PAs in North Dakota no longer need physician supervision

[VA Hopeful Dr]

It really makes you wonder what's the point of med school and residency

No it doesn't

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[VA Hopeful Dr]

Why the hell should PC docs be forced to endure four years of medical school and 3 years of garbage cheap labor just be paid the same as a PA/NP?

Complete nonsense. Bring back the system where a medical student only has to do one year of intern before given full practice right for primary care.

Because we think it's worth being a master of what we're doing and not someone who just goes through the motions but doesn't really understand it?

and in a very large number of states you can get a full license to practice after intern year.

 

[Boatswain2PA]

It's inevitable, there is no way for their profession to remain viable without independent practice rights when NP's are being given that right. I don't see a realistic way of stopping independent practice rights for mid-levels. I think the best strategy is to push them to put-up or shut-up and pushing them all into independent practice is the first step. Next would be something of a new Flexner Report for mid-level education and actually standardizing the curriculum to at least get them into the same century as physician education. This is the only viable way I see of protecting patients.

I think a "new" Flexner report would show that PA programs put out a good product in a new graduate who needs to be supervised. NP programs would be forced to vastly improve and standardize.

 

[Boatswain2PA]

. Put your own skin in. The number of times I've seen shoulders shrugged after a missed critical diagnosis is nauseating. But, why should it matter when the rug isn't pulled out from under you...

While I agree with your sentiment, I certainly do have skin in the game with my own malpractice, and my own wealth on the line for any awards over my malpractice limits.

 

[Black Coffee 24/7]

Because we think it's worth being a master of what we're doing and not someone who just goes through the motions but doesn't really understand it?

and in a very large number of states you can get a full license to practice after intern year.

Complete nonsense. I and some older docs know real FP docs that can run circles around FM, IM, and EM docs out there. Most of these people graduated in an era with full practice after one year of intern.

Your out of touch sentiment and comment are the reason why my current classmates have very low opinions of current docs in general not looking for the best interest of the future generations in the profession.

From the exploding tuition to the upcoming stagnated wages, the current generation of medical students are being nicked and dimed from all directions. When will common sense finally be realized? My guess is that it won’t slowly be realized until docs either suffered staggered wages or struggled to find jobs in decent areas.

It has already happened in Anesthesiology where they are slowly being sold as commodities right now. My guess is that you don’t gaf in your current position bc you will be out of practice by then. Not your problem.

 

[DeadCactus]

I think a "new" Flexner report would show that PA programs put out a good product in a new graduate who needs to be supervised. NP programs would be forced to vastly improve and standardize.

The problem is not PA programs. The problem is a subset of NP programs, the NP push for independent practice, and the need for PA's to now push for independent practice to maintain employability.

Complete nonsense. I and some older docs know real FP docs that can run circles around FM, IM, and EM docs out there. Most of these people graduated in an era with full practice after one year of intern.

Your out of touch sentiment and comment are the reason why my current classmates have very low opinions of current docs in general not looking for the best interest of the future generations in the profession.

From the exploding tuition to the upcoming stagnated wages, the current generation of medical students are being nicked and dimed from all directions. When will common sense finally be realized? My guess is that it won’t slowly be realized until docs either suffered staggered wages or struggled to find jobs in decent areas.

It has already happened in Anesthesiology where they are slowly being sold as commodities right now. My guess is that you don’t gaf in your current position bc you will be out of practice by then. Not your problem.

Do you have a point you're trying to make or is this just ranting and weird animosity toward other physicians?

 

[GeneralVeers]

I understand the concern with MLPS. Our salaries have gone up with more and more use of MLPs. It's a simple math equation. My first job out of residency we used minimal PAs, and the salary was always around $160/hour. That makes sense if you think about it. If I see 2 pts/hr, and the group collects on average $100/pt, that's $200/hour I'm generating. Take off malpractice, benefits, and cost of doing business and I am left with $160/hour. If I supervise a PA, together we can see 4 pts per hour. That means we are generating $400/hour in collections. Subtract the $60/hour the PA is paid, and cost of doing business, and I get $300/hour. There is almost no other way to hit that magic $300/hour number, unless you use MLPS and get credit for their patients. Sure we could stop using them, but I hope everyone on this forum is okay with going back to sub $200/hr jobs.

 

[miacomet]

I understand the concern with MLPS. Our salaries have gone up with more and more use of MLPs. It's a simple math equation. My first job out of residency we used minimal PAs, and the salary was always around $160/hour. That makes sense if you think about it. If I see 2 pts/hr, and the group collects on average $100/pt, that's $200/hour I'm generating. Take off malpractice, benefits, and cost of doing business and I am left with $160/hour. If I supervise a PA, together we can see 4 pts per hour. That means we are generating $400/hour in collections. Subtract the $60/hour the PA is paid, and cost of doing business, and I get $300/hour. There is almost no other way to hit that magic $300/hour number, unless you use MLPS and get credit for their patients. Sure we could stop using them, but I hope everyone on this forum is okay with going back to sub $200/hr jobs.

