Seems like we're getting ripped off, one way or the other

[deleted128562]

With all of the recent threads about PA/NP autonomy (I'm far more worried about NP's), I've been thinking a lot about this. It seems like we as medical students (and soon to be residents) are getting ripped off big time - one way or the other. One of the two following scenarios has to be true. Either:

1) Mid-levels really can provide an equivalent product. I'd hate to admit that's the truth, but we gotta consider the possibility. If this is true, then medical school and residency are a huge waste of time (except perhaps for super specialization) and quite the rip-off. Kind of analogous to that rare jerk professor who makes some poor schlub work in his lab for 8 or 9 years before he'll let them get their PhD, despite them being totally qualified after 4 or 5. I think some serious studies need to be done looking into this (not funded by the nursing union), because if they really do provide an equivalent product then it is time to rebel BIG TIME against the medical education establishment and cut the length and cost of training significantly.

2) Mid-levels do not provide an equivalent product. In this case, our skill set and knowledge are being totally crapped on by government, the public, hospital administrations, etc etc. We are busting our tails to provide a better service, but are not being recognized for what we do. We are told that we have to go through years and years of school, then years and years of residency and fellowship to be competent to practice, but then get slapped in the face when the guy or gal with 1/5 of the training gets to practice "independently" while we are told that we are still not competent to practice on our own during year 6 of residency.

So which is it, Mr. Government, Ms. Hospital, and Mr. Public? Are MD/DO's and mid-levels equivalent or not???? If yes then cut out the insane educational hurdles we go through and let us get to practice after school and an intern year - enough of the years of slave labor. And if no, then cut the crap about us being equivalent, and stop allowing NP's to continue to increase their practice rights. One or the other. But enough of making us go through 10X the pain and then calling everyone the same.

I've had it, and I'm going to get involved.

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[jackets5]

Many mid-levels are very good. Although IMO PA's are far in a way superior to NP's just based on better education, clinical training and in my own personal interactions with them. I felt as a 4th year student i was able to manage a good majority of bread and butter medicine that we saw on the medicine floors or in the clinics that were not complicated. The problem comes when things get complicated and the person dosent know to what to do, ask for help or even recognize that there is a complication. Thats when patients get harmed. Its easy to say just give the mid-levels the easy straight forward cases but you never know which patient has some serious issues going on but it just looks like a basic problem. That is the purpose of residency and fellowship training. Anyone can follow an algorithm to treat diabetes, but figuring out when the basic is starting to get more serious is something the vast majority of mid-levels do not have the training or the background to understand.

 

[oceanillusion42]

With all of the recent threads about PA/NP autonomy (I'm far more worried about NP's), I've been thinking a lot about this. It seems like we as medical students (and soon to be residents) are getting ripped off big time - one way or the other. One of the two following scenarios has to be true. Either:

1) Mid-levels really can provide an equivalent product. I'd hate to admit that's the truth, but we gotta consider the possibility. If this is true, then medical school and residency are a huge waste of time (except perhaps for super specialization) and quite the rip-off. Kind of analogous to that rare jerk professor who makes some poor schlub work in his lab for 8 or 9 years before he'll let them get their PhD, despite them being totally qualified after 4 or 5. I think some serious studies need to be done looking into this (not funded by the nursing union), because if they really do provide an equivalent product then it is time to rebel BIG TIME against the medical education establishment and cut the length and cost of training significantly.

2) Mid-levels do not provide an equivalent product. In this case, our skill set and knowledge are being totally crapped on by government, the public, hospital administrations, etc etc. We are busting our tails to provide a better service, but are not being recognized for what we do. We are told that we have to go through years and years of school, then years and years of residency and fellowship to be competent to practice, but then get slapped in the face when the guy or gal with 1/5 of the training gets to practice "independently" while we are told that we are still not competent to practice on our own during year 6 of residency.

So which is it, Mr. Government, Ms. Hospital, and Mr. Public? Are MD/DO's and mid-levels equivalent or not???? If yes then cut out the insane educational hurdles we go through and let us get to practice after school and an intern year - enough of the years of slave labor. And if no, then cut the crap about us being equivalent, and stop allowing NP's to continue to increase their practice rights. One or the other. But enough of making us go through 10X the pain and then calling everyone the same.

I've had it, and I'm going to get involved.

Preach

 

[chemsmith]

let me earn my MD online in one year from walden and then we can call them equivalent

 

[Silent Cool]

With all of the recent threads about PA/NP autonomy (I'm far more worried about NP's), I've been thinking a lot about this. It seems like we as medical students (and soon to be residents) are getting ripped off big time - one way or the other. One of the two following scenarios has to be true. Either:

1) Mid-levels really can provide an equivalent product. I'd hate to admit that's the truth, but we gotta consider the possibility. If this is true, then medical school and residency are a huge waste of time (except perhaps for super specialization) and quite the rip-off. Kind of analogous to that rare jerk professor who makes some poor schlub work in his lab for 8 or 9 years before he'll let them get their PhD, despite them being totally qualified after 4 or 5. I think some serious studies need to be done looking into this (not funded by the nursing union), because if they really do provide an equivalent product then it is time to rebel BIG TIME against the medical education establishment and cut the length and cost of training significantly.

2) Mid-levels do not provide an equivalent product. In this case, our skill set and knowledge are being totally crapped on by government, the public, hospital administrations, etc etc. We are busting our tails to provide a better service, but are not being recognized for what we do. We are told that we have to go through years and years of school, then years and years of residency and fellowship to be competent to practice, but then get slapped in the face when the guy or gal with 1/5 of the training gets to practice "independently" while we are told that we are still not competent to practice on our own during year 6 of residency.

So which is it, Mr. Government, Ms. Hospital, and Mr. Public? Are MD/DO's and mid-levels equivalent or not???? If yes then cut out the insane educational hurdles we go through and let us get to practice after school and an intern year - enough of the years of slave labor. And if no, then cut the crap about us being equivalent, and stop allowing NP's to continue to increase their practice rights. One or the other. But enough of making us go through 10X the pain and then calling everyone the same.

I've had it, and I'm going to get involved.

http://mynorthwest.com/11/549415/Nurses-care-just-as-good-as-doctors-study-says

 

[oceanillusion42]

http://mynorthwest.com/11/549415/Nurses-care-just-as-good-as-doctors-study-says

awesome

 

[deleted128562]

http://mynorthwest.com/11/549415/Nurses-care-just-as-good-as-doctors-study-says

Fine. So this is my point exactly. If this is true, I am getting ripped off big time by the med school pathway. 4 yrs undergrad + 4 yrs med school + 3-4 yrs EM residency = 11-12 total yrs training. Versus 4 yrs BSN + 1 yr working in ED + 2 yrs NP school (while I can still work full time!) = 7 yrs training. And accordinh to this article I would be an equal or better provider. So if this article is true, I am being needlessly robbed of 4-5 years of my life by the medical establishment. Which should be grounds for some serious lawsuits.

On the other hand, if the article is crap (excellent peer reviewed piece though it is, haha), I am being seriously ripped off by all those who would try to make NPs equivalent to me and write articles like this. And the public is being put in serious danger by being lied to about midlevel equivalency.

One of these two scenarios is true, and doctors are getting majorly screwed over either way.

 

[ivfmd]

So which is it, Mr. Government, Ms. Hospital, and Mr. Public? Are MD/DO's and mid-levels equivalent or not???? If yes then cut out the insane educational hurdles we go through and let us get to practice after school and an intern year - enough of the years of slave labor. And if no, then cut the crap about us being equivalent, and stop allowing NP's to continue to increase their practice rights. One or the other. But enough of making us go through 10X the pain and then calling everyone the same.

I've had it, and I'm going to get involved.

Great question. Who decides equivalence or not? Well, do you all assume that a committee, bureaucrat or politician should decide this question?

How about let the patient decide on a case by case basis?

I understand that the specialty of REI is different because it is a less-bureaucratic medical model, but if you humor me anyway, I'll share with you some real-life examples.

Practice A: All procedures and office visits are performed by MD/DO only.
Practice B: Many procedures and visits are performed by inferior mid-levels who clearly don't do their job nearly as well as the MD/DO's.
Practice C: Many procedures and visits are performed by stellar mid-levels who do as good a job as the MD/DO's.

So in reality, how do things play out?

