The impending doom of medical profession has started to unfold

[Perrotfish]

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I think if hiring decisions were left to Doctors (not like they don't have enough to do I know) then this problem could be solved; instead what you have are people who focus almost solely on the bottom line and how many positive patient satisfaction surveys they get back.
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Interestingly one of the things that nurses often complain about is that when physicians are left in charge of hiring nursing staff (as in a private practice group or in some physician owned HMOs) they only care about the bottom line and hire the lowest level of training available. RNs get replaced by LPNs, LPNs get replaced by CNAs, and CNAs get replaced by high school volunteers.

 

[turkeyjerky]

For those advocating a shortened physician training time...

We may take the longest to train our physicians and surgeons, but we also produce the best doctors. You can go on about mortality rates, etc. in other countries being higher but that is because of lifestyle issues, not disease treatment. I'm talking about, when Arabian kings need heart surgery, where do they go? Not Europe. Not China. The training time and dedication required to become a physician here is why we have the most respected medical establishment in the world.

I will take the lengthened training time if it means I'll be the best physician/surgeon I can be.

Cost is another issue.

Agree 100% with this--during my rural family med clerkship I had the pleasure of working w/ a preceptor who treated several members of the saudi royal family. He told me it was commonplace for foreign dignitaries and kings to fly to Hibbing, Minnesota to receive primary care. Unfortunately a nearby NP-run clinic had recently opened and was siphoning off some of the Bahraini princes; he was okay with this since their insurance reimbursed poorly for preventative care.

 

[sunset823]

In general physicians:

1) Hate the idea of the government regulating their profession or trying to control costs in any way. They cry 'socialism!' and 'let the market decide!' and whine that people have the right to make their own choices.

2) Hate the idea of any free market competition from anyone. They cry 'we must protect our patients!' and whine that their patients are far too ignornant and helpless to decide who takes care of them.

What doctors really want to do is to increase ther job security and drive up their salaries by rigging the market. They want to artifically decrease the supply of practicioners by creating insanely rigid standards for medical residencies and making sure no one without a residency can legally practice, and THEN they want to let the free market balance that limited supply against a gigantic demand to keep their salaries insanely high. For patients that's the worst of all worlds.




BTW I would just like to say I would be very happy if NPs crashed the market for Derm. No where is the cynicism of medicine more obvious than that field. In Derm many of what should have been our very best physicians work 20 hours/week for insane salaries while helping almost no one. That profession is ONLY lucrative because they artificially keep the supply so far below the demand. There is no other reason why it should be more competitive than, or compensated better than, Internal Medicine or Family Practice.

qft.

This is the most intelligent thing I have ever read concerning the US health care system. ever.

As someone who is a true free market capitalist, I say all the power to the NPs, cuz if they can successfully 'crash' a market, it means that the FREE MARKET needs them in some way. I've never understood this 'let's highly regulate this free market that we love so much cuz it makes us so much money' thing from doctors. Choose one side or the other, you can't have your cake and eat it too.

P.S. You couldn't pay me a million dollars to do derm. I couldn't care less about either money or lifestyle; I think I'm more into power over life and death or something. If I had the grades I'd probably want to go into cardiothoracic surgery, which neither pays that great these days nor has much of a lifestyle. I just think that money drives society, and if you want to keep your $500k salaries you need to realize not everyone wants to pay you as such and other alternatives will inevitably crop up in a free market.

 

[random cell]

Yeah okay Johnson, go ahead and write them. You think they care about you? The AMA doesn't even give a damn what you think. Do you really think the vacuous old sloths on Capital Hill are going to listen to you, a mere peon? Go ahead and take a look at your President, playing basketball and hosting weekly parties with drug-addicted celebrities as though he is King Ludwig II of Bavaria. There's your representation.

No, forget the politicians, they are totally useless in this regard (at least and especially at the national level). There needs to be a massive movement by practicing physicians to join up with the lowest scum lawyers in the country to sue as many of the mid-levels who screw up as possible while practicing independently. If they really do provide inferior treatment, the cases will be there and the trusted 🙂barf🙂 malpractice lawyers will put an end to their independence right quick. Most of the rural primary care practices are owned by the public hospital in the county and that is where mid-levels currently enjoy the most autonomy.

On the other hand, if NPs do provide treatment equivalent to that of a family medicine or general IM physician (as they often say), then there won't be the huge uptick in injuries and deaths following (increased) parity that many physician advocacy groups are predicting. In that case, the rural medical education track I am enrolled in will quickly become a huge waste of time and money for me, but I really won't have an argument other then I should've just went to Noctor school.

How...did you know...my name is Johnson?

As far as your plan, that will happen with or without doctors joining forces with malpractice lawyers. They are sharks. Also people with your attitude are exactly why doctors have little political power. There is no unity. If all the doctors stood together and said, "alright we're on strike until this BS stops and see how you like medicine with nurses as doctors, which is what they are aiming for" then we would get somewhere. Hospital without doctors. Nurses performing surgeries. Imagine that. Of course it will never happen.

 

[cbrons]

How...did you know...my name is Johnson?

As far as your plan, that will happen with or without doctors joining forces with malpractice lawyers. They are sharks. Also people with your attitude are exactly why doctors have little political power. There is no unity. If all the doctors stood together and said, "alright we're on strike until this BS stops and see how you like medicine with nurses as doctors, which is what they are aiming for" then we would get somewhere. Hospital without doctors. Nurses performing surgeries. Imagine that. Of course it will never happen.

So the belief that political action is futile is what leads to disunity. Got it. So what's your ideal solution? Encourage MDs to leave the hospitals, take to the streets with inane signs and bell-whistles and bullhorns and probably even Jessie Jackson himself 🙄...

but then admit that it will

never happen.

 

[random cell]

So the belief that political action is futile is what leads to disunity. Got it. So what's your ideal solution? Encourage MDs to leave the hospitals, take to the streets with inane signs and bell-whistles and bullhorns and probably even Jessie Jackson himself 🙄...

but then admit that it will

No my solution is basically the same as yours. Nature will right itself when lawyers smell the scent of DNPs in the water. I know the whole unity thing will never happen, just joking about that. And writing your rep doesn't hurt, so why not? If it doesn't work oh well, lawsuits will take care of it. If it does work, it will speed up the process.

 

[random cell]

There's been a lot of talk about unity, strike, standing up to the man etc.
As many have said, it will never happen. And the reason is because of the nature of med students, residents and doctors. Think about it, to get into a good college you have kiss up to the man. To get into a US med school you have to play nice, pull together the "ideal" resume and kiss up to the man. Then to get into residency, fellowship etc you have to, that's right, kiss up to the man. We've either been socially bred to obey or we've been selected out as the society's most obedient.

I concur.

