Physicians and Midlevels

[Pink Angel]

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I keep reading on medical websites about the terms primary care provider, provider, and midlevel. Some people don’t mind being referred to as a midlevel and others get extremely offended because they feel being called a midlevel as a nurse practitioner or physician assistant is saying they provide a lower standard of medical care.

People keep talking about a shortage of primary care providers. What I don’t understand is why physicians that didn’t get a residency slot are not treating patients like midlevel providers do. A physician before residency has more complex training so why aren’t they getting malpractice insurance, treating patients, and in some states working independently like midlevel providers. Patients should have the option of seeing a physician that didn’t get a residency slot instead of a nurse practitioner or physician assistant. A physicians training and standards are the same in each state. Physicians that didn’t get a slot, residents, and attendings are all physicians.

Please tell me what nurse practitioners and physician assistants can do that a physician without residency can’t do. Why are physicians without residency not filling the primary care shortage?

 

[Law2Doc]

I keep reading on medical websites about the terms primary care provider, provider, and midlevel. Some people don’t mind being referred to as a midlevel and others get extremely offended because they feel being called a midlevel as a nurse practitioner or physician assistant is saying they provide a lower standard of medical care.

People keep talking about a shortage of primary care providers. What I don’t understand is why physicians that didn’t get a residency slot are not treating patients like midlevel providers do. A physician before residency has more complex training so why aren’t they getting malpractice insurance, treating patients, and in some states working independently like midlevel providers. Patients should have the option of seeing a physician that didn’t get a residency slot instead of a nurse practitioner or physician assistant. A physicians training and standards are the same in each state. Physicians that didn’t get a slot, residents, and attendings are all physicians.

Please tell me what nurse practitioners and physician assistants can do that a physician without residency can’t do. Why are physicians without residency not filling the primary care shortage?

A physician without residency is not useful. You learn how to be a doctor in residency. basically you are a sports car without an engine -- the foundation is there, but not what makes it useful.

Midlevels don't provide equivalent levels of care, but for what they are qualified to do, experience trumps a med school education.

There is no mechanism for someone on the MD path to become a PA or NP or equivalent. They are separate careers with separate training and certification. It's the same as asking why cant someone who washes out of the police academy just go become a fireman, since they both have jobs involving sirens.

The shortage of physicians isn't a shortage of non physician care. You can only address it with residency trained physicians, probably getting them to redistribute themselves to undersubscribed regions. So the people who don't get into residencies are not part of the solution. We aren't facing a shortage of non physicians.

 

[neusu]

There is no mechanism for someone on the MD path to become a PA or NP or equivalent. They are separate careers with separate training and certification. It's the same as asking why cant someone who washes out of the police academy just go become a fireman, since they both have jobs involving sirens.

Your analogy is laughable.

Simply because there currently is not a mechanism for an MD without residency to practice does not mean that in the future there can not or will not be such an avenue. Historically, an MD graduate would complete an internship, hang up a shingle, and be the doctor. Unfortunately, changing medial dynamics, often spurred by insurance companies and litigation, has pushed medicine to the expectation of board certification and specialization.

 

[mimelim]

Your analogy is laughable.

A fireman's job and a policeman's job have about as much in common as a PA/NP and an MD.

 

[Perrotfish]

A fireman's job and a policeman's job have about as much in common as a PA/NP and an MD.

NPs are hired to do the exact same job as physicians. Maybe you don't think they're qualifed to do it, and maybe you want the system to change back to what it was before they entered the market, but the fact remains that they see the same patients at the same clinic and perscribe the same medications. How in the world are an MD and an NP as different as a fireman and a policeman?

Simply because there currently is not a mechanism for an MD without residency to practice does not mean that in the future there can not or will not be such an avenue.

For there to be such an avenue we would need to go back to a time when medical students could accumulate significant experience IN medical school. When this sytems was designed medical students actually did thing in school: surgeries, minor procedures, following patients on the ward without close supervision, etc. They did this all under the distant supervision of attendings, just like Interns and residents do now. That's where the experience came from. As it is that kind of experience has been kicked up the ladder to Intern year and increasling into the later years of residency. Medical school now is more about book learning and box checking. Medical students therefore graduate without much in the way of real experience, and therefore aren't ready to practice.

 

[facetguy]

For there to be such an avenue we would need to go back to a time when medical students could accumulate significant experience IN medical school. When this sytems was designed medical students actually did thing in school: surgeries, minor procedures, following patients on the ward without close supervision, etc. They did this all under the distant supervision of attendings, just like Interns and residents do now. That's where the experience came from. As it is that kind of experience has been kicked up the ladder to Intern year and increasling into the later years of residency. Medical school now is more about book learning and box checking. Medical students therefore graduate without much in the way of real experience, and therefore aren't ready to practice.

What do you see as ways of making improvements to the medical education system?

 

[swamprat]

Yeah but idk I work with an np student currently in a family med office that went straight through from nursing school into this 1.5 year program and she knows nothing. She's there for half days has some lectures etc and that's it. In a year she will be able to practice independently even in some states.. I'm teaching her things. And I oddly don't understand how u can treat and diagnose things if uve never heard of them like I'm sure they go through basics of htn diabetes etc but there is soo much more things I feel u have to know to practice competently and not hurt someone. It just doesn't make any sense to me how this even happens although it makes me laugh sometimes now when I hear ppl worried there gunna take physician jobs lol

 

[mimelim]

NPs are hired to do the exact same job as physicians. Maybe you don't think they're qualifed to do it, and maybe you want the system to change back to what it was before they entered the market, but the fact remains that they see the same patients at the same clinic and perscribe the same medications. How in the world are an MD and an NP as different as a fireman and a policeman?

