PAs/NPs attempting to "cancel culture" the AMA

[Malik144]

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I would be very interested to see from another perspective the disdain for NP’s and PA’s. Also curious why they are so often grouped together

 

[fldoctorgirl]

I'm rotating on cards now and the other day an NP from another service cancelled the order my doc put in on a patient. The doctor was absolutely livid but there were zero actual repercussions for said NP. I just don't understand..how on earth can someone who got an online degree while working as a floor nurse have the ability to cancel the orders of a CARDIOLOGIST. Like, this is someone who did an IM residency and then 2 fellowships on top of it. This is the problem with 95% of NPs I have met-- they're just way too cocky and have this huge chip on their shoulder constantly. I have met some good ones, but this has just been my experience with the majority of them. I agree that bedside nursing is dying. Half of the nurses I talk to on the floor are telling me how they're doing online school as we speak.

Another NP: "I should sign my charts "Dr. XYZ" because I got my doctorate technically hehe!!!"

The problem is that any time anything like this is brought up, you're just accused of bashing nursing.

 

[Deltasidearm]

They could learn it, but it would take years, at which point why not just take NCLEX and be a nurse.

One could say that a medical student caring for a ICU patient may be capable of providing some care as a novice in the exact same way a unsupervised NP is capable of working in primary care. They both might be fine for awhile but eventually something would go wrong that they don’t have sufficient training for. See what I did there?

I actually have come to agree with you and @atnightingale in that a physician cannot do the job of a well-trained nurse (however, please note that I never said that should happen regardless--this is a big distinction) and to suggest otherwise is biased or misinformed.

However, this is what I will say. I strongly believe you could put any freshly graduated medical student into the onboarding process of a new-grad nurse and they would have no issue completing and succeeding in the technical standards with their training (although their emotional standards may need improvement). I do not believe you could throw a freshly graduated nurse into a residency program or even a trained nurse into an attending position and expect reasonable success.

I think this is is because, although they are different skill sets, the training deficit between nursing and medicine is greater than the difference between medicine and nursing. Surely, a physician needs additional training to function as a nurse, but a nurse needs significantly more training than is even provided in advanced, terminal degrees and a history of practicing to fulfill the role of a physician.

Regardless, suggesting that physicians could even hypothetically replace or complete the role of a nurse is not helpful to this discussion at all and should be avoided, except in pointing out how their objection mirrors our own.

 

[Deltasidearm]

I would be very interested to see from another perspective the disdain for NP’s and PA’s. Also curious why they are so often grouped together

I think it's important for everyone to consciously remember that the target here is a select group of midlevel providers and to be cautious of unfairly treating all NP's and PA's the same, especially since they need to be our allies.

Personally, I have seen much more push and arrogance from NP's than PA's and I think PA's are a lesser issue since they are at least under the scrutiny and standardization of the medical board, but this is probably a bias from just being exposed to a lot more NP's than PA's.

 

[Matthew9Thirtyfive]

I think it's important for everyone to consciously remember that the target here is a select group of midlevel providers and to be cautious of unfairly treating all NP's and PA's the same, especially since they need to be our allies.

Personally, I have seen much more push and arrogance from NP's than PA's and I think PA's are a lesser issue since they are at least under the scrutiny and standardization of the medical board, but this is probably a bias from just being exposed to a lot more NP's than PA's.

Trust me, they are not our allies. They want independent practice just as much as the NPs, it’s just a harder fight for them. There’s a reason they are trying to change their name and push through optimal-whatever-the-hell-they-call-it-but-is-actually-independent-practice. They definitely have a better education than NPs, but they are still midlevels and still need supervision. Their society president pushes tirelessly for independent practice, calls herself doctor all over social media, and openly gaslights physicians constantly.

 

[Matthew9Thirtyfive]

I'm rotating on cards now and the other day an NP from another service cancelled the order my doc put in on a patient. The doctor was absolutely livid but there were zero actual repercussions for said NP. I just don't understand..how on earth can someone who got an online degree while working as a floor nurse have the ability to cancel the orders of a CARDIOLOGIST. Like, this is someone who did an IM residency and then 2 fellowships on top of it. This is the problem with 95% of NPs I have met-- they're just way too cocky and have this huge chip on their shoulder constantly. I have met some good ones, but this has just been my experience with the majority of them. I agree that bedside nursing is dying. Half of the nurses I talk to on the floor are telling me how they're doing online school as we speak.

Another NP: "I should sign my charts "Dr. XYZ" because I got my doctorate technically hehe!!!"

The problem is that any time anything like this is brought up, you're just accused of bashing nursing.

Yes, they have gotten really good at gaslighting. The only way this will change is if we are willing to deal with short term consequences. If the cardiologists told the hospital that either they get a leash on the NPs or they walk, and they were willing to actually do it, there would be change. A hospital isn’t going to jeopardize losing its money makers. Some specialties don’t have this option because they don’t make money for the hospital.

 

[DrNotaDr]

I actually have come to agree with you and @atnightingale in that a physician cannot do the job of a well-trained nurse (however, please note that I never said that should happen regardless--this is a big distinction) and to suggest otherwise is biased or misinformed.

However, this is what I will say. I strongly believe you could put any freshly graduated medical student into the onboarding process of a new-grad nurse and they would have no issue completing and succeeding in the technical standards with their training (although their emotional standards may need improvement). I do not believe you could throw a freshly graduated nurse into a residency program or even a trained nurse into an attending position and expect reasonable success.

I think this is is because, although they are different skill sets, the training deficit between nursing and medicine is greater than the difference between medicine and nursing. Surely, a physician needs additional training to function as a nurse, but a nurse needs significantly more training than is even provided in advanced, terminal degrees and a history of practicing to fulfill the role of a physician.

Regardless, suggesting that physicians could even hypothetically replace or complete the role of a nurse is not helpful to this discussion at all and should be avoided, except in pointing out how their objection mirrors our own.

SDN attestation:

Post seen and examined independently. Agree with the documentation above.

Dr.NotADoctor
12/04/2020

 

[DrNotaDr]

I'm rotating on cards now and the other day an NP from another service cancelled the order my doc put in on a patient. The doctor was absolutely livid but there were zero actual repercussions for said NP. I just don't understand..how on earth can someone who got an online degree while working as a floor nurse have the ability to cancel the orders of a CARDIOLOGIST. Like, this is someone who did an IM residency and then 2 fellowships on top of it. This is the problem with 95% of NPs I have met-- they're just way too cocky and have this huge chip on their shoulder constantly. I have met some good ones, but this has just been my experience with the majority of them. I agree that bedside nursing is dying. Half of the nurses I talk to on the floor are telling me how they're doing online school as we speak.

Another NP: "I should sign my charts "Dr. XYZ" because I got my doctorate technically hehe!!!"

The problem is that any time anything like this is brought up, you're just accused of bashing nursing.

It’s entirely possibly the attending told the NP to cancel that order. Things like that happen fairly often.

 

[Matthew9Thirtyfive]

It’s entirely possibly the attending told the NP to cancel that order. Things like that happen fairly often.

Why would the attending be livid that the NP canceled an order (s)he told him/her to cancel?

 

[fldoctorgirl]

It’s entirely possibly the attending told the NP to cancel that order. Things like that happen fairly often.

Nope, not what happened. And it wasn't the NP's attending, either, as her "supervising doctor" was informed of the situation and confirmed he was not involved in the decision. NP just straight up cancelled a cardiologist's order for a cardiology medication. I mean, it's not like a cards NP cancelling a hospitalist's cards medicine order or something.

 

[Eye-eye]

They could learn it, but it would take years, at which point why not just take NCLEX and be a nurse.

