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.

Response of the President of the ASA (http://www.beckersasc.com/anesthesia/asa-president-offers-6-observations-on-study-of-crnas-as-sole-provider-of-anesthesia-services.html): "Dr. Alexander A. Hannenberg: As President of the ASA, I appreciate the opportunity to provide important perspective on the study "No Harm Found When Nurse Anesthetists Work Without Supervision By Physicians" from the anesthesiologists' viewpoint. The following is ASA's overview of the study along with the resources that support the points. 1. The study's methodology relies on weak billing data: It examines data based around the -QZ modifier, which overstates independent practice by a CRNA It does not distinguish between complications resulting from surgery or anesthesia It does not discriminate between conditions existing prior to surgery and those resulting from surgical or anesthetic care A surgeon is still present and participating in patient care in opt-out states [*]481,000 cases analyzed in the study would have produced two deaths related to anesthesia, an obviously insufficient number to support any conclusions about mortality 2. Anesthesiologists are experts in patient safety. Recent data showed one death per 200,000-300,000 anesthetics administered. (Committee on Quality of Healthcare in America, Institute of Medicine: "To Err is Human, Building a Safer Health System." Edited by Kohn L, Corrigan J, Donaldson M. Washington, National Academy Press, 1999, p. 241) 3. Anesthesiologists not only care for patients undergoing the most complex procedures (base unit differential) but also the sicker patients undergoing all procedures (unrecognized selection bias). These considerations would suggest dramatically better outcomes for CRNAs, but this is not seen. In fact, CRNA only cases (-QZ) actually showed worsening mortality and complications, while other groups improved (see table below). Even equivalent outcomes with lower risk cases is a troubling finding. And the most significant improvement in mortality and complications took place in the anesthesia care team (ACT) model of practice, further supporting the value of anesthesiologists involvement in care. (Reference: Jeffrey Silber, MD, PhD, 2000 study "Anesthesiologist Direction and Patient Outcomes": >6 excess deaths/1000 cases from failure to rescue from surgical or anesthetic complication in absence of anesthesiologist) From Table 4 in "No Harm Found When Nurse Anesthetists Work Without Supervision" study: The authors of the study make no apology for the disturbing trend in their own data toward increasing frequency of mortality and complications in nurse-administered anesthesia during the opt-out "experiment" as compared to improved outcomes in physician and ACT cases. 4. Cost of care is equivalent. Considering that the payment for anesthesia services under Medicare's system (adopted by most private insurers, too) is identical whether provided by an unsupervised nurse, solo physician or the physician/CRNA team, the fallacy of the "cost effective" claim is evident. 5. The study understates the differences in training of anesthesiologists and nurse anesthetists. Nurse anesthetists typically receive approximately 2.5 years of post-baccalaureate education; anesthesiologists receive eight years, including a broad foundation in general medicine, intensive care and pain management. The prolonged period of training is to acquire the knowledge base and skills to provide expert care of the patient and all their co-existing disease before, during and after surgery. 6. Overwhelming public preference for physician supervision (A 2001 study by The Terrance Group, titled "National Anesthesia Study III: A Survey of Public Opinion Attitudes," revealed that 70 percent of all respondents (and 77 percent of Medicare beneficiaries) would oppose allowing a nurse anesthetist to administer anesthesia without medical supervision if an MD could supervise the nurse at no additional cost to the patient. Sixty-three percent of all respondents (and 70 percent of Medicare beneficiaries) opposed the decision to drop the requirement for anesthesia supervision by a doctor.). Public policy should reflect this preference."

