Doctoring, Without the Doctor
May 27, 2015 5:33 AM   Subscribe

Nebraska became the 20th state to adopt a law that makes it possible for nurses in a variety of medical fields with most advanced degrees to practice without a doctor’s oversight. Maryland’s governor signed a similar bill into law this month, and eight more states are considering such legislation, according to the American Association of Nurse Practitioners. Now nurses in Nebraska with a master’s degree or better, known as nurse practitioners, no longer have to get a signed agreement from a doctor to be able to do what their state license allows — order and interpret diagnostic tests, prescribe medications and administer treatments.
posted by wondrous strange snow (53 comments total) 11 users marked this as a favorite
 
Yeah, this is the future of healthcare in the US: most of us will get our primary care from nurse practitioners and physician assistants who increasingly work with only nominal physician supervision. The AMA complains about it, and they may be right, but they also seem completely uncommitted to figuring out how to provide adequate primary care to under-served areas. Hell, they seem pretty uncommitted to figuring out how to provide adequate primary care, period. Someone has to do it, and it doesn't seem like doctors are willing to, so it's going to fall to the PAs and NPs.
posted by ArbitraryAndCapricious at 5:40 AM on May 27, 2015 [35 favorites]


The next step is educating the public about what a nurse practitioner is and what they're capable of doing. I once filed an H-1B petition for a nurse practitioner and had the case rejected because the USCIS agent didn't know the difference between a nurse practitioner and a nurse (which is not an H-1B eligible position). I wrote a lengthy, snark-filled response, and the case was approved.
posted by Faint of Butt at 5:43 AM on May 27, 2015 [2 favorites]


Not sure how it will work in Nebraska, but in New York NPs still have to "collaborate" with an physician for some period of time before they become independent. I believe it's something like 5,000 hours. Nurse Midwives in NY may practice independently as well.
posted by brevator at 5:44 AM on May 27, 2015


Nurses > Doctors in every medical situation I've ever been in when it comes to level of attention to detail, expertise, and bedside manner. This may be a cost-saving measure but I don't really see a downside.
posted by Potomac Avenue at 5:45 AM on May 27, 2015 [9 favorites]


This is also going to happen in dentistry by way of "dental therapists," i.e., hygienists who are also trained to drill and fill teeth. As in this situation, this system will be permitted/forbidden on a state-by-state basis, and will track pretty predictably with where the medical professions hold sway in the state government and economy (for instance, I think it'll be a chilly day in hell when Massachusetts makes this legal).

I wonder what the malpractice insurance is going to be like for these practitioners.
posted by overeducated_alligator at 5:45 AM on May 27, 2015 [3 favorites]


If the AMA doesn't like it, they could increase the number of residency spots (which hasn't changed since 1996) to eliminate the physician shortage. But they like the physician shortage, because it drives up their salaries.
posted by hydropsyche at 5:48 AM on May 27, 2015 [35 favorites]


As in this situation, this system will be permitted/forbidden on a state-by-state basis, and will track pretty predictably with where the medical professions hold sway in the state government and economy (for instance, I think it'll be a chilly day in hell when Massachusetts makes this legal).
I think that's part of it, but I also think that it has to do with geography. Basically, there's a real crisis in rural medical care, and states like Nebraska are partly responding to a real need. My friend's dad is a small-town dentist in a heavily-rural state, and he's desperate to retire, but he can't find a dentist who will take over his practice. At some point, he's going to have to stop working, and there's no other dentist for like seventy miles in any direction. He hates the idea of "dental therapists," but he also acknowledges that people aren't going to have access to care once he stops practicing, and they may end up turning to practitioners whom he doesn't think are really qualified.
If the AMA doesn't like it, they could increase the number of residency spots (which hasn't changed since 1996) to eliminate the physician shortage.
I think that's part of it, but they also have to figure out ways to minimize doctors' debt, because there's not a ton of money in primary care. In general, a big part of the problem is that there are big incentives for doctors to go into lucrative specialties, rather than primary care. And there are particular challenges getting doctors to work in rural areas, which is what this particular article was about.
posted by ArbitraryAndCapricious at 5:52 AM on May 27, 2015 [5 favorites]


I see this as a potential boon to the mental health services provided in rural and high need areas. There's a worldwide shortage of psychiatrists. I worked for a while as a physician recruiter, and finding a psychiatrist willing to practice in a high poverty area is often like searching for hen's teeth. Psych NPs could potentially fill in some of the gap left by psychiatrists. The need is a critical one, as some of those who are the most vulnerable and in the greatest need of care live in the most underserved areas.
posted by batbat at 5:52 AM on May 27, 2015 [5 favorites]


The AMA complains about it, and they may be right, but they also seem completely uncommitted to figuring out how to provide adequate primary care to under-served areas.

Or in general, it seems like. Primary care is not a popular thing among people going to med school, and for good reason. It's not lucrative compared to other fields, but I think it's not just the money--it's the money combined with the perceived headaches of primary care. I'd rather see more actual doctors with less actual debt. I've had some bad experiences with NPs. Despite that, I'm in favor of this, because said bad experiences with NPs? Came in states that required "supervision". Allegedly there was a supervising doctor. But I couldn't see that person, and my insurance didn't give me a clear path to escalate the issue when it wasn't getting better, so I'm not sure I see the point, you know?
posted by Sequence at 5:57 AM on May 27, 2015 [4 favorites]


I think that's part of it, but I also think that it has to do with geography. Basically, there's a real crisis in rural medical care, and states like Nebraska are partly responding to a real need. My friend's dad is a small-town dentist in a heavily-rural state, and he's desperate to retire, but he can't find a dentist who will take over his practice. At some point, he's going to have to stop working, and there's no other dentist for like seventy miles in any direction. He hates the idea of "dental therapists," but he also acknowledges that people aren't going to have access to care once he stops practicing, and they may end up turning to practitioners whom he doesn't think are really qualified.