One could say that a medical student caring for a ICU patient may be capable of providing some care as a novice in the exact same way a unsupervised NP is capable of working in primary care. They both might be fine for awhile but eventually something would go wrong that they don’t have sufficient training for. See what I did there?

You really think there's so little overlap between med school/residency and nursing that it would take an MD or Do 5 years to learn to be a competent nurse? Sure, there are tasks and ways of thinking that we don't use as often, but all of the examples of things "only nurses can do" are things we should see, honestly before we finish M3 of med school. And while I wouldn't be comfortable changing a wound vac right now, I have seen it done and could pick it up pretty quick. I wasn't entirely comfortable placing my first trocar or doing my first intubation, but I did them nonetheless, and unless it's a challenging one, I'm comfortable doing them now. It's not the tasks; nurses could do many physician tasks and vice versa, with relatively little training needed. It's the knowledge base that's built up over years to know when to do these interventions and when not, all of the complications and how to manage them, that you just can't get as fully as the med school/residency/fellowship pathway gives it. That's the difference in training that you just can't fully replicate in NP or PA school. It's just not long enough to pack it all in there, for one.

 

[VA Hopeful Dr]

I think you don’t know what you don’t know. Have you ever done what I just described?

EDIT: you do know it takes 5 years of full time ICU RN nursing to be considered “competent” in the role.

OK I'm glad you added that edit there because that ICU scenario you mentioned previously couldn't be handled by plenty of the nurses I've met either.

 

[DrNotaDr]

You really think there's so little overlap between med school/residency and nursing that it would take an MD or Do 5 years to learn to be a competent nurse? Sure, there are tasks and ways of thinking that we don't use as often, but all of the examples of things "only nurses can do" are things we should see, honestly before we finish M3 of med school. And while I wouldn't be comfortable changing a wound vac right now, I have seen it done and could pick it up pretty quick. I wasn't entirely comfortable placing my first trocar or doing my first intubation, but I did them nonetheless, and unless it's a challenging one, I'm comfortable doing them now. It's not the tasks; nurses could do many physician tasks and vice versa, with relatively little training needed. It's the knowledge base that's built up over years to know when to do these interventions and when not, all of the complications and how to manage them, that you just can't get as fully as the med school/residency/fellowship pathway gives it. That's the difference in training that you just can't fully replicate in NP or PA school. It's just not long enough to pack it all in there, for one.

I’m not the one saying it. The AACN are the ones saying it.

 

[PunkRockMD]

I would be very interested to see from another perspective the disdain for NP’s and PA’s. Also curious why they are so often grouped together

The reason they are grouped together is that the AAPA has become the next AANP. Until PAs hold their organization accountable they are lumped in with NPs. I would trust a PA over an NP any day, but neither of them should be practicing independently.

 

[atnightingale]

You really think there's so little overlap between med school/residency and nursing that it would take an MD or Do 5 years to learn to be a competent nurse? Sure, there are tasks and ways of thinking that we don't use as often, but all of the examples of things "only nurses can do" are things we should see, honestly before we finish M3 of med school. And while I wouldn't be comfortable changing a wound vac right now, I have seen it done and could pick it up pretty quick. I wasn't entirely comfortable placing my first trocar or doing my first intubation, but I did them nonetheless, and unless it's a challenging one, I'm comfortable doing them now. It's not the tasks; nurses could do many physician tasks and vice versa, with relatively little training needed. It's the knowledge base that's built up over years to know when to do these interventions and when not, all of the complications and how to manage them, that you just can't get as fully as the med school/residency/fellowship pathway gives it. That's the difference in training that you just can't fully replicate in NP or PA school. It's just not long enough to pack it all in there, for one.

I think the disconnect here is in the difference between how nursing and medicine handle the training after med school and nursing school. Medicine has formal residency and fellowship in those years. A nurse's continuing training is generally informal and on the job. A grad nurse isn't really fully baked yet. This is known and expected. Many hospitals now offer "Residencies" which often offer 4-6 months of 1:1 training on a particular unit and a year of extra support and supervision. This might be "only" to work as a floor nurse in Med Surg, or maybe the Postpartum Unit. Sometimes there are programs directly into ICU or ER, but those are still controversial for some. The conventional wisdom has long been you put a few years in on med surg then you can transfer and receive more training in PACU, ICU, ER, Labor and delivery etc. But once you get there you still need more training and mentorship and that experience clock kind of restarts. That 5 years figure is a recognition that you really need about 10,000 hours of something before you really have mastery. In medicine, all or most of those hours happen in Residency. In nursing, they don't. So would some of that transfer from medicine? Yes, to the extent that you are doing the same things, and seeing the same patients. But it still wouldn't be 5 years of doing THAT job in that role.

I don't want an intern MD as my ICU nurse any more than I want a new grad nurse. Do you?

 

[DrNotaDr]

The reason they are grouped together is that the AAPA has become the next AANP. Until PAs hold their organization accountable they are lumped in with NPs. I would trust a PA over an NP any day, but neither of them should be practicing independently.

The PA’s support PA independence, they just don’t want to discuss it with you.

 

[Deltasidearm]

I think the disconnect here is in the difference between how nursing and medicine handle the training after med school and nursing school. Medicine has formal residency and fellowship in those years. A nurse's continuing training is generally informal and on the job. A grad nurse isn't really fully baked yet. This is known and expected. Many hospitals now offer "Residencies" which often offer 4-6 months of 1:1 training on a particular unit and a year of extra support and supervision. This might be "only" to work as a floor nurse in Med Surg, or maybe the Postpartum Unit. Sometimes there are programs directly into ICU or ER, but those are still controversial for some. The conventional wisdom has long been you put a few years in on med surg then you can transfer and receive more training in PACU, ICU, ER, Labor and delivery etc. But once you get there you still need more training and mentorship and that experience clock kind of restarts. That 5 years figure is a recognition that you really need about 10,000 hours of something before you really have mastery. In medicine, all or most of those hours happen in Residency. In nursing, they don't.

Well, sure. But a freshly graduated resident who is now an attending is not really fully baked yet, either. The very nature of healthcare is a continual process of learning and improving and anyone involved in healthcare has completely failed if they forget that. Frankly, most nurses should be well experienced enough to be competent well before 5 years. Does that mean they know everything and will never need help? Of course not. Competent =/= expert.

I don't want an intern MD as my ICU nurse any more than I want a new grad nurse. Do you?

No, but literally no one wants to be treated by anyone but the best (i.e. why can't the attending see me instead of the resident/student?) so I don't really see the point of the question. Everyone recognizes that freshly graduated students in healthcare need additional training and support, and no one operates in some sort of vacuum. I would take the intern, who has a better understanding of my complex physiological issues and ability to analyze/correct my treatment plan, over the new grad nurse any day though. Especially considering either one of them will have oversight by experienced ICU nurses that will make sure everything is done okay (and I know the onboarding process of new grad and unit transfer nurses for the ICU very well, considering my time as a nursing assistant was spent primarily in MI/SI while my mother was the clinical director).

 

[Matthew9Thirtyfive]

I’m not the one saying it. The AACN are the ones saying it.

And the AANP and AAPA say that NPs and PAs are equivalent to MD/DO. An organization saying something doesn’t make it true.

 

[Malik144]

The reason they are grouped together is that the AAPA has become the next AANP. Until PAs hold their organization accountable they are lumped in with NPs. I would trust a PA over an NP any day, but neither of them should be practicing independently.

So what would you suggest from a career standpoint that PA’s or more so the AAPA do to increase job security of their profession. I think we’ve all seen the rise of NP’s which is 66% to the PA’s 21% along with Physician shortages. And with NP autonomy already very much present and advancing, wouldn’t PA’s eventually become non-marketable?

