The impending doom of medical profession has started to unfold

[officedepot]

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OK so now we have pre-medical students who are arguing on the competency of NPs and PAs. Come on guys, you haven't even worked with them. Everything you say is pure opinion unless you cite specific research articles on the matter that are well accepted as truth (and even those are up for debate). I assure you they are competent (at least the ones I work with). Residents are advised to seek out a NP if they have questions on a patient and the attending is not around. What does that tell you? It's just going to be something you'll learn when you start rotations.

You also need to check your ego at the door the first day med school begins or the first day you walk into a hospital... you're smart now in undergrad but med school is completely different... and you may be smart in the preclinical years of med school but a hospital environment with real patient care is different and you'll be put in your place real quick if you act like an arrogant douche. Also your teammates will be able to see right through any preconceived attitudes you may have because a lot of them probably had similar thoughts at one point in time. This will reflect poorly on you by the way.

Physicians work closely with NPs and often discuss patients as a team. By the way, NPs are above residents in the heirarchy command. PA (depending on level of experience) are also above them. Attendings I have worked with hold them in a higher regard. So please this argument is not helpful to the flow of patient care in the real world setting. You shouldn't sit there and think the other people you work with are dumber than you just because your degree is "MD" and theirs is "NP" or "PA". Same thing goes for any of you reading this who think just because a doc is a plastic surgeon he is automatically smarter than a doc who is a pediatrician.

 

[Charles_Carmichael]

OK so now we have pre-medical students who are arguing on the competency of NPs and PAs. Come on guys, you haven't even worked with them. Everything you say is pure opinion unless you cite specific research articles on the matter that are well accepted as truth (and even those are up for debate). I assure you they are competent (at least the ones I work with). Residents are advised to seek out a NP if they have questions on a patient and the attending is not around. What does that tell you? It's just going to be something you'll learn when you start rotations.

Your anecdotes don't mean much because good research suggesting that NPs/DNPs are just as competent as physicians (or close) does not exist.

And I've never heard of residents being told to seek an NP if they had questions. All the residents I interact with can easily run circles around midlevels. But, like I said, anecdotes are useless (both yours and mine).

You also need to check your ego at the door the first day med school begins or the first day you walk into a hospital... you're smart now in undergrad but med school is completely different... and you may be smart in the preclinical years of med school but a hospital environment with real patient care is different and you'll be put in your place real quick if you act like an arrogant douche. Also your teammates will be able to see right through any preconceived attitudes you may have because a lot of them probably had similar thoughts at one point in time. This will reflect poorly on you by the way.

It's not ego or arrogant to ask for evidence.

Physicians work closely with NPs and often discuss patients as a team. By the way, NPs are above residents in the heirarchy command. PA (depending on level of experience) are also above them. Attendings I have worked with hold them in a higher regard. So please this argument is not helpful to the flow of patient care in the real world setting. You shouldn't sit there and think the other people you work with are dumber than you just because your degree is "MD" and theirs is "NP" or "PA". Same thing goes for any of you reading this who think just because a doc is a plastic surgeon he is automatically smarter than a doc who is a pediatrician.

No one said that NPs are dumb. What we have said is that they don't have anywhere close to the same level of training as physicians do (and I've provided, IMO, pretty good evidence supporting that with the curricular analysis) and that there is a lack of data supporting the idea that it's a good idea for them to practice independently.

 

[tm12]

so now you're finally in med school whining about your future salary and are distraught to find yourself surrounded by "do-gooders" who don't give a ****

Too bad - boohoo

 

[Wilf]

Same thing goes for any of you reading this who think just because a doc is a plastic surgeon he is automatically smarter than a doc who is a pediatrician.

This statement that you love to make interests me. Are you being banal and pointing out that someone who is the smartest in their med school class could choose to go into pediatrics? Or are you saying that in general plastic surgeons aren't smarter than pediatricians?

 

[VA Hopeful Dr]

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.

Incorrect, most of them are only tested against placebo. Its too risky to compare it to an existing drug which might still work better.

 

[redsquareblack]

Incorrect, most of them are only tested against placebo. Its too risky to compare it to an existing drug which might still work better.

On the other hand, it can be unethical to test a drug candidate against a placebo when there's already an accepted therapy in place.

 

[The Coon]

By the way, NPs are above residents in the heirarchy command. PA (depending on level of experience) are also above them. Attendings I have worked with hold them in a higher regard.

I don't agree with this. Every instance I have encountered, the residents have been above the NP/PA on the hierarchy. The PA/NP are still above medical students and maybe a little above interns initially, but come on, a second or third year resident?

 

[tm12]

I think it depends on the particular institution and NP/PA. On general surgery at a major academic center, the residents were above PA's. On a small psych consult team, the NP was above the residents (she had been there for decades). On an ob rotation at a community hospital, the PA's were above the residents which the residents absolutely hated.

