Which specialties are most immune from midlevel turf wars?

[footcramp]

Two questions, does midlevel involvement actually make life/salary better for physicians? Anesthesia was a very unpopular field because of the fear of CRNA but if anything they're richer than before. Same with primary care that incorporates PAs. The PAs in those practices handle the low yield cases and enable the physician to still maintain high per capita reimbursement from insurance contracts. (i.e. charge some people per procedure/intervention while being able to see all the different pts under contract with health providers, if that makes any sense)

But in case there is a long term negative impact, which specialties are the most immune? I thought surgery was the most immune but I have heard some rumblings about midlevels performing appys.

Thank you.

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[billydoc]

Two questions, does midlevel involvement actually make life/salary better for physicians? Anesthesia was a very unpopular field because of the fear of CRNA but if anything they're richer than before. Same with primary care that incorporates PAs. The PAs in those practices handle the low yield cases and enable the physician to still maintain high per capita reimbursement from insurance contracts. (i.e. charge some people per procedure/intervention while being able to see all the different pts under contract with health providers, if that makes any sense)

But in case there is a long term negative impact, which specialties are the most immune? I thought surgery was the most immune but I have heard some rumblings about midlevels performing appys.

Thank you.

I don't think that any field of medicine/surgery is completely safe from "midlevel's turf wars" or from any other physician compatitors, for that matter. PAs aren't the only mid-levels. At least as a physician you have the direct control over their practice, in most States anyway.But with advanced practice nursing (CRNA, NP,CNM)....as a doc you're pretty much srewed. They are absolutely autonomous, and are regulated by nursing, not medical boards. Many are in solo practices just hiring docs for "consulting". Hate it or love it, it's today's healthcare reality.

Good Luck

 

[neilc]

call me crazy, but every practice that i have seen that uses mid levels is pretty much thriving. the MD's work less and make more. it seems that the mid levels do the routine stuff cheaply, and the docs they work for get to bill full price and simply pay them a salary. this really applies to the PA's and NP's that are in a practice, and not autonomous.

however, i would think that by utilizing them for the routine office visits, and making good contacts with them, you could get lots of referalls for the stuff that they cannot do (ie many procedures), and therefore spend more of your time doing stuff that pays better.

i may be way off of reality, but it seems like properly utilized, they can be a huge asset, in terms of providing good care, while really not threatening (and actually potentially increasing) income.

 

[Mumpu]

Midlevels tend to do a lot of scutwork (e.g. doing all the "intern" work in some hospitalist practices). I don't see them ever replacing a physician.

 

[billydoc]

Midlevels tend to do a lot of scutwork (e.g. doing all the "intern" work in some hospitalist practices). I don't see them ever replacing a physician.

Mid-levels were never designed to replace physicians. But they do play very important role with current shortage, esp in PCP world. There are many who are happy doing what they do, naking as much $$$$ as some doctors, and having pretty good life styles. The sooner ppl realize that it's a practice based on cooperation, not compitition, the better it is for all parties involved.

 

[schutzhund]

I can assure you that there are a LOT of nurse practitioners (and others) that are looking for more than a "cooperative" role. It is human nature. I could not tell you how many times I've heard "I can do everything that a physician can" and "I know just as much as the doctor does." *Before I get slammed by the midlevels, I do have to state that I believe this is more of an issue with the nurses and not the PAs*

If you don't believe me, start looking at the nursing journals or take a look at what the nursing schools are telling their NP students. There is a HUGE push to increase autonomy and eliminate physician oversight (largely successful I might add) and to receive 100% of physician reimbursement from Medicare. Take a look at some of the recent posts in the anesthesia forum by NPs and CRNAs. Look at the increasing number of clinics that are opening staffed solely by NPs.

These are not the actions of people wanting cooperation. It may not be the majority but there are a whole bunch of midlevels that want the practice rights, autonomy, respect and equal pay as physicians.