A fireman and a policeman are hired to drive government vehicles and respond to 911 calls. Therefore their jobs are exactly the same right?

There are aspects of a physician's job that were historically reserved for only physicians. People have long since realized that those aspects can be performed by NPs, PAs, and a whole host of others. Personally, this is a good thing. It is inefficient for physicians to be bogged down in a lot of aspects of medicine, including large parts of primary care. I am a big advocate of midlevel providers taking over a lot of those roles. Not only because I personally have no interest in those, but because it will be more cost effective without sacrificing quality. One does not need to go through bachelors, MD, and residency to diagnose and treat a lot of ambulatory conditions and perhaps even 90%+ of the volume at a given practice. Some, if not many MDs choose to go into specialties or simply practices that can be replaced by a good midlevel. However...

On the other hand, some of us are being trained slightly differently. I sewed a 6 day old's aorta together a week ago. In the same procedure, I learned how to do a coronary artery bypass on that same 6 day old. Now, I could teach a high school student how to sew an anastamosis and if one was reasonably gifted, they could physically do what I am being taught. But, they would not have the training or the know how to know when to operate or even when to take the many different turns that we took during that case. It is easy to look at a cookbook and know how to follow a recipe, the hard part is being able to adapt and practice good medicine when there either isn't a recipe to follow.

Now, many medical schools may be poor teachers and students may be poor learners, but undergrad and medical school isn't about learning content. It is about learning how to think, to prepare you to be a problem solver. While not everyone will subscribe to this philosophy, if one compares medical school to PA or nursing schooling, this is crystal clear.

The point is that while the field in which NPs and MDs practice may be the same, they are distinct professions with distinct training paths. While there will be some blurring of the rolls at one or several interfaces, by and large they are very different. There are a lot of NPs that work on our teaching services. They are very interchangeable with our residents on the floor, if anything they are superior to us on the floor. They are there explicitly, to reduce the floor load so that we can spend more time in the OR and in clinic, to afford us a better learning experience. Other than being able to do floor work the same as us, there is almost nothing in common.

 

[mimelim]

For there to be such an avenue we would need to go back to a time when medical students could accumulate significant experience IN medical school. When this sytems was designed medical students actually did thing in school: surgeries, minor procedures, following patients on the ward without close supervision, etc. They did this all under the distant supervision of attendings, just like Interns and residents do now. That's where the experience came from. As it is that kind of experience has been kicked up the ladder to Intern year and increasling into the later years of residency. Medical school now is more about book learning and box checking. Medical students therefore graduate without much in the way of real experience, and therefore aren't ready to practice.

I agree that this is a disturbing trend and schools make it more and more difficult to get the good experiences that you are talking about. However, I first assisted with 50+ cases as a medical student with either just the attending or fellow. I carried the team pager and handled floor calls. Heck, I even ran two trauma activations as an MS4. The opportunities to learn through experience exist. They simply must be looked for rather than forced on you as a student. At the same time, nursing and PA schools are going the same direction with very little real practical experience gleaned from time in school.

 

[duckie99]

Yeah but idk I work with an np student currently in a family med office that went straight through from nursing school into this 1.5 year program and she knows nothing. She's there for half days has some lectures etc and that's it. In a year she will be able to practice independently even in some states.. I'm teaching her things. And I oddly don't understand how u can treat and diagnose things if uve never heard of them like I'm sure they go through basics of htn diabetes etc but there is soo much more things I feel u have to know to practice competently and not hurt someone. It just doesn't make any sense to me how this even happens although it makes me laugh sometimes now when I hear ppl worried there gunna take physician jobs lol

This is very true. I have worked with multiple NP and PA students as well as NPs and PAs who have significant experience. The students are essentially totally useless and no better than a M2 would be. New NPs and PAs are no better than M3s.

The NPs and PAs with lots of experience are like midlevel residents in whatever field they are in and depending on the exact job they do. For example, a peds NP and PA I saw both with lots of experience in the outpatient setting saw the more basic patients with less issues going on. The biggest difference was the depth of knowledge they both possessed compared to the physician. The physician was far superior. The same is true for a ICU NP I worked with. She was decent at what she did and just as good as an upper level resident or fellow (who has done several ICU rotations) BUT this NP had no knowledge beyond the algorithms. She was good at stabilizing patients, sending off lots of labs, starting the algorithm antibiotics, etc but she could not make detailed differential diagnoses, know what to do if the algorithm wasn't working, etc. Suffice to say I could generate a better differential than her and answer the "pimp" questions when she could not (she wasn't pimped because there would be no point). However the physician was pretty dang smart and had no trouble handling these issues having a very deep level of knowledge. Furthermore, this NP could only do stuff in the ICU, she would not be able to function well on the wards vs clinic etc while the physician was also pulm trained and could do bronchs, have clinic, followed ward patients with various issues, etc.

Also NPs and PAs are often delegated to very specific tasks. A great example is in the OR or cath lab. They are first assists. That is it. They do not see ward patients or clinic patients. They are just very good at being the first assist and therefore increase productivity.

