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Discussion in 'General Residency Issues' started by M.Furfur, May 28, 2008.
I blame the AMA. This article in the Wall Street Journal health care blog by Brian Klepper a PhD Health Care analyst working on national reform issues relates that the AMA secret advisory committe known as the RVS Update committee has been heavily dominated by specialists and served to heavily influence the CMS or centers for medicare and medicaid services to implement reimbursement patterns extremely favorably to specialist at the expense of undermining primary care physicians and utimately the U.S. health care systme as a whole.
Instead of concentrating on preserving medicine they have abused the system using their influence to drive up procedure costs and leaving primary care physicians out in the cold so much so that the AMA in my opinion has lost all credibility. The AMA has been roundly criticized and have built the a gigantic ship that is doomed to sink and still they do not recognize their errors but continue along the same paths. If the health care system is to be saved and seniors with complex medical problems not thrown to undereducated to inappropriately educated midlevels it's going to be through the efforts of the american association of family practice physicians and the internal medicine american academy of physicians and senators like Max Baucus Democrat from Montana.
FYI: Your link is dead.
And you might want to refresh yourself on the current state of procedural reimbursements and RVUs especially in the case of general surgery in which reimbursement has dropped every year, with more to come.
That is unless you think $500 or less for an appendectomy is "extremely favorable" for the years of training, the pre-op evaluation, the possible complications, the cost of malpractice and the 90 days post-op of care bundled into that reimbursement (assuming the patient even has insurance).
While it has been true in the past that specialists were reimbursed much more than PCPs, to continue to hold that opinion in light of the above, seems a tad outdated to me.
What do you think the solution is? Can medicine or primary care in particular be saved? or is the solution to superspecialize and leave everything else to midlevels?
Heh, you know... you could argue that General Surgery is part of primary care. Surgeons could have brilliantly done what OBGYN did and made the "must have" procedures done by Family Medicine more like open appendectomies and open cholecystectomy.. that way they can focus on more profitable not-so-primary procedures (Single Incision Lap Appendectomy or Single Incision Lap Cholecystectomy). I say this jokingly because I know surgeons would rather kill and maim than lets anyone else do an appendectomy/cholecystectomy.
Regardless.. hospitals treat general surgeons very much as primary care because they have to do certain procedures regardless so its hard to still call general surgery as not-primary care. Gotta get that surgery consult. General Surgery has become as primary care as Internal Medicine.
I do not believe that most surgeons are interested in doing primary care. I can not recall a general surgeon ever telling me they would like to see patients in follow-up in order to manage hyperlipidemia, hypertension, diabetes, PAP smears, etc.
Yet in my rural hometown -- which happens to have a good number of FM and IM primary care docs -- all 3 of the general surgeons also see patients for the rash, sore throat, HTN, etc. They are older and have done so since the early 1970's. In short, they are out there, I would suspect mostly in rural areas.
Here is a quote from the cafeteria line this morning with a good friend who is an ER RN.
Me: "So, how are you enjoying the ER? Think you'll be there for the duration?"
Friend: "I really like it, but I want to go get my DNP"
Me: "Really? Why? Ever thought about PA school?"
Friend: "Because I want to have autonomy. PA school doesn't offer the autonomy NP school does, and it's time for docs to understand that nurses need to be trusted more, and that we are here to stay".
When a good friend of mine becomes borderline malignant in tone (and content), can you imagine what the typical nurse thinks? I took an informal survey in the ICU the other day, and amongst n = 5, the 2 older nurses said: "Let docs practice medicine, nurses should stay out", one male, one female, while the 3 younger nurses (<35) said that not only did they trust NP's more, but that they were "more knowledgeable and better clinically than most physicians out there", and when confronted with the actual clinical hours of training, they said : " NP's can read outside of work and EASILY catch up with physicians ".
Guys, I'm telling you: the DNP issue affects every area of medicine, nobody is immune. Anesthesiology and Primary Care are on the front lines, but it's spreading, and it's malignant..
Thats not unusual at all. The older generation is all bout hard work and just doing your job. They know that everyone has a role to play and they do theirs well. This applies to all fields not just medicine.
The younger generation is all about telling aurthority figures to F off. Because gosh dang it I'm the best and I know I am because thats what they've been telling me since grade school. Screw having a role to play and the overall well being of the patient. It's all about me and if someone tells me I can't do something I'm gonna throw the worlds biggest hissy fit.
Case in point back in undergrad I worked with this girl who wanted to be a nurse. About a year into it she changed her mind saying she just didn't want to be "just a nurse." She then set her sights on PA school. She changed her mind on that stating that she didn't want to have a boss and didn't want to take orders from anyone. So she set her sights on Med School because "I want to call the shots." Gave up on that after finding out that medical training involved taking orders from higher ups for a good 7-10 years. I lost contact with her but I wouldn't be shocked if she was on her way to a DNP degree now.