I don't agree with this. Every instance I have encountered, the residents have been above the NP/PA on the hierarchy. The PA/NP are still above medical students and maybe a little above interns initially, but come on, a second or third year resident?

 

[45408]

By the way, NPs are above residents in the heirarchy command. PA (depending on level of experience) are also above them. Attendings I have worked with hold them in a higher regard.

Yeah, no. Our attendings have said quite the opposite, and their actions support their words. Maybe if a resident from a different field is rotating through your service, that may apply (e.g., the transitional year rotating through a surgical subspecialty), but not when they're both in the same field.

 

[justaregularmed]

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.

I really have to disagree. Unless you really, really know your organic chemistry in all honesty you don't REALLY understand most of biochem (which most people don't and its just fine), you can memorize it and repeat it but you don't get it. And if you don't have gen chem (with some fun orgo + biochem) then you don't *REALLY* understand acid base disorders. And everything that builds off these things...yeah thats just how it is.

It's all really how you look at it in the end, and where you want to draw the line in understanding.

It's always fun to talk about this sort of thing because in the end you don't know what you don't know (at least this is the case for most people).

 

[mTOR]

who the hell cares if you "REALLY" understand anything or not if that knowledge has no bearing on your ability to effectively practice medicine?

You can make the argument for increased depth of understanding ad infinitum until you've reduced medical science so far you're knee deep in complex mathematical formulas explaining quantum mechanics -- but it won't help save Joe Smith from his MI.


Trees vs forest. For clinicians (as opposed to researchers) emphasis should obviously be on clinical relevance not wasting time on inconsequential minutiae.


And this is coming from someone who LOVES minutiae -- but then again, I love basic science research as well.

 

[justaregularmed]

who the hell cares if you "REALLY" understand anything or not if that knowledge has no bearing on your ability to effectively practice medicine?

You can make the argument for increased depth of understanding ad infinitum until you've reduced medical science so far you're knee deep in complex mathematical formulas explaining quantum mechanics -- but it won't help save Joe Smith from his MI.


Trees vs forest. For clinicians (as opposed to researchers) emphasis should obviously be on clinical relevance not wasting time on inconsequential minutiae.


And this is coming from someone who LOVES minutiae -- but then again, I love basic science research as well.

As I attempted to allude to above. You can absolutely get away with memorizing stuff and not know a damn thing about how things work, I for one am not ok with that, we don't need to cheapen the profession any more then it already is.

But getting rid of the basic sciences is basically getting rid of the profession. It's literally the only thing unique to being a medical doctor and I rather not be a proponent to making myself even less relevant then I already am.

 

[Taurus]

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)

This is probably the most naive med student I've heard in a long time.

You assume that you will still always have some job and your income will hold up, despite welcoming midlevels whole-heartedly. That's about the dumbest thing I've heard in a while. I don't know how to respond.

If you were smart, you should have avoided primary care including ED. Surgical fields are more protected than others from encroachment.

 

[random cell]

I used to worry, but once people start dying because their noctor (aka nurse doctor aka not a doctor) screwed up it will make physicians look like gods.

But to be serious for a sec, if this bullsh*t was really about primary care what is with the CRNAs and DNP specialities? It's a joke and you people supporting this BS are all jokes.

 

[Perrotfish]

Yeah, no. Our attendings have said quite the opposite, and their actions support their words. Maybe if a resident from a different field is rotating through your service, that may apply (e.g., the transitional year rotating through a surgical subspecialty), but not when they're both in the same field.

I'm honestly not sure what it means for a resident to be 'above' or 'below' a resident in the heirarchy. If you're talking about who has the ultimate authority in clinical decision making I've been through four teaching hospital systems now and I have never, ever seen a midlevel and a resident cover the same patient. I guess it might come up if they both ran to the same code blue, but other than that I feel like it's a meaningless distinction.

In terms of who gets treated better by their boss, that's situational. How hard is the midlevel to replace in the current job market? Who does the midlevel actually work with? What are the personal relationships between everyone involved? Who, ultimately, does the midlevel actually report to? I don't think it comes down to a job title.

If you were smart, you should have avoided primary care including ED. Surgical fields are more protected than others from encroachment

Don't count on that. I could see procedural specialties having a very rapid collapse. The reason why there are no nurse surgeons is that it would take a much longer and more formal training program, comperable to what they've developed for CRNAs, and the nursing community hasn't developed/sold that yet. However, when they get around to it, and I feel like they will, I think the surgical subspecialties are going to crash WAY harder than general and subspecialty medicine. There's just a lot more money to be saved.

 

[Nasrudin]

"Naive." "Traitor."

These labels are directed at those of us who see worthwhile elements in a different educational model. Who are not myopically focused on the threat of security. Who might consider alternative workplace roles. Who do not believe we have much public opinion traction on issues of opposing other professions.

