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[W19]

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Not sure if you are insinuating that I'm advocating for shorter residencies. I don't think anyone in their right mind would argue for that, including myself (if you read my post)...

There are not many people here who are advocating to eliminate residency, though there might be a case about shortening FM to 2-year. In any cases, I would like to know what differentiate a 3-year vs. 4-year trained EM doc... A lot of these stuff might be arbitrary to be honest...

Anyway, the only post I made about shortening residency was relating a story about a friend who was trained in PR... He told me they eliminate the PCP shortage and NP/PA encroachment by mandating all insurance companies to reimburse GP physicians for their service... Because of that, a lot students who want become PCP have chosen to do 1-year residency (or intern). There are even programs that do not pay their interns and are able to recruit many IMG... That eliminates the backdoor that PA/NP have to practice medicine. He also told me even the big ER over there are mostly staffed with EM and GP docs... Overall, there is no need to become a PA/NP since they don't even use them. He also said studies have shown that access to healthcare have increased while referral to specialists, morbidity/mortality haven't. But I did not care to look into that.

 

[WingedOx]

As long as antibiotics are not included in that, many of us would be OK with this...

As someone who spent the day cleaning up multiple patients on awful combinations of benzos and stimulants... f-ck that noise.

 

[Pacna]

Just out of curiosity, are the drugs which have been de-regulated/decriminalized in those countries schedule 1 and schedule 2 drugs here? i.e. are drugs like cocaine, heroine, and meth legal? Additionally, are these countries with similar socioeconomic demographics as the U.S.? I've heard that argument before, and it always fails to take into account the vast differences in between the 2 countries being compared.

Portugal is the longest 'trial', but there are many other countries which might surprise you. Have a (short) read. Morbidity/mortality is down massively.

However, like I said previously, it's not a question of utility. It's a question of whether anyone has the right to intervene between 2 consenting adults. The answer has always been no. That's as far as I need to delve to find my position.

View attachment 200330

Plausible. I think people are generally better than that. Or they think they are. I think people legitimately felt they were doing the right thing. You know what they say about the road to Hell.

 

[Pacna]

As someone who spent the day cleaning up multiple patients on awful combinations of benzos and stimulants... f-ck that noise.

Then welcome aboard.

"Portugal decriminalised drugs 14 years ago – and now hardly anyone dies from overdosing"

http://www.independent.co.uk/news/w...dly-anyone-dies-from-overdosing-10301780.html

 

[VA Hopeful Dr]

As someone who spent the day cleaning up multiple patients on awful combinations of benzos and stimulants... f-ck that noise.

I've had to learn xanax detoxing of late. Every time I get a patient on 6mg of xanax daily I want to find whoever started them on it and slash their tires.

 

[VA Hopeful Dr]

The state is not a moral agent. It is a group of people. They do not have any more moral authority than any other group of people. The fact that they claim to is both laughable and tragic.

Edit: It is indeed physicians claiming moral authority in this regard. The fact that they're outsourcing the enforcement to people in blue costumes is irrelevant to the ethical culpability.

You honestly don't seem to get it. Physicians only have any authority over other physicians. We are not responsible for anything other than licensed physicians. I'm truly not sure how this isn't clear.

 

[Mad Jack]

Portugal is the longest 'trial', but there are many other countries which might surprise you. Have a (short) read. Morbidity/mortality is down massively.

However, like I said previously, it's not a question of utility. It's a question of whether anyone has the right to intervene between 2 consenting adults. The answer has always been no. That's as far as I need to delve to find my position.



Plausible. I think people are generally better than that. Or they think they are. I think people legitimately felt they were doing the right thing. You know what they say about the road to Hell.

I used to think people were better than that, but I've learned since then just how far lobbying dollars go.

 

[WingedOx]

I've had to learn xanax detoxing of late. Every time I get a patient on 6mg of xanax daily I want to find whoever started them on it and slash their tires.

People don't know how to tell their patients "no." Particularly when they're suffering.

Today's case was a patient I inherited who's been on xanax 1 mg TID for like 18 years. Increased stressors lately so she cranked it up to 4x/5x per day (I've found that the frequency of xanax is usually more damaging than the amount). I've made it pretty clear that if she does that she's not getting early refills from me. I'd be a bigger hardass about this and do a forced taper but one of the stressors is the death of her husband over xmas. Still, she expects her psychiatrist to be able to basically prescribe a happy pill that will make the fact that she's now alone after 40 years of marriage suddenly ok.

Stimulants are still a bigger pain in the ass for me though.

 

[WingedOx]

Then welcome aboard.

"Portugal decriminalised drugs 14 years ago – and now hardly anyone dies from overdosing"

http://www.independent.co.uk/news/w...dly-anyone-dies-from-overdosing-10301780.html

That's nice and all, but ODs are a rare end-point, and not the one I'm having to manage. It's long-term sequelae from chronic use that I (and the patient) need to deal with if someone isn't regulating these meds.

 

[VA Hopeful Dr]

People don't know how to tell their patients "no." Particularly when they're suffering.

