Who Will Be Your Doctor?

[osli]

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The flaw in your logic is that part of not recognizing a specific zebra is that quite often you may not even realize it is a zebra of any sort. Not knowing what a mystery illness is and sending it out for a referral/consult is one thing... mistaking a great pretender (porphyrias, wilson's, vasculitis diseases, hundreds of others) for something routine because your training only included the routine can be not only costly, but fatal. That's a large area of malpractice in current medicine, and I don't know how DNP and similar programs purport to get around that.

So what is the plan... have a real doctor first diagnose the patient's disease and work them up for any other possible missed pathologies, and then send them on to the DNP only for further maintainence of their condition? The DNP is trained to handle the hypertensive patient or the diabetic patient, but only after a real doctor has excluded all other confounding disease processes? The DNP can manage, but not diagnose? Seems like a very broken model of providing health care. But once you start to argue that the nurses can diagnose the "routine" problems equally well, what you are saying is that they won't miss those malpractice landmines, and thus will have equal training and education as real doctors; yet I don't see that training outlined in any of these programs.

Here's the bottom line: when a program trains you to see only the following categories: 'cow, pig, duck, dog, cat, elephant, deer'... you will tend to shoehorn the fox, moose, goose and skunk into one of those predefined categories. And if being a goose is deadly, you just opened a can of worms you didn't want.

 

[soonereng]

The flaw in your logic is that part of not recognizing a specific zebra is that quite often you may not even realize it is a zebra of any sort. Not knowing what a mystery illness is and sending it out for a referral/consult is one thing... mistaking a great pretender (porphyrias, wilson's, vasculitis diseases, hundreds of others) for something routine because your training only included the routine can be not only costly, but fatal. That's a large area of malpractice in current medicine, and I don't know how DNP and similar programs purport to get around that.

So what is the plan... have a real doctor first diagnose the patient's disease and work them up for any other possible missed pathologies, and then send them on to the DNP only for further maintainence of their condition? The DNP is trained to handle the hypertensive patient or the diabetic patient, but only after a real doctor has excluded all other confounding disease processes? The DNP can manage, but not diagnose? Seems like a very broken model of providing health care. But once you start to argue that the nurses can diagnose the "routine" problems equally well, what you are saying is that they won't miss those malpractice landmines, and thus will have equal training and education as real doctors; yet I don't see that training outlined in any of these programs.

Here's the bottom line: when a program trains you to see only the following categories: 'cow, pig, duck, dog, cat, elephant, deer'... you will tend to shoehorn the fox, moose, goose and skunk into one of those predefined categories. And if being a goose is deadly, you just opened a can of worms you didn't want.

You missed the entire point. How often do you see a zebra running around on the plains of the United States?

 

[Hernandez]

Mary O' Neil Mundinger, Dr.P.H., is the Dean of the Columbia University School of Nursing, which was the first to pioneer the DNP concept.

Consider the source, but I needed a good laugh after living through the ED shift change dump.

 

[Flopotomist]

You missed the entire point. How often do you see a zebra running around on the plains of the United States?

In the metaphor, there are enough zebras running around to warrant knowing what a striped horse-like animal is.

 

[Hernandez]

You missed the entire point. How often do you see a zebra running around on the plains of the United States?

If you don't know to look for it, you'll never find it. By god I will have diagnosed a Bronchiolitis obliterans with organizing pneumonia by the end of my intern year

 

[osli]

You missed the entire point. How often do you see a zebra running around on the plains of the United States?

No, you missed the point. It only takes ONE to equal huge malpractice suit. It happens too often now with real physicians trained to look for them. When you take the same patient population and send them to DNP's, what do you think will be the outcome? What do you expect the fallout would be?

I don't see how the "doctorate" NP/PA/whatever programs intend to deal with this. If they are going to cherry pick patients, or take only pre-diagnosed patients, then what ultimate benefit does this new "level" of health care provider actually provide?

 

[alwaysaangel]

If they are going to cherry pick patients, or take only pre-diagnosed patients, then what ultimate benefit does this new "level" of health care provider actually provide?

They provide primary care. Thats the whole point. How many zebras do you think an FM doc sees? Not many. And when they can't figure out a diagnosis they refer it out. Its the same premise.

The midlevel providers are completely capable of managing diabetes, hypertension, HIV, and other chronic illnesses. They are also able to handle basic screenings for these illnesses, gyn services, physicals, etc.

