New organization.

[erichaj]

I think all physicians should get together and start a new organization.

The Organization to Ban all NPs and PA from practicing Medicine. We can lobby like crazy and eliminate the whole thing.

---

Members don't see this ad.

 

[8744]

I think all physicians should get together and start a new organization.

The Organization to Ban all NPs and PA from practicing Medicine. We can lobby like crazy and eliminate the whole thing.

Har har. Good luck.

 

[erichaj]

Har har. Good luck.

I bet you would love to see it happen. wouldnt you?

 

[Faebinder]

Nah, we are circling the real issue..

Medicare and Medicaid suck ass.

 

[erichaj]

Nah, we are circling the real issue..

Medicare and Medicaid suck ass.

So I guess you enjoy giving away your power and years of training to the NP and Pa?

 

[deleted87716]

Moving to Topics in Healthcare.

 

[deleted6669]

I think all physicians should get together and start a new organization.

The Organization to Ban all NPs and PA from practicing Medicine. We can lobby like crazy and eliminate the whole thing.

yeah, call it pucker-
physicians unable to cope with everyday reality.....

 

[ForbiddenComma]

I think all physicians should get together and start a new organization.

The Organization to Ban all NPs and PA from practicing Medicine. We can lobby like crazy and eliminate the whole thing.

We should be concerned with non-medical people dictating how to practice medicine: the MBAs and the JDs, and the politicians that they pay for. They are infesting the system like the nasty little useless spirochetes that they are, feeding from the host and giving back nothing in return.

Unlike PAs and NPs, who work hard to actually help people.

 

[DropkickMurphy]

Exactly......NP's and PA's play a valuable role (although they have their place and some need to be reminded of that), but the real reform should be directed at raising physician salaries back to a respectably gratuitous level.

 

[8744]

I bet you would love to see it happen. wouldnt you?

No. I am anti-monopoly and anti-protectionist. If a PA or an NP can do the job they can and should. In other words, if there's no qualitative difference between the physician and the mid-level it's going to become apparent eventually and we might as well deal with it.

If your job can be done by a PA then you need a new job. I happen to think that physicians are unnecessarily worried about encroachment. There is a difference. A typical third year medical resident, for example, knows a hell of a lot more than a typical PA, even one with many years of training. That's just the way it is.

Whether physicians are necessary in primary care is another question.

 

[sdn1977]

Where I am, all NP's & PA's are hired by physicians or physician groups. That perhaps is not the case in all areas....

You don't have to hire them...you can make your practice whatever you want. If you want to do all the tasks.....just choose that style of practice.

They obviously serve a function & purpose for those who hire them & the physicians in the groups I know who hire them love them.

So...why the desire to dictate how another physician might want to practice?

 

[8744]

So I guess you enjoy giving away your power and years of training to the NP and Pa?

That's life. I think you over-estimate the amount of power conferred by your medical degree. We don't have power. What we have is a certain level of moral authority which was actually earned, not by us, but by physicians that have come before us.

You may as well say it's unfair that the computer put typewriter manufacturers out of business.

Have a little faith in your education and the training you will get. When I started as a third year medical student I was impressed by the knowledge and skill of the PAs we worked with. Now that I'm a PGY-2 I'm not so impressed.

 

[erichaj]

That's life. I think you over-estimate the amount of power conferred by your medical degree. We don't have power. What we have is a certain level of moral authority which was actually earned, not by us, but by physicians that have come before us.

You may as well say it's unfair that the computer put typewriter manufacturers out of business.

Have a little faith in your education and the training you will get. When I started as a third year medical student I was impressed by the knowledge and skill of the PAs we worked with. Now that I'm a PGY-2 I'm not so impressed.

I will talk to you when you are out of training, say a couple years out, your view of the real world will be well formed at that time.

 

[8744]

I will talk to you when you are out of training, say a couple years out, your view of the real world will be well formed at that time.

Fair enough. I do know that when money is involved, as in insurance companies, consumers, and governments looking for a bargain, almost nothing can stand in its way.

