We must be doing something wrong...

[JamesBond15]

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On my fam med rotation there are PAs who are working alongside the MDs. The PAs see the same patients, do everything the MDs do. If it wasn't for the name tag you wouldn't know the difference. Yet I takes us 7 years to train a fam med doc while the PAs can do it in a 2-3 years.
Why even bother become an MD? (aside from the slight bump in pay :/
😕
Especially since they want to be called "physician associates" wft

 

[ppfizenm]

On my fam med rotation there are PAs who are working alongside the MDs. The PAs see the same patients, do everything the MDs do. If it wasn't for the name tag you wouldn't know the difference. Yet I takes us 7 years to train a fam med doc while the PAs can do it in a 2-3 years.
Why even bother become an MD? (aside from the slight bump in pay :/
😕
Especially since they want to be called "physician associates" wft

obvious troll obviously knows nothing

 

[JamesBond15]

obvious troll obviously knows nothing

Not trolling at all. Just frustrated.

 

[Rendar5]

On my fam med rotation there are PAs who are working alongside the MDs. The PAs see the same patients, do everything the MDs do. If it wasn't for the name tag you wouldn't know the difference. Yet I takes us 7 years to train a fam med doc while the PAs can do it in a 2-3 years.
Why even bother become an MD? (aside from the slight bump in pay :/
😕
Especially since they want to be called "physician associates" wft

I don't know any PA's that ask to be called physician associates, honestly, and I work with a ton of them.. The reason to become an MD is to oversee them for the 5-10% of the time that additional expertise is needed.

 

[officedepot]

.

 

[QuizzicalApe]

Not trolling at all. Just frustrated.

He called you a troll because it would be impolite to assume someone posting in the med student forum would be this ignorant.

 

[myhandsarecold]

On my fam med rotation there are PAs who are working alongside the MDs. The PAs see the same patients, do everything the MDs do. If it wasn't for the name tag you wouldn't know the difference. Yet I takes us 7 years to train a fam med doc while the PAs can do it in a 2-3 years.
Why even bother become an MD? (aside from the slight bump in pay :/
😕
Especially since they want to be called "physician associates" wft

At our institution, PA/NP only see established patients (seen previously by attendings...) and usually only for follow up of treatment. Resident/attendings also review what it is that they are coming in for and whether it requires a formal work up by a physician. Residents/Attendings see all new patients, consults, acutely deteriorating people; this is an institutional rule that all patients need to be seen by a physician...so there's a difference. As a physician, you're still incharge of the patient's care and delegate whatever you feel your midlevel can handle, nonemergent. Also, attendings are usually always watching from afar and most of the time will require the midlevels to "staff out" all their patient encounters before letting patients go or after end of each shift. point is, there's a lot of oversight.

 

[SteinUmStein]

I agree that medical education for physicians is far from efficient, but I don't think we're doing it completely wrong. A quick glance at any PA program's curriculum makes it obvious how limited their scope of understanding/practice really is without some kind of fellowship:

http://paprogram.mc.duke.edu/PA-Program/Curriculum/

 

[Morsetlis]

I agree that medical education for physicians is far from efficient, but I don't think we're doing it completely wrong. A quick glance at any PA program's curriculum makes it obvious how limited their scope of understanding/practice really is without some kind of fellowship:

http://paprogram.mc.duke.edu/PA-Program/Curriculum/

Duke is also where the medical students complete Basic Medical Sciences in 1 year...

 

[SteinUmStein]

Duke is also where the medical students complete Basic Medical Sciences in 1 year...

I just pulled a random curriculum off Google. They are all about the same, there's not much wiggle room:

http://paprogram.medicine.uiowa.edu/Site/tabletwocurriculum.html

I don't see the major difference as being in the basic sciences, although you could argue that there is less depth there than what Duke's 1 year curriculum contains. That's not really the point, I think the biggest difference is in the clinical training. One year of PA rotations != a full intense M3 year, not to mention rotations 4th year and, oh yeah, residency.

Quick edit: I'm not bashing on PA students here. In fact, most PA students could have easily got into med school somewhere in the US if they chose to apply. Take Iowa's PA class stats as an example:

For the class admitted in 2011, the successful applicant averaged a cumulative G.P.A. of 3.70 on 139 semester hours of college credit, a science GPA of 3.68 on 73 semester hours, an average of 2,776 hours of health care and 589 hours of research experience, and the following GRE scores: verbal = 509, quantitative = 662, and written (analytical) = 4.4. The class average age was 25 years.

As a side note, I think every med school could and probably should do one year of basic sciences and up the necessary requirements from undergrad. If we're going to require a full bachelor's degree (which most countries don't), we might as well get the introductory sciences all finished up so med school can start with pathophysiology (i.e. start with M2 year and make med school 3 years total). I don't think that's much of a stretch at all, as Duke is having no issues with it. If they want their 4 years of tuition I guess we can all do year-long research projects. Yippee... 🙄

 

[GladifImakeit]

I don't think he or she was trolling. Agree with venting. I've seen NPs precepting medical students, residents and fellows. NP is preceptor for pulm fellow in asthma clinic at my school??? (so it's more like WHY should I bother to get a MD other than the pay???) vs. saying there is no difference. Obviously there is a difference in training, fund of knowledge, critical thinking, etc. The issue of midlevel creep and declining physician prestige is not a new one.

 

[Shnurek]

If I can chime in...

The problem with medical education in America is that it is indeed inefficient. It starts too late in life. We should specialize at a younger age. Why? You may ask.

If you have taken neuroscience 101 you would know that the brain is most neuroplastic when it comes to fluid intelligence and processing ability at around age 26. After all Albert Einstein published his Theories of General and Special Relativity at age 26 for example.

Notice this chart:

Fluid intelligence (Gf)
Processing speed (Gs)
Crystallized intelligence (Gc)
Source: http://www.highiqpro.com/iq-cognitive-health-aging/the-5-factors-of-intelligence-over-the-lifespan

Fluid intelligence and processing speed peak at around age 26. Crystallized intelligence goes on and lingers a lot longer because it is made up of facts and life experiences we have had.

So now onto my point: Medical education should start sooner by at least 2 years if not 4. Have direct programs to enter the medical college. Almost every other foreign nation graduates their MDs by age 21 or so. This way at age 21 and for the next 5-8 years or so the residents are exposed to the most critical part of their training during the time they are the most cognitively proficient.

Early specialization is just more efficient plain and simple. Having students graduating at age 26 with an MD and having to go through another 3-8 years of residency after they have passed their peak is just not the best way to go about it. If something is not done to change things, midlevels will just keep creeping up because a lot of them are trained at a younger age and it is more intuitive for them. Notice my profession for example. We have only 4 years of eye school and we can do laser eye surgery in 2 states at age 26 and prescribe oral medications in 47/50 states. Why? Because we specialize at the critical period and we know what we are doing. Its not about increasing training time to 3 decades. Its about getting trained at the right time.

 

[Morzh]

.....Its not about increasing training time to 3 decades. Its about getting trained at the right time.

(I’m really sorry for hi-jacking this thread)

Shnurek,

I’ve been noticing your posts on a variety of issues for a couple of months now. I generally enjoy reading your insights and think you’re a great contributor. However, I’ve noticed that this idea (RE: medical students are too old in this country because their fluid intelligence is past its prime, and this is the root of a lot of problems) is something of a pet interest for you. You seem to bring it up a lot. And as much as I respect your other contributions I’m finally going to call you out on this. I think you are over-reaching and extrapolating data way too much.

