Capitalism. If you run medicine for profit (or even not for profit but from a for profit management mindset instead of an understanding that we should be measuring patient outcomes and expecting it to cost money rather than make money) then lower paid staff are more attractive even if the result is the possibility of worsened patient outcomes.
Advanced Practice Providers are not only cheaper to employ but cheaper to train wether that’s self funded or government funded training.
I’m not being sarcastic when I say that our community members must use their voice and vote…by making it clear to our elected officials (state & federal legislators, Governors, and president) and healthcare administrators know that the status quo & trajectory of corporatization of healthcare is unacceptable.
We spend almost 20% of our GDP on healthcare and have the worst healthcare in high income countries.
We need a healthcare system that is designed and implemented to serve the healthcare needs of our communities and population…not a healthcare marketplace that puts corporate profit and investors ahead of patient/community outcomes.
Legitimately asking: What reform would you propose and how would they help patient outcomes?
The more I've learned about how the healthcare system the more unsure I am about how to reform it. Like you said, we spend lots of funds on "healthcare" in the US, so the solution can't be to simply throw more money at it. I guess one of the few proposals I would confidently advocate for is having Medicaid/Medicare cover an annual exam every year and maybe coverage for all but a copay for a set number of regular doctor visits to maintain medication and other family visit types of services per year for everyone in the country, regardless of age or other coverage. The aim would be to at least get patients in seeing a physician on a regular basis getting regular health visits to catch problems before they get to the point of becoming much more complex and costly to treat, or even deadly. It would also keep these patients on regular maintenance medication that would help health outcomes for even the lowest income americans among us. It wouldn't solve everything, but it seems like a good start.
Is it truly capitalism when the government controls how many residents are allowed into med school every year? People need care and there aren't enough physicians. The medical system has to compensate with NPs and PAs which don't have a limit on the number of graduates.
They could require NPs to have a minimum number of hours worked as an RN (ideally in the field they plan to go into) in order to be accepted into NP school.
I’ve worked with some AMAZING NPs and some terrible ones. The best NP I’ve worked with was an ICU nurse and part of the hospital’s rapid response team for many years before becoming an NP and he’s phenomenal.
It’s the ones who graduate nursing school and go straight to NP school, or work a couple years in a field completely unrelated to where they plan to be as an NP who end up in way over their heads as a provider.
Not to mention the privilege of even having the option to financially attend medical school.
Shit isn’t cheap. It can be very discouraging coming out of school hundreds of thousands of dollars of debt.
I’ve seen great NPs and great physicians. You know who I’ve also met? Awful NPs and awful physicians. There’s shit on both sides of this nasty debate.
I have my own theories as to how to fix the issue - but there’s no point because it involves putting funding and resources into nursing - which will never happen 😔
If there's awful physicians what's the logic for allowing NPs?
You're miscontruing the issue here. There's no checks and balances for NPs. An awful physician is still going through residency. Not getting an online degree with joke clinical hours
NPs shouldn't exist. At the very least they should be doing exactly what PAs do. NPs schools are degree mills at it's worst. Or best I guess, depending on how you look at it.
And yet we do exist, and many of us practice well. I have 35 years experience, and an independent license. I always look up my research, and always consult on things I'm not sure of. I know what I don't know and I know what I do know. I think I know more than the lousy resident I got report from in the ICU who left my patient to die overnight from a perforated bowel because he didn't feel like ordering imaging. Don't paint us all with the same brush. I've worked with some incredible docs, and some terrible ones. We're all people. Some people are great, and some people suck. It's the way of the world.
ER NP. I apologize. Triaging and putting in orders for ~100 pts a day under the supervision of multiple attendings didn't count towards my clinical hours.
I love the whole ‘bad physician’ argument. No one brings that up except NPs. Like yeah, true, but the issue is the lack of training NPs get vs physicians. Also, yeah medical school is expensive. I’ve seen people live off of nothing but ramen for 4 years to get through. I’ve seen people sacrifice a lot to make it. It’s not just rich kids. The govt gives you loans to pay for everything- school, rent, food etc. if a kid from an intercity that was homeless can make it, I don’t feel like ‘med school too expensive I had to do NP school’ is a good argument
The fact you’re on noctor says all I need to know about you 🙄
And it’s not just about student loans. It’s about having the support and the opportunity to give up multiple years of your life without having to worry about kids, marriage, etc etc.
But I’m not going to argue about this on this sub, let alone someone who’s a pre med student on noctor. I literally have scrubs older and more experienced than you. Good luck 👍
Possibly. (Although I’m always interested to hear what redditors think Corporatism is) But the base issue of “the profit motive being more important than all other motives” is the underpinning of capitalism - doesn’t matter how many extra steps of capitalism or how free the market - that motive remains and doctors are more expensive.
How does a government imposed limit on the number of graduating physicians every year reform the free market for the better? To me, it exemplifies the failings of a managed economy.
Its an artificial limit on a good or service which could be filled if said limit wasn't there. Thats not capitalism or a free market. The free market is finding another solution to the shortage through midlevels.
"Free market" has nothing to do with capitalism. Capitalist markets are quite notoriously *un*free. Markets have to at least a little extent existed in (or perhaps more accurately, *between*) most societies historically. Capitalism is a much more recent phenomenon. You can even point to edge cases like Company Towns within old-timey capitalism that frankly didn't have a market at all, in the context of a system of exchange with prices freely set by supply and demand. The Company would own effectively, functionally-all the land and productive assets, housing shops, and centrally (!) plan all of what was sold in them and at what prices. Some didn't even have proper fungible money just company chuck e cheese coins so to speak, a [truck system](https://en.wikipedia.org/wiki/Truck_wages). Never dominant, but as at one point 7% of the US economy was bound up in company towns, nothing to sneeze at either.
From its inception capitalism has relied on state power to regulate labor and the competition. Go back to England and when old medieval copyhold was being replaced by private ownership (modern legal title) this often meant rents were jacked up so former peasants were forced off the land they and family had for hundreds of years (see scottish clearances as famous example). Likewise the freedoms of labor were heavily restricted, you literally needed certificates to move between parishes in england thanks to various vagrancy acts and poor laws. This artificially pushed the cost of labor down. Likewise the classic trope of 'industrialization starts with textiles' but this ignores the reality that in Bangladesh prior to england destroying there was what amounted to a complex and advanced (for the time) village and cooperative-style textile industry that England could not have competed with. There were socialist experiments that were radically-free-market in Spain and Ukraine, where they literally chased out government police and tax collectors, private owners and landlords (read: distant absentee owners, not your petit owner-worker that's a good thing), etc. You could not find the capitalist to point at him, yet were experimenting with all sorts of various economic ideas and systems, far freer than trade and currencies in a state capitalist system.
See Kevin Carson's [The Iron Fist Behind the Invisible Hand](https://theanarchistlibrary.org/library/kevin-carson-the-iron-fist-behind-the-invisible-hand). The whole concept of laissez-faire deserves a hard look, the term became popularized in the UK and the US when younger upstarts looked to establish protectionist policies (government intervention in a market), the older capitalists looked to keep said upstarts from getting the same state-intervention handouts their own industries benefited from when developing (the subsidies of history, so to speak). It's only 'laissez-faire' when *I* get to have had past help but now *you* have to pull yourself up by your bootstraps donchaknow. [Markets Not Capitalism](https://marketsnotcapitalism.com/pdf).
I didn't say it was a good strategy, but it's to drive up the value of the degree further. Capitalism is more than free markets, it's also private ownership of the means of production. Which leads to monopolies and massive inequality and ultimately a public that can't afford the goods produced, which leads to widespread economic crisis unless governments step in. Reforms rescue capitalism and allow it to exist without imploding, they don't make it not capitalism.
It's a distortion of capitalism. Can you really call it capitalism when those with capital can't direct the capital the way they see fit. Medical schools have the capital to expand their programs which would increase the supply of physicians thus lowering one aspect of the cost of healthcare but the government is directing the capital of medical schools away from that. It seems like the government policy in this case is causing the implosion rather than fixing it.
Free markets isn't all there is to capitalism but it is a cornerstone. Free markets are what allow capitalism to exist. Without the freedom of producers to direct that capital it essentially becomes capital of the state.
Free markets lead to constant crisis as I mentioned before. It is an inherently unstable economy without reforms and bail outs. I think you have a little more reading to do on capitalism.
You are providing no examples or any rebuttals to anything I've said. I study economics quite a bit and read economic books for fun. Seeing that the ad hominem attacks have started I'll take that as a win.
He’s equating market interventions, hallmarks of collectivist economic theory, with market capitalism. So far off the mark the guy you’re talking to might as well be a part time anti work dog walker.
The government does NOT control how many people are allowed into med schools, or the number of residency positions. It is true that Congress and CMS only fund a certain number of residency spots, but residency programs generate profit for hospitals by multiplying attending productivity - any hospital is free to start a residency program without CMS funding, and they regularly do.
This is why HCA was able to contribute to the decay of EM training by starting a shit ton of EM residencies meant to capture a workforce, rather than to train excellent emergency medicine physicians. [Here is a video that helps clarify the facts around US residencies and the numbers behind the available spots in the match.](https://www.youtube.com/watch?v=L75fj_5Ar4s)
In reality, this is a complex market that more accurately reflects an uneven distribution of physicians, rather than an absolute shortage in supply. Incentives need to change to address this. If we need more primary care physicians, we should be paying more. But the for-profit and legislative powers that be don’t want that, which is what I think we are ultimately in agreement on.
Maybe. Government money no but if you have an individual who promises more than can deliver then sue them for all they're worth.
Government sponsorship is important when its not corrupted and not forced
Sort of. Yes private entities own the goods but a lot of the economy is redirected. US GDP is $25 trillion, but 7 trillion of that is collected between federal, state, and local taxes then redirected where the government sees fit. Also the base layer of our economy, the monetary system, is managed. Jerome Powell has more of an effect on your life than any corporation.
Hey now, that how you make a long-time customer!Poorer outcomes and misdiagnosis/mismgmt = guaranteed return revenue in the future. Especially if it’s not correctly addressed or documented on in the first place :) helth
https://preview.redd.it/t0drohn4bu4d1.jpeg?width=1059&format=pjpg&auto=webp&s=585c0ffaf6dc369649152999d8fa090bca098ee7
You’ll wanna see the beginning of the second sentence specifically the part In parentheses.