Oh yeah absolutely. In the case of dentistry, the ADA really looked like assholes when they decided to take on the dental therapists in remote Alaska. The need is there and the practitioners aren't. To be fair to the ADA, one of the problems with lower-level practitioners is misdiagnosis which can lead to increased morbidity. But the fact remains that sub-optimal care is better than no care at all.

And why are there no doctors/dentists racing to open practices in rural Wherever, USA? Because of the crippling debt that is now practically inescapable for those pursuing medical/dental education. The cost is absurd. There are some loan forgiveness programs now for those who practice in underserved areas like Indian reservations and urban ghettos, but I believe the qualifications for these programs are more restrictive than they ought to be. The "lower-middle class" rural patient/practitioner populations suffer the same way that all such people do in means-tested programs: too poor to attract a young graduate who needs $200,000 a year to pay off his/her debt; too rich to qualify for aid.

If you go online to medical/dental student discussion forums now, you see a lot of graduates being advised by their peers to join the military for some hope of debt remission.
posted by overeducated_alligator at 6:02 AM on May 27, 2015 [6 favorites]


I read the headline backwards and was all set to rant about how inane it was that states were going along with the AMA on this. I'm glad I didn't read it correctly!

My BIL is a doctor in a rural area - Kansas paid off a his student loan debt (which was in the six figures, I think) to practice someplace that wasn't Kansas City or Lawrence, basically. That's fine but it's not enough; there isn't going to be one solution to a shortage of medical professionals in rural areas.
posted by dismas at 6:07 AM on May 27, 2015


This is also going to happen in dentistry by way of "dental therapists," i.e., hygienists who are also trained to drill and fill teeth. As in this situation, this system will be permitted/forbidden on a state-by-state basis, and will track pretty predictably with where the medical professions hold sway in the state government and economy (for instance, I think it'll be a chilly day in hell when Massachusetts makes this legal).

I assume that there is a supply problem for dentists as there is with doctors, where they control the number of medical school graduates and create barriers to doctors from overseas freely entering the profession here. (I assume that the theory is limiting supply will push up salaries, which clearly works, but at significant social costs.)

Given those barriers to more doctors, and given how few doctors are willing to work in rural areas, it seems like the choice is between expanding the number of people, like nurse practitioners, who can provide care, or just handing out copies of Where There Is No Doctor and Where There Is No Dentist and wishing people good luck.
posted by Dip Flash at 6:09 AM on May 27, 2015 [1 favorite]


one of the problems with lower-level practitioners is misdiagnosis which can lead to increased morbidity

Misdiagnosis is a problem for practitioners of all types of education. That said, for NPs there is a "growing body of evidence that the quality of primary care delivered by nurse practitioners is equivalent to that by physicians."
posted by brevator at 6:13 AM on May 27, 2015 [6 favorites]


I am a specialist MD and I don't have NPs or PAs in my office (yet). But the main issue that some of my primary care colleagues have with NP near-autonomy is that in most cases, they still require some level of "supervision." But this doesn't mean that the supervising MD/DO actually sees or hears about or even knows about every patient. But what happens when there is a medical error (or perceived error) and a lawsuit? The supervising physician gets roped in and is often held to a higher standard by the legal system than the NP. I think that in certain circumstances, NP autonomy in a primary care setting is outstanding, but I'd like to see the system revamped so that doctors aren't held accountable in these situations and NPs are responsible for their own malpractice insurance.
posted by robstercraw at 6:15 AM on May 27, 2015 [12 favorites]


I suppose the question is which is a bigger problem for American health care right now, misdiagnosis at the entry point into the health care systems, or no diagnosis because people don't get into that system at all for early warning symptoms and routine checkups.
posted by CBrachyrhynchos at 6:24 AM on May 27, 2015 [3 favorites]


I've worked with NP, PA, and doctors as a medical student. The main thing I've seen determine quality is A)how much the person cares about doing a good job, B) how curious they are continuing there education(formally or informally), and C) how long they have been doing it. Getting any of these degree or certifications does not really guarantee any of the above.
The AMA does not restrict the number of residency spots. That is actually controlled by congress funding of Medicare for graduate medical education. This is actually a big problem as the number of medical students has increase the number of residency spots has only gone up by half as much. Right now to make up for it fewer foreign grads are getting spots, but we really could use everyone. Particularly since foreign grads tend to work rural and less "desirable" areas.
posted by roguewraith at 6:31 AM on May 27, 2015 [7 favorites]


I was going to say that Governor Hogan in MD finally did something OK, but I'm not sure yet.
posted by josher71 at 6:33 AM on May 27, 2015 [3 favorites]


There are a number of ways to fix the problem of "not enough doctors" as everyone has pointed out, any one of which we could do as a country/with the AMA if we wanted to. Apparently we've decided "more NPs" instead of subsidizing med school/making it cheaper/etc. It may or may not be the best solution.

Generally, I've had as good or better treatment from NPs as from doctors. I've only seen my current doc once, as a matter of fact. He gave me a fist bump and diagnosed my obvious case of infected sinuses (he calls my husband Boss; he's a total bro-doc). Anything really complicated would get me sent for tests/to a specialist anyway.
posted by emjaybee at 6:50 AM on May 27, 2015 [2 favorites]


Has The Doctor ever been to Nebraska?
posted by maryr at 6:56 AM on May 27, 2015


misdiagnosis at the entry point into the health care systems

Is there evidence that this is actually an issue with NPs, though? Brevator's link suggests that primary care outcomes may actually be the same between NPs and MDs/DOs.

Assuming that the NP or PA is in an area where they have doctors to refer to, and assuming that they are able to correctly identify and refer the complex or higher-risk cases, it would seem like they would be able to manage the more common and lower-acuity cases as well as doctors (or possibly better, if they get more time to spend per patient). Is an MD or DO really needed for routine things like high blood pressure management or ear infections?

