NPs gone wild - another pill mill, now with sex scandals

[Agast]

Nurse practitioner unlawfully distributing drugs arrested

McCallum prescribed 2 million opioid pills and 900,000 Benzos in 4 years, had sexual relationships with her patients and brought sex toys to work. Also ripped a door off its hinges. Heart of a nurse, brain of an ox.

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[Agast]

Was not expecting her to look like a Karen to be honest

 

[Pain Applicant1]

I don't think what you're doing is cool. You're being a bully. You're cherry-picking cases and constantly exposing them to help stereotype an entire group of people. These are similar tactics that extremists such as white supremacists, racists (of all races), and antisemites use.

I can do the exact same thing to doctors if I wanted to. I'm finding that more often than not when a pain doctor is charged with overprescribing, they seem to share certain characteristics. Should I start posting these cases to make a point?

If you feel threatened by NPs or PAs or whatever then don't go to one and just welcome the competition and let the market decide. If you can offer a better product from your training, then you should have nothing to worry about as the pts, the customers, will choose you.

 

[Ducttape]

your statement implies you think NPs should be prescribing opioid medications without physician oversight...


noone should be overprescribing opioids or prescribing them inappropriately.

generally speaking, in terms of opioid prescribing training, pain physicians are probably receiving the most training and are monitored most highly. most of the referrals for inappropriate use are amongst physicians because nursing boards are even more reluctant to chastise their members than medical boards.

 

[Agast]

Anyone can see I've posted about physician pill mills as well. Part of pain management is being aware of what is going around you, and I find this kind of thing interesting. Any pill mill that closes means an influx of those patients going to YOUR clinics. If you don't want to see that, just hit the "ignore" button

 

[macman]

I don't think what you're doing is cool. You're being a bully. You're cherry-picking cases and constantly exposing them to help stereotype an entire group of people. These are similar tactics that extremists such as white supremacists, racists (of all races), and antisemites use.

I can do the exact same thing to doctors if I wanted to. I'm finding that more often than not when a pain doctor is charged with overprescribing, they seem to share certain characteristics. Should I start posting these cases to make a point?

If you feel threatened by NPs or PAs or whatever then don't go to one and just welcome the competition and let the market decide. If you can offer a better product from your training, then you should have nothing to worry about as the pts, the customers, will choose you.

More so the tactic that CNN and MSNBC uses, no?

I would say that when docs do things wrong you will also find it here in these forums.

I have no problem with these cases being brought to light

It is true that there are many and higher hurdles to get a MD/DO, not to mention all the post grad training. Assuming all that training and MOC means something, i.e. better training, more stringent acceptance criteria, it is worth looking at what can go wrong especially in *specialty fields*

 

[Pain Applicant1]

More training doesn't necessarily equate to better outcomes, especially in pain. You guys love the literature so much so let's post some studies which show improved outcomes for pain docs vs NPs. Then we can have a valid argument. I would definitely support that. They must be out there somewhere. Someone less lazy than me care to look?

I haven't looked for pain but I did look at things when my wife was pregnant. Outcomes didn't seem to be any different for MDs, NPs, or midwives. Correct me if I'm wrong.

Everyone should be posted when doing something wrong but it seems that the NP thing is really emphasized such as in the past few posts. No need to ignore. I enjoy standing up to bullying, lol.

 

[lobelsteve]

More training doesn't necessarily equate to better outcomes, especially in pain. You guys love the literature so much so let's post some studies which show improved outcomes for pain docs vs NPs. Then we can have a valid argument. I would definitely support that. They must be out there somewhere. Someone less lazy than me care to look?

I haven't looked for pain but I did look at things when my wife was pregnant. Outcomes didn't seem to be any different for MDs, NPs, or midwives. Correct me if I'm wrong.

Everyone should be posted when doing something wrong but it seems that the NP thing is really emphasized such as in the past few posts. No need to ignore. I enjoy standing up to bullying, lol.

You are wrong. Go visit the Anes forum and see how the stories go with crna vs md. Folks who do not have adequate training are creeping their scope of practice to eliminate the MD entirely.

 

[Pain Applicant1]

You are wrong. Go visit the Anes forum and see how the stories go with crna vs md. Folks who do not have adequate training are creeping their scope of practice to eliminate the MD entirely.

I'm not saying it doesn't ever, I'm just saying it doesn't equate. Naturally the anesthesia forum is going to pump up docs and disparage the crna so bad example to prove your point. You know, the whole vested interest thing.

Post some studies specifically for pain. Lots of pain pts going around so lots of data. There must be something published out there that shows our outcomes are better. I don't know and don't care to look.

I personally think most things are learned on the job and it comes down to the individual.

Anecdotally, I did see a crna save an interventional pain anesthesiologist's butt during fellowship following a cesi. N of 1 so doesn't mean anything but kind of supports the notion that it comes down to the individual.

Perhaps a lot of minutia in medical school training is not necessary to improve outcomes. If that's the case, maybe the frivolous things in the med school curriculum can be eliminated and the cost and time of the education can be lessened. Just a thought.

 

[lobelsteve]

I'm not saying it doesn't ever, I'm just saying it doesn't equate. Naturally the anesthesia forum is going to pump up docs and disparage the crna so bad example to prove your point. You know, the whole vested interest thing.

Post some studies specifically for pain. Lots of pain pts going around so lots of data. There must be something published out there that shows our outcomes are better. I don't know and don't care to look.

I personally think most things are learned on the job and it comes down to the individual.

Anecdotally, I did see a crna save an interventional pain anesthesiologist's butt during fellowship following a cesi. N of 1 so doesn't mean anything but kind of supports the notion that it comes down to the individual.