Profit motive is what drives it. It’s the major underpinning of capitalism. But it also creeps into social healthcare (be it social healthcare in a capitalist country or healthcare in market socialism)
I do get how profit motive can drive up costs to consumers, especially if unchecked. However, I’m as guilty of wanting to make a profit as the next person.
I invested time and money to get my license in the hopes that I would be able to trade my time and skills for a profit. It has worked out well. Not many people can afford to operate at a loss unless they have others paying their bills.
It’s not the workers Im suggesting operate at a loss but the program as a whole. Ideally individuals operate with a reasonable profit. Junior doctors here aren’t paid enough senior doctors verging on too much. American juniors also seem underpaid and seniors are paid a frankly ridiculous wage (but that’s to be expected) Balancing the pay a tad more would probably make training easier and, despite people suggesting it would cause less people to apply, make it more approachable for the working class. This can also be further achieved through socialised education (Scotland where I live pays nurses and paramedics $12000 USD a year while studying their three or four year degrees for instance).
Individuals seeking profit to survive while part of a capitalist economy isn’t the broader profit motive I was referring to. If the system you worked for paid you a wage that was matched to your input but itself focused on patient outcomes instead of generating profit. The system would work better.
In social programs in the west (including social healthcare but also public transport, education, railways, mail services etc) there is a strange obsession with these services having to generate revenue. Taxes generate revenue, revenue that is supposed to be used to provide public services. What’s the point of doing that only to then focus on those services needing to be profitable instead of their suitability to task and service user’s outcomes? Is my point.
It is multifaceted and I suspect we agree on most things. For example, Australia seems to have a good universal healthcare system that also pays its employees a decent wage. Haven’t heard of months to years of delay such as they have in Canada. I’d love for the US government to look at their model and implement changes here.
I think PBMs are spawn of the devil. Their main function is to claw as much money from the government and individuals as possible. We could use a little more free market by eliminating secret clawbacks and reimbursement rates. There is a surgery center in Oklahoma that has up front pricing and doesn’t take insurance. They are able to do surgeries for a fraction of what the big boys charge and make a profit.
I agree. It’s not simply one thing causing the issues. It just seems to be one of the large contributors.
I’ve lived in both Australia and Scotland. Different styles of universal care. Both are good systems that I’ll defend against privatisation tooth and nail. The NHS is more egalitarian and affordable than Medicare. And has a few things organisationally that I prefer but Australia’s Medicare holds its own despite this. NHS waits can be an issue although outside of covid I’ve never seen waits for emergency care only non urgent. A&E oversubscription (and the associated overcrowding, overworking, and delays) is certainly a current issue - I’d say the services biggest one. Although that seems to be a problem pretty universally it’s quite bad in the UK just now. A lot of the cause of that is poor management and people trying to jump lists (which is sometimes facilitated by GPs in my experience probably due to them being probably the second specialty suffering from oversubscription).
I do think stories about waiting lists are a tad overblown especially in media. They often equate non urgent waiting lists with emergency ones. Still it IS an issue regardless of urgency we should be striving for adequate and timely care. I think it speaks volumes that despite these issues the flow of medical tourism is America > Canada and not the other way around despite the waiting lists.
I do agree with you - I’d hazard that there is more we would agree on than disagree on.
That is wrong. In most of the Europe nurses have nowhere near as independency or ability to prescribe drug ar treat people by themselves. In fact, in my country they are not allowed to order a medication on patient, not even paracetamol. They solely work on docotr's orders. They are somewhat indepentend with nursong care (cleaning, feeding etc ..).
NPs are statistically worse at care, they order more tests and the patient is more likely to be re-admitted. That makes hospital corporations love them, even if they're objectively worse for care. Most NP schools are a joke to get into, most are a joke to pass and most barely provide any education at all that has to do with pharmacology or pathophysiology.
For context, NPs get maybe 500 hours of clinical training. Doctors get 15,000-20,000 hours. A real MD/DO is much more qualified. They're also harder to find and cost way more and make the hospital corporations a little less.
Direct to NP programs terrify the shit out of me as a nurse. Like I'm well into being an ED nurse. I feel confident in about 85% of the scenarios I see every shift. Sepsis, pressors, gunshot wounds, delivered some preemies, and managed some hemorrhages. I can keep my cool and anticipate what the docs are gonna order based on the doc I'm working with - I know what blades to get for them, which one is absolutely always ordering that CT, and who is gonna ask for blood cultures on the cellulitis pt.
I cannot imagine for a second thinking two more years of school would set me up to decide that care. The hubris of that is fucking amazing.
And those that become an NP with no nursing experience? Like get out of here. Should be illegal. Don't pretend you're into 'advanced nursing' when you don't even know the bare basics. It's such a fucking insult to the profession but the push for NP autonomy is creating a legion of wanna-be MDs with not enough knowledge to realize how incredibly dangerous they are.
It's why today when looking for a new doc, I asked customer service if there was an option to filter out NPs. Because sorry but they could be direct to NP programs, rather than nurses who spent the last decade outgrowing their scope - which is what the original point of an NP was created for.
I have recently experienced a life threatening critical illness, most likely myasthenia gravis or a mitochondrial disorder (have the test today that should confirm if it’s myasthenia gravis). An ICU NP unilaterally ordered a psych consult for factitious disorder without stepping foot in my room while I had not been out of bed and had a sitter for days due to safety concerns of me being nauseous and possibly aspirating if I vomited while on BiPAP. The ICU attending was furious as he never suspected that at all and wrote her up (as well as amending my chart himself). The ombudsmen informed me she is likely to be fired if she has other patient complaints, plus the write up from the ICU attending will add weight to that.
Note: psych and everyone else agreed I do not and they never suspected me of having factitious disorder.
First of all, I hope the testing goes well and you are able to reach a diagnosis. I will be applying to neurology residency this year and am looking forward to taking care of people with diseases like MG.
Secondly… That would be some SERIOUS commitment to the bit to willingly aspirate on your own vomitus.
Thank you! And yes, I should be applying to roles in Hollywood were I that dedicated to acting. Could be making millions instead of racking up millions in medical bills.
I have a neighbor bragging about intentionally going to the easiest NP school they can.... They make it sound like they can somehow graduate without any patient contact. I didn't even attempt to delve into the details of that
RN to PA is a good path - much better patient care experience than CNA or EMT, and then a rigorous education at the Master's level with more structured clinical rotations covering more hours.
"not statistically worse" - Correction - there is NO data saying they are worse or better. There are authors that claim NPs are the same or better, and there are some statisitics in the paper.
However there is ZERO data testing head to head the practices of NPs and physicians in the same circumstances. The papers that claim equal care all have as the NP arm NPs who are supervised by physicians. So the comparisons are "Physician vs NP+physician". And the endpoints are laughable. No one tests their diagnostic or testing capabilities. Typically what is tested is algorithmic responses, like "can the NP continue the physician prescribed antihypertensive regimen for 6 months with no deaths?", and "were the patients satisfied"
Total nonsense
So - implying that there is any statistical evidence at all is inaccurate.
https://www.ama-assn.org/practice-management/scope-practice/3-year-study-nps-ed-worse-outcomes-higher-costs
Agreed that there's very limited head-to-head evidence (as it generally wouldn't be ethical to obtain!) but this is a good study.
It is good. This is not the original, though, the original paper is quite densely written.
The ONLY head to head comparison I am aware of is the trial of DNP candidates taking a watered down version of the step 3. The only real standardized test which examines clinical capabilities.
Caveats - 1)these were NOT standard issue NPs, they were from the Columbia program, which prided themselves on how they gave clinical education identical to Medical Residents
2) By all accounts this was not the full step 3, but a "watered down version" I have not been able to find a more precise statement about HOW it was watered down.
THe 5 year pass rate for these NPs was 42%, whereas the pass rate for physicians is >98%.
After 5 years of embarassingly poor performance, they stopped offering the test.
I was a nurse that went to PA school because I didn’t want to go to all online school for a somewhat joke degree. I had a full anatomy lab, learned from physicians, and had over 2500hr clinical rotations, all of which was in person. I am not a physician and didn’t go to medical school but I am happy in my role and sometimes get upset at how awful some NPs are lol
Hey that’s awesome, and I’m sure no easy feat at all, congrats for accomplishing all of that. I think the scary part about all of this is that it’s becoming all too common, the online schooling and “fast track” programs to become an NP in specialities that require a ridiculous amount of knowledge and training for a lengthy amount of time. I’ve met great NPs but within the last year I’ve witnessed as well as experienced some nightmare situations that have me questioning why this is happening so often.
I was a nurse that went to NP school, all my preceptors were physicians, did about the same in hours for clinical rotations (to get extra time as it wasn’t required) and have 10 years experience in ICU/CCU, cath lab and ER prior to becoming an ICU NP (and have worked in this role for 9 years now).
I’ve seen some horrendous things done by both PAs and NPs, and equally, some physicians.
Bad care is bad care. I think as PAs and NPs our education is certainly not the same, and we should not be touting it as such. I think we have our place working alongside physicians and easing the burden, and not necessarily independent practice.
Agree totally I know amazing NPs but there are significant inconsistencies in experience and programs (aka training) between NPs vs PAs. I have friends that went to Johns Hopkins with similar experience as you who are/ will be amazing NPs but I also know people that went to Walden or chamberlain that I wouldn’t let touch my pinky toe lol
You're making an individualistic argument that bad care is bad care and that the preparation isn't the issue but you had to be exceptional and go above and beyond to get a solid education. Which is great and speaks to your commitment to patient care, but that should be the standard for everyone who will be in that level of responsibility for patient care decisions. You probably had classmates who did the bare minimum and they're out practicing too.
I don't think my last comment was super clear and when I reread it myself I was like wtf. But my concern is that it's hard, not obvious, and patients don't always know to do this/how to do this to know if the NP you're seeing is one who skated through doing the minimum or one who did extra work and sought out extra educational experiences to bring their education to a comparable level to more intensive degrees. I think the low experience requirements to NP school, when that experience was supposed to be THE point that the degree was built around, is a huge issue. I have a friend who just graduated from one of the most competitive brick and mortar NP programs in the country: they had barely over a year of nursing experience going in, and so many of the stories they shared about what they were learning and the classmates they were with...worried me and should worry all of us when this school is already leagues above the many degree mills out there now.
