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

[Goro]

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

I swear, SDN could make even a thread about toasters into complaints about midlevels.

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[Sephirakra]

I swear, SDN could make even a thread about toasters into complaints about midlevels.

The nursing lobby is obviously in bed with Big Gluten, so we should expect NPs to start recommending toast as a panacea to their patients.

 

[deleted393595]

I swear, SDN could make even a thread about toasters into complaints about midlevels.

SDN is like neurology. It'll expend tremendous energy mentally masticating about a subject only to end up doing nothing in real life about it

 

[JustOnePing]

I've been treated by General Practitioners overseas for primary care and was happy with my treatment. They were physicians that had completed their intern year in a government hospital and were now working in outpatient primary care clinics.

We messed up big eliminating them here in this country.

 

[VA Hopeful Dr]

I've been treated by General Practitioners overseas for primary care and was happy with my treatment. They were physicians that had completed their intern year in a government hospital and were now working in outpatient primary care clinics.

We messed up big eliminating them here in this country.

We didn't eliminate them, something like 2/3rd of states still allow them.

 

[JustOnePing]

We didn't eliminate them, something like 2/3rd of states still allow them.

Really? Why aren't they able to get credentialed with hospitals and / or boarded with insurance companies unless working for a federal facility then? By definition, they've been phased out of existence in this country.

 

[VA Hopeful Dr]

Really? Why aren't they able to get credentialed with hospitals and / or boarded with insurance companies unless working for a federal facility then? By definition, they've been phased out of existence in this country.

Because hospitals and insurance companies believe that being residency-trained has value?

 

[Mass Effect]

I've been treated by General Practitioners overseas for primary care and was happy with my treatment. They were physicians that had completed their intern year in a government hospital and were now working in outpatient primary care clinics.

We messed up big eliminating them here in this country.

Overseas countries have different medical school curriculums.

 

[JustOnePing]

Because hospitals and insurance companies believe that being residency-trained has value?

General Practitioners completed one year of residency until ABMS and AAFP came along and put a stop to that. Nurse practitioners don't complete a residency, they bill out independently now. Explain that.

 

[VA Hopeful Dr]

General Practitioners completed one year of residency until ABMS and AAFP came along and put a stop to that. Nurse practitioners don't complete a residency, they bill out independently now. Explain that.

So you want to lower physicians to the level of nurses? Good call. No way that'll backfire on us.

GPs can still find work. There's plenty of threads in this forum about it.

 

[JustOnePing]

So you want to lower physicians to the level of nurses? Good call. No way that'll backfire on us.

GPs can still find work. There's plenty of threads in this forum about it.

The government is doing that for us because there is no other practical solution to shorten physician training at this point. Physicians have largely acquiesced by infighting over this. The reality on the ground is that Nurse Practitioners will become the de facto primary care providers because General Practitioners no longer exist to fill this role.

 

[VA Hopeful Dr]

The government is doing that for us because there is no other practical solution to shorten physician training at this point. Physicians have largely acquiesced by infighting over this. The reality on the ground is that Nurse Practitioners will become the de facto primary care providers because General Practitioners no longer exist to fill this role.

Do what now? Because we no longer have lots of GPs we've given up primary care to the NPs?

There's 80,000 FPs and 70,000 internists who would disagree: The Number of Practicing Primary Care Physicians in the United States

Probably actually much higher as that data is 10 years old.

 

[JustOnePing]

Do what now? Because we no longer have lots of GPs we've given up primary care to the NPs?

There's 80,000 FPs and 70,000 internists who would disagree: The Number of Practicing Primary Care Physicians in the United States

Probably actually much higher as that data is 10 years old.

There's nearly twice as many of them (NP Fact Sheet) now doing the roles GPs used to do. There is no such thing as a Nurse Practitioner in most Western countries. This is an American phenomenon due to the lack of GPs.

 

[VA Hopeful Dr]

There's nearly twice as many of them (NP Fact Sheet) now doing the roles GPs used to do. There is no such thing as a Nurse Practitioner in most Western countries. This is an American phenomenon due to the lack of GPs.

Its not the lack of GPs that are causing this. Even if we brought back GPs and credentialed them everywhere it wouldn't change anything. There are a set number of PGY-1 spots. We wouldn't get more PCPs if we let them all practice after 1 year. You still have the same number of residency graduates every year.

Plus, quite frankly, an intern year is no longer sufficient to practice primary care safely. This is due to a combination of increasing medical knowledge and decreasing autonomy in med school. Go talk to doctors that graduated in the 80s. There medical school clinical experience is much MUCH different than it was even 10 years ago much less now.

