New Career For MDs by Aaron Levine MD

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There are several alternative careers for physicians. Robin Cook and Michael Crichton became authors and screen writers. Sir Conan Doyle created Sherlock Holmes. Some entered politics. There was a radio commercial this past spring about a husband/wife physician team who ventured out to a form of home remodeling as an alternative to their practice. Now for an ever better career. I was shaving while listening to the Houston PBS show this morning (does this mean I have to up my pledge?) and the story involved how vendors at the local renaissance fair are changing careers and making the tour a full time job.  It turns out that there is a physician selling dead rats (stuffed, I presume) at The Plague Shop. The reporter said he was trained in wound care, but was now transitioning to this as a full time occupation by covering several renaissance fairs in the country.

PAs and FNPs are allowed to perform abortions unsupervised in California (lets not get diverted by the abortion argument). Texas will allow triplicate medications to be prescribed by them as well. The VA has taken the policy that PAs and FNP can practice unsupervised in VA hospitals and clinics. I was not clear if this included specialty clinics or general clinics.   I learned there are plenty of rats in the New York Subway system and the Houston Astrodome to allow the doctor a profitable alternative career.

I guess when the President said you can keep your doctor, this is what he meant?

Douglas Farrago MD

Douglas Farrago MD is a full-time practicing family doc in Forest, Va. He started Forest Direct Primary Care where he takes no insurance and bills patients a monthly fee. He is board certified in the specialty of Family Practice. He is the inventor of a product called the Knee Saver which is currently in the Baseball Hall of Fame. The Knee Saver and its knock-offs are worn by many major league baseball catchers. He is also the inventor of the CryoHelmet used by athletes for head injuries as well as migraine sufferers. Dr. Farrago is the author of four books, two of which are the top two most popular DPC books. From 2001 – 2011, Dr. Farrago was the editor and creator of the Placebo Journal which ran for 10 full years. Described as the Mad Magazine for doctors, he and the Placebo Journal were featured in the Washington Post, US News and World Report, the AP, and the NY Times. Dr. Farrago is also the editor of the blog Authentic Medicine which was born out of concern about where the direction of healthcare is heading and the belief that the wrong people are in charge. This blog has been going daily for more than 15 years Article about Dr. Farrago in Doximity Email Dr. Farrago – [email protected] 

  36 comments for “New Career For MDs by Aaron Levine MD

  1. Ricky
    November 9, 2013 at 7:21 am

    The PA school i went to had the same instructors and same classwork as the DO students. The only difference was that we were taught the information in 15 months and med students were taught it in 18 months (some of the classes we were in the same room with the DO students at the same time gettingthe same lecture). Now i have been doing practice for just under 14 years being supervised by a Physician. But the DO students i was in class with and was taught the same information by the same instructors did a 2-5 year stent with “a supervising Physician”(residency) and i am less educated and less trained? I know a ton of DO and MD providers that i wouldnt take my dead rotting dog to. I have even quit two seperate practices due to pathetic excuses of MD and DO. I also know there are tons of horrible PA and NP providers i feel the same about. I know and have worked with several MD and DO providers that are AWESOME. And i know and have worked with some GREAT PAs.

    As far as going to med school. I took the MCAT (and did VERY well by the way) and WAS accepted into med school which would have cost me between $400,000 to $600,000 total or go to PA school for $80,000. Well i sat down and did the math and with the less salary it was in my best interest to not spend a half million dollars for miserable hours, abuse by administrators, disrespect from patients, and huge liability. I got all that for 1/5 the price!!!
    I personally am one who is against “independant” practice by PA providers. I work closely with my supervising Physicians. I respect them they know and repect me. I know my limitations and share that information with them often.
    I also work in the rural settings, never was a big city kind of guy, and i can tell you if it was not for the PA providers (we have no NP in town) there would be a HUGE part of the population that would have to drive 3+ hours to get a snotty nose checked due to the limited numbers of MD and DO providers we have locally.

    • Doug Farrago
      November 9, 2013 at 10:17 am

      Yes, by definition you are LESS EDUCATED and LESS TRAINED. You even said it yourself You also chose to “not spend a half million dollars for miserable hours, abuse by administrators, disrespect from patients, and huge liability”. I did and lost my youth to this profession. So are we equal? No. This does not denigrate midlevels. It is just a fact. Sorry. This is NOT about intelligence. This is a debate on whether this education and training means something. I believe it does. Can an EMT do what a PA does? Maybe, but they are not trained or educated as well Can a nurse do what a NP does? Well, the NPs who respond here and attack me would be offended at that statement! How dare I say a nurse is equal to an NP. An NP has more education and training. Exactly.

      • Sir Lance-a-lot
        November 9, 2013 at 10:32 am

        Thanks, Doug.

        I would just like to point out explicitly the implication of the often-heard “we do the same job as you” claim.

        If we all, doctors and PAs alike, accept that physicians are more extensively trained than PAs (something about “half million dollars for miserable hours, abuse by administrators, disrespect from patients, and huge liability”), but PAs and NPs are still demanding similar treatment, similar “respect,” etc., then there must be something else going on.

        That “something else” is the idea that our extra training has no practical use (or “marginal utility,” as I believe the economists would say). Yes, we all agree that docs are more highly trained, but, the PA and NPs say, “So what?” In spite of the huge differences in training, they can still do our jobs as well as, or even better than, we can.
        That means that,
        1. Our extra training was a total waste of time, energy, and money, both for us, and for society as a whole, and,
        2. We overtrained doctors with unreasonable expectations of respect and compensation can be eliminated and replaced by PAs and NPs, with no reduction in quality of care delivered, but with a huge reduction in cost.

