Finally The AAFP Grew Some Balls!

The American Academy of Family Physicians shot back at the whole physician extender “is as good as a doctor” trend.  You might remember that the government/hospitals/insurance companies are supporting this movement for ONE reason only.  They are cheaper.    Take a look at this AAFP stance here.  Here is a quick summary:

The AAFP report takes issue with the movement to grant nurse practitioners (NPs) independent practice authority at a time when the PCMH model is being rolled out across the nation. NPs are a vital part of the health care team, says the report, but “they cannot fulfill the need for a fully trained physician.

If you are a member of the AAFP, leave a comment.  Here was mine:

Finally, you did something right.  You took a damn stance.  Hiring LELTs (less educated, less trained) is thought to be the answer to our healthcare dilemma.  Look at Massachusetts and how they doing the same thing with PAs.  NPs and PAs are not bad people.  They are helpers in the healthcare arena.  But they are NOT doctors.  They used a trojan horse (to help the poor and needy in the rural areas) to gain traction and now they want to compete with us.  It should have been game on at that time.  They have killed our negotiating leverage with hospitals and the government.  Finally, the AAFP has grown some metaphorical balls and stood up to this.  You were warned.  Us members begged you but you had to be the nice guys and appease all.  Well, unfortunately it is too late and we have lost.  Your only shot is to spend our dues on media ads explaining your stance listed above!  Hammer them!  Be mean!  And then walk away from the RUC and let those idiots come to us.   Man up!!!!!  We have no time to sit back!

I am leaving it here because they could take it down as it was a little rough.    I expect, as always, to get hammered by my PA, NP readers.  Whatever.  Using the term LELT is the most nonjudgemental and accurate acronym I could come up with.  It is indisputable.  It is a fact.  Do I hate PAs and NPs.  Hell, no.  Can they be great clinicians in their scope of practice?  Hell, yes.  But both your groups have affected my livelihood and if you get mad at me for protecting my legitimate turf than go right ahead. Game on.

And unlike the pathetic organization that represents me, it has always been game on for years.   Why they never saw this coming is beyond me.


  15 comments for “Finally The AAFP Grew Some Balls!

  1. Stacy RN
    September 29, 2012 at 11:30 am

    Whoa, people. Does it really take an RN to play peacemaker here? As a person who takes orders from all of you, I see where you all fit into the food chain, so to speak. Look, NPs and PAs are not trained in the same way as MDs and DOs and should not replace them. I must say, I’ve seen NPs who are some of the best practitioners you can imagine. But, could they replace a MD? Absolutely not.

    I’d like to tell you a little story. I once received an order from an NP that I not only questioned, but thought was insane. (No, truly, I thought she might have lost her mind.) I called the doctor on it. I told him the order. He thought it over and asked me why I thought it was crazy; I gave him my reasoning. He gave me fresh orders and told me to ignore the NPs orders. I was sure that the NP was going to be offended at me going to the doctor and the doctor overriding her (even though that is his Ohio-state-given right). She wasn’t. She said that she gave her orders from her scope of practice, and that the orders I was given by the doctor were beyond her training. She had no issues with it.

    Now, if you want my two cents (and remember, I’m paid a lot less than all of you, so appreciate it when I offer up my hard earned two cents), I see NPs and PAs every day. I see doctors every day. The NPs and PAs round on my patients give some of the basic orders and then report back to the docs what they’ve done. The docs come in and can focus their rounding. It’s a system that works.

    Here’s two more cents: in this state, there’s a wrench about to be thrown into that system. Now, new NPs will need to have a DNP to practice. The “old” NPs will be grandfathered in to the system, but the new ones will be required to get it. I know a lot of NPs scared that they’ll be replaced by these new “super-NPs” and a lot of RNs who have decided not to advance their careers because an MSN plus a DNP plus the clinical time required by both now makes it just about as many years (not as many hours, but just as many years – 3 years for a good MSN program, then 2-3 years for a good DNP program) as going to medical school, but you come out as an NP and not a doctor – less knowledge, less training, less pay. Is it worth it, they ask?