Today's case was a patient I inherited who's been on xanax 1 mg TID for like 18 years. Increased stressors lately so she cranked it up to 4x/5x per day (I've found that the frequency of xanax is usually more damaging than the amount). I've made it pretty clear that if she does that she's not getting early refills from me. I'd be a bigger hardass about this and do a forced taper but one of the stressors is the death of her husband over xmas. Still, she expects her psychiatrist to be able to basically prescribe a happy pill that will make the fact that she's now alone after 40 years of marriage suddenly ok.

Stimulants are still a bigger pain in the ass for me though.

I've started requiring neuropsych testing for adults wanting ADHD meds, really weeds out the BSers

 

[WingedOx]

I've started requiring neuropsych testing for adults wanting ADHD meds, really weeds out the BSers

I do it too unless I've got documented evidence that they've already had treatment. Still, it doesn't tell you much more than what you probably already knew unless they're not very bright and fail a TOMM or something (and there's quite a bit of discussion about this over on the psych forums).

Even with a positive neuropsych test, you have situations where I need to be like "well of course your concentration sucks. You're working a full-time job and driving for uber for 4 hours after you're done, and as a result you get maybe 5 hours of sleep per night. Of course your concentration sucks." They're insisting they're on the verge of getting fired from work because of poor concentration/performance and already living paycheck to paycheck, but honestly what they really need to hear is "you need to sleep more."

 

[Pacna]

You honestly don't seem to get it. Physicians only have any authority over other physicians. We are not responsible for anything other than licensed physicians. I'm truly not sure how this isn't clear.

Because it's not correct.

Before the AMA, physician was just another career. Many worked jobs in addition to being doctors. The AMA established the monopoly we currently hold. They're fighting (lobbying) to maintain that monopoly. Therefore, physicians explicitly endorse threats of violence on any who would encroach on their market.

 

[Psai]

Because it's not correct.

Before the AMA, physician was just another career. Many worked jobs in addition to being doctors. The AMA established the monopoly we currently hold. They're fighting (lobbying) to maintain that monopoly. Therefore, physicians explicitly endorse threats of violence on any who would encroach on their market.

What are you on about

 

[badasshairday]

Because it's not correct.

Before the AMA, physician was just another career. Many worked jobs in addition to being doctors. The AMA established the monopoly we currently hold. They're fighting (lobbying) to maintain that monopoly. Therefore, physicians explicitly endorse threats of violence on any who would encroach on their market.

What are you on? I have a feeling you are not a medical student. We only have jurisdiction over those in our profession. Hence the degree creep by NP's to confuse patients by calling themselves "doctor" after getting their DNP. If we had control, we would have squashed that our of interest for our patients.

 

[Stagg737]

Portugal is the longest 'trial', but there are many other countries which might surprise you. Have a (short) read. Morbidity/mortality is down massively.

However, like I said previously, it's not a question of utility. It's a question of whether anyone has the right to intervene between 2 consenting adults. The answer has always been no. That's as far as I need to delve to find my position.

First, almost every country on your wikipedia list states that while they were legalized for possession/personal use, it was still illegal to sell drugs and drug use in general was also highly regulated. Even in Portugal, it's still illegal and punishable to produce, sell, or possess large quantities of drugs. So your presumption that there is no interference between two consenting adults there is just wrong.

As for the bolded, there are plenty of examples where such a view can be described as complete bs, as there are many things that 2 adults can consent to which affect far more people than just themselves. If your argument is that a person should be able to do whatever drugs they want because it won't effect other people, then you have very little experience with hard drug users and the impact they have on those around them.

 

[calvnandhobbs68]

I always find these hardcore libertarian types that somehow pop up on allo every few months kind of dull.

Medicine is not a perfect market. It never can be and never will be, even if we were to totally get rid of all governmental regulation. Don't they teach you about information asymmetry in like Econ 101 or 102? We can work to get a balance but like most things in life the answer lies in the middle.

 

[Pacna]

What are you on? I have a feeling you are not a medical student. We only have jurisdiction over those in our profession. Hence the degree creep by NP's to confuse patients by calling themselves "doctor" after getting their DNP. If we had control, we would have squashed that our of interest for our patients.

I thought that I addressed exactly this in my previous post. I apologize if I was unclear. Let me try again.

We maintain the sole right to use the term physician, as well as prescribe certain medications, through state power. "Squashing" NPs from using the term "physician" for themselves and writing certain prescriptions means what exactly? Putting people in jail for doing so without an MD or DO. The AMA supports this through lobbying (both via initial licensing in most states + ever-expanding prescribing laws). The fact that it is a law necessitates a threat of violence. That's just what a law is.

I hope that clears up my point.

First, almost every country on your wikipedia list states that while they were legalized for possession/personal use, it was still illegal to sell drugs and drug use in general was also highly regulated. Even in Portugal, it's still illegal and punishable to produce, sell, or possess large quantities of drugs. So your presumption that there is no interference between two consenting adults there is just wrong.

As for the bolded, there are plenty of examples where such a view can be described as complete bs, as there are many things that 2 adults can consent to which affect far more people than just themselves. If your argument is that a person should be able to do whatever drugs they want because it won't effect other people, then you have very little experience with hard drug users and the impact they have on those around them.