The majority of the population is healthy - we just go to the doctor to make sure we're still healthy. Or we're not healthy but our condition is manageable and we are already diagnosed. Whatever it may be MOST of the American population can have their medical care covered by midlevel providers with no problem. Which is the whole point.

I really don't understand what you're arguing about. FM docs and IM docs that spend their life doing primary care wouldn't recognize zebras either. Thats why we have referrals.

 

[soonereng]

In the metaphor, there are enough zebras running around to warrant knowing what a striped horse-like animal is.

So how common and obscure must it be at the same time to qualify as this elusive multicolored equine? It is hard to hit a moving target you see.

If you don't know to look for it, you'll never find it. By god I will have diagnosed a Bronchiolitis obliterans with organizing pneumonia by the end of my intern year

Or in your case, you may find it because you want to. What's the old saying, when you hear hoof beats, think of horses....

 

[PeepshowJohnny]

They provide primary care. Thats the whole point. How many zebras do you think an FM doc sees?

...Snip...

I really don't understand what you're arguing about. FM docs and IM docs that spend their life doing primary care wouldn't recognize zebras either. Thats why we have referrals.

You'd be surprised. Sure you may have one case every few years, but when you've been in practice long enough, that starts to add up. Ask outpatient FP and IM docs some of the weird stuff they've seen and you'll be surprised.
And while they may not make the diagnosis immediately, at least they've gone to medical school and heard of such things. That gives them a much more of a fighting chance than midlevels which (from everything I've seen) don't have have the training to have have heard of these things.

 

[soonereng]

No, you missed the point. It only takes ONE to equal huge malpractice suit. It happens too often now with real physicians trained to look for them. When you take the same patient population and send them to DNP's, what do you think will be the outcome? What do you expect the fallout would be?

As midlevels already see this same patient population, and have for over 20 years, I really don't see much of a fallout happening anytime soon.

The fact that a "real physician trained to look for them" misses the zebra even with all that extra training actually increases the strength of my argument rather than bolstering your own. You treat what you are used to seeing, sometimes even if you know that it could be something else.

I have a friend whose PCP missed her adult onset Type I diabetes and she wound up in the hospital with ketoacidosis despite seeing the PCP 3 times the previous 2 weeks with classic presentation of type I. Is that a zebra? No, the doc was looking for flu because it was flu season, so it doesn't have to be a real zebra to act like one.

 

[alwaysaangel]

You'd be surprised. Sure you may have one case every few years, but when you've been in practice long enough, that starts to add up. Ask outpatient FP and IM docs some of the weird stuff they've seen and you'll be surprised.
And while they may not make the diagnosis immediately, at least they've gone to medical school and heard of such things. That gives them a much more of a fighting chance than midlevels which (from everything I've seen) don't have have the training to have have heard of these things.

Yeah but the argument was that somehow these midlevel providers are going to assume some basic wrong diagnosis and kill the patient...

Thats not likely to happen. If its not a cut and dry case of hypertension they're going to refer it to someone more capable of making the diagnoses. And even if the FM doctor can recognize that its some rare godawful disease instead of hypertension - they'll still probably send it out for treatment.

In the end you have the same thing.

NPs, PAs...all the midlevel providers are not stupid. They cover their ass - unless its something that is very obviously something simple then they refer it out. But its not like that happens so often that 100% of their patients have to be referred to a doctor so their usefulness is null and void. Very few patients have to be referred up. So even though the midlevel providers have to refer zebras away - there are enough horses around that they take care of that they do help the lack of primary care providers significantly.

That was my point.

 

[Hernandez]

The first time you have your orders questioned and refuted on say something like treatment of a beta-blocker overdose, you'll question allowing nurses full practice rights.

Or in your case, you may find it because you want to. What's the old saying, when you hear hoof beats, think of horses....

thank you med student for edumacating me on making diagnoses.

 

[Hernandez]

Yeah but the argument was that somehow these midlevel providers are going to assume some basic wrong diagnosis and kill the patient...

Here's my experience with a PA a few years out of school. We got consulted to help out after the PA tried for over a week to manage a pt with Chron's, C-diff, and pyleonephritis by himself. he was giving IV vanc for both the pylo and C-diff

People who think they know more than they do scare me, as they're the ones who will trod along without bothering to ask what are they missing and what potential bad outcomes are coming down the rode.

