In a fight between nurses and doctors, the nurses are slowly winning
March 18, 2016 12:12 PM Subscribe
Florida and West Virginia have joined the list of states that allow "advanced practice" nurses to practice what have traditionally been physician-only medical procedures, including prescribing drugs. The changes in West Virginia came about largely via an alliance of the AARP, the Koch-funded Americans for Prosperity, and the liberal West Virginia Citizen Action Group..
And Americans For Prosperity, the Koch-funded free markets organization, took up the cause as part of a broader push to wipe out barriers to entry in skilled fields.
Best euphemism for depressing professional wages by deskilling that I've heard in some time. It sounds so progressive and democratic, "wiping out" these "barriers to entry"!
posted by RogerB at 12:18 PM on March 18, 2016 [49 favorites]
Best euphemism for depressing professional wages by deskilling that I've heard in some time. It sounds so progressive and democratic, "wiping out" these "barriers to entry"!
posted by RogerB at 12:18 PM on March 18, 2016 [49 favorites]
Yeah it does appear that with the Kochs involved it means this is about paying people less money for the same work than anything else. Although I do respect nurses and they seem to know what they want and I trust them in general. But combine this with a push to drive down nurse's salaries, and you may end up benefitting huge for profit healthcare companies more than patients or nurses.
posted by cell divide at 12:22 PM on March 18, 2016 [11 favorites]
posted by cell divide at 12:22 PM on March 18, 2016 [11 favorites]
The Koch Brothers support a complex range of issues, including scientific reports that confirm global warming.
From the article in the OP:
posted by filthy light thief at 12:22 PM on March 18, 2016 [19 favorites]
From the article in the OP:
For Beth Baldwin, president of the West Virginia Nurses Association, the measure was aimed at meeting the needs of people who live in rural areas where the nearest physicians might be miles away — especially as the Affordable Care Act has expanded the pool of those with access to insurance.Wiping out barriers may actually benefit people, in that there are skilled professionals in their area who can now provide them more services.
“Who’s going to provide the care for that? If there’s nowhere for them to take the card and get the care, it’s not helpful,” Baldwin says. In some places, when a doctor retires, another has to be brought in on a temporary basis to make sure patients can still get their medications. “We in no way feel that we’ll be replacing physicians," Baldwin says. "But physicians can be focusing on the people they need to see.”
posted by filthy light thief at 12:22 PM on March 18, 2016 [19 favorites]
At doctors who support Team Koch policies but complain about lower-paid professionals taking over their responsibilities (and revenue streams) I can only laugh. (I know a couple.)
posted by Lyme Drop at 12:24 PM on March 18, 2016 [1 favorite]
posted by Lyme Drop at 12:24 PM on March 18, 2016 [1 favorite]
Best euphemism for depressing professional wages by deskilling that I've heard in some time. It sounds so progressive and democratic, "wiping out" these "barriers to entry"!
The problem is that in this specific case, there are genuine barriers to entry that only enable rent seeking, put in place by a politically powerful profession. And those barriers are causing genuine issues with the cost of health care. The reality is that first tier primary medical care doesn't need to be done by a doctor, and those impediments are artificially constraining the pool of primary medical providers.
See also: the war on midwifery.
posted by NoxAeternum at 12:25 PM on March 18, 2016 [83 favorites]
The problem is that in this specific case, there are genuine barriers to entry that only enable rent seeking, put in place by a politically powerful profession. And those barriers are causing genuine issues with the cost of health care. The reality is that first tier primary medical care doesn't need to be done by a doctor, and those impediments are artificially constraining the pool of primary medical providers.
See also: the war on midwifery.
posted by NoxAeternum at 12:25 PM on March 18, 2016 [83 favorites]
This is great! I am sure that this will allow nurses to practice other common procedures like abortion.
There is no way that state legislators would ever hold abortion procedures to a different standard than other medical procedures!
posted by flarbuse at 12:25 PM on March 18, 2016 [42 favorites]
There is no way that state legislators would ever hold abortion procedures to a different standard than other medical procedures!
posted by flarbuse at 12:25 PM on March 18, 2016 [42 favorites]
From personal experiences, I've seen both doctors and nurse practitioners in California and New Mexico when I needed general check-up type stuff for myself and my sons. It's been great, because I've been able to see a trained health professional more quickly thanks to NPs being available, and if they are uncertain about something, they have had doctors to support them.
posted by filthy light thief at 12:26 PM on March 18, 2016 [4 favorites]
posted by filthy light thief at 12:26 PM on March 18, 2016 [4 favorites]
In the United States, compared to many other countries, the number of medications that require a prescription is higher. Furthermore, we have far fewer physicians per capita. Meanwhile, it is not at all clear that our standard of care is any better.
I don't think we will suffer at all if NPs can prescribe birth control pills, prescription-level ibuprofen, and entry-level antibiotics.
We are already at the point where the bulk of a primary care physician's job is to refer the patient to a specialist. If NPs do this, then it relieves part of the burden from primary care docs so they can focus on higher value treatments for other patients.
I also assume that these NPs will be the primary medical staff at places like rural clinics where there simply won't be a nearby MD within easy access to prescribe drugs and make referrals.
posted by deanc at 12:26 PM on March 18, 2016 [12 favorites]
I don't think we will suffer at all if NPs can prescribe birth control pills, prescription-level ibuprofen, and entry-level antibiotics.
We are already at the point where the bulk of a primary care physician's job is to refer the patient to a specialist. If NPs do this, then it relieves part of the burden from primary care docs so they can focus on higher value treatments for other patients.
I also assume that these NPs will be the primary medical staff at places like rural clinics where there simply won't be a nearby MD within easy access to prescribe drugs and make referrals.
posted by deanc at 12:26 PM on March 18, 2016 [12 favorites]
If a nurse or PA prescribes antibiotics after a nasty cut, that's cool with me. If a nurse or PA prescribes orphan drugs after a single office visit, that's not cool.
posted by infinitewindow at 12:27 PM on March 18, 2016 [2 favorites]
posted by infinitewindow at 12:27 PM on March 18, 2016 [2 favorites]
I'm for this especially in the field of mental health care. There's a global shortage of psychiatrists, which disproportionately affects low income folks. For instance, in my region, there's only one who takes medicaid. She has a waitlist a mile long. I'm thrilled by the prospect of people who need care receiving it.
posted by batbat at 12:31 PM on March 18, 2016 [7 favorites]
posted by batbat at 12:31 PM on March 18, 2016 [7 favorites]
One issue that occurs to me - if nurses are responsible for primary care decisions, they are the ones liable for malpractice. Nurses aren't really paid enough for the sort of insurance that would require (they have malpractice insurance now, but it's still mostly optional and I'm sure it will cost much more when they make primary care decisions).
posted by Mitrovarr at 12:32 PM on March 18, 2016 [4 favorites]
posted by Mitrovarr at 12:32 PM on March 18, 2016 [4 favorites]
Although the aim might be to depress doctors' wages, I think they're probably the one demographic out there whose wages ought to be depressed. I would stipulate that they should also receive a commensurate decrease in the cost of their education. Perhaps that would bring down the cost of care, allow more people to be doctors, and get rid of the uncaring folks with dollar signs in their eyes.
posted by constantinescharity at 12:34 PM on March 18, 2016 [18 favorites]
posted by constantinescharity at 12:34 PM on March 18, 2016 [18 favorites]
On one hand, good deal - more primary care providers, more care provided. On the other hand, the smells to me like separating rich people care from poor people care, especially given its supporters.
posted by Mooski at 12:35 PM on March 18, 2016 [4 favorites]
posted by Mooski at 12:35 PM on March 18, 2016 [4 favorites]
See also: the war on midwifery.
That might be related to the fact that the midwife advocacy groups have been caught time and again fudging the numbers on how many women have birth complications, including child and mother mortality figures.
That might also be related to the fact that midwife credentials vary widely, and are almost always considered sub-par for the task they're being asked to perform, and you shouldn't want a midwife who you can't verify to have had adequate training.
I'm not sure you can compare that to professional nursing at the Masters and Doctorate levels (in most cases, what's being discussed -- for being able to prescribe meds and run your own business without contract to a physician -- is only Doctorate).
posted by mystyk at 12:36 PM on March 18, 2016 [12 favorites]
That might be related to the fact that the midwife advocacy groups have been caught time and again fudging the numbers on how many women have birth complications, including child and mother mortality figures.
That might also be related to the fact that midwife credentials vary widely, and are almost always considered sub-par for the task they're being asked to perform, and you shouldn't want a midwife who you can't verify to have had adequate training.
I'm not sure you can compare that to professional nursing at the Masters and Doctorate levels (in most cases, what's being discussed -- for being able to prescribe meds and run your own business without contract to a physician -- is only Doctorate).
posted by mystyk at 12:36 PM on March 18, 2016 [12 favorites]
That might be related to the fact that the midwife advocacy groups have been caught time and again fudging the numbers on how many women have birth complications, including child and mother mortality figures.
Source?
posted by brevator at 12:39 PM on March 18, 2016 [3 favorites]
Source?
posted by brevator at 12:39 PM on March 18, 2016 [3 favorites]
I explicitly seek out the nurse practitioner at my doctor because she's kind and helpful and much better at explaining what's going on than the very well qualified doctor who basically just tells me to stop being fat whenever I see him.
posted by Bulgaroktonos at 12:40 PM on March 18, 2016 [20 favorites]
posted by Bulgaroktonos at 12:40 PM on March 18, 2016 [20 favorites]
There is a deliberately engineered Dr's shortage in the US, and worse, the shortage means most full MD's are pushing to go into a lucrative specialty rather than deal with being an overworked and underpaid (relatively) GP.
PA's and RN's still make good money, and with modern systems and training can be trusted to make routine health decisions - think of this as an expanded and empowered triage system, where the cases requiring more skilled care are remanded to the GP or appropriate specialist by a knowledgeable Nurse/PA.
I'm for it, as it will expand healthcare, improve a patient's access to competent and attentive healthcare, and increase the demand for well-paid licensed and trained Nurses and PA's.
The Koch's are looking after their bottom line, absolutely, but look at this as more of a broken clock being right twice a day rather than a reason to resist this.
posted by Slap*Happy at 12:41 PM on March 18, 2016 [17 favorites]
PA's and RN's still make good money, and with modern systems and training can be trusted to make routine health decisions - think of this as an expanded and empowered triage system, where the cases requiring more skilled care are remanded to the GP or appropriate specialist by a knowledgeable Nurse/PA.
I'm for it, as it will expand healthcare, improve a patient's access to competent and attentive healthcare, and increase the demand for well-paid licensed and trained Nurses and PA's.
The Koch's are looking after their bottom line, absolutely, but look at this as more of a broken clock being right twice a day rather than a reason to resist this.
posted by Slap*Happy at 12:41 PM on March 18, 2016 [17 favorites]
Although the aim might be to depress doctors' wages, I think they're probably the one demographic out there whose wages ought to be depressed.
Really? A profession with long educational requirements, that works crazy hours, has immense responsibility, requires continuing education, and is extremely stressful? Frankly, if anyone in the entire world is allowed to be rich, it should be doctors.
posted by Mitrovarr at 12:42 PM on March 18, 2016 [27 favorites]
Really? A profession with long educational requirements, that works crazy hours, has immense responsibility, requires continuing education, and is extremely stressful? Frankly, if anyone in the entire world is allowed to be rich, it should be doctors.
posted by Mitrovarr at 12:42 PM on March 18, 2016 [27 favorites]
"Of course, the physicians weren’t happy either. The local chapter of the AMA had maintained that West Virginia doesn’t have a serious doctor shortage, and that nurses need to be supervised to prevent them from over-prescribing medications. "
And this is why this is going to continue to happen. The AMA believes that it doesn't have to reform anything about the way we train and place doctors in order to serve areas like West Virginia, or Western Kansas, that are woefully underserved. Someone has to serve these places, and it has to be done for a reasonable amount of money.
I've had procedures done on me by PA's twice in the past year. The first time I wasn't even seen by a doctor until after the procedure started, the second time the doctor came in for less than 60 seconds, then explained how to do the procedure to the PA for about 2 more minutes because this was the PA's first time ever draining an abscess apparently. In addition, the first time the procedure should not have happened, it was a misdiagnosis of the problem (according to the surgeon who looked at it on follow-up several days later). We have already created a system where normal people don't receive quality care from the doctors who are supposedly overseeing these nurses and PAs. Laws like this aren't doing anything to fix that problem, but they are at least acknowledging it and opening the door for the cost to reflect the service we are actually getting.
Would be nice to have better medical care available though.
posted by teh_boy at 12:42 PM on March 18, 2016 [1 favorite]
And this is why this is going to continue to happen. The AMA believes that it doesn't have to reform anything about the way we train and place doctors in order to serve areas like West Virginia, or Western Kansas, that are woefully underserved. Someone has to serve these places, and it has to be done for a reasonable amount of money.
I've had procedures done on me by PA's twice in the past year. The first time I wasn't even seen by a doctor until after the procedure started, the second time the doctor came in for less than 60 seconds, then explained how to do the procedure to the PA for about 2 more minutes because this was the PA's first time ever draining an abscess apparently. In addition, the first time the procedure should not have happened, it was a misdiagnosis of the problem (according to the surgeon who looked at it on follow-up several days later). We have already created a system where normal people don't receive quality care from the doctors who are supposedly overseeing these nurses and PAs. Laws like this aren't doing anything to fix that problem, but they are at least acknowledging it and opening the door for the cost to reflect the service we are actually getting.
Would be nice to have better medical care available though.
posted by teh_boy at 12:42 PM on March 18, 2016 [1 favorite]
The fact is MDs' salaries are not driving the US's insane cost of care (what is? administrative costs!), but please, do go on with the awful divisive crab-bucket labor politics about whose wages "ought to be" depressed. We don't hear enough of that already in America.
posted by RogerB at 12:47 PM on March 18, 2016 [59 favorites]
posted by RogerB at 12:47 PM on March 18, 2016 [59 favorites]
Maybe the idea is to get Americans used to a lower standard of medical care
NPs do not deliver sub-standard care. Multiple studies have found parity in this regard. Note that many of the states shown to have expanded scope of practice for NPs are those which are heavily rural, precisely the kind of places where physicians can be thin on the ground.