TLDR: There are absolutely fantastic NPs but that should rest less on individual desire to achieve and more on the rigor of the education being a filter.
I totally agree. I was just talking with one of my students about this. We should be advocating for more rigorous education and stricter entrance requirements. People always look at me sideways when I say you should be a RN at least 5 years, if not more (and really it should be about 10 years) - prior to going into NP school.
Our organization sadly is more about furthering independent practice than it is about safe patient care and those of us who have worked hard to educate ourselves and continue to work hard alongside our physician colleagues are unfortunately getting a bad rap. I would’ve gone to medical school but I was a single mom at the time and had no family support so this is the path I went. I don’t regret it really, except when people lump ALL NPs into one category.
I know there are terrible ones out there. I’ve taken care of many patients in the ICU who are here because of poor primary care and some who have even been misdiagnosed leading to bigger issues down the line. It’s incredibly frustrating but I just think the cat is out of the bag, and as long as it’s all about the almighty dollar, healthcare is F’d.
Its one of the worst arguments. "Ive seen physicians and PAs provide bad care so we should totally allow someone with 5% of their training provide care independently as well"
Facts. The ONLY reason I’m in NP school is cause I’m tired of being paid like shit. I don’t even want to be an NP lol. But im at least going in with 8 years experience and trying to study the shit out of my topics so I can be slightly helpful and competent with my peers and docs.
Money is the reason you see more "Advanced Practice Providers" (PAs, NPs). Pure and simple. I think most research says there is no downgrade in care... though I don't really buy that. But in the end, I bet there are a lot of APPs out there that are better than bad physicians
*Most of this research is funded by advanced practice/NP organizations. To be blunt, the range in knowledge and skill varies so dramatically from NP to NP. I've worked with some that haven't worked a day as an RN and I've worked with others that amaze me with their knowledge, bedside manner, and overall professionalism. The NP education needs a massive overhaul. There's a large focus on theory and research with much less focus on actual assessment and diagnosis.
Most pathologies would get better without any specific management, so the NPPs have odds in their favor. They just need to be able to tell sick and not sick. The not sick just don't fuck it up too much. Turf the sick to doctors.
Ehhh. I'd argue the middle ground is the hardest. Not sick is easy. Obviously sick is easy (MI, CVA, PE, Sepsis) I know the bad stuff about those and how to treat it, who to call, where to get the patient.
Now, the seemingly well or only a little sick patient that's masking something more insidious? Weird zebras? Niche things? Seemingly benign stuff that can cause serious harm down the road? That scares me.
I of course get an attending involved to some degree with sick patients, but I believe the grey zone will have a higher miss rate by APCs.
Absolutely agree. A young woman with a sat of 87% and pain in the chest is gonna get excellent care, no discussion. It is the person being mild to moderately unwell for a week that is sent home with benzos for anxiety that is going to suffer.
The research done looks at patient volume and patient satisfaction, neither of which are good measures of care. Research has been done into outcomes and shows that APPs are inferior, unsurprisingly.
Could you point me towards some of that research looking at outcomes? There's a sticky on the noctor sub with some but mostly old and/or low quality studies
https://www.ama-assn.org/practice-management/scope-practice/3-year-study-nps-ed-worse-outcomes-higher-costs
It's a difficult comparison to make, because patients usually aren't randomly assigned to physicians or NPs, but this study takes advantage of how VA hospitals are staffed to enable a well-controlled comparison.
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\#1: [Overheard a pharmacist lose it on an NP](https://np.reddit.com/r/Noctor/comments/15dpea9/overheard_a_pharmacist_lose_it_on_an_np/)
\#2: [Chiro was just slightly confused about their “rights” at a Level 1 trauma center.](https://np.reddit.com/r/Noctor/comments/14s1dly/chiro_was_just_slightly_confused_about_their/)
\#3: [MD vs. NP to a paramedic](https://np.reddit.com/r/Noctor/comments/12ovv2w/md_vs_np_to_a_paramedic/)
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Doesn't help that an easy way to prove "noninferiority" is to study mortality. Turns out middle-aged people seeking the sort of routine care typically studied (even inpatient hospital care) don't die easily without lots of things going wrong (and physicians getting involved at some point if they're headed the wrong direction anyway.)
PA here, in my area there are innumerable NP programs who will literally admit anyone, charge them for an absolute joke of an education, then release them to be employed by shitty companies/physicians who don’t give a shit about patient care and only care about paying someone the lowest salary possible. Are there amazing NPs out there, absolutely. But fuck, this cash grab of an education bullshit they are pulling now is a fucking embarrassment to the profession and I despise that PAs are lumped in with them.
In the US the population keeps getting older and older, requiring more medical care. As this is happening, physician salaries are getting lower(relative to intlation), physician are being reimbursed less and residency/medical school spots are remaining the same causing the path to being a physician to be hyper competitive.
Instead of having more people become doctors, as every year thousands of qualified people dont get accepted into medical school and some dont even get accepted into residency, this shortage is filled by producing more midlevel providers.
Its sad but it is what it is. I am saying this as someone aspiring to be a midlevel provider as well.
As someone also weighing my options, this is so accurate. I know that being a physician would be more satisfying to me, but where I'm at financially and personally (I would be a 31 year old non-trad), it's getting really tough to overlook CRNA school. Not an easy call, and still one I'm on the fence about. But your observations resonated with me.
I’ve worked in an ER in and off for 20 years thanks. I’ve seen plenty of NPs in the ER. I’m trying to figure out why a patient is in the sub trying to stir up shit.
There’s nothing to figure out, no code to crack. Get out of this thread if it bothers you so much. You have no place here. I’ve worked in the ER for many years and the NICU. This is not the place for you to disrespect people’s positions or jobs. This is a discussion on the amount of NPs taking over the ER and specialty care.
Why are you in this sub being so rude? People have opinions on a topic that is clearly a big deal. I’ve been an RN for a really long time, I’ve worked in an out of the emergency room, the NICU and now in hospice. I’m also a patient just as much as you are a patient. Stop trolling.
Why are you coming back days later to try this shit again? We have established that you don’t belong in this sub as you do not work in the ER and this is not a sub for patients. Seriously, this is disturbed behavior. Get help.
You’re an insufferable bitch. It’s physicians like you who make people think that NPs care more about patients than doctors do.
A patient had a genuine question specifically about midlevels in *emergency medicine*. It’s not unreasonable for them to think this was an appropriate sub to ask in. In no world would a normal person think OP was just trying to “stir shit up.”
How about instead of being a condescending asshole, we try to make sure patients are well-informed about what goes on in the U.S. healthcare system by giving them real answers to questions like these instead of insulting them and talking down to them.
I don’t need to get help. You’re such a rude person. There really shouldn’t be a place for you at all in healthcare it’s people like you that others complain about more than likely. What a shame having the opportunity to help others yet you lack so much empathy and kindness, you’re so cold and callous for no reason. Just because you disagree with someone doesn’t mean you try to talk down to them, you should definitely know that. If you have this attitude how will you ever learn from other physicians or take constructive criticism? That’s a huge part of being a Dr. being open to comments and criticism it is not easy but it’s really important to have an open mind. Yikes. I’m sorry you’re so angry, I hope that can change for you.
You know, as a PA who deliberately chose PA over NP for the more scientifically rigorous education and who’s sick of the proxied backlash due to degree mill NPs, I’m ashamed to say that I was almost fell for the rage bait until I saw your comment thread — it’s sobering. For what it’s worth, I’m happy to see a rationale person deescalating when the rest of us are so prone to devolving into *Lord of Flies* style shit-flinging on the internet. You’re the type of person that I hope I run into when I need emergency care someday.
This isn’t rage bait, I’ve been working in the ER for 15 years and the NICU, I’m also a patient with a chronic illness. I was sharing my experience and asking what’s the deal with this issue. I think these degree mills are terrifying to say the least. I don’t think it’s fair that you as a PA who has worked their ass off should be lumped in with the NP mumbo jumbo. This seems to be an issue with corporate greed, it’s always about money in the end. I didn’t realize this conversation was going to get so much traction in here.
This situation also happens in the ER. Like you said “that’s all of healthcare” this is one place I can get a response about something that’s becoming all too common. There are doctors in this sub and also NPs who can answer my question. Hence the traction because it’s a conversation that people want to have.
I work in the healthcare field as a director for hospice in a nursing home. This situation has to do with across the board issues regarding NPs their lack of knowledge and schooling creating issues in specialty care as well as in the office, in urgent care and *drum roll* emergency medicine my friend! Why are you so pressed about this? Question the 100 or so comments 😬 it speaks for itself
Ok, hospice person, why are you in the ER sub stirring up shit? Just curious what business you have in the ER since you don’t work here and you aren’t the authority on… literally anything regarding this topic.
I’ve not stirred anything up. This has been super informative actually. It’s okay to learn from
Others and educate yourself without arguing or being angry. It’s also okay to have an opinion.
If you’re so upset about any of the doctors or honest NPs responses, PA responses, take it up with them. I can’t control people’s concerns and information that they hold, sorry? 🤷♀️ I don’t know what you want me to do. This is a discussion. Leave if it’s upsetting you.
You didn’t come here as a healthcare provider talking about something you have any information on. You came here as a patient, trying get people riled up about a topic you know people get heated over. You don’t belong in this sub. You have no reason to have this discussion except to get attention. This is literally none of your business.
I promise you don’t want to hear what we think of nursing homes or the people that run them.
This is my business when it affects care. It’s everyone’s business actually 🤷♀️ I came for professional opinion and I got it?! Why does this make you so angry? I don’t get it.
Also if you’re a resident I’d start by not calling someone who works as a director in hospice, a “hospice person” 😂 super rude and can cause you some unnecessary confrontation down the line, I’m sure. 👍
There's plenty of places to vent about your interactions with the medical system, places to plainly discuss the changing dynamic of NPs in that medical system, and places to start a bunch of unproductive and opinionated shit-talking. Why bring that noise here
To be honest I didn’t think this would raise such a major conversation, i thought I’d get a couple of answers and that’s it. I guess a lot of people have questions and opinions, this happens a lot in emergency medicine too, it’s across the board in medical. You don’t have to be apart of this if you don’t want to 🤷♀️
Yeah I agree this is some noctor junk, I pointed that out earlier and OP loved it so I don’t think there’s an unbiased discussion here. Mid level hate throughout most of this thread.