 

[JustOnePing]

Its not the lack of GPs that are causing this. Even if we brought back GPs and credentialed them everywhere it wouldn't change anything. There are a set number of PGY-1 spots. We wouldn't get more PCPs if we let them all practice after 1 year. You still have the same number of residency graduates every year.

Plus, quite frankly, an intern year is no longer sufficient to practice primary care safely. This is due to a combination of increasing medical knowledge and decreasing autonomy in med school. Go talk to doctors that graduated in the 80s. There medical school clinical experience is much MUCH different than it was even 10 years ago much less now.

In the time it takes to train one class of FPs you would have three times as many GPs in the field. How would this not change anything if you are pumping out three times as many GPs in this theoretical scenario?

I don't disagree with you about increasing medical knowledge and decreasing autonomy in medical school. The latter is the failings of our litigous society. However, it doesn't justify to me why British, Australian, German, Irish doctors, etc. still can be General Practitioners if they don't pursue training in Family or Internal Medicine and we cannot. It's sad and our system is broken when a nurse practitioner can come in willy nilly and not only bounce between different specialties but is deemed superior compared to a graduated MD/DO who finished their intern year of residency. APRNs and PAs have essentially become the GPs of yore.

 

[VA Hopeful Dr]

In the time it takes to train one class of FPs you would have three times as many GPs in the field. How would this not change anything if you are pumping out three times as many GPs in this theoretical scenario?

I don't disagree with you about increasing medical knowledge and decreasing autonomy in medical school. The latter is the failings of our litigous society. However, it doesn't justify to me why British, Australian, German, Irish doctors, etc. still can be General Practitioners if they don't pursue training in Family or Internal Medicine and we cannot. It's sad and our system is broken when a nurse practitioner can come in willy nilly and not only bounce between different specialties but is deemed superior compared to a graduated MD/DO who finished their intern year of residency. APRNs and PAs have essentially become the GPs of yore.

I don't think you understand how math works.

Every year we graduate roughly 4000 FM graduates. That means that there are 4000 PGY-3 positions in FM. This also means that there are 4000 PGY-2 spots and 4000 PGY-1 spots. If we did away with PGY2/3, that still leaves just 4000 PGY-1 spots. Now you could make the argument that if we made GPs a common thing again we'd get an immediate 8000 extra PCPs that first year (which is true), but then we'd be right back at the 4000 graduates a year. So you'd have 1 year with 3X the graduates, but only 1 year. As someone who has gone through an FM residency, you couldn't just make all of those 12,000 spots PGY-1 spots.

British GPs actually have about the same amount of schooling that we do: After graduating med school, they have a 2 year foundation program and then an 18 month GP-specific program. Canada doesn't have many GPs either. The UK, Australia, NZ, and Germany have longer med school than we do, usually 6 years (but don't usually require undergrad - that's a whole separate debate) so their total time from starting medical training to being able to practice is about the same as ours - 6-7 years in total.

 

[JustOnePing]

I don't think you understand how math works.

Every year we graduate roughly 4000 FM graduates. That means that there are 4000 PGY-3 positions in FM. This also means that there are 4000 PGY-2 spots and 4000 PGY-1 spots. If we did away with PGY2/3, that still leaves just 4000 PGY-1 spots. Now you could make the argument that if we made GPs a common thing again we'd get an immediate 8000 extra PCPs that first year (which is true), but then we'd be right back at the 4000 graduates a year. So you'd have 1 year with 3X the graduates, but only 1 year. As someone who has gone through an FM residency, you couldn't just make all of those 12,000 spots PGY-1 spots.

British GPs actually have about the same amount of schooling that we do: After graduating med school, they have a 2 year foundation program and then an 18 month GP-specific program. Canada doesn't have many GPs either. The UK, Australia, NZ, and Germany have longer med school than we do, usually 6 years (but don't usually require undergrad - that's a whole separate debate) so their total time from starting medical training to being able to practice is about the same as ours - 6-7 years in total.

I don't appreciate the snark. Here is the overarching point from the scenario above: for the amount of Medicare funding we spend to train one FM doctor (in the form of PGY training years) we could have trained three GPs (aka MD/DO who completed intern year) doing the work that an NP and PA is eligible to do with way less education and training.

Why isn't that option available for the plethora of US MD/DO doctors who don't want to complete specialty training (for various reasons)?

 

[Splenda88]

So you want to lower physicians to the level of nurses? Good call. No way that'll backfire on us.

GPs can still find work. There's plenty of threads in this forum about it.

That is not true and that is not fair to compare physicians who have been thru med school, passed step 1/2(cs/ck)/3 plus ~6000 hrs training to NP. It's ok that you are against these physicians having full medical practice privilege, but comparing them to NP is assassined.

