<p>^^ GTalum - My point exactly … seeing a nurse instead of a doc may reduce costs a few dollars, but it has no effect on the major healthcare cost drivers. </p>
<p>As to the OP’s inquiry, it’s really hard to say which parts of healthcare service are being eroded. What I told my D’s, both of whom were considering Medical School, was “Don’t be the last licensed Primary Care Doc who borrows $$$ for Med School.” It’s not certain the USA will start paying to train healthcare providers. But it’s a lot more likely than it was 20 years ago. My Primary Care Doc is 43 years old. He has two part time jobs in addition to his full time practice. (He wants to pay for his kid’s UG education.) Who ever thought a Doc would be taking on extra work so his kids could go to college???</p>
<p>When you are a patient in the hospital the quality of care you receive will depend FAR more on the skill, intelligence, and dedication of the nurses at that institution than it will on the genius and high education of the doctors.</p>
<p>^ Hey, I’ve got a funny story for you. When D#3 was six months old she was hospitalized for pneumonia. A week later she seemed to be doing fine, so we asked the nurse when D might be discharged. “She’s not ready” was the response. Another day goes by, and though D can breath fine without the oxygen mask, she still has it on. We ask the nurse when she’ll be off oxygen. “She’s not ready” was the reply. Another day goes by and we ask the Attending when D can be discharged. “I’ll have the nurse test her.” That afternoon, the nurse comes in and shuts off the oxygen. D starts choking after 30 seconds or so. “See, I told you she wasn’t ready.” </p>
<p>Yep, the oxygen mask was a sealed unit (ie, one with no ventillation holes). We waited until the nurses shift changed and asked the Attending to re-administer the test. D was discharged the next morning.</p>
<p>It really does depend on the individual, regardless of training. (And yes, I have a nice collection of “Stupid Doctor” stories also.)</p>
<p>"Hey, mini, doesn’t your wife teach nurses or something? "</p>
<p>No, she is a hospice nurse with a two-year RN (actually, it’s three years with the pre-reqs), and three years of experience, who will, after all expenses, net more this year than my primary care doc (with 20 years of experience). (But it was much more “selective” for my wife to get into nursing school than for my primary care doc to get into UVA med school). </p>
<p>“Mini - there is nothing about having an MD after your name that guarantees quality of care. In my practice, the PA and NP meet quality of care indicators about 90% of the time with the physicians being around 50-60%.”</p>
<p>Of course, especially as the MD can only see me for six minutes. (Well, not mine, which is why she doesn’t make any money.) In addition, MDs get far less required training in behavioral health (which affects about 35% of patients) than does a two-year RN. </p>
<p>Whether this is a good trend or not? I don’t know. Canada doesn’t depend as heavily on mid-level practitioners as we do now, and certainly not in the future. For people currently uninsured, or those with uncoordinated fee-for-service Medicaid, it may turn out to be a good development in terms of health.</p>
<p>Just a few points about board certified ob/gyns and nurse midwives delivering babies and the high cost of care for a “normal” pregnancy. </p>
<p>Regardless of who works with the patient during office visits and during labor and delivery, it’s the MD who has the ultimate responsibility and legal liability. Your nurse midwife may be wonderful, competent, and able to spend much more time with you, but if anything goes wrong at anytime the OB is the one who gets called in, and he/she’s the one who will be sued. Nurses and doctors both have to carry tail insurance. For an OB in my state, malpractice insurance runs $120K per year, and parents have the right to sue their OB until the child is 18. OBs and many nurses therefore have to carry “tail insurance” for 18 years after their last delivery.</p>
<p>Nurses and NP’s have been trying to convince they are just as good as doctors for a a long time. My old next door neighbor was an NP. I have heard this whole thing many times over.</p>
<p>If nurses really want to be doctors then they should do 2 semesters orgo, 1 gen chem, 2 semesters bio, 2 semesters physics, 2 semester calculus. Carry > 3.5. Take the MCAT, do well. Go to medical school for four years, then a residency. It’s a pretty linear pathway.</p>
<p>Success in such courses don’t have much to do with how good you are at taking care of patients. NPs don’t try to claim they are “just as good as doctors.” They may claim they are just as good or better with some things such as: Managing acute and chronic illnesses and routine physicals. Primary care practice ain’t rocket science. </p>
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<p>Both the midwife and supervising MD will get sued.</p>
<p>I believe “mid-levels” do provide an excellent spot in the medical realm. But to me, they are of little use actually. I do not refer my patients to a “mid-level” ever. Why? Because if I have to refer a patient, I need an x-ray, MRI, or concussion evaluation done. </p>