 

[Chronic Student]

So, the years that I spent working sixty hour weeks and taking 15 semester hours of classes , the years I spent in school and the 100,000 plus in student loans would just be summarily taken away from me after I earned my degree and credentials.

Simply because some people in a larger group don't like it, nice. Put yourself in my place and imagine how you would feel if someone wanted to take away your livelihood [sp?] summarily.

I have a question for you. I know that you don't like PA's (and NP's), but can you show me some objective evidence of how we are ruining the healthcare system?

I do deserve a little respect and are you really saying that my level of training does not qualify me to assist in surgery and see post-op patients. My Sp (a Doctor) seems to trust me to do this and other things, under his supervision.

If I recall rightly, he is the one who put the ad out, hired me and is paying me!

Sorry for the rant, but I do take it kinda personally.

-Mike

 

[Miami_med]

In a capitalist system, they all have a place. NPs, PAs came into existence because there was a demand. I am only concerned that in a single payer system, the government will muscle out physicians in many areas because they cost more, and the people receiving the services will not have a real option to pay the difference.

I for one will happily see a PA or an NP for a minor primary care problem. I am a second year medical student and could handle many of these problems. Of course they can handle it. I don't mind a PA or an NP ASSISTING in my surgery with a trained surgeon. I also don't mind these players operating with some autonomy after many years of practice and experience, as there is more than one way to learn medicine.

On the other hand, I do not want to see a PA or NP for a major and complex problem. They don't have the same background in the sciences, and I would like the most knowledgeable guy in the room if I have cancer or an aortic aneurysm or such. I want atleast ONE board certified surgeon running my operation if I need surgery. Also, I think a good Primary Doctor is really essential for most patients. The NP or PA can handle some complaints, but someone with broad exposure to all of the fields of medicine and good understanding of underlying pathophysiology is essential for organizing the overarching treatment plan of a patient. It is unfortunate that some Primary docs have let this slip, because some are excellent.

In the end, the doctor's superior training will continue to pay for itself in a capitalist system. Don't knock the midlevels. You don't need an engineer to change your oil or your break pads, and you really don't an MD to treat every sprained finger or otitis media.

 

[erichaj]

So, the years that I spent working sixty hour weeks and taking 15 semester hours of classes , the years I spent in school and the 100,000 plus in student loans would just be summarily taken away from me after I earned my degree and credentials.

Simply because some people in a larger group don't like it, nice. Put yourself in my place and imagine how you would feel if someone wanted to take away your livelihood [sp?] summarily.

I have a question for you. I know that you don't like PA's (and NP's), but can you show me some objective evidence of how we are ruining the healthcare system?

I do deserve a little respect and are you really saying that my level of training does not qualify me to assist in surgery and see post-op patients. My Sp (a Doctor) seems to trust me to do this and other things, under his supervision.

If I recall rightly, he is the one who put the ad out, hired me and is paying me!

Sorry for the rant, but I do take it kinda personally.

-Mike

1. The years you spent working and the money you spent for school are not the issue. Doctors did all that and more.

2. I don't really want to take away you livelihood summarily. I just want to make you a nurse again or strongly limit your scope of practice. So you will still have a job, it just won't be as it may be now. Especialy in primary care.

3. You work for a surgeon, and you free up his time to do surgery or assist. That is OK, because you are not directly attempting to do what he does. In primary care however, the PA or NP want to do the same exact thing as the Doctor. There is just one problem, they are not doctors. I take offense to that. Because I too spent thousand in medical school and had 80 hour weeks. I don't like it when someone with (and you have to agree with this part) far less medical knowledge and experience wants to do the SAME thing that I do.

So now you have an answer to your questions, and have the respect too.

 

[erichaj]

"I also don't mind these players operating with some autonomy after many years of practice and experience, as there is more than one way to learn medicine."

And the above statement is what opened the gates and the flood waters came rushing in. You see you are still a medical student. When you are a doctor, your view will change.

"Some Autonomy" as long as it is under direct supervision of the docotor and as long as they never get to be able to practice "independently".

but it's too late, they already are.