 

[soonereng]

thank you med student for edumacating me on making diagnoses.

I was merely pointing out that the saying exists for a reason.

 

[MacGyver]

They provide primary care. Thats the whole point. How many zebras do you think an FM doc sees? Not many. And when they can't figure out a diagnosis they refer it out. Its the same premise.

You are an absolute FOOL if you think this stops at primary care. Read the Mundinger op-ed again. She states specifically that the DNPs are going to be superior to MDs in both primary care AND specialties.

She wants the whole pie, not just primary care.

 

[alwaysaangel]

You are an absolute FOOL if you think this stops at primary care. Read the Mundinger op-ed again. She states specifically that the DNPs are going to be superior to MDs in both primary care AND specialties.

She wants the whole pie, not just primary care.

Yeah well I want 100 million dollars.

Doesn't mean I'm going to get it.

You believe everything you hear huh?

 

[MSKalltheway]

I find it interesting about how she was talking about putting the skills of a physician and a nurse together to form a complete practitioner. They are two completely different skill sets...so if you are learning how to diagnose and treat, how can you improve your nursing skills at the same time?

I agree that I dont think the point is really to put these skills together for the benefit of the patient. It seems like the nursing thing is thrown in there to make it sound good...you cant work on being a good nurse if you are busy studying how to diagnose and treat. If anyone asked me if these programs would be worth it, I would just say they may as well go to medical school.

 

[brightness]

The whole idea is that the people all already nurses, or already NPs, and then want to continue on. I guess they don't want to start over. But, it does seem like if you are RN with a bachelors degree, going all the way for medical school might be a good choice.
As far as all the 'not recognizing zebras' stuff, that is why midlevels should have to work with physician oversight.

 

[MacGyver]

Yeah well I want 100 million dollars.

Doesn't mean I'm going to get it.

You believe everything you hear huh?

You foolishly brush this aside as if it poses no threat to you. That same kind of attitude is what got the midlevels this far to begin with.

DNPs are much much closer to getting specialty penetration than you are to getting 100 million dollars. Wake up and smell the coffee....

 

[alwaysaangel]

You foolishly brush this aside as if it poses no threat to you. That same kind of attitude is what got the midlevels this far to begin with.

DNPs are much much closer to getting specialty penetration than you are to getting 100 million dollars. Wake up and smell the coffee....

Actually my boyfriends father is really rich - so my 100 million is just a few decades off. J/k

But seriously - you can be afraid of it all you want. I don't feel it threatens my job security and frankly, I think they provide a great service.

You disagree. Lets agree to disagree and call it a day.

 

[PlasticMan]

Can they be sued like physicians?

Do they have to pay malpractice insurance like physicians?

 

[soonereng]

Can they be sued like physicians?

Do they have to pay malpractice insurance like physicians?

Yes, my wife is an NP and she pays malpractice just like physicians, and in my state, she practices under her own license and not under that of the physician like PAs do, so she can be sued independently of any physician.

 

[45408]

They provide primary care. Thats the whole point. How many zebras do you think an FM doc sees? Not many. And when they can't figure out a diagnosis they refer it out. Its the same premise.

Not many FM docs see zebras, but the majority of zebras probably see FM docs. Again, it's not an issue of a mid-level being presented with a bewildering array of symptoms and deciding to refer, but an issue of a mid-level not recognizing the constellation of average symptoms as being characteristic of something much worse.

 

[Taurus]

practice independently in every clinical setting.

medical knowledge of a physician, with the added skills of a nursing professional.

clinical outcomes comparable to those of primary-care physicians.

alwaysaangel, this is going way over your head. There's a time to talk and a time to listen. The more you talk, the more naive you sound on this topic. Get some more years of medical school under your belt so that you can appreciate how difficult it can be to put all the pieces together to make a diagnosis.

Mundinger is not referring just to primary care. She's referring to all settings. Anyone here interested in procedural fields like cards, GI, derm, etc? Good, because the DNP's are interested too because that's where the money is really at.

Believing the propaganda that their leaders feed them, a number of DNP's with inferiority complexes already believe that they are as good as board-certified physicians. We all know how delusional they are, but common sense won't stop them from trying to put themselves on par with physicians. Most nurses know that they can't compete directly with the physicians, but what they lack they make up for through marketing tactics and political maneuvering to blur the distinction between the physician and DNP. That Mundiger article was published in mainstream Forbes magazine. The nurses are trying to sell themselves directly to the public.

