A reader brings up a great question. How long is enough to be trained to take care of patients?
I speak from personal experience. As an intern,I had the confidence of a rock. Just when I thought I was ready, along comes a situation where I froze. Where I looked to a supervisor for help. A situation that put me in my place. I was not a complete provider of primary care. In fact, I would say my care was so incomplete, I would fear for the patients I was taking care of. These situations were common. I was in the process of learning more about what information to gather and how to separate important information from noise. I see this in first year family medicine residents I work with now. Many are still in the medical student mode. Acting as data gatherers. Collecting information from the history and physical. Then looking to me to formulate the plan. Many don't have the confidence to formulate a plan, because the basis of their foundation is not yet built.
albatross said...
I'm curious how anyone knows the right amount of training needed for treating patients. I mean, it sure *seems* intuitive that someone who went to medical school and did a residency is going to do a better job than someone who has had less training. But is there evidence about this, in terms of better outcomes for comparable patients?
This question kind-of hangs over all these discussions of shorter hours in residencies and the use of PAs/NPs, right? How much difference does it make in patient outcomes if you get the MD with 15,000 hours of residency, or the one with 10,000 hours due to work-hour restrictions, in terms of outcomes when they're practicing? How much difference does it make if it's a PA instead of an MD? Is there good data about this?
It would be pretty remarkable if the historical number of hours of training happened to be optimal, right? That number is pretty clearly a trade off between economics and the advantages of training.
January 26, 2009 10:32 AM
I speak from personal experience. As an intern,I had the confidence of a rock. Just when I thought I was ready, along comes a situation where I froze. Where I looked to a supervisor for help. A situation that put me in my place. I was not a complete provider of primary care. In fact, I would say my care was so incomplete, I would fear for the patients I was taking care of. These situations were common. I was in the process of learning more about what information to gather and how to separate important information from noise. I see this in first year family medicine residents I work with now. Many are still in the medical student mode. Acting as data gatherers. Collecting information from the history and physical. Then looking to me to formulate the plan. Many don't have the confidence to formulate a plan, because the basis of their foundation is not yet built.
By year two, supervisor roles are introduced. At the academia mecca I trained at, our team consisted of two interns, a supervisory resident the attending and a gaggle of medical students. As a supervisor, my role was to make sure the interns didn't f**k up. My job was to guide them. By now, after a year of intense internship and exposure to thousands of patient experiences, the ability to filter the information into an appropriate plan starts to take shape.
Being able to determine who needs a CT scan and who doesn't. Who needs an urgent ICU transfer and who doesn't. Along with the daily educational lectures and morning reports and conferences, the patient experiences were constant. Repetition, repetition, repetition. Seeing 500 cases of COPD. Seeing 100 cases of Sepsis. Seeing acute shortness of breath a 1000 times. The work up is enforced and ingrained. The subtle nuances of knowing what data to gather and what to do with it once you have it. That is learned by 1000's of hours of repetition. There are no shortcuts. It can't be learned in a 2000 hour residency. The shear volume of information and permutations simple doesn't allow it.
I can say that with pure confidence. Because I wouldn't trust myself to take care of ANY patient independently at the end of my intern year. I was just then learning how to evaluate the patient, let alone formulating an adequate plan.
By year three, the experience as a supervisor, the countless hours of repetition finally sinks in. Being able to weed out worthless information. Being able to connect the dots. Being able to create dispositions. Communicating with families. Educating patients. It takes 1000's of hours to learn. Do I have data to back that up? Yes. Ask any physician if they felt comfortable evaluating and managing after their intern year and I'm sure more than 100% would say that assertion is laughable.
Now go out and ask any NP if they feel comfortable being a complete provider of primary care after they graduate and I'm sure you will find many that do. There in lies the difference between MDs and NPs who wish to practice independently. Once you experience a physician level residency training program, you gain a deep appreciation for what it takes to be a true independent provider of primary care. Those that haven't undergone the process simply do not understand. They choose rather to denigrate the physician process and question its necessity while pushing an agenda of minimal academic rigor in an effort to legitimize their own educational process.