Perhaps a lot of minutia in medical school training is not necessary to improve outcomes. If that's the case, maybe the frivolous things in the med school curriculum can be eliminated and the cost and time of the education can be lessened. Just a thought.

Warped point of view. Talking points include thousands of fewer hours of training, education that is nowhere close to intensive or detailed as an MD.

 

[Tony C anesthesia]

More training doesn't necessarily equate to better outcomes, especially in pain. You guys love the literature so much so let's post some studies which show improved outcomes for pain docs vs NPs. Then we can have a valid argument. I would definitely support that. They must be out there somewhere. Someone less lazy than me care to look?

I haven't looked for pain but I did look at things when my wife was pregnant. Outcomes didn't seem to be any different for MDs, NPs, or midwives. Correct me if I'm wrong.

Everyone should be posted when doing something wrong but it seems that the NP thing is really emphasized such as in the past few posts. No need to ignore. I enjoy standing up to bullying, lol.

Outcome was no different? well, maybe the outcome was so poor to begin with.

 

[Ferrismonk]

I'm not saying it doesn't ever, I'm just saying it doesn't equate. Naturally the anesthesia forum is going to pump up docs and disparage the crna so bad example to prove your point. You know, the whole vested interest thing.

Post some studies specifically for pain. Lots of pain pts going around so lots of data. There must be something published out there that shows our outcomes are better. I don't know and don't care to look.

I personally think most things are learned on the job and it comes down to the individual.

Anecdotally, I did see a crna save an interventional pain anesthesiologist's butt during fellowship following a cesi. N of 1 so doesn't mean anything but kind of supports the notion that it comes down to the individual.

Perhaps a lot of minutia in medical school training is not necessary to improve outcomes. If that's the case, maybe the frivolous things in the med school curriculum can be eliminated and the cost and time of the education can be lessened. Just a thought.

I've had the same thought, perhaps it's not that mid-level providers are undertrained, perhaps we're overtrained. If you look at medical training elsewhere in the world, it's much more like NP training than our system.

Also, as Medicine has moved away from actual thinking and more towards whatever the insurance company allows and whatever algorithm guidelines dictate, perhaps a mid-level is just as good. It's not rocket science to suggest a facet block for axial back pain with pain on facet loading.

That being said, I've had several instances when the depth of my understanding, which I take for granted, is surprisingly woefully absent in the mid-level I'm talking to. It's been scary enough that I won't let my family see mid-level providers unless I already know what's wrong. They WILL and DO miss stuff.

Fwiw, I also work OB anesthesia and work frequently with CRNAs, NPs, and Nurse Midwives as well. I observe the same thing there. Many close calls where the doc had to rush in an clean up the mess.

Docs can be just as stupid (and arrogant) and make mistakes. But it's usually because they got lazy or greedy, not because of education.

 

[lobelsteve]

Officials: Metro Atlanta doctor, pharmacists charged with operating ‘pill mills’

Though Anthony Mills, 55, was a licensed physician with a specialty in gynecology, he did not maintain a gynecology practice listed with the Medical Board or Drug Enforcement Administration, the U.S. Attorney’s Office for the Northern District of Georgia said in a press release. Instead, he...

www.ajc.com

Speaking of OB…..

 

[powermd]

Thought experiment: How exactly would you design a meaningful study to measure differences in outcomes between two different practitioners of pain medicine, regardless of background?

There's a saying about pornography. "I'm not sure how to describe it, but I know it when I see it". Same goes for quality of care in medicine.

 

[Orin]

I personally think most things are learned on the job and it comes down to the individual.

This is true.

As you can likely imagine, there aren't many level-1 RCTs comparing APP-only vs MD-only practices (The Burlington randomized trial of the nurse practitioner - PubMed). In general though, the outcomes appear comparable. Obviously, that doesn't mean you should sign up for a lap chole with an APP because it's cheaper than the MD.

As you can also imagine, there's a lot of heavily invested folks on both sides (Quality of Nurse Practitioner Practice vs Does Science Support NP Independence? - Physicians for Patient Protection)

The OP though is egregiously bad regardless of who's doing it.

 

[Agast]

Officials: Metro Atlanta doctor, pharmacists charged with operating ‘pill mills’

Though Anthony Mills, 55, was a licensed physician with a specialty in gynecology, he did not maintain a gynecology practice listed with the Medical Board or Drug Enforcement Administration, the U.S. Attorney’s Office for the Northern District of Georgia said in a press release. Instead, he...

www.ajc.com

Speaking of OB…..

I read another article that said their pharmacies charged $500-900 to fill the oxycodone prescriptions (and then entered a different charge in the computer to look more legitimate). That would really eat into your profit margin as a dealer. I wonder if they ever look further to see if there is involvement with organized crime.

 

[SSdoc33]

it seems to me that, in general, doctors are more sleazy and financially driven. physician extenders tend to work harder, do better documentation, and are more caring.

Problem is: PAs and NPs never know what to do and routinely make poor decisions. If there is any sort of deviation from a standard algorithm -- which there always seems to be -- then a visit to the PA or NP is a waste of time. You dont want the newbie flying the plane or investing your money or doing your root canal.

 

[sloh]

it seems to me that, in general, doctors are more sleazy and financially driven. physician extenders tend to work harder, do better documentation, and are more caring.

Problem is: PAs and NPs never know what to do and routinely make poor decisions. If there is any sort of deviation from a standard algorithm -- which there always seems to be -- then a visit to the PA or NP is a waste of time. You dont want the newbie flying the plane or investing your money or doing your root canal.

Heart of a nurse, brain of a…..


Sent from my iPhone using Tapatalk

 

[Agast]

it seems to me that, in general, doctors are more sleazy and financially driven. physician extenders tend to work harder, do better documentation, and are more caring.

