Who needs doctors

[MAC10]

If you guys have not already check out the USNews cover story. Who needs doctors? Why your future doctor may not be an MD..and you may be better off for it.

The nurses were all huddled around it
I dont know about you guys but the nurses around here can barely record I&Os right, much less manage a patient all by their lonesome

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[scootad.]

LOL!

 

[SOUNDMAN]

These people are nurse practitioners, so there is a difference than a regular nurse.

 

[doc05]

These people are nurse practitioners, so there is a difference than a regular nurse.

right. not to mention the fact that outpatient medicine is far simpler than inpatient medicine.

 

[erichaj]

In the hospital I did residency, the PA and NP did the rounding for the MD. In other words they did all scud work. This way the GI guys could do their scopes.

I think that US news report is something to fear. As a patient, I would want my healthcare provider to be an M.D.

However, the way medicine is moving, I think that the days of the GP may be limited. This will be mostly due to Insurance companies.

EH

 

[raptor5]

I think that the days of the GP may be limited.

How do you phase out that many doctors in the system? Do you just slowly decrease FP spots while increasing IM Med/Peds spots. What about the rural FPs. Med/Peds or something of that nature surely doesn't provide the scope (i.e. breadth) of training that is needed for those FPs. Could it be that the FP cirriculum needs to be re-tooled for the 21st century.

 

[Fantasy Sports]

You want to take your v-fibbing father to a nurse practitioner... be my guest.

As long as people have a choice, they will choose to go to a doctor. This isnt to say that other healthcare professionals aren't needed... we all have a role to play, and our education determines that role. Its not like we are sitting around for 8-10 years doing nothing, we are learning useful things to help patients with. It is not likely that someone with half the training would do the same thing, not because of intelligence or whatnot, but because of the length of training.

And if you think malpractice is bad now, imagine a world where people with half your training have the same rights and privileges that you do...

Not even the socialized healthcare systems are that crazy.

 

[Museless]

My dad died years ago, but if he had vfib, given that he'd have just minutes to live if he didn't convert to sinus on his own, I'd take him to whoever's standing closest. Now if he had afib, I'd rather he see a cardiologist.

What I always wonder about these reports is - will there be changes that bring increased autonomy to mid-level providers? If not there will always be a role for at least a small number of supervising docs.

 

[Fantasy Sports]

My dad died years ago, but if he had vfib, given that he'd have just minutes to live if he didn't convert to sinus on his own, I'd take him to whoever's standing closest. Now if he had afib, I'd rather he see a cardiologist.

What I always wonder about these reports is - will there be changes that bring increased autonomy to mid-level providers? If not there will always be a role for at least a small number of supervising docs.

Im sorry to continue this thread of conversation, since I didnt mean for something like this to be said, but Im implying you have a choice between a doctor and a nurse.

And increasing autonomy to mid-level providers is fine, but the problem is if studies show they make more mistakes or aren't as cost-effective as once thought, there will be an uproar to bring back the "old" (current) system.

Midlevel practioners chose their field because they wanted to do medicine but didnt want the time/work/liability commitment that doctors have. I dont know how many of them would want to have the life of a doctor.

 

[typeB-md]

i've been saying this for years... it's only a matter of time.

next are ER physicians and anesthesiologists.

 

[Ross434]

As long as people have a choice, they will choose to go to a doctor.

I have a choice for who to go to for my derm appointments. I chose a PA. It doesnt really matter for something routine. I had a PA do my workups for CT surgery as well. I could have had a doctor, but, did it matter? No.

As healthcare becomes more and more complex, there will be more and more complicated diagnoses and treatment plans. Doctors will need to spend more time thinking about these and less time dealing with the common cold. (Or, in my PA's case, acne). I think its good that somebody wants to step in and do the boring stuff.

 

[dry dre]

I have a choice for who to go to for my derm appointments. I chose a PA. It doesnt really matter for something routine. I had a PA do my workups for CT surgery as well. I think its good that somebody wants to step in and do the boring stuff.

If I had one major gripe against midlevels, it would be the utter waste in testing that the average midlevel with whom I have worked has ordered. A few useless (but rudimentary logical) tests per day can cost more than a physician's salary for the same period. This is particularly terrible with midlevels in the ED.

