What's your opinion on future of EM?

[traxxradiorocks]

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I know that this has been discussed extensively on this forum over the past decade but things are rapidly evolving and I just want to hear some fresh opinions from those who are currently practicing or doing their residencies.

Earlier today when I was working with my FM attending (we work on several public health projects together), I noticed that he was also working on a new curriculum for nurse practitioner program. We ended up talking about the quality of the nps at our hospital (which leaves much to desire...) but we are not doing a good job limiting their expansion. The original focus of the np program at the hospital is to help create more primary care positions to fill the underserved communities but this is ultimately coming back to bite us in the ass as the NPs are now gaining more bargaining rights in the primary care field as well as EM and whatnot.... At the end, he actually suggested me thinking twice before I head for the EM route because he thinks that the field will be undermined by the NPs. He predicts that there will be a surplus of EM physicians because their positions will be filled by the NPs and the salaries will be lowered substantially to their levels.

As I have mentioned in other threads, I am interested in Ob/Gyn and ED and are planning for my 4th year (I know it's a little early but I need to figure out what to do with my 4 month research block from Nov to march). I am not solely looking into a field based on salary but I do expect a certain level of respect from the hospital and other physicians and compensation for the work that I do. It would be a damn shame if the field is "easily replaceable" by those with a fraction of the amount of training (I am still appalled by the arrogant NPs. Their argument is essentially comparing a line cook at MacDonalds to a chef at a restaurant)

What do you guys think?

 

[Antibodies]

Yeah, I am interested too. All this talk about NPs, CRNAs, and the "studies" that prove equality makes me very nervous.

 

[deleted65604]

Let me get this straight, a family medicine doctor thinks that you shouldn't go into EM, because ERs are going to be staffed more and more by NPs. Is that right?

The less desirable, lower paying jobs (those currently filled by FPs) may use NPs increasingly.

No hospital administration anywhere is going to be nuts enough to give the ER contract to a bunch of NPs. Until that happens, NPs will be pimped out by physicians, who will rake in the money and pay them less than the profit they generate.

Did he warn you that you shouldn't go into FP because the scope of practice is too broad? Did he warn you that reimbursement is falling and that increasingly, NPs will replace FPs? Did he warn you that reimbursement for FP is lower than almost any other field? Did he warn you that 50 percent of the training time in FP is spent on peds, and OB, 2 fields that FPs essentially spend no time on in real practice (Come on, do physicians send their kids to FP docs?)

Until he admits this to you, you can ignore his advice to you and chalk it up to one more physician who is mad that ER docs have funner, better paying jobs. PCPs are scared that they themselves are going away, to be replaced by an army of foreign medical graduates, PAs, and NPs. Especially in academia, family medicine attendings are extremely frustrated by the poor quality of applicants that they get to their programs. Whereas ER residencies recieve hundreds of applicants for their spots, FP residencies get 2-3 applications for each spot. They are usually relieved when they can get an applicant that can actually speak English well and is likely to pass their board exams.

This is obviously a lame attempt at getting you to apply to FM, in hopes that you will apply to their program. Be flattered by the attention, but don't let it sway your decision in any way shape or form.

 

[danielmd06]

Interesting question. I've actually wondered this a bit myself.

No hospital administration anywhere is going to be nuts enough to give the ER contract to a bunch of NPs.

Yeah, I agree that common sense would suggest this...but since when do hospital administrators care about logic? This is what's happening in Anesthesiology...you can have one or two figurehead physicians and a handful of physician extenders at a fraction of the price. Do you guys think that it's absolutely impossible in the ER? If so, why?

...you can ignore his advice to you and chalk it up to one more physician who is mad that ER docs have funner, better paying jobs. Hey no fair! 🙂 I've often tried to sway people away from ER myself and/or been critical of the job beyond residency... and I was offered a residency position in ER and turned it down to stay in neurology (of all things). So not all of us out here are jealous. My questions are serious.

PCPs are scared that they themselves are going away, to be replaced by an army of foreign medical graduates, PAs, and NPs. Heh. I'm scared they are, too. The cost of medicine will likely go up from this (because of over-ordering and over-referral) and the quality of primary care could easily go down. Not so much with foreign graduates as you seem to suggest, but definitely with PA's and NP's (who have much less training).

I suppose ANY provider is better than NO provider.

 

[The White Coat Investor]

I've worked with a lot of NPs and PAs at ~7 different hospitals. Some are quite good and some aren't. None of them are comfortable managing a truly sick patient and most of them aren't comfortable even doing what I consider bread and butter EM-chest pain and abdominal pain.

My reimbursement may go down in the future for lots of different reasons, but this isn't one I worry much about.

 

[traxxradiorocks]

Interesting question. I've actually wondered this a bit myself.

No hospital administration anywhere is going to be nuts enough to give the ER contract to a bunch of NPs.

Yeah, I agree that common sense would suggest this...but since when do hospital administrators care about logic? This is what's happening in Anesthesiology...you can have one or two figurehead physicians and a handful of physician extenders at a fraction of the price. Do you guys think that it's absolutely impossible in the ER? If so, why?

...you can ignore his advice to you and chalk it up to one more physician who is mad that ER docs have funner, better paying jobs. Hey no fair! 🙂 I've often tried to sway people away from ER myself and/or been critical of the job beyond residency... and I was offered a residency position in ER and turned it down to stay in neurology (of all things). So not all of us out here are jealous. My questions are serious.

PCPs are scared that they themselves are going away, to be replaced by an army of foreign medical graduates, PAs, and NPs. Heh. I'm scared they are, too. The cost of medicine will likely go up from this (because of over-ordering and over-referral) and the quality of primary care could easily go down. Not so much with foreign graduates as you seem to suggest, but definitely with PA's and NP's (who have much less training).

I suppose ANY provider is better than NO provider.

That's exactly what I am worried about. There are already CRNA or NP students demonstrating enough arrogance to say that they want to operate independently. We had a mixer a couple months back and one actually told me that he thinks it's a waste of time and money to do medical school because he will be able to have the same level of practice within 10 years since their trainings are preparing them to do so. Obviously I was annoyed by that comment saying, "learning how to wipe ass for four years is not equivalent to 4yrs of busting ass in medical school". I am just worried that they are going to lobby hard for independence.
I do agree that some NPS, especially the older NPs are God's gifts to us. They are experienced, they are modest and they are team-players. Though I think they are a dying breed, soon to be replaced by these doctors-wannabe who cannot get into med schools and are now on a vengeance for revenge.

 

[gro2001]

you can have one or two figurehead physicians and a handful of physician extenders at a fraction of the price. Do you guys think that it's absolutely impossible in the ER? If so, why?