Doctors are not innately sleazier - it’s the lack of oversight that lends itself to opportunity. Once you run your own clinic, no one is watching to make sure you do the right thing. When given the opportunity, there are mid levels who will do the same thing because it’s human nature. Not training. Being a doctor is not a genetic trait or character flaw.

As far as better documentation and more caring, the referral notes I get from PCPs and PA/NPs are equally bad but the latter has more time with the patient because they have fewer patients to see. An independent mid level seeing 40 patients a day will suffer the same amount of less time per patient. The end result is the patient pays the same amount of money to see someone for the same amount of time, who happens to have less training.

 

[cowboydoc]

it seems to me that, in general, doctors are more sleazy and financially driven. physician extenders tend to work harder, do better documentation, and are more caring.

Problem is: PAs and NPs never know what to do and routinely make poor decisions. If there is any sort of deviation from a standard algorithm -- which there always seems to be -- then a visit to the PA or NP is a waste of time. You dont want the newbie flying the plane or investing your money or doing your root canal.

Following an algorithm with systemic oversight decreases opportunity for “sleazy and financially driven” decisions.

I don’t know any extenders that worked 80-120 hours a week. Most I know want to work about 35/week.

In medicine, the length of documentation is typically inversely proportional to knowledge. I’m not sure this a valid measure.

If your job is following an algorithm, you are probably going to be replaced by a computer soon…

 

[powermd]

In medicine, the length of documentation is typically inversely proportional to knowledge. I’m not sure this a valid measure.

Smart people can explain complicated ideas in simple terms.

 

[epidural man]

I am VERY disappointed with the content of this thread.

In my experience, things with the title "Girls Gone Wild" followed by another descriptor (in this case...NPs) seem to show a different type of content than what I am seeing here.

I'm just saying, I've been misled.

Kind of like when your kindergarten teacher would say "We have a special TREAT for you kids today!" and you think..."Holy crap! rice crispy treats...I know it!" And the teacher follows that with "We have the Chief of the Fire Department visiting today." Oh man...that is NOT what I thought a treat meant.

 

[clubdeac]

It’s concerning to see a presumable doc, painapplicant, inferring that NP training and knowledge is adequate enough to supplant most physicians. If that’s the case why did you waste your time and money on medical training. It’s physicians like you that lead to lower quality healthcare in the US and the end of medical doctor as a profession

 

[anonperson]

More training doesn't necessarily equate to better outcomes, especially in pain. You guys love the literature so much so let's post some studies which show improved outcomes for pain docs vs NPs. Then we can have a valid argument. I would definitely support that. They must be out there somewhere. Someone less lazy than me care to look?

I haven't looked for pain but I did look at things when my wife was pregnant. Outcomes didn't seem to be any different for MDs, NPs, or midwives. Correct me if I'm wrong.

Everyone should be posted when doing something wrong but it seems that the NP thing is really emphasized such as in the past few posts. No need to ignore. I enjoy standing up to bullying, lol.

You aren't standing up to any bullies. You are acting like a sell out to your profession.

Where are these magical well trained mid levels that I keep hearing about. I have worked with mid levels in some capacity in residency, fellowship and now in practice.

They range from terrible to less terrible.

They can manage very basic things and even then, not very well. Always need help etc.

Regarding the Obstetrics side. It's easy to have good outcomes with low risk patients who will blindly listen to whatever you have to say.

When I was still taking call, we always had a few patients a year get brought in by ambulance for a mid wife screw up/ mis management.

It doesn't get publicized because it mainly happens in the community and their patent population seems less litigious.

Hell, I still recall a derm PA and GYN NP completely bungle a case that I had to clean up with some of my medical colleagues.

You can't tell me with a straight face that DNPXYZ letter salad these mid levels have is equivalent to MD/DO.

Most people know the truth.

 

[hyperalgesia]

It’s concerning to see a presumable doc, painapplicant, inferring that NP training and knowledge is adequate enough to supplant most physicians. If that’s the case why did you waste your time and money on medical training. It’s physicians like you that lead to lower quality healthcare in the US and the end of medical doctor as a profession

If I recall correctly, someone close and personal to him is an NP. That's probably why he's on a hair trigger to jump in and support their inferior training and capability.

There is absolutely no comparison between NPs and physicians. They are apples and oranges. NPs are physician extenders and always should be.

Ethics is a whole different question and I think it's important to expose (and mock) lapses wherever they occur, as @Agast has always done.

 

[Agast]

If I recall correctly, someone close and personal to him is an NP. That's probably why he's on a hair trigger to jump in and support their inferior training and capability.

There is absolutely no comparison between NPs and physicians. They are apples and oranges. NPs are physician extenders and always should be.

Ethics is a whole different question and I think it's important to expose (and mock) lapses wherever they occur, as @Agast has always done.

America is a meritocracy, we believe that hard work and brains should rise to the top.

But we also love underdogs, so we want to believe that chubby asthmatic kids can beat Olympic-level athletes with 1 second left on the clock, because they have ~*h*e*a*r*t*~

The real underdog story is the inner city kid who makes it to medical school with good mentorship and financial aid so that they get the training to be at the top. Trying to reap the rewards without the work is not a feel-good story, it's handing out participation trophies.

 

[Pain Applicant1]

Lol, popular this morning.

Let's play with the way things are noted here. Let's exchange the words to see how things look. Say an egregious crime is committed. A suicide bombing, mass shooting, robbery, etc. We document it here and say: _____________ gone wild again. Fill in the blank with your favorite ethnic/racial group, etc. Doesn't look so good and you'd probably be banned.

Question 1. Do you know of any bad anest/pain docs?
Question 2. Do you know of any good crnas?