 

[FutureSurgical]

So what would you suggest from a career standpoint that PA’s or more so the AAPA do to increase job security of their profession. I think we’ve all seen the rise of NP’s which is 66% to the PA’s 21% along with Physician shortages. And with NP autonomy already very much present and advancing, wouldn’t PA’s eventually become non-marketable?

Lobby against the AANP so that NP's don't gain independent practice rights.

 

[Malik144]

The PA’s support PA independence, they just don’t want to discuss it with you.

But I’m more so asking about the non-separation of the professions. You can’t call a medical doctor a surgeon, even though a surgeon is a doctor. Wouldn’t it be more beneficial to assign them by their roles and by their ability through statistics and just release data. If NP’s or PA’s are causing decline in patient care, shouldn’t we isolate the target instead of diluting the stats. For example if PA’s are on average more likely to give sufficient care than NP’s, wouldn’t using APP’s or midlevels as data/majorative lead to skewed up trending results and a deviation from non-physician lead care?

 

[Malik144]

Lobby against the AANP so that NP's don't gain independent practice rights.

NP’s have already done that for the most part. There are 3 million+ Nurses, 300k NP’s associated with their own nursing board. AAPA is about 160k in total, including DO/MD’s which is about 950k that would still only be 1/3 the lobbying power. AMA seemed to have made it clear they don’t stand with AAPA and AANP makes it clear they don’t care about either. So wouldn’t lobbying be already at a disadvantage with 2 organizations making up 1/3 of nursing lobby power, let alone just the AAPA. Seems that they would eventually lobby there way out of a job while NP’s cornered the market. Unless I’m looking at it the wrong way?
I believe that their was a legislation to make DMSc w/ a residency and some sort extra education become comparable to MD/DO by Lincoln memorial. PA’s actually testified against it saying it didn’t make sense, however, NP’s gained autonomy not much time after.

 

[DrNotaDr]

But I’m more so asking about the non-separation of the professions. You can’t call a medical doctor a surgeon, even though a surgeon is a doctor. Wouldn’t it be more beneficial to assign them by their roles and by their ability through statistics and just release data. If NP’s or PA’s are causing decline in patient care, shouldn’t we isolate the target instead of diluting the stats. For example if PA’s are on average more likely to give sufficient care than NP’s, wouldn’t using APP’s or midlevels as data/majorative lead to skewed up trending results and a deviation from non-physician lead care?

That might be more useful, but do we have studies comparing NP’s to PA’s?

 

[Malik144]

That might be more useful, but do we have studies comparing NP’s to PA’s?

I’ve seen some done by AANP but they used them to show positive trending, but I also have heard they are bias in one way or another. AMA’s, I think I came across one but it was more so focused on outpatient airway stats/number of malpractice with Physicians vs PA vs NP. But I think it was called Bias because they didn’t differentiation whether they were considering residents Dr’s or student Doctors. And i think it generalized it’s conclusion to an oddly specific outpatient specialty. AAPA, I haven’t really come across anything except their statistics quotes in their response to the AMA, not sure where it came from but I don’t really think they differentiated PA’s from NP’s just an upward trend.

 

[Matthew9Thirtyfive]

I’ve seen some done by AANP but they used them to show positive trending, but I also have heard they are bias in one way or another. AMA’s, I think I came across one but it was more so focused on outpatient airway stats/number of malpractice with Physicians vs PA vs NP. But I think it was called Bias because they didn’t differentiation whether they were considering residents Dr’s or student Doctors. And i think it generalized it’s conclusion to an oddly specific outpatient specialty. AAPA, I haven’t really come across anything except their statistics quotes in their response to the AMA, not sure where it came from but I don’t really think they differentiated PA’s from NP’s just an upward trend.

There are several studies comparing MDs and NPs, but none of them are comparing NPs practicing independently. In every study they had access to physicians for consulting, and in the only couple of studies that were actually good (read, not significantly biased by COI), they were only providing equivalent care about 50-60% of the time. And that was with access to physician help. Imagine how low it would be if they were independent in those studies.

There are some studies comparing PAs and MDs, but again they are supervised. So not really useful. There is good data showing that both NPs and PAs order more tests and prescribe more expensive medications and are more likely to prescribe opioids (20x more likely actually). So I’d say overall even though PA school is more standardized, they are not much better than NPs in practice.

Anecdotally, I have had almost nothing but bad experiences with them outside of surgery and the ones I know in real life think there isn’t much to know for primary care.

 

[FutureSurgical]

NP’s have already done that for the most part. There are 3 million+ Nurses, 300k NP’s associated with their own nursing board. AAPA is about 160k in total, including DO/MD’s which is about 950k that would still only be 1/3 the lobbying power. AMA seemed to have made it clear they don’t stand with AAPA and AANP makes it clear they don’t care about either. So wouldn’t lobbying be already at a disadvantage with 2 organizations making up 1/3 of nursing lobby power, let alone just the AAPA. Seems that they would eventually lobby there way out of a job while NP’s cornered the market. Unless I’m looking at it the wrong way?
I believe that their was a legislation to make DMSc w/ a residency and some sort extra education become comparable to MD/DO by Lincoln memorial. PA’s actually testified against it saying it didn’t make sense, however, NP’s gained autonomy not much time after.

The move for autonomy is reactionary; mainly because hospital systems can hire cheap labor for the same job (in their eye only. Obviously it isn't "the same thing." Not by a long shot.) I've seen message boards and posts about PAs losing jobs/contracts and having a hard time finding work because of the AANP using the pandemic as an excuse to fulfill their agenda.

The thing though, is the AANP is in the pockets of RWJ, Johnson & Johnson, and CVS Healthcare. Studies have shown midlevels prescribe more antibiotics, opioids, and order more unnecessary testing than MD's/DO's (evidence is on page 4, where I link many studies showing this.) It isn't just about the numbers within the organizations - though it certainly does help.

The AMA doesn't stand with the AAPA simply due to independent practice OpTiMuM tEaM pRaCtIcE. It is a politician's way of saying "we want to be the doctor without doing the necessary training and the added stress." The AMA doesn't have the balls to come out to say "we don't believe midlevels should practice independently because they don't have the knowledge base nor the training to do it." That's how you get the public to hate doctors more.

What you're going to see happen is a two-tier healthcare system in this country. The disadvantaged/rural/minority populations are going to have declining health in general while the privileged class of people will have better health outcomes overall. The less fortunate are stuck with midlevels; the privileged get to see the physicians. This assumes that NP's and PA's will actually go out to rural areas, which isn't even true.

I’ve seen some done by AANP but they used them to show positive trending, but I also have heard they are bias in one way or another. AMA’s, I think I came across one but it was more so focused on outpatient airway stats/number of malpractice with Physicians vs PA vs NP. But I think it was called Bias because they didn’t differentiation whether they were considering residents Dr’s or student Doctors. And i think it generalized it’s conclusion to an oddly specific outpatient specialty. AAPA, I haven’t really come across anything except their statistics quotes in their response to the AMA, not sure where it came from but I don’t really think they differentiated PA’s from NP’s just an upward trend.

I'll give a very tl;dr version of what the book "Patients at Risk" beautifully said: the AANP is full of s**t. Plain and simple. There are no studies showing NP's provide equal care. The only study worth a damn is the Burlington study in Canada in the 90's, where FM physicians trained NPs to manage low-acuity/follow-up patients who followed algorithms and protocols for treatment. When they were supervised by the physicians, they saw an increase in patients seen and patients treated. That study also showed, as @Matthew9Thirtyfive pointed out, that they provided similar care for these low-acuity patients 55% of the time. However, you can also say they provided worse care for these low-acuity patients 45% of the time. Patients that the AANP claims they can easily handle.