Only a med student, so take this with a grain of salt, but given the level of quality and freedom from error that the American public expects from their emergency care, the first time an ED working under the model you suggest misses something major and the patient dies will be followed by a rapid re-evaluation of the policy (ones the REAL cost-effectiveness of independent/semi-independent NPs is factored in; ie: adjusted for the expected malpractice fees).

 

[danielmd06]

...given the level of quality and freedom from error that the American public expects from their emergency care, the first time an ED working under the model you suggest misses something major and the patient dies will be followed by a rapid re-evaluation of the policy (ones the REAL cost-effectiveness of independent/semi-independent NPs is factored in; ie: adjusted for the expected malpractice fees).

I'm not so sure. Again, isn't this exactly what we have with CRNA's working in operating rooms under the supervision of physicians? Also, the same argument about "quality of care" applies to primary care. Primary care practice isn't easy, and has the potential for huge errors. Yet, many of us expect this to become a big part of Family Practice in the future.

I think a fraction of the ER attendings could continue to be personally present for advanced cases and otherwise present for supervision of the ancillary staff cases...and would still be liable for the mistakes made by NP's or PA's under their authority for those supervised cases. So you get your cheaper costs (because less people are making what a full-fledged physician makes), increased availability of an important provider service to patients, and you can still sue somebody for lots of money if a mistake is made.

Make no mistake...I don't WANT this to happen. I think that x-many hundred hours do not qualify someone for physician-level work and physician-level responsibility (that' what medical school was for, right?).

 

[gro2001]

I'm not so sure. Again, isn't this exactly what we have with CRNA's working in operating rooms under the supervision of physicians? Also, the same argument about "quality of care" applies to primary care. Primary care practice isn't easy, and has the potential for huge errors. Yet, many of us expect this to become a big part of Family Practice in the future.

I think a fraction of the ER attendings could continue to be personally present for advanced cases and otherwise present for supervision of the ancillary staff cases...and would still be liable for the mistakes made by NP's or PA's under their authority for those supervised cases. So you get your cheaper costs (because less people are making what a full-fledged physician makes), increased availability of an important provider service to patients, and you can still sue somebody for lots of money if a mistake is made.

Make no mistake...I don't WANT this to happen. I think that x-many hundred hours do not qualify someone for physician-level work and physician-level responsibility (that' what medical school was for, right?).

I hear what you are saying, and they are very valid arguments. However, an important aspect that has been brought up before in this discussion is that in Anesthesia, the vast majority of the time (and 100% of the time a CRNA is the anesthetist) the situation is well controlled, straight forward, allows for preparation, screening of difficult cases, and anticipatory referral to an MD if things look like they might get complicated. Very often in the ED there is no way to tell what the situation is going to be like. In fact, vis a vis intubation, we assume the patient is coming to us on a full stomach. It would seem that the potential to do some serious damage is much greater in the ED as compared to the OR.

In primary care, while consequences of mistakes may be serious, they are not usually as dramatic as in the ED. Drama sells courts and policy.

 

[Charles_Carmichael]

Only a med student, so take this with a grain of salt, but given the level of quality and freedom from error that the American public expects from their emergency care, the first time an ED working under the model you suggest misses something major and the patient dies will be followed by a rapid re-evaluation of the policy (ones the REAL cost-effectiveness of independent/semi-independent NPs is factored in; ie: adjusted for the expected malpractice fees).

Most people these days agree that the cost of the delivery of medical care is the biggest problem with our health care system. In my opinion, as the nursing community keeps pushing with the whole "we're-more-cost-effective-than-physicians" while at the same time saying that they're equivalent/superior to physicians (and the vocal leaders have said this), the public and politicians will just see "cost-effective" and go with that. At that point, second best becomes good enough.

It's also easy to say that your specialty is protected from NPs/DNPs and only family practice will go under. But the problem is, it would be pretty easy for midlevels, once they've gained a strong foothold in family practice, to say that they could do the same thing in other specialties. I hate slippery slopes as much as the next person, but every time a new "study" is put out by the nursing community, I feel like something like this truly has the potential of happening.

 

[Charles_Carmichael]

I hear what you are saying, and they are very valid arguments. However, an important aspect that has been brought up before in this discussion is that in Anesthesia, the vast majority of the time (and 100% of the time a CRNA is the anesthetist) the situation is well controlled, straight forward, allows for preparation, screening of difficult cases, and anticipatory referral to an MD if things look like they might get complicated. Very often in the ED there is no way to tell what the situation is going to be like. In fact, vis a vis intubation, we assume the patient is coming to us on a full stomach. It would seem that the potential to do some serious damage is much greater in the ED as compared to the OR.

In primary care, while consequences of mistakes may be serious, they are not usually as dramatic as in the ED. Drama sells courts and policy.

While I fully agree with you and understand the logic behind what you're saying, I don't think that reality will work out just like this.

It's much more likely that the nursing midlevels will use studies (like the recent diagnostic accuracy one) that are looking at simple things and extrapolate them (wrongly) to the entire realm of a specialty. I mean, NPs/DNPs in primary care are saying that because they have better patient satisfaction than physicians, they're providing equivalent/superior care and deserve to have a full scope of practice. And it seems like things are heading that way. They've already gained independence in a number of states. With that precedent, it's hard not to imagine that in the future, all 50 states will give independence to NPs/DNPs. I think something similar could really happen to every medical specialty (even the surgical ones...if you take the time to read some nursing forums, you'll that there are many threads discussing that they should be allowed to do "minor" surgeries with a few extra classes).

All they need to do after graduating NP school is complete a "residency" (500-1000 hrs) for them to say that they're "board certified in [insert specialty]." I believe USF is already offering nursing residencies in lucrative specialties like derm, cardiology, etc.

With things like this happening with relative ease (ie. doesn't look like physicians are really trying to stop this...or maybe they just don't care enough), it's hard not to be worried about the future of medicine. Particularly when I'm currently in the process of applying and won't be practicing independently for another decade, when things might be drastically different.

 

[n2b8me]

😉

 

[danielmd06]

At the end, he actually suggested me thinking twice before I head for the EM route because he thinks that the field will be undermined by the NPs.

That reminds me of attending advice I heard in med school like:

1. Any ER can be staffed by a medicine resident and a surgical resident
2. soon every inpatient ward team will have a geneticist on their service because we will have specific therapy relating to their genome
3. medicine isn't what it used to be I'd think about a different career if I had to do it over.

You left out that we would be driving solar powered cars by now, too.

Seriously though, the federal government (at least part of it) is making mid-level providers and cheapening of health care costs a very big priority right now...they don't (and didn't) care about adding a geneticist to every inpatient hospital team. But point taken...predictions are difficult.

But it seems plausible to me that there is certainly greater concern for NP's and PA's to invade lots of medical specialties than waiting for an explosion of medical technology/therapy in say...acute stroke.

