The impending doom of medical profession has started to unfold

[Kaustikos]

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This whole post reeks of pre-medism, but 👎 @ this ESPECIALLY. You can't be serious. The fear of litigation and defensive medicine drives A LOT of studies and procedures that the ordering physician truly KNOWS is not needed but orders to COVER HIS/HER OWN ASS. This is ROUTINE and COMMONPLACE.

I'm sorry, but are you disagreeing with me or not? They do drive up studies, yes, but do you know what happens after? Oh wait, no, you don't. Because you think that the billing affairs magically wisp away to wonderland and never come back to bite you in the ass. Medicare/medicaid declining to reimburse for tests/procedures that are even sometimes needed, tests that were run on a hunch, whatever; You're confusing me because I'm saying this is what drives up costs and it obviously is. And you say it happens all the time. What's your point? That it doesn't? You just started off by flaming me and then linking **** that partly proved me right. In addition to the rising costs of new equipment/testing and reimbursements being a bitch to get a hold of.

Oh, that access to a family practice will cut down on that. Obviously. THAT's why it's true 🙄 Also, don't ever insult me again. I didn't insult anyone else in my post.

OBVIOUSLY Adequate access to care by a familiar provider (for instance, through a Medical Home as the article linked by the OP discusses -- yes, even one ran by NPs) would cut down crap like that.

Also, I read the link you put up - interesting -

Private offices/physicians can just tell jerks to take a hike. They can screen up front with firm secretaries/nurses that don’t put up with guff, and will tell people “Pay the co-pay or get the heck out of this office. Behave yourself, or we will call the police.”.

So private practices can do that, what's to stop them from doing that now?

4.Abuse by other doctors.

I cannot wait to see that happen outside of the ER to NP/PAs stepping on their turf

Again, your post made absolutely no sense. Aside from that unnecessary insult, you basically agreed with me and then linked me more info proving me right? 😕

 

[NotAsking4Much]

Here's my question with respect to that point-- why hasn't this happened already to existing, potentially-inferior alternatives to MD care? I pass chiropractor offices all the time-- I know that they're different scopes of practice and that very few DCs are going to attempt to diagnose and treat, say, a heart condition (though there are plenty who will), but nobody is suing them out of existence, even though I'm sure the relationship of care provided (or not provided) to outcomes is similar. Same thing with naturopaths, reikei healers, or whatever-- obviously they're all different, and none of them are writing scripts, but these are still people who are seen as sort-of PCPs for common ailments/checkups-- I don't see any of them getting sued for malpractice, but perhaps that's because the courts have established a "Well, you shoulda known better" precedent? (Oh, and my mom is a super-competent NP, so before anyone flames me for comparing her to a DC/ND/ReikiD/etc., please understand that I know the difference.)

Not disagreeing with you, just wondering if anyone else sees a parallel there or if the scopes of practice are so different that it's an apples😳ranges comparison.

Quoted for truth.

I think the main difference is that all the above mentioned occupations are recognized as not mainstream forms of medicine. They are not going to be covered by insurance, and as rightfully named are alternative practices of medicine. They have no medical responsibility, but NPs do in a clinic. Also, chiropractors can be sued for example if they pose damage when manipulating the spine for example. It's just a less risky profession, so we hear about it less. However, NPs should carry a lot of responsibilities if people think that they're going to encroach on our turf.

I think if a NP comes from a top program practices, no one is going to disagree with that. If our practice gets flooded with NPs with online degrees, then we should worry. I highly doubt the latter will happen.

 

[RuseMD]

I believe that while they should be used as midlevels, the knowledge base is severely lacking in an NP vs. an MD. C'mon, there is no comparison.

 

[Dr Oops]

Your usually a pretty good poster and I respect your post but just because your tired doesn't give you the right to act like a jerk. I(as a PA-I actually had relief) and these nurses you just bashed have had to cover hospitals in Post-Hurricane conditions without for relief for DAYS. So just because your tired give it a break. Quit bashing nurses before you do it on the job and they keep you up ALL NIGHT LONG-> seen it done before to docs/mlps that weren't liked due to attitude problems and I will let you guess who is the loser in those battles(besides that patient).

Also, it seems like in your post your tone is that of an attack on your future colleague and I hope that changes before you become a resident. I also dislike NPs and I am biased for several reasons and won't deny it. I will take the hit on that lol.

Again bro not an attack at you, we are all in the same boat but try to calm/soften your attitude.

I also respect your posts Makati. I suppose I was being a bit of a jerk. I guess that post just set me off. Your absolutely right that being tired doesnt give you the right to be a jerk, but it has been shown that the more tired you are the more your affect is blunted. The poster also said that the nurses worked harder than the residents, my contention was more that the residents were working much longer shifts, I could have said it better. That example of the nurses working for days isnt a very good one, im sure everyone, docs nurses techs, and just anybody off the street were working for many days trying to help people.

NPs absolutely have their place in healthcare, but practicing independently is NOT that place.

I wont be bashing nurses or anyone on the job (besides I stay up all nite anyway ). Theres two arenas, the political landscape where we are getting wiped up by the nurses and the workplace. I would not create a hostile work environment, thats just not the way I am. But I will shout it from the rooftops about the agenda of Nursing organizations.

I, in no way feel ready to practice independently, yet I have been in school for about the same time as an NP, its really scary that they think they can do everything a doc can.

I have seen very competent NPs. Also, I am very sure if a bunch of NPs just went into the job market with very little competence, they will either be sued out of a job or word will perpetuate to the point that they will never be hired. Sure NPs can get an online degree, but it doesn't merit that they will find a job for certain. For example, there are tons of online MBAs program but they hold no merit. Therefore, NPs that graduate from UPenn for example will be much more likely hired and thus be the ones who are competent and actually practicing.

Will our salary drop in the future? I think so, but not because of this issue. There are certain specialties that are way overpaid and others that are underpaid, and my hope is that sooner or later that will somehow be balanced.

Will be out of jobs? Hardly so. Also, NPs supposedly will need PhD's by 2015 and I'm sure at that point, it will be much discouraging to many.

I really believe that in this profession, few will become dirt poor and also very few will be super rich. We will have our jobs and be financially comfortable, and if you wanted anything else, you picked the profession for the wrong reasons.

They dont need to be very competent, they can find jobs at those minute clinics easy, and in some states just open up their own practice. The problem is, that the kinds of problems they will create are hard to trace back to them. Thus the lawyers will have hard times picking them up. Most likely it will be misdiagnosing things, or not diagnosing things (cant see what you dont know), or just poor management of people with lots of comorbidities, due to lack of basic science understanding of how all the systems interact.

In this day and age people are living longer and as a result having many more health problems, rather than just HTN, you have HTN w DM etc.

We are learning more about the body all the time, medical education needs to be longer if anything, not shorter.

NPs will cost the system more money in the long run; not only are they pushing for pay parity, but they will then also have to refer patients out, bascially adding a middle man.

 

[random cell]

I'm pretty much on your side but you are going off on irrelevant tangents that aren't helping us make our argument.

Sent on the Sprint® Now Network from my BlackBerry®

It's not a tangent...it's an analogy to demonstrate how this wouldn't fly anywhere else. MS = Nurse, PhD = Doc

 

[Brigade4Radiant]

Why are doctors seemingly the only group who are willing to sabotage their own? You don't see lawyers, real estate agents, whatever saying that their fellow colleagues don't deserve their compensation.