First off, your primary source in in this post is “highiqpro.com”. Looking into that website it appears to be a site that sells an IQ-improvement regimen. Not that a biased information source alone is enough reason to discount the information they present (because some of it is true), but the fact that it’s coming from a commercial, totally non-peer-reviewed source adds a bit of skepticism right off the bat.

Yes, it is true that average fluid intelligence (Gf) decreases gradually after full adulthood is reached. Yes, it is true that Gf can be improved with mental exercise and practice. The end. That’s really the extent of the data right there. Anything beyond that is extrapolation.

So here are a few reasons I’m pulling the BS-flag on the “med school/residency should start at a younger age” idea:

1 - There have been no studies, that I’m aware of, that look at Gf in medical students and residents explicitly. You’ve got to separate them from the general populace. Most average people are done with formal education by their mid-20s and your average job doesn’t require an excessive amount of Gf use, but rather relies on the execution of memorized protocols. Thus, perhaps the peak age of Gf is significantly higher for med students or others (like yourself) who are pursuing advanced education.

2 - According to the graph you posted from that commercial website, giving it the benefit-of-the-doubt and assuming it to be accurate for a moment, the “peak” doesn’t really seem to drop off significantly until the average person’s mid-30s. This leads me to suspect that, even if everything else you’re saying is right, the effects of having slightly older medical students/residents are far less exaggerated than you’re making them out to be.

3 - The science that you are basing your assumptions on actually weakens your argument. If Gf tends to decrease with age, and if Gf can be improved with training, than isn’t it possible that the rigorous critical thinking involved in medical education could actually increase Gf? Or at least “cancel-out” the deleterious effects of aging?

4 - This, to me, the most important thing… even if you are totally correct in all your assumptions, is having a marginally higher Gf at the time of medical training really worth the potential trade-offs in maturity, emotional and social competency, and overall “well-roundedness” that a slightly (we’re talking 2-3 years here…) older and more seasoned medical student/resident brings to the table?

5 - There is a huge, glaring gap between where the science ends and where you propose that medical education occurs at a suboptimal age. There is an even HUGER and 1000 times wider gap between that presumption and the notion that midlevel providers (or ODs, since you brought it up) are able to match physicians' level of expertise because, even though they trained for less time, they got more “bang for their buck” because they were a few years younger. I mean really?? Is that really the argument you wanted to make? Because that’s what your concluding paragraph suggests.

For those interested, here are the nuts and bolts of the actual evidence on these matters:

(Jaeggi, Buschkuehl, Jonides, & Perrig, 2008)

Improving fluid intelligence with training on working memory.

Abstract: Fluid intelligence (Gf) refers to the ability to reason and to solve new problems independently of previously acquired knowledge. Gf is critical for a wide variety of cognitive tasks, and it is considered one of the most important factors in learning. Moreover, Gf is closely related to professional and educational success, especially in complex and demanding environments. Although performance on tests of Gf can be improved through direct practice on the tests themselves, there is no evidence that training on any other regimen yields increased Gf in adults. Furthermore, there is a long history of research into cognitive training showing that, although performance on trained tasks can increase dramatically, transfer of this learning to other tasks remains poor. Here, we present evidence for transfer from training on a demanding working memory task to measures of Gf. This transfer results even though the trained task is entirely different from the intelligence test itself. Furthermore, we demonstrate that the extent of gain in intelligence critically depends on the amount of training: the more training, the more improvement in Gf. That is, the training effect is dosage-dependent. Thus, in contrast to many previous studies, we conclude that it is possible to improve Gf without practicing the testing tasks themselves, opening a wide range of applications.

(Feiyue, Qinqin, Liying, & Lifang, 2009)

Study on Improving Fluid Intelligence through Cognitive Training System Based on Gabor Stimulus

Abstract: General fluid intelligence (Gf) is a human ability to reason and solve new problems independently of previously acquired knowledgeand experience. It is considered one of the most important factors in learning. One of the issues which academic people concentrates on is whether Gf of adults can be improved. According to the Dual N-back working memory theory and the characteristics of visual perceptual learning, this paper put forward cognitive training pattern based on Gabor stimuli. A total of 20 undergraduate students at 24 years old participated in the experiment, with ten training sessions forten days. Through using Raven's Standard Progressive Matrices as the evaluation method to get and analyze the experimental results, it was proved that training pattern can improve fluid intelligence of adults. This will promote a widerange of applications in the field of adult intellectual education.

(Tranter & Koutstaal, 2008)

Age and flexible thinking: an experimental demonstration of the beneficial effects of increased cognitively stimulating activity on fluid intelligence in healthy older adults.

Abstract: The disuse hypothesis of cognitive aging attributes decrements in fluid intelligence in older adults to reduced cognitively stimulating activity. This study experimentally tested the hypothesis that a period of increased mentally stimulating activities thus would enhance older adults' fluid intelligence performance. Participants (N=44, mean age 67.82) were administered pre- and post-test measures, including the fluid intelligence measure, Cattell's Culture Fair (CCF) test. Experimental participants engaged in diverse, novel, mentally stimulating activities for 10-12 weeks and were compared to a control condition. Results supported the hypothesis; the experimental group showed greater pre- to post-CCF gain than did controls (effect size d=0.56), with a similar gain on a spatial-perceptual task (WAIS-R Blocks). Even brief periods of increased cognitive stimulation can improve older adults' problem solving and flexible thinking.

Conclusion:

In summary, we have demonstrated that even a relatively brief period of increased cognitively stimulating activity had clear beneficial effects on the cognitive test performance of healthy older adults as measured by a widely accepted measure of fluid intelligence. These experimental outcomes add to a large and still growing body of evidence pointing to considerable plasticity in human intelligence functioning, including forms of thought and reasoning deemed most susceptible to age-related decline. With increased opportunities for novel and continuing exploration, and the full (and playful) use rather than disuse of our cognitive abilities, decrements in our capacity to creatively and flexibly grapple with the world, in ways that do not rely on prior learning or knowledge, may not be as severe, as sharp, or as early as—without such stretching towards mental flexibility—they otherwise would be.

Feiyue, Q., Qinqin, W., Liying, Z., & Lifang, L. (2009).Study on Improving Fluid Intelligence through Cognitive Training System Based on Gabor Stimulus. Paper presented at the 1st International Conference on Information Science and Engineering (ICISE).