Really, the AMA itself has to shoulder a lot of the blame for the growth of mid-level providers like NPs and PAs. They've been slow to ratchet up funding and slots for medical education/residencies in order to get more MDs trained. Add in the fact that getting an MD means about a decade of graduate and post-graduate training (after grueling through undergrad to get the scores and GPA to even get accepted), and its a huge commitment. Then when you throw on the guaranteed 6 figure student loan debt of medical school, it becomes an even greater commitment, and one which has seen an increasing number of MDs head for higher paying specialties to justify enormous cost in both money and time.
All of this means that becoming a primary care, generalist, "country/family" doctor has become a less appealing prospect. Instead, med school grads are headed towards being highly trained and specialized physician-scientists. That thinning of basic primary care is where NPs and PAs have moved in to fill the gap.
posted by Panjandrum at 12:48 PM on March 18, 2016 [29 favorites]
NPs do not deliver sub-standard care. Multiple studies have found parity in this regard. Note that many of the states shown to have expanded scope of practice for NPs are those which are heavily rural, precisely the kind of places where physicians can be thin on the ground.
Really, the AMA itself has to shoulder a lot of the blame for the growth of mid-level providers like NPs and PAs. They've been slow to ratchet up funding and slots for medical education/residencies in order to get more MDs trained. Add in the fact that getting an MD means about a decade of graduate and post-graduate training (after grueling through undergrad to get the scores and GPA to even get accepted), and its a huge commitment. Then when you throw on the guaranteed 6 figure student loan debt of medical school, it becomes an even greater commitment, and one which has seen an increasing number of MDs head for higher paying specialties to justify enormous cost in both money and time.
All of this means that becoming a primary care, generalist, "country/family" doctor has become a less appealing prospect. Instead, med school grads are headed towards being highly trained and specialized physician-scientists. That thinning of basic primary care is where NPs and PAs have moved in to fill the gap.
posted by Panjandrum at 12:48 PM on March 18, 2016 [29 favorites]
RogerB: "The fact is MDs' salaries are not driving the US's insane cost of care (what is? administrative costs!), but please, do go on with the awful divisive crab-bucket labor politics about whose wages "ought to be" depressed. We don't hear enough of that already in America."
Sure, administrative costs are crazy, but US doctors are overpaid compared to their international counterparts.
posted by crazy with stars at 12:52 PM on March 18, 2016 [4 favorites]
Sure, administrative costs are crazy, but US doctors are overpaid compared to their international counterparts.
posted by crazy with stars at 12:52 PM on March 18, 2016 [4 favorites]
I've had a few doctors throughout my life and I've never really felt like any of them gave a damn about me. My latest left his office to join a new practice where you have to pay an extra $1000 a year on top of other costs. I said screw that and one of the nurse practitioners helped me. She was great. The second time I came in I was told that I could have her be my primary care physician, I said yes, and suddenly I knew what it felt like to have a physician actually help care for you. She prescribes medicine if I need it, refers me to specialists if necessary and gives great advice for taking care of myself.
So I don't know about the economic effects of this, but I'm all for having a NPs as primary care physicians.
posted by charred husk at 12:52 PM on March 18, 2016 [6 favorites]
So I don't know about the economic effects of this, but I'm all for having a NPs as primary care physicians.
posted by charred husk at 12:52 PM on March 18, 2016 [6 favorites]
The Koch Brothers support a complex range of issues, including scientific reports that confirm global warming.
Not to derail, but until the Koch brothers spend a butt load of money trying to educate people about the reality of climate change, then their balance is still on the deniers, side
posted by CheeseDigestsAll at 12:53 PM on March 18, 2016 [5 favorites]
Not to derail, but until the Koch brothers spend a butt load of money trying to educate people about the reality of climate change, then their balance is still on the deniers, side
posted by CheeseDigestsAll at 12:53 PM on March 18, 2016 [5 favorites]
The fact is MDs' salaries are not driving the US's insane cost of care (what is? administrative costs!)
The article you linked doesn't actually show this, just that the highest paid staff at most hospitals is administrative. Its the same as saying the cost of college has gone up due to football coach salaries because they're the highest paid staff at many colleges. Football coaches, and hospital CEOs could work for free and there would not be a huge decrease in healthcare costs, because there just aren't that many of them.
Having a the highest maximum value for a group be in a certain subgroup does not mean that subgroup makes up a large part of the group's total.
posted by hermanubis at 12:55 PM on March 18, 2016 [10 favorites]
The article you linked doesn't actually show this, just that the highest paid staff at most hospitals is administrative. Its the same as saying the cost of college has gone up due to football coach salaries because they're the highest paid staff at many colleges. Football coaches, and hospital CEOs could work for free and there would not be a huge decrease in healthcare costs, because there just aren't that many of them.
Having a the highest maximum value for a group be in a certain subgroup does not mean that subgroup makes up a large part of the group's total.
posted by hermanubis at 12:55 PM on March 18, 2016 [10 favorites]
the smells to me like separating rich people care from poor people care, especially given its supporters.
If there's one thing I have realized, it's that people make decisions on matters other than the bottom line. A rich person probably would want to pay the premium to see an MD when he has a cold, and will also pay extra to visit the doctor who has a fancy office. Someone else might prefer the provider who is nice to them and spends time "listening," even if the outcome from the terse Doctor is pretty much the same.
The important issue is not whether the rich get something different than the poor. The important issue is that the poor can get good care. A new Lexus is nice, but it will get you to work in the same amount of time as a used Camry.
posted by deanc at 12:57 PM on March 18, 2016 [8 favorites]
If there's one thing I have realized, it's that people make decisions on matters other than the bottom line. A rich person probably would want to pay the premium to see an MD when he has a cold, and will also pay extra to visit the doctor who has a fancy office. Someone else might prefer the provider who is nice to them and spends time "listening," even if the outcome from the terse Doctor is pretty much the same.
The important issue is not whether the rich get something different than the poor. The important issue is that the poor can get good care. A new Lexus is nice, but it will get you to work in the same amount of time as a used Camry.
posted by deanc at 12:57 PM on March 18, 2016 [8 favorites]
midwife credentials vary widely
Keep in mind that a Certified Nurse Midwife (CNM) is different from anyone else who might be calling themselves a midwife. A CNM is a specific kind of advanced practice registered nurse requiring a masters degree or higher, specialized education and training, and state licensure that requires continuing education and periodic recertification for that license.
posted by Panjandrum at 12:57 PM on March 18, 2016 [22 favorites]
Keep in mind that a Certified Nurse Midwife (CNM) is different from anyone else who might be calling themselves a midwife. A CNM is a specific kind of advanced practice registered nurse requiring a masters degree or higher, specialized education and training, and state licensure that requires continuing education and periodic recertification for that license.
posted by Panjandrum at 12:57 PM on March 18, 2016 [22 favorites]
Something like 89% of sick-child visits are six common ailments, frequently which the patent has already accurately identified and which a nurse-practitioner can rule in or out in a matter of minutes. That frees up preditricians for well-child developmental visits and the confusing 20%, rather than having to look at an obviously infected ear on a six-year-old who's had a dozen prior ear infections. Everywhere I've been, NPs work within guidelines that are very strict about when they have to hand off.
"but with those forces behind it, I can't imagine it actually is. "
Even a broken clock is right twice a day.
posted by Eyebrows McGee at 1:01 PM on March 18, 2016 [13 favorites]
"but with those forces behind it, I can't imagine it actually is. "
Even a broken clock is right twice a day.
posted by Eyebrows McGee at 1:01 PM on March 18, 2016 [13 favorites]
broken Kloch, surely
posted by prize bull octorok at 1:05 PM on March 18, 2016 [23 favorites]
posted by prize bull octorok at 1:05 PM on March 18, 2016 [23 favorites]
I'm not sure how this separates care by income. Most doctors (at least in my area) are in group practices and most practices have PAs and NPs. My mother's oncologist has a fantastic NP who also has her doctorate in nursing, she's the one that does the bone marrow biopsies. His PA makes rounds every day, so my mom was seen by both of them every day when she was in the hospital. My GP is fantastic, but his NP is also great and we can almost always get in to see her for a last minute/same day appt. Usually health insurance covers the entire practice, not just one particular doctor-so it doesn't matter how much money you have when you make the appt. There's no sorting being done like having the NP only see Medicaid and self pay patients.
posted by hollygoheavy at 1:06 PM on March 18, 2016 [1 favorite]
posted by hollygoheavy at 1:06 PM on March 18, 2016 [1 favorite]
The local chapter of the AMA had maintained that West Virginia doesn’t have a serious doctor shortage, and that nurses need to be supervised...
WV may not have a doctor shortage - but it sure does have a distribution problem. Not all WV residents live in or even near the cities. Some rural residents have to drive three hours to get to a medical facility. I see NPs as an excellent solution.
posted by Gyre,Gimble,Wabe, Esq. at 1:12 PM on March 18, 2016 [4 favorites]
WV may not have a doctor shortage - but it sure does have a distribution problem. Not all WV residents live in or even near the cities. Some rural residents have to drive three hours to get to a medical facility. I see NPs as an excellent solution.
posted by Gyre,Gimble,Wabe, Esq. at 1:12 PM on March 18, 2016 [4 favorites]
One issue that occurs to me - if nurses are responsible for primary care decisions, they are the ones liable for malpractice. Nurses aren't really paid enough for the sort of insurance that would require (they have malpractice insurance now, but it's still mostly optional and I'm sure it will cost much more when they make primary care decisions).
My uneducated guess is that a middle-tier malpractice insurance would emerge that would be more expensive than it is now but less expensive than a doctor's, because the set of permitted medications/practices would be much more tightly controlled.
posted by en forme de poire at 1:14 PM on March 18, 2016 [2 favorites]
My uneducated guess is that a middle-tier malpractice insurance would emerge that would be more expensive than it is now but less expensive than a doctor's, because the set of permitted medications/practices would be much more tightly controlled.
posted by en forme de poire at 1:14 PM on March 18, 2016 [2 favorites]
"Liberals for Koch: This right-wing clock isn't broken twice a day"
posted by RogerB at 1:19 PM on March 18, 2016
posted by RogerB at 1:19 PM on March 18, 2016
My doc started using NPs several years ago, and it's been great. I see her for minor issues, and save the serious problems for my doc. Frankly, there can't be too many trained medical practitioners in the world.
posted by Thorzdad at 1:21 PM on March 18, 2016 [4 favorites]
posted by Thorzdad at 1:21 PM on March 18, 2016 [4 favorites]
I've been seeing an NP for my semi-annual checkup, and she's fine. I have a few chronic medical conditions that are well-managed, and I don't need to take up a doctor's time to have someone look at my latest bloodwork and tell me that my Metformin dosage can stay just where it has been for some time.
posted by Halloween Jack at 1:23 PM on March 18, 2016 [4 favorites]
posted by Halloween Jack at 1:23 PM on March 18, 2016 [4 favorites]
My uneducated guess is that a middle-tier malpractice insurance would emerge that would be more expensive than it is now but less expensive than a doctor's, because the set of permitted medications/practices would be much more tightly controlled.
I would imagine that nurses wouldn't be opposed to the sorts of reforms that would reduce malpractice incidences, such as crackdowns on repeated offenders, that doctors fight tooth and nail.
posted by NoxAeternum at 1:25 PM on March 18, 2016 [1 favorite]
I would imagine that nurses wouldn't be opposed to the sorts of reforms that would reduce malpractice incidences, such as crackdowns on repeated offenders, that doctors fight tooth and nail.
posted by NoxAeternum at 1:25 PM on March 18, 2016 [1 favorite]
I work with a lot of NPs and don't really have a problem with this. Let's see what happens. I predict market forces will continue to be the de facto arbiter of quality.
posted by fraxil at 1:29 PM on March 18, 2016
posted by fraxil at 1:29 PM on March 18, 2016
Please note that this article and thread are confusing the totally not-interchangeable terms of nurse and nurse practitioner.
posted by Dashy at 1:31 PM on March 18, 2016 [20 favorites]
posted by Dashy at 1:31 PM on March 18, 2016 [20 favorites]
"but with those forces behind it, I can't imagine it actually is. "
Even a broken clock is right twice a day.
And people can support worthy goals because they view them as being useful for advancing other less awesome ideas. Some of my income in recent years probably has Koch-stink on it, but it was all earned for working on government transparency projects. Stuff I did helped get data into Sunrise Foundation tools and Wikipedia reports as well as other transparency groups. I imagine some of the motivation for that was a belief that if people hear about specific spending it'll be easier to convince them to oppose it, and I am positive that I had a different opinion about some of that illuminated spending than they did.
But I'm still a huge proponent of transparency and FOIA. Hitler liked dogs. Nothing wrong with questioning whether something is as good as you thought, once you discover someone/thing you loathe loves it. But just like most DNA is shared across every living creature, icky groups sometimes like good things too.
posted by phearlez at 1:33 PM on March 18, 2016 [5 favorites]
Even a broken clock is right twice a day.
And people can support worthy goals because they view them as being useful for advancing other less awesome ideas. Some of my income in recent years probably has Koch-stink on it, but it was all earned for working on government transparency projects. Stuff I did helped get data into Sunrise Foundation tools and Wikipedia reports as well as other transparency groups. I imagine some of the motivation for that was a belief that if people hear about specific spending it'll be easier to convince them to oppose it, and I am positive that I had a different opinion about some of that illuminated spending than they did.
But I'm still a huge proponent of transparency and FOIA. Hitler liked dogs. Nothing wrong with questioning whether something is as good as you thought, once you discover someone/thing you loathe loves it. But just like most DNA is shared across every living creature, icky groups sometimes like good things too.
posted by phearlez at 1:33 PM on March 18, 2016 [5 favorites]
Maybe the idea is to get Americans used to a lower standard of medical care, or something.
I'm pretty sure the idea is just that if we take a bunch of the responsibilities of a job title held mostly by men and shove them onto job titles overwhelmingly held by women, we can pay them a lot less for doing the same thing because fuck women.
posted by ROU_Xenophobe at 1:43 PM on March 18, 2016 [12 favorites]
I'm pretty sure the idea is just that if we take a bunch of the responsibilities of a job title held mostly by men and shove them onto job titles overwhelmingly held by women, we can pay them a lot less for doing the same thing because fuck women.
posted by ROU_Xenophobe at 1:43 PM on March 18, 2016 [12 favorites]
The NPs I work with are amazing. I would send psychiatric referrals their way in a heartbeat.
posted by Jernau at 1:46 PM on March 18, 2016
posted by Jernau at 1:46 PM on March 18, 2016
Someone else might prefer the provider who is nice to them and spends time "listening," even if the outcome from the terse Doctor is pretty much the same.
