<p>For ARNPs, more required training in communications skills, behavioral health, and (in some programs), drug interactions. Don’t know about PAs. </p>
<p>In HMOs, PAs and, especially, ARNPs work as “care coordinators”.</p>
<p>Other difference is pay, obviously.</p>
<p>“What I’m saying is that I largely bypass the primary care physician with my patients.”</p>
<p>So if you aren’t a primary care physician, PA, or ARNP, who are you? LOL! (How do you get to make referrals at all?)</p>
<p>
</p>
<p>A Certified Athletic Trainer. Most of my patients are high school athletes.</p>
<p>@419marye - and as a specialist, have you never seen a mismanaged case from an MD? </p>
<p>If not, perhaps you should see my friend, a former cop, who was injured trying to make an arrest. For two years, his physician told him his headaches were nothing to worry about and kept prescribing pain killers. </p>
<p>He’s now totally disabled with irreversible brain damage - and a dependency on pain killers. </p>
<p>And it took him three years and a court ruling to get disability benefits because no insurance claim was filed within a year - because for two years, those headaches were nothing to worry about, right? </p>
<p>Guess what - some MDs are incompetent too.</p>
<p>The answer is the education. Those extra years in school and in internship/residency/fellowship cannot be underestimated. It is intense! Day after day, sick patients to care for, pathology to learn, rounding over and over with peers and professors who have seen it all. Morning report, grand rounds-cases reviewed and just torn apart for all to understand. Those attending physicians questioning your every thought and deed to help your decision-making processes. Teaching those younger than you, being taught by those older. Taking call every other, every third night and being the first person the nurse calls to handle every urgent or not so urgent issue. Just even learning to recognize when someone is truly sick is not as easy as it sounds. </p>
<p>Everyone wants someone who is caring and competant to take care of them and their family. The question is how does one determine competence?</p>
<p>I work in the alcohol/drug field - we’ve seen literally hundreds and hundreds of cases like this (until, finally, the state had to pass a law to control physician prescribing practice.) The reality is that (at least at our state medical schools) physicians have to take NO course work related to substance abuse, and not a heck of a lot in effective pain control. So it isn’t surprising when they run into difficulties. It turns many patients into drug seekers (I helped write new state emergency department guidelines for the use of prescription painkillers in treating pain in the emergency room, and we’ve just initiated a new ED information sharing agreement, because patients/addicts will go from ER to ER seeking drugs to feed their habits.) We’ve been moderately successful, but one of the results is a massive turn by patient/addicts from prescription-type opiates to heroin.</p>
<p>UW has just initiated a new program to familiarize future physicians with rural practice. At the end of the program’s first year, some 85% of future physicians reported they would never choose to work in a rural area. The main reason by far they gave was the overwhelming number of patients with drug problems, with which they were never trained to deal.</p>
<p>Annasdad,
Yes, you are right. Some should not be practicing. No doubt about it. And some NP/PA’s outshine MD’s. However I feel the public is getting the sense that seeing an NP/PA is equal to seeing their family practice doc.</p>
<p>How does one determine competence? Apparently not by an MD diploma hanging on the wall, if my friend’s experience is any guidance. </p>
<p>And don’t get me started on the misdiagnosis of my wife’s cancer at one of the world-renowned cancer centers, when a surgeon proclaimed a diagnosis based on a needle biopsy. Fortunately that one had a happier ending when a second, competent physician at the same place questioned the diagnosis and the methodology behind it…
EDIT: cross-posted</p>
<p>My young adult D sees an APRN as a primary care provider in a clinic for people with developmental disabilities.
In that setting, it works splendidly. My D is medically quite healthy but has cognitive and behavioral issues. The RN spends much time with her and also with me as a backup/translator when needed. She monitors her diet and exercise closely and quizzes her on social and interpersonal interactions that could affect her health.
I truly believe DD receives more thorough care from the RN than she would from a primary care MD.