Practice A is able to command a higher fee and/or higher patient popularity due to the perceived value of "you will get to see the doctor at every visit"
Practice B can accommodate a much higher volume of patients, which lends itself well to signing many managed care contracts, but patient satisfaction is low and most self-pay patients will go elsewhere, while HMO patients will predominate
Practice C commands nearly as high a fee and has nearly as high a patient satisfaction as Practice A.

So who decides if a practice is a B-type where the mid-levels are way inferior to the doctors, or a C-type where the mid-levels are nearly equivalent to the doctor? Some committee? Some politician? Some insurance company?
No. The public does. Over time, patients learn and will migrate to each practice based on their preferences and on their budgets. By the way, patients not only learn from direct interaction. There is quite a bit of dissemination of information via word of mouth, ESPECIALLY within special communities in real life and online. So a SLE support group meets and four of the members rave about Dr. A and his/her office staff. Over time, more patients gravitate to his office. If the members criticize Dr. Z and his/her office, over time, patients leave that office except the ones whose plan makes it more financially desirable for them to stay there and put up with less desirable care.

Also in case you think patients choose solely based on fees, that is completely not true. Time and time again, patients will willingly go out of their network and pay a little bit more out of pocket (sometimes a lot more out of pocket) if they perceive they are getting their money's worth.

OK. Now the counterargument. "There is not enough transparency in medicine to make this work." Fair enough. Just to clarify, that statement loosely translates to "patients do not have access to good intel to know whether a midlevel is as good or not as good as a doctor". Well, yes and no. There is not 100% transparency, but there is not 0% transparency neither. Over time, with the internet, transparency goes up. All of you can attest to that with respect to using Yelp for restaurants or studentdoctor.net for choosing schools / residencies. And the more things that favor a doctor actually caring about his/her reputation, the more powerful the transparency because doctors will not only be motivated to provide great care, they will be motivated to find ways to try and prove to the public that they are providing great care (such as going above and beyond to make the patient experience truly 5-star).

If I help a patient get pregnant, sure they are a little grateful. But they may not rave about it. However, if I help a patient get pregnant and all along the way, my staff give them top of the line service to explain everything, answer their questions, keep waiting room times short, smile pleasantly and be attentive to their needs, they are not only going to be happy. They will make it their life mission to shout it from the highest mountain, to go out to all their friends/family and proclaim the praises of our practice so that in the next five years, many more patients flock to our practice that otherwise would not have known about us. So it's win/win. The patients win because they get great care, even if it means we have to put extra effort in (not always easy). The doctor/practice wins because we get more patients who are willing to compensate us better.

OK, I get it. Transparency is not 100%. When choosing a cytopathologist to read your Pap, you don't have an easy time finding out who is better. When choosing an ER to save your life during the precious seconds that count, you don't have time to check doctor ratings. However, transparency is not 0% neither. And the bottom line is that patients' judgment and opinions count for a lot more than the insurance companies and politicians would want us to believe. The politicians and the insurance companies that lobby them want to set things up so that they have the control to squeeze the doctor between a rock and hard place and to date, they have done a pretty stellar sneaky job of making that reality. Ask any doctor practicing today who also practiced 20 years ago.

I welcome your thoughts.

 

[oceanillusion42]

ivfmd,

You raise valid points and certainly this isn't a cut and dry issue. That being said, I would argue that the public lacks the desire to educate themselves enough to make a decision about their practitioner.

At a basic economic level, people who are satisfied with a service are more likely to continue to utilize it and to spread the word. But that has nothing to do with the care that is being rendered. Obviously you won't revisit a practitioner who did a "bad job" but how does the public really know when a care provider has exhausted all possibilities and has provided their patient with the best service possible? If I see a NP and get a 15 minute visit and a prescription, how do i know that that experience is any better or worse than sitting down with a physician for 15 mintues and getting the same prescription? The public views these as equal and therefore in their mind NP/Dr./PA are essentially all the same. In the case of a visiting a primary care doctor for blood pressure management this may not be far from the truth... a NP will probably give you equivalent care as a physician... and in fact this is the POINT of a midlevel provider.

In cases with increased complexity, however, the tables turn. How can we get the public to recognize what constitutes complexity? Most people are confused enough by all the meds they're on let alone now having to gauge what type of provider they should be seeing. Add to this the fact that all we keep hearing about is how everyone is equal now... physicians are no longer allowed to be the top of the medical hierarchy, we need to spread the wealth. I guess that also reflects society as a whole... no one is allowed to be better than anyone else any more.

The best place to START is to educate the public and that would require a physician response to all the "NPs are better than physicians" nonsense that is popping up all over the place.

 

[ivfmd]

ibut how does the public really know when a care provider has exhausted all possibilities and has provided their patient with the best service possible? If I see a NP and get a 15 minute visit and a prescription, how do i know that that experience is any better or worse than sitting down with a physician for 15 mintues and getting the same prescription?

Thank you. I appreciate your willingness to discuss this.

So let's play out a thought experiment or two.

You get to call the shots. Take a scenario of your choosing, as complex or as simple as you want. This will not be the holy grail to end this debate, because I agree with you that this is not a cut and dried issue.

My position is that "The patient knows enough to be allowed a lot of autonomy in the decision to see a NP or MD and that the patient actually CARES about this issue"
I think your position is, in your words, "the public lacks the desire to educate themselves enough to make a decision about their practitioner. You can modify/clarify if you wish.

First we can distinguish between the public not having a DESIRE to research the difference vs the public not having the CAPABILITY to research the difference.

I can't buy the argument that the public does not have the desire. People are selfish and they care. If it were the case they didn't care, then it's a moot point and it become irrelevant who cares for them, NP or MD. Then bureaucrats/politicians/insurance execs should be able to call the shots, because as is said "the public has no desire to care about the difference"

Therefore, can we then focus on a more relevant argument that the public may not have the CAPABILITY to research the difference? This assumes the public does care what kind of care they get, but they might be able to accurately evaluate it. I'll buy that.

I'll buy that, but again, I will go out on a limb and argue that they actually have enough ability to assess, so that they should be afforded a lot of leeway and power in the decision process.

Shall we play a game?

Let's pick a scenario where two different patients's paths deviate.

Patient A sees MD
Patient B sees NP/PA

You describe the scenario as you desire and make the case for us that the public should not be allowed to make the decision whom to see and that instead the decision should be made for them by some "wiser" or "more benevolent" third party (committee, politician, insurance company folks) instead.

I will not put you on the spot. If anybody else wants to chime in and play, the floor is open.

 

[Silent Cool]

Check out this article:

http://www.ama-assn.org/amednews/2009/06/08/prl10608.htm

 

[FIREitUP]

http://mynorthwest.com/11/549415/Nurses-care-just-as-good-as-doctors-study-says

I lol'd when they spelled "stethascope" wrong

 

[MilkmanAl]

let me earn my MD online in one year from walden and then we can call them equivalent

I dunno, that's pretty much what I did, anyway.

 

[bigkahunaburger]

IVF, I'll play this game, however we first need to address the idea that the public is not able to accurately determine the competence of a physician vs a midlevel. Go look in the NP forums, they aren't even able to determine an answer to that question, hell, they keep wanting to push the envelope for more practice rights. So how can we reasonably expect the public to make this distinction? The public fails to realize the cost of unnecessary labs/imaging studies, nor are they able to (should I say, don't care) reasonably assess antibiotic resistance due to overprescribing. They may go to an NP that gives them a full workup and think that that's great care, or since they have the flu get the abx they want which would also make the NP a hero in their eyes.

 

[ivfmd]

IVF, I'll play this game, however we first need to address the idea that the public is not able to accurately determine the competence of a physician vs a midlevel. Go look in the NP forums, they aren't even able to determine an answer to that question, hell, they keep wanting to push the envelope for more practice rights. So how can we reasonably expect the public to make this distinction? The public fails to realize the cost of unnecessary labs/imaging studies, nor are they able to (should I say, don't care) reasonably assess antibiotic resistance due to overprescribing. They may go to an NP that gives them a full workup and think that that's great care, or since they have the flu get the abx they want which would also make the NP a hero in their eyes.

Good job. You may have come across a potential example where the perceived quality of care by the public may be directly opposed to the reality.

Let me see if I can take the cue and lay out the scenario:

Patient A goes to MD c/o URI sx's and is told "You have a virus. Nothing we can do other than symptom palliation. Get rest. Drink fluids. Go home" Pt dissatisfied.
Patient B goes to NP/PA c/o URI sx's and is told "I am here to save the day. Here is a prescription for GorillaCillin" Pt goes home happy.