BTW, for those of you that think I'm exaggerating the problem, I'm a "convert." I stopped pursuing an advanced practice nursing degree to go to medical school. I've personally seen their propaganda for years. The worst thing that we can do for our profession is to ignore or underplay this issue. That NP you hire to do you're "scut" and make you rich is likely using you for some experience before they try to replace you. I've seen it happen and you're naive if you don't believe it.

 

[Mumpu]

To act as the devil's advocate for a bit, primary care is in huge trouble. Physicians, having invested 4 years of college, 4 years of med school, and 3 years of residency, and gobs of money into their education are unwilling to bend over for Uncle Medicare and slave away for the rest of their lives. However, many NP's with 4 years of college-level education and some work experience (don't know the details, sorry) have much less time and money invested and would be happy settle for family doc salaries.

I'm glad someone is filling the void -- we need primary care providers. Time will tell if the quality of care is different between docs and midlevels. I suspect that if NPs act the same way as good FPs (that is, have very realistic understanding of the limits of their knowledge and skills) the quality of care for 99% of what walks through the door will be the same. As for "doctor stuff" like OB or colonoscopies, I wouldn't trust an FP anyway.

 

[MacGyver]

Surgical fields are the most immune to midlevels. There are zero NPs/PAs in this country that can replace a surgeon. However, there are many NPs who are totally replacing FPs, IMs, peds, in primary care.

Somebody said above that you can make more money with midlevels. Thats true ONLY in the interim period before the scope of practice laws get changed.

Midlevels are happy to work under MDs for the interim period. During this interim period, they are compiling data. Data showing that they do most of what an MD does with very little actual oversight. Then they take this data to the state legislatures and the representatives change the scope of practice to give them total autonomy from MDs.

After that interim period, when MDs no longer have supervising capacity over midlevels, the income of MDs will fall dramatically because they will be in direct competition with the midlevels. Midlevels are perfectly happy working for 70k per year. Which means that gradually the salaries of MDs will fall to those levels.

 

[Mman]

After that interim period, when MDs no longer have supervising capacity over midlevels, the income of MDs will fall dramatically because they will be in direct competition with the midlevels. Midlevels are perfectly happy working for 70k per year. Which means that gradually the salaries of MDs will fall to those levels.

And under what circumstances are these midlevels magically removed from requiring MD supervision and put on an equal playing field? Certainly isn't happening much in anesthesia despite their best efforts.

 

[schutzhund]

And under what circumstances are these midlevels magically removed from requiring MD supervision and put on an equal playing field? Certainly isn't happening much in anesthesia despite their best efforts.

I have to agree with MacGyver on this one, to a point anyway. As much as people knock him, he has some good points that we all should think about.

There have been attempts by midlevels, mostly successful, for increasing practice rights and autonomy in many, if not most, states recently. In fact, a friend of mine just finished his NP and had the same number of hours in classes like "Advanced Nursing as a Political Force" as he did classes in pathology. Think about that one for a minute.

It's not "magic" it's called legislation. Slowly but surely certain groups are pushing for increased autonomy and scope of practice. All it takes is some activists to persuade the legislators to change the way they are regulated and poof, no physician oversight. There is no state law that I'm aware on this issue that cannot be changed by a new superceding law. There are many states where advanced practice nursing is regulated entirely by the state board of nursing (read: no physician (or anybody for that matter) oversight)).

I've worked in healthcare for a long time and things are a' changing. Again, I think that we are largely ignoring this issue or believe it's not really a problem and it will come back to bite us.

http://www.minuteclinic.com/
http://www.takecarehealth.com/

 

[billydoc]

Surgical fields are the most immune to midlevels. There are zero NPs/PAs in this country that can replace a surgeon. However, there are many NPs who are totally replacing FPs, IMs, peds, in primary care.

Somebody said above that you can make more money with midlevels. Thats true ONLY in the interim period before the scope of practice laws get changed.