Jaeggi, S. M., Buschkuehl, M., Jonides, J., & Perrig, W.J. (2008). Improving fluid intelligence with training on working memory. [Research Support, N.I.H., Extramural Research Support, Non-U.S. Gov't Research Support, U.S. Gov't, Non-P.H.S.]. Proc Natl Acad Sci U S A, 105(19), 6829-6833.doi: 10.1073/pnas.0801268105

Tranter, L. J., & Koutstaal, W. (2008). Age and flexible thinking: an experimental demonstration of the beneficial effects of increased cognitively stimulating activity on fluid intelligence in healthy older adults.[Randomized Controlled Trial Research Support, Non-U.S. Gov't]. Neuropsychol Dev Cogn BAging Neuropsychol Cogn, 15(2), 184-207. doi: 10.1080/13825580701322163

 

[eagle34]

A while ago, I thought that someone became a PA or NP because they weren't smart enough to get into med school. I am now engaged to a PA - and getting to know her at first and her friends who are PAs, trust me, that is not at all the truth. She wanted to become a PA because of her own independent reasons - much better hours than MDs, less stress, ability to switch fields throughout the career. She works in private ortho practice, and there's usually not much independence there; she sees her own post-ops/follow-ups, but for all consults/initial patient visits, there's always MD involved. It's different in fam med - PA/NPs see their own patients; while they're usually established less complicated patients, that is not always true. During my family medicine rotation, I saw a number of pretty complicated patients with the NPs. And why can't PAs precept fellows/residents? If they have been in this field for a long period of time, I have no doubts that they have more knowledge in the field than a resident/fellow.
Overall, both NP/PAs are essential in medicine to work alongside MDs. They make the job much easier - especially when it comes to the most annoying stuff, like documentation/notes. Also, insurances pay for PA/NP visits too to much less than for MD visits, and yet, PAs get paid much less than MDs, so offices/hospitals make very good profits off PAs.

 

[SoundofSilver]

I think we're heading towards a primary care model where the majority of patients are seen by PA's and NP's with a physician in a supervisory role who only sees the most complicated cases. This will cut costs.

I guess this is why it makes sense to specialize if you're an MD these days. However, I do anticipate the highly inflated salaries of those such as radiologists and other specialists to start to come down a bit. Why should a radiologist make over twice as much as a PCP?

 

[badasshairday]

I made a thread similar to this in the Topics in Healthcare forum. It is titled "Streamline medical education." Med school should be 3 years. Also we should have doctors teaching future doctors. But these days it seems like it is doctors teaching NP/PA's only, while the residents and med students have to learn "independently" because "spoon feeding" is bad. The best was when I saw an NP student being taught by the IR NP (who learned from physicians) how to do basic procedures, while nobody taught me anything unless I really put myself out there. Definitely frustrating but it worked out for me in terms of learning, but the expectations are so different for us.

 

[gasknight]

(I’m really sorry for hi-jacking this thread)

Shnurek,

I’ve been noticing your posts on a variety of issues for a couple of months now. I generally enjoy reading your insights and think you’re a great contributor. However, I’ve noticed that this idea (RE: medical students are too old in this country because their fluid intelligence is past its prime, and this is the root of a lot of problems) is something of a pet interest for you. You seem to bring it up a lot. And as much as I respect your other contributions I’m finally going to call you out on this. I think you are over-reaching and extrapolating data way too much.

First off, your primary source in in this post is “highiqpro.com”. Looking into that website it appears to be a site that sells an IQ-improvement regimen. Not that a biased information source alone is enough reason to discount the information they present (because some of it is true), but the fact that it’s coming from a commercial, totally non-peer-reviewed source adds a bit of skepticism right off the bat.

Yes, it is true that average fluid intelligence (Gf) decreases gradually after full adulthood is reached. Yes, it is true that Gf can be improved with mental exercise and practice. The end. That’s really the extent of the data right there. Anything beyond that is extrapolation.

So here are a few reasons I’m pulling the BS-flag on the “med school/residency should start at a younger age” idea:

1 - There have been no studies, that I’m aware of, that look at Gf in medical students and residents explicitly. You’ve got to separate them from the general populace. Most average people are done with formal education by their mid-20s and your average job doesn’t require an excessive amount of Gf use, but rather relies on the execution of memorized protocols. Thus, perhaps the peak age of Gf is significantly higher for med students or others (like yourself) who are pursuing advanced education.

2 - According to the graph you posted from that commercial website, giving it the benefit-of-the-doubt and assuming it to be accurate for a moment, the “peak” doesn’t really seem to drop off significantly until the average person’s mid-30s. This leads me to suspect that, even if everything else you’re saying is right, the effects of having slightly older medical students/residents are far less exaggerated than you’re making them out to be.

3 - The science that you are basing your assumptions on actually weakens your argument. If Gf tends to decrease with age, and if Gf can be improved with training, than isn’t it possible that the rigorous critical thinking involved in medical education could actually increase Gf? Or at least “cancel-out” the deleterious effects of aging?

4 - This, to me, the most important thing… even if you are totally correct in all your assumptions, is having a marginally higher Gf at the time of medical training really worth the potential trade-offs in maturity, emotional and social competency, and overall “well-roundedness” that a slightly (we’re talking 2-3 years here…) older and more seasoned medical student/resident brings to the table?

5 - There is a huge, glaring gap between where the science ends and where you propose that medical education occurs at a suboptimal age. There is an even HUGER and 1000 times wider gap between that presumption and the notion that midlevel providers (or ODs, since you brought it up) are able to match physicians' level of expertise because, even though they trained for less time, they got more “bang for their buck” because they were a few years younger. I mean really?? Is that really the argument you wanted to make? Because that’s what your concluding paragraph suggests.

For those interested, here are the nuts and bolts of the actual evidence on these matters:

(Jaeggi, Buschkuehl, Jonides, & Perrig, 2008)



(Feiyue, Qinqin, Liying, & Lifang, 2009)



(Tranter & Koutstaal, 2008)





Feiyue, Q., Qinqin, W., Liying, Z., & Lifang, L. (2009).Study on Improving Fluid Intelligence through Cognitive Training System Based on Gabor Stimulus. Paper presented at the 1st International Conference on Information Science and Engineering (ICISE).

Jaeggi, S. M., Buschkuehl, M., Jonides, J., & Perrig, W.J. (2008). Improving fluid intelligence with training on working memory. [Research Support, N.I.H., Extramural Research Support, Non-U.S. Gov't Research Support, U.S. Gov't, Non-P.H.S.]. Proc Natl Acad Sci U S A, 105(19), 6829-6833.doi: 10.1073/pnas.0801268105

Tranter, L. J., & Koutstaal, W. (2008). Age and flexible thinking: an experimental demonstration of the beneficial effects of increased cognitively stimulating activity on fluid intelligence in healthy older adults.[Randomized Controlled Trial Research Support, Non-U.S. Gov't]. Neuropsychol Dev Cogn BAging Neuropsychol Cogn, 15(2), 184-207. doi: 10.1080/13825580701322163

 

[dr zaius]

Viewpoint in the current issue of JAMA


They made some pretty good points about inefficiencies in medical education ranging from the pre-med level through fellowships.

 

[SpecterGT260]

PAs or NPs can treat essential htn. They can see routine OB f/u patients. It's sort of a waste of a MDs time to do so if he has other pts he could be seeing. But PAs and NPs cannot deal with things that don't fall in their algorithm. That's why you need MDs to be trained like they do. We're the only ones with a critical thinking ability. Also be aware the MDs hire NPs and PAs so they can make more money. The downside is that PAs or NPs might get cocky as a group and want equal licensing laws. But I'm not convinced that's going to happen any time soon.

Also I don't mean to be condensing but I would not necessarily prop up every MD you see as some genius. Granted I still think they're smarter than any PA or NP but not all doctors are good doctors. There's lots out there who just want to make as much money as possible (which I don't think is a bad thing) but they will do it at the expense of the patient and take advantage of them (ordering unnecessary tests and procedures they do themselves so they get paid more - which obviously is bad).

