed environment. We need to educate medical students and nursing students, and PA students TOGETHER.

There was discussion about not only grading you on tests, but grading medical students on TEAMWORK, by giving them real patient scenarios, and then grading the WHOLE team. NOT the individuals.

We need to think outside the box.

Health care by committee doesnt work. This symposium sounds so communistic. "A classless society" = Everyone in the hospital is equal.

Doctors and nurses are two different professions. Let doctors be doctors and nurses be nurses.

A Think the OP and many others in healthcare (nurses) have serious inferiority complexes. Why is that? I dont know, but making an orderly take biochemisty when he is gonna wipe butts all day just doesnt make sense

 

[chessknt]

Well, there was discussion on Day two ABOUT shortening and condensing medical school.

The point is, we need to work as a team. I have physicians often ask my opinion about certain conditions, and treatments for them, as they might have a question. I ask them at times with my own patients. Many, if not most of my patients don't need to see a physician, but some do. Sometimes a physician has a question that I might or might not know the answer too.

The point is, the entire educational system needs to change. Dramatically. We need to break down the current siloed environment. We need to educate medical students and nursing students, and PA students TOGETHER.

There was discussion about not only grading you on tests, but grading medical students on TEAMWORK, by giving them real patient scenarios, and then grading the WHOLE team. NOT the individuals.

We need to think outside the box.

Can you identify what, exactly, the current education system alone is responsible for that is causing so many problems?

Medical professionals do work as a team now. Maybe it isnt a perfectly functioning team, but what is in real life? What you are proposing is to remove any sense of leadership from a team environment (or best case scenario, muddy the lines of leadership so much that it becomes a significant issue). How do you think that is going to impact the health care field?

Like I said, just because nurse X took Y classes on subject Z, does not automatically make her more qualified then Dr Q, but nurse X might THINK she is. How do you handle that scenario? Who would the legal fallout be directed at if the patient died because of a confusion over leadership?

 

[physasst]

Health care by committee doesnt work. This symposium sounds so communistic. "A classless society" = Everyone in the hospital is equal.

Doctors and nurses are two different professions. Let doctors be doctors and nurses be nurses.

A Think the OP and many others in healthcare (nurses) have serious inferiority complexes. Why is that? I dont know, but making an orderly take biochemisty when he is gonna wipe butts all day just doesnt make sense

This is EXACTLY the attitude that Jordan Cohen, MD described as anachronistic, and something that is no longer needed in medicine.

This was not a conference of PA's and nurses. I was one of only TWO PA's there, and there were maybe 5-6 nurse representatives. This was overwhelmingly MD's representing the ACGME, ACCME, American Board of Internal Medicine, etc.etc.etc.

I have no inferiority complex. I am not an MD, have never claimed to be. I, after almost 20 years of practice can comfortably see about 90-95% of what walks into an ER on my own, but I can't see everything on my own.

No one there talked about replacing doctors. In fact, there was a lot of discussion about increasing enrollment due to projected provider shortages. The point was, physicians are not always the "go to" person anymore, and they need to be FAR more cognizant of the fact that there are plenty of people on the team who may be just as knowledgeable as them about certain subjects.

Physicians need to realize that they work in a team environment now. They may have the final say on all things medical, and no one was suggesting taking that away. BUT, they need to learn that they are not the only one present, and may not be the most informed in many circumstances to make the final decisions without significant input from others.

 

[physasst]

Can you identify what, exactly, the current education system alone is responsible for that is causing so many problems?

Medical professionals do work as a team now. Maybe it isnt a perfectly functioning team, but what is in real life? What you are proposing is to remove any sense of leadership from a team environment (or best case scenario, muddy the lines of leadership so much that it becomes a significant issue). How do you think that is going to impact the health care field?

Like I said, just because nurse X took Y classes on subject Z, does not automatically make her more qualified then Dr Q, but nurse X might THINK she is. How do you handle that scenario? Who would the legal fallout be directed at if the patient died because of a confusion over leadership?

the physician is still the leader at the end of the day. However, recent studies have suggested that nurse will often NOTICE a physician making a mistake or error, and because of fear of reprisal, or belittlement, not bring it to their attention.

Darrell Kirch, MD, who is the head of the American Association of Medical Schools gave a great presentation on this, and his comments are spot on.

The point is, as several others made, including Richard Baron, MD, President of the American Board of Internal Medicine, that no physician works in a vacuum, and that no PA or NP does. We are all in this together, and at the end of the day, we need to think about one thing only.

The patient.

The real mind bender was when several of the physician leaders there, well, when they started talking about changing the dynamic of the physicians autonomy.

Also, it does work. The military does a project called Team STEPPS. We are doing it now in Mayo's ER. It works.

 

[Danbo1957]

Look, the reality is that there is need for more clinical primary physicians. Efforts should center at getting more MD's into the system, NOT, giving up and just "promoting" mid-levels to do clinical work for which they are NOT trained.

Do you want to see the M&M numbers ten years from now if "we" allow mid-levels to do patient care that is now done by MD's? Do you really?

