dgenthusiast

Correct me if I am wrong, but you seem to run a primarily cash only practice. Most physicians don't do that. Obviously, you're not facing the same hassles and problems that physicians face since you only deal with a couple of insurance companies. And, like I mentioned earlier, you seem to charge more for office visits, etc, than what the Medicare reimbursement rate is. Physicians will always be at the top of the health care delivery food chain precisely because of their extensive training. Even if they weren't, it would never be midlevels or nurses at the top, if you were hoping for that. Rather, it would be more administrators (ie. businessmen).

I respectfully point out that the 3-7 years of residency after medical school is still training. Medical school is considered as undergraduate medical education while residency is considered graduate medical education.

What you're still referring to is a cultural problem, not one that is inherent with the medical/nursing training system. Even if our health care workers switched to treating psychiatric patients the way they're treated in third world countries, once the patients are released the way American society reacts to them (ie. with stigma) will have an incredibly negative effect on the patients.

Forgive me, but I don't see how that suggests there's a problem with medical or nursing training in the US. What you're referring to is a cultural issue. People with psychological issues tend to do better in third world countries because their culture doesn't see it as a stigma and looks at these individuals as needing help from the entire community. It's better to ask others for help than take drugs discreetly. It doesn't have much to do with the health care providers in their country. In the US, psychological disease is seen as a stigma, which has a negative impact in the recovery of these patients. It's easier to take drugs discreetly than ask others for help and risk being isolated. Once again, it doesn't really have anything to do providers. So, I'm a little confused as to why you're suggesting that a cultural issue means that something is wrong with the way health care providers are trained. Perhaps you can clarify?

Unfortunately, that's a very bad stance to take in the realm of healthcare. Policies and protocols need to be driven by substantial evidence resulting from extensive studies. I would think that practically everyone involved in healthcare, and even those not involved (ie. politicians), care at least to some extent about studies. Studies are what drive evidence-based medicine. Try telling any researcher (who generally tend to be better versed in statistics and experimental design than most clinicians) that studies don't matter and see what kind of response you'll get. Citation please. No anecdotes! It's just hard to believe that, when residency directors are thinking of extending family practice residency by an additional year because of how much primary care physicians need to know to be competent, a fraction of the training is enough to be a fully independent midlevel. I can't imagine allowing a beginning third year med student (who has more basic science training and similar clinical hours as most NP/DNP curricula provide) or a beginning fourth year med student (who has more basic science training and far more clinical hours of training than most NP/DNP curricula provide) to practice independently. I'm genuinely curious about the logic behind the concept that less training is better than more training when taking care of patients. I hope that you can respond to me without resorting to mudslinging and insults like you have against viral. The same could be said for yours and mine as well. So, why are we arguing on an anonymous forum when we know that no one on either side will be changing their views? This battle should be taking place in the political scene and the courts, not on message boards. Actually, I don't think viral ever implied that NPs aren't smart enough to do anything. What he/she did say was that midlevel training isn't enough to be practicing autonomously. Two very different things. Don't be so quick to think that every statement not supporting independent practice is an insult.

Unfortunately, it's not up to me to prove anything. The hallmark of statistics and experimental design is that it's up to the person making the claim (here, it's you) to provide evidence supporting their claim. So far, there's not a single study that does this.

And I'm sure physicians feel the same way when midlevels suggest that they're equivalent or have equal training as physicians. As a side note, did you really have to resurrect a thread that's been dead for over a month just to make a comment about independent practice that everyone already knew about?

Thanks for the info. I appreciate it.

Unfortunately, there aren't any (yes I mean absolutely none) well-done studies that suggest that outcomes are equivalent beyond providing care for minor things that really don't require any training at all. There are many studies performed with flawed methods, looking at useless metrics such as patient satisfaction, etc, that are commonly cited on these forums. I urge you to read the studies yourself and to read them with a critical eye. If someone can conduct a study that definitively shows equivalent outcomes, no matter what the complexity of the patient is, then I would be more than happy to publicly retract my statements. If it's obvious that outcomes are equal, as you say they are, you should be able to easily get IRB approval to conduct a prospective trial with patients randomized into physician and NP arms without regard to complexity (kind of like how you'd see patients in a clinic without physician oversight). Obviously, there would be no physician back-up for the midlevel arm. After about 2 years or so (because primary care requires long-term management of conditions, it'd be nearly impossible to notice difference in a time period shorter than 1-2 years), the data can be analyzed. Then, we can draw conclusions about whether NPs/DNPs should be allowed to practice independently. Genuine questions, and I hope you don't take it the wrong way: Logically, if someone with a vast amount of training (ie. physicians) make some horrible mistakes, do you really think that others with a fraction of that training will make fewer/less horrendous mistakes? Please explain to me the logic behind that. I honestly cannot see how that works out. Surely you know something I don't and I would love it if you could reveal that secret to me. Thanks! Eh, for the proof part, please read what I wrote above. To be honest, I wouldn't leave primary care to anyone but physicians. Primary care is one of the hardest medical specialties out there because of the sheer depth and breadth of knowledge one needs to have. I want to leave it to the people who have exactly that: the greatest amount of depth and breadth of knowledge out of all providers. As one wise attending told me, "it's easy to provide mediocre primary care; however, it's incredibly hard to provide good primary care." Just because there aren't enough primary care physicians doesn't mean you replace them with individuals with a fraction of the training. What you have to do is provide incentives for med students to enter primary care. Obviously, giving equivalent scope of practice, etc, to midlevels would not entice many medical students into the field.