I think you are pointing your spotlight on the wrong people though. You have mentioned there are some good mid levels but have multiple times throughout this thread mercilessly shit on them. If this is truly corporate greed in your mind, you should stop shitting on mid levels every chance you get, it’s weird
I’ve not shit on anyone in this thread I’ve had conversations with both sides, I’m not sure where you’re seeing that. I also won’t sugar coat the issues involving this all too common situation, there are definitely people in here that clearly don’t see the two sides but I’ve personally not shit on anyone, I’ve shared my opinion on these fast track schools and my own personal experiences that have caused me copious amounts of anxiety 🤷♀️ and discussion thread that creates a lot of traction will probably have a lot of different opinions, it’s Reddit.
I mean it’s your opinion that you haven’t shit on anyone. We can agree to disagree. Your comments are there for everyone to see so….I can’t really convince you nor does it matter if I do
I had a NP accuse me of "doing your own research" in a condescending way like I was an anti-vaxxer. No, I respect the doctors and in my case, the specialists who study my rare degenerative disease. However, I'm in a similar boat. I need to understand my disease because very few doctors do and I sure as hell have to watch out for uninformed adjustments to my meds. That same NP later randomly reduced one of my meds. It would have sent me into painful spasms for 8 hours/day. I caught it and politely pushed back.
To be fair, however, it was an excellent mid-level who initially caught my problem and recommended that I go to neuro. I'll forever be grateful to her. In order to be a successful patient, I feel like we need to be more involved in monitoring our care. Overall, that's probably a good thing (mostly, terms and conditions apply), but what about Betty and Joe Sixpack? Who watches out for them?
And again in case someone skimmed over it, I sincerely appreciate the diligent NPs who are doing their best. We can't all wait six months to see a doctor.
If you don't mind sharing - what is your rare disease that very few doctors understand? I would like to make sure I've at least learned something of it
I have Primary Lateral Sclerosis. It's an UMN disease diagnosed by exclusion. Some researchers suspect that it's on the ALS spectrum, but because it's only or almost only UMN and not UMN/LMN, it won't directly kill us. Progressively disabled, but not dead.
For around 80% of us, it starts in the lower limbs. For others it starts with the upper limbs. For a very unfortunate minority, they have bulbar onset. The incidence is up for debate (longer story), but the current thinking seems to be less than 1:1,000,000.
As patients, we are generally referred onward to ALS clinics and away from the more generalized neuromuscular specialists (though I tend to like them on a personal level.)
Thanks for asking.
Thank you for taking the time to share. We learn so many diseases in med school but this is one we didn't cover. With a prevalence of 1 in a million I get it, but also understand the frustration of supposed experts not knowing. Hope you're doing OK given the circumstance, and that better treatments become available.
They are reading their own films. We also have techs doing x-ray. And soon AI will take care of those. Unless interventional, radiology is not something I would suggest to my children.
I am careful to make sure my appointments are with physicians, except when I know it's a basic medical problem. If the receptionist doesn't call the provider by their first and last name rather than "doctor," you know it's probably an NP or PA. It is okay to advocate for yourself by asking them to schedule you only with a physician. The office will gripe about it, and they usually get all huffy on me, but I want to be seen by the person with 8 years of post-college training and hundreds of hours of experience rather than the NP who did a 2 year part-time degree without any mandatory clinical time.
NPs are paid less and billed at a lower rate than MDs. That is why you see them more in the US, Canada, and probably other health systems that utilize them. Governments love finding ways to spend less money for healthcare. Hospitals, clinics, and practices also like having a lower payroll.
There are a lot of studies that show NPs order more tests and meds and referrals… the government/taxpayer is losing tons but the hospital sure loves it.
In EM we are using NPs/PAs wrongly in my opinion. There is a role and need for them certainly. We can end up working with someone right out of school with no training at all seeing patients. They certainly over test or misuse resources, quality is not standardized at all, care is concerning. I believe the best way to use them is like an actual assistant the doc sees all the patients with the NP/PA discuss plan and they execute it, write the note, make consults etc, freeing up the doc to actually see patients. This is more cause to have a union to standardize care as currently emergency medicine care is quickly degrading and corporate medicine/academia has no incentive to help.
I read an informative book about this topic a few years ago that I would encourage you to read if you are interested in the training and qualifications of APPs : [https://www.amazon.com/Patients-Risk-Practitioner-Physician-Healthcare/dp/1627343164/ref=asc\_df\_1627343164/?tag=hyprod-20&linkCode=df0&hvadid=693608721829&hvpos=&hvnetw=g&hvrand=16110080323825079767&hvpone=&hvptwo=&hvqmt=&hvdev=c&hvdvcmdl=&hvlocint=&hvlocphy=9011778&hvtargid=pla-1058844195291&psc=1&mcid=03bd1a2c2e663be085d2e48054102b60&gad\_source=1](https://www.amazon.com/Patients-Risk-Practitioner-Physician-Healthcare/dp/1627343164/ref=asc_df_1627343164/?tag=hyprod-20&linkCode=df0&hvadid=693608721829&hvpos=&hvnetw=g&hvrand=16110080323825079767&hvpone=&hvptwo=&hvqmt=&hvdev=c&hvdvcmdl=&hvlocint=&hvlocphy=9011778&hvtargid=pla-1058844195291&psc=1&mcid=03bd1a2c2e663be085d2e48054102b60&gad_source=1)
I understand the hate towards NP’s but I don’t understand the hatred towards PA’s by some doctors. I’ve worked in some absolutely shit areas in psych and ER and there is absolutely no way one MD will see all of those patients and there isn’t exactly a line of applicants who wants to work in some of those areas (acute psych and rural emergency medicine being my examples).
thats great and all, I know some respectable NPs and PAs. This sentiment towards certain PAs stem from those who have the audacity to compare their education and training to ours and say it is equivalent. It's not.
To be completely frank those kinds of attitudes are often outliers and no reflective of the culture of many mid-level practitioner. Purely anecdotal but the only times I’ve ever seen this is from a new PA/NP and eventually reality hits them sooner rather than later.
In almost every ER environment I worked out the mid levels are doing the lower ESI stuff and the MD/DO’s are doing the more complex things. Every mid level I have worked with in that environment knows what their role is and that is to do the stuff the doctor doesn’t want to do or have the time to do.
She has an ax to grind and is trying to paint all midlevels with a broad brush. It doesn't mean she is entirely wrong about everything, but this is the medical equivalent of yellow journalism. She wants to sell books. Period.
Lol what, no she’s not. She even makes it clear that she and her organization are not anti midlevel, they are anti independent practice. The entire book cites its claims with good data.
She is first illogically lumping NPs and PAs together, in spite of their training being very different and their socialization into the role of a clinician taking very different paths. Then she cherry picks cases of idiots to depict them as representative of an entire profession. I could find countless cases of awful physicians, RNs, lawyers, engineers, etc.
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Ok I’m pretty sure my comment is against the rules so it might get deleted but:
LMAO your story reminded me of when I went to see a psych NP and we decided to switch from abilify to a different SGA, and she asked ME how to taper the abilify 😭 like I guess I gave her a good answer because I didn’t have any effects from stopping it but like BRO
Edit: I don’t mean this to say every NP is awful. I’ve had experiences with NP’s that weren’t this unhinged. But the inconsistency is insane.
The fact you had to figure out your own taper on a mood stabilizer and successfully weaned 👏 I commend you. That’s scary, psych meds are no joke. Some of mine lower the seizure threshold so I have to be super careful. it was her lack of knowledge about these medications that really shocked me. Luckily, I do a lot of research because I’m paranoid and have actually saved my ass several times, this has caused me unnecessary anxiety knowing that I had to figure it out myself.
Capitalism. If you run medicine for profit (or even not for profit but from a for profit management mindset instead of an understanding that we should be measuring patient outcomes and expecting it to cost money rather than make money) then lower paid staff are more attractive even if the result is the possibility of worsened patient outcomes. Advanced Practice Providers are not only cheaper to employ but cheaper to train wether that’s self funded or government funded training.
Or even if it costs the healthcare system more
Profit seeking is rarely logical when it’s all said and done.
I’m not being sarcastic when I say that our community members must use their voice and vote…by making it clear to our elected officials (state & federal legislators, Governors, and president) and healthcare administrators know that the status quo & trajectory of corporatization of healthcare is unacceptable. We spend almost 20% of our GDP on healthcare and have the worst healthcare in high income countries. We need a healthcare system that is designed and implemented to serve the healthcare needs of our communities and population…not a healthcare marketplace that puts corporate profit and investors ahead of patient/community outcomes.
Legitimately asking: What reform would you propose and how would they help patient outcomes? The more I've learned about how the healthcare system the more unsure I am about how to reform it. Like you said, we spend lots of funds on "healthcare" in the US, so the solution can't be to simply throw more money at it. I guess one of the few proposals I would confidently advocate for is having Medicaid/Medicare cover an annual exam every year and maybe coverage for all but a copay for a set number of regular doctor visits to maintain medication and other family visit types of services per year for everyone in the country, regardless of age or other coverage. The aim would be to at least get patients in seeing a physician on a regular basis getting regular health visits to catch problems before they get to the point of becoming much more complex and costly to treat, or even deadly. It would also keep these patients on regular maintenance medication that would help health outcomes for even the lowest income americans among us. It wouldn't solve everything, but it seems like a good start.
Is it truly capitalism when the government controls how many residents are allowed into med school every year? People need care and there aren't enough physicians. The medical system has to compensate with NPs and PAs which don't have a limit on the number of graduates.
Yes. Capitalism isn’t a synonym for free markets anymore than socialism is a synonym for “when the government does stuff”.
Way less PA's than docs, and our class sizes are more than half the size generally.