I'm not sure I stated this clear enough...but my drift is that because of federal impetus and perceived cost savings invasion of ER mid-levels seems more probable than plenty of people (including myself) would care to admit.

 

[danielmd06]

I've worked with a lot of NPs and PAs at ~7 different hospitals. Some are quite good and some aren't. None of them are comfortable managing a truly sick patient and most of them aren't comfortable even doing what I consider bread and butter EM-chest pain and abdominal pain.

First of all, thanks to both ER attendings for answering my questions. I didn't say that before.

I guess I'm still waiting to hear this concept specifically addressed (beyond just "they aren't skilled/comfortable enough to do it"):

The whole idea of physician expanders as applied to anesthesia (or primary care too) is that they are force-multipliers. It seems to me (in my admittedly limited experience) that there are plenty of non-sick people in the ER that an NP or PA could easily take care of with a physician supervisor (or maybe without one for many of the non-sick ones). The ER physicians would, of course, still be expected to see the sicker patients and any patients that the mid-levels had questions about. Maybe they would supervise the mid-levels on ALL of the cases that they saw. Such a practice as the latter would STILL save time. Like residents function for ER in an academic setting.

Since lots of ER medicine seems to devolve into streamlined histories, exams, pre-set algorithm labs/scans, and lots of consultations to specialists or internists...it begs my question of why someone with less training couldn't do the same job with supervision?

 

[Apollyon]

Since lots of ER medicine seems to devolve into streamlined histories, exams, pre-set algorithm labs/scans, and lots of consultations to specialists or internists...it begs my question of why someone with less training couldn't do the same job with supervision?

You seem to have a preconceived idea into which your fold your arguments.

The doctor doesn't need to be there for maybe 90 or 95% of the ED patients, appys, choles, or child births - it's the 5 or 10% that are not straightforward that need the doctor. That is NOT the time to go halfway or "almost as good". Which would you prefer for your grandmother - holding her hand and telling the family that, although uncomfortable, we'll make her passing better by giving her pain meds, or me doing a pericardiocentesis, and she can now breathe and feels a LOT better, and is not going to die?

Hell, most of medicine could be done by a monkey, or a machine. It's that percent of the unknown why we're there.

You speak of "force multipliers" - how many riflemen do you need? Then squad leaders, then platoon leaders, then company commanders, then battalion commanders? You're right - the "bullet catchers" can do most of the work. When the "big guns" are needed, they're ready to roll.

 

[AmoryBlaine]

One thing that is 100% certain is that you should not let a single (or even multiple) prophetic voice influence your specialty decision in any way. None of us can really predict was is going to happen.

That said, the studies on the EM doc workforce never predict a surplus and usually predict a pretty large shortage. ED visits are not decreasing anywhere. The ED has become a central point (one could argue the central point) in the American healthcare system. I make no comment on whether this is good, bad, or neutral but it is a fact.

The reason I don't worry about NPs in EM is threefold:

1. CRNAs have not made life worse the anesthesiologists (quite the opposite in most cases).

2. Mid-levels have not broken into any field other than anesthesia in any meaningful way.

3. There will always be a huge role in EM for the presence of well-trained docs. That whole "anything could come through the door" aspect of EM will mandate it. No hospital will want to be the place where the young person with acute upper airway obstruction died b/c the 2 mid-levels were unable to secure the airway and there was no MD backup.

 

[deleted65604]

http://forums.studentdoctor.net/showthread.php?t=522952

This thread is from the FAQ page at the top of the ER page. Good discussion a couple of years ago.

Interesting comment in that discussion:

Nobody's proposing single payer either. I wish they were, but that's just another straw man at this point.

What about the following clip? Are they proposing a single payer system?

http://www.washingtonexaminer.com/p...ama-wants-a-single-payer-system-52699182.html

http://www.pnhp.org/news/2008/june/barack_obama_on_sing.php

My point in adding this is that I believe the biggest danger to ER is not PAs/NPs, but the increasing involvement of government in medicine in general. ER will not fall without the fall of the entire house of medicine. The same issues facing us, face all physicians.

 

[danielmd06]

You seem to have a preconceived idea into which your fold your arguments.

Right. I'm asking for clarification. In no way am I attempting to attack EM as a field. And judging from the posted links I've just read...I'm not the only one to have such arguments. Plenty of ER people are asking these questions, too.

The doctor doesn't need to be there for maybe 90 or 95% of the ED patients, appys, choles, or child births - it's the 5 or 10% that are not straightforward that need the doctor. That is NOT the time to go halfway or "almost as good". Which would you prefer for your grandmother - holding her hand and telling the family that, although uncomfortable, we'll make her passing better by giving her pain meds, or me doing a pericardiocentesis, and she can now breathe and feels a LOT better, and is not going to die?

Well obviously I choose the better care. It's why I support physicians versus physician expanders in ALL areas of medicine. But how often are you doing those pericardiocenteses? I expect there to always be a board certified ER doctor (or three) to be present for cases like this.

Hell, most of medicine could be done by a monkey, or a machine. It's that percent of the unknown why we're there.

I totally disagree with you on this. Maybe a "monkey" could do most of the work in *some* specialties. But I cannot believe it would fly with complex practices like Ophthamology, Neurosurgery, Cardiology, and Radiology (to name a handful and purposefully excluding my own).

You speak of "force multipliers" - how many riflemen do you need? Then squad leaders, then platoon leaders, then company commanders, then battalion commanders? You're right - the "bullet catchers" can do most of the work. When the "big guns" are needed, they're ready to roll. But we're in agreement about this point, aren't we? You'll always need "big guns," but that's not an argument against having more "bullet catchers." If anything, you need more foot soldiers...

 

[Antibodies]

One thing that is 100% certain is that you should not let a single (or even multiple) prophetic voice influence your specialty decision in any way. None of us can really predict was is going to happen.

That said, the studies on the EM doc workforce never predict a surplus and usually predict a pretty large shortage. ED visits are not decreasing anywhere. The ED has become a central point (one could argue the central point) in the American healthcare system. I make no comment on whether this is good, bad, or neutral but it is a fact.

The reason I don't worry about NPs in EM is threefold:

1. CRNAs have not made life worse the anesthesiologists (quite the opposite in most cases).

2. Mid-levels have not broken into any field other than anesthesia in any meaningful way.

3. There will always be a huge role in EM for the presence of well-trained docs. That whole "anything could come through the door" aspect of EM will mandate it. No hospital will want to be the place where the young person with acute upper airway obstruction died b/c the 2 mid-levels were unable to secure the airway and there was no MD backup.