Midlevels are happy to work under MDs for the interim period. During this interim period, they are compiling data. Data showing that they do most of what an MD does with very little actual oversight. Then they take this data to the state legislatures and the representatives change the scope of practice to give them total autonomy from MDs.

After that interim period, when MDs no longer have supervising capacity over midlevels, the income of MDs will fall dramatically because they will be in direct competition with the midlevels. Midlevels are perfectly happy working for 70k per year. Which means that gradually the salaries of MDs will fall to those levels.

My info is quite to the contrary. CRNAs work absolutely indepent of MD/As. The only doc that's presnt is an operating sergeon. They are also doing their direct billing, or paid by the sergeons. It's vertually imposible to control "advance practice" nursing for a very reason that's nursing. Unlike PAs/AAs who are governed by the boards of medicine, NPs/CRNAs/CNMs are under the nursing boards. Their practice is governed by the State's Nursing Practice Act, not (un)restricted pracice of medicine. So, there isn't really much that can be done to control nursing midlevels.

 

[MacGyver]

And under what circumstances are these midlevels magically removed from requiring MD supervision and put on an equal playing field? Certainly isn't happening much in anesthesia despite their best efforts.

What the hell are you talking about? many many states have already dissolved all regulations requiring MD oversight of CRNAs.

There are some states that still require MD supervision, but they are becoming a rare animal. Furthermore, "MD supervision" of CRNAs, even where its required, is a joke. Its common for the "supervising MD" to be working in a hospital on the other side of town while the CRNA is working 100% independently. After the case, the supervising MD might call the CRNA for a 5 minute conversation. The CRNAs take note of this "supervision" and then run to the legislatures. The legislatures see that this "supervision" is a total sham, and then usualy they give the CRNAs 100% autonomy to do their own procedures.

I have no clue where you got the idea that MD supervision is required for anesthesia. The trend is moving AWAY from that and CRNAs have made huge strides in gaining independence. Might not be in your state yet, but its coming soon

 

[DigableCat]

Louisiana CRNAs want to practice Interventional Pain


Just a matter of time...

 

[person2004]

The trend is moving AWAY from that and CRNAs have made huge strides in gaining independence. Might not be in your state yet, but its coming soon

CRNA's shouldn't push it too much. It'll only take a few "Do you want your life in the hands of a nurse or a doctor during surgery?" commercials before patients start demanding anesthesiologists. CRNAs can pretend to be the same by introducing themselves as 'your anesthesia provider' etc., but if patients learn to see through this ruse you'll find your services refused. I don't think that would be good for anyone by the way, it's probably fine to have you do the boring cases, but you CRNurseAs should back off.

 

[Monty Python]

CRNA's shouldn't push it too much. It'll only take a few "Do you want your life in the hands of a nurse or a doctor during surgery?" commercials before patients start demanding anesthesiologists. CRNAs can pretend to be the same by introducing themselves as 'your anesthesia provider' etc., but if patients learn to see through this ruse you'll find your services refused. I don't think that would be good for anyone by the way, it's probably fine to have you do the boring cases, but you CRNurseAs should back off.

To begin, I'm a CRNA with 12 years fulltime experience in all types of settings (team model in private practice with anesthesiologists, completely independent in the charity hospital system [and alone at 0200 when the horrendousectomy hits the OR], completely independent deployed by the military to remote locations, etc.). I also start medical school this coming August.

My comments here are not meant to further the debate. I offer the comments strictly as facts to dispel some of the misinformation offered in previous posts.

CRNA practice is regulated by the state nurse practice act. About 50% of the state have given CRNAs completely independent practice rights. The other states mandate physician/dentist supervision of CRNA practice. (and in some of these states, the main reason is due to the paperwork required to stay in compliance with narcotics laws and pharmacy boards).

No state specifically mandates CRNA oversight by an anesthesiologist.