If you are a physician, every DNP you hire is a potential future competitor, albeit inferior one. Imagine a DNP goes to work for a cards or GI. After a few years, the DNP feels comfortable and thinks he can handle any cards or GI case. He then quits the practice and opens up his own. What's to stop that from happening?

Unlike soonereng, I won't sell out my profession because I'm not married to a NP. 😛 More than 95% of (D)NP's work for physicians. Most don't want to practice independently because they understand that their training is not enough for them to handle the complicated case and hence dodge the lawsuits. One lost lawsuit may equal $20 million. However, it only takes a few people like Mundiger to cause problems.

To send a loud and clear message to the nurses, I think that physicians can most effectively respond to this aggressive action by the nurses by placing a hiring preference for PA's and AA's who fall under the boards of medicine. Physicians should use market forces instead of marketing and political contributions to shape the future. We can use the laws of supply and demand to our advantage.

To those who wonder why Mundiger keeps referring to DNP's as both physician and nurse, it's because if she dropped the nursing reference then the nurses couldn't argue that DNP's fall under the boards of nursing even though DNP's really practice medicine. DNP's are desperate to keep themselves aligned with the boards of nursing, even though I think that could be challenged successfully in court.

 

[soonereng]

Unlike soonereng, I won't sell out my profession because I'm not married to a NP. 😛

Well, sleeping with the enemy does have its intrinsic benefits... 😉

But I'm not selling out the profession either. Market forces demand more health care providers. If medical schools would get off their dead natal clefts and have a real revision of their curriculum and delivery methods (rather than just to PBL or not to PBL), we might not be in this situation; however, in the past the medical powers that be wanted to keep the manufactured monopoly for the fewest people they could until the gov't stepped in with an alternate solution via the midlevels. Again, it's our own fault.

 

[deleted77919]

however, in the past the medical powers that be wanted to keep the manufactured monopoly for the fewest people they could until the gov't stepped in with an alternate solution via the midlevels. Again, it's our own fault.

I wasn't aware that the government created midlevels. I thought individuals did that and then fought for recognition and ever expanding scope of practice.

Which senator created the DNP?

 

[soonereng]

I wasn't aware that the government created midlevels. I thought individuals did that and then fought for recognition and ever expanding scope of practice.

Which senator created the DNP?

No senator created the DNP. That is just a degree like a PhD or an MD and means absolutely nothing; however, every state did create the role of the advanced practice nurse in their version of the nurse practice act.

The monopoly that the physicians have held is only due to the government permitting it. When the government has enough reason to give away part of that monopoly, it is their prerogative to do so since they created the monopoly in the first place.

 

[TysonCook]

I call BS on 99% of you. Doctors are Pu33ys, always have been. For all the big talk that i see here, over and over, year after year...Its honestly amazing how many people write a practical book on this website, yet don't have the ball$ to call/email/write a political letter, 1 paragraph op/ed section piece, etc.
Seriously,
1)How many of you have written to your senator/rep?
2)How many of you belong to AMA (I hate AMA, but they lobby fairly well sometimes).
3)How many of you have sent an email or spoken with your department chairman, PD, or director re: consultants and screening.
4)How many of you have sent an email to your colleagues.

Lastly, and most important....how many of you would NOT hire an MLP? There is the crux of this whole conversation. Almost every specialty has hired on a MLP because IT MAKES THEM MONEY. As a MD, we make money off of MLP by basically "seeing" more patients and billing a higher rate. I love PA's, they have a function and do a great job, they are part of the team that works well.

As for the Noctor degree...

If you want to look at encroachment, look no futher than your own groups and hiring practice.

People no longer say, "I want to go to medical school"....its almost exclusively "I want to go to PA school". Half the time in classes, half the competition, and when you break it down hr per hr pay, its pretty close to the MD with half the hassles.

Why do nurses want this....it's the same as above. Taurus was completely on point with it comes down to $ and respect, without EARNING them.

4 years competing with pre-RN students.....I'll respect your degree if you take the SAME tests I take with the same passing score. Pass the MCAT, USMLE I, II, and III and then I might....just....possibly....refer to you as Noctor, but most likely I'll still call you nurse.

 

[drfunktacular]

Pass the MCAT, USMLE I, II, and III and then I might....just....possibly....refer to you as Noctor, but most likely I'll still call you nurse.