I personally have seen NPs, PAs, MDs, and DOs at various points, and anecdotally, I'd agree with roguewraith -- the person I'm seeing and how much they research things matters a lot more than their degree. I've had MDs/DOs say some truly wacky things and I've had PAs who obviously were committed to continuing education.

I've also noticed that (again, anecdotally) NPs tend to be more aware of costs to the patient -- the specialists I've seen will routinely order $500 in blood tests on a whim, while my NP checks to make sure any tests will be covered and also was delighted to hear from me that steroid nasal spray is now over the counter (and called the pharmacy while I was still there to make sure that my price OTC was cheaper than the pharmacy price).
posted by pie ninja at 6:57 AM on May 27, 2015 [4 favorites]


I think this is cool. Up with PAs! Up with NPs! I hope that they are compensated accordingly for their increased responsibilities. And, tangentially: the hilarity of arch-conservative and libertarian doctors complaining about governmental over-regulation while benefiting from a system that artificially restricts the supply of doctors -- I will never, ever get over it.
posted by (Arsenio) Hall and (Warren) Oates at 7:12 AM on May 27, 2015 [4 favorites]


This is great news. Several years ago I worked for one of the state medical associations, and from what I saw they were significantly less interested in advocating for medical professionals and patients than they were in romancing insurance companies. I wouldn't trust the AMA to acknowledge competent care even if it was wearing a name tag that said Dr. Competent Care.
posted by Orange Dinosaur Slide at 7:12 AM on May 27, 2015



I assume that there is a supply problem for dentists as there is with doctors, where they control the number of medical school graduates and create barriers to doctors from overseas freely entering the profession here. (I assume that the theory is limiting supply will push up salaries, which clearly works, but at significant social costs.)


Part of the "supply problem" is also because to teach more dental students, you need more infrastructure - you can admit more people up to a point, but eventually you run out of dental chairs, can't recruit enough patients, can't hire enough faculty, don't have enough classrooms. Many dental schools are OLD. Dentistry isn't sexy and exciting like certain medical fields (#notallmedicalfields) and capital improvements are super expensive for this type of thing - it's not even like just building new labs, you need a LOT of equipment (whereas with new lab space, you mostly expect the PIs to fund their own equipment).

Just because everyone should know this - the University of Minnesota School of Dentistry has a program for dental therapists and indeed has pioneered a lot of stuff associated with dental therapy. The UMN Dental School - and I say this as a person who is pretty cynical about/anarchist about most things like this - has genuinely tried quite hard to reach underserved populations, recruit students from diverse racial and economic backgrounds and promote a "rural track" to encourage dentists to work in rural/outstate MN. What is holding Minnesota back?

1. Lack of support from the legislature. The rural track program and associated community care projects were just denied a modest-in-the-grand-scheme-of-things funding request. The university is forging ahead but the money for enlarging the program isn't there.

2. Lack of support from the legislature for building maintenance, which translates into tuition increases. Everyone thinks that universities are doing nothing but spending all their money on giant new buildings, and in some fields that's true - but large public institutions like the UMN have many non-sexy fields/schools where the buildings date back to the fifties-seventies and cost a LOT in upkeep. The UMN dental school's HVAC system is OLD and it's incredibly expensive to maintain and update, plus the school needs at least some contemporary technology in terms of, oh, teaching students to use stuff. There is a perception, again, that universities are spending all their money on $500,000/year vice deans for basket weaving - and in some places that's true. But again, in the less sexy fields, it is far less true.

3. Student reluctance to practice in rural areas for all kinds of reasons. Some people go into dentistry because it pays very well and is quite secure, so they want to practice in more lucrative areas. Some people want to practice in the city or the suburbs because there's better infrastructure, the insurance situation is easier and patients find it easier both to get to the clinic and to pay for services - all reasonable concerns. Some people don't want to practice in rural areas because, honestly, they want to live somewhere with more going on. Some people don't want to practice in rural areas because of the perception - sometimes real, sometimes not - that rural areas will be racist against them, etc. Basically, if we want dental care in rural areas, we need a LOT of money to throw at the problem - loan forgiveness, incentives for practice, material support for rural clinics....all these things would overcome new dentist reluctance if properly designed. But where is the money to come from?

You can have a program that is fairly radical for a dental school and still have a LOT of trouble because the money is not there - good people with real commitments to underserved communities (and - knowing several people who do this work through the UMN, I can say that there are plenty of these people in the dental school) can try and try, but without state support, better insurance and grant support, they can achieve only partial results.
posted by Frowner at 7:26 AM on May 27, 2015 [11 favorites]


I think this is an interesting development when you look at it from an international perspective, because the U.S. (and I believe Canadian) medical school system is somewhat unusual in requiring a regular 4-year bachelor's degree (typically in some sort of "pre-med" track) before even starting a 4-year medical school program that combines classroom and clinical rotations. It's much more common in other countries to have some arrangement that results in a 5-7 year direct-entry degree program of more focused classroom/clinical courses.

The end result is that while in the U.S. a doctor graduates from med school with 8 years of university classes under their belt (and then completes a residency), half of those 8 years is spend in a more general program (biology or chemistry, for example). Elsewhere, doctors spend fewer years in the classroom in a more narrowly focused program. I could easily see where NP graduates with 6 years of coursework could have a better education in the sorts of care they will be providing than a US MD with 8 years of broader coursework, as well as being equivalent or better than the education of doctors in other countries who are licensed to practice following a 6-year academic degree.
posted by drlith at 7:35 AM on May 27, 2015 [3 favorites]


The AMA does not restrict the number of residency spots. That is actually controlled by congress funding of Medicare for graduate medical education.