<p>Sure, they can order an x-ray or an MRI, but can they read it? And can they handle the injury if the imaging is positive? No, they’re going to refer to an orthopedic in that situation so why not send the patient there from the start?</p>
<p>In Illinois, a “mid-level” is useless when it comes to concussions. The Illinois High School Association does not recognize a nurse practitioner or a physician assistant as qualified to recognize and manage concussions. If I refer them on, they MUST be seen by an MD or a DO.</p>
<p>I would refuse to be seen only by a physician’s assistant/nurse. I always look up a physician to whom I’m referred to check for board certification in his/her specialty. If not board certified, I check the insurance program for another doctor. I would not want to be seen only by a PA.</p>
<p>I’ve used NPs for the last decade with our family for routine things like sinus infections, checking for strep, poison ivy and mostly things where I just need a scrip or need someone to confirm something I already knew. I think they provide a valuable service and one can generally get scheduled much quicker than with the family docs or internists. I can’t remember the last time my family doc “read” a radiology report…radiologists read those and the docs read the radiology report. I think the days of a physician who “did it all” are numbered. Everything is becoming more and more specialized. I know my father was surprised that he was seen by hospitalists during a recent ICU stay and didn’t see his “regular” family practitioner except for one night when he stopped by to say hello to my dad. It’s complex, but for young people interested in medicine there are many avenues these days. It’s interesting to read mini’s comment that mid-levels are not as prevalent in Canada.</p>
<p>"If nurses really want to be doctors then they should do 2 semesters orgo, 1 gen chem, 2 semesters bio, 2 semesters physics, 2 semester calculus. Carry > 3.5. "</p>
<p>If doctors really want to be nurses, then they should do a couple of semesters in communications skills. LOL! (Actually, one semester was required before entry into my wife’s program.) They should also get all A’s in their biology/chemistry, etc. prereqs - none of this 3.5 or 3.6 GPA nonsense.</p>
<p>Referrals will go the other way - from ARNP’s and PAs to specialists (mostly bypassing primary care docs altogether - if that’s the way the ACO wants it.)</p>
<p>"“Well, sure insurers and Obamacare will try very hard to get Americans to accept nurses as the medical decision makers in terms of diagnosis and treatment strategies. Does anyone actually think this will play?”</p>
<p>Most certainly it will play. PAs and ARNPs have been the bread-and-butter of many HMOs for 20 years, and it has nothing to do with ObamaCare, And it will be the ACOs themselves (hospitals, or physician groups) who will lead the charge (they make more money that way.)</p>
<p>So what your saying is that you would not send to a primary care provider, MD, PA, or NP.</p>
<p>What patients really care about is that they are seeing a provider who is competent and caring. That person can be a NP, PA, or MD. Obviously, sewhappy will only want to see an MD, which is fine and she should have a choice. But, many will want to see their NP or PA for most primary care issues.</p>
<p>What I’m saying is that I largely bypass the primary care physician with my patients. Not all insurances will allow for that; not all parents will do it. It is ultimately the parents’ decision, but my suggestion is seldom for a kid to see their primary care physician unless it is to rule out a fracture via x-ray and to get a script for PT. If I am concerned about a ligament injury, I send them to either an orthopedic surgeon or a sports medicine doctor.</p>
<p>My DD does NOT want to be a doctor. She has taken all of the above courses, and has a dual major bachelors in Bioengineering and Biology. She wants to either be a PA or NP…to be determined when she returns from her current assignment.</p>
<p>You know…the doctor thing IS quite linear…if that’s what you want to do. If not, it’s nice that there are other options for those who choose them. AND NO…my DD does not expect she will be treated like a doctor…since she won’t be one.</p>
<p>I can’t imagine a physician “referring” to a mid-level unless it was a mid-level that had an area of interest where they were a specialist like one that sees many menopause patients, or osteo patients, or something like that, but in general I imagine more patients seek out or request a mid-level than a physician referring. Typically our family sees referrals to specialists because whatever is going on is outside the scope of our family physician’s normal practice which would generally put it out of range for a mid-level. GTAlum reflects my views that if I need care I want to see some one who is competent and knowledgeable about whatever ails me.</p>
<p>What is the intended purpose of the NP or PA? Many of them work in a similar fashion as an MD/DO. What is the major difference between the “mid-levels” and the “physicians” other than the education? </p>