Well. I think anyone who spends significant energy on this is wasting their time. All the physicians who employ midlevels out there are making money on them. Extending their ability to oversee the care of more patients.

I'm not planning on moving to the country. What do I have to say then about physicians out there employing NP's to care for a larger panel of patients. Nothing. And what do I have to say about HMO's going with midlevels to manage follow up care in acute settings. Nothing.

Do we really think that deaths and injuries system-wide are racking up as we speak? All because we incorporated a wider spectrum of training in managing clinical care.

Nurses have used this same argument to restrict the use of LPN's and LVN's by their employers. Except that when HMO's can no longer afford to empoly an exclusive unionized all-RN workforce and use LVN's more. No more injury or deaths to patients take place.

That's because. Quite simply. There is no difference in most settings. Or not enough data supporting the effects of damage given the cheaper costs.

We either believe our training is superior and that attornies will take it to the streets. And the Public will decide.

Or we need to reduce the amount of nonsense in ours. And get it done quicker. With less overhead.

Otherwise all you guys are talking about it maintaining a Good Old Boy network and a medical frat house.

 

[Taurus]

"Naive." "Traitor."

These labels are directed at those of us who see worthwhile elements in a different educational model.

When DNP's only have 700 hours of clinical training and can even get their degree online and their leader then goes around proclaiming that they are equivalent to physicians even though physicians have at least 17,000 hours of clinical training, that's when physicians need to stand up and correct the record.

I don't have a problem with NP's per se. However, when they purposely try to deceive patients by knowing that introducing themselves as "doctor" does not accurately convey to patients their level of training, that's when I have a problem. Let NP's compete with physicians fairly. If you use deception, you need to be shut down. Period.

 

[Nasrudin]

When DNP's only have 700 hours of clinical training and can even get their degree online and their leader then goes around proclaiming that they are equivalent to physicians even though physicians have at least 17,000 hours of clinical training, that's when physicians need to stand up and correct the record.

I don't have a problem with NP's per se. However, when they purposely try to deceive patients by knowing that introducing themselves as "doctor" does not accurately convey to patients their level of training, that's when I have a problem. Let NP's compete with physicians fairly. If you use deception, you need to be shut down. Period.

Well. I say let them walk their own plank then. Your assumption is that the public lacks the capacity to rectify this situation. Attornies, who are so fond of that one witness who will cite some piece of clinical rectitude to bury another physician, will be more than happy to make their living wholesaling NP's.

However. We haven't been very well-liked in a long time. We make more than the vast majority of our patients. So unless they themselves feel they've been decieved. We lose in all scenarios. Especially this macho idea that we need to "stick it to these uppity b!tches" and to make sure "all these idiots" don't get hurt.

That's just not gonna fly. And it's not like you can organize a bunch aggressively comppetitive 6-figure earning @ssholes into a union. A union--or it's "profgessional" equivalent--is for people who need one. To get some basic rights and benefits and aren't afraid to fight for them. You can't do that from these lush quarters. You can barely do it from the firehouses of Wisconsin.

And. Most of the people that agree with you. Have nothing of the high-minded organizational rhetoric of our blue collar brethen. All they've got is angry little weenieish opinions about how we're a bunch of communist p@ssies.

And you want me to join you?

 

[officedepot]

This statement that you love to make interests me. Are you being banal and pointing out that someone who is the smartest in their med school class could choose to go into pediatrics? Or are you saying that in general plastic surgeons aren't smarter than pediatricians?

well my opinion on the matter is that pretty much all med students are really smart. Therefore all the boards and clinical grades do is slightly separate out all really smart people. Yes it is harder to get a plastic surg residency than peds but this is due to a large variety of reasons I won't get into. I do think, in general, a plastic surgeon is probably a "more intelligent" individual among already very intelligent people. However, a trained plastic surgeon could not go and be a great pediatrician for example (without the proper training). A person who goes into plastics could do peds though just as easily, if not better, than a person who has "no chance" of making into a plastics program and decides peds.

I have seen very smart people in my classes choose to go into less competetive programs for a variety of reasons. But I think a common attitude among med students from what I have seen is that, for example, just because a derm or plastics program is hard to match into automatically makes those people the smartest. That's just flawed reasoning I think. It is my belief that our profession would be better as a whole if people didn't have those beliefs.

That is not to say there aren't bad docs out there because there are a lot of them sadly (what defines bad doc is up for debate I am sure and I won't get into now). But unless it can be shown that these "bad docs" are concentrated more in a certain field than I would be hesitant to say any one field of medicine contains people significantly smarter/better than another. All fields are really interconnected.

 

[officedepot]

When DNP's only have 700 hours of clinical training and can even get their degree online and their leader then goes around proclaiming that they are equivalent to physicians even though physicians have at least 17,000 hours of clinical training, that's when physicians need to stand up and correct the record.