BOLD: Yes
B/I/U: YES YES YES
RED: ehhh.... you lost me bro.

Mid-level providers are good at the "bread and butter" cases. We have them in our student health facility - where most people come in with a random sore throat, STD (undergrad campus assoc. 😉), the sniffles, or whatever. They can provide a good screening service for physicians, and siphon off the easy cases so that a physician can concentrate on the harder things, I am still somewhat conflicted about them in primary care. I understand the need for more primary care providers, and I understand not utilizing physicians for easy things.....

but we cannot always know when a case is "easy", and in my experience a PA who is unaware that a case is not as easy as it appears and still treats accordingly will do harm to the patient. I am not saying that physicians don't also make mistakes, but you are more likely to make them more often with less training. Training provides a level of proficiency on a broad scale, while experience only lends proficiency in those things you see commonly. I only bring that up because a common argument is "well i've practiced 10+ years....", yes but that still doesn't fill the gap in training. I am not aware of a strict identification system for DNPs and PAs to refer out to physicians, but I think that may be the happy medium to satisfy our need for PCPs and our need to avoid treating a serious condition like it is the sniffles.


as far as the intelligence thing goes.... I am a chemist by training, so i've been taught to think of pretty much everything in terms of a continuum and distribution. If there are 2 gaussian distributions with two different maxima, there are still points on the lower distribution that are higher than the maxima of the higher distribution - i.e. it is perfectly reasonable for an individual in a group with lower average intelligence or ability to have a higher intelligence and ability than someone belonging to a group with a higher average. If you wan't to blow your mind quick.... think about the principles behind quantum tunneling and the "probability distribution function". The probability of finding a particle at a given place at a given time decays asymptotically at 0, never meeting or crossing 0 at any point. This means there is a positive finite probability that an electron belonging to one of my atoms is currently found in your body (however small).

If we dumb the comparison of two professions down to that degree (ignoring self selection) we still cannot say that all of one group are smarter than all of the others if they are described by any sort of a distribution no matter how far the gap. If we allow for self-selection, there is no rule barring the smartest man in the entire world from becoming a plumber to the "all or none" sort of statements still don't stand. It is more reasonable to say "on average one group has a higher ability than the other"

 

[theseeker4]

BOLD: Yes
B/I/U: YES YES YES
RED: ehhh.... you lost me bro.

Mid-level providers are good at the "bread and butter" cases. We have them in our student health facility - where most people come in with a random sore throat, STD (undergrad campus assoc. 😉), the sniffles, or whatever. They can provide a good screening service for physicians, and siphon off the easy cases so that a physician can concentrate on the harder things, I am still somewhat conflicted about them in primary care. I understand the need for more primary care providers, and I understand not utilizing physicians for easy things.....

but we cannot always know when a case is "easy", and in my experience a PA who is unaware that a case is not as easy as it appears and still treats accordingly will do harm to the patient. I am not saying that physicians don't also make mistakes, but you are more likely to make them more often with less training. Training provides a level of proficiency on a broad scale, while experience only lends proficiency in those things you see commonly. I only bring that up because a common argument is "well i've practiced 10+ years....", yes but that still doesn't fill the gap in training. I am not aware of a strict identification system for DNPs and PAs to refer out to physicians, but I think that may be the happy medium to satisfy our need for PCPs and our need to avoid treating a serious condition like it is the sniffles.


as far as the intelligence thing goes.... I am a chemist by training, so i've been taught to think of pretty much everything in terms of a continuum and distribution. If there are 2 gaussian distributions with two different maxima, there are still points on the lower distribution that are higher than the maxima of the higher distribution - i.e. it is perfectly reasonable for an individual in a group with lower average intelligence or ability to have a higher intelligence and ability than someone belonging to a group with a higher average. If you wan't to blow your mind quick.... think about the principles behind quantum tunneling and the "probability distribution function". The probability of finding a particle at a given place at a given time decays asymptotically at 0, never meeting or crossing 0 at any point. This means there is a positive finite probability that an electron belonging to one of my atoms is currently found in your body (however small).

If we dumb the comparison of two professions down to that degree (ignoring self selection) we still cannot say that all of one group are smarter than all of the others if they are described by any sort of a distribution no matter how far the gap. If we allow for self-selection, there is no rule barring the smartest man in the entire world from becoming a plumber to the "all or none" sort of statements still don't stand. It is more reasonable to say "on average one group has a higher ability than the other"

I agree with you about the bread and butter cases. My only question is what you raise above yourself: do the PA's and NP's know when a presentation that looks like one disease, could actually be a more serious, rarer disease? Doctors, in theory at least, have enough knowledge and experience to recognize indications that what looks like the flu, or gastroenteritis, etc. is actually a more sever condition that needs more attention. What if the PA or NP sends the random flu-symptoms patient home after a quick review and sign-off by the doctor, when something more rare and dangerous is really behind the symptoms? I believe it was in Panda Bear's blog that I read the biggest problem with nid-levels isn't their lack of knowledge about what they are trained to do, but that they don't have the knowledge necessary to recognize the zebras.

 

[Postictal Raiden]

If I can chime in...

The problem with medical education in America is that it is indeed inefficient. It starts too late in life. We should specialize at a younger age. Why? You may ask.

If you have taken neuroscience 101 you would know that the brain is most neuroplastic when it comes to fluid intelligence and processing ability at around age 26. After all Albert Einstein published his Theories of General and Special Relativity at age 26 for example.

Notice this chart:

Fluid intelligence (Gf)
Processing speed (Gs)
Crystallized intelligence (Gc)
Source: http://www.highiqpro.com/iq-cognitive-health-aging/the-5-factors-of-intelligence-over-the-lifespan

Fluid intelligence and processing speed peak at around age 26. Crystallized intelligence goes on and lingers a lot longer because it is made up of facts and life experiences we have had.

So now onto my point: Medical education should start sooner by at least 2 years if not 4. Have direct programs to enter the medical college. Almost every other foreign nation graduates their MDs by age 21 or so. This way at age 21 and for the next 5-8 years or so the residents are exposed to the most critical part of their training during the time they are the most cognitively proficient.

Early specialization is just more efficient plain and simple. Having students graduating at age 26 with an MD and having to go through another 3-8 years of residency after they have passed their peak is just not the best way to go about it. If something is not done to change things, midlevels will just keep creeping up because a lot of them are trained at a younger age and it is more intuitive for them. Notice my profession for example. We have only 4 years of eye school and we can do laser eye surgery in 2 states at age 26 and prescribe oral medications in 47/50 states. Why? Because we specialize at the critical period and we know what we are doing. Its not about increasing training time to 3 decades. Its about getting trained at the right time.

I think the data counteract your argument rather than supporting it. Giving the study the benefit of the doubt, the graph shows that human intelligence is at its highest between the age of 25 and 35. Most medical students and residents fall within this cohort.

 

[SpecterGT260]

I agree with you about the bread and butter cases. My only question is what you raise above yourself: do the PA's and NP's know when a presentation that looks like one disease, could actually be a more serious, rarer disease? Doctors, in theory at least, have enough knowledge and experience to recognize indications that what looks like the flu, or gastroenteritis, etc. is actually a more sever condition that needs more attention. What if the PA or NP sends the random flu-symptoms patient home after a quick review and sign-off by the doctor, when something more rare and dangerous is really behind the symptoms? I believe it was in Panda Bear's blog that I read the biggest problem with nid-levels isn't their lack of knowledge about what they are trained to do, but that they don't have the knowledge necessary to recognize the zebras.