There are no shortcuts to the process of providing independent care.
Why those with less intense training and education feel they could is why I always say you don't know what you don't know. Walk in the shoes of a residency. You will understand after just a month, Heck even a week, why there are no shortcuts to independent practice of medicine. You cannot learn what you need to learn to be a complete provider of care in 1/10 the time.
This is not irrational thought. And if others out there think I'm being irrational or degrading, so be it. I speak the truth.
This issue is crucial to the fate of primary care: what is the appropriate level of training to provide a service in the setting of new advancements in decision support and IT? The history of professional development suggests that at some point all disciplines face a crisis where technology enables a lower skilled worker to replicate 80-90% of a higher skilled worker. Society then must decide if the 10-20% lost is worth it for wider, cheaper access to workers. I'm sure master builders and carpenters bemoaned the lower quality furniture of factories just like we docs bemoan limited skill extenders.
ReplyDeleteNew model: Instead of a primary care doc managing a patient as a single, holistic provider we will have NPs referring patients to specialists and performing the role of air traffic controller. The good news is that the NP is a lot cheaper than the primary care doctor. The bad news is that the 10 specialists are a lot more expensive. That is what I see happening from where I sit as an MD in medicine with business training. The system is working that way because medicare is incentivizing specialiazation and thinks narrowly that lower salary costs for PA-Cs and NPs is actually less expensive care. It is at the facility, but not for the system.
I really don't know what the right answer is -- one thing I would suggest, however, is that primary doctors who want to remain relevant need to find a way of managing a larger burden of chronic disease and not referring on to specialists. That means they need to get better reimbursement for longer visits. If they don't shift what they do, they risk truly placing themselves out of a job but turning their practice into a massive referral farm.
If mid-levels are smart (-er than me, lowly family practitioner) they will go on to do cardiology, gastroenterology, dermatology, etc. And they do! I get consult letters back continually from CNPs who are doing the office grunt work so that cardiologists et al don't ever have to leave their sweet procedure suite. Cha-ching.
ReplyDeleteI will say in their favor that generally I get c/s letters back superfast when a midlevel is involved. I throw a little party when I get a letter back from a physician. But I digress...
I have a feeling that smart PAs and NPs will dabble in primary care, then realize (just like medical students) that it's too hard, too messy, and too exhausting for payment in circus peanuts.
But what if Primary Care Armageddon happens, and all the primary care MDs spontaneously combust at once (probably all victims of one too many prior auths for generic omeprazole from Caremark) and mid-levels were left to provide care? Don't count patients out! The lawsuits for all those crazy outcomes from the patients rude enough to stray from algorithms would send primary care mid-levels running for the hills, into the arms of dermatologists.
In this hellish scenario, I would like to be the fly on the wall at the ENT's office, when mid-levels start referring all that complicated, messy stuff that is part and parcel for 75% of my day. I would LOVE to see the look on the ENT's after he finished the obligatory fiberoptic nasopharyngeal scope when the patient says, "Listen, thanks for telling me about the sinusitis, but I have a couple other problems. I can't sleep. And whenever I do sleep I have to get up 10 times a night to pee. And about six weeks ago I pooped pure blood. And I think this is all really getting me down." How long would it take for the ENT to escape from the room?
Must go attend to the three year old....
Several years ago, a primary care friend told me that within a decade, the standard PCP office will be a thing of the past. He told me that NPs and PAs were going to take over the practices, and that generalists were going to back up into fields like hospitalists, and emergency care.
ReplyDeleteThe thought of that happening never ceases to frighten me. In the past, I've seen how difficult it is for a good PCP to manage and stay on top of the care of a patient with multiple chronic illnesses ... the communication between the PCP and specialists is sometimes almost nonexistent.
Then there are the hospital stays - where the PCP never even shows his nose ... continuity is nearly impossible.
If my PCP MDs can't organize and stay on top of my care, then how in the world is a PA or an NP going to do it?