I don't have a problem with NP's per se. However, when they purposely try to deceive patients by knowing that introducing themselves as "doctor" does not accurately convey to patients their level of training, that's when I have a problem. Let NP's compete with physicians fairly. If you use deception, you need to be shut down. Period.

I agree with you. I do not think it is honest for a DNP to say they are "dr. soandso". Yes they have a doctorate but in nursing, not medicine. When someone is in the hospital and you hear "doctor" you will assume medical doctor. It is just not being honest with patients. Granted we as doctors and future doctors shouldn't really care so much about a title because all that really matters is that we know what we are doing, but something like this isn't really fair to the patients. And sadly I hate to add that we sweat blood and tears for that title and the respect that goes along with it. Yeah it shouldn't be a driving force, but hey we still wear those useless white coats...

Also I'm not going to be the one to put NPs in their place on this matter. I think it would have to be a more institutional policy that your title reflect you training level. A NP should state they are a nurse practioner to a patient and not a doctor in the hospital setting. Let's put it this way, I'm not going to call a NP "doctor" when I am a resident (now if I'm a student and they introduce themselves that way then that is another story haha).

Though this whole thing is just a power struggle really. NPs can only do so much. They are trained to follow algorithms. Yes they know their stuff and are smart but if a patient doesn't fall neatly into their planned algorithm they, I think, will have a hard time adjusting just because they don't have the experience of physicians. NPs I believe are fine for primary care type settings. But as soon as it becomes more specialized they need to work directly under/with a physician otherwise it could result in negative outcomes. NPs are a great help both to residents who are learning (this applies to more PGY1 level I'd say) and physicians who need an extra hand and to patients who can't get a family doctor and need regular follow-up. However, they should not have the same independce as a fully trained physician. If they want it they should go to medical school (and to be honest I think the people who are NPs could have gone to med school but for one reason or another chose a different route).

Though as I have said before I do not have a problem with NPs or PAs having more independce in family/primary care - just not in anything more specialized. And again the reason is that there are more and more patients that need primary care but less and less physicians choosing those fields. If physicians become the specialists then NPs and PAs can take over more in the primary care field to some degree.

 

[mTOR]

Jumped the gun 🙂

 

[officedepot]

Yeah, no. Our attendings have said quite the opposite, and their actions support their words. Maybe if a resident from a different field is rotating through your service, that may apply (e.g., the transitional year rotating through a surgical subspecialty), but not when they're both in the same field.

ok well maybe they aren't "above" residents in the sense of respect from attendings and even patients. What I was getting at was that those NPs who have been practicing in a field for 15 or 20 years know more than at least the PGY1 or the resident rotating through on a service. At a certain point this changes but I don't think that can be quantified. I think it's about egos clashing however to a degree. But a NP does have valuable experience that can help residents in certain areas.

And yeah this only applies to fields in which NPs take a more active role in patient care such as primary care, pediatrics, even neurology for example. In surgerical fields I don't think it applies quite the same way. And I haven't worked yet with enough NPs in different fields to get a good grasp of the varieties out there and their level of knowledge/skill in any particular area.

 

[officedepot]

I don't agree with this. Every instance I have encountered, the residents have been above the NP/PA on the hierarchy. The PA/NP are still above medical students and maybe a little above interns initially, but come on, a second or third year resident?

no yeah I had to restate that. See my previous post.

However, honestly I do think it depends on the field. A third year resident in family medicine may not know or have seen quite as much as a 20 yr NP vetern. But a third year surgery resident will/should hopefully know more than an NP in the field (though to be honest I'm not even sure what NPs do in the surgery field besides more basic clinic stuff such as post-op followups and what not since they obviously don't do the procedures).

But yeah I'm a fan of NPs mainly because the ones I have seen are pretty dang smart (and yeah this is coming from a student so I am a little biased probably). As as a resident this might change if I start to see the flaws in how they are trained.



But look, in the primary care setting all we really need is a competent person (NP or PA) who WON'T MISS SERIOUS ILLNESS. I mean come on most family docs refer their patients if it is something that is getting to be too complicated to handle (refractory HTN, complicated endocrine abnormalities, pulm issues, etc etc etc). They handle follow-up care and treat simpler less life threatening illness for the most part (they do see patients however who have life threatening illness but their job in that case is not really to treat it but to send them to people who treat it for a living). Therefore NPs and PAs should be trained to be a SENSITIVE group of practioners in that they won't miss serious disease and are more than capable of handling follow-up care and more basic health physicals. You just don't need a doctor with I think with 4 years of med school and maybe 4 more years of residency to be doing wellness checkups all day and changing some HTN medication... That is just my opinion.

 

[MCAT guy]

Though as I have said before I do not have a problem with NPs or PAs having more independce in family/primary care - just not in anything more specialized.

