I have been following your discussions here on the recent media coverage of the primary gap, and NPs place in it. I posted this on another forum that I moderate, and felt it was only fair to give you all a chance to chime in. I hope it doesn't come across as an attack, but rather a clinician of a different stripe with some real questions about how we market ourselves. The text below is addressed to PAs, so read in that context:
I have been reading the coverage of the recent articles from CNN and Time that we discuss here, in particular the responses on allnurses.
Of course I have to provide my PA disclaimer.....I work with NPs.....about a dozen of them at my institution. I have never had a negative experience with any of them, and have no need to write a "hit piece". We confer, they give medical feedback, I give surgical, etc....collegial and pleasant.
That being said, I have read over and over again about the presumed advantage NPs provide over docs (this is in their words) becuase they offer a "nursing perspective", "treat the patient, not the disease", "look at the patient as a whole", "offer prevention as well as treatment", etc.....
I really don't see this as NP bashing, but I see these comments as somewhat elitist....or at least "leading the argument". The NPs I work with practice the same medicine (!) as the rest of us, PAs, MDs, etc. Their preop cardiac workups look just like any other. And they're good. A clinic NP treating OM...are they really offering that much of an edge over a non-NP due to their nursing background? What does the nursing backgroud teach about listening, empathy, and thinking about interdependent body systems that our medical model education does not?
This all seems like a phoney selling point that is SO subjective that there is no way to argue it, putting NPs in a position which is easy to defend and impossible to refute.
Thoughts?
Do you feel like you treat your patients any less holistically b/c you were trained in the medical model?
1) Because it would not make sense to pay someone a greater salary because they spend 10-15 years (on average) of college, professional, and post graduate training to do a profession that is among the most challenging, has one of the highest rates of liability (i.e. medical malpractice), and still one of the most respected professions ? In addition, physicians have the highest consumer confidence ratings among professions.
And again (again), it has everything to do with maintaining costs. Most of the problem is administrative costs to deal with insurance companies, A recent survey (5/09) found that physicians spend an average of around $70,000 just on costs directly related to dealing with insurance companies (which is a large proportion of income).
L. P. Casalino, S. Nicholson, D. N. Gans et al., "What Does It Cost Physician Practices to Interact with Health Insurance Plans?" Health Affairs Web Exclusive, May 14, 2009, w533-w543.
In addition, the average student debt of the graduating medical student is $155,000 which equates to a $1,700 monthly payment. Assuming monthly payback that's approximately $60,000 in interest (which generally increases since the salary of residents prohibits most from beginning the payback until after residency which adds the compounded interest).
10 - 15 years? I hardly think so. More like 8 years. All professions are challenging, you however insist that being a physician is more challenging than any other profession and deserves more respect, more money and more power than any other profession on earth. I disagree. Physicians asked for third party payers more than thirty years ago. They were on board with it because they could control it at the time. Now that they no longer have control over it, they cry about having to deal with it. That is just a cost of doing business, and if it cuts into what a physician can pay themselves, that is their own problem. With regard to the student loan debts, the $155,000 is directly proportionate to what the physician can make in their first year of practice. The same is true for most other professions. They exit school and enter practice with a student loan debt that mirrors what their starting salary is. So there is no disproportionate burden on physicians, and therefore, I see absolutely no reason to feel sorry for them.
Patients are more satisfied because of what NPs currently can provide (i.e. more time, patient education), but that will change with independent practice - between administrative costs, time spent with health insurance (see above), and pressure to increase number of patient visits. Also, frequently satisfaction may not correlate with outcomes - just because I like you as a provider may not mean my HTN or DM is under control.
Also, please do not minimize what one year of education provides. It has already been emphasized about the lack of clinical coursework involved in NP educational programs and that one year of medical school or rotations involves more coursework or clinical hours in one week than any graduate program (most systems courses range from 10-15 credits - and there are 4-5 systems per semester !). That adds a lot in terms of education and while it may not be immediately quantifiable (since yes the average patient does not have a rare disorder or disease), it is still very important.
There are not fires every day in the average suburb, yet firefighters train regularly to fight them (and train for different types of fires). If I only trained to fight house fires, and one day a year there was a fatal car fire, then overall you would say that I did a good job because I trained for what was more common. Unfortunately, if that's my car I would probably feel otherwise.
Satisfaction always corelates with outcomes. If I stay sick, I will be very unsatisfied. You are missing the point on administrative costs and independent practice. The administrative costs are not necessarily the same for an NP for starters, you however insist on assuming that they are. The NP can do the job for less money, which means they don't have to see as many patients in a day as the physicians does.
I don't say that you can't learn anything in one year of college, but I do think one year of experience is worth 5 in the classroom.
If it costs an additional $5 million a year to train to put out the car fire, there would be a cost benefit analysis, and the people would make a judgement call that it isn't worth $5 million a year to save the $30,000 car, don't you think?
If an RN with a few extra classes has even the option to practice independently then that's a problem. RN programs train nurses to assess patients and follow protocols and standards - not make independent diagnoses and prescribe medications.