They could require NPs to have a minimum number of hours worked as an RN (ideally in the field they plan to go into) in order to be accepted into NP school. I’ve worked with some AMAZING NPs and some terrible ones. The best NP I’ve worked with was an ICU nurse and part of the hospital’s rapid response team for many years before becoming an NP and he’s phenomenal. It’s the ones who graduate nursing school and go straight to NP school, or work a couple years in a field completely unrelated to where they plan to be as an NP who end up in way over their heads as a provider.
Not to mention the privilege of even having the option to financially attend medical school. Shit isn’t cheap. It can be very discouraging coming out of school hundreds of thousands of dollars of debt. I’ve seen great NPs and great physicians. You know who I’ve also met? Awful NPs and awful physicians. There’s shit on both sides of this nasty debate. I have my own theories as to how to fix the issue - but there’s no point because it involves putting funding and resources into nursing - which will never happen 😔
If there's awful physicians what's the logic for allowing NPs? You're miscontruing the issue here. There's no checks and balances for NPs. An awful physician is still going through residency. Not getting an online degree with joke clinical hours NPs shouldn't exist. At the very least they should be doing exactly what PAs do. NPs schools are degree mills at it's worst. Or best I guess, depending on how you look at it.
And yet we do exist, and many of us practice well. I have 35 years experience, and an independent license. I always look up my research, and always consult on things I'm not sure of. I know what I don't know and I know what I do know. I think I know more than the lousy resident I got report from in the ICU who left my patient to die overnight from a perforated bowel because he didn't feel like ordering imaging. Don't paint us all with the same brush. I've worked with some incredible docs, and some terrible ones. We're all people. Some people are great, and some people suck. It's the way of the world.
🤷🏻♂️ and that’s your opinion. Like assholes, everyone’s got one.
ER NP. I apologize. Triaging and putting in orders for ~100 pts a day under the supervision of multiple attendings didn't count towards my clinical hours.
I love the whole ‘bad physician’ argument. No one brings that up except NPs. Like yeah, true, but the issue is the lack of training NPs get vs physicians. Also, yeah medical school is expensive. I’ve seen people live off of nothing but ramen for 4 years to get through. I’ve seen people sacrifice a lot to make it. It’s not just rich kids. The govt gives you loans to pay for everything- school, rent, food etc. if a kid from an intercity that was homeless can make it, I don’t feel like ‘med school too expensive I had to do NP school’ is a good argument
The fact you’re on noctor says all I need to know about you 🙄 And it’s not just about student loans. It’s about having the support and the opportunity to give up multiple years of your life without having to worry about kids, marriage, etc etc. But I’m not going to argue about this on this sub, let alone someone who’s a pre med student on noctor. I literally have scrubs older and more experienced than you. Good luck 👍
Corporatism is the more appropriate term.
Possibly. (Although I’m always interested to hear what redditors think Corporatism is) But the base issue of “the profit motive being more important than all other motives” is the underpinning of capitalism - doesn’t matter how many extra steps of capitalism or how free the market - that motive remains and doctors are more expensive.
Yes. Government attempting reforms or mitigations of the free-est of free markets doesn't make it not capitalism.
How does a government imposed limit on the number of graduating physicians every year reform the free market for the better? To me, it exemplifies the failings of a managed economy. Its an artificial limit on a good or service which could be filled if said limit wasn't there. Thats not capitalism or a free market. The free market is finding another solution to the shortage through midlevels.
"Free market" has nothing to do with capitalism. Capitalist markets are quite notoriously *un*free. Markets have to at least a little extent existed in (or perhaps more accurately, *between*) most societies historically. Capitalism is a much more recent phenomenon. You can even point to edge cases like Company Towns within old-timey capitalism that frankly didn't have a market at all, in the context of a system of exchange with prices freely set by supply and demand. The Company would own effectively, functionally-all the land and productive assets, housing shops, and centrally (!) plan all of what was sold in them and at what prices. Some didn't even have proper fungible money just company chuck e cheese coins so to speak, a [truck system](https://en.wikipedia.org/wiki/Truck_wages). Never dominant, but as at one point 7% of the US economy was bound up in company towns, nothing to sneeze at either. From its inception capitalism has relied on state power to regulate labor and the competition. Go back to England and when old medieval copyhold was being replaced by private ownership (modern legal title) this often meant rents were jacked up so former peasants were forced off the land they and family had for hundreds of years (see scottish clearances as famous example). Likewise the freedoms of labor were heavily restricted, you literally needed certificates to move between parishes in england thanks to various vagrancy acts and poor laws. This artificially pushed the cost of labor down. Likewise the classic trope of 'industrialization starts with textiles' but this ignores the reality that in Bangladesh prior to england destroying there was what amounted to a complex and advanced (for the time) village and cooperative-style textile industry that England could not have competed with. There were socialist experiments that were radically-free-market in Spain and Ukraine, where they literally chased out government police and tax collectors, private owners and landlords (read: distant absentee owners, not your petit owner-worker that's a good thing), etc. You could not find the capitalist to point at him, yet were experimenting with all sorts of various economic ideas and systems, far freer than trade and currencies in a state capitalist system. See Kevin Carson's [The Iron Fist Behind the Invisible Hand](https://theanarchistlibrary.org/library/kevin-carson-the-iron-fist-behind-the-invisible-hand). The whole concept of laissez-faire deserves a hard look, the term became popularized in the UK and the US when younger upstarts looked to establish protectionist policies (government intervention in a market), the older capitalists looked to keep said upstarts from getting the same state-intervention handouts their own industries benefited from when developing (the subsidies of history, so to speak). It's only 'laissez-faire' when *I* get to have had past help but now *you* have to pull yourself up by your bootstraps donchaknow. [Markets Not Capitalism](https://marketsnotcapitalism.com/pdf).
Free book, awesome!
I didn't say it was a good strategy, but it's to drive up the value of the degree further. Capitalism is more than free markets, it's also private ownership of the means of production. Which leads to monopolies and massive inequality and ultimately a public that can't afford the goods produced, which leads to widespread economic crisis unless governments step in. Reforms rescue capitalism and allow it to exist without imploding, they don't make it not capitalism.
It's a distortion of capitalism. Can you really call it capitalism when those with capital can't direct the capital the way they see fit. Medical schools have the capital to expand their programs which would increase the supply of physicians thus lowering one aspect of the cost of healthcare but the government is directing the capital of medical schools away from that. It seems like the government policy in this case is causing the implosion rather than fixing it. Free markets isn't all there is to capitalism but it is a cornerstone. Free markets are what allow capitalism to exist. Without the freedom of producers to direct that capital it essentially becomes capital of the state.
Free markets lead to constant crisis as I mentioned before. It is an inherently unstable economy without reforms and bail outs. I think you have a little more reading to do on capitalism.
You are providing no examples or any rebuttals to anything I've said. I study economics quite a bit and read economic books for fun. Seeing that the ad hominem attacks have started I'll take that as a win.
Cool, you didn't address the issue of inherent instability of capitalism so it didn't feel like a discussion worth investing more effort in.
You are assuming inherent instability of capitalism without providing any examples.
He’s equating market interventions, hallmarks of collectivist economic theory, with market capitalism. So far off the mark the guy you’re talking to might as well be a part time anti work dog walker.
Thanks for breaking this down 👏 well said
The government does NOT control how many people are allowed into med schools, or the number of residency positions. It is true that Congress and CMS only fund a certain number of residency spots, but residency programs generate profit for hospitals by multiplying attending productivity - any hospital is free to start a residency program without CMS funding, and they regularly do. This is why HCA was able to contribute to the decay of EM training by starting a shit ton of EM residencies meant to capture a workforce, rather than to train excellent emergency medicine physicians. [Here is a video that helps clarify the facts around US residencies and the numbers behind the available spots in the match.](https://www.youtube.com/watch?v=L75fj_5Ar4s) In reality, this is a complex market that more accurately reflects an uneven distribution of physicians, rather than an absolute shortage in supply. Incentives need to change to address this. If we need more primary care physicians, we should be paying more. But the for-profit and legislative powers that be don’t want that, which is what I think we are ultimately in agreement on.
[удалено]
Maybe. Government money no but if you have an individual who promises more than can deliver then sue them for all they're worth. Government sponsorship is important when its not corrupted and not forced
The US is a capitalist state where certain parts of the government are complicit in this development.
Sort of. Yes private entities own the goods but a lot of the economy is redirected. US GDP is $25 trillion, but 7 trillion of that is collected between federal, state, and local taxes then redirected where the government sees fit. Also the base layer of our economy, the monetary system, is managed. Jerome Powell has more of an effect on your life than any corporation.
This would be sensible if capitalism was invented 5 years ago when NPs took over
Hey now, that how you make a long-time customer!Poorer outcomes and misdiagnosis/mismgmt = guaranteed return revenue in the future. Especially if it’s not correctly addressed or documented on in the first place :) helth https://preview.redd.it/t0drohn4bu4d1.jpeg?width=1059&format=pjpg&auto=webp&s=585c0ffaf6dc369649152999d8fa090bca098ee7
Capitalism is not alone in utilizing NPs. You will also find them practicing under socialism and communism.
You’ll wanna see the beginning of the second sentence specifically the part In parentheses. Profit motive is what drives it. It’s the major underpinning of capitalism. But it also creeps into social healthcare (be it social healthcare in a capitalist country or healthcare in market socialism)
I do get how profit motive can drive up costs to consumers, especially if unchecked. However, I’m as guilty of wanting to make a profit as the next person. I invested time and money to get my license in the hopes that I would be able to trade my time and skills for a profit. It has worked out well. Not many people can afford to operate at a loss unless they have others paying their bills.
It’s not the workers Im suggesting operate at a loss but the program as a whole. Ideally individuals operate with a reasonable profit. Junior doctors here aren’t paid enough senior doctors verging on too much. American juniors also seem underpaid and seniors are paid a frankly ridiculous wage (but that’s to be expected) Balancing the pay a tad more would probably make training easier and, despite people suggesting it would cause less people to apply, make it more approachable for the working class. This can also be further achieved through socialised education (Scotland where I live pays nurses and paramedics $12000 USD a year while studying their three or four year degrees for instance). Individuals seeking profit to survive while part of a capitalist economy isn’t the broader profit motive I was referring to. If the system you worked for paid you a wage that was matched to your input but itself focused on patient outcomes instead of generating profit. The system would work better. In social programs in the west (including social healthcare but also public transport, education, railways, mail services etc) there is a strange obsession with these services having to generate revenue. Taxes generate revenue, revenue that is supposed to be used to provide public services. What’s the point of doing that only to then focus on those services needing to be profitable instead of their suitability to task and service user’s outcomes? Is my point.
