An article appeared today in the New York Times as a followup to a bill passed in New York granting nurse practitioners the right to provide primary care without the oversight of a physician. The authors of the bill state "mandatory collaboration with a physician no longer serves a clinical purpose and reduces much-needed access to primary care". The need for more primary care providers is due to the shortage of primary-care physicians, the aging boomer population, and the Affordable Care Act.
Although the president of the American Association of Nurse Practitioners feels that the current "hierarchical, physician-centric structure" is not necessary, many physicians disagree citing that the clinical importance of the physician's expertise is being underestimated and that the cost-effectiveness of nurse practitioners is being over-estimated.
Many physicians also feel that "nurse practitioners are worthy professionals and are absolutely essential to patient care. But they are not doctors."
What are your thoughts on this? Where do nurse practitioners fit into the healthcare hierarchy?
Specializes in burn ICU, SICU, ER, Trauma Rapid Response.
Every year 100s of medical students walk away with no spot in anything and have an expensive piece of paper that they can't get a job with until they complete a residency?
I am curious about this comment. The vast majority of IM residents I work with are from India, various African countries, Pakistan, Russia and middle eastern countries (the ones without oil).
Are these 100's of med school grads who can't get a residency graduates of American medical schools? If so why do so many residencies go to foreign med school grads?
I have also known a number of Americans who went to med school in other countries and came back here for a residency. They didn't seem to have any trouble getting a residency in IM, or even gen surgery. Are they just lucky?
You wouldn't say physicians don't want the jobs, but then immediately afterwards claim that it's not a desirable field among physicians anymore. Did I misunderstand or did you contradict yourself? Primary care residencies fill up 100%, and thousands of physicians are left begging for anything. So what, the NPs who actually want to be primary care providers should bugger off so some resentful medical students get placed into their safety net residency? And why because they paid more for their education? This sounds like an internal problem within the medical community (putting out too many physicians for the positions available, or not training physicians to the standard required for placement) akin to the nursing community's problem of putting out too many graduate nurses for the positions available. If that is the case, perhaps the medical community should reconcile its own problems?
i said that it's not as desirable, which I stand by. The best and the brightest are not being pulled en masse into primary care. They are going where the money and lifestyle is. It doesn't mean that money is the only thing but if you could do something you enjoy AnD greatly increase your earning potential, wouldn't you? That being said, there are only so many spots in competitive specialties and then there are people like me that say salary be damned and go into a primary care field because I truly loved it and saw myself being happiest in it. Like I've mentioned, all the primary care residencies are filled, they are churning out doctors. There are plenty of people that want the job.
NPs becoming providers doesn't impact medical students getting their "safety net residency." Residencies are controlled by Medicare funding so they are the ones holding back the physicians from family med, well one reason.
I think the whole "NPs want to go into primary care while you doctors want nothing to do with it" is another grenade that nurses/APNs like to throw at physicians that is an unfair characterization. There are plenty of NPs working in critical care and specialties and I guarantee if/after being firmly planted as independent in primary care many will try to make the same move for specialties. It has nothing to do with desire to do primary care and loving patients more, it has to do with the most money for your degree. Right now PC independence is the height for NPs while PCP is the lowest paying and least training required.
Specializes in burn ICU, SICU, ER, Trauma Rapid Response.
I think the whole "NPs want to go into primary care while you doctors want nothing to do with it" is another grenade that nurses/APNs like to throw at physicians that is an unfair characterization. There are plenty of NPs working in critical care and specialties and I guarantee if/after being firmly planted as independent in primary care many will try to make the same move for specialties. It has nothing to do with desire to do primary care and loving patients more, it has to do with the most money for your degree. Right now PC independence is the height for NPs while PCP is the lowest paying and least training required.
Ya, that is pretty much true. The health system I work full time in didn't used to use NPs in specialties. However when they reduced resident's work hours to "only" 80 hours a week, suddenly lots of NP positions opened up in specialties.
