PA's and NP's Don't Help.

Dr Scalpel gives his experience of extenders from an ED perspective and why they don't really help all that much in ED medicine. He talks of fraud. What I read him saying is I want to practice medicine, but I don't want to sacrifice the time and energy to be an expert in the field. I would rather gain a superficial understanding of the complexities of the human body with a program of training 1/10 in scope of residency trained medical doctors. I want to treat patients with only a fraction of the required knowledge to understand how complex the human body is.

What do I think?  I think people and doctors and nurse practitioners and physician assistants are all going to have a different opinion based on their own personal experiences.  Some patients will love PAs and NPs and some patients will hate them.  Some doctors higher large teams of non physician providers and follow tens of thousands of patients in people mills they call their clinic.  Some NPs and PAs are highly qualified and some don't know their foot from their hand.  The same can be said of some physicians too.

I have worked with some excellent mid level practitioners through the years.  Nurse practitioners and physician assistants have a role in health care.   That role is dynamic.  Some work very close with their sponsoring physicians.  Some are given complete freedom to practice at will with no oversight.  Some states allow and some states don't allow independent practice by nurse practitioners.  By definition, physician assistants must always have a sponsoring physician.

The level of education and experience varies greatly in the  mid level fields and can lead to a great medical care and patient experience.  As a hospitalist, we have physician assistants and nurse practitioners that work closely with us to provide excellent care.   They provide a valuable service for our physicians and our patients.  As healthcare funding declines and physician and hospital budgets get stretched, more and more "cheaper labor" will be deployed to take care of patients.  Is their care worse?  Is their care better?  Those questions are impossible to answer because great care can't be defined by any single variable and many variables can't be measured.  At the end of the day, I think it's important to keep all this drama in perspective because most of the time we're all guessing anyway,  as this original Happy Hospitalist ecard helps to explain!

"Most of the time we're just guessing.  Surprise! --- your doctor."

Most of the time we're just guessing.  Surprise!  Your doctor ecard humor photo.

This post is for entertainment purposes only and likely contains humor only understood by those in a healthcare profession. Read at your own risk.

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19 Outbursts:

  1. This is what you get when you have government involved in healthcare and health insurance.

    The solution is not so much to tinker with pay rates as it is to get government out of the equation.

    BTW, I favor fully independent practice for PAs and NPs. They would be fully accountable for their decisions and their overhead expenses. No need for a physician to "sign off" on the care, taking all liability. The customer then decides who he wants to see.


  2. It's still better to have docs see all the patients. The key is to schedule coverage so that the docs have enough work to stay busy but aren't so busy that they have a high LWBS rate.

  3. Wow, you are truly condescending. You must be just an absolute treat to work with.
    Do you find nurses as loathesome as you do midlevels?

  4. Our hospitalist program has been understaffed for more than 1 year... In response we hired NP's to help ease the burden, but as a supervising physician (ultimate responsibility for the care falls on me) I am still unconvinced that we have added much capacity. I want and need the extenders to work, but am having trouble identifying patients sick enough for hospitalization which don't need physician level supervision.... I am wondering if the complex case-mix and rapid turnover of an inpatient medicine ward filled with 80 year olds with multiple problems lends itself to midlevel care. I am sure a very experienced practioner could manage some of my patients, but we don't have that. And, without sharing a common level and type of training I am unable to assume my practitioner's ability to recognize and handle the hundreds of situations which may crop up in the day... I suspect I have trust issues, but there are also training and practitioner experience issues. Unlike hiring a physician who comes more or less fully formed, I now expect our practitioner to require at lease a year of training and supervision to be useful to our practice. And, even then her role will likely be different than a physician as her training is different...

  5. I totally agree about the payment schedule. We see elderly patients in our gerontological practice. It is impossible to do a good job in under 1/2 hour a visit with patients with 6 or more active problems. Many of my patients tell me their visit with me is the first time they were examined thoroughly and were able to understand their treatment. We aren't making money and don't know how long we can go on like this even with the lower pay we NP and PA's receive. How long can we subsidize Medicare?

  6. My goodness. I guess only geniuses can do 4 years of anatomy and biochem, followed by 7 years of rapidly escalating salaries.
    Perhaps not quite 7 years for many hospitalists.
    In the harder sciences like engineering, physics, etc, we study longer and publish more, but we're not as distracted by golf and tropical vacations.
    Or as they're sometimes called, "CME's."
    Here at our happy little firm, our fiancial engineers, actuaries, computer scientists, and other quants let you MD's and DO's think you're geniuses, even though we study and use real science.
    We humor you, in other words, because we're smarter. So there.

  7. Not sure where he got 4 years of biochem and anatomy (which were one semester intense classes first year for us) out of 4 years of undergrad, 4 years of med school and 3-7 years of residency/fellowship. Meaning 11-15years total. Biochem and anatomy is just a small part of medicine.