We should be sticking together to protect our profession, not wishing that specialties you wish you could've gone into have their salaries lowered.

Lawyers fight one another on a daily basis and due to the expansion of Law schools being a lawyer is not an attractive profession.

 

[EgotiStick]

Whenever I see a lot of these turf battle posts regarding NP movement into primary care, I seriously question the aptitude of my fellow doctors. At WORST it will make things slightly more competitive for new and existing MDs. You have to be a doomsdayer and (honestly) a wimp if thats enough to make you question your career. In ANY specialty you're going to have to factor in local competition, but you (as the MD) SHOULD already have a leg up on the NPs.

This should instead be an opportunity (for PCPs) to INCREASE income by making it easier to set-up large primary care practices. The NPs and PAs can help the relatively fewer MDs keep the money in-house by helping to manage easier patients and the MD's overhead goes down. MD spends less time watching over NPs too and has more time for patients and self. Seems fine as long as the MDs have a pair.

 

[Makati2008]

PA's are tied to their collaborating's license, they do something wrong and it's you who they go after. At least NPs are on their own in that sense. The new NPs who obtained their degrees online are horrendous. However, I would put an old-school educated NP over a PA any day. NP's are starting to specialize, I know an NP Who is being paid by Geisinger to do a neurology rotation alongside medical students and subsequently be hired in neurology. So someday in the foreseeable future they will be leeching into specialties too.

Thats quite funny. An old school NP I saw when I was rotating as a PA-S couldn't do a lot of the basic procedures that I could lol. I have also seen this in the job field-NP's being fired and replaced by PA's->ER is where this occurred. I would definitely like to see how an Old school RN turned NP would match up vs. EMT turned PA. I think you would not see much of a difference until you got to the truly sicker patients,intubations, and other procedural medicine things.

 

[Makati2008]

I also respect your posts Makati. I suppose I was being a bit of a jerk. I guess that post just set me off. Your absolutely right that being tired doesnt give you the right to be a jerk, but it has been shown that the more tired you are the more your affect is blunted. The poster also said that the nurses worked harder than the residents, my contention was more that the residents were working much longer shifts, I could have said it better. That example of the nurses working for days isnt a very good one, im sure everyone, docs nurses techs, and just anybody off the street were working for many days trying to help people.

NPs absolutely have their place in healthcare, but practicing independently is NOT that place.

I wont be bashing nurses or anyone on the job (besides I stay up all nite anyway ). Theres two arenas, the political landscape where we are getting wiped up by the nurses and the workplace. I would not create a hostile work environment, thats just not the way I am. But I will shout it from the rooftops about the agenda of Nursing organizations.

I, in no way feel ready to practice independently, yet I have been in school for about the same time as an NP, its really scary that they think they can do everything a doc can.



They dont need to be very competent, they can find jobs at those minute clinics easy, and in some states just open up their own practice. The problem is, that the kinds of problems they will create are hard to trace back to them. Thus the lawyers will have hard times picking them up. Most likely it will be misdiagnosing things, or not diagnosing things (cant see what you dont know), or just poor management of people with lots of comorbidities, due to lack of basic science understanding of how all the systems interact.

In this day and age people are living longer and as a result having many more health problems, rather than just HTN, you have HTN w DM etc.

We are learning more about the body all the time, medical education needs to be longer if anything, not shorter.

NPs will cost the system more money in the long run; not only are they pushing for pay parity, but they will then also have to refer patients out, bascially adding a middle man.

Cool. Are you doing medicine this month with the crazy hours or Gen surgery(dreading that rotation with a passion)

 

[officedepot]

Statements like this make me sick. The thing that most egalitarians don't understand is just how important very intelligent and educated people really are and how much they would miss them if they were gone. This isn't only true in the medical profession of course. I wish ignorant people like this could see what life would be like without innately intelligent and well educated engineers, scientists, professors, and doctors.

dude what year are you?? Have you worked with other people in the field of medicine or do you automatically assume that a plastic surgeon is the absolute best doc around? Do you think he/she could care for new born infants off the off the top of his head? Do you think he could go into a room, comfort a soon to be mom, deliver the baby, and be able to address any complications at all and extremely quickly that could arise with either the kid or mom? Do you think he could go around to rooms with people with strange neurological conditions and in 5 minutes know what is wrong?

seriously you have to grow up. NP, PAs, nurses, etc are valuable to medical care and each have their place. Yes nurses sometimes suck bc they do their work slow, are mean/rude, ignore you, etc (kinda depends on the hospital if you ask me). But you are naive if you think a MD is an alround genius who knows how to do everything (most residents don't know how to do jack).

My attitude isn't one that is naive/egalitarian. It's one that has experience working. Maybe you should get some.

 

[officedepot]

I believe that while they should be used as midlevels, the knowledge base is severely lacking in an NP vs. an MD. C'mon, there is no comparison.

are you sure you're a medical student? Yeah NPs don't go to the OR and do surgery but they are more than capable (good ones) of taking a H&P, determining the cause of an illness, and then providing appropriate medication. I wouldn't say their knowledge base is "severely lacking". It generally is pretty close after a certain time practicing in the field.

I will add however that not all nurses are good and there are some that don't deserve respect. I classify these people however on a person to person basis and generally reserve it for a group of nurses that overall are slow, rude, and annoying (ie you only ever see them talking to each other and very rarely doing work).

 

[Charles_Carmichael]

dude what year are you?? Have you worked with other people in the field of medicine or do you automatically assume that a plastic surgeon is the absolute best doc around? Do you think he/she could care for new born infants off the off the top of his head? Do you think he could go into a room, comfort a soon to be mom, deliver the baby, and be able to address any complications at all and extremely quickly that could arise with either the kid or mom? Do you think he could go around to rooms with people with strange neurological conditions and in 5 minutes know what is wrong?

seriously you have to grow up. NP, PAs, nurses, etc are valuable to medical care and each have their place. Yes nurses sometimes suck bc they do their work slow, are mean/rude, ignore you, etc (kinda depends on the hospital if you ask me). But you are naive if you think a MD is an alround genius who knows how to do everything (most residents don't know how to do jack).

My attitude isn't one that is naive/egalitarian. It's one that has experience working. Maybe you should get some.

No one argued that they don't. What people have been arguing is that their place is not independent practice as physician-equivalents. That's what the nursing leadership is pushing for and already achieved in several states.

Instead of giving your personal anecdotes (which are useless, along with mine), why don't you provide some actual data instead? Oh wait, I forgot...there isn't a single well-done study that suggests that it's a good idea to give independence to NPs/DNPs.

I've asked this question a couple of times in this thread but none of the pro-NP/DNP people have answered: do you support full independence for M4s? By the time a med student finishes 3rd year of med school, he/she has far superior basic science training and has several times as many clinical hours of training than what any NP/DNP program in the country offers. The average NP graduates with approx. 500 hours of clinical training. A DNP program adds another 500 hours (1000 in some cases, but those seem to be rarer). That's what? Like 2 months of residency? Like I said, your 3rd year rotations alone will provide more clinical hours of training than the NP/DNP programs do.

Edit: Just wanted to add the clinical hours of training NPs/DNPs get are not all hands-on. Some schools will offer decent hands-on training, but since there's such a lack of standardization of curricula, many do not. If you go on nursing forums, you'll see tons of threads where NP students are complaining that they essentially shadowed their preceptor for the duration of their clinical hours. Not exactly a comforting thought.

