Should we make it easier for physicians to practice independently on one year of residency?

[CidHighwind]

From what I understand, while physicians are able to practice independently with just one year of residency, it’s impractical to do so. In my opinion, someone that has gone through medical school, passed their boards, and has taken care of patients in a supervised setting is more capable of independent practice than a nurse that has taken a few online classes and done some shadowing.

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[VA Hopeful Dr]

Just because the nurses are doing it doesn't mean we should do the same

 

[libertyyne]

I think most states will allow you to practice, getting credentialed and insurance to reimburse is more problematic without board certification. I do think its a little hypocritical that NPs can bill just fine in these same states and not have similar issues as a physician without board cert.

This is definitely a place where legislative push might help. The problem is our leadership does not want this, for a plethora of reasons both valid and stupid.

 

[Sephirakra]

From what I understand, while physicians are able to practice independently with just one year of residency, it’s impractical to do so. In my opinion, someone that has gone through medical school, passed their boards, and has taken care of patients in a supervised setting is more capable of independent practice than a nurse that has taken a few online classes and done some shadowing.

Granting an unrestricted license after X number of GME years is state-dependent, and many states have different requirements for USMDs, DOs, and IMGs. Not every physician can obtain an independent license after just an internship.

 

[deleted393595]

Just because the nurses are doing it doesn't mean we should do the same

Why not? If NPs are getting to practice independently with a fraction of our clinical hours, then why can't we?

 

[CidHighwind]

Granting an unrestricted license after X number of GME years is state-dependent, and many states have different requirements for USMDs, DOs, and IMGs. Not every physician can obtain an independent license after just an internship.

Well maybe they should change this.

 

[Sephirakra]

Well maybe they should change this.

So your solution to NPs practicing without adequate training is physicians practicing without adequate training?

 

[CyrilFiggis]

Why not? If NPs are getting to practice independently with a fraction of our clinical hours, then why can we?

Let them provide crappy care, not us.

 

[Mass Effect]

From what I understand, while physicians are able to practice independently with just one year of residency, it’s impractical to do so. In my opinion, someone that has gone through medical school, passed their boards, and has taken care of patients in a supervised setting is more capable of independent practice than a nurse that has taken a few online classes and done some shadowing.

If you want to push for legislation, it should be that no one can practice independently without going to med school AND graduating residency. I am in favor of MO's law however where doctors without residency can practice with attending supervision. That's as far as it should go for anyone, NPs included.

 

[Tenk]

Would you want to be taken care of by a solo pgy2?

I sure as hell wouldn’t.

 

[libertyyne]

If you want to push for legislation, it should be that no one can practice independently without going to med school AND graduating residency. I am in favor of MO's law however where doctors without residency can practice with attending supervision. That's as far as it should go for anyone, NPs included.

All of this would be great if the cat wasnt already out of the bag and NPs didnt already have indepdent practice in a majority of states. Good luck trying to fight that battle.

Would you want to be taken care of by a solo pgy2?

I sure as hell wouldn’t.

I wouldnt think that anyone would want to go to an NP, yet here we are.

 

[Tenk]

All of this would be great if the cat wasnt already out of the bag and NPs didnt already have indepdent practice in a majority of states. Good luck trying to fight that battle.

I wouldnt think that anyone would want to go to an NP, yet here we are.

People also put stones in their vaginas because a celebrity told them to btw.

I would say people are like sheep, but I don’t even think sheep are that stupid.

 

[Splenda88]

~33 states allow US MD practice independently but getting credentialed from insurance companies is another story...


For US DO is probably close to all states

 

[hallowmann]

~33 states allow US MD practice independently but getting credentialed from insurance companies is another story...


For US DO is probably close to all states

For DOs it's like 36-37 states.

 

[Splenda88]

For DOs it's like 36-37 states.