There is an MD that runs the clinic and is available for consult. Has not been necessary for the 3 years DD has been in this practice.</p>
<p>That said, I just visited an orthopedist that specializes in hand surgery. My bailing water in basement during Irene wrist injury is not healing and I suspect I need an injection or hopefully not, surgery. So, I do believe there is a need for providers with various skill sets.</p>
<p>
</p>
<p>You are right 419marye. This is why NPs and PAs should not manage complex hospitalized patients unless being thoroughly supervised by an MD. Currently, both NPs and PAs are master’s level programs. Both professions are contemplating having a doctorate as the entry level requirement. But, 2 years of intense training certainly allows you to manage most primary care problems and refer that which can’t be managed. You are correct that recognizing what is not known is a challenge, but I found that a PA just out of school is often better than an experienced MD who is getting out of the habit of looking for zebras. </p>
<p>Back to the original topic of jobs: My DD is considering med school, but is resisting it as the best care she has received (she has a number of primary care concerns and a number of athletic injuries one which required surgery) has been from the NPs and PAs that she sees. I’m unfortunately discouraging her as the average entry level salary in my area for a PA is 70K and that for a family physician is 170K. I know all about the loans for med school. But, a PA I know went to a top PA school and is 80K in debt. The family physician would leave 160K in debt. The work is the same, with the possibility that the physician gets more perks. From a math perspective, it’s a no-brainer. Get an MD.</p>
<p>
</p>
<p>And this is so true…No, you wouldn’t want a NP to treat a head injury, but, OTOH, you don’t need an MD to treat a sore throat or cold (which are, BTW, the two most common diagnoses seen in the ER). A PA or NP can very effectively managed mild hypertension and will probably spend a lot more time in counseling the patient in diet and exercise than a physician. But if I had severe hypertension, I would probably be seeing a specialist.</p>
<p>There is a continuum of care, folks. And if you believe in the future you are always going to have a choice about only seeing a doctor, I have a bridge to sell you. If you have independent means to pay for it, then yes. If you are covered by Medicare, then no, you may have no choice AND we are beginning to see commercial insurers moving toward handing over the risk to providers under an ACO model. Once that risk is handed over to the provider, it then becomes the provider’s choice on how they will deliver care. The premise of an ACO (very similar to capitation) is that being required to manage a population on a fixed amount of money forces the providers to develop high-quality, cost effective protocols and delivery model. Cut corners and your patients end up sicker and you lose money. Provide unnecessary care and you lose money. I don’t think anyone is looking to cut the physicians out of the loop but there are many things mid-level providers can do. And there simply aren’t going to be enough primary care physicians to go around when the current crop starts retiring.</p>
<p>To give you an example, at our OB/GYN residency clinic (mainly Medicaid and low income patients) the NPs see the majority of patients. They see probably 5 patients for every one our residents see. Those NPs (not the residents) have developed a model that had resulted in a significant lowering of premature births and babies who end up in the NICU. Hospitals and physicians contact us all the time about how we do it. The care those patients get is exceptional. We now have more private insurance patients (who have been followed by OB/GYNS) ending up in the NICU than Medicaid patients who have been seeing NPs.</p>
<p>You don’t need a sledgehammer to crack a nut. A simple nutcracker will do. We’ve gotten use to using a sledgehammer for every minor illness. It’s time to start using the most appropriate tool for the situation.</p>
<p>
</p>
<p>Excellent example and yet we want to reserve such excellent care for the poor.</p>
<p>
</p>
<p>A bit of an overkill. The appropriate specialist is a nephrologist and there are not enough nephrologists to see all the patients with severe hypertension. The specialist will likely put you on the same meds and monitor you similarly as the specialist at a higher cost. An example from our clinic shows that the NP and PA in our clinic appropriately monitor their hypertension patients 80-90% of the time while the primary care MDs appropriately monitor their hypertension patients about 50-60% of the time (and yet their pay is twice that of a mid-level??). Such monitoring in includes the correct labs and scheduled visits in order to monitor for chronic kidney disease in order to see if a visit to the nephrologist is necessary.</p>
<p>I hate this dislike physicians have for NPs and PAs. The kids going to med school these days do not want to do primary care. They all want to be specialists as there is little money in primary care. Without NPs and PAs, there will be no primary care providers when this current crop who are in their 40-60’s retires. This is the wave of the future. And we are good at what we do.
As I have said on previous posts, I do not want to be a doctor, nor do I present myself as one. I am a mid level provider, and I am good at what I do. I have worked with many doctors who say I am as good, if not better, than others doctors they have worked with. I know my limits and am not afraid to ask questions or refer if I am unsure. And, most importantly, my patients trust me. Sometimes, I have to insist that they see the doctor, because I want another set of eyes looking at them.