 

[cpants]

Of course the physician isn't ALWAYS in charge. There will be plenty of cases where the NP/PA is the more qualified person, and the doctor will defer to them. For example, in the OR, the surgeon isn't going to interfere with the CRNA's anesthesia duties. The MD probably isn't going to second guess the PA's orders for a patient that the PA has been following. In general, though, the person with the most training is the most qualified and should make the final call. All members of the team are certainly not on equal footing when it comes to experience, training, and responsibility for the patient.

As a PA would you want to consider the 3rd year medical student an equal member of the team with equal input in decision making? As an NP, do you consider the RN an equal member with equal input? As an RN, do you consider the CNA an equal member with equal input? I would guess the answer would be no. This is the same way MD's feel when you ask them to consider less trained practitioners to be their equals.

This concept applies with MD's of different training as well. The surgeon doesn't really want to hear from the PCP about what procedure should be performed and post op management. In the same way, the PCP doesn't want advice from that surgeon on managing the patient's diabetes. Yes we are all a team, but our roles are distinct and usually not equal in a given situation.

 

[physasst]

Look, the reality is that there is need for more clinical primary physicians. Efforts should center at getting more MD's into the system, NOT, giving up and just "promoting" mid-levels to do clinical work for which they are NOT trained.

Do you want to see the M&M numbers ten years from now if "we" allow mid-levels to do patient care that is now done by MD's? Do you really?

you of course have evidence to support that assertion. This thread is not simply about "mid-levels", which is an inaccurate term to begin with, performing more care. It is about reforming our health education system for EVERYONE.

The ACP is currently predicting a shortage of 35,000 to 45,000 internists by the year 2025. PA's and NP's are going to have to pick up a significant portion of that workload.

Today, I am working at the ER in Waseca Medical Center. There is no
physician on site. It is solely staffed by PA's, and has been for some time.

Today, I have managed an acute renal failure, an excacerbation of CHF, and a posterior wall STEMI, among many other minor illnesses. No physician was involved in the initial management, and wow. NO ONE DIED.

There are also numerous NP and PA owned practices across the country.

One would postulate, that if in fact, your assertion that M&M stats would rise significantly were true, that we would already be seeing that in the data. Which, btw, we are not.

There is more than enough work for ALL of us.

Even if we were able to increase enrollment of medical students, the simple fact is. THERE WILL NOT BE ENOUGH OF YOU. Supply trends and facts are stubborn things.

NOW, if you want to argue about the NP's pursuing (and getting in some states) complete independence, versus the PA working in concert with a physician (NOTE, I did not say UNDER), than you may be on to something. Otherwise, you need to bring some data to back up your assertions.

 

[physasst]

Of course the physician isn't ALWAYS in charge. There will be plenty of cases where the NP/PA is the more qualified person, and the doctor will defer to them. For example, in the OR, the surgeon isn't going to interfere with the CRNA's anesthesia duties. The MD probably isn't going to second guess the PA's orders for a patient that the PA has been following. In general, though, the person with the most training is the most qualified and should make the final call. All members of the team are certainly not on equal footing when it comes to experience, training, and responsibility for the patient.

As a PA would you want to consider the 3rd year medical student an equal member of the team with equal input in decision making? As an NP, do you consider the RN an equal member with equal input? As an RN, do you consider the CNA an equal member with equal input? I would guess the answer would be no. This is the same way MD's feel when you ask them to consider less trained practitioners to be their equals.

Wrong, I do consider the 3rd years input, and in fact, try to engage them in an order to use it as a teaching moment. Many times, I have been very impressed by 3rd year students. Other times, I have scratched my head in bewilderment at them.

Your final quote is emblematic of the culture we are thinking (speaking collectively) needs to change. EVERYONE is equal, in their own way. I actually do listen if a CNA tells me something.

 

[Danbo1957]

I don't care about turf wars.

Current M&M numbers do reflect quality of caregivers. Hospitalists make a huge difference in outcomes at hospitals.

In the future, unless there is an increase in MD's, economic and political considerations will allow Mid-levels to garner more clinical work that excedes their training. By definition: fewer the number of doctors, the less quality of patient care - including the ER. Period.

 

[cpants]

Wrong, I do consider the 3rd years input, and in fact, try to engage them in an order to use it as a teaching moment. Many times, I have been very impressed by 3rd year students. Other times, I have scratched my head in bewilderment at them.

Your final quote is emblematic of the culture we are thinking (speaking collectively) needs to change. EVERYONE is equal, in their own way. I actually do listen if a CNA tells me something.

Considering their input is a lot different than considering them equals, and your relationship with the students is, of course, hierarchical. I'm not saying we should ignore each other, and a physician better listen when anyone, including a CNA or even an orderly, brings up a concern. That doesn't mean they are equals in the clinic. Everyone is equal in their own way, huh? I guess I can agree with that, but some animals are more equal than others in this case.

 

[physasst]

I don't care about turf wars.