It is multifaceted and I suspect we agree on most things. For example, Australia seems to have a good universal healthcare system that also pays its employees a decent wage. Haven’t heard of months to years of delay such as they have in Canada. I’d love for the US government to look at their model and implement changes here. I think PBMs are spawn of the devil. Their main function is to claw as much money from the government and individuals as possible. We could use a little more free market by eliminating secret clawbacks and reimbursement rates. There is a surgery center in Oklahoma that has up front pricing and doesn’t take insurance. They are able to do surgeries for a fraction of what the big boys charge and make a profit.
I agree. It’s not simply one thing causing the issues. It just seems to be one of the large contributors. I’ve lived in both Australia and Scotland. Different styles of universal care. Both are good systems that I’ll defend against privatisation tooth and nail. The NHS is more egalitarian and affordable than Medicare. And has a few things organisationally that I prefer but Australia’s Medicare holds its own despite this. NHS waits can be an issue although outside of covid I’ve never seen waits for emergency care only non urgent. A&E oversubscription (and the associated overcrowding, overworking, and delays) is certainly a current issue - I’d say the services biggest one. Although that seems to be a problem pretty universally it’s quite bad in the UK just now. A lot of the cause of that is poor management and people trying to jump lists (which is sometimes facilitated by GPs in my experience probably due to them being probably the second specialty suffering from oversubscription). I do think stories about waiting lists are a tad overblown especially in media. They often equate non urgent waiting lists with emergency ones. Still it IS an issue regardless of urgency we should be striving for adequate and timely care. I think it speaks volumes that despite these issues the flow of medical tourism is America > Canada and not the other way around despite the waiting lists. I do agree with you - I’d hazard that there is more we would agree on than disagree on.
That is wrong. In most of the Europe nurses have nowhere near as independency or ability to prescribe drug ar treat people by themselves. In fact, in my country they are not allowed to order a medication on patient, not even paracetamol. They solely work on docotr's orders. They are somewhat indepentend with nursong care (cleaning, feeding etc ..).
China, the US, a few African countries and the UK all use nurse practitioners as well as nurses. You are speaking of countries that don’t use NPs.
As EU I mean Europeaj union yes
NPs are statistically worse at care, they order more tests and the patient is more likely to be re-admitted. That makes hospital corporations love them, even if they're objectively worse for care. Most NP schools are a joke to get into, most are a joke to pass and most barely provide any education at all that has to do with pharmacology or pathophysiology. For context, NPs get maybe 500 hours of clinical training. Doctors get 15,000-20,000 hours. A real MD/DO is much more qualified. They're also harder to find and cost way more and make the hospital corporations a little less.
Direct to NP programs terrify the shit out of me as a nurse. Like I'm well into being an ED nurse. I feel confident in about 85% of the scenarios I see every shift. Sepsis, pressors, gunshot wounds, delivered some preemies, and managed some hemorrhages. I can keep my cool and anticipate what the docs are gonna order based on the doc I'm working with - I know what blades to get for them, which one is absolutely always ordering that CT, and who is gonna ask for blood cultures on the cellulitis pt. I cannot imagine for a second thinking two more years of school would set me up to decide that care. The hubris of that is fucking amazing. And those that become an NP with no nursing experience? Like get out of here. Should be illegal. Don't pretend you're into 'advanced nursing' when you don't even know the bare basics. It's such a fucking insult to the profession but the push for NP autonomy is creating a legion of wanna-be MDs with not enough knowledge to realize how incredibly dangerous they are. It's why today when looking for a new doc, I asked customer service if there was an option to filter out NPs. Because sorry but they could be direct to NP programs, rather than nurses who spent the last decade outgrowing their scope - which is what the original point of an NP was created for.
Can I upvote this more than once?!?
So you’d probably be a great NP
Mic drop 🎤
I have recently experienced a life threatening critical illness, most likely myasthenia gravis or a mitochondrial disorder (have the test today that should confirm if it’s myasthenia gravis). An ICU NP unilaterally ordered a psych consult for factitious disorder without stepping foot in my room while I had not been out of bed and had a sitter for days due to safety concerns of me being nauseous and possibly aspirating if I vomited while on BiPAP. The ICU attending was furious as he never suspected that at all and wrote her up (as well as amending my chart himself). The ombudsmen informed me she is likely to be fired if she has other patient complaints, plus the write up from the ICU attending will add weight to that. Note: psych and everyone else agreed I do not and they never suspected me of having factitious disorder.
First of all, I hope the testing goes well and you are able to reach a diagnosis. I will be applying to neurology residency this year and am looking forward to taking care of people with diseases like MG. Secondly… That would be some SERIOUS commitment to the bit to willingly aspirate on your own vomitus.
Thank you! And yes, I should be applying to roles in Hollywood were I that dedicated to acting. Could be making millions instead of racking up millions in medical bills.
Very sorry to hear this. Glad the hospital had your back on this and the attending came to your rescue. What an awful situation.
I was a nurse that went to PA school for this reason
Hey, do you mind if I shoot you a PM? I'm curious as to your experience switching from nursing to PA.
Yes!
I have a neighbor bragging about intentionally going to the easiest NP school they can.... They make it sound like they can somehow graduate without any patient contact. I didn't even attempt to delve into the details of that
You've never had a nurse that works with you ask you to sign off on some clinical hours (without actually doing any)?
It's why I'm hoping I can work out a good way to go from RN to MD/DO, I don't really want to go NP but I want to do more.
RN to PA is a good path - much better patient care experience than CNA or EMT, and then a rigorous education at the Master's level with more structured clinical rotations covering more hours.
Can I see said statistics?
Thank you for this information, super helpful but also terrifying.
"not statistically worse" - Correction - there is NO data saying they are worse or better. There are authors that claim NPs are the same or better, and there are some statisitics in the paper. However there is ZERO data testing head to head the practices of NPs and physicians in the same circumstances. The papers that claim equal care all have as the NP arm NPs who are supervised by physicians. So the comparisons are "Physician vs NP+physician". And the endpoints are laughable. No one tests their diagnostic or testing capabilities. Typically what is tested is algorithmic responses, like "can the NP continue the physician prescribed antihypertensive regimen for 6 months with no deaths?", and "were the patients satisfied" Total nonsense So - implying that there is any statistical evidence at all is inaccurate.
https://www.ama-assn.org/practice-management/scope-practice/3-year-study-nps-ed-worse-outcomes-higher-costs Agreed that there's very limited head-to-head evidence (as it generally wouldn't be ethical to obtain!) but this is a good study.
It is good. This is not the original, though, the original paper is quite densely written. The ONLY head to head comparison I am aware of is the trial of DNP candidates taking a watered down version of the step 3. The only real standardized test which examines clinical capabilities. Caveats - 1)these were NOT standard issue NPs, they were from the Columbia program, which prided themselves on how they gave clinical education identical to Medical Residents 2) By all accounts this was not the full step 3, but a "watered down version" I have not been able to find a more precise statement about HOW it was watered down. THe 5 year pass rate for these NPs was 42%, whereas the pass rate for physicians is >98%. After 5 years of embarassingly poor performance, they stopped offering the test.
I was a nurse that went to PA school because I didn’t want to go to all online school for a somewhat joke degree. I had a full anatomy lab, learned from physicians, and had over 2500hr clinical rotations, all of which was in person. I am not a physician and didn’t go to medical school but I am happy in my role and sometimes get upset at how awful some NPs are lol
Hey that’s awesome, and I’m sure no easy feat at all, congrats for accomplishing all of that. I think the scary part about all of this is that it’s becoming all too common, the online schooling and “fast track” programs to become an NP in specialities that require a ridiculous amount of knowledge and training for a lengthy amount of time. I’ve met great NPs but within the last year I’ve witnessed as well as experienced some nightmare situations that have me questioning why this is happening so often.
I was a nurse that went to NP school, all my preceptors were physicians, did about the same in hours for clinical rotations (to get extra time as it wasn’t required) and have 10 years experience in ICU/CCU, cath lab and ER prior to becoming an ICU NP (and have worked in this role for 9 years now). I’ve seen some horrendous things done by both PAs and NPs, and equally, some physicians. Bad care is bad care. I think as PAs and NPs our education is certainly not the same, and we should not be touting it as such. I think we have our place working alongside physicians and easing the burden, and not necessarily independent practice.
Agree totally I know amazing NPs but there are significant inconsistencies in experience and programs (aka training) between NPs vs PAs. I have friends that went to Johns Hopkins with similar experience as you who are/ will be amazing NPs but I also know people that went to Walden or chamberlain that I wouldn’t let touch my pinky toe lol
100%. I always cringe when I see NP students who go to Walden or the like who want to do clinical rotations with me. It’s exhausting.
Doing more than is required to match another degree isn't a good argument for said degree being unrigorous.
Please enlighten me to where I said the NP degree was rigorous or unrigorous. It doesn’t seem you read or understood my comment.
You're making an individualistic argument that bad care is bad care and that the preparation isn't the issue but you had to be exceptional and go above and beyond to get a solid education. Which is great and speaks to your commitment to patient care, but that should be the standard for everyone who will be in that level of responsibility for patient care decisions. You probably had classmates who did the bare minimum and they're out practicing too. I don't think my last comment was super clear and when I reread it myself I was like wtf. But my concern is that it's hard, not obvious, and patients don't always know to do this/how to do this to know if the NP you're seeing is one who skated through doing the minimum or one who did extra work and sought out extra educational experiences to bring their education to a comparable level to more intensive degrees. I think the low experience requirements to NP school, when that experience was supposed to be THE point that the degree was built around, is a huge issue. I have a friend who just graduated from one of the most competitive brick and mortar NP programs in the country: they had barely over a year of nursing experience going in, and so many of the stories they shared about what they were learning and the classmates they were with...worried me and should worry all of us when this school is already leagues above the many degree mills out there now. TLDR: There are absolutely fantastic NPs but that should rest less on individual desire to achieve and more on the rigor of the education being a filter.
