We Choose NPs

[evilbooyaa]

Don't know the numbers, but just based on logic, NPs will probably have higher rates of litigation since they will likely have higher miss rates for emergent conditions, probably give inappropriate treatments, and be a easier, juicier target for an attorney than an educated physician.

Mismanagement of PCP issues is a chronic issue most of the time, and lawsuits are unlikely as NPs just shuffle any patients of questionable stability to the local ER for dumping. Many malpractice suits are brought on not because of a bad outcome, but because of dissatisfaction with the tone or attitude of the person involved in their care.

NPs will smile, give Abx (and whatever else patients want), miss chronic diagnoses (that may not catastrophically manifest until later), and send patients to the ED when there is any instability to them. This is likely to mitigate their malpractice risk (compared to the not knowing aspect which increases it). I imagine patients who are educated enough to know about the lower level of education of NPs will self-select out of an NP's practice and go see MDs only.

I would encourage PCP MDs to not accept 'referrals' from independent practice NPs who have been monitoring a patient's progressive symptoms for 5 years without doing anything about it, and since their cookie cutter 'medicine' has not fixed it, they send to somebody else to manage it. Independent NPs will order more imaging studies, more consults, more testing than the average physician PCP.

At least, I think.

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[RustedFox]

Wow thank you for the thorough write-up. I’m a lifelong Floridian wanting to practice in Florida. (Current M3)



Can verify #1. I live in Clearwater where I am completing 3rd year rotations. Primary care is readily available.



Can I use this in my advertising since I was an RN? (well, am... my license is active for another year. Long enough to see if I matched before I let it go.)



Some of the hardest anti-mid level people on this forum will hate on me for this, but... a couple of these things *are* okay for mid levels. My PCP is in an office with 2 other doctors and 1 shared NP. Today, I needed my AAMC immunization forms signed for 4th year elective apps. I called at 10am and got a 3:30 appt with the NP and got it done.

"I need paperwork." Should never be a reason for visit.

 

[VA Hopeful Dr]

"I need paperwork." Should never be a reason for visit.

For y'all, no. For me, quite common. Easiest $60 in the world.

 

[Apollyon]

Independent NPs will order more imaging studies, more consults, more testing than the average physician PCP.

At least, I think.

Affirmatively true at my last place. Lies, damn lies, and statistics.

 

[sunshinefl]

"I need paperwork." Should never be a reason for visit.

I mean, I need my immunization paperwork signed. This was at my PCP’s office, not the ED.

For y'all, no. For me, quite common. Easiest $60 in the world.

Yeah it was a <5 minute visit. Vitals with the MA, then the NP flipped through my documentation proof and then signed the form.

 

[GeneralVeers]

PCP is totally appropriate for this. I always decline virtually all paperwork in the ED except for work notes and Worker's comp forms.

 

[RustedFox]

I mean, I need my immunization paperwork signed. This was at my PCP’s office, not the ED.



Yeah it was a <5 minute visit. Vitals with the MA, then the NP flipped through my documentation proof and then signed the form.

I stand corrected.
My apologies.

 

[EM2023]

So if the real reason why the market is choosing NPs is the cheaper cost, do we have a cost effective solution to offer as a rebuttal? Obv the argument that we are better trained is not working.

Do we have any studies that objectively show worse patient outcomes with mid-levels? The n=1 examples of NP errors we take to lawmakers are silly because physicians make mistakes all the time too. Healthcare corporations will save billions if NPs almost completely take over primary care and EDs. We have no lobbies and no convincing arguments. Too little too late on our part, should have seen this coming years ago.


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[TheSingularity]

You do workers comp forms? I refuse.

PCP is totally appropriate for this. I always decline virtually all paperwork in the ED except for work notes and Worker's comp forms.

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[deleted480308]

So if the real reason why the market is choosing NPs is the cheaper cost, do we have a cost effective solution to offer as a rebuttal? Obv the argument that we are better trained is not working.

Do we have any studies that objectively show worse patient outcomes with mid-levels? The n=1 examples of NP errors we take to lawmakers are silly because physicians make mistakes all the time too. Healthcare corporations will save billions if NPs almost completely take over primary care and EDs. We have no lobbies and no convincing arguments. Too little too late on our part, should have seen this coming years ago.


Sent from my iPhone using SDN

not when they then push for equal pay (like in oregon)

 

[Apollyon]

You do workers comp forms? I refuse.

Sent from my Pixel 3 using SDN mobile

Not the WC forms to be off forever, but when someone has a WC injury, you know, like, no work for 3 days, or no heavy lifting, no stairs, keep the wound clean, sutures it in 5-7 days, those forms.