All other studies had very high p-values - of note, the #1 study the AANP LOVES to quote, have p-values of 0.75-0.9. This meant that their claims of "equivalent care" had upwards of a 90% chance being completely random. You could not make any sort of conclusion worth a damn from that study. The other issue is that the studies the AANP claims are "proof" are heavily biased. They were funded by pro-nursing organizations and, miraculously, showed what they wanted. Conflicts of interest were not stated and some studies (such as the one conducted at Columbia University in 1997) didn't state that the NP's were 100% supervised and had pediatric cases pulled from the NP's if the child was deemed "too high-risk."

This is an example of showing how CRNA's don't provide equal care as an Anesthesiologist (it opens as a PDF file.)

 

[Malik144]

There are several studies comparing MDs and NPs, but none of them are comparing NPs practicing independently. In every study they had access to physicians for consulting, and in the only couple of studies that were actually good (read, not significantly biased by COI), they were only providing equivalent care about 50-60% of the time. And that was with access to physician help. Imagine how low it would be if they were independent in those studies.

There are some studies comparing PAs and MDs, but again they are supervised. So not really useful. There is good data showing that both NPs and PAs order more tests and prescribe more expensive medications and are more likely to prescribe opioids (20x more likely actually). So I’d say overall even though PA school is more standardized, they are not much better than NPs in practice.

Anecdotally, I have had almost nothing but bad experiences with them outside of surgery and the ones I know in real life think there isn’t much to know for primary care.

I will say it does create a somewhat nonsensical dilemma for APP's. If care is hypothetically comparable to Physicians or would so happen to exceed care, wouldn't the causality just be linked to SP presence? *If you could link that study i would love to read the data though to get a more broad perspective.

I have heard something to that affect and i found the article, it's a lot more information than i expected, i believe its the link i provided at the bottom. I will definitely look through the data to get a better perspective.
Differences in Opioid Prescribing Among Generalist Physicians, Nurse Practitioners, and Physician Assistants

I think we risk too much being anecdotal in healthcare, especially since many patients aren't very familiar with hospital policies, procedures and education. For example, i personally have never been treated by a Physician who i felt gave me appropriate care (Which encompasses a wide range of things i personally consider "appropriate"). I often felt like a to-do list, i understand the workload of a Physician is nothing to be scoffed at. However, I've also met APP's both NP's and PA's who I've found to be competent and seem to actually care.

That being the case i still wouldn't ever make the claim that Physicians don't care as much as APP's. Being a Physician, APP, nurse or healthcare provider, does not make you inherently good or inherently smart. Every profession in and outside healthcare have bad apples, but i would say that's the minority, however, this is a very hypersensitive profession where 1-2 bad apples is still too high.

 

[Matthew9Thirtyfive]

I will say it does create a somewhat nonsensical dilemma for APP's. If care is hypothetically comparable to Physicians or would so happen to exceed care, wouldn't the causality just be linked to SP presence? *If you could link that study i would love to read the data though to get a more broad perspective.

I have heard something to that affect and i found the article, it's a lot more information than i expected, i believe its the link i provided at the bottom. I will definitely look through the data to get a better perspective.
Differences in Opioid Prescribing Among Generalist Physicians, Nurse Practitioners, and Physician Assistants

I think we risk too much being anecdotal in healthcare, especially since many patients aren't very familiar with hospital policies, procedures and education. For example, i personally have never been treated by a Physician who i felt gave me appropriate care (Which encompasses a wide range of things i personally consider "appropriate"). I often felt like a to-do list, i understand the workload of a Physician is nothing to be scoffed at. However, I've also met APP's both NP's and PA's who I've found to be competent and seem to actually care.

That being the case i still wouldn't ever make the claim that Physicians don't care as much as APP's. Being a Physician, APP, nurse or healthcare provider, does not make you inherently good or inherently smart. Every profession in and outside healthcare have bad apples, but i would say that's the minority, however, this is a very hypersensitive profession where 1-2 bad apples is still too high.

No offense, but if you’re pre-health you don’t really know what appropriate care is (in the medicine sense). It’s unfortunate that you felt like a checklist, but MLPs spending more time with you doesn’t mean they are providing good care. But yes, I can post some links.

 

[Malik144]

The move for autonomy is reactionary; mainly because hospital systems can hire cheap labor for the same job (in their eye only. Obviously it isn't "the same thing." Not by a long shot.) I've seen message boards and posts about PAs losing jobs/contracts and having a hard time finding work because of the AANP using the pandemic as an excuse to fulfill their agenda.

The thing though, is the AANP is in the pockets of RWJ, Johnson & Johnson, and CVS Healthcare. Studies have shown midlevels prescribe more antibiotics, opioids, and order more unnecessary testing than MD's/DO's (evidence is on page 4, where I link many studies showing this.) It isn't just about the numbers within the organizations - though it certainly does help.

The AMA doesn't stand with the AAPA simply due to independent practice OpTiMuM tEaM pRaCtIcE. It is a politician's way of saying "we want to be the doctor without doing the necessary training and the added stress." The AMA doesn't have the balls to come out to say "we don't believe midlevels should practice independently because they don't have the knowledge base nor the training to do it." That's how you get the public to hate doctors more.

What you're going to see happen is a two-tier healthcare system in this country. The disadvantaged/rural/minority populations are going to have declining health in general while the privileged class of people will have better health outcomes overall. The less fortunate are stuck with midlevels; the privileged get to see the physicians. This assumes that NP's and PA's will actually go out to rural areas, which isn't even true.


I'll give a very tl;dr version of what the book "Patients at Risk" beautifully said: the AANP is full of s**t. Plain and simple. There are no studies showing NP's provide equal care. The only study worth a damn is the Burlington study in Canada in the 90's, where FM physicians trained NPs to manage low-acuity/follow-up patients who followed algorithms and protocols for treatment. When they were supervised by the physicians, they saw an increase in patients seen and patients treated. That study also showed, as @Matthew9Thirtyfive pointed out, that they provided similar care for these low-acuity patients 55% of the time. However, you can also say they provided worse care for these low-acuity patients 45% of the time. Patients that the AANP claims they can easily handle.

All other studies had very high p-values - of note, the #1 study the AANP LOVES to quote, have p-values of 0.75-0.9. This meant that their claims of "equivalent care" had upwards of a 90% chance being completely random. You could not make any sort of conclusion worth a damn from that study. The other issue is that the studies the AANP claims are "proof" are heavily biased. They were funded by pro-nursing organizations and, miraculously, showed what they wanted. Conflicts of interest were not stated and some studies (such as the one conducted at Columbia University in 1997) didn't state that the NP's were 100% supervised and had pediatric cases pulled from the NP's if the child was deemed "too high-risk."

This is an example of showing how CRNA's don't provide equal care as an Anesthesiologist (it opens as a PDF file.)

I am definitely interested in that research, i appreciate you for spreading data with your perspective. I would give a little push back on the agenda of AANP. I 100% agree they did/ do use the pandemic as a way of gaining more autonomy. I just think that this is a common place tactic, from a pure business standpoint. "Patients at risk", i listened to a podcast by one of the co-author's. A synopsis was done and one of the examples was the death of a young women, explained by the interpretations of the actions by an NP. The Physicians for Patient care used example of "bad medicine" to push the agenda that all APP's are untrained and didn't really differentiate NP's from PA's. She even compared their clinical hours to less than barbers and cosmetologists. In reality a genius tactic and any objective person who isnt familiar with healthcare would say "The chart says this, let me google it".