Is that a good depiction of what you had in mind? If not, please clarify.

 

[xenotype]

Good job. You may have come across a potential example where the perceived quality of care by the public may be directly opposed to the reality.

Let me see if I can take the cue and lay out the scenario:

Patient A goes to MD c/o URI sx's and is told "You have a virus. Nothing we can do other than symptom palliation. Get rest. Drink fluids. Go home" Pt dissatisfied.
Patient B goes to NP/PA c/o URI sx's and is told "I am here to save the day. Here is a prescription for GorillaCillin" Pt goes home happy.

Is that a good depiction of what you had in mind? If not, please clarify.

This is exactly the point; the public at large doesn't even care that it puts them at risk for antibiotic associated diarrhea, the xanax they want will get them horribly addicted with terrible withdrawal, or the cheeseburgers they eat are slowly killing them. The public is NOT capable of judging the quality of the healthcare they receive, thus they will not be able to make an informed decision between an NP or an MD for care.

 

[FutureInternist]

http://mynorthwest.com/11/549415/Nurses-care-just-as-good-as-doctors-study-says

Check out this article:

http://www.ama-assn.org/amednews/2009/06/08/prl10608.htm

This is comparable to the ever stated but oft false statement regarding females being able to do the same things men can - "just as well, and sometimes better"
It is not PC to say so, so the mantra is repeated over & over again until people start believing it
When I was in residency I started handing out a form that one of the organisations had prepared comparing the hours of teaching/training for residents vs NPs/PAs (I wish I still had it) to a whole bunch of people in the ICU when the NP/PAs were getting a big head about being able to admit (& then do a crappy job) patients to the ICU

 

[bigkahunaburger]

That depiction is correct IVF

 

[ivfmd]

I'll grant you that is pretty good example of a situation where patients fail to accurately assess better care vs worse care.

I also think it tends to support your argument because it brings into play the theoretical harm of other people being harmed. (by cultivating resistant strains).

The situations with the Xanax addition or the iatrogenic diarrhea are bad examples because they WILL know about it if they get those. Loud and clear!

By the way, for those who are on the NP/PA side of the argument, I concede that it's wrong to automatically assume that the MD will not prescribe abx and the NP will. We're just using this as an example.

So in summary, I agree this is an example where the patient THINKS his interests have been served by getting the abx rx, while in reality he wasted some money and may have struck a blow for damage to nature as a whole.

My viewpoint has been swayed. Now instead of believing that patients are wise enough to decide for themselves 85% of the time, I'll adjust my scale to maybe 60%. Thanks!

This is the first time anybody came up with a valid example to that question. Nice job.

 

[einstein1990]

I'm just a lurking premed and don't want to step on toes, but this is a topic which will eventually have an impact on my career. Just wanted to add a thought/observation. My perspective may be irrelevant to many of you, but I think I have a valid point here.

Something that I've noticed is that the general public seems to lack any insight into the education/training that is required for each practitioner's degree. This is a generalization, but many patients are uninformed about medical education as a whole. I'm not sure many people have a clue to what the differences are between these professions. It doesn't help that many new pharmacists, nurses, PAs, etc. all wear white coats, which usually leads people to jump to the conclusion of "doctor". The line is becoming blurred between many professions.

Perhaps if patients knew the vast differences in training that lies behind every degree, they might be less inclined to bite at all of the "NPs can provide equal, if not better, care than doctors" press that's out there. There is a reason that each profession (and education) has the scope of practice that it does. However, I'm sure that even when fully informed, many people would believe their (NPs/PAs/whomevers) education is "good enough". But it's interesting to toy with the idea anyways.

 

[deleted128562]

IVFMD, I have certainly enjoyed your posts (and everyone else's too!). The antibiotic example is good, I will try to broaden the answer now by using an analogy:

I have zero engineering expertise. I would be unable to pick out the bridge designed by a structural engineer versus the one designed by someone unqualified. It's not that I'm dumb or don't want to know which bridge is the safe one - it's just that there is no way for me to be able to determine the answer as I wouldn't know what to look for. Same is true of medicine, the public cannot be expected to understand why certain things should or shouldn't be done. It's not like going to the burger joint where it's obvious if they forgot the cheese or ketchup. Know what I mean?

Now you could say, well hey, you'll know which bridge was designed by the non-engineer when it breaks on you. Two problems though: 1) That is a terrible way to have to find out. 2) What if the guy who designed the bad bridge misrepresented himself as an engineer? Case in point, DNPs calling themselves Doctor in the clinical setting. The patient thinks they are seeing a physician so they don't even know what level of care they are getting.

In the end, all I want to know is if midlevels are equivalent or not. If they are, it is time to bulldoze medical schools and just start using their far more efficient model for everyone. If they are not, it is time to start fighting their militant factions' claims that they are.

 

[oceanillusion42]

This is exactly the point; the public at large doesn't even care that it puts them at risk for antibiotic associated diarrhea, the xanax they want will get them horribly addicted with terrible withdrawal, or the cheeseburgers they eat are slowly killing them. The public is NOT capable of judging the quality of the healthcare they receive, thus they will not be able to make an informed decision between an NP or an MD for care.

This is what I had in mind and I admittedly did a poor job at expressing it (trying to fire off some paragraphs here and there between studying for an exam). I said the public doesn't have the desire to educate themselves... by this I mean that they are both incapable and unwilling. Incapable meaning patients's aren't doctors and as a result are incapable of understanding the intricacies of their care... that's obvious. Unwilling or having a lack of desire comes across in that as a general rule, people are in the dark about health care. They demand tests, treatments, etc. irregardless of cost, effectiveness, etc (i.e. as was stated above: demanding antibiotics for a viral URI). Additionally the majority of people have no idea about the health reform going on in our country. If people wanted to educate themselves and take responsibility for their care they could also use that desire to inform themselves of the aforementioned.

I am politically conservative and the last thing I want (personally) is government run health care and more bureaucracy... I don't believe that will solve our problems. I believe that people should have a choice. I believe that people should be EDUCATED and thus able to make that choice. With healthcare, however, it isnt so simple because in many situations the general public does not possess the knowledge to make an informed choice.

Knowledge and incentive are the two ingredients that must be present for the public to take on a more active role. Knowledge to understand the role of practitioners in their care as well as knowledge to understand the broader healthcare system.... that an ER visit might not be the best choice for your URI, but rather a clinic. The way to make people become educated is to create an incentive. The worlds best incentive? MONEY! If people were held accountable in monetary terms for their healthcare usage then they would be a lot more willing to educate themselves, learn what's important and what's not and understand ways to utilize the health care system efficiently and effectively. (i.e. healthcare savings accounts)

Ultimately, despite an educated populous, there still needs to be a medical authority that oversees midlevel providers and can step in if a patient exceeds their area of clinical comfort. I would like to think that such a midlevel provider would refer said patient to someone with greater expertise, but can you guarantee that that will occur? And if it doesn't and a patient is harmed as a result, the patient will have to live with the fact that they sought care from a midlevel provider and not a physician. Would it have made a difference? Who gets to decide that?

So,
Patient A goes to an MD with ______. Doctor begins treatment with_____. Doctor recognizes complication as they had witnessed a few times during residency and intervenes.

Patient B presents to NP/PA with above and treated as above, but complication is not recognized and pt is left disabled due to ensuing decline.

 

[oceanillusion42]

Now you could say, well hey, you'll know which bridge was designed by the non-engineer when it breaks on you. Two problems though: 1) That is a terrible way to have to find out. 2) What if the guy who designed the bad bridge misrepresented himself as an engineer? Case in point, DNPs calling themselves Doctor in the clinical setting. The patient thinks they are seeing a physician so they don't even know what level of care they are getting.

Awesome point

 

[xenotype]

A good example is wiring in houses. A poorly wired house can be incredibly dangerous to its occupants, from getting 120V just from touching your stove or a short causing a rapidly burning fire. Much of the time, an improperly wired house with a live ground or a lack of a ground can end up hurting no one over decades of being in its condition. Occasionally, the results are tragic. How is the public supposed to know the difference between an electrician that is incompetent or cuts corners and an electrician who is honest and thorough? How many of the people in this thread have any idea whether their dryer/dishwasher/stove or even their entire dwelling are properly grounded? An electrician that has excellent reviews for prompt, friendly, and affordable customer service on Angie's list could be leaving houses in dangerous conditions that take years to become apparent.

This is what standards of competence are there for. Most trained and certified electricians will ensure that houses are safe and up to code. What would happen if you took whatever standards they have and reduced them by 80%? Would the public even notice? How many house fires would it take for people to notice that something was wrong?

 

[xenotype]

Knowledge and incentive are the two ingredients that must be present for the public to take on a more active role. Knowledge to understand the role of practitioners in their care as well as knowledge to understand the broader healthcare system.... that an ER visit might not be the best choice for your URI, but rather a clinic. The way to make people become educated is to create an incentive. The worlds best incentive? MONEY! If people were held accountable in monetary terms for their healthcare usage then they would be a lot more willing to educate themselves, learn what's important and what's not and understand ways to utilize the health care system efficiently and effectively. (i.e. healthcare savings accounts)

HSAs do not reduce healthcare spending reliably because patients forgo necessary care rather than pay the higher upfront fees for preventative medicine. $150 office visits deincentivize taking care of problems before they become catastrophic. Another example of how patients do not know better, and the complexity of economic incentives.

 

[oceanillusion42]

HSAs do not reduce healthcare spending reliably because patients forgo necessary care rather than pay the higher upfront fees for preventative medicine. $150 office visits deincentivize taking care of problems before they become catastrophic. Another example of how patients do not know better, and the complexity of economic incentives.

I'd argue that a restructuring of the health system as a whole would prevent that from happening. HSAs with certain stipulations/requirements (not a 100% HSA model but an HSA "based" model) would ensure that preventative medicine would not be lost. And again, people respond to money... its better to pay $x to manage your diebetes now than $10x to pay for your lantus and humalog down the road. But I don't want to thread-jack.

 

[deleted128562]

Forget my previous feeble analogy.... this one hits it right on the head.

A good example is wiring in houses. A poorly wired house can be incredibly dangerous to its occupants, from getting 120V just from touching your stove or a short causing a rapidly burning fire. Much of the time, an improperly wired house with a live ground or a lack of a ground can end up hurting no one over decades of being in its condition. Occasionally, the results are tragic. How is the public supposed to know the difference between an electrician that is incompetent or cuts corners and an electrician who is honest and thorough? How many of the people in this thread have any idea whether their dryer/dishwasher/stove or even their entire dwelling are properly grounded? An electrician that has excellent reviews for prompt, friendly, and affordable customer service on Angie's list could be leaving houses in dangerous conditions that take years to become apparent.

This is what standards of competence are there for. Most trained and certified electricians will ensure that houses are safe and up to code. What would happen if you took whatever standards they have and reduced them by 80%? Would the public even notice? How many house fires would it take for people to notice that something was wrong?

 

[oceanillusion42]

a good example is wiring in houses. A poorly wired house can be incredibly dangerous to its occupants, from getting 120v just from touching your stove or a short causing a rapidly burning fire. Much of the time, an improperly wired house with a live ground or a lack of a ground can end up hurting no one over decades of being in its condition. Occasionally, the results are tragic. How is the public supposed to know the difference between an electrician that is incompetent or cuts corners and an electrician who is honest and thorough? How many of the people in this thread have any idea whether their dryer/dishwasher/stove or even their entire dwelling are properly grounded? An electrician that has excellent reviews for prompt, friendly, and affordable customer service on angie's list could be leaving houses in dangerous conditions that take years to become apparent.

This is what standards of competence are there for. Most trained and certified electricians will ensure that houses are safe and up to code. What would happen if you took whatever standards they have and reduced them by 80%? Would the public even notice? How many house fires would it take for people to notice that something was wrong?

+1

 

[alpinism]

A good example is wiring in houses. A poorly wired house can be incredibly dangerous to its occupants, from getting 120V just from touching your stove or a short causing a rapidly burning fire. Much of the time, an improperly wired house with a live ground or a lack of a ground can end up hurting no one over decades of being in its condition. Occasionally, the results are tragic. How is the public supposed to know the difference between an electrician that is incompetent or cuts corners and an electrician who is honest and thorough? How many of the people in this thread have any idea whether their dryer/dishwasher/stove or even their entire dwelling are properly grounded? An electrician that has excellent reviews for prompt, friendly, and affordable customer service on Angie's list could be leaving houses in dangerous conditions that take years to become apparent.

This is what standards of competence are there for. Most trained and certified electricians will ensure that houses are safe and up to code. What would happen if you took whatever standards they have and reduced them by 80%? Would the public even notice? How many house fires would it take for people to notice that something was wrong?

Great analogy. Completely agree.

 

[evilbooyaa]

This is a bunch of people patting each other on the back and sharing tales.

You are all preaching to the choir in this forum. I would say if you are serious in your ambitions, then become active, somehow. Best of luck to all of you. My solution for this is to specialize.

As horrible as this sounds, I foresee the future of healthcare being DNPs/PAs that run primary care (independently) and whenever they unfortunately miss something a competent Famiy Med/IM/Peds doc would've caught, they'll end up in the hospital. How often that happens will determine whether MDs get the reins back or not.

 

[xenotype]

This is a bunch of people patting each other on the back and sharing tales.

You are all preaching to the choir in this forum. I would say if you are serious in your ambitions, then become active, somehow. Best of luck to all of you. My solution for this is to specialize.

As horrible as this sounds, I foresee the future of healthcare being DNPs/PAs that run primary care (independently) and whenever they unfortunately miss something a competent Famiy Med/IM/Peds doc would've caught, they'll end up in the hospital. How often that happens will determine whether MDs get the reins back or not.

You are insane if you think they are going to stop at primary care, or that they won't try to do procedures, or that they aren't going to try to take over inpatient/ICU as well.

 

[CDI]

This is a bunch of people patting each other on the back and sharing tales.

You are all preaching to the choir in this forum. I would say if you are serious in your ambitions, then become active, somehow. Best of luck to all of you. My solution for this is to specialize.

As horrible as this sounds, I foresee the future of healthcare being DNPs/PAs that run primary care (independently) and whenever they unfortunately miss something a competent Famiy Med/IM/Peds doc would've caught, they'll end up in the hospital. How often that happens will determine whether MDs get the reins back or not.

Not everyone can specialize though. And here's what I think is the worst part of all...

The US is (basically) forcing the bottom-performing AMGs into primary care positions which they probably don't want. This is happening over the next 3-5 years, right. Now an underperforming AMG with heavy loans may someday have NO residency spot, even their primary care position may be lost to a really good IMG.

Here's a another question, Why/how did we determine that we need 3 years of residency for primary care fields? If DNPs/PAs are proving that they're capable of doing just as much and possibly equally as effectively in less time, maybe there needs to be a movement for shorter residencies. This would effectively drive down the burden on Medicare, and more doctors could be created given the shorter residency. We'd have more MDs.

How much more does a 3rd year (primary care) resident know than a 2nd year resident? I don't know but I bet someone else can answer that.

Bottomline, in a few years, everyone (here in this forum) will be too busy making money while establishing themselves in the system to really care about legislative involvement.

I do plan to take ~20 mins (someday) to write to my local/state representatives with ideas on how to at the least help solve the residency spots problem.

 

[CDI]

HSAs do not reduce healthcare spending reliably because patients forgo necessary care rather than pay the higher upfront fees for preventative medicine. $150 office visits deincentivize taking care of problems before they become catastrophic. Another example of how patients do not know better, and the complexity of economic incentives.

Yep. I have an HSA. Unless I get blindsided by a semi...it's pretty much useless. I need to pay like $5000 out of pocket before it kicks in. I won't be seeing a doctor anytime soon if I can help it.

 

[evilbooyaa]

You are insane if you think they are going to stop at primary care, or that they won't try to do procedures, or that they aren't going to try to take over inpatient/ICU as well.

Agree with you on that. However, I think increasing acuity of care (at least for the most part) will lead there to be at least MD oversight. I think the (unfortunate) thing that is going to need to happen is that NPs will get independent practice, and then 1 of 2 things need to happen: Healthcare costs are not reduced due to excessive testing/imaging, or Patient morbidity/mortality increase significantly compared to a MD supervised practice.

It is quite unfortunate that proper studies to compare NP care (not going to generalize NPs together with PAs for the most part) without oversight (without limiting them to 'easy' cases only) are essentially impossible to get approved.

I would be interested (if it exists) in data between NP/PA run ICUs compared to traditional ICUs (after stratifying patients based on overall acuity and general sickness levels).

 

[xenotype]

I would be interested (if it exists) in data between NP/PA run ICUs compared to traditional ICUs (after stratifying patients based on overall acuity and general sickness levels).

They have a study for that and I believe it was residents vs NP/PA with MD oversight. I don't think the acuity was the same so their results were garbage anyways. They still claim equivalency in ICU anyways. What is the incentive for a hospital/hospital system to keep an MD for oversight?

 

[sazerac]

Yep. I have an HSA. Unless I get blindsided by a semi...it's pretty much useless. I need to pay like $5000 out of pocket before it kicks in. I won't be seeing a doctor anytime soon if I can help it.

I don't think you understand your health insurance plan very well.

The HSA is a savings account, at a bank. It's your money. You can use it to buy an aspirin on Jan 1st if you wanted to. You have an HSA to pay for the usual and predictable medical expenses that crop up during the year.

Your HDHP (high deductible health plan) is what kicks in after you spend the first $5,000 on healthcare. And that's what insurance is, shared risk for unforseen catastrophic costs.

Using health insurance to pay for the first $5,000 in health expenses (and then paying it back right away in premiums) isn't insurance at all... it's financing. It's no different than putting those charges on a visa card and paying it back. Except using health insurance for this task is far less efficient than using Visa or an HSA.

 

[xenotype]

Using health insurance to pay for the first $5,000 in health expenses (and then paying it back right away in premiums) isn't insurance at all... it's financing. It's no different than putting those charges on a visa card and paying it back. Except using health insurance for this task is far less efficient than using Visa or an HSA.

I know it appears to make a lot of sense, but people just are not wired that way. They will avoid seeing a physician if they have to pay sticker price. The low copays seen in PPO plans are there because free means people go too often, but the full price means people avoid it at almost all cost. A 30$ copay means people will go to their PCP if they are feeling cruddy and they are afraid it could be a more serious problem, but it disincentivizes appointments for (in the patient's perspective) frivolous issues. Most people don't even bother doing routine maintenance on their cars and then are shocked when there is a serious problem that costs hundreds to thousands of dollars to fix. You really think they would be willing to fork over $200 every three months for their A1c and an admonition about eating too many ho-hos?

 

[ucbsmd]

I don't think you understand your health insurance plan very well.

The HSA is a savings account, at a bank. It's your money. You can use it to buy an aspirin on Jan 1st if you wanted to. You have an HSA to pay for the usual and predictable medical expenses that crop up during the year.

Your HDHP (high deductible health plan) is what kicks in after you spend the first $5,000 on healthcare. And that's what insurance is, shared risk for unforseen catastrophic costs.

Using health insurance to pay for the first $5,000 in health expenses (and then paying it back right away in premiums) isn't insurance at all... it's financing. It's no different than putting those charges on a visa card and paying it back. Except using health insurance for this task is far less efficient than using Visa or an HSA.

A few mistakes with this info.

You couldn't use HSA money for aspirin unless you have a prescription since changes were made in 2011 if I remember correctly.

The contributions to the HSA are made with pre-tax money. This means that $5000 deductible is really closer to $3500 for those that are employed. Also, for many people with company sponsored HSA's the company provides them with part of their deductible every year where as HDHP's don't tend to have this benefit.

You may have ment FSA (Flex Spend Accounts) which are accounts that you contribute to each year. They are paid with pre-tax money, have don't have premiums (although some do carry a nominal monthly charge of a dollar or two) and unused funds expire at the end of each year(Actually Feb or March of the following year). They have the same restrictions about only being able to be used for co-pay; co-insurance; medical bill for providers and facility; and prescription medications and medical goods.

 

[impact2d]

Good job. You may have come across a potential example where the perceived quality of care by the public may be directly opposed to the reality.

Let me see if I can take the cue and lay out the scenario:

Patient A goes to MD c/o URI sx's and is told "You have a virus. Nothing we can do other than symptom palliation. Get rest. Drink fluids. Go home" Pt dissatisfied.
Patient B goes to NP/PA c/o URI sx's and is told "I am here to save the day. Here is a prescription for GorillaCillin" Pt goes home happy.

Is that a good depiction of what you had in mind? If not, please clarify.

This happens at the clinic I work at all the time. The medical director chewed out a PA for continually prescribing a high level brand new fluroquinolone to everyone with a cough-no fever, no sputum test, and no discoloration of mucous. He told me that he does know a few docs that do this which he finds frustrating, but at least when they over prescribed antibiotics they are smart enough to use a first line antibiotic.

Also, as the nurses adopted the title Doctor the lines become more blurred. We how are patients supposed to know the difference when they introduce themselves as DR Jane, aprn. They don't know acronyms.

We had an NP with 10 years experience and we are a supervision state. While generally competent there were frequent mistakes when it came to prescribing or working with specialists. Primary care docs all rotate through most of the specialties once in med school and often again in residency. To me this understanding of each specialist role and basic protocol is their biggest weakness (and why PAs are better trained IMHO). I've seen them write some odd orders especially with radiology, pathology, cardiac, and labs. One of them didn't know if the patient should be referred to a nephrologist or urologist because she didn't really know the difference. How would she? They don't rotate like med students/residents.


Sent from my SCH-I535 using SDN Mobile

 

[ivfmd]

The participation on this site rivals the sites that are restricted to practicing doctors. Good job.

You bring up many great topics. I'll try to address as many as I can. Here goes.

MISREPRESENTION BY NON DOCTORS: I agree that this is a particularly abhorrent practice. As a resident, we encountered one of the most egregious examples. I can share the essence without revealing identifying info by disguising the details a bit. Imagine a nurse-midwife who, by rule, is required to identify herself as such. So she goes and gets herself an correspondence course PhD in some bogus field like Underwater Basket Weaving or whatever. Easy enough to do. So guess what? Now, she walks into the patient rooms in her long white coat and tells the patients she is Dr. so-and-so. Technically correct, although her doctorate has nothing to do with the practice of medicine. Compound this with a hefty percentage of the patients being Spanish-speaking only and you have a classic situation of egregious misrepresentation. Anyway, regardless of what side you are on in the NP/MD debate, there is no excuse for a NP/PA to be able to call himself/herself a doctor.

VOLUNTARY PERSUASION vs FORCE:
OK, so putting that aside, one of you came up with a great example of the electrician doing wiring in the house and how people don't know the wiring is faulty until the house burns down. Very valid example. I also read where one of you advocated diligent education of the public as an approach. Very good. In my opinion, this is certainly more palatable ethically than clamoring for the use of FORCE to block/curb NP's.

Basically the new question becomes: At what point, if any, can we tell a grown adult patient that because something is so much "for your own good" and because "you are too stupid of a layperson to make an informed decision" that we can force our policy down your throat rather than let you make up your own mind.

An example of using voluntary persuasion would be "Hey, you should know, that this is the danger you face if you allow yourself to be cared for by a NP/PA instead of one of us MD's. Here are a list of cases where a patient was mismanaged by a NP/PA and didn't know about it until years later, an underlying problem was revealed which by then caused great irreversible damage. So I urge you to think twice before you agree to be seen by the NP/PA for your complex health problem". The reason this approach is ethical because it has automatic built-in checks and balances. If in fact, NP/PA's are dangerous in whatever capacity you are citing, then logic dictates, you should easily be able to find examples. Nobody has to make a case that getting drunk and jumping out windows is a bad idea. The Journal of YouTube Stupidity attests to that. If however, this is not for patient protection, but just a case of a more elite ranked individual trying to protect his own interests, his own turf, from lower-cost competition, it will fall flat on its face for lack of any evidence.

In other words, using your great electrician example, one should be able to say "Hey, you think you're saving money using the NP electrician. Well, did you know that last year alone, there were 1000 fatal house fires that resulted from faulty wiring approved by a mid-level electrician! Here is the data. Now are your family's lives really worth saving a few bucks?"

However, if the truth of the matter is that in the past 5 years, there were only 2 fatal house fires from faulty wiring done by mid-level electricians, you could still try to argue it as "Even though it was only 2 fires, what if it were YOUR family that died?", and it might be convincing to some patients (who will then choose to see MD only), and less convincing to others (who will shrug and say, OK I've been warned, but it's not enough to make me avoid the NP/PA).