Actually, the AMA/AAMC do restrict the number of residency spots, because the reason the blanket cap exists is because the AMA/AAMC refuses to allow the federal government to make more fine grained decisions on how many of each specialty are granted residencies.
posted by NoxAeternum at 7:43 AM on May 27, 2015 [2 favorites]


As a medical student I recognize that this is the future of primary care, and I think it's a good move especially in rural areas. But I hope people recognize that these policies will have an unintended side effect of decreasing what little incentive remains for a medical student to pursue primary care. The added burden of years of training and considerable debt, coupled with (relatively) low incomes compared to other specialties means that only the true believers end up pursuing primary care. I'm not even sure that's a bad thing given that there's simply no way that our medical system could produce enough primary care physicians to close the gap in demand.

With that being said prior to coming to medical school I thought primary care would be the medicine that required the least knowledge or medical complexity. I was totally wrong. There's a common refrain in my medical school that the most capable people end up in specialties that require the smallest subset of knowledge, while primary care requires the greatest depth and breadth of knowledge. It may seem simple from the outside, but the amount of knowledge and training that goes into making even the simplest primary care decision is astounding. Then you have to factor in the time pressure, and the increasing burdens of documentation. It's amazing that they function at all.

Also, I feel like I should personally apologize to all the people in this thread who've had terrible experiences with doctors. I feel like there's been a huge shift in the culture of medical education to remedy some of the problems y'all have described, and with any luck the new doctorlings about to hatch this July will be a bit better prepared.
posted by ghostpony at 7:56 AM on May 27, 2015 [16 favorites]


This seems to be a nice case of competition in capitalism actually helping consumers/patients, particularly those in rural areas. I have a cousin who recently started practicing as a pediatric ENT specialist, pretty explicitly because it pays more. He is now whining about how he might not earn the kind of money he expected because of all the changes taking place in medicine lately (mostly blaming Obamacare). I'm not inside his brain or heart, but it seems a lot like he went into medicine as a way to become wealthy. That is fundamentally icky and not right.

All of that to say: if we can't get a single-payer system, I am in favor of anything that in any way shifts healthcare away from the model of maxxxximum profit. If an MD can't compete with an also-competent NP or PA, too bad. Let the market decide!
posted by witchen at 8:01 AM on May 27, 2015 [2 favorites]


@witchen Ugggh. That's so sad. Pediatric ENT is such an amazing field and the one surgical specialty I'm interested. It is strange, though as it's widely recognized that any pediatric specialty inherently pays less, so maybe he didn't think that one all the way through?
posted by ghostpony at 8:20 AM on May 27, 2015


Why will NPs enjoy low-paying rural practice more than MDs will once they have more options? Ultimately, the incentives for nurse practitioners are the same as they are for MDs. Notably, specialist nurse practitioner practice is desirable for a lot of nurse practitioners.
posted by internet fraud detective squad, station number 9 at 8:28 AM on May 27, 2015


Nurses > Doctors in every medical situation I've ever been in when it comes to level of attention to detail, expertise, and bedside manner. This may be a cost-saving measure but I don't really see a downside.
posted by Potomac Avenue at 5:45 AM on May 27 [8 favorites +] [!]


Much less accountability, much more referring out, much less depth of experience and clinical judgement due to the sheer fact of less education and experience.

Don't get me wrong, more NP's is a really good thing, but don't ever think that when you come in with something non-routine or esoteric that you aren't better off with a physician with many times the experience and training.
posted by docpops at 8:30 AM on May 27, 2015 [7 favorites]


ghostpony - To be fair, I think he does enjoy the work, and likely chose the pediatric specialty because that's what he actually wants to practice. It's just that in every conversation about "how's work?" the first response is money grumbling.
posted by witchen at 8:35 AM on May 27, 2015


I'm not inside his brain or heart, but it seems a lot like he went into medicine as a way to become wealthy. That is fundamentally icky and not right.

witchen: I'm not sure I agree that it is "fundamentally icky," but I do see where you're coming from. We are frustrated these days because our compensation is decreasing every year. It's still quite enough to live on, but it's tough to see the numbers go down, down, down, no matter where they started, especially when our costs are going up, up, up with new government and insurance regulations.

So many factors go into the decision to pursue medicine as a career. First for me was the "calling" to medicine and the desire to make a difference. It's the cliche med school interview answer because it's so true for so many. But I can't say that the money - and more than that, the security - didn't factor into my decision to practice ENT. I think it's one of the nicer ways to make a buck, but I won't pretend that my decision was 100% altruistic. I did feel like I was well-suited to be a surgeon and also, I just couldn't bring myself to deal with hedge funds or insurance or the law or any of the other not-always-as-nice ways to ensure a high income.
posted by robstercraw at 8:47 AM on May 27, 2015 [2 favorites]


The AMA is—or rather it functions indistinguishably from and therefore ought to be regarded as—a supply-side cartel, and basically anything that makes it howl is probably a Good Thing as far as patients are concerned. If a single entity exerted as much control over any other industry as it does over medicine, it would be broken up.

I don't think the problem is individual physicians per se. The system is set up in a very particular way: we only turn out a very small number of MDs each year, all of whom have to pay exorbitant amounts (generally getting heavily indebted in the process), and then when they come out the other side they find the easiest way to recoup those costs is to do assembly-line medicine where you only see each patient for a few minutes (in a busy hospital it's probably seconds; surgeons get more time but it's no picnic either). The burnout rate for MDs, particularly when you figure in the cost of schooling and how long it takes to get there—it's not something you get into casually—is stupendously high.

So I'm more than willing to give individual doctors the benefit of the doubt and assume that they all went into medicine for something other than the paycheck. (Also, only a person who doesn't understand how compound interest works goes into an MD program for the money. Prestige, maybe.) But the AMA has been absolutely complicit in both building and perpetuating the broken system that exists today, and it's a system that's bad both for patients and for doctors who want to practice good medicine.