I like the old saying that goes something like "there is little difference between a having a good doctor and having no doctor while there is a tremendous difference between having no doctor and having a bad doctor."

 

[dry dre]

As healthcare becomes more and more complex, there will be more and more complicated diagnoses and treatment plans. Doctors will need to spend more time thinking about these and less time dealing with the common cold. (Or, in my PA's case, acne). I think its good that somebody wants to step in and do the boring stuff.

Traditionally, when you went to the doctor, a fully medically trained practitioner looked you over from top to bottom. Physicians are trained to pick up everything from top to bottom.

Midlevels are not trained to pick up everything insofar as they don't receive the same breadth of training. As a medical student I picked up on a West Nile case that a midlevel sent home the day before from the ED after he re-presented with the same history and symptoms (and I'm no rocket scientist).

I seriously don't think that the majority of patients who know the difference in expertise between a midlevel and a regular physician would choose to see a midlevel if given a choice. At the same time, patients who go to the healthcare system to ~seek attention etc will more likely more value the practitioner who has more time/interest to jabber with patients over non-medically important issues.

 

[docB]

i've been saying this for years... it's only a matter of time.

next are ER physicians and anesthesiologists.

An excellent point. My group uses PAs and I think the future will have an expanding role for them with a reciprocal decreasing role for docs. The question is if this is a bad thing. Flindophile points out very correctly that

The objectives of patients and doctors are not always aligned.

Now if a patient can pay less and get the same treatment which would be the case for minor ailments (although in my ERs they pay the same to see me or my PA) then that's good for the patient.

There's one thing I will say definitively. PAs and NPs should NOT be used by groups that train residents. If a training program is using midlevels they are taking away training opportunities from their residents. In many programs (including mine) midlevels were used in the "fast track" setting so the residents could be in the main ER. The idea that the midlevels can see the "easy stuff" means the residents don't get the experience dealing with the easy stuff so they can tell the difference. Also the fast track type patients often turn into real issues and you have to know how to deal with them. I'm using fast track as an example due to my being EM but it applies to everything.

 

[ALMD2B]

sorry to sidetrack...

but could someone find the link to the article that the original poster wrote about? I tried searching on US news but didn't find anything.

thanks.

A.

 

[OzDDS]

interesting..

check out this thread as well.

http://forums.studentdoctor.net/showthread.php?t=176012

 

[Jeff05]

only about 3% of the actual cost of medicine is spent of physician's salaries. the rest is spent on labs, equipment, administration, buildings, nsg, etc. in fact, that extra MRI that is ordered by a PA in the ED would more than make up for the differnce of having an MD there instead - for the rest of the week.

i mean, if you can't get an MD, midlevels should be utilized. but, there should never be enough competition that would make it undesirable for people to attend medical school. i mean, if i'm not sure whether or not i can get a job after graduation or i'm gonna graduate after 4 years of college (and pre-med is a bit tougher than nsg school), 4 med school, and at least 4 years of residency and make f'n 75k/yr, i'm definitely not going to take out that 250k loan.

quick story. i had bell's palsy during med school. so i went to the student health center and saw a nurse practitioner. she actually looked in a book to confirm her dx (in front of me). then she gave me an eye patch and sent me home. she did not do a neuro exam. she did not stratify me for possibly receiving steroids. of course, not all nurse practitioners are like that.

finally, midlevels are great for the population (save money overall, increase access to healthcare and make preventative medicine more prevalent) but, they're bad for the individual (because they will not pick up the more rare dxs - the stuff that will killya). when i have a health issue, i want to see someone that is on the cutting edge of EBM and that has the ability to understand and navigate the comlexity of medicine. i only trust an MD to do that...and not all MDs, at that. but, that's just me.





"Now, if a patient can pay less and get the same treatment which would be the case for minor ailments (although in my ERs they pay the same to see me or my PA) then that's good for the patient.