If only that was how it works.

 

[tachyon34]

does anyone think that besides all the talk about compensation etc, that its ironic that having NP take over "primary care" will just cause all future medical students to consider specialities instead of primary care.

really its such a ridiculous idea. If anything this will only worsen the physician shortage in primary care. Who wants to compete with low salary online-degree nurse practitioners?

What are they gonna do when nurse practioners replace all of primary care doctors. Who will supervise the NP's? Who's gonna make that diagnosis when its not just a simple cold/skin rash? Plus how is this proposal going to help the nurse shortage?

 

[VA Hopeful Dr]

On the other hand, it can be unethical to test a drug candidate against a placebo when there's already an accepted therapy in place.

True, new chemo drugs have to consider that as did that new oral anticoagulant v. coumadin.

 

[redsquareblack]

Don't count on that. I could see procedural specialties having a very rapid collapse. The reason why there are no nurse surgeons is that it would take a much longer and more formal training program, comperable to what they've developed for CRNAs, and the nursing community hasn't developed/sold that yet. However, when they get around to it, and I feel like they will, I think the surgical subspecialties are going to crash WAY harder than general and subspecialty medicine. There's just a lot more money to be saved.

Oh my god outcomes will tank.

 

[DoctwoB]

I love how every pre-med (and some med students) assumes that primary care is just a piece of cake and anyone can do it. In fact, I've always heard the opposite from docs (both specialists and PCPs) in that its more difficult to be a good generalist then to be a good specialist.

Managing hypertension may not be the toughest thing in the world, but what about the hypertensive, hyperlipidemic, diabetic with CHF, renal dysfunction, and psych problems? Cookbook medicine runs in issues real quick with multiple co-morbidities.

 

[45408]

Don't count on that. I could see procedural specialties having a very rapid collapse. The reason why there are no nurse surgeons is that it would take a much longer and more formal training program, comperable to what they've developed for CRNAs, and the nursing community hasn't developed/sold that yet.

Not in my lifetime. What procedures do you really think a nurse/NP/noctor is going to do? One of the reasons I picked general surgery is that there aren't very many holes that a general surgeon can dig that he can't get himself out of on his own. Sh-t happens, sometimes very quickly in what seemed like a benign situation. Imagine an NP/PA "specialist" doing a lap chole or appendectomy and they shove the trochar into the inferior vena cava. It happens. Do you really think they're going to feel comfortable turning it into an ex lap and doing a vascular repair? Do you know any vascular surgeons who would be willing to be the back-up for this kind of situation? I sure don't.

However, when they get around to it, and I feel like they will, I think the surgical subspecialties are going to crash WAY harder than general and subspecialty medicine. There's just a lot more money to be saved.

Serious question: how would they set up such a program, and how in the world would they get it approved?

I'm a general surgery intern who has done well on all Steps 1-3, the ABSITE, and I've gotten good reviews from my attendings. I feel stupid on a very regular basis and overwhelmed at the mind-boggling amount of information I need to learn to become a truly competent surgeon. Unless they devise a training program that is of similar rigor to medical school and a surgery residency, I don't even see how they could be competent.

Lastly, what is the point? It really wouldn't save that much money. Surgery is expensive because you're admitted for 1-10 days, spending time in the ICU, spending time in the OR at $50-100 per minute, paying the cushy salary of the CRNA 😉 and getting $10,000 worth of hardware/biologics placed in your body. If someone wants to be a surgeon, go to med school.

 

[MCAT guy]

I'm honestly not sure what it means for a resident to be 'above' or 'below' a resident in the heirarchy. If you're talking about who has the ultimate authority in clinical decision making I've been through four teaching hospital systems now and I have never, ever seen a midlevel and a resident cover the same patient. I guess it might come up if they both ran to the same code blue, but other than that I feel like it's a meaningless distinction.

In terms of who gets treated better by their boss, that's situational. How hard is the midlevel to replace in the current job market? Who does the midlevel actually work with? What are the personal relationships between everyone involved? Who, ultimately, does the midlevel actually report to? I don't think it comes down to a job title.



Don't count on that. I could see procedural specialties having a very rapid collapse. The reason why there are no nurse surgeons is that it would take a much longer and more formal training program, comperable to what they've developed for CRNAs, and the nursing community hasn't developed/sold that yet. However, when they get around to it, and I feel like they will, I think the surgical subspecialties are going to crash WAY harder than general and subspecialty medicine. There's just a lot more money to be saved.

😕😕

Agreed with Prowler and Taurus on the naivete of this statement:

I could see procedural specialties having a very rapid collapse. The reason why there are no nurse surgeons is that it would take a much longer and more formal training program, comperable to what they've developed for CRNAs, and the nursing community hasn't developed/sold that yet. However, when they get around to it, and I feel like they will, I think the surgical subspecialties are going to crash WAY harder than general and subspecialty medicine. There's just a lot more money to be saved.