 

[Wilf]

dude what year are you?? Have you worked with other people in the field of medicine or do you automatically assume that a plastic surgeon is the absolute best doc around? Do you think he/she could care for new born infants off the off the top of his head? Do you think he could go into a room, comfort a soon to be mom, deliver the baby, and be able to address any complications at all and extremely quickly that could arise with either the kid or mom? Do you think he could go around to rooms with people with strange neurological conditions and in 5 minutes know what is wrong?

seriously you have to grow up. NP, PAs, nurses, etc are valuable to medical care and each have their place. Yes nurses sometimes suck bc they do their work slow, are mean/rude, ignore you, etc (kinda depends on the hospital if you ask me). But you are naive if you think a MD is an alround genius who knows how to do everything (most residents don't know how to do jack).

My attitude isn't one that is naive/egalitarian. It's one that has experience working. Maybe you should get some.

Your post didn't really address what mine was about, but you made good use of ad hominems. Never did I say that nurses and PAs aren't valuable to medical care in their places. But this thread is about them trying to get to a higher and more autonomous level of care where they really do not belong. My post however was addressing your egalitarian idea that med students aren't special or different in comparison to other students. We are generally at the highest level of education and intelligence. There is more that separates a medical student and an NP student than just their choice of schooling. They are innately different.

And your statement that most residents don't know to do "jack" is completely ridiculous.

 

[betsywetsy]

.

 

[Pleepl3us]

My wife comes home today and tells me that her friend/co-worker just took her 3 day old baby in for her checkup and was seen by an NP. The baby sustained a few scratches to her scalp during the episiotomy and when the NP asked where she got them from the mom explained.

The NP then replied that her story didnt make sense because the baby would have been delivered by the time the episiotomy would have been started. She then said the mother must be confusing an episiotomy with a C-section.

Simply wow.

 

[p1acebo]

My wife comes home today and tells me that her friend/co-worker just took her 3 day old baby in for her checkup and was seen by an NP. The baby sustained a few scratches to her scalp during the episiotomy and when the NP asked where she got them from the mom explained.

The NP then replied that her story didnt make sense because the baby would have been delivered by the time the episiotomy would have been started. She then said the mother must be confusing an episiotomy with a C-section.

Simply wow.

That is wow, I have to post wow on this thread just for reading that. ><

Was her degree from online?

 

[officedepot]

Your post didn't really address what mine was about, but you made good use of ad hominems. Never did I say that nurses and PAs aren't valuable to medical care in their places. But this thread is about them trying to get to a higher and more autonomous level of care where they really do not belong. My post however was addressing your egalitarian idea that med students aren't special or different in comparison to other students. We are generally at the highest level of education and intelligence. There is more that separates a medical student and an NP student than just their choice of schooling. They are innately different.

And your statement that most residents don't know to do "jack" is completely ridiculous.

seems like we didn't quite understand each other (happens on the internet). the second half of my post I guess wasn't really directed at your post it was more of just a statement by me. And by "jack" I mean they (at least initially) don't know how to do a lot of simple things like drawing blood - believe it or not - that nurses know how to do. Of course they know material but they aren't as smart as students make them out to be (yeah they're smarter than us but honestly they don't remember a lot of stuff from other rotations understandably - e.g. the proper way to do a complete neuro exam since most docs who aren't neurologists don't do one). So that was kinda my point.


And I wasn't thinking about med students being different or special though I guess I came off that way. Yeah so with regards to that I think med students are "special" in the sense that we will be doctors one day and, for example, nursing students and pa students won't. Therefore we perhaps are allowed more freedom in what we are allowed to do and what is expected of us. But my egalitarian view applies to everyone (docs/residents and students) in general in that I don't think it is good for the profession or patients to bash other health care professionals (well at least the ones backed by medical science) like nursing (assuming the nurses you work with are actually good ones), NPs, PAs, etc. I also don't think we as med students and docs should be bashing other MDs which I commonly see on my rotations - at least from the arrogant people anyway and they are in every field by the way.


I also feel giving NPs and PAs more freedom, at least with regards to primary care, is not necessarily a bad thing seeing as how less medical students are choosing that field but the patient population is ever expanding. I think the important thing when it comes to primary care with NPs and PAs is to essentially have them trained to be extremely sensitive in that they don't miss serious illness. This can be accomplished I believe and does not necessarily need a physician because lets be honest - it for the most part is not worth a MDs time to manage simple hypertension, for example, and this is something a NP or PA could do just as easily. Long term consequences of this can be debated but I don't happen to think there will be more detremental outcomes. Someone here pointed out in a patient experience how a NP thought acute angle closure glaucoma and a Family med doc thought TIA (which turned out to be correct) but regardless in that situation (and the way it was presented did make it sound like the former is on the differential) as long as the patient was sent to the ER and a workup was done there the outcome would have probably been the same. So that's my point about their expanding role. These professions, if they want to have more freedom, should subsequently require more standardized licencing procedures (like MDs) and perhaps a little more training. This kinda stuff needs to be regulated to avoid causing more negative outcomes.

 

[Pleepl3us]

That is wow, I have to post wow on this thread just for reading that. ><

Was her degree from online?

Not sure. I could not believe it when she told me.

 

[cbrons]

Life goes on boys. Believe me..

Sent on the Sprint® Now Network from my BlackBerry®

 

[farrago]

We don't have these high licensing standards in many fields that affect lots of human lives. What makes medicine so unique? Do you need a government mandated license to practice as an architect? How many buildings do you see collapsing because of this lack of certification? Even in your example, mechanical engineers build all kinds of things that would kill people if they were designed badly. You name it- poorly designed planes, nuclear power plants, or ships would cost thousands of lifes if they weren't designed right, and people in these career fields sure don't train for 14 years.

According to Friedman, having these standards of quality assurance in medicine is a good thing, but why can't they be on a voluntary basis (i.e. private licensure should be the mark of competence to patients, but not a gov't requirement to practice medicine), and why not let anyone compete in the marketplace? The only thing gov't should regulate against is fraud- if the NP advertising herself as a "Dr." or "physician", she would be prosecuted for fraud. If they botch a procdeure or diagnosis, they would absolutely be liable for malpractice. In a system without licensure, the patient would be far more inclined to research the credentials of the practitioner and make an individual choice as to whether he wanted to see a noctor or a board-certified physician. The market would ultimately determine who is delivering the superior product, and I'm not sure the NPs practicing independently would survive in the long run.

First of all, structural engineers build buildings, not architects. Do you think there are no licensing requirements in engineering? There are - the tests are hard, and it takes some years of working as an engineer to be eligible for a PE license. (Architects have licenses, too.)

Now, I'm all for less government intervention in our lives, but I'm not sure what moving to voluntary from government mandated licensure would accomplish. People are used to physicians being highly educated/regulated/licensed/tested - if you were serious about being a physician, would you choose to strike out on your own as opposed to attaching yourself to an established training institution? If we suddenly went to a completely unregulated system, the most ambitious and competent would remain attached to already established schools and training programs - in fact, it would probably drive credentialism through the roof as the smart/competent students/doctors tried to distinguish themselves from all the crazy quacks flooding the market. I mean, are the current licensing standards really that unreasonable? Who are all these people that are being denied a medical education who would be flooding the market and competing successfully with existing physicians? Where are they now? What are they doing?

 

[hopefuldoc97239]

On another thread in this forum someone recently wrote:

With the amount of information that you will get thrown at you on a daily basis it's hilariously futile to attempt to remember everything. Everyone memorizes tons of facts that are then dumped immediately after the exam.

