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Future of PAs, NPs (and Assistant Physicians??)


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Hi all. This is my first post so please take it easy on me. I'm an undergraduate student and have only recently become intrigued with healthcare. While considering the possibility of continuing my education, I've found myself looking through my crystal ball to conceive what healthcare will look like in 15-20 years. Tonight I stumbled upon this article: http://healthaffairs.org/blog/2014/07/28/revisiting-primary-care-workforce-data-a-future-without-barriers-for-nurse-practitioners-and-physicians/. First off, it's important to note that all three authors were NPs. I know the topics of NP vs. PA, and the recent influx of mid-level healthcare graduates (so it appears to me...) have been addressed in these forums before. I just found this article interesting and wanted to share. Of course, if any practicing PAs have any ideas about the direction the market is going to go with mid-level providers in terms of scope of practice, salary, etc. I'd really appreciate any comments.

 

Thanks!

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Guest Paula

There is no such thing as a mid-level provider.  Wipe it out of your vocabulary. Search the Forum for the reason.

 

The article clearly is elevating the NP profession to be equal to the primary care physician by using medical residency matching terminology that sounds much like the medical schools.

 

They are brilliant in their marketing and writing.  Not so much so for the PAs.  Sad. Sad.Sad.Sad.

 

I  need a drink.

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There is no such thing as a mid-level provider. Wipe it out of your vocabulary. Search the Forum for the reason.l.p.

Yep. The more it gets repeated, the more it becomes fact. Even newbies are being indoctrinated.

 

Sent from my Kindle Fire HDX using Tapatalk 2

 

 

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Read the doc's comment at the end. That sentiment is what you need to know about in order to understand where you want to go professionally.

 

We need data about the outcomes AND cost of care provided by MD/DO/PA/NP.

NPs overtest/overdiagnose/overprescribe? We need proof.

Until then more nursing endorsed data about noninferiority of care will drive the case for equal reimbursement.

 

Just saw this recently:

 

http://www.clinicianreviews.com/articles/news/article/diabetes-outcomes-similar-with-physicians-advanced-practice-providers/71131dd94db006479ec787d2a8e02c9c.html?utm_source=071914&utm_medium=email&utm_campaign=PE?email=CTSMEA@VMMC.ORG&ocid=4821521

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The VA, Indian health services, public health service corp, and the military are the only areas where I see PAs routinely being used appropriately (and NPs for that matter).  The primary care issue is one that is frustrating because, while we are fully capable of managing a full panel of patients with the same comorbidities and conditions (and making the same diagnoses) as our other primary care counterparts, private practices seem to be in large part misusing PAs and NPs by shunting all the "less complex" patients to them.  It's dumb.  I'm not arguing for degrading our collaborative relationship - we should all have that whether NP or PA - but freakin' let us manage the patients who need managed.  Maybe I'm the only one who is seeing this trend.  Let us be primary care providers and reimburse our services appropriately so we can keep our practices solvent.  My hope is that this wall will come tumbling down in the near future. 

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LOL, this Harvard-trained endocrinologist published a study showing that NPs with ZERO residency training in endocrinology are just as good as he is at managing diabetes.  Sounds to me like his Harvard medical school and Harvard endocrinology fellowship were a complete waste of time.  

 

I hope some of the NPs who work at his endocrine clinic ask him why he's the boss or gets paid 3 times more than they do, when in fact his own study shows that the "lowly" NPs are just as good as the HAAAVAAD trained doctor.

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LOL, this Harvard-trained endocrinologist published a study showing that NPs with ZERO residency training in endocrinology are just as good as he is at managing diabetes.  Sounds to me like his Harvard medical school and Harvard endocrinology fellowship were a complete waste of time.  

 

I hope some of the NPs who work at his endocrine clinic ask him why he's the boss or gets paid 3 times more than they do, when in fact his own study shows that the "lowly" NPs are just as good as the HAAAVAAD trained doctor.

Turns out, patients can manage their own diabetes.  I have a friend with type I diabetes who is very good at it.  I don't think that says much.  An endocrinologist really doesn't need to be managing simple diabetes.

 

misusing PAs and NPs by shunting all the "less complex" patients to them.  It's dumb.  I'm not arguing for degrading our collaborative relationship - we should all have that whether NP or PA - but freakin' let us manage the patients who need managed.  

Here's the thing: managing patients is easy.  Diagnosing them is the difficult part.  Why?  Because people cannot diagnose something if they are unaware it exists.

 

I've seen a practitioner successfully manage 3 COPD exacerbations w/ a pneumonia diagnosed by chest xray in a 3 month period.  They probably thought they were doing a good job.

 

When I saw the patient, I could tell it was cancer in the first 5 minutes of the interview.  CT scan confirmed.  The first guy saw a COPD diagnoses, assumed the radiology read was correct and 'successfully' treated it.  Never mind the whole diagnosis was incorrect.

