PA vs Residents

[Matthew9Thirtyfive]

---

Members don't see this ad.

Lots of places have multiple EDs. My town of 35,000 has 2 with a third 10 miles outside of town.

And if they all have mostly midlevels?

 

[GoSpursGo]

But how does that affect the free market? They get mad, but they can't choose which provider to see.

If they're truly sick and get triaged to an APP who mismanages them, then presumably there will be a malpractice lawsuit, and said ED will need to re-evaluate the role APPs play in their evaluation of patients.

 

[Matthew9Thirtyfive]

If they're truly sick and get triaged to an APP who mismanages them, then presumably there will be a malpractice lawsuit, and said ED will need to re-evaluate the role APPs play in their evaluation of patients.

Isn't that why they keep a couple docs on staff? To absorb the liability? Or is that just tinfoil hat thoughts from the EM forum?

 

[VA Hopeful Dr]

Isn't that why they keep a couple docs on staff? To absorb the liability? Or is that just tinfoil hat thoughts from the EM forum?

It helps but doesn't absolve the hospital/CMG/SDG of all liability.

 

[Goro]

That’s a very low estimate for all comers.

Even more reason to keep one's eyes on the prize!!!!

 

[alprazoslam]

Make no mistake, a good deal of the complaints (especially the more hysterical ones) about mid level encroachment come not from the valid points made in this thread, but from "I went to school for 17 years and they didn't!!!" For some people, it seems like their claim to superiority is that they had a pre-clinical education. I've taught PA students...their material is about 75% that of our OMSIs and IIs, and their clinical savvy was great than the med students.

NPs? Good for shots and sniffles.




But getting back to the OP, as has been mentioned previous, and is worth mentioning yet again. yonce you're out of residency, one will be making a avg of what, $250K? Keep your eyes on that prize.

Goro did u get snubbed by a noctor nurse?

 

[Goro]

Goro did u get snubbed by a noctor nurse?

Let's just say I learned the hard way that what people on SDN are saying about them is true.

I've dated PhDs and grad students, but only once an MD/PhD.

My daughter wants to be a nurse; I'm OK with that.

 

[alprazoslam]

Let's just say I learned the hard way that what people on SDN are saying about them is true.

I've dated PhDs and grad students, but only once an MD/PhD.

My daughter wants to be a nurse; I'm OK with that.

Nursing’s not bad it’s just our ugh organizations are too progressive and overshoot what nursing can really do for healthcare. Hence why I left it for medicine and would never look back. Plus the job was mostly boring and mindless work following orders. Honestly most people say the RN degree was more difficult than their APRN degree, which I find non reassuring. ESP since med school is 100 times harder than nursing school ever was and I assume PA school while shorter is up there in difficulty also.

Not to say nursing isn’t important but many think what they do equate to what physicians do but it does not even come close. Having been there I know.

It’s just one of those roles that should have stayed a diploma or apprenticeship type trade but somehow bloated into masters and doctorate level voodoo

 

[Wordead]

I'd have no objection if y'all looked over the note we send and make the determination as to who sees the patient first based on that.

If memory serves, you're ENT. Feel free to have the PA see the cerumen impaction or persistent serous otitis. Both of those are usually people I'm just tired of dealing with anyway.

But if the NP sees the thyroid nodule I send you or the concerning lymph node that's been there for 2 months and is rock hard on exam on the first visit, there will not be another.

If you're sending them for surgical excision of a suspected malignant lymph node (or really anything that's urgently surgical) - yes, it is pointless for the PA/NP to see it anyway.

But I disagree about the thyroid nodule. We dont just excise those. If you're sending them for eval after a thyroid nodule that has been FNA'd under ultrasound and it shows some pathology that may need to come out, great. If it's just "thyroid nodule" which we get a lot with no ultrasound or no FNA, no thyroid labs, then no. Not a great referral. That can be seen by the midlevel - who can complete the workup and follow the the nice algorithmic guidelines for serial guidelines of thyroid nodules if the FNA doesnt indicate something needs to be removed.

I will say that I've seen practices where the primary care docs are on point - everything sent over has been fully worked up, patient medically optimized, and is basically just there to meet the surgeon. High hit rate in terms of % of new patient visits going to the OR. Awesome. But especially these days with the rise of midlevels that seems to be rare. The vast majority of referrals are just complaints that have had garbage workups - rhinitis, dizziness, ear pain, throat pain, trouble swallowing. Things that a PCP should be able to get the ball rolling on.

 

[VA Hopeful Dr]

If you're sending them for surgical excision of a suspected malignant lymph node (or really anything that's urgently surgical) - yes, it is pointless for the PA/NP to see it anyway.