Given that the AMA doesn't show much sign of relaxing its grip on the supply side of things, doctors ought to welcome greater involvement by NPs and others, to help spread the load. Sure, it's not going to help them with their loans, but it will help reduce the pressures that make it such a misery-inducing profession to actually work in (to the tune of a med-school class per year just to replace the doctors who commit suicide).
posted by Kadin2048 at 8:48 AM on May 27, 2015 [6 favorites]


Why will NPs enjoy low-paying rural practice more than MDs will once they have more options?
Think about Murlene Osburn, the Nebraska NP who is profiled in the article. She is 55 years old, and she grew up in the area like the one where she currently practices. She qualified as a nurse as a young woman, and then she moved to rural Nebraska to work and raise a family. She didn't become an NP until she was in her 50s, presumably after her kids were grown (and, tragically, one of them had died.) She probably doesn't have a huge amount of debt, because she'd paid off her undergrad debt long before she went to grad school and because a nursing masters isn't nearly as expensive as med school. So basically, this is someone who wants to practice in her particular rural area and who took advantage of a career path that would not have been available to someone who went to med school.
posted by ArbitraryAndCapricious at 8:51 AM on May 27, 2015 [4 favorites]


I went into medicine so I could live anywhere and be useful. It was important to me to have a skill that would be tailored to my personality and be challenging. I never considered money. I like the job security, but I don't know any doctors that feel rich. We like our work and we really like the feeling of helping people, especially when you feel close to burning out. Fatter paychecks really don't ease psychic distress past the point of paying the bills. If you don't like the art of understanding and dealing with people (often at their most scared and/or worst behavior) you will hate any branch of medicine except maybe pathology. But there is something to be said for the surreal rigors of medical training. As awful as it is, it tends to attract a certain sort of person. You may not always like them, but under the surface there's a stability and commitment in most doctors that is critical to the practice of good medicine. If the barriers to entry are lowered that won't be there in many cases. Not always a bad thing, just different.
posted by docpops at 8:55 AM on May 27, 2015 [4 favorites]


It is easier to become a lawyer then it is to become a doctor, and lawyers are pretty miserable. They are also frequently unemployed. I am not sure that increasing the supply of doctors is anywhere near a panacea. I think that professions that encourage students to sign up for multiple years of graduate school, take on mountains of debt, and commit themselves heavily to highly specific area when they are 22, are going to produce people who dislike their profession but feel trapped in it for various reasons. There is also a strong correlation between intelligence and various mental disorders. That correlation cannot be discounted when you're looking at professions that would require an unusually high level of intelligence, and then wondering why the people in them have more mental disorders.
posted by internet fraud detective squad, station number 9 at 9:11 AM on May 27, 2015 [4 favorites]


I'm not inside his brain or heart, but it seems a lot like he went into medicine as a way to become wealthy. That is fundamentally icky and not right.

Very few today go into medicine as a way to become wealthy. However, many medical students ultimately choose their specialty as a way to repay their crippling, non-dischargeable debt.
posted by telegraph at 9:26 AM on May 27, 2015 [4 favorites]


I sit on a local board in a very rural area. We had a meeting recently with a proposed low-income clinic coming to town and the clinic from the town down the road sitting in. Let's just say there's some conflicts but that's another matter. Both admitted to being severely fatigued by the struggle to find physicians. NPs and PAs are their only way of dealing with this. In my five years of going to the clinic down the road, I've seen a PA much more than a MD.

We've also got severe cold up here so some candidates just look on the map and figure "there's no way I'd survive up there." The thing is I know plenty of people who have moved from other parts of the US and most admit "you know, once you get used to it, winter's not so bad, it beats the humidity in the South any day."

Our clinics are looking at paying off debt as an enticement for young doctors and then getting them for a five year deal. The hope is that sooner or later, one will go local, get married, and stick around.
posted by Ber at 10:07 AM on May 27, 2015 [2 favorites]


I grew up in a rural area and, after the week when I was born, didn't see an actual doctor until I was 27. PA's, NP's give excellent care and are the answer to providing quality rural health care. Alaska is working hard on creating mid-level dental care as well. I think they are modeling it after similar programs in New Zealand and the Alaskan Native health system is an innovator in this new realm of care. This gives a little overview of the levels of care. I've seen the statistics from Southeast Alaska and rural dental health has improved an amazing amount.
posted by Foam Pants at 10:56 AM on May 27, 2015 [1 favorite]


Don't get me wrong, more NP's is a really good thing, but don't ever think that when you come in with something non-routine or esoteric that you aren't better off with a physician with many times thfe experience and training.

I think that's true so far as it goes, but I would gently suggest that most patients who present in a primary care clinic don't need a referral for some esoteric disease nearly as often as they need somebody who can spend more than ten minutes working with them on the long-term management of their common and unsexy chronic conditions.

If the outcome of this shift is that a few cases of Kawasaki disease or what have you go misdiagnosed, but more people can get effective care for their diabetes, asthma or high blood pressure, that's still a big net win for public health.
posted by strangely stunted trees at 11:40 AM on May 27, 2015 [6 favorites]


It is easier to become a lawyer then it is to become a doctor, and lawyers are pretty miserable. They are also frequently unemployed.

I'm not sure what this has to do with anything. It's easier to do lots of things than it is to become a lawyer, including things that can lead to misery.

Businesses in 2015 have less need for lawyers than businesses did, say, ten years ago. The market for legal services has not grown to scale with the number of lawyers. In comparison, we still have a lot of humans who get sick and need doctors - and in the near future we're going to have more of those because we have a lot of people getting old (ie, Baby Boomers.)