I don't see any anesthesiologist rejoicing over CRNAs in the anesthesia forum. (Quite the opposite)

 

[Charles_Carmichael]

The doctor doesn't need to be there for maybe 90 or 95% of the ED patients, appys, choles, or child births - it's the 5 or 10% that are not straightforward that need the doctor. That is NOT the time to go halfway or "almost as good". Which would you prefer for your grandmother - holding her hand and telling the family that, although uncomfortable, we'll make her passing better by giving her pain meds, or me doing a pericardiocentesis, and she can now breathe and feels a LOT better, and is not going to die?

Hell, most of medicine could be done by a monkey, or a machine. It's that percent of the unknown why we're there.

It's a little disheartening to hear such comments from a physician. Now I'm left wondering why I'm considering entering into this field (medicine) if I'm only going to be useful (compared to midlevels) in 5-10% of the cases I'll see.

I feel that these are the exact arguments nurses will make to justify that they should be favored above physicians. It's going to come down to a cost/benefit argument. Is it worth it to spend hundreds of thousands (millions?) of dollars more on physicians if they're only useful in 5-10% of the cases? And, honestly, if that's truly how it is, I cannot imagine a future where nursing midlevels do not have the same scope of practice as physicians. Like I said previously, it's getting close to the point, in terms of cost, where the public will be willing to say that second best is "good enough." And if physicians confirm it by saying that they're only better than midlevels in a very small percentage of cases, why shouldn't the public and the lawmakers support the midlevels over physicians?

 

[Charles_Carmichael]

I don't see any anesthesiologist rejoicing over CRNAs in the anesthesia form. (Quite the opposite)

Agreed. The ASA is having a hell of a time fighting the AANA. It's too late though. Unless something drastic happens (ie. something along the lines of a huuuuge public ad campaign), it is very likely that, during our careers, the CRNA will be fully equivalent to an anesthesiologist.

 

[Apollyon]

It's a little disheartening to hear such comments from a physician. Now I'm left wondering why I'm considering entering into this field (medicine) if I'm only going to be useful (compared to midlevels) in 5-10% of the cases I'll see.

That 5-10% is fulfilling. Also, the straightforward stuff also can be fulfilling - when I don't have to expend the brainpower or technology to figure out something (when it takes me - literally - seconds to maybe a minute to figure out what is something, vs someone less trained who take minutes or, maybe, hours to get to the same result), I can talk with the patients, and develop rapport, or maybe just make their day a bit better while treating their problem (instead of making their day better instead of treating their problem).

If it's more than 20 or 25% of the time, that gets draining on you. It's not like the way they showed it on TV - that would burn anyone out.

Edit: the problem is that the 5-10% is randomly distributed, so the doc has to be there. To farm it out to a midlevel can happen, but the doc still needs to be there to do it.

And it's just the way it is with child birth or straightforward operations - there is a lot of technical competence needed in medicine without intellectual power.

 

[Apollyon]

Hell, most of medicine could be done by a monkey, or a machine. It's that percent of the unknown why we're there.

I totally disagree with you on this. Maybe a "monkey" could do most of the work in *some* specialties. But I cannot believe it would fly with complex practices like Ophthamology, Neurosurgery, Cardiology, and Radiology (to name a handful and purposefully excluding my own).

Totally disagree? 100%? Really? No question? At all?

In 100 years, the Da Vinci robots will be doing it automatically, without a human hand, more precisely. Ophtho, neurosurg, cards, rads? Absolutely. Ophtho and neurosurg - as a neurosurgeon told me, "I don't have to be smart, but precise - but we tend to be smart, and that's by tradition - that's who we are, and that's who we select to train". The flap made for my LASIK, when another doc saw it, he asked if it was done by machine (actually by hand, by one of the top 12 in the country); the surgery itself was all automated (25X more accurate than manual). How does a cardiologist estimate EF? Visually, exclusively. No hard science. Rads is pattern recognition, and the computers of today just don't have the juice to make something of that lung nodule.

You purposefully (apparently) don't mention your specialty, so I don't know know what field you feel is especially outside the realm of automation. Psych? Even then, a talking machine that can "emote" will work for a LOT of people. (I can't find the article from the mid 90s from the UK that said that sincerity is best, but, failing that, faking it is just as good.)

Medicine just ain't all of that. People have been around for 10,000 years before doctors. We haven't even had antibiotics for 100 years yet. What killed Cro-Magnon man? Dental abscess. Life expectancy is longer due to hand washing, public sanitation, and antibiotics.

 

[Coastie]

This is the completely wrong argument with regards to crnas and mds. In anesthesiology, quite often, things can go from calm to crazy in a matter of seconds. The potential for damage in the OR is just as great or greater...If you don't believe me, come watch somebody come off pump in an open heart room.

Listen, CRNAs are the "marines of nursing". Anesthesiologists screwed it up bigtime,and I think our specialty may go away because of it.

It took them decades to get to this point, but the next specialty that falls won't take as long. Why? Because they've broken down so many barriers through legislation and lies that the next time will be easier.

NPs just came out with a study claiming equivalence to ER docs for "minor ailments". Yeah, minor ailments? O RLY? The study was poor, but who cares? Noctors definitely don't. Combine that with DNPs, already existing "residencies" in other specialties for the noctors, you have a DANGEROUS situation.

It isn't just about one specialty now, it's about laying the groundwork for taking over all of medicine by saying DNP = MD.

DONT follow our mistakes in anesthesiology. Fight this as hard as you can, tooth and nail, or else you'll be sorry..and so will the public when they show up to the ED only to be met by Dr. Nurse Robert, LPN, RN, BSN, ARNP, DNP, LMFAO

I hear what you are saying, and they are very valid arguments. However, an important aspect that has been brought up before in this discussion is that in Anesthesia, the vast majority of the time (and 100% of the time a CRNA is the anesthetist) the situation is well controlled, straight forward, allows for preparation, screening of difficult cases, and anticipatory referral to an MD if things look like they might get complicated. Very often in the ED there is no way to tell what the situation is going to be like. In fact, vis a vis intubation, we assume the patient is coming to us on a full stomach. It would seem that the potential to do some serious damage is much greater in the ED as compared to the OR.

In primary care, while consequences of mistakes may be serious, they are not usually as dramatic as in the ED. Drama sells courts and policy.

 

[Coastie]

Spot on. You're pre-med? You have a better handle on the situation than most full professors at top institutions.

While I fully agree with you and understand the logic behind what you're saying, I don't think that reality will work out just like this.

It's much more likely that the nursing midlevels will use studies (like the recent diagnostic accuracy one) that are looking at simple things and extrapolate them (wrongly) to the entire realm of a specialty. I mean, NPs/DNPs in primary care are saying that because they have better patient satisfaction than physicians, they're providing equivalent/superior care and deserve to have a full scope of practice. And it seems like things are heading that way. They've already gained independence in a number of states. With that precedent, it's hard not to imagine that in the future, all 50 states will give independence to NPs/DNPs. I think something similar could really happen to every medical specialty (even the surgical ones...if you take the time to read some nursing forums, you'll that there are many threads discussing that they should be allowed to do "minor" surgeries with a few extra classes).