If your answer to either is Yes then you must agree that it comes down to the individual.

If all of the training MDs receive is far superior, and I'm not necessarily saying it's not, then MD outcomes should clearly be better. If CRNAs replaced all MDs in a hospital then outcomes should worsen. More complications should occur. More dead pts because CRNA training is not adequate to manage the atypical issues. This becomes noted by the higher-ups and by the community. Word spreads and the reputation of the hospital becomes impacted. People choose to have their surgeries elsewhere. Is this happening? If not, why not?

I'm not worried about crnas or other docs creeping in on my catchment area because I'm not worried about the competition. I welcome it. If the pts like me, they'll continue to see me. If not, then the market has spoken. I evolve or I die just like everything else in this world.

You guys can sit in here and bi*ch and moan about reality all you want or you can evolve and adapt to it. If what you offer is a superior product, you have nothing to worry about. If it isn't, maybe things need to be revamped.

 

[pastafan]

Anesthesiologist direction and patient outcomes - PubMed

Both 30-day mortality rate and mortality rate after complications (failure-to-rescue) were lower when anesthesiologists directed anesthesia care. These results suggest that surgical outcomes in Medicare patients are associated with anesthesiologist direction, and may provide insight regarding...

pubmed.ncbi.nlm.nih.gov

Read the full study, not just summary.

 

[Ducttape]

it does not just come down to the individual. the lack of knowledge does not equate to equal care.

and yes, one could say that the older generation of physicians did not have that sort of knowledge with regards to opioids, but more recent training in medical school does incorporate opioid related training.

that is not to say that they cannot provide quality care without a physician. they do, and often do so better because their focus is often more on patient care than financial renumeration...

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continuing your analogy, someone who has been brainwashed in to thinking that suicide bombing against a capitalistic system thinks he is right.

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there is noone interested in studying an NP vs MD comparison. its a no win because from the MD standpoint, most NPs are still supposed to be monitored. if the data shows that the NPs perform worse, then the MDs supervising them look bad. and it affects physician reimbursement. clearly makes the NPs look bad. but then it directly shows that the push from major nursing organizations of independence is not helpful for patient care.

same thing with CRNA care. even worse because the risk of anesthetic complications is low overall. its like looking for a needle in a haystack and then asking "was it a threaded needle or not?"

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as someone who has worked more with NPs and PAs than you will ever have or will, i can most assuredly tell you that they are not physicians. and all the good ones agree, not out of deference to me. they also recognize all the responsibility and burden of safe patient care may start with them but ultimately falls on their collaborating physician.

 

[Pain Applicant1]

it does not just come down to the individual. the lack of knowledge does not equate to equal care.

and yes, one could say that the older generation of physicians did not have that sort of knowledge with regards to opioids, but more recent training in medical school does incorporate opioid related training.

that is not to say that they cannot provide quality care without a physician. they do, and often do so better because their focus is often more on patient care than financial renumeration...

---
continuing your analogy, someone who has been brainwashed in to thinking that suicide bombing against a capitalistic system thinks he is right.

---
there is noone interested in studying an NP vs MD comparison. its a no win because from the MD standpoint, most NPs are still supposed to be monitored. if the data shows that the NPs perform worse, then the MDs supervising them look bad. and it affects physician reimbursement. clearly makes the NPs look bad. but then it directly shows that the push from major nursing organizations of independence is not helpful for patient care.

same thing with CRNA care. even worse because the risk of anesthetic complications is low overall. its like looking for a needle in a haystack and then asking "was it a threaded needle or not?"

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as someone who has worked more with NPs and PAs than you will ever have or will, i can most assuredly tell you that they are not physicians. and all the good ones agree, not out of deference to me. they also recognize all the responsibility and burden of safe patient care may start with them but ultimately falls on their collaborating physician.

So then you should have nothing to worry about.

I don't care much for anesthesia since it doesn't affect me. I just used anesthesia in response to an earlier post to make a point. Let's try to keep it focused to interventional pain management since that directly impacts me and most people on here.

 

[Ferrismonk]

Lol, popular this morning.

Let's play with the way things are noted here. Let's exchange the words to see how things look. Say an egregious crime is committed. A suicide bombing, mass shooting, robbery, etc. We document it here and say: _____________ gone wild again. Fill in the blank with your favorite ethnic/racial group, etc. Doesn't look so good and you'd probably be banned.

Question 1. Do you know of any bad anest/pain docs?
Question 2. Do you know of any good crnas?

If your answer to either is Yes then you must agree that it comes down to the individual.

If all of the training MDs receive is far superior, and I'm not necessarily saying it's not, then MD outcomes should clearly be better. If CRNAs replaced all MDs in a hospital then outcomes should worsen. More complications should occur. More dead pts because CRNA training is not adequate to manage the atypical issues. This becomes noted by the higher-ups and by the community. Word spreads and the reputation of the hospital becomes impacted. People choose to have their surgeries elsewhere. Is this happening? If not, why not?

I'm not worried about crnas or other docs creeping in on my catchment area because I'm not worried about the competition. I welcome it. If the pts like me, they'll continue to see me. If not, then the market has spoken. I evolve or I die just like everything else in this world.

You guys can sit in here and bi*ch and moan about reality all you want or you can evolve and adapt to it. If what you offer is a superior product, you have nothing to worry about. If it isn't, maybe things need to be revamped.

In general, I agree with your free-market view on this subject. Biggest issue I see is patients often don't get a choice in the matter and even if they did, they don't understand the differences. Do you get a choice of your anesthesia provider when getting surgery or are you just stuck with whomever works at surgical site? I used to have a PA at my last pain clinic and many patients called him "Dr. XYZ" because of course he is a doctor, right? My wife recently had a sleep study done and the initial visit was with a NP, we didn't get a choice (I was very upset by that btw).