I don't really think it should be considered a luxury to have a doctor who spends time "listening" to me if I am talking about things affecting my health. It's not just about being terse, it's about patients being ignored or interrupted when providing information about how their bodies are functioning.
I'm a (fat bipolar) woman, so in fact it IS a luxury to have a doctor take me seriously and I also go to Nurse Practioners when possible, but I don't think that having someone treat you with kindness when you are feeling scared and vulnerable and don't have the experience or training they do should be out of reach of people who have to be aware of how much things cost. We shouldn't restrict access to healthcare professionals who listen (a bit part of making an appropriate diagnosis!) to people with a lot of money.
posted by Mrs. Pterodactyl at 1:51 PM on March 18, 2016 [10 favorites]
I don't really think it should be considered a luxury to have a doctor who spends time "listening" to me if I am talking about things affecting my health. It's not just about being terse, it's about patients being ignored or interrupted when providing information about how their bodies are functioning.
I'm a (fat bipolar) woman, so in fact it IS a luxury to have a doctor take me seriously and I also go to Nurse Practioners when possible, but I don't think that having someone treat you with kindness when you are feeling scared and vulnerable and don't have the experience or training they do should be out of reach of people who have to be aware of how much things cost. We shouldn't restrict access to healthcare professionals who listen (a bit part of making an appropriate diagnosis!) to people with a lot of money.
posted by Mrs. Pterodactyl at 1:51 PM on March 18, 2016 [10 favorites]
Butting in without reading all the prior comments, but I feel the point needs to be made (or repeated, in which case, apologies):
Nursing is a graduate entry profession these days, with rather more education and training than MDs got prior to the 1950s.
Meanwhile, medicine is balkanizing into a host of over-specialized vertical silos.
The Nurse-Practitioner thing is happening in the UK as well (American exceptionalism does not apply: nor is it the Koch brothers twirling their evil villain mustachios) and it's filling a pretty important need for front-line medical auxilliaries. Meanwhile, general practitioners are turning into glorified triage nurses: diagnose and treat the easy cases, refer the rest.
posted by cstross at 1:56 PM on March 18, 2016 [27 favorites]
Nursing is a graduate entry profession these days, with rather more education and training than MDs got prior to the 1950s.
Meanwhile, medicine is balkanizing into a host of over-specialized vertical silos.
The Nurse-Practitioner thing is happening in the UK as well (American exceptionalism does not apply: nor is it the Koch brothers twirling their evil villain mustachios) and it's filling a pretty important need for front-line medical auxilliaries. Meanwhile, general practitioners are turning into glorified triage nurses: diagnose and treat the easy cases, refer the rest.
posted by cstross at 1:56 PM on March 18, 2016 [27 favorites]
Sure, administrative costs are crazy, but US doctors are overpaid compared to their international counterparts.
Maybe so, but how many hundreds of thousands of dollars' worth of student loan debt (and debts racked up while underpaid during residency and fellowship(s)) do their international counterparts usually accrue?
I imagine that cutting physicians' salaries without doing anything to fix the costs of their education will only further reduce the already limited number of physicians who can carry out procedures. It doesn't seem like cutting administrative costs would have the same downside.
posted by cobra_high_tigers at 2:19 PM on March 18, 2016 [9 favorites]
Maybe so, but how many hundreds of thousands of dollars' worth of student loan debt (and debts racked up while underpaid during residency and fellowship(s)) do their international counterparts usually accrue?
I imagine that cutting physicians' salaries without doing anything to fix the costs of their education will only further reduce the already limited number of physicians who can carry out procedures. It doesn't seem like cutting administrative costs would have the same downside.
posted by cobra_high_tigers at 2:19 PM on March 18, 2016 [9 favorites]
Practically speaking: 75 million in the US will be over 65 years of age by 2035. That group will consume the majority of healthcare for the 30 years after that.
Many doctors are in that cohort, and given their relative wealth, many will retire. The number of younger health practitioners capable of patient contact needs to go up, and go up rapidly.
Given the apparent foot dragging by the accrediting bodies and residency organizations, the tendency towards specialization, and the general increase in medical costs, someone is going to be needed. We're running out of options.
posted by underflow at 2:27 PM on March 18, 2016 [9 favorites]
Many doctors are in that cohort, and given their relative wealth, many will retire. The number of younger health practitioners capable of patient contact needs to go up, and go up rapidly.
Given the apparent foot dragging by the accrediting bodies and residency organizations, the tendency towards specialization, and the general increase in medical costs, someone is going to be needed. We're running out of options.
posted by underflow at 2:27 PM on March 18, 2016 [9 favorites]
Maybe so, but how many hundreds of thousands of dollars' worth of student loan debt (and debts racked up while underpaid during residency and fellowship(s)) do their international counterparts usually accrue?
I imagine that cutting physicians' salaries without doing anything to fix the costs of their education will only further reduce the already limited number of physicians who can carry out procedures. It doesn't seem like cutting administrative costs would have the same downside.
Both have to be dealt with in the long run to manage health care costs. Also, it's worth noting that the pool of senior doctors and administrators has significant overlap - this was a key point in Gawande's piece about health care costs from a few years back.
posted by NoxAeternum at 2:28 PM on March 18, 2016 [3 favorites]
I imagine that cutting physicians' salaries without doing anything to fix the costs of their education will only further reduce the already limited number of physicians who can carry out procedures. It doesn't seem like cutting administrative costs would have the same downside.
Both have to be dealt with in the long run to manage health care costs. Also, it's worth noting that the pool of senior doctors and administrators has significant overlap - this was a key point in Gawande's piece about health care costs from a few years back.
posted by NoxAeternum at 2:28 PM on March 18, 2016 [3 favorites]
I may be off on this--I often am--but I just had a para legal do a task for me and I will be billed at a law firm's charge; an NP at my general doctor's office does the job and I get charged at a doctor's fee; my dentist now has an assistant, the guy who cleans teeth, now inject the pain killer before the dentist does the work--all these tasks make it easier and more efficient for the work to be done but in each case I pay for what the office charges, and that is based on a fee that is no less because the work done by an assistant of some sort.
posted by Postroad at 2:32 PM on March 18, 2016 [9 favorites]
posted by Postroad at 2:32 PM on March 18, 2016 [9 favorites]
I had a doctor I loved working with. She literally saved my life.
When she moved out of state, her patients were taken over by two NPs. One is far more competent than the other, but I have had actual MDs provide far worse care than either of them. I live in a very rural area and the practice they work in cares for many very poor patients. They have been actively seeking another doctor to work their for years, but it is hard to find doctors willing to work so far from a major city for so little money. If it weren't for these NPs, a lot of people wouldn't be getting care.
The care they provide is fairly basic. They prescribe antibiotics for people with infections and give tamiflu to people with the flu. They provide vaccinations and help people manage diabetes and high blood pressure. They do basic wound care. Anything out of the ordinary or a sudden change in condition generally gets referred to a specialist, but 95% of visits involve them giving the care any RN could give, but without having doctor sit there to tell them to do it. And that care would vanish for better than half their patients if these ladies weren't there to provide it.
posted by pattern juggler at 2:36 PM on March 18, 2016 [6 favorites]
When she moved out of state, her patients were taken over by two NPs. One is far more competent than the other, but I have had actual MDs provide far worse care than either of them. I live in a very rural area and the practice they work in cares for many very poor patients. They have been actively seeking another doctor to work their for years, but it is hard to find doctors willing to work so far from a major city for so little money. If it weren't for these NPs, a lot of people wouldn't be getting care.
The care they provide is fairly basic. They prescribe antibiotics for people with infections and give tamiflu to people with the flu. They provide vaccinations and help people manage diabetes and high blood pressure. They do basic wound care. Anything out of the ordinary or a sudden change in condition generally gets referred to a specialist, but 95% of visits involve them giving the care any RN could give, but without having doctor sit there to tell them to do it. And that care would vanish for better than half their patients if these ladies weren't there to provide it.
posted by pattern juggler at 2:36 PM on March 18, 2016 [6 favorites]
This is giving me echos of the whole Rick Perry pushing Gardasil thing.
Yes, this is probably good for patients in a lot of ways. But the folks behind it make me worry that some ulterior motive is being served.
In the Gardasil case, it was just Rick Perry lining his pockets - a price that might be reasonable to pay to lower the prevalence of cervical cancer. I'm skeptical of this because I don't know for sure what's in it for the Koch brothers yet.
posted by sparklemotion at 2:50 PM on March 18, 2016 [1 favorite]
Yes, this is probably good for patients in a lot of ways. But the folks behind it make me worry that some ulterior motive is being served.
In the Gardasil case, it was just Rick Perry lining his pockets - a price that might be reasonable to pay to lower the prevalence of cervical cancer. I'm skeptical of this because I don't know for sure what's in it for the Koch brothers yet.
posted by sparklemotion at 2:50 PM on March 18, 2016 [1 favorite]
Really if you have children with their routine childhood ailments like ear infections and strep throat, NPs are very helpful. Waiting six hours to see the regular pediatrician, or having to go to urgent care after hours, is a big hassle. Being able to get in with a pediatric NP is great. (My pediatrics practice has an NP who basically takes within-the-hour sick-child visits, and participate in a shared after-hours staffed primarily with NPs supervised by a doctor, cutting the need for urgent care or overnight ER visits WAY DOWN.) Mostly they just need a strep test or an ear-look and then antibiotics. Or to give parents the care instructions for croup or viral coughs or whatever. A lot of our (general our) medical needs are pretty basic, but the necessary care is restricted to doctors and -- yeah -- GPs are way oversubscribed because there aren't enough of them. I've actually wondered if the medical profession was eventually going to introduce a short-entry doctor credential for doctors who could be certified only for general practice and had to work in a supervised setting, because SO MUCH of what GPs do are the same basic diagnoses over and over, and the same basic care over and over. NPs are pretty much that same thing.
I already get a lot of my primary care from a certified nurse midwife in an ob/gyn practice of both Ob/gyns and CNMs. (My state does not allow midwives to attend home deliveries and has among the higher certification requirements.) Routine (non-pregnancy) pelvic exams and a lot of the routine pregnancy check-ups are handled by midwives, and I like mine. When they find something weird, or there's a pregnancy complication, you get seamlessly handed off to the Ob/gyns. I like the model a lot. When you're healthy you get lower-key (and less-expensive) care; the instant there's a problem they have the ob in the room with the midwife you've been seeing all along, and there's no stress or hassle of switching practices or chasing medical records -- you're just suddenly with the specialist, with your well-care practitioner in the room too.
"Something like 89% of sick-child visits"
That was meant to be 80%, 89% is weirdly specific for a remembered guesstimate figure. Fat fingered.
"broken Kloch, surely"
NOICE.
posted by Eyebrows McGee at 2:55 PM on March 18, 2016 [5 favorites]
I already get a lot of my primary care from a certified nurse midwife in an ob/gyn practice of both Ob/gyns and CNMs. (My state does not allow midwives to attend home deliveries and has among the higher certification requirements.) Routine (non-pregnancy) pelvic exams and a lot of the routine pregnancy check-ups are handled by midwives, and I like mine. When they find something weird, or there's a pregnancy complication, you get seamlessly handed off to the Ob/gyns. I like the model a lot. When you're healthy you get lower-key (and less-expensive) care; the instant there's a problem they have the ob in the room with the midwife you've been seeing all along, and there's no stress or hassle of switching practices or chasing medical records -- you're just suddenly with the specialist, with your well-care practitioner in the room too.
"Something like 89% of sick-child visits"
That was meant to be 80%, 89% is weirdly specific for a remembered guesstimate figure. Fat fingered.
"broken Kloch, surely"
NOICE.
posted by Eyebrows McGee at 2:55 PM on March 18, 2016 [5 favorites]
The idea that anything the Kochs' support is bad reminds me of the tribalism of the right: romneycare good, Obamacare bad, etc.
posted by mikek at 2:56 PM on March 18, 2016 [8 favorites]
posted by mikek at 2:56 PM on March 18, 2016 [8 favorites]
A profession with long educational requirements, that works crazy hours, has immense responsibility, requires continuing education, and is extremely stressful?
That describes most professionals.
posted by jpe at 3:01 PM on March 18, 2016 [4 favorites]
That describes most professionals.
posted by jpe at 3:01 PM on March 18, 2016 [4 favorites]
Right in before they put in opioid prescription limits on doctors. Good timing.
posted by destro at 3:04 PM on March 18, 2016 [1 favorite]
posted by destro at 3:04 PM on March 18, 2016 [1 favorite]
We are already at the point where the bulk of a primary care physician's job is to refer the patient to a specialist.
Depends. In the suburbs of a large city you often run into patients demanding a specialist for routine issues, and thus can be more of a referrals specialist. Outside of that most of the people you see will generally want very much to not waste time with another practitioner and ask that you solve whatever is going on. So as others have pointed out, there's no way in hell we will manage the demand for primary care without advanced nursing options or PA's staffing community health clinics.
posted by docpops at 3:18 PM on March 18, 2016 [1 favorite]
Depends. In the suburbs of a large city you often run into patients demanding a specialist for routine issues, and thus can be more of a referrals specialist. Outside of that most of the people you see will generally want very much to not waste time with another practitioner and ask that you solve whatever is going on. So as others have pointed out, there's no way in hell we will manage the demand for primary care without advanced nursing options or PA's staffing community health clinics.
posted by docpops at 3:18 PM on March 18, 2016 [1 favorite]
A profession with long educational requirements, that works crazy hours, has immense responsibility, requires continuing education, and is extremely stressful?
That describes most professionals.
posted by jpe at 3:01 PM on March 18 [+] [!]
Name me a couple, outside of piloting commercial aircraft. Again, something comparable to 4 years of post-grad medical training, minimum 3-7 years of residency, and with the unpredictable demands of time and human behavior coupled with the threat and risk of harm to human health and risk to personal livelihood.
posted by docpops at 3:21 PM on March 18, 2016 [5 favorites]
That describes most professionals.
posted by jpe at 3:01 PM on March 18 [+] [!]
Name me a couple, outside of piloting commercial aircraft. Again, something comparable to 4 years of post-grad medical training, minimum 3-7 years of residency, and with the unpredictable demands of time and human behavior coupled with the threat and risk of harm to human health and risk to personal livelihood.
posted by docpops at 3:21 PM on March 18, 2016 [5 favorites]
The important issue is that the poor can get good care. A new Lexus is nice, but it will get you to work in the same amount of time as a used Camry.