    I’m one of those asking that question. Nursing is my second career and was supposed to be a pit-stop on the way to advance practice. When I went to nursing school, I had thought of taking the MCAT and applying to med school instead at that time. But, I thought I’d take the route of getting a bit of money in the bank account first. Fast forward a few years: I’m ready to start toward my advance practice degree. Over the last few years, I thought of going to get the NP rather than taking my hard earned money and sinking it all into med school, and then some. Then, the new regs start. Oops! Now, I’m going to end up with a crap-ton of debt anyway (a bit less than med school, but…), spend as many years in school (not as many over-all hours, but as many years) as the MD and end up still being an NP. Is that worth it? If they’re going to make me do all of that, would I feel I deserve a little more with the NP title behind my name? I sure as hell would feel entitled to it. But I still wouldn’t be a doctor; and I still couldn’t do all the things that a MD/DO could and should do. I join the millions of RNs asking themselves, is going for the NP worth it? Probably not. So I’m back to weighing the original plan of med school. Still a lot of time. Still a crap-ton of debt. But better than the end result of the alternative, where I may or may not be pushed out of my scope of practice by those who don’t believe in the team approach.

    (And, for what it’s worth, do I know any NPs who believe they are equal to docs? No. Do I know NPs who want complete independence from docs? No, not a single one. Do I know NPs who wish for a little more respect? Yes. Do I know NPs who feel that the government is pushing them into practicing outside of their intended scope of practice so that there are more people pushed through our sick-care system? Yes.)

    I’ve talked to plenty of NPs, plenty of docs, and plenty of NPs-turned-MDs. They all reject “separate but equal” because it’s acually “together in a chain of command and knowledge”. They all know that the team still has a pecking order.

    Respectfully yours,
    The RN that wants you all
    to get along so we can get
    back to business

    • Doug Farrago
      September 29, 2012 at 2:48 pm

      Good stuff! Thanks.

  2. RJM
    September 27, 2012 at 2:04 am

    I’m normally just read these and move on, but since I’m taking the week off to study for my 10 year MOC in Cardiothoracic Surgery, I’ve got a little extra time on my hands.

    Fred – you seem like a nice guy – but you are less trained and less educated than a physician. Your two BS and Masters are quite an accomplishment – especially if you did it while continuing to work. However, when you compare these degrees to a MD/residency, it becomes clear that you don’t know what you don’t know. My first two years of medical school were 25 -30 credit hours each semester – basically those two years were the equivalent of four years of college. My life for those first two years wouldn’t have been any different if they locked me away in prison and let me out just to go to classes. Tests were routinely given after weekends and holidays (meaning we spent all weekend/holiday at the library studying) because “sick people don’t take days off”. Part of this was to prepare us for our chosen profession and part was to weed out those who might not be up to the demands of being a physician.

    The next two years were clinical at a major U.S. teaching hospital. No summer break, two straight years. Depending on the rotation, there would be one, maybe two days a month off – usually a Sunday. Hours were basically the same as the residents or longer. While we were typically “scut monkeys”, it was an appropriate introduction to hospital based practice and you got what you gave. An example, My medical school roommate wanted to go to Duke for residency, so he did an elective month in their Ortho program. He wanted to make a good impression so he bought 30 pairs of underwear before he left, That way he wouldn’t have to leave the hospital to shower/change/do laundry. He lived in the hospital for a month! Bet you didn’t consider doing that for your masters. BTW it worked, he went to Duke and has done very well.

    Somewhere around this time I took a series of 3 standardized written tests to become an MD

    Next came residency. For me, six years general surgery and two years thoracic. This is clearly longer than FP/Internal Medicine, but the concept is the same and can be best explained with the following – What’s the difference between a cow patty and an intern? Nobody goes out of their way to step on a cow patty. Was it rough? you bet. Necessary? not all of it, but I’m comfortable that the physicians trained with this method will have the appropriate sphincter tone needed to answer that pager, check that lab/Xray, get out of bed and drive to the ER, etc.

    Somewhere around this time I took oral and written boards for general and thoracic surgery. MOC for each board every ten years.

    Bottom line, training/education/continuing education is significantly different for physicians than PA/NP. Clearly, there can be a roll for PA/NP in the medical field – I’m not sure primary patient responsibility is it. It would be a little like having the replacement refs in the NFL. Good, well- intentioned people, whose skill set isn’t quite the same as the real Refs. Only this isn’t a game.