You're right, of course, about regulation still being present. My argument wasn't intended to imply that Portugal had achieved the apex of moral laws. In retrospect, I should have been more clear about that. I'm arguing that a clear, tangential departure from our current 'war on drugs' in favor of laxity yields promise.

I was also much less clear than I thought here. Specifically, I mean that nobody outside of that interaction can interfere violently. If I'm buying a banana from a banana farmer, you can't (ethically) point a gun and stop us. However, if I'm hiring a hitman, then you CAN because my actions implicitly breach someone else's rights. There are not plenty of examples in which voluntary interaction should be intervened in this way. (though I'm interested to hear some examples!) Certainly not drugs.

People should be able to do whatever drugs they want because they have a better claim to their body than anyone else does. The fallout from that does indeed impact others, and that's tragic. I'm not pro-drug-use.

 

[VA Hopeful Dr]

Because it's not correct.

Before the AMA, physician was just another career. Many worked jobs in addition to being doctors. The AMA established the monopoly we currently hold. They're fighting (lobbying) to maintain that monopoly. Therefore, physicians explicitly endorse threats of violence on any who would encroach on their market.

OK, I get what you're saying now. I don't agree, but you are logically consistent so I can't fault that. I'm just less hardcore liberterian than you are. You and sb47 would get along well.

 

[Stagg737]

You're right, of course, about regulation still being present. My argument wasn't intended to imply that Portugal had achieved the apex of moral laws. In retrospect, I should have been more clear about that. I'm arguing that a clear, tangential departure from our current 'war on drugs' in favor of laxity yields promise.

I was also much less clear than I thought here. Specifically, I mean that nobody outside of that interaction can interfere violently. If I'm buying a banana from a banana farmer, you can't (ethically) point a gun and stop us. However, if I'm hiring a hitman, then you CAN because my actions implicitly breach someone else's rights. There are not plenty of examples in which voluntary interaction should be intervened in this way. (though I'm interested to hear some examples!) Certainly not drugs.

People should be able to do whatever drugs they want because they have a better claim to their body than anyone else does. The fallout from that does indeed impact others, and that's tragic. I'm not pro-drug-use.

For the examples, do you have any experience with what people going through withdrawal will do to get more drugs? Especially some of the more addictive and harder drugs like heroine or meth (having friends that have been mugged by some of these individuals I can say it can get very serious). Certain drugs like LSD or bath salts may alter the mind so much in relatively small doses that people become more aggressive while high. Add the example of the person who uses a mind-altering substance then decides to operate heavy machinery or a vehicle (yes, I include alcohol in that example). I have a close friend that used to smoke pot before going on deliveries for a package delivery service and he got in multiple accidents while mildly high. n=1, but it literally happens every day. There's 3 broad examples which I could come up with a million situations for in which others would be adversely affect

In theory, I understand what you're saying and agree. A person should be able to do what they want with their body without others interfering assuming their in a proper state of mind to make that decision. However, I think your assumption that these substances can be used by most without adversely affecting others around them is too short-sided and skewed from the actual reality. Idk if you just don't have enough experience with individuals under the influence or if you just have too much faith in those people, but allowing people to use drugs is not a decision I feel would go well in the U.S.

As a sidenote, I'd be interested to see the stats for non-OD related drug deaths and injuries in the countries you mentioned. Idk about Europe, but I know that in several Latin and South American countries alcohol-related deaths (specifically drunk driving-related incidents) are one of the biggest problems their law enforcement faces on the local levels. I have little faith that people here would be responsible enough to not do stupid things while under the influence, and making more mind-altering substances legal would only add to that issue.

 

[Pacna]

OK, I get what you're saying now. I don't agree, but you are logically consistent so I can't fault that. I'm just less hardcore liberterian than you are. You and sb47 would get along well.

For the examples, do you have any experience with what people going through withdrawal will do to get more drugs? Especially some of the more addictive and harder drugs like heroine or meth (having friends that have been mugged by some of these individuals I can say it can get very serious). Certain drugs like LSD or bath salts may alter the mind so much in relatively small doses that people become more aggressive while high. Add the example of the person who uses a mind-altering substance then decides to operate heavy machinery or a vehicle (yes, I include alcohol in that example). I have a close friend that used to smoke pot before going on deliveries for a package delivery service and he got in multiple accidents while mildly high. n=1, but it literally happens every day. There's 3 broad examples which I could come up with a million situations for in which others would be adversely affect

In theory, I understand what you're saying and agree. A person should be able to do what they want with their body without others interfering assuming their in a proper state of mind to make that decision. However, I think your assumption that these substances can be used by most without adversely affecting others around them is too short-sided and skewed from the actual reality. Idk if you just don't have enough experience with individuals under the influence or if you just have too much faith in those people, but allowing people to use drugs is not a decision I feel would go well in the U.S.