Law and medicine are two fields that can be expensive to enter, have some level of professional accreditation to practice, and have traditionally been both lucrative and prestigious. They are not, however, equivalent in skillset or market.
posted by Tomorrowful at 11:44 AM on May 27, 2015


My grandfather was a country doctor in rural Nebraska. This was in the middle of the last century before outmigration really started taking its toll on the regional social fabric. But still, he was one of the most important people in the community, because he was the only doctor for umpteen miles in every direction.

Probably because of this legacy I have always been partial to GPs, PAs, NPs, and family doctors. I prefer to see such folks over specialists even here in the big city a bare mile from a world-class research hospital. (“Some of my best friends are orthopedic surgeons…”) IME Generalists are less apt to overprescribe, don’t rush into surgery, and will do nice things like write long letters to my insurance company arguing for lower premiums.

Just this year my GP of 13 years left general practice for sports medicine. He told me there just wasn’t the money in family practice, and the modern system of insurance + healthcare networks had basically turned him into a referral machine.

I often reflect on how much education my grandpa would have had in the 1930s. Probably much less than a modern Nurse Practitioner. Yet he set bones, performed surgeries, delivered babies (and sometimes calves) and all the other usual doctor stuff. Maybe I just think modern doctors are over educated or at least over specialized. Every time I meet a doctor socially (srsly there are a lot of orthopedic surgeons in my social network…) I ask, can you deliver a baby? Set a bone? Remove an appendix? Like, if there was an apocalypse and we were scavenging the wasteland for canned goods and I was giving birth what would you do? They still teach that stuff in med school, right? FTR this question universally makes them nervous.
posted by axoplasm at 11:50 AM on May 27, 2015 [1 favorite]


The massive shortage of healthcare exists not just in rural areas, but in urban ones as well. As others have mentioned, there's a tremendous shortage of primary care physicians in the country, and there's little incentive for people to go into proving such care: massive debt, comparatively lower pay, less respect.

I was lucky enough to consolidate all of my student loans to a rate that's lower than the rate of inflation. I don't know what it is now, but some of the residents I've worked with in the recent past have stated that their rates are higher than 8-9%. This is ridiculous.

Pay for primary care physicians sucks rocks compared to subspecialists. They're often viewed as being lower on the totem pole, which is completely wonky when it one considers where the need is. And then you've got academic medicine, where really smart people work really hard for really good reasons for comparatively low pay.

All this pushes people in one of two directions: toward specialization and away from medical school and toward NP/PA programs. I think the latter is a pretty good direction for a lot of people to go in, because a) med school sucks, b) being a physician can often suck, c) you can get paid well and live a decent life being an NP or PA.

I've worked closely with both NPs and PAs. Like physicians, there are good ones and bad ones. But there's been a huge push for people/hospitals/groups to hire NPs and PAs which I think can be very detrimental to medicine as a whole.

It's not because they're not qualified, it's because at most places the practice of medicine is structured such that NPs and PAs have oversight. A supervising MD or DO has to sign off on their work. This would be fine, but when healthcare systems try to maximize patient encounters and revenue by hiring more NPs and PAs at a lower cost than MDs or DOs, the risk of overloading physicians runs great.

Take, for example, emergency departments. I'm not an ED physician (perhaps the other physicians on MeFi can comment on this), and I'm only speaking about the region I have experience with. What's been happening is that hospitals have been hiring more PAs for the EDs. Some are great, some are not, but the big point is that all of a sudden, MDs and DOs have to sign off on a LOT more charts. There's a ton of responsibility and liability here.

So much of the business of medicine is based on metrics. For emergency departments, much of it is about time. How long does it take for a patient to get registered? How long does it take for a patient to get into the bed in the ED? How long before they're seen by a physician? The list goes on. There's tremendous incentive to get people through the door, seen, and either discharged or admitted as quickly as possible.

Add to this electronic medical records and templating: EMRs are great for a lot of reasons. They also can encourage really bad behaviors and practices: using templates but not making appropriate changes, or cutting-and-pasting prior records or medication lists. I've seen practitioners of all types of medicine, in pretty much every field, make terrible, lazy errors in documentation: a physical exam is templated: did the person really examine the patient's feet when the patient's shoes and socks are still on and there's a huge ulcer on the bottom of his foot with part of a toothpick sticking out of it? Was the patient really eating a piece of cake every day they're seen, as documented in the daily progress notes?

I've some friends who are ED physicians who've quit and moved to other hospital systems because they felt like there was just too much risk and liability in overseeing so many PAs. They couldn't possibly review every single note and documentation and make adjustments and meet their metrics at the same time. Now my friends are experiencing the same thing at the hospitals they're moved on to.


On the flip side, I've worked with NPs and PAs who are stellar practitioners of medicine in every sense of the word, whom I'd trust with my own life. They make good money, they didn't go through a lot of the bullshit that med school and residency entails, they have a decent home life, and, well, they're just good people. Their secret is the same secret that MDs and DOs must learn: know your limits, know when to ask for help from your colleagues, don't overwork yourself, and try to give a damn all the damn time.


It's a terrible shame that medicine in the US is structured the way it is. I certainly don't have a solution for it. I think PAs and NPs get good training and can be an extremely valuable part of a healthcare team, and know some who can certainly practice some medicine solo. But, like myself (and I'm an MD), none of us can do everything by ourselves. Period. The solution to a healthcare crisis as we're dealing with here is not to poke and prod and push up specific areas of medicine: it's to somehow lift the entire supportive base up. In the face of a couple generations of primary care physicians retiring and the huge void this creates, the relatively lower interest and desire for medical students to go into primary care, and the strangely contradictory claim for healthcare systems' desire to pursue preventive medicine, I am terrified.

I mean, in general. Most days I just try to focus on the day-to-day goal of doing a decent job of either practicing good medicine and being a good person, or maximizing slack, decompressing, and being lazy.
posted by herrdoktor at 11:54 AM on May 27, 2015 [9 favorites]


And here I just wanted to echo what docpops wrote. There's a lot of mistrust of physicians, justified or not, that'd I've encountered here on MetaFilter. But please do try to remember that we're not all bad people, driven toward the goals of Money, Power and Respect.