I see one to two patients an hour and make well over two hundred plus full bennies. No PAs or midlevels of any kind.

 

[GeneralVeers]

I see one to two patients an hour and make well over two hundred plus full bennies. No PAs or midlevels of any kind.

You must be collecting close to $200/pt. If so you must work somewhere with a spectacular payor mix, and high acuity.

 

[miacomet]

You must be collecting close to $200/pt. If so you must work somewhere with a spectacular payor mix, and high acuity.

Low acuity, lots of lacs and ortho, very good payor mix. I am not aware that acuity pays.

 

[GeneralVeers]

Low acuity, lots of lacs and ortho, very good payor mix. I am not aware that acuity pays.

Sounds like you get lots of procedures that pay well and insured patients. Acuity pays because you can bill for more level 5 visits if someone requires an extensive workup, and admission. Critical care will also bump the collections. All things being equal, I'd rather see high acuity patients. I can see and treat at least two level 5 patients in the time it would take me to repair a laceration, or do an ortho procedure.

 

[miacomet]

Sounds like you get lots of procedures that pay well and insured patients. Acuity pays because you can bill for more level 5 visits if someone requires an extensive workup, and admission. Critical care will also bump the collections. All things being equal, I'd rather see high acuity patients. I can see and treat at least two level 5 patients in the time it would take me to repair a laceration, or do an ortho procedure.

Not if they need intubation, a central line, consults, admission etc- that can take awhile.

Doesn't take much time to reduce a wrist, glue a facial lac, pop a shoulder back in, yank on a finger, or call ortho for a tib-fib that doesn't need any ER care, but you still get to bill a ton. But I agree that procedures in general can take awhile.

And I don't have to sign PA charts, or deal with PAs, or argue with PAs.

 

[GeneralVeers]

Not if they need intubation, a central line, consults, admission etc- that can take awhile.

Doesn't take much time to reduce a wrist, glue a facial lac, pop a shoulder back in, yank on a finger, or call ortho for a tib-fib that doesn't need any ER care, but you still get to bill a ton. But I agree that procedures in general can take awhile.

And I don't have to sign PA charts, or deal with PAs, or argue with PAs.

Sounds like a dream job! Hold on to that one. Places I've worked have averaged $100-125 per patient collections. Of that I typically see $70-$80 in my paycheck. I'd be curious to see other data people here may have.

 

[miacomet]

Sounds like a dream job! Hold on to that one. Places I've worked have averaged $100-125 per patient collections. Of that I typically see $70-$80 in my paycheck. I'd be curious to see other data people here may have.

Meh. There are plenty of negatives, like no night differential and a slightly unforgiving schedule. The weird thing is...it's a hospital-employed position in a popular area. Strange, no?

 

[Birdstrike]

I understand the concern with MLPS. Our salaries have gone up with more and more use of MLPs. It's a simple math equation. My first job out of residency we used minimal PAs, and the salary was always around $160/hour. That makes sense if you think about it. If I see 2 pts/hr, and the group collects on average $100/pt, that's $200/hour I'm generating. Take off malpractice, benefits, and cost of doing business and I am left with $160/hour. If I supervise a PA, together we can see 4 pts per hour. That means we are generating $400/hour in collections. Subtract the $60/hour the PA is paid, and cost of doing business, and I get $300/hour. There is almost no other way to hit that magic $300/hour number, unless you use MLPS and get credit for their patients. Sure we could stop using them, but I hope everyone on this forum is okay with going back to sub $200/hr jobs.

That's great that you're getting that much, with PAs. I never did. Good for you, though. I hope that keeps up.

 

[GeneralVeers]

That's great that you're getting that much, with PAs. I never did. Good for you, though. I hope that keeps up.

Really? It should be the norm when doctors are supervising the PAs. At this point I wouldn't work anywhere that I'm not getting paid for their patients. I've seen two models, the first one (which I prefer) ties each patient staffed by the MLP with the physician to his individual RVUS. The second way is that all the MLP RVUs go into the pool and are paid out as part of the productivity bonus monthly.

 

[Birdstrike]

Really? It should be the norm when doctors are supervising the PAs. At this point I wouldn't work anywhere that I'm not getting paid for their patients. I've seen two models, the first one (which I prefer) ties each patient staffed by the MLP with the physician to his individual RVUS. The second way is that all the MLP RVUs go into the pool and are paid out as part of the productivity bonus monthly.

