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

[Tim]

Qualifying Standards:
•The issue is not with the aptitude nor the achievement. •The issue is not with the effort nor ethics.
•The issue is can an individual demonstrate the knowledge and ability to perform a variety of tasks and responsibilities effectively?

The educational methods differ in terms of breadth, depth, and duration. So what? It is actually extremely important. Standardized testing only samples knowledge and skills needed. And even then, teaching to the test doesn’t translate to good medicine necessarily.
Structured learning and experience combined with qualifying testing is the only debate.
NP’s want a different standard. What could go wrong?

The Olympics and CFP (college football playoff) have the same problem, how to measure qualifying.
https://en.wikipedia.org/wiki/Qualifying_standards_in_athletics
https://en.wikipedia.org/wiki/College_Football_Playoff

NP’s, PA’s, and MD’s there is a difference. It just hasn’t been defined nor measured.

[CordMcNally]

Tim wrote:

The Olympics and CFP (college football playoff) have the same problem, how to measure qualifying.

Click to expand...

Don't they use the "eye test" for the CFP?

[Panscan]

They will take over primary care at least for majority of people on Medicare/medicaid. People with private insurance will be able to see docs.

I would be very leery about going into primary care now.

Above statements are predictions, not what I consider ideal. Docs are foolish, unable to organize and thusly allow this crap to proliferate. Being replaced by online degrees, it's pretty pathetic tbh.

[Lordosis]

jm129 wrote:

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

Click to expand...

This is really what it is.  There is a market for this now so "schools" are popping up to certify warm bodies and take the cash.

Getting into med school is hard.  Look at how many people try and fail.

Getting through med school is hard but the matriculation rate is quite good for US MD schools.  The match weeds out the borderline students.  Residency is hard no matter what specialty choice you choose.  It is a minimum of 3 years of high intensity supervised work.  Some much more.

What we are talking about bypasses the 2 main things to make competent docs.

Poor student selection and minimal training.

 

[trebizond]

Not just primary care but hospitalist medicine as well. The repercussions for mistakes are not nearly what we think they are. There is a huge disconnect between actual malpractice and the perception of malpractice, and the latter is as much if not more so down to physician demeanor/bedside manner and patient personality/entitlement/litigiousness. Can't tell you how many cases I've seen of blatant mismanagement by specialists and generalists and the patients who were victims of said mismanagement either didn't realize what had happened or it wouldn't cross their mind to sue. And vice versa, horrible entitled patients threatening doctors and the medical system with lawsuits despite getting standard of care (and beyond it) which wasn't to their liking.

Unless there is a spate of high profile cases in the courts and media where a midlevel mismanaged someone out of ignorance and subpar training, and that patient suffered bad morbidity or an untimely death, and the legislatures are lobbied to make a change, nothing is going to change with midlevel encroachment. With these integrated large medical systems (satellite urgent cares, low threshold to send to ED, specialist consultation), this becomes an even less likely possibility. Patients will suffer unnecessary procedures, morbidity from inappropriate medications and misdiagnosis - which will have to be addressed and rectified by physicians more often than not, and very occasionally death from the same. Patients will rarely have the insight as to what happened to them, and even more rarely will file suits against the specific provider at fault. They'll name entire lists of people involved in their bad outcome (e.g. from the NP who started an ESRD patient on lovenox to the critical care team that managed their RP bleed in the ICU to the IR team that failed to find the artery to embolize, etc.), thereby diluting the primary impact of mistakes made early on in the unfortunate chain of events (i.e. the lovenox). And the healthcare systems will go on making a profit.

I don't know what the answer is. I suspect that the more subspecialized (yet versatile) we are, the more adept we are at diagnosing and treating rare and complicated conditions or performing procedures/surgeries, the less likely there will be competition. But that's a universal principle.

[Lordosis]

Panscan wrote:

They will take over primary care

Click to expand...

I hope not.

Panscan wrote:

at least for majority of people on Medicare/medicaid

Click to expand...

Okay that would be fine.

But it would not stop there.  Even people with resources do not spend them if there are other cheaper options available most of the time.  Especially if the cheaper options give them the opiates and antibiotics they want.

[Lordosis]

trebizond wrote:

Unless there is a spate of high profile cases in the courts and media where a midlevel mismanaged someone out of ignorance and subpar training, and that patient suffered bad morbidity or an untimely death, and the legislatures are lobbied to make a change, nothing is going to change with midlevel encroachment.

Click to expand...

Even if this happens they will probably just blame it on bad supervising docs.

[mkintx]

Honestly, there are some bad supervising docs who deserve the blame.  If you agree to "supervise" in return for a payment, but are in a different location, different specialty, or just don't do anything other than lend your license for the fee, you should be blamed.  Real supervision requires close oversight and interaction in a meaningful way.  NPs don't seem to think they need this, and physicians seem eager to make the money without doing the work a lot of the time.  Administration and corporations forcing physicians to "supervise" without allowing the time and resources to do so are another part of the problem.  The midlevel model worked well when a physician would add a well trained NP or PA to her practice and actual supervise him.  That just isn't the case anymore.

[jm129]

AANP leadership seems to have "two prongs" strategy. At the front end, flood the system with as many NPs as possible (by turning a blind eye towards quality of education) and at other end lobby for independent practice.

being a doctor is not just ready for the job but to understand and appreciate all the nuances of medical sciences. It requires certain kind of individuals and intellectually rigorous process.

Most of our daily "bread and butter" cases are algorithmic and that is necessary to maintain efficiencies.  If we believe the algorithm is the medicine then any smart high school graduate can do our jobs. As facts have short half-lives, the algorithms change with new understandings.

