New idea for NP/PA to MD

Trauma Columnist · Sep 9, 2010

Wow - do you work at a critical access hospital? Maybe the federal funds that support it could help to fund this program.

FNPinKS · Sep 10, 2010

Wow - do you work at a critical access hospital? Maybe the federal funds that support it could help to fund this program.

I sure do. The federal funding is exactly what I am aiming for in the long run; and I think it is readily available for this kind of program. There are about 250,000 NPs/PAs, and the predicted primary care MD/DOs in 2020 is 40,000. I think we could completely fill this gap with such a program, and Kathleen Sebelius will eventually read this idea, even if I have to sit on her porch until she gets home from work.

core0 · Sep 10, 2010

I sure do. The federal funding is exactly what I am aiming for in the long run; and I think it is readily available for this kind of program. There are about 250,000 NPs/PAs, and the predicted primary care MD/DOs in 2020 is 40,000. I think we could completely fill this gap with such a program, and Kathleen Sebelius will eventually read this idea, even if I have to sit on her porch until she gets home from work.

There are a number of problems with your proposal that make it unlikely ever to happen. The first is the structure of medical school. The LCME and COCA accredit medical school in the United States. They have their own standards but also adhere to standards set forth by the World Health Organization. One of the WHO standards is that Medical School entail at a minimum 36 months of full time instruction. The reason that the Medical School that you refer to does not meet requirements for a significant number of states is that they require physical presence on the campus. So even if you could get this by either LCME or COCA you would have to change a number of state laws.

Next to practice medicine in the US you would have to attend an ACGME or osteopathic equivalent residency. The residency requirements are set by the various specialties and do not give advanced credit for any experience outside of residency. The reason for this is that long experience has taught them that progressive experience is the only way to properly train physicians. Consider that a physician that practiced FP in a foreign country for many years is not given any advanced standing. The reason for this dates to the 60's and 70's when the medical community experimented with a number of different entry points with fairly disastrous results. There is also a growing body of evidence that the safest medical practice is by fully residency trained board certified physicians. Its unlikely that any of the governing bodies are going to change to a lesser standard. Instead they are increasing the standards including re-certifying at certain intervals.

Finally there is no reason for any medical school to do anything but what they are doing now. There are more than enough fully qualified students willing to pay the full freight right how. In fact medical schools are projecting an increase of 30% by 2015. This will largely cover the "projected shortage" if it exists. In reality this will simply shift the residency slots from FMGs to US residents since the residency slots are not increasing.

In reality your proposal does nothing to address the real problems in rural medicine. There has never been a physician shortage. There has been a shortage of physicians willing to work in rural areas due to isolation, lack of payment and payor mixes. Your proposal doesn't do anything to address this.

The truth, at least in studies done on the PA side show that PAs are more willing to work in rural areas than physicians. We have known the solution to the rural health problem for a number of years. That is to train providers from the area in the area that they live in. University of Washington's MEDEX program has used this model by building extension programs in Yakima and Alaska. There are a number of programs that use similar methods.

If you want to solve the rural health crisis the answer is to work to remove barriers for NPs and PAs to provide services in these areas as well as develop more rural programs. If you want to get the title "Doctor" as in physician the medical community is unlikely to be responsive unless you are willing to do the work (as in going to medical school).

David Carpenter, PA-C

FNPinKS · Sep 10, 2010

There are a number of problems with your proposal that make it unlikely ever to happen. The first is the structure of medical school. The LCME and COCA accredit medical school in the United States. They have their own standards but also adhere to standards set forth by the World Health Organization. One of the WHO standards is that Medical School entail at a minimum 36 months of full time instruction. The reason that the Medical School that you refer to does not meet requirements for a significant number of states is that they require physical presence on the campus. So even if you could get this by either LCME or COCA you would have to change a number of state laws.
Next to practice medicine in the US you would have to attend an ACGME or osteopathic equivalent residency. The residency requirements are set by the various specialties and do not give advanced credit for any experience outside of residency. The reason for this is that long experience has taught them that progressive experience is the only way to properly train physicians. Consider that a physician that practiced FP in a foreign country for many years is not given any advanced standing. The reason for this dates to the 60's and 70's when the medical community experimented with a number of different entry points with fairly disastrous results. There is also a growing body of evidence that the safest medical practice is by fully residency trained board certified physicians. Its unlikely that any of the governing bodies are going to change to a lesser standard. Instead they are increasing the standards including re-certifying at certain intervals.
Finally there is no reason for any medical school to do anything but what they are doing now. There are more than enough fully qualified students willing to pay the full freight right how. In fact medical schools are projecting an increase of 30% by 2015. This will largely cover the "projected shortage" if it exists. In reality this will simply shift the residency slots from FMGs to US residents since the residency slots are not increasing.
In reality your proposal does nothing to address the real problems in rural medicine. There has never been a physician shortage. There has been a shortage of physicians willing to work in rural areas due to isolation, lack of payment and payor mixes. Your proposal doesn't do anything to address this.
The truth, at least in studies done on the PA side show that PAs are more willing to work in rural areas than physicians. We have known the solution to the rural health problem for a number of years. That is to train providers from the area in the area that they live in. University of Washington's MEDEX program has used this model by building extension programs in Yakima and Alaska. There are a number of programs that use similar methods.
If you want to solve the rural health crisis the answer is to work to remove barriers for NPs and PAs to provide services in these areas as well as develop more rural programs. If you want to get the title "Doctor" as in physician the medical community is unlikely to be responsive unless you are willing to do the work (as in going to medical school).
David Carpenter, PA-C

I realize this will require a lot of change. Just because I'm not willing to go to traditional medical school doesn't mean I'm not willing to do the work. I guarantee I can get through a medical class in one location just as I can at another. We're talking about two different spots of dirt for God's sake.