 

[Giovanotto]

That is not true and that is not fair to compare physicians who have been thru med school, passed step 1/2(cs/ck)/3 plus ~6000 hrs training to NP. It's ok that you are against these physicians having full medical practice privilege, but comparing them to NP is assassined.

It's amazing to me as an MS4 to realize just how little physicians think of medicals students. You would think these physicians were born out of thin air. Adds another piece to the puzzle that is midlevel ambivalence within the medical community.

 

[VA Hopeful Dr]

I don't appreciate the snark. Here is the overarching point from the scenario above: for the amount of Medicare funding we spend to train one FM doctor (in the form of PGY training years) we could have trained three GPs (aka MD/DO who completed intern year) doing the work that an NP and PA is eligible to do with way less education and training.

Why isn't that option available for the plethora of US MD/DO doctors who don't want to complete specialty training (for various reasons)?

It isn't snark to point out that what you think would happen wouldn't happen.

The rate limiting step isn't money, otherwise there wouldn't be new residencies opening up or programs wouldn't be adding spots. The issue is training locations and rotations. At my residency, there just aren't enough patients for 27 PGY-1 residents. It could handle 27 total residents because each year did different things. Most places are like that, at least for FM. Beyond that, at this time every hospital in my state with the volume and facilities to support a residents has at least an FM program.

I don't quite understand the obsession with comparing us to midlevels. Just because they do something doesn't make it a good idea for us to do it too. Also bear in mind that if organized medicine had its way, there would be no independent practice for them. But just because they have a good lobby doesn't mean we should start pushing for doctors to have less training.

 

[VA Hopeful Dr]

That is not true and that is not fair to compare physicians who have been thru med school, passed step 1/2(cs/ck)/3 plus ~6000 hrs training to NP. It's ok that you are against these physicians having full medical practice privilege, but comparing them to NP is assassined.

People on SDN are quite good at taking analogies in the most literal way possible.

What I was going for is that for quite some time now nurse practitioners have been trying to cheapen their own degrees - the rise of online schooling, throwing out of significant prior work experience, and the massive expansion of their programs in general.

We should not be doing the same. In America, the expectation is that physicians are residency trained. We would need an exceptionally compelling reason for that to be changed in a less-trained direction

 

[VA Hopeful Dr]

It's amazing to me as an MS4 to realize just how little physicians think of medicals students. You would think these physicians were born out of thin air. Adds another piece to the puzzle that is midlevel ambivalence within the medical community.

You have to realize, many of us were medical students not all that long ago. MS4 me was in no way prepared to practice medicine independently.

At the same time, this forum is full of people who complain that their rotations have even less clinical experience than they did when I was a medical student. That doesn't exactly inspire confidence.

 

[Dave1980]

You have to realize, many of us were medical students not all that long ago. MS4 me was in no way prepared to practice medicine independently.

Agreed. 3 years of residency should be the absolute minimum required for independent practice. We in radiology do 6.

 

[Chemist0157]

It's amazing to me as an MS4 to realize just how little physicians think of medicals students. You would think these physicians were born out of thin air. Adds another piece to the puzzle that is midlevel ambivalence within the medical community.

It’s almost as if practicing physicians have a different perspective compared to medical students that has been molded by their experience beyond medical school and of which students have not had yet.

I wouldn’t interpret what is being said here as putting students down. It is a measure of ability. An intern+1 day in the current system has minimal outpatient experience and is not well prepared to provide quality outpatient care.

Heck, go ask the interns at your hospital if they are comfortable with being an outpatient PCP in less than 4 months.

Again, if this was to be done well, I could see an accelerated GP track come together. But let’s not jump into the hole the NPs are digging themselves into.

 

[Dave1980]

It’s almost as if practicing physicians have a different perspective compared to medical students that has been molded by their experience beyond medical school and of which students have not had yet.

lol

well said

 

[Epilepsy365]

It wasn’t long ago that today GPs only had to do one year of intern and then go straight to clinical medicine. It’s time for the current physicians to look at themselves in the mirror and stop putting up new hurdles in order to suppress the number of physicians while cheering for more mid level providers.

It starts first with respecting the clinical education of medical students and allowing them to take more active roles in the hospital.

 

[Lexdiamondz]

It wasn’t long ago that today GPs only had to do one year of intern and then go straight to clinical medicine. It’s time for the current physicians to look at themselves in the mirror and stop putting up new hurdles in order to suppress the number of physicians while cheering for more mid level providers.

It starts first with respecting the clinical education of medical students and allowing them to take more active roles in the hospital.

The problem with that is that patients are often reluctant to let junior learners do more than take H&Ps.