I am not sure I understand ur question..... raise above myself? in terms of medicine.... only a more experienced doctor whose opinion I trust (once I am a doctor too lol.......)

But the rest of your post is exactly my point. doctors are fallible, but will mis a zebra less often than a PA will. my biggest concern is in weighing the benefit of available primary care vs the harm in missing a zebra. I don't have a good solution so the best I can do is acknowledge the concern. anecdotally I know of several situations where a PA has discharged someone where their diagnosis was actually more severe than was determined. saw mono go home, saw a broken femur almost go home as a soft tissue injury to the knee in a little girl. luckily the father was a physician and remineded the PA that pain in the femur can refer to the knee so we should have xrayed the whole leg rather than just where she pointed to and said "ouch". There are a few others but id have to think a bit to remember the speciffics.

 

[SpecterGT260]

I think the data counteract your argument rather than supporting it. Giving the study the benefit of the doubt, the graph shows that human intelligence is at its highest between the age of 25 and 35. Most medical students and residents fall within this cohort.

that is what i am seeing.....

 

[Shnurek]

(I'm really sorry for hi-jacking this thread)

Shnurek,

First off, your primary source in in this post is "highiqpro.com". Looking into that website it appears to be a site that sells an IQ-improvement regimen. Not that a biased information source alone is enough reason to discount the information they present (because some of it is true), but the fact that it's coming from a commercial, totally non-peer-reviewed source adds a bit of skepticism right off the bat.

Its the first chart comparing a full scale of age to fluid intelligence and crystallized intelligence I found in google images. Its not wrong its just not of a "reputable" source as you desire.

There have been no studies, that I'm aware of, that look at Gf in medical students and residents explicitly. You've got to separate them from the general populace. Most average people are done with formal education by their mid-20s and your average job doesn't require an excessive amount of Gf use, but rather relies on the execution of memorized protocols. Thus, perhaps the peak age of Gf is significantly higher for med students or others (like yourself) who are pursuing advanced education.

Are you saying that Medical students age less quickly? Perhaps. Because looking at medical students they look pretty young overall. A selective pressure for neoteny? I can see how slower senescence may cause Gf to not go down as fast for people that choose advanced professions. Maybe I have an inferiority complex and you are right about the system being fine as it is. In any case to look at my argument at a different point you can consider critical periods. Learning languages for example is extremely easy in pre-pubescent years and maybe even early teens.

The further you go in higher education the more hours you have to spend to try to absorb the same amount of information that you could absorb quicker when you are younger. I know this is anecdotal but I'm sure some psychologists/psychiatrists/neurologists can chime in on this. My friend who is 27 and got an MCAT of 32 still states that even 2-3 years ago he was sharper in his mental processing. Can you honestly tell me that you believe that learning pathology for example would be easier at age 30 than at age 15? (Not considering pre-requisite knowledge as a variable) Or how about extending physician training to age 35 such as being done with fellowships nowadays. Is this really more efficient and/or beneficial to society? Less years to practice in your lifetime because you decided to learn something that is harder for you to learn at such an advanced age.

I think the data counteract your argument rather than supporting it. Giving the study the benefit of the doubt, the graph shows that human intelligence is at its highest between the age of 25 and 35. Most medical students and residents fall within this cohort.

I don't know how you are reading this chart but I am focusing on fluid intelligence and processing speed which are highest in the range of ages of ~21 to 30.

This is when basically all non-American residency education takes place. After age 30 they are full practitioners and build up their crystallized intelligence more because they see and have seen the diseases and know what to do. The learning or fluid intelligence phase is ending slowly.

 

[Postictal Raiden]

Its the first chart comparing a full scale of age to fluid intelligence and crystallized intelligence I found in google images. Its not wrong its just not of a "reputable" source as you desire.



Are you saying that Medical students age less quickly? Perhaps. Because looking at medical students they look pretty young overall. A selective pressure for neoteny? I can see how slower senescence may cause Gf to not go down as fast for people that choose advanced professions. Maybe I have an inferiority complex and you are right about the system being fine as it is. In any case to look at my argument at a different point you can consider critical periods. Learning languages for example is extremely easy in pre-pubescent years and maybe even early teens.

The further you go in higher education the more hours you have to spend to try to absorb the same amount of information that you could absorb quicker when you are younger. I know this is anecdotal but I'm sure some psychologists/psychiatrists/neurologists can chime in on this. My friend who is 27 and got an MCAT of 32 still states that even 2-3 years ago he was sharper in his mental processing. Can you honestly tell me that you believe that learning pathology for example would be easier at age 30 than at age 15? (Not considering pre-requisite knowledge as a variable) Or how about extending physician training to age 35 such as being done with fellowships nowadays. Is this really more efficient and/or beneficial to society? Less years to practice in your lifetime because you decided to learn something that is harder for you to learn at such an advanced age.



I don't know how you are reading this chart but I am focusing on fluid intelligence and processing speed which are highest in the range of ages of ~21 to 30.

This is when basically all non-American residency education takes place. After age 30 they are full practitioners and build up their crystallized intelligence more because they see and have seen the diseases and know what to do. The learning or fluid intelligence phase is ending slowly.

For both Gf and Gs, the W score at is 35 is slightly higher or equal to that at 21 years.

Regardless, most American physicians, started med school when they were 23-25. This means that the entire medical education plus at least the internship was is done before the age of 30.

The 4+4 model, regardless of its efficiency, has shown its success for the last few decades; it produces more rounded, matured, emotionally stable, and competent physicians. Why should we change it now?

 

[C5toC9]

I think part of the reason is when MD's start saying stuff like they don't want to see "easy" cases or that benign regular stuff is a "waste" of their time. This is where midlevel providers are creeping in, and the problem will only get worse because there is no limit. As was mentioned already, "easy" cases is a very subjective term.

In every other country outside the US, there are no PAs or NPs who see patients independently and act as MDs. It would be totally ridiculous to suggest to patients. When you start saying things are a waste of your time, you are basically inviting the midlevels to take over your jobs.

 

[SpecterGT260]

I think part of the reason is when MD's start saying stuff like they don't want to see "easy" cases or that benign regular stuff is a "waste" of their time. This is where midlevel providers are creeping in, and the problem will only get worse because there is no limit. As was mentioned already, "easy" cases is a very subjective term.

In every other country outside the US, there are no PAs or NPs who see patients independently and act as MDs. It would be totally ridiculous to suggest to patients. When you start saying things are a waste of your time, you are basically inviting the midlevels to take over your jobs.

But how else do we provide the fast food healthcare experience?

 

[Rothbard]

nm

 

[Postictal Raiden]

I think medicine is a field that is not particularly reliant on fluid intelligence. The great mathematicians and physicists did their best work in their 20's (sometimes in their teens). Doctors do their best work in their 40's in 50's. Medicine is a field that requires experience more than anything else (including intelligence, I'd argue). The fraction of medical education that requires fluid intelligence is completed in the early to mid twenties.

