Would you feel safe with a PA as your PCP?

[tatsuchi]

Undergrad has zero bearing on medical knowledge but it often gives good insight into someone's natural intelligence.

Of the average person, sure.

How much insight does it give to a physician compared to their board scores/residency training in determining the competency of the person as a practitioner of medicine?

The answer is "not much."

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[IlDestriero]

I am a brand new attending in Dermatology and work with two PAs. One has been working in Derm for 22 years, the other 18.

They are both good guys, and can handle a good bit of the straight forward stuff; however, it is unbelievable how limited their overall knowledge fund is, but also nice to see how eager they are to learn. I've casually mentioned interesting or challenging cases I've encountered and am usually met with "wow, what is that?" or "intersting....can you tell me more about that?" And these are not zebras or "tertiary care interesting". Just a few instances of conditions or presentations you don't see every single day in private practice dermatology.

Obviously this is just one person's experience, but it has actually surprised me how shallow their pool of knowledge goes.

No no no. They take the same classes and the same exams and have the exact same expectations, and they do it in less time. Haven't you been following along. Yours must have gone to shady fly by night schools.
Is this the CRNA forum?


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Il Destriero

 

[IsleyOfTheNorth]

As of this writing, I'm cancer-free because my PCP (MD) noticed early signs of cancer. Would a PA notice and know what he/she was looking at? I don't know - and that's why I'd prefer an MD/DO.

 

[tatsuchi]

No no no. They take the same classes and the same exams and have the exact same expectations, and they do it in less time. Haven't you been following along. Yours must have gone to shady fly by night schools.
Is this the CRNA forum?

Only in the US do physicians have to constantly fight to explain how mid-levels are actually mid-level providers.

And only in the US do mid-levels feel entitled enough to proclaim they are not.

 

[giantswing]

Are you suggesting that a PA would miss something and an MD/DO would necessarily catch it? I can provide case reports of MD/DOs missing things but PAs catching it. There have been recent case reports of a PA diagnosing a 30-something y/o F with an MI after she was d/c from an ED with "MSK chest wall pain" but the PA got troponins and a 12 lead which confirmed a STEMI.

Dude. Anyone who's seen greys anatomy could diagnose a stems with elevated trops. That's not something to brag about.

 

[vendtex]

I'm not saying that. I'm saying I don't want to take any chances with dumb physicians.

Do you really think that, on average, the 3.4/25 crowd is going to be sharper than the 3.6/30 crowd? Please. Give me a break.

Your presumption is that the skill set to score well is strongly correlated with those skills that identify the good doctors. I'm not sure that is the case because not infrequently other issues like personality play a roll and also it underestimates the significance of the residency program which far exceeds that of college gpa and mcats IMO.


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[giantswing]

I see the level of discussion here has a rather low bar. Perhaps it was a mistake coming here and hoping to engage in professional and respectful conversation.

You're mad bc we're not telling you what you want to hear. Also, you're on an Internet forum, looking for professional respectful conversation?

I love how people complain about Drs being snotty and out of touch, then when docs do normal stuff like swear everyone else goes that's not professional!

 

[VA Hopeful Dr]

Perhaps you didn't understand or read what I wrote, which is consistent with the content of your posts. We were brought back to the lecture hall to revisit JNC 8 as when we originally took the HTN classes JNC 8 was not yet out. Because it was such a big shift in management of HTN our program insisted that we not become "cookbook clinicians" and instead have lectures in pathophysiology, pharmacology, and clinical medicine in order to fully explore JNC 8.


No. The fact that you even say this demonstrates a belittling mindset and completely disrespectful attitude.

Needlessly hostile, belittling, and personal, way to go there Hoss. Ironic that you're complaining about the lack of professional responses in this forum when you say things like the above bolded...

JNC-8 did not change our understand of the pathophys of hypertension, it was just an update of the evidence that changed the algorithm of treating hypertension. Maybe I am just being slow, but I really don't see why JNC-8 would require revisiting anything except, at most, why the changes were made. I can do that for the major changes in 2 sentences - it turns out that CCBs are as effective as diuretics in all comers at treating HTN and preventing HTN-related complications and ACE-Is were as effective in non-blacks. Also, we were being a bit aggressive in shooting for perfect numbers so let's relax our goal BP a little bit.