Hospital staff by-laws can always be more restrictive than state law, and require anesthesiologist (or simply "physician") oversight of CRNA practice.

There is an ever-increasing shortage of anesthesia providers (MDs, CRNAs, AAs) all over the country. It would be impossible to provide physician-only anesthesia in the US. Many rural areas of the country do not have an anesthesiologist in the county.

 

[Mman]

What the hell are you talking about? many many states have already dissolved all regulations requiring MD oversight of CRNAs.

Care to hazard a guess as to what percentage of general anesthetics in this country are administered by CRNA's in solo practice? It's not nearly as high as you think.

 

[Monty Python]

Care to hazard a guess as to what percentage of general anesthetics in this country are administered by CRNA's in solo practice? It's not nearly as high as you think.

Rather than guess, I refer you to this URL:

http://www.aana.com/crna/ataglance.asp

(snip) ..... Certified Registered Nurse Anesthetists (CRNAs) are anesthesia professionals who administer approximately 65% of all anesthetics given to patients each year in the United States.

CRNAs are the sole anesthesia providers in approximately two thirds of all rural hospitals in the United States, enabling these healthcare facilities to offer obstetrical, surgical, and trauma stabilization services. In some states, CRNAs are the sole providers in nearly 100% of the rural hospitals.

 

[billydoc]

Rather than guess, I refer you to this URL:

http://www.aana.com/crna/ataglance.asp

(snip) ..... Certified Registered Nurse Anesthetists (CRNAs) are anesthesia professionals who administer approximately 65% of all anesthetics given to patients each year in the United States.

CRNAs are the sole anesthesia providers in approximately two thirds of all rural hospitals in the United States, enabling these healthcare facilities to offer obstetrical, surgical, and trauma stabilization services. In some states, CRNAs are the sole providers in nearly 100% of the rural hospitals.

Hi Trinityalumnus!
Thanks for the info. I knew it only in more general terms. I'm an RN myself, accepted to a few major Carib schools (didn't apply in the States, but now really thinking I should). If you don't me asking "Why med school now?", after 12 yrs of CRNA.
Please pm me if not for the public board.
TIA

 

[neilc]

Rather than guess, I refer you to this URL:

http://www.aana.com/crna/ataglance.asp

(snip) ..... Certified Registered Nurse Anesthetists (CRNAs) are anesthesia professionals who administer approximately 65% of all anesthetics given to patients each year in the United States.

CRNAs are the sole anesthesia providers in approximately two thirds of all rural hospitals in the United States, enabling these healthcare facilities to offer obstetrical, surgical, and trauma stabilization services. In some states, CRNAs are the sole providers in nearly 100% of the rural hospitals.

the question was how many are done by CRNAs in SOLO practice. how many cases are done by solo, independent CRNAs?

 

[Monty Python]

the question was how many are done by CRNAs in SOLO practice. how many cases are done by solo, independent CRNAs?

Realizing that 28 of the 50 states have granted CRNAs independent practice, assuming that 75% of those independent CRNAs are not restrained by tighter (more restrictive) hospital by-laws, and that 50% of independent CRNAs are in solo, rural areas, we have:

N anesthetics/yr * 28/50 * .75 * .5 = approximately 21% of US anesthetics.
Add to that another percentage point or two for the military, Indian Health Service, and VA, which recognize CRNAs as "Licensed Independent Practitioners."

 

[3dtp]

I can assure you that there are a LOT of nurse practitioners (and others) that are looking for more than a "cooperative" role. It is human nature. I could not tell you how many times I've heard "I can do everything that a physician can" and "I know just as much as the doctor does." *Before I get slammed by the midlevels, I do have to state that I believe this is more of an issue with the nurses and not the PAs*

It is not just the nurses. I have heard the same comments from PAs. "We can do anything a resident can do, with just a masters."