 

Treating/managing a patient is easy.  There's more to it than that.  I've seen this happen MANY times, and I'm not even talking about more complicated things like genetic disorders.

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LOL, this Harvard-trained endocrinologist published a study showing that NPs with ZERO residency training in endocrinology are just as good as he is at managing diabetes.  Sounds to me like his Harvard medical school and Harvard endocrinology fellowship were a complete waste of time.  

 

I hope some of the NPs who work at his endocrine clinic ask him why he's the boss or gets paid 3 times more than they do, when in fact his own study shows that the "lowly" NPs are just as good as the HAAAVAAD trained doctor.

That Bostonian accent LOL

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Turns out, patients can manage their own diabetes.  I have a friend with type I diabetes who is very good at it.  I don't think that says much.  An endocrinologist really doesn't need to be managing simple diabetes.

 

Here's the thing: managing patients is easy.  Diagnosing them is the difficult part.  Why?  Because people cannot diagnose something if they are unaware it exists.

 

I've seen a practitioner successfully manage 3 COPD exacerbations w/ a pneumonia diagnosed by chest xray in a 3 month period.  They probably thought they were doing a good job.

 

When I saw the patient, I could tell it was cancer in the first 5 minutes of the interview.  CT scan confirmed.  The first guy saw a COPD diagnoses, assumed the radiology read was correct and 'successfully' treated it.  Never mind the whole diagnosis was incorrect.

 

Treating/managing a patient is easy.  There's more to it than that.  I've seen this happen MANY times, and I'm not even talking about more complicated things like genetic disorders.

 

Agreed with this, but the underlying notion that the diagnosis in a difficult patient cannot be made by anyone other than a physician is inaccurate.

 

I practice in a complex spine clinic. I've made many diagnoses that others have missed, or more often, have to correct inaccurate an inaccurate diagnosis made by primary care.

 

I've even came up with my own axiom....(stolen from the House of God)...."If the primary care provider thinks there is 'spinal stenosis' present, there can be no stenosis there".

 

Mainly because I seem to see many patients with axial back pain with no pseudoclaudicatory symptoms who are sent for evaluation of their "stenosis". I end up explaining to them that spinal stenosis does not cause axial back pain ( I know, I know, there is some argument in the spine community that upper lumbar central stenosis, at L1-2, L2-3 might cause axial symptoms, but that is rather controversial, and no one can prove that). They are reluctant to believe me, because their primary doctor told them that it was their "stenosis".....I usually tell them that I am the specialist here, and that they were sent to see me by their primary doctor.

 

BTW, I also see a lot of patients with stenosis, but they are sent in for "weakness" or "radiculopathy"....:)

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Agreed with the diagnosis part.  I've caught things the doc and NP I work with missed including 2 cases of cancer recently.  They have probably picked up on things I've missed.   Aren't we all to be a TEAM?  

 

Getting back to the original article....has anyone else picked up on the subtle way the NP associations and writers have changed the way they describe themselves?  I've noted this over the last 3-4 years.

 

Inch by inch it's a cinch but by the yard it's hard. NPs will take over primary care in the next 10 years and physicians will totally agree with it. 

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LOL, this Harvard-trained endocrinologist published a study showing that NPs with ZERO residency training in endocrinology are just as good as he is at managing diabetes.  Sounds to me like his Harvard medical school and Harvard endocrinology fellowship were a complete waste of time.  

 

I hope some of the NPs who work at his endocrine clinic ask him why he's the boss or gets paid 3 times more than they do, when in fact his own study shows that the "lowly" NPs are just as good as the HAAAVAAD trained doctor.

1. They are just as good at managing one aspect of diabetes, not the entire disease

2. Endocrine (or any fellowship) is about more than one disease state. It's like saying Cardiology is a waste b/c NP/PA can manage HTN.

 

We are good at what we do but don't make a false leap.

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Darn phy, I've got dibs on quoting the best reference medical manual out there (HOG).  BTW, your statement regarding spinal stenosis shows how little time PCPs put into understanding the condition and the associated symptoms based upon the mechanism of encroachment (they couldn't tell you the difference between central canal and foraminal stenosis).  I used to see the same thing decades ago in spine.

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Well said, andersenpa!

 

These type of arguments are advocated by countless PAs, and make our profession look utterly foolish. There is a difference between PAs and MDs (though not as large as the public thinks) that is useless to deny. It's a sign of insecurity more than anything else.

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Turns out, patients can manage their own diabetes.  I have a friend with type I diabetes who is very good at it.  I don't think that says much.  An endocrinologist really doesn't need to be managing simple diabetes.

 

Here's the thing: managing patients is easy.  Diagnosing them is the difficult part.  Why?  Because people cannot diagnose something if they are unaware it exists.

 

I've seen a practitioner successfully manage 3 COPD exacerbations w/ a pneumonia diagnosed by chest xray in a 3 month period.  They probably thought they were doing a good job.