Thanks for the correction... That shows you state legislatures have no idea what they are doing when it comes to physician practice right (or privilege). There are a few states where DO can practice 1-yr postgrad training while US MD can't.

 

[allantois]

How would you refer to your physician partner in practice who only did pgy 1? Let’s say this was a neurology practice, would they be considered a neurologist?

 

[deleted1005514]

Isn’t that what GPs were, back before FM, IM, etc became mainstream?

I grew up in a rural area, and your General Practitioner often delivered you and treated you your whole life, along with all your family members and everyone else in the community. I don’t think my doctor ever specialized. I can remember the first time we got an ‘Internist’ at our little hospital, and nobody had a clue what that was at the time...and I’m an 80s baby, so not too old.

 

[CidHighwind]

Isn’t that what GPs were, back before FM, IM, etc became mainstream?

I grew up in a rural area, and your General Practitioner often delivered you and treated you your whole life, along with all your family members and everyone else in the community. I don’t think my doctor ever specialized. I can remember the first time we got an ‘Internist’ at our little hospital, and nobody had a clue what that was at the time...and I’m an 80s baby, so not too old.

Right. GP should still be an avenue to practice medicine for those students that don’t match into a residency. GP was a valid way to practice medicine for many years, but now everyone is brainwashed into thinking you need 3. If 1 Year is good enough to be a GMO in the military, why isn’t it good enough to treat rural areas?

 

[Splenda88]

Right. GP should still be an avenue to practice medicine for those students that don’t match into a residency. GP was a valid way to practice medicine for many years, but now everyone is brainwashed into thinking you need 3. If 1 Year is good enough to be a GMO in the military, why isn’t it good enough to treat rural areas?

Well, you said it. Academia brainwashed us to think we are all specialists even if 80%+ of the time we are treating HTN, DM, HLD, URI, PNA, Asthma, COPD, contact dermatitis etc... and doing health screening/maintenance...

 

[ace_inhibitor111]

So your solution to NPs practicing without adequate training is physicians practicing without adequate training?

There is no research comparing outcomes after one year of residency versus three years of residency for primary care. In my opinion, there are diminishing returns. You have residents moonlighting independently in EM and Psych after only one year of training. Meanwhile, all the academics want to increase EM training to 4 years, General surgery to 7 years and pediatric hospitalist to 6 years for no reason lol. There’s even a General Internal Medicine fellowship where you spend 3 years of extra training after IM to learn administrative BS lol

 

[Sephirakra]

There is no research comparing outcomes after one year of residency versus three years of residency for primary care. On the other hand, you have residents moonlighting independently in EM and Psych after only one year of training. Meanwhile, all the academics want to increase EM training to 4 years, General surgery to 7 years and pediatric hospitalist to 6 years for no reason lol. There’s even a General Internal Medicine fellowship where you spend 3 years of extra training after IM to learn administrative BS lol

Not sure what point you're trying to make here.

 

[CidHighwind]

Not sure what point you're trying to make here.

There point is that we may be spending too much time in residency while that time may not be that beneficial to our ability to practice medicine. Didn’t seem too difficult to grasp IMO

 

[Sephirakra]

There point is that we may be spending too much time in residency while that time may not be that beneficial to our ability to practice medicine. Didn’t seem too difficult to grasp IMO

They literally start their post by saying that there's no research on the subject, then give an opinion. How does that translate into evidence that too much time is spent in residency? Since neither you, nor they, nor I have done any residency training at this point, what position are we in to determine what's enough?

Oh, and hold the put-downs next time.

 

[VA Hopeful Dr]

Right. GP should still be an avenue to practice medicine for those students that don’t match into a residency. GP was a valid way to practice medicine for many years, but now everyone is brainwashed into thinking you need 3. If 1 Year is good enough to be a GMO in the military, why isn’t it good enough to treat rural areas?

GP is still something you can do in the majority of states. One of my classmates in residency did I think 2 years of OB, got burned out, quit her program, and worked as a GP for 15 years. The job opportunities do exist. They're harder to find but not impossible by any means.