 

[EM2023]

not when they then push for equal pay (like in oregon)

I doubt that will pass on a wide scale. The only reason they are doing well with gaining practice rights is because they are cheaper, and they know that.


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[Mad Jack]

We choose inferior care because it is more widely available and the longer visits make us feel important

 

[MechEDoc]

In all honesty, why do we have NPs (and to some extent), PAs in the ER for? They can't really work up simple things with knowledge or depth and clearly struggle with difficult things.

Easier stuff..
Sore throat - little knowledge or application of Centor criteria, prevalence (or lack thereof) of M-proteins, when to look for EBV, HIV, fusiform bacteria, gonorrhea, Lemierre's disease, etc. It's just influenza + strep swab (positive or negative results) -> abx + steroids.

Penile lesion - just a few days ago. "doc, the patient has a painful lesion on his penis, it must be syphilis". Umm, painful lesions typically aren't syphilis, have you considered haemophilus ducreyi? "Umm, no..."

Influenza - "the rapid flu swab is negative". Yes, but it's still probably influenza!

Sort of hard things like...
Anemia? Can't interpret the CBC, can't determine the need for a transfusion (or lack of indications), doesn't understand what tests to order next. Goes into a pseudoseizure of consulting. "Go to ER!"... patient get's bounced back to NP. "Go to heme-onc!". WTF?

Pneumonia - "what does he have, his chest x-ray is clear?" Mind you a one view chest x-ray in a septic patient with a productive cough, leukocytosis, fever, and procalcitonin elevation... Yep, it was multi-focal pneumonia on the CT.

Harder yet!
Then we've got harder things like chest pain (your workup sucked and your patient bounced back dead), headaches (missed that dissection!), belly pain (oops, the ovary was torsed), that cellulitis (necrotizing fasciitis), trauma (missed dissection again).

If I'm paying for a MD (or DO), don't give me an NP!

 

[bronx43]

So if the real reason why the market is choosing NPs is the cheaper cost, do we have a cost effective solution to offer as a rebuttal? Obv the argument that we are better trained is not working.

Do we have any studies that objectively show worse patient outcomes with mid-levels? The n=1 examples of NP errors we take to lawmakers are silly because physicians make mistakes all the time too. Healthcare corporations will save billions if NPs almost completely take over primary care and EDs. We have no lobbies and no convincing arguments. Too little too late on our part, should have seen this coming years ago.


Sent from my iPhone using SDN

Such studies will not be done

The only possible way to escape this is if legislation puts leverage back in favor of physicians by weakening hospital systems. The hospitals have ALL the incentive to use NPs since they will order tests (ancillary revenue), refer more patients to specialists (more revenue), and get paid less.

If reimbursement schemes change and hospitals don't get ridiculously high reimbursement rates for being a "facility" then the landscape will shift back to independent physician practices, which will more or less contain the mid-level encroachment.

 

[bronx43]

In all honesty, why do we have NPs (and to some extent), PAs in the ER for? They can't really work up simple things with knowledge or depth and clearly struggle with difficult things.

Because the bean counters counted the beans, and decided that midlevels gave them more beans - seeing how bean counters are sustained by the difference between beans produced and beans consumed by the midlevel.

 

[MechEDoc]

Because the bean counters counted the beans, and decided that midlevels gave them more beans.

I agree, but it breaks my heart. I'm still a sucker deep down and really want to provide and see patients get good care.

 

[deleted109597]

Yes, there is literally no data that says NPs cost less.
They are paid less
The visit costs the same, or even more considering they do more tests.
Thy're just paid less, so the hospital/office makes more.,


That's literally it.

 

[TooMuchResearch]

But since they take longer, are they actually saving money?

We hire our midlevels. We train them. I still can't get them to admit or discharge patients when I tell them to get it done.

Yes, there is literally no data that says NPs cost less.
They are paid less
The visit costs the same, or even more considering they do more tests.
Thy're just paid less, so the hospital/office makes more.,


That's literally it.

 

[jw3600]

In all honesty, why do we have NPs (and to some extent), PAs in the ER for? They can't really work up simple things with knowledge or depth and clearly struggle with difficult things.

Easier stuff..
Sore throat - little knowledge or application of Centor criteria, prevalence (or lack thereof) of M-proteins, when to look for EBV, HIV, fusiform bacteria, gonorrhea, Lemierre's disease, etc. It's just influenza + strep swab (positive or negative results) -> abx + steroids.

Penile lesion - just a few days ago. "doc, the patient has a painful lesion on his penis, it must be syphilis". Umm, painful lesions typically aren't syphilis, have you considered haemophilus ducreyi? "Umm, no..."

Influenza - "the rapid flu swab is negative". Yes, but it's still probably influenza!