Beyond that, with the increases in workload in respect to charting, billing, etc medical students are practically speaking a massive time sink in a attending or resident's workflow. While I agree that medical students should be taking more active roles in the hospital, in some contexts that just isn't really practical and can cause more problems.

 

[JustOnePing]

It isn't snark to point out that what you think would happen wouldn't happen.

The rate limiting step isn't money, otherwise there wouldn't be new residencies opening up or programs wouldn't be adding spots. The issue is training locations and rotations. At my residency, there just aren't enough patients for 27 PGY-1 residents. It could handle 27 total residents because each year did different things. Most places are like that, at least for FM. Beyond that, at this time every hospital in my state with the volume and facilities to support a residents has at least an FM program.

I don't quite understand the obsession with comparing us to midlevels. Just because they do something doesn't make it a good idea for us to do it too. Also bear in mind that if organized medicine had its way, there would be no independent practice for them. But just because they have a good lobby doesn't mean we should start pushing for doctors to have less training.

"I don't think you understand how math works." = feel free to PM me if you'd like to sling back and forth with passive-aggressiveness like this to bolster your arguments.

It's definitely money and even the AAMC states it here (The Role of GME Funding in Addressing the Physician Shortage) re: the 1997 cap on Medicare support for graduate medical education (GME). If it wasn't for this there'd probably be at least 10,000 more training positions since 1997. How can you say there are 'only enough patients' when the capacity and infrastructure to see more in an educational setting has been capped for 23 years?

The US military employs hundreds of General Medical Officers (GMO) and Flight Surgeons throughout the entire Department of Defense in treating active duty military and their dependents. These doctors are not residency trained. Is it such a leap of imagination to have something equivalent in civilian medicine?

 

[Lexdiamondz]

It's definitely money and even the AAMC states it here (The Role of GME Funding in Addressing the Physician Shortage) re: the 1997 cap on Medicare support for graduate medical education (GME). If it wasn't for this there'd probably be at least 10,000 more training positions since 1997. How can you say there are 'only enough patients' when the capacity and infrastructure to see more in an educational setting has been capped for 23 years?

The US military employs hundreds of General Medical Officers (GMO) and Flight Surgeons throughout the entire Department of Defense in treating active duty military and their dependents. These doctors are not residency trained. Is it such a leap of imagination to have something equivalent in civilian medicine?

Institutions have been funding their own residency spots for years - a relatively large % of ACGME residency spots are not funded by medicare at all and residency spots have indeed been expanding year after year for the last decade. The biggest rate limiting step for expansion of residency spots has been ACGME certification and most hospitals simply don't meet the standards to host a residency due to lack of teaching faculty, lack of research activity or simply lack of a diversity of clinical settings.

As for GMOs - don't delude yourself into thinking that our servicemen/women are necessarily getting good care from GMOs. Most are young and healthy 20-30 somethings without many comorbidities who are not hard to care for at all, and the ones who are sick often get horrendously mismanaged.

 

[VA Hopeful Dr]

It's definitely money and even the AAMC states it here (The Role of GME Funding in Addressing the Physician Shortage) re: the 1997 cap on Medicare support for graduate medical education (GME). If it wasn't for this there'd probably be at least 10,000 more training positions since 1997. How can you say there are 'only enough patients' when the capacity and infrastructure to see more in an educational setting has been capped for 23 years?

The US military employs hundreds of General Medical Officers (GMO) and Flight Surgeons throughout the entire Department of Defense in treating active duty military and their dependents. These doctors are not residency trained. Is it such a leap of imagination to have something equivalent in civilian medicine?

The AAMC has no clue what they are talking about:

"While medical schools continue to increase enrollment, the number of residency trainings effectively has not increased "

That's utter nonsense. In 2010 there were 22.8k PGY-1 positions. In 2016 there were 27.8k PGY-1 positions. That's an almost 22% increase in 6 years. By contrast, from 1991 through 1997 (when the cap went into place) total PGY-1 spots went up less than 1%. I know in my state 3 brand new FP programs have started since I finished in 2013.

I was going to write more but the post above me hits on all the other points I was going to make.

 

[VA Hopeful Dr]

My family and I received great care while in the US Navy by GMOs for primary care needs. I must be deluded. They served a purpose (ie treat healthier patients) while specialists saw more complex cases. In civilian life, NPs/PAs have now taken this role. My last three appointments for my children were first seen by PAs in the ER and outpatient setting. I would've trusted a GMO/FS to be just as competent and even *gasp* better.

You continue to make the incorrect assumption that any of us are arguing for increased midlevels. We are not.

 

[JustOnePing]

You continue to make the incorrect assumption that any of us are arguing for increased midlevels. We are not.