Right now, it is virtually impossible for a GP to get a new position (ie an MD plus 1 year of residency, fully licensed). Why is this? Because a PA/NP can be had for cheaper without the cost and liability of a GP. Board certification is required of MDs to get work/practice opportunities because of the increasing use of PAs. An MD who completed 1- 2 years of residency and has an unrestricted license to practice, and a DEA number cannot find a job. In days gone by, an MD who wanted a PA spot could take a "challenge" exam and become a PA-C. Now, an MD who wants to become a PA (for the above reasons) must take the 2 year MS program and then can sit for the PA-C exam.

The mid levels have locked the doors to all but their own, they are increasing production and now lobbying for increased scope of practice. This is all bad news for MDs, especially those not boarded. Is it bad news for patients? I don't know the answer to this question. If the same quality of care is delivered, with the same depth of knowledge, then perhaps not, but the PAs by their own admission are not trained to the same depth.

Nursing is a different profession with a different outlook on patient care. At least they used to think this way, with their own role. Now, the increasing scope of practice demands of the profession are moving them into the role of the GP, without the training, and mindset of the medical school educated physician. Is this in the best interest of the patients? Again, I don't think we know the answer.

On the OPs original question, I think that nuc med, interventional and most aspects of diagnostic radiology and radiation oncology will have extremely limited to non-existant roles of MLP since they need to use radioisotopes, and the NRC has very rigorous training requirements to get source licenses.

 

[lowbudget]

Naw. I'm not too worried about it. I've seen the quality of some of their work.

If midlevels want full autonomy, they need to be prepared to take on full liability.

PA and NP Workforce Trends
http://www.graham-center.org/onepager37.xml
(My question is, if it's such a no-brainer to go with midlevels, why are the numbers falling?)

 

[sophiejane]

I suspect that if NPs act the same way as good FPs (that is, have very realistic understanding of the limits of their knowledge and skills) the quality of care for 99% of what walks through the door will be the same. As for "doctor stuff" like OB or colonoscopies, I wouldn't trust an FP anyway.

This is just too unbelievably condescending not to reply to.

Do you have any idea what rural family docs do on a regular basis? Do you even care what would happen to the largest population of patients in America (rural and underserved) if their FP's DIDN'T do OB and colonoscopies (quite competently, I might add)? Would you rather the NPs and PAs start doing these procedures? Because there sure as heck isn't a line of specialists clamoring to practice in these areas.

You say that we need primary care physicians, and you then go on to blast the folks who are on the front lines and in the trenches, delivering that needed care every day. What is it exactly that FPs do all day, if it's not "doctor stuff"???

You should do some research (as I have) into what kind of training family docs actually have. There are many rural docs who do TONS of OB and colonoscopies yearly, and their residencies have trained them very well to do these procedures and many more.

Of course it is foolish to allow someone with very little experience in a procedure to get their practice on you (but of course that's what medical students and residents do every day, isn't it?), but to lump all FPs into this giant pile of numbskulls whose greatest attribute is knowing their own weaknesses is insulting and wrong.

 

[medlaw06]

hey all....was reading this and the debate is getting more and more interesting....now, I DO NOT wanna offend the midlevels, the FPs, IM (heck, I'm going into IM myself), or anyone, but here is something that I think all the MD/DOs will HAVE to (whether you like it or not) agree with:

physicians are WAY TOO complacent when it comes to things like getting involved in the politics of healthcare....(FYI...the 4.4% cut is going into effect)...always wondered why that was...is it b/c physicians are too busy making $$$ (there's absolutely nothing wrong with that)...is it b/c physicians are too arrogant to get involved in "dirty" politics....is it b/c physicians are in the "heck, I've already made my millions, what the hell do I care anymore" mentality...etc, etc...

the reason why I say this is b/c as a person with a (soon) medical degree and a law degree, one of my interests lies in politics...(sorry to say, but if nurses, PAs, and everyone else is fighting for theirs, why the hell can't I fight for my colleagues)...I got involved in the acts that we eventually lost (see above--4.4% cuts) at the state level and at my med school trying to get the word out to people to write to congress....whether they did or not is completely irrelevant (as is this post, for that matter )....anyways, the point is is that I am about to give up my "political" stuff because I see SO LITTLE SUPPORT FROM MY SO CALLED COLLEAGUES!!!