That being said, let's be honest, most of the time, clinically, any difference isn't really a big deal. Even in anesthesia where we routinely paralyze people and breath for them. Practically, any reasonable mid-level provider with the mind and hands to do so can learn anything procedural. See one, do one, teach one. Most things we do are not rocket science.

However, there IS a difference in some of the mental things we do. In the anesthesia world, differences are in things like did the patient die because the CRNA pushed propofol to intubate during a code or would the patient have just died anyway? Did the patient need 4 anti-emetics (and the potential side effects) for surgery when there were zero PONV risk factors? Was time to discharge 2 hours longer that it had to be? Is the elderly patient's dementia worse because the CRNA gives everyone 2 of Versed whether they have anxiety or not? Did that sickle cell patient have a worse outcome because oxygen tension and fluid balance weren't optimized?

In the pain clinic, did we give unnecessary steroids to the severe osteoporotic patient? Did we cause a fall by using a TCA in the elderly when a different nerve medication would have been a better choice? Was it really radiculopathy and sacroiliitis or was it just the piriformis?

These are things that are difficult to measure, but are real.

 

[clubdeac]

Lol, popular this morning.

Let's play with the way things are noted here. Let's exchange the words to see how things look. Say an egregious crime is committed. A suicide bombing, mass shooting, robbery, etc. We document it here and say: _____________ gone wild again. Fill in the blank with your favorite ethnic/racial group, etc. Doesn't look so good and you'd probably be banned.

Question 1. Do you know of any bad anest/pain docs?
Question 2. Do you know of any good crnas?

If your answer to either is Yes then you must agree that it comes down to the individual.

If all of the training MDs receive is far superior, and I'm not necessarily saying it's not, then MD outcomes should clearly be better. If CRNAs replaced all MDs in a hospital then outcomes should worsen. More complications should occur. More dead pts because CRNA training is not adequate to manage the atypical issues. This becomes noted by the higher-ups and by the community. Word spreads and the reputation of the hospital becomes impacted. People choose to have their surgeries elsewhere. Is this happening? If not, why not?

I'm not worried about crnas or other docs creeping in on my catchment area because I'm not worried about the competition. I welcome it. If the pts like me, they'll continue to see me. If not, then the market has spoken. I evolve or I die just like everything else in this world.

You guys can sit in here and bi*ch and moan about reality all you want or you can evolve and adapt to it. If what you offer is a superior product, you have nothing to worry about. If it isn't, maybe things need to be revamped.

Sorry but patients liking you isn’t going to provide job security nor are patient outcomes. Anyone who thinks so in our current climate of corporatized medicine and private equity ownership is naive. The deck is stacking against high paid physicians. It’s all about the money and if someone can do it cheaper, that’s the only thing that matters

 

[Pain Applicant1]

Sorry but patients liking you isn’t going to provide job security nor are patient outcomes. Anyone who thinks so in our current climate of corporatized medicine and private equity ownership is naive. The deck is stacking against high paid physicians. It’s all about the money and if someone can do it cheaper, that’s the only thing that matters

Agree with you here. The main issue is not who provides better care but job security. Honesty is important. Either our field evolves and adapts or we get muscled out.

 

[Ducttape]

So then you should have nothing to worry about.

I don't care much for anesthesia since it doesn't affect me. I just used anesthesia in response to an earlier post to make a point. Let's try to keep it focused to interventional pain management since that directly impacts me and most people on here.

diversion. and for someone who doesnt care much about anesthesia, quite a bit of your post is about CRNAs.



regardless, the rest of my statement applies.

NPs and PAs are great. but they are not MDs or DOs. they do not have the same training nor the same knowledge base.

potential sleeziness is applicable to every profession.

 

[Tramadeezy]

New midlevels in my group follow a doc around for 2 days and then have a light clinic where they are seeing patients and shadowing another NP. They learn the absolute basics from mostly other NPs. There are no books, no lectures, no learning from Academic gurus, no studying for hours, no boards etc. Just because the equivalency RCT doesnt exist doesnt mean we have to pretend we are equals. Im all for separating docs and midlevels and letting the market decide. Im confident we would win the battle.

 

[Pain Applicant1]

diversion. and for someone who doesnt care much about anesthesia, quite a bit of your post is about CRNAs.



regardless, the rest of my statement applies.

NPs and PAs are great. but they are not MDs or DOs. they do not have the same training nor the same knowledge base.

potential sleeziness is applicable to every profession.

As I mentioned, it was in response to a post to make a point. Happy to hear your opinions and anecdotes. From your other posts, it seems that you like studies to support conclusions. You may feel there aren't studies to support the difference but a quick google search shows that they don't feel this way. Look at some of the things they're posting

Numerous peer-reviewed studies have shown that CRNAs are safe, high-quality, and cost-effective anesthesia professionals who should practice to the full extent of their education and abilities. According to a 2010 study published in the journal Health Affairs, there are similarly low rates of adverse events for CRNAs and other anesthesia providers and anesthesia delivery models. Researchers studying anesthesia safety found no differences in care between nurse anesthetists and physician anesthesiologists based on an exhaustive analysis of research literature published in the United States and around the world, according to a scientific literature review prepared by the Cochrane Collaboration, the internationally recognized authority on evidence-based practice in healthcare. A study published in Medical Care (June 2016) found no measurable impact in anesthesia complications from nurse anesthetist scope of practice or practice restrictions

Or check this out:

Myth vs. Fact: Anesthesiologist vs. CRNA Education and Training - South Carolina Association of Nurse Anesthetists

I personally don't care one way or the other so back to pain. While I may hate to say this, I think an NP or a PA can be a better pain noctor than me if they commit themselves to it. While I'd like to think I'm great and special I know in reality I am only to my kids and wife and the world would get along just fine without me, lol.