 

When I saw the patient, I could tell it was cancer in the first 5 minutes of the interview.  CT scan confirmed.  The first guy saw a COPD diagnoses, assumed the radiology read was correct and 'successfully' treated it.  Never mind the whole diagnosis was incorrect.

 

Treating/managing a patient is easy.  There's more to it than that.  I've seen this happen MANY times, and I'm not even talking about more complicated things like genetic disorders.

 

 

That's why I said, "And making the same diagnoses."  I agree - management is relatively easy but diagnosis is the hard part.  I struggle with it in my practice of urgent care because I see a patient for 15 minutes and they have a condition which looks, walks, and quacks like a duck (a COPD exacerbation duck for example) and I call it a duck and move on.  When I see them for the same thing 2 wks later I say "Hold on...."  but we have tailored our group to avoid a lot of "frequent flyers" to the urgent care and when I see them I generally set them up with their PCP for f/u (often I will physically schedule them an appt myself).   Anyway... 

 

Back to the article: I can see NPs owning primary care in 10 years even though we do a better job of it.  If something doesn't change regarding our lobby or the physicians with whom we collaborate, it will be problematic. 

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I can see NPs owning primary care in 10 years even though we do a better job of it. If something doesn't change regarding our lobby or the physicians with whom we collaborate, it will be problematic.

Is this because PAs are choosing more specialty jobs (like physicians) over primary care spots or because NPs are out-competing PAs for primary care careers?

 

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I practice in a complex spine clinic. I've made many diagnoses that others have missed, or more often, have to correct inaccurate an inaccurate diagnosis made by primary care.

You have specialized knowledge from working in a specialty field.  I would expect you to make additional diagnoses.

 

I'm just saying, I get really angry when people say "primary care is easy." or something to that extent.  ACTUALLY,  a good primary care provider has to be able to identify all the diagnoses that every specialty treats.  Otherwise, the referral will never be made.  I feel people that say it's easy do not respect what they do not know, and I definitely would not want them as my provider.

 

As for NP vs PA - they both seem similar to me.  Hate me if you want.  I don't expect to see it changing much.  I think individual qualifications are more important than whether the person is a PA or NP.

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As for NP vs PA - they both seem similar to me. Hate me if you want. I don't expect to see it changing much. I think individual qualifications are more important than whether the person is a PA or NP.

With the exception of the joint PA-NP program in CA, I haven't seen an NP masters program come close to the clinical hours and classroom time that is standard for PA programs. NP programs are usually 1/2 the credit hours and 1/4 or less rotation time.

 

Although they are both called the "M-word", I don't see how training that dramatically different can routinely produce the same providers, regardless of "individual qualifications".

 

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Guest Paula

Primary care is the hardest specialty of all.  I don't think it's easy either and the unfortunate thing about PC is that other specialist practitioners think it's easy and therefore has less respect.  We are the bottom feeders  in the medical hierarchy, I guess.  It that better than a M-L?  LOL!  I advocate for a PC residency for PAs beyond the 2,000 hrs of clinical rotations during our last year of education.  There are a few available now.  

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Primary care is the hardest specialty of all.  I don't think it's easy either and the unfortunate thing about PC is that other specialist practitioners think it's easy and therefore has less respect.  We are the bottom feeders  in the medical hierarchy, I guess.  It that better than a M-L?  LOL!  I advocate for a PC residency for PAs beyond the 2,000 hrs of clinical rotations during our last year of education.  There are a few available now.  

 

EVERY single time NCCPA emails me about another CAQ I reply that they MUST have one for use lowly IM/Medicine PAs

Politically we have to do something to catch up to the DNP movement

Politically we have to do something to support out push towards getting out from underneath the thumb of the doc's for the routine items - ie ordering VNA, hospice, and a slew of other things that we are restricted

PC is not the easiest - it is the easiest to fake - just refer everyone, but it is the hardest to master (yeah right I will never master primary care  ;-))

 

There really should be an internship year for PAs, A CAQ, and an option of getting a clinical doctorate in IM (or in my case geriatrics)

 

I am so tired of having AAPA and NCCPA say that PAs are trained for primary care so there is no need for additional training.  By this logic then brand new med school grads should be able to full fledged medicine docs.... yeah right.....  It is a 3 year post grad program to be an IM doc and an additional year for Geriatrics - why not have a CAQ for us?

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I am so tired of having AAPA and NCCPA say that PAs are trained for primary care so there is no need for additional training.  By this logic then brand new med school grads should be able to full fledged medicine docs.... yeah right.....  It is a 3 year post grad program to be an IM doc and an additional year for Geriatrics - why not have a CAQ for us?

 

Have you tried contacting NCCPA and asking what you can do to get involved in the development for a general IM or a geriatrics CAQ? You said you reply to their emails but have you tried emailing their BOD about the issue?

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