Agreed, but I've never seen a case of 'separate but equal' that worked for anyone but the people doing the separating.
posted by Mooski at 3:24 PM on March 18, 2016 [2 favorites]
Agreed, but I've never seen a case of 'separate but equal' that worked for anyone but the people doing the separating.
posted by Mooski at 3:24 PM on March 18, 2016 [2 favorites]
The idea that anything the Kochs' support is bad reminds me of the tribalism of the right: romneycare good, Obamacare bad, etc.
To the extent that doctors are an informal union, insofar as doctors — via the AMA — regulate the supply of doctors in the United States, this seems pretty consistent with the general pursuit of union-busting by the Koch family. People are probably right to be generally skeptical of anything those guys have their hands in.
posted by a lungful of dragon at 3:29 PM on March 18, 2016 [2 favorites]
To the extent that doctors are an informal union, insofar as doctors — via the AMA — regulate the supply of doctors in the United States, this seems pretty consistent with the general pursuit of union-busting by the Koch family. People are probably right to be generally skeptical of anything those guys have their hands in.
posted by a lungful of dragon at 3:29 PM on March 18, 2016 [2 favorites]
I'm trying to find the sinister lining to this as much or more than anyone, but I can tell you that finding even a single competently trained family doctor interested in anything like the normal workday of a typical primary care physician is getting harder by the year. Combined with normal attrition rates for maturing doctors in primary care and it will be a miracle if anyone under the age of 35 grows old with an actual family doctor. We need as many well-trained bodies as possible who can do the nuts and bolts work of basic primary care, most of which is treating lifestyle diseases, ie hypertension, obesity, pain management, and situational stress issues as well as common community acquired simple acute illnesses. I can train any reasonably mature college sophomore to do that for most people in under a year.
posted by docpops at 3:44 PM on March 18, 2016 [10 favorites]
posted by docpops at 3:44 PM on March 18, 2016 [10 favorites]
I think part of this is many doctors insist on being partner/owners of their own practice rather than simply employees of a hospital or whatever, and they end up "outsourcing" things like renewing prescriptions to their medical assistants anyway. Definitely the cost of education is too high, and I think this is a secret effort to ensure that the next generation of health practitioners is more likely to accept "employment" status rather than "partner" and to accept that compromise with less pain (residency being brutal). Doctors often insist on having the lowest skilled worker perform any function possible but then they get involved in business and board meetings and patient care can suffer if they don't have dedicated PAs, NPs, or MAs juggling the balls.
posted by aydeejones at 4:13 PM on March 18, 2016 [1 favorite]
posted by aydeejones at 4:13 PM on March 18, 2016 [1 favorite]
And yep there is so little incentive for any doctor in the US to be a primary care / internal med / pediatrician. So much responsibility, so little profit. For a year or two of extra fellowship training you can be a highly paid surgeon or radiologist and kill it, with the compromise being that as a surgeon you will be on call, but can hyper specialize and get really good at a handful of common surgeries (knee and shoulder for example).
posted by aydeejones at 4:16 PM on March 18, 2016
posted by aydeejones at 4:16 PM on March 18, 2016
PAs and ARNPs are increasing because they make doctors money. It's hard to hire a new doctor - they want crazy money.
You can hire a PA for 60-100k; ARNPs are better trained and command a bit more. Plus benefits, payroll expenses, etc, you're out 140-160k/yr. They can easily collect 250-350k. Separate malpractice insurance is not necessary - mid-level practitioners are covered by the supervising MD's policy and he or she bears the liability.
Hospital and insurance co. owned practices particularly like PAs and ARNPs because $$$.
(Source: partner in group practice that employs mid-levels and MDs.)
posted by sudogeek at 4:18 PM on March 18, 2016 [5 favorites]
You can hire a PA for 60-100k; ARNPs are better trained and command a bit more. Plus benefits, payroll expenses, etc, you're out 140-160k/yr. They can easily collect 250-350k. Separate malpractice insurance is not necessary - mid-level practitioners are covered by the supervising MD's policy and he or she bears the liability.
Hospital and insurance co. owned practices particularly like PAs and ARNPs because $$$.
(Source: partner in group practice that employs mid-levels and MDs.)
posted by sudogeek at 4:18 PM on March 18, 2016 [5 favorites]
Really? A profession with long educational requirements, that works crazy hours, has immense responsibility, requires continuing education, and is extremely stressful? Frankly, if anyone in the entire world is allowed to be rich, it should be doctors.
Maybe if they weren't so desperate to control the supply of doctors they wouldn't be so overworked, eh?
Maybe so, but how many hundreds of thousands of dollars' worth of student loan debt (and debts racked up while underpaid during residency and fellowship(s)) do their international counterparts usually accrue?
This isn't an argument for high salaries its an argument for reforming a fucked-up system, which doctors and their advocates are largely responsible for.
If I had my way, doctors would be on government salaries and their school fees would be (partially) forgiven. Medicine is no more difficult or risky than geoscience or engineering, yet the typical doctor makes 3x as much as an engineer or more.
I think the defensiveness of (some) doctors about this issue is mostly about class anxiety. Sorry guys, you're special, but you're not that special.
posted by klanawa at 4:19 PM on March 18, 2016 [7 favorites]
Maybe if they weren't so desperate to control the supply of doctors they wouldn't be so overworked, eh?
Maybe so, but how many hundreds of thousands of dollars' worth of student loan debt (and debts racked up while underpaid during residency and fellowship(s)) do their international counterparts usually accrue?
This isn't an argument for high salaries its an argument for reforming a fucked-up system, which doctors and their advocates are largely responsible for.
If I had my way, doctors would be on government salaries and their school fees would be (partially) forgiven. Medicine is no more difficult or risky than geoscience or engineering, yet the typical doctor makes 3x as much as an engineer or more.
I think the defensiveness of (some) doctors about this issue is mostly about class anxiety. Sorry guys, you're special, but you're not that special.
posted by klanawa at 4:19 PM on March 18, 2016 [7 favorites]
So here's the thing. There are not currently enough primary care doctors. There isn't currently a serious proposal to provide enough primary care doctors, and the need is only going to get more acute as the population ages. Doctors seem to think that the solution is just that a lot of people should be denied care. I think that's really evil, and it makes me think that the solution to this issue is going to have to come from outside the medical profession and perhaps over the objections of doctors.
posted by ArbitraryAndCapricious at 4:20 PM on March 18, 2016 [5 favorites]
posted by ArbitraryAndCapricious at 4:20 PM on March 18, 2016 [5 favorites]
For quite some time, the model at a few local hospitals' outpatient clinics -- the University of Washington Medical Center and Seattle Children's Hospital are the ones I'm familiar with -- is that at your first appointment, you meet with a nurse practitioner specialist, and in most cases that person will be your care provider. You bump up to the MD if your case is complicated, severe, rapidly worsening, or potentially surgical . It's worked out GREAT for us, I have to say; both of my kids saw specialist ARNPs at Children's who were completely capable of managing their care, and when I was at the ENT clinic at UW to be evaluated for sinus surgery, the ARNP wasted no time in ordering a CT and bumping me up to the surgeon. And these are big, urban medical centers. The supply of MDs is artifically restricted and they are waaaaaaaay overtrained for a lot of primary care, or even a lot of specialist care. Moving to PAs and ARNPs is a great choice.
posted by KathrynT at 4:21 PM on March 18, 2016 [7 favorites]
posted by KathrynT at 4:21 PM on March 18, 2016 [7 favorites]
The issue with administrative costs being a bigger issue than doctor salaries is complicated by the fact that many doctors run private practices, own ambulatory surgery centers, or even start hospital partnerships with "non-profits" in order to cash in on every band-aid and overpriced Vicodin pill. They see salaries or collection rates slipping and start finding ways to profit "vertically." It's extra complicated by things like workers compensation insurance or even Medicare paying out obscenely for things like a shoulder sling, because it has an extra piece of Velcro strapping and the doctor took the time to explain how to put it on...that'll be $300
posted by aydeejones at 4:28 PM on March 18, 2016 [1 favorite]
posted by aydeejones at 4:28 PM on March 18, 2016 [1 favorite]
Now we just need more states to allow psychologists to prescribe psych meds.
posted by Obscure Reference at 4:32 PM on March 18, 2016 [4 favorites]
posted by Obscure Reference at 4:32 PM on March 18, 2016 [4 favorites]
Now we just need more states to allow psychologists to prescribe psych meds.
LCSW? No. God no. After some of the LCSWs I've gone to I wouldn't ever want them giving out meds. We shouldn't even be having PCPs giving out psych meds.
posted by Talez at 4:37 PM on March 18, 2016 [2 favorites]
LCSW? No. God no. After some of the LCSWs I've gone to I wouldn't ever want them giving out meds. We shouldn't even be having PCPs giving out psych meds.
posted by Talez at 4:37 PM on March 18, 2016 [2 favorites]
LCSWs aren't psychologists. But I'm seriously curious: if you don't think that PCPs should be able to prescribe psych meds, do you have a proposal to make sure that people who need them can get them? Because there is also a big shortage of psychiatrists, particularly in rural areas that already have high rates of untreated mental illness and suicide, and many people are not going to have any access to psych meds if they need to be able to see a psychiatrist to get them.
posted by ArbitraryAndCapricious at 4:41 PM on March 18, 2016 [7 favorites]
posted by ArbitraryAndCapricious at 4:41 PM on March 18, 2016 [7 favorites]
I have been saying this for years and every year it gets closer to reality: doctors as we know them will become obsolete. Within the next ten years a large percentage of general practitioners (and to varying amounts specialists, depending on the field - radiology will have huge job loss I think, surgery will take longer) will be replaced by a combination of AI (Watson, future competitors) and nurses/PAs. The things we pay doctors the big bucks for are memorizing large amounts of data and the ability to follow diagnostic algorithms - incidentally, that's what computers are absolutely excellent at doing, with a much larger memory capacity and less room for error. The future I envision is one "super-doctor" supervising dozens of nurses, NPs and PAs who talk to patients (and who actually LISTEN to patients) and enter the symptoms into an AI interface, and a doctor is only called in when the AI cannot specify a diagnosis above a given % certainty. Eventually doctors will only be kept on for liability reasons, the same way self-driving cars currently need a driver in the seat.
Anyway, this legislation is a great move. Doctors are often egotistical holdovers from a less enlightened era then our own. Compassionate and people-centric medicine is where we need to go, and paradoxically I think computers will help us get there.
posted by permiechickie at 4:43 PM on March 18, 2016 [5 favorites]
Anyway, this legislation is a great move. Doctors are often egotistical holdovers from a less enlightened era then our own. Compassionate and people-centric medicine is where we need to go, and paradoxically I think computers will help us get there.
posted by permiechickie at 4:43 PM on March 18, 2016 [5 favorites]
As far as I can tell, the AMA does want more doctors. Most medical schools have been increasing their class sizes, and more medical schools have recently opened. The bottle neck is the number of residency positions (funded by the graduate medical education system - GME) and AMA wants more GME funding from congress.
“The AMA believes the number of residency slots must be increased to produce an appropriately sized and geographically distributed physician workforce to accommodate our country’s future health care needs”
posted by bobobox at 4:54 PM on March 18, 2016 [5 favorites]
“The AMA believes the number of residency slots must be increased to produce an appropriately sized and geographically distributed physician workforce to accommodate our country’s future health care needs”
posted by bobobox at 4:54 PM on March 18, 2016 [5 favorites]
But I'm seriously curious: if you don't think that PCPs should be able to prescribe psych meds, do you have a proposal to make sure that people who need them can get them? Because there is also a big shortage of psychiatrists, particularly in rural areas that already have high rates of untreated mental illness and suicide, and many people are not going to have any access to psych meds if they need to be able to see a psychiatrist to get them.
I don't have any proposal. That's why I said should. We're really not in an ideal world so we have to resort to PCPs handing out Prozac like Halloween candy.
posted by Talez at 4:54 PM on March 18, 2016
I don't have any proposal. That's why I said should. We're really not in an ideal world so we have to resort to PCPs handing out Prozac like Halloween candy.
posted by Talez at 4:54 PM on March 18, 2016
One thing about medical care in WV is that the vast majority is paid for by government sources like Medicare, Medicaid, and the black lung settlement. I have very rarely had a doctor that wasn't an immigrant to the US, which we were told is because if they work in impoverished communities it helps their immigration process. Doctors get paid shit here. If it weren't for nurses and nurse practitioners many of us would never receive community care and hardly anyone from here would get medical training. We need more doctors, more nurses, more of everything. There's just no money to pay for it. We're grateful for what we can get, even if the old people have trouble understanding the new doctor from Benin or Pakistan.
posted by irisclara at 5:06 PM on March 18, 2016 [9 favorites]
posted by irisclara at 5:06 PM on March 18, 2016 [9 favorites]
NoxAeternum: "The problem is that in this specific case, there are genuine barriers to entry that only enable rent seeking, put in place by a politically powerful profession"
I take meds for a well known and managed condition. I've been taking them for 20+ years without changes. My old doctor would write scripts for six months. My new doctor will only go four months so I see him 50% more often. And there is no reason why some form of masters/phd nurse couldn't see me instead as a friend with the same condition does. Sure if I develop one of the side effects I should be shunted to a Doctor but maintenance issues like this could be handled much cheaper and without consuming limited family practice doctor resources.
posted by Mitheral at 5:16 PM on March 18, 2016 [5 favorites]
I take meds for a well known and managed condition. I've been taking them for 20+ years without changes. My old doctor would write scripts for six months. My new doctor will only go four months so I see him 50% more often. And there is no reason why some form of masters/phd nurse couldn't see me instead as a friend with the same condition does. Sure if I develop one of the side effects I should be shunted to a Doctor but maintenance issues like this could be handled much cheaper and without consuming limited family practice doctor resources.
posted by Mitheral at 5:16 PM on March 18, 2016 [5 favorites]
On a very practical level, the fact is that during hospital stays you have no idea who the Hospitalist you see is going to be on any given occasion or if a physician will even bother to review your chart before seeing you and charging you fee after fee by marking the "full exam" (or whatever the notation is in a particular system happens to be) toggle. This sounds like just anecdata, but if you or a loved one has been in-patient in the last couple years, you have experienced this.