The last place I worked, which was for the largest portion of my EM years did claim to pay us for excess collections above the PAs salaries. But it never materialized to the numbers you quoted. The money had a funny way of never making it in to our pockets. There was always some nebulous excuse as to why the pay sucked.

 

[VA Hopeful Dr]

Complete nonsense. I and some older docs know real FP docs that can run circles around FM, IM, and EM docs out there. Most of these people graduated in an era with full practice after one year of intern.

Your out of touch sentiment and comment are the reason why my current classmates have very low opinions of current docs in general not looking for the best interest of the future generations in the profession.

From the exploding tuition to the upcoming stagnated wages, the current generation of medical students are being nicked and dimed from all directions. When will common sense finally be realized? My guess is that it won’t slowly be realized until docs either suffered staggered wages or struggled to find jobs in decent areas.

It has already happened in Anesthesiology where they are slowly being sold as commodities right now. My guess is that you don’t gaf in your current position bc you will be out of practice by then. Not your problem.

Your ignorance across multiple threads is startling. In many states (mine included) you can get an unrestricted licence after intern year. I did. I could have quit residency after intern year and gone out to practice without a word from the medical board. Granted no one would hire me and few insurances would credential me, but legally I could have done so easily.

As for old school FP running circles around IM and EM - codswallop. Are there FPs who've been practicing in the ED since the 80s who are on par with current EM-trained docs? Naturally. Are those same doctors my equal in outpatient FM? Not even close because I do that all day every day and they haven't done it in 20+ years. Someone who does multiple things is rarely going to be as good as someone who only does one of those things.

I would be very cautious taking the word of older doctors. Lots of them keep current and work hard to stay that way, lots also fall behind and nothing is ever as good as the old days.

 

[W19]

It's amazing that a CRNA can make 250k+/yr which more than what most FM/IM/ID/Peds doctors make... It's a crazy system.

 

[VA Hopeful Dr]

It's amazing that a CRNA can make 250k+/yr which more than what most FM/IM/ID/Peds doctors make... It's a crazy system.

Meh. I don't love it, but most midlevels make roughly 50-60% of what the docs in their field do so those numbers are about right.

 

[lemurcatta]

Big News for OTP in North Dakota
A bit unprecedented for PAs. Expect more dominoes to fall.

No. The board of medicine in the state voted to support upcoming legislation. You are spreading throughly false information with your thread title. Nothing has changed for PA practice in North Dakota as of yet.

Also, optimal team practice ("OTP") =/= independant practice. And PAs would *not* have a need to push this legislation if you guys did something about NPs years ago. The real reason for OTP is because the profession has recently run into problems with hiring when hospital systems want NPs instead because they don't come with the burden of state-mandated, prescriptive forms of supervision. Our profession is actually fairly conservative (the first iteration of OTP was actually called "full practice authority" and was tossed out, and the much more reasonable OTP idea replaced it). For us, the ideal situation is that PAs work with physicians and that the level of physician supervision is determined at the practice level. We want to get rid of specific, signed supervisory agreements with a single physician and replace it with practice-level decision making led by the docs, base on the experience the PA has and the level of trust in the relationship.

 

[Stagg737]

Anybody in this thread actually willing to work in rural North Dakota? According to the AAMC, there are 76 EM docs practicing in that state. Most of those are probably in Fargo and Bismarck. What if the nearest physician is 50 miles away?

If my wife weren't adamantly opposed to being more than 20 miles from a major metro I'd do it in a heartbeat. Better pay, lower cost of living, and fantastic state for docs in legal terms and you can basically retire after practicing 15 years.

Edit: I'm not EM, but wouldn't change my decision regardless of field.

 

[deleted109597]

No. The board of medicine in the state voted to support upcoming legislation. You are spreading throughly false information with your thread title. Nothing has changed for PA practice in North Dakota as of yet.

Also, optimal team practice ("OTP") =/= independant practice. And PAs would *not* have a need to push this legislation if you guys did something about NPs years ago. The real reason for OTP is because the profession has recently run into problems with hiring when hospital systems want NPs instead because they don't come with the burden of state-mandated, prescriptive forms of supervision. Our profession is actually fairly conservative (the first iteration of OTP was actually called "full practice authority" and was tossed out, and the much more reasonable OTP idea replaced it). For us, the ideal situation is that PAs work with physicians and that the level of physician supervision is determined at the practice level. We want to get rid of specific, signed supervisory agreements with a single physician and replace it with practice-level decision making led by the docs, base on the experience the PA has and the level of trust in the relationship.

Not that I don't believe you, but based on what some physician friends of mine who work in ND are saying, I don't have an answer. I mean, optimal team practice does sound nice.
Based on the link I provided in the OP though,

Supervisory agreements currently mandatory for licensure in North Dakota will no longer be required. This means that PA’s will be responsible for the care they provide and the need to have a supervising physician will no longer be necessary.