That said, I would never see one personally. What people sometimes fail to realize is that the amount of medical knowledge we possess has increased dramatically in the 50 years since FM became a thing (1968 if anyone cares) and GPs started getting phased out. No caths, no laparoscopy, 3 drugs for DM, no cephalosporins, tetracycline, or amoxicillin. No CT or MRI. There were only a fraction of the labs we now have available. There just much more to know than there used to be.

Beyond that, I am still young enough that I can remember where I was ability-wise at the end of intern year. The extra 2 years beyond that made a huge difference.

 

[VA Hopeful Dr]

There is no research comparing outcomes after one year of residency versus three years of residency for primary care. In my opinion, there are diminishing returns. You have residents moonlighting independently in EM and Psych after only one year of training. Meanwhile, all the academics want to increase EM training to 4 years, General surgery to 7 years and pediatric hospitalist to 6 years for no reason lol. There’s even a General Internal Medicine fellowship where you spend 3 years of extra training after IM to learn administrative BS lol

Yeah a lot of that is nonsense, I don't think the majority of practicing physicians would disagree with you there.

The trouble with primary care outcomes is that they take years if not decades to actually matter. I've yet to see a study over 5 years and that's just not enough time. As I tell patients, hypertension and CV disease prevention is a game of decades.

 

[Dantrolene FC]

It would be very difficult to do a study today to look at the differences in outcomes because it will have inherent biases. The study would have to be retrospective in nature because it would be unethical, or at least unfeasible, to have a randomized controlled trial, and you would be biased towards having physicians who didn't fully match has your GP cohort. So your results could be due to a lack of skill, or ability, rather than a lack of training.

So for the time being, we will go off of expert opinion that physicians need at least 3 years of residency training.

 

[sab3156]

We should NOT have any practice rights for people who have not completed at least a 3 year fully-accredited residency training program.

We know that the most dangerous enemies of patients are those pretending to be their advocates. Let's remind ourselves who they are:

Nursing Scope of Practice | American Nurses Association

Scope of practice describes the services that a qualified health professional is deemed competent to perform, and permitted to undertake – in keeping with the terms of their professional license.

www.nursingworld.org

Reading this page should make you want to throw up. Please, let's not become like this. We should take pride in the fact that physicians have the training they do. We shouldn't ever allow it to get watered down.

If you feel strongly about patients getting the best care with the best possible people (fully trained and licensed physicians), join this organization:

Home - Physicians for Patient Protection

35

www.physiciansforpatientprotection.org

 

[Mass Effect]

How would you refer to your physician partner in practice who only did pgy 1? Let’s say this was a neurology practice, would they be considered a neurologist?

No. By definition, a neurologist is someone who completed neurology training.

I'd argue that if such a person wanted to practice independently, they would be referred to by the old term general practitioner (NOT FM).

 

[Mass Effect]

Isn’t that what GPs were, back before FM, IM, etc became mainstream?

I grew up in a rural area, and your General Practitioner often delivered you and treated you your whole life, along with all your family members and everyone else in the community. I don’t think my doctor ever specialized. I can remember the first time we got an ‘Internist’ at our little hospital, and nobody had a clue what that was at the time...and I’m an 80s baby, so not too old.

Medicine has changed as has medical education. I wouldn't be at all reassured by the skillset of a GP.

 

[deleted1005514]

Medicine has changed as has medical education. I wouldn't be at all reassured by the skillset of a GP.

I wasn’t claiming that a GP would have thorough knowledge of modern medicine equal to a residency trained FM doc at all, I was just stating that GPs used to be common, especially in rural areas.

I do think GP > NP, just by virtue of deeper knowledge through standardized medical education.

 

[EM2023]

Just because the nurses are doing it doesn't mean we should do the same

What is your solution to the NP problem then?

