You wasted your time in med school.

[urge]

• “We found that care is likely to be comparable regardless of whether patients are seen by a nurse practitioner, physician assistant or physician.”

http://journals.lww.com/lww-medical..._of_Nurse_Practitioners,_Physician.98777.aspx

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[Consigliere]

I knew I wasted my time in medical school well before this article came out.

 

[Timeoutofmind]

http://journals.lww.com/lww-medical..._of_Nurse_Practitioners,_Physician.98777.aspx

That is not what I have found in clinical practice.
The difference is extremely pronounced.

 

[d9sccr]

That is not what I have found in clinical practice.
The difference is extremely pronounced.

Yeah but that's just anecdotal evidence, this is peer-reviewed evidence-based literature

 

[Man o War]

That is not what I have found in clinical practice.
The difference is extremely pronounced.

Me too.
My wife saw an NP at urgent care who misdiagnosed swimmers ear as an inner ear infection. Shocker,the systemic antibiotic didn't do anything. Saw an actual doctor and he couldn't believe someone could mistake the two.

 

[Consigliere]

Yeah but that's just anecdotal evidence, this is peer-reviewed evidence-based literature

That's funny. That's like saying the Big Mac is a fine steak.

 

[BLADEMDA]

"Findings from our study should be reassuring to patients who rely on community health centers for their care," said Ellen Kurtzman, associate professor in the GW School of Nursing and lead author of the paper. "We found that care is likely to be comparable regardless of whether patients are seen by a nurse practitioner, physician assistant or physician."

As the country grows more dependent on community health centers, particularly in medically underserved areas that tend to serve low-income, uninsured, immigrant and minority populations, the health care system is increasingly relying on non-physician clinicians to provide primary care.

To assess the care patients received in community health centers, Dr. Kurtzman and her team reviewed five years of data from the National Ambulatory Medical Care Survey's Community Health Center subsample and compared nine patient outcomes by practitioner type. The patient outcomes were:

• Three quality indicators (smoking cessation counseling, depression treatment, ordering/prescribing of statins for hyperlipidemia [high levels of fat particles in the blood])
• Four measures of service utilization (physical exams, total number of health education/counseling services, imaging services, total number of medications)
• Two measures of referral pattern (return visits at a specified time, physician referrals)

The researchers found that visits to nurse practitioners and physician assistants received similar quality, services and referrals as those made to physicians.

The research is encouraging for health center administrators who must meet the medical demands of their communities without compromising care. It is also important for policymakers who establish occupational policies that often restrict the autonomy of non-physician clinicians, such as nurse practitioners and physician assistants.

Another recent study led by Dr. Kurtzman that used the same dataset found that nurse practitioner outcomes did not vary in states with and without occupational restrictions of these clinicians. This suggests that lawmakers may be able to ease state restrictions without compromising the quality of patient care. The study, "Does the Regulatory Environment Affect Nurse Practitioners' Patters of Practice or Quality of Care in Health Centers?" was published in Health Services Research on Jan. 27.

 

[zero0]

Yeah but that's just anecdotal evidence, this is peer-reviewed evidence-based literature

Careful, people who don't know any better might think you're serious.

 

[VA Hopeful Dr]

"Findings from our study should be reassuring to patients who rely on community health centers for their care," said Ellen Kurtzman, associate professor in the GW School of Nursing and lead author of the paper. "We found that care is likely to be comparable regardless of whether patients are seen by a nurse practitioner, physician assistant or physician."

As the country grows more dependent on community health centers, particularly in medically underserved areas that tend to serve low-income, uninsured, immigrant and minority populations, the health care system is increasingly relying on non-physician clinicians to provide primary care.

To assess the care patients received in community health centers, Dr. Kurtzman and her team reviewed five years of data from the National Ambulatory Medical Care Survey's Community Health Center subsample and compared nine patient outcomes by practitioner type. The patient outcomes were:

• Three quality indicators (smoking cessation counseling, depression treatment, ordering/prescribing of statins for hyperlipidemia [high levels of fat particles in the blood])
• Four measures of service utilization (physical exams, total number of health education/counseling services, imaging services, total number of medications)
• Two measures of referral pattern (return visits at a specified time, physician referrals)

The researchers found that visits to nurse practitioners and physician assistants received similar quality, services and referrals as those made to physicians.