As a sidenote, I'd be interested to see the stats for non-OD related drug deaths and injuries in the countries you mentioned. Idk about Europe, but I know that in several Latin and South American countries alcohol-related deaths (specifically drunk driving-related incidents) are one of the biggest problems their law enforcement faces on the local levels. I have little faith that people here would be responsible enough to not do stupid things while under the influence, and making more mind-altering substances legal would only add to that issue.

First paragraph:
Absolutely no question that drugs cause people to do stupid things and act against their own interest. As with alcohol, they are still liable for damages. This doesn't make alcohol, cannabis, or any other substance inherently immoral to ingest.

Second paragraph:
(bolded) - I do not make this assumption.
I see that it's a question of utility to you. I encourage you to explore utilitarianism further if you have not done so already. Some of the conclusions it arrives at are shocking to say the least.

Third:
I would also be interested in seeing those stats. But I agree with your conclusion.

 

[Stagg737]

Second paragraph:
(bolded) - I do not make this assumption.
I see that it's a question of utility to you. I encourage you to explore utilitarianism further if you have not done so already. Some of the conclusions it arrives at are shocking to say the least.

Third:
I would also be interested in seeing those stats. But I agree with your conclusion.

For the 'second paragraph' response do you have studies/stats in the U.S.? Just curious because I feel like the general attitude of the average U.S. citizen would yield different results than studies of our European counterparts. I'd also add that my point was meant to be less utilitarian and more of an attempt to stick to foundation of your libertarian argument where individuals may govern themselves so long as they are not affecting others in an undesirable way.

For the third point, here's some stats for L.A. countries. It's a longer document, so you can skip to page 8 and just read through the next few pages. They give some basic stats and show how much of a problem alcohol is in all the Americas. There are some pretty startling figures, like "50% of alcohol-attributable deaths are due to injury" and "20-50% (I know, huge range) of road-traffic fatalities are alcohol related". Here's the paper (from the WHO):

http://www.who.int/substance_abuse/publications/alcohol_public_health_americas.pdf

 

[Pacna]

For the 'second paragraph' response do you have studies/stats in the U.S.? Just curious because I feel like the general attitude of the average U.S. citizen would yield different results than studies of our European counterparts. I'd also add that my point was meant to be less utilitarian and more of an attempt to stick to foundation of your libertarian argument where individuals may govern themselves so long as they are not affecting others in an undesirable way.

For the third point, here's some stats for L.A. countries. It's a longer document, so you can skip to page 8 and just read through the next few pages. They give some basic stats and show how much of a problem alcohol is in all the Americas. There are some pretty startling figures, like "50% of alcohol-attributable deaths are due to injury" and "20-50% (I know, huge range) of road-traffic fatalities are alcohol related". Here's the paper (from the WHO):

http://www.who.int/substance_abuse/publications/alcohol_public_health_americas.pdf

I don't have any stats on hand, no.

There is a component of reasonable intent to the NAP. It's not immoral to read the paper even if you inadvertently cause a butterfly-effect tsunami to hit Japan. Whereas if you KNOW reading the paper would cause that, of course that would be immoral. Drugs use is somewhere in the middle, but basing our understanding of 'reasonable' on current sentiment surrounding alcohol, it follows that drugs which make you more aggressive wouldn't be immoral to take if you took them in an environment where you were very unlikely to cause harm (locked in a room, etc). Otherwise, the same principle as drunk driving holds: you may not have been mentally capable when you were driving, but you were when you chose to drink.

Those are sobering (no pun intended) numbers, indeed! I don't think you are calling for prohibition of alcohol. In fact, I'd wager you fancy a beer or glass of wine from time to time?

 

[AvrgPreMedKid]

From an MD I work with:

PA's/NP's = r-species
Physicians = K-species

In today's highly variable environment, the r-species has the advantage.

For those unfamiliar:
R vs. K Selected Species

• K selected species live in populations that are at or near equilibrium conditions for long periods of time. Competition for limited resources is very important in these environments.

• Examples; lemurs, giraffes, elephants, bats

• R selected species live in populations that are highly variable. The fittest individuals in these environments have many offspring and reproduce early.

• Examples; mosquitoes, Daphnia, goldenrod

(Source: http://www.uic.edu/classes/bios/bios101/Demography/tsld031.htm)

He later told me that there are also r/K species at the physician level, and he said primary care (he is IM working in primary care) is among the r-species. Cardiothoracic surgery is among the K species.

 

[Stagg737]

I don't have any stats on hand, no.

There is a component of reasonable intent to the NAP. It's not immoral to read the paper even if you inadvertently cause a butterfly-effect tsunami to hit Japan. Whereas if you KNOW reading the paper would cause that, of course that would be immoral. Drugs use is somewhere in the middle, but basing our understanding of 'reasonable' on current sentiment surrounding alcohol, it follows that drugs which make you more aggressive wouldn't be immoral to take if you took them in an environment where you were very unlikely to cause harm (locked in a room, etc). Otherwise, the same principle as drunk driving holds: you may not have been mentally capable when you were driving, but you were when you chose to drink.

Those are sobering (no pun intended) numbers, indeed! I don't think you are calling for prohibition of alcohol. In fact, I'd wager you fancy a beer or glass of wine from time to time?