 

[8744]

...And the above statement is what opened the gates and the flood waters came rushing in. You see you are still a medical student. When you are a doctor, your view will change...

If anything, the more I work with PAs the less threatened (if I can use that word) I feel.

After a lifetime of being anti-union, anti-protectionism, and pro-free trade I'd feel like a hypocrite trying to enforce a monopoly to protect my narrow financial interests. The question you have to ask is if you are protecting your interests or the patient's. If you can make a case that the patients get substandard care from midlevels then I'm right behind you.

One of the reasons I got out of Familiy Medicine was because I could not honestly see how a PA could not do most if not all of it.

We have PAs in Emergency Medicine but (and this is my limited experience) the acute stuff needs to be seen by a team with a physician in the lead. That doesn't mean that the PAs, respiratory therapists, and nurses don't know what they're doing because they do and I am humble enough to learn from them. Still, there's no comparing the knowledge and skill of our typical attending with any mid-level you would care to name.

I am also very much in favor of nurse-midwives, especially after my interactions with them at Duke, but I'd still want my wife to see an OB/Gyn for anything out of the ordinary.

Let's face it. Most of primary care is ordinary. Most of most medicine is ordinary to it's practitionors.

 

[deleted87716]

Let's face it. Most of primary care is ordinary. Most of most medicine is ordinary to it's practitionors.

So is most of emergency medicine, my friend. People who think primary care is all bull**** either haven't really done it, or aren't very good at it. I'm no more worried about midlevels taking my job than you are.

 

[Miami_med]

"I also don't mind these players operating with some autonomy after many years of practice and experience, as there is more than one way to learn medicine."

And the above statement is what opened the gates and the flood waters came rushing in. You see you are still a medical student. When you are a doctor, your view will change.

OK, I guess that it did. I still say that there is more than one way to learn medicine. I am deep in the throes of my second year, being bombarded left and right with lectures on subjects like peristalsis. I know the value in this. However, I learned to deal with some basic GI issues before I ever studied GI. I learned these in my preceptors office or working at the free clinic. This is clinical learning. PAs and NPs have clinical learning.

I don't think my view will change. I agree with P. Bear. I don't believe in protectionism. As I said in my post. I do not fear for my future job in a free market. I'd like to keep the government out. The midlevels will rise to the level of incompetence (The Peter Principle). Their deficiencies will become obvious to the public in the future. The skiils that they do have, I believe that they should be able to use. As for us, I hope that we in the medical profession will show through our work why we should be paid more and put in charge. Complaining and strong arming the other guy out will make us look bad and is a poor strategy for the long term maintenance of respect of the profession.

 

[Chronic Student]

1. The years you spent working and the money you spent for school are not the issue. Doctors did all that and more.

2. I don't really want to take away you livelihood summarily. I just want to make you a nurse again or strongly limit your scope of practice. So you will still have a job, it just won't be as it may be now. Especialy in primary care.

3. You work for a surgeon, and you free up his time to do surgery or assist. That is OK, because you are not directly attempting to do what he does. In primary care however, the PA or NP want to do the same exact thing as the Doctor. There is just one problem, they are not doctors. I take offense to that. Because I too spent thousand in medical school and had 80 hour weeks. I don't like it when someone with (and you have to agree with this part) far less medical knowledge and experience wants to do the SAME thing that I do.

So now you have an answer to your questions, and have the respect too.

That brings to mind several points.

1. So answer me this, you want to limit my scope of practice because I don't do my job effectively and well or just because you don't like it?

2. I'm still waiting for some objective evidence that PA's have proven to be substandard caregivers.

3. I've got a fair amountof student loans and I only make 70,000 a year. Half of the RN's out there make more than I do and if you limit my scope of practice I become less valuable and well may be driven out of a job by market forces.

4. When you say that PA's do they same thing as a primary care Doc (Yes, but with a huge caveat). While I can't speak for NP's, every PA must be supervised by an MD and that is where I don't quite get what you are so upset about. If the MD chooses to let the PA run wild or let them treat patients when they clearly don't know what they are doing than that is at least partially the MD's fault.