Corollary to this is that NPs and DNPs work efficiently and are often better rated by patients because of the different focus in care the two groups function under. The Not My Doctor you get in CCU or on a Step-Down floor (or elsewhere in an in-patient environment) could very likiley be some sort of Advanced Practice Nurse (which is much larger category than just NPs--such as Nurse Anesthetist).
So there are so many factors going into the shift to so many Advanced Practices Nurses. However, the question is really--can they do the job, if yes, then what's the issue.
(As an aside, when I was skimming, I saw someone say something along the lines of "of course pycicians are better, what with the grad school, interning, an continuing ed" You mean like Advanced Practice Nurses?)
posted by syncope at 5:45 PM on March 18, 2016
Corollary to this is that NPs and DNPs work efficiently and are often better rated by patients because of the different focus in care the two groups function under. The Not My Doctor you get in CCU or on a Step-Down floor (or elsewhere in an in-patient environment) could very likiley be some sort of Advanced Practice Nurse (which is much larger category than just NPs--such as Nurse Anesthetist).
So there are so many factors going into the shift to so many Advanced Practices Nurses. However, the question is really--can they do the job, if yes, then what's the issue.
(As an aside, when I was skimming, I saw someone say something along the lines of "of course pycicians are better, what with the grad school, interning, an continuing ed" You mean like Advanced Practice Nurses?)
posted by syncope at 5:45 PM on March 18, 2016
klanawa: Medicine is no more difficult or risky than geoscience or engineering, yet the typical doctor makes 3x as much as an engineer or more.
Um, yes. Yes, it is.
First of all, look at the education. Engineers need four years and to pass an exam. Doctors need four years, then three or so more years, and then three or four years of special, supervised work. That's over double the length of the educational process. And the medical one is also harder; an engineering major isn't easy, but pre-med is already pretty hard, med school is brutal, and residency is legendarily brutal.
Second, think of the consequences of malpractice. Sure, a few engineers can hurt people - maybe even a lot of people - if they mess up. But a lot of engineers, surely the majority, work in situations where there is absolutely no danger to anyone.. And most engineers also work in teams or with supervision by other engineers. On the other hand, essentially any doctor can kill someone with a bad enough mistake, and most doctors could fail to save someone by not being talented enough and missing a diagnosis or something.
posted by Mitrovarr at 5:49 PM on March 18, 2016 [5 favorites]
Um, yes. Yes, it is.
First of all, look at the education. Engineers need four years and to pass an exam. Doctors need four years, then three or so more years, and then three or four years of special, supervised work. That's over double the length of the educational process. And the medical one is also harder; an engineering major isn't easy, but pre-med is already pretty hard, med school is brutal, and residency is legendarily brutal.
Second, think of the consequences of malpractice. Sure, a few engineers can hurt people - maybe even a lot of people - if they mess up. But a lot of engineers, surely the majority, work in situations where there is absolutely no danger to anyone.. And most engineers also work in teams or with supervision by other engineers. On the other hand, essentially any doctor can kill someone with a bad enough mistake, and most doctors could fail to save someone by not being talented enough and missing a diagnosis or something.
posted by Mitrovarr at 5:49 PM on March 18, 2016 [5 favorites]
Most medical schools have been increasing their class sizes, and more medical schools have recently opened.Right, but we would need more doctors just to keep up with the increasing population and replace the ones who are retiring. (A lot of doctors are old: it's a consequence of starting their careers relatively late because of the length of the training.) And the issue is not just that the population is increasing, as it generally does: it's also that the population is getting older and needing more care. Finally, older doctors are more likely to be primary care providers than younger doctors are, so the PCP shortage is going to be even more acute than it would seem at first glance. We're not creating new medical school seats fast enough to keep up.
posted by ArbitraryAndCapricious at 5:56 PM on March 18, 2016 [2 favorites]
Second, think of the consequences of malpractice. Sure, a few engineers can hurt people - maybe even a lot of people - if they mess up. But a lot of engineers, surely the majority, work in situations where there is absolutely no danger to anyone.. And most engineers also work in teams or with supervision by other engineers. On the other hand, essentially any doctor can kill someone with a bad enough mistake, and most doctors could fail to save someone by not being talented enough and missing a diagnosis or something.
Malpractice is a bad apple problem, and one doctors have fought against fixing for years, with deleterious effects to the rest of us. When the medical profession starts cracking down on these bad actors, then I'll take the arguments more seriously.
posted by NoxAeternum at 6:04 PM on March 18, 2016 [5 favorites]
Malpractice is a bad apple problem, and one doctors have fought against fixing for years, with deleterious effects to the rest of us. When the medical profession starts cracking down on these bad actors, then I'll take the arguments more seriously.
posted by NoxAeternum at 6:04 PM on March 18, 2016 [5 favorites]
I've worked closely with PAs, ARNPs and MDs for over a decade, at a teaching institution. I myself use an ARNP. It is a cost saving measure, mainly for the providers and institutions, but until the medicine education system gets unfucked, ARNPs and PAs are a godsend, IMO, and an absolutely necessary median step.
There just aren't enough GPs/FMPs.
posted by eclectist at 6:11 PM on March 18, 2016 [5 favorites]
There just aren't enough GPs/FMPs.
posted by eclectist at 6:11 PM on March 18, 2016 [5 favorites]
The current congress is a do-nothing, obstruction-at-all-costs congress. They will fund exactly 0 new residencies, especially if it means "sticking it" to Obamacare. The AMA knows this, and is quite happy with their members affording horse farms and personal planes, plural, so they put up exactly the required protest to keep things as they are.
It's nurses or nothing, and on a state-by-state level. For now. (Supreme Court Justice picks really, really, really matter. The wrong president will mean Doctor or Jack at the federal level in a Supreme Court lawsuit - preferably Jack, so you can go and die, Poor.)
posted by Slap*Happy at 6:13 PM on March 18, 2016
It's nurses or nothing, and on a state-by-state level. For now. (Supreme Court Justice picks really, really, really matter. The wrong president will mean Doctor or Jack at the federal level in a Supreme Court lawsuit - preferably Jack, so you can go and die, Poor.)
posted by Slap*Happy at 6:13 PM on March 18, 2016
The AMA knows this, and is quite happy with their members affording horse farms and personal planes, plural, so they put up exactly the required protest to keep things as they are.
How much fucking money do you imagine doctors actually make???
posted by docpops at 6:25 PM on March 18, 2016 [7 favorites]
How much fucking money do you imagine doctors actually make???
posted by docpops at 6:25 PM on March 18, 2016 [7 favorites]
On the other hand, essentially any doctor can kill someone with a bad enough mistake, and most doctors could fail to save someone by not being talented enough and missing a diagnosis or something.
BTW, not that it's really pertinent, but none of those qualify as malpractice. Just fucking it up and making a mistake doesn't qualify as malpractice, even if it's a fairly boneheaded mistake. In order for it to be malpractice, the doctor has to have made a conscious decision to deviate from standard practices or disregard patient safety, or to have been so blindingly incompetent that their care obviously falls below the standards of the profession.
posted by KathrynT at 6:28 PM on March 18, 2016 [8 favorites]
BTW, not that it's really pertinent, but none of those qualify as malpractice. Just fucking it up and making a mistake doesn't qualify as malpractice, even if it's a fairly boneheaded mistake. In order for it to be malpractice, the doctor has to have made a conscious decision to deviate from standard practices or disregard patient safety, or to have been so blindingly incompetent that their care obviously falls below the standards of the profession.
posted by KathrynT at 6:28 PM on March 18, 2016 [8 favorites]
In order for it to be malpractice, the doctor has to have made a conscious decision to deviate from standard practices or disregard patient safety, or to have been so blindingly incompetent that their care obviously falls below the standards of the profession.
posted by KathrynT at 6:28 PM on March 18 [+] [!]
Maybe in a perfect world, and with an attorney that looks more carefully at the facts of the case. The overwhelming number of lawsuits are brought by dissatisfied or angry patients regardless of the quality of care. Terrible care goes on all the time that never gets questioned. And lawsuits drag on for years in many cases while doctors try to keep up practice. The most nihilistic and least healthy patients with the most chronic [self-inflicted] health issues often sue over care delivered in the fruitless attempt to pull them back from a brink of their own creation.
posted by docpops at 6:35 PM on March 18, 2016 [3 favorites]
posted by KathrynT at 6:28 PM on March 18 [+] [!]
Maybe in a perfect world, and with an attorney that looks more carefully at the facts of the case. The overwhelming number of lawsuits are brought by dissatisfied or angry patients regardless of the quality of care. Terrible care goes on all the time that never gets questioned. And lawsuits drag on for years in many cases while doctors try to keep up practice. The most nihilistic and least healthy patients with the most chronic [self-inflicted] health issues often sue over care delivered in the fruitless attempt to pull them back from a brink of their own creation.
posted by docpops at 6:35 PM on March 18, 2016 [3 favorites]
Well OK, yes, the actual real-world application of medical malpractice lawsuits differs rather substantially from the Platonic ideal. But I see people confusing "the doctor fucked up" with "the doctor committed malpractice" all the time and it drives me bonkers, even though I'm neither a doctor nor a lawyer. Apparently I'm just a pedant.
posted by KathrynT at 7:16 PM on March 18, 2016 [4 favorites]
posted by KathrynT at 7:16 PM on March 18, 2016 [4 favorites]
The last time I read an article on MeFi that involved the Koch Brothers, the headline was "criminal law must be based on the principle of mens rea in the name of justice!" and the fine print was "a Koch-owned petrochemical plant responded to a systems problem by welding a bypass around their pollution controls and fabricating paperwork to cover it up, releasing tons of benzene to the environment, and yielding a record EPA settlement when they were caught".
They worked very hard to earn the level of mistrust they engender. It would be rude not to treat everything they touch with the full measure of skepticism it deserves.
posted by traveler_ at 7:23 PM on March 18, 2016 [2 favorites]
They worked very hard to earn the level of mistrust they engender. It would be rude not to treat everything they touch with the full measure of skepticism it deserves.
posted by traveler_ at 7:23 PM on March 18, 2016 [2 favorites]
I'm an RN who's in school finishing up my APN. I'll be able to prescribe opiates and I won't *have* to work under an MD. I'm a palliative care/hospice RN and plan on continuing to stay in end of life care as an APN. Obviously I work with a lot of physicians, some are amazing but most are truly awful. Awful people, awful clinicians, morally and ethically bankrupt. Physicians bill for procedures and visits they don't do, they are at best rude to patients and families, paternalistic, arrogant and ill informed. I sincerely hope that all of my future (and current) patients never ever feel like I'm dismissing their concerns, ignoring their pain and providing unwanted care. My hospice work is very rewarding and I love my patients and families; the doctors are why I come home frustrated and sad every night, not the dying.
posted by yodelingisfun at 8:13 PM on March 18, 2016 [15 favorites]
posted by yodelingisfun at 8:13 PM on March 18, 2016 [15 favorites]
Mod note: One comment deleted. It's fine to talk about your own experiences, just don't make it about another person in the thread.
posted by LobsterMitten (staff) at 8:16 PM on March 18, 2016
posted by LobsterMitten (staff) at 8:16 PM on March 18, 2016
> It would be rude not to treat everything they touch with the full measure of skepticism it deserves.
Their motives certainly deserve skepticism, but deciding to be skeptical of something they agree with or support just because they do is not actually a skeptical thing to do.
posted by rtha at 8:30 PM on March 18, 2016 [2 favorites]
Their motives certainly deserve skepticism, but deciding to be skeptical of something they agree with or support just because they do is not actually a skeptical thing to do.
posted by rtha at 8:30 PM on March 18, 2016 [2 favorites]
How much fucking money do you imagine doctors actually make???
Do you want a general figure? Which part of the country?
Attentive GP's in my very-densely populated and well-off corner of the NE are very hard to find. They retire reeeealy quick. Their successors tend not to be all that attentive. Or interested. Or competent. Nurses, of which I am related to five, have all noticed this trend as well, and it's at the point I trust them more than the equestrian/pilot-senior-partner/practitioner, as the nurses and PA's actually pay attention to what's going on.
posted by Slap*Happy at 8:56 PM on March 18, 2016 [1 favorite]
Do you want a general figure? Which part of the country?
Attentive GP's in my very-densely populated and well-off corner of the NE are very hard to find. They retire reeeealy quick. Their successors tend not to be all that attentive. Or interested. Or competent. Nurses, of which I am related to five, have all noticed this trend as well, and it's at the point I trust them more than the equestrian/pilot-senior-partner/practitioner, as the nurses and PA's actually pay attention to what's going on.
posted by Slap*Happy at 8:56 PM on March 18, 2016 [1 favorite]
Um, yes. Yes, it is.
First of all, look at the education. Engineers need four years and to pass an exam. Doctors need four years, then three or so more years, and then three or four years of special, supervised work. That's over double the length of the educational process. And the medical one is also harder
UK MDs are trained for 5 years as an undergraduate degree. The UK ranks #1 among rich countries for healthcare, the USA is #11. I don't think those extra years do much besides increase the opportunity cost to be a doctor.
posted by benzenedream at 9:07 PM on March 18, 2016 [17 favorites]
First of all, look at the education. Engineers need four years and to pass an exam. Doctors need four years, then three or so more years, and then three or four years of special, supervised work. That's over double the length of the educational process. And the medical one is also harder
UK MDs are trained for 5 years as an undergraduate degree. The UK ranks #1 among rich countries for healthcare, the USA is #11. I don't think those extra years do much besides increase the opportunity cost to be a doctor.
posted by benzenedream at 9:07 PM on March 18, 2016 [17 favorites]
yodelingisfun
At least some of your patients family members are well aware of your dedication and frustrations. Your peers did a great job for me and mine.
posted by ridgerunner at 9:10 PM on March 18, 2016 [1 favorite]
At least some of your patients family members are well aware of your dedication and frustrations. Your peers did a great job for me and mine.
posted by ridgerunner at 9:10 PM on March 18, 2016 [1 favorite]
Obviously I work with a lot of physicians, some are amazing but most are truly awful. Awful people, awful clinicians, morally and ethically bankrupt.