I completely agree, and there are many people that can/could handle such substances responsibly, and I'm not calling for prohibition (and would in fact support legalization of marijuana). Ideally, I agree with the bolded, but realistically we both know that does not occur far too often. However, as you alluded to, the question for me comes down to a utilitarian perspective of when do the rights of the individual supersede the very likely possibility that an individual may injure or kill an uninvolved party.

You are correct with your last statement as well. In fact, I'm enjoying a bottle HopDevil IPA at the moment.

 

[Pacna]

I completely agree, and there are many people that can/could handle such substances responsibly, and I'm not calling for prohibition (and would in fact support legalization of marijuana). Ideally, I agree with the bolded, but realistically we both know that does not occur far too often. However, as you alluded to, the question for me comes down to a utilitarian perspective of when do the rights of the individual supersede the very likely possibility that an individual may injure or kill an uninvolved party.

You are correct with your last statement as well. In fact, I'm enjoying a bottle HopDevil IPA at the moment.

Well I'm glad you're for legalization of a substance. It's a start!

As for people hurting each other while under these substances, I think that's at least in part due to the punishments currently in place. How differently would people behave if the drug use/possession itself was not illegal, but they were still liable for their actions? Impossible to say, but I'd wager quite a big change! Incentives are important. 🙂

 

[FoundInStudy]

Well I'm glad you're for legalization of a substance. It's a start!

As for people hurting each other while under these substances, I think that's at least in part due to the punishments currently in place. How differently would people behave if the drug use/possession itself was not illegal, but they were still liable for their actions? Impossible to say, but I'd wager quite a big change! Incentives are important. 🙂

Intervention, regardless of morality, is the only sane way to proceed. Letting people drink is one thing but when they plow a family down or mame a surgical resident driving home in the middle of a night and he/she loses the ability to make their livelihood, who pays? The one drinking who no one could stop because it would be "immoral?" What are the odds they have the millions of dollars to compensate the resident for the loss of their livelihood. What are the odds they have the ability to rehabilitate that person by themselves. Obviously they are incapable of being fully "liable" unless they can provide full recompense by themselves.. which is impossible.

So when a patient comes in and has cancer or is a hypertensive and refuses treatment.. is it moral when they come in with late stage cancer and are spending [not their own] money for hospitalization or hospice or whatever. Is it moral when they refuse hypertension treatment, stroke out, and require around the clock care for the rest of their lives? They use up money that the rest of the society could be using to better itself. A cheap problem (hypertension) becomes an expensive problem (stroke) and those who were 'responsible' enough to decide they didn't want treatment, etc. are no longer responsible for dealing with the cost of their actions because they don't have the means to. It's impossible in a society to avoid taking some level of responsibility for the members of the society.

If you wanna avoid cancer treatment and can afford to pay for your hospitalization without requiring insurance money or assistance in other ways, then sure - go ahead. If you want to be truly responsible for your own decisions in the near, mid, and long term and can reasonably take full responsibility, then do whatever. But a vast majority of society is not able to. So in society, you gain the benefits of the society by losing your right to be an anti-social member. One can only say that their decisions affects only themselves if they are short sighted to the point they can't see beyond their own nose.

Physicians - those with the most knowledge of not just short term prognosis but of long term morbidity - they, as members of society, need to ensure that patients get the best possible care so patients do not end up hurting others directly or indirectly (through avoidable expenses patient's can't afford, etc.).

It's delusional to believe that people can be truly held completely responsible for any of their actions so limitations of their actions are necessary. A heroin addict has what ability to provide full reparation for their actions that inevitably hurt others?

 

[cbrons]

More news to ruin your evening: http://forums.studentdoctor.net/threads/acep-emailing-unchallenged-n-p-propaganda.1184402/

 

[Pacna]

A heroin addict has what ability to provide full reparation for their actions that inevitably hurt others?

Irrelevant. $ per $ != morality.

 

[FoundInStudy]

Irrelevant. $ per $ != morality.

Where in that quote did I mention money? That is your assumption that its only about money. They cannot undo psychological damage, physical damage, etc. There is no real way for someone to be fully responsible for their actions. People are able to cause a lot more harm in a society than they are able to fix.
None of your solutions proposed involve any sort of reality - just short sighted idealism.

Look, I'll help you out. If you believe that PA/NPs should be allowed to practice medicine.. that is something I can agree with in a limited context. I believe that there should be a better path for high performing nurses/PAs to take on higher levels of leadership/responsibility in medicine.
But what is going on now is not about morals, its a simple power play. Nurses/PAs could/should be advocating for better training (comparable to medical training) instead of advocating for more power. Once they are well trained, why would anyone want to avoid utilizing their services/training and give them more power. Giving them power would be a moot point. But that isn't what is happening. They are trying to shoehorn their way into medicine while trying to avoid doing the same level of training. I don't think its "moral" or "fair" to expect the same level of responsibility/compensation as someone else without doing a comparable level of preparation.