All they need to do after graduating NP school is complete a "residency" (500-1000 hrs) for them to say that they're "board certified in [insert specialty]." I believe USF is already offering nursing residencies in lucrative specialties like derm, cardiology, etc.

With things like this happening with relative ease (ie. doesn't look like physicians are really trying to stop this...or maybe they just don't care enough), it's hard not to be worried about the future of medicine. Particularly when I'm currently in the process of applying and won't be practicing independently for another decade, when things might be drastically different.

 

[Coastie]

One thing that is 100% certain is that you should not let a single (or even multiple) prophetic voice influence your specialty decision in any way. None of us can really predict was is going to happen.

That said, the studies on the EM doc workforce never predict a surplus and usually predict a pretty large shortage. ED visits are not decreasing anywhere. The ED has become a central point (one could argue the central point) in the American healthcare system. I make no comment on whether this is good, bad, or neutral but it is a fact.

The reason I don't worry about NPs in EM is threefold:

1. CRNAs have not made life worse the anesthesiologists (quite the opposite in most cases).

2. Mid-levels have not broken into any field other than anesthesia in any meaningful way.

3. There will always be a huge role in EM for the presence of well-trained docs. That whole "anything could come through the door" aspect of EM will mandate it. No hospital will want to be the place where the young person with acute upper airway obstruction died b/c the 2 mid-levels were unable to secure the airway and there was no MD backup.

You're wrong, man. Fight any hint of NP to the bone in EM. You guys are definitely not immune by any stretch. CRNAs have made our lives worse, overall. Supervision sucks, and they are trying to destroy our medical specialty.

Mid-levels are cracking through all over the place, and while CRNAs are the marines, they have broken down the wall, and are pouring into every specialty with a vengence...

EM docs will always be around, but your airway example isn't a good one. I'd wager the average CRNA is better than 99% of EM attendings at airway..If you intubate as much as they do, you're bound to be better than someone who doesn't do it as often.

 

[gro2001]

I'd wager the average CRNA is better than 99% of EM attendings at airway..If you intubate as much as they do, you're bound to be better than someone who doesn't do it as often.

I somewhat disagree with that. From my admittedly limited experience in both fields, it seems that most of the intubations in the ED are rapid sequence inductions (with paralysis, obviously) while in the OR most practitioners prefer to intubate without paralysis. There are advantages and disadvantages to both, with RSI being more suitable in the ED while IMP (intubation minus paralysis) is more suitable in the OR, the ICU, etc. So it is really 2 very different experiences: RSI on a full stomach patient that may have just been seizing vs IMP on a fasting, pre-assessed patient who is always sufficiently pre-oxygenated. Even if they do more of the latter, that does not make them better at the former.

 

[Apollyon]

EM docs will always be around, but your airway example isn't a good one. I'd wager the average CRNA is better than 99% of EM attendings at airway..If you intubate as much as they do, you're bound to be better than someone who doesn't do it as often.

From what I saw at Duke, I wouldn't give them 99%. By one's own admission, he was a "Miller cripple" - said he had never, in 30 years, used a Mac, and probably couldn't if he had to. He was working ASA-1 and 2 cases at an ASC.

There was a trauma patient I actually held the inline stabilization right into the OR. The CRNA was to intubate. Pt starts to puke - reflexive by the CRNA was to turn the head (while I'm holding stabilization). Good thing I was good at my job. The anesthesiologist bumped her right out of the way (after the surgical attending almost blew a gasket), suctioned the pt, and got the trauma tube in cleanly.

How many CRNAs are tubing crash airways that haven't been NPO since midnight, premedicated with some glyco or atropine, and not optimized? If all you do is B or C-ball, what happens when you step up to AAA or the major leagues?

 

[Coastie]

I somewhat disagree with that. From my admittedly limited experience in both fields, it seems that most of the intubations in the ED are rapid sequence inductions (with paralysis, obviously) while in the OR most practitioners prefer to intubate without paralysis. There are advantages and disadvantages to both, with RSI being more suitable in the ED while IMP (intubation minus paralysis) is more suitable in the OR, the ICU, etc. So it is really 2 very different experiences: RSI on a full stomach patient that may have just been seizing vs IMP on a fasting, pre-assessed patient who is always sufficiently pre-oxygenated. Even if they do more of the latter, that does not make them better at the former.

The above situation isn't a realistic picture of anesthesiology airways. Take ED airways as our baseline (admittedly, we do have chipshots as well), and then also add calls from the ED for airways that have been manipulated >4 times already.

We also intubate all ages regularly (on average). We also use relaxant for nearly every airway, except peds.

 

[Coastie]

Most CRNAs have zero advanced airway skills, I'll give you that. Maybe the 99% thing was a stretch, but if you have CRNAs intubating ~ 50 times a month, and you have an EM attending intubating..what....5-10 times a month? The CRNAs will be better, on average. Remember, not all anesthesia airways are as described by the med student above...We have trauma, we have fatties, we have floor intubations, we have non-NPO cases, etc.

I hope zero CRNAs are intubating the situation you described, I think they should be limited to ASA1/2's (supervised) anyway. Fat chance of that happening, though. 🙁

Of note, regarding blades: If you're an all-star at a MAC (which I'm not saying the Duke guy was..and btw, Duke CRNAs are generally arrogant and way, way out-of-line I'm told), and you suck at a miller, why not just stick to mac?

Of my intubations (N>1000), except for kiddies, I've never found the airway to "require" a miller. It's all about how you use the mac. I've used both, just for practice, but I love the mac 3..and can intubate a gravid ant (to quote some anesthesia guys) with it in just about any situation.

From what I saw at Duke, I wouldn't give them 99%. By one's own admission, he was a "Miller cripple" - said he had never, in 30 years, used a Mac, and probably couldn't if he had to. He was working ASA-1 and 2 cases at an ASC.

There was a trauma patient I actually held the inline stabilization right into the OR. The CRNA was to intubate. Pt starts to puke - reflexive by the CRNA was to turn the head (while I'm holding stabilization). Good thing I was good at my job. The anesthesiologist bumped her right out of the way (after the surgical attending almost blew a gasket), suctioned the pt, and got the trauma tube in cleanly.

How many CRNAs are tubing crash airways that haven't been NPO since midnight, premedicated with some glyco or atropine, and not optimized? If all you do is B or C-ball, what happens when you step up to AAA or the major leagues?

 

[Apollyon]

...and can intubate a gravid ant (to quote some anesthesia guys) with it in just about any situation.