Don't get too down on your career choice. A FP or IM is still the gold standard in primary care and as such, you will be able to open a retainer practice. Anyone who takes their health seriously will know a physician is worth the money for their health. DNPs have simply started the foundation for a two tiered system.
I predict if we go universal coverage it is a matter of time until the bean counters reduce everything to just costs and physicians are phased out for an army of DNPs. Docs cost too much to train for a system like that to support. Conversely, if the economy tanks hard enough and medicare simply collapses and the government loses its controlling influences the market will take over. You can bet, that once people have to start using their own money once again for primary care that gives them the greatest bang for their buck, DNPs will quickly be seen for what they are. But for as long as the gov controls our health and sets the tone for the insurance industry, you can bet, the only future is direct to patient care for those who recognize what we can trully do for their health.
Nah, we're pretty safe in the surgical subspecialties.
I look at the new generation of nurses, nurse practioners, and physician assistants, and although they talk a good game about autonomy and clinical skills, none that I have ever worked with had the same dedication to patients as physicians do. NPs and PAs work 40 hours a week and shift all the responsibility to interns, junior/senior residents, and attendings. Do they take call? No. Do they work at night? Very few, but they still get 3+ days off a week. Do they take responsibility for a crashing patient? Not really. Do they do whatever it takes to get the job done, or do they defer to the intern? Do they work weekends?
These midlevels will NEVER come close to taking over primary care or any other field of medicine. They simply do not understand what it takes to be the primary caretaker of another human being. Their limitations are not so much that they lack book knowledge or clinical experience. They lack the dedication that every physician has PROVEN by virtue of having to be the best and brightest all their life, do an internship, and complete residency. Having to go through all these hoops have weeded out most of those who simply lack the dedication that a physician requires. That means coming in during the middle of the night. Taking call. Working weekends, working holidays. Making tough decisions, taking responsibility.
I have not met a single PA or NP that does all of the above. Not one. Every single NP/PA maxes out their sick days. I have seen some surgical residents take sick days, like when they were having surgery done on them, but the vast majority of us hasn't take a single sick day this year.
Once these nurses and PAs realize that being called a doctor means more than just earning six figures, and that it actually requires working nights, weekends, getting sued, being the last line of defense for patients, their hunger for more autonomy will quickly dissipate.
I have no fear whatsoever about nurses doing my job.
That's an interesting thought.
This is really the crux of the matter and the current reason why midlevels have set their own glass ceiling. Striving for equality to them tends to have more to do with prestige and pay than workload. The hardest working midlevels with whom I have worked are still 8-5, no nights, no weekend types of people.
I worked on a busy surgery service that had a strong PA as part of the "team." She was actually very smart and knew alot about the particular branch of Gen Surg. The problem was that this PA wanted to run the show and still work 7-3. We (residents/students) would have already pre-rounded/rounded and would have started on the plans when she would show up and demand to run the list. Usually the senior just kind of handled her, making her feel important and then she would start working on dispo/placement issues. Students quickly learned or were told to ignore her. Although she had the potential to be an integral part of the team her "normal" work ethic relegated her to the position of a social worker on a power trip. Oh yeah, if she was feeling yucky she took a sick day. Definitely never came in on a weekend no matter how busy the list was or how sick the people were. But it was still "her" service. Give me a break.
Don't get me wrong, in her role she was excellent. She knew alot about the disease processes, was awesome at placement, and stellar at sitting down with families. Knowing one's place is a vital part of being on a medical team.
Posted this before I think, but I had a similar situation on a neurology rotation. NP wanted those hours, and claimed to not only be "certified in critical care", but also 15+ years in Neurology.
As a BRAND new intern (think July), I picked some things up from her. Within 2weeks, I was seeing 2-3 times the patients, with longer differentials, etc, etc, etc. She isn't the one to worry about, it's the people she pays dues to who lobby on Capitol Hill, and attend parties with ice sculpture busts of Mary Mundinger.
Coastie, with your permission, I'd like to use this as my tagline.
I'll point out a few things. I can't speak for the NPs, but the PAs that you are working with are the minority. More than 80% of PAs work for private practice groups. They take call, they come in in the middle of the night, they do what they are paid to do. As PAs we always have the option to defer to the physician, which is part and parcel of the job. On the other hand we have a duty to make sure that what we do doesn't set the physician up for failure.