If nurses/PAs were intent on being better providers of medicine and elevating themselves, their boards/organizations would be working to improve the rigor of their training, the selectivity, etc. They could be working with ACGME/AOA to help get their best into residencies.

At the end of the day, you do not want to dilute a product/service. Cheaper and cheaper products with lower quality is unsustainable as a model. Instead, keeping the price while improving the quality is sustainable (its what the longest running companies do, in general).

Instead of adding medical providers with lower levels of training in terms of rigor/hours, why not create programs that are comparable to medical training or expand medical training in fields that could use it in areas that could use it. Or just add spots in general. Nurses/PAs shouldn't be forced to train in rural areas but they should be willing to compete more for more desirable locations and fields - just like med students do.

If I were a residency PD, I would gladly take a 15 year PA to train who has great references from people they've worked with and is a proven quantity and proven experience. They should be very low risk for attrition. Ditto for the best nurses/NPs since they've already gotten their feet wet. If they are lacking some science background, I don't see why residencies can't have electives for them to shore up their science knowledge before taking the licensing exams.

This method would address qualms about the lack of training hours or the lack of rigor (due to accusations of management type courses in mid level training like DNP/NP programs).
This is just an idea but, in my opinion, a lot more realistic than using a specious moral argument.

 

[Pacna]

Where in that quote did I mention money?

What are the odds they have the millions of dollars to compensate the resident for the loss of their livelihood.

1. That is your assumption that its only about money.
2. They cannot undo psychological damage, physical damage, etc. There is no real way for someone to be fully responsible for their actions. People are able to cause a lot more harm in a society than they are able to fix.
3. None of your solutions proposed involve any sort of reality - just short sighted idealism.

1. Isn't.
2. Not contested.
3. I'm not proposing solutions.

1. Look, I'll help you out.
2. If you believe that PA/NPs should be allowed to practice medicine.. that is something I can agree with in a limited context. I believe that there should be a better path for high performing nurses/PAs to take on higher levels of leadership/responsibility in medicine.
3. But what is going on now is not about morals, its a simple power play.
4. I don't think its "moral" or "fair" to expect the same level of responsibility/compensation as someone else without doing a comparable level of preparation.

1. Aw, thanks.
2. Glad you agree.
3. Yeah, from their point of view it's totally about power, not morality. You're spot on. I'm arguing that physicians have been exerting unjust (read: immoral) power.
4. Strawman down! Call 9-1-1!

At the end of the day, you do not want to dilute a product/service. Cheaper and cheaper products with lower quality is unsustainable as a model. Instead, keeping the price while improving the quality is sustainable (its what the longest running companies do, in general).

Of course physicians don't want to dilute their market. That's why we established a monopoly in the first place. Removing that monopoly is the only ethical choice. You think price is currently sustainable? I don't even know what to say to that.

1. Instead of adding medical providers with lower levels of training in terms of rigor/hours, why not create programs that are comparable to medical training or expand medical training in fields that could use it in areas that could use it. Or just add spots in general. Nurses/PAs shouldn't be forced to train in rural areas but they should be willing to compete more for more desirable locations and fields - just like med students do.

2. If I were a residency PD, I would gladly take a 15 year PA to train who has great references from people they've worked with and is a proven quantity and proven experience. They should be very low risk for attrition. Ditto for the best nurses/NPs since they've already gotten their feet wet. If they are lacking some science background, I don't see why residencies can't have electives for them to shore up their science knowledge before taking the licensing exams.

3. This method would address qualms about the lack of training hours or the lack of rigor (due to accusations of management type courses in mid level training like DNP/NP programs).

4. This is just an idea but, in my opinion, a lot more realistic than using a specious moral argument.

1. That's one possible scenario if physicians release their strangle-hold on the market, sure. I see no issue with that. Oddly specific, but OK.
2. Sure, works for me.
3. Definitely sounds plausible.
4. I agree. Did you have a specious moral argument in mind? Those are easy to refute.

 

[delco714]

As an example, they do all of the scut work at the hospitalist program near here, basically functioning as interns for life. They do all the annoying discharge and admit stuff, while the patient gets to do a full eval of the patient. Less complicated things get bumped off to them so the physician can focus on the more complicated patients. The PA basically does a lot of the BS paperwork and administration, freeing up the doctors to do a lot more doctoring and a lot less annoying regulatory crap. Each doctor has a PA, which basically lets them nearly double their productivity, all for a fraction of the cost of two physicians (hospitalists are paid on the low end for work here because we're in the NE and there's more supply than demand in the better hospitals, pay's only about 80k to start, 100k with experience, while the hospitalists start at 190 and can make up to 240).

In other environments, such as derm, you can oversee four PAs that do procedures for you, while you just do the evals and tell them which procedures to do- you diagnose, they cut. PAs will do all of the uncomplicated and low-paying follow-up work, as well as the high-paying and fast procedures, allowing you to substantially increase your earning power.

In primary care, they can see your uncomplicated patients, saving you time for the more complicated ones. I read a report that put the average amount of money earned per midlevel at about 40k over expenses, so if you were overseeing four of them, you could pull an extra 160k per year if you were willing to stomach the liability. Far more if you added ancillary services like cosmetic botox injections, laser hair removal, and other crap.