That said, I do think that we'd save a lot of headache and money, without sacrificing much by way of quality of care, if we hacked med education down to about 50% of what it currently is.

It already is compacted as it is. How would trimming 50% of the material even be feasible?

...unless you meant cutting down on undergrad GE's. However, many would argue that those classes help in producing more rounded individuals.

 

[45408]

The PAs I know who are really good at something are the ones who have been doing the same thing for a long time. You would hope that most competent people would improve with great repetition. You can't compare a PA with 20 years of experience in cardiac surgery to a med student or even a surgery resident, because there's a lot to be said for that repetition. The big difference is that while they often know what to do, most of them don't seem to know the why as well as physicians. Plus, they're only that experienced after they've had that much on-the-job training. Looking at a student/resident compared to a subspecialty PA isn't that relevant. When you compare a surgeon with decades of experience to a PA with decades of experience, the difference again becomes readily obvious.

 

[Butler]

PAs or NPs can treat essential htn. They can see routine OB f/u patients. It's sort of a waste of a MDs time to do so if he has other pts he could be seeing. But PAs and NPs cannot deal with things that don't fall in their algorithm. That's why you need MDs to be trained like they do. (1)We're the only ones with a critical thinking ability. Also be aware the MDs hire NPs and PAs so they can make more money. The downside is that PAs or NPs might get cocky as a group and want equal licensing laws. (2)But I'm not convinced that's going to happen any time soon.

Also I don't mean to be condensing but I would not necessarily prop up every MD you see as some genius. (3)Granted I still think they're smarter than any PA or NP but not all doctors are good doctors. There's lots out there who just want to make as much money as possible (which I don't think is a bad thing) but they will do it at the expense of the patient and take advantage of them (ordering unnecessary tests and procedures they do themselves so they get paid more - which obviously is bad).

1. Umm...are you trying to imply that only physicians have the ability to think critically? Wow, admissions committees must be doing a terrific job selecting the only cohort of humans on the planet that have this amazing ability.

2. It is happening right now. Mid levels are attempting to push laws to increase their autonomy with medications, procedures and scope of practice through federal and state legislation AS WE SPEAK. Whether this helps or hurts patients, I don't know for sure because the evidence has not been elucidated sufficiently. But know that when I have an eye problem I still choose to see an ophthalmologist, not an optometrist.

3. How are you measuring intelligence? IQ? I can guarantee you not every MD will out score every PA/NP on an IQ test.

I don't mean to pick on you officedepot, I am just flabbergasted and amazed by some of your arguments 😎.

 

[SpecterGT260]

I think medicine is a field that is not particularly reliant on fluid intelligence. The great mathematicians and physicists did their best work in their 20's (sometimes in their teens). Doctors do their best work in their 40's in 50's. Medicine is a field that requires experience more than anything else (including intelligence, I'd argue). The fraction of medical education that requires fluid intelligence is completed in the early to mid twenties.

That said, I do think that we'd save a lot of headache and money, without sacrificing much by way of quality of care, if we hacked med education down to about 50% of what it currently is.

I disagree.

experience is not bad, but it in no way replaces formal training. The difference between physicians and PAs is training, not experience. I could pluck a janitor from anywhere, put him in scrubs, and given enough time he would have the experience to be proficient with the day-to-day doings of a doctor. While lacking the intelligence (assuming we are not in a "good will hunting" situation) and lacking the training.

To rely solely on experience condemns us to learn only by our mistakes. We can only treat what we know, and we can only know what we've seen. Therefore we are bound to treat something we have not seen as if it were something we have seen.... which is the very concern I made previously.

I understand that experience based learning can be augmented by more experienced peoples lending expertise... but IMO that is beside the point. An emphasis on application-centered understanding is what we really need our physicians to have, not more clinic hours.

 

[SpecterGT260]

1. Umm...are you trying to imply that only physicians have the ability to think critically? Wow, admissions committees must be doing a terrific job selecting the only cohort of humans on the planet that have this amazing ability.

2. It is happening right now. Mid levels are attempting to push laws to increase their autonomy with medications, procedures and scope of practice through federal and state legislation AS WE SPEAK. Whether this helps or hurts patients, I don't know for sure because the evidence has not been elucidated sufficiently. But know that when I have an eye problem I still choose to see an ophthalmologist, not an optometrist.

3. How are you measuring intelligence? IQ? I can guarantee you not every MD will out score every PA/NP on an IQ test.

I don't mean to pick on you officedepot, I am just flabbergasted and amazed by some of your arguments 😎.

when I quoted him earlier I missed ur #1. I agree... it is unreasonable to say we are the only group that has critical thinking ability. I do believe it is selected for at a higher degree, but as I said in my previous post with all the math and garbage.... there is still the potential for the most critical-thinkinest dude/ette among us to go PA or DNP. Simply because one group has a higher AVERAGE does not meed every member of that group is higher than every member of the lower group..... i believe I have said that in about 900 different threads around here due to posts like the one u quoted.

 

[mjl1717]

PAs or NPs can treat essential htn. They can see routine OB f/u patients. It's sort of a waste of a MDs time to do so if he has other pts he could be seeing. But PAs and NPs cannot deal with things that don't fall in their algorithm. That's why you need MDs to be trained like they do. We're the only ones with a critical thinking ability. Also be aware the MDs hire NPs and PAs so they can make more money. The downside is that PAs or NPs might get cocky as a group and want equal licensing laws. But I'm not convinced that's going to happen any time soon.

Also I don't mean to be condensing but I would not necessarily prop up every MD you see as some genius. Granted I still think they're smarter than any PA or NP but not all doctors are good doctors. There's lots out there who just want to make as much money as possible (which I don't think is a bad thing) but they will do it at the expense of the patient and take advantage of them (ordering unnecessary tests and procedures they do themselves so they get paid more - which obviously is bad).

You will have many people ask you:

What makes M.Ds smarter the PAs or NPs?? 😴

 

[Shnurek]

Whether this helps or hurts patients, I don't know for sure because the evidence has not been elucidated sufficiently. But know that when I have an eye problem I still choose to see an ophthalmologist, not an optometrist.
.

You do that but if you have a eye muscle problem such as convergence insufficiency an ophthalmologist will push you to allow him/her to perform strabismus surgery on you because that is what reimburses them the most from insurance when all you may need is some vision therapy or prism lenses. Optometrists nowadays are like the internal medicine doctors of the eyes. Ophthalmologists are being pushed more towards surgery and we are taking over the medicine portion slowly. Our malpractice insurance rates are 1/10th of ophthos....think about that. And no its not just cause they do more invasive procedures.

 

[Whiskeypunch]

.

 

[preDoGuy24]

You do that but if you have a eye muscle problem such as convergence insufficiency an ophthalmologist will push you to allow him/her to perform strabismus surgery on you because that is what reimburses them the most from insurance when all you may need is some vision therapy or prism lenses. Optometrists nowadays are like the internal medicine doctors of the eyes. Ophthalmologists are being pushed more towards surgery and we are taking over the medicine portion slowly. Our malpractice insurance rates are 1/10th of ophthos....think about that. And no its not just cause they do more invasive procedures.

Cool story bro.