 

[Pain Applicant1]

Im all for separating docs and midlevels and letting the market decide. Im confident we would win the battle.

Probably the most insightful and intelligent post on here so far. Kudos to you. Respect.

 

[callmeanesthesia]

As I mentioned, it was in response to a post to make a point. Happy to hear your opinions and anecdotes. From your other posts, it seems that you like studies to support conclusions. You may feel there aren't studies to support the difference but a quick google search shows that they don't feel this way. Look at some of the things they're posting

Numerous peer-reviewed studies have shown that CRNAs are safe, high-quality, and cost-effective anesthesia professionals who should practice to the full extent of their education and abilities. According to a 2010 study published in the journal Health Affairs, there are similarly low rates of adverse events for CRNAs and other anesthesia providers and anesthesia delivery models. Researchers studying anesthesia safety found no differences in care between nurse anesthetists and physician anesthesiologists based on an exhaustive analysis of research literature published in the United States and around the world, according to a scientific literature review prepared by the Cochrane Collaboration, the internationally recognized authority on evidence-based practice in healthcare. A study published in Medical Care (June 2016) found no measurable impact in anesthesia complications from nurse anesthetist scope of practice or practice restrictions

Or check this out:

Myth vs. Fact: Anesthesiologist vs. CRNA Education and Training - South Carolina Association of Nurse Anesthetists

I personally don't care one way or the other so back to pain. While I may hate to say this, I think an NP or a PA can be a better pain noctor than me if they commit themselves to it. While I'd like to think I'm great and special I know in reality I am only to my kids and wife and the world would get along just fine without me, lol.

I believe the ASA has responded extensively to those studies and their flaws. If I recall correctly, those studies are misleading because they rely on billing data. If you bill anesthesiologist supervision, the claim is paid split between the anesthesiologist and CRNA. However, the supervising anesthesiologist must attest that they were present for critical portions of the case, and document as such, and be careful to never document they were in 2 places at once (ie simultaneous starts where they may be bouncing back and forth to two adjacent rooms). If the CRNA bills as if they had independently performed the case, even if there was physician supervision, the reimbursement is the same but the oversight documentation requirement is not. Thus, like many other PA/NP overreach issues, it arose from doctors prioritizing short term gain for themselves over the long term integrity of the field and specialty.

 

[anonperson]

I personally don't care one way or the other so back to pain. While I may hate to say this, I think an NP or a PA can be a better pain noctor than me if they commit themselves to it. While I'd like to think I'm great and special I know in reality I am only to my kids and wife and the world would get along just fine without me, lol.

Geez, this low self esteem is something else. It's embarrassing. You may feel that way but trust me when I say you are in the minority of physicians.

Cost effective actually means the following for admin:

" The amount we save on salaries is greater than the malpractice payouts so mid levels are cost effective. Who cares if there is a random death or maiming?"

 

[lobelsteve]

As I mentioned, it was in response to a post to make a point. Happy to hear your opinions and anecdotes. From your other posts, it seems that you like studies to support conclusions. You may feel there aren't studies to support the difference but a quick google search shows that they don't feel this way. Look at some of the things they're posting

Numerous peer-reviewed studies have shown that CRNAs are safe, high-quality, and cost-effective anesthesia professionals who should practice to the full extent of their education and abilities. According to a 2010 study published in the journal Health Affairs, there are similarly low rates of adverse events for CRNAs and other anesthesia providers and anesthesia delivery models. Researchers studying anesthesia safety found no differences in care between nurse anesthetists and physician anesthesiologists based on an exhaustive analysis of research literature published in the United States and around the world, according to a scientific literature review prepared by the Cochrane Collaboration, the internationally recognized authority on evidence-based practice in healthcare. A study published in Medical Care (June 2016) found no measurable impact in anesthesia complications from nurse anesthetist scope of practice or practice restrictions

Or check this out:

Myth vs. Fact: Anesthesiologist vs. CRNA Education and Training - South Carolina Association of Nurse Anesthetists

I personally don't care one way or the other so back to pain. While I may hate to say this, I think an NP or a PA can be a better pain noctor than me if they commit themselves to it. While I'd like to think I'm great and special I know in reality I am only to my kids and wife and the world would get along just fine without me, lol.

Based on this, I have to hit ignore. Suggest others do same.

 

[Pain Applicant1]

I believe the ASA has responded extensively to those studies and their flaws. If I recall correctly, those studies are misleading because they rely on billing data. If you bill anesthesiologist supervision, the claim is paid split between the anesthesiologist and CRNA. However, the supervising anesthesiologist must attest that they were present for critical portions of the case, and document as such, and be careful to never document they were in 2 places at once (ie simultaneous starts where they may be bouncing back and forth to two adjacent rooms). If the CRNA bills as if they had independently performed the case, even if there was physician supervision, the reimbursement is the same but the oversight documentation requirement is not. Thus, like many other PA/NP overreach issues, it arose from doctors prioritizing short term gain for themselves over the long term integrity of the field and specialty.

I'm not sure either way just responding to the post. I don't want to get dragged into that issue as it is of no importance to me so I'm not going to respond any further to it. Happy to discuss IPM of course.

 

[Pain Applicant1]

Based on this, I have to hit ignore. Suggest others do same.

Big loss for me

If you didn't hit ignore yet, didn't you go to med school in the Caribbean? You know, there's a lot of denigrating talk about these students too among those who graduated from a US school.