There's one thing I will say definitively. PAs and NPs should NOT be used by groups that train residents. If a training program is using midlevels they are taking away training opportunities from their residents. In many programs (including mine) midlevels were used in the "fast track" setting so the residents could be in the main ER. The idea that the midlevels can see the "easy stuff" means the residents don't get the experience dealing with the easy stuff so they can tell the difference. Also the fast track type patients often turn into real issues and you have to know how to deal with them. I'm using fast track as an example due to my being EM but it applies to everything.[/QUOTE]

 

[southerndoc]

Nurse practitioners and physician assistants are the wave of the future. Many more will open up independent practices, get autonomy to prescribe medicines without physician oversight, and generally be a bigger provider in the healthcare field. Nurse practitioners will be called "doctors" as NP education centers are now pushing for PhD-level nurse practitioners.

Why will NP's and PA's have such a dramatic explosion? A couple of reasons:
1. Less malpractice insurance - since they do not have the track record of lawsuits like physicians have, they will have initially lower malpractice rates.
2. Physician shortages - 'nuff said.
3. They are accustomed to lower salaries - they won't be pushing themselves to see more patients to keep high salaries.

BTW, I am not a PA or NP, so this is an outside perspective.

 

[Fantasy Sports]

Nurse practitioners and physician assistants are the wave of the future. Many more will open up independent practices, get autonomy to prescribe medicines without physician oversight, and generally be a bigger provider in the healthcare field. Nurse practitioners will be called "doctors" as NP education centers are now pushing for PhD-level nurse practitioners.

Why will NP's and PA's have such a dramatic explosion? A couple of reasons:
1. Less malpractice insurance - since they do not have the track record of lawsuits like physicians have, they will have initially lower malpractice rates.
2. Physician shortages - 'nuff said.
3. They are accustomed to lower salaries - they won't be pushing themselves to see more patients to keep high salaries.

BTW, I am not a PA or NP, so this is an outside perspective.

1. Your malpractice insurance is GENERALLY correlated to your salary, since higher fee procedures GENERALLY are more risky. A neurosurgeon makes tons of dough because brain surgery is hard, and the risks are high. They also pay high malpractice. Very few specialties are immune to this trend, so I dont see how your #1 and #3 reconcile.

2. It only makes sense that NPs and PAs will have either as bad or worse malpractice than doctors. Even though they don't have the track record, they will quickly realize the same legal problems that doctors have, since they are doing doctors work. Add to that their much shorter training time, and you have a recipe for high malpractice, which means you would have to raise salaries for NP and PA (to levels of... a GP?)


Honestly though, the best thing that could happen to doctors long-run is for the American public to see what a disaster having NPs and PAs being psuedo-GP docs, optometrists doing eye surgery, nurse anesthesiologists taking over for anesthesiologists, etc would have on the quality of healthcare. Unfortunately, the short-run ramifications of such a switch are completely undesireable, considering the number of people that would be hurt in the process.

 

[kristing]

Wow

Do you guys all remember the study that showed the docs that get sued more are the ones that spend less time with patients and are perceived as not listening to their patients REGARDLESS OF OUTCOME? Guess what? Every NP I have ever seen has been a good listener and, in general, done a more thorough history with me. Guess who my son's first "pediatrician" was? An NP. Guess who I see for all of my OB-Gyne stuff? A CNM. Guess what I am going to be in June? A doctor.

Get off your high horse people. Recognize all the training in the world will not make you more compassionate. Some of us who KNOW the difference still CHOOSE the mid-levels.

 

[DPPM]

KristenG, just wondering, what made you decide to become a doc if you could do a lot of the same things as a PA? I ask this because I'm seriously contemplating med school, but one thing that has been making me balk is what has been mentioned. I'm thinking about pediatrics, but if there aren't any big advantages to training all those extra years (as opposed to being an NP or PA), then I may decide against it.

I agree with your point about compassion. Compassion is innate and can't really be learned, no matter how many years of training you undergo.

 

[toughlife]

I started feeling nauseated, distended, vomiting, appetite was zero, and had no bowel movements for two days. Two weeks earlier I had detected an inguinal hernia while showering.
Concerned about a possible partial obstruction secondary to hernia incarceration or strangulation, I went to the student health center and was seen by an NP who told me that the hernia was a "lower GI" thing and the vomiting, nausea and distension was an "upper GI thing" so the two could NOT be related. Being a third year student and having seen my share of obstructions, I ended up cutting my visit short and asking for a referral to a gen surg.