And, I must admit, I've never, ever, in any literature, in any discussion, in any dream, heard someone say there "isn't a physician shortage". Even the AAFP has countless articles on that very topic. You can turn it into distribution issues, but it really doesn't change anything.

To be honest, I like your answer better for me personally. Removing barriers for PAs and NPs to just take it all over would be super easy for me. Then, I wouldn't have to learn anything additional at all.

I think the real problem is unless you go through pledge week, you'll never be a member of the sacred fraternity.

Trauma Columnist · Sep 10, 2010

I think you've said it all with the thought about going thru pledge week before you can join the fraternity. There is a huge "I've had it hard, so you have it hard," mentality in the physician ranks.

Remember a few years ago when the new legislation came out that residents could ONLY work 80 hours/week? Whew! What a bunch of nasty attending comments I heard. And....they were said to the residents too.

There is a foodchain mentality among physicians that I see to some extent in the NP/APN community when we discuss direct entry - "what do you mean you don't have any nursing experience?"

core0 · Sep 11, 2010

I realize this will require a lot of change. Just because I'm not willing to go to traditional medical school doesn't mean I'm not willing to do the work. I guarantee I can get through a medical class in one location just as I can at another. We're talking about two different spots of dirt for God's sake.
And, I must admit, I've never, ever, in any literature, in any discussion, in any dream, heard someone say there "isn't a physician shortage". Even the AAFP has countless articles on that very topic. You can turn it into distribution issues, but it really doesn't change anything.
To be honest, I like your answer better for me personally. Removing barriers for PAs and NPs to just take it all over would be super easy for me. Then, I wouldn't have to learn anything additional at all.
I think the real problem is unless you go through pledge week, you'll never be a member of the sacred fraternity.

There is probably some element of the guild system involved. Especially for the more prosperous specialties there is an incentive to limit the number of new members in order to maintain a hold on the market, but when we are talking primary care the bar to entry for physicians is low (more than 100 unfilled residency spots per year).

Its easy to call it pledge week but you have to remember why the system evolved. In the 1900's the system was roughly what you propose. Students went to "medical school" which was completely unregulated. The students received an indifferent curriculum with an "apprenticeship" of variable value and then started practicing medicine. If you read the Flexner report it is an indictment of the state of American medical education at that time. The report recommended specific standards and over the next 20-30 years almost 2/3 of US medical schools were closed. This led to a period of standardization of training and didactic material. This was used by other countries as a model for medical education. Other methods have been tried but none have been shown to successful as the current methods. Currently medical schools may offer select subjects online but their experience has shown that the bulk of clinical instruction must include personal instruction by a trained cadre of professionals who are able to properly train and evaluate the students.

After world war II the medical profession further standardized the Medical training in regards to the residency. The key to this and what states realized through practice is that by recognizing these standards they guarantee a homogeneous group of medical professionals and the state can license them without having to individually evaluate each physician to assess their skill level. This is why graduation from a US medical school and completion of a US residency will allow any physician to be licensed in any state. Medical insurers have further reinforced this by requiring board certification after realizing that there is significant differences in care between physicians that have finished a residency and those who have not. Given the myriad shortcomings that are evident in physicians not trained in a traditional manner there is little reason for the medical community to do anything but what they have been doing.

You see a similar process with nursing after the 1970's when the multitude of nursing programs and licensing exams led the State BONs to establish the NCLEX to ensure all RNs were taught and tested to the same level.

As far as a physician shortage I would stand by my statement, it has always been a distribution problem. The current US level of 27 physicians per 10000 US population is above the level of 3/4 of the world population and is above the level of the UK and Canada. This does not count the contributions of the PA and NP providers who make up 20% of the US provider population (a unique situation in regards to amount of care provided). The shortage is of physicians willing to work in a particular area or with a particular population. Speaking specifically of primary care, I would be willing to state that there is no suburban area in the US where the average income is more than 4x the US poverty level where there is any shortage of primary care providers. Instead the shortage is in poor and rural areas where economics make it difficult if not impossible to make a living as a primary care physician. Add in the problem of professional isolation in rural areas and what you have are local shortages due to economics or location. This is similar to the situation in nursing. There has never been a nursing shortage. What there is, is a shortage of nurses willing to work a particular job/location for the wage offered. If you wanted to address the primary care shortage you could start by examining the reasons that 40% of NPs that are educated as NPs are not working as NPs (including the substantial percentage not working as nurses). Similary any effort to address primary care shortages has to revolve around changing payment from procedure based to reimbursing for clinical practice.