Pretty sure I'm not misinterpreting that.
If this is a boon for rural areas, and they can spread that model to the rest of the US, then I applaud this. However, seeing what happened in multiple other states with NPs, all it does is allow them to open up private practice clinics with no supervision.

 

[Angry Birds]

Not that I don't believe you, but based on what some physician friends of mine who work in ND are saying, I don't have an answer. I mean, optimal team practice does sound nice.
Based on the link I provided in the OP though,

Pretty sure I'm not misinterpreting that.
If this is a boon for rural areas, and they can spread that model to the rest of the US, then I applaud this. However, seeing what happened in multiple other states with NPs, all it does is allow them to open up private practice clinics with no supervision.

I wonder how long I can hold on to my sweet rural gig.

 

[wholeheartedly]

Seriously, if anyone wants a rural gig, I got the hookup.

 

[enalli]

It still blows my mind that CRNAs exist. The fact that we as a society have given nurses control over patients' cardiopulmonary physiology during surgery should serve as a warning to all of you jumping on the "I'm ok supervising MLPs" bandwagon that none of your jobs are safe.

 

[lemurcatta]

Not that I don't believe you, but based on what some physician friends of mine who work in ND are saying, I don't have an answer. I mean, optimal team practice does sound nice.
Based on the link I provided in the OP though,

Pretty sure I'm not misinterpreting that.
If this is a boon for rural areas, and they can spread that model to the rest of the US, then I applaud this. However, seeing what happened in multiple other states with NPs, all it does is allow them to open up private practice clinics with no supervision.

We will have to see what ultimately comes down the pipes. But to be clear no law has changed. It isn't really the spirit of OTP to allow unfettered PA practice is no physician oversight; it really is meant to shift supervisory decisions to the practice level (from the state level). This should play out in a way that does not allow PAs to hang out their own shingle, or to practice in a hospital/clinic setting with zero physician reporting structure.

 

[RustedFox]

It still blows my mind that CRNAs exist. The fact that we as a society have given nurses control over patients' cardiopulmonary physiology during surgery should serve as a warning to all of you jumping on the "I'm ok supervising MLPs" bandwagon that none of your jobs are safe.

I had a long reply. I edited it down.
See you later.

 

[deleted109597]

This should play out in a way that does not allow PAs to hang out their own shingle, or to practice in a hospital/clinic setting with zero physician reporting structure.

Should, but it hasn't been true for NPs across the nation. I hope we can actually make team based practice, but I'm pessimistic about it.

 

[DubbiDoctor]

Wait. Are you guys serious? As someone going through interview season right now and have over 200k in debt, this is kind of terrifying.

The "bright" side is physician income will never fall below midlevel income, so you won't have a problem with paying off your debts. Even in the increasingly likely worst-case scenario of nation-wide independent practice for NPs and PAs, physicians will likely still be paid a hefty premium relative to midlevels owing to their greater training and skill-set. Physician self-advocacy -- advertising to the public that it's in their best interest to see physicians for their healthcare needs -- will help ensure that physicians continue to be compensated fairly relative to midlevels.

 

[thegenius]

Low acuity, lots of lacs and ortho, very good payor mix. I am not aware that acuity pays.

Acuity probably doesn't pay....a complicated level 5 (99285) pt makes 4.9 RVUs, might take 30-45 minutes of your time when you include everything like talking to doctors, consults, pharmacy because you ordered something wrong, discussing results with patients, etc.

A moderately complicated patient, like a young guy with epigastric pain because he ate bad food, will be level 4 (99284), makes 3.32 RVUs. However he will require like 5-10 minutes of your time.

Probably better off seeing ankle sprains, pregnancy vag bleeders, dysuria, than level 5 patients if your goal is simply to maximize income

 

[thegenius]

It still blows my mind that CRNAs exist. The fact that we as a society have given nurses control over patients' cardiopulmonary physiology during surgery should serve as a warning to all of you jumping on the "I'm ok supervising MLPs" bandwagon that none of your jobs are safe.

Well...are there worse outcomes with CRNA's controlling cardiopulmonary physiology? Perhaps outcomes are the same and the cost is reduced. At the end of the day, I recall that most bad outcomes in anesthesia have to do with the airway, and if that is secured then for most elective surgeries the chance of bad outcomes are low. Plus an anesthesiologist is just around the corner and can come in if the BP or EtCO2 begins to drop.

Perhaps we are looking at this all wrong.
Why do we need 4 years of medical education?
Then another 3-4 years of residency for EM?

8 years of toil and very very hard work to make $350K, where 2 years will make you $150K?

 

[GeneralVeers]

Acuity probably doesn't pay....a complicated level 5 (99285) pt makes 4.9 RVUs, might take 30-45 minutes of your time when you include everything like talking to doctors, consults, pharmacy because you ordered something wrong, discussing results with patients, etc.