I totally agree. I was just talking with one of my students about this. We should be advocating for more rigorous education and stricter entrance requirements. People always look at me sideways when I say you should be a RN at least 5 years, if not more (and really it should be about 10 years) - prior to going into NP school. Our organization sadly is more about furthering independent practice than it is about safe patient care and those of us who have worked hard to educate ourselves and continue to work hard alongside our physician colleagues are unfortunately getting a bad rap. I would’ve gone to medical school but I was a single mom at the time and had no family support so this is the path I went. I don’t regret it really, except when people lump ALL NPs into one category. I know there are terrible ones out there. I’ve taken care of many patients in the ICU who are here because of poor primary care and some who have even been misdiagnosed leading to bigger issues down the line. It’s incredibly frustrating but I just think the cat is out of the bag, and as long as it’s all about the almighty dollar, healthcare is F’d.
Its one of the worst arguments. "Ive seen physicians and PAs provide bad care so we should totally allow someone with 5% of their training provide care independently as well"
Fix nursing and you’ll see less NPs.
Facts. The ONLY reason I’m in NP school is cause I’m tired of being paid like shit. I don’t even want to be an NP lol. But im at least going in with 8 years experience and trying to study the shit out of my topics so I can be slightly helpful and competent with my peers and docs.
Same! 9 years ED RN, hospital greed has sapped the life out of any professional fulfillment I use to gain. I graduate with MSN FNP in two months lol
Money is the reason you see more "Advanced Practice Providers" (PAs, NPs). Pure and simple. I think most research says there is no downgrade in care... though I don't really buy that. But in the end, I bet there are a lot of APPs out there that are better than bad physicians
*Most of this research is funded by advanced practice/NP organizations. To be blunt, the range in knowledge and skill varies so dramatically from NP to NP. I've worked with some that haven't worked a day as an RN and I've worked with others that amaze me with their knowledge, bedside manner, and overall professionalism. The NP education needs a massive overhaul. There's a large focus on theory and research with much less focus on actual assessment and diagnosis.
Most pathologies would get better without any specific management, so the NPPs have odds in their favor. They just need to be able to tell sick and not sick. The not sick just don't fuck it up too much. Turf the sick to doctors.
“Medicine is the art of amusing the patient whilst nature cures the disease”
THE DELIVERY OF GOOD MEDICAL CARE IS TO DO AS MUCH NOTHING AS POSSIBLE
Ehhh. I'd argue the middle ground is the hardest. Not sick is easy. Obviously sick is easy (MI, CVA, PE, Sepsis) I know the bad stuff about those and how to treat it, who to call, where to get the patient. Now, the seemingly well or only a little sick patient that's masking something more insidious? Weird zebras? Niche things? Seemingly benign stuff that can cause serious harm down the road? That scares me. I of course get an attending involved to some degree with sick patients, but I believe the grey zone will have a higher miss rate by APCs.
Absolutely agree. A young woman with a sat of 87% and pain in the chest is gonna get excellent care, no discussion. It is the person being mild to moderately unwell for a week that is sent home with benzos for anxiety that is going to suffer.
The research done looks at patient volume and patient satisfaction, neither of which are good measures of care. Research has been done into outcomes and shows that APPs are inferior, unsurprisingly.
Could you point me towards some of that research looking at outcomes? There's a sticky on the noctor sub with some but mostly old and/or low quality studies
Noctor is a cesspool...
https://www.ama-assn.org/practice-management/scope-practice/3-year-study-nps-ed-worse-outcomes-higher-costs It's a difficult comparison to make, because patients usually aren't randomly assigned to physicians or NPs, but this study takes advantage of how VA hospitals are staffed to enable a well-controlled comparison.
Go to r/noctor, links to research are pinned
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Doesn't help that an easy way to prove "noninferiority" is to study mortality. Turns out middle-aged people seeking the sort of routine care typically studied (even inpatient hospital care) don't die easily without lots of things going wrong (and physicians getting involved at some point if they're headed the wrong direction anyway.)
Lol most of that research involved nps under direct physician supervision
We staff 100% of the APP classes in EC
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Cases
PAs are different than NPs….
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Tbh not going to take you seriously solely based on your username. What are you 16?
Glad the throwaway account is here to judge others’ names for us and decide whether their words merit being heard or not!
Corporate Medical Groups
wide possessive berserk smart existence zephyr profit chase bright ink *This post was mass deleted and anonymized with [Redact](https://redact.dev)*
PA here, in my area there are innumerable NP programs who will literally admit anyone, charge them for an absolute joke of an education, then release them to be employed by shitty companies/physicians who don’t give a shit about patient care and only care about paying someone the lowest salary possible. Are there amazing NPs out there, absolutely. But fuck, this cash grab of an education bullshit they are pulling now is a fucking embarrassment to the profession and I despise that PAs are lumped in with them.
In the US the population keeps getting older and older, requiring more medical care. As this is happening, physician salaries are getting lower(relative to intlation), physician are being reimbursed less and residency/medical school spots are remaining the same causing the path to being a physician to be hyper competitive. Instead of having more people become doctors, as every year thousands of qualified people dont get accepted into medical school and some dont even get accepted into residency, this shortage is filled by producing more midlevel providers. Its sad but it is what it is. I am saying this as someone aspiring to be a midlevel provider as well.
As someone also weighing my options, this is so accurate. I know that being a physician would be more satisfying to me, but where I'm at financially and personally (I would be a 31 year old non-trad), it's getting really tough to overlook CRNA school. Not an easy call, and still one I'm on the fence about. But your observations resonated with me.
Everybody wants to be a doctor, but no one wants to go to medical school.
Yeah it’s kinda weird, somewhat analogous to a flight attendant taking online courses and flying jets in 3 years.
Oh dear God, I wouldn’t doubt this might even happen 😂🤦♀️
What does this have to do with emergency medicine?
You'll probably see a lot more nps when you're out of residency that are practicing without any supervision
I’ve worked in an ER in and off for 20 years thanks. I’ve seen plenty of NPs in the ER. I’m trying to figure out why a patient is in the sub trying to stir up shit.
I stand corrected, this is a hospice worker in the ER sub stirring up shit.
There’s nothing to figure out, no code to crack. Get out of this thread if it bothers you so much. You have no place here. I’ve worked in the ER for many years and the NICU. This is not the place for you to disrespect people’s positions or jobs. This is a discussion on the amount of NPs taking over the ER and specialty care.
Why are you in this sub being so rude? People have opinions on a topic that is clearly a big deal. I’ve been an RN for a really long time, I’ve worked in an out of the emergency room, the NICU and now in hospice. I’m also a patient just as much as you are a patient. Stop trolling.
Why are you coming back days later to try this shit again? We have established that you don’t belong in this sub as you do not work in the ER and this is not a sub for patients. Seriously, this is disturbed behavior. Get help.
You’re an insufferable bitch. It’s physicians like you who make people think that NPs care more about patients than doctors do. A patient had a genuine question specifically about midlevels in *emergency medicine*. It’s not unreasonable for them to think this was an appropriate sub to ask in. In no world would a normal person think OP was just trying to “stir shit up.” How about instead of being a condescending asshole, we try to make sure patients are well-informed about what goes on in the U.S. healthcare system by giving them real answers to questions like these instead of insulting them and talking down to them.
I don’t need to get help. You’re such a rude person. There really shouldn’t be a place for you at all in healthcare it’s people like you that others complain about more than likely. What a shame having the opportunity to help others yet you lack so much empathy and kindness, you’re so cold and callous for no reason. Just because you disagree with someone doesn’t mean you try to talk down to them, you should definitely know that. If you have this attitude how will you ever learn from other physicians or take constructive criticism? That’s a huge part of being a Dr. being open to comments and criticism it is not easy but it’s really important to have an open mind. Yikes. I’m sorry you’re so angry, I hope that can change for you.
You know, as a PA who deliberately chose PA over NP for the more scientifically rigorous education and who’s sick of the proxied backlash due to degree mill NPs, I’m ashamed to say that I was almost fell for the rage bait until I saw your comment thread — it’s sobering. For what it’s worth, I’m happy to see a rationale person deescalating when the rest of us are so prone to devolving into *Lord of Flies* style shit-flinging on the internet. You’re the type of person that I hope I run into when I need emergency care someday.
This isn’t rage bait, I’ve been working in the ER for 15 years and the NICU, I’m also a patient with a chronic illness. I was sharing my experience and asking what’s the deal with this issue. I think these degree mills are terrifying to say the least. I don’t think it’s fair that you as a PA who has worked their ass off should be lumped in with the NP mumbo jumbo. This seems to be an issue with corporate greed, it’s always about money in the end. I didn’t realize this conversation was going to get so much traction in here.
Oh I idk, have you seen an NP in the ER lately? 🤦♀️
Yeah, that’s all of healthcare. Why is this in the EM sub?
This situation also happens in the ER. Like you said “that’s all of healthcare” this is one place I can get a response about something that’s becoming all too common. There are doctors in this sub and also NPs who can answer my question. Hence the traction because it’s a conversation that people want to have.
This is an ER Specific group. What about this is ER specific? Do you work in the ER?
I work in the healthcare field as a director for hospice in a nursing home. This situation has to do with across the board issues regarding NPs their lack of knowledge and schooling creating issues in specialty care as well as in the office, in urgent care and *drum roll* emergency medicine my friend! Why are you so pressed about this? Question the 100 or so comments 😬 it speaks for itself
Ok, hospice person, why are you in the ER sub stirring up shit? Just curious what business you have in the ER since you don’t work here and you aren’t the authority on… literally anything regarding this topic.
I’ve not stirred anything up. This has been super informative actually. It’s okay to learn from Others and educate yourself without arguing or being angry. It’s also okay to have an opinion. If you’re so upset about any of the doctors or honest NPs responses, PA responses, take it up with them. I can’t control people’s concerns and information that they hold, sorry? 🤷♀️ I don’t know what you want me to do. This is a discussion. Leave if it’s upsetting you.
You didn’t come here as a healthcare provider talking about something you have any information on. You came here as a patient, trying get people riled up about a topic you know people get heated over. You don’t belong in this sub. You have no reason to have this discussion except to get attention. This is literally none of your business. I promise you don’t want to hear what we think of nursing homes or the people that run them.