But I disagree about the thyroid nodule. We dont just excise those. If you're sending them for eval after a thyroid nodule that has been FNA'd under ultrasound and it shows some pathology that may need to come out, great. If it's just "thyroid nodule" which we get a lot with no ultrasound or no FNA, no thyroid labs, then no. Not a great referral. That can be seen by the midlevel - who can complete the workup and follow the the nice algorithmic guidelines for serial guidelines of thyroid nodules if the FNA doesnt indicate something needs to be removed.

I will say that I've seen practices where the primary care docs are on point - everything sent over has been fully worked up, patient medically optimized, and is basically just there to meet the surgeon. High hit rate in terms of % of new patient visits going to the OR. Awesome. But especially these days with the rise of midlevels that seems to be rare. The vast majority of referrals are just complaints that have had garbage workups - rhinitis, dizziness, ear pain, throat pain, trouble swallowing. Things that a PCP should be able to get the ball rolling on.

Say what you want, if I send a thyroid nodule to you (which will have an ultrasound if I send it) and it goes to your mid-level without ever seeing an MD it will be the last referral you ever get from me.

But you and I have disgreed before about clerical stuff so I don't expect any better from you.

 

[762513]

I agree with you to a point. I think the subspecialty NPs with lots of experience can be great (and often are). But for example, I am friends with more than one former NP who were RNs for years before going back to NP school. They went to supposedly excellent NP schools, but when they graduated and went to practice, they decided to go back to being an RN because they felt unprepared to do primary care with little to no supervision. Small n, I know. But I think they are just the ones who are honest with themselves.

Why would that midlevel choose a unsupervised primary care position as a new graduate? I certainly did not.

I read this akin to the political diatribes spewing from various political parties about needing to protect their own at all costs. I'm not pro-midlevel. I am not anti-physician or pro-physician. While your sole focus is clearly on protecting your own self interest and maybe those in your profession some of us take a far larger look at the world around us. Helpful? Surely you are joking? Your zealous, us vs. them rantings and ravings help no one. You are protectionist and in no way looking for solutions to providing maximal healthcare to a population. I have a hard time respecting or really even having a reasoned conversation with someone who is only motivated by self interest and beyond that lacks really any experience in this field. We get it, you are an MS4 that look up to your interns and PGY2s, those of us that have spent years training people at that level know their limitations a hell of a lot better than you. I'm sorry, I don't pull rank or cite hierarchy, but given your proclivity for outlandish claims with zero basis and seem fixated on that point, it seems necessary.

More than your lack of 'years' of experience, my real issue lies with your foundation for a lot of your claims. How many years of non-academic center experience do you have? The vast majority of healthcare in the US is not delivered in the environment that most medical schools are in and it gives a false view of the realities of delivering healthcare in the US. We have a major healthcare problem in our country. It is multifaceted and obviously extremely complex without simple solutions. That problem arrises from a multitude of sources, but one of the major sources is shortage and maldistribution of healthcare providers. Unlike you, I don't claim to have all the answers. But, I do claim that mid-levels are going to be a part of virtually every solution that will be proposed and frankly, they should be given the realities of physician education and where/how physicians practice.

I'm really happy to read this post. I have many physician friends on volleyball, bowling leagues, etc. No one behaves like these SDN med students. These people really are on the fringe, and seem to be radicalizing each other. I have had frank discussions with our chief of medicine about the role of midlevels, and we agree that independence out of school is not safe, but strict supervision after a decade of experience is probably not beneficial to the needs of the healthcare sector, either. Thank you for this post.

 

[Wordead]

Say what you want, if I send a thyroid nodule to you (which will have an ultrasound if I send it) and it goes to your mid-level without ever seeing an MD it will be the last referral you ever get from me.

But you and I have disgreed before about clerical stuff so I don't expect any better from you.

Fair enough.

In the spirit of trying to be helpful, there is no reason why you cant order a FNA of the largest or most concerning nodule. You may not be comfortable managing whatever it is and ENT can discuss how to proceed but there is no reason why you cant order one if it's indicated. It's what we have to do anyway and saves your patient an extra trip to see us.

 

[operaman]

But how does that affect the free market? They get mad, but they can't choose which provider to see.

The free market meaning for those EM or gas mid level jobs and the glut of applicants putting downward pressure on wages.

There’s obviously a second market in terms of patients. You’re right that this behaves differently in that patients often don’t have much choice or even understanding of how all of this works. That said, I think it’s only a matter of time before more affluent hospitals start advertising that patients who come to their ED will be seen by a real physician.