 

[bucks2010]

1) It might be that Royalty comes to the US for treatment not because we have the best system in the world so much as because we have such a large cash market. There isn't really another first world country where a really rich guy can be seen right away by half a dozen of the best experts in a field just by virtue of being rich. If they could see the best doctors in England they might do that instead but that's just not an option for a foreign national flying into England to buy his way to the front of the line. In terms of the training that our medical schools provide there have been studies that show that that physicians who immigrated to the US actually provide a comperable level of care, as measured by negative outcomes, to US trainined American doctors. Anecdotally my school's faculty has multiple foreign trained physicians and they're all excellent.

2) Counter intuitive though it may be, being the best physician you can be is not necessarily the best thing you can do for your patients. We have developed this idea that more is always better in terms of training, and it can significantly limit the access of patients to healthcare by both removing you from the job market for several years and then necessarily passing at least part of the cost of your training on to them. To be worth it the improved quality of your care not only needs to reduce negative outcomes for all the patients you do see, but that reduction needs to be so large it more than makes up for all the negative outcomes of the patients that you don't see.

Imagine the Army Corps of Engineers decided to rebuild the New Orleans levees out of iridium, rather than dirt, because in every measurable sense irridium is a tougher, stronger, and all around better material. Unfortunately, due to the fact that they have a finite budget and a finite amount of build time, that means that New Orleans only gets 350 meters worth of levees rather than 350 miles. Did they make the right decision when they decided not to accept anything other than the best?

Cost & training time are significant issues here, but they're not the main one. The main issue is density. My medium-sized city has a lot of FP docs to go around. But if you were to look at the poor & rural parts of my state, accessibility plummets. These parts of the country are where docs are needed the most.

To get FP's to these parts of the country is going to take a lot more than reduced training time/cost. If it took you 5 years to be a practicing MD, would you be any more likely to up and move to podunk US because of it? Honestly, I wouldn't. The accessibility crisis exists mainly in places where few people - docs & NP's included - want to live. A cheaper MD does not make these places more desirable.

 

[Perrotfish]

Cost & training time are significant issues here, but they're not the main one. The main issue is density. My medium-sized city has a lot of FP docs to go around. But if you were to look at the poor & rural parts of my state, accessibility plummets. These parts of the country are where docs are needed the most.

To get FP's to these parts of the country is going to take a lot more than reduced training time/cost. If it took you 5 years to be a practicing MD, would you be any more likely to up and move to podunk US because of it? Honestly, I wouldn't. The accessibility crisis exists mainly in places where few people - docs & NP's included - want to live. A cheaper MD does not make these places more desirable.

I would move if the other option was unemployment. In a normal economy the most desirable places get the best practicioners and then everyone else goes to podunk USA. However at the moment, even with the NPs, the prime realestate alone has enough demand to absorb every practicioner who isn't spiritually attached to rural America. If you keep increasing the supply eventually the more desirable locations will saturate and people will move out into rural America because they have to.

 

[JaggerPlate]

As someone who is a true free market capitalist

In what sense? How is a market that's regulated and controlled by a third party payer system (heavily influenced by the government nonetheless) a 'true free market' in any sense of the term? If it were truly competition in a free market, NPs would offer differences and try to compete for volume based upon these laurels, not lobby for equivalent medicare reimbursements.

Additionally, if you really wanted to make it a free market, then there shouldn't be any sort of real qualifier, besides start-up capital, as to who can set up a shop and start practicing medicine. By this logic, my mechanic should be able to open up an orthopedic practice.

However, this is moot because the U.S. health service system simply isn't a free market, so 'rooting' for NPs (at your own expense) isn't applicable to some sort of scenario where two competing car dealerships open up on opposite corners of an intersection.

From all I've learned, the simple principles are just different and influenced by a variety of other sources. Could you clarify?

I say all the power to the NPs, cuz if they can successfully 'crash' a market, it means that the FREE MARKET needs them in some way.

It doesn't mean that the market NEEDs them by any means. Again, the way I understand it, if you want to bring 'need' into the equation, then you're essentially defeating the purpose of a 'free market' in the first place because now we're entering the realm of necessary services which are traditionally defined by more of a federal, social category, and we've all seen what those types of agencies do with competition - hell, look at what the PPA/ACA did with private owned, specialty hospitals in light of NPO-hospitals and their inability to 'compete.' Additionally, this type of competition is more of an administrative issue.

However, if you want to talk about competition in the sense of the free market (wants, desires, not necessities), then anything making an impact would be seen as a 'need.' I heard snuggies sold like wildfire during the recent holiday season, but I don't think the free market responded to this out of a visceral need for robe-blankets.

I've never understood this 'let's highly regulate this free market that we love so much cuz it makes us so much money' thing from doctors. Choose one side or the other, you can't have your cake and eat it too.

I think you're confusing some sort of basic level of competence to enter the 'game' with totalitarian, government, socialized regulation. It's not the same thing.

There is nothing wrong with allowing for various practitioners to enter the health service market and practice without overt regulations, but because these providers are dealing with people (and not some sort of mass produced, tangible item - which again, dismisses the 'free market' principle with regard to U.S. health services), there needs to be a basic level of competency measured and approved before you're able to practice.

Otherwise, everyone - high school dropouts, janitors, lawyers, housewives, should be able to hang a shingle in the sake of true 'free market competition.' Granted, not many people would probably see these individuals, but would a single death really be worth the 'spirit' of some principle that a. isn't even being violated by this level of 'regulation' (which could easily be overseen by clinician appointed and run groups) and b. doesn't even equate to this situation.

Obviously, there needs to be SOME type of qualifier, and I see no reason why this SHOULDN'T be medical school + residency if you intend to practice medicine.

 

[JaggerPlate]

even with the NPs, the prime realestate alone has enough demand to absorb every practicioner who isn't spiritually attached to rural America.

Really? I feel like most large cities, nice areas, places within driving distance of a beach, aren't suffering from any perceived 'shortage' of health practitioners, and that the real areas suffering were the 'rural' ones described above. I'm not going to get into the irony of NPs lobbying on the basis of increasing care to these needing individuals and then opening a practice in Los Angeles, but I'm uncertain that the situation is completely wide open in desirable areas.

Granted, I think you'll be able to find a job, but I don't think places like LA, NY, Miami, Atlanta, etc, are suffering from ANY type of physician shortage akin to the one explained to us during medical school interviews.

 

[Coastie]

Good. Its the direction medicine is going. All docs are specializing and most of care is completed by specialists.

I think having NPs and PAs handle a lot of the primary care (checking on stable conditions, refilling prescriptions and handling routine tests) is a very good idea. Medical education costs too much for most physicians to go into primary care and we have a huge shortage.

I think giving NPs and PAs more responsibility is a great idea - there will always be specialists when we need them. (and this comes from someone who has been misdiagnosed by an NP)

Don't buy the BS.

Medicine should be practiced by physicians, and primary care is far more demanding than many specialties.

Primary care should pay more, and DOES pay more when you get away from a payor mix dominated by the disaster known as gov't "insurance".