Sort of hard things like...
Anemia? Can't interpret the CBC, can't determine the need for a transfusion (or lack of indications), doesn't understand what tests to order next. Goes into a pseudoseizure of consulting. "Go to ER!"... patient get's bounced back to NP. "Go to heme-onc!". WTF?

Pneumonia - "what does he have, his chest x-ray is clear?" Mind you a one view chest x-ray in a septic patient with a productive cough, leukocytosis, fever, and procalcitonin elevation... Yep, it was multi-focal pneumonia on the CT.

Harder yet!
Then we've got harder things like chest pain (your workup sucked and your patient bounced back dead), headaches (missed that dissection!), belly pain (oops, the ovary was torsed), that cellulitis (necrotizing fasciitis), trauma (missed dissection again).

If I'm paying for a MD (or DO), don't give me an NP!

Good post.

Except for centor criteria. That’s garbage but your point stands. They miss the nuance of the easy stuff and can’t handle hard stuff. Rather have more docs with good scribes and good ancillary staff.

 

[TooMuchResearch]

I think strep testing is one of our MIPS criteria, so Centor is completely irrelevant for us.

Good post.

Except for centor criteria. That’s garbage but your point stands. They miss the nuance of the easy stuff and can’t handle hard stuff. Rather have more docs with good scribes and good ancillary staff.

 

[deleted109597]

I think strep testing is one of our MIPS criteria, so Centor is completely irrelevant for us.

Even IDSA says test and treat or test and don't treat, not to follow Centor.

 

[PikminOC]

Don't get me wrong, I'd love for both of those to happen.

But...

The money in primary care isn't all that bad in truth. Most of the FPs in my group who have been here at least 2 years are pulling in 250k+, several are over 300. That's not what you EPs are making, but for bankers hours with no nights/weekends/holidays its not too shabby.

As for paperwork, if you're doing more than signing stuff you haven't trained your staff well enough.

That's not the norm for most FP's.

 

[VA Hopeful Dr]

That's not the norm for most FP's.

2019 MGMA agrees with me

 

[MechEDoc]

Even IDSA says test and treat or test and don't treat, not to follow Centor.

Fine, I get it that Centor isn't that great, but the point stands. There isn't much nuance to their "simple workups". The very fact that we're debating this makes a point about physician level of care about the practice of medicine.

 

[deleted109597]

Fine, I get it that Centor isn't that great, but the point stands. There isn't much nuance to their "simple workups". The very fact that we're debating this makes a point about physician level of care about the practice of medicine.

I mean, there is the "don't test don't treat" option.
And we all know the maddening patient who comes back positive for flu AND strep. Or flu AND strep AND RSV.


Besides, who else would receive Tamiflu (or Xofluza now), a Z pack, and a medrol dose pack but these patients? Best part is they get the same regardless of the tests. The NPs are great at knowing the patients want the test, regardless of the result.

 

[PikminOC]

2019 MGMA agrees with me

Please post.

Many PCP I know are in Private practice. They are not making that much. Lots of overhead

 

[VA Hopeful Dr]

Please post.

Many PCP I know are in Private practice. They are not making that much. Lots of overhead

Mean in 255k, median is 240k for 2018

 

[PikminOC]

Mean in 255k, median is 240k for 2018

These salary survey things always seem to be overinflated

 

[VA Hopeful Dr]

These salary survey things always seem to be overinflated

Not in my experience

 

[thegenius]

I mean, there is the "don't test don't treat" option.
And we all know the maddening patient who comes back positive for flu AND strep. Or flu AND strep AND RSV.


Besides, who else would receive Tamiflu (or Xofluza now), a Z pack, and a medrol dose pack but these patients? Best part is they get the same regardless of the tests. The NPs are great at knowing the patients want the test, regardless of the result.

I just had a pt the other day...she was complaining of some nonsense like a sore throat or something.
Our urgent care diagnosed her with Influenza and Strep Throat a few days earlier and she was on Tamiflu and Abx.

I said to her "You really think you have both at the SAME TIME?!?!" She said "I guess I do, that's what the tests said"

 

[Splenda88]

These salary survey things always seem to be overinflated

They are actually under inflated based on my limited experience...

 

[bronx43]

These salary survey things always seem to be overinflated

They are overinflated if you work in a major metro. They are deflated if you work in BFE.

 

[CCM-MD]

Family Medicine (with OB)
Mean: $286,641
Median: $268,954
75th: $332,594
90th: $406,515

Family Medicine (without OB)
Mean: $266,709
Median: $247,253
75th: $302,492
90th: $379,079

Internal Medicine: Ambulatory Only (No Inpatient Work)
Mean: $280,995
Median: $259,732
75th: $329,272
90th: $403,462

Above is from the 2019 MGMA. In my experience, MGMA & AMGA are the most commonly utilized and most accurate. Primary care pays better than people think, especially considering the Mon-Fri schedule.