This can be a little misleading. FM isn't the only field. Primary care also includes IM, Peds, Ob-Gyn. I would be less than honest if I tried to claim that medical students are fighting each other to go into primary care, but that doesn't mean we aren't churning out doctors in primary care fields. For family medicine the residencies fill every year, almost 100% in the match and any that didn't will get any med students that weren't able to get a spot in the match or the soap. Every year 100s of medical students walk away with no spot in anything and have an expensive piece of paper that they can't get a job with until they complete a residency, so it isn't true to say "look they don't want to go into primary care! None of them are going into PC residencies." They are. There just aren't enough residency spots to crank out enough FM docs... And that many who do complete the residency don't want to work in underserved areas, like the one another poster described. Add to that the docs who go through IM, Peds often specialize.
We have a huge access problem and I agree, we have more spots than we have physicians to fill. However, the scope for NPs keeps expanding and expanding. I know it's n=1 but many NPs I know say they gain their skills from clinical experience AFTER their NP program, similar to what residency would be for us (since many NPs function in similar roles to residents where they see patients but are supervised by patients. Why not standardize the clinical experience to make sure all NPs receive the proper training. In the studies that are repeatedly mentioned do they indicate if these Studies were done without MD "supervision."
I still don't understand if 2 people, NP and FM doc, are doing the exact same job and seeing the same patients but they take diff exams, they have different licensing, and different malpractice liability. Can anyone explain that?
Where is the documentation that all these medical students are not getting residencies? I didn't find it, but I am sure it happens to some extent.
The data doesn't seem to be that there are that many U.S. medical students not matching with some kind of residency. Maybe this is changing since last year with all the new residency programs opening up..?
The data that I could find still suggests that U.S. medical school graduates overwhelming avoid FP residencies, and NPs working independently can and do fill that gap.
Malpractice is based on the provider's group of malpractice claims, so overall that means that NPs generally have less malpractice claims than physicians. That could be for a variety of reasons. I worked with some FP physicians that chose to practice OB, do c-sections, and tonsillectomies. This physicians are probably mostly retired now, but you aren't going to find FNPs doing any of these besides possibly some well OB checks. There are also FP physicians that practice interventional pain medicine, do a variety of office surgeries, and all of these things can increase liability/malpractice rates.
I am curious about this comment. The vast majority of IM residents I work with are from India, various African countries, Pakistan, Russia and middle eastern countries (the ones without oil).
Are these 100's of med school grads who can't get a residency graduates of American medical schools? If so why do so many residencies go to foreign med school grads?
I have also known a number of Americans who went to med school in other countries and came back here for a residency. They didn't seem to have any trouble getting a residency in IM, or even gen surgery. Are they just lucky?
for by hose that don't know, "the match" is the process that medical students have to go through to get a residency. We don't pick our residency outright, a computer program matches us to one on our list - or if none of the programs on your list want you, you go unmatched and 1) try to scramble into whatever residency spot is open or 2) take a year off and try again or 3) walk away from medicine with an MD but no ability to practice or do anything with it. This actually happened to a friend and it's horrific, but I digress.
So if we look at table 4 it says 975/5.6% of US seniors in MD schools did not match into a first year spot (PGY1) while 47-50% of FMGs did not match. Now there's no data to show how many of those US grads scrambled into an open spot vs the FMGs, but the FMG have greater numbers and the US grads have a much higher chance just by being from a US school.
i would say the foreign docs you see probably applied very broadly (100s of hospitals), played the game correctly and matched into a residency. So they are a combination of smart and lucky. By doing this they avoid the chaos of being unmatched and fighting over scraps, but it typically means they settle for residencies at community hospitals that are not very competitive. Go on SDN and search for threads titled SOAP (that's the name of the process for unmatched seniors) or unmatched and you will see a mixed bag.
Specializes in burn ICU, SICU, ER, Trauma Rapid Response.
So if we look at table 4 it says 975/5.6% of US seniors in MD schools did not match into a first year spot (PGY1)
I appreciate the explanation. I am shocked at the 975 US seniors who didn't match. Are these people who have something very wrong with them, or were they too picky about what would they accept? Could all of them have matched if they had been willing to take any residency in any area?