 

[dry dre]

Do you guys all remember the study that showed the docs that get sued more are the ones that spend less time with patients and are perceived as not listening to their patients REGARDLESS OF OUTCOME? .

Some of us chose our providers based on outcomes and not lawsuit rates.

If/when I have children of my own, I will chose the provider that is most competent to detect and manage disease, not the provider who placates me. If, when they are of age, they choose to pick touchy-feely over better outcomes, I'll turn them loose.

 

[Fantasy Sports]

Wow

Do you guys all remember the study that showed the docs that get sued more are the ones that spend less time with patients and are perceived as not listening to their patients REGARDLESS OF OUTCOME? Guess what? Every NP I have ever seen has been a good listener and, in general, done a more thorough history with me. Guess who my son's first "pediatrician" was? An NP. Guess who I see for all of my OB-Gyne stuff? A CNM. Guess what I am going to be in June? A doctor.

Get off your high horse people. Recognize all the training in the world will not make you more compassionate. Some of us who KNOW the difference still CHOOSE the mid-levels.

And do you realize that those studies are conducted in the status quo environment in which doctors and surgeons take up responsbility for any remotely difficult case?

And honestly, if those professions can do what we can better, why did you choose medicine? Sounds like you're not putting your money where your mouth is...

 

[binswanger]

The US News & World report story was one I eagerly read when my issue came in the mail.......then I laughed and laughed. A couple of thoughts come to mind:

#1 If you want to "practice medicine" go to medical school. These mid-levels providers are seeing patients on daily basis and missing things they don't even know they are missing secondary to their lack of training. We all have our stories.......

#2 People need to remember the last what the last word on P.A. stands for and what the first word in N.P. is......

 

[southerndoc]

The US News & World report story was one I eagerly read when my issue came in the mail.......then I laughed and laughed. A couple of thoughts come to mind:

#1 If you want to "practice medicine" go to medical school. These mid-levels providers are seeing patients on daily basis and missing things they don't even know they are missing secondary to their lack of training. We all have our stories.......

#2 People need to remember the last what the last word on P.A. stands for and what the first word in N.P. is......

The same can be said of GP's. Cardiologists, neurologists, etc. might argue that patients should only be seen by them and that GP's are routinely missing things they don't even know due to their lack of in-depth training in specialties.

I think for the general stuff, NP's and PA's are just fine.

Regarding malpractice insurance rates that I mentioned earlier, the lower malpractice premiums would equal over time. However, they wouldn't equal until after NP's and PA's establish themselves. (i.e., the malpractice rates won't increase as a result of their "establishing themselves," but rather lower malpractice rates will allow them to better establish themselves by having lower charges, better negotiate with HMO's, etc.).

 

[Freeeedom!]

My biggest concern is that the applicant pool for the mid level professions is NOT what it used to be. At one time, PA's (primarily military) were extensively trained prior to school, be it as EMT's or EMT-P's etc. Today the pool is diluted due to the high amount of PA programs out there and the ever increasing NP programs. Virtually EVERY person that I have spoken to that want to pursue midlevel training do so because "I don't think I can get into medical school...or I don't think I want to be in school for that long". Holy crap that is scary. In reality it takes little more than a pulse to get into nursing school...and NP programs are taken as night classes or simply a day or two a week.
Listen, I have had to precept some pretty bad midlevel students and I honestly fear for the future.
There is no shortcut to medical training.

I have worked at a military base (where 1/3 of the medical staff are PA's... ) and the care is so SUB standard with the PA's, the testing is so wasteful, and the over prescribing is so rampant...no wonder our military is the most wasteful on the planet.
It is a sad place we are in.

 

[Pili]

I have a choice for who to go to for my derm appointments. I chose a PA. It doesnt really matter for something routine. I had a PA do my workups for CT surgery as well. I could have had a doctor, but, did it matter? No.

As healthcare becomes more and more complex, there will be more and more complicated diagnoses and treatment plans. Doctors will need to spend more time thinking about these and less time dealing with the common cold. (Or, in my PA's case, acne). I think its good that somebody wants to step in and do the boring stuff.