A moderately complicated patient, like a young guy with epigastric pain because he ate bad food, will be level 4 (99284), makes 3.32 RVUs. However he will require like 5-10 minutes of your time.

Probably better off seeing ankle sprains, pregnancy vag bleeders, dysuria, than level 5 patients if your goal is simply to maximize income

I disagree. Part of having a good EM practice is efficiency. High acuity patients are very efficient. They generally are too sick to talk (or talk much) so I might spend 1-2 minutes in the room talking to relatives, and doing a quick exam. I exclaim "your relative is very sick, so I need to order some meds immediately!" and depart the room quickly. Usually spend about 5 minutes on chart review. Talking to consultants doesn't take much time, as I give each of them a 30 second blurb about the patient. Unless they are being difficult they don't ask too many follow-up questions. Total time actually spent on a high acuity (but stable) patient is 10-15 minutes.

The worst are ambulatory low acuity patients, especially rich people or elderly. They all want to "tell their story" and they talk and talk and talk about their rash, pinky toe pain, or chronic diarrhea they've had for eleventy bajillion years. Honestly the time it takes to deal with a Worried Well Walker and convince them that they aren't dying and to go home is equal to what I spend on a sick NSTEMI patient who's getting admitted.

 

[TheComebacKid]

What if I perform the exact same H&P, entertain the exact same ddx, make the exact same diagnosis, and then do the exact same intervention....would you still be taking better care of a crashing patient with RV failure, hypotension, and massive PE than me? What if I also entertain AAA (or renal artery dissection, etc) as the ddx for someone with flank pain, discuss risk factors with the patient, and then in collaboration with the patient decide whether or not to scan them for these relatively rare pathologies?

But you don't though. That's the problem. I don't know why you are speculating "what if I manage sick patients the same way as a physician" because that's not reality. Are all MLPs created equal? No. Are some better than others? Probably. But that doesn't change the fact that many are horrible and are routinely sending home reproductive age females without a pregnancy test. It's not that "I'm so smart", it's that some MLPs are really just that bad. Some of this stuff, a first year medical student understands.

With respect to sick patients, you guys simply do not have the training for it. It's not a personal attack against you. I could probably replace the water heater in my house if I had the training, but I don't, and I don't pretend to. The scariest part about MLPs is how many of you have zero understanding of scope of practice and seem to believe that you can do something without training. As an EM doctor, there are many things that I cannot do, and I am trained to understand this.

I get the sense that MLPs are fed ego stroking nonsense during their training about the "equivalency" of their education to an MDs, which is extremely detrimental to patient care.

There are studies that show MLPs do more testing. I know I often do more testing simply to cover my SPs arse.

That is the most ridiculous excuse I have ever heard. I'm not even going to really go down this rabbit hole of you, with the exception of saying that the majority of midlevels without question order more tests because they simply don't know what they are looking for and lack clinical gestalt. Your training is algorithmic i.e. abdominal pain = CT scan. Maybe YOU don't do those things in particular, but MANY, MANY MLPs do.

Residency supervision is certainly one kind of supervision, but hardly the only kind of supervision out there. While it is often the only kind of supervision that physicians understand (because that's the only kind they have ever seen), it's not really appropriate supervision for MLPs. While residency supervision is there to ensure good patient care, it is also there to provide further education for the resident whose primary job IS to learn.

It's the kind of supervision that physicians value because it's the kind of supervision that works, and makes good clinicians. There is no substitute for good residency training. We have seen this in other physicians who worked in the ED without being residency trained whether it was an internal medicine resident moonlighting for extra money or a psychiatrist. It is absolutely appropriate supervision for MLPs when you guys have LESS training than these other providers when it comes to basic medicine.[/QUOTE]

I am interested to see how this will play out if it actually happens. While states can enact their own laws regarding MLP supervision, so can hospital committees. Hospitals might still end up saying 'we don't want to change the status quo, we are not comfortable assuming more liability, if an MLP wants to work at our hospital, they have to be supervised...'

I mean, just look at how many hospitals want you to have an updated ATLS certification despite being ABEM certified? There's no laws requiring that, but committees made up their own rules...

This is wishful thinking. The bottom line will trump all. It makes financial sense (not ethical sense when it comes to patient care) to hire more midlevels, which is why midlevel expansion will continue to be unprecedented. If you have ever set on a hospital committee (I have) you will see what their motivations are.

Wait. Are you guys serious? As someone going through interview season right now and have over 200k in debt, this is kind of terrifying.

You should be terrified. You (and myself) and many others in this forum have made the 200K mistake by going to medical school during a time when there is unprecedented midlevel expansion. They are coming for your job, in EM especially. The best thing you can do is be a part of physician advocacy i.e AAEM (less so ACEP since they indirectly support unregulated MLP expansion despite what they say) and try to stop this not just for yourself but for your patients.