Having worked in private practice and then academia I can however see where you are coming from. There is no real incentive in academia to work harder. In private practice, if I worked harder (or more efficiently) and brought in more collections then my bonus was bigger. In academia there is no relation to how hard you work and how much you make. The same thing applies to sick days. In private practice either your fellow PAs or the physicians have to pick up the slack. This provides a social disincentive to use your sick days. In academic practices this disincentive seems not to exist. In seven years in private practice I used 2 sick days (both for fever >103). In an academic practice I am told to use my sick days for "mental health days" or if I have a Doctors appointment. I still have enough pride in my work not to do this.
You are correct in saying that for the most part PAs aren't as vested in the practice of medicine. While there are some PAs that have partnership or ownership in practices, for the most part we are employees. As such I look at it as a job. I take pride what I do and work hard to do the best for the patients, but the physicians that own the practice own the patients. They have ultimate responsibility for the patients and I'm fine with that.
There are a lot of hard working PAs out there that love their jobs. Don't assume that what happens in an academic environment is what happens in the real world.
David Carpenter, PA-C
Here's the working URL: http://www.thehealthcareblog.com/the_health_care_blog/2007/12/bad-medicine-ho.html
Careful there man, you might violate the sacred SDN myth that nurses know more than interns!
According to this article I googled, Mary Mundinger wants to start a 'clinical doctorate in nursing' program. It's a four-year post-BS degree followed by a year-long residency. Depending on what was actually contained in those 5 years, it could come close enough to MD training to fill the currently existing dearth of primary care providers.
The influx of midlevels is itself a response to market forces. There aren't enough MDs doing primary care, but primary care has to get done; so somebody else is going to step in if we don't pick up our own slack.
As others in this thread have noted, this has not occurred in any of the nations that currently have universal coverage. Did you know that administrative costs are 4x higher for private than public insurance companies? A big slice of the health care costs in the US goes towards paying bureaucrats at insurance companies to figure out ways to deny claims.
See, I'd predict just the opposite. The advantage of an MD (vs NP) as your PCP is that the MD has the broad-based training to pick up on the small percentage of cases that are actually worrisome. But for 90% of the population 90% of the time, the care isn't that complicated. I don't need an MD to give me some cough syrup and Tylenol when I have the sniffles, or to do my Pap smears. So few healthy people will notice the difference between the MD and the NP, certainly not enough to pay the extra cost of the MD. I wouldn't, at least not at my current age and state of health.
This is comparable to the current situation with paying for health insurance. Under currently operating free market principles, insurance companies have NO financial incentive to provide better coverage - because relatively few people will have the bad luck to need the coverage and realize how poor it actually is. When only a small proportion of your customers will ever use your product, the best way to fatten your bottom line is to provide the cheapest possible product and some really nice-looking glossy brochures.
When I was a medical student doing PC rotations in private practices a whole day which consisted of about 20-30 patients and of those only about 5 were the sniffles or simple procedures ie paps. The rest were elderly patients with multiple or complex conditions, COPD exacerbations, or had the American tripple cocktail (HTN, DM, cholesterol).
So while the majority of people are healthy the majority of office visits are not healthy individuals.
I guess it depends on the particular practice. I remember a lot of URIs, routine pregnancy visits, and muscle/back strains.
Also, I'd like to point out that the cost of health insurance in the US drives healthy people out of the payer pool. With more cheaply available providers, we might have a better shot both at preventative care and at keeping a buffer of healthy payers in the system (without which the insurance system can't work). An NP can start working on obesity and metabolic syndrome long before it turns into runaway insulin dependence and end-organ damage requiring the oversight of a physician.
It will only be a question of time till this one year residency will become,a 2-year residency, then a 3 years residency......
If nurses want to practice medicine, they should go to medical school.
This is why this project has to be stopped, the shortage in primary care is nothing near the shortage in nursing, so before they write articles accusing family medicine residencies are attracting 3rld world countries doctors away from their countries where they are needed. Let them evaluate what this and similar programs will do to the more acute nursing shortage in the USA.
Physicians need to take this argument straight to the public and start informing people about the difference between a doctor and a nurse/PA, CRNA or whatever else these allied health folks have cooked up. No more "we are a team" nonsense while they try to upsatge physicians. If the public decides they would rather take their illness to a nurse, it needs to be an informed decision, not one based on confusion and trickery as is the case now. And yes, I wll support campaign adds that use words like "an actual doctor".
I just went and PubMedded around to see what I could find out about comparison of outcomes between NPs and MDs in primary care.
Seale et al., J Adv Nurs. 2006 Jun;54(5):534-41.
Laurant et al., Cochrane Database Syst Rev. 2005 Apr 18;(2):CD001271.
Mundinger et al., JAMA. 2000 Jan 5;283(1):59-68.
Overall it looks like quantifiable outcomes don't generally differ between NPs and MDs. Patient satisfaction tends to be higher with the NPs because they spend more time talking to the patients.