Bottom line is that the American medical educational system delivers an outstanding product which is realistically without peer in the Western world. Why should the American public accept an unproven product with compromised standards?

David Carpenter, PA-C

wowza · Sep 11, 2010

Just curious, how would the curriculum be structured... that is, what would you cut out from the current medical curriculum?

elkpark · Sep 11, 2010

Heavens, it's bad enough that nursing has watered down its educational standards so much over the years -- I would hate to see medicine start down that road!

FNPinKS · Sep 11, 2010

There is probably some element of the guild system involved. Especially for the more prosperous specialties there is an incentive to limit the number of new members in order to maintain a hold on the market, but when we are talking primary care the bar to entry for physicians is low (more than 100 unfilled residency spots per year).
Its easy to call it pledge week but you have to remember why the system evolved. In the 1900's the system was roughly what you propose. Students went to "medical school" which was completely unregulated. The students received an indifferent curriculum with an "apprenticeship" of variable value and then started practicing medicine. If you read the Flexner report it is an indictment of the state of American medical education at that time. The report recommended specific standards and over the next 20-30 years almost 2/3 of US medical schools were closed. This led to a period of standardization of training and didactic material. This was used by other countries as a model for medical education. Other methods have been tried but none have been shown to successful as the current methods. Currently medical schools may offer select subjects online but their experience has shown that the bulk of clinical instruction must include personal instruction by a trained cadre of professionals who are able to properly train and evaluate the students.
After world war II the medical profession further standardized the Medical training in regards to the residency. The key to this and what states realized through practice is that by recognizing these standards they guarantee a homogeneous group of medical professionals and the state can license them without having to individually evaluate each physician to assess their skill level. This is why graduation from a US medical school and completion of a US residency will allow any physician to be licensed in any state. Medical insurers have further reinforced this by requiring board certification after realizing that there is significant differences in care between physicians that have finished a residency and those who have not. Given the myriad shortcomings that are evident in physicians not trained in a traditional manner there is little reason for the medical community to do anything but what they have been doing.
You see a similar process with nursing after the 1970's when the multitude of nursing programs and licensing exams led the State BONs to establish the NCLEX to ensure all RNs were taught and tested to the same level.
As far as a physician shortage I would stand by my statement, it has always been a distribution problem. The current US level of 27 physicians per 10000 US population is above the level of 3/4 of the world population and is above the level of the UK and Canada. This does not count the contributions of the PA and NP providers who make up 20% of the US provider population (a unique situation in regards to amount of care provided). The shortage is of physicians willing to work in a particular area or with a particular population. Speaking specifically of primary care, I would be willing to state that there is no suburban area in the US where the average income is more than 4x the US poverty level where there is any shortage of primary care providers. Instead the shortage is in poor and rural areas where economics make it difficult if not impossible to make a living as a primary care physician. Add in the problem of professional isolation in rural areas and what you have are local shortages due to economics or location. This is similar to the situation in nursing. There has never been a nursing shortage. What there is, is a shortage of nurses willing to work a particular job/location for the wage offered. If you wanted to address the primary care shortage you could start by examining the reasons that 40% of NPs that are educated as NPs are not working as NPs (including the substantial percentage not working as nurses). Similary any effort to address primary care shortages has to revolve around changing payment from procedure based to reimbursing for clinical practice.
Bottom line is that the American medical educational system delivers an outstanding product which is realistically without peer in the Western world. Why should the American public accept an unproven product with compromised standards?
David Carpenter, PA-C

It does deliver an outstanding product. But regardless whether or not a town in rural America doesn't have a physician because they are somewhere else or they don't exist means the same thing to that rural place. What I am proposing will be a program that will produce MDs with licenses that are restricted to only practice primary care in Health Professional Shortage Areas. Basically instead of these towns being left with NPs and PAs only in the near future (which I don't think would be the end of the world), they have an option to still be cared for by physicians who are trained to be physicians in a different way than what we all know at this point.

You are right, an easier fix would be just to push more money into primary care, but I never count on the government or insurance companies to do something like that.

FNPinKS · Sep 11, 2010

Just curious, how would the curriculum be structured... that is, what would you cut out from the current medical curriculum?

That's tough to say, because you could either just force everyone through the same program based on a review of the similarities and differences, or you could have a testing program that evaluates strengths and weaknesses. I really would need a panel of PAs and NPs as well as MDs to come together and figure this out collectively. I really don't trust any one of us to do something that big without input from several of each profession.

FNPinKS · Sep 11, 2010

Heavens, it's bad enough that nursing has watered down its educational standards so much over the years -- I would hate to see medicine start down that road!

It's not impossible to develop a training program that is specific for primary care that reduces the content for people who have been trained and experienced enough to already be practicing the same thing, and not "water it down". I think making something less redundant is possible, but it's also possible to water it down so it must be developed carefully by a panel of members of each profession (NP, PA, and MD).