NP student cannot find pediatrician to agree to have her for 6 week preceptorship

[fatlittlepig]

OUSOONERDOC wrote:

Whenever discussing NP/PAs I always go back to my last month as a Family Medicine resident. I was seeing a 6yo girl for fever, the mother had taken them to walk-in clinics 3 times over 3 days because of the fever and was seen by NP every time. She wasnt getting better and even worse per the mother. They had just been to the walk-in clinic right before she came to see me. The NPs had RX ABX for ear infection. The child did not have an ear infection. Within a minute of seeing the kid and getting the history and just a visual exam I knew they had Kawasaki Disease…it was a textbook presentation. Moral of the story is you dont know what you dont know. Thats why I always get upset when they (admin) want NPs to see the “easy” cases. Had similar encounter with a patient who had viral meningitis.

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It’s a good story, but what about the hundreds of other cases where the NP provided good care at a fraction of the cost? In addition many other MDs may not have been as astute as you to make that diagnosis. Not sure what the right answer is or what the right balance is. I almost hate to say it but I think a good NP or PA could probably do a lot of what I do everyday delivering a similar quality of care (treating pneumonia, diuresing CHF patients, calling GI to scope etc etc)

[childay]

fatlittlepig wrote:

I almost hate to say it but I think a good NP or PA could probably do a lot of what I do everyday delivering a similar quality of care (treating pneumonia, diuresing CHF patients, calling GI to scope etc etc)

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Of course they can!  I mean I could train a high-school student to do most of my usual care.  But that training would require many hours and lots of effort and they would not know what to do in unusual zebra cases.. The issue is the NP training appears to be totally nonstandardized and unchecked.  I am sure some of them get good training.  And as I mentioned many get the needed heavy supervision after they graduate.  But what is the percentage that don't?

[G]

Agree, a monkey could do my job.

Usually. (Especially with liberal consults.)

But that's the crux of the issue, yeah?

Vagabond, look at the hornet's nest you whacked.

[q-school]

AR wrote:

  But if we take a look at the group of docs that passes the boards and the group of docs that doesn’t, I’m certain that the average doc from the first group is a better doc than the average doc from the second by any reasonable metric.

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i am not sure i agree with this statement.  so hard to validate.

i think they are better test takers and things that measure test taking will show better values.

i have a hard time defining what makes a better doc, so i have a hard time knowing.  i've known many physicians who i would consider great docs who never passed boards and i've known (what I would consider) terrible physicians who ace the boards.  certainly most docs pass the boards so hard to say.  we've had experienced docs pass the initial boards and fail the recert, and some who seem to barely pass only by virtue of taking one month off and going to three prep classes.  i hope the amount of energy and resources are justified by the certification somehow.  i tend to have my doubts as to whether the tests reflect good physician from bad physician, but certainly that is my personal bias.

 

[Lordosis]

G wrote:

Agree, a monkey could do my job. Usually. (Especially with liberal consults.)

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As mentioned before NPs in my experience use more testing then I do.  Every abdominal pain does not need a CT.  Every chest pain a stress test. Every leg pain an US to R/O DVT.

I realize there are docs who practice defensibly too but in my experience it seems to lean more to midlevels.

[mkintx]

Lordosis wrote:

Are NPs and PAs still reimbursed less then Physicians by Medicare?  It was 85%.  Is this still true?

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Depends on where you live.  There is a push for pay parity laws.  In Oregon, it is illegal to pay NPs less than MDs.

https://www.oregonrn.org/page/670

[jm129]

I am not against NPs or PAs but against the online diploma mills, unregulated standards of education, low barriers of entry.

 

as a physician, we all know that most of what we learn in medical school gets outdated pretty soon. Its a life long learning.

 

a well educated NP can do descent job on par with any physicians if he/she continues to learn and hone the skills. However, they should first have substantial nursing experience before getting into NP role. Be a nurse first and then a practitioner.

[AR]

q-school wrote:

AR wrote:

  But if we take a look at the group of docs that passes the boards and the group of docs that doesn’t, I’m certain that the average doc from the first group is a better doc than the average doc from the second by any reasonable metric.

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i am not sure i agree with this statement.  so hard to validate.

i think they are better test takers and things that measure test taking will show better values.

i have a hard time defining what makes a better doc, so i have a hard time knowing.  i’ve known many physicians who i would consider great docs who never passed boards and i’ve known (what I would consider) terrible physicians who ace the boards.  certainly most docs pass the boards so hard to say.  we’ve had experienced docs pass the initial boards and fail the recert, and some who seem to barely pass only by virtue of taking one month off and going to three prep classes.  i hope the amount of energy and resources are justified by the certification somehow.  i tend to have my doubts as to whether the tests reflect good physician from bad physician, but certainly that is my personal bias.

 

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I agree that it's a hard hypothesis to test, but if we could, I'd bet everything I had that it was true.

Remember I'm talking about the average.  I think you have to have a really warped view of reality to believe that the average non-passer is better than the average passer by some reasonable metric.