What in the world are you basing this on?

I feel like you threw reason out the window and you're just pushing an agenda at this point

 

[MCAT guy]

Not in my lifetime. What procedures do you really think a nurse/NP/noctor is going to do? One of the reasons I picked general surgery is that there aren't very many holes that a general surgeon can dig that he can't get himself out of on his own. Sh-t happens, sometimes very quickly in what seemed like a benign situation. Imagine an NP/PA "specialist" doing a lap chole or appendectomy and they shove the trochar into the inferior vena cava. It happens. Do you really think they're going to feel comfortable turning it into an ex lap and doing a vascular repair? Do you know any vascular surgeons who would be willing to be the back-up for this kind of situation? I sure don't.


Serious question: how would they set up such a program, and how in the world would they get it approved?

I'm a general surgery intern who has done well on all Steps 1-3, the ABSITE, and I've gotten good reviews from my attendings. I feel stupid on a very regular basis and overwhelmed at the mind-boggling amount of information I need to learn to become a truly competent surgeon. Unless they devise a training program that is of similar rigor to medical school and a surgery residency, I don't even see how they could be competent.

Lastly, what is the point? It really wouldn't save that much money. Surgery is expensive because you're admitted for 1-10 days, spending time in the ICU, spending time in the OR at $50-100 per minute, paying the cushy salary of the CRNA 😉 and getting $10,000 worth of hardware/biologics placed in your body. If someone wants to be a surgeon, go to med school.

👍

I think Perrot has overstepped the boundaries on this one. His anti-establishment attitude is shinning brightly while speaking of things he knows little about.

 

[Perrotfish]

Serious question: how would they set up such a program, and how in the world would they get it approved?

My scenario:

It's going to begin, like all midlevel programs, with a handful of legitimately well studied and intelligent midlevels with some leadership experience (probably military), a strong surgical background, and even stronger ideals in a desperately underserved state. They're already functioning at the level of a second or third year surgical residents, they know they have the knowledge and the skills (15 years of managing the floors and first assists count for something), and in conjunction with their union representation and a few sympatheic surgeons they will pilot a program (3-4 years of residency like training) that will certify them to do certain basic procedures like lap choles, I&Ds, etc in a hospital where a physician is physicially present in the hospital (though not in the room) to relieve them in case of an emergency. After all, they argue, they're just providing more surgical care to area that doesn't have nearly enough and the physician is always there to step in if needed. Hospitals sign on because it's cheap and there's a desperate need. Surgeons sign on to supervise because 'supervising' is a huge income stream that doesn't interupt their day job and requires very little actual work.

Once the first program is piloted the floodgates open. Similar programs spring up across the state in other underserved states with strong nursing unions. Meanwhile some of the best NPs are steadily expanding the array of procedures and operation that they offer. Now they're doing Ex-laps, they're doing trauma, they're running their own clinics, etc. Also a combination of strong lobbying and physician greed causes a a steady reduction in the definition of 'supervision'. Suddenly there's a state where supervision now just means a physician is within a 20 minute drive, and then it means there's a physician available to phone conference, and then it just means a physician signing off on 10% of the charts/surgical reports. Finally one particularly underserved state, in a bid to attract more practicioners of any kind, allows surgical NPs to practice independently of surgical supervision. When no flood of deaths/lawsuits materializes other states follow suit.

It happened with CRNAs and Anesthesiologists, I don't see why it can't happen with Surgical midlevels and Surgeons

What in the world are you basing this on?

Mostly the rapid rise of CRNAs, but also just the common economic sense that the higher a physician's salary relative to what an midlevels can charge the greater the potential for midlevels to crash the market. People worry a lot about midlevels in primary care, which I think is odd because, worst case scenario, a midlevel dominated market isn't likely to collapse the already low salaries found there. On the other hand in a field where providers are scarce and reimbursement is high, like Derm/Rads/Optho/Gas/Surgery, cheap training models have the potential to send physician salaries into free fall.

 

[45408]

My scenario:

It's going to begin, like all midlevel programs, with a handful of legitimately well studied and intelligent midlevels with some leadership experience (probably military), a strong surgical background, and even stronger ideals in a desperately underserved state. They're already functioning at the level of a second or third year surgical residents, they know they have the knowledge and the skills (15 years of managing the floors and first assists count for something), and in conjunction with their union representation and a few sympatheic surgeons they will pilot a program (3-4 years of residency like training) that will certify them to do certain basic procedures like lap choles, I&Ds, etc in a hospital where a physician is physicially present in the hospital (though not in the room) to relieve them in case of an emergency.