I understand the concern with MLPS. Our salaries have gone up with more and more use of MLPs. It's a simple math equation. My first job out of residency we used minimal PAs, and the salary was always around $160/hour. That makes sense if you think about it. If I see 2 pts/hr, and the group collects on average $100/pt, that's $200/hour I'm generating. Take off malpractice, benefits, and cost of doing business and I am left with $160/hour. If I supervise a PA, together we can see 4 pts per hour. That means we are generating $400/hour in collections. Subtract the $60/hour the PA is paid, and cost of doing business, and I get $300/hour. There is almost no other way to hit that magic $300/hour number, unless you use MLPS and get credit for their patients. Sure we could stop using them, but I hope everyone on this forum is okay with going back to sub $200/hr jobs.

I am absolutely OK with it.

I think it's faulty reasoning to assume that because you can bill for more while working with a PA that this is somehow in the best interest for EM as a whole. If you work at a place with 1 physician and 3 PAs, sure that 1 EM physician can collectively bill for more. But you have 3 EM physicians that lose an opportunity of employment at that location.

One of the aspects of this whole debate that makes me irate is the older physicians who are in well established practices and have earned the ability to hit that "magic number" and don't seem to care about working with PAs/NPs because they are in a cush position. This doesn't help those coming in and those who make up the future of the speciality.

 

[thegenius]

That is the most ridiculous excuse I have ever heard. I'm not even going to really go down this rabbit hole of you, with the exception of saying that the majority of midlevels without question order more tests because they simply don't know what they are looking for and lack clinical gestalt. Your training is algorithmic i.e. abdominal pain = CT scan. Maybe YOU don't do those things in particular, but MANY, MANY MLPs do.

This is true....very often MLPs order tests and then decide what the diagnosis is. I very often ask our MLPs when they take care of a dizzy patient what their differential is and they just don't have one. Or they have the same template response like "stroke, anemia, vertigo" and a few other non-sense things. I try very hard to encourage them to come up with a differential FIRST, then test to narrow that down.

"Instead of just doing a dizzy workup on a patient, why do you think they are dizzy?"
"I'm not sure....I don't know."

Now there are MDs and DOs who do this too. But a lot more with MLPs.

 

[Southpaw]

Well...are there worse outcomes with CRNA's controlling cardiopulmonary physiology? Perhaps outcomes are the same and the cost is reduced. At the end of the day, I recall that most bad outcomes in anesthesia have to do with the airway, and if that is secured then for most elective surgeries the chance of bad outcomes are low. Plus an anesthesiologist is just around the corner and can come in if the BP or EtCO2 begins to drop.

Perhaps we are looking at this all wrong.
Why do we need 4 years of medical education?
Then another 3-4 years of residency for EM?

8 years of toil and very very hard work to make $350K, where 2 years will make you $150K?

The ‘why do we need X number of years of education before practice’ argument is made daily by CRNAs who claim equivalence with less training (though they try awful hard to increase the hours of training by including everything they’ve done since basically pre-K).

Do you need an anesthesiologist to push propofol for you while you have a colonoscopy? I guess not, unless it goes bad. Even then it didn’t help poor Joan Rivers in that poorly run office setting. Do you want an anesthesiologist easing you on and off cardiopulmonary bypass and reading TEE? Placing the block for your rotator cuff surgery? Dunno, what if it’s you?

I’m an anesthesiologist. I stand with y’all as I sat beside you in the grueling years of everything we did to get where we are. But the simple fact is that once you let midlevels in the door, you can’t go back. Once you let corporate Wall Street in the door, you can’t go back. No one should expect anything other than change for the next few decades of our careers. Maybe it’ll be beneficial for us and our patients, but likely not.

 

[Boatswain2PA]

But you don't though. That's the problem. I don't know why you are speculating "what if I manage sick patients the same way as a physician" because that's not reality.

How do you know it's not reality? You probably don't know why I'm speculating that because you don't understand that it is, indeed, possible.

Let's explore that a little further. Could an older FP trained doc, who has been working in a busy ED for the past 30 years, manage the patient the same way (or better) than you?

many are horrible and are routinely sending home reproductive age females without a pregnancy test.

Then they should be fired.

you guys simply do not have the training for it.

There are many ways to get training to take care of sick people. I absolutely agree that an EM/CC physician residency is the BEST way. You likely think it's the "only" way because it's the only way you've seen.

The scariest part about MLPs is how many of you have zero understanding of scope of practice and seem to believe that you can do something without training. As an EM doctor, there are many things that I cannot do, and I am trained to understand this.

So, as an EM doctor you're trained to know what you cannot do because you're not trained to do it, but nobody else can have the skill to know what they can't do because they're not trained to do it?