Gravid FIRE ant, brother!

 

[BADMD]

There is an additional concern and it is one that we may not be able to defend against.

Yet another analysis has predicted a shortage of physicians, across all fields: http://www.medicalnewstoday.com/articles/203179.php

We may find that NPs are able to worm their way into EDs simply because they are there. These programs are shorter and easier to set up than a residency program. NPs, are also much cheaper to train. The programs that train them can respond much more rapidly to turn out additional NPs.

Initially ED groups may be reluctant to higher in NPs into roles that are traditionally for EPs, but may start, as they are going to need bodies to fill positions. However, I suspect that hospital administration will quickly enjoy the cost saving of employing an NP directly. Need will be the first justification, then administrators will bend overbackward, to support NP only practice, especially at smaller EDs.

I don't think we can stop this by yelling and screaming. What I think we need to do is start creating clear distinctions and rules. Establish early on what the standard for NPs are and firmly oppose all attempts to stretch. I realize this has been a losing strategy for Anesthesia, but has worked for Critical Care. I suspect we are already too late to prevent them from entering the realm of EM in the next 5-10 years.

 

[danielmd06]

Other people are making and defending my same argument. I'm worried about mid-level encroachment into medicine, and I feel that EM is an area that is an inviting target. The arguments that it won't happen in EM that are being offered here aren't very convincing. As others are stating more eloquently than I.

Totally disagree? 100%? Really? No question? At all?

Yes. Yes. Really. No question. At all.

In 100 years, the Da Vinci robots will be doing it automatically, without a human hand, more precisely. Ophtho, neurosurg, cards, rads? Absolutely.

No matter how advanced, the robots are still controlled by humans. They don't think. They don't do the work by themselves. You still need an operator and you always will. You think robots will give prenatal care and deliver babies, too?

Yeah, I could be wrong, but this just reminds me too much of television programs in the 1950's talking about how we would be living in pressurized cities on Mars in 100 years. And have Jetson-esque spaceships and robot maids, too. My wife is still pushing a vacuum cleaner around, and housewives still spend just as much time on housework as the did in the 1960's don't they? This is in line with "every inpatient team will have a geneticist because we'll utilize gene therapy for curing everything."

Right now, I'd settle for better antivirals and cures for myasthenia gravis, multiple sclerosis, ALS, or myotonic dystrophy. Yeah, right. Here's hoping.

You purposefully (apparently) don't mention your specialty, so I don't know know what field you feel is especially outside the realm of automation.

I'm in neurology. I didn't mention it in lieu of other specialties because I was trying to avoid talking like my personal field couldn't be easily done by a robot or mid-level. And I said some fields which I thought were "more" outside the purview of automation. Another would be Pulmonology. Let's take Ophthamology. An eye exam is subtle. I'm personally terrible at it. And differences on what you see can lead you down very different treatment paths. A robot is going to do this? A mid-level? Most doctors can't. I suppose we'll have to agree to disagree.

Overall, I'm just saying that I think certain specialties like FP and EM are much more vulnerable to mid-level encroachment than you seem to think, and I was hoping to hear solid arguments about why I was wrong. So far, I really haven't, though I'd like to. Many of the reasons (including some I hadn't thought of) why EM is arguably more vulnerable than some other specialties are suggested by EM people and debated in the link posted above.

Medicine just ain't all of that. People have been around for 10,000 years before doctors. We haven't even had antibiotics for 100 years yet. What killed Cro-Magnon man? Dental abscess. Life expectancy is longer due to hand washing, public sanitation, and antibiotics.

Sorry. I respectfully disagree once again. You're saying that technology is so awesome that it'll replace neurosurgeons in 100 years, but that it hasn't helped us much beyond hand washing and antibiotics in the past 10,000? Medicine is a wonderful area to spend your life working. Look at the advancements in cancer, stroke, critical care, heart attack, on and on and on. I think those advancements have helped us a bit in the life expectancy category too, no?

Anyway. Best wishes. Interesting thread.

 

[Apollyon]

Overall, I'm just saying that I think certain specialties like FP and EM are much more vulnerable to mid-level encroachment than you seem to think,

I don't think that EM is not vulnerable to our turf being appropriated. There just aren't enough bodies to go around. CRNA mills are pouring out grads. However, OR beds are relatively static. The ED has an open door, and the numbers just keep going up. More providers are needed, and the NPs are divvied up between all sorts of disciplines, whereas the CRNA is a one-track operation.

I see that things could change, but I don't see it with as dire an immediate prognosis as is occurring with anesthesiology.

 

[dilated]

I've worked with a lot of NPs and PAs at ~7 different hospitals. Some are quite good and some aren't. None of them are comfortable managing a truly sick patient and most of them aren't comfortable even doing what I consider bread and butter EM-chest pain and abdominal pain.

My reimbursement may go down in the future for lots of different reasons, but this isn't one I worry much about.

Good one. I was shocked to interview at a "Top 10 US News" hospital where the NPs have their own resident-free autonomous ICU team that has only cursory attending supervision. If you think they can largely run a unit and not think they can handle the ED you've got another thing coming.

There are also "critical care residencies" popping up for PAs. I'm sure there will be one for NPs soon. They'll (claim to) be plenty comfortable with sick patients. Bury your head in the sand at your own risk.

 

[Charles_Carmichael]

That 5-10% is fulfilling. Also, the straightforward stuff also can be fulfilling - when I don't have to expend the brainpower or technology to figure out something (when it takes me - literally - seconds to maybe a minute to figure out what is something, vs someone less trained who take minutes or, maybe, hours to get to the same result), I can talk with the patients, and develop rapport, or maybe just make their day a bit better while treating their problem (instead of making their day better instead of treating their problem).

If it's more than 20 or 25% of the time, that gets draining on you. It's not like the way they showed it on TV - that would burn anyone out.

Edit: the problem is that the 5-10% is randomly distributed, so the doc has to be there. To farm it out to a midlevel can happen, but the doc still needs to be there to do it.

And it's just the way it is with child birth or straightforward operations - there is a lot of technical competence needed in medicine without intellectual power.

It doesn't matter if that 5-10% (or the rest) is fulfilling or not. It also doesn't matter if that 5-10% is randomly distributed. The only thing that matters is that when a cost/benefit analysis is done, and when physicians agree that 90-95% of the time their jobs could be done by people with less than 10% of their training, the lawmakers and lay public will be swayed by the nursing midlevels. Why spend millions of dollars on extra training and reimbursing physicians if midlevels can take care of 90-95% of the things that walk through the door at a fraction of the cost? It's as simple as that.

And that's exactly the argument the nursing organizations are making. That they're cost-effective compared to physicians. And because they're cost-effective and "equivalent (superior in many cases too!)" to physicians, they deserve to have the same scope of practice as physicians.