Jesus. I don't work with them, so perhaps they warp into different people on the clock, but I live with a resident and am friends with many more and while there are some assholes in the bunch (as there will be with any group of people), on the whole, they are among the hardest-working and most conscientious people I have ever met. You're painting with an awfully broad brush there.
posted by protocoach at 9:36 PM on March 18, 2016 [6 favorites]
Jesus. I don't work with them, so perhaps they warp into different people on the clock, but I live with a resident and am friends with many more and while there are some assholes in the bunch (as there will be with any group of people), on the whole, they are among the hardest-working and most conscientious people I have ever met. You're painting with an awfully broad brush there.
posted by protocoach at 9:36 PM on March 18, 2016 [6 favorites]
I'm seeing a NP in lieu of a psychiatrist at the moment. My psych of eight years recently moved. It was kind of traumatic... She was the first mental health professional I saw in a very long process to untangle some lifelong undiagnosed mental illness. She saw me through the most difficult transitions, and was not technically a therapist, but truly she was the best therapist I've had. I processed her leaving like I would grieve for any major loss. She's one doctor I'd describe as a healer first and foremost, and exceptionally rare for her field. I got lucky to have found her at all, especially for my first visit and throughout the years when I really needed someone highly competent to diagnose and assess my mental health & meds. And she worked for a non-profit, and the clinic took insurance and was reasonably priced overall.
Anyway, the clinic who employed her is rural, and they're having a hard time replacing her. In the meantime, I am seeing a NP at that clinic once every three months for refills on my medications. However, it's just maintenance visits for meds, and if any issues come up which require further diagnoses or major changes to my meds, I really need to see another psychiatrist. Unfortunately, they're in demand, many with waiting lists, and most do not take insurance anymore. But a NP is a good choice for the interim for me, as the visits are cheap and covered by insurance.
posted by krinklyfig at 10:53 PM on March 18, 2016
Anyway, the clinic who employed her is rural, and they're having a hard time replacing her. In the meantime, I am seeing a NP at that clinic once every three months for refills on my medications. However, it's just maintenance visits for meds, and if any issues come up which require further diagnoses or major changes to my meds, I really need to see another psychiatrist. Unfortunately, they're in demand, many with waiting lists, and most do not take insurance anymore. But a NP is a good choice for the interim for me, as the visits are cheap and covered by insurance.
posted by krinklyfig at 10:53 PM on March 18, 2016
This is my experience and it's certainly not any common feeling among other nurses I know. I'm sure your physician friends are all different and wonderful. I know too that the culture in medicine can be vastly different depending on location, maybe you live somewhere where it's just opposite of here...but yeah, I thought I'd really respect and admire doctors until I started working as an RN. My brush is how it is from lived experience.
posted by yodelingisfun at 10:54 PM on March 18, 2016 [2 favorites]
posted by yodelingisfun at 10:54 PM on March 18, 2016 [2 favorites]
Mitrovarr: " Engineers need four years and to pass an exam."
Is that how it works in the US? In Canada the four years of school just allows you to qualify for Engineer in Training (exact name varies from province to province) status. At which point you generally have to spend three to four years minimum and up to nine years as an EIT under the supervision of a Registered Engineer.
posted by Mitheral at 11:03 PM on March 18, 2016 [3 favorites]
Is that how it works in the US? In Canada the four years of school just allows you to qualify for Engineer in Training (exact name varies from province to province) status. At which point you generally have to spend three to four years minimum and up to nine years as an EIT under the supervision of a Registered Engineer.
posted by Mitheral at 11:03 PM on March 18, 2016 [3 favorites]
We need as many well-trained bodies as possible who can do the nuts and bolts work of basic primary care, most of which is treating lifestyle diseases, ie hypertension, obesity, pain management, and situational stress issues as well as common community acquired simple acute illnesses. I can train any reasonably mature college sophomore to do that for most people in under a year.
Wow. It seems obvious when you put it like that, but I never understood what time would be involved in training for this type of medical care. We should be doing this.
posted by krinklyfig at 11:11 PM on March 18, 2016
Wow. It seems obvious when you put it like that, but I never understood what time would be involved in training for this type of medical care. We should be doing this.
posted by krinklyfig at 11:11 PM on March 18, 2016
As far as I can tell, the AMA does want more doctors. Most medical schools have been increasing their class sizes, and more medical schools have recently opened. The bottle neck is the number of residency positions (funded by the graduate medical education system - GME) and AMA wants more GME funding from congress.
This fight's been going on for a few decades now. See, the AMA wants Congress to provide more funding for GME - but what they don't want (and what Congress and the federal government wants) is for greater control by the feds over what residencies get funded, because they'd like the number of specialists to better reflect the actual needs of the country. The result is that neither side gives, and the old system with caps continues.
And this gets to the issue - the AMA isn't really a union, but a guild, in the original sense of the term. The way medical education is done in the US isn't because of necessity, but because the length and cost are meant to indoctrinate new doctors into the guild mentality (because there's nothing like a quarter million dollars of debt to get one's mind focused on preserving high salaries.) They had been able to get away with a lot of this when our old system let them hide the costs, but one of the benefits of the ACA is that it's forcing a lot of the underlying costs in the system to the surface.
posted by NoxAeternum at 11:51 PM on March 18, 2016 [6 favorites]
This fight's been going on for a few decades now. See, the AMA wants Congress to provide more funding for GME - but what they don't want (and what Congress and the federal government wants) is for greater control by the feds over what residencies get funded, because they'd like the number of specialists to better reflect the actual needs of the country. The result is that neither side gives, and the old system with caps continues.
And this gets to the issue - the AMA isn't really a union, but a guild, in the original sense of the term. The way medical education is done in the US isn't because of necessity, but because the length and cost are meant to indoctrinate new doctors into the guild mentality (because there's nothing like a quarter million dollars of debt to get one's mind focused on preserving high salaries.) They had been able to get away with a lot of this when our old system let them hide the costs, but one of the benefits of the ACA is that it's forcing a lot of the underlying costs in the system to the surface.
posted by NoxAeternum at 11:51 PM on March 18, 2016 [6 favorites]
We need as many well-trained bodies as possible who can do the nuts and bolts work of basic primary care, ....I can train any reasonably mature college sophomore to do that for most people in under a year.
Hey Doc, get them while they're young and raise them right. The Navy has been training bright kids as young as 17 for the Hospital Corps, less than 5 months training to start with. It seems to work out well for them in a variety of situations.
I'm pretty sure the physicians pushing for professional EMTs had been exposed to Corpsman and Medics under trying circumstances. Wikipedia clams: "The first physician assistants were selected from Navy corpsmen who had combat experience in Vietnam."
posted by ridgerunner at 12:35 AM on March 19, 2016 [1 favorite]
Hey Doc, get them while they're young and raise them right. The Navy has been training bright kids as young as 17 for the Hospital Corps, less than 5 months training to start with. It seems to work out well for them in a variety of situations.
I'm pretty sure the physicians pushing for professional EMTs had been exposed to Corpsman and Medics under trying circumstances. Wikipedia clams: "The first physician assistants were selected from Navy corpsmen who had combat experience in Vietnam."
posted by ridgerunner at 12:35 AM on March 19, 2016 [1 favorite]
I knew a nurse who had trained in ?Taiwan? And said (IIRC) that all doctors there had first been trained as orderlies, then nurses, and finally doctors and then specialists, and it wasn't unheard of for someone to work in one slot for years before training for the next. She thought the system produced a lot more mutual respect than the US system.
posted by clew at 1:55 AM on March 19, 2016 [4 favorites]
posted by clew at 1:55 AM on March 19, 2016 [4 favorites]
minimum 3-7 years of residency, and with the unpredictable demands of time and human behavior coupled with the threat and risk of harm to human health and risk to personal livelihood
Residency is paid. In the context of the student loans that many MDs have, they pay may not be great compared to what they will make at the end of residency. But it is callous to elide over the fact that it is actually paid at a far higher rate than any average entry-level real JOB, and more than many mid-level professional jobs. It also comes with health benefits.
On the other hand, many professionals leave grad school with levels of debt comparable (100k+) to doctors, where they have to find their own job and even if they do they are lucky if their first year of pay is anywhere near what a first year resident makes.
In today's working world, almost any job, especially but not exclusively non-union jobs, can make unpredictable demands of time and human behavior, and carry great risk of harm to personal livelihood. In fact, the less that jobs pay, the more ridiculous demands they are likely to make (like jobs that require you to be available 60+ hours a week and give you less than 40 hours per week of work, on a different schedule every week that you may not know the week before, and have no benefits).
I think that a lot of people (non-doctors too) who established their careers before the current economic climate do not realize how bad it is out there. 3-7 years of residency - where as long as you don't badly fuck up you are essentially in a secure job with benefits and intense job training that leaves you eminently more employable at much higher rates - seems more like a gift than a chore. Complain about the hours and demands if you like, but preferably only in front of your peers. I think that the people hobbling together multiple low paid, no benefits job to make far less than a resident makes with no hope of upward career trajectory probably don't want to hear it. (Especially if they're also carrying educational and/or medical debt that may be comparable, especially in relative to wage but even in absolute terms, to an MD grad in residency).
posted by Salamandrous at 7:12 AM on March 19, 2016 [6 favorites]
Residency is paid. In the context of the student loans that many MDs have, they pay may not be great compared to what they will make at the end of residency. But it is callous to elide over the fact that it is actually paid at a far higher rate than any average entry-level real JOB, and more than many mid-level professional jobs. It also comes with health benefits.
On the other hand, many professionals leave grad school with levels of debt comparable (100k+) to doctors, where they have to find their own job and even if they do they are lucky if their first year of pay is anywhere near what a first year resident makes.
In today's working world, almost any job, especially but not exclusively non-union jobs, can make unpredictable demands of time and human behavior, and carry great risk of harm to personal livelihood. In fact, the less that jobs pay, the more ridiculous demands they are likely to make (like jobs that require you to be available 60+ hours a week and give you less than 40 hours per week of work, on a different schedule every week that you may not know the week before, and have no benefits).
I think that a lot of people (non-doctors too) who established their careers before the current economic climate do not realize how bad it is out there. 3-7 years of residency - where as long as you don't badly fuck up you are essentially in a secure job with benefits and intense job training that leaves you eminently more employable at much higher rates - seems more like a gift than a chore. Complain about the hours and demands if you like, but preferably only in front of your peers. I think that the people hobbling together multiple low paid, no benefits job to make far less than a resident makes with no hope of upward career trajectory probably don't want to hear it. (Especially if they're also carrying educational and/or medical debt that may be comparable, especially in relative to wage but even in absolute terms, to an MD grad in residency).
posted by Salamandrous at 7:12 AM on March 19, 2016 [6 favorites]
I know many people who are applying to med school or in one of its various stages. Becoming a doctor entails committing yourself to ~15 years of intense competition, stress, and long hours while your friends go out and enjoy their youth (because it starts in undergrad). They must put thoughts of long term relationships and family on hold, unless they're able to find a partner who is OK with them being basically absent for long chunks of time. On top of that all of them are facing down $300k+ of student loan debt by the end, and then massive malpractice insurance costs once they're actually practicing.
The mental calculus that leads to pursuing the increased salaries from specialization isn't borne of base greed from robotic overachievers. It's because the training they go through comes at a staggering personal and financial costs.
I am not surprised doctors get a reputation for being cold or arrogant either, because kindness, humility, and gentleness gets winnowed out both for lack of emphasis during training and out of necessity. Remember--most doctors do all this during the most crucial period of adult development.
I really do not think there is any other professional certification that is quite as brutal, and I say this as a doctoral student in the sciences at an Ivy League school. If we want to pay doctors less, then we need a training program that does not require them to sacrifice quite so much. Otherwise the shortage will only get worse.
posted by Anonymous at 7:47 AM on March 19, 2016
The mental calculus that leads to pursuing the increased salaries from specialization isn't borne of base greed from robotic overachievers. It's because the training they go through comes at a staggering personal and financial costs.
I am not surprised doctors get a reputation for being cold or arrogant either, because kindness, humility, and gentleness gets winnowed out both for lack of emphasis during training and out of necessity. Remember--most doctors do all this during the most crucial period of adult development.
I really do not think there is any other professional certification that is quite as brutal, and I say this as a doctoral student in the sciences at an Ivy League school. If we want to pay doctors less, then we need a training program that does not require them to sacrifice quite so much. Otherwise the shortage will only get worse.
posted by Anonymous at 7:47 AM on March 19, 2016
I'm actually curious: I can't see any good reason that people should have to pay to attend medical school, when academic grad school is often funded. What if we made med school free? What if we had loan forgiveness for current doctors who were still paying off their medical debt? Would doctors be willing to accept salaries that were more in line with other elite professionals if they didn't have so much debt?
posted by ArbitraryAndCapricious at 7:55 AM on March 19, 2016 [3 favorites]
Otherwise the shortage will only get worse.There is absolutely not a shortage of qualified medical school applicants. Med schools are turning away scads of people who would have easily been admitted 25 years ago. There are lots of reasons for the shortage, but one of them is not that qualified people are looking at the lifestyle and deciding that it's not worth it.
posted by ArbitraryAndCapricious at 7:55 AM on March 19, 2016 [3 favorites]
Disclosure: I am an MD in anesthesia.
I've never been sold on some of the claimed benefits of independent midlevel practice. Attracting MDs to rural areas is hard, but so is attracting NPs. NPs aren't getting a license that says "rural areas only" on it, and they want the money and perks that go with living in a city just as much as MDs. To the extent it's been easier so far, I think it reflects a generational effect where the smart women from rural areas 30 years ago could not practically go to medical school. Many returned home because of cultural obligations and because nursing salaries did not have the huge variance that MDs did. Now many of these areas are age-inverted and can't attract young professionals of any kind. The early cohort of independent NPs will not reflect later ones in my opinion. Most of the CRNAs who leave our SRNA program (or quit after a few years in the city) go to the suburbs rather than the countryside. The way to get people into rural areas is to increase pay until it's desirable.
I've loved working with NPs, but I think that their generally more patient-interaction centered approach comes from having spent a lot of time as RNs and how they get paid. NPs and CRNAs I've worked with who went straight through and work side-by-side with MDs face the same production pressure and act like MDs. Nursing school with attached NP doctorate will just become cheaper slightly easier to get into medical school from a practice-culture perspective.
I also worry about hollowing out the MD-PCP workforce. NPs aren't in the near future going to become surrogate interventional cardiologists, surgeons, ED attendings, dermatologists, or other highly paid highly skilled specialties (although they have made a substantial footprint in anesthesia and psychiatry). They are further going to depress the already crappy wages of primary care physicians, making it even less attractive to newly minted MDs.