 

[Ducttape]

you are posting a position statement from an organization that has bias.

they are using nursing critical care experience as part of their "training"
in truth, they are not being trained. this critical care experience - including MICU, surgical stepdown, ER - is working at a job. it is a fallacy that there is any education during this working.

there are multiple other flaws, but getting from this flawed argument of yours to your point about pain management:

Opioid Prescribing Patterns and Patient Outcomes by Prescriber Type in the Oregon Prescription Drug Monitoring Program - PubMed

Our analysis suggests significant differences in opioid prescription profiles and opioid-related hospitalization and mortality among patients receiving opioid prescriptions from nurse practitioners, naturopathic physicians, or medical clinicians in Oregon. However, these differences appear...

pubmed.ncbi.nlm.nih.gov

Results: There were 5,935 prescribers registered during the study period. Patients of NPs or NDs received more high-risk opioid prescriptions than patients of MDs/DOs/PAs. For example, they received greater proportions of high-dose prescriptions (NP 12.9%, ND 15%, MD/DO/PA 11.1%), and had greater opioid-related hospitalization (NP 1.7%, ND 3.1%, MD/DO/PA 1.2%; P < 0.005 for all). However, patients of NPs or NDs were also more likely to have four or more prescribers (NP 45.3%, ND 58.5%, MD/DO/PA 27.1%), and most of their patients' high-risk opioid prescriptions came from prescribers in other disciplines.

Conclusion: Our analysis suggests significant differences in opioid prescription profiles and opioid-related hospitalization and mortality among patients receiving opioid prescriptions from nurse practitioners, naturopathic physicians, or medical clinicians in Oregon. However, these differences appear largely due to differences in patient mix between provider types rather than discipline-specific prescribing practices.

Differences in Opioid Prescribing Among Generalist Physicians, Nurse Practitioners, and Physician Assistants - PubMed

We find relatively high rates of opioid prescribing among NPs and PAs, especially at the upper margins. This suggests that well-designed interventions to improve the safety of NP and PA opioid prescribing, along with that of their physician colleagues, could be especially beneficial.

pubmed.ncbi.nlm.nih.gov

Results: There were 36,999 generalist clinicians (physicians, NPs, and PAs) with at least one year of Part D prescription drug claims data between 2013 and 2016. The number of adjusted total opioid claims across these four years for physicians was 660 (95% confidence interval [CI] = 660-661), for NPs was 755 (95% CI = 753-757), and for PAs was 812 (95% CI = 811-814).

Conclusions: We find relatively high rates of opioid prescribing among NPs and PAs, especially at the upper margins. This suggests that well-designed interventions to improve the safety of NP and PA opioid prescribing, along with that of their physician colleagues, could be especially beneficial.

Opioid Prescribing by Primary Care Providers: a Cross-Sectional Analysis of Nurse Practitioner, Physician Assistant, and Physician Prescribing Patterns - Journal of General Internal Medicine

Background Prescription opioid overprescribing is a focal point for legislators, but little is known about opioid prescribing patterns of primary care nurse practitioners (NPs) and physician assistants (PAs). Objective To identify prescription opioid overprescribers by comparing prescribing...

link.springer.com

Key Results​

Among 222,689 primary care providers, 3.8% of MDs, 8.0% of NPs, and 9.8% of PAs met at least one definition of overprescribing. 1.3% of MDs, 6.3% of NPs, and 8.8% of PAs prescribed an opioid to at least 50% of patients. NPs/PAs practicing in states with independent prescription authority were > 20 times more likely to overprescribe opioids than NPs/PAs in prescription-restricted states.

Conclusions​

Most NPs/PAs prescribed opioids in a pattern similar to MDs, but NPs/PAs had more outliers who prescribed high-frequency, high-dose opioids than did MDs. Efforts to reduce opioid overprescribing should include targeted provider education, risk stratification, and state legislation.

Opioid Prescribing to Medicare Part D Enrollees, 2013–2017: Shifting Responsibility to Pain Management Providers

To examine opioid prescribing frequency and trends to Medicare Part D enrollees from 2013 to 2017 by medical specialty and provider type.We conducted a retrospective, cross-sectional, specialty- and provider-level analysis of Medicare Part D prescriber ...

www.ncbi.nlm.nih.gov

Results​

From 2013 to 2017, pain management providers increased Medicare Part D opioid claims by 27.3% to 1,140 mean claims per provider in 2017; physical medicine and rehabilitation providers increased opioid claims 16.9% to 511 mean claims per provider in 2017. Every other medical specialty decreased opioid claims over this period, with emergency medicine (–19.9%) and orthopedic surgery (–16.0%) dropping opioid claims more than any specialty. Physicians overall decreased opioid claims per provider by –5.2%. Meanwhile, opioid claims among both dentists (+5.6%) and nonphysician providers (+10.2%) increased during this period.

Conclusions​

From 2013 to 2017, pain management and PMR increased opioid claims to Medicare Part D enrollees, whereas physicians in every other specialty decreased opioid prescribing. Dentists and nonphysician providers also increased opioid prescribing. Overall, opioid claims to Medicare Part D enrollees decreased and continue to drop at faster rates.

non physician providers (ie NPs and PAs) did not get the memo about decreasing opioids...

 

[Laryngospasm]

At the end of the day our profession continues to be denigrated, demoralized, and dumbed down. The last 30years have been very depressing.
To hear people who have gone through the same 13 years of school and training hoping to help people (and giving up the best years of our lives to medicine) joining in the process of minimalizing physicians makes me sad.

The market will get what it has asked for.