It's a shame what we are doing to ourselves!!! Unfortunately, we will ONLY realize this AFTER the s hits the fan and we are left to scramble, but by that time, it's way too late and the powers have shifted!!

To my physician "so-called" colleagues: start to seriously think about what's going on in the periphery before its too late

Some have tinkered w/ the thought of physician unionization....whether its right or not, I still don't know enough about it to formulate an opinion, but I am glad to see that ATLEAST we are talking about this....

I am ABSOLUTELY appalled at the lack of strength that physicians, who literally have had at 1 point or another someone's life in their hands and face death square in the face on a day to day basis, have when it comes to lawsuits, lawyers, and politicians....true, I am an MSIV and what the hell do I know about the realities of medicine, but I know one thing for sure which I have seen with my own eyes on more than 1 occasions: the melting of a physician in front of a lawyer OR the lackluster, blase attitude that physicians have in terms of having someone else taking their turf....SAD!!!

---END SOAPBOX---

BTW: I agree w/ the post the interventional stuff is immune!!

 

[schutzhund]

Well said my brother.

 

[Hurricane]

physicians are WAY TOO complacent when it comes to things like getting involved in the politics of healthcare....(FYI...the 4.4% cut is going into effect)...always wondered why that was...is it b/c physicians are too busy making $$$ (there's absolutely nothing wrong with that)...is it b/c physicians are too arrogant to get involved in "dirty" politics....is it b/c physicians are in the "heck, I've already made my millions, what the hell do I care anymore" mentality...etc, etc...

Perhaps it is because we learn about the adminstrative/political aspects of medicine from either limited personal experience or listening to older physicians bitch about stuff. Whereas, as someone mentioned either in this thread or another recent thread, NPs actually take classes dealing with heathcare politics. The politics of heathcare is such a huge subject, and it's overwhelming to think about mastering it on your own without some formal structure. Our med school had one lecture/roundtable on the subject during one of my clinical rotations, and I really enjoyed it, and wished we had more. But I'm a dork that way, and I know the last thing most medical students want is more classes to go to...

 

[lowbudget]

Well, y'all should have done that as an undergrad.

 

[Hurricane]

Well, y'all should have done that as an undergrad.

Bah, I wasn't one of those people who knew I wanted to be a doctor since birth. I didn't even decide to apply to med school until the last minute...

 

[Mumpu]

Sophie, Just because you CAN do a treatment intervention doesn't mean you should. This applies to all MDs, DOs, PAs, RNs, etc. A colon cancer missed by a non-GI boarded provider would not stand up well in court and rightfully so - even the busiest FP does not do scopes all day every day. I've seen OB patients with crits of 10 because a rural doc was trained to do c-sections but not hysterectomies (an OB surgical procedure) and could not control the bleeding atonic uterus. Do pros screw up as well? Sure they do! Do they do it less? I've seen no studies on the subject but it's a great question and one that should be answered in order to properly validate FPs as uterus-opening scope-driving docs. Until such time, I'm taking my money and my colon to the specialists.

There is a lot to be said for job-specific training. This applies to every level and profession of medical providers. FPs, having the broadest training with the least depth (sorry, but it's true, FPs combine 3 years of IM, 3 years of peds, 4 years of ortho, and 4 years of OB into 3 years), are more vulnerable to competition from midlevel providers who also have very broad training. Having said that, as I stated before I'm glad there are FPs and midlevels to fill the huge void of primary care providers. Hats off to you.

I've been on the "inside" for long enough to be terribly afraid of doctors in general. For me personally, the only way to minimize the risk is to go to the most trained person.