Where is the documentation that all these medical students are not getting residencies? I didn't find it, but I am sure it happens to some extent.
The data doesn't seem to be that there are that many U.S. medical students not matching with some kind of residency. Maybe this is changing since last year with all the new residency programs opening up..?
The data that I could find still suggests that U.S. medical school graduates overwhelming avoid FP residencies, and NPs working independently can and do fill that gap.
Malpractice is based on the provider's group of malpractice claims, so overall that means that NPs generally have less malpractice claims than physicians. That could be for a variety of reasons. I worked with some FP physicians that chose to practice OB, do c-sections, and tonsillectomies. This physicians are probably mostly retired now, but you aren't going to find FNPs doing any of these besides possibly some well OB checks. There are also FP physicians that practice interventional pain medicine, do a variety of office surgeries, and all of these things can increase liability/malpractice rates.
So residency positions have actually been static since the 1990s. Most people assume more medical schools = more doctors, but sadly this isn't true. After the "call to action" to increase the number of docs to take care of baby boomers, medical schools started increasing enrollment and a bunch of new medical schools opened up. So now we have increased the number of medical students but the number of residencies have remained stagnant. In the past, you went to medical school, you picked your residency, and continued with your career. Now we are approaching the "jaws of death" where the number of medical students will surpass the number of residency spots and you can go through a US MD education and have no residency to go to after you finish. Without a residency our degree means diddly beyond consulting for big business and other non clinical things - and little means to pay off those big loans you took on because you thought you had job security. The increase in med students has made applying for residency significantly more competitive and there are basically no more guarantees anymore.
thank you for explaining the malpractice! I'd imagine that the cost would probably increase over time with independent practice then?
I appreciate the explanation. I am shocked at the 975 US seniors who didn't match. Are these people who have something very wrong with them, or were they too picky about what would they accept? Could all of them have matched if they had been willing to take any residency in any area?
I know right? I was shocked too when I first found out about it. I wish I knew what I knew now before I went to medical school. I still would go, I love my job, but I would have thought long and hard about the risk and cost-benefit before signing that dotted line.
It can be a mix. Some of them have some type of red flag. Maybe they failed a step exam (we have to take step 1, step 2 clinical skills, step 2 clinical knowledge). Maybe they failed a class. Maybe they have bad recommendations. Maybe they interview horrible. Since it's getting more and more competitive and their are plenty of people for each spot, residencies can be picky. Any combination of those red flags can leave you without a residency ranking you.
the others that go unmatched are typically students applying to super competitive fields with much more applicants than residency spots. The ones that go unmatched are either applicants that had borderline exam scores and couldn't land a spot -or- someone with amazing numbers, great application, but was overconfident or maybe interviewed poorly and didn't rank enough programs on their list, assuming some of these top programs would most likely take them. They get passed up and end up unmatched.
i went to a "top 10" medical school and every year we always have at least 1-3 med students that don't match. It happens at every medical school.
if you go unmatched you get an email during match week. You immediately meet with the dean and start applying for the leftover spots. You could have been trying to become an orthopedic surgeon in Florida, go unmatched, and if you are lucky end up in a pediatrics residency in Idaho. Those are the lucky ones. Majority will end up in a preliminary year. That's one year in a residency, usually either medicine or surgery, where you are basically a slave for a year, and have to apply all over again to try to land a residency a 2nd time around. A friend who was trying to go into ENT and went unmatched had to do this and he matched this year into anesthesiology. It's hell.
SO it turns out you are about 99% right and I am ALMOST completely wrong. So plenty of medical schools do not list a bachelors degree as a requirement, but almost all who get accepted do have an undergad degree. In my career I have known three residents who did not have a degree. They graduated from the University of Chicago, The Medical College of Wisconsin, and Ross University. I called one who is a fishing buddy of mine and according to him he was a special circumstance and was admitted without a bachelors degree, though he did have more than 90 credits and all premed requirements. Because of the relatively high number of non bachelors degreed residents I have known (3) I was under the impression it was higher. So I will stand corrected. However even if I was right and you were wrong I wouldn't want you to go away. I appreciate your perspective.