The reason only med students and very early residents are worried is because 1. they don't know very much themselves, 2. haven't worked with NP/PA students, 3. haven't worked with actual NPs or PAs. Once you all have it will become obvious that midlevels are not much of a threat. People do not want to see the "nurse" or "physician assistant"... they want the physician.

 

[notbobtrustme]

Your analogy is laughable.

Simply because there currently is not a mechanism for an MD without residency to practice does not mean that in the future there can not or will not be such an avenue. Historically, an MD graduate would complete an internship, hang up a shingle, and be the doctor. Unfortunately, changing medial dynamics, often spurred by insurance companies and litigation, has pushed medicine to the expectation of board certification and specialization.

Answer this question:

Would you refer yourself or a family member to a physician who wasn't board-certified or board-eligible. sight unseen?

 

[neusu]

Answer this question:

Would you refer yourself or a family member to a physician who wasn't board-certified or board-eligible. sight unseen?

Vs a PA/NP? Absolutely.

 

[88845]

Vs a PA/NP? Absolutely.

+1

I'd rather see a mechanism for non-residency trained USIMGs / FMGs to practice at the current mid-level scope of practice than to see further expansion of PA / NP independence.

 

[mimelim]

Vs a PA/NP? Absolutely.

There is a PA that works in one of the surgical ICUs that I trained in. I would trust him over any of the residents or critical care MDs with my family members. Limited scope of practice, but in that instance, absolutely no question in my mind, minute by minute management, he was the best clinician there.

When it comes to care in a specific instance, WHO the individual is matters a hell of a lot more than the NP, PA, MD, DO, or PhD after their name. If you seriously think a seasoned PA/NP is inferior to a non-residency trained MD or even a residency trained MD that is simply bad, you are getting poorer care.

 

[FSU2013]

I can't be sure, but I think ya'll just got trolled.

 

[KnuxNole]

This is very true. I have worked with multiple NP and PA students as well as NPs and PAs who have significant experience. The students are essentially totally useless and no better than a M2 would be. New NPs and PAs are no better than M3s.

The NPs and PAs with lots of experience are like midlevel residents in whatever field they are in and depending on the exact job they do. For example, a peds NP and PA I saw both with lots of experience in the outpatient setting saw the more basic patients with less issues going on. The biggest difference was the depth of knowledge they both possessed compared to the physician. The physician was far superior. The same is true for a ICU NP I worked with. She was decent at what she did and just as good as an upper level resident or fellow (who has done several ICU rotations) BUT this NP had no knowledge beyond the algorithms. She was good at stabilizing patients, sending off lots of labs, starting the algorithm antibiotics, etc but she could not make detailed differential diagnoses, know what to do if the algorithm wasn't working, etc. Suffice to say I could generate a better differential than her and answer the "pimp" questions when she could not (she wasn't pimped because there would be no point). However the physician was pretty dang smart and had no trouble handling these issues having a very deep level of knowledge. Furthermore, this NP could only do stuff in the ICU, she would not be able to function well on the wards vs clinic etc while the physician was also pulm trained and could do bronchs, have clinic, followed ward patients with various issues, etc.

Also NPs and PAs are often delegated to very specific tasks. A great example is in the OR or cath lab. They are first assists. That is it. They do not see ward patients or clinic patients. They are just very good at being the first assist and therefore increase productivity.

The reason only med students and very early residents are worried is because 1. they don't know very much themselves, 2. haven't worked with NP/PA students, 3. haven't worked with actual NPs or PAs. Once you all have it will become obvious that midlevels are not much of a threat. People do not want to see the "nurse" or "physician assistant"... they want the physician.

Unless they don't tell the patient they are a nurse or assistant, or places where people aren't paying attention to who is examining them...

 

[link2swim06]

There is a PA that works in one of the surgical ICUs that I trained in. I would trust him over any of the residents or critical care MDs with my family members. Limited scope of practice, but in that instance, absolutely no question in my mind, minute by minute management, he was the best clinician there.

When it comes to care in a specific instance, WHO the individual is matters a hell of a lot more than the NP, PA, MD, DO, or PhD after their name. If you seriously think a seasoned PA/NP is inferior to a non-residency trained MD or even a residency trained MD that is simply bad, you are getting poorer care.

I think that is a fair point. However, few of us have the luxury of knowing more than a few PA/NP's that well.

For sake of discussion we are comparing everything against the average NP/PA.

Here is an example which shows the ridiculousness in comparing extremes: Michael Jackson's doctor didn't even know how to do CPR correctly. Most summer lifeguards likely would have...does this mean lifeguards know more about medicine than doctors? Of course not.

 

[moto_za]

There is a NP at the hospital I work at who introduces herself as the hospitalist 😱

 

[Perrotfish]

What do you see as ways of making improvements to the medical education system?

I wasn't exactly describing a problem. Though I do think there are many problems with medical education, the book learning in your first through third years of medical school aren't it. They're foundational work for when you actually begin to get experience as a resident. In fact of the 8 miserable years you spend getting to residency, I would say that 75% of the actual learning happens in those two.

If I would change anything, I would try to streamline this process to make it shorter. Eliminate undergrad. Get rid of some MS1 classes. Have profession specific tracks so that future Pediatricians don't spend a 12 weeks doing surgery rotations (and vice versa). I think you should be able to get to residency within 5 years of graduating from high school, maybe less.