But while it's commonly accepted that nobody remembers this stuff from their basic science years, people still insist that it somehow is absolutely essential information:

By the time a med student finishes 3rd year of med school, he/she has far superior basic science training

This whole thread is basically the med-school version of a similar argument... that's the one where pre-meds whine endlessly about how unnecessary organic chemistry is, then turn around and s*** on nursing students for getting to take the light version.


Cry me a f***ing river!

------

Like it or not: Nurses are the most trusted profession. Whatever they're doing to win that trust, we future- and current-physicians should try to learn from them.

 

[dap]

I'm talking about, when Arabian kings need heart surgery, where do they go?

Istanbul. Depending on what you mean by "Arabian king," maybe Jerusalem. Amman. Beirut. This is just without leaving the region, because we could also take into account Germany, India for certain groups, and yes, in fact, much of the rest of Europe. Certainly lots of wealthy international medical travelers come to the United States. But the US also has a whole lot MORE options for advanced practitioners, and that ain't because more years of school (subtle hint: America is a huge country with a lot of rich people). In fact, and I may be going out on a limb here, I would imagine that you would be hard-pressed to find a wealthy Arab, outside of those affiliated with health/medical sciences, that can tell you much of any differences in European and American medical training, or perceived competency.

Actually, last time I was at a hospital in Istanbul their international services department just went on-and-on about their services and packages for wealthy Americans, and how many of them they attract, which is rapidly increasing. Saw a surprising number of them myself, actually.

I also find it slightly amusing, given the example that you chose, that the reason I was there was because I was working with patients and families from Iraq, in a ward with quite a few Arabs, who were there for...

...heart surgeries.

 

[tm12]

Del

 

[tm12]

I find these comments very disturbing. You knew or should have known this is how medicine was before you started. Had you expressed these thoughts during your interviews, there is no way you would have been accepted to medical school.

This is part of the problem.. medical schools are filled with people like you. Why don't you work for free, its probably the only right thing to do because we shouldn't care about money or titles or anything, everyone should be equal. You can be even more altruistic by sending part of your salary over here so I can pay off my compounding interests on my gigantic loans.

 

[surftheiop]

While it might make my job market a little tougher or salary a little lower, I don't really mind the influx of advanced nurses. The market/lawyers will work things out, if they truly are under trained then pretty quickly they will be pushed out by litigation. But on the other hand if it actually isn't necessary to have an MD's training to practice at an acceptable level of safety/efficacy, then society can save a HUGE amount of resources and man hours that goes into medical school.

 

[MDofIre]

On another thread in this forum someone recently wrote:



But while it's commonly accepted that nobody remembers this stuff from their basic science years, people still insist that it somehow is absolutely essential information:



This whole thread is basically the med-school version of a similar argument... that's the one where pre-meds whine endlessly about how unnecessary organic chemistry is, then turn around and s*** on nursing students for getting to take the light version.


Cry me a f***ing river!

------

Like it or not: Nurses are the most trusted profession. Whatever they're doing to win that trust, we future- and current-physicians should try to learn from them.

Oh attempts to argue a point out of complete and utter ignorance. Oh and BTW not all, but a large part of the basic science material you learn in med school is pretty dang applicable to practice. And guess what you can't efficient learn that material with out have a solid understanding of the basics for undergrad. Now scurry along back to the premed forum and worry about getting ready for MS1 and leave this discussion to the big boys and girls that actual have some idea of what is going on here.

 

[Perrotfish]

Oh attempts to argue a point out of complete and utter ignorance. Oh and BTW not all, but a large part of the basic science material you learn in med school is pretty dang applicable to practice. And guess what you can't efficient learn that material with out have a solid understanding of the basics for undergrad. Now scurry along back to the premed forum and worry about getting ready for MS1 and leave this discussion to the big boys and girls that actual have some idea of what is going on here.

Bull****.

The only classes from undergrad that carred over to medical school at all were the biologies, general chemistry, and maybe statistics, and I'm pretty sure I would have done fine without even those classes. I have never found the slighted use for any of the advanced chemistries they made us take and you can give me an example of when you used organic chemistry, even in your preclinicals, I'd love to hear it. The schools that require calculus are out of their f-ing minds.

The medical school classes, on the other hand, are all useful to someone. The issue, though, is that I can't think of much from MS1 that's useful to even a strong majority of physicians, which begs the question why we all need to learn them rather than just incorporating them into the appropriate residencies rather than forcing everyone to take them. Can you think of any earthly reason why an Ortho needs to have taken neuroanatomy? Why does an internal medicince doctor needs to know one tenth of the details we learn in general anatomy? Why does ANYONE, outside of a select few physicians involved in certain kinds of bench research, need to take biochem?

98% of what you need to learn to be a physician is taught in two years: MS2 and MS3. Everything else that's useful in your 4-6 years of premedicine and your two other years of medical school could probably be condensed to a single year.

 

[cbrons]

on another thread in this forum someone recently wrote:



But while it's commonly accepted that nobody remembers this stuff from their basic science years, people still insist that it somehow is absolutely essential information:



This whole thread is basically the med-school version of a similar argument... That's the one where pre-meds whine endlessly about how unnecessary organic chemistry is, then turn around and s*** on nursing students for getting to take the light version.


Cry me a f***ing river!

------

like it or not: Nurses are the most trusted profession. Whatever they're doing to win that trust, we future- and current-physicians should try to learn from them.

lol

 

[farrago]

Bull****.

The only classes from undergrad that carred over to medical school at all were the biologies, general chemistry, and maybe statistics, and I'm pretty sure I would have done fine without even those classes. I have never found the slighted use for any of the advanced chemistries they made us take and you can give me an example of when you used organic chemistry, even in your preclinicals, I'd love to hear it. The schools that require calculus are out of their f-ing minds.

The medical school classes, on the other hand, are all useful to someone. The issue, though, is that I can't think of much from MS1 that's useful to even a strong majority of physicians, which begs the question why we all need to learn them rather than just incorporating them into the appropriate residencies rather than forcing everyone to take them. Can you think of any earthly reason why an Ortho needs to have taken neuroanatomy? Why does an internal medicince doctor needs to know one tenth of the details we learn in general anatomy? Why does ANYONE, outside of a select few physicians involved in certain kinds of bench research, need to take biochem?

98% of what you need to learn to be a physician is taught in two years: MS2 and MS3. Everything else that's useful in your 4-6 years of premedicine and your two other years of medical school could probably be condensed to a single year.

It's astounding that you would even ask the questions you have asked here. You are training to be a physician - meaning, someone at the highest level of knowledge and skill regarding the diagnosis and treatment of disease. You are not training to be some sort of monkey. Given the interrelated nature of a lot of conditions, I'm not sure how you could possibly fragment training so that some people would only study a little bit of this, other people only a little bit of that. When a patient comes to see you and asks some sort of general question about their body/health, it should at least be in the realm of possibility that you can answer them instead of sputtering about like some imbecile that graduated from a six month online course. It is you, as the physician, who should be the ultimate authority for patients - I mean, who do you propose fill this role? Generally, intelligent, ambitious people want to expand their knowledge base instead of taking the path of least resistance. For example, I can't understand why someone who wants to be a physician wouldn't want to know (to some reasonable degree of detail) neuroanatomy, or biochemistry, just for its own sake, even. I can't understand people with such circumscribed interests that they can't be bothered with the basic foundational knowledge of their profession.