        This, as I noted elsewhere, is where we are heading, and this is the argument we will be hearing.
        “Why should we be paying you $XXX,XXX, when we can pay him $XX,XXX to do the same job just as well?”
        Unless we have an answer that appeals to the MBAs and the politicians (ie: not based in the realities of medicine), we’ve had it.

      • Steven Gilles
        November 9, 2013 at 8:24 pm

        Doug,

        Sure, the education that a PA (or NP) gets is less than that of a physician.

        An internal medicine physician has more training in adult medicine than an FP. A pediatrician has more training in pediatric medicine than an FP. Does this mean, based on your argument that FPs should not be seeing anything past basic bread and butter preventive primary care? Of course not!

        I have seen patients refuse to see FPs because they feel they get better care from IM or Pediatrics. I have seen specialists refer to IM instead of FP because they don’t feel an FP can hack the complexity of a patient. I have seen FPs get upset, and “feel disrespected” when this happens.

        My point is Doug, that certainly there are differences in education levels between PAs and MDs. An idiot would say otherwise. MDs have more training, this is FACT and TRUTH. But simply stating something as a fact and then attaching your opinions to it doesn’t also make the opinion faInstead, be an objective clinician about it and say, “PAs have less training than MDs. I want to know if this in fact results in poorer outcomes for patients. I have concerns that it might, so I want to insure that I work with my MD colleagues and collaborate with PAs to insure that patient care is being delivered in a safe and reasonable manner
        I will tell the readers huse MDs have been dicks to NPs for ages! The reason that PAs are slowly wanting less to do with MDs is for the same reason.

        I mentioned it before. PAs were formed by MDs, we were formed with medical training in mind, we were formed to assist MDs and yet MDs continue to be angry at us for approaching the table with an open hand.

        You are the problem Doug. You and physicians like you. Who state facts and then based on conjecture alone attach your opinions to it about PAs and NPs.

        You have a right to your opinions. Absolutely. 100% you do . . but separate the facts from opinions, and try to realize that your inflammatory nature is what drives NPs and PAs away from wanting to collaborate with physicians and physician groups.

        We ALL suffer from the same issues in medicine. I wish you would acknowledge that. The FPs get screwed by the specialists. The FPs are marginalized as the red headed step child of specialties. Articles are published questioning the important of FPs and whether or not they should exist. This must feel horrible. It must feel terrible to question the career you chose, the specialty you chose and to feel like others in medicine disrespect you.

        Can you understand in a teeny, tiny, most microscopic way how it feels for PAs? Does some empathy exist within you Doug to say, “Gee, I never looked at it that way. PAs just want to help out and all this time I never realized they feel like we do and all my polite distaste of what it is they represent might just be adding to the problem.”

        I can hope I guess.

  2. Sir Lance-a-lot
    November 7, 2013 at 8:20 pm

    Alright, here comes another comment…

    I am an MD and an FP, working for a hospital doing urgent care.
    I generally work with two other people, who could be docs, PAs, or both (the “model” is for one doc and two PAs, but the realities of scheduling dictate otherwise on some days).

    I do consider the PAs with whom I work to be “colleagues,” because they are very intelligent and experienced, and I respect those qualities in them. There are sometimes things they don’t know that I do, and there are sometimes things that I don’t know that they do. They are good workers, treat their patients well and appropriately, and come to me if they have any questions. I have not seen them making any mistakes in their patient care or overlooking anything important. In fact, I have seen them catch things that patients’ pcps have missed. They tend to be a bit more “by the book,” and tend to order more tests “just to be sure,” but I have no objections to the job they are doing.

    That being said, it doesn’t make me feel any better about PAs in general.
    They do fine in this context offering care in a narrowly defined field, with a doctor available if they have any questions. That is not the same as flat-out practicing medicine. These particular PAs are also very intelligent, and could easily have attended medical school if they had been as foolish as I was. That doesn’t mean that all PAs are that smart.

    The problem is not with PAs (or NPs) themselves, though, and because of that, I hold nothing against them. The problem is with doctors, and, specifically, with doctors who were practicing in the seventies, eighties, and nineties. These doctors who preceded us thought they were getting away with something by having PAs practice with them and do some of the lifting, and, in fact, they were.
    So long as you , the doctor, were the business owner, you could employ PAs and NPs to work for you, at a lower salary than your own, but collecting fees that were the same as the ones you collected. In this way, a “physician extender” was an “income extender,” a smaller investment that brought a bigger return.

    This changed as it became harder and harder for doctors to make ends meet, as reimbursements declined and expenses increased. These trends led doctors to sell their practices to hospitals, and this led to physicians and PAs both being employees of the same organizations, in the same locations, doing, as far as the administrators were concerned, the same job. Once that had happened, PAs and doctors became natural competitors, the PAs pushing to bump their salaries up closer to the doctors’, who, after all, were “doing the same job,” and the doctors, trying to keep their salaries where they’d always expected they would be, in the face of administrators showing them financial sheets that clearly demonstrated that they were more of a liability than an asset.

    If doctors are to remain in the primary care field, their only chance is to distinguish the care that they provide financially from that of PAs, so that they are either adding more value, or doing some job or part of the job that PAs are incapable of doing. Since this is impossible (doctors may be able to provide better care, but there is no way that they can provide clearly cheaper care), physicians will be phased out of all primary care positions within the next twenty to thirty years, and the specialties of Family Practice, Internal Medicine, and Pediatrics will be dead (I’m not optimistic about General Surgery either). There is no way to put back in the bottle this genie that earlier doctors unwittingly released. If doctors seem hostile toward PAs, it’s because they see PAs literally taking their livelihoods, for which they have worked for decