(Serious) Why do 4th year students need supervision but midlevels don't?

[W19]

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Before you get riled up, try reading the thread/posts. We’re talking about med students BEFORE they finish 3rd/4th year 🙄

No one here claims a finishing 2nd year med student is better than a PA... We are talking about 3rd/4th year.

 

[neusu]

Not to pour gas on the fire, but it made no sense to me how the med student, resident, and MLP supervision is determined.

For example, me, as a PGY-7 chief resident in neurosurgery needed supervision for everything from writing, to clipping aneurysms or doing brain stem tumors to daily progress notes to seeing patients in the ER or clinic. Meanwhile, day 1 out of school PA/NP was fully independent.

To add a whole level of dynamic, I could not bill for anything. They could. So my experience doing hundreds of bedside central lines or ventricular drains counted for naught, but their 2 years of school made the difference.

 

[W19]

You may wish to know my qualifications. I was a prior lobbyist (had a fancier name, but lets call it what it is) for the AMA. If there is a person more against inappropriate practice by midlevels - i haven't met them. I got the job because i was so good at towing the pro-doctor line. But there is totally appropriate practice environments too.

Let me put it that way because people are arguing different things in this thread.

A newly NP vs. someone who just graduated from a US med school... Who do you think has more medical knowledge?

 

[niko327]

So PA magically learn these thing after 12 months of clinical training...

No W19. You missed the part of my post where I say an experienced PA (say a guy with 7-8 years experience). Go back and read where you quoted me, its right there.

 

[niko327]

So someone who completed 4th year med school can not be supervised for the first 12-24 months just like PA...

Sure you can. In your case it will be a residency and by the 3rd year of residency, you will likely have as much autonomy if not more than an experienced (5-8 years experience) PA. I just wouldn't expect that degree of latitude in your 3rd or 4th year of medical school or your intern year. Compared to a first year PA, you'll probably have more latitude one week in to your intern year. Calm down dude.

 

[W19]

Sure you can. In your case it will be a residency and by the 3rd year of residency, you will likely have as much autonomy if not more than an experienced (5-8 years experience) PA. I just wouldn't expect that degree of latitude in your 3rd or 4th year of medical school or your intern year. Compared to a first year PA, you'll probably have more latitude one week in to your intern year. Calm down dude.

You are not comparing residency with a PA/NP who is working with physician...

 

[MedicineZ0Z]

Seriously! What do you think 3rd/4th year medical school is? Our clinical training is overall better than PA/NP's... You have no idea what you are talking about.

Actually PA/NP training isn't even close.

Before you get riled up, try reading the thread/posts. We’re talking about med students BEFORE they finish 3rd/4th year 🙄

Well the thread title says 4th year, so... lollll

I don't get it either why people think PA clinical training is better than med school when you can google them and see they are on par with our 3rd year curriculum... I just did a EM rotation and I was responsible to see 6+ patients in 7 hrs, write the notes, put in orders, come up with 3+ likely differentials etc... I rotated with PA in 3rd year and they did not ask them to do all these things...

PA students I've seen were responsible for exactly half of a med student.
Also this thread is more targeting NPs given their independent (and expanding) practice rights.

 

[MedicineZ0Z]

Not to pour gas on the fire, but it made no sense to me how the med student, resident, and MLP supervision is determined.

For example, me, as a PGY-7 chief resident in neurosurgery needed supervision for everything from writing, to clipping aneurysms or doing brain stem tumors to daily progress notes to seeing patients in the ER or clinic. Meanwhile, day 1 out of school PA/NP was fully independent.

To add a whole level of dynamic, I could not bill for anything. They could. So my experience doing hundreds of bedside central lines or ventricular drains counted for naught, but their 2 years of school made the difference.

Perfect example to illustrate my entire point.

 

[Mt Kilimanjaro]

None of it makes any sense. MS-4 needs a cosign for a chest X-ray. First day NP with online master's degree can order full body CT with none.

The whole training process makes little sense in the context of midlevels. A new PA grad hired into a specialty group would essentially be in "training" for several years while learning all of the various conditions/treatments, but still making 50-100% more than a resident physician. The most recent attempt to change this was in 2002. Not sure how and when this changes, but hopefully someday residents will not be paid pennies while NP and PA's make much more money with better hours and benefits.

Challenging the Medical Residency Matching System through Antitrust Litigation, Feb 15 - American Medical Association Journal of Ethics (formerly Virtual Mentor)

 

[Redpancreas]

Perfect example to illustrate my entire point.

Fully indepdendent doing what?

 

[W19]

None of it makes any sense. MS-4 needs a cosign for a chest X-ray. First day NP with online master's degree can order full body CT with none.

The whole training process makes little sense in the context of midlevels. A new PA grad hired into a specialty group would essentially be in "training" for several years while learning all of the various conditions/treatments, but still making 50-100% more than a resident physician. The most recent attempt to change this was in 2002. Not sure how and when this changes, but hopefully someday residents will not be paid pennies while NP and PA's make much more money with better hours and benefits.

Challenging the Medical Residency Matching System through Antitrust Litigation, Feb 15 - American Medical Association Journal of Ethics (formerly Virtual Mentor)

The sad thing about that whole nonsense is that you find med students and even physicians defending these things... To be honest, I understand why some physicians coming to the defense of NP since some of them are making money off NP... But for the life of me, I don't get why med students are doing it.

 

[W19]

Fully indepdendent doing what?

NP are fully independent in over 20 states where they can open their clinics without no MD/DO oversight... The ones that do that usually market themselves as PCP. The physicians community probably with start to open their eyes when NP start marketing themselves as (GI, card etc...) specialists.

 

[UnoMas]

The sad thing about that whole nonsense is that you find med students and even physicians defending these things... To be honest, I understand why some physicians coming to the defense of NP since some of them are making money off NP... But for the life of me, I don't get why med students are doing it.

Political correctness, specialty of interest other than primary care/EM/Gas, PA/RN in prior life or just sheer stupidity. Pick one

 

[Redpancreas]

NP are fully independent in over 20 states where they can open their clinics without no MD/DO oversight... The ones that do that usually market themselves as PCP. The physicians community probably with start to open their eyes when NP start marketing themselves as (GI, card etc...) specialists.

How can NPs practice as IM specialists that take anywhere from PGY6-8 to obtain immediately out of a dumbed down version of M3?!? That’s absurd.

 

[niko327]

You are not comparing residency with a PA/NP who is working with physician...

I'm just trying to give you an idea of what to expect through analogy and the best comparisons I can, but you are exhausting dude. Your mind is already made up, that much is obvious. So honestly W19, best of luck to you. Avoid controversy with the allied health staff during your residency.

 

[W19]

How can NPs practice as IM specialists that take anywhere from PGY6-8 to obtain immediately out of a dumbed down version of M3?!? That’s absurd.

I agree... But remember that a physician can treat anything but we are so well regulated that no hospitals will give an IM doc privilege to do things they are not trained to do... All it will take for physicians to take notice is for a bold DNP to open a clinic in one of these states and put in his/her office door: Dr Natasha Glenworth, specialist in skin conditions.

 

[W19]

I'm just trying to give you an idea of what to expect through analogy and the best comparisons I can, but you are exhausting dude. Your mind is already made up, that much is obvious. So honestly W19, best of luck to you. Avoid controversy with the allied health staff during your residency.

Lol... As for now, I am not going to clash with anyone, but once I am out, don't expect me to train NP students and hire NP. I am ok with PA though.

 

[UnoMas]

I'm just trying to give you an idea of what to expect through analogy and the best comparisons I can, but you are exhausting dude. Your mind is already made up, that much is obvious. So honestly W19, best of luck to you. Avoid controversy with the allied health staff during your residency.

W19 got some good points, I dont suppose you would change your mind either.

The thing is I will go into residency and beyond with eyes and ears wide open. The mid-level problem is on my radar and I will try to contain it as much as I can

 

[DocEspana]

Let me put it that way because people are arguing different things in this thread.

A newly NP vs. someone who just graduated from a US med school... Who do you think has more medical knowledge?

Its a different world. A newly minted NP comes in two flavors - has a lot of nurse experience vs doesnt. That nurse experience does translate into more leeway. So id check in on them often but id also let them do their stuff without me over their shoulder so i can see what their natural skills are. A direct from school np... I havent met one yet. Our hospital requires 3 months of shadowing another NP in the ED... but id basically be on their case all the time for a while until i had shaped their style to my liking.

PAs tend to not have the same prior exposure as NPs... bht their clinical education is better than NPs. So they come out roughly as good as a new intern. Its person dependent. But id trust a PA to really know limits from day 1. They really have good training in recognizing *that* something is abnormal, though not always why.

New interns? They *have* yo learn autonomy so we throw them into the fire. There will be mistakes. But their is an entire heirarchy breathing down their neck to catch them early.

So who would i trust *brand new*? Its not yhe same as who id trust after a few months. But brand new?

NP with a lot of clinical experience
New PA <----> new intern
NP without a lot of clinical experience.

You could find reasons to put either new pa or new intern higher. Their esoteric and subjective. The other two rankings arent.

But the takeaway really is that NPs and PAs, in proper practice, filter the easy **** off of your work load and then report back to you after and report immediately if something odd comes up. They can be at 50 or 60 or 70 or 80% of their maximal potential out of school if they just know to ask for help. A new intern is at... maybe... 10% of their potential. But they will only get good if theyre in a system where they do make independent decisions as long as their is a good oversight system to catch errors and teach good habits - residency.

 

[Instatewaiter]

This thread needs to die. It’s rife with miscommunication and is just pissing off both sides.


Statement: M3s know more than PAs/NPs.

Where it’s true: In terms of mechanisms of disease, presentations, and depth yes the MD student wins hands down.

Where it’s false: A lot of knowledge the medical students count is not stuff nurses respect or are wary of because it’s not really useful to everyday practice. Midlevels on the other hand are more versed with a better fund of practical knowledge so they can do something to help.

An intern is essentially worthless on day 1. You M3s/M4s think you're hot **** and know so much and then when day 1 of internship hits, it becomes clear to you how little you know. It is both functional knowledge and true knowledge that you lack as a new intern.

There is nothing wrong with this. This is how medical training is set up. So that you build sequentially more knowledge. By the end of internship you should how to identify a sick patient and gain significant functional knowledge.

Know that as an M3 you know more than an NP does. Then you realize how much there is to know as an intern. When midlevels think they can be independent, it will become clear to you as a physician how little they do know. They don't know what they don't know

Now, with regard to NPs/PAs it depends on their years of experience and how bright they are. It is rare for a new midlevel to be very good. It is also common for an experienced midlevel to be not so good. That said, there are many NPs/PAs with years of experience who would have been competent doctors had they gone to medical school but never did. These midlevels tend to be reasonable but even still, the extra years of training make the MDs nearly universally better.

I get that you’re also frustrated that physicians are selling out by giving PAs/NPs increased autonomy to increase efficiency/$$$ because they don’t care about investing resources in teaching a medical student.

Realize it is much more than this. There are too many patients to be taken care of by the MDs out there. More people providing care are needed. As a doc, even if you are terrible, you will probably have more patients than you can provide care to

 

[MedicineZ0Z]

None of it makes any sense. MS-4 needs a cosign for a chest X-ray. First day NP with online master's degree can order full body CT with none.

The whole training process makes little sense in the context of midlevels. A new PA grad hired into a specialty group would essentially be in "training" for several years while learning all of the various conditions/treatments, but still making 50-100% more than a resident physician. The most recent attempt to change this was in 2002. Not sure how and when this changes, but hopefully someday residents will not be paid pennies while NP and PA's make much more money with better hours and benefits.

Challenging the Medical Residency Matching System through Antitrust Litigation, Feb 15 - American Medical Association Journal of Ethics (formerly Virtual Mentor)

Exactly.

Fully indepdendent doing what?

In 20+ states NPs can do anything a doctor can, on day 1, with 0 supervision. Soon it'll be 30+ states, then 40+ and eventually 50. We're quite close to that actually...

The sad thing about that whole nonsense is that you find med students and even physicians defending these things... To be honest, I understand why some physicians coming to the defense of NP since some of them are making money off NP... But for the life of me, I don't get why med students are doing it.

Well it's easy to be a sell out for our profession just for a few extra bucks.

Its a different world. A newly minted NP comes in two flavors - has a lot of nurse experience vs doesnt. That nurse experience does translate into more leeway. So id check in on them often but id also let them do their stuff without me over their shoulder so i can see what their natural skills are. A direct from school np... I havent met one yet. Our hospital requires 3 months of shadowing another NP in the ED... but id basically be on their case all the time for a while until i had shaped their style to my liking.

PAs tend to not have the same prior exposure as NPs... bht their clinical education is better than NPs. So they come out roughly as good as a new intern. Its person dependent. But id trust a PA to really know limits from day 1. They really have good training in recognizing *that* something is abnormal, though not always why.

New interns? They *have* yo learn autonomy so we throw them into the fire. There will be mistakes. But their is an entire heirarchy breathing down their neck to catch them early.

So who would i trust *brand new*? Its not yhe same as who id trust after a few months. But brand new?

NP with a lot of clinical experience
New PA <----> new intern
NP without a lot of clinical experience.

You could find reasons to put either new pa or new intern higher. Their esoteric and subjective. The other two rankings arent.

But the takeaway really is that NPs and PAs, in proper practice, filter the easy **** off of your work load and then report back to you after and report immediately if something odd comes up. They can be at 50 or 60 or 70 or 80% of their maximal potential out of school if they just know to ask for help. A new intern is at... maybe... 10% of their potential. But they will only get good if theyre in a system where they do make independent decisions as long as their is a good oversight system to catch errors and teach good habits - residency.

What you're saying literally makes no sense. How is it even possible that new PAs come out as good as interns when they literally have half of the training?

How can NPs practice as IM specialists that take anywhere from PGY6-8 to obtain immediately out of a dumbed down version of M3?!? That’s absurd.

Easy... look up what tests to order and prescribe drugs you googled.

Pain? Here's a CT. UC refractory to tx? Here's a TNF-a we'll order. Oh now you have active TB cause I forgot to check? oops

 

[MedicineZ0Z]

I agree... But remember that a physician can treat anything but we are so well regulated that no hospitals will give an IM doc privilege to do things they are not trained to do... All it will take for physicians to take notice is for a bold DNP to open a clinic in one of these states and put in his/her office door: Dr Natasha Glenworth, specialist in skin conditions.

Well we have NPs running the ICU now...

Realize it is much more than this. There are too many patients to be taken care of by the MDs out there. More people providing care are needed. As a doc, even if you are terrible, you will probably have more patients than you can provide care to

USA has more doctors per capita than most western countries yet most western countries have little to no midlevels. PAs barely exist in Canada and they have far fewer NPs, yet they get by just as good as USA. We absolutely do not need midlevels... their main purpose has traditionally been to make life easier for doctors + save money for the corp overlords.

Simple answer is other countries utilize family doctors more to treat complex conditions. But family doctors don't do that due to liability yet we have midlevels treating complex stuff. Everything is backwards...

 

[Redpancreas]

An intern is essentially worthless on day 1. You M3s/M4s think you're hot **** and know so much and then when day 1 of internship hits, it becomes clear to you how little you know. It is both functional knowledge and true knowledge that you lack as a new intern.

There is nothing wrong with this. This is how medical training is set up. So that you build sequentially more knowledge. By the end of internship you should how to identify a sick patient and gain significant functional knowledge.

Know that as an M3 you know more than an NP does. Then you realize how much there is to know as an intern. When midlevels think they can be independent, it will become clear to you as a physician how little they do know. They don't know what they don't know

Now, with regard to NPs/PAs it depends on their years of experience and how bright they are. It is rare for a new midlevel to be very good. It is also common for an experienced midlevel to be not so good. That said, there are many NPs/PAs with years of experience who would have been competent doctors had they gone to medical school but never did. These midlevels tend to be reasonable but even still, the extra years of training make the MDs nearly universally better.




Realize it is much more than this. There are too many patients to be taken care of by the MDs out there. More people providing care are needed. As a doc, even if you are terrible, you will probably have more patients than you can provide care to

Thanks for clearing this up man . Hope fellowship is treating you well!

 

[sliceofbread136]

This thread. Wow. I really am not going to add anything to the endless mid level debate.

I will say I find rntomd87’s attitude about...well everything absolutely disgusting. I’m starting residency in 3 months and working with nurses like that is legitimately my biggest fear.

Pretty common. Each day you will spend a large portion of your time listening to whatever issue they’ve picked the day to complain about which usually results in an not needed intervention (these types very rarely actually have a meaningful contributions). I’ve even had some colleagues have unnecessary rrts called on their patients... just part of the job, a good solution is take the long way around the unit to avoid said nurse

 

[Redpancreas]

I agree... But remember that a physician can treat anything but we are so well regulated that no hospitals will give an IM doc privilege to do things they are not trained to do... All it will take for physicians to take notice is for a bold DNP to open a clinic in one of these states and put in his/her office door: Dr Natasha Glenworth, specialist in skin conditions.

I don’t think this will happen with GI/Cards.

 

[DocEspana]

Exactly.

In 20+ states NPs can do anything a doctor can, on day 1, with 0 supervision. Soon it'll be 30+ states, then 40+ and eventually 50. We're quite close to that actually...

Well it's easy to be a sell out for our profession just for a few extra bucks.


What you're saying literally makes no sense. How is it even possible that new PAs come out as good as interns when they literally have half of the training?

Easy... look up what tests to order and prescribe drugs you googled.

Pain? Here's a CT. UC refractory to tx? Here's a TNF-a we'll order. Oh now you have active TB cause I forgot to check? oops

Well I could explain to you how bad interns are when they arrive. I could explain to you the fact that most PAs are trained by attendings who want to make sure the PA knows exactly how to do clinical medicine, rather than how to understand the theories of medicine as taught by a resident. And Yes the theory of medicine is very important when you have to answer complicated questions that should only be answered by the doctor. I could also reiterate for the 3rd time that PAs serve a different purpose than residents do and they need to learn a different skill, when they are in over their head, then residents do.

I could do all of these things, but instead I'm simply going to say that it must be really baffling to be as oblivious to reality as you are. But it's OK. We were all a little like you would be were medical students and even early residents. When you become an attending you'll realize that it's true but it doesn't make residents inferior to PAs. Especially since this absurd question is asking about day 1 skill.. but theyre just simply doing different things. The utlity to me and readiness to practice day 1 is just not the same because the level of practice expected and the style of education received set them up differently for day 1.

 

[DocEspana]

Sorry for my little snark. But it felt good.

 

[niko327]

W19 got some good points, I dont suppose you would change your mind either.

The thing is I will go into residency and beyond with eyes and ears wide open. The mid-level problem is on my radar and I will try to contain it as much as I can

You are probably right about that. I can not change my mind to accept something that directly contradicts the last > dozen years of my clinical practice. All this cowboy stuff is just not what you say it is, for me. I hope you understand. And I wish you too the very best of luck as you make your way to residency.

 

[MedicineZ0Z]

Well I could explain to you how bad interns are when they arrive. I could explain to you the fact that most PAs are trained by attendings who want to make sure the PA knows exactly how to do clinical medicine, rather than how to understand the theories of medicine as taught by a resident. And Yes the theory of medicine is very important when you have to answer complicated questions that should only be answered by the doctor. I could also reiterate for the 3rd time that PAs serve a different purpose than residents do and they need to learn a different skill, when they are in over their head, then residents do.

I could do all of these things, but instead I'm simply going to say that it must be really baffling to be as oblivious to reality as you are. But it's OK. We were all a little like you would be were medical students and even early residents. When you become an attending you'll realize that it's true but it doesn't make residents inferior to PAs. Especially since this absurd question is asking about day 1 skill.. but theyre just simply doing different things. The utlity to me and readiness to practice day 1 is just not the same because the level of practice expected and the style of education received set them up differently for day 1.

Why the focus on PAs only? NPs are the bigger issue yet you ignore them... nice.

The point of mentioning PAs was comparing levels of knowledge & competence for a fresh PA vs. 4th year student. Maybe your personal experience teaching PAs was different but in most settings they learn what med students do during 3rd year - except a lot less. So it is quite fair to look at a 4th year subI and compare them to a fresh PA.

I wouldn't trust either one in any shape or form but would expect the 4th year to come up with a better assessment & plan.

 

[DocEspana]

Why the focus on PAs only? NPs are the bigger issue yet you ignore them... nice.

The point of mentioning PAs was comparing levels of knowledge & competence for a fresh PA vs. 4th year student. Maybe your personal experience teaching PAs was different but in most settings they learn what med students do during 3rd year - except a lot less. So it is quite fair to look at a 4th year subI and compare them to a fresh PA.

I wouldn't trust either one in any shape or form but would expect the 4th year to come up with a better assessment & plan.

Fresh one?

I wouldn't. Id take the PA about 80% of the time. Again. Its because im asking them to do different things and they really are ready to do more out the door because they *can* say "this is too complex". A new intern is just a medical adverse outcome machine with unrivaled hubris.

This changes dramatically over a few months

And NPs got ignored because you didnt bring them up at all in the part i was referring to. I thought my initial addressing of "they are worth as much as the experience they had before np training until they have real years under their belt" was sufficient.

 

[W19]

I don’t think this will happen with GI/Cards.

Go over the gas forum... CRNA are claiming they are as good or even better than MD/DO.

 

[W19]

Fresh one?

I wouldn't. Id take the PA about 80% of the time. Again. Its because im asking them to do different things and they really are ready to do more out the door because they *can* say "this is too complex". A new intern is just a medical adverse outcome machine with unrivaled hubris.

This changes dramatically over a few months

And NPs got ignored because you didnt bring them up at all in the part i was referring to. I thought my initial addressing of "they are worth as much as the experience they had before np training until they have real years under their belt" was sufficient.

The tasks you will ask the PA to do, intern won't be able to do them. You are saying intern won't be able to say this is 'too complex'.

You are basically saying when Missouri implement the AP law, these Assistant Physicians (AP) who passed step1/2/3 and who will be working under physicians' supervision will be worse than a newly minted PA. So if you were living in Missouri you would be more comfortable hiring a newly minted PA over an AP... I just don't get it!

 

[sliceofbread136]

Fresh one?

I wouldn't. Id take the PA about 80% of the time. Again. Its because im asking them to do different things and they really are ready to do more out the door because they *can* say "this is too complex". A new intern is just a medical adverse outcome machine with unrivaled hubris.

This changes dramatically over a few months

And NPs got ignored because you didnt bring them up at all in the part i was referring to. I thought my initial addressing of "they are worth as much as the experience they had before np training until they have real years under their belt" was sufficient.

Ah cmon man, interns aren’t that bad. Sure we like to complain but most of us aren’t out hurting patients

 

[Perrotfish]

None of it makes any sense. MS-4 needs a cosign for a chest X-ray. First day NP with online master's degree can order full body CT with none.

If you're interested in advocacy, it would probably be a lot easier to lobby to change the first thing than the second thing. There was some progress this year when CMS ruled that schools can once again bill for medical student notes. It probably wouldn't take much of a push get at least some states to authorize teaching licenses for medical students under the direct supervision of a physician that would allow students to place orders without a cosignature.

 

[Perrotfish]

nvm

 

[MedicineZ0Z]

Fresh one?

I wouldn't. Id take the PA about 80% of the time. Again. Its because im asking them to do different things and they really are ready to do more out the door because they *can* say "this is too complex". A new intern is just a medical adverse outcome machine with unrivaled hubris.

This changes dramatically over a few months

And NPs got ignored because you didnt bring them up at all in the part i was referring to. I thought my initial addressing of "they are worth as much as the experience they had before np training until they have real years under their belt" was sufficient.

This is a theoretical discussion. We're talking about who functions better alone, not factoring in when they need to get help.

 

[W19]

The nursing organizations have succeeded in brainwashing everyone--even physicians.

 

[MedicineZ0Z]

The nursing organizations have succeeded in brainwashing everyone--even physicians.

While we continue the stupid MD vs. DO , medicine vs. surgery, generalist vs specialist arguments. They're unified and that's how they progress. We're so fixated on belittling those beneath us or around us in our own profession but bend over for expanded midlevel rights.

 

[W19]

While we continue the stupid MD vs. DO , medicine vs. surgery, generalist vs specialist arguments. They're unified and that's how they progress. We're so fixated on belittling those beneath us or around us in our own profession but bend over for expanded midlevel rights.

FM and maybe gas might not exist as specialties in a couple of decades the way thing are moving. It's a sad state of affair when physicians knowingly or unknowingly are pushing the nursing agenda...

 

[MedicineZ0Z]

FM and maybe gas might not exist as specialties in a couple of decades the way thing are moving. It's a sad state of affair when physicians knowingly or unknowingly are pushing the nursing agenda...

Gas I can see, though FM due to its generalist nature will likely exist because you have your own patient panel & can also carve out a niche anyway. We should have FMs more involved in a wider scope of practice and thereby prevent midlevels from finding work in specialties. The wider FM scope is exactly what a lot of western countries do anyway.

 

[W19]

Gas I can see, though FM due to its generalist nature will likely exist because you have your own patient panel & can also carve out a niche anyway. We should have FMs more involved in a wider scope of practice and thereby prevent midlevels from finding work in specialties. The wider FM scope is exactly what a lot of western countries do anyway.

I agree wider scope might save FM, but this is unlikely to happen. If things continue to get worse with NP being independent in all 50 states, the government can say we are not funding GME spots for FM anymore if NP are as good as FM docs... Lets just pump more NP to the market.

 

[VA Hopeful Dr]

This is a theoretical discussion. We're talking about who functions better alone, not factoring in when they need to get help.

And he said multiple times that he is against independent mid-level practice...

 

[RNtoMD87]

I agree... But remember that a physician can treat anything but we are so well regulated that no hospitals will give an IM doc privilege to do things they are not trained to do... All it will take for physicians to take notice is for a bold DNP to open a clinic in one of these states and put in his/her office door: Dr Natasha Glenworth, specialist in skin conditions.

What suprises me is when I have an attending order a medication for me and pharmacy shoots it down and says "hospital parameters are that this medication cant be given over so and so amount"

Never happens with narcotics. I believe it was with xanax or ativan. I think it was like 2mg ativan or something like that. And the pharmacy changed it to 1mg and told me the above.

 

[RNtoMD87]

This thread. Wow. I really am not going to add anything to the endless mid level debate.

I will say I find rntomd87’s attitude about...well everything absolutely disgusting. I’m starting residency in 3 months and working with nurses like that is legitimately my biggest fear.

What is your fear?

 

[RNtoMD87]

This thread needs to die. It’s rife with miscommunication and is just pissing off both sides.


Statement: M3s know more than PAs/NPs.

Where it’s true: In terms of mechanisms of disease, presentations, and depth yes the MD student wins hands down.

Where it’s false: A lot of knowledge the medical students count is not stuff nurses respect or are wary of because it’s not really useful to everyday practice. Midlevels on the other hand are more versed with a better fund of practical knowledge so they can do something to help.

All this finger pointing and examples of some ditzy nurse who can’t divide 8 by 3 serves to do is antagonize midlevels and they’ll criticize us for being clueless about practical stuff like lines, tubes, med administration, etc. which is understandable for students to not know based on what we focus on now and then they say we have god complex. I will say though to any non-MD students who are NPs/PAs who think you are or ever will be equivalent to a physician, you are not even close and you never will be but it does not seem like anyone on here is saying that.

@MedicineZ0Z , you need to stop fanning the flames here. I get that you’re nearing the end of your M3 year and are frustrated because you’ve been treated like garbage by everyone from surgical/OB attending/resident physicians to floor nurses who think you’re dumb. I get that you’re also frustrated that physicians are selling out by giving PAs/NPs increased autonomy to increase efficiency/$$$ because they don’t care about investing resources in teaching a medical student. The solution though is not to point the finger at midlevels even if it’s true that there are very pathetic standards at some programs. You can only control what’s in your sphere of influence and here there are only MD/DO students. Something more productive to talk about is how M3 medical students refuse to even help each other unless they can be in earshot of those grading them.

So much accurate. Everything I have been thinking but did not know how to put into words. Many times patients will talk about how clueless "this baby faced doctor is" who came into the room, but I explain "Well hes a doctor. He knows way more than I do, hes just learning the practical application of very indepth scientific knowledge". Ive heard many times "he didnt even know how to start an IV" and I say "even though it seems pretty basic, thats just something they don't really do much of".

They don't have the "polish" yet. Thats the biggest thing I see. No different than any new field. Thats the reason I hate comparing residents to midlevels. Most midlevels I know have been doing their job for a long time, and have both more knowledge, and more "polish" than I have. Many residents or med students look clueless because theyre new. They look like... me. When i first started my nursing career as a student. I don't think its really fair to compare the two.

 

[DocEspana]

And he said multiple times that he is against independent mid-level practice...

Im sure a PA fresh out of their school would listen better than this... im assuming hes a 4th year med student.



Had to

 

[MedicineZ0Z]

Im sure a PA fresh out of their school would listen better than this... im assuming hes a 4th year med student.



Had to

It's not black and white. What is the level of supervision exactly over midlevels? Majority of the time: none. Even though they're "supervised" on paper. And then the question, what is the difference between minimal supervision & none?

Fact remains... there are an enormous number of graduating midlevels (far greater than physicians). They are unified and will push for more practice rights. Doctors will become medical managers of half a dozen midlevels (or more). At least what's what every MD/DO on the business side of things says.

 

[Cryc_to_the_point]

Anyone else mostly disturbed by the notion that "nursing experience," is being seen as equal to medical education? Pattern recognition isn't the same as critical thinking and I'm noticing it's easier (or was for me) to "monkey see, monkey do," but prior clinical experience has not given me some massive leg up in medical critical thinking. So, why give more leeway to someone with prior experience executing orders, but none arriving at the need for and then giving orders? Never mind that NP schools are dropping experience requirements like stones...

Of my own feeble knowledge, I can say without the requisite background medical education, I was not able to accurately discern certain nuances in patient presentation. After adding to my prior knowledge base, I was able to grow and apply my experiences, but I doubt simply repeating those patterns without the needed understanding would yield the same results as I could not "know what I don't know."

 

[MedicineZ0Z]

Anyone else mostly disturbed by the notion that "nursing experience," is being seen as equal to medical education? Pattern recognition isn't the same as critical thinking and I'm noticing it's easier (or was for me) to "monkey see, monkey do," but prior clinical experience has not given me some massive leg up in medical critical thinking. So, why give more leeway to someone with prior experience executing orders, but none arriving at the need for and then giving orders? Never mind that NP schools are dropping experience requirements like stones...

Of my own feeble knowledge, I can say without the requisite background medical education, I was not able to accurately discern certain nuances in patient presentation. After adding to my prior knowledge base, I was able to grow and apply my experiences, but I doubt simply repeating those patterns without the needed understanding would yield the same results as I could not "know what I don't know."

Honestly, the logistics and nuances are picked up very quickly.
Your point about pattern recognition is ironic because it's what midlevels primarily do. And it actually * does * work for many chief complaints. Unfortunately, it doesn't work for very similar chief complaints and the midlevel will not know.

 

[RNtoMD87]

I dont think the main problem is "mid-levels: dey took er jerrbs"

I think the main problem is the fact that you have a major doctor shortage because there are so many sick people, because no-one really seems to care about their health anymore, and physicians are bogged down with paperwork and only have 10-15 minutes for each patient. This is not nearly enough.

We need more prevention, but it has to start with the patients.Almost every single one of my patients is either old, a drug addict, an alcoholic, BMI >35, or a heavy smoker. Very few are injuries with no other history, or chronic problems not their fault.

I recently started assisting teaching diabetes prevention classes, and its frustrating because even the class misses the mark. "Cut fat as low as possible. Drink fruit juice" etc. Not good advice. Theyre still teaching people to avoid fat especially saturated fat at all costs. Strength training is not encouraged. Its really sad.

It isnt really that hard to be healthy, unless youve been unhealthy your whole life. We're NEVER going to have enough doctors for all of these sick americans.