I don't assume that you are arguing for increased midlevels whatsoever. Please understand that I recognize you aren't for that. However, due to the shortage of available MD/DOs as GPs we have accepted NPs/PAs in these roles once occupied by physicians.

I, instead, feel that the bar we place on ourselves in medicine is unnecessarily raised higher and higher by our own educational infrastructure. A few scenarios come to mind: MOCA and the battle with the ABMS boards, how several general surgery PDs call for an additional year of GS training due to "not getting enough experience", how even there are calls to make Hospitalist medicine an additional fellowship or even a separate residency. When will this madness stop? All the while PAs with 27 months of PA school can hop into any subspecialty and command low six-figures while a graduated MD/DO cannot.

 

[VA Hopeful Dr]

I don't assume that you are arguing for increased midlevels whatsoever. Please understand that I recognize you aren't for that.

I, instead, feel that the bar we place on ourselves in medicine is unnecessarily raised higher and higher by our own educational infrastructure. A few scenarios come to mind: MOCA and the battle with the ABMS boards, how several general surgery PDs call for an additional year of GS training due to "not getting enough experience", how even there are calls to make Hospitalist medicine an additional fellowship or even a separate residency. When will this madness stop?

I don't know enough to comment on surgical training, but I completely agree that hospitalist fellowships for general peds/IM are ridiculous.

MOC for FM isn't that bad. It took my roughly 3-4 hours in January to do everything I needed for this 3 year cycle. They're also going away from the big 10 year exam and going to quarterly 25 question open book tests across the last 4 years of a 10 year cycle.

At the same time, I don't think we should be going backwards. We moved away from the GP model for good reasons. Those reasons haven't changed.

 

[Candidate2017]

I wouldn’t interpret what is being said here as putting students down. It is a measure of ability. An intern+1 day in the current system has minimal outpatient experience and is not well prepared to provide quality outpatient care.

Heck, go ask the interns at your hospital if they are comfortable with being an outpatient PCP in less than 4 months.

That's precisely the difference. Ask a newly minted NP/PA and they'd say "Yes!"

Med students/interns are different from NP/PAs: They're brighter, know they don't know everything, are afraid of making mistakes, seek to learn/read more, always open to looking for the zebras, can accelerate their learning curve quickly. There are some NP/PAs that are somewhat ok but they aren't the same. The difference between the intellectual curiosity of an NP/PA and med student/intern is night and day. The NP/PAs I've seen rarely read or discuss medicine other than what the pharm sales rep tells them. The older NPs/PAs seem to be in a rut where it's just a wellpaying job they show up in order to pay for their next vacation. The younger NP/PAs are worse, "Tee hee, I'm wearing a white coat."

I wouldn't be opposed to med school graduates entering an apprentice model for most specialties or primary care. Let them work fulltime at $100k under a supervising physician for 1-3 years longer than their resident counterparts, then give them some of type of full license. Hospital MBAs that depend on resident labor would lobby hard against that though.

 

[Chemist0157]

That's precisely the difference. Ask a newly minted NP/PA and they'd say "Yes!"

Med students/interns are different from NP/PAs: They're brighter, know they don't know everything, are afraid of making mistakes, seek to learn/read more, always open to looking for the zebras, can accelerate their learning curve quickly. There are some NP/PAs that are somewhat ok but they aren't the same. The difference between the intellectual curiosity of an NP/PA and med student/intern is night and day. The NP/PAs I've seen rarely read or discuss medicine other than what the pharm sales rep tells them. The older NPs/PAs seem to be in a rut where it's just a wellpaying job they show up in order to pay for their next vacation. The younger NP/PAs are worse, "Tee hee, I'm wearing a white coat."

I wouldn't be opposed to med school graduates entering an apprentice model for most specialties or primary care. Let them work fulltime at $100k under a supervising physician for 1-3 years longer than their resident counterparts, then give them some of type of full license. Hospital MBAs that depend on resident labor would lobby hard against that though.

I'm going to go ahead and invoke my patented law:
Chemist0157's lawTM - "As an SDN thread grows longer, the probability of derailment by a PA/NP discussion approaches 1."

Are we talking about if it is reasonable for intern+1 day residents are ready for independent practice, or are we were talking about NP/PA graduates are ready for independent practice? The answer can be "no" to both. The idea that new PA/NP graduates would claim they are ready for independent practice does not change whether new second year residents can provide quality care. There really is an obsession in this subforum that is confounding other discussions.

I am not opposed to an accelerated program. This is the third time I am saying this. The current system is not configured for the task. Whatever blanket statements that can be made with how midlevels behave does not change that.