You would see that this is true on the surface but i would say the majority of the population would either stop there or not look at all (thanks social media). The other smaller subset, would maybe dive deeper but still not enough to know the different models and governing boards of PA's and NP's. Than an even smaller subset of people would break down education, vs clinical hours, vs resume, vs gpa, vs competitiveness, full time vs part time, prior training ect ect. The nerds (me lol) as the laymen would call it. Than you objectively say, that's a misrepresentation of data.

I don't think either tactic for pushing an agenda is right but i think it has to be acknowledge that this a commonplace business tactic not reserved to any group.

I think AMA is too split to make that consensus. It seems that they got enough push back from Physicians to retract the tweet that they made about CRNA, NP'S and PA's but still enough support to stand their ground. I also don't think this is and education issue. DO's are still seen as less than by MD's and i really don't know any DO's who actually practice osteopathic medicine. I think the teamcare prospective come from the idea that if PA's are doing 75%-90% of a Physicians job, we have to analyze a situation. Does an "EM PA" whose been trained and working with an EM Attending for a decade have comparable knowledge or more so than a EM fellow? To what degree are they able to use their knowledge and how can they become a bigger part of the healthcare team?

There seems to be narrative that APP's are individuals who didnt want to go to medical school. I don't like this ideology because i do believe that medicine both PA school and MD/DO school is class restricted. The argument to that i usually hear is, "i was poor and i went to medical school, it takes dedication and hard-work". While i do agree with that sentiment, we also have to consider multiple variables. Access to education, environment, degree of poverty, family, lifestyle, workplace discrimination and bias ect ect. You have to dedicate a big portion of your life to being a Physician and i think if there was more access to becoming a Physician most would go that route.

Rural area statistics i've see kind of point in the direction that it's impossible for PA's and NP's to work in rural area's even if they wanted too. 12% of physicians work in rural area's and about 18% of NP's and 12% of PA's. Small population size, professional advancement and appropriate workload/pay isn't regulated. Also since supervision is required they really don't have much in ways of job opportunity. Even if there are about 100k physicians practicing in rural area's, that gives us about 54k NP's and 20k. Family own practices can use nurses, MA's and other physicians. So why would they hire NP's/PA's, who make 95-120k on average. Healthcare professionals shouldn't use money or their career as a way of avoiding rural area's or certain settings/patients. However, i would say no one is likely to take a job or work in a setting they know will have a negative impact on their career, family or mental health.

I'm going to read the article on anesthesia you gave and once again i appreciate it. I dont wan't to speak on a topic i haven't research on yet. However i will say i did notice something that seemed a little deceiving. It says 2/3 of summary research were independently funded but they were all researched by Physicians. I'm assuming the 1/3 was by AMA or Physician affiliates but assumptions make an ass out of you me, so excuse me ahead of time.
I'm not sure who the funding was coming from but i think knowing the organization who funded it can lead to more clear bias but i could also say that independently doesn't mean non-biased/ unaffiliated to any means.

I'm going to look through all the data of course, I would also note that, miller et al 2015 from what I've skimmed thus far is saying due to "affiliations of Anesthesiologist, "the numbers are less likely to be accurate for NP solo practice". I don't know to what degree affiliation is being considered but it also does seem to have potential bias interpretation. Again to research i will go!

Silber et al 2000
-Jeffrey H. Silber, MD, PhD
Memtsoudis et al 2012
-Stavros G. Memtsoudis, MD, PhD
Miller et al 2015 (QZ Study
-Dr. Amr E. Abouleish, MD
James F Cawley MPH-PA-C

Anesthesiologist direction and patient outcomes - PubMed

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

pubmed.ncbi.nlm.nih.gov

 

[Matthew9Thirtyfive]

Than you objectively say, that's a misrepresentation of data.

If you actually read the book, they do differentiate between PAs and NPs, and they delve very deeply into their respective training. Even though PAs have more standardized training and more clinical hours, they still have only a small fraction of the training a physician does and should not be practicing independently. So in that sense, they can be lumped together.

And it's not a misrepresentation of the data. A dog groomer at PetSmart has more hands-on hours than an NP. After about 4 months of pre-work, they have 480 hours of hands-on directly supervised training and learning followed by 6 months of supervised work until they are certified. They end up with about 1,500 hours of hands-on, supervised work. That's 3 times as much as the minimum required hours for NPs and almost 2 times as much as the average number of hours for NPs.

 

[Malik144]

No offense, but if you’re pre-health you don’t really know what appropriate care is (in the medicine sense). It’s unfortunate that you felt like a checklist, but MLPs spending more time with you doesn’t mean they are providing good care. But yes, I can post some links.

I'm long past pre-health, I've been in both a provider role, administrative role and supervisory role in terms of healthcare. I dont consider myself an affiliate with any organization, so i choose to not disclose my occupation. I have my own opinions that conflict with all 3 organizations and my role is no longer any of the former.

Appropriate care has never and will never be defined by practitioners. It's the interpretation of such care by said patient, i was just fortunate enough to be able to see the medical standpoint but i am by far in the minority. You as a provider could do the best care you possibly could but if it's deemed as insufficient by the patient, it's insufficient. Treating the patient like you know what is best for them better than they do isn't how medicine is practiced. It's too variable. So based on the care i wanted (which was minimal compared to others) a Physician has not be able to provide it thus far. I also never said they spent more time, i would say it was probably about the same or non-comparable.

 

[Matthew9Thirtyfive]

I'm long past pre-health, I've been in both a provider role, administrative role and supervisory role in terms of healthcare. I dont consider myself an affiliate with any organization, so i choose to not disclose my occupation. I have my own opinions that conflict with all 3 organizations and my role is no longer any of the former.

Appropriate care has never and will never be defined by practitioners. It's the interpretation of such care by said patient, i was just fortunate enough to be able to see the medical standpoint but i am by far in the minority. You as a provider could do the best care you possibly could but if it's deemed as insufficient by the patient, it's insufficient. Treating the patient like you know what is best for them better than they do isn't how medicine is practiced. It's too variable. So based on the care i wanted (which was minimal compared to others) a Physician has not be able to provide it thus far. I also never said they spent more time, i would say it was probably about the same or non-comparable.

Then you might want to fix your status, because it says pre-health. I also don't think you're a physician or a medical student.

 

[Malik144]

If you actually read the book, they do differentiate between PAs and NPs, and they delve very deeply into their respective training. Even though PAs have more standardized training and more clinical hours, they still have only a small fraction of the training a physician does and should not be practicing independently. So in that sense, they can be lumped together.

And it's not a misrepresentation of the data. A dog groomer at PetSmart has more hands-on hours than an NP. After about 4 months of pre-work, they have 480 hours of hands-on directly supervised training and learning followed by 6 months of supervised work until they are certified. They end up with about 1,500 hours of hands-on, supervised work. That's 3 times as much as the minimum required hours for NPs and almost 2 times as much as the average number of hours for NPs.

I feel like you don't read all my replies. I didn't say they didnt differentiate, i said they "didn't really differentiate". I'll state my point with that same logic. A dermatologist of a decade is equivalent in education to a 10 year Family practice Physician. So i can go to either doctor and receive the same care.

That doesn't follow, they practice medicine but their scope is focused, experiences and education are not the same even though they are standardized. PA's and Np's are not even taught under the same model. That small fraction of training is also bias, residency is considered training for Physicians. So by the end of their 11 years, "training" is indeed much longer. But NP's and PA's have been in actual practice for 4-5 years if you start at the matriculation of all 3 into programs. Lumping them together is diluting stats and hurting PA's and Physicians. I would say it mostly helps NP's since they are progressing so fast but i guess that's open to interpretation.