 

[DiveMD]

"medical knowledge of a physician, with the added skills of a nursing professional"

This is a ridiculous, false and unethical statement.

 

[Hernandez]

I was merely pointing out that the saying exists for a reason.

There's another saying, you see what you know. Conditions like Boop are frequently overlooked as merely a troublesome bronchitis. If you didn't know about it, you'd never find it.

 

[cfdavid]

No senator created the DNP. That is just a degree like a PhD or an MD and means absolutely nothing; however, every state did create the role of the advanced practice nurse in their version of the nurse practice act.

The monopoly that the physicians have held is only due to the government permitting it. When the government has enough reason to give away part of that monopoly, it is their prerogative to do so since they created the monopoly in the first place.

Sure, and given that the government is the single largest PAYER of healthcare, by which "reason" do you think they'll make such a decision? Competence, or cost?

 

[soonereng]

Sure, and given that the government is the single largest PAYER of healthcare, by which "reason" do you think they'll make such a decision? Competence, or cost?

Of course money is always going to play a factor in every decision, however, there have been studies to show the equivalent successful treatment of NPs vs physicians in primary care, and published in NP journals and even OUR medical journals. 😱 Here is a reference for one in particular from Taurus' favorite author (but there are a lot of people from pretty respectable med schools with MD after their name on this paper too):

Mundinger MO, Kane RL, Lenz ER et al. Primary care outcomes in patients treated by nurse practitioners or physicians. JAMA. 2000; 283:59-68


I'm really tired of physicians assuming that our model of education is the best and only way to produce competent providers. If physicians want the gov't to quit letting the NPs scope of practice expand, we will have to bear the burden of proof to say that they aren't competent since they have already done their part to prove that they are. We can no longer simply rely on posturing and lobbying.

 

[Sean2tall]

Its like people bitching about immigrants working in low level, non-skilled jobs like agriculture, McDonald's, etc. If it wasn't for the fact that Americans won't take these jobs because they don't pay enough and they think they're "too good" for the jobs then it would have never happened. The void wouldn't have existed to fill.

This is precisely the origin of the problem. I think you are looking at it backwards. It's not that Americans are "too good" for these jobs, it's that companies like McDonald's etc. take advantage of the fact that there are people like immigrants and teenagers who are willing to work for unreasonably low wages and set the new standard there.

For example, teenagers just want extra money to buy a car, new clothes, video games, or go to the movies. They do not need health insurance, a mortgage, a retirement plan etc. Why would McDonald's pay all of those benefits to an American adult, when they could hire 2 part time teenagers for $5.50/hr and no benefits? Next, how can Burger King afford to stay in business if McDonald's is hiring cheap labor and they are not? Then Burger King begins the same practice. All like companies follow suit and the new standard laborer gets minimum wage and no benefits.

There was a time when you could "work for a summer" in this country and pay your college tuition with that money. Now, reasonably, a young person can make $3000 in a summer against a tuition that could be $15,000 - 20,000 or more.

I would argue not that the cheap laborers are "filling a necessary void" of working at McDonald's, but rather McDonald's is taking advantage of people who are willing to work for unreasonably low wages.

In the same way, if "nursing doctors" have less student debt/years of training and they are willing to perform a Pap smear for - I'm making this up - $30 (which, let's say, leaves them will still a nice little profit) compared to a doctor, who charges $100, then Medicare will consider $30 to be the new standard and reimburse $30 to anyone who performs a Pap smear.

This is already the case in many places, Medicare will reimburse all physicians the same amount that the cheapest physician costs. Another example is the gas station, surely you have seen that the major chains always have prices far lower than Mom & Pop locations? Thus, less people go to the Mom & Pop and they must raise prices yet higher to stay alive, which even fewer people are willing to pay.

 

[kronickm]

The fact of the matter is, if you ask the vast majority of patients if they would prefer to be treated by an M.D./D.O. or a DNP, what do you think they will say?

I don't see the answer changing anytime in the near future.

 

[alwaysaangel]

This is precisely the origin of the problem. I think you are looking at it backwards. It's not that Americans are "too good" for these jobs, it's that companies like McDonald's etc. take advantage of the fact that there are people like immigrants and teenagers who are willing to work for unreasonably low wages and set the new standard there.

No. Talk to any analyst, poli sci professor, etc.