 

[swamprat]

I find these comments very disturbing. You knew or should have known this is how medicine was before you started. Had you expressed these thoughts during your interviews, there is no way you would have been accepted to medical school.

Too bad - boohoo

 

[startswithb]

It's astounding that you would even ask the questions you have asked here. You are training to be a physician - meaning, someone at the highest level of knowledge and skill regarding the diagnosis and treatment of disease. You are not training to be some sort of monkey. Given the interrelated nature of a lot of conditions, I'm not sure how you could possibly fragment training so that some people would only study a little bit of this, other people only a little bit of that. When a patient comes to see you and asks some sort of general question about their body/health, it should at least be in the realm of possibility that you can answer them instead of sputtering about like some imbecile that graduated from a six month online course. It is you, as the physician, who should be the ultimate authority for patients - I mean, who do you propose fill this role? Generally, intelligent, ambitious people want to expand their knowledge base instead of taking the path of least resistance. For example, I can't understand why someone who wants to be a physician wouldn't want to know (to some reasonable degree of detail) neuroanatomy, or biochemistry, just for its own sake, even. I can't understand people with such circumscribed interests that they can't be bothered with the basic foundational knowledge of their profession.

👍

 

[deleted191570]

You are not training to be some sort of monkey.

Wait, what??

I want my money back.

 

[deleted191570]

It is you, as the physician, who should be the ultimate authority for patients - I mean, who do you propose fill this role?

I think this view is where everything diverges. I don't believe physicians are authority figures. Patients don't, and shouldn't (IMO), "submit" to their docs. They receive advice and follow counsel if they choose.

Medical professionals provide a service; some better than others.

 

[Perrotfish]

It's astounding that you would even ask the questions you have asked here. You are training to be a physician - meaning, someone at the highest level of knowledge and skill regarding the diagnosis and treatment of disease. You are not training to be some sort of monkey. Given the interrelated nature of a lot of conditions, I'm not sure how you could possibly fragment training so that some people would only study a little bit of this, other people only a little bit of that. When a patient comes to see you and asks some sort of general question about their body/health, it should at least be in the realm of possibility that you can answer them instead of sputtering about like some imbecile that graduated from a six month online course. It is you, as the physician, who should be the ultimate authority for patients - I mean, who do you propose fill this role? Generally, intelligent, ambitious people want to expand their knowledge base instead of taking the path of least resistance.

What I would propose we do is the thing that we are already doing anyway: have each physician fill the role as the ultimate autority on his particular area of expertise and consult with other expers on other areas. Let the neurologist handle neurology, the Orthopod can work on his bones, and the chemists can deal with the chemical reactions. I don't understand this deep down shame that physicians have in admitting that they're not experts in the parts of medicine that they don't practice. Anyway there are good reasons for trying to minimize superfulous education:

1) As I've argued, over and over again, while a broad knowledge is good access to care and low cost of training is better. Your patients need you in practice and they need to be able to afford you. When you come back at the age of 35, finally finished with your training and armed with a broad knowledge of conditions which you will never consult on you will cost more than they can afford (to pay for your years of extra training and all the debt you incured) and you will never make up for the patients you didn't see when you were stuck in school. Right now the only people that are being served by the endless length of medical training are the people raking in our tuitions. The patients get fewer, more expensive providers and physicians, who can't pass ALL of the cost of their training onto patients, get to lose years and fortunes into the medico-educational complex.

2) There is a lifetime of learning in every subspecialty of medicine without any need to delve into subjects that you don't apply in practice. The idea that physicians should have a broad understand of the entire body and, in fact, the entire realm of the physicial an biological sciences (with a strong foundation in the liberal arts) was developed at a time when all of that knowledge put together could barely be stretched out into a four year course of study. These days you can, and many physicians do, spend half a decade learning the mechanisms and treatments of just half a dozen conditions. With the infinite plurality of data at our disposal everything we put into breadth of knowledge necessarily sacrifices depth of knowledge and/or time in practice. So right now we have a biochemistry course that isn't good enough for research, an anatomy course that is no where near sufficent for a surgical resident, chemistry prerequisites that don't make you competent to work as a chemist, etc, and all of it gets forgotten as soon as it's taught because we never use it again. I think it's reasonable to have a more focused course of study.

. For example, I can't understand why someone who wants to be a physician wouldn't want to know (to some reasonable degree of detail) neuroanatomy, or biochemistry, just for its own sake, even. I can't understand people with such circumscribed interests that they can't be bothered with the basic foundational knowledge of their profession

The idea that biochemistry and neuroanatomy are foundational to our profession is circular. My whole argument is that they're not foundational, they're tangential. They're related to medicine in the sense that quantum physics is related: if you dig deep enough there's certainly a connection, but there's no practical application for it.

As for the idea that I should enjoy these subjects for their own sake... well if your idea of a good time is memorizing the Krebs cycle and broca's areas then go ahead, I happen to have other hobbies.

For that matter I'm betting that you're not brushing up on OChem for it's own sake either. If you needed to know it 'in a reasonable level of detail' to be a good physician, shouldn't you be making sure you maintain that reasonable level of detail going forward? Work a couple of SN1 and SN2 reactions every morning to stay fresh? It was a hoop, you jumped through it, and now you're trying to come up with a good reason for doing that other than that they told you you had to.

 

[Residual]

It's astounding that you would even ask the questions you have asked here. You are training to be a physician - meaning, someone at the highest level of knowledge and skill regarding the diagnosis and treatment of disease. You are not training to be some sort of monkey. Given the interrelated nature of a lot of conditions, I'm not sure how you could possibly fragment training so that some people would only study a little bit of this, other people only a little bit of that. When a patient comes to see you and asks some sort of general question about their body/health, it should at least be in the realm of possibility that you can answer them instead of sputtering about like some imbecile that graduated from a six month online course. It is you, as the physician, who should be the ultimate authority for patients - I mean, who do you propose fill this role? Generally, intelligent, ambitious people want to expand their knowledge base instead of taking the path of least resistance. For example, I can't understand why someone who wants to be a physician wouldn't want to know (to some reasonable degree of detail) neuroanatomy, or biochemistry, just for its own sake, even. I can't understand people with such circumscribed interests that they can't be bothered with the basic foundational knowledge of their profession.

Fair enough, just don't come crying if you find out that some sort of monkey can do most of your job with less training and for less money.

I suppose you'll still be able to answer people's general questions about their body, though. Maybe you can charge people for that and make a living, at least until they figure out what google/the library is.

 

[Wilf]

I think this view is where everything diverges. I don't believe physicians are authority figures. Patients don't, and shouldn't (IMO), "submit" to their docs.

Even today quite a few people view doctors as authority figures in a way.

 

[Dr Oops]

What I would propose we do is the thing that we are already doing anyway: have each physician fill the role as the ultimate autority on his particular area of expertise and consult with other expers on other areas. Let the neurologist handle neurology, the Orthopod can work on his bones, and the chemists can deal with the chemical reactions. I don't understand this deep down shame that physicians have in admitting that they're not experts in the parts of medicine that they don't practice. Anyway there are good reasons for trying to minimize superfulous education:

1) As I've argued, over and over again, while a broad knowledge is good access to care and low cost of training is better. Your patients need you in practice and they need to be able to afford you. When you come back at the age of 35, finally finished with your training and armed with a broad knowledge of conditions which you will never consult on you will cost more than they can afford (to pay for your years of extra training and all the debt you incured) and you will never make up for the patients you didn't see when you were stuck in school. Right now the only people that are being served by the endless length of medical training are the people raking in our tuitions. The patients get fewer, more expensive providers and physicians, who can't pass ALL of the cost of their training onto patients, get to lose years and fortunes into the medico-educational complex.