 

[VA Hopeful Dr]

What you say has some truth but it is incomplete. Undergrad has zero bearing on medical knowledge but it often gives good insight into someone's natural intelligence. I am at the end of residency and it long ago became apparent that your last two sentences are inaccurate.

Well according to a guy who has finished residency (me) and agreed with by my wife (who has also finished a different residency) my previous points are not inaccurate. I might be willing to admit that the clinical years of med school are somewhat helpful but that was such variation between schools that I hesitate on that front.

 

[IlDestriero]

We were brought back to the lecture hall to revisit JNC 8 as when we originally took the HTN classes JNC 8 was not yet out. Because it was such a big shift in management of HTN our program insisted that we not become "cookbook clinicians" and instead have lectures in pathophysiology, pharmacology, and clinical medicine in order to fully explore JNC 8.

So they don't want you to be "cookbook clinicians" but you have 3 mostly redundant lectures and a 100 question also mostly redundant exam on how to follow the marginally changed consensus hypertension recipe? Is there a different JNC8 out there for some very complex topic that I'm not aware of?
I'm all for evidenced based medicine, consensus guidelines, appropriate standardization, etc. but nothing in the JNC8 is fundamentally new information requiring multiple lectures and an exam. In fact, it's bizarre.
It's odd that you think these consensus guidelines and flow diagrams to guide your practice are not cookbook medicine, as it appears to me to be the definition of cookbook medicine. Though that's not necessarily a bad thing. There are a lot of people that are not current on the latest recommendations, don't even follow the old recommendations correctly, have non standard and inappropriate protocols, etc. There's a lot of variability out there and it's easy to pontificate from the ivory tower, the best practice probably lies somewhere in the middle.


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Il Destriero

 

[IsleyOfTheNorth]

Are you suggesting that a PA would miss something and an MD/DO would necessarily catch it?

No, definitely not. That would be dumb. Someone having an MD after their name doesn't make them infallible.

What I'm saying is that an MD is more likely to recognize it than a PA. I have two rationales for this:
1. MDs undergo more training.
2. A PA has less responsibility than an MD.

Why does #2 matter? PA's have a responsibility "safety net" - the MD. If the PA misses it, well they're only the first (or second, or third, etc.) line of defense. The MD is the last line of defense and is thus (by my reasoning anyway) more likely to be on the alert. The guy/gal with the most training is the person who is ultimately responsible for what happens to the patient.

http://www.medscape.com/viewarticle/775746

"Why Midlevels Are Usually Sued: Midlevel providers and their employers are typically sued for inadequate supervision or when the PA or NP practices beyond the scope of their training."

"Doctors need to remember that while you can delegate a task, you haven't delegated the liability," said Robin Diamond, RN, JD, Senior Vice President and Chief Patient Safety Officer for The Doctors Company, a liability insurer based in Napa, California."

 

[IsleyOfTheNorth]

Another interesting tidbit, from the same article:

"A 2010 decision by the Tennessee Supreme Court held that a supervising physician can be held vicariously liable for the negligence of his or her PA even if the physician never saw or treated the patient. This means that the doctor may automatically be held liable if the PA is found to have been negligent."

 

[PlutoBoy]

Are you suggesting that a PA would miss something and an MD/DO would necessarily catch it? I can provide case reports of MD/DOs missing things but PAs catching it. There have been recent case reports of a PA diagnosing a 30-something y/o F with an MI after she was d/c from an ED with "MSK chest wall pain" but the PA got troponins and a 12 lead which confirmed a STEMI.

Diagnosing acute coronary syndromes is not that hard at all. There is no way a ER doc would miss one.

Some mid levels in my clinic order troponins for patients with chest pain in the clinic.

That's kind of dumb. If you have reason to believe that the patient may be havin an acute coronary syndrome you should be sending them to the ER, not calling the patient the next day to tell them "Oh, btw, you had a NSTEMI yesterday". Not to mention that they can't read EKGs and instead rely on having their supervisor review it a few days after it is done.

I'll take MD/DO. Thank you very much.