In psych, psychiatrists will often manage the more complicated patients and new consults, while having their PAs run through all of the med checks that come in ever 3-6 months, which essentially just amount to a quick "you doin' okay? Here's your script" and a lot of paperwork. You can make a fortune off of midlevels in psych if you know how to run things efficiently.

Now, the trouble comes with when you teach a midlevel too much and they start to think they can work without you. Let them do some of your job, but don't make yourself replaceable if you want to avoid going the way of anesthesia.

You are as ignorant as you are arrogant. You need to spend some one on one time with some of us PAs that would make your head spin. What doesn't change? Our respect for our physician counterparts, even when it isn't always given back. Most of this ignorance here is spewed by the likes of you. Pre med and med students who think they have some type of premature seniority and holier than though attitude. Perhaps you will be the physician that the patients don't really like and would "rather see the PA".

 

[Mad Jack]

You are as ignorant as you are arrogant. You need to spend some one on one time with some of us PAs that would make your head spin. What doesn't change? Our respect for our physician counterparts, even when it isn't always given back. Most of this ignorance here is spewed by the likes of you. Pre med and med students who think they have some type of premature seniority and holier than though attitude. Perhaps you will be the physician that the patients don't really like and would "rather see the PA".

You do not know me. And as they say to the PA who has not attended medical school, you don't know what you don't know. I merely stated that PAs should not be unsupervised, and that the more complicated cases should remain with physicians. If that offends you, perhaps you should have gone to medical school so that you might understand why I say it. It is not arrogant of me to state that physician training is superior to that of a PA, nor that the most complicated of patients should be left to physicians. Too much knowledge is a dangerous thing, never forget that.

As to my future patients "rather seeing the PA," your attacking my character to compensate for my stating things the way they are is both sad and ridiculous. I like PAs, but they have their place in medicine. That place is not replacing physicians, it is as a force multiplier to maximize the utilization of our skills over the greatest number of patients possible. I can't see why you would be offended when I state that our assistants should be our assistants, not our replacements, when it is you that choose to train in the capacity of a physician assistant.

 

[delco714]

You do not know me. And as they say to the PA who has not attended medical school, you don't know what you don't know. I merely stated that PAs should not be unsupervised, and that the more complicated cases should remain with physicians. If that offends you, perhaps you should have gone to medical school so that you might understand why I say it. It is not arrogant of me to state that physician training is superior to that of a PA, nor that the most complicated of patients should be left to physicians. Too much knowledge is a dangerous thing, never forget that.

As to my future patients "rather seeing the PA," your attacking my character to compensate for my stating things the way they are is both sad and ridiculous. I like PAs, but they have their place in medicine. That place is not replacing physicians, it is as a force multiplier to maximize the utilization of our skills over the greatest number of patients possible. I can't see why you would be offended when I state that our assistants should be our assistants, not our replacements, when it is you that choose to train in the capacity of a physician assistant.

What about me makes me an assistant? It's all about the team..clearly you've never actually thought about a true team approach. Additionally, don't know what we don't know is a complete cop out. At least for PAs. We know our limitations and seek guidance prn.

On top of that, if you're going to tell me that md don't forget most of what they learn in school then whatever. We all know residency is where the doctor is shaped. PAs have a fast paced and saturated program that gets us ready to practice with a physician-lead team. After years of practicing, if all you think we're good for is runny noses, then I believe you need to open your eyes quite a bit more. I agree with leaving the more complicated cases to the M.D., but experience and the team dictate just how complicated that patient or scenario must be. No one should ever think PAs are going the np route and trying to break off and form a cult. We're part of a team. We're all under the AMA. Getting less barricades to treat patients, especially by those well seasoned, sounds reasonable. Oh and last thing, what also irritates me? When the physicians rely so heavily on their PAs, that when a PA reaches out for help and is stating they are a bit over their head, and señor MD says "you're capable, You'll figure it out", bc they are apparently THAT busy. Also I don't need to know you personally to get the close minded, holier than thou, arrogance. Working and learning from my superiors is something I enjoy. Luckily I don't work with any who think I'm a HS drop out scut money. MD was my back up, not the other way around. Fancy that

 

[Psai]

What about me makes me an assistant? It's all about the team..clearly you've never actually thought about a true team approach. Additionally, don't know what we don't know is a complete cop out. At least for PAs. We know our limitations and seek guidance prn.

On top of that, if you're going to tell me that md don't forget most of what they learn in school then whatever. We all know residency is where the doctor is shaped. PAs have a fast paced and saturated program that gets us ready to practice with a physician-lead team. After years of practicing, if all you think we're good for is runny noses, then I believe you need to open your eyes quite a bit more. I agree with leaving the more complicated cases to the M.D., but experience and the team dictate just how complicated that patient or scenario must be. No one should ever think PAs are going the np route and trying to break off and form a cult. We're part of a team. We're all under the AMA. Getting less barricades to treat patients, especially by those well seasoned, sounds reasonable. Oh and last thing, what also irritates me? When the physicians rely so heavily on their PAs, that when a PA reaches out for help and is stating they are a bit over their head, and señor MD says "you're capable, You'll figure it out", bc they are apparently THAT busy. Also I don't need to know you personally to get the close minded, holier than thou, arrogance. Working and learning from my superiors is something I enjoy. Luckily I don't work with any who think I'm a HS drop out scut money. MD was my back up, not the other way around. Fancy that

Lol so insecure
You can say it was a backup after you get in and choose not to go. Don't be another one of those "yeah i could have went to medical school but decided not to to go".