5. I in no way equate my knowledge to that of an MD. I know my place and am aware of limitations and if anything, I am a little too cautious when I think something might be out of my leauge. Most PA schools actually build this sort of thinking into their curriculum.

6. This is the last point and I'll drop it, just hear me out. You spent four years in Medical School and I spent 27 months in PA School.

The only pre-reqs that are different (at least at the majority of Medical Schools) are that I did not take the second part of organic, calculus or physics (I took a bunch of other classes that are germaine, but we're talking about most PA's and not me specifically).

For your 24 months of basic sciences, I took 15. We have to cover the same general material (No histo and a few others) just not in near the depth you had to go through. We took gross anatomy right alongside the med students and had some PBL classes with them. We took pathophys, radiology, patient assessment, pharmacology, EKG's, Clinical medicine I and II, skills practicum, etc, etc. Once again, not to near the same depth.

Then you all had 24 months of clinicals. Well, you had third year plus whatever was managed in fourth year. I spent 12 months in clinicals, right alongside the med students. At least where I was at we had the same responsibilities (patient loads, knowledge expected of us during pimping, etc) and were treated in every respect just like the med students(With the exception of no SHELF tests, although we had our own end of rotation tests). I delivered babies, got to put in chest tubes, intubate, sutured quite a few lacs, had to write the same obnoxiously long medicine notes and while on a neurosurgery elective I even got to put in two ventrics and do several lumbar punctures.

Even after all of that I am humbled by how much I don't know. In addition, you get to go on and I am (no matter how many years of experience or background) forever an intern or very junior resident and must have supervision. That's cool, I made that choice and no one forced me into it.

In addition, quite a large percentage of PA's had a career in healthcare before matriculation and one could make an argument that makes their learning experience in PA school a little more fruitful.

Even after all that, you to say that I need to have an extremely limited scope of practice. Are you implying that I can't treat strep throat or manage simple hypertension, well that rankles me just a little bit.

Do PA's make mistakes? Of course they do, as does every other sort of healthcare provider.

You had classmates that you wondered about. You know the ones, you sat next to them in class and wondered if they were a legacy admit or if their parents made a large donation to the school. I had them in PA school, but overall I was very impressed with the caliber of classmates I had and I would be shocked if they missed a whole lot of serious dx's and/or did not know when they needed help.

Yes, you can give me the horror story about the PA that did this or that and I can counter with stories of surgeons putting pedicle screws into the vena cava or treating the s/p CVA pt w/a BP of 210/100 with 25 mg of HCTZ and streeting them.

Once again, sorry for the long rant. I just happen to disagree with you.

-Mike

 

[deleted6669]

you won't get through to him. he is just bitter that other docs in his neighborhood who use pa's make more and work less than he does.
what probably really gets to him is that specialty pa's make more than he does and have no debt, don't take call, and don't see inpatients.

 

[erichaj]

you won't get through to him. he is just bitter that other docs in his neighborhood who use pa's make more and work less than he does.
what probably really gets to him is that specialty pa's make more than he does and have no debt, don't take call, and don't see inpatients.

Wrong on both counts.

 

[erichaj]

So is most of emergency medicine, my friend. People who think primary care is all bull**** either haven't really done it, or aren't very good at it. I'm no more worried about midlevels taking my job than you are.

I'm not worried about taking my job, I'm worried about the f ing insurance companies watching the Pa and NP doing what to their simple minds appears to be my job and lowering the reimbursements to their level.

That is what is happening. The is the real bull****.

Wake up.

 

[sdn1977]

I'm not worried about taking my job, I'm worried about the f ing insurance companies watching the Pa and NP doing what to their simple minds appears to be my job and lowering the reimbursements to their level.

That is what is happening. The is the real bull****.

Wake up.

So....its your choice what insurances you will accept. Our cardiologist won't accept Cigna PPO anymore....ok - his choice..no problem! We're in a huge area of cardiologists who will. There are no hard feelings on either end - his or ours.

You can make your choice of what insurance you will accept & what you won't - how you practice & how you won't....