The research is encouraging for health center administrators who must meet the medical demands of their communities without compromising care. It is also important for policymakers who establish occupational policies that often restrict the autonomy of non-physician clinicians, such as nurse practitioners and physician assistants.

Another recent study led by Dr. Kurtzman that used the same dataset found that nurse practitioner outcomes did not vary in states with and without occupational restrictions of these clinicians. This suggests that lawmakers may be able to ease state restrictions without compromising the quality of patient care. The study, "Does the Regulatory Environment Affect Nurse Practitioners' Patters of Practice or Quality of Care in Health Centers?" was published in Health Services Research on Jan. 27.

Ding ding ding, we have a winner.

So they counseled smokers at the same rate doctors did, started some kind of depression treatment for those that screened positive, and treated cholesterol with statins at the same rate.

Fantastic. This proves what we've all known for a very long term: nurses do great with algorithms.

Same applies to utilization. Doing the same number of exams doesn't mean anything, it just means that they saw the same number of patients (assuming that's the units used). Referring for health education is an algorithm, I'd bet that's mostly diabetic education. Imaging and meds are interesting but I'd be curious about the breakdown by type of imaging ordered.

Not sure how one measures referral patterns exactly.

 

[mikey014]

Ding ding ding, we have a winner.

So they counseled smokers at the same rate doctors did, started some kind of depression treatment for those that screened positive, and treated cholesterol with statins at the same rate.

Fantastic. This proves what we've all known for a very long term: nurses do great with algorithms.

Same applies to utilization. Doing the same number of exams doesn't mean anything, it just means that they saw the same number of patients (assuming that's the units used). Referring for health education is an algorithm, I'd bet that's mostly diabetic education. Imaging and meds are interesting but I'd be curious about the breakdown by type of imaging ordered.

Not sure how one measures referral patterns exactly.

So true. That's exactly what I was thinking. They didn't make true outcomes. They measured how well non physicians adhere to algorithms. It's not rocket science to prescribe a statin to someone with hyperlipidemia. Nor is it difficult to write an antidepressant for a patient with a mood disorder.

Their "outcomes" aren't really outcomes at all. They measured adherence to protocols not clinical acumen.

The research that this RN DNP MSN BSN publishes is not true research.

 

[BLADEMDA]

All that matters is that the politicians are buying the garbage she is selling.

 

[BLADEMDA]

So true. That's exactly what I was thinking. They didn't make true outcomes. They measured how well non physicians adhere to algorithms. It's not rocket science to prescribe a statin to someone with hyperlipidemia. Nor is it difficult to write an antidepressant for a patient with a mood disorder.

Their "outcomes" aren't really outcomes at all. They measured adherence to protocols not clinical acumen.

The research that this RN DNP MSN BSN publishes is not true research.

http://www.cnbc.com/2017/03/03/trumps-obamacare-fix-is-focused-on-the-wrong-thing-commentary.html

Read the Op-Ed above for a similar "opinion" about healthcare in the USA.

"The simple solution to this is to tear down as many of those barriers to entry as possible. The government and the medical school community need to relax some of their more questionable requirements, and even allow for the return of the old medical "night schools" that offered cheaper and more fast-track training for internists and other less specialized areas of medicine."

Jay Novak, CNBC

 

[GravelRider]

This is a bad study. Anyone can design a study to come to any conclusion they want. Think of all the "rigorous" RCTs that have been contradicted by future studies. This is not a rigorous RCT.

With all that said, the midlevel vs physician argument is based on politics and economics. It has nothing to do with science, evidence, or what is best for patients. What may happen to our healthcare system is a have and have nots type of system. Those who can afford to see experts (physicians), will do so. Those who can't, will see the algorithm followers. Maybe they'll even be replaced by robots. Who needs an NP to score a depression questionnaire and prescribe an SSRI when a algorithm following robot and do it just as well.

 

[deleted162650]

the algorithm followers

This needs to be the name of an all NP band.

 

[GravelRider]

This needs to be the name of an all NP band.

Like a bad indie emo band?

 

[nimbus]

The problem is that quality studies almost never measure actual quality. They look at surrogate markers that are easy to measure but completely unrelated to quality. We have a problem defining quality in healthcare but we know it when we see it or it's absence.