2) There is a lifetime of learning in every subspecialty of medicine without any need to delve into subjects that you don't apply in practice. The idea that physicians should have a broad understand of the entire body and, in fact, the entire realm of the physicial an biological sciences (with a strong foundation in the liberal arts) was developed at a time when all of that knowledge put together could barely be stretched out into a four year course of study. These days you can, and many physicians do, spend half a decade learning the mechanisms and treatments of just half a dozen conditions. With the infinite plurality of data at our disposal everything we put into breadth of knowledge necessarily sacrifices depth of knowledge and/or time in practice. So right now we have a biochemistry course that isn't good enough for research, an anatomy course that is no where near sufficent for a surgical resident, chemistry prerequisites that don't make you competent to work as a chemist, etc, and all of it gets forgotten as soon as it's taught because we never use it again. I think it's reasonable to have a more focused course of study.



The idea that biochemistry and neuroanatomy are foundational to our profession is circular. My whole argument is that they're not foundational, they're tangential. They're related to medicine in the sense that quantum physics is related: if you dig deep enough there's certainly a connection, but there's no practical application for it.

As for the idea that I should enjoy these subjects for their own sake... well if your idea of a good time is memorizing the Krebs cycle and broca's areas then go ahead, I happen to have other hobbies.

For that matter I'm betting that you're not brushing up on OChem for it's own sake either. If you needed to know it 'in a reasonable level of detail' to be a good physician, shouldn't you be making sure you maintain that reasonable level of detail going forward? Work a couple of SN1 and SN2 reactions every morning to stay fresh? It was a hoop, you jumped through it, and now you're trying to come up with a good reason for doing that other than that they told you you had to.

I agree wit you that orgo is pretty useful, but physics and chemistry are very much helpful.

We are supposed to be the highest level of knowledge. We have a systems based curriculum and we started doing systems by the end of our first year.

for simpliticys sake I will use a general example, the psychiatrist, there are many medical illnesses that can present with psych sx. If you dont know any of the associated sx with those medical illnesses, you'll just go on thinking this is a psychiatric problem.

A solid knowledge and understanding of the basic sciences is what separates us from the mid levels. I cant remember every single detail I learned but I can pull bits and pieces and at the very least use those pieces to know where to look, while other times i will straight out just remember things that stuck in my head for whatever reason.

 

[Charles_Carmichael]

On another thread in this forum someone recently wrote:



But while it's commonly accepted that nobody remembers this stuff from their basic science years, people still insist that it somehow is absolutely essential information:

I've actually heard the opposite from the physicians I generally interact with. They pretty much say something similar to what Dr Oops says, that even if they don't remember every single detail, it's surprising how much they actually remember and use. I myself have been surprised on several occasions when I've asked a question regarding the pathophysiology behind a certain disease and I get a very thorough answer from the attending.

This whole thread is basically the med-school version of a similar argument... that's the one where pre-meds whine endlessly about how unnecessary organic chemistry is, then turn around and s*** on nursing students for getting to take the light version.


Cry me a f***ing river!

------

Like it or not: Nurses are the most trusted profession. Whatever they're doing to win that trust, we future- and current-physicians should try to learn from them.

I don't really know what exactly your point is here. People aren't "crying" because they feel threatened for our future jobs or something. As others, including myself, have repeatedly pointed out, there is a lack of convincing evidence that letting nursing midlevels practice independently is a good idea. If anything, it's the patients who should feel threatened, not physicians.

Also, it looks like physicians are in the top 5 of the "most trusted professions" list as well (although, IMO, such surveys are fairly useless). Nurses are likely above physicians because they spend more time with patients than physicians do. Just speculating there though.

...

Your issue is with medical training, we get it. However, because you find fault in the medical training model doesn't mean that it's okay to let someone who has barely has more of a scientific background than undergrad bio majors do practice independently after a few hundred hours of clinical training. There's a paucity of outcomes data and it's unlikely that solid studies will come out anytime soon (what patient is willing to be potentially randomized into the NP/DNP arm after being informed of the training differences?).

If you feel that medical training needs to be reformed, and I can see where you're coming from, that's fine. Fight for reform in medical training then. That doesn't mean we let others with less than a quarter of the training (less than 1/10 of the clinical hours physicians get, for example) practice freely without substantial evidence to support that.

Fair enough, just don't come crying if you find out that some sort of monkey can do most of your job with less training and for less money.

I suppose you'll still be able to answer people's general questions about their body, though. Maybe you can charge people for that and make a living, at least until they figure out what google/the library is.

Your argument there is flawed because there aren't any well-done studies suggesting that NPs/DNPs can handle most things at a level that equivalent to that of physicians. Also, since NPs/DNPs are pushing to be reimbursed at the same rate as physicians, you''re not saving the patient any money either. What'll end up happening is that you'll be paying the "physician price" to be taken care of by someone who has nowhere close to the level of training that a physician gets. I don't know about you, but that sounds like a terrible deal.

 

[Perrotfish]

Your issue is with medical training, we get it. However, because you find fault in the medical training model doesn't mean that it's okay to let someone who has barely has more of a scientific background than undergrad bio majors do practice independently after a few hundred hours of clinical training. There's a paucity of outcomes data and it's unlikely that solid studies will come out anytime soon (what patient is willing to be potentially randomized into the NP/DNP arm after being informed of the training differences?).

Your argument there is flawed because there aren't any well-done studies suggesting that NPs/DNPs can handle most things at a level that equivalent to that of physicians. Also, since NPs/DNPs are pushing to be reimbursed at the same rate as physicians, you''re not saving the patient any money either. What'll end up happening is that you'll be paying the "physician price" to be taken care of by someone who has nowhere close to the level of training that a physician gets. I don't know about you, but that sounds like a terrible deal.

1) NPs and DNPs may be fighting to be reimbursed equally with physicians but it hasn't happened yet and they certainly arent paid the same amount by the hospitals as physicians. There is, currently, a definite savings here.

2) From an economics perspective, even if NPs do manage to get equal reimbursement, letting them practice still saves patients money. The NP price might be equal to the MD price but if their are more providers that's an increase in supply vs a constant demand, everyone's salary gets depressed, and the price of medical care goes down.

3) Poor patients, to save money, commonly agree to be treated by student dentists, treated with experimental drugs, to subject themselves to medical students at free clinics. You really think they wouldn't be willing to do a randomized trial of NP vs MD care for similar incentives? Heck, they've probably been seen by at least one NP when they were paying full price.

4) But, again, I still disagree that NPs should suddenly need double blind randomized trials to justify their right to sell a product to a product to the public, especially when they have been practicing independently in underserved enviornments for over a decade. I don't think patients need to be protected from themselves, and if they're willing to see an NP I don't think it's the place of the government to step in and say that they are too ignorant to make their own decisions.

 

[Residual]

CRNAs do anesthesia; there are plenty of opt-out states where they do it solo.

Same with NPs in primary care.

Can you show me anything that indicates they do it poorly?

So far I've seen a lot of people insisting that they have less training and not a whole lot of evidence that it matters...