We have drastically failed to present a cost saving physician option. This is common sense economics which physicians tend to suck at. We have refused to give them our own “mid-level option” even as it is clear as day this is what the market wants now. We left a huge gapping hole when we moved from the GP model. And the nursing leadership is filling it rapidly with their own.

All we do now is point out the n=1 examples of NP errors as if physicians don’t make mistakes too. The legislators know that we are not perfect either, far from it. Trust me, the balance of malpractice cost vs salary savings has been figured out and still tips highly in favor of using the lesser trained for general medicine, or we wouldn’t be in this situation.

Our constant in-fighting about board certification, FM should not work
in the ED etc. is what has got us here. NPs will have full practice rights across the country within the next 2 years, no question.


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[Chemist0157]

A second year resident who just finished internship that was primarily inpatient care is not well prepared to carry out quality primary care. That might be better than an independently practicing NP, but that is not a reasonable goal.

I could see a world where perhaps a program could be allowed to create a track that is primary care and could be attractive as it would be shorter. Two years of 90+% primary care training. Perhaps intern year could remain about the same and transition into a one year of primary adult care. No pediatrics, no OBGYN. Just get good at IM - primary care and hit the ground running. I'd rather see someone like that than an NP or an intern+1 day physician.

 

[VA Hopeful Dr]

What is your solution to the NP problem then?

We have drastically failed to present a cost saving physician option. This is common sense economics which physicians tend to suck at. We have refused to give them our own “mid-level option” even as it is clear as day this is what the market wants now. We left a huge gapping hole when we moved from the GP model. And the nursing leadership is filling it rapidly with their own.

All we do now is point out the n=1 examples of NP errors as if physicians don’t make mistakes too. The legislators know that we are not perfect either, far from it. Trust me, the balance of malpractice cost vs salary savings has been figured out and still tips highly in favor of using the lesser trained for general medicine, or we wouldn’t be in this situation.

Our constant in-fighting about board certification, FM should not work
in the ED etc. is what has got us here. NPs will have full practice rights across the country within the next 2 years, no question.


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Well my state hasn't done independent practice yet and I'm fighting that battle.

But as you point out, that genie is mostly out of the bottle. At this point its a matter of doing good work and winning over 1 patient at a time. That and the rapid expansion of NP schools will do a lot of the work for us.

 

[ACSurgeon]

From what I understand, while physicians are able to practice independently with just one year of residency, it’s impractical to do so. In my opinion, someone that has gone through medical school, passed their boards, and has taken care of patients in a supervised setting is more capable of independent practice than a nurse that has taken a few online classes and done some shadowing.

no. We should advocate having less autonomy for undertrained people, not give more autonomy to undertrained doctors.

it would be nice if doctors with some or even no training had a way to earning an ok living.

 

[throwaway1000000]

Yes. If a PA and NP can do it with a fraction of training that a MD that graduated has, then the unmatched MDs can do it as well. Especially after a prelim year. Of course, they probably have to be supervised. But, mid-levels are lobbying for more and more unsupervised practice so there is that.

 

[throwaway1000000]

So your solution to NPs practicing without adequate training is physicians practicing without adequate training?

I think it's a very poor solution but seems better than the alternative which is what we have now.

On the other hand, I can see the arguments that just because is doing it, doesn't mean we should too. But I do feel bad if there are unmatched medical students who never find a permanent residency and people with fraction of their training are able to practice independently.

 

[Splenda88]

no. We should advocate having less autonomy for undertrained people, not give more autonomy to undertrained doctors.

it would be nice if doctors with some or even no training had a way to earning an ok living.

The ideal world would be having no NP at all at best or having NP practicing under supervision at worst... But we are not in an ideal situation right now. If we are concerned about patients' wellbeing (as we said we are), we should be advocating for someone with more training to "fill up the void." If you think NP/PA who are "filling up the void" are better trained than an MD with 1-yr internship, the system is ok as it is now.