 

[W19]

Midlevel providers supervision is a laughable concept... Physicians let these people run wild. I am not going to be sympathetic to any physicians who got sued because of midlevel incompetence...

 

[NimbleNavigator]

You're literally saying that the fact that they got a low college gpa and MCAT has more bearing on your decision than that they had a good Step and medical school performance. I don't see evidence to support that view.

This entire post can be summed up as "I'm not saying that...I'm more-than-implying it. Don't you agree with my implication?"

Whatever. You take the DO/URM-Action doctor. I'll take the MD. If you don't mind, I don't mind.

 

[IlDestriero]

How do you know who benefited from their URM status? I guess it's a white male, Asian or Indian MD only for you?


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Il Destriero

 

[Azete]

Whatever. You take the DO/URM-Action doctor. I'll take the MD. If you don't mind, I don't mind.

Honestly, if I had a serious ailment, I'd want the doctor that actually commits the time rather than focusing on the highest volume without getting sued (I realize this is often not the physician's fault). Given the appropriate attention, I think most physicians would be well equipped to handle even the most complex cases in their specialty -- URM/DO or otherwise. Time seems to be the limiting reagent, not intellect.

 

[vendtex]

Honestly, if I had a serious ailment, I'd want the doctor that actually commits the time rather than focusing on the highest volume without getting sued (I realize this is often not the physician's fault). Given the appropriate attention, I think most physicians would be well equipped to handle even the most complex cases in their specialty -- URM/DO or otherwise. Time seems to be the limiting reagent, not intellect.

Judgment training and experience are more important in my opinion.


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[mehc012]

Whatever. You take the DO/URM-Action doctor. I'll take the MD. If you don't mind, I don't mind.

Deal. At least that way I don't have to worry about the risk of speaking to you irl in the waiting room or something. That sounds like it'd be painful for everyone involved.

 

[TedStark]

If you're a google doctor and are okay with your arrogance and naivety potentially leading to your premature death, by all means save that $20 and go see an assistant or nurse for your healthcare. There aren't enough physicians to go around anyways. Natural selection comes to mind.

Assistant/nurse: "Your salts low. You need some Gatorade."

Physician: "hyponatremia--> SIADH--> chest x-Ray --> pulmonary vascular marking --> further work up for small cell carcinoma

They don't teach that kind of thinking in nursing or assistant school, sorry.

"But I've got twenty years of experience!" So does everyone else who has had a career. Unfortunately experience isn't universal.

 

[deleted245139]

Whatever. You take the DO/URM-Action doctor. I'll take the MD. If you don't mind, I don't mind.

You requesting UG GPAs and MCAT scores before you see your PCP, or ER doc? Interesting....

-a DO

 

[jw3600]

Whatever. You take the DO/URM-Action doctor. I'll take the MD. If you don't mind, I don't mind.

I've been on SDN for quite some years now. Either you are a great troll (completely ******ed yet just subtle enough) or you are one of the most insufferable medical students I have ever seen post.

 

[NimbleNavigator]

You requesting UG GPAs and MCAT scores before you see your PCP, or ER doc? Interesting....

-a DO

So just out of curiosity, what was your undergrad GPA/MCAT score?

 

[Kazaki]

would you feel safe with al baghdadi as your baby sitter ?

you win

 

[Kazaki]

Not advocating PA autonomy, but I've seen them perform just about every function an MD does -- including many advanced surgical procedures start to finish.

yeah nice try...

 

[Kazaki]

I am in a three year PA program within a medical school. We take a number of our classes with the medical students and have the same exams and same educational expectations. Our clinical medicine classes are taught by the medical school professors who say they teach them no differently. Our physical examination and OSCE courses are the same. The pharmacology classes (three semesters long, 4 credits each) are taught by PharmDs who are tenured in their departments are engaged in research. We are trained in general primary care, to be active in CME, and never let our knowledge become stale. As an example we recently had several lectures and a lengthy exam in the JNC 8 guidelines in order to ensure that our knowledge is up to date. We are also required to do a capstone project on original research. PAs complete a full year (50 weeks, 2000 hours) of clerkships which last for five weeks. PAs are also able to do 1-1.5 year long post-graduate residencies/fellowships which often take place alongside the newly graduated MDs. Clearly MD/DOs have more years of training, both didactic and clinical. PAs do not dispute or minimize the importance of this.