/devil's advocate

 

[Charles_Carmichael]

1) NPs and DNPs may be fighting to be reimbursed equally with physicians but it hasn't happened yet and they certainly arent paid the same amount by the hospitals as physicians. There is, currently, a definite savings here.

It's bound to happen sooner or later, considering the amount of success they've had in gaining independence in multiple states. However, I'm speculating there and don't have hard evidence of their future success in attaining equal reimbursement rates.

2) From an economics perspective, even if NPs do manage to get equal reimbursement, letting them practice still saves patients money. The NP price might be equal to the MD price but if their are more providers that's an increase in supply vs a constant demand, everyone's salary gets depressed, and the price of medical care goes down.

It may drive down cost of health care, but it's extremely unlikely to make a significant impact. Physician income makes up what? 7-10% of the health care costs from what I remember. Even cutting incomes by 50% isn't going to make a significant dent in reducing the cost of healthcare in the US.

And any money saved by utilizing NPs/DNPs is very unlikely to go back into patients' pockets.

3) Poor patients, to save money, commonly agree to be treated by student dentists, treated with experimental drugs, to subject themselves to medical students at free clinics. You really think they wouldn't be willing to do a randomized trial of NP vs MD care for similar incentives? Heck, they've probably been seen by at least one NP when they were paying full price.

No, I don't think patients will subject themselves to the NP/DNP arm of a randomized trial once they've been fully-informed of the training differences between the providers. A recent survey by the AMA suggests that many (the majority?) of patients are confused as to who is actually their physician and who is not. I highly doubt that all patients would be okay with risking being treated by someone with a fraction of the training a physician gets.

4) But, again, I still disagree that NPs should suddenly need double blind randomized trials to justify their right to sell a product to a product to the public, especially when they have been practicing independently in underserved enviornments for over a decade. I don't think patients need to be protected from themselves, and if they're willing to see an NP I don't think it's the place of the government to step in and say that they are too ignorant to make their own decisions.

I don't know how many NPs/DNPs practice in underserved areas, but current reports show that the majority of NPs/DNPs aren't practicing in primary care. I don't know off the top of my head if they're significantly more likely than physicians to practice in underserved areas, but I seem to remember the answer being no. There's a reason why primary care and underserved areas are unattractive to physicians. They don't become magically attractive areas to practice in for nursing midlevels. I'm pretty certain about the majority of NPs/DNPs not going into primary care (they tend to go into lucrative specialties just like physicians do) but I'm not completely certain regarding the underserved areas; I'll need to refresh my memory regarding that and I can get back to you later.

Either way, I disagree with you that we don't need randomized trials comparing physicians and nursing midlevels. We spend a hell of a lot more time, money, and effort putting interventions (that may help only a small number of people) through rigorous trials; it's ridiculous, IMO, to make such a drastic change in policy (allowing those with less than a quarter of a physician's training practice independently as physician-equivalents) without substantial evidence to back up that idea.

 

[Charles_Carmichael]

CRNAs do anesthesia; there are plenty of opt-out states where they do it solo.

Same with NPs in primary care.

Can you show me anything that indicates they do it poorly?

So far I've seen a lot of people insisting that they have less training and not a whole lot of evidence that it matters...

/devil's advocate

You're misunderstanding the concept of burden of proof. The burden of proof lays on the person making the claim. In this case, the NPs/DNPs are claiming that they're equivalent to physicians. It's up to them to actually support that with evidence. It's not up to the rest of society to show that they're wrong.

It's the same idea when a new drug is developed. The drug is tested against the current gold standard before hitting the market. It's stupid to release the drug into the market and force others to show that the drug isn't working, has unacceptable toxicity, etc.

 

[Perrotfish]

It may drive down cost of health care, but it's extremely unlikely to make a significant impact. Physician income makes up what? 7-10% of the health care costs from what I remember. Even cutting incomes by 50% isn't going to make a significant dent in reducing the cost of healthcare in the US.

One of the issues with healthcare is that there are so many things screwed up with it that it's very easy to get side tracked into other arguments. You argue over provider salaries and someone mentions that what we should be talking about is tort reform and defensive medicine. You talk about tort reform and someone brings up the need for increased access and preventative medicine. You talk about that for awhile and someone says the real problem is balooning entitlement programs and the need for a real cash market for medicine.

Everyone's right, those are all problems and I could (and will) argue about any of them. However you need to focus on one argument at a time to get anywhere and this thread is about provider training and cost. Also I would strongly disagree that 10% of a 2.5 trillion dollar healthcare market is insignificant. It is 250 billion dollars worth of significant. Also I would point out that provider salary is a much greater part of the cost in the fields that we most need to expand access to: primary care. In fact, in the family practice business models I was presented the provider cost was almost half of the cost of practice, if not more. In primary care if you could cut the cost of the provider in half you could be giving the patient a 25% reduction in the price of his care. That difference in price could make medical followup financially feasable for a lot of patients. .

 

[Residual]

You're misunderstanding the concept of burden of proof. The burden of proof lays on the person making the claim. In this case, the NPs/DNPs are claiming that they're equivalent to physicians. It's up to them to actually support that with evidence. It's not up to the rest of society to show that they're wrong.

It's the same idea when a new drug is developed. The drug is tested against the current gold standard before hitting the market. It's stupid to release the drug into the market and force others to show that the drug isn't working, has unacceptable toxicity, etc.

On the other hand, if the drug has already been released and has been prescribed for years in some states, patients seem to like it and think it works, and no one can find any harm done, the burden of proof shifts to those who want to take it off the market/prevent other states from allowing it there.

CRNAs and NPs aren't just making claims: they're practicing and have been for years. You'd think if they were so bad at it there would be some evidence for that, wouldn't there?

 

[Charles_Carmichael]

One of the issues with healthcare is that there are so many things screwed up with it that it's very easy to get side tracked into other arguments. You argue over provider salaries and someone mentions that what we should be talking about is tort reform and defensive medicine. You talk about tort reform and someone brings up the need for increased access and preventative medicine. You talk about that for awhile and someone says the real problem is balooning entitlement programs and the need for a real cash market for medicine.

Everyone's right, those are all problems and I could (and will) argue about any of them. However you need to focus on one argument at a time to get anywhere and this thread is about provider training and cost. Also I would strongly disagree that 10% of a 2.5 trillion dollar healthcare market is insignificant. It is 250 billion dollars worth of significant. Also I would point out that provider salary is a much greater part of the cost in the fields that we most need to expand access to: primary care. In fact, in the family practice business models I was presented the provider cost was almost half of the cost of practice, if not more. In primary care if you could cut the cost of the provider in half you could be giving the patient a 25% reduction in the price of his care. That difference in price could make medical followup financially feasable for a lot of patients. .

Let's just agree to disagree then. The only reason I brought up the cost-saving issue is because others had mentioned it and the current literature doesn't seem to suggest that nursing midlevels will save the system a significant amount of money.

On the other hand, if the drug has already been released and has been prescribed for years in some states, patients seem to like it and think it works, and no one can find any harm done, the burden of proof shifts to those who want to take it off the market/prevent other states from allowing it there.

CRNAs and NPs aren't just making claims: they're practicing and have been for years. You'd think if they were so bad at it there would be some evidence for that, wouldn't there?