What if there was some cutaneous T cell lymphoma with your acne? Point is, you cannot identify that which you don't know. NPs and PAs tend to diagnose the same things ad nauseam, and miss oh so many things.
I for one will stay clear of them for my health needs. Their role is to assist, not be in charge. It's ridiculous that the US news is trying to confound the public, given that it's just a mater of money, nothing else.
If I were the AMA, I would take serious action now. The report is biased and inaccurate.

 

[Sinnman]

I honestly cannot see how a soon-to-be physician would go to an NP. Its one thing to pull the wool over the eyes of the lay public but it should be an entirely different thing to someone who has seen all the complexities of medicine.

As someone who was going to enter an NP program (and actually took some classes) and is now in the middle of medical school, I can tell you there is a WORLD of difference in the education. Before starting medical school, I would have gone to an NP for something simple like a cold, but now I would not even to that. I'm going to pick the most highly trained person any day of the week.

Granted, it does not take 8+ years of graduate and post-graduate training to treat a runny nose but that's not all you getting. What you are getting is expertise. What looks like a kid with a simple rash may be ITP. A physicians' detailed knowledge of anatomy, physiology, pathology and pharmacology are light years ahead of the midlevels. A nurse does not have the education to think through complex biomedical problems. Before people get offended, what I'm say is that an NP may be the brightest person around, but you cannot receive adequate training going to school one day a week for 18 months. Accepting lesser education in our healthcare providers may work most of the time, but people will pay the price with their lives.

I think it's a shame that physicians of all people accept a decreasing level of healthcare.

 

[neutropeniaboy]

Thankfully I work in a field that is not as overflowing with PAs and NPs as other fields.

I feel cleaved on the issue. In many regards, an NP can do the same thing that an FP/GP can do. However, working in a tertiary referral center as a specialist, the referrals I get from NPs (compared to GPs) are generally crap. (An episode of otitis being referred for tubes. A patient on 4 bp medications complaining of lightheadedness being referred for "vertigo, r/o tumor." Congestion. Wax.)

I agree with Southerndoc: NPs and PAs are the wave of the future. Depending on how you view it, it will make you rich as a specialist or just plainly annoy the hell out of you. As someone else said, perhaps we need some time with NPs and PAs working independently so the public can see just how bad it gets.

 

[jetmetnet]

i've been saying this for years... it's only a matter of time.

next are ER physicians and anesthesiologists.

This is such a ridiculous statement. anesthesia is going through a boom and are at the highest salaries even with the nurse anesthetist. The job market is so good that they do not fill their fellowships because private practice is so hot now. Subspecialists in anesthesia are being recruited out west for over$500K. At any top hospital the nurse anesthetist do the eye surgeries, plastic surgeries, and other cases that are deemed not educational. At MGH, BWH, BID where the CRNA have more independence, I only saw them do tummy tucks and other menial cases. Stop saying these baseless charges. Anesthesia departments are one of the most profitable departments, which is why they pay applicants for their hotels, dinners and some even pay for flights. I asked all the chairmans about the CRNA issue and all said it is not an issue because they serve their purpose and MD's serve their purposes. I want to remind you how they had said that anesthesiologists would be out of a job because of fewer jobs, well explain to me why anesthesiologists are second to orthopods in salaries.

 

[MAC10]

This happened today and made be think back to that article again

I am on surgery service right now. I happened to be in the acute care clinic next to the ED wating on my senior res to call back so I could present a patient. I over hear one of the PAs in the next exam room talking to a patient with 1 week history of relentless runny diarrhea. The guy gets the HPI, no other PMHX/PSHX etc, no physical exam. After the HPI he says ok im going to send you over to get an abdominal X-ray to make sure there is no kind of obstruction

Just as i suspected, 30 min later a get a call from the acute care clinic for a surgery consult to evaluate the patient for obstruction or ehhh acute abdomen

The acute care clinic here is mostly staffed with PAs/NPs unfortunatly they dont have to sign out to an MD, they can order what they want, and consult who they want and we have to come see the patient. 98% of the stuff they consult for is BS, no surgical indication, or something that can be seen in surgery clinic. So therefore I get consults like this all day and all night and it goes an and on..reducible herinas patients have had for months, hemmorrhoids patinets have had for months, simple abcess any "doctor" working in the ED should be able to I&D and then followed up in surgery clinic if need be. Its really on the verge of resident abuse sometimes the way they consult. There is a REAL difference between the quality of the consults recieved from DOCTORS working in the ED and PAs/NP.