 

[Butler]

You do that but if you have a eye muscle problem such as convergence insufficiency an ophthalmologist will push you to allow him/her to perform strabismus surgery on you because that is what reimburses them the most from insurance when all you may need is some vision therapy or prism lenses. Optometrists nowadays are like the internal medicine doctors of the eyes. Ophthalmologists are being pushed more towards surgery and we are taking over the medicine portion slowly. Our malpractice insurance rates are 1/10th of ophthos....think about that. And no its not just cause they do more invasive procedures.

Shnurek, don't perpetrate the stereotype of optometrist being indignant and self-righteous sycophants that are trying to rudely stick their foot into eye care by pushing out MDs. That sort of mentality will not get you far in practice, and will certainly not get you far on this forum. There are certainly good and bad doctors, just like there are good and bad optometrists. Furthermore, let me comment on this hypothetical situation you have created in an attempt to prove your point, with no evidence I might add, but I will play along. If my doc recommended I have surgery, I would definitely get a second opinion first before he/she started cutting on me. While some future and current allied health professionals like yourself like to perpetuate the evil doctor just out for the money stereotype, I guaranttee you that there are not that many of them out there. And the ones that are don't stay in practice for long without being very, very smart. Selfish endeavors that compromise good patient care are not something patients or their lawyers tolerate very well in our current health system (as it should be, I might add). You would get absolutely nailed to the wall if you routinely ignored proper surgical indications when choosing your OR cases.

Btw, your malpracticed rates are so low for precisely that reason. Look at average surgical malpracticed rates vs non-surgical malpractice rates for different medical specialties. There are astronomical differences in these numbers. That's because you are not going to sever someone's optic nerve and blind them for life when you are prescribing a new set of eye glasses. The rates have to be bigger because the risks are higher. That doesn't take a rocket scientist to figure out.

 

[mTOR]

The PAs I know who are really good at something are the ones who have been doing the same thing for a long time. You would hope that most competent people would improve with great repetition. You can't compare a PA with 20 years of experience in cardiac surgery to a med student or even a surgery resident, because there's a lot to be said for that repetition. The big difference is that while they often know what to do, most of them don't seem to know the why as well as physicians. Plus, they're only that experienced after they've had that much on-the-job training. Looking at a student/resident compared to a subspecialty PA isn't that relevant. When you compare a surgeon with decades of experience to a PA with decades of experience, the difference again becomes readily obvious.

These differences are easily remedied as they are emergent from the different health care expectations on the positions (and not necessarily from differences in pre-clinical training, per se). Consequently, this is hardly an argument for why PA's shouldn't be allowed do something. Change the expectation, and they there's no reason to believe they wouldn't be able to meet it (given the desire to do so).

1. Umm...are you trying to imply that only physicians have the ability to think critically? Wow, admissions committees must be doing a terrific job selecting the only cohort of humans on the planet that have this amazing ability.

2. It is happening right now. Mid levels are attempting to push laws to increase their autonomy with medications, procedures and scope of practice through federal and state legislation AS WE SPEAK. Whether this helps or hurts patients, I don't know for sure because the evidence has not been elucidated sufficiently. But know that when I have an eye problem I still choose to see an ophthalmologist, not an optometrist.

3. How are you measuring intelligence? IQ? I can guarantee you not every MD will out score every PA/NP on an IQ test.

I don't mean to pick on you officedepot, I am just flabbergasted and amazed by some of your arguments 😎.

lol, agreed.

I disagree.

experience is not bad, but it in no way replaces formal training. The difference between physicians and PAs is training, not experience. I could pluck a janitor from anywhere, put him in scrubs, and given enough time he would have the experience to be proficient with the day-to-day doings of a doctor. While lacking the intelligence (assuming we are not in a "good will hunting" situation) and lacking the training.

Education and intelligence are not one in the same. And experience is paramount and the most decisive factor in developing clinical expertise.

 

[SpecterGT260]

These differences are easily remedied as they are emergent from the different health care expectations on the positions (and not necessarily from differences in pre-clinical training, per se). Consequently, this is hardly an argument for why PA's shouldn't be allowed do something. Change the expectation, and they there's no reason to believe they wouldn't be able to meet it (given the desire to do so).



lol, agreed.



Education and intelligence are not one in the same. And experience is paramount and the most decisive factor in developing clinical expertise.

I didnt say they are one and the same. I said that experience alone will support a system adept in common ailments which also falters with rare ones.

To address your link directly: I only got an abstract so I can only comment on that. They did not say that experience is paramount, as you suggested...... they said what most greatly impacts expertise is multiple representations, notpresentations. multiple presentations is what I have discussing when I say experience. Formal training, in my opinion, gives more representations i.e. the same situations in multiple forms from multiple angles - lending a greater understanding of the process as a whole.

 

[facetguy]

There's a subtle (or in some cases not so subtle) undercurrent that PAs may miss a diagnosis and can therefore put patients at risk. Is anyone aware of any data looking at this? If PAs really do miss things and endanger patients, there should be something in the literature to this effect.

 

[C5toC9]

There's a subtle (or in some cases not so subtle) undercurrent that PAs may miss a diagnosis and can therefore put patients at risk. Is anyone aware of any data looking at this? If PAs really do miss things and endanger patients, there should be something in the literature to this effect.

Wish there was some literature on this

 

[mTOR]

^Google scholar. Pubmed. There's a wealth of literature on this going back to the 70's showing care provided by NPs or PA's as effectively equivalent (and in some cases better) to that provided by MD's -- at least in the ambulatory and primary care setting.

Random sampling of studies:

• "In an ambulatory care situation in which patients were randomly assigned to either nurse practitioners or physicians, and where nurse practitioners had the same authority, responsibilities, productivity and administrative requirements, and patient population as primary care physicians, patients' outcomes were comparable." -- JAMA, 2000
• "Overall, this study suggests that PAs and NPs are providing primary care in a way that is similar to physician care." -- Health Affairs, 2001
• "Conclusion: Increasing availability of nurse practitioners in primary care is likely to lead to high levels of patient satisfaction and high quality care." -- BMJ, 2002
• "The results are consistent with the 6-month findings and with a growing body of evidence that the quality of primary care delivered by nurse practitioners is equivalent to that by physicians." -- MCRR, 2004
• "Twenty-one studies in which care given by nurse practitioners or physician's assistants was directly compared with that given by physicians are analyzed. These studies show that nurse practitioners and physician's assistants provide office-based care that is indistinguishable from physician care. " -- Annals, 1979 (back when the data was still in its infancy)

 

[SpecterGT260]

you do understand in a study design such as you posted, one could walk in and SHOOT A PATIENT IN THE FACE and not bring statistical significance to the study one way or the other. This study design looking at gross outcomes and satisfaction is exactly what is concerning us.

the vast majority of the time they will correctly identify the horse. These studies make no comment on the ability and accuracy of identifying the zebra.

I am not saying the studies are wrong, i am saying they are not addressing the question asked here. This is a "greater good" vs "needs of one" sort of situation and those studies are implying that overall it will be better with an increase in PA and NP because they do not show a statistical increase in error among the total population.