I have a very bad case of "no confidence" ... and I can't imagine ever feeling any differently. So far, I've managed to avoid the NPs and PAs, but it's becoming more and more difficult.
Facing an uncertain future where healthcare is concerned, I find the thought of growing old with my multiple health problems quite frightening. I think that those who are happy with the NPs and PAs just don't understand the risk they're taking.
It's going to be a rough ride ...
I agree with your post Happy. It does take years. I have been at this for over a decade, and I am certainly not able to see every single problem on my own. Can I see far more than I did initially? Of course, this is the nature of experience. I am also a supervisor for our group, and often speak with the attendings regarding our newer grads, both NP and PA to see how they are doing. Without a doubt, they consult the attendings more frequently than the other senior members, which they are happy about, and is only appropriate. You know where I work Happy, and in the immortal words of Charles M. "That which is in the best interest of the patient, is the only interest to be considered". I have doubts about new graduate NP's practicing with complete independence, as I know that when I first finished PA school, (after being a Navy Corpsman for years), I was certainly nowhere close to adept as I am now.
ReplyDeleteEconomically, we are here to stay, you can either bemoan the fact, or work to help us. WORK TO HELP MAKE SURE PA's and NP's are competent qualified providers. Why not precept some PA students Happy? In fact, I am sure I could arrange that, if you are willing.
My best friend, and close classmate from school owns his own primary care practice in rural Florida....WHY? Well, the previous physician died, and despite an INTENSE recruitment effort, they could not find another phsyican willing to live in BFE and run the practice, as my friend knew the deceased quite well, they eventually contacted him. He had to hire a supervising physician who comes by once weekly to reveiw charts and see any patients that my friend is having a difficult time with. This is happening everywhere. MD's don't want to work in primary care, and the ones that do, certainly don't want to work in the rural areas.
Moof, if you have never seen a PA or NP, then how can you be so certain that they could not meet your primary care needs?
ReplyDeleteI only ask that you try and see us with an open mind, and that you give us a chance. IF after you see a PA or NP, you are dissatisfied, or feel that you were given inappropriate care, then by all means, avoid us like the plaque, but I wonder how you can objectively dismiss us, without having seen a PA or NP.
Just a quick point:
ReplyDeleteIt seems you use the words "training" and "education" interchangeably while speaking on this topic.
To me the words are completely different.
Training is specific to developing skills to do a specific job or task. Training is hands-on, procedural, algorithm based thinking, if A do B, the ABC's type approach to patient care. You can train anybody to perform procedures, memorize algorithms and flow charts. And perhaps this is where NPs and PAs get away with treating patients: they are highly trained. But what about patients that do not fit ridged algorithms for care? The PAs and NPs are unable to function independently.
Education is fundamentally about critical thinking and problem solving. Why are we doing procedure X? What are the possible consequences of procedure X? If A fails do we try B or go directly to C? This is the reason MDs in my opinion are more skilled at treating primary care patients: they are highly trained and highly educated.
Education requires schooling.
It is for this reason that my PCP will always be an MD.
Physasst, my sister in law went to school for 3 years to become a PA. She graduated with flying colors. She was then hired by an OB/GYN practice, and she told me that there had been nothing to prepare her for the actual experience. Her conscience bothered her enough to leave her PA job, and go back to teaching.
ReplyDeleteAs I said above, even my MDs are sometimes unable to juggle all of my meds, lab work, scheduling for procedures, figuring out "what the heck is going on this time", etc ... and they have BOTH the education *and* the training do so ...
I'm supposed to trust a glorified RN, or someone who took a 3 year course in college to do all of that?
You say to try one of you ... and "give you a chance"! Dear heart, if I did that, likely I wouldn't LIVE to "avoid [you] like a plague".
I will stay with MDs and/or DOs ... and if someday they are no longer available in primary care, I guess I'll just end up being yet another person who makes use of the emergency room for non-emergent problems.
If you're cocky enough to feel certain that you can do as well as an MD, then you're far more dangerous to the patients than you realize.