I don't get the whole "it's not going to affect me or my career" kind of thinking either. That's what the anesthesiology attendings of old did and look how they screwed over the current residents/junior attendings. Once the ball really starts rolling (in terms of the NP/DNP movement), it's going to be very hard to stop. The only way to be effective, really, is to make sure that the ball never begins to move in the first place. Unfortunately, it's much too late for that and the movement's already gaining significant momentum. Unless physicians take action soon, instead of being complacent, it will be too late in a few years to do anything about it. Remember, once a law is passed, it's very hard to get rid of it.

 

[Apollyon]

It doesn't matter if that 5-10% (or the rest) is fulfilling or not. It also doesn't matter if that 5-10% is randomly distributed.

You questioned whether you even should become a doctor. You said that what I'd said disheartened you. To me, yes, it does matter. For you to say it doesn't, well, I can't help you with that. I can't make all the people that come into the ED need the intense, nuanced brilliance of a highly educated and trained doctor. If medics in the military can do lacerations by protocol, well, how complex can you make that? How often does the police officer have to shoot someone? On how many calls do firefighters have to go to deploy a hose and actually put out a fire? How often is the plumber really needed when he makes a house call? In many, many professions, much of the job is not the pinnacle for which everyone is trained in their specific discipline.

Only about half of the spots in EDs are filled by EM trained/boarded docs. As I said, visits keep going up (so the theoretical number of beds increases). It's different than the anesthesiologists who are competing with CRNAs for finite OR beds.

My head is not in the sand. It is good to look at trends, but the sky is not falling.

 

[Arcan57]

It's a little disheartening to hear such comments from a physician. Now I'm left wondering why I'm considering entering into this field (medicine) if I'm only going to be useful (compared to midlevels) in 5-10% of the cases I'll see.

I feel that these are the exact arguments nurses will make to justify that they should be favored above physicians. It's going to come down to a cost/benefit argument. Is it worth it to spend hundreds of thousands (millions?) of dollars more on physicians if they're only useful in 5-10% of the cases? And, honestly, if that's truly how it is, I cannot imagine a future where nursing midlevels do not have the same scope of practice as physicians. Like I said previously, it's getting close to the point, in terms of cost, where the public will be willing to say that second best is "good enough." And if physicians confirm it by saying that they're only better than midlevels in a very small percentage of cases, why shouldn't the public and the lawmakers support the midlevels over physicians?

Ok, here's a way of thinking about the idea of relatively few cases requiring an MD. What percentage of MIs are you willing to miss? What percentage of MIs are the people that pay your salary willing to miss? If one out of ten or one out of twenty patients thats walks into the emergency department has a preventable bad outcome, how long do the ED providers get to stay employed and how many millions does that hospital pay out in settlements?

I guarantee you that if 10% or even 5% of anesthesia cases required an MDs skill to prevent a bad outcome AND you had no way of preselecting patients based on risk then no one would ever have heard of CRNAs

 

[Coastie]

Ok, here's a way of thinking about the idea of relatively few cases requiring an MD. What percentage of MIs are you willing to miss? What percentage of MIs are the people that pay your salary willing to miss? If one out of ten or one out of twenty patients thats walks into the emergency department has a preventable bad outcome, how long do the ED providers get to stay employed and how many millions does that hospital pay out in settlements?

I guarantee you that if 10% or even 5% of anesthesia cases required an MDs skill to prevent a bad outcome AND you had no way of preselecting patients based on risk then no one would ever have heard of CRNAs

We bail out CRNAs all the time, so your % game is off.

Listen, we docs have to stick together. EM is at much greater risk than you guys appear to think it is...I don't buy the "finite OR beds" argument either. We have to band together and squash these midlevels who are destroying medicine before it's too late.

 

[Apollyon]

I don't buy the "finite OR beds" argument either.

What I meant by that is, regardless of the demand for the OR, #s of OR beds are not increasing, and the irony of the CRNA is that, if it was to work 24 hours a day in shifts in the OR to make most use, they wouldn't.

But I do agree - we have to stick together.

 

[Arcan57]

We bail out CRNAs all the time, so your % game is off.

I should have said, nobody would ever have heard of SOLO CRNAs. I wasn't saying that 5% of anesthesized patients needed an MD. I was pointing out that a 1:20 patients with preventable bad outcomes is outrageously high. The premeds posting on here don't seem to understand how little risk we will tolerate. I don't know your recent literature, but isn't the fatality rate for anesthesia somewhere in the 1:10,000 range?

 

[danielmd06]

But I do agree - we have to stick together.

Absolutely agree, too.

 

[WilcoWorld]

Listen, we docs have to stick together. EM is at much greater risk than you guys appear to think it is...I don't buy the "finite OR beds" argument either. We have to band together and squash these midlevels who are destroying medicine before it's too late.

Genuine, interested question here; What action(s) do you suggest we take?

 

[Taurus]

Genuine, interested question here; What action(s) do you suggest we take?

First and foremost, kick the NP's out of the ED. Replace them with PA's.

Do real studies to demonstrate differences. This will directly undercut the NP's arguments that they are equivalent to physicians. You guys need to understand how important these bogus studies are to the NP's. They use the studies as a launching pad to advance their agenda with lawmakers and hospitals.

 

[Hamhock]

First and foremost, kick the NP's out of the ED. Replace them with PA's.

Do real studies to demonstrate differences. This will directly undercut the NP's arguments that they are equivalent to physicians. You guys need to understand how important these bogus studies are to the NP's. They use the studies as a launching pad to advance their agenda with lawmakers and hospitals.

I am fully behind anesthesiologists and against the idea of solo CRNAs...please don't doubt me on that...and I feel that other fields must carefully watch or perhaps even act against similar situations.

However, I have some trouble with anesthesiologists suggesting that EM docs "kick the NPs out of the ED" and "do real studies to demonstrate differences" when, at least as far as I am aware, anesthesiology hasn't done that.

[It is similar to the anesthesiology attendings saying med students shouldn't apply to residencies that train CRNAs or anesthesiology residents saying attendings should work for physician-only practices]

I have seen many sham studies by CRNAs and nurses, but I am not aware of a single study by anesthesiologists showing what you suggest.

I guess I have a bad reaction to anesthesia requesting that EM should take care of this when there has not been an equivalent effort for anesthesia.

I agree we should all stick together and perhaps EM should follow your suggestions (kick out NPs, research), but I think I would be more receptive to yours suggestions if you were coming from an experience of kicking out nurses and producing such research.

Perhaps, instead, we should group together and limit DNPs in general and the idea that nurses can prescribed medication and practice medicine without supervision.