PAs required to retake our licensing exam (called the PANRE) every ten years and it's a brand new test every ten years which reflects the latest in medical education and medical knowledge. This ensures we are practicing with the latest and greatest which medicine has to offer. I'm trying to paint the picture that there is far more in common between PA and MD education than there are differences. Certainly MDs are the king-of-the-castle and PAs have no interest in changing the physician-lead dynamic. We always want the MD (or DO) to be in collaboration with us and to be available for the particularly complicated patients. We do wish that our education and experience be valued for the high quality and intensive nature that it is and for it not to be belittled.

I would be very scared if myself or a family member were to come under the care of an NP, who have more education on "nursing philosophy" and don't know what they don't know.

you are no different than a nurse

 

[Kazaki]

In basically every other country in the world, people accept no less than a physician for their treatment. We are the only nation that has, on a large scale, decided that not everyone deserves providers with the full depth and breath of medical training to provide for them. .

I thought I'd never see an American say this.

 

[IlDestriero]

If you're a google doctor and are okay with your arrogance and naivety potentially leading to your premature death, by all means save that $20 and go see an assistant or nurse for your healthcare. There aren't enough physicians to go around anyways. Natural selection comes to mind.

Assistant/nurse: "Your salts low. You need some Gatorade."

Physician: "hyponatremia--> SIADH--> chest x-Ray --> pulmonary vascular marking --> further work up for small cell carcinoma

They don't teach that kind of thinking in nursing or assistant school, sorry.

"But I've got twenty years of experience!" So does everyone else who has had a career. Unfortunately experience isn't universal.

This is so right on so many levels.
And it illustrates one of the problems with cookbook medicine today and midlevel providers. They can follow the algorithm better than any MD. If they use that as an endpoint in their equality studies they will always have better compliance. That's the problem. We are trained to run complex differential diagnoses and think outside the box. They are trained to aways stay in the box. Someone's got to be the 1:100k who they've never seen "in their 20 years of experience" who is SIADH, renal artery stenosis, or whatever zebraish rule out that you can't test everyone for. Physicians will be better at teasing that out overall because of their longer experience in school and training and better understanding of pathology and physiology. Physicians can miss these things as well, but I'm at a zebra referral center and I see these delayed diagnoses regularly. More reliance on algorithms will only make that worse.
Though as I noted earlier, standardization and guidelines can be good for a number of things. ACS, and stroke guidelines are a couple that immediately come to mind.


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Il Destriero

 

[deleted245139]

So just out of curiosity, what was your undergrad GPA/MCAT score?

Let's just say some peak in HS, some peak in college... Some just do better at every step lol.
Anywho, I'd strongly advise you to stop fixating on college. You don't wanna be the guy who peaked in college.

 

[67552931811]

I've been on SDN for quite some years now. Either you are a great troll (completely ******ed yet just subtle enough) or you are one of the most insufferable medical students I have ever seen post.

He/She is a pre-med.....

 

[67552931811]

.

 

[jw3600]

He/She is a pre-med.....

Honestly having pre meds post in allo isn't necessarily a big deal in itself but there should an incredibly short leash for mods warning/banning when they are **** posting.

 

[NimbleNavigator]

Let's just say some peak in HS, some peak in college... Some just do better at every step lol.
Anywho, I'd strongly advise you to stop fixating on college. You don't wanna be the guy who peaked in college.

Your post does nothing to refute my point.

 

[Psai]

Perhaps you didn't understand or read what I wrote, which is consistent with the content of your posts. We were brought back to the lecture hall to revisit JNC 8 as when we originally took the HTN classes JNC 8 was not yet out. Because it was such a big shift in management of HTN our program insisted that we not become "cookbook clinicians" and instead have lectures in pathophysiology, pharmacology, and clinical medicine in order to fully explore JNC 8.


No. The fact that you even say this demonstrates a belittling mindset and completely disrespectful attitude.

Wait LOL it takes 10 minutes to go through jnc 8 and understand it. It's not that different from jnc7 and you definitely shouldn't need extra classes to go through it. What kind of pathophysiology are you going through for essential hypertension?