You seemed to have intentionally hyper-focused on NP's and not acknowledged the PA bias, which is a clear misinterpretation. I'll just focus on NP than. Go through a variety of NP educational sites and program acceptance rates if you dont trust the AANP stats. The average is 2 years of RN experience or roughly 4,500 clinical hours as the majority. There is a minority of Direct MSN programs, i'm not a supporter of them, but that once again is a minority. I would also like to acknowledge that every institution has this issue. I

it's commonly suggested by MD's that pre-medical students should apply to DO School and Medical school depending on their GPA, MCAT. Is DO school less than MD school? I would argue that MD/DO's are both very heavily trained.

There are also Caribbean medical schools, which have US residencies class matches as high as 94%. Requirements are lower by far on average, feel free to look up the statistics and is often used as a recommendation for those who dont think they can get into MD/DO school. Essentially if you slacked off, but have enough money, you can still become a Physician

So no it's not equivalent to being a "groomer at petsmart". That's the definition of data misrepresentation. I would also imagine the requirements and education vary since one doesn't require a degree but recommends a high school diploma. Also you dont have to be certified to be a pet groomer, however there are certifications. Your minimum to be a nurse is 4 years, and minimum to be a NP is 6.5-7. Should i go into competitive rates or do you have a better comparison?

 

[Malik144]

Then you might want to fix your status, because it says pre-health. I also don't think you're a physician or a medical student.

I'm not speaking as a provider or student of any kind so why is that relevant? I just stated i wasn't affiliated nor did i claim to be any of the former you mentioned. I am familiar with healthcare and have been in roles i mentioned previously. Patients and research data i am very familiar with, i am looking for more data and different interpretations of data as well as perspectives. I felt as medical professions both student and practicing, i would be able to have healthy and research driven conversation and opinions.

I also don't think you have to be very familiar with healthcare to know when you have been treated poorly by a provider or healthcare professional. Shown by plenty of research data of those not affiliated with healthcare on their perspective of their treatment as well as malpractice suits that corroborate those claims from a wide spectrum of professionals in healthcare.

 

[Steve_Zissou]

I'm long past pre-health, I've been in both a provider role, administrative role and supervisory role in terms of healthcare. I dont consider myself an affiliate with any organization, so i choose to not disclose my occupation. I have my own opinions that conflict with all 3 organizations and my role is no longer any of the former.

Appropriate care has never and will never be defined by practitioners. It's the interpretation of such care by said patient, i was just fortunate enough to be able to see the medical standpoint but i am by far in the minority. You as a provider could do the best care you possibly could but if it's deemed as insufficient by the patient, it's insufficient. Treating the patient like you know what is best for them better than they do isn't how medicine is practiced. It's too variable. So based on the care i wanted (which was minimal compared to others) a Physician has not be able to provide it thus far. I also never said they spent more time, i would say it was probably about the same or non-comparable.

So the heroin addict looking for narcotics didn’t get appropriate care unless I gave them the whole supply of narcotics the clinic has to satisfy their habit?

The idea that appropriate care hinges on the patient being satisfied is ludicrous and definitely sounds like administrator “quality metric” BS. Sure, we should try to satisfy patients as much as possible and we definitely should give them the autonomy to choose their care, but I’m not going to give antibiotics for a likely viral sinusitis no matter how upset they are that they aren’t getting it.

 

[Malik144]

So the heroin addict looking for narcotics didn’t get appropriate care unless I gave them the whole supply of narcotics the clinic has to satisfy their habit?

The idea that appropriate care hinges on the patient being satisfied is ludicrous and definitely sounds like administrator “quality metric” BS. Sure, we should try to satisfy patients as much as possible and we definitely should give them the autonomy to choose their care, but I’m not going to give antibiotics for a likely viral sinusitis no matter how upset they are that they aren’t getting it.

No because that's a clear example of when an addict is asking for drugs, that you don't give them drugs. So i imagine your ---> Appropriate <--- care wouldn't come into play, outside of other legal and ethical reasons.

I said *appropriate care*, patients don't know the medicine a majority of the time. So yes it is *Appropriate* to not give them anti-biotics (or drugs of any kind) if you don't explicitly think that they need them.

However, there is an anti-biotic crisis so i don't know if providers are really adhering to that.

However, i imagine if a patient comes into see you and they felt uncomfortable due to how you evaluated them, than yes that patient can consider themselves as not receiving appropriate care. Whether you think you gave them a good evaluation is not the debate, every perception is different. Culture, economics, past experiences, hell even just having a bad day can play a role. In healthcare you have a privilege to practice medicine and you have put in the work and time for your title and have proven that you are intelligent and capable enough to wield it. That may come with inherent respect from others in healthcare.

That however means nothing to someone who doesn't know you. A 1st year resident has no more right to deem themselves above a patient or their feelings than even a 10 year seasoned attending.

Practicing medicine, nursing or just being in healthcare in general, means that as health care professionals, the job is never done, the learning never ends and there will always be people who need help. Personal improvement as well as self-evaluation, new concerns and constant criticism is what makes health care a linear progression.

So i do believe that a patient has the right to call that care into question. It may be completely off base and maybe even unfair at times but i imagine as individuals who aim to be better and better not only to improve the lives of their patients but also their own lives, family and peers that this should be welcomed not disfavored. (Although i understand no one enjoys being put down, but hey comes with territory).

 

[Matthew9Thirtyfive]

I'm not speaking as a provider or student of any kind so why is that relevant? I just stated i wasn't affiliated nor did i claim to be any of the former you mentioned. I am familiar with healthcare and have been in roles i mentioned previously. Patients and research data i am very familiar with, i am looking for more data and different interpretations of data as well as perspectives. I felt as medical professions both student and practicing, i would be able to have healthy and research driven conversation and opinions.

It’s relevant because you’re trying to say when you’ve gotten appropriate care. If you aren’t a physician or at the very least a medical student (and even that’s just the bare minimum), then you don’t really know what appropriate care is. You may have not felt like you got good care because you didn’t feel like they did what you wanted or like they didn’t really listen, but that’s subjective. Just because you don’t get what you want doesn’t mean you didn’t get appropriate care. People who want antibiotics for their “sinus infection” or bronchitis and don’t get them will tell you they got crappy care, but they’re wrong.

I also don't think you have to be very familiar with healthcare to know when you have been treated poorly by a provider or healthcare professional. Shown by plenty of research data of those not affiliated with healthcare on their perspective of their treatment as well as malpractice suits that corroborate those claims from a wide spectrum of professionals in healthcare.

I’m only a second year med student, but I’ve been in healthcare for over a decade. I have worked with surgeons I wouldn’t let take a skin tag off me whose patients feel like they’re the best thing since sliced bread because they are friendly and personable to them. They are still terrible surgeons.

While I believe the patient’s perception of their care is important because having your patient buy into the treatment is a crucial part of adherence, patient satisfaction does not determine good care.

 

[Matthew9Thirtyfive]

No because that's a clear example of when an addict is asking for drugs, that you don't give them drugs. So i imagine your ---> Appropriate <--- care wouldn't come into play, outside of other legal and ethical reasons.

I said *appropriate care*, patients don't know the medicine a majority of the time. So yes it is *Appropriate* to not give them anti-biotics (or drugs of any kind) if you don't explicitly think that they need them.

However, there is an anti-biotic crisis so i don't know if providers are really adhering to that.

However, i imagine if a patient comes into see you and they felt uncomfortable due to how you evaluated them, than yes that patient can consider themselves as not receiving appropriate care. Whether you think you gave them a good evaluation is not the debate, every perception is different. Culture, economics, past experiences, hell even just having a bad day can play a role. In healthcare you have a privilege to practice medicine and you have put in the work and time for your title and have proven that you are intelligent and capable enough to wield it. That may come with inherent respect from others in healthcare.