This use of persuasion rather than force is still the preferred tactic from a moral approach.

Here are some more reasons why, again using your electrician example.

Let's say your best argument is that the MD electrician always flawlessly wires the house while the NP electrician makes an error that results in a fatal fire 10% of the time. If this were the case, you would not need to do much education. The truth would speak for itself. Word would eventually get around quite emphatically and any person with half a brain would be quite insistent to have their house wired by MD only. If this were the case, we would not be even having this debate, because in that case, it would be common knowledge that NP's are vastly inferior to MD's and nobody would gamble any significant healthcare into their hands.

But what if MD electricians were not themselves perfect and their wiring results in 2 fires per 100,000 while NP electricians' wiring results in 5 fires per 100,000? How significant is that difference?
What if the overwhelming majority of these fires were not fatal, but say caused $20000 worth of damage to the house?
What if it costs $10,000 to have your wiring done by MD-level and it costs $3000 to have your wiring done by NP-levels?
What if some companies offered wiring done by NP-levels, but always with a final sign-off by a supervising MD-level?

One of you said it well in that this issue is not cut and dried. It certainly isn't.

Reversing roles and speaking for myself as a patient, I would gladly pay a $5000 deductible to have my angioplasty done by a MD rather than have a free one done by a NP. But if I had a ingrown toenail that needed I&D, would I pay $400 for the MD vs free by the NP? Not sure.

PREACHING TO THE CHOIR: One of you pointed out that the majority of people here have their minds made up on this issue and agree that NP/PA's must be stopped or drastically limited in their scope. Fine. What can you do then? The classic fallacious answer is "WRITE YOUR CONGRESSMAN". "Be an activist to make sure the right people are elected". Do a reality check. Of the 1000's of problems in this country (war, senseless war on marijuana, predatory lawsuits, corporate welfare and bailouts, incarceration of minorities, corruption in government,illiteracy), how many have been resolved satisfactorily by writing congressmen, activism or voting? 99%? 75%? How about < 5%?
Ask yourself of the following which does the most to influence lawmaker actions? Really.
A: Voting
B: Petitions/Activism
C: Letter writing to politicians
or D: Multimillion dollar lobbying by special interests.

OK. It's late and I realize that I could be guilty of being one of those people who point out all the problems without proposing a solution. If we were slaves on a plantation back in the day and I tried to convince you all that the system of slavery is unjust and we need to open our eyes to how wrong it is, you could very justifiably throw back at me "Well, suppose we agree with you that it's wrong. What do we do about it?" my unsatisfying answer is "I don't know. I don't have a fast/powerful solution, but I do believe it STARTS with realizing the nature of the problem is the system itself." Instead of fighting if we should vote for slavemaster A or slavemaster B, perhaps we can begin by examining whether the slavery system is fundamentally corrupt?

Furthermore, although there is no fast/easy GLOBAL solution, I would challenge that there is a solution for each and every one of you on an individual level and those solutions differ from person to person. For one of you it might very well to explore your choice of specialty. For another of you who had her heart set on primary care, it might be exploring the concept of concierge medicine. For another of you, it might be, chill out, accept it for what it is and plan on having great hobbies and family life and seeing your doctor job as a stable way to clock in/clock out and pay the bills.

In any case, I may be at a disadvantage in my arguments because honestly, I love my work. Fundamentally nothing beats the opportunity to change people's lives by the proper manipulation of medicine, surgery and the art of medicine. But my heart still weeps for my colleagues who have grown coldly bitter as they stood by, watching their profession becoming increasingly bureaucratized and overtaken by insurance companies and politicians. Best wishes to all of you. The fact that are engaging in discussion proves that you care.


TL/DR:
1. Persuading the public is a more moral approach than using legal force to disempower lower level competition.
2. Politicians are human beings and as such, will have their own best interests first, so effectively persuading them requires that you have millions to lobby them with

 

[deleted128562]

Enjoying this discussion, thanks everyone for the input! IVFMD, you bring up some great points and I'd like to answer them.

1) Special interest lobbying - yeah, I think you are probably completely right. Writing to our congressman isn't going to do jack squat. Money talks, and that's the sad political reality in this country. We band together and get a lobby stronger than the nursing lobby, and we'll be golden. So perhaps that is where we need to be focusing our efforts. The AMA isn't going to do it, so I think it would require an entirely new group. Something for us all to think about.

2) Voluntary persuasion vs force: You make some excellent points, and being a red-blooded capitalist I by and large have no problem with a free market and customer choice. However, I am not a complete fringe libertarian and I do recognize that there is a role for regulation in certain circumstances. Let me bring up a few points:

a) Like it or not, there are plenty of precedents in this country for minimum requirements to do a job. Can I practice law without a license? Can I teach elementary school without a teaching certificate? I could assist minimally by being a paralegal or a teacher's aide, but no one would ever even think to let me take on a full law or teaching job. So why is it different in medicine? Heck, in my state I could get fined and/or arrested for selling cars to the general public without a license. I'm not even allowed to say I'm equivalent to the used car salesman down the street. So why is this being allowed in medicine?

b) If you do want to allow a free market in medicine, then really make it a free market. How can a government body decide that an NP is just as qualified as an MD, but then at the same time force the MD to pay egregious licensing fees and meet a bunch of requirements (educational and otherwise) that they don't make the NP meet? Isn't this utter hypocrisy? Further, I would be 100% fine with letting PA's, NP's, CNA's, or your cousin Lenny practice independently as long as I don't have to take any of their risk. They screw up, they get sued and lose their house. Seems that NP's want to be "as good or better than a doctor" and practice on their own..... until something goes wrong. At which point Dr. Smith was the supervising doctor that day, so you can go sue him. Nope. Gotta be pay to play. No more of this I'm independent and equal until the crap hits the fan - either you are or you aren't, and you gotta bear the consequences of your choice.

c) Heck, you have to have a NURSING LICENSE to practice NURSING. I 100% guarantee you a good paramedic or even EMT-basic (with a little training in administering meds) could walk into a hospital today and do just fine in 95% of nursing duties, and might well not hurt anyone in doing them. So let's suggest that they start being allowed to go into the hospital as, say, EMT-practitioners, and do the job for a little less $$$. Would be good for hospital bottom lines and the burden on healthcare overall as there are a lot more nurses than doctors. They could even say "All the knowledge of a nurse, with the added benefit of being a first-line emergency provider!". I'm sure the nursing unions would totally go for this one, right? My point being - why do you have to meet certain minimum standards to work as a NURSE - heck to work as a CNA for that matter - but yet we want to allow a totally "free market" to practice MEDICINE?!?!

d) We have to consider not just harm to the individual but societal harm as well. If someone with inadequate training treats an active TB with a fluoroquinolone, mistaking it for PNA, they could see some "results" in the short term while still causing danger down the road to the people who come in contact with this person. This is probably why my city can't hire me and my two pretty smart friends to design a bridge, even though there's a chance we could get it done alright if we set our minds to it. So if Mr. Jones were just risking his own health by going to the NP or ND or your cousin Lenny, then hey cool - but when it starts to risk the health of my family, your family, etc. then an argument can be made for why minimum standards must be in place.

3) This goes back to my original post and a point that still hasn't really been touched on in the conversation. If they government and other bodies eventually agree that an NP is equivalent to an MD, then they have thereby established that the standard for practicing medicine is an NP degree. IN WHICH CASE ALL MEDICAL SCHOOLS SHOULD BE BULLDOZED IMMEDIATELY - because they are far less efficient and far more expensive at putting out providers who meet the standard of practice, which is detrimental to society in terms of costs - both financial and opportunity. If 4 yrs undergrad (BSN) + 2 yrs NP school for a total of 6 YEARS TRAINING is equal to 4 yrs undergrad + 4 yrs med school + 3 yrs residency (minimum) for a total of 11 YEARS TRAINING (at least), then not only are 5 years of my life being ripped off an wasted, but society is being robbed of providers since NP schools can basically churn them out twice as fast. Think of the billions of dollars that would be saved by the government just by no longer having to fund residencies, and think of the benefits to society when twice the competent providers are being churned out.