 

[MedicineZ0Z]

Make no mistake, a good deal of the complaints (especially the more hysterical ones) about mid level encroachment come not from the valid points made in this thread, but from "I went to school for 17 years and they didn't!!!" For some people, it seems like their claim to superiority is that they had a pre-clinical education. I've taught PA students...their material is about 75% that of our OMSIs and IIs, and their clinical savvy was great than the med students.

NPs? Good for shots and sniffles.

But getting back to the OP, as has been mentioned previous, and is worth mentioning yet again. yonce you're out of residency, one will be making a avg of what, $250K? Keep your eyes on that prize.

If PA students have more clinical acumen than med students, then those are some abysmal med students you're pumping out. Even our lazy med students were well ahead of the most enthusiastic med students on rotations. It wasn't ever close.
I did have fun teaching practicing PAs about basic things like reading ekgs though 🙂

 

[VA Hopeful Dr]

Fair enough.

In the spirit of trying to be helpful, there is no reason why you cant order a FNA of the largest or most concerning nodule. You may not be comfortable managing whatever it is and ENT can discuss how to proceed but there is no reason why you cant order one if it's indicated. It's what we have to do anyway and saves your patient an extra trip to see us.

Order a FNA? Not sure how that would work. Everywhere I've ever worked, those are only done by endocrine or ENT and neither would take kindly to me ordering them to do one, and I prefer ENT currently because the endocrine group in town is terrible. I suspect I'm not the only one who thinks that way as when I met the local ENTs when I moved to town they made a point of saying I could send them all of my thyroid nodules and they'd do the work up.

 

[762513]

If PA students have more clinical acumen than med students, then those are some abysmal med students you're pumping out. Even our lazy med students were well ahead of the most enthusiastic med students on rotations. It wasn't ever close.
I did have fun teaching practicing PAs about basic things like reading ekgs though 🙂

Who hurt you? Honestly your behavior is pathological at this point. I know being a student is hard, but is coming on here and blasting another profession really making you feel better about yourself?

 

[MedicineZ0Z]

Who hurt you? Honestly your behavior is pathological at this point. I know being a student is hard, but is coming on here and blasting another profession really making you feel better about yourself?

I'm only concerned about midlevels taking a short cut to practicing infront of me.

 

[Goro]

If PA students have more clinical acumen than med students, then those are some abysmal med students you're pumping out. Even our lazy med students were well ahead of the most enthusiastic med students on rotations. It wasn't ever close.
I did have fun teaching practicing PAs about basic things like reading ekgs though 🙂

I should have clarified, I was comparing the PA students to our pre-clinical students.

 

[MedicineZ0Z]

I should have clarified, I was comparing the PA students to our pre-clinical students.

Different story then

 

[RNtoMD87]

Why do PA's and APRNs get paid 2x much as residents, even though residents work crazier hours and are also licensed. I was talking to an emergency medicine PA and she told me she made 114k, meanwhile the intern is lucky to get 60k. There isn't much difference between the two (correct me if I am wrong), if anything senior residents can actually carry out an entire procedure w/ minimal assistance whilst the PA cannot do so. Why can't we form a union?

I am not even an APRN, and I made 115k my first year out with a two year education.

Residents get paid less because they're still an unfinished product. And you're eventually going to make 150-400k...

1) Its illegal for physicians to strike
2) Residencies are exempt from anti trust laws.

So you can't sue and you can't strike. You CAN unionize (some residencies do) but without the ability to sue or strike I have never understood how that's any different from just having the residents write down their concerns and email them to the PD.

Are you sure? https://physicianlaw.foxrothschild.com/2015/01/articles/health-reform/physicians-go-on-strike/

Nursing’s not bad it’s just our ugh organizations are too progressive and overshoot what nursing can really do for healthcare. Hence why I left it for medicine and would never look back. Plus the job was mostly boring and mindless work following orders. Honestly most people say the RN degree was more difficult than their APRN degree, which I find non reassuring. ESP since med school is 100 times harder than nursing school ever was and I assume PA school while shorter is up there in difficulty also.

Not to say nursing isn’t important but many think what they do equate to what physicians do but it does not even come close. Having been there I know.

It’s just one of those roles that should have stayed a diploma or apprenticeship type trade but somehow bloated into masters and doctorate level voodoo

100%
Most nurses I see are good, but the ones leading the profession are a bunch of dinosaurs from a bygone era, with an anti male chip on their shoulder (Fight the physician patriarchy!) and like you say pushing for more power without regard to whether its good for the patients.
Right also about the diploma. I learned NOTHING between my RN diploma and my BSN. BSN is a JOKE. I have also heard the same about the NP licensing exam being easier than the NCLEX.


I don't understand why physicians are afraid of NPs though. There's no strong foundation so eventually there will be plenty of research on how APRNs that practice independently have poorer outcomes and it will all come crashing down.