I might also change the way residency was structured, and go back a formal intern year an then something like a journeyman license where you're licensed to work, but for the first several years you need to work for someone else with a license until you get a full license.

However I think that MS3's book learning paired with a responsibility free 'fake doctor' year is one of the few sane developments in this system. I wouldn't change it. I just also wouldn't ask any medical school graduate for medical advice before they've completed Intern year, because they don't have any real experience yet.

 

[Law2Doc]

There is a NP at the hospital I work at who introduces herself as the hospitalist 😱

Yeah, Many NPs are holding themselves out a doctor, and are even allowed to thanks to the DNP degree. Additionally there are many venues where you go to see a "doctor", but all they have are NPs. The CVS and Walmart clinics see tons of patients, and the NP acts as "doctor" and patients don't care. The notion that patients only want to see the doctor and not n NP is absurdly inaccurate. The patient just wants to see someone in a white coat. 90% of your patients will have no clue what schooling or training you have.

It s foolish and short sighted to suggest that this doesn't adversely impact all doctors, even if the infringement is not yet into your specialty. It's just a matter of time.

But back to the OPs original question, no you aren't qualified to work as a Midlevel. Without residency, you aren't qualified to do much.

 

[Pink Angel]

A physician without residency is not useful. You learn how to be a doctor in residency. basically you are a sports car without an engine -- the foundation is there, but not what makes it useful.

Midlevels don't provide equivalent levels of care, but for what they are qualified to do, experience trumps a med school education.

There is no mechanism for someone on the MD path to become a PA or NP or equivalent. They are separate careers with separate training and certification. It's the same as asking why cant someone who washes out of the police academy just go become a fireman, since they both have jobs involving sirens.

The shortage of physicians isn't a shortage of non physician care. You can only address it with residency trained physicians, probably getting them to redistribute themselves to undersubscribed regions. So the people who don't get into residencies are not part of the solution. We aren't facing a shortage of non physicians.

It looks like (links below) in Wisconsin PAs don't need experience and a lot of the program can be done online. Even if a person doesn't get a slot they are still an MD and I don't understand why physicians can't treat patients with a limited scope of practice like a PA/NP. Physicians could use their training, get experience, pay off debt, and try to get another residency slot.

http://www.physicianassistantforum.com/forums/showthread.php/37857-Online-PA
http://www.fammed.wisc.edu/pa-program/distance-education

 

[SpecterGT260]

NPs are hired to do the exact same job as some physicians in some states. Maybe you don't think they're qualifed to do it, and maybe you want the system to change back to what it was before they entered the market, but the fact remains that they see the same patients at the same clinic and perscribe the same medications. How in the world are an MD and an NP as different as a fireman and a policeman?

FTFY.

Unless I am mistaken, most states still require some level of physician collaboration for NPs to practice, and then, it is nearly exclusively primary care (hence the "some physicians"). They are trying to break into psych and pain, but so far the courts have been on our side more often than not.

 

[SpecterGT260]

It looks like (links below) in Wisconsin PAs don’t need experience and a lot of the program can be done online. Even if a person doesn't get a slot they are still an MD and I don’t understand why physicians can’t treat patients with a limited scope of practice like a PA/NP. Physicians could use their training, get experience, pay off debt, and try to get another residency slot.

http://www.physicianassistantforum.com/forums/showthread.php/37857-Online-PA
http://www.fammed.wisc.edu/pa-program/distance-education

you are talking about an MD not matching when you say "are still an MD" right?

I had always thought that there was some capacity to work once licensed (post intern year). Is that not a thing anymore? Yes, that is post match as well so kind of off topic, but some of the posts have maybe implied that this doesn't work anymore.

 

[Textbookversion]

you are talking about an MD not matching when you say "are still an MD" right?

I had always thought that there was some capacity to work once licensed (post intern year). Is that not a thing anymore? Yes, that is post match as well so kind of off topic, but some of the posts have maybe implied that this doesn't work anymore.

The issue is almost exclusively with IMG/FMG's. Most states require them to do a full 3 year residency before getting an unrestricted medical license. So the issue is an intern year isn't enough.

For those with an unrestricted medical license yes there are some opportunities like urgent care or starting your own practice. Pretty tough/impossible to get malpractice coverage or privileges at a hospital or on insurance panels but that doesn't preclude being a GP. The question is why you'd ever deal with all those drawbacks (and the financial consequences of them) as a US grad (md or do) when there are unfilled FM/IM residencies.

 

[SpecterGT260]

The issue is almost exclusively with IMG/FMG's. Most states require them to do a full 3 year residency before getting an unrestricted medical license. So the issue is an intern year isn't enough.

For those with an unrestricted medical license yes there are some opportunities like urgent care or starting your own practice. Pretty tough/impossible to get malpractice coverage or privileges at a hospital or on insurance panels but that doesn't preclude being a GP. The question is why you'd ever deal with all those drawbacks (and the financial consequences of them) as a US grad (md or do) when there are unfilled FM/IM residencies.

Oh I agree. I just thought maybe the law had changed but I guess not.

Sent from my DROID RAZR using SDN Mobile

 

[iheartsharks]

http://www.fsmb.org/usmle_eliinitial.html

This link breaks it down by state.

Sent from my ADR6300 using Tapatalk

 

[Law2Doc]

Oh I agree. I just thought maybe the law had changed but I guess not.