 

[rakotomazoto]

Mid levels are great box-checkers, everyone already knows this. You could create an app that would perform just as well or better than them and save lots of time and money for everyone. Since the mid levels would all then be out of a job, they could all go to medical school and residency. Bye bye, doctor shortage. Problem solved. You're welcome, 'Murica.

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[hankbb02]

Suprise suprise some nurses think they are as good as doctors.

 

[epidural man]

Just a rhetorical question...

Is it possible that this study is correct (even though it is a bad study)?

Meaning...medicine has become highly specialized, and time with the clinician so small - that a PCP is left with checking the boxes. It is quit possible that a family practice physician is no longer needed, AND they are way over trained for what the job now requires?

They have so many check-box metrics they have to meet, and are left with no time to discuss real health issues in the way it needs to be addressed (like diet). Think about all the crazy science we learned in medical school that obviously was important on some level, but perhaps not so important to someone who just is a gait keeper to specialized medicine.

When I was 14, a general practitioner (not even an FP) took out my tonsils! FP and GP's used to have to know a ton of stuff and do a lot of stuff. What do they do know? They make sure a PHQ-2, AUDIT -C, and a dozen other questionairres are completed, and make sure they document a HgA1C, etc.

It is possible they are no longer needed.

I can't imagine going into FP today. I feel bad for them - such a great calling, such a horrible job (because the calling is no longer what the job requires).

 

[nimbus]

When I was 14, a general practitioner (not even an FP) took out my tonsils! FP and GP's used to have to know a ton of stuff and do a lot of stuff. What do they do know? They make sure a PHQ-2, AUDIT -C, and a dozen other questionairres are completed, and make sure they document a HgA1C, etc.

Just like Ronald Dahl in Boy. The way he describes it in the the memoir, his tonsils were out before he even realized what was happening. That same general practitioner sewed his nearly severed nose back on after a car accident.

 

[GravelRider]

Just a rhetorical question...

Is it possible that this study is correct (even though it is a bad study)?

Meaning...medicine has become highly specialized, and time with the clinician so small - that a PCP is left with checking the boxes. It is quit possible that a family practice physician is no longer needed, AND they are way over trained for what the job now requires?

They have so many check-box metrics they have to meet, and are left with no time to discuss real health issues in the way it needs to be addressed (like diet). Think about all the crazy science we learned in medical school that obviously was important on some level, but perhaps not so important to someone who just is a gait keeper to specialized medicine.

When I was 14, a general practitioner (not even an FP) took out my tonsils! FP and GP's used to have to know a ton of stuff and do a lot of stuff. What do they do know? They make sure a PHQ-2, AUDIT -C, and a dozen other questionairres are completed, and make sure they document a HgA1C, etc.

It is possible they are no longer needed.

I can't imagine going into FP today. I feel bad for them - such a great calling, such a horrible job (because the calling is no longer what the job requires).

Yup. When there is public discussion about why med students aren't going into primary care, the answer always comes back to money and greedy doctors. The problem is framed around the desire for the higher income of a specialist and not the fact that the job is just awful. Who wants to spend 4 years of med school and 3 years of residency checking boxes on an electronic medical record all day?

 

[deleted162650]

With the establishment of boutique practices, primary care may enjoy a bit of a renaissance. Finish FM residency, move to a fairly affluent area, hook up with a long standing FM doc in the community, and roll from there. (At least it sounds easy when I say it).

 

[deleted162650]

This needs to be the name of an all NP band.

They can be the opening act for The Box Checkers which of course is band composed of GYN NP's.

 

[zero0]

Just a rhetorical question...

Is it possible that this study is correct (even though it is a bad study)?

Meaning...medicine has become highly specialized, and time with the clinician so small - that a PCP is left with checking the boxes. It is quit possible that a family practice physician is no longer needed, AND they are way over trained for what the job now requires?

They have so many check-box metrics they have to meet, and are left with no time to discuss real health issues in the way it needs to be addressed (like diet). Think about all the crazy science we learned in medical school that obviously was important on some level, but perhaps not so important to someone who just is a gait keeper to specialized medicine.

When I was 14, a general practitioner (not even an FP) took out my tonsils! FP and GP's used to have to know a ton of stuff and do a lot of stuff. What do they do know? They make sure a PHQ-2, AUDIT -C, and a dozen other questionairres are completed, and make sure they document a HgA1C, etc.