I'm not seeing it. I have no idea why a surgeon would back such a program. Surgeons LIKE operating. For many of them, everything else is just ancillary. Many would be happy to hand over their clinic/ward responsibilities to someone else, but I don't know who would hand off their OR time.

Fifteen years of first assisting is very different than doing it yourself. Typically, the first assistant is retracting, suctioning, cauterizing between the surgeon's right angle, tying knots, and applying the bandage at the end of the case. Trust me, I've done it many times.

After all, they argue, they're just providing more surgical care to area that doesn't have nearly enough and the physician is always there to step in if needed. Hospitals sign on because it's cheap and there's a desperate need. Surgeons sign on to supervise because 'supervising' is a huge income stream that doesn't interupt their day job and requires very little actual work.

Negative. The surgeon WANTS his day job to be operating. For many/most, it's the BEST part of his job. Anesthesiologists have often told me that they're very happy to duck out of an OR as soon as the patient has stabilized, because there's nothing else to do. On my anesthesia rotation, the skilled anesthesiologists are happiest when they're managing a tough case, placing lines, doing a TEE in the middle of a valve replacement, pushing lots of drugs, etc, because they like doing things. All of surgery involves doing things. Anesthesia has frequently been compared to flying: hours and a hours of boredom interspersed by a few moments of sheer terror. No one makes that comparison about surgery. There's no point at which you hand off the controls to someone and go drink a cup of coffee.

Now they're doing Ex-laps, they're doing trauma, they're running their own clinics, etc. Also a combination of strong lobbying and physician greed causes a a steady reduction in the definition of 'supervision'. Suddenly there's a state where supervision now just means a physician is within a 20 minute drive, and then it means there's a physician available to phone conference, and then it just means a physician signing off on 10% of the charts/surgical reports.

No, they're not. It is absolutely inconceivable to me that you would have a noctor doing an ex-lap with no one available to help them within 20 minutes. You'd have a chopper fly that patient to a hospital that had a surgeon. If the patient couldn't survive the transport, then they're far too sick for a facility that doesn't even have a surgeon.

It happened with CRNAs and Anesthesiologists, I don't see why it can't happen with Surgical midlevels and Surgeons

Because CRNAs are sitting and watching their patient about 95% of the time, if not more. I'm not saying they should be doing any differently, but it's not exactly a high-stress job. They're on overnight call every two weeks (and done at 7am), and they're often done between 1-3pm.

CRNAs make a boatload of money for pretty cush hours. Surgery has terrible hours and doesn't really pay well relative to the workload. It makes no sense for a mid-level to approach this.

Mostly the rapid rise of CRNAs, but also just the common economic sense that the higher a physician's salary relative to what an midlevels can charge the greater the potential for midlevels to crash the market. People worry a lot about midlevels in primary care, which I think is odd because, worst case scenario, a midlevel dominated market isn't likely to collapse the already low salaries found there. On the other hand in a field where providers are scarce and reimbursement is high, like Derm/Rads/Optho/Gas/Surgery, cheap training models have the potential to send physician salaries into free fall.

Derm or surgery? Those are about the two least comparable specialties you could imagine.

 

[bucks2010]

CRNA's are a bad comparison to make considering the mortality rate for anesthesia is down to 1:200,000 ... orders of magnitude lower than any general surgical procedure.

 

[samuraiR]

what kind of ***** patient would agree to have a nurse operate on them? I def. dont see midlevels getting into any surgical field and actually performing surgeries.

 

[Wilf]

what kind of ***** patient would agree to have a nurse operate on them? I def. dont see midlevels getting into any surgical field and actually performing surgeries.

Exactly. It's important to remember that the people here on SDN are typically more liberal than most Americans and liberal usually means egalitarian even if it makes no sense. Most of my friends and my family's friends would not see an NP or PA for routine care, and would be shocked at the idea of them trying to do surgery. Most educated people or people with insurance will want to see an MD for primary care.

 

[justaregularmed]

I think everyone in this post has missed the boat on the issue.

Advanced practice nurses can unionize.

Game, set, match, we lose.

Look forward to having a noctor as your boss.

 

[tachyon34]

the answer is that we must unionize as well. A lot of doctors hate unions but guess what i think its about time. We have almost no collective bargaining power whatsoever. The AMA is totally useless- thats why we get pushed around by lobbyists from other professions, lawyers, politicians, the general public.

Its either now or wait until we become public servants of the government medicare/medicaid system or run out of business by mid level providers.

 

[MCAT guy]

This thread has officially destroyed any hint of desire I had to enter anything resembling primary care.

Thanks SDN.

 

[MCAT guy]

I think everyone in this post has missed the boat on the issue.

Advanced practice nurses can unionize.

Game, set, match, we lose.

Look forward to having a noctor as your boss.

Lol, noctor unions!

One of the scariest ideas possible.

 

[JaggerPlate]

Tachy,

From the way I understand it, it's actually illegal for physicians to unionize.