That said, I am good because of my training. I spent 7 years as a nurse in ICU prior to getting my NP. When the doctor I work with asks how I know so much, I tell her it’s because of my training as nurse, which served as the foundation for my advanced practice. I am very concerned about these fast track programs that are graduating NPs and PAs with very little actual hands on training. My personal feeling is that these graduates should be required to do a residency program prior to practice. JMHO</p>
<p>
</p>
<p>Don’t feel bad…they tend to dislike other physicians in competing specialties also. I’ve sat around in meetings and watched cardiologists, vascular surgeons and CT surgeons duke it out. Their dislike for each other is intense. Any time someone is threatening someone else’s livelihood, there is bound to be a lot of animosity.</p>
<p>^
but the good news is they can usually agree on one thing-- they all hate attorneys :)</p>
<p>Doctors are mostly good people. My problem is that they are not as well trained as ARNPs, PAs, and in some areas, even two-year RNs. They receive no required training in communications skills, nutrition, none in behavioral health and substance abuse (resulting in an almost universal failure to diagnose), none in effective pain management (and the associated risks). Without these, they are hamstrung in effectively treating a range of very common conditions, starting with diabetes. </p>
<p>For people with a range of very common medical conditions, being seen by an ARNP or PA, and managed by an RN, will be a step up.</p>
<p>"In the new ACOs, screening for “behavioral health conditions” (substance abuse/mental health) will all likely be done by nurses, under the supervision of nurse care managers. The incentives in the ACOs will be heavy (as they have been in some HMOs for the past 20 years), to keep patients away from physician specialists. "</p>
<p>I only have a minute before my electricity shuts off, but I beleive this contributes to increase costs based on overuse of psychotropics. In thesystem I work in, I beleive limiting the use of psychiatrists has driven up the use of psychotropics, with asolutelyno evidence base. Yesterday I learned fluoxetine for “depression” costs more than about 26 sessions of cognitive behavioral therapy after just 9 months, and the outcomes and effect sizes would reallysurprise some people. And fluoxetine is the cheapest psychotropic out there, with no need for testing of blood sugar, EKG’s, ect…</p>
<p>I think there is data to show this is true with other “exteneders” as well. It IS complicated.</p>
<p>Ooops. Just got to post #36; nevermind.</p>
<p>Hmm. To me, the overuse of psychotropics is clear. But I always thought of that as being the result of the psychiatric profession remaking itself (DSM, etc.) as the guardians and gatekeepers to the wonderful world of psychopharmaceuticals. Is Whitaker’s book “The Anatomy of an Epidemic” that far off?</p>
<p><a href=“http://www.amazon.com/Anatomy-Epidemic-Bullets-Psychiatric-Astonishing/dp/0307452425/ref=sr_1_1?ie=UTF8&qid=1319386985&sr=8-1[/url]”>http://www.amazon.com/Anatomy-Epidemic-Bullets-Psychiatric-Astonishing/dp/0307452425/ref=sr_1_1?ie=UTF8&qid=1319386985&sr=8-1</a></p>
<p>I am sure that ARNPs, etc., get less in the way of training in psychopharmacology than psychiatrists, but maybe more than most docs. They certainly get quite a bit more in behavioral health.</p>
<p>Yes, it is complicated.</p>
<p>
</p>
<p>Shrinkrap - aren’t the majority of psychotropics prescribed by primary care physicians? In my area, psychiatrists do absolutely nothing but prescribe and management medications. No talk therapy and certainly no CBT.</p>
<p>I agree on the CBT. I just finished three years of weekly CBT sessions and it is great. I had previously been on Zoloft for 5 years. My insurance would not pay for the CBT sessions but it would pay for the Zoloft. There is something so messed up with that. OTOH, learning cognition behavioral skills was a lot of work and took a lot of time. We live in a society where people are always drawn to the quick fixes.</p>
<p>If you study health plan costs of employers, the number one drug cost is anti-depressants. The vast majority are prescribed by primary care physicians, and when you do cross studies to other medical claims…most people taking anti depressants are not seeing any sort of mental health specialists.</p>
<p>I find it appalling and scarey. We all just want a little pill to make us feel better, we just dont want to do the work to figure out what it takes to live a life free of drugs. </p>
<p>I am glad those drugs are there when they need to be and should be. I just wish more folks actually saw mental health professionals to do the work to address the underlying issues. It isn’t always about permanent chemical imbalances in the brain.</p>
<p>
</p>
<p>It’s that way for everything and it’s nuts. We’d all be skinny and have zero obesity problems if only we had a pill that led to weight loss in the same manner exercise does…</p>