 

[Mass Effect]

It wasn’t long ago that today GPs only had to do one year of intern and then go straight to clinical medicine. It’s time for the current physicians to look at themselves in the mirror and stop putting up new hurdles in order to suppress the number of physicians while cheering for more mid level providers.

It starts first with respecting the clinical education of medical students and allowing them to take more active roles in the hospital.

GPs still only have to do one year as an intern to get their license, in some states. Go to one of those states, do your year, hang your jingle and you're done. Why are you whining about it here?

 

[Doohickey550]

I am a first year FM resident and I am actually strongly considering leaving after this year and opening my own DPC practice. As an intern, I have basically been managing patients on my own with the way things work at my hospital. There may be a lot more medical knowledge needed in today’s world compared to the old world, but with today’s resources one can easily look up expert and peer reviewed information within minutes. It’s already impossible to know everything and looking things up is key. I would be starting to moonlight independently at urgent cares next year anyway, so what’s the difference?
Regardless of what one thinks about NPs and PAs, the fact remains that they are starting to take over the primary care world. We need more physicians in primary care, and by making it easier for fully licensed physicians after one year of training go into primary care, we can significantly improve the level of care in the community. GPs back in the day had far fewer resources at their fingertips than the GP of today.

 

[throwaway1000000]

I am a first year FM resident and I am actually strongly considering leaving after this year and opening my own DPC practice. As an intern, I have basically been managing patients on my own with the way things work at my hospital. There may be a lot more medical knowledge needed in today’s world compared to the old world, but with today’s resources one can easily look up expert and peer reviewed information within minutes. It’s already impossible to know everything and looking things up is key. I would be starting to moonlight independently at urgent cares next year anyway, so what’s the difference?
Regardless of what one thinks about NPs and PAs, the fact remains that they are starting to take over the primary care world. We need more physicians in primary care, and by making it easier for fully licensed physicians after one year of training go into primary care, we can significantly improve the level of care in the community. GPs back in the day had far fewer resources at their fingertips than the GP of today.

I think the problem is if we do the same thing as them that is cut short our training and start practice, why would there be a salary gap? The only reason MD PCPs are paid 100-150k more than midlevels is because of this extra training. If we didn't have the extra level of training, not sure why insurance companies would be reimbursing us higher than midlevels. Cutting short 2 years of training and risking decreased reimbursement in private practice or salary at employment models for your entire career doesn't seem too appealing.

You are going into DPC which is a different business model but ultimately how are you going to separate yourself from an NP or PA next door that opens the same DPC practice.

Not questioning you. Just curious to hear your thoughts.

 

[Doohickey550]

I think the problem is if we do the same thing as them that is cut short our training and start practice, why would there be a salary gap? The only reason MD PCPs are paid 100-150k more than midlevels is because of this extra training. If we didn't have the extra level of training, not sure why insurance companies would be reimbursing us higher than midlevels. Cutting short 2 years of training and risking decreased reimbursement in private practice or salary at employment models for your entire career doesn't seem too appealing.

You are going into DPC which is a different business model but ultimately how are you going to separate yourself from an NP or PA next door that opens the same DPC practice.

Not questioning you. Just curious to hear your thoughts.

A physician after one year of internship has far more training and clinical experience than a mid-level. Again, this is what the PCP traditionally was, and as I said above, I would argue that the GP of today is MORE capable than the GP of old because of all the resources at our fingertips today. I don’t just mean UpToDate and Epocrates, I’m also about online specialist consultants etc.

To me it seems like the obvious answer to help with the pcp shortage. Check out Dr. Edward Canfield’s articles on the topic from a few years back at the AOA.

 

[Mass Effect]

A physician after one year of internship has far more training and clinical experience than a mid-level. Again, this is what the PCP traditionally was, and as I said above, I would argue that the GP of today is MORE capable than the GP of old because of all the resources at our fingertips today. I don’t just mean UpToDate and Epocrates, I’m also about online specialist consultants etc.

To me it seems like the obvious answer to help with the pcp shortage. Check out Dr . Edward Canfield’s articles on the topic from a few years back at the AOA.

I wonder something. If there's ever a malpractice suit, would the standard be what another FM doc would do or would it be what someone with only intern year under their belt would do? Anyone know?

 

[zero0]

I'm all for expanding scope of practice for GPs. It would fill a role that is being filled badly by NP/PAs today. People are getting hurt because that is the best care they can get sometimes and it's about time this became a viable option.