Another example, last week, the same NP consults for a guy with epigastric abdominal pain, nausea, vomitng, diaphoresis. He thinks this patient needs his galbadder out stat. We go evaluate the patient and after a thorough history and physical its clear that this guys problem is cardiac. EKG shows he is having an inferior MI. He ended up coding later that night and died. Would the extra hour he spent in front of the NP and wating on SURGERY (not cardiology) have made a difference? Dont know but even as an intern i could tell that this mans problem was not his galbladder.

I think the broad medical knowledge and clinical experiences that is involved in becoming an MD makes us far superior "doctors". No one can understand what I mean unless you go through it, not pre-meds, not nurses, not NPs,not cRNAs, not patients. Im going into anestheisa and I have not done one drop of anesthesia this year but I have managed just about every other kind of patient. This level of training is invaluable. I would hate to see medicine degraded to this level. Lets not forget PA are just that, assistants, i think they need to sign out to a physcian, hellll I have to and im an MD. NPs are still nurses and I dont see how they have the knowledge or clincal experience to practice independently either. And i cant help but wonder if there were and real "doctor" in that dam acute care clinic, would be able to get more sleep at night.

Sincerely,
Disgruntled Intern

 

[OzDDS]

"Recently, at the national level a decision was made to transition all advanced nursing practice masters to the clinical doctoral level. Programs that educate NPs, CNS, anesthetists, and midwives must all convert to the Doctorate of Nursing Practice not later than 2015."

http://www.up.edu/up_sub.asp?ctnt=121&mnu=40&chl=300&lvl=2

Here we go!

 

[pikachu]

Thankfully I work in a field that is not as overflowing with PAs and NPs as other fields.

I feel cleaved on the issue. In many regards, an NP can do the same thing that an FP/GP can do. However, working in a tertiary referral center as a specialist, the referrals I get from NPs (compared to GPs) are generally crap. (An episode of otitis being referred for tubes. A patient on 4 bp medications complaining of lightheadedness being referred for "vertigo, r/o tumor." Congestion. Wax.)

The pa/np referrals I have seen working in oncology rotations as a 4th year med student have been even worse (as in tragic mismanagement), like - 65 year old with 50 pack year smoking hx and 1 pint of alcohol qday has complained of sore throat for a couple months, was put on 4 courses of antibiotics (for strep throat, because common things are common, right?) and he failed all of them - now he's got this huge, hard "lump" in his neck - gee, what could that be?

or, 50's ish Mexican lady with jaundice - infectious hepatitis workup that took 2 months has been negative - but she's at risk for hepatitis, because she's Mexican - oh, wait, her poop is white and there's a huge mass in her pancreas -

As someone else said, perhaps we need some time with NPs and PAs working independently so the public can see just how bad it gets.

I couldn't agree with this more - I just hope some senator's sister or something like that gets screwed over by an undertrained allied health type soon, b/c only then would we see some changes.

 

[binswanger]

The same can be said of GP's. Cardiologists, neurologists, etc. might argue that patients should only be seen by them and that GP's are routinely missing things they don't even know due to their lack of in-depth training in specialties.

I'm sure there is stuff that gets missed by GP's but were are talking percentages here, at least by the time GP's get done with their 7 years of training the have extensively studied neurology, cardiology, passed 3 board exams dealing with neurology, cardiology etc and done most likely multiple rotations with MD/DOs in the field - the same can't be said for NP/PA. Your quote almost made wonder if you are even familiar with scant training or requirements for these "Mid-Levels".


Quote: "I think for the general stuff, NP's and PA's are just fine."
That's the problem - the public doesn't know the difference between "general" stuff and subtle serious stuff. Examples abound, can you honestly tell me Southern Doc you would go to a PA / NP for anything??