    One more thought – when I was younger I wanted to be a Doctor… So I went to Medical School and became one. As far as I know, that opportunity still exists for anyone who wants to be a physician.

    • Fred
      September 27, 2012 at 8:08 pm

      Dear RJM,
      Thanks for taking the time away from your studies to reply. I don’t think I can replace an MD. I think NPs and PAs play a vital but different role than physicians. I don’t want to perform cardiothoracic surgery but I also know a hell of a lot from hours if recovering “fresh hearts” straight from the OR. Having done this in a smaller hospital where there was not a CT surgeon in the building or even a surgical resident at the bedside meant I had to know my hemodynamics in and out, make critical decisions, etc etc. I know this knowledge will make me a valuable resource much like the hundreds of NPs and PAs in CT surgery groups around the U.S. that are part of a TEAM approach to managing patients.
      You claim I “don’t know what i don’t know.” Well please stop with the assumptions. PAs and NPs have boards and recertifications as well. Actually every 6 yrs if you want to know. Yes, I could have gone to med school and actually continue to be urged by colleagues to do so. But, my wife has two docs as parents and doesn’t want to lose me as a second parent and partner in our childrens lives. I also have a mortgage and need to keep food on the table. More importantly I think my training and experience as an RN as well as a long time community activist suits me better for the role of NP.
      Thanks for the belittling comments but you should direct your frustrations to your studying and your own professional organization. NPs don’t want to take away your OR, we do want to work with you to improve your patient management.

  3. dr o
    September 26, 2012 at 10:13 pm

    Had a patient with a complex urologic problem. He wanted a second opinion, which is fine with me. He wound up seeing a newly minted LELT. Made my day. 🙂

  4. SR Boden
    September 26, 2012 at 4:41 pm

    I fully agree with the motivation of the LELT community. Working in the federal system already we have PAs and NPs working along side as Primary Care Managers. The patients refer to them as “Doctor” and while some will correct the misconception others will not. PAs and NPs have a vital function as physician extenders. The problem is that we have stopped being “doctors” and accepted the roll as “health care provider.” There is a huge difference in training and education. I would venture to say it is along the lines of the difference between my training as a pediatrician and the training of the family practice residents that was done in my same hospital. Their 3 months of training is not close to the 3 years of training that I received. Would I take my kids to see a FP trained physician…yes, I would and have. Would I take my kids to see one who did not recognize the difference between my training and his…no way. We have different training for a reason.

  5. Richard W. Mondak
    September 26, 2012 at 3:19 pm

    PArtners… maybe not like Hawkeye and Trapper and definitely not like the Lone Ranger and Tonto or Batman and Robin – although sometimes it felt that way. Maybe a little like Ben Rumson and Pardner (Lee Marvin / Clint Eastwood).

  6. Fred Watters
    September 26, 2012 at 10:23 am

    I continue to love your weekly writing and ranting but I just have to comment on this. I know your pissed about NPs and PAs “moving in on your territory.” But you can’t really have it both ways. Ranting about the lack for primary care MDs at the same time you rail against a legitimate answer to the problem just isn’t logical. Your defense of using the term LELT is weak at best. By the time I finish my MSN this spring I will have two bachelor’s degrees and master’s. That will be more than 10 years of academic training as well as 10 years of clinical work as a critical care and emergency room RN. Do you really have the balls to claim that I’m less educated and less trained. That’s more education and training than the average MD.
    Let me be clear, I believe that the role of NPs is FAR different than that of MDs and I look forward to a role as an ancillary to their care management not a replacement. I was originally in a BSN to MSN program at an Ivy Tower school. I decided to stop before completing my MSN in order to obtain more clinical experience as an RN prior to becoming an NP. I think these ‘shake-and-bake’ don’t serve patients, NPs, or the medical system. I do NOT see myself replacing MDs but accentuating and extending their work. Get real Doug, the healthcare system is collapsing and we need all the help we can get. Your derogatory use of LELTs isn’t helping. I urge you to make your points in a different manner if you want to be heard and bring more people to your side of the argument.
    Keep us laughing and keep up the good work,