 

[3dtp]

Do pros screw up as well? Sure they do! Do they do it less? I've seen no studies on the subject but it's a great question and one that should be answered

Amen! But there are some boards (ABOG/ACOG is one of them) that have written in their by-laws that if you say anything to minimize the importance of being boarded in their specialty they can kick you out, and then they get to report you to the NPDB and you can git them steadily depressing low down mind messin' workin' at the car wash blues. I bet they'd think that someone in their society proposing such a study unworthy of being in the club!

Where are the prospective randomized controlled studies that demonstrate that BC is better? We have gone from internship to internship plus CME to BC - lifetime to BC - time limited (6-10 years) to BC-timelimited + Maintenance of Cert, but no one has done a study that says any of this is really beneficial to the patient.

Does it make it better? or does it make it more expensive? or Both? or Neither?

 

[Monty Python]

Hi Trinityalumnus!
Thanks for the info. I knew it only in more general terms. I'm an RN myself, accepted to a few major Carib schools (didn't apply in the States, but now really thinking I should). If you don't me asking "Why med school now?", after 12 yrs of CRNA.
Please pm me if not for the public board.
TIA

For lack of better verbage (and with apologies if this sounds egotistical) it was becoming less stimulating and less challenging after 10 years. Coinciding with that, a CRNA in my Navy reserve unit went to med school after 15 years as an anesthetist, and began to constantly harp on me to follow his footsteps, saying he could tell I wanted to do it and could do it.

It was also something which had been in the back of my mind for years, but there always was a major "life hurdle" of one sort or another in the way.

I began to really think and pray about it, and decided I wanted/needed to increase my scope of practice, responsibility level, and have more intellectual challenge and stimuation. Noting that all the major life hurdles of the past years had faded away, I decided to roll the dice and see what happened; if it was meant to be, it would come to pass. I also wanted to take this step via formal education and not by legislative fiat.

 

[sophiejane]

There is a lot to be said for job-specific training. This applies to every level and profession of medical providers. FPs, having the broadest training with the least depth (sorry, but it's true, FPs combine 3 years of IM, 3 years of peds, 4 years of ortho, and 4 years of OB into 3 years), are more vulnerable to competition from midlevel providers who also have very broad training. Having said that, as I stated before I'm glad there are FPs and midlevels to fill the huge void of primary care providers. Hats off to you.

I have spent time with colorectal surgeons and GI docs and they DON'T do endo all day every day--they tend to do about 10-12 a week from what I've seen. A busy rural FP who has put in the time to get lots of endo training on their residency and beyond can do 2-3 endoscopies a week. As long as there is a surgeon on call that can handle a laparotomy if things go south (which GI docs also need), I don't see the issue in FPs providing this service.

As for C-sections, again--it's about knowing your limits, as you said. But there are rural FPs I've spent time with whose practice is 80% OBGYN, so obviously they are doing something right. If they were killing off or maiming more patients that the OBGYN down the street, I would think their business would drop off--but it's going gangbusters, in fact. People like that the same person who delivers their kids also takes care of them when they are sick.

I think this is an interesting discussion because it has many of the same issues that the PA/NP debate has brought up. It all comes down to money, and anyone who takes away precious procedures from the specialists will face the same criticism, even if they are absolutely competent and well-trained, with years of experience.

Until we have specialists willing to serve the poor and the underserved in rural areas, I'll be more than happy to be a scope-driving and/or uterus-cutting rural FP, paying a nice low overhead, having a big house and land for 1/4 of what I'd pay in the city, and cashing in on the procedures.

And by the way...rural family docs are among the least often sued of all the medical professions. This is not because they never screw up, but because their patients are their neighbors and friends, and that goes a long way toward building trust and goodwill.

 

[Mumpu]

True, good patient relationships are a proven insurance against malpractice suits.