Sent from my DROID RAZR using SDN Mobile

A US grad can apply for a license after intern year in most states. IMGs generally require 2 or more years of residency. The MD doesn't qualify you to do anything until you are licensed, just as a JD doesn't qualify you to do anything until you pass the bar. That's just the norm in a license based profession. Without the license, you are not a Doctor, you are not a midlevel. Basically you are just a guy with a worthless piece of paper, that you hopefully can convert into value down the road. You don't become a doctor until you jump through all the hoops of licensure, which in this country is 1-3 years of residency (based on states and depending on whether you are IMG), passage of all the steps, and approval after investigation by a state agency. Until then, saying you are "still an MD" is pretty hollow.

Not to mention that most of the people on here with a few years of residency under their belt will be quick to tell you that you learn medicine and doctoring in residency, not in med school. It's nice to feel like you've accomplished something when you received your MD, but truth of the matter is you aren't at the "doctor" level yet, just the doctorate level.

 

[badasshairday]

Well for what it is worth, after intern year I will be looking into moonlighting in urgent care, low acuity ED, or LTAC. I will also be continuing my training in my specialty. The side money and keeping up clinical skills is my motivation for moonlighting. I will have taken Step 3 though.

 

[SpecterGT260]

A US grad can apply for a license after intern year in most states. IMGs generally require 2 or more years of residency. The MD doesn't qualify you to do anything until you are licensed, just as a JD doesn't qualify you to do anything until you pass the bar. That's just the norm in a license based profession. Without the license, you are not a Doctor, you are not a midlevel. Basically you are just a guy with a worthless piece of paper, that you hopefully can convert into value down the road. You don't become a doctor until you jump through all the hoops of licensure, which in this country is 1-3 years of residency (based on states and depending on whether you are IMG), passage of all the steps, and approval after investigation by a state agency. Until then, saying you are "still an MD" is pretty hollow.

Not to mention that most of the people on here with a few years of residency under their belt will be quick to tell you that you learn medicine and doctoring in residency, not in med school. It's nice to feel like you've accomplished something when you received your MD, but truth of the matter is you aren't at the "doctor" level yet, just the doctorate level.

Ok thanks 👍 This is what I thought. I guess I got a little confused reading some of the earlier posts. Looking back they did say this after all.

 

[ophthope]

Well for what it is worth, after intern year I will be looking into moonlighting in urgent care, low acuity ED, or LTAC. I will also be continuing my training in my specialty. The side money and keeping up clinical skills is my motivation for moonlighting. I will have taken Step 3 though.

I'm doing a prelim medicine intern year this year before starting an Ophthalmology residency and I'm curious as to which moonlighting opportunities you feel comfortable working in with your intern year? I'd like to keep up those basic medicine skills and make some side cash if I can.

 

[FSU2013]

I'm doing a prelim medicine intern year this year before starting an Ophthalmology residency and I'm curious as to which moonlighting opportunities you feel comfortable working in with your intern year? I'd like to keep up those basic medicine skills and make some side cash if I can.

A lot or states won't let you moonlight your first year.

 

[45408]

NPs are hired to do the exact same job as physicians.

No, they're not. They're physician extenders. They see the consults initially and write notes or do post-op checks, but they don't do caths for the cardiologists, ERCPs for the gastroenterologists or CABGs for the CT surgeons. They don't even get to decide who gets those procedures.

Maybe you don't think they're qualifed to do it, and maybe you want the system to change back to what it was before they entered the market, but the fact remains that they see the same patients at the same clinic and perscribe the same medications. How in the world are an MD and an NP as different as a fireman and a policeman?

There's a huge world outside of sitting in clinic and filling out scripts.

For there to be such an avenue we would need to go back to a time when medical students could accumulate significant experience IN medical school. When this sytems was designed medical students actually did thing in school: surgeries, minor procedures, following patients on the ward without close supervision, etc. They did this all under the distant supervision of attendings, just like Interns and residents do now. That's where the experience came from. As it is that kind of experience has been kicked up the ladder to Intern year and increasling into the later years of residency. Medical school now is more about book learning and box checking. Medical students therefore graduate without much in the way of real experience, and therefore aren't ready to practice.

Agreed on this part.

Have profession specific tracks so that future Pediatricians don't spend a 12 weeks doing surgery rotations (and vice versa). I think you should be able to get to residency within 5 years of graduating from high school, maybe less.

But then you're just asking a high school senior (or someone 1-2 years after that) if they want to be a pediatrician or a otolaryngologist. I think there needs to be a longer common track.

 

[mehc012]

I keep reading on medical websites about the terms primary care provider, provider, and midlevel. Some people don't mind being referred to as a midlevel and others get extremely offended because they feel being called a midlevel as a nurse practitioner or physician assistant is saying they provide a lower standard of medical care.

People keep talking about a shortage of primary care providers. What I don't understand is why physicians that didn't get a residency slot are not treating patients like midlevel providers do. A physician before residency has more complex training so why aren't they getting malpractice insurance, treating patients, and in some states working independently like midlevel providers. Patients should have the option of seeing a physician that didn't get a residency slot instead of a nurse practitioner or physician assistant. A physicians training and standards are the same in each state. Physicians that didn't get a slot, residents, and attendings are all physicians.

Please tell me what nurse practitioners and physician assistants can do that a physician without residency can't do. Why are physicians without residency not filling the primary care shortage?