There are problems with that reasoning:

1) With CRNAs, anesthesia has already been made ridiculously safe by anesthesiologists and researchers that it's rare to see adverse outcomes no matter who the provider is. This is further confounded by the fact that we don't know how many times anesthesiologists step in to take care of anything serious that a CRNA encounters during a case. As far as I know, there's no study regarding this issue. And since the majority of CRNAs don't practice independently, that issue of how much of a role the anesthesiologist plays in difficult cases is an important one and you can't just say "well, there's no evidence that CRNAs aren't having bad outcomes." In addition to that, the recent study funded by the AANA itself, while it showed that CRNAs and anesthesiologists have same error rates (IIRC), it came with the caveat that anesthesiologists tended to be involved in more difficult cases (it was statistically significant in the study). So that begs the question: if CRNAs tend to do easier cases, why is their morbidity/mortality rate the same as anesthesiologists, who tend to take on more difficult cases? Logic dictates that the CRNAs should have a lower morbidity/mortality rate.

2) With NPs/DNPs, the same issues exist. The majority are still working under physician supervision. So, it's very hard to figure out what the outcomes of NP/DNP only intervention are because we don't know how much of a role the supervising physician plays in making treatment decisions. In addition to that, while current reports suggest that the majority of NPs/DNPs are gravitating towards specialties and not primary care, a significant portion does practice in the primary care setting. In a primary care setting, I would imagine that malpractice is not as easy to prove as in a surgery/procedural case where the outcome is acute. It might take years for a bad decision a PCP made to reveal itself; by then, it's unlikely for the mistake to be traced back to the provider who made the initial bad decision.

 

[Residual]

Enough CRNAs and NPs practice independently that studies showing independent practice is dangerous would have had plenty of data to work with.

For CRNAs, the fact that anesthesia is so safe is exactly the point. You may not need 8-10 years of postgrad training to sit around for four hours and occasionally fiddle with knobs while the machines do most everything for you. And yeah, I know it's not that simple...which is why CRNAs do at least have a fair bit of training. Or so the story goes.

For NPs in primary care...again, excuses for lack of data aren't going to convince anybody. You can speculate that there might be mistakes being made, but if the patients are happy and you can't show anything is wrong, you won't have any luck convincing a third party.

 

[Charles_Carmichael]

Enough CRNAs and NPs practice independently that studies showing independent practice is dangerous would have had plenty of data to work with.

Not really. First of all, there's severe lack of studies. And the studies that do exist are flawed in major ways (not minor ones that most studies come with). The data is unlikely to be there. Who's building up a database regarding this stuff with the data we're interested in (ex. long-term patient outcomes without physician intervention)? It's the lack of data that makes this a dangerous endeavor.

For CRNAs, the fact that anesthesia is so safe is exactly the point. You may not need 9-10 years of postgrad training to sit around for four hours and occasionally fiddle with knobs while the machines do most everything for you. And yeah, I know it's not that simple...which is why CRNAs do have a fair bit of training. Or so the story goes.

CRNAs still receive just a fraction of the training that anesthesiologists get. Even if you took med school out of the equation, the volume of cases and the amount of clinical hours of training that anesthesiology residency provides is >>>>>>>>>> any CRNA program. And, like you said, it's not that simple. There are too many variable and, currently, too little data regarding nursing midlevels to make any conclusive statements.

For NPs in primary care...again, excuses for lack of data aren't going to convince anybody. You can speculate that there might be mistakes being made, but if the patients are happy and you can't show anything is wrong, you won't have any luck convincing a third party.

Again, the lack of data is a huge deal and I don't understand why you're dismissing it so quickly. Patient satisfaction =/= quality medical care. I've had patients tell me they loved talking to me far more than they liked interacting with the nurses and doctors in the ER I used to volunteer in. That does not mean that I was providing quality care.

If I can't speculate that mistakes are being made, then you (and others) can't speculate that mistakes aren't being made either. The fact remains that we desperately need data regarding this issue. The only reason that NPs/DNPs have independence in several states is not because of education or data; it's because the nursing lobby is very powerful.

I mean, honestly, if these are the best arguments that physician organizations can make to lawmakers, I don't see a stop to spread of independent practice happening.

It's too late to put a stop to independent practice, IMO. I'm predicting that within the next 5-10 years (max), every state in the US will grant full independence to nursing midlevels. Again, this is not because there's data suggesting that this is a good idea; it's because the nursing lobby is powerful. The only thing we can do now is to put checks in place so that nursing midlevels graduate with a minimum competency. This battle against NP/DNP independence was lost a while back.

Curious question to you though, since your status says you're a premed: why are you pursuing medicine when you feel that nursing midlevels are equivalent to physicians (at least, that's the sense I'm getting from your posts...feel free to correct me if I'm wrong)? You could easily enter a direct entry program and be practicing independently within 2-3 years if you went the NP route compared to the minimum of 7 years it'll take for you to practice independently as a physician.

 

[Residual]

Sure, we need data. Agreed.

I don't think I ever said they were equivalent. What I did say was that as far as I know, and as far as anyone can show with actual data, they may be.

I also said that the people who take the attitude of "Who cares if it's relevant to practice, we need to learn EVERYTHING about the body so that we can keep being proud of how much we know, and damn the cost to ourselves and the patients! We're training physicians, not procedure monkeys!" shouldn't be surprised when someone figures out that a minimally trained procedure monkey can come by and take over the easiest and most lucrative parts of their jobs and leave them with a lot of wonderful scientific training and nothing much to do with it.

 

[Charles_Carmichael]

Sure, we need data. Agreed.

I don't think I ever said they were equivalent. What I did say was that as far as I know, and as far as anyone can show with actual data, they may be.

I also said that the people who take the attitude of "Who cares if it's relevant to practice, we need to learn EVERYTHING about the body so that we can keep being proud of how much we know, and damn the cost to ourselves and the patients! We're training physicians, not procedure monkeys!" shouldn't be surprised when someone figures out that a minimally trained procedure monkey can come by and take over the easiest and most lucrative parts of their jobs and leave them with a lot of wonderful scientific training and nothing much to do with it.

Fair enough. I apologize for interpreting your posts as "NP/DNP = physician."

However, I still want to see good data regarding this issue before I even consider throwing my support behind the NP/DNP movement. That's what I've been trying to argue so far. That there is actually no solid evidence behind any of this. We can't say that nursing midlevels "may be" good enough because, honestly, the literature doesn't exist. Who knows? Maybe Perrotfish will fight for reform regarding medical training and we may get data a couple of decades from now suggesting that you can be an excellent physician with only a couple of years of post-high-school training (though I doubt it).

But until such data exists, I'll continue to argue against increasing scope of practice for NPs/DNPs (though I do feel that it's too late by this point...).

 

[MossPoh]

Enough CRNAs and NPs practice independently that studies showing independent practice is dangerous would have had plenty of data to work with.

For CRNAs, the fact that anesthesia is so safe is exactly the point. You may not need 8-10 years of postgrad training to sit around for four hours and occasionally fiddle with knobs while the machines do most everything for you. And yeah, I know it's not that simple...which is why CRNAs do at least have a fair bit of training. Or so the story goes.

For NPs in primary care...again, excuses for lack of data aren't going to convince anybody. You can speculate that there might be mistakes being made, but if the patients are happy and you can't show anything is wrong, you won't have any luck convincing a third party.

Good anesthesia is incredibly difficult and is not cookie cutter and it isn't safe to have all the CRNAs doing things. Just because a person has their driver's license and can drive to the grocery store, doesn't mean they've mastered driving and are ready to head off to Le Mans.