I get the sense that MLPs are fed ego stroking nonsense during their training about the "equivalency" of their education to an MDs, which is extremely detrimental to patient care.

You're merging PAs with NPs. I don't know of ANY PA program who would even begin to infer that, mostly because it is a ridiculous notion. 2.5 years of intense medical training of PA program <<<med school & residency.

Unfortunately there are many NPs, especially now that they have the DNP, who do make that assertion.

That is the most ridiculous excuse I have ever heard. I'm not even going to really go down this rabbit hole of you,

Really? You don't sometimes do a test on a patient you're going to admit just because you know the hospitalist would want it? I don't really care what the BNP is in the ED, but the hospitalist is going to ask for it, so I'll get it.

Your training is algorithmic i.e. abdominal pain = CT scan.

My training wasn't, and neither is my thought pattern.

It's the kind of supervision that physicians value because it's the kind of supervision that works, and makes good clinicians.

Agree. But there are other methods of supervision if you cared to expand your leadership toolkit.

There is no substitute for good residency training.

Agree that residency training is the best way, but people can certainly learn a lot outside of residency. Again, lots of FP trained docs are true experts in EM.

We have seen this in other physicians who worked in the ED without being residency trained whether it was an internal medicine resident moonlighting for extra money or a psychiatrist.

I don't "moonlight" in the ED. Emergency medicine is my profession. I certainly started at a huge deficit in comparison to a residency trained EP, but it has been my professional goal to give the EXACT same level of care to my patients that you give to yours. Am I there yet? No. Will I ever get there? I dunno...but I'm going to keep trying.

 

[Psai]

I don't "moonlight" in the ED. Emergency medicine is my profession. I certainly started at a huge deficit in comparison to a residency trained EP, but it has been my professional goal to give the EXACT same level of care to my patients that you give to yours. Am I there yet? No. Will I ever get there? I dunno...but I'm going to keep trying.

I'm glad to hear that you will be applying to medical school

 

[Boatswain2PA]

I'm glad to hear that you will be applying to medical school

I'm too old, or I would try.

 

[hurtem&healem]

I thought I was following this thread, but apparently I wasn't. Apologies if I missed something while skimming.

optimal team practice ("OTP") =/= independant practice... Our profession is actually fairly conservative (the first iteration of OTP was actually called "full practice authority" and was tossed out, and the much more reasonable OTP idea replaced it). For us, the ideal situation is that PAs work with physicians and that the level of physician supervision is determined at the practice level. We want to get rid of specific, signed supervisory agreements with a single physician and replace it with practice-level decision making led by the docs, base on the experience the PA has and the level of trust in the relationship.

Can you elaborate on what exactly OTP means? On the surface "Practice level decisions" on PA supervision sounds the same as "Independent practice rights unless I'm employed by someone who wants to supervise me." Maybe I'm wrong; maybe it's the tone of these threads; maybe I'm just cynical.
Assuming all current parties do indeed have the best intentions, what specific passages in this proposed legislation prevent what the physicians here are concerned about: short sighted and greedy execs (and some doctors) granting PA's in their practice full autonomy regardless of how (in-)capable the individual is? Because, let's be real here, the C-suite has a fiduciary responsibility mandated attitude of F* patients, Make money.

I think it's faulty reasoning to assume that because you can bill for more while working with a PA that this is somehow in the best interest for EM as a whole.

If you work at a place with 1 physician and 3 PAs, sure that 1 EM physician can collectively bill for more. But you have 3 EM physicians that lose an opportunity of employment at that location.

So, here's part of the problem with these threads. There are two separate discussions being had. You are worried about your job and salary, which is completely reasonable. Others are worried about the swaths of for real rural land in this country where the physicians aren't going. Do you work in Rugby, ND? Do you know anyone willing to work in Bowman? There are no EP's out there. Where you do see a hospital or Emergency Room, they have a single FP doctor and a handful of PA/FNP. This has been talked about over and over, but the issue is twofold: a) Physicians don't want to live there. b) there's not enough volume to justify the price it would take to allure any physicians. Oh, you don't want to take q1 call, and you want to have a few days vacation here and there? Now we're down to zero physicians and only a few midlevels to care for patients while you're unavailable. How do we address that? Can an NP deal with a kid with mild frostbite or drain cauliflower ear? Can a PA set a broken finger? Or are those patients better served driving another 3+ hours to the next 24 hour location where, hopefully, there's a physician to sign the chart?