Wait, guys...this one is actually a DIFFERENT PA vs MD debate. It's not discussing PAs doing MD jobs, it's attempting to ask why non-BC MDs can't be hired in a PA role.

Valid question...I personally can't think of why they would be unable to fulfill that role. I suppose it's more a matter of licensing: there simply isn't much (if any) demand for a MD-to-PA license conversion. Most people who put in the work and time to earn their MD would want to reap the benefits (a physician's job). I don't know the stats on how many students don't match or how many residents fail to pass the boards, but I imagine that the final number of non-BC MDs who actually give up on becoming licensed physicians is not large enough (or vocal/reputable enough) to effect any change in licensing policies. Furthermore, it wouldn't exactly benefit the educational systems either...it costs a lot more money to pay for med school and residency than to train a PA, so no one really wins by transitioning some MDs to PA.

I suppose it could be useful for recent MD grads to earn some money before/during residency without the liability risks of moonlighting? I know that malpractice/liability issues often prevent moonlighting during research years, but perhaps if they worked in a PA role, that issue could be circumvented and it could be an opportunity to earn some extra cash?

 

[Law2Doc]

Wait, guys...this one is actually a DIFFERENT PA vs MD debate. It's not discussing PAs doing MD jobs, it's attempting to ask why non-BC MDs can't be hired in a PA role.

Valid question...I personally can't think of why they would be unable to fulfill that role. I suppose it's more a matter of licensing: there simply isn't much (if any) demand for a MD-to-PA license conversion. Most people who put in the work and time to earn their MD would want to reap the benefits (a physician's job). I don't know the stats on how many students don't match or how many residents fail to pass the boards, but I imagine that the final number of non-BC MDs who actually give up on becoming licensed physicians is not large enough (or vocal/reputable enough) to effect any change in licensing policies. Furthermore, it wouldn't exactly benefit the educational systems either...it costs a lot more money to pay for med school and residency than to train a PA, so no one really wins by transitioning some MDs to PA.

I suppose it could be useful for recent MD grads to earn some money before/during residency without the liability risks of moonlighting? I know that malpractice/liability issues often prevent moonlighting during research years, but perhaps if they worked in a PA role, that issue could be circumvented and it could be an opportunity to earn some extra cash?

It's not a new question -- this one comes up every few months, by folks who can't find or complete residencies. PA and NP are separate fields from physician. Sure there is overlap in healthcare knowledge, but for state purposes they are distinct jobs with distinct roles and it's not like one is a stepping stone to the other such that if you can't make the next step, this is a fallback. A PA isn't a partially trained MD, and it's an exercise in futility to query why an incompletely trained MD can't just go and be a PA. Not to mention that there's a Huge liability issue as MDs get held to a much higher expectation in litigation. Your MD is a License to be sued based on superior knowledge. So your insurance costs as an MD dwarf that of the PA, as litigation judgments will be much higher. So given the choice to hire a PA versus an MD without residency, you have to hire the PA every time, because if less liability, more focused and differing training, and less likelihood to be hoping to change jobs. So really it's a very old, moot question and not worth thinking about.

 

[SpecterGT260]

It's not a new question -- this one comes up every few months, by folks who can't find or complete residencies. PA and NP are separate fields from physician. Sure there is overlap in healthcare knowledge, but for state purposes they are distinct jobs with distinct roles and it's not like one is a stepping stone to the other such that if you can't make the next step, this is a fallback. A PA isn't a partially trained MD, and it's an exercise in futility to query why an incompletely trained MD can't just go and be a PA. Not to mention that there's a Huge liability issue as MDs get held to a much higher expectation in litigation. Your MD is a License to be sued based on superior knowledge. So your insurance costs as an MD dwarf that of the PA, as litigation judgments will be much higher. So given the choice to hire a PA versus an MD without residency, you have to hire the PA every time, because if less liability, more focused and differing training, and less likelihood to be hoping to change jobs. So really it's a very old, moot question and not worth thinking about.

In many schools, the full extent of PA training is somewhere between "practically" to "literally" MS2-MS3 years of medical school. As it is safe to assume that any graduated medical student has also passed MS2-3, I actually do see a pretty valid argument for allowing non-matched medical students to be hired as PAs. Of course it is probably a legal/license thing that stops it at the state level, but I can't think of any valid reason other than red tape that stops this from happening.

The liability thing can be easily written away as well... Because there isn't a precedent for this yet it is all speculation on both of our parts.


However, non-matching medical grads are a pretty small group all together, so the original question about why can't they fill the gap is kind of a moot point. You aren't really going to plug that cannonball hole in your boat with a few handfulls of sawdust.

 

[mehc012]

It's not a new question -- this one comes up every few months, by folks who can't find or complete residencies. PA and NP are separate fields from physician. Sure there is overlap in healthcare knowledge, but for state purposes they are distinct jobs with distinct roles and it's not like one is a stepping stone to the other such that if you can't make the next step, this is a fallback. A PA isn't a partially trained MD, and it's an exercise in futility to query why an incompletely trained MD can't just go and be a PA. Not to mention that there's a Huge liability issue as MDs get held to a much higher expectation in litigation. Your MD is a License to be sued based on superior knowledge. So your insurance costs as an MD dwarf that of the PA, as litigation judgments will be much higher. So given the choice to hire a PA versus an MD without residency, you have to hire the PA every time, because if less liability, more focused and differing training, and less likelihood to be hoping to change jobs. So really it's a very old, moot question and not worth thinking about.