But...why condemn your peers, who actually CHOOSE to employ the PA's & NP's for doing what they feel works for them & the kind of practice they choose to have? The insurance company already makes the decision what proton pump inhibitor you can prescribe, what ACE inhibitor you can prescribe, etc...Now.....you can choose to prescribe anyone you want..but the reality is - your patient will be sorely pissed off if you can't justify that prior auth for what you so strongly feel is superior - which in many cases cannot be justified.

A previous poster already mentioned...the market of healthcare is not driven by providers. We must work with those who drive healthcare reimbursement to make it the most profitable, effective & safe for all concerned. You can choose whichever way the system will best work for you, your personality, your patient population, your practice setting, etc.....

 

[erichaj]

So....its your choice what insurances you will accept. Our cardiologist won't accept Cigna PPO anymore....ok - his choice..no problem! We're in a huge area of cardiologists who will. There are no hard feelings on either end - his or ours.

You can make your choice of what insurance you will accept & what you won't - how you practice & how you won't....

But...why condemn your peers, who actually CHOOSE to employ the PA's & NP's for doing what they feel works for them & the kind of practice they choose to have? The insurance company already makes the decision what proton pump inhibitor you can prescribe, what ACE inhibitor you can prescribe, etc...Now.....you can choose to prescribe anyone you want..but the reality is - your patient will be sorely pissed off if you can't justify that prior auth for what you so strongly feel is superior - which in many cases cannot be justified.

A previous poster already mentioned...the market of healthcare is not driven by providers. We must work with those who drive healthcare reimbursement to make it the most profitable, effective & safe for all concerned. You can choose whichever way the system will best work for you, your personality, your patient population, your practice setting, etc.....

Medicare is planning to make a 5% cut for the next 5 years. The private insurance companies will follow them.

So lets take the best case scenerio and say that the best insurance company pays 75 dollars for a 99213 now. reduce that by 30 % in five years.

that is 52 dollars. That what medicare pays now for a 99213. So, I challenge anyone to try to run an office on that and continue to keep the same salary for themselves. That means that they are actively working towards reducing payments to PA and NP levels.

We as physicians are responsible for that. We allowed it to happen. It has nothing to do with personality or population. We keep making the same mistakes over and over again. We give an inch and they take a mile. Then we get together in some stupid organization and try to work ourselves out of the hole we got ourselves into.

 

[Sol Rosenberg]

Medicare is planning to make a 5% cut for the next 5 years. The private insurance companies will follow them.

So lets take the best case scenerio and say that the best insurance company pays 75 dollars for a 99213 now. reduce that by 30 % in five years.

that is 52 dollars. That what medicare pays now for a 99213. So, I challenge anyone to try to run an office on that and continue to keep the same salary for themselves. That means that they are actively working towards reducing payments to PA and NP levels.

We as physicians are responsible for that. We allowed it to happen. It has nothing to do with personality or population. We keep making the same mistakes over and over again. We give an inch and they take a mile. Then we get together in some stupid organization and try to work ourselves out of the hole we got ourselves into.

That's why many FP docs are using PAs in their office, as it allows them to operate their practice more profitably (sp?) in the face of declining reimbursement.

Don't blame the PAs, blame the insurance companies/medicare.

 

[sdn1977]

That's why many FP docs are using PAs in their office, as it allows them to operate their practice more profitably (sp?) in the face of declining reimbursement.

Don't blame the PAs, blame the insurance companies/medicare.

yep - your rant is directed towards insurance reimbursement. That is an entirely different topic, however, the use of PA's & NP's as jota pointed out is how some have chosen to try to maximize their reimbursements & see more patients.

Whether this is the "right" approach or not is debatable, but the expansion of mid-levels in the field is a response to a need - their presence did not create the need.

 

[erichaj]

yep - your rant is directed towards insurance reimbursement. That is an entirely different topic, however, the use of PA's & NP's as jota pointed out is how some have chosen to try to maximize their reimbursements & see more patients.

Whether this is the "right" approach or not is debatable, but the expansion of mid-levels in the field is a response to a need - their presence did not create the need.