 

[maxxor]

So, here's part of the problem with these threads. There are two separate discussions being had. You are worried about your job and salary, which is completely reasonable. Others are worried about the swaths of for real rural land in this country where the physicians aren't going. Do you work in Rugby, ND? Do you know anyone willing to work in Bowman? There are no EP's out there. Where you do see a hospital or Emergency Room, they have a single FP doctor and a handful of PA/FNP. This has been talked about over and over, but the issue is twofold: a) Physicians don't want to live there. b) there's not enough volume to justify the price it would take to allure any physicians. Oh, you don't want to take q1 call, and you want to have a few days vacation here and there? Now we're down to zero physicians and only a few midlevels to care for patients while you're unavailable. How do we address that? Can an NP deal with a kid with mild frostbite or drain cauliflower ear? Can a PA set a broken finger? Or are those patients better served driving another 3+ hours to the next 24 hour location where, hopefully, there's a physician to sign the chart?

I agree the rural physician problem is a real problem. However, the solution isn’t statewide removal of supervision.

How about the state board actually do their job and evaluate specific locations based on need for expanded scope of practice? What’s happening with NPs in expanded scope states is that they suddenly stop working in rural areas and open up clinics in desirable areas. If militant non-physicians want expanded scope, then they need to put their money where their mouth is and go to rural areas where it’s needed. They’d be actually doing what their political mouthpieces claim. However, if they no longer need to go to the rural sites to get independence, they will leave and then you have the same distribution problem that plagues physicians and rural places.

I’m a radiologist. I directly benefit from midlevels who over order imaging. I think the whole concept of mid level independence makes no sense. Either residency is the standard of care, or we should just shut them all down / cut off years of training and make it “fair”. Don’t even get me started on the “NPs practice nursing “ garbage. They are practicing medicine without a license.

 

[Fox800]

The state should issue a certificate of need that allows midlevels to only practice without on-site supervision in rural areas. That would clear up this medspa/Botox business lickety-split.

 

[bravotwozero]

The state should issue a certificate of need that allows midlevels to only practice without on-site supervision in rural areas. That would clear up this medspa/Botox business lickety-split.

Why hasn’t anyone else thought of this?!


Sent from my iPhone using Tapatalk

 

[hurtem&healem]

Why hasn’t anyone else thought of this?!


Sent from my iPhone using Tapatalk

I'm sure plenty of people have. I even suggested something to the same effect earlier in one of these threads (are there 3 going right now?).

Thing is, that's not actually the agenda of the nursing lobby. The rural physician shortage is just a Trojan Horse for their plans of full autonomy. [/s]

 

[Hamhock]

"What about incest and rape?" for the baby killers.

I so enjoy some humorous hyperbole.
I even like it when it makes some people a bit uncomfortable.
But "rape" as an excuse for "baby killers"?
This is an example not of an insightful yet a bit uncomfortable humor that further explains a point, but of thoughtless misunderstanding and useless inflammatory rhetoric.
Assuming you are referring to abortion (and not infanticide), your last line is remarkably ironic -- in that you have used the Trojan horse of infanticide to hide the destruction of embyros or fetuses.
It seems you don't have a problem with the use of the Trojan horse in general...only when it's used against you .

HH

 

[Hamhock]

I hope we (hurt&heal and I) didn't distract this thread too much.

Please return to the original and primary discussion.

The idea of wavers for rural areas is an interesting one that I would like to hear explored more.

HH

 

[hurtem&healem]

I so enjoy some humorous hyperbole.
I even like it when it makes some people a bit uncomfortable.
This is an example not of an insightful yet a bit uncomfortable humor that further explains a point, but of thoughtless misunderstanding and useless inflammatory rhetoric.
your last line is remarkably ironic
It seems you don't have a problem with the use of the Trojan horse in general...only when it's used against you .
HH

Maybe it was too far for mixed company. I was trying to make it clear the entire point was being made in irony. I've changed it to be more, and less, explicit. I don't actually think any of them were designed to be Trojan horses, but they all do certainly lend themselves to use as such, and there's more than a few people in this thread who think that is the intent of the nursing lobby and AAPA.



So back on topic. @lemurcatta , I am legitimately waiting for answers to my previous questions.

 

[RustedFox]

Maybe it was too far for mixed company. I was trying to make it clear the entire point was being made in irony. I've changed it to be more, and less, explicit. I don't actually think any of them were designed to be Trojan horses, but they all do certainly lend themselves to use as such, and there's more than a few people in this thread who think that is the intent of the nursing lobby and AAPA.



So back on topic. @lemurcatta , I am legitimately waiting for answers to my previous questions.

Off-topic.

We come from the land of the ice and snow
From the midnight sun, where the hot springs flow
The hammer of the gods
W'ell drive our ships to new lands
To fight the horde, and sing and cry
Valhalla, I am coming!


Eff yeah, man.

 

[GonnaBeADoc2222]

This thread has taken a turn for the worse.

 

[Angry Birds]

Seriously, if anyone wants a rural gig, I got the hookup.

What state/area?