That however means nothing to someone who doesn't know you. A 1st year resident has no more right to deem themselves above a patient or their feelings than even a 10 year seasoned attending.

Practicing medicine, nursing or just being in healthcare in general, means that as health care professionals, the job is never done, the learning never ends and there will always be people who need help. Personal improvement as well as self-evaluation, new concerns and constant criticism is what makes health care a linear progression.

So i do believe that a patient has the right to call that care into question. It may be completely off base and maybe even unfair at times but i imagine as individuals who aim to be better and better not only to improve the lives of their patients but also their own lives, family and peers that this should be welcomed not disfavored. (Although i understand no one enjoys being put down, but hey comes with territory).

Patient satisfaction scores have been one of the worst things to happen to medicine actually. It turns out that the majority of people will say they’re dissatisfied with their care any time they don’t get what they want and will use that as a way to threaten physicians.

Assuming nothing objectively inappropriate happened (like harassment, etc), you feeling like a physician didn’t give you a good encounter is subjective. People sometimes don’t click, and if you feel like your physician isn’t listening to you, you should tell them that. If things don’t change then get a new physician. That’s your right and you should do that because everyone should feel like their physician understand them.

But that’s a separate issue from providing medically appropriate care. The communication piece is important, but so much of it is subjective. I’ve literally seen med students in my class use exact phrasing taught to us by our professors when talking to real patients, and have it be great with one patient and completely backfire and upset the next. They weren’t providing inappropriate care, it’s just that people are different.

 

[underthesun]

And the AANP and AAPA say that NPs and PAs are equivalent to MD/DO. An organization saying something doesn’t make it true.

Do they actually say that they’re EQUIVALENT to MD/DO? I’m asking bc if so this situation is far more shocking than I realized. My guess is that they’re saying the outcomes are equivalent, although we all know those studies are BS.

 

[Matthew9Thirtyfive]

Do they actually say that they’re EQUIVALENT to MD/DO? I’m asking bc if so this situation is far more shocking than I realized. My guess is that they’re saying the outcomes are equivalent, although we all know those studies are BS.

They say "PAs (or NPs depending on the org) provide equal or better care than physicians." That might not be exactly the same as saying they are equivalent, but to the public saying they provide equal or better care is the same as saying they are equal or better. The AANP and AAPA know this.

 

[underthesun]

They say "PAs (or NPs depending on the org) provide equal or better care than physicians." That might not be exactly the same as saying they are equivalent, but to the public saying they provide equal or better care is the same as saying they are equal or better. The AANP and AAPA know this.

Threads like these are just pointless though. I was a healthcare professional prior to medical school and thought that I was hot ****. On the other side of medical school, I know that I was foolish and completely unaware of how much I didn't know. Once, I accidentally stuck an IV in a brachial artery. I didn't think that it was a big deal, and I removed it. What I didn't realize was that brachial artery sticks are notoriously difficult to compress and can be limb-threatening depending on the location of the stick. Dumb people do things like this all of the time in healthcare.

The entrenched nurses/NPs in this thread are the way they are because they haven't gone to med school. If you put them through it, their tune would change dramatically. Even now as an MS4, I feel like I am just starting to catch a glimpse of this vast world of medicine that I know very little about. I would be poorly equipped to operate in a freaking primary care setting at this point.

The bottom line is that these people have no point of reference for their own knowledge base, and it is a fool's errand to try to teach stupid. We're better off establishing our superiority by lobbying and by putting them in their place via unapologetic social media campaigns. Sometimes ya gotta fight fire with fire.

 

[Matthew9Thirtyfive]

Threads like these are just pointless though. I was a healthcare professional prior to medical school and thought that I was hot ****. On the other side of medical school, I know that I was foolish and completely unaware of how much I didn't know. Once, I accidentally stuck an IV in a brachial artery. I didn't think that it was a big deal, and I removed it. What I didn't realize was that brachial artery sticks are notoriously difficult to compress and can be limb-threatening depending on the location of the stick. Dumb people do things like this all of the time in healthcare.

The entrenched nurses/NPs in this thread are the way they are because they haven't gone to med school. If you put them through it, their tune would change dramatically. Even now as an MS4, I feel like I am just starting to catch a glimpse of this vast world of medicine that I know very little about. I would be poorly equipped to operate in a freaking primary care setting at this point.

The bottom line is that these people have no point of reference for their own knowledge base, and it is a fool's errand to try to teach stupid. We're better off establishing our superiority by lobbying and by putting them in their place via unapologetic social media campaigns. Sometimes ya gotta fight fire with fire.

I agree with this whole post, except I wouldn't say "stupid." They aren't necessarily stupid, they're just ignorant (meaning they don't know better). Ignorant =/= stupid. Otherwise, I think you nailed it.

 

[Redpancreas]

Those medfluencer's on instagram are all weird. They all have the same looking profile and the random 10 + stories that nobody cares about.

I personally feel ZDogg came about with good intentions. His material started out as parodying the worst aspects of medicine to combat burn out and encourage thoughtful discussion in the physician community. He made the mistake of letting a significant part of his viewership become NP/PAs who felt like he was speaking to them too. He didn't care at the time because it's just more followers. Now though anytime he says something even remotely related to midlevels not being the same as MD/DOs he creates a firestorm in his own community so he can't afford really afford to speak his mind on that front anymore. I still think he's a net-positive for healthcare. Take the beginning of the pandemic for example and he was a voice for reason about COVID hoaxes, public health, etc. I like him.

Instagram/TikTok/YouTube Medfluencers (MDs/DOs) on the other hand are the worst kinds of people and real sell outs. You can see them from a mile away. They started off as premeds who wore Figs and arranged their desks to look like they were studying for medicine to get brand endorsements. Once they get their medical school acceptance they cash that in for social media clout which allows them to start advertising for overpriced brands while pretending like they're using their social medial presence to "help people apply to med school" when there's really nothing to say besides getting good grades, scoring well on the MCAT, doing volunteer/shadowing stuff, and applying. Then as residents they're "burnt out" after a few months because they went into medicine for all the wrong reasons and are browsing side gig communities looking for how to make money opening sham med spas. I am willing to wager that if a company claimed their luxury mask offered better protection than a surgical mask without a RCT, a lot of medfluencers would roll with it and mislead a lot of people.

 

[Malik144]

It’s relevant because you’re trying to say when you’ve gotten appropriate care. If you aren’t a physician or at the very least a medical student (and even that’s just the bare minimum), then you don’t really know what appropriate care is. You may have not felt like you got good care because you didn’t feel like they did what you wanted or like they didn’t really listen, but that’s subjective. Just because you don’t get what you want doesn’t mean you didn’t get appropriate care. People who want antibiotics for their “sinus infection” or bronchitis and don’t get them will tell you they got crappy care, but they’re wrong.



I’m only a second year med student, but I’ve been in healthcare for over a decade. I have worked with surgeons I wouldn’t let take a skin tag off me whose patients feel like they’re the best thing since sliced bread because they are friendly and personable to them. They are still terrible surgeons.

While I believe the patient’s perception of their care is important because having your patient buy into the treatment is a crucial part of adherence, patient satisfaction does not determine good care.

My feelings about my own care are by definition objective. If i feel sad, and i say im sad. (objective). If i feel sad and you tell me i'm not. (subjective). I'm sure you've written enough HPI's to know the distinction. In order for a point to be fact, it has to also inversely correlate. With your logic, if a medical student or higher deems care appropriate, that makes it appropriate. You keep using drug abuse and improper prescribing, i've already made the distinction above.