I encourage people to actually critically read the entire study, not the news articles, before posting on it. It's not a matter of "typical flamers" starting arguments. It's hard to discuss literature when one party (for example, the original poster) has not even read the study beyond an abstract or what a journalist wrote. Two things that drastically hurt this study's conclusions: 1. "This research was funded by the American Association of Nurse Anesthetists." It's hard to deny that the AANA doesn't have an agenda to push, namely that of increased scope of practice and independent rights for advanced practice nurses. It's sort of how you wouldn't trust a study on a new drug when the company that's making the drug puts out the study. 2. The study itself states: "In opt-out and non-opt-out states, the mean number of base units in the anesthesiologist solo group was about a full point higher than in the certified registered nurse anesthetist solo group (p Easier cases (ie. those performed by CRNAs) = lower mortality?! Shocking! What I'd like to see in the future is a study that, instead of relying on existing Medicare data, which is pretty weak in the first place, looks at a prospective database that's set up precisely to detect changes in outcome with different levels of supervision. But, once again, I highly recommend that you actually read the study and draw your own conclusions from it rather than relying on what journalists (with minimal training in critically reading literature) say. Don't get into the bad habit of posting "conclusions" from studies that you yourself have never read. Don't let someone else do the thinking for you.

I cannot tell if you're a troll or if you're serious. If you're actually serious, that is one of the worst reasons to get a doctorate in any field.

Wanted a quick clarification here. You say that NPs are trained more as specialists but from a quick glance at several PA curricula, it looks like PAs receive more training (more clinical hours) in a particular specialty than an NP who is a specialist. That's in addition to the generalist training they get in several other specialties also. Furthermore, with regards to prereq science courses, a significant number of schools offer easier classes for nursing students. I know for a fact that nursing students took the intro versions to chemistry, physics, etc at my undergrad. Those classes were reserved for nurses and even non-majors weren't allowed to take those classes to fulfill requirements. I don't know how prevalent it is in the rest of the US but there are a good number of schools that do this where the nursing students do not take courses at the same level of difficulty as majors/non-majors do. Just wanted to point that out. I wish NP programs would look towards standardizing and improving their curricula (more basic sciences, more clinical hours, less nursing theory/other clinically irrelevant stuff) before setting their sights on a mandatory doctorate.

That should never be a positive thing to hear...

This is what I mentioned before. The current med students, residents, junior attendings, and even premeds, are becoming more and more politically active against any potential encroachment. This is largely been, IMO, due to increased awareness of midlevels (ie. the many NP/DNP articles in the recent months where NPs/DNPs have been quoted saying either that they're equivalent to physicians or, in some cases, that they're better than physicians). I can't imagine a physician at any level of training taking those types of comments lightly. Either way, I think within the next few years, this entire debate will become even more heated than it already is and will likely spill out from anonymous forums into the courts.

You're right, we do keep arguing the same things over and over again. And neither of us are going change our minds. You're of the opinion that no evidence is needed to move forward while I'm skeptical and want evidence before okaying something. If it makes you feel better to think that I want to inconvenience the "overwhelming majority of the population," go right ahead. Not only that, I didn't make that comment in my post. It's directly from the nursing study. http://www.bmj.com/cgi/content/full/324/7341/819 "...further research is needed to confirm that nurse practitioner care is safe in terms of detecting rare but important health problems." Why don't you try refuting what I said instead of attacking me? I've never been anti-NP. I support midlevels of all kinds. What I don't support, however, is this push towards complete independence and equivalency to physicians that the nursing leaders are pushing for.

Would you be kind enough to define healing and curing please? Not being sarcastic; I'm genuinely curious. Because as far as I understand, science is moving further and further away from voodoo medicine, not closer to it. I shudder to think how bad the state of medicine would be if shamanistic medicine was predominant.

I think most of your colleagues on this forum would vehemently disagree with you here. They would say they're practicing advanced nursing rather than medicine. I mean, don't get me wrong, I think that they're practicing medicine too. If walks like a duck, looks like a duck, and quacks, it's a duck. But it looks like if a nurse practices medicine, it falls under the category of advanced nursing. Otherwise, you'd have to be completely regulated by the BoM.

You're putting words in wowza's mouth. Where did he/she say that they would refer to the professor or scientist by their first name? Wowza just said that the professor wouldn't be referred to as a doctor and that's pretty understandable because in a hospital setting, patients equate doctor with physician. I personally have never met a non-physician doctor who got upset over something as silly as this. They all seem to understand it just fine...I don't see why it's such a big deal on these forums.