SAME MISTAKES OVER AND OVER AGAIN. THE MORE YOU SELL OUT THE LESS YOU GET IN T HE END.

 

[ForbiddenComma]

erichaj -- even if you believe that NPs/PAs are being used as tools to weaken the medical profession -- why isn't your rage directed at the people using them as such? There are plenty of managed-care-related villains such as hospital executives, pharm reps, HMO directors, malpractice lawyers, and politicians far more deserving of scorn. The vast majority of midlevels themselves do not have an agenda of displacing MDs/DOs, no matter what the current trends of managed care are.

 

[erichaj]

erichaj -- even if you believe that NPs/PAs are being used as tools to weaken the medical profession -- why isn't your rage directed at the people using them as such? There are plenty of managed-care-related villains such as hospital executives, pharm reps, HMO directors, malpractice lawyers, and politicians far more deserving of scorn. The vast majority of midlevels themselves do not have an agenda of displacing MDs/DOs, no matter what the current trends of managed care are.

1. They do have an inderect agenda. Why would a nurse want to be a ARNP if they did not want to do similar things as a physician and get paid more. If they are getting paid more, someone is getting paid less. Physicians. There is only so much to go around. law of supply and demand.

2. Why would somone go to PA school to begin with. Becasue they know they can make 80K per year. They could not do this several years ago. In fact PA school was not very popular until the recent past. So, If you can cut out several years of schooling and make a **** load. why not. Physicians are OK with it. Right. NOT. SUPPLY AND DEMAND.

3. All those people you mention listen and more importantly watch physician action. If they see us give away the house, they figure we chose it. "you made your bed, now sleep in it" kind of thing.

3. Malpractice lawyers and pharm reps are not the problem. They have other problems but we can start a whole new post on them.

 

[NonTradMed]

I figure if someone with less training than me can provide the same level of care, at perhaps less expensive cost, then I am wasting my time providing that care. I'd rather deal with the hard stuff that only training allows, hence I don't mind NPs and PAs as long as they are providing good care. Otherwise, why bother having doctors train for so long if the same level of care can be provided by midlevels? Isn't that how our society functions? Those that can (fairly) provide the same services/goods for a lower price/cost will win out? I know people are worried about their livelihood because of reimbursement but I don't think we can blame the midlevels for that....we should focus on trying to reform healthcare so that doctors can cut through some of the red tape rather than trying to set up artificial barrier to 'our' turf.

 

[Faebinder]

You know when you should start worrying? When they starting giving different billing codes to doctors vs midlevels.... then start to panic... because that's when having a PA/NP will be unprofitable for the FMs and it will be the time when insurance companies decide they want to go with PA/NP for their patients cause they are cheaper.

A medical doctor is a scientist + practioner of medicine...... unfortunately many in primary care neglect the scientist part which can distinguish them from the midlevels.

 

[southerndoc]

As an emergency physician, I love the idea of having multiple PA's in the ED seeing patients and a physician overseeing them. I think this is the wave of the future: physicians supervising PA's and NP's who provide all the care and work to the patient.

In a very crowded ED (even in a suburban ED), it is more feasible to have one physician who supervises two-three PA's than it is to have three physicians seeing patients. PA's are perfectly capable of doing the same procedures as ED physicians.

I'm more concerned with chiropracters practicing "naturopathic medicine" and the naturopaths out there than I am about the PA's and NP's who are legitimately helping out.

 

[deleted6669]

As an emergency physician, I love the idea of having multiple PA's in the ED seeing patients and a physician overseeing them. I think this is the wave of the future: physicians supervising PA's and NP's who provide all the care and work to the patient.

In a very crowded ED (even in a suburban ED), it is more feasible to have one physician who supervises two-three PA's than it is to have three physicians seeing patients. PA's are perfectly capable of doing the same procedures as ED physicians.

I'm more concerned with chiropracters practicing "naturopathic medicine" and the naturopaths out there than I am about the PA's and NP's who are legitimately helping out.

thank you. this is the model where I work.