You're saying that there are more factors to care than individual perception. Which is my point so i don't know what your argument is.

I didn't say patient satisfaction determines good care. I said people are entitled to their perception of their care.

If as an M2 you compare your self in anyway to a Physician or practicing APP, than best of luck truly to you in all endeavors. However, i can debate feelings in my profession anytime i choose, looking for more fact based conversation.

 

[DrNotaDr]

I am definitely interested in that research, i appreciate you for spreading data with your perspective. I would give a little push back on the agenda of AANP. I 100% agree they did/ do use the pandemic as a way of gaining more autonomy. I just think that this is a common place tactic, from a pure business standpoint. "Patients at risk", i listened to a podcast by one of the co-author's. A synopsis was done and one of the examples was the death of a young women, explained by the interpretations of the actions by an NP. The Physicians for Patient care used example of "bad medicine" to push the agenda that all APP's are untrained and didn't really differentiate NP's from PA's. She even compared their clinical hours to less than barbers and cosmetologists. In reality a genius tactic and any objective person who isnt familiar with healthcare would say "The chart says this, let me google it".

You would see that this is true on the surface but i would say the majority of the population would either stop there or not look at all (thanks social media). The other smaller subset, would maybe dive deeper but still not enough to know the different models and governing boards of PA's and NP's. Than an even smaller subset of people would break down education, vs clinical hours, vs resume, vs gpa, vs competitiveness, full time vs part time, prior training ect ect. The nerds (me lol) as the laymen would call it. Than you objectively say, that's a misrepresentation of data.

I don't think either tactic for pushing an agenda is right but i think it has to be acknowledge that this a commonplace business tactic not reserved to any group.

I think AMA is too split to make that consensus. It seems that they got enough push back from Physicians to retract the tweet that they made about CRNA, NP'S and PA's but still enough support to stand their ground. I also don't think this is and education issue. DO's are still seen as less than by MD's and i really don't know any DO's who actually practice osteopathic medicine. I think the teamcare prospective come from the idea that if PA's are doing 75%-90% of a Physicians job, we have to analyze a situation. Does an "EM PA" whose been trained and working with an EM Attending for a decade have comparable knowledge or more so than a EM fellow? To what degree are they able to use their knowledge and how can they become a bigger part of the healthcare team?

There seems to be narrative that APP's are individuals who didnt want to go to medical school. I don't like this ideology because i do believe that medicine both PA school and MD/DO school is class restricted. The argument to that i usually hear is, "i was poor and i went to medical school, it takes dedication and hard-work". While i do agree with that sentiment, we also have to consider multiple variables. Access to education, environment, degree of poverty, family, lifestyle, workplace discrimination and bias ect ect. You have to dedicate a big portion of your life to being a Physician and i think if there was more access to becoming a Physician most would go that route.

Rural area statistics i've see kind of point in the direction that it's impossible for PA's and NP's to work in rural area's even if they wanted too. 12% of physicians work in rural area's and about 18% of NP's and 12% of PA's. Small population size, professional advancement and appropriate workload/pay isn't regulated. Also since supervision is required they really don't have much in ways of job opportunity. Even if there are about 100k physicians practicing in rural area's, that gives us about 54k NP's and 20k. Family own practices can use nurses, MA's and other physicians. So why would they hire NP's/PA's, who make 95-120k on average. Healthcare professionals shouldn't use money or their career as a way of avoiding rural area's or certain settings/patients. However, i would say no one is likely to take a job or work in a setting they know will have a negative impact on their career, family or mental health.

I'm going to read the article on anesthesia you gave and once again i appreciate it. I dont wan't to speak on a topic i haven't research on yet. However i will say i did notice something that seemed a little deceiving. It says 2/3 of summary research were independently funded but they were all researched by Physicians. I'm assuming the 1/3 was by AMA or Physician affiliates but assumptions make an ass out of you me, so excuse me ahead of time.
I'm not sure who the funding was coming from but i think knowing the organization who funded it can lead to more clear bias but i could also say that independently doesn't mean non-biased/ unaffiliated to any means.

I'm going to look through all the data of course, I would also note that, miller et al 2015 from what I've skimmed thus far is saying due to "affiliations of Anesthesiologist, "the numbers are less likely to be accurate for NP solo practice". I don't know to what degree affiliation is being considered but it also does seem to have potential bias interpretation. Again to research i will go!

Silber et al 2000
-Jeffrey H. Silber, MD, PhD
Memtsoudis et al 2012
-Stavros G. Memtsoudis, MD, PhD
Miller et al 2015 (QZ Study
-Dr. Amr E. Abouleish, MD
James F Cawley MPH-PA-C

Anesthesiologist direction and patient outcomes - PubMed

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

pubmed.ncbi.nlm.nih.gov

That studies data is 30 years old. There are attendings practicing medicine today who weren’t alive when that data was collected. Not impressed.

 

[Malik144]

Threads like these are just pointless though. I was a healthcare professional prior to medical school and thought that I was hot ****. On the other side of medical school, I know that I was foolish and completely unaware of how much I didn't know. Once, I accidentally stuck an IV in a brachial artery. I didn't think that it was a big deal, and I removed it. What I didn't realize was that brachial artery sticks are notoriously difficult to compress and can be limb-threatening depending on the location of the stick. Dumb people do things like this all of the time in healthcare.

The entrenched nurses/NPs in this thread are the way they are because they haven't gone to med school. If you put them through it, their tune would change dramatically. Even now as an MS4, I feel like I am just starting to catch a glimpse of this vast world of medicine that I know very little about. I would be poorly equipped to operate in a freaking primary care setting at this point.

The bottom line is that these people have no point of reference for their own knowledge base, and it is a fool's errand to try to teach stupid. We're better off establishing our superiority by lobbying and by putting them in their place via unapologetic social media campaigns. Sometimes ya gotta fight fire with fire.

You're an MS4. I'll be honest, most people know if you stick a needle into something big, it will get a hole. Nurses, who put in more IV's than anyone, i imagine understand the concept of artery compliance and pressure. Please use facts. Your intelligence is not a reflection on other people's intelligence.

"Sometimes you have to fight fire with fire". Isn't that exactly what AMA complaints are with AAPA and AANP organizations, using Covid as fear tactics to gain practice authority. Please stop commenting on others intelligence. Thank you in advance.

 

[Matthew9Thirtyfive]

My feelings about my own care are by definition objective. If i feel sad, and i say im sad. (objective). If i feel sad and you tell me i'm not. (subjective).

Honestly I stopped here because this makes zero sense. If you don’t even understand the difference between objective and subjective measures, then there’s not really much else to say.

 

[DrNotaDr]

Honestly I stopped here because this makes zero sense. If you don’t even understand the difference between objective and subjective measures, then there’s not really much else to say.

The point he’s making is perception is reality, and healthcare is a capitalistic enterprise. It’s a valid point.

 

[Matthew9Thirtyfive]

The point he’s making is perception is reality, and healthcare is a capitalistic enterprise. It’s a valid point.

And like I said, if your perception is that your physician is not giving you good care, find another one. Your perception is subjective and does not necessarily mean you are not getting good care. I gave multiple examples of this. It is not a difficult concept.

 

[DrNotaDr]

And like I said, if your perception is that your physician is not giving you good care, find another one. Your perception is subjective and does not necessarily mean you are not getting good care. I gave multiple examples of this. It is not a difficult concept.

So the doctor who’s giving good care but the patient doesn’t perceive their care as good gets destroyed on Yelp or rate my doctor or gives “never” answers on press ganey and hospital loses business and money. So perception equals reality.