HH

 

[Taurus]

I am fully behind anesthesiologists and against the idea of solo CRNAs...please don't doubt me on that...and I feel that other fields must carefully watch or perhaps even act against similar situations.

However, I have some trouble with anesthesiologists suggesting that EM docs "kick the NPs out of the ED" and "do real studies to demonstrate differences" when, at least as far as I am aware, anesthesiology hasn't done that.

[It is similar to the anesthesiology attendings saying med students shouldn't apply to residencies that train CRNAs or anesthesiology residents saying attendings should work for physician-only practices]

I have seen many sham studies by CRNAs and nurses, but I am not aware of a single study by anesthesiologists showing what you suggest.

I guess I have a bad reaction to anesthesia requesting that EM should take care of this when there has not been an equivalent effort for anesthesia.

I agree we should all stick together and perhaps EM should follow your suggestions (kick out NPs, research), but I think I would be more receptive to yours suggestions if you were coming from an experience of kicking out nurses and producing such research.

Perhaps, instead, we should group together and limit DNPs in general and the idea that nurses can prescribed medication and practice medicine without supervision.

HH

I do not speak on behalf of anesthesia or any particular medical group.

If you follow my posts, I am interested in defending every corner of medicine from the encroachment of nursing. Whether that be in anesthesia, primary care, or EM. Because if one area falls, it creates a dangerous precedent for more areas of medicine to fall. We, as physicians, should never let that happen. We need to see this attack on anesthesia, primary care, and EM as an attack on us all.

Let's be clear on what the goals of nursing is. They want equivalency in every way as physicians (respect, hospital privileges, income levels) and they want to practice independently in every setting (the founder of the DNP degree even flatly states this). They want all of this for a fraction of the time and cost of becoming a physician. What they can't achieve through training, they publish garbage studies to claim equivalency. Probably the most dangerous and poorly recognized goal of nursing is that they want to control referral patterns. They want to see patients in their primary care clinics and then be able to refer to their NP cardiologist or dermatologist colleague. They are in the process of creating residencies for DNP's in various fields like derm, cards, EM, etc. You know it's just a matter of time before a "residency-trained derm" NP claims that they are equivalent to a derm physician. And so on and so on.

We as physicians have to ask what do we want our future to look like? What do we want for our patients?

My issue with nursing is that I am highly offended when an inferiorly trained group uses garbage studies, deceptive tactics, propaganda, and political lobbying to achieve their goals instead of putting in the time and hard work on the wards and clinics.

 

[Charles_Carmichael]

You questioned whether you even should become a doctor. You said that what I'd said disheartened you. To me, yes, it does matter. For you to say it doesn't, well, I can't help you with that. I can't make all the people that come into the ED need the intense, nuanced brilliance of a highly educated and trained doctor. If medics in the military can do lacerations by protocol, well, how complex can you make that? How often does the police officer have to shoot someone? On how many calls do firefighters have to go to deploy a hose and actually put out a fire? How often is the plumber really needed when he makes a house call? In many, many professions, much of the job is not the pinnacle for which everyone is trained in their specific discipline.

Only about half of the spots in EDs are filled by EM trained/boarded docs. As I said, visits keep going up (so the theoretical number of beds increases). It's different than the anesthesiologists who are competing with CRNAs for finite OR beds.

My head is not in the sand. It is good to look at trends, but the sky is not falling.

Ok, here's a way of thinking about the idea of relatively few cases requiring an MD. What percentage of MIs are you willing to miss? What percentage of MIs are the people that pay your salary willing to miss? If one out of ten or one out of twenty patients thats walks into the emergency department has a preventable bad outcome, how long do the ED providers get to stay employed and how many millions does that hospital pay out in settlements?

I guarantee you that if 10% or even 5% of anesthesia cases required an MDs skill to prevent a bad outcome AND you had no way of preselecting patients based on risk then no one would ever have heard of CRNAs

Don't get me wrong. I really do understand what you're saying and I really do appreciate the time you're taking to respond to me. When I said I was disheartened, I meant it kind of like "Why am I willing to go through the rigors of med school/residency if according to the nurses, and you, I can pretty much do everything a physician can do by taking easy online courses for a year or two?" I wasn't questioning the fulfillment that medicine offers.

What I'm saying though, is the the nurses and the public will not see it that way and are likely to think in that rigid cost/benefit way I presented my material. It's getting to the point where cost is the overwhelming biggest problem with the health care system. And if it keeps increasing further, it will cause the public to say that second best is good enough (especially if they can handle 90-95% of all cases) because second best costs a lot less than the best.

I absolutely agree with you and others that all physicians need to band together and fight against this encroachment. That's really the only way to slow the movement down (along with public campaigns, etc).

 

[Arcan57]

Kaushik,
Unless there is significant tort reform, the economic incentive is there to miss nothing. In reality, most of the common acutely deadly diseases (MI, PE, etc) hover around a 1-2% miss rate. And we spend hundreds of millions TRYING to drive that rate down to 0%. Why? Because each miss is so expensive to litigate that it makes economic sense to admit every young, low-risk chest pain, even if the literature says stressing people under 40 yo is useless. So unless you are specifically able to exclude potentially high-risk presentations, doctors end up being cheaper than solo mid-levels to their employers.

Store-based clinics work because the list of diseases they treat don't actually require treatment in the vast majority of cases. URIs and sprains (at least acutely) don't require medical treatment, and it's not suprising that the NPs are able to show equivalence for those diseases. Solo CRNAs work (from an economic standpoint) because anesthesiologists have become very proficient at prospectively identifying difficult cases, have established guidelines regarding these cases, and the CRNAs can usually refer those cases to another center.

 

[jbar]

One question is if mid levels in the ED really are cheaper. I know they are in terms of salary, but I wonder how utilization patterns differ for tests like CTs for the same kind of patients. I would expect that people with less training would be more likely to fall back on testing and admission because they don't feel comfortable with being able to justify "this person probably does't have a PE so I won't scan them." Or if there are more referrals because they are able to handle less fractures without ortho coming to splint, etc.

I'm don't know that this is true, but I don't think we should assume that just because someone with less training has a lower salary they are cheaper for the system. You have to look at cost of insurance, lawsuits, length of stay of the patient, tests used, supplies used etc.

 

[FulfilledDeer]

Someone mentioned that what is really needed are good studies showing non-equivalence between the care of NP's and MD's (or DO's....but that just didn't have the same rhythm). I'm actually in a bit of a position to (maybe) do a study like that - I have strong ties to the Statistics Department (well, whatever it is called now) at the University of Denver, and I know that I can get a couple of statisticians (including a program evaluator) in on this. I'm actually late to work so I haven't done any research on this topic at all yet, but what exactly would need to be in the study? That is to say, for people working with NP's, where do you see the gaps, and what kind of study (how) should be designed to illuminate these differences?