Medical training in general has become a runaway scam for cheap labor. Anesthesiology used to be 3 years, radiology used to be 4 years. FM used to be 1, etc. Now the academic bigwigs and leeching MBAs are joining forces to suggest longer training for just about everybody again. Old guard surgeons are saying "I worked 120 hours a week and these pansies with their 80-hour work week restrictions (which aren't even enforced) will never be good surgeons, let's add another year of training." Then you have FM docs acting like managing a panel of 90% diabetes/HTN/URIs is rocket science and insisting they need the extra training because there's more to know. Yes, there is, but we have also become exceedingly efficient at learning it and have much better resources available. The quality of FPs a lot of community programs put out is questionable anyway. I've seen a competent M4 run circles around the bottom-of-the-class tier PGY3s that usually fill these programs when managing patients. You wanna tell me this person wouldn't be a capable physician after one additional year of training? Granted, they weren't as adept as charting, codes, paperwork, and social work bs.

I'd be all for it if these suggestions for longer training were actually coming from a good place, but most of the time it's just dinosaurs with big egos and people who just want to profit from cheap resident labor.

Then, to keep the cheap labor train rolling, there's a fellowship out there for literally anything you can think of, 90% of which are useless. When will it end?

 

[deleted947265]

I wonder something. If there's ever a malpractice suit, would the standard be what another FM doc would do or would it be what someone with only intern year under their belt would do? Anyone know?

It's technical, circumstance specific and probably locality specific but if what they were doing was in their scope of practice it would be the same standard of care. If they were practicing outside their scope of practice it would still be malpractice.

 

[Link0358]

I'm all for expanding scope of practice for GPs. It would fill a role that is being filled badly by NP/PAs today. People are getting hurt because that is the best care they can get sometimes and it's about time this became a viable option.

Medical training in general has become a runaway scam for cheap labor. Anesthesiology used to be 3 years, radiology used to be 4 years. FM used to be 1, etc. Now the academic bigwigs and leeching MBAs are joining forces to suggest longer training for just about everybody again. Old guard surgeons are saying "I worked 120 hours a week and these pansies with their 80-hour work week restrictions (which aren't even enforced) will never be good surgeons, let's add another year of training." Then you have FM docs acting like managing a panel of 90% diabetes/HTN/URIs is rocket science and insisting they need the extra training because there's more to know. Yes, there is, but we have also become exceedingly efficient at learning it and have much better resources available. The quality of FPs a lot of community programs put out is questionable anyway. I've seen a competent M4 run circles around the bottom-of-the-class tier PGY3s that usually fill these programs when managing patients. You wanna tell me this person wouldn't be a capable physician after one additional year of training? Granted, they weren't as adept as charting, codes, paperwork, and social work bs.

FM isn’t anywhere close to 90% HTN/DM/URI. Stating this demonstrates complete ignorance of the field. It’s the most broad field in medicine, and is why we need a 3 year residency to be close to competent in it.

If during a busy clinic day you have the time to look up the work up of asymptomatic elevated LFTs, chronic testicular pain, generalized neuropathy, chronic pediatric limb pain, etc. etc. then maybe we don’t need a residency.

But an attending in a busy clinic is not going to have the time to look up the work up of every other patient that comes through the door.

 

[Doohickey550]

FM isn’t anywhere close to 90% HTN/DM/URI. Stating this demonstrates complete ignorance of the field. It’s the most broad field in medicine, and is why we need a 3 year residency to be close to competent in it.

If during a busy clinic day you have the time to look up the work up of asymptomatic elevated LFTs, chronic testicular pain, generalized neuropathy, chronic pediatric limb pain, etc. etc. then maybe we don’t need a residency.

But an attending in a busy clinic is not going to have the time to look up the work up of every other patient that comes through the door.

Whether or not this is so, personally, with the DPC model I would not be seeing a million patients a day. 8-10 patients per day and not having to deal with insurance related paperwork etc. would give me ample time to look things up as needed. But you have to admit that the majority of patients will have a limited number of common conditions. I assume the post above quoting 90% was probably exaggerating.

 

[Mass Effect]

Whether or not this is so, personally, with the DPC model I would not be seeing a million patients a day. 8-10 patients per day and not having to deal with insurance related paperwork etc. would give me ample time to look things up as needed. But you have to admit that the majority of patients will have a limited number of common conditions. I assume the post above quoting 90% was probably exaggerating.

The most dangerous doctors are the ones who don't know what they don't know.

 

[Doohickey550]

The most dangerous doctors are the ones who don't know what they don't know.

Agreed. But one can still know what they don’t know after one year. Knowing what you dont know is a mindset, not a level of training. If a GP is not comfortable managing something, they need to refer out. Same as anyone else.

 

[ace_inhibitor111]

I’m of the opinion that the value in medical education is selecting for individuals who are able to rapidly absorb, recognize, and interpret information, especially new information. If we are arguing that the amount of experience trumps all then there really is no difference between us and NPs (who already have on the job training).