It is possible they are no longer needed.

I can't imagine going into FP today. I feel bad for them - such a great calling, such a horrible job (because the calling is no longer what the job requires).

I'm probably stepping out of line here, but I'd caution you against this type of thinking. Respect your fellow physicians and their skillset. NPs miss red flags all the time that would otherwise be picked up by an FM. They still went to med school and are far more equipped to decide when someone needs a specialist referral.

Surgeons like to joke about how anesthesia can be done just as well by nurses and I'm sure most of us would disagree, but you see where that's gotten us. We can only lose by undermining the title of fellow physicians. The midlevels are doing a fine enough job of that without our help.

 

[epidural man]

I'm probably stepping out of line here, but I'd caution you against this type of thinking. Respect your fellow physicians and their skillset. NPs miss red flags all the time that would otherwise be picked up by an FM. They still went to med school and are far more equipped to decide when someone needs a specialist referral.

Surgeons like to joke about how anesthesia can be done just as well by nurses and I'm sure most of us would disagree, but you see where that's gotten us. We can only lose by undermining the title of fellow physicians. The midlevels are doing a fine enough job of that without our help.

Umm...I'm not showing disrespect their skill set. I didn't think I said anything derogatory to their expertise. What I did say - was because of JC and other regulatory bodies that have mandated certain boxes be checked, the PCP physicians are unable use their skill set. So if that is the case - they may not be needed anymore.

 

[trainofe4]

Nurse practitioners aside, most medical schools are at the best meh. Most medical education is poorly taught and inefficient. But there is too much money and political pressure to ever change things for the better in a meaningful way.

 

[Iso4ane]

Nurse practitioners aside, most medical schools are at the best meh. Most medical education is poorly taught and inefficient. But there is too much money and political pressure to ever change things for the better in a meaningful way.

While I don't necessarily disagree, how good can nursing school be in comparison?

 

[trainofe4]

While I don't necessarily disagree, how good can nursing school be in comparison?

Nursing school is great for the purpose of creating nurses. Nurses, by virtue of what they do, are easier to train. Nursing education is necessarily different from medical school because the purpose of our education is different. Nurses can't do what we do because our theoretical knowledge base is wider and built upon a more rigorous understanding of the human body and illness. This base, from m1 onwards allows us to have a more birds eye view of a patient and illness course. We supplement that with a clinical education built about asking why, what can go wrong, how do I get ahead of this, and most importantly, what did I do wrong. Iterations of this with our preclinical knowledge makes us physicians.

Nurses don't get that preclinical knowledge depth and their clinical knowledge is mainly centered around immediate and common medical problems. This lends itself well to algorithm use.

So no nursing education does not make a doctor. But comparing them is a mute point except for addressing threats from a profit driven industry.

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[deleted126335]

Nursing school is great for the purpose of creating nurses. Nurses, by virtue of what they do, are easier to train. Nursing education is necessarily different from medical school because the purpose of our education is different. Nurses can't do what we do because our theoretical knowledge base is wider and built upon a more rigorous understanding of the human body and illness. This base, from m1 onwards allows us to have a more birds eye view of a patient and illness course. We supplement that with a clinical education built about asking why, what can go wrong, how do I get ahead of this, and most importantly, what did I do wrong. Iterations of this with our preclinical knowledge makes us physicians.

Nurses don't get that preclinical knowledge depth and their clinical knowledge is mainly centered around immediate and common medical problems. This lends itself well to algorithm use.

So no nursing education does not make a doctor. But comparing them is a mute point except for addressing threats from a profit driven industry.

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Maybe you should explain it to them.

 

[dhb]

When i see how dumb nurses are, i have a hard time understanding how they became equivalent to MDs in the US.

 

[cbrons]

Yeah but that's just anecdotal evidence, this is peer-reviewed evidence-based literature

This is observational retrospective "outcomes"-based research done and sponsored by nurses where whether you were told to stop smoking (more specifically, whether provider charted that they told you to stop smoking) = better care.

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[d9sccr]

This is observational retrospective "outcomes"-based research done and sponsored by nurses where whether you were told to stop smoking (more specifically, whether provider charted that they told you to stop smoking) = better care.

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That was complete sarcasm

 

[Machinery]

All that matters is that the politicians are buying the garbage she is selling.