MCAT,

The California Nusring lobby is notoriously aggressive. My aunt is a nurse in CA and also a staunch Democrat (the family dinners when her and my NRA member, 2x Bush voting Father start discussing politics are hilarious), she's for a universal option, etc, and even she thinks the CA nursing lobby is way too socialist and aggressive.

To everyone else making the surgery comments, a few thoughts:

1. Is it highly, highly unlikely that NPs will invade surgery? Yes. Is it impossible? I personally don't think so. I think if you told Anesthesiologists and Dermatologists 20 years ago that nurses with online degrees would start poaching their territory, they would have laughed in your face and said 'will never happen.'

Additionally, I'm involved in an identical discussion in pre-DO, and a guy in there is friends with someone currently becoming an 'Orthopedic NP.' Doesn't seem like too far of a leap into surgery from there.

Again, 99% sure it won't happen ... but I've been positive this crap wouldn't happen in the first place, so don't count on it.

2. Planning on specializing your arse off until the NPs can't touch you isn't an efficient strategy IMO. It may sound (really) corny, but I think that an attack/encroachment on one area of medicine should be viewed as encroachment on PHYSICIANS in general, and we should all feel a little bit of a sense of defensiveness whether you're a Neurosurgeon or FM doc.

Granted, I'm not trying to spark up that rahh, rahh, fraternity thing here, but I just don't think the answer is to consider certain specialties 'done' and just move on to where they can't touch. Now, if you were interested in surgery to begin with, all the better job security wise, but I think you'd have a hard time telling a PD you want to be a surgeon because the NPs can't steal your scalpel.

 

[swamprat]

CRNA's are a bad comparison to make considering the mortality rate for anesthesia is down to 1:200,000 ... orders of magnitude lower than any general surgical procedure.

Maybe its just me but doesn't that seem a little high? Think about all the surgeries that go on across the world everyday

 

[BPlaysItCool]

Tachy,

From the way I understand it, it's actually illegal for physicians to unionize.

MCAT,

The California Nusring lobby is notoriously aggressive. My aunt is a nurse in CA and also a staunch Democrat (the family dinners when her and my NRA member, 2x Bush voting Father start discussing politics are hilarious), she's for a universal option, etc, and even she thinks the CA nursing lobby is way too socialist and aggressive.

To everyone else making the surgery comments, a few thoughts:

1. Is it highly, highly unlikely that NPs will invade surgery? Yes. Is it impossible? I personally don't think so. I think if you told Anesthesiologists and Dermatologists 20 years ago that nurses with online degrees would start poaching their territory, they would have laughed in your face and said 'will never happen.'

Additionally, I'm involved in an identical discussion in pre-DO, and a guy in there is friends with someone currently becoming an 'Orthopedic NP.' Doesn't seem like too far of a leap into surgery from there.

Again, 99% sure it won't happen ... but I've been positive this crap wouldn't happen in the first place, so don't count on it.

2. Planning on specializing your arse off until the NPs can't touch you isn't an efficient strategy IMO. It may sound (really) corny, but I think that an attack/encroachment on one area of medicine should be viewed as encroachment on PHYSICIANS in general, and we should all feel a little bit of a sense of defensiveness whether you're a Neurosurgeon or FM doc.

Granted, I'm not trying to spark up that rahh, rahh, fraternity thing here, but I just don't think the answer is to consider certain specialties 'done' and just move on to where they can't touch. Now, if you were interested in surgery to begin with, all the better job security wise, but I think you'd have a hard time telling a PD you want to be a surgeon because the NPs can't steal your scalpel.

Jagger,

I generally like your perspective. But what I don't get is this notion of being attacked. When many more of us are pimping out a stable of NP's to widen their revenue net that there are of us being displaced in the workforce. Especially on the upswing of Baby Boomer Health care consumption.

This is a 1910-12 american public. Wherein our affairs might as well be the intriques of Prussian royalty. They're not going to be sympathetic to more expensive labor. When we cannot demonstrate the poorer outcomes of our competitiors. And again when so many of us are profiting off their proxy use of our licenses. You would need a sinking of the Lusitania. To swing them. A few landmark cases. It's possible.

And please. You cannot be serious about the possibility of organizing physicians into a union. You don't understand the labor movement if you think that's possible. A marketing campaign. Lobbyists with more cash to stuff in the right pockets. Sure. But a union. Not until the whole thing goes up in flames. And we return to trading work for chickens. We might could come up with a brotherly organization like the Free Masons or something. Way in the inconceivable future.

 

[JaggerPlate]

Bcool,

Sorry, attack was a poor choice in words, and definitely more hyperbolic than intended. Additionally, I wouldn't ever support a physicians union, and was simply pointing out to another member who brought it up that it is illegal for physicians to do so regardless.