As a point of interest, the Medical College of Wisconsin is starting a 3 year medical school not far from my home.
I was including them, since they usually head directly to medical school from secondary school. BTW while it is well understood that the MBBS is equivalent, it is called a bachelor degree. Maybe you don't yet know this but in nursing what a degree is actually called is far more important than the education behind it, as we have seen from many recent discussions on this list.
They are very common where I work.
It may not be important to medical types, but it is all important in nursing. As we have seen with the ADN vs BSN debate where the ADN programs are essentially providing the same nursing education as the BSN, but in no way is considered equivalent to the BSN. Same goes for the MSN vs DNP debate for APNs.
You mean except the ones that don't. MBBS.
Or three years medical doctorate with the recent rise of three year medical schools in the USA.
How much of that 8 years of school is something other than medical education? Isn't the non medical education about the same for both?
i just saw this. I didn't even know that was a possibility! That's crazy. Needless to say your friends must have been pretty exceptional cases. It's definitely not common, but good to know. I wish I knew I could have saved myself a few thousand!
The 3 year program is starting to catch on and I'm all for it. I'm not sure if it's actually 3 years (I think at nyu it is) but what I've seen most commonly is that it is still 4 years but 1 year is research. It's really interesting.
i think you are right, the non medical education is about the same for both. We get 4 years of non medical education (our bachelors degree).
So I actually had to do a presentation on this for medical school. Please excuse me while I geek out a moment haha. This pretty much sums it up: MMS: Error
So residency positions have actually been static since the 1990s. Most people assume more medical schools = more doctors, but sadly this isn't true. After the "call to action" to increase the number of docs to take care of baby boomers, medical schools started increasing enrollment and a bunch of new medical schools opened up. So now we have increased the number of medical students but the number of residencies have remained stagnant. In the past, you went to medical school, you picked your residency, and continued with your career. Now we are approaching the "jaws of death" where the number of medical students will surpass the number of residency spots and you can go through a US MD education and have no residency to go to after you finish. Without a residency our degree means diddly beyond consulting for big business and other non clinical things - and little means to pay off those big loans you took on because you thought you had job security. The increase in med students has made applying for residency significantly more competitive and there are basically no more guarantees anymore.
thank you for explaining the malpractice! I'd imagine that the cost would probably increase over time with independent practice then?
I read that more residency locations had opened up in 2012-2013, so hopefully this won't be that big of an issue. I also wonder how the military plays into these numbers for matching. Each one of the military services limits their medical school (USUHS and HPSP) graduates even more than the civilian side. What we end up is GMOs( general medical officers) that are basically medical school graduates working in a military clinic somewhere waiting to be placed in a residency program usually outside of FP or general surgery.
I don't think the malpractice will change that much for NPs. I think physicians will always seek to expand their practice into new areas as much as possible, and NPs will remain more conservative in their practices.
I can only comment from a patient perspective. I've seen NP's for the last half a dozen years for my primary care. I am listened to, taken seriously, and actually get some answers with NPs. Don't get me wrong, I also love my Doctor, he's great, but he doesn't take the time with me that my NP does, and I get better care with her. (my np). As a patient I would feel totally comfortable with it, as long as there was an MD she could consult if she felt she needed to.
PMFB-RN, RN
5,351 Posts
I am curious about this comment. The vast majority of IM residents I work with are from India, various African countries, Pakistan, Russia and middle eastern countries (the ones without oil).
Are these 100's of med school grads who can't get a residency graduates of American medical schools? If so why do so many residencies go to foreign med school grads?
I have also known a number of Americans who went to med school in other countries and came back here for a residency. They didn't seem to have any trouble getting a residency in IM, or even gen surgery. Are they just lucky?