 

[xenotype]

TL/DR:
1. Persuading the public is a more moral approach than using legal force to disempower lower level competition.
2. Politicians are human beings and as such, will have their own best interests first, so effectively persuading them requires that you have millions to lobby them with

Your opinions are colored by the fact that you are in a well reimbursed procedural specialty that is very isolated from the threat of managed care and midlevels themselves. One must recognize their own biases, and I think your bias is substantial in your attitude and approach towards this problem.

Society is built and bound by legal force. Legal force at the end of the day determines who can do what to whom and how. It determines how you buy a house, a car, how you get a job, how you lose a job, how you establish a business, how that business distributes profit, and how it handles bankruptcy. Legal force determines what you can say, what you cannot say, when you can say it, where you can say it, how you can say it, and what others are allowed to say to you. If you are going to play the morality card, I think it is perfectly moral to use legal force to prevent incompetent or poorly trained individuals from misrepresenting themselves and potentially harming others. I believe that companies shouldn't be allowed to sell peanut butter with deadly E. coli contamination. I believe kids toys shouldn't be allowed to have paint containing toxic compounds. I believe gasoline should be unleaded. I believe the manufacturing plant up the street shouldn't be able to dump its waste into a nearby stream. I believe the use of legal force to prevent these things is moral. Education could be an effective response to all of the above problems, but it would certainly carry a cost in lives lost in the process. Legal force was/is required to solve all of the above problems, because the agents involved had powerful economic incentives to hurt people.

If you believe otherwise, that is why politics exists. Physicians need a powerful and well funded lobby to use legal force to control the expansion of NPs.

You missed a major point of my house fires analogy. It is nearly impossible to know how many house fires are due to poorly trained electricians, or which electricians may be responsible. The number of house fires cannot accurately be tracked or studied, much like how the NP issue has not been well studied. PBS Frontline had an entire series on how many local fire departments have fire investigators that have no qualifications or formal training and are very frequently dead wrong about the cause of fires. Thus we run into the same problem, where you can never know exactly how many house fires are due to MDs vs NPs on average. The data collection capability is not there.

If we had real data on NPs vs MDs, this debate would not even be worth having. If NPs were clearly equivalent, then medical schools need drastic reform. If MDs are clearly superior, then NPs need to be subjugated. It is that simple.

 

[DreamingTheLive]

This is a bunch of people patting each other on the back and sharing tales.

You are all preaching to the choir in this forum. I would say if you are serious in your ambitions, then become active, somehow. Best of luck to all of you. My solution for this is to specialize.

As horrible as this sounds, I foresee the future of healthcare being DNPs/PAs that run primary care (independently) and whenever they unfortunately miss something a competent Famiy Med/IM/Peds doc would've caught, they'll end up in the hospital. How often that happens will determine whether MDs get the reins back or not.

Because DNPs/PAs aren't already infiltrating places like Derm, EM and Anesthesia w/ CRNAs and AAs lol. I don't know **** about the surgical specialties but I'm sure there is something brewing there as well.

 

[DreamingTheLive]

The participation on this site rivals the sites that are restricted to practicing doctors. Good job.

You bring up many great topics. I'll try to address as many as I can. Here goes.

MISREPRESENTION BY NON DOCTORS: I agree that this is a particularly abhorrent practice. As a resident, we encountered one of the most egregious examples. I can share the essence without revealing identifying info by disguising the details a bit. Imagine a nurse-midwife who, by rule, is required to identify herself as such. So she goes and gets herself an correspondence course PhD in some bogus field like Underwater Basket Weaving or whatever. Easy enough to do. So guess what? Now, she walks into the patient rooms in her long white coat and tells the patients she is Dr. so-and-so. Technically correct, although her doctorate has nothing to do with the practice of medicine. Compound this with a hefty percentage of the patients being Spanish-speaking only and you have a classic situation of egregious misrepresentation. Anyway, regardless of what side you are on in the NP/MD debate, there is no excuse for a NP/PA to be able to call himself/herself a doctor.

VOLUNTARY PERSUASION vs FORCE:
OK, so putting that aside, one of you came up with a great example of the electrician doing wiring in the house and how people don't know the wiring is faulty until the house burns down. Very valid example. I also read where one of you advocated diligent education of the public as an approach. Very good. In my opinion, this is certainly more palatable ethically than clamoring for the use of FORCE to block/curb NP's.

Basically the new question becomes: At what point, if any, can we tell a grown adult patient that because something is so much "for your own good" and because "you are too stupid of a layperson to make an informed decision" that we can force our policy down your throat rather than let you make up your own mind.

An example of using voluntary persuasion would be "Hey, you should know, that this is the danger you face if you allow yourself to be cared for by a NP/PA instead of one of us MD's. Here are a list of cases where a patient was mismanaged by a NP/PA and didn't know about it until years later, an underlying problem was revealed which by then caused great irreversible damage. So I urge you to think twice before you agree to be seen by the NP/PA for your complex health problem". The reason this approach is ethical because it has automatic built-in checks and balances. If in fact, NP/PA's are dangerous in whatever capacity you are citing, then logic dictates, you should easily be able to find examples. Nobody has to make a case that getting drunk and jumping out windows is a bad idea. The Journal of YouTube Stupidity attests to that. If however, this is not for patient protection, but just a case of a more elite ranked individual trying to protect his own interests, his own turf, from lower-cost competition, it will fall flat on its face for lack of any evidence.

In other words, using your great electrician example, one should be able to say "Hey, you think you're saving money using the NP electrician. Well, did you know that last year alone, there were 1000 fatal house fires that resulted from faulty wiring approved by a mid-level electrician! Here is the data. Now are your family's lives really worth saving a few bucks?"

However, if the truth of the matter is that in the past 5 years, there were only 2 fatal house fires from faulty wiring done by mid-level electricians, you could still try to argue it as "Even though it was only 2 fires, what if it were YOUR family that died?", and it might be convincing to some patients (who will then choose to see MD only), and less convincing to others (who will shrug and say, OK I've been warned, but it's not enough to make me avoid the NP/PA).

This use of persuasion rather than force is still the preferred tactic from a moral approach.

Here are some more reasons why, again using your electrician example.

Let's say your best argument is that the MD electrician always flawlessly wires the house while the NP electrician makes an error that results in a fatal fire 10% of the time. If this were the case, you would not need to do much education. The truth would speak for itself. Word would eventually get around quite emphatically and any person with half a brain would be quite insistent to have their house wired by MD only. If this were the case, we would not be even having this debate, because in that case, it would be common knowledge that NP's are vastly inferior to MD's and nobody would gamble any significant healthcare into their hands.

But what if MD electricians were not themselves perfect and their wiring results in 2 fires per 100,000 while NP electricians' wiring results in 5 fires per 100,000? How significant is that difference?
What if the overwhelming majority of these fires were not fatal, but say caused $20000 worth of damage to the house?
What if it costs $10,000 to have your wiring done by MD-level and it costs $3000 to have your wiring done by NP-levels?
What if some companies offered wiring done by NP-levels, but always with a final sign-off by a supervising MD-level?

One of you said it well in that this issue is not cut and dried. It certainly isn't.

Reversing roles and speaking for myself as a patient, I would gladly pay a $5000 deductible to have my angioplasty done by a MD rather than have a free one done by a NP. But if I had a ingrown toenail that needed I&D, would I pay $400 for the MD vs free by the NP? Not sure.

PREACHING TO THE CHOIR: One of you pointed out that the majority of people here have their minds made up on this issue and agree that NP/PA's must be stopped or drastically limited in their scope. Fine. What can you do then? The classic fallacious answer is "WRITE YOUR CONGRESSMAN". "Be an activist to make sure the right people are elected". Do a reality check. Of the 1000's of problems in this country (war, senseless war on marijuana, predatory lawsuits, corporate welfare and bailouts, incarceration of minorities, corruption in government,illiteracy), how many have been resolved satisfactorily by writing congressmen, activism or voting? 99%? 75%? How about < 5%?
Ask yourself of the following which does the most to influence lawmaker actions? Really.
A: Voting
B: Petitions/Activism
C: Letter writing to politicians
or D: Multimillion dollar lobbying by special interests.

OK. It's late and I realize that I could be guilty of being one of those people who point out all the problems without proposing a solution. If we were slaves on a plantation back in the day and I tried to convince you all that the system of slavery is unjust and we need to open our eyes to how wrong it is, you could very justifiably throw back at me "Well, suppose we agree with you that it's wrong. What do we do about it?" my unsatisfying answer is "I don't know. I don't have a fast/powerful solution, but I do believe it STARTS with realizing the nature of the problem is the system itself." Instead of fighting if we should vote for slavemaster A or slavemaster B, perhaps we can begin by examining whether the slavery system is fundamentally corrupt?