Giving unqualified NPs and PAs more responsibility..which by their training, they are and will always be, is dangerous..for patients, for physicians, and for the profession of medicine.

 

[random cell]

In what sense? How is a market that's regulated and controlled by a third party payer system (heavily influenced by the government nonetheless) a 'true free market' in any sense of the term? If it were truly competition in a free market, NPs would offer differences and try to compete for volume based upon these laurels, not lobby for equivalent medicare reimbursements.

Additionally, if you really wanted to make it a free market, then there shouldn't be any sort of real qualifier, besides start-up capital, as to who can set up a shop and start practicing medicine. By this logic, my mechanic should be able to open up an orthopedic practice.

However, this is moot because the U.S. health service system simply isn't a free market, so 'rooting' for NPs (at your own expense) isn't applicable to some sort of scenario where two competing car dealerships open up on opposite corners of an intersection.

From all I've learned, the simple principles are just different and influenced by a variety of other sources. Could you clarify?




It doesn't mean that the market NEEDs them by any means. Again, the way I understand it, if you want to bring 'need' into the equation, then you're essentially defeating the purpose of a 'free market' in the first place because now we're entering the realm of necessary services which are traditionally defined by more of a federal, social category, and we've all seen what those types of agencies do with competition - hell, look at what the PPA/ACA did with private owned, specialty hospitals in light of NPO-hospitals and their inability to 'compete.' Additionally, this type of competition is more of an administrative issue.

However, if you want to talk about competition in the sense of the free market (wants, desires, not necessities), then anything making an impact would be seen as a 'need.' I heard snuggies sold like wildfire during the recent holiday season, but I don't think the free market responded to this out of a visceral need for robe-blankets.



I think you're confusing some sort of basic level of competence to enter the 'game' with totalitarian, government, socialized regulation. It's not the same thing.

There is nothing wrong with allowing for various practitioners to enter the health service market and practice without overt regulations, but because these providers are dealing with people (and not some sort of mass produced, tangible item - which again, dismisses the 'free market' principle with regard to U.S. health services), there needs to be a basic level of competency measured and approved before you're able to practice.

Otherwise, everyone - high school dropouts, janitors, lawyers, housewives, should be able to hang a shingle in the sake of true 'free market competition.' Granted, not many people would probably see these individuals, but would a single death really be worth the 'spirit' of some principle that a. isn't even being violated by this level of 'regulation' (which could easily be overseen by clinician appointed and run groups) and b. doesn't even equate to this situation.

Obviously, there needs to be SOME type of qualifier, and I see no reason why this SHOULDN'T be medical school + residency if you intend to practice medicine.

WINNING.👍

 

[Coastie]

Good. They are filling a gap in rural medicine and urban medicine in those examples.

Sorry, I've worked with some amazing PAs and NPs in both primary care and specialty positions. I have no problem with it. I will have a job one way or another, and if my salary drops and the cost of healthcare improves then again GOOD.

I have no problem with NPs and PAs in the emergency department.

For that matter I have no problem with them in ob/gyn offices, anesthesia or surgical teams, etc. etc. etc.

Cost of healthcare improves? Amazing PAs and NPs in primary care and specialties? So maybe we should let them practice all medicine solo? You have no probs with solo noctors in the ER, or surgery, or anesthesiology?

Cost would improve if we had high school kids trained in nothing but the technical aspect of heart caths..or appendectomies..which they could easily be trained in..Don't you think that xbox skills make them superior in eye-hand coordination to many current surgeons? I do.

I see you went to Berkeley. You may be a lost cause in the liberal, feel-good battle to destroy medicine to "improve access" via Noctors. Just remember, more access isn't necessarily a good thing.....Unleashing assassins to practice medicine without medical training will improve the funeral home's bottom line, or perhaps click off more nurse STUPIDvisor's boxes, but that's about it.

 

[Coastie]

Your ignorance regarding the economics both in payments and in actual medical value produced is staggering.

A true berkeley product indeed. I know your type...they usually end up in some liberal hole of academic medicine...or chair the DNC. Bright future! 😀

Sorry. I'm not one of those people. This is a job to me. A job that I quite frankly regret going into, its not worth it. There are so many other things I could have done with my life with just as much "job stability" and not nearly as many sacrifices. Not only that, but I have 200k in debt which will balloon to well over 250k even if I do IBR during residency.

However, I do think that MOST specialists make damn good salaries, some excessive (600k/year neurosurgeon?? really?). As an EM doc I will make anywhere from 200k-500k/year. Would I cry if my salary ranged 150k-300k instead because of some PAs and NPs helping out. No. Thats still a damn good salary and more than enough to pay my loans, have a nice life, go on some cushy vacations and help my kids through college.

Primary Care MDs are really the only ones who have the right to freak out if their salary is going to get cut a little.

 

[Coastie]

👍👍👍👍👍

Big kudos for mentioning the barefoot docs. People forget that the "rural access" crap is just another reason for gov't to sap away power from the private physicians....

Same old commie playbook, a few decades later. When will we ever learn!? You can't get somethin' for nothin'.

Wow. Such vitriol. 🙄

Let me give you a history lesson from a country that has a much larger medical need than the US: China in the Mao era had a huge medical need. Their solution was to produce thousands of "barefoot doctors" who were people who were trained from no medical knowledge to full practitioner in two years and sent back to their villages. This was great for solving their medical needs but it produced massive inconsistencies in skill and China eventually required all the barefoot doctors to pass national exams to become full MDs or, if they could not pass, to be health aides to treat those with chronic conditions. These barefoot doctors during training were highly encouraged to attend medical school as well and a good proportion of them did.

This program is still remembered as a huge success but even China's decision after this experiment was that if you wanted to practice as a doctor, you should be certified as a doctor. Period.

Likewise, I would not be opposed to PAs and NPs and others who have experience and wanted to become physicians to be allowed to do so by going through the MD licensing process and skip medical school but they should be required to show that they have the knowledge. To allow multiple paths with very different rigor to lead to the same thing only causes confusion and distrust.

When there is a need for more medical care in a particular area, the solution is to produce more doctors or produce incentives for doctors to practice in those fields, NOT produce shortcuts to care.

 

[Coastie]

Shortening residency is a bad idea..same with med school.

Undergrad? Debatable.

If anything, we need to lengthen residency....or make it vastly more efficient with the same amount of time. Hospitals use residents to accomplish scut for cheap...and it's not necessary.

The point is that the schools and residencies are 1) insanely overpriced and 2) completely full. The insanely high price (both in terms of student debt and opportunity cost) plus the artificialy scarcity of medical education means that the patients often either can't find a provder or are priced out of medical care.

Physicians need to face up to the reality that, by endlessly elongating the training process, we've made healthcare a lot more expensive that it needs to be and its killing patients. The patients are hurt because they don't get access to care, and the sad thing is that we don't even really benifit because our higher salaries just go to paying down debt and making up for all those unemployed years. Do you know anyone else who can get paid a six figure salary and feel poor?