Yes, the average American thinks that the illegal immigrant problem stems from the companies but the fact of the matter is it doesn't.

The void came first, the illegal immigrants came second - its a fairly accepted concept in academia. I can't count the number of times I've had a class covering that.

And I still feel the midlevel provider scheme follows the same pattern.

 

[alwaysaangel]

The fact of the matter is, if you ask the vast majority of patients if they would prefer to be treated by an M.D./D.O. or a DNP, what do you think they will say?

I don't see the answer changing anytime in the near future.

The answer is generally, I don't care - believe it or not. As I said very early in this thread. Most women on this forum who are in their 20s probably almost never see a doctor (and most probably don't even realize or care). Gyn (at least in California) is practically exclusively NP anymore. Do I care if the person prescribing my BC and giving me a pap is a doctor or an NP who does it 10 million times a day? Nope.

And for a lot of americans...the answer is the same. This same conversation has been had about DO vs. MD - most people just don't care. As long as they feel their provider is competent and they are getting what they want - they just don't care.

 

[TysonCook]

I forgot to post this earlier, but there are great resources at this link. Has forms that can fill out and will automatically go to your designated reps etc.

http://www.ama-assn.org/ama/pub/category/13097.html

you don't have to support the AMA, but this is a great action website.


...and while in general people don't care, trust me, when you start practicing, you will care...

 

[deleted77919]

No senator created the DNP. That is just a degree like a PhD or an MD and means absolutely nothing; however, every state did create the role of the advanced practice nurse in their version of the nurse practice act.

My point was only that the degree came first and then a fight for recognition. "The government" did not sit down and say "there is a shortage of heath care providers, lets make up a new system and find a way to care for our population."

It is very rare for large groups to sit down and attempt to figure out what is best for the population as a whole, rather everyone fights for their best individual position and trys to convince everyone else that it also serves their interests. Physicians are not immune from this either, and is part of the reason we are in this position.

 

[3dtp]

The answer is generally, I don't care - believe it or not. As I said very early in this thread. Most women on this forum who are in their 20s probably almost never see a doctor (and most probably don't even realize or care). Gyn (at least in California) is practically exclusively NP anymore. Do I care if the person prescribing my BC and giving me a pap is a doctor or an NP who does it 10 million times a day? Nope.

And for a lot of americans...the answer is the same. This same conversation has been had about DO vs. MD - most people just don't care. As long as they feel their provider is competent and they are getting what they want - they just don't care.

And I treated a bulky Stage Ib/IIA cervical cancer last year. The sad part was, that the last three paps she had were "scant cellularity--inadequate for diagnosis." They were done by a mid-level from a rural area with minimal oversight. Improperly done paps without review do cost, and you should care. The zebra v. horse debate is important. There was also no record in the chart of a bimanual finding of a mass that had to have been there for a while. The diagnosis came after vag bleeding triggered an ER visit and a gyn exam by a gynecologist, who palpated the mass on bimanual.

Primary care physicians are the first line of defense against very bad diseases. This remains true even if 99% of what they see are the worried well.

This is a very real problem and I submit that without the broad and comprehensive knowledge, training and currency of education, we will ultimately increase both cost and morbidity/mortality. The cost of a properly done pap is around fifty bucks. The cost of a LEEP/CKC is around $3-4k, the cost of chemo/rads is around $60k.

If we decide, as a society to enhance minimal training, allow those minimally trained to carry on the roles of those extensively trained, then we should not be surprised when the overall quality of our health declines and the overall cost of health care rises, or alternatively is denied to those who need advanced care, due to the former.

 

[Sean2tall]

No. Talk to any analyst, poli sci professor, etc.

Yes, the average American thinks that the illegal immigrant problem stems from the companies but the fact of the matter is it doesn't.

The void came first, the illegal immigrants came second - its a fairly accepted concept in academia. I can't count the number of times I've had a class covering that.

And I still feel the midlevel provider scheme follows the same pattern.

Ok, so the egg came before the chicken, but now that there are chickens, does it really matter? As you said, that is an academic point, but does it change the situation? There are less good jobs for young people today. Pensions do not exist. Graduating college is a necessary luxury which people can barely afford and many college grads are moving back in with their parents at later ages. Am I mistaken about this?

It is a fact that Medicare will undercut all providers who do not charge the lowest possible price for a service. Are you trying to say this is not really happening?