My theory is that the lack of MDs in underserved areas is what started the whole NP/PA independence trend and it is very much continuing to fuel it. It's very easy for the lobbying organizations to sell things like "if you let our NPs do colonoscopies, we can improve patient care in the underserved areas." Of course, it's like applying to a state med school -- everyone wants to be a rural family doc until the day after they receive the acceptance letter.

 

[krust3]

lets not fret too much about losing turf to midlevels yet... not in regard to PA's at least. i'm not sure if anyone has noticed but it seems the new trend is for the PhD level NP programs- WTF . seems awfully similar to PT programs going to the doctor of physical therapy degree to compete (at least politically) with D.C.'s.

i do not agree with NPs having physician independence and that goes for other practitioners too. standard of care medicine can be at risk with ND's, D.C.'s, NP's and such replacing M.D.s in primary care.

most PAs are content with their limited role and dependence on M.D.'s. those who aren't likely go back to school like i am. it's tough for PA's to replace M.D.'s in my opinion (unless we're talking about residents, but even then we're more expensive).

 

[3dtp]

lets not fret too much about losing turf to midlevels yet... not in regard to PA's at least. i'm not sure if anyone has noticed but it seems the new trend is for the PhD level NP programs- WTF . seems awfully similar to PT programs going to the doctor of physical therapy degree to compete (at least politically) with D.C.'s.

Too true. Pharmacists underwent this same evolution. They were originally BSPharm, then became PharmD, same degree, but are now Dr. Druggist.

My wife is a PhD nurse, went to grad school to be a professor after years of critical care nursing. She told me that she had little use for NPs who wanted to be docs without doing the work of med school/residency. The Nursing PhD is a 3-4 year beyond the BSN at her university. Her opinion is that the roles are vastly different and should remain so.

i do not agree with NPs having physician independence and that goes for other practitioners too. standard of care medicine can be at risk with ND's, D.C.'s, NP's and such replacing M.D.s in primary care.

Interesting. We got a lecture on this from our risk management group recently. An ENT doc got sued for failure to diagnose when the MLP (I forget or was asleep when they said it was a PA or NP) saw a referral patient with OM gave the patient steroids and never staffed the patient with the ENT, and a year later the patient showed up with a massive nasalpharyngeal cancer. The interesting part was that the MLP did not get sued, even though they saw the patient, did (or more importantly did not do) the work-up and handled the patient. The ENT never saw or heard about the patient. The lawyer talking about this said that the court held that since the MLP did not have independent practice privileges, the root cause was inadequate supervision by the ENT. Result -- bad malpractice settlement.

most PAs are content with their limited role and dependence on M.D.'s. those who aren't likely go back to school like i am. it's tough for PA's to replace M.D.'s in my opinion (unless we're talking about residents, but even then we're more expensive).

I wonder what would have happened if the same had happened in remote west Egypt Arizona with an "independent practice" NP? That's why I'll choose for myself and my family a good FP any day and any time over an NP. Sometimes amidst the horses, zebras really are found!

 

[nebrfan]

The lawyer talking about this said that the court held that since the MLP did not have independent practice privileges, the root cause was inadequate supervision by the ENT. Result -- bad malpractice settlement.

That's funny - NPs claim they only require "consulting" physician until someone gets hurt - then it's outside of their scope of practice.

Which is why I think that NPs may never get true independent practice - once true liability is passed from the "consulting" physician to the NP, lawsuits may add up

 

[billydoc]

That's funny - NPs claim they only require "consulting" physician until someone gets hurt - then it's outside of their scope of practice.

Which is why I think that NPs may never get true independent practice - once true liability is passed from the "consulting" physician to the NP, lawsuits may add up

But that's the "beauty" of the NP practice..."consulting". It does not require a physical presence of MD/DO, no chart co-sighning. They already have all the indepence they want, without the liability aspect of it. Sure it's a "screw the doc" thing, but it's the smartest way to practce medicine without ever going to med school