I've said this before: the way you keep NPs and PAs from taking physician jobs is not to regulate them out of existence, it's to CREATE A CHEAPER WAY TO MAKE DOCTORS. Premedicine needs to disappear, and medical school and residency might need to get shorter. We need to relax regulations on what constitutes a residency so that more can be created. There is no reason in the world it should take us 11 years and 500K to turn a highschooler into an FP when the rest of the first world does it in 5-7 years for much less.

If we don't do that, the market will find another way to correct itself, because it always does.

 

[Coastie]

For those advocating a shortened physician training time...

We may take the longest to train our physicians and surgeons, but we also produce the best doctors. You can go on about mortality rates, etc. in other countries being higher but that is because of lifestyle issues, not disease treatment. I'm talking about, when Arabian kings need heart surgery, where do they go? Not Europe. Not China. The training time and dedication required to become a physician here is why we have the most respected medical establishment in the world.

I will take the lengthened training time if it means I'll be the best physician/surgeon I can be.

Cost is another issue.

+1.

We do have the best medical training..that's why everyone is pounding the doors to come into our hospitals...

Take the best hospitals in the UK...Oz....They probably wouldn't crack top 25 here. Almost any uni hospital here would be in the top 10 of any other country in the world.

It's not even close.

 

[Coastie]

Just my thoughts after reading.

Am I wrong in thinking that a big part of the problem here is hospital administration? Allowing DNP's to privilege creep and self-inflate themselves to being somewhat equal to a physician does nothing positive for a practice (aside from the cost savings). It's a disruptive element to bring into the health care team and leads to having a bunch of people who don't know what they don't know trying to be something they were never trained to be. I think if hiring decisions were left to Doctors (not like they don't have enough to do I know) then this problem could be solved; instead what you have are people who focus almost solely on the bottom line and how many positive patient satisfaction surveys they get back.

I mean this problem wouldn't exists if people weren't hiring them. But my opinion is an uneducated one and it's just that, an opinion.

It's a huge problem.

Hospital admins don't give two rats about physicians. It's killing medicine.

 

[Coastie]

You can get the best private care in the UK if you have $.

The best private care in the UK doesn't compare to the best in the US (Mayo, Harvard system, Columbia, Hopkins, UCLA, Stanford, Duke..need I go on?).

That's why we get the rich guys.

I appreciate your New Orleans example, but it doesn't hold water (har har). Noctors don't meet the minimum requirement to practice solo..

Amongst docs, there are dirt levees and there are iridium levees.

Noctors are a beaver dam built to hold back the japanese tsunami of disease..it only ends in massive death and over-radiation in the form of extra CT scans ordered to make up for lack of physical exam skills..

1) It might be that Royalty comes to the US for treatment not because we have the best system in the world so much as because we have such a large cash market. There isn't really another first world country where a really rich guy can be seen right away by half a dozen of the best experts in a field just by virtue of being rich. If they could see the best doctors in England they might do that instead but that's just not an option for a foreign national flying into England to buy his way to the front of the line. In terms of the training that our medical schools provide there have been studies that show that that physicians who immigrated to the US actually provide a comperable level of care, as measured by negative outcomes, to US trainined American doctors. Anecdotally my school's faculty has multiple foreign trained physicians and they're all excellent.

2) Counter intuitive though it may be, being the best physician you can be is not necessarily the best thing you can do for your patients. We have developed this idea that more is always better in terms of training, and it can significantly limit the access of patients to healthcare by both removing you from the job market for several years and then necessarily passing at least part of the cost of your training on to them. To be worth it the improved quality of your care not only needs to reduce negative outcomes for all the patients you do see, but that reduction needs to be so large it more than makes up for all the negative outcomes of the patients that you don't see.

Imagine the Army Corps of Engineers decided to rebuild the New Orleans levees out of iridium, rather than dirt, because in every measurable sense irridium is a tougher, stronger, and all around better material. Unfortunately, due to the fact that they have a finite budget and a finite amount of build time, that means that New Orleans only gets 350 meters worth of levees rather than 350 miles. Did they make the right decision when they decided not to accept anything other than the best?

 

[bucks2010]

I'm not sure if I'd describe wealthy urban areas as having a 'shortage', but they're definitely not oversaturated. There is basically no where in the nation, right now, where there are a significant number of doctors without patients. As long as every physician, however bad, has a line waiting for him at his doc in a box shop then there's still a demand.

Saturation is when you can no longer find a job in an area, or more accurately when the oversupply of practicioners has depressed prices to the point where it's no longer practical for anyone to work there. If you pump enough physicians into the nation we will eventually get to that point.

If urban markets become truly oversaturated with FP's, I'd wager that more would either (a) find another specialty or (b) find another line of work. A proportion, maybe even a slight majority, would work in rural parts, but most of them would do so just long enough to pay off their loans, then high-tail it back to where they actually want to live. I highly doubt most people would put up with a job they like but in a terrible location, for very long. Rural jobs as a general rule already pay much better than those in urban areas. Increasing the # of docs in rural areas will only decrease their desirability because wages will fall. And more will leave medicine altogether.

Additionally, with the loans med students take on, adding job insecurity by oversaturating the market could very well lead to a student loan crisis among med students. I doubt many students would be fully aware of bad job prospects once they're $250,000 in debt.

 

[Perrotfish]

If urban markets become truly oversaturated with FP's, I'd wager that more would either (a) find another specialty or (b) find another line of work. A proportion, maybe even a slight majority, would work in rural parts, but most of them would do so just long enough to pay off their loans, then high-tail it back to where they actually want to live. I highly doubt most people would put up with a job they like but in a terrible location, for very long. Rural jobs as a general rule already pay much better than those in urban areas. Increasing the # of docs in rural areas will only decrease their desirability because wages will fall. And more will leave medicine altogether.

Additionally, with the loans med students take on, adding job insecurity by oversaturating the market could very well lead to a student loan crisis among med students. I doubt many students would be fully aware of bad job prospects once they're $250,000 in debt.

I feel like your second paragraph sort of negates your first. You say that a rural practicioner would probably work just long enough to pay off his loans... which with the amount of debt most people have would mean a 20 year career. This seems like a reasonable plan to me.

 

[Doublecortin]

The problem (among everything else wrong with your argument and point of view) is that nurse practitioners, for the most part, have no real intention of graciously filling this 'gap in primary care.'

The most recent reports show that only 35% are even entering a primary care field, meaning the overwhelming majority is simply following the reimbursement rates like everybody else.

The 'filling a crucial gap in primary care' is something these groups use to lobby congress, get a foot in the door (before moving on to more specialized, better paying fields), and get the public on their side. However, if this were true, I really doubt we'd see the current battles trying to keep NPs in pain management from doing injections (are we really suffering from a shortage of pain management docs doing injections in well populated cities); I doubt we'd see things like the University of South Florida 'Nursing Dermatology Residency' - where apparently the brave, courageous nurses are filling that CRUCIAL gap in the South Florida cosmetic dermatology market, etc, etc, etc x 10,000.