Oh, also I am curious why you have had too many political science classes to count as a medical student?

 

[cfdavid]

No. Talk to any analyst, poli sci professor, etc.

Yes, the average American thinks that the illegal immigrant problem stems from the companies but the fact of the matter is it doesn't.

The void came first, the illegal immigrants came second - its a fairly accepted concept in academia. I can't count the number of times I've had a class covering that.

And I still feel the midlevel provider scheme follows the same pattern.

So, why do we not have 100% unemployment if there was such a shortage of workers? If you define millions of Americans that would rather (or have financial incentive not to work) milk the system rather than start at the "bottom" as a void, then you are correct, the "void" came first.

I'm curious how you'll respond to this one.

 

[cfdavid]

And I treated a bulky Stage Ib/IIA cervical cancer last year. The sad part was, that the last three paps she had were "scant cellularity--inadequate for diagnosis." They were done by a mid-level from a rural area with minimal oversight. Improperly done paps without review do cost, and you should care. The zebra v. horse debate is important. There was also no record in the chart of a bimanual finding of a mass that had to have been there for a while. The diagnosis came after vag bleeding triggered an ER visit and a gyn exam by a gynecologist, who palpated the mass on bimanual.

Primary care physicians are the first line of defense against very bad diseases. This remains true even if 99% of what they see are the worried well.

This is a very real problem and I submit that without the broad and comprehensive knowledge, training and currency of education, we will ultimately increase both cost and morbidity/mortality. The cost of a properly done pap is around fifty bucks. The cost of a LEEP/CKC is around $3-4k, the cost of chemo/rads is around $60k.

If we decide, as a society to enhance minimal training, allow those minimally trained to carry on the roles of those extensively trained, then we should not be surprised when the overall quality of our health declines and the overall cost of health care rises, or alternatively is denied to those who need advanced care, due to the former.

Thanks for the input. It strikes me as insane that we're so willing (as a society) to dismiss the "silly nuances" that are so "useless", under our current system of medical education. Especially given that medical knowledge is expanding more than ever before, and at a faster rate. Yet, who needs a physician? All those pesky details and all just aren't necessary to practice good medicine........ Yikes!

Hell, let's just go back pre-Flexner!!

 

[MacGyver]

The one good thing about these 33 new med schools that are coming with no new residency slots is that there is going to be a huge surge in primary care, because most of those grads will have no choice but to go into FP, IM, or peds.

If Mundinger wants a war, well she'll have one.

 

[soonereng]

Hell, let's just go back pre-Flexner!!

I always hear this comment, but the fact that we are still following the guidelines of the Flexner report is part of the problem. The system back then was such that after the 4 years of medical education one was fully trained to practice medicine.

Everyone knows that the 4th year of medical school is really a coasting year preparing for residency and trying out some subspecialties while the majority of the real learning comes in the first 3 years. The fact that we now do residencies on top of this 4 years is part of the problem.

Only in the medical training model does one get a professional degree that is basically worthless the day you graduate. You couldn't go get a job in a clinic with your brand new MD if you wanted to, despite the fact that you already have more training than the new PA or NP that they hired last week for double what you will be making during your residency. The lawyer who went to school for 3 years and will be suing you by the time you get done with residency has a job with a fair market wage, but you won't.

The institutionalization of residencies is a major problem with the medical education system. In the other professional degree programs, after graduation, you get a job, hopefully in an area that you want to work, and learn the nuances on the job from those who are licensed and more experienced, just like in residencies. You then have to pass some sort of licensing examination after this training period to ensure that you are minimally competent. The only difference is that these other professions are getting the market wage for the job, aren't told where they are going to be working by some nebulous computer program, and their bosses aren't protected by Teddy Kennedy from antitrust litigation.

If the MD went to 3-3.25 years straight through with still the same requirements for the completion of "residency," which would now be an actual job that paid the market rate for physician services, albeit lower at the beginning, there would still be the required licensure exams, etc., but perhaps more people would go into the primary care areas since there would be appropriate pay from the beginning. Then we wouldn't need midlevels to fill these roles.

Nah, screw it, let's just go back to pre-Flexner. 🙄

 

[cfdavid]

I always hear this comment, but the fact that we are still following the guidelines of the Flexner report is part of the problem. The system back then was such that after the 4 years of medical education one was fully trained to practice medicine.