 

[Sephirakra]

I think it's a very poor solution but seems better than the alternative which is what we have now.

On the other hand, I can see the arguments that just because is doing it, doesn't mean we should too. But I do feel bad if there are unmatched medical students who never find a permanent residency and people with fraction of their training are able to practice independently.

The existence of unmatched medical students is a separate issue entirely. No med student went unmatched because NP/PAs exist.

 

[Splenda88]

The existence of unmatched medical students is a separate issue entirely. No med student went unmatched because NP/PAs exist.

We already have NP and they will be independent in all 50 states w/in 5 years...


Hypothetical here:

If they force you to choose between an NP who just graduated from the best NP school (1st day on the job) and a FM/IM PGY2 + 1st day from a random program to take care of your grandma, which one would you choose assuming you know nothing about them?


Why can't we have a better trained professional to "fill up the void."?

 

[throwaway1000000]

The existence of unmatched medical students is a separate issue entirely. No med student went unmatched because NP/PAs exist.

I am not sure what you mean by students going unmatched because of NP and PAs.
My point is if there are students that went unmatched even after doing a prelim year and want to practice in the capacity that mid-levels are practicing, I do not see anything wrong with it.
It is a poor solution but I would definitely prefer like the above poster said a PGY1 resident in the role a mid-level than a NP/PA with fraction of training seeing patients independently.

 

[Sephirakra]

We already have NP and they will be independent in all 50 states w/in 5 years...

Maybe they will, but that wasn't my point.

Hypothetical here:

If they force you to choose between an NP who just graduated from the best NP school (1st day on the job) and a FM/IM PGY1 + 1 day from a random program to take care of your grandma, which one would you choose assuming you know nothing about them?


Why can't we have a better trained professional to "fill up the void."?

So I don't know anything about these two professionals, but somehow I know their training backgrounds...? Strawman arguments get us nowhere.

 

[Sephirakra]

I am not sure what you mean students going unmatched because of NP and PAs.

You stated:

But I do feel bad if there are unmatched medical students who never find a permanent residency and people with fraction of their training are able to practice independently.

Feel bad all you want, but the fact that there are medical students who do not match has nothing to do with whether NPs should be able to practice. They are separate issues. The NPs in your scenario have met whatever standards are in place for their profession, and therefore are able to practice. We can debate all day about whether those standards are sufficient (and I don't believe they are), but it has no bearing on whether a med student matches and is able to practice. Separate. Issues.

My point is if there are students that went unmatched even after doing a prelim year and want to practice in the capacity that mid-levels are practicing, I do not see anything wrong with it.
It is a poor solution but I would definitely prefer like the above poster said a PGY1 resident in the role a mid-level than a NP/PA with fraction of training seeing patients independently.

Moving goal posts, I see. Those who complete PGY-1, even if they do not continue further in residency training, are no longer medical students. I don't necessarily have a problem with someone in this position obtaining a license and operating as a GP, but I don't think it's something that we as a profession should be encouraging. I see it more as a last resort option.

 

[throwaway1000000]

You stated:

Feel bad all you want, but the fact that there are medical students who do not match has nothing to do with whether NPs should be able to practice. They are separate issues. The NPs in your scenario have met whatever standards are in place for their profession, and therefore are able to practice. We can debate all day about whether those standards are sufficient (and I don't believe they are), but it has no bearing on whether a med student matches and is able to practice. Separate. Issues.

Moving goal posts, I see. Those who complete PGY-1, even if they do not continue further in residency training, are no longer medical students. I don't necessarily have a problem with someone in this position obtaining a license and operating as a GP, but I don't think it's something that we as a profession should be encouraging. I see it more as a last resort option.

Yeah I do think I mixed up my terminology there.
I think prelim PGY1 who were unmatched med students and who go unmatched again into a categorical spot after their prelim PGY1 year should be able to practice in the level that the mid-level is now. Maybe with some supervision. Now I don't know if they are already able to. Are unmatched PGY1s able to practice as easily as mid-levels are now?
It might be a poor solution but definitely better than watching mid-levels with less experience practicing independently.