 

[giantswing]

What about me makes me an assistant? It's all about the team..clearly you've never actually thought about a true team approach. Additionally, don't know what we don't know is a complete cop out. At least for PAs. We know our limitations and seek guidance prn.

On top of that, if you're going to tell me that md don't forget most of what they learn in school then whatever. We all know residency is where the doctor is shaped. PAs have a fast paced and saturated program that gets us ready to practice with a physician-lead team. After years of practicing, if all you think we're good for is runny noses, then I believe you need to open your eyes quite a bit more. I agree with leaving the more complicated cases to the M.D., but experience and the team dictate just how complicated that patient or scenario must be. No one should ever think PAs are going the np route and trying to break off and form a cult. We're part of a team. We're all under the AMA. Getting less barricades to treat patients, especially by those well seasoned, sounds reasonable. Oh and last thing, what also irritates me? When the physicians rely so heavily on their PAs, that when a PA reaches out for help and is stating they are a bit over their head, and señor MD says "you're capable, You'll figure it out", bc they are apparently THAT busy. Also I don't need to know you personally to get the close minded, holier than thou, arrogance. Working and learning from my superiors is something I enjoy. Luckily I don't work with any who think I'm a HS drop out scut money. MD was my back up, not the other way around. Fancy that

PAs are awesome and a vital part of the team. MDs or DOs are the captain of the team. Thats all. Have a seat. Have all the seats.

 

[Mad Jack]

What about me makes me an assistant? It's all about the team..clearly you've never actually thought about a true team approach. Additionally, don't know what we don't know is a complete cop out. At least for PAs. We know our limitations and seek guidance prn.

On top of that, if you're going to tell me that md don't forget most of what they learn in school then whatever. We all know residency is where the doctor is shaped. PAs have a fast paced and saturated program that gets us ready to practice with a physician-lead team. After years of practicing, if all you think we're good for is runny noses, then I believe you need to open your eyes quite a bit more. I agree with leaving the more complicated cases to the M.D., but experience and the team dictate just how complicated that patient or scenario must be. No one should ever think PAs are going the np route and trying to break off and form a cult. We're part of a team. We're all under the AMA. Getting less barricades to treat patients, especially by those well seasoned, sounds reasonable. Oh and last thing, what also irritates me? When the physicians rely so heavily on their PAs, that when a PA reaches out for help and is stating they are a bit over their head, and señor MD says "you're capable, You'll figure it out", bc they are apparently THAT busy. Also I don't need to know you personally to get the close minded, holier than thou, arrogance. Working and learning from my superiors is something I enjoy. Luckily I don't work with any who think I'm a HS drop out scut money. MD was my back up, not the other way around. Fancy that

>never actually thought about the team approach

I spent six years working as parts of teams as a licensed provider in allied health, cupcake. But here's the thing- I'm an entrepreneur, and when I'm running an office, I'm running things and you're my employee. That, by definition, makes me your superior. Yes, I work with you, yes, I ensure you are well compensated and even have a degree of profit sharing, and yes, you serve an important role in my practice, but at the end of the day I hired you for one thing and one thing only- to make me or my group more money. Hospitals and physicians may say, "oh, we brought midlevels on board to help with patient safety/satisfaction/to provide greater access," but don't ever forget that your position really only exists for one reason: $$$. All of your talk of equality and teamwork neglects the fact that PAs are almost universally employees, while physicians are often partners, owners, and employers.

>something something high school dropout something something I chose this

I spent a long time agonizing over PA versus MD myself. I don't think PAs are untalented, nor do I believe they are unintelligent. What I do believe, however, is that they have limited capabilities within a given field. And that many would have preferred (and were perfectly capable of attaining) the career of a physician, but put their life and lifestyle first. There's nothing wrong with that, but it leads to a lot of people with chips on their shoulders. I didn't force you into your role, one that I appreciate greatly, but one that is not equal to my own.

 

[W19]

I spent a long time agonizing over PA versus MD myself. I don't think PAs are untalented, nor do I believe they are unintelligent. What I do believe, however, is that they have limited capabilities within a given field. And that many would have preferred (and were perfectly capable of attaining) the career of a physician, but put their life and lifestyle first. There's nothing wrong with that, but it leads to a lot of people with chips on their shoulders. I didn't force you into your role, one that I appreciate greatly, but one that is not equal to my own.

You chose neither...😛

 

[Mad Jack]

You chose neither...😛

Haha, touche. Should edit that to PA versus physician, I was just going with the common way the argument is presented rather than complicating things.