And we're not all negative about NPs and PAs practicing solo because we fear for our jobs or losing Money, Power or Respect.
posted by herrdoktor at 11:58 AM on May 27, 2015 [7 favorites]


My GP is a small town doctor, he is kind and polite and wouldn't think of talking down to me. He paints pictures of the Apollo moon landing. He's a full on fun nerd, who delights in sharing information. Memorably he gently physically scooted me aside to draw a picture on that weird butcher paper on the exam table to elaborate on how, based on my blood work, our geographical location meant that I should probably take a vitamin D supplement and then got sidetracked talking about Ecuador. We're all in this together.
posted by Divine_Wino at 12:28 PM on May 27, 2015 [1 favorite]


Actually, the AMA/AAMC do restrict the number of residency spots, because the reason the blanket cap exists is because the AMA/AAMC refuses to allow the federal government to make more fine grained decisions on how many of each specialty are granted residencies.

How does this work, exactly? Serious question. How does the AMA or anyone else "refuse to allow" the federal government to grant residency slots in the manner they see fit?
posted by throwaway account at 1:53 PM on May 27, 2015 [1 favorite]




I graduated from med school two weeks ago and will start working for an urban, academic Family Medicine program in June [Thanks, MeFi!].

NPs in the state wish to practce independently, where they are currently required to practice under a collaborative agreement with a physician. In the words of SB 717, the PA agreement mandates "immediate availability of a licensed physician to a certified registered nurse practitioner through direct communications or by radio, telephone or telecommunications." Collaborative agreements represent a legal requirement that the channel be open. The NPs' lobbying group is currently fighting for SB 717, the Modernization of the Professional Nursing Law, which effectively ends that requirement. The Pennsylvania Academy of Family Physicians is lobbying against NP independent practice, arguing that these agreements promote patient safety by serving as a structural resource for when the demands of the case exceed the trained competencies of the NP.

So does it promote patient safety? The American Academy of Family Physicians argues that because NPs get about half the training of a physician they ought not practice independently. Page 11 of their white paper has a pretty good infographic, demonstrating that the average family doc trains for 21,700 hours, compared to roughly 5,400 hours for an NPs. The Nurse Practitioners retort with a review article that despite this disparity, NPs generate similar patient mortality, hospitalization rates, satisfaction, and chronic disease control. Docs point out that NPs order more imaging studies, but the consensus is that there's not much difference in outcomes.

I feel like I should advocate for the docs a little. The extra time I spend in the classroom and clinic is valuable. I spent the last year of medical school learning with and working for docs in hospice and palliative care, child maltreatment, and community medicine, four times more hours spent in direct patient contact than even my best-trained NP colleagues. My residency training lasts three years and will require 60-80h/wk of didactics and patient care in everything from obstetrics and pediatrics to addiction medicine. All this-- before I can take care of a patient without the supervision of a senior physician.

But if the evidence suggests similar outcomes, why do I do all that extra work? It's possible that I've been wasting my time with the extra learning & patient care. My biochemistry professor made us memorize the structures of all the amino acids, and the metabolic order in which carbons got added onto the DNA sugar backbone. Thrilling as that information was, most NP schools don't go into that amount of detail because it's tough to demonstrate its direct relevance to clinical decision-making. This program, for instance, doesn't have a dedicated biochemistry course (or neurology, or anatomy) I've worked with some truly brilliant NPs during med school, and they taught me most of what I know about case management and indigent care. In turn, I'd like to think that I helped some of my NP colleagues understand more about statistics and pathophysiology.

In a supportive setting, collaboration can enrich everyone. Medicine is heading in the direction of an integrated, team-based model where techs, billing specialists, social workers, nurses, doctors, NPs, and PAs all work together in what's called a Patient-Centered Medical Home-- everyone practicing to the fullest extent of their licence but collaborating frequently on tasks like patient education/motivation and care coordination. I think that this arrangement would be the ideal, but there's this health staffing issue:

A HRSA report suggests that by 2020, the primary care provider deficit could be as high as 20,400. NP indpendent practice could decrease that deficit to 6,400. The report reads: "if fully utilized, the percent of primary care services provided by NPs and PAs will grow from 23 percent in 2010 to 28 percent in 2020" with docs' primacy falling from 77% to 72%.

Am I worth the extra expense? Can the world of the future stand to see an NP 5% more often? I don't know. I'm starting in the Emergency Department, where in the words of Shem, "all you've got is the body barreling through the doors. It's all fresh, not preprocessed." I hope I'll know what to do, but I'm truly glad that I'll have a whole team of people to lean on when I feel I'm getting out of my depth.
posted by The White Hat at 4:50 PM on May 27, 2015 [5 favorites]


As someone who has the utmost respect for both the nursing and medical professions, and who works with medical professionals and medical and nursing students at every level, I feel like a lot of my routine medical care can be taken care of by an experienced NP, who can conduct the physical examination and kick something up to an MD on staff if it's out of her pay grade.
posted by Halloween Jack at 8:04 PM on May 27, 2015


Medicine is heading in the direction of an integrated, team-based model where techs, billing specialists, social workers, nurses, doctors, NPs, and PAs all work together

I am super lucky to have good insurance and live in an area where this is an option for me. I go to the Osher Center for Integrative Medicine, where I have seen an Internal Medicine MD, NP, and currently am going weekly to a chiropractor and massage therapist for a back pain issue. They coordinated well with gynecology specialists within the same hospital system when I had an irregular PAP (like, knew and recommended specific doctors by name which was comforting). It's really nice to have most of my care in one place.