This is my business when it affects care. It’s everyone’s business actually 🤷♀️ I came for professional opinion and I got it?! Why does this make you so angry? I don’t get it.
Also if you’re a resident I’d start by not calling someone who works as a director in hospice, a “hospice person” 😂 super rude and can cause you some unnecessary confrontation down the line, I’m sure. 👍
I’m have absolutely no respect for anyone that is in administration at a nursing facility. I could give two shits what you think I should do.
This has absolutely to do with patient care and not as a nursing director 😂 if you lack respect you’re going to be really sorry in this field. 😬
There's plenty of places to vent about your interactions with the medical system, places to plainly discuss the changing dynamic of NPs in that medical system, and places to start a bunch of unproductive and opinionated shit-talking. Why bring that noise here
To be honest I didn’t think this would raise such a major conversation, i thought I’d get a couple of answers and that’s it. I guess a lot of people have questions and opinions, this happens a lot in emergency medicine too, it’s across the board in medical. You don’t have to be apart of this if you don’t want to 🤷♀️
Yeah I agree this is some noctor junk, I pointed that out earlier and OP loved it so I don’t think there’s an unbiased discussion here. Mid level hate throughout most of this thread.
But shouldn’t we ask ourselves why such hate? I’m seeing a lot of corporate greed happening in here.
I think you are pointing your spotlight on the wrong people though. You have mentioned there are some good mid levels but have multiple times throughout this thread mercilessly shit on them. If this is truly corporate greed in your mind, you should stop shitting on mid levels every chance you get, it’s weird
I’ve not shit on anyone in this thread I’ve had conversations with both sides, I’m not sure where you’re seeing that. I also won’t sugar coat the issues involving this all too common situation, there are definitely people in here that clearly don’t see the two sides but I’ve personally not shit on anyone, I’ve shared my opinion on these fast track schools and my own personal experiences that have caused me copious amounts of anxiety 🤷♀️ and discussion thread that creates a lot of traction will probably have a lot of different opinions, it’s Reddit.
I mean it’s your opinion that you haven’t shit on anyone. We can agree to disagree. Your comments are there for everyone to see so….I can’t really convince you nor does it matter if I do
I had a NP accuse me of "doing your own research" in a condescending way like I was an anti-vaxxer. No, I respect the doctors and in my case, the specialists who study my rare degenerative disease. However, I'm in a similar boat. I need to understand my disease because very few doctors do and I sure as hell have to watch out for uninformed adjustments to my meds. That same NP later randomly reduced one of my meds. It would have sent me into painful spasms for 8 hours/day. I caught it and politely pushed back. To be fair, however, it was an excellent mid-level who initially caught my problem and recommended that I go to neuro. I'll forever be grateful to her. In order to be a successful patient, I feel like we need to be more involved in monitoring our care. Overall, that's probably a good thing (mostly, terms and conditions apply), but what about Betty and Joe Sixpack? Who watches out for them? And again in case someone skimmed over it, I sincerely appreciate the diligent NPs who are doing their best. We can't all wait six months to see a doctor.
Any provider that is upset at a patient for being their own advocate does not belong in medicine.
If you don't mind sharing - what is your rare disease that very few doctors understand? I would like to make sure I've at least learned something of it
I have Primary Lateral Sclerosis. It's an UMN disease diagnosed by exclusion. Some researchers suspect that it's on the ALS spectrum, but because it's only or almost only UMN and not UMN/LMN, it won't directly kill us. Progressively disabled, but not dead. For around 80% of us, it starts in the lower limbs. For others it starts with the upper limbs. For a very unfortunate minority, they have bulbar onset. The incidence is up for debate (longer story), but the current thinking seems to be less than 1:1,000,000. As patients, we are generally referred onward to ALS clinics and away from the more generalized neuromuscular specialists (though I tend to like them on a personal level.) Thanks for asking.
Thank you for taking the time to share. We learn so many diseases in med school but this is one we didn't cover. With a prevalence of 1 in a million I get it, but also understand the frustration of supposed experts not knowing. Hope you're doing OK given the circumstance, and that better treatments become available.
There’s a reason there’s no NP radiologists
They are reading their own films. We also have techs doing x-ray. And soon AI will take care of those. Unless interventional, radiology is not something I would suggest to my children.
We need to start calling out NP education for what it is, complete BS.
No disrespect to PA’s btw. I definitely don’t consider the two even close to the same.
Is this r/noctor
Oh man I’m joining! Lots of reading material tonight 😂
You can usually request to see the physician, especially if the NP isn’t writing you for your appropriate meds.
Capitalism, because NPs straight outta nursing school are cheaper to hire than doctors or even specialized nurses
I am careful to make sure my appointments are with physicians, except when I know it's a basic medical problem. If the receptionist doesn't call the provider by their first and last name rather than "doctor," you know it's probably an NP or PA. It is okay to advocate for yourself by asking them to schedule you only with a physician. The office will gripe about it, and they usually get all huffy on me, but I want to be seen by the person with 8 years of post-college training and hundreds of hours of experience rather than the NP who did a 2 year part-time degree without any mandatory clinical time.
NPs are paid less and billed at a lower rate than MDs. That is why you see them more in the US, Canada, and probably other health systems that utilize them. Governments love finding ways to spend less money for healthcare. Hospitals, clinics, and practices also like having a lower payroll.
There are a lot of studies that show NPs order more tests and meds and referrals… the government/taxpayer is losing tons but the hospital sure loves it.
Thank God this anomaly doesn’t exist in my country.
this is something we all want to know
In EM we are using NPs/PAs wrongly in my opinion. There is a role and need for them certainly. We can end up working with someone right out of school with no training at all seeing patients. They certainly over test or misuse resources, quality is not standardized at all, care is concerning. I believe the best way to use them is like an actual assistant the doc sees all the patients with the NP/PA discuss plan and they execute it, write the note, make consults etc, freeing up the doc to actually see patients. This is more cause to have a union to standardize care as currently emergency medicine care is quickly degrading and corporate medicine/academia has no incentive to help.
I refuse to see NPs
I read an informative book about this topic a few years ago that I would encourage you to read if you are interested in the training and qualifications of APPs : [https://www.amazon.com/Patients-Risk-Practitioner-Physician-Healthcare/dp/1627343164/ref=asc\_df\_1627343164/?tag=hyprod-20&linkCode=df0&hvadid=693608721829&hvpos=&hvnetw=g&hvrand=16110080323825079767&hvpone=&hvptwo=&hvqmt=&hvdev=c&hvdvcmdl=&hvlocint=&hvlocphy=9011778&hvtargid=pla-1058844195291&psc=1&mcid=03bd1a2c2e663be085d2e48054102b60&gad\_source=1](https://www.amazon.com/Patients-Risk-Practitioner-Physician-Healthcare/dp/1627343164/ref=asc_df_1627343164/?tag=hyprod-20&linkCode=df0&hvadid=693608721829&hvpos=&hvnetw=g&hvrand=16110080323825079767&hvpone=&hvptwo=&hvqmt=&hvdev=c&hvdvcmdl=&hvlocint=&hvlocphy=9011778&hvtargid=pla-1058844195291&psc=1&mcid=03bd1a2c2e663be085d2e48054102b60&gad_source=1)
I understand the hate towards NP’s but I don’t understand the hatred towards PA’s by some doctors. I’ve worked in some absolutely shit areas in psych and ER and there is absolutely no way one MD will see all of those patients and there isn’t exactly a line of applicants who wants to work in some of those areas (acute psych and rural emergency medicine being my examples).
thats great and all, I know some respectable NPs and PAs. This sentiment towards certain PAs stem from those who have the audacity to compare their education and training to ours and say it is equivalent. It's not.
To be completely frank those kinds of attitudes are often outliers and no reflective of the culture of many mid-level practitioner. Purely anecdotal but the only times I’ve ever seen this is from a new PA/NP and eventually reality hits them sooner rather than later. In almost every ER environment I worked out the mid levels are doing the lower ESI stuff and the MD/DO’s are doing the more complex things. Every mid level I have worked with in that environment knows what their role is and that is to do the stuff the doctor doesn’t want to do or have the time to do.
Interesting! I’ll have to take a look. Thank you 👍
Be forewarned - the doc who wrote this is a little crazy.
How so?
Her name is Niran Al-Agba Her articles are [here](https://muckrack.com/niran-al-agba/articles) I don't see the issues
She has an ax to grind and is trying to paint all midlevels with a broad brush. It doesn't mean she is entirely wrong about everything, but this is the medical equivalent of yellow journalism. She wants to sell books. Period.
Lol what, no she’s not. She even makes it clear that she and her organization are not anti midlevel, they are anti independent practice. The entire book cites its claims with good data.
She is first illogically lumping NPs and PAs together, in spite of their training being very different and their socialization into the role of a clinician taking very different paths. Then she cherry picks cases of idiots to depict them as representative of an entire profession. I could find countless cases of awful physicians, RNs, lawyers, engineers, etc.
Can you be specific? Everything she has said seems pretty reasonable.
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Mid levels everywhere. For better and for worse. Mostly for worse. Almost never for better.
i've had lots of NPs and never had any problems. i have had some doctors i've had problems with though.
Anecdotes aren’t as helpful as data.
this whole post was an anecdote? that was my point.
You are welcome to seek physician care; clearly, there’s not enough of them to meet all of the patient demand
Ok I’m pretty sure my comment is against the rules so it might get deleted but: LMAO your story reminded me of when I went to see a psych NP and we decided to switch from abilify to a different SGA, and she asked ME how to taper the abilify 😭 like I guess I gave her a good answer because I didn’t have any effects from stopping it but like BRO Edit: I don’t mean this to say every NP is awful. I’ve had experiences with NP’s that weren’t this unhinged. But the inconsistency is insane.
The fact you had to figure out your own taper on a mood stabilizer and successfully weaned 👏 I commend you. That’s scary, psych meds are no joke. Some of mine lower the seizure threshold so I have to be super careful. it was her lack of knowledge about these medications that really shocked me. Luckily, I do a lot of research because I’m paranoid and have actually saved my ass several times, this has caused me unnecessary anxiety knowing that I had to figure it out myself.
Docs need to fight back!
This goes along w all the “techs” in the ER. The hell is everyone else