10 - 15 years? I hardly think so. More like 8 years. All professions are challenging, you however insist that being a physician is more challenging than any other profession and deserves more respect, more money and more power than any other profession on earth. I disagree. Physicians asked for third party payers more than thirty years ago. They were on board with it because they could control it at the time. Now that they no longer have control over it, they cry about having to deal with it. That is just a cost of doing business, and if it cuts into what a physician can pay themselves, that is their own problem. With regard to the student loan debts, the $155,000 is directly proportionate to what the physician can make in their first year of practice. The same is true for most other professions. They exit school and enter practice with a student loan debt that mirrors what their starting salary is. So there is no disproportionate burden on physicians, and therefore, I see absolutely no reason to feel sorry for them.
Four years of undergraduate training, four years of medical school, and 3-10 years in residency (average 3 for FP, 5-6 for IM). As for student loan debt, remember that most other professions either enter their chosen field earlier or allow for participants to work or make some income during school - not an option in medical school. There IS a disproportionate burden on physicians. And yes, medicine is more challenging than other professions. Also, this cost of business will affect NPs too.
Satisfaction always corelates with outcomes. If I stay sick, I will be very unsatisfied. You are missing the point on administrative costs and independent practice. The administrative costs are not necessarily the same for an NP for starters, you however insist on assuming that they are. The NP can do the job for less money, which means they don't have to see as many patients in a day as the physicians does.
I don't say that you can't learn anything in one year of college, but I do think one year of experience is worth 5 in the classroom.
If it costs an additional $5 million a year to train to put out the car fire, there would be a cost benefit analysis, and the people would make a judgement call that it isn't worth $5 million a year to save the $30,000 car, don't you think?
They will be the same for an NP assuming independence as a practitioner. If the NP is charging less then why would they be able to see the same number of patients in a day ?
Unfortunately one year of experience is a lot different than one year of "college" (btw medical school is not "college"). In addition, one year of working in a low acuity community hospital is a lot different than an urban hospital. I can learn in the office/hospital that you give antibiotics for strep throat or diuretics for CHF, but if I don't understand why they work then there's alot of things that can go wrong.
And unfortunately, people don't make that call. It cost more than that per year in taxes to train, staff, and pay for apparatus for a fire department - yet it is paid nonetheless.
Four years of undergraduate training, four years of medical school, and 3-10 years in residency (average 3 for FP, 5-6 for IM). As for student loan debt, remember that most other professions either enter their chosen field earlier or allow for participants to work or make some income during school - not an option in medical school. There IS a disproportionate burden on physicians. And yes, medicine is more challenging than other professions. Also, this cost of business will affect NPs too.
Residency is the same as on the job training, and med students do get paid for it. You still want us to cry for you the same way that you cry for yourself. The burden is not disproportionate for physicians, in fact, since they have more disposable income, it is easier for them to pay the loans than someone who enters their field making $45,000/year who only has $60,000 in student loan debt. Medicine is different, but that doesn't make it more challenging. Just because someone can think through a complex diagnosis, it doesn't make them smarter than someone trying to estimate reserves for loan losses. Both require intense scrutiny and training as well as experience. What kind of stupid comment is this about cost of business will affect NPs too. Cost of business affects everyone, but how it affects you is all about how you handle it and react to the market. That is something that physicians know nothing about how to handle, hence the adverse affects on their business.
If an RN with a few extra classes has even the option to practice independently then that's a problem. RN programs train nurses to assess patients and follow protocols and standards - not make independent diagnoses and prescribe medications.
You have yet to explain why that worries you personally.
They will be the same for an NP assuming independence as a practitioner. If the NP is charging less then why would they be able to see the same number of patients in a day ?
Unfortunately one year of experience is a lot different than one year of "college" (btw medical school is not "college"). In addition, one year of working in a low acuity community hospital is a lot different than an urban hospital. I can learn in the office/hospital that you give antibiotics for strep throat or diuretics for CHF, but if I don't understand why they work then there's alot of things that can go wrong.
And unfortunately, people don't make that call. It cost more than that per year in taxes to train, staff, and pay for apparatus for a fire department - yet it is paid nonetheless.
Because they don't have to make the take home pay of $150,000/year to "stay in business" as you claim physicians have to.
One year of experience in what you plan to do when you start practicing independently is what is important. If you want to go get a job, that is typically what you are asked, "do you have experience in doing what we need for you to do"?? The reason that is the interview question? Because it is the most important factor in whether or not you can do the job well.
People do make the call, they do it with their votes. Last time I checked we do have democratic elections, and democratically elected officials make those calls and pass the laws. I made no comment about the cost of the fire department, but under your logic, we would be better off if we had firefighters that all had masters degrees in firefighting. That would make much better firefighters and keep us all safer, even though we would have to pay the firefighter twice as much. After all, more education is always better, isn't it? And if you are more educated, you deserve to get paid more, don't you?