While refusing to see mid-levels themselves.

 

[kjamess]

I'm probably stepping out of line here, but I'd caution you against this type of thinking. Respect your fellow physicians and their skillset. NPs miss red flags all the time that would otherwise be picked up by an FM. They still went to med school and are far more equipped to decide when someone needs a specialist referral.

Surgeons like to joke about how anesthesia can be done just as well by nurses and I'm sure most of us would disagree, but you see where that's gotten us. We can only lose by undermining the title of fellow physicians. The midlevels are doing a fine enough job of that without our help.

This. That post was unfortunately filled with many misconceptions and a lack of understanding of outpatient medicine. Skilled and knowledgeable FM/outpatient internists are worth their weight in gold. I see these same comments made about EM, anesthesia etc and we all know isn't even remotely true.

 

[StevenSeagull]

Try making the best seller list with NP or PA at the end of your name

 

[PressureSupport]

Actually pretty easy to do as long as you have a bullsit voodoo naturopathic or chiropractic degree and love calling yourself "Wellness Physician."

 

[epidural man]

This. That post was unfortunately filled with many misconceptions and a lack of understanding of outpatient medicine. Skilled and knowledgeable FM/outpatient internists are worth their weight in gold. I see these same comments made about EM, anesthesia etc and we all know isn't even remotely true.

So teach me.

But first, in your own words, what do you think my point was?

 

[MaximusD]

No way x 1000. Let's just say when i was a flight surgeon (a GMO with only internship training) and participated in peer review... there were a few NPs and PAs that I wouldn't trust to care for anyone I've ever met. Horrible documentation, terrible diagnostics, questionable decisions.

 

[epidural man]

No way x 1000. Let's just say when i was a flight surgeon (a GMO with only internship training) and participated in peer review... there were a few NPs and PAs that I wouldn't trust to care for anyone I've ever met. Horrible documentation, terrible diagnostics, questionable decisions.

So what.

The whole point is - there is no CHOICE to be made anymore. It is all done by checklist and algorithms.

 

[trainofe4]

So the sky is falling down. This field is screwed. I'll eventually finish my residency and fellowship from an ivory tower place and settle down to taking orders from some DNP/MHA/MBA type person while I keep my head down.

There are 2 takeaways: people don't give a f*ck about individuals in healthcare and you have to look out for yourselves in this militarized healthcare complex. The growling we do here won't change anything.

So it might be more useful to talk about strategies to make the most out of this situation. Ideas I've heard so far:

1.) Go to a high paying PP job, work hard for a couple decades, live cheaply, make enough to gain relative financial independence.
2.) Go into academics, since the PP-Academia pay gap is getting obliterated thanks to AMC takeovers
3.) Definitely get a fellowship, maybe even 2.

What I would be interested in hearing about is how we as physicians can do what nurses do and rise in the ranks and stop being such weakly interacting massive particles. How do we get on committees? How do we get involved in advocacy? How do we start getting our hands on the pens that let us write the rules?

 

[pgg]

How do we get on committees?

It's easy, just volunteer.

You don't see many anesthesiologists on hospital committees because most anesthesiologists get nauseous at the thought and don't want to be there. It's not like there's a high barrier to entry.

But once there, you'll find we are welcomed and valued.

It's just painful work ... and worse, it's often undervalued by our peers, who need to cover for us while we're in those meetings. Many of them don't really understand how much better you're making their lives by slogging through those meetings and just resent you for taking nonclinical time on their clock.

 

[rakotomazoto]

How do we start getting our hands on the pens that let us write the rules?

Ask Paul Yost:

CalOptima Names Allied Anesthesia Physician Paul Yost New Board Chair

 

[deleted126335]

It's easy, just volunteer.

You don't see many anesthesiologists on hospital committees because most anesthesiologists get nauseous at the thought and don't want to be there. It's not like there's a high barrier to entry.

But once there, you'll find we are welcomed and valued.

It's just painful work ... and worse, it's often undervalued by our peers, who need to cover for us while we're in those meetings. Many of them don't really understand how much better you're making their lives by slogging through those meetings and just resent you for taking nonclinical time on their clock.

That is absolutely true... Assuming the person doing administrative committee work leverages their access for the benefit of the group. It is not uncommon for the person who represents the department to leverage their access for their own benefit.