 

[PikminOC]

Family Medicine (with OB)
Mean: $286,641
Median: $268,954
75th: $332,594
90th: $406,515

Family Medicine (without OB)
Mean: $266,709
Median: $247,253
75th: $302,492
90th: $379,079

Internal Medicine: Ambulatory Only (No Inpatient Work)
Mean: $280,995
Median: $259,732
75th: $329,272
90th: $403,462

Above is from the 2019 MGMA. In my experience, MGMA & AMGA are the most commonly utilized and most accurate. Primary care pays better than people think, especially considering the Mon-Fri schedule.

In the RVU model and the manipulation that hospitals do, I dont know many people who have as cush hours as VA Hopeful. Including getting the notes into EMR as well.

 

[SXMMD]

In the RVU model and the manipulation that hospitals do, I dont know many people who have as cush hours as VA Hopeful. Including getting the notes into EMR as well.

Coming out of fm residency I'm getting offers that are reflected in the mgma data and the docs I'm talking to 3, 5, 10 years into practice are meeting wRVU targets easily, not taking work home with them, etc. It's more common than you think.

My experience in the job search with large metros is different- overworked and underpaid is the theme

 

[WildcatS11]

Not in my experience

“I make moneeeeeeey”

 

[VA Hopeful Dr]

In the RVU model and the manipulation that hospitals do, I dont know many people who have as cush hours as VA Hopeful. Including getting the notes into EMR as well.

I know 50-ish FPs who do (the rest of my group).

Also @Blue Dog is part of a large group that I suspect does better than we do and they are PP.

 

[PikminOC]

I know 50-ish FPs who do (the rest of my group).

Also @Blue Dog is part of a large group that I suspect does better than we do and they are PP.

Hospitals I've seen ratchet down rvu value after the guarantee

 

[VA Hopeful Dr]

Hospitals I've seen ratchet down rvu value after the guarantee

Granted I've only been out of residency for 7 years, but the 3 hospitals I've worked for in that time haven't changed their RVU value in those 7 years.

Talking to some of the older guys here (who've been employed by these hospitals since the early 2000s), the RVU value has never gone down and in fact has gone up around $5 in the last 15 years.

 

[evilbooyaa]

Why are you guys (likely to be EM and not FP) arguing with the FP about how much money FPs make?

 

[bronx43]

Hospitals I've seen ratchet down rvu value after the guarantee

This usually happens with a large initial guarantee, which doesn't specify the comp per RVU. If they actually give you a comp per RVU offer, I have not seen that this number is down adjusted after said guarantee.

 

[Fox800]

Anyone feel so kind as to send the MGMA data around for EM?

 

[PikminOC]

Quick Google search fm
$181,782/year$239,243
Family Medicine Physician Salary Comparison by Location
Nationwide
United States
$207,051
La Crosse, WI
WI
$181,782

 

[PikminOC]

This usually happens with a large initial guarantee, which doesn't specify the comp per RVU. If they actually give you a comp per RVU offer, I have not seen that this number is down adjusted after said guarantee.

I've seen it. They wait until you're settled and then rachet

 

[deleted109597]

Why are you guys (likely to be EM and not FP) arguing with the FP about how much money FPs make?

Since when has ignorance of a situation precluded the ability for people to make misinformed comments?

 

[deleted480308]

I've seen it. They wait until you're settled and then rachet

Aaah, like 2-3yrs in. Your kids have school friends, your wife likes church and has some gym friends.......then boom, $8 off per rvu and you are less likely to go through the hassle of leaving now?

 

[PikminOC]

Aaah, like 2-3yrs in. Your kids have school friends, your wife likes church and has some gym friends.......then boom, $8 off per rvu and you are less likely to go through the hassle of leaving now?

Yes I have seen it. Just because others haven't doesn't mean it doesn't happen

 

[PikminOC]

Since when has ignorance of a situation precluded the ability for people to make misinformed comments?

This is more what I have seen irl
Quick Google search fm
$181,782/year$239,243
Family Medicine Physician Salary Comparison by Location
Nationwide
United States
$207,051
La Crosse, WI
WI
$181,782

 

[VA Hopeful Dr]

Aaah, like 2-3yrs in. Your kids have school friends, your wife likes church and has some gym friends.......then boom, $8 off per rvu and you are less likely to go through the hassle of leaving now?

I'm sure that does happen on occasion, but that's not the usual practice in my experience.

If my hospital did that, I would absolutely quit and I wouldn't have to move my family to find a new job. The hospital knows that as well as I do.