  8. HH:
    I don't know, I found your thread/line of thought understandable. I wouldn't appreciate somone's "critique" who on her own website drips with saracasm and a condenscending attitude to coworkers (doctors, other nurses, other staff) AND patients. Not to mention such meaningless cutsey words like "dood" and "just sayin". Keep up the good work and ignore the ignorant comments.

  9. As stated in other blogs, comparing years in school is like comparing apples to oranges. THe undergrad for PA/med students is the same. Med school is 4 years,while PA school is 2-3 years. There is a 1-2 YEAR difference, but it isnt uncommon for PA students to have 8-12 hours of class per day, without any significant holiday breaks or summers off. So when you break down the hours in class (a more accurate measure), med students spend less than a year longer in the classroom.

    The main difference comes during residency, which isn't required for PA students.

    So the claims of the education being so profoundly different is unwarranted, and the loss of the residency can be made up with less responsiblity, supervision, and years of on the job experience (plus the fact that most PA schools require years of previous expereince in healthcare before you get into the program).

  10. Wow, as I said on Scalpel's page, at one of my moolighting jobs, I run a small ER with absolutely no physician on's just me. I also work at a large prestigious medical center, and lecture/teach residents, precept med students, and manage very complex cases with a minimal of supervision. I am also involved academically, publishing, and speaking. It frightens me to think that you have such a negative attitude towards PA's. I would say that approximately 85-90% of patients that present to the ED I would feel fully comfortable managing independently. I cannot however, speak for other PA's. And please stop using the term "midlevel"...that is completely insulting.

  11. Actually, our entire profession is debating a name change to "Physician Associate", as many within our profession consider assistant to be a denigrating and demeaning term. Whether or not it will come to pass is of course debatable.

    Where on earth did you get that I am "equal" to an EM physician. I have never stated that. I am a PA, not an MD. I have also never claimed that I want to practice with absolutely NO oversight. Even in the smaller ED, there is a physician available by phone. If we get in over our heads, we call him. They don't staff a physician there because, quite simply, it's not busy enough, and it costs too much money for someone to be there all the time for maybe 12-20 patients in a 24 hour period.

    That is a major difference between PA's and NP's. We do not want independent practice, and have always stated that we are dependent practitioners. NP's, are now pursuing a doctoral degree as their entry level they will now be addressing themselves as doctor to patients. The PA profession has no desire to go this route. I am finishing my doctorate currently, but not for a clinical reason.

    I am finishing a doctoral degree in health sciences with an emphasis on public health and policy work, as I am pretty involved in health policy circles as well.

    I have never claimed equality, but I am also far better trained and more experienced than being referred to as someone that shouldn't be seeing patients on their own.

  12. I believe the comment you are harping on regarding equality after ten years is taken out of context. The poster stated that with years of experience, the difference between a PA and a physician is decreased, but it never is completely overcome. PAs are dependent practitioners, and do not claim to be doctors. You are simply changing words to create new arguments until someone calls you out on it, which you will then harp on something else.

    A PA 1 year out of college is light years away from an MD 1 year post residency. After 10 years of real life training, the difference is much smaller, to the point where a PA could perform 85+% of what a physician does. They are not claiming to be a physician, and the 15% that they do not know is immediately brought to the SP's attention for proper care.

    Believe it or not, both physicians and PAs may run into something they do not fully understand, and I would assume that both are fully capable of using available resources (other MDs, literature, etc.) in order to solve this problem.

  13. If you wanted me to find these individuals, Im sure I could but that would not change your mind. Ive known cardiac PAs who place their own CABGs, IR PAs who place their own piccs, thorocentesis, paracentesis, and the majority of procedures IR radiologists perform, general surgery PAs who have completed large majority of cases with the MD in the room but not directly watching every move. I can go on if you really want...

    Can/should they do the fine + inticate details of the work a MD can in these fields? no. But those details do not add up to 15+% of the work.

    Often in the surgical specialties, the PAs do more of the clinical work and post-op work, leaving the MD more time in the OR. However, PAs are utilized in what is most beneficial to the MD and the PA, which is different depending on various situations.

    Comparing cardiac surgery (something that takes 7+ years of residency and fellowship) to a 3 year FP residency is a pointless debate. If the medical community has required different lengths of residency for proficiency in these areas, surely a difference must exist, and the amount of time/amount of expertise a PA can gain in certain field likely correlates to the length of the respecive MD residency in that field.

  14. The debate between specialties is not pointless. Someone clearly stated that a PA could do 85% of what an EM or FP doc does after 10 years, independently of oversight. That line of thinking must extrapolate to all specialties, because there is nothing special about any of them, when compared with each other. All specialties are certified in their field.

    Taking 3 years for FM vs 5 years for orthopaedics? It makes no difference. That line of thinking says a PA can do 85% of an orthopaedic doc 12 years (I added two years for your convenience to account for the extra two years of training) after graduation.

    I would expect to see PAs doing whole knee replacements and making all clinical decisions regarding when to operate and what approach to take, independently, without any oversight. I would expect them to be able to handle every possible complication that arises from said knee surgery.