Furthermore, although there is no fast/easy GLOBAL solution, I would challenge that there is a solution for each and every one of you on an individual level and those solutions differ from person to person. For one of you it might very well to explore your choice of specialty. For another of you who had her heart set on primary care, it might be exploring the concept of concierge medicine. For another of you, it might be, chill out, accept it for what it is and plan on having great hobbies and family life and seeing your doctor job as a stable way to clock in/clock out and pay the bills.

In any case, I may be at a disadvantage in my arguments because honestly, I love my work. Fundamentally nothing beats the opportunity to change people's lives by the proper manipulation of medicine, surgery and the art of medicine. But my heart still weeps for my colleagues who have grown coldly bitter as they stood by, watching their profession becoming increasingly bureaucratized and overtaken by insurance companies and politicians. Best wishes to all of you. The fact that are engaging in discussion proves that you care.


TL/DR:
1. Persuading the public is a more moral approach than using legal force to disempower lower level competition.
2. Politicians are human beings and as such, will have their own best interests first, so effectively persuading them requires that you have millions to lobby them with

Bring up many valid points and I appreciate reading the ongoing dialogue. However, your perspective seems similar to a lot of Attendings that I've talked with who have already "made it"....they generally tend to not really give a **** what happens to future physicians/turf battels w/ PAs, etc...they've got their money, had a good run, and a lot of them have admittedly told me they're "wiping their hands clean of all the **** going on"...they don't consider it their fight. Sad.

 

[evilbooyaa]

Because DNPs/PAs aren't already infiltrating places like Derm, EM and Anesthesia w/ CRNAs and AAs lol. I don't know **** about the surgical specialties but I'm sure there is something brewing there as well.

Atleast in EM and Anesthesia (AFAIK), I am doubtful that people in these fields want absolutely 0 oversight into all of their activities.

If an EM PA is the slightest bit unsure of the diagnosis, he/she almost immediately consults the attending on staff.

If a CRNA notes some slightly refractory hypotension, the call immediately goes out to the covering anesthesiologist.

The issue with outpatient medicine is that there is not the same acuity present on a daily basis. If a true surgical emergency is not recognized by the ED, or hypotension not quickly controlled by anesthesia, patients die. People aren't happy when their friends and family die.

There will definitely be attempts at infiltration, but I think midlevel autonomy will be an outpatient model (at least at first), and we'll see where it goes from there.

 

[ivfmd]

Bring up many valid points and I appreciate reading the ongoing dialogue. However, your perspective seems similar to a lot of Attendings that I've talked with who have already "made it"....they generally tend to not really give a **** what happens to future physicians/turf battels w/ PAs, etc...they've got their money, had a good run, and a lot of them have admittedly told me they're "wiping their hands clean of all the **** going on"...they don't consider it their fight. Sad.

Hmm, that's harsh. But I can understand your thinking. I'll tell you, though, that the very reason I'm here is because I DO care. Very very much. I just don't think your strategy is going to bear fruit for you. Sure, you are entitled to choose whatever tactic you want to put your energy towards to advance your future. If your way works, then I'm happy for you. However, if I have reasonable suspicion that what you are doing will not effectively benefit you, I can either respectfully present my case and warn you or I can choose to live my happy life and let you fall. Right?

Let me see if I get this straight. Clarify if you will, but this is how I see your view to be.

"One of our immediate enemies is the PA/NP community who want to intrude on our turf. If we MD's gather together and beg the politicians really really hard, they will throw us a bone and change the laws to limit PA/NP's. So let's give more and more power to our trusted friends, the politicians, and have them USE that power on our behalf"

If you think that is the solution to get enough doctors mass effect together, then I can see why you would get mad at any other fellow doctor who doesn't want to play your way. Fine. I can understand that.

So meanwhile, what do you think the PA/NP's are doing? They are joining forces and collectively going to the politicians (and the corporations that influence them) and begging as hard as THEY can to let them do more. They are saying "Let's give the politicians more and more power so that they can use that power on our behalf"

Elsewhere, the patient population who want access to quality care at cheap prices (or maybe even for free) are saying, "Let's give the politicians more and more power to take over healthcare so that we can get at "those greedy doctors" whose fees are obviously too high and force them to work more for less pay so we can get free universal healthcare.

Meanwhile the politicians are thrilled to see all the peons fighting among ourselves. They will placate the doctors, placate the NP's, placate the patients with eloquent words of promise.

As they pretend to listen to all three groups, they will REALLY listen to those who contribute the most to their campaign fund. The AMA and whatever the NP/PA version of that is called will never make a dent in the actions of the lawmakers. I am sure of that.

But you are welcome to go ahead and go for it. Spend your energy giving over more power to the politicians on the hopes that they will look out for you. If it works, great! If it doesn't, then come back and we'll talk.

Unless, you are right and I really don't care. Then I'll guess I'll be somewhere else.

 

[JP2740]

"Most of what we take care of is the primary care types of things such as diabetes, hypertension, birth control, shortness of breath." Smithing said these are all conditions doctors normally treat.

 

[ivfmd]

If we had real data on NPs vs MDs, this debate would not even be worth having. If NPs were clearly equivalent, then medical schools need drastic reform. If MDs are clearly superior, then NPs need to be subjugated. It is that simple.

Does it have to be one answer and one answer only?

Is it possible that there are some tasks in which NP's are near equivalent, which makes it highly inefficient for a intensively-trained doctor to be doing those tasks? Is it possible that there are other tasks in which MD's are clearly superior and NP's should not be doing at all?

This doesn't even have to be universally defined one answer and one answer only for each specific task or procedure. It can also depend on the individual MD and NP, involved, the supporting infrastructure of the hospitals/facilities and the system by which each team member interacts or is supervised.

Central-planning attempts at solutions tend to fail because they do not consider case-by-case but rather paint with a one-size-fits-all brush.

 

[JP2740]

Is it possible that there are some tasks in which NP's are near equivalent,.

no

 

[DreamingTheLive]

Hmm, that's harsh. But I can understand your thinking. I'll tell you, though, that the very reason I'm here is because I DO care. Very very much. I just don't think your strategy is going to bear fruit for you. Sure, you are entitled to choose whatever tactic you want to put your energy towards to advance your future. If your way works, then I'm happy for you. However, if I have reasonable suspicion that what you are doing will not effectively benefit you, I can either respectfully present my case and warn you or I can choose to live my happy life and let you fall. Right?

Let me see if I get this straight. Clarify if you will, but this is how I see your view to be.

"One of our immediate enemies is the PA/NP community who want to intrude on our turf. If we MD's gather together and beg the politicians really really hard, they will throw us a bone and change the laws to limit PA/NP's. So let's give more and more power to our trusted friends, the politicians, and have them USE that power on our behalf"

If you think that is the solution to get enough doctors mass effect together, then I can see why you would get mad at any other fellow doctor who doesn't want to play your way. Fine. I can understand that.

So meanwhile, what do you think the PA/NP's are doing? They are joining forces and collectively going to the politicians (and the corporations that influence them) and begging as hard as THEY can to let them do more. They are saying "Let's give the politicians more and more power so that they can use that power on our behalf"

Elsewhere, the patient population who want access to quality care at cheap prices (or maybe even for free) are saying, "Let's give the politicians more and more power to take over healthcare so that we can get at "those greedy doctors" whose fees are obviously too high and force them to work more for less pay so we can get free universal healthcare.

Meanwhile the politicians are thrilled to see all the peons fighting among ourselves. They will placate the doctors, placate the NP's, placate the patients with eloquent words of promise.

As they pretend to listen to all three groups, they will REALLY listen to those who contribute the most to their campaign fund. The AMA and whatever the NP/PA version of that is called will never make a dent in the actions of the lawmakers. I am sure of that.

But you are welcome to go ahead and go for it. Spend your energy giving over more power to the politicians on the hopes that they will look out for you. If it works, great! If it doesn't, then come back and we'll talk.

Unless, you are right and I really don't care. Then I'll guess I'll be somewhere else.

You're right. That came across as way too harsh. I apologize for that...I really ment that the other attendings I referenced...sorry again. I really do appreciate your input into this forum and of course, the fact that you DO care. Sorry again.