Sorry! I didn't mean to imply that it was new...all I was saying was that it was a different question than the discussion was answering!

I think it's worth a little more consideration than that. I do understand the liability and insurance issues, though I apologize that my references to them were buried in a ramble of text before...However, I see those as constraints imposed by the current system, rather than obstacles limiting us TO this system.

As I said before, I believe the knowledge is there, but the demand for MD->PA license conversions is too low to overcome the mountain of red tape. Few med school graduates actually legitimately wish to practice as a PA.

I still think that, if this system were in effect, more people would be interested in moonlighting as a PA during, say, a research year where they were unable to do so as an MD due to liability concerns. Of course, this would be pretty far from ideal from the perspective of those hiring the PA...unlike a career PA, who would lack experience for the first few years and gradually improve, they'd be stuck with a loong cycle of inexperienced midlevels and a high turnover rate. So it wouldn't even really help the shortage even if an equivalency system were somehow implemented; at the end of the day, too few MD graduates would switch to make a difference.

 

[Law2Doc]

In many schools, the full extent of PA training is somewhere between "practically" to "literally" MS2-MS3 years of medical school. As it is safe to assume that any graduated medical student has also passed MS2-3, I actually do see a pretty valid argument for allowing non-matched medical students to be hired as PAs. Of course it is probably a legal/license thing that stops it at the state level, but I can't think of any valid reason other than red tape that stops this from happening.

The liability thing can be easily written away as well... Because there isn't a precedent for this yet it is all speculation on both of our parts.


However, non-matching medical grads are a pretty small group all together, so the original question about why can't they fill the gap is kind of a moot point. You aren't really going to plug that cannonball hole in your boat with a few handfulls of sawdust.

It's more than just red tape. No group can decide unilaterally that they are equivalently qualified to do the job of another state certified profession. An MS2 or 3 isn't qualified to be a PA because the governing body that certifies the award of PA degree hasn't trained or certified this person, and doesn't deem them qualified, any more then the PA can claim they are qualified to be an NP and so on. And becoming a PA is in no way a stepping stone to becoming a Doctor, --- it's not like you can stop at a point in your training and just be a PA -- it's basically a different highway you are on and they never meet, although perhaps you can argue that to some extent they run parallel for a bit.

And yes, there absolutely is plenty of legal precedent for saying that an MD will get held to a higher legal standard than a PA. You don't get to achieve your MD and then claim, I'm only working as X so I shouldn't be held to the same standard as the MD working as an MD. Doesn't work this way and there's a ton of law that says so. The law bestows upon you a higher duty and expectation of care once you get the MD letters on your name.

So no, this is an old question with a well vetted answer. A doctor is not a PA plus residency. A doctor is. Doctor, PA is a PA. Not the same path or training or certification, so no point whining about an inability to become one.

 

[SpecterGT260]

It's more than just red tape. No group can decide unilaterally that they are equivalently qualified to do the job of another state certified profession. An MS2 or 3 isn't qualified to be a PA because the governing body that certifies the award of PA degree hasn't trained or certified this person, and doesn't deem them qualified, any more then the PA can claim they are qualified to be an NP and so on. And becoming a PA is in no way a stepping stone to becoming a Doctor, --- it's not like you can stop at a point in your training and just be a PA -- it's basically a different highway you are on and they never meet, although perhaps you can argue that to some extent they run parallel for a bit.

And yes, there absolutely is plenty of legal precedent for saying that an MD will get held to a higher legal standard than a PA. You don't get to achieve your MD and then claim, I'm only working as X so I shouldn't be held to the same standard as the MD working as an MD. Doesn't work this way and there's a ton of law that says so. The law bestows upon you a higher duty and expectation of care once you get the MD letters on your name.

So no, this is an old question with a well vetted answer. A doctor is not a PA plus residency. A doctor is. Doctor, PA is a PA. Not the same path or training or certification, so no point whining about an inability to become one.

IIRC the cert for both doctors and PAs goes through a single group. Unlike nurses whose governing body is entirely different

And since anMD cannot work as a PA, how is there legal precedent for this? I am not aware of any MDs working as not MDs in healthcare being sued

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[oldbearprofessor]

And yes, there absolutely is plenty of legal precedent for saying that an MD will get held to a higher legal standard than a PA. You don't get to achieve your MD and then claim, I'm only working as X so I shouldn't be held to the same standard as the MD working as an MD. Doesn't work this way and there's a ton of law that says so. The law bestows upon you a higher duty and expectation of care once you get the MD letters on your name.

L2D: You keep saying this and it puzzles me a bit, at least from my corner of the world. I am NOT disagreeing with you, I just am confused by this. Lets suppose the standard of care is that anyone who attends a newborn delivery should be able to provide expected NRP standard of care including intubation. Now, in many hospitals the "first provider" who is there at the delivery is a non-physician, often nurses or sometimes PAs. If they fail to provide the standard of care for that situation, in my experience, they (or their carrier, which is usually the hospital) are fully liable. I've never heard anyone say that the standard is different if the first provider has the MD letters (or DO, which I'm sure you meant.🙂)

So, my question is, can you point to specific "law" that says that for performing the same task, a physician is held to a higher standard than someone who does not have an MD but is functioning in the same care role? Really curious about such laws.