Unfortunately I couldn't find any long-term studies - longest followup isn't ever more than a year or two. I'd expect the differences to show up over time as the small proportion of patients for whom the NP/MD difference really matters accumulates to statistical significance.
Again this is part of the trickery I am talkig about. Decieve the patient into seeing an NP when they think they are seeing a physician, then take a survey afterwards on customer satisfaction as proof that there is no difference. Until you show me a survey that most patients that see NPs start out intending to see an NP, I will continue to call this what it is, good old fashion deceit.
? I understand your point. But I actually like the design. How about if they said the MD was a NP and the NP was MD? I bet they'd rank the MD's lower. It wouldnt surprise me.
From my N=1 perspective. I hated the derm MD I saw b/c she spent two seconds with me and had no interest in educating me about anything. the NP actually took time to explain things.
Look at the designs of the studies more carefully before you draw conclusions. Not all studies are well designed.
For example, Mundinger's study is a poor study with low power, using pre-diagnosed patients, etc. Of course if you spend more time with a patient, they feel more satisfied. But if an NP opens her own clinic, will she spend more time with the patient than the physician? No, because you need to churn through so many patients to make a decent profit in primary care. No studies show that NP's can diagnose and treat equally as well as physicians. Using some common sense, the burden to show proof is on the NP's, not the twisted logic that because there are no studies that show that NP's are not worse therefore they are the same. Yet, Mundinger uses this study as the basis for her claim that DNP's are equally good at diagnosing and treating as physicians. What a joke.
The thing you have to learn about nurses is that they put out a lot of junk studies and use propaganda to advance their agenda. What they can't achieve through education they try to do it politically. Don't take everything they put out at face value.
Prediagnosed patients dont make a good argument for good primary care when we all know the hardest part of the primary care physician is actually slapping an accurate diagnosis (not just naming a symptom and sending it off to the specialist).
I get tired of seeing the bad study placed in JAMA where NPs manage patients vs. physicians where the patients are mostly diabetes... Gimme a break... A collection of 1000 patients is not made of simple diabetes. Why dont we toss some undeclared cancers at both physicians and nps then watch who catches them first.
The Laurant study is a meta-analysis of sixteen studies. Anyway, I agree that the available evidence is scarce and too limited to assess the real impact on patient outcomes of training NPs to work more independently. But I haven't seen a study that suggests specific harm. Everyone's just assuming it.
Talk about tarring with a broad brush.
Then you need to read their propaganda and what they're up to politically.
Here's a good start:
Just have to point out that this is a gross generalization on your part and may or may not reflect reality (at least as far as most PAs are concerned.). Maybe that flies in an academic setting, but I can tell you from personal experience that its is not even close to how my world works.
Here is a taste of my last week.
Started call on the 23rd of May and we got slammed over the weekend. We had ATV accidents, motorcycle accidents, head bleeds, spinal cord injuries, people falling off ladders you name it.
In addition, we are covering for the other neurosurgeon who is out of town and we are covering all of his patients (currently managing over 25 patients). We operated most of the weekend and then Monday morning my boss calls me and states that we have 4 new consults and to go start seeing them so he could get some sleep. I do the consults and make all the rounds at both hospitals. He follows behind me a few hours later to follow-up on the consults. We get another call for a bleed and operate late into the night.
I go home and crash. 5 am the phone rings and its my boss tells me we have another bleed (p-fossa) that needs to go to surgery now. I throw on my scrubs and get to the hospital. No shower, no breakfast, no deodorant and no prilosec (big issue for me).
Anyway, we get the ventric and crani done and then do our regularly scheduled cases, we don't stop for lunch. I did grab an orange juice. We finish the surgeries and there are new consults and rounds to do. We split up and he does the consults and I do the rounds.
We have lots of big operations the rest of the week and a few other emergent cases. Clinic is slammed on Friday because of the holiday on Monday.
I am making rounds this weekend and my boss is taking it easy. I round on the weekends that we have call. He takes the weekends that we are off call. We have an extended call so the last time I had a day off was the 18th and my next day off will be the 7th and we finally are off call Tuesday at 7AM.
That is my cush 40 hour, whiny, taking sick days off PA life. Oh did I mention I have never taken a sick day off.
One pdf flew over the cuckoo's nest....
Well, if neurosurgeons would increase their spots in residency then we'd start seeing more neurosurgeons around instead of seeing one with a bunch of extenders (not necessarily PAs either!). It's crappy care and they are getting away with it. They might get surprised some day if vascular surgery and interventional neurology takes their glory like cardio did to thoracic surgery.
Don't feel bad, neurosurgery is like this everywhere, wont change till competition enters the field.