 

[bucks2010]

Well the oversaturation assumes that the time/cost of training is reduced, which has been the running idea of the thread. If you cut the principal in half (highly unlikely), the time required for repayment will be much lower, even with a reimbursement that trends downward.

It's all a moot point, really, because as others have noted, shaving time off of medical school would be very unlikely to happen, and that's where the vast majority of our debt is accumulated. And we know tuition isn't going to go down - anyone know of a reputable school that has actually cut tuition.... ever?

 

[Old Grunt]

Blame the so called "defensive medicine". Doing useless procedures and tests to cover your butt from a freakin lawsuit (that makes medicine suck).

As someone interested in going to primary care, it kinda pisses me off that anyone can think they can do the job of a a FP. My mom is one, and I talk to her quite often about it, and despite 80% of her cases being so called normal and easy, the other 20% actually require the medical knowledge she got during med school and residency, something through which NPs don't go through.

I just know that I wouldn't feel comfortable with having a family member being seen by a mid level provider without supervision.

Why not? "Defensive medicine" gets blamed for everything else.

Where would we be without our red herrings?

 

[MCAT guy]

qft.

This is the most intelligent thing I have ever read concerning the US health care system. ever.

You must not read much.

 

[BPlaysItCool]

At the unbearable risk of being a communist. Well ok. I can deal.

I agree generally with Perrotfish.

I think physicians are missing the boat. We can no longer afford ourselves.

Sure the Saudi's can get great healthcare here. And? What happens when the majority of people who live here can't get anything. Is a US specialist the most trained in the world. Arguable yes. But maybe what we need is tons more prenatal care. Basic access for more people.

In this sense we make too much of ourselves. An FM doc is better trained. Is s/he better trained to do 98% of what takes place in practice. Not really. So 2%. Is that worth twice the money for the average person? What happens when it's no longer a choice for the average person. Approaching us as we speak. There will be a point when we must get faster training. Pay less money for it. And earn less money. The American Empire--speaking of the inanity of free market evangelists--is losing it's artificial grasp on international market force. We are going down. Our children will live at a lower standing of living than us or our parents. And this will continue for some generations i would think.

So it's not about the best anymore. It's about what is the extent of mercy. How many kids cant get this or that procedure. Tough choices will be made with or without us.

I'm thinking we will stratify. A few of us will train longer for higher specialization. And whole new niches in the workforce will up for not just midlevels. But midlevel physicians. Giving enough of what most people can pay what they can for. It's inevitable.

As to the sacredness of this fraternity. Count me out.

 

[Charles_Carmichael]

Are you guys comfortable with medical students practicing independently after finishing 3rd year? Because they have more basic science training and clinical hours of training than an NP/DNP does. Using the logic that NPs/DNPs are equivalent to physicians and provide safe care, we should be lobbying for independence for M4s as well.

Here's part of an old post of mine:

"Here's a sample curriculum from a BSN-DNP program (at Duke): http://nursing.duke.edu/wysiwyg/down...t_MAT_Plan.pdf

You need 73 credits to go from a college degree to a doctorate. That turns out to be less than 3 years.

Research Methods (3 credits), Health Services Program Planning and Outcomes Analysis (3 credits), Applied Statistics (2 credits), Research Utilization in Advanced Nursing Practice (3 credits), Data Driven Health Care Improvement (4 credits), Evidence Based Practice and Applied Statistics I & II (7 credits), Effective Leadership (2 credits), Transforming the Nation's Health (3 credits), DNP Capstone (6 credits), Health Systems Transformation (3 credits), Financial Management & Budget Planning (3 credits).Population-Based Approach to Healthcare (3 credits), Clinical Pharmacology and Interventions for Advanced Practice Nursing (3 credits), Managing Common Acute and Chronic Health Problems I (3 credits), Selected Topics in Advanced Pathophysiology (3 credits), Diagnostic Reasoning & Physical Assessment in Advanced Nursing Practice (4 credits), Common Acute and Chronic Health Problems II (3 credits), Sexual and Reproductive Health (2 credits), Nurse Practitioner Residency: Adult Primary Care (3 credits), Electives (12 credits).

So, out of the 73 credits needed to go from BSN to DNP, a significant portion of courses are potentially not clinically useful. In addition, the number of required clinical hours is 612 hours (unless I miscounted something)!! Wow! And the NP program is designed the same way and requires 612 hours as well: http://nursing.duke.edu/wysiwyg/down...rriculum_2.pdf

Here are the curricula to several other programs:

• University of Arizona: http://www.nursing.arizona.edu/OSA/P...ndout_2008.pdf
  
• Loyola's MSN to DNP: http://www.luc.edu/nursing/dnp/curriculum.shtml (where are the basic science classes? They're all public health classes!!)
• MGH BSN to DNP: http://www.mghihp.edu/nursing/postpr...ulum.html?cw=1 (35/72 credits for Adult DNP are potentially not useful clinically while 46/83 credits for DNP in FM aren't)

It's kinda scary how inadequate that training is in order to practice medicine independently. You can't really count prior nursing experience as time practicing medicine because you weren't practicing medicine. Nursing clinical hours might help you transition into medicine but they are NOT a replacement for medical clinical hours.

Now, just for comparison, let's look at a med school curriculum. Here's an example from Baylor School of Medicine for M1/M2 (http://www.bcm.edu/osa/handbook/?PMID=5608) and for M3/M4 (http://www.bcm.edu/osa/handbook/?PMID=7463):

Patient, Physician, and Society-1 (4.5 credits), Patient, Physician, and Society-2 (6 credits), Bioethics (2.5 credits), Integrated Problem Solving 1 & 2 (10 credits).

Foundations Basic to Science of Medicine: Core Concepts (14.5 credits), Cardiovascular-Renal-Resp (11.5 credits), GI-Met-Nut-Endo-Reproduction (14 credits), General Pathology & General Pharmacology (6.5 credits), Head & Neck Anatomy (4.5 credits), Immunology (5 credits), Behavioral Sciences (6.5 credits), Infectious Disease (13 credits), Nervous System (14 credits), Cardiology (4.5 credits), Respiratory (3.5 credits), Renal (4 credits), Hematology/Oncology (5 credits), Hard & Soft Tissues (3 credits), Gastroenterology (4 credits), Endocrinology (3.5 credits), GU/Gyn (3 credits), Genetics (3 credits), Age Related Topics (2.5 credits).