 

[EM2023]

The ideal world would be having no NP at all at best or having NP practicing under supervision at worst... But we are not in an ideal situation right now. If we are concerned about patients' wellbeing (as we said we are), we should be advocating for someone with more training to "fill up the void." If you think NP/PA who are "filling up the void" are better trained than an MD with 1-yr internship, the system is ok as it is now.

I see the problem as that physicians want neither lesser trained physicians nor NPs to fill the void. The market is asking for it to be filled but we are saying no—-take us as very highly trained as we are, or leave it. All or nothing. Our bluff is being called, and will result in salary decreases for even highly trained physicians. A race to the bottom with the NPs. It’s already happening in hourly rate offers.


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[DrNotaDr]

At this junction in the history of healthcare the medical student cartel on SDN still can’t help but devote another redundant thread attacking midlevels? Those of us in the hospital as providers instead of salty med students know there’s much more important things to be discussing right now.

 

[differentiating]

As someone finishing up intern year - absolutely not. I could see allowing them to practice with significant supervision, similar to midlevels, but no way would I trust myself or my co-interns to manage patients independently at this point in time.

How would you refer to your physician partner in practice who only did pgy 1? Let’s say this was a neurology practice, would they be considered a neurologist?

This person would have received 0 neurology training in this instance (neurology is an advanced program), so they’d have no grounds to claim being a neurologist. Agreed with the earlier poster that GP would probably be the most accurate term.

 

[EM2023]

At this junction in the history of healthcare the medical student cartel on SDN still can’t help but devote another redundant thread attacking midlevels? Those of us in the hospital as providers instead of salty med students know there’s much more important things to be discussing right now.

It is all the more important now IMHO. Telemedicine is blowing up, and the need has skyrocketed. One platform over the past few days has had up to 1000 patients at any given time across the country waiting for hours in a queue for a doctor to talk to them.

There is now talk of opening up this platform to NPs because there are “not enough board certified doctors” signed up. Meanwhile they will not accept even 3rd year residents.


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[DrNotaDr]

It is all the more important now IMHO. Telemedicine is blowing up, and the need has skyrocketed. One platform over the past few days has had up to 1000 patients at any given time across the country waiting for hours in a queue for a doctor to talk to them.

There is now talk of opening up this platform to NPs because there are “not enough board certified doctors” signed up. Meanwhile they will not accept even 3rd year residents.


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This is not the time for the 109,074 NP’s-are-awful-people-and-should-be-fired thread. Our healthcare system could be overwhelmed in the next few months. How about you all get together as medical students and figure out a way you can help our country instead of attacking others. NP’s are needed right now to care for the falls, fractures, diabetics while the physicians try to keep the corona virus patients alive. Try to be constructive instead of destructive. Actual front line care givers are putting politics as usual on hold. How about you get onboard?

 

[EM2023]

This is not the time for the 109,074 NP’s-are-awful-people-and-should-be-fired thread. Our healthcare system could be overwhelmed in the next few months. How about you all get together as medical students and figure out a way you can help our country instead of attacking others. NP’s are needed right now to care for the falls, fractures, diabetics while the physicians try to keep the corona virus patients alive. Try to be constructive instead of destructive. Actual front line care givers are putting politics as usual on hold. How about you get onboard?

No one said “NPs are awful people” here. The system (and other doctors) are screwing the younger doctors. That is the point. Btw I am a physician too. But my help is apparently not needed at this time.


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[DrNotaDr]

No one said “NPs are awful people” here. The system (and other doctors) are screwing the younger doctors. That is the point. Btw I am a physician too. But my help is apparently not needed at this time.


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Wait awhile, you will be. Look at Italy if you want a prediction on where this is headed.