    Again. You chose FM and EM because you don't know what you don't know. These fields are not interchangeable with independent practice for 85% of the stuff after 10 years of clinical PAmanship, unless of course you believe the same to be true for all others specialists as well.

    You make it sound like the intricate details of a surgeon are any different than the intricate details of an FM or EM doc.

    Hint. They are not. Every medical problem. EVERY medical problem has intricate details. It's called the expanded differential diagnosis. It's called complications. It's called understanding the long tail.

    Why you feel you are capable of doing that after ten years in FM or EM but not do the intricate details of a surgery are beyond me.

    You are one of those people that scare me. Not because you spout off about what you know, that supposed 85%, but because of what you don't know. And in my opinion, you have your statistics reversed.

    As for practicing independent in a small town ED with a doc "on call" by phone, the last time I had a patient sent to my by an extender who was the only person in the ED in small town USA at 2 am, I was told had acute heart failure. I was told they had "fluidity" in the lungs. That was the medical term used to describe my soon to be patient. I was told the patient was given Lasix and I was to accept them for acute heart failure and volume overload.

    I accepted them to a cardiac floor in my hospital. When they showed up, their pressurs were in the 60's systolic. It took me all of 3 minutes to determine that the patient was in severe septic shock and the treatment was not lasix but liters and liters of fluid. This was a cut and dry case in my mind and 99% of all FM, EM or internists that would have seen that patient.

    So tell me, where was the doc that night? That extender almost killed a patient. I asked them where their supervising doc was that night and they told me he was at home sleeping.

    Pathetic. Just pathetic. Not only for the doc but also for that pathetic extender that thought they were all that. That almost killed a patient for a very easy diagnostic presentation.

    Remember, knowing what you don't know is far more deadly than telling the world what you do. Because I assure you that your 85% is not only not accurate but that confidence will kill patients, like it almost did to my patient.

  15. +1000 to the comment about assessing a patient.

  16. "If you send all the easy ones to extenders for 1/2 the cost, you have just killed a model that allows docs to care for the old and decrepit Medicare patients. The only solution, in this model of sending the easy patients to the extenders, is to double or triple the payment rate for the complex medical patients. The extenders aren't qualified to handle these patients. That's what residency level training is for. "


    Happy, That's the point...the reason extenders exist is because as a system we're moving toward a rationed approach to health care which will provide these "complex patients" with hospice care at best. Under a single payer system, there's nowhere for 'complex patients' who take 40 minutes to get through their first 3 of 10 medical problems to go...they get 30 minutes of the doctor's time, just like anyone else, and they get whatever can be provided in that time. If that's not enough, they're welcome to make another appointment in the next available slot, 4 months down the road....or they can go to the ED, spend 2 days there and be sent home without care because they don't meet the standards (age, earning capacity) imposed by the government. Of course, you still need more doctors, so you speed up the process of getting them graduated and certified (which is easy to do since they all work for the government) and turn the majority of them into what we now call.....extenders!

    (Been enjoying your blog....good stuff!)

  17. What's funny is PA's usually have more of a life outside of work than do MD's... Now that is precisely why I would choose a few snobs questioning my intelligence over having no life. MD's who question the PA profession as a whole are just trying to make up for the fact that they are miserable, motivated by money and slowly loosing their humanity.

  18. It is inaccurate to say that PA's have the same undergraduate requirements. Some schools require an undergraduate degree but it can be in anything. A PA at the Cleveland Clinic has an undergraduate degree in art.
    The other inaccuracy is that PA's want to practice only under a supervising physician. As they are competing with NP's who are independent, they are working toward this same model.
    And the fact that they are upset over the term "assistant" and want to be called "associate" should tell you that ego is involved here. Of course, there are going to be some really sharp PA's and NP's but on average, IF you've got the brains and the drive, you are going to go to med school. You can choose to be "married" to your job to any degree you want.
    What I see with PA's are people who either don't have the brains or drive but want to be doctors. They don't want to put the time into training or into the practice of medicine. I never see the PA's at my hospital working weekends, evenings, or holidays. don't want to do the same premed, med school, internship or residency.....but you want to be seen as a "Physician Associate", work independently and make the same pay.
    Oh, and by the way, the next gem is that PAs are working on a phoney bridge degree where PAs can slide into year 3 or 4 of med school and get an M.D. This sort of blows the "I don't want to be a doctor and married to my job" out of the water. What they really mean is "If I can do a shortcut to an M.D......well, that would be great!
    The passage of Obamacare was no doubt celebrated in the PA community. In the future, a patient will likely be forced to see a nondoctor even when they want to. This is a boon to the wannabes but not so great for patients with complex illnesses.

    The medical profession has let this get out of hand. PA's and NP's should only be dealing with simple cases with strict (not phoney) oversight. Patients should always have the opportunity to see their physician if they so choose.

    I don't think I would feel comfortable having that art major with a few extra years of training take care of a critically ill loved one.


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