Online degrees to become practitioners is disrespect to the complexity of the human body.

this is basically a mockery of medical education and residency training.

As a conscientious physician, I would refuse to work with any NP or NP2B who do not have a minimum of 7-8 years of nursing experience and gladly work with those who have that experience.

 

[Tim]

Is one of the problems the threshold for disciplinary action? Mistakes are made, but the only avenues are quite severe.
The state medical board route is drastic.
The malpractice litigation has financial issues.

Any corrective actions would be kept “secret” because of potential ramifications being so severe. Even is a “provider” is terminated, zero information will be released. No “transcript” or evaluations available . It’s pass/fail with huge penalties for failing.

[VagabondMD]

jm129 wrote:

As a conscientious physician, I would refuse to work with any NP or NP2B who do not have a minimum of 7-8 years of nursing experience and gladly work with those who have that experience.

Click to expand...

I know of two NPs that I have worked with for 20 years or more. During most of that time, they worked as nurses, one in the medical ICU (eventually as the charge nurse) and the other rotating between the Cardiovascular ICU assisting the cardiac surgeons managing post-op patients and the office seeing pre and post op cardiac surgery patients. They were very good nurses and likely on top of the nurse pay scale and probably wanted more autonomy and compensation.

It makes perfect sense for these two experienced, talented, vetted nurses to attend NP school and graduate and function semi-autonomously. What is somewhat disappointing to me is that both of these women are now seeing ankle sprains and runny noses in the urgent care center, surely earning more than they did as nurses and dealing with lower stress and acuity. I guess if they are content doing so, who am I to argue?

[MPMD]

One interesting thing I've noted is that nearly every APP I've ever worked with has welcomed and desired significant oversight. We have a bunch of truly stellar APPs in my dept, they run in what I call the sweet spot of non-physician practitioner practice -- handle the easy stuff and ask for help when needed. It's a great model of practice.

I don't personally see much agitating for independent practice. I know it's happening just not in front of my eyes.

What's most interesting to me about this stuff is that my practice involves my working with the full spectrum of trainees -- from PA students to PGY4 EM residents. There is a subset of cases, admittedly a very small subset, where I am truly needed as a relatively experienced attending with years of practice under my belt. It's interesting to me to do kind of internal debriefs on those cases and ask myself why I had to step in. The most common reasons in rough order are:

1. Failure to recognize that a subtly ill patient is headed for the rocks e.g. 80 f w/ cholangitis and a few soft BPs, maybe we'll just send her to the floor and they can stent at some point tomorrow? No, she needs the unit and ERCP right now.

2. Failure to recognize a very predictable but early clinical course e.g. anticoagulated trauma patient w/ subtle +FAST in RUQ, we'll take things slow b/c she's "hemodynamically stable" That stability is a house of cards and the wind is blowing.

3. Relatively classic presentations of things that aren't zebras but also aren't horses -- endocarditis, Kawasaki, PMR etc.

I'm not going to go too far down the road of why these things happen and require old MPMD to step in, just noting that they happen relatively frequently and the playlist is on both shuffle and repeat.

[Tim]

@MPMD,
Just a guess. The rigors of your institution in hiring, training, and accountability are FAR above average.
Subpar training and performance are noted, addressed, and corrected in some fashion. There are shortcomings that are expected, tolerable and corrected. If not, your checks and balances will end up forcing change.

The second is that your institution is by design a training environment. The culture is to learn to be proficient and then to learn more.

Good raw material, good training and feedback with good supervision is a great place to be. Congratulations!
Benefits the patients and “providers” immensely.

[StarTrekDoc]

fatlittlepig wrote:

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.

Click to expand…

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)

Click to expand...

I wouldn't expect a general RNP having the ability to do each and every one of those quickly listed off cases.

Here is what we typically see with a general RNP:

PNA on CXR-  Abx, order CT, refer back to PCP in 1-2 days or specialist.

CHF excerbation - echo (regardless of recent one or not); cards referral, and serial BNPs in short order

Gastritis  -  GI consult for scope -- HPylori WU or trial of PPI based on symptoms and Risk factors.

--Point is, RNPs tend to lean heavy on resource demand.  In the coming of Value Based Care, this actually may not factor well for ACOs.

 

[q-school]

StarTrekDoc wrote:

fatlittlepig wrote:

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.

Click to expand…

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)

Click to expand…

I wouldn’t expect a general RNP having the ability to do each and every one of those quickly listed off cases.

Here is what we typically see with a general RNP:

PNA on CXR-  Abx, order CT, refer back to PCP in 1-2 days or specialist.

CHF excerbation – echo (regardless of recent one or not); cards referral, and serial BNPs in short order

Gastritis  –  GI consult for scope — HPylori WU or trial of PPI based on symptoms and Risk factors.

–Point is, RNPs tend to lean heavy on resource demand.  In the coming of Value Based Care, this actually may not factor well for ACOs.

 

Click to expand...

yes but they tend to be trainable and superficially cheap.  that may net factor well for ACOs. 

For all physicians, APPs we can see high variance.

if you have an eisenhower box or four quadrant graph, you can put ethics on one axis and hard work on the other.  ideally everyone would be high ethic and hard worker.  however, you can live with low ethics and hard worker (sees lots of patients but can miss stuff) or lazy worker but high ethics (orders lots of tests and carefully arranges follow up with someone else) if they are in the right setting.  the disasters come from low ethic and lazy (won't even order tests that need to get ordered and won't follow up and get them to the right place to get care).

health care is a mess.  all the administrators are overly focused on cost rather than care.  they call it value based but is it really? 

jmo

ymmv