    • Doug Farrago
      September 26, 2012 at 10:50 am

      I did a master’s degree. So what. I don’t count that in my comparison. Your training isn’t even close to my four years medical school and three years residency. Your profession drew first blood by claiming cooperation but quickly moving to competition. I WILL NOT APOLOGIZE. You may not see yourself replacing MDs but your profession does and has STATED SUCH!!!! LELT is factual. It is only derogatory only if you have self-esteem issues. I DON’T CARE IF ANYONE comes to my side of the argument. My organization, the AAFP, is a bunch of wussies. I blame my granola eating, appease everybody, let’s all get along PEERS who work as family doctors. They gave away the farm and now we cannot even negotiate for a fair salary because the government/hospital systems/insurance companies are going to prefer NP and PAs. And don’t give me that the studies show their quality is the same shit. You are not. You are just cheaper.

      • Fred Watters
        September 26, 2012 at 11:04 am

        I can see the vessels in your forehead from here. I think your points are completely valid but we actually need to solve this thing called health ‘care.’ I think that the NP organizations are getting ready to shoot themselves in the face by forcing NPs to get doctorates or PhDs in the future. Then they will try to get the same payments as doctors and your worse fears will be realized. Luckily in Maine it’s still against the law to walk into a patient room and call your self ‘doctor’ without an MD or DO degree. The payments for NP work are presently directly tied to level of care provided in the office in which they work, ie whether there is a doctor in the building or not. This should continue. I guess what I’m asking for you to do is, if we are all in the same sandbox, stop throwing sand and help figure our which trucks we each get to play with and when.
        Do you see a role for NPs and PAs in healthcare at all? I just keep thinking of my father-in-law, an MD, who when he learned that his daughter was going to DO school basically said he considered it a form witch-doctor training. NPs have a different focus and different role. I think the studies able NP vs MD results that you have such disdain for are valid but also miss the point. None of us can do this alone.
        Thanks for you response,
        Cheaper but Better (sometimes)

        • Doug Farrago
          September 26, 2012 at 11:24 am

          How to play nice? Collaborative. Working as a team. Not competitive. NPs and PAs would have to retreat from their independent push for me not to be defensive. I did not bring this battle to them (you). It was brought to me. Now we have the PCP shortage but NO increase in salaries. Why? Because of NPs and PAs forcing this. And yes, they may bill to the same level of care but you will be employed and so you will be getting a much lesser salary – in effect, your billing doesn’t matter. In fact if you bill the same then the administrators just make more money off you and this reinforces their decision to hire cheaper but NOT better practitioners

          • Fred
            September 26, 2012 at 11:46 am

            Thanks for the response,
            And sorry for all the typos. Tapping away on the little cellphone screen when I should be studying HTN management is tricky. I guess I got defensive cause fundamentally I think you are absolutely right but I also feel strongly that my years of school and clinical work DO give me expertise. My biggest concerns as I start applying for jobs next summer will be:
            1) Finding a group with a collaborative spirit and physicians that will both willing to teach and be open to learning from a new NP.
            2) Finding a group that uses a EMR that encourages good care rather than stifle it.

            If and when the Board of Nursing tries to force NPs to get PhDs or DNPs I hope you show up with me to argue against it.
            Keep up the good fight Doug. You inspire even us lowly mid-levels struggling to provide high-level care…

          • Doug Farrago
            September 26, 2012 at 12:16 pm

            You DO give good care. You are not lowly. There IS A ROLE FOR YOU in a collaborative environment. We can work together and have a great time doing it. But not as competitors.



  7. Pat
    September 21, 2012 at 9:14 am

    Hehehe, Dough I think the unapologetic force of your argument has scared the LELT’s into silence.

    • rokosz
      September 26, 2012 at 1:49 pm

      And this from a lay-person:
      Anecdotal only, sure. But I appreciated the effort and the logic behind it.

      Regularly I need one ear cleared of cebum. My GP performed it early on. The last few times a LPN has completed it. This made so much sense. The MD doesn’t need to be hands-on for such a simple,mundane task. I suppose an RN or another of the LELT acronyms could do it too. Should an orderly? Of course not, but an LPN is a great alternative. As long as the practice is passing cost savings on to the patient/insurer.

      With everyone running to the doctor for everything from hangnails to a child’s fever that’s lasted more than 6 hours (or earwax removal!) there is a place for educational modifiers on the coding chart.

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