Everyone knows that the 4th year of medical school is really a coasting year preparing for residency and trying out some subspecialties while the majority of the real learning comes in the first 3 years. The fact that we now do residencies on top of this 4 years is part of the problem.

Only in the medical training model does one get a professional degree that is basically worthless the day you graduate. You couldn't go get a job in a clinic with your brand new MD if you wanted to, despite the fact that you already have more training than the new PA or NP that they hired last week for double what you will be making during your residency. The lawyer who went to school for 3 years and will be suing you by the time you get done with residency has a job with a fair market wage, but you won't.

The institutionalization of residencies is a major problem with the medical education system. In the other professional degree programs, after graduation, you get a job, hopefully in an area that you want to work, and learn the nuances on the job from those who are licensed and more experienced, just like in residencies. You then have to pass some sort of licensing examination after this training period to ensure that you are minimally competent. The only difference is that these other professions are getting the market wage for the job, aren't told where they are going to be working by some nebulous computer program, and their bosses aren't protected by Teddy Kennedy from antitrust litigation.

If the MD went to 3-3.25 years straight through with still the same requirements for the completion of "residency," which would now be an actual job that paid the market rate for physician services, albeit lower at the beginning, there would still be the required licensure exams, etc., but perhaps more people would go into the primary care areas since there would be appropriate pay from the beginning. Then we wouldn't need midlevels to fill these roles.

Nah, screw it, let's just go back to pre-Flexner. 🙄

Please go back and read your own post. I don't even no where to begin.

 

[alwaysaangel]

Ok, so the egg came before the chicken, but now that there are chickens, does it really matter? As you said, that is an academic point, but does it change the situation? There are less good jobs for young people today. Pensions do not exist. Graduating college is a necessary luxury which people can barely afford and many college grads are moving back in with their parents at later ages. Am I mistaken about this?

It is a fact that Medicare will undercut all providers who do not charge the lowest possible price for a service. Are you trying to say this is not really happening?

Oh, also I am curious why you have had too many political science classes to count as a medical student?

My point is we're bringing it on ourselves by choosing not to take the "lower specialties" theres a huge difference between them infringing on our practice and just filling a void that we left. It changes the argument about if they're going to move into specialties because if there is no void in specialties then they aren't going to be moving into them - just like immigrants aren't becoming investment bankers.

And I'm just barely a med student now. I meant classes in undergrad/highschool. I had several teachers in high school cover that concept, and I took several political classes in college (well lets face it any class at Berkeley becomes political...haha). I never said I took the classes in med school.

This one class I took just covered it over and over again - it was called "The repeopling of America" yeah dumb name - but super interesting class. Basically covered every group of immigrants that came to the US in the 18th and 19th century and its a pattern that has been seen over and over again. Immigrants come and take jobs that are open because "Americans" don't want them. And then everyone hates that particular group - then it passes and starts again. Happened to the Chinese, Japanese, Irish, Russian Jews, etc. etc. etc.

 

[alwaysaangel]

So, why do we not have 100% unemployment if there was such a shortage of workers? If you define millions of Americans that would rather (or have financial incentive not to work) milk the system rather than start at the "bottom" as a void, then you are correct, the "void" came first.

I'm curious how you'll respond to this one.

Thats actually the exact argument. Most Americans would prefer to be unemployed and milk the system than go out into a field and pick produce.

 

[cfdavid]

Thats actually the exact argument. Most Americans would prefer to be unemployed and milk the system than go out into a field and pick produce.

MOST Americans? Really? That's what your liberal college professors forgot to elaborate on. I didn't know that the vast majority of our unemployed actually had skills qualifying them for better jobs than those you've described. It's NOT "most" Americans, just some that would rather sit on their a.s rather than take an entry level laborers job that they're "too good for". Again, something I'm sure the libs out at Berkley conveniently left out of their propaganda.

 

[JayneCobb]

I tell myself and the students who rotate with me that what we don't know can kill people, and I'm very hesitant to allow people with a fraction of the training hap-hazardously manage people. As long as the training is up to par at least in the area the they will be practicing, then I don't have an issue. But sub-specialized midlevels, or even in-patient midlevels for high acuity issues makes me nervous.

Now if were we to sub-divide and have CHF midlevels, HTN/DM/hyperlipidemia midlevels, etc, then I wouldn't be as opposed to this, but this isn't what this author is proposing.