Core Clerkships during M3:Medicine (24 credits, 12 weeks), Surgery (16 credits, 8 weeks), Group A selective (8 credits, 4 weeks), Psychiatry (16 credits, 8 weeks), Neurology (8 credits, 4 weeks), Pediatrics (16 credits, 8 weeks), Ob/Gyn (16 credits, 8 weeks), Family & Community Medicine (8 credits, 4 weeks), Clinical Half-Day (includes Clincal Application of Radiology, Clinical Application of Pathology, Clinical Application of Nutrition, Clinical Evidence Based Medicine, Longitudinal Ambulatory Care Experience, and Apex -- 23 credits).

So, without even taking into consideration M4 electives and required subinternships (which are usually in Medicine and Surgery), medical students already have a far superior medical training than NPs or DNPs. Other examples of med school curricula:

• UMich M1/M2: http://www.med.umich.edu/lrc/medcurr...gram/m1m2.html
• UMich M3/M4: http://www.med.umich.edu/lrc/medcurr...gram/m3m4.html
• Duke: http://medschool.duke.edu/modules/so...index.php?id=2

You can get a BSN to DNP in about 3 years according to many programs I've looked at. Medicine involves 4 years of medical school and a minimum of 3 years of residency before allowing independent practice. Here's the math:

BSN to DNP: 2.5 - 3 years of training; longer if courses taken part-time; 600-1000 clinical hours!
BS/BA to MD/DO: 4 years med school + 3-5 years residency: 7-11 years of training; not possible part-time; clinical hours > 17000

And to the people who think that NPs/DNPs are equivalent to physicians, where's the data? There isn't a single well-done study suggesting equivalency in outcomes. There are several flawed studies that look at useless measures like patient satisfaction and equate that to good medical care (because it's so true right?). Not only that, there are a couple of studies the nurses themselves funded showing that nursing midlevels take longer to get to the same diagnosis as a physician and that nursing midlevels are more likely to refer out than primary care physicians are. At this moment, there are no well-designed studies suggesting that it's a good idea to give NPs/DNPs a scope of practice that's equivalent to that of physicians. The AAFP has only recently been putting effort into generating good data.

 

[Old Grunt]

There needs to be a massive movement by practicing physicians to join up with the lowest scum lawyers in the country to sue as many of the mid-levels who screw up as possible while practicing independently. If they really do provide inferior treatment, the cases will be there and the trusted 🙂barf🙂 malpractice lawyers will put an end to their independence right quick.

So malpractice litigation does serve a role in patient protection, but only when directed at NP/PAs?

 

[sunset823]

Well the oversaturation assumes that the time/cost of training is reduced, which has been the running idea of the thread. If you cut the principal in half (highly unlikely), the time required for repayment will be much lower, even with a reimbursement that trends downward.

It's all a moot point, really, because as others have noted, shaving time off of medical school would be very unlikely to happen, and that's where the vast majority of our debt is accumulated. And we know tuition isn't going to go down - anyone know of a reputable school that has actually cut tuition.... ever?

Actually, Texas is leaps and bounds ahead in medical education in two ways 1) all of its schools, even prestigious ones like Baylor, have extremely reasonable tuition rates and 2) Texas Tech recently opened a 3 year program for only those who would enter family practice. There's no doubt that shaving a year off of med school and the tuition associated with it (even though it's pretty cheap, comparatively, in Texas) would attract some people who are already interested in primary care. I don't think the school has graduated anybody from this program yet, so we'll see how successful it is, but it's a great idea in theory. The 4th year of med school is sort of a waste if you want to do primary care anyway.

You must not read much.

hardy har har. Actually, as a political junkie with a masters in policy, I read too much (well, at least I did until I sold my soul to Robbins, Goljan, and Katzung), but please show me examples of unbiased, relatively amoral treatises on the health care reform bill or health care generally, from either the left or the right (or the, mostly nonexistent, middle). I've never understood the emotionally charged nature of health care, but Perrotfish made some reasonable and largely factual conclusions that it would be difficult for anybody from either side of the aisle to disagree with.

 

[MCAT guy]

hardy har har. Actually, as a political junkie with a masters in policy, I read too much (well, at least I did until I sold my soul to Robbins, Goljan, and Katzung), but please show me examples of unbiased, relatively amoral treatises on the health care reform bill or health care generally, from either the left or the right (or the, mostly nonexistent, middle). I've never understood the emotionally charged nature of health care, but Perrotfish made some reasonable and largely factual conclusions that it would be difficult for anybody from either side of the aisle to disagree with.

Hardy har har 😕

Hmmm, we went from:

This is the most intelligent thing I have ever read concerning the US health care system. ever.

To:

reasonable and largely factual conclusions that it would be difficult for anybody from either side of the aisle to disagree with.

Two very different statements.

 

[MCAT guy]

At the unbearable risk of being a communist. Well ok. I can deal.

I agree generally with Perrotfish.

I think physicians are missing the boat. We can no longer afford ourselves.

Sure the Saudi's can get great healthcare here. And? What happens when the majority of people who live here can't get anything. Is a US specialist the most trained in the world. Arguable yes. But maybe what we need is tons more prenatal care. Basic access for more people.

In this sense we make too much of ourselves. An FM doc is better trained. Is s/he better trained to do 98% of what takes place in practice. Not really. So 2%. Is that worth twice the money for the average person? What happens when it's no longer a choice for the average person. Approaching us as we speak. There will be a point when we must get faster training. Pay less money for it. And earn less money. The American Empire--speaking of the inanity of free market evangelists--is losing it's artificial grasp on international market force. We are going down. Our children will live at a lower standing of living than us or our parents. And this will continue for some generations i would think.

So it's not about the best anymore. It's about what is the extent of mercy. How many kids cant get this or that procedure. Tough choices will be made with or without us.

I'm thinking we will stratify. A few of us will train longer for higher specialization. And whole new niches in the workforce will up for not just midlevels. But midlevel physicians. Giving enough of what most people can pay what they can for. It's inevitable.

As to the sacredness of this fraternity. Count me out.

Another dumb argument that makes sense until we realize that nurse are going after specialty fields. They want derm, cosmetics, CRNA positions, etc. They aren't in some way "filling the gaps", they are siphoning in the same way doctors have, to the $.

How many kids need those botox injections. Think of the children!

 

[MCAT guy]

I'm sad I have to call some of you colleagues one day.

 

[sunset823]

In what sense? How is a market that's regulated and controlled by a third party payer system (heavily influenced by the government nonetheless) a 'true free market' in any sense of the term? If it were truly competition in a free market, NPs would offer differences and try to compete for volume based upon these laurels, not lobby for equivalent medicare reimbursements.

However, this is moot because the U.S. health service system simply isn't a free market, so 'rooting' for NPs (at your own expense) isn't applicable to some sort of scenario where two competing car dealerships open up on opposite corners of an intersection.


I think you're confusing some sort of basic level of competence to enter the 'game' with totalitarian, government, socialized regulation. It's not the same thing.

There is nothing wrong with allowing for various practitioners to enter the health service market and practice without overt regulations, but because these providers are dealing with people (and not some sort of mass produced, tangible item - which again, dismisses the 'free market' principle with regard to U.S. health services), there needs to be a basic level of competency measured and approved before you're able to practice.