Even so, on my last visit I waited over an hour to see my NP, and there was a bit of a hiccup when she ordered x-rays for me; something about the computer system over at the imaging department didn't seem to like not having an MD order them. It got worked out though.

My only other complaint is that my Internal Medicine MD who I considered my PCP left the center to do this Executive Health thing which I gather is where rich people go to pay lots of money to actually get decent, non-rushed care. I got no notice of her leaving, and had been sending the results of the annual wellness tests my company does for our insurance program to her without even realizing I wasn't her patient anymore. That was kind of a bummer.
posted by misskaz at 8:07 AM on May 28, 2015


I'm not sure what this has to do with anything. It's easier to do lots of things than it is to become a lawyer, including things that can lead to misery.

That statement was specifically responding to the implied causal relationship between the limited supply of doctors and their satisfaction/happiness/mental health. The obvious solution to their miseries was said to be a increase in the supply of doctors. The relatively unrestricted supply of attorneys and their relative misery (and substantial unemployment) is pretty good evidence to the contrary. Obviously, no analogy is perfect, but if you really can't see the relevance you're not trying very hard.
posted by internet fraud detective squad, station number 9 at 8:30 AM on May 28, 2015


The focus on clinical hours can be a be misleading. I know and work with a plethora of MDs and NPs and while most of the former went directly from undergrad to med school, most of the latter got licensed as RNs, and then pursued an MSN while working as a nurse. This is doubly true for those nurses I know who are pursuing a DNP or a PhD; all of them have years working as a nurse. The years a NP typically spends working in clinical care outside of program requirements should not be discounted, particularly as the degree requirement for certifying as a NP is currently looking like it will move from a masters level to a doctoral level.

In part, this is why mid-level providers like PAs and NPs are so attractive compared to going for an MD; it scales to the effort and desire of the degree seeker. You can get an RN or other entry-level position which provides clinical care (PA programs typically require something like 1000+ hours of direct patient care), and if that satisfies you, then you can stay at that level. If you want to move into being a direct provider though, you can seek the great scope of practice afforded by being a NP/PA.

Medical degrees, as they are granted in the US currently, do not allow for this modular progression. You go into medical school, and if you graduate, then you go into residency as an MD. It's a highly specialized path for an increasingly highly specialized field, which does not allow for someone to "hang out" in a mid-level provider position for a few years until they are ready and willing to progress. I know a nurse who was an RN for 10+ years who decided to advance her career by becoming a NP. I have no doubt that she was more trained and capable than a 1st year intern, but more importantly, I don't see an equivalent ability to transition between scope of care provided by the current US medical education; you're either in or out.

The modular nature of nursing is even more apparent when you look at the post-nomials. I know a couple of NPs who have so many letters after their names it's like a dictionary threw up. These are earned certification based upon practical experience which is then tested. So a wound care and ostomy nurse (WOC) has specific knowledge of certain physiological and disease processes, while an oncology certified nurse (OCN) may have a very different skillset. This is reflected in their certifications. Someone with an MD after their name may be an endocrinologist, psychiatrist, or oncologist, without much distinction other than the residency they pursued. The MD presumable qualifies them to speak and diagnose in any of those fields, though any legitimate physician would demur if asked to expound outside their specialty.

The point is, we already have a fracturing of medical care into varying sub-disciplines. Yet, we consider the generalist MD degree to be competent in dealing with all of them, despite what any physician would attest to feeling comfortable in dealing with. Primary care, unfortunately, is one of those silo'd specialties, and the most neglected due to the increasing cost and focus of medical schools in turning out physician-scientists who are more and more specialized in a particular area of interest. NPs and PAs have moved into this gap.

I'd love to see medical education in this country become more open. As it is, getting into a medical school and then getting placed in a residency feels like something you need to start training for in the womb. I'd also love to see medical education and licensing recognize that primary care is distinct from more specialized fields like hematology, oncology, infectious disease, etc. The shortage of physicians could be solved today without the growth of NP/PAs if the licensing and scope of practice in the US could recognize a mid-level provider coming out of medical school.

Basically, if it were feasible to get accepted to a medical school and graduate without the herculean efforts and debt it now takes, then go into primary care, we would not be having this debate. The problem is that the current path of medical education basically requires specialization in order to justify the tremendous effort and expense of getting an MD. The boom or bust nature of medical education in the US demands an alternative supply of primary care/mid-level providers like NP/PAs.
posted by Panjandrum at 3:20 PM on May 28, 2015 [4 favorites]


I should have mentioned the age/experience/hours wrinkle in my last comment. It's true, many NPs worked as nurses and other mid-level providers prior to going back to school-- some of them did it for decades. This 2011 survey of Family NPs found that half had worked for more than 20 years.

That's impressive, but such experience is not a hard and fast requirement for an NP license, nor is it a requirement for independent practice in the legislation proposed here in my home state of Pennsylvania. My biggest concern here is that under-resourced or unscrupulous care organizations will hire inexperienced NPs on the cheap and send them to work in underserved areas, effectively creating a two-tier system.

We do not have to work in hypotheticals, though. There is data:

HRSA conducted a workforce survey of around 13,000 NPs back in 2012 (highlights), and I spent some time this afternoon running the data through R. The sample included a cohort of 221 NPs who earned their RNs in 2008 or later, making them the least-experienced NPs in the sample. More than half (55%) worked in a practice setting where a physician was on site at 76-100% of the time to discuss patient problems, but 22% had either limited (<25% availability) or no access to an on-site physician. More than 80% of these NPs were working in urban outpatient clinics.

In a survey of 13,000 NPs, a handful of less-experienced recent grads working without access to a physician does not portend a national threat to patient safety, but it does suggest that care organizations are already putting NPs with comparatively little experience in positions where they are practicing independently at least some of the time.
posted by The White Hat at 3:38 PM on May 29, 2015 [1 favorite]


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