 

[VA Hopeful Dr]

Whether or not this is so, personally, with the DPC model I would not be seeing a million patients a day. 8-10 patients per day and not having to deal with insurance related paperwork etc. would give me ample time to look things up as needed. But you have to admit that the majority of patients will have a limited number of common conditions. I assume the post above quoting 90% was probably exaggerating.

This is an extremely bad idea for several reasons.

First, if you have a DPC you're expecting patients to pay cash. You have to offer quality in exchange for that. A decent subset of your patients will care that you both didn't finish residency and aren't board certified. When I had my DPC practice somewhere around 50% of patients asked if I was board certified. Now if you're the only DPC in your area and don't care if you only get the patients who have no where else to go (uninsured, hate the other groups in town, super libertarian) this might not matter as much but that's a risk.

Second, in DPC you actually need to be better trained than the average FP since many of your patients won't be able to access specialists. Where I was, the only rheumatology practice would not see self-pay patients whatsoever which means I had to manage these patients' RA, lupus, psoriatic arthritis, you get the idea. Being able to look things up certainly helped, but you need a certain amount of previous knowledge and experience for it to be even reasonably safe. Same thing with ortho stuff. I had quite a few patients needing injections for things I hadn't trained to do but because I had done lots of injections in other areas the skills transferred well. Its like how surgeons don't have to go back to residency to learn every new procedure that comes out because they have a solid foundation of knowledge/skills.

Third, FM residency is somewhat unique in that we have significantly more elective time in the later years than most - its why there is such a wide range of practices in the field. You're really screwing yourself if you throw away the only chance you'll have to learn directly from the various specialists your program will have you rotate with. If you're driven, you can even learn more unique skills that can really help a DPC practice - vasectomy, ultrasound, splinting/casting, more advanced GYN procedures (endometrial biopsies, IUD placement), stuff like that.

Fourth, if your DPC practice doesn't work out for any reason if you aren't residency-trained and board certified finding another job is much more difficult. Not impossible, but your options will be severely limited.

 

[Doohickey550]

This is an extremely bad idea for several reasons.

First, if you have a DPC you're expecting patients to pay cash. You have to offer quality in exchange for that. A decent subset of your patients will care that you both didn't finish residency and aren't board certified. When I had my DPC practice somewhere around 50% of patients asked if I was board certified. Now if you're the only DPC in your area and don't care if you only get the patients who have no where else to go (uninsured, hate the other groups in town, super libertarian) this might not matter as much but that's a risk.

Second, in DPC you actually need to be better trained than the average FP since many of your patients won't be able to access specialists. Where I was, the only rheumatology practice would not see self-pay patients whatsoever which means I had to manage these patients' RA, lupus, psoriatic arthritis, you get the idea. Being able to look things up certainly helped, but you need a certain amount of previous knowledge and experience for it to be even reasonably safe. Same thing with ortho stuff. I had quite a few patients needing injections for things I hadn't trained to do but because I had done lots of injections in other areas the skills transferred well. Its like how surgeons don't have to go back to residency to learn every new procedure that comes out because they have a solid foundation of knowledge/skills.

Third, FM residency is somewhat unique in that we have significantly more elective time in the later years than most - its why there is such a wide range of practices in the field. You're really screwing yourself if you throw away the only chance you'll have to learn directly from the various specialists your program will have you rotate with. If you're driven, you can even learn more unique skills that can really help a DPC practice - vasectomy, ultrasound, splinting/casting, more advanced GYN procedures (endometrial biopsies, IUD placement), stuff like that.

Fourth, if your DPC practice doesn't work out for any reason if you aren't residency-trained and board certified finding another job is much more difficult. Not impossible, but your options will be severely limited.

Thanks for these thoughts. I definitely do agree that it’s not the IDEAL position to be in and I agree with the points you’ve made. In my case, there are various factors that are playing a part in my decision. I wanted to do the DPC thing anyway, but now there are various reasons that are pushing me to leave residency early. DPC practice with GP status seems like still a good option.

 

[VA Hopeful Dr]

Thanks for these thoughts. I definitely do agree that it’s not the IDEAL position to be in and I agree with the points you’ve made. In my case, there are various factors that are playing a part in my decision. I wanted to do the DPC thing anyway, but now there are various reasons that are pushing me to leave residency early. DPC practice with GP status seems like still a good option.

I would also suggest looking at the jobs available for GPs out there to make sure you're OK with those as a worst-case scenario in case DPC doesn't work out for whatever reason.

Ideally you'd find a way to make residency work since as a BC FP you can quite literally find work anywhere, but being a GP isn't the end of the world either. Just make 100% sure that you can't suffer through another 2 years before you make your final decision.