Btw following a guideline is the definition of cookbook medicine.

Are you suggesting that a PA would miss something and an MD/DO would necessarily catch it? I can provide case reports of MD/DOs missing things but PAs catching it. There have been recent case reports of a PA diagnosing a 30-something y/o F with an MI after she was d/c from an ED with "MSK chest wall pain" but the PA got troponins and a 12 lead which confirmed a STEMI.

The fact that you have case reports of catching MIs tells me everything I need to know. Who writes case reports about MIs? Everyone with even a hint of chest pain in the ED buys themselves an ecg, cxr and trop x 2. Things can present very atypically and the chance of a 30 year old with MI is low. Things can take time to express themselves. You might get a person coming in with trop negative x2 but later you found out that they actually did have a stemi just you didn't see trops rise yet

 

[NimbleNavigator]

Wait LOL it takes 10 minutes to go through jnc 8 and understand it. It's not that different from jnc7 and you definitely shouldn't need extra classes to go through it. What kind of pathophysiology are you going through for essential hypertension?

Btw following a guideline is the definition of cookbook medicine.



The fact that you have case reports of catching MIs tells me everything I need to know. Who writes case reports about MIs? Everyone with even a hint of chest pain in the ED buys themselves an ecg, cxr and trop x 2. Things can present very atypically and the chance of a 30 year old with MI is low. Things can take time to express themselves. You might get a person coming in with trop negative x2 but later you found out that they actually did have a stemi just you didn't see trops rise yet

Great post, took the words right out of my mouth tbh

 

[K.E.]

I'm asking PURELY because I'm switching PCPs and have the option of either a PA who can see me in a week or a DO that I have to wait over a month to see.

I'm healthy now, but my concern is a PA might miss something subtle which might lead to late diagnosis of some illness I develop in the future.

THIS IS NOT MEANT TO STIR UP ANY MD VS DO VS PA DEBATE. Answer purely from your personal perspective. Would you personally trust a PA with your health?

I don't understand why the Pro-NP people are basically saying, "If I think it might be actually serious, then I want to see an MD. If not, an NP will do."

Don't you think that part of the reason why you go to a physician is because you are not qualified to determine what's serious and what's not so serious?

Also, I think that physicians would do well to refer to "nurse practitioners" and the like simply as advanced nurses. That's what they are.

 

[Mr Roboto]

So just out of curiosity, what was your undergrad GPA/MCAT score?

0/10

:troll:

 

[cbrons]

refer to the appropriate provider

Does anyone hate this word as much as I do?

Do you realize that the word "provider" is being used deliberately in order to make MDs seem equivalent to NP/PA?

 

[cbrons]

Sure, then maybe the testing and matching system is completely flawed. On the other hand, maybe your standards are.

Sorry, you're going to have to show me something with substance before I'm going to take "DOs and the (relatively) few Carib students who actually make it are dangerous because they were worse students back in undergrad even though they pass all measures in medical school" makes logical sense to me. You're basically saying that MCAT/undergrad performance is more relevant to your ability to practice medicine than Step/medical school performance, which I have yet to see any support for.

News flash - "Step" isn't even relevant to your ability to practice medicine, just your ability to match into the area you want to practice in.

 

[vendtex]

Midlevel providers supervision is a laughable concept... Physicians let these people run wild. I am not going to be sympathetic to any physicians who got sued because of midlevel incompetence...[/QUOTE

Although it may be dangerous, I sometimes think it would be better to let them be independent so no one else's license and malpractice is affected other than their own.

 

[Mr Roboto]

Does anyone hate this word as much as I do?

Do you realize that the word "provider" is being used deliberately in order to make MDs seem equivalent to NP/PA?

Well he's a PA student, so...

 

[cbrons]

Are you suggesting that a PA would miss something and an MD/DO would necessarily catch it? I can provide case reports of MD/DOs missing things but PAs catching it. There have been recent case reports of a PA diagnosing a 30-something y/o F with an MI after she was d/c from an ED with "MSK chest wall pain" but the PA got troponins and a 12 lead which confirmed a STEMI.