Otherwise, everyone - high school dropouts, janitors, lawyers, housewives, should be able to hang a shingle in the sake of true 'free market competition.' Granted, not many people would probably see these individuals, but would a single death really be worth the 'spirit' of some principle that a. isn't even being violated by this level of 'regulation' (which could easily be overseen by clinician appointed and run groups) and b. doesn't even equate to this situation.

Obviously, there needs to be SOME type of qualifier, and I see no reason why this SHOULDN'T be medical school + residency if you intend to practice medicine.

For starters, I am a product of the Rust Belt whose family and entire livelihood has been in the auto industry, so my political and economic views have largely been colored by that. The argument you are making is in your definition of a free market, anybody and everybody can enter any industry (whether it is making widgets or providing a service). I really do not think there exists a pure free market as you describe, and therefore the term 'free market' cannot be used with this narrow definition. I think everyone can agree that the auto industry is largely considered to run as a free market that makes widgets (or at least it was until the government bailout, but the factors that led to that are beyond the scope of this discussion) but cars, just like medicine, can be matters of life and death, and therefore are subject to regulation. As is toilet paper.

So what I meant in describing medicine as a free market is that people have the right to choose whatever provider they want to see based on whatever factors they consider important to them, be it safety, money, convenience, or whatever else, just like people can buy cars based on the same factors (sure, I'd love to have a mercedes benz e-class with 'Attention Assist', but my price point as a broke med student means I currently have a subcompact that would probably not do that well in a crash or if I fell asleep at the wheel, but which is cheap with good fuel economy)

And with this whole rampant desire to keep the salaries of medical professionals inflated, people with or without health insurance are priced out of the system and turn to ERs, urgent care centers, or minute clinics at CVS or Walmart based on their personal mixture of cost, safety, and convenience. I'm not making an argument one way or the other about the quality of NPs, I'm just saying it's a reality that unless you create a completely socialist system where you eliminate all health care providers besides full-fledged physicians, alternative options are going to arise. Just like you can't mandate everyone buy a Benz because it is the 'full-fledged physician' of the highway.

Yes, I realize that cars and medical practice have different financing systems, that's not the point. The point is, both are regulated industries that have diverse market needs (or wants, or whatever you want to call it).

 

[MCAT guy]

I think there are just enough smart, cynical, loner-type doctors out there to splinter our crew and allow nurses to band together tightly and commandeer any and every arena of medicine they set eyes on.

It is one of the reasons I would avoid any specialty nurses are advancing into today and instead seek immunity in the field of surgery.

I feel like Michael Corleone in the Godfather, looking into the eyes of a backstabbing brother.

[YOUTUBE]FcFlp6kl508[/YOUTUBE]

You broke my heart.

 

[da8s0859q]

You must not read much.

Hardy har har

Another dumb argument that makes sense until we realize that nurse are going after specialty fields.

I feel like Michael Corleone in the Godfather, looking into the eyes of a backstabbing brother.

I'm sad I have to call some of you colleagues one day.

Really?

 

[BPlaysItCool]

I make no arguments for anything. Keep saying good morning kid. If we ever say it to each other at sign out. The last thing you'll be worried about is my politics.

Good luck with the Russians are coming bit. We're a couple of decades from being a **** poor mob. Nobody cares about the plight of the samurai class.

 

[Old Grunt]

I think there are just enough smart, cynical, loner-type doctors out there to splinter our crew and allow nurses to band together tightly and commandeer any and every arena of medicine they set eyes on.

It is one of the reasons I would avoid any specialty nurses are advancing into today and instead seek immunity in the field of surgery.

I feel like Michael Corleone in the Godfather, looking into the eyes of a backstabbing brother.

[YOUTUBE]FcFlp6kl508[/YOUTUBE]

You broke my heart.

Yeah. Surgery is one of those fields you should just saunter into for job security............

 

[random cell]

At the unbearable risk of being a communist. Well ok. I can deal.

I agree generally with Perrotfish.

I think physicians are missing the boat. We can no longer afford ourselves.

Sure the Saudi's can get great healthcare here. And? What happens when the majority of people who live here can't get anything. Is a US specialist the most trained in the world. Arguable yes. But maybe what we need is tons more prenatal care. Basic access for more people.

In this sense we make too much of ourselves. An FM doc is better trained. Is s/he better trained to do 98% of what takes place in practice. Not really. So 2%. Is that worth twice the money for the average person? What happens when it's no longer a choice for the average person. Approaching us as we speak. There will be a point when we must get faster training. Pay less money for it. And earn less money. The American Empire--speaking of the inanity of free market evangelists--is losing it's artificial grasp on international market force. We are going down. Our children will live at a lower standing of living than us or our parents. And this will continue for some generations i would think.

So it's not about the best anymore. It's about what is the extent of mercy. How many kids cant get this or that procedure. Tough choices will be made with or without us.

I'm thinking we will stratify. A few of us will train longer for higher specialization. And whole new niches in the workforce will up for not just midlevels. But midlevel physicians. Giving enough of what most people can pay what they can for. It's inevitable.

As to the sacredness of this fraternity. Count me out.

I barfed a little reading this. You should quit med school and go into politics.

 

[Doublecortin]

well, ladies and gets, looks like we are getting bombarded from all sides

Why Some States Want Psychologists To Prescribe Antidepressants


http://www.npr.org/blogs/health/201...ists-to-prescribe-antidepressants?ps=sh_sthdl

We better wake up and smell the roses before we are overrun by the mid-level mob

 

[Old Grunt]

I barfed a little reading this. You should quit med school and go into politics.

If political opinions had any bearing on professional competency, Ron Paul's unique views on HIV and evolution would have cost him his medical license long ago.

 

[BPlaysItCool]

Another dumb argument that makes sense until we realize that nurse are going after specialty fields. They want derm, cosmetics, CRNA positions, etc. They aren't in some way "filling the gaps", they are siphoning in the same way doctors have, to the $.

How many kids need those botox injections. Think of the children!

I barfed a little reading this. You should quit med school and go into politics.

on second thought

 

[Perrotfish]

Another dumb argument that makes sense until we realize that nurse are going after specialty fields. They want derm, cosmetics, CRNA positions, etc. They aren't in some way "filling the gaps", they are siphoning in the same way doctors have, to the $.

How many kids need those botox injections. Think of the children

In terms of improving access to care and crashing the market for overtrained specialties is important too. Incresing access is definitly the most important reason to promote more midlevels, but lowering the prices of other popular services so that they're in rech of the masses isn't a bad reason either. If NPs can do the job, there's no reason that skin care should be limited to the few people rich enough to pay the best physicians in the United States, in cash, in advance. It's not life and death but there's no reason botox needs to be insanely overpriced either.

 

[Charles_Carmichael]

C'mon guys. Let's try to keep it civil.