 

[Pain Applicant1]

you are posting a position statement from an organization that has bias.

they are using nursing critical care experience as part of their "training"
in truth, they are not being trained. this critical care experience - including MICU, surgical stepdown, ER - is working at a job. it is a fallacy that there is any education during this working.

there are multiple other flaws, but getting from this flawed argument of yours to your point about pain management:

Opioid Prescribing Patterns and Patient Outcomes by Prescriber Type in the Oregon Prescription Drug Monitoring Program - PubMed

Our analysis suggests significant differences in opioid prescription profiles and opioid-related hospitalization and mortality among patients receiving opioid prescriptions from nurse practitioners, naturopathic physicians, or medical clinicians in Oregon. However, these differences appear...

pubmed.ncbi.nlm.nih.gov

Differences in Opioid Prescribing Among Generalist Physicians, Nurse Practitioners, and Physician Assistants - PubMed

We find relatively high rates of opioid prescribing among NPs and PAs, especially at the upper margins. This suggests that well-designed interventions to improve the safety of NP and PA opioid prescribing, along with that of their physician colleagues, could be especially beneficial.

pubmed.ncbi.nlm.nih.gov

Opioid Prescribing by Primary Care Providers: a Cross-Sectional Analysis of Nurse Practitioner, Physician Assistant, and Physician Prescribing Patterns - Journal of General Internal Medicine

Background Prescription opioid overprescribing is a focal point for legislators, but little is known about opioid prescribing patterns of primary care nurse practitioners (NPs) and physician assistants (PAs). Objective To identify prescription opioid overprescribers by comparing prescribing...

link.springer.com

Opioid Prescribing to Medicare Part D Enrollees, 2013–2017: Shifting Responsibility to Pain Management Providers

To examine opioid prescribing frequency and trends to Medicare Part D enrollees from 2013 to 2017 by medical specialty and provider type.We conducted a retrospective, cross-sectional, specialty- and provider-level analysis of Medicare Part D prescriber ...

www.ncbi.nlm.nih.gov

non physician providers (ie NPs and PAs) did not get the memo about decreasing opioids...

I'm not making an argument. I'm telling you what they said and for the last time I don't care. Get over your butthurtness and let's move on.

 

[Pain Applicant1]

Geez, this low self esteem is something else. It's embarrassing. You may feel that way but trust me when I say you are in the minority of physicians.

Cost effective actually means the following for admin:

" The amount we save on salaries is greater than the malpractice payouts so mid levels are cost effective. Who cares if there is a random death or maiming?"

Wait, let me understand. Most doctors don't feel the way I do? Do you mean they feel that they're great and better than everyone else? You got to be kidding me.

Low self-esteem is not something I've ever been accused of having. I have enough confidence in myself to have accomplished quite a bit in my life.

I'm just being realistic.

 

[macman]

More training doesn't necessarily equate to better outcomes, especially in pain. You guys love the literature so much so let's post some studies which show improved outcomes for pain docs vs NPs. Then we can have a valid argument. I would definitely support that. They must be out there somewhere. Someone less lazy than me care to look?

I haven't looked for pain but I did look at things when my wife was pregnant. Outcomes didn't seem to be any different for MDs, NPs, or midwives. Correct me if I'm wrong.

Everyone should be posted when doing something wrong but it seems that the NP thing is really emphasized such as in the past few posts. No need to ignore. I enjoy standing up to bullying, lol.

So if the training is just as good, you are comfortable having CRNAs, NPs, and PAs passing the same board exams as MD/DO?

The other factor when looking at outcomes is triage. In most clinics and hospitals, there is triage right? The MD gets the harder pts, the most complex, etc.

 

[rexed]

I'm not saying it doesn't ever, I'm just saying it doesn't equate. Naturally the anesthesia forum is going to pump up docs and disparage the crna so bad example to prove your point. You know, the whole vested interest thing.

Post some studies specifically for pain. Lots of pain pts going around so lots of data. There must be something published out there that shows our outcomes are better. I don't know and don't care to look.

I personally think most things are learned on the job and it comes down to the individual.

Anecdotally, I did see a crna save an interventional pain anesthesiologist's butt during fellowship following a cesi. N of 1 so doesn't mean anything but kind of supports the notion that it comes down to the individual.

Perhaps a lot of minutia in medical school training is not necessary to improve outcomes. If that's the case, maybe the frivolous things in the med school curriculum can be eliminated and the cost and time of the education can be lessened. Just a thought.

Very considerate of you to be so open minded. Let's talk in 5-7 years when your position has been replaced by an NP or CRNA.

 

[Pain Applicant1]

Very considerate of you to be so open minded. Let's talk in 5-7 years when your position has been replaced by an NP or CRNA.

Honest post. This is what it comes down to. Job security. Feeling threatened.

I'm not an employee so I can't be replaced. I own my own practice so I could be put out of business. I'm not too concerned about it and I welcome the competition. This is how the world works and as I mentioned several times, I evolve or I die. I'd rather fight for my money and not ask big brother to help stifle my competition. I'd prefer for the game to be fair. If someone can offer a better or equal product for less money then so be it. That's progress and the market will help determine that.

The same people who complain of gov't interference seem to be the same ones who are crying and begging for its help.

 

[Pain Applicant1]

So if the training is just as good, you are comfortable having CRNAs, NPs, and PAs passing the same board exams as MD/DO?

The other factor when looking at outcomes is triage. In most clinics and hospitals, there is triage right? The MD gets the harder pts, the most complex, etc.

I think the more important question to ask is do the board exams make you a better health care provider? I'm not so sure of it. It seems like most of the posters here agree as I constantly see people complaining about how useless and unproductive they are.

It seems like standardized tests overall are going the way of the dinosaur.

Edit: I'm not necessarily saying the training is just as good (although really all I'm seeing are opinions from those with a vested interest). I just didn't like the OP's dirty tactics.