i'm confused. where did i ever say it was okay for another study (led by physicians) to use the same data? if the other study did that as well, that's a flawed study too. it doesn't matter who conducts a study. if there's a flaw in the methods, i will call it out. as should everyone. just because you support one organization doesn't mean you should be okay with flawed studies. and what are you talking about with regards to patient choice? i never mentioned anything regarding that. i do absolutely think (and i'd imagine most people versed even in the basics of medical experimental design would agree) that patient satisfaction is one of the worst measures to use to predict the competency of providers or the medical outcome. please don't put words in my mouth. once again, you're attributing something to me when i didn't take a stance on it at all. i question the validity of all studies that use weak billing data. even that recent one about medical errors costing the system $20 billion per year. i'm not okay with badly done studies just because they show medicine in a positive light. i would hope you're mature enough to know not to do that with your profession as well (however, it seems like you went right ahead and agreed with the "conclusions" that the journalists reached without reading the study yourself). it's simple, in my opinion. if you didn't read a study yourself, you shouldn't be drawing conclusions from it. notice that i didn't draw any conclusions from the silber study or any other study you seem to attribute to me because i haven't read it. that copy-and-paste was the response of the asa president in case people on here were interested in reading the asa response to the study. they're not my words. i hope you realize that much at least. i'm honestly thoroughly confused as to what you're trying to say here. what's a hoot? you realize that bc physicians do have maintain certification right? and that this maintenance of certification requires examinations? for example, here's a link to the abim maintenance of certification exam: http://www.abim.org/pdf/blueprint/im_moc.pdf. were you trying to say that physicians don't have to retake any medical exams once they become board certified? based on glancing at various specialties' maintenance of certification exams, i would have to say you're wrong. from the american board of internal medicine's website: "passing the abim exam is a requirement for both certification and maintenance of certification (recertification)." looks like they do have to retake their boards. hope that clears it up for you. i disagree. i think, in order to be a competent provider, you have to know all the complex material as well. otherwise, how else would you recognize that your patient presenting with "simple" symptoms is actually hiding something far worse? that it's just one of those "rare" diseases you never studied in nursing school presenting itself as a common one. you realize that there are many sinister diseases/syndromes that occasionally present as common ones right? that's one main reason why i'm against the independent practice of non-physicians. i'm not against nps or dnps. i'm against their push for independent practice. what study am i fond of from 2000? what study that i like so much? once again, i must ask you to please stop putting words in my mouth. the only study i responded to in this thread was the recent one put out by the aana. i hope that symposium does put a smile on your face. maybe we can get back to discussing the study at hand in a civil manner rather than you making (wrongful) accusations at me.

It's interesting that you say that many physicians don't accept Medicare, Tricare, or Medicaid, but when I looked at the site you linked (presumably where you work), you seem to have a cash-only type of practice for the most part (with the exception of those 3 insurances). For example, you charge $60 for an office visit whereas Medicare pays about half of that and Medicaid pays even less. Not only that, it seems you guys treat (for the most part) minor things. I can't imagine those take up a majority of your time, so I would think you'd be seeing greater patient volumes than physicians who have to deal with everything from minor to very complex cases. Seems like you can easily make up for the loss of money due to patients with those 3 insurances from the patients who pay with cash/credit. I wonder how many of the physicians you're complaining about run primarily cash practices...Feel free to correct me if I'm wrong, of course. Edit: Don't take what I said the wrong way. I'm genuinely curious about how your practice works. Thanks.

M3 is the first year dedicated solely to clinical training. But clinical exposure at most med schools these days begins within the first few weeks of starting M1. During the preclinical years, the clinical training teaches you to take proper H&Ps, conduct basic exams (ie. a comprehensive neurological exam, etc), follow patients for at least a short period of time, etc. It's important to have a solid foundation in this stuff before M3 so that you can hit the ground running instead of wasting time learning all this then.

To be honest, I do not see the point in doing that. I'm also not entirely sure what you mean by "fusing" clinical training with didactics. It would be incredibly hard to have basic science lectures, exams, etc, like you would in the preclinical years at the same time when students are pulling 80 hour weeks in the hospital (in addition to the reading and studying done at home in order to do well on rotations). Furthermore, practically every med school in the US starts clinical exposure during the first year. The clinical training one receives during the preclinical years is supposed to build a solid foundation in taking H&Ps, knowing what questions to ask, basic exams, etc, so that when you hit the clinical years, you don't waste time learning all this and can hit the ground running.

The problem with that line of thought is that it assumes students applying to medical school already have determined what specialty to go into. That's very unlikely. The majority of people who enter med school with a specialty in mind go into a completely different specialty. In addition, it would be a very bad idea to get rid of any of the basic science courses. As far as I know, no med school in the US is considering this. Even the 3-year DO program that fast-tracks to primary care still retains both basic science years. The basic sciences lay the foundation for learning clinical medicine. Physicians are taught to thoroughly understand the mechanisms of physiology and pathophysiology. This is an essential foundation required for building clinical knowledge upon. No amount of experience can be a replacement for understanding the basic science behind medicine.

I actually disagree with you there. I don't think there are "a lot of people" questioning whether the lengthy and rigorous medical training for physicians is necessary. In fact, many people who are involved in medical education (ie. program directors, attendings, etc) are thinking that even more training is needed in some specialties than is currently provided. For example, there have been recent talks of increasing the family practice residency length by an additional year (from three years to four). This would essentially increase clinical training by thousands of hours. In my experience, the only place where I really see that lesser and lesser education is considered a good thing is on these forums.