Current M&M numbers do reflect quality of caregivers. Hospitalists make a huge difference in outcomes at hospitals.

In the future, unless there is an increase in MD's, economic and political considerations will allow Mid-levels to garner more clinical work that excedes their training. By definition: fewer the number of doctors, the less quality of patient care - including the ER. Period.

I agree with this to some degree. I don't care about turf wars either. They are counterproductive, and only produce acrimony. Unfortunately, there will simply not be the money, in either the educational system, the reimbursement system, or the provider supply side to allow for a physician to see every patient. Those days are long gone now.

We can pine for their return, OR, I would suggest that perhaps we try to increase collaboration and learning, so that when a PA or NP, or if we follow the UK model, an RN sees a patient on their own, they have the knowledge to so safely, and to deliver effective care.

As William Mayo said, "That which is in the best interest of the patient, is the only interest to be considered". I believe that with all my being.

 

[MOHS_01]

Umm, wooo.... This whole thread and the premise behind it scares the living sh** out of me.... I do agree wholeheartedly, however, with the previous post -- there needs to be increased utilization of midlevels for the very reasons stated; although I cannot think of a clinical situation in my daily practice where I would defer to the expertise of the midlevel (much less an RN), however. The burden of evidence falls squarely upon the shoulders of those who wish to prove their worth to the system; when lesser trained individuals can demonstrate that they reliably and reproducibly provide effective, virtually equal care to MD's the tone of the conversation can change...and the need for medical school, residency, and fellowship ceases to exist. Until that point everyone needs to assume their appropriate position in the pecking order and learn to live with it. Docs (MD's, not the half baked DNP BS) need to assume the leadership role here and not allow this to degenerate any further.

As an aside, in financial terms, the "Billy Mayo model" only works because it employs a collection of individuals who (wittingly or not) trade financial remuneration for either the name (ego), collaboration (academic mindset, need for reassurance, etc), or other personal motivations that their system provides. I'm not a fan of the Mayo model, declined their job offer, and have met more people who simply decided "they were not a good fit" because of their socialistic organization and compensation formulas.

 

[physasst]

Umm, wooo.... This whole thread and the premise behind it scares the living sh** out of me.... I do agree wholeheartedly, however, with the previous post -- there needs to be increased utilization of midlevels for the very reasons stated; although I cannot think of a clinical situation in my daily practice where I would defer to the expertise of the midlevel (much less an RN), however. The burden of evidence falls squarely upon the shoulders of those who wish to prove their worth to the system; when lesser trained individuals can demonstrate that they can provide effective, virtually equal care to MD's the tone of the conversation can change... until that point everyone needs to assume their appropriate position in the pecking order and learn to live with it. Docs (MD's, not the half baked DNP BS) need to assume the leadership role here and not allow this to degenerate any further.

As an aside, in financial terms, the "Billy Mayo model" only works because it employs a collection of individuals who (wittingly or not) trade financial remuneration for either the name (ego), collaboration (academic mindset, need for reassurance, etc), or other personal motivations that their system provides. I'm not a fan of the Mayo model, declined their job offer, and have met more people who simply decided "they were not a good fit" because of their socialistic organization and compensation formulas.

It's important to recognize that the recommendations coming out of this Symposium are not SOLELY Mayo's. They are a collaborative effort from all of the participants. Brookings Institute held a similar meeting as well, and the final recommendations to the legislature will likely be a combination of the two centers.

And yet there is published information, although variable depending on the study (and most seem to be quite superficial) that a PA in primary care, can perform approximately 84% of the duties of a primary care physician. NOTE....NOT 100%. We as PA's have never claimed to be doctors. I would hypothesize that the 84% is a median value, and that some PA's may be under that benchmark, and other more experienced, seasoned, and capable PA's may be above it as well.

As with physicians, there is variablility between providers. I know MD's I wouldn't trust to treat my dog, and I know PA's that I would trust with my life.....and vice versa.

 

[MOHS_01]

It's important to recognize that the recommendations coming out of this Symposium are not SOLELY Mayo's. They are a collaborative effort from all of the participants. Brookings Institute held a similar meeting as well, and the final recommendations to the legislature will likely be a combination of the two centers.

And yet there is published information, although variable depending on the study (and most seem to be quite superficial) that a PA in primary care, can perform approximately 84% of the duties of a primary care physician. NOTE....NOT 100%. We as PA's have never claimed to be doctors. I would hypothesize that the 84% is a median value, and that some PA's may be under that benchmark, and other more experienced, seasoned, and capable PA's may be above it as well.

As with physicians, there is variablility between providers. I know MD's I wouldn't trust to treat my dog, and I know PA's that I would trust with my life.....and vice versa.

Now that is a sensible reply, and one that I happen to largely agree with. MD's tend to be far too territorial and dismissive of midlevels, when the reality of the situation is that much of what we do does not absolutely require MD level attention... and the reimbursement environment (which will only be compounded by the governmental payor mix expansion) will progressively dictate that we ration MD time to those cases that are more severe, complex, or interventional in nature....