This would be my solution, yes. I believe the function of an NP or PA is to allow someone to function at the top of their license. I believe an FM or IM doc could safely manage and oversee multiple APPs with low risk and uncomplicated problems while funneling complicated patients to the MD. I believe a surgeon could use them to offload almost all non operative work and work up for new consults and allow said surgeon to do one pre-op visit and the operation for patients proceeding along pathway with normal recovery. Not everything - you still round on patients once a day. If they deviate from routine recovery you see them. But even when they deviate sometimes you don’t need to physical see them for the next step to be performed - maybe they need a CT first, and then they come see the surgeon. That is a visit and evaluation that could safely be done by my PAs currently and expedites and streamlines care.
I wonder how appealing being a mid level manager, with a couple patients here and there, is to most people. Sure you make more money, but there’s no way you can make sure your midlevels didn’t miss things on however many patients you’re giving them every day.
I hear your crusade and don’t disagree but the problem is a medicolegal issue. There are only certain, very small, very specific parts of your work that can be used and billed for and not have to be duplicated. It creates a problem in high volume places that are busy.
Iirc there's a recent revision to make med student notes billable:
forums.studentdoctor.net
That’s totally fair and I can’t argue with that, but in the same vein I think you’d have trouble arguing that with how robust evidence based medicine is becoming that a lot of it isn’t formulaic. New patient comes in with hypertension can be boiled down to a protocol and unless x deviations exist gets x work up and started on x drug; if x deviation, notify MD. A protocol like that should be made by an MD in my opinion but can safely and cheaply be carried out by an APP. Do you disagree with that?
We can’t delegate procedures to Med students unsupervised, ever. That’s the key difference and it’s wildly important. Once an intern learns how to do a line they can do a line independently. A Med student can never, ever do that. Doesn’t matter how competent you are - if you screw up or there’s a complication (even if it’s not your fault) that is a set up to get sued and lose a medical license real quick.Iirc there's a recent revision to make med student notes billable:
MD & DO - Medical Student Notes Now Billable
Title is pretty self-explanatory, but here's a link for those interested: https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2018Downloads/R3971CP.pdf Thoughts? Critiques? Overly-dramatic opinions about the end of medicine as we know it?
I was thinking to delegate the procedures to MS4s/sub Is to keep them busy (even if it's like a dozen) and let MS3s to do the orders and wound checkups, even if they aren't interested in surgery?
This probably depends on the curriculum. In a 1 yr preclinical model, the interest in surgery can be solidified by 3rd year. So there'll be more interested MS3s and MS4s to help out
It’s formulaic until it isn’t. If that were the case, why would we need mid levels? Why not just have your CNA take their vitals and have them fill out some boxes on a digital spreadsheet?
If/when I go to hire my own PA what I’m going to be looking for is someone who can recognize when something deviates from protocol. They don’t need to necessarily know what to do next (over time they might), that’s the MDs role, but learning that sort of pattern recognition is the value of PA school to me and what they should be taught pre-graduate, and that can be done without going to medical school. Medical school teaches people to deal with every eventuality and the consequences of doing something. That’s what I believe the difference to be.
What I’m saying is, why do you even need a PA or NP if all you need is a protocol and a warning when someone’s situation deviates from it? Taking your formulaic idea further, why not just get rid of half of internists, have some CNAs memorize a sheet of questions, and treat patients that way?
They are licensed and credentialed. Medical students are not. Yes, the supervising physician is responsible, and a certain level of complications is expected no matter who’s hands a procedure is in. But that’s different from an unlicensed and uncredentialed trainee. I don’t know how else to explain it than that. It’s malpractice to let someone with no license do things unsupervised. APPs have licenses and credentials.
You’re comparing a medical student to a mid level. That’s not equivalent. Comparing a Med student to an NP or PA student would be more appropriate, from a licensing and liability perspective.
...no. That’s like saying if a resident ****s up the resident should be liable and not the attending. Incorrect. Attending is responsible. If you feel that an APP or resident isn’t qualified to do something safely then you don’t allow them to do it. Otherwise you be prepared to deal with the consequences if/when something goes wrong.
If a mistake/complication occurred while a medical student (unlicensed) was working, it costs them their future. If a mistake/complication occurred while a NP/PA (licensed) was working, it falls on the hands of the supervising physician. Seems like there should be more consequences for NPs/PAs. And I understand why it is problematic for unlicensed personnel to practice (legal nightmare), but shouldn't there be more severe consequences for NPs/PAs ? seems like they want their cake and eat it too. Just my thoughts.
Seems like the physicians hiring them and not giving them proper oversight want to have their cake and eat it too. If we’re working within the framework that they are not well enough trained to be independent, then the physician should get sued to all hell if their NP or PA ****s up and they don’t catch it. If we cede that they should be able to practice independently, then med levels should bear the brunt of their mistakes.
I agree with everything here.
I guess I’m still not doing a good enough job explaining this but residents and APPs do not always need supervision but are still under the liability umbrella of the attending. The way this worked in my residency was that there was a set criteria and training for central line placement. Once you did five supervised lines with no input from the supervising person successfully you were deemed safe to do them without supervision and that at that point you should have an acceptable complication rate compared to everyone else in the facility doing that procedure. If something goes wrong while you’re doing it unsupervised then the attending needs to be able to safely handle the complication.
I'm more upset that EM gets viewed as "dumb" or "annoying folks" in these consult calls, but i just hate specialty bashing of any kind
@Neopolymath
You exemplify what is wrong with many surgeons that I've come across: you think you're more important than other physicians and/or you think your work is more important than the work other physicians do.
Sorry you feel that way. I am not a god nor do I think I am. I don't think the work other physicians do is more or less important. But I do think my first duty is to my patients, my self, and my family. I need help to have my life not suck and my hours not get worse and to provide optimal care to my patients. It is provided to me by APPs where I work. If you think I have a god complex for not wanting to work more than 12 hours a day than maybe you should be evaluating yourself more than me.
Umm, nope.
The biggest problem that many do not understand is that nurse practitioners are not held to the same legal standards as physicians. For instance, if a FNP was being sued for negligence, you could not use a physician as an expert witness, as professions are not deemed to be able to judge the capability of other professions. This makes it just as hard to sue a FNP but you get far less return, as you need to find one of their own to sell them out and they aren't held to the same standards as physicians despite arguing that they can do the same work
Med students really do slow me down. I enjoy working with them but it's like a chef teaching their child to cook, you just can't do it as quickly or efficiently as doing it alone because you're retreading basics and checking their work. There's some small areas where they make life easier but generally teaching is something you do because the next generation needs to learn, not because they are immediately useful
Shortsighted selfishness.. will ultimately lead to your perpetual professional demise..!
Do what now?