The idea that UK MDs take just 5 years compared to 4+4+(3:7) is flat wrong. It's true that in the UK MDs don't get a 4 year undergrad degree. There are a handful of universities in the US that offer a combined undergrad-MD in 6 years, and it used to be much more common to abbreviate the undergrad, but this went away as med school and residency applications became increasingly competitive. In the UK, after the 5 year MD junior doctors have a 2 year internship and at least 3 years of supervised practice to become a GP compared to a minimum of 1+2 years in the us, usually 1+3. The time to become a senior doctor (called a consultant) is a great deal longer, more like 7 years post MD. In the US it is usually 1-2 years of post-residency fellowship. My understanding is that the time-to-consultant is being lengthened to 9 years post MD, and that for surgeons actually complying with the european work hour directive will lengthen it further.
You could get rid of the undergraduate degree in the US, but this makes it harder for medical schools to be picky. 18 year olds have had a lot fewer opportunities to prove themselves and figure out what they really want to do before assuming vast debt; they also have a much stronger effect of being from disadvantaged high schools. To eliminate the undergrad degree, you would also need to greatly subsidize medical education to decrease the risk, accept that a fair number will fail (especially if you are trying to recruit underrepresented minorities), and accept that you will miss out on many of the most talented individuals.
Nursing school provides a nice alternative because the initial outlay is low, and those who aren't going to make it all the way can parachute out to less competitive nursing jobs along the way. Nurses who grow later in life can become managers or return for the add-on qualification. MDs have less opportunity of stop climbing, but it can be done.
The cry to cut MD salaries and make medical school free/cheap would require an enormous up-front expense to forgive the debt of those who would otherwise be stuck in the have-debt-low-salary group and be very disruptive to how the MD workforce is organized.
posted by a robot made out of meat at 7:59 AM on March 19, 2016 [9 favorites]
I've never been sold on some of the claimed benefits of independent midlevel practice. Attracting MDs to rural areas is hard, but so is attracting NPs. NPs aren't getting a license that says "rural areas only" on it, and they want the money and perks that go with living in a city just as much as MDs. To the extent it's been easier so far, I think it reflects a generational effect where the smart women from rural areas 30 years ago could not practically go to medical school. Many returned home because of cultural obligations and because nursing salaries did not have the huge variance that MDs did. Now many of these areas are age-inverted and can't attract young professionals of any kind. The early cohort of independent NPs will not reflect later ones in my opinion. Most of the CRNAs who leave our SRNA program (or quit after a few years in the city) go to the suburbs rather than the countryside. The way to get people into rural areas is to increase pay until it's desirable.
I've loved working with NPs, but I think that their generally more patient-interaction centered approach comes from having spent a lot of time as RNs and how they get paid. NPs and CRNAs I've worked with who went straight through and work side-by-side with MDs face the same production pressure and act like MDs. Nursing school with attached NP doctorate will just become cheaper slightly easier to get into medical school from a practice-culture perspective.
I also worry about hollowing out the MD-PCP workforce. NPs aren't in the near future going to become surrogate interventional cardiologists, surgeons, ED attendings, dermatologists, or other highly paid highly skilled specialties (although they have made a substantial footprint in anesthesia and psychiatry). They are further going to depress the already crappy wages of primary care physicians, making it even less attractive to newly minted MDs.
The idea that UK MDs take just 5 years compared to 4+4+(3:7) is flat wrong. It's true that in the UK MDs don't get a 4 year undergrad degree. There are a handful of universities in the US that offer a combined undergrad-MD in 6 years, and it used to be much more common to abbreviate the undergrad, but this went away as med school and residency applications became increasingly competitive. In the UK, after the 5 year MD junior doctors have a 2 year internship and at least 3 years of supervised practice to become a GP compared to a minimum of 1+2 years in the us, usually 1+3. The time to become a senior doctor (called a consultant) is a great deal longer, more like 7 years post MD. In the US it is usually 1-2 years of post-residency fellowship. My understanding is that the time-to-consultant is being lengthened to 9 years post MD, and that for surgeons actually complying with the european work hour directive will lengthen it further.
You could get rid of the undergraduate degree in the US, but this makes it harder for medical schools to be picky. 18 year olds have had a lot fewer opportunities to prove themselves and figure out what they really want to do before assuming vast debt; they also have a much stronger effect of being from disadvantaged high schools. To eliminate the undergrad degree, you would also need to greatly subsidize medical education to decrease the risk, accept that a fair number will fail (especially if you are trying to recruit underrepresented minorities), and accept that you will miss out on many of the most talented individuals.
Nursing school provides a nice alternative because the initial outlay is low, and those who aren't going to make it all the way can parachute out to less competitive nursing jobs along the way. Nurses who grow later in life can become managers or return for the add-on qualification. MDs have less opportunity of stop climbing, but it can be done.
The cry to cut MD salaries and make medical school free/cheap would require an enormous up-front expense to forgive the debt of those who would otherwise be stuck in the have-debt-low-salary group and be very disruptive to how the MD workforce is organized.
posted by a robot made out of meat at 7:59 AM on March 19, 2016 [9 favorites]
There is absolutely not a shortage of qualified medical school applicants.
I was referring to PCPs, sorry I didn't make that clear.
At least from my wholly anecdotal experience, yes. if there wasn't the financial costs hanging over there heads there would be a lot more PCPs. I know many med students/docs who started with dreams of a family practice or being a rural doctor, Young Doctor's Notebook-style, but by the time they're out the culture and debt have pretty well smashed those.
It's not just paying off the base tuition either, it's the interest that really screws you.
posted by Anonymous at 9:46 AM on March 19, 2016
I was referring to PCPs, sorry I didn't make that clear.
At least from my wholly anecdotal experience, yes. if there wasn't the financial costs hanging over there heads there would be a lot more PCPs. I know many med students/docs who started with dreams of a family practice or being a rural doctor, Young Doctor's Notebook-style, but by the time they're out the culture and debt have pretty well smashed those.
It's not just paying off the base tuition either, it's the interest that really screws you.
posted by Anonymous at 9:46 AM on March 19, 2016
I teach biology at a college no one's ever heard of in a suburban area with a high poverty city on one side and rural areas on every other side. 20% of my students speak English as a second language. 60% are first generation college students. Every year, I mentor hard working students who are brilliant and compassionate and care deeply about their community and would love to go to medical school and then come back home and be a primary care doc in their immigrant community or their rural town. But it is quite rare for them to go to medical school because although they have done well in all their classes, they don't have a perfect GPA (a 3.5 won't cut it because it really matters whether you got a B in Calculus II if you're going to med school) and they don't have a huge range of extra-curricular activities because they work 20+ hours per week and care for siblings or grandparents or their own children.
These students know a ton about the real world and hard work and caregiving and have proven they can handle a work load that would completely exhaust me. But they can't compete in med school applications with the 4.0 from a fancy private college who has done cool volunteer work in developing countries and in research labs while also starting their own non-profit. And so my students, who are perfect candidates for and would love nothing more than to be primary care docs serving the communities they grew up in, are instead becoming NPs (or PAs if they have the clinical hours because that part time job was as an EMT) because those are the schools that will admit them.
posted by hydropsyche at 9:54 AM on March 19, 2016 [13 favorites]
These students know a ton about the real world and hard work and caregiving and have proven they can handle a work load that would completely exhaust me. But they can't compete in med school applications with the 4.0 from a fancy private college who has done cool volunteer work in developing countries and in research labs while also starting their own non-profit. And so my students, who are perfect candidates for and would love nothing more than to be primary care docs serving the communities they grew up in, are instead becoming NPs (or PAs if they have the clinical hours because that part time job was as an EMT) because those are the schools that will admit them.
posted by hydropsyche at 9:54 AM on March 19, 2016 [13 favorites]
I'm a third year medical student in the US. I worked prior to returning to medical school and I will agree with many of the previous posters that most doctors-in-training lack a perspective about what it's like for the rest of the working world. It's a dangerous echo chamber that leads to a culture of entitlement. With that being said, medical school and residency necessitates a frankly absurd amount of work and personal sacrifice. Yes, residents get paid around 50k a year. But you'd be hard pressed to find somebody who puts in more hours to earn that 50k. Most residents I know are working at or slightly above the maximum 80 hours/week. They then go home to read journal articles, prepare presentations, study for the boards, none of which counts against duty hours.
Does it have to be that way? I don't know. There are some medical schools who are already planning on having a three year curriculum as a fast-track to primary care fields. I think realistically what will happen is further expansion of mid-level providers like PAs and APNs. In part that's because the more APNs and PAs there are the less interest and motivation there is for an MD to become a PCP. Primary Care was pitched to me by the media and popular literature as the promise land of longitudinal relationships with patients, but more and more it seems like the job is fast becoming who can manage and oversee the most PAs and APNs. And given that more and more states don't even require MD oversight for prescription there is even less reason for MDs to go into primary care.
One of the biggest misconceptions many people (including myself prior to med school) have about primary care is that it is relatively easy or straightforward. Ha. Prescribing antibiotics? Not straightforward. Poor antibiotic stewardship is one of the biggest contributors to MRSA and VRE, etc. Hypertension management? Those drugs are complicated, and if you have any comorbidities like diabetes which, oh, you know a third of the country has, the possibility of doing harm is significant. Then imagine that you see 100 things that all look exactly the same but one of them is actually a ticking time bomb that you absolutely can't miss. This stuff isn't easily translatable to AI, either. It's messy and human and requires somebody who knows how to ask the right questions.
I left my family medicine rotation with tremendous respect for the MDs who go into primary care. I also met a ton of PAs and APNs who knew the practice cold, but most of them only got to where they are after years of experience before pursuing a masters. They were the same people who warned me about this new generation of nurses who were skipping working as an RN and instead going straight to becoming an APN.
At the end of the day, one of the things that medical school has hammered home is that preserving human health is really really complicated. It necessitates a sophisticated understanding of not only pathophysiology, but also human nature. I'm currently working with a breast cancer surgeon, and her understanding of tumor biology, chemotherapy, surgical practices and all the randomized control trials you can shake a stick at are only as good as her ability to explain it all to her patient, to help them make what is likely the hardest decision they've ever made. At the end of the day it really does necessitate a tremendous amount of training, and any short cuts that we take will lead to somebody receiving substandard care somewhere along the line.
Also, I've said this in previous threads, but to all the people who've had terrible experiences with physicians, I am so so sorry. There is nothing that makes me angrier than hearing about sub-standard care, especially when it's coming from an MD. I've met my fair share of "bad doctors", but I have a lot of hope because the medical students and residents I work with on a daily basis are some of the most amazing, compassionate, intelligent and caring people around. They are one of the many reasons why being a doctor remains the best job in the world.
posted by ghostpony at 10:16 AM on March 19, 2016 [7 favorites]
Does it have to be that way? I don't know. There are some medical schools who are already planning on having a three year curriculum as a fast-track to primary care fields. I think realistically what will happen is further expansion of mid-level providers like PAs and APNs. In part that's because the more APNs and PAs there are the less interest and motivation there is for an MD to become a PCP. Primary Care was pitched to me by the media and popular literature as the promise land of longitudinal relationships with patients, but more and more it seems like the job is fast becoming who can manage and oversee the most PAs and APNs. And given that more and more states don't even require MD oversight for prescription there is even less reason for MDs to go into primary care.
One of the biggest misconceptions many people (including myself prior to med school) have about primary care is that it is relatively easy or straightforward. Ha. Prescribing antibiotics? Not straightforward. Poor antibiotic stewardship is one of the biggest contributors to MRSA and VRE, etc. Hypertension management? Those drugs are complicated, and if you have any comorbidities like diabetes which, oh, you know a third of the country has, the possibility of doing harm is significant. Then imagine that you see 100 things that all look exactly the same but one of them is actually a ticking time bomb that you absolutely can't miss. This stuff isn't easily translatable to AI, either. It's messy and human and requires somebody who knows how to ask the right questions.
I left my family medicine rotation with tremendous respect for the MDs who go into primary care. I also met a ton of PAs and APNs who knew the practice cold, but most of them only got to where they are after years of experience before pursuing a masters. They were the same people who warned me about this new generation of nurses who were skipping working as an RN and instead going straight to becoming an APN.
At the end of the day, one of the things that medical school has hammered home is that preserving human health is really really complicated. It necessitates a sophisticated understanding of not only pathophysiology, but also human nature. I'm currently working with a breast cancer surgeon, and her understanding of tumor biology, chemotherapy, surgical practices and all the randomized control trials you can shake a stick at are only as good as her ability to explain it all to her patient, to help them make what is likely the hardest decision they've ever made. At the end of the day it really does necessitate a tremendous amount of training, and any short cuts that we take will lead to somebody receiving substandard care somewhere along the line.
Also, I've said this in previous threads, but to all the people who've had terrible experiences with physicians, I am so so sorry. There is nothing that makes me angrier than hearing about sub-standard care, especially when it's coming from an MD. I've met my fair share of "bad doctors", but I have a lot of hope because the medical students and residents I work with on a daily basis are some of the most amazing, compassionate, intelligent and caring people around. They are one of the many reasons why being a doctor remains the best job in the world.
posted by ghostpony at 10:16 AM on March 19, 2016 [7 favorites]
Yes, residents get paid around 50k a year. But you'd be hard pressed to find somebody who puts in more hours to earn that 50k. Most residents I know are working at or slightly above the maximum 80 hours/week.
The U.S. has the most dysfunctional medical training system in the world. In the European Union residents are limited to 48 hours a week and studies have shown no reduction in patient care or doctor proficiency.
The reason for the long hours in the U.S. is primarily financial. Hospitals can reduce costs by having residents work long hours for no extra pay. But this is under the control of the AMA. Why don't they fix it? That is because established doctors benefit from this system because the less money that goes to residents, the more available for board certified specialists. And there is a continuing tradition like fraternity hazing. "I had to do it so so should they" even if this abuse serves no useful purpose.
posted by JackFlash at 10:55 AM on March 19, 2016 [5 favorites]
The U.S. has the most dysfunctional medical training system in the world. In the European Union residents are limited to 48 hours a week and studies have shown no reduction in patient care or doctor proficiency.