Note that this assumes everyone involved is fully NRP certified and thus it is an issue of meeting the standard that they are certified for.

 

[Smurfette]

Personally, I would be concerned that an incompletely trained MD who becomes a PA may overstep their role. A case of the individual not knowing what s/he doesn't know, or thinking they can handle something beyond their training and abilities, and perhaps failing to ask for help when it's needed. Or feeling like s/he has "something to prove", which could be dangerous when it comes to patient care. For someone who is used to the MD training and role to suddenly become a PA and work under someone else, to whom they are accountable, takes some getting used to.

 

[Mass Effect]

For there to be such an avenue we would need to go back to a time when medical students could accumulate significant experience IN medical school

How much experience do PAs accumulate while IN PA school? It's my understanding that PA rotations are just about identical to third-year rotations in med school. Is this not the case? If so, then how can you argue that PAs are qualified to hold a PA job upon graduation, but MDs/DOs aren't?

 

[Law2Doc]

L2D: You keep saying this and it puzzles me a bit, at least from my corner of the world. I am NOT disagreeing with you, I just am confused by this. Lets suppose the standard of care is that anyone who attends a newborn delivery should be able to provide expected NRP standard of care including intubation. Now, in many hospitals the "first provider" who is there at the delivery is a non-physician, often nurses or sometimes PAs. If they fail to provide the standard of care for that situation, in my experience, they (or their carrier, which is usually the hospital) are fully liable. I've never heard anyone say that the standard is different if the first provider has the MD letters (or DO, which I'm sure you meant.🙂)

So, my question is, can you point to specific "law" that says that for performing the same task, a physician is held to a higher standard than someone who does not have an MD but is functioning in the same care role? Really curious about such laws.

Note that this assumes everyone involved is fully NRP certified and thus it is an issue of meeting the standard that they are certified for.

It's a pretty basic legal principle, and based on case law not statute. You can look up what cases cover standard of care for physicians and non physicians and you'll find language to this effect, with regional variations ( maybe check out a Hornbook like Prosser on Torts if you are seriously interested.) standard of care isn't just with respect to the action, but it is standard of expected conduct based on your level of experience and underlying degree. And not to mention that whether the standard of care was met is decided by the jury, and they are more likely to decide the MD should have known better. Basically an md is a Target on your back. Alternatively, if you have MDs and non MDs doing similar functions, you can just check with your insurer and see what the premiums they are paying for each of the parties.

 

[oldbearprofessor]

It's a pretty basic legal principle, and based on case law not statute. You can look up what cases cover standard of care for physicians and non physicians and you'll find language to this effect, with regional variations ( maybe check out a Hornbook like Prosser on Torts if you are seriously interested.) standard of care isn't just with respect to the action, but it is standard of expected conduct based on your level of experience and underlying degree. And not to mention that whether the standard of care was met is decided by the jury, and they are more likely to decide the MD should have known better. Basically an md is a Target on your back. Alternatively, if you have MDs and non MDs doing similar functions, you can just check with your insurer and see what the premiums they are paying for each of the parties.

I don't agree about the jury being more likely to decide against you in the example I posted related to neonatal resuscitation. But that's okay, I'm probably wrong.

 

[andon]

Unfortunately, changing medial dynamics, often spurred by insurance companies and litigation, has pushed medicine to the expectation of board certification and specialization.

preach.

 

[link2swim06]

How much experience do PAs accumulate while IN PA school? It's my understanding that PA rotations are just about identical to third-year rotations in med school. Is this not the case? If so, then how can you argue that PAs are qualified to hold a PA job upon graduation, but MDs/DOs aren't?

Why would any US grad want to become a PA?

Do 1 year of internship at 50% of a PA's pay, take step 3 and get an unrestricted medical license. Granted you would have to commute to rural areas to find a job....but you would still do far better than any PA.

 

[SpecterGT260]

Why would any US grad want to become a PA?

Do 1 year of internship at 50% of a PA's pay, take step 3 and get an unrestricted medical license. Granted you would have to commute to rural areas to find a job....but you would still do far better than any PA.

actually I kinda doubt it.

 

[link2swim06]

actually I kinda doubt it.

Avg PA salary is in mid 90s. Moonlighting gigs in rural america are going to easily going to let you break 100K. Probably over 150K.

 

[SpecterGT260]

Avg PA salary is in mid 90s. Moonlighting gigs in rural america are going to easily going to let you break 100K. Probably over 150K.

So nearr avg PCP anyways? Doubtful.

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[link2swim06]

So nearr avg PCP anyways? Doubtful.

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150K isn't the PCP average, closer to 200K. Plus rural pays better anyhow.

Let me put it this way:

$60/hr X 40 hrs week X 50 weeks per year = $120,000

$60/hour is pretty low for a physician....most gigs I hear about pay more.


To be averaging PA pay you would have to be making closer to $45/hr.

 

[SpecterGT260]

150K isn't the PCP average, closer to 200K. Plus rural pays better anyhow.

Let me put it this way:

$60/hr X 40 hrs week X 50 weeks per year = $120,000

$60/hour is pretty low for a physician....most gigs I hear about pay more.


To be averaging PA pay you would have to be making closer to $45/hr.

You said "over 150"

And I said "near avg PCP"

Where is the confusion?

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