Residency is the same as on the job training, and med students do get paid for it. You still want us to cry for you the same way that you cry for yourself. The burden is not disproportionate for physicians, in fact, since they have more disposable income, it is easier for them to pay the loans than someone who enters their field making $45,000/year who only has $60,000 in student loan debt. Medicine is different, but that doesn't make it more challenging. Just because someone can think through a complex diagnosis, it doesn't make them smarter than someone trying to estimate reserves for loan losses. Both require intense scrutiny and training as well as experience. What kind of stupid comment is this about cost of business will affect NPs too. Cost of business affects everyone, but how it affects you is all about how you handle it and react to the market. That is something that physicians know nothing about how to handle, hence the adverse affects on their business.
More disposable income ? How do you arrive at that conclusion ? Also, medicine IS more challenging, otherwise college would be shorter, training would be easier, and there would be no standardized testing. I am not talking about someone being smarter than someone else - but to go through school and training and amass the knowledge to practice medicine is a task that is definitely more challenging than an accountant's job. Numbers on a page do not change, people have an infinite number of variables, many of which cannot be measured or factored in when a diagnosis is made or when a treatment is prescribed.
I am just wondering why you have this opinion that physicians don't know how to manage their money ? I am sorry, but just because someone is an NP doesn't make them experts at practice management or money management and doesn't make them selfless enough to say that they will charge enough to break even and only see 5 patients a day.
You have yet to explain why that worries you personally.
Ok....i thought i did - it's no different than my argument all along. If someone does not have the training and education to perform the job then people will die or get suboptimal care.
Because they don't have to make the take home pay of $150,000/year to "stay in business" as you claim physicians have to.
One year of experience in what you plan to do when you start practicing independently is what is important. If you want to go get a job, that is typically what you are asked, "do you have experience in doing what we need for you to do"?? The reason that is the interview question? Because it is the most important factor in whether or not you can do the job well.
People do make the call, they do it with their votes. Last time I checked we do have democratic elections, and democratically elected officials make those calls and pass the laws. I made no comment about the cost of the fire department, but under your logic, we would be better off if we had firefighters that all had masters degrees in firefighting. That would make much better firefighters and keep us all safer, even though we would have to pay the firefighter twice as much. After all, more education is always better, isn't it? And if you are more educated, you deserve to get paid more, don't you?
Experience is NOT the most important factor. If you are practicing independently then you have no one to "train you", something that is the whole idea behind a residency and is especially important if you have very little clinical training and would benefit from physician oversight.
Sounds like what the nursing profession is advocating in BSNs and DNPs - in fact that's exactly what they are looking to do. It's all about the money.
More disposable income ? How do you arrive at that conclusion ? Also, medicine IS more challenging, otherwise college would be shorter, training would be easier, and there would be no standardized testing. I am not talking about someone being smarter than someone else - but to go through school and training and amass the knowledge to practice medicine is a task that is definitely more challenging than an accountant's job. Numbers on a page do not change, people have an infinite number of variables, many of which cannot be measured or factored in when a diagnosis is made or when a treatment is prescribed.
I am just wondering why you have this opinion that physicians don't know how to manage their money ? I am sorry, but just because someone is an NP doesn't make them experts at practice management or money management and doesn't make them selfless enough to say that they will charge enough to break even and only see 5 patients a day.
Disposable income is a very simple economic concept. The fact that you don't comprehend it goes further to prove my point that you have absolutely zero business acumen. Everyone requires a certain amount of money to provide for the necessities of life. The amount that is left over is disposable income. Doctors make more money than others and thus have more disposable income. Very simple concept. Just because the education is delivered differently doesn't make it more challenging. Accountants train more on the job than the physician model. And they spend most of their careers working very long hours. The first few years are very tough and there is a lot to learn under supervision before they are really trained to do the job. Numbers on a page can be every bit as complex as the human body. Have you ever tried to interpret a 10-K? Ever even tried to read one? I bet you can't tell me the first thing about it after you do. You simply won't understand it. And I know you can't tell me how you would go about making the complex estimates that go into it. It takes years of experience and professional judgement to do it. Don't try to compare your profession to others and assume you are better smarter or even more challenged than others before you walk a mile in their shoes. This is exactly the attitude that makes physicians poor businesspeople. They don't think that they can take professional advice from someone because they are so much smarter than everyone else. NPs don't seem to have the GOD complex and are certainly more willing to take business advice from an expert instead of thinking that they are their own business expert and can do it exactly the way that they want to and make money at it.
mbreaz1
132 Posts
10 - 15 years? I hardly think so. More like 8 years. All professions are challenging, you however insist that being a physician is more challenging than any other profession and deserves more respect, more money and more power than any other profession on earth. I disagree. Physicians asked for third party payers more than thirty years ago. They were on board with it because they could control it at the time. Now that they no longer have control over it, they cry about having to deal with it. That is just a cost of doing business, and if it cuts into what a physician can pay themselves, that is their own problem. With regard to the student loan debts, the $155,000 is directly proportionate to what the physician can make in their first year of practice. The same is true for most other professions. They exit school and enter practice with a student loan debt that mirrors what their starting salary is. So there is no disproportionate burden on physicians, and therefore, I see absolutely no reason to feel sorry for them.