The reason for the long hours in the U.S. is primarily financial. Hospitals can reduce costs by having residents work long hours for no extra pay. But this is under the control of the AMA. Why don't they fix it? That is because established doctors benefit from this system because the less money that goes to residents, the more available for board certified specialists. And there is a continuing tradition like fraternity hazing. "I had to do it so so should they" even if this abuse serves no useful purpose.
posted by JackFlash at 10:55 AM on March 19, 2016 [5 favorites]
On top of that all of them are facing down $300k+ of student loan debt by the end.
The median student debut for graduating doctors in the U.S. is $170,000. If you have $300K of debt, you are doing it wrong.
For all the complaints about the burden of debt for doctors, as a percentage of disposable income at graduation, it is no more than for graduates in less lucrative fields of study. Any reasonably frugal doctor can pay off their debts within a few years of finishing while for those in other fields it can take decades.
The reason doctors go into high paying specialties is not because they are forced by student debt. It is simply because they can.
posted by JackFlash at 11:05 AM on March 19, 2016
The median student debut for graduating doctors in the U.S. is $170,000. If you have $300K of debt, you are doing it wrong.
For all the complaints about the burden of debt for doctors, as a percentage of disposable income at graduation, it is no more than for graduates in less lucrative fields of study. Any reasonably frugal doctor can pay off their debts within a few years of finishing while for those in other fields it can take decades.
The reason doctors go into high paying specialties is not because they are forced by student debt. It is simply because they can.
posted by JackFlash at 11:05 AM on March 19, 2016
I can't see any good reason that people should have to pay to attend medical school, when academic grad school is often funded.
Residency is funded by taxpayers. The government hands $100,000 per year to residents, half of which they get as salary and half of which pays for their training. A surgery resident is given $500,000 by taxpayers so that they can get the training to more than double their salary from $150,000 to $350,000 per year. There is no other profession that is subsidized by taxpayers to this extent to provide higher salaries.
posted by JackFlash at 11:16 AM on March 19, 2016 [3 favorites]
Residency is funded by taxpayers. The government hands $100,000 per year to residents, half of which they get as salary and half of which pays for their training. A surgery resident is given $500,000 by taxpayers so that they can get the training to more than double their salary from $150,000 to $350,000 per year. There is no other profession that is subsidized by taxpayers to this extent to provide higher salaries.
posted by JackFlash at 11:16 AM on March 19, 2016 [3 favorites]
I think MD-PhD students are normally funded like PhD students, so if you're good enough to do serious research while doing your MD, then you could take that route. It's assumed you'll stay largely in research, but It's okay to change course and do a normal residency if you find yourself ill suited to the researcher life.
posted by jeffburdges at 11:46 AM on March 19, 2016 [1 favorite]
posted by jeffburdges at 11:46 AM on March 19, 2016 [1 favorite]
Median debt is much lower than the sticker price partly because of financial aid, but also because a huge fraction of medical students come from well off families. To pick an example that I've never been affiliated with, UNC for out of state students costs about $51k/year just for tuition. Add in the cost of keeping body and soul together, licensing exams, and applications getting to a $300k outlay is easy.
MD-PhD programs are generally funded because otherwise the cost would be outrageous to the student. Those going into research are already sacrificing future income (research pays less than private clinical work); the lost income of 4-5 years in a PhD program + postdoc time is quite substantial, say $200k x 6 years. It's quite a bit worse than the $300-$500k they're getting up front.
Taxpayers fund GME, but IIRC the cost is no worse than having attending physicians do the same work. It's a bit complicated because resident physicians do actual work that otherwise the hospital would bill for.
posted by a robot made out of meat at 12:01 PM on March 19, 2016
MD-PhD programs are generally funded because otherwise the cost would be outrageous to the student. Those going into research are already sacrificing future income (research pays less than private clinical work); the lost income of 4-5 years in a PhD program + postdoc time is quite substantial, say $200k x 6 years. It's quite a bit worse than the $300-$500k they're getting up front.
Taxpayers fund GME, but IIRC the cost is no worse than having attending physicians do the same work. It's a bit complicated because resident physicians do actual work that otherwise the hospital would bill for.
posted by a robot made out of meat at 12:01 PM on March 19, 2016
As an aside, there is a visible personality difference between doctors in Europe, who do not pay far medical school, and American doctors who do. American doctors come off as more ambitious, while the Europeans come off as more serious and trustworthy.
American RNs do not come off that way. I suspect America has many good potential MDs who pursued another career path, like RNs, engineers, etc., simply because their family background did not instil in them the financial risk taking required for medical school. In Europe, a career choice between MD or RN would be determined almost entirely by your grades, not any predisposition towards financial risk taking.
It's actually the "sticker price" of medical school that matters here, not the final masked price. And American MDs come from rich families not just because the family can pay but because the family teaches them to take the risk.
posted by jeffburdges at 12:02 PM on March 19, 2016 [3 favorites]
American RNs do not come off that way. I suspect America has many good potential MDs who pursued another career path, like RNs, engineers, etc., simply because their family background did not instil in them the financial risk taking required for medical school. In Europe, a career choice between MD or RN would be determined almost entirely by your grades, not any predisposition towards financial risk taking.
It's actually the "sticker price" of medical school that matters here, not the final masked price. And American MDs come from rich families not just because the family can pay but because the family teaches them to take the risk.
posted by jeffburdges at 12:02 PM on March 19, 2016 [3 favorites]
Err, I meant to say: American doctors come off as more financially ambitious.
posted by jeffburdges at 12:07 PM on March 19, 2016
posted by jeffburdges at 12:07 PM on March 19, 2016
And American MDs come from rich families not just because the family can pay but because the family teaches them to take the risk.
I don't know if it's so much "teaching" them to take the risk as it is enabling them to take the risk. It is a hell of a lot easier to take financial risks if you know you've got a network of family/friends who've got your back, over a network of family/friends who are barely holding on or you may even be supporting yourself. Not to mention what hydropsyche says about kids with fewer resources just not having the access to extracurriculars and academic help that one does in a better financial situation.
posted by Anonymous at 12:17 PM on March 19, 2016
I don't know if it's so much "teaching" them to take the risk as it is enabling them to take the risk. It is a hell of a lot easier to take financial risks if you know you've got a network of family/friends who've got your back, over a network of family/friends who are barely holding on or you may even be supporting yourself. Not to mention what hydropsyche says about kids with fewer resources just not having the access to extracurriculars and academic help that one does in a better financial situation.
posted by Anonymous at 12:17 PM on March 19, 2016
I wholeheartedly agree with the "sticker price" phenomenon. It's one of the reasons why loan forgiveness programs just don't seem to be all that successful or popular.
One of the more interesting propositions I've heard of involves medical students applying to MD via two tracks, and that if you choose to pursue primary care you pay no tuition. No one would stop you from switching from primary care to a specialty, but if you did you would owe all the tuition, plus some sort of added financial penalty to cover interest.
Something along these lines used to exist via the federal government. It was the National Health Service Corps (NHSC) but it required a complicated application, and not everybody who applied could get it. They scrapped the upfront scholarship and switched to a less favorable loan forgiveness model.
Complicating all this is that as more and more students graduate with larger amounts of medical school debt it only further polarizes future physicians towards financial self-preservation, which likely explains the AMA's reticence in tackling these issues (who as it happens started this whole debacle when they first lobbied to limit the number of residency slots as a protectionist measure in the 80s).
I will confirm that most people in medical school come from a background that either A. is financially secure enough to tackle the upfront cost of medical school, or B. recognizes that the reward of securing an MD far outweighs the financial risk of heavy debt burden. I would argue that 85% of my class are either the children of well-educated immigrants, or the children of doctors (often both).
A huge issue in encouraging people from different backgrounds to apply to medical school is just the astounding upfront cost of applying. You have to apply to 15+ programs at $100 a pop (some will waive if you're of a lower economic status), you have to interview EVERYWHERE on the dates that they set (>$2000 in travel costs) to have a decent shot, and that's before you even have the privilege of learning how astonishingly expensive the next four years will be. And if I recall correctly, even if you save judiciously and have leftover federal student loans you're not allowed to use them for this purpose (same applies for med student loans and residency interviews).
posted by ghostpony at 12:26 PM on March 19, 2016 [2 favorites]
One of the more interesting propositions I've heard of involves medical students applying to MD via two tracks, and that if you choose to pursue primary care you pay no tuition. No one would stop you from switching from primary care to a specialty, but if you did you would owe all the tuition, plus some sort of added financial penalty to cover interest.
Something along these lines used to exist via the federal government. It was the National Health Service Corps (NHSC) but it required a complicated application, and not everybody who applied could get it. They scrapped the upfront scholarship and switched to a less favorable loan forgiveness model.
Complicating all this is that as more and more students graduate with larger amounts of medical school debt it only further polarizes future physicians towards financial self-preservation, which likely explains the AMA's reticence in tackling these issues (who as it happens started this whole debacle when they first lobbied to limit the number of residency slots as a protectionist measure in the 80s).
I will confirm that most people in medical school come from a background that either A. is financially secure enough to tackle the upfront cost of medical school, or B. recognizes that the reward of securing an MD far outweighs the financial risk of heavy debt burden. I would argue that 85% of my class are either the children of well-educated immigrants, or the children of doctors (often both).
A huge issue in encouraging people from different backgrounds to apply to medical school is just the astounding upfront cost of applying. You have to apply to 15+ programs at $100 a pop (some will waive if you're of a lower economic status), you have to interview EVERYWHERE on the dates that they set (>$2000 in travel costs) to have a decent shot, and that's before you even have the privilege of learning how astonishingly expensive the next four years will be. And if I recall correctly, even if you save judiciously and have leftover federal student loans you're not allowed to use them for this purpose (same applies for med student loans and residency interviews).
posted by ghostpony at 12:26 PM on March 19, 2016 [2 favorites]
God, that reminds me of applying to grad school. Applications were $50-$100. I was extremely poor then and basically limited my applications to places that had fee-waiver programs (which was quite a few, thankfully), but many of those still required me to put up the cost upfront and then would reimburse me at least a month or so later. When I later attended interviews I noticed a direct relationship between how serious a program was about attracting diverse candidates and how easy it was to get a fee reimbursement. The most serious ones didn't have a fee at all.
Here's the thing though: once you got an interview the school paid for travel costs and everything else, including any food you brought while traveling. I was gobsmacked to find out the med school applicants were paying for all that.
Oh, and of course then there's the difference in the cost of the GRE versus the MCAT ($160 vs. $300) and how much more MCAT prep classes and med school guidebooks and all that costs in comparison to simple grad school. Oh, and if you have bad credit your admission can be deferred. I knew I wasn't cut out for med school, but I wouldn't have even been able to afford it if I was.
posted by Anonymous at 12:43 PM on March 19, 2016
Here's the thing though: once you got an interview the school paid for travel costs and everything else, including any food you brought while traveling. I was gobsmacked to find out the med school applicants were paying for all that.
Oh, and of course then there's the difference in the cost of the GRE versus the MCAT ($160 vs. $300) and how much more MCAT prep classes and med school guidebooks and all that costs in comparison to simple grad school. Oh, and if you have bad credit your admission can be deferred. I knew I wasn't cut out for med school, but I wouldn't have even been able to afford it if I was.
posted by Anonymous at 12:43 PM on March 19, 2016
Mitheral:
It works similarly in the US:
1) ABET-accredited undergraduate degree (3-years minimum, 4-years typical)
2) FE exam (6-hours)
3) Work as an EIT under a PE for a set amount of time (4-years typical)
4) PE exam (8-hours)
posted by teatime at 1:24 PM on March 19, 2016
It works similarly in the US:
1) ABET-accredited undergraduate degree (3-years minimum, 4-years typical)
2) FE exam (6-hours)
3) Work as an EIT under a PE for a set amount of time (4-years typical)
4) PE exam (8-hours)
posted by teatime at 1:24 PM on March 19, 2016
There is absolutely not a shortage of qualified medical school applicants. Med schools are turning away scads of people who would have easily been admitted 25 years ago.
I could be wrong but I think the biggest reason only so many people are admitted to medical school every year is the availability of residency slots. If a medical school admissions team is not confident that you are likely to get a placement in a residency program at the end of four years, you're not likely to be accepted. If there were more residency slots available, there would be more doctors a few years later.
posted by kat518 at 3:46 PM on March 19, 2016
I could be wrong but I think the biggest reason only so many people are admitted to medical school every year is the availability of residency slots. If a medical school admissions team is not confident that you are likely to get a placement in a residency program at the end of four years, you're not likely to be accepted. If there were more residency slots available, there would be more doctors a few years later.
posted by kat518 at 3:46 PM on March 19, 2016
The AAMC has actually really beefed up its fee assistance program, schroedinger. On the other hand, the assistance doesn't cover some pretty big expenses, like the cost of traveling to interviews and buying an interview outfit. Also, while they do provide some free MCAT prep materials, most successful applicants take an MCAT prep course, and those things cost more than a thousand dollars. So even with generous fee assistance, poor applicants are still at a pretty big disadvantage.
My sense is that the AAMC would really, really like to increase the economic diversity of the applicant pool and of accepted students. And I don't think that economically disadvantaged kids are put off by the sticker price. If anything, I think that pre-med students are disproportionately from first-generation and economically-disadvantaged backgrounds. I think the barriers are more the things that hydropsyche mentioned: they have to spend more time working for pay, they have fewer opportunities for fancy resume-padding activities, they often have worse academic preparation and therefore lower grades, and they don't have as good sources of information about what makes people competitive for medical school.
posted by ArbitraryAndCapricious at 3:53 PM on March 19, 2016
My sense is that the AAMC would really, really like to increase the economic diversity of the applicant pool and of accepted students. And I don't think that economically disadvantaged kids are put off by the sticker price. If anything, I think that pre-med students are disproportionately from first-generation and economically-disadvantaged backgrounds. I think the barriers are more the things that hydropsyche mentioned: they have to spend more time working for pay, they have fewer opportunities for fancy resume-padding activities, they often have worse academic preparation and therefore lower grades, and they don't have as good sources of information about what makes people competitive for medical school.
posted by ArbitraryAndCapricious at 3:53 PM on March 19, 2016
schroedinger: Here's the thing though: once you got an interview the school paid for travel costs and everything else, including any food you brought while traveling. I was gobsmacked to find out the med school applicants were paying for all that.
That's so weird considering most grad programs pay so little you might actually qualify for public assistance.
posted by Mitrovarr at 10:50 AM on March 20, 2016
That's so weird considering most grad programs pay so little you might actually qualify for public assistance.
posted by Mitrovarr at 10:50 AM on March 20, 2016
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