I caught several misdiagnoses by Nurse Practitioners when I was a 3rd year medical student. So there.

 

[cbrons]

Although it may be dangerous, I sometimes think it would be better to let them be independent so no one else's license and malpractice is affected other than their own.

No. They didn't put in anywhere near the sacrifice to be independent, they don't deserve it.

What makes me sick is these NPs calling themselves "doctor-so-and-so." Their education is a complete joke, their X-years of nursing experience is NOT relevant to the practice of medicine, and their degree (DNP) is a complete joke. At least the PAs will never be independent and have to do some medical school (though they don't do an actual residency). The PAs will never be called "Doctor" because we won't let them. The NPs will do whatever they want because they are controlled by the board of nursing and their lobbying organization is extremely powerful.

In this idiotic state, the corrupt politicians recently allowed NPs and PAs to write for schedule II controlled substances. In one of the worst areas of the country for opioid and amphetamine abuse, the *****s thought it was wise to give these people full prescriptive authority.

 

[mehc012]

News flash - "Step" isn't even relevant to your ability to practice medicine, just your ability to match into the area you want to practice in.

I know...honestly I don't think either is what makes you a good doctor, I just think that relying on undergraduate GPA and MCAT scores to judge a good doctor is even more ridiculous than using Step. The previous poster was making it sound as if going to an easier-to-get-into school says more about a doc than whatever the residency saw to let them in (which at least includes interviews and audition rotations). I thought that was ridiculous and said as much, and that's the extent of the statement I want to make on this front with the limited experience I have.

 

[AnatomyGrey12]

Whatever. You take the DO/URM-Action doctor. I'll take the MD. If you don't mind, I don't mind.

says the troll who once posted about a DO school scholarship...

So just out of curiosity, what was your undergrad GPA/MCAT score?

Guess what, I will be going to a DO school, and by how the statistics work out I almost certainly have a higher MCAT score than you. But I guess that you won't see a doctor who went to a state school either because there is a good chance they had lower than a 30.

For the thread, I will never see a mid-level provider as my primary physician. They are good in their role but that isn't to be my doctor. When my baby was in the NICU it was scary how much more I knew than the NP that would round on them from time to time... And she even had direct physician oversight.

 

[deleted245139]

So just out of curiosity, what was your undergrad GPA/MCAT score?

Tell you what... if you get accepted, lets talk after you take steps.
Take heart though... if you bomb them, at least you have your MCAT and GPA in college to talk about at cocktail parties.
Med school is a rude awakening gang... EVERYONE in medical school is smart. Good idea to learn that early.
Work hard, be successful.

 

[NimbleNavigator]

Guess what, I will be going to a DO school, and by how the statistics work out I almost certainly have a higher MCAT score than you. But I guess that you won't see a doctor who went to a state school either because there is a good chance they had lower than a 30.

Guess what, I got a 39. Unlikely.

 

[GinnyWeasley]

Guess what, I got a 39. Unlikely.

If you had to go to the emergency room, and it was urgent, would you pause and ask the doctor to identify where they went to medical school, undergrad GPA/MCAT, where they went to undergrad, what they got on their first orgo test, etc ? Of course, I assume you won't even give the doctor a chance if they are a URM?

 

[IlDestriero]

I scored well below both of you, probably had a much lower GPA as well, yet went to a top 20 school, on a full ride (+ an additional scholarship), trained at a premier program, and have been faculty at 2 top 10 medical schools working at world class specialty hospitals. And I'm most certainly not disadvantaged or a URM, unless New England WASPs are now all going into finance and have been granted URM status. Numbers are just a part of your application. If you picked physicians by MCAT and GPA you'd be in rough shape. Lots of high flyers crashed and burned, badly. They coasted, got lazy, gave up. Who knows, who cares. That's their problem. Everyone comes in full of hope and dreams, cocky with their heads held high, only to find they brought a knife to a gun fight.
Boom!
Lol.


--
Il Destriero

 

[raiderette]

I had a PA as my GYN provider for most of my adult life. I was sometimes treated by a doctor for one abnormal lab, but it made sense to see her as I was the less complicated, typical patient. Now I would never let my mother with asthma see a PA or my grandfather who has multiple health issues.