I'd readily agree that there are some, even many, non-passers who are better docs than many who pass.  But that's not what I'm talking about.

[legobikes]

CM wrote:

childay wrote:

Also I question whether these APRNs (or MD / DO students / residents) should be doing rotations exclusively in non-academic / referral-center type places.

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They should not.

We have some local DO students doing rotations at my rural hospital, but they are just inserted into the preceptor’s regular clinic day. The preceptor does not have time set aside for teaching and the students don’t have any real responsibilities. They are passive observers for the most part. It’s a terrible education and I’m sure that internship will come as quite a shock.

Students ought to have direct patient care responsibilities that are well defined, and they should be taught by experienced clinicians who are well versed in the latest literature, and those clinicians should have devoted teaching time set aside as part of their regular job. In other words, they ought to have rigorous training in a university setting.

It’s difficult enough to become expert even with rigorous training. Off-the-cuff, make-it-up-as-you-go training is nuts.

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Nonsense. Students should be trained by the oldest, most experienced doctors available. (Even if those doctors sometimes prescribe albuterol syrup PO.) There's no other way to get a better understanding of the breadth of practice, (including the notion, already mentioned in this thread, that most of the time, with most of your patients, most of the things you do will neither really help nor hinder their health,) while also granting them the wisdom of lived experience, as well as dimishing the effect of the 'provinciality of time' - the ongoing cultural conviction that we are smarter than everyone who came before, when in reality we know more and more about less and less. That quote from the AANP, taken in or out of context, is a testament to that same narrow provinciality, where words are made meaningless through their repeated use to communicate mere ideological commitments.

"Safe, effective, patient-centered, timely, efficient, equitable and evidenced based." Those words don't even have meaning when it comes to doctors, let alone NPs.

P.S. edit: A photo I recently took of a note by a recently graduated MD. This ************************ is weak, and this weakness exists on all levels in the business of "providing" "health" "care".

 

[VagabondMD]

G wrote:

Vagabond, look at the hornet’s nest you whacked.

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How dare you accuse me of stirring the pot!



 

[MPMD]

CordMcNally wrote:

fatlittlepig wrote:

Is it possible that you don’t need to be a MD to provide outpatient or even good inpatient care? Maybe much of medical school is unnecessary and what’s more important is doing training/residency, maybe NPs can play a valuable role. Just a thought… 

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They can standardize their curriculum and start having actual preceptorships (instead of calling a friend of a friend who is a dermatologist and shadow them for 15 hours a week who then signs off on their “rotation”) then we’ll talk. I’m open to having a conversation but not while AANP actively over boasts the role of an NP while putting down the role of a physician.

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Well said and this is the crux for me, you can't rationally advocate for independent practice while simultaneously refusing to provide semi-standardized clinical training.

It's actually kind of funny to read this discussion as a faculty member at a med school. If anything the LCME is pushing for even more accountability if not standardization in MD training. There is this relatively new concept of the Entrustable Professional Activity, the goal being that it's not just up to the med school to complete rotations etc but that they need to prove that the grad can, for example, recognize a critical patient who requires immediate assistance. It's somewhat onerous but it's far from the worst idea anyone ever had.

When you compare that to the system you're describing of casting about for ad hoc, totally unvetted clinical opportunities... I mean if you're bored look at that linked document for EPAs for graduates entering residency, how many NP grads are at that level?

[StateOfMyHead]

jm129 wrote:

I am not against NPs or PAs but against the online diploma mills, unregulated standards of education, low barriers of entry.

 

as a physician, we all know that most of what we learn in medical school gets outdated pretty soon. Its a life long learning.

 

a well educated NP can do descent job on par with any physicians if he/she continues to learn and hone the skills. However, they should first have substantial nursing experience before getting into NP role. Be a nurse first and then a practitioner.

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I wish I could "like" this multiple times.

[Steve]

I have never understood how the NP schools think that their 500 hours of clinical shadowing is going to come anywhere close to the 24,000 hours of supervised practice that I did in 6 years of residency/fellowship. This is difference we need to continue to point out to the policy makers. It isn’t that doctors are better people, or even necessarily smarter people, it is just we have a lot more education and training.

[HandFellow]

 

P.S. edit: A photo I recently took of a note by a recently graduated MD. This ************************ is weak, and this weakness exists on all levels in the business of “providing” “health” “care”.

 

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I like that they under-billed too.  an established 3 for 3 chronic problems for which you don't know the answers to?  an NP could easily do that.

[AR]

Echo wrote:

I have never understood how the NP schools think that their 500 hours of clinical shadowing is going to come anywhere close to the 24,000 hours of supervised practice that I did in 6 years of residency/fellowship. This is difference we need to continue to point out to the policy makers. It isn’t that doctors are better people, or even necessarily smarter people, it is just we have a lot more education and training.

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Better is debatable.  Smarter isn't.  Certainly not on average.

I agree that the educational difference is what needs to be emphasized the most.  But I wouldn't concede smarter.  Best play is to just not even bring it into the conversation.