To stay on topic, the important question to ask, IMO, is whether there is convincing data suggesting that independent NPs/DNPs provide care equivalent to that of residency-trained physicians. Or are we increasing the scope of practice for a model that hasn't yet been proven solely as a way to reduce costs/improve access? I certainly haven't come across any well-designed study comparing NP/DNP outcomes (long-term) with that of board certified physicians.

I don't know how much cost independent NPs/DNPs will save considering they're also lobbying to be reimbursed at the same rate as physicians. And, as someone else already mentioned, recent reports suggest that NPs/DNPs are no more likely than physicians are to practice in underserved areas. So, to those who think it's a good idea to expand the scope of practice for nursing midlevels, what exactly is the benefit of that? With the lack of adequate outcome data as well as the fact that NPs/DNPs receive only a fraction of the training physicians get (as I pointed out in my previous post with a curricular comparison), will the patients really benefit?

Edit: Just wanted to add that I'm talking about independently practicing NPs/DNPs here, not those who work under the supervision of a physician.

 

[Jolie South]

Alright folks. Let's calm it down in here. No need to resort to personal attacks. Keep it civil or this thread will be closed.

 

[Dr Oops]

In terms of improving access to care and crashing the market for overtrained specialties is important too. Incresing access is definitly the most important reason to promote more midlevels, but lowering the prices of other popular services so that they're in rech of the masses isn't a bad reason either. If NPs can do the job, there's no reason that skin care should be limited to the few people rich enough to pay the best physicians in the United States, in cash, in advance. It's not life and death but there's no reason botox needs to be insanely overpriced either.

except that we already know expanding mid level scope is going to do nothing for the shortage.

You dont need to be derm to be able to do botox.

Forget, NPs lets just train people off the street in a weekend seminar then we can really crash the market and pay pennies for our botox!

When you and your family get sick you can goto the NP i'll goto the doctor.

 

[Perrotfish]

C'mon guys. Let's try to keep it civil.

To stay on topic, the important question to ask, IMO, is whether there is convincing data suggesting that independent NPs/DNPs provide care equivalent to that of residency-trained physicians. Or are we increasing the scope of practice for a model that hasn't yet been proven solely as a way to reduce costs/improve access? I certainly haven't come across any well-designed study comparing NP/DNP outcomes (long-term) with that of board certified physicians.

I don't know how much cost independent NPs/DNPs will save considering they're also lobbying to be reimbursed at the same rate as physicians. And, as someone else already mentioned, recent reports suggest that NPs/DNPs are no more likely than physicians are to practice in underserved areas. So, to those who think it's a good idea to expand the scope of practice for nursing midlevels, what exactly is the benefit of that? With the lack of adequate outcome data as well as the fact that NPs/DNPs receive only a fraction of the training physicians get (as I pointed out in my previous post with a curricular comparison), will the patients really benefit?

Edit: Just wanted to add that I'm talking about independently practicing NPs/DNPs here, not those who work under the supervision of a physician.

I've gone into some detail abou why I think patients would benifit from an increased number of practicioners and why I think we need to pump out more providers of some kind, whether they're doctors or NPs.

In terms of the NP training model being unproven/untested, I feel like you're implying that our current training model was proven through some sort of carefully considered double blind test. It wasn't. Premedicine was created when a bunch of women wanted admissions to Hopkins and medical school suddenly morphed from a undergraduate program into a graduate program. Post graduate training has slowly expanded from a single Intern year into 3-12 year nightmare of residencies and fellowships we now endure based entirely on the opinions of program directors who, BTW, get to use residents for free labor for the duration of their residencies. Considering how unscientific the development of medical training has been, I feel like it's a little unfair to turn around and ask NPs for double blind trials before they can practice.

 

[Charles_Carmichael]

I've gone into some detail abou why I think patients would benifit from an increased number of practicioners and why I think we need to pump out more providers of some kind, whether they're doctors or NPs.

In terms of the NP training model being unproven/untested, I feel like you're implying that our current training model was proven through some sort of carefully considered double blind test. It wasn't. Premedicine was created when a bunch of women wanted admissions to Hopkins and medical school suddenly morphed from a undergraduate program into a graduate program. Post graduate training has slowly expanded from a single Intern year into 3-12 year nightmare of residencies and fellowships we now endure based entirely on the opinions of program directors who, BTW, get to use residents for free labor for the duration of their residencies. Considering how unscientific the development of medical training has been, I feel like it's a little unfair to turn around and ask NPs for double blind trials before they can practice.

I'm not talking about premedicine. I'm talking about medical training. I would contend that the current medical training model, though not tested in an RCT (what would the other arm be though in order to ensure equipoise?), is time tested. Medical school and residency, for the most part, put out physicians who can competently practice independently.

I would also argue that the reason medical training has become longer over the years is due to the surge in biomedical research and increased understanding/realizing the complexity of mechanisms of disease. It makes intuitive sense, then, that medical training would keep becoming longer. I don't know what's going to happen in the future when research reveals vastly more information than we know now, but it doesn't make sense to me to shorten the training period.

I don't think it's unfair at all to ask for a comparison between physicians and NPs/DNPs. When medicine was developing, there was really nothing else to compare the medical model to (unless you take into account the model before the Flexner report came out). Physicians today are considered the "gold standard" in the delivery of medical care. You can't just ignore that and equate another group to physicians without substantial evidence. Especially when it's fact that NPs/DNPs receive a small fraction of the training that physicians get.

Let me ask a question: Do you think it's a good idea to let medical students practice independently after finishing 3rd year? As I said previously, by this point the med student would have vastly superior basic science training and several-fold more hours of clinical training than any NP/DNP program provides. If you think that NPs/DNPs are fully capable of practicing independently, by extension it only makes sense that M4s will be also. Perhaps we should be lobbying for allowing M4s to practice independently?

 

[bucks2010]

In terms of improving access to care and crashing the market for overtrained specialties is important too. Incresing access is definitly the most important reason to promote more midlevels, but lowering the prices of other popular services so that they're in rech of the masses isn't a bad reason either. If NPs can do the job, there's no reason that skin care should be limited to the few people rich enough to pay the best physicians in the United States, in cash, in advance. It's not life and death but there's no reason botox needs to be insanely overpriced either.

That's the big if. No sufficiently-powered study has been released demonstrating equal effectiveness with MD's, in any setting. Any such true, unbiased study would settle the gist of this argument.

In any case, if I was a physician and saw that I'm no more effective than a DNP with vastly less training... I'd feel the need to up my game.

 

[random cell]

How can anyone expect people with inferior, shorter training (NPs) to perform the same or better than people with superior, longer training (physicians)?

This whole mindset just blows my...well, mind. People always want a free lunch and something for nothing. It's human nature, tragedy of the commons. I share MCAT guy's sentiments...the future looks bleak, especially with future colleagues that are either oblivious to the endgame or support it. 🙁