To put it another way, a test which is highly specific will not have many false negatives. But the % of false negatives seen is also a function of the population tested. What we have established is by these papers is that PAs and NPs have a strong sensitivity diagnostically, but not necessarily a strong positive predictive value.

as such, it is again a matter of opinion and judgement if such a situation is allowable and beneficial

EDIT:
From one of your articles
Some differences did exist. When a physician was seen either alone or with a PA or an NP, the patients were more likely to be older than those seen by a PA or an NP without a physician. Also, the mean patient age was highest for the physician-only group. In addition, this group appeared to be attending the more complicated cases—patients who were older and required more diagnostic tests.


The BMJ article http://www.bmj.com/content/324/7341/819.short
does not even calculate outcomes... their measures of success are satisfaction and quality of care including "communication". This does not mean the same thing as having equal diagnostic ability.

Same problem with the Sage article... not that it isnt a valuable article, but it is looking at patient reported values of "health" and in doing so will not in any way detect relative levels of misdiagnosis when the average patient is not misdiagnosed to begin with.


the major flaw in logic in applying these studies to the mentioned concern is in what both groups are doing. lets apply this to weight lifting.

One man can bench press 400lbs. Another man can bench press a max of 200 lbs.
The day to day requirements of these men is to each walk over to a group of weights, and lift them up.
The average weight of each is 50lbs.
any analysis of performance between the two will never show a statistically significant difference between their relative abilities to handle such tasks.

The concern is what happens when one of the weights is 350lbs? none of the study designs can handle this.... even if there were a few of these that got in, they would not stand out significantly from the ever-present background error in both groups. So a different study design is needed. We are not asking how happy the patients are at the end... honestly I could bungle a diagnosis and nearly kill someone and have them leave quite satisfied based on interpersonal factors... A more appropriate study design is to look at a group of patients with illnesses known to get missed and compare their outcomes across physicians and PAs/NPs. Or look at cross incidence of correction by physicians towards PAs or NPs as compared to physician error rate... The first paper I quoted even said that some possibilities for differences in time to treat could be because the PAs are consulting with a physician, which would negate the validity of the study

 

[Butler]

^Google scholar. Pubmed. There's a wealth of literature on this going back to the 70's showing care provided by NPs or PA's as effectively equivalent (and in some cases better) to that provided by MD's -- at least in the ambulatory and primary care setting.

Random sampling of studies:

• "In an ambulatory care situation in which patients were randomly assigned to either nurse practitioners or physicians, and where nurse practitioners had the same authority, responsibilities, productivity and administrative requirements, and patient population as primary care physicians, patients' outcomes were comparable." -- JAMA, 2000
• "Overall, this study suggests that PAs and NPs are providing primary care in a way that is similar to physician care." -- Health Affairs, 2001
• "Conclusion: Increasing availability of nurse practitioners in primary care is likely to lead to high levels of patient satisfaction and high quality care." -- BMJ, 2002
• "The results are consistent with the 6-month findings and with a growing body of evidence that the quality of primary care delivered by nurse practitioners is equivalent to that by physicians." -- MCRR, 2004
• "Twenty-one studies in which care given by nurse practitioners or physician's assistants was directly compared with that given by physicians are analyzed. These studies show that nurse practitioners and physician's assistants provide office-based care that is indistinguishable from physician care. " -- Annals, 1979 (back when the data was still in its infancy)

I have seen most of these articles before, except the last one which is new to me. What's interesting, although not surprising considering the results, is that 3/5 articles listed an RN as first author. One was written by a PhD whom does nothing but sing the unequivocal praises of NPs and particularly PAs in almost every article he writes. The final one is the only article written by an MD, which I definitely will take a thorough read through when I get the chance. I appreciate the articles.

Just so readers don't get the wrong idea, I don't hate or even dislike PAs, NPs or any allied health professional. They all provide extremely valuable services that help patients and expedite medical care to those in need. However, I firmly believe a physician should take the lead on medical care and decision making whenever possible due to extended periods of training in both biomedical and clinical arenas.

 

[SpecterGT260]

again, I would like this point to not get missed.

These study designs are not able to detect mis diagnoses.
We are talking about a rare outcome so it is inappropriate to look at total population satisfaction. As I mentioned previously, I could have walked into one of the patients rooms in the study and SHOT THEM IN THE FACE. A single patients data point would not skew one group or the other into or out of statistical significance.

let me put it another way.

An NP's patient demographic is 99% "bread and butter" (not real data... just go with it). Even if they always miss the 1%. i.e. 100% MISDIAGNOSIS on the "zebras" in a population that is 99% non zebras, we would still not see a statistical difference via the study designs above.

We need to remove "non zebras" from the mix to really discuss the stated concern. Nobody is saying that they are out there killing people left and right. What I (and a few others) said is that for all the ones they get right, they are more likely to miss the guy who really needs the correct diagnosis - the guy who isnt a simple infection, cold, cough, virus, whatever.

 

[JP2740]

What I don't get:

If PA's and NP's want a bigger piece of the patient care pie, then why don't they just become doctors? Isn't that a very relevant question?

I think it's either they can't make it or don't want to go through the more rigorous training. Honestly both professions are very, very useful but at the end of the day, I would want a doctor treating me. Not the person who went into a field with less scope and now wants to do what he wasn't trained for.

 

[phltz]

What I don't get:

If PA's and NP's want a bigger piece of the patient care pie, then why don't they just become doctors? Isn't that a very relevant question?

I think it's either they can't make it or don't want to go through the more rigorous training. Honestly both professions are very, very useful but at the end of the day, I would want a doctor treating me. Not the person who went into a field with less scope and now wants to do what he wasn't trained for.

In getting my own medical care, I've often been frustrated at the hoops that one needs to jump through to see a doctor for something that really isn't very complicated. I came back from a camping trip with classic symptoms of giardia, and wanted to get it treated. I got a minor scalp laceration while wrestling with friends, and needed a couple stitches. I needed a TB skin test for school. All of these things are straightforward and easily handleable by a competent mid-level practitioner. But I had to see a doctor, for some reason, and so it was much more of a pain in the ass than it needed to be to schedule an appointment/wait around in the ER, and I assume it ended up costing my insurance company (and thus, eventually, me) a lot more money.

I have no problem with letting people with slightly less training handle the easy cases, and using the more highly trained folks for the difficult ones. What possible reason would you have to want anything different, other than avarice?

 

[Shnurek]

That may have something to do with giving someone the wrong eyeglasses isn't going to lead to an expensive lawsuit...

Yes, but misdiagnosing glaucoma, removing a foreign body incorrectly by scarring the corneal stroma and not prescribing oral acyclovir for herpes keratitis might.

 

[SpecterGT260]

In getting my own medical care, I've often been frustrated at the hoops that one needs to jump through to see a doctor for something that really isn't very complicated. I came back from a camping trip with classic symptoms of giardia, and wanted to get it treated. I got a minor scalp laceration while wrestling with friends, and needed a couple stitches. I needed a TB skin test for school. All of these things are straightforward and easily handleable by a competent mid-level practitioner. But I had to see a doctor, for some reason, and so it was much more of a pain in the ass than it needed to be to schedule an appointment/wait around in the ER, and I assume it ended up costing my insurance company (and thus, eventually, me) a lot more money.

I have no problem with letting people with slightly less training handle the easy cases, and using the more highly trained folks for the difficult ones. What possible reason would you have to want anything different, other than avarice?

you cannot necessarily know ahead of time which are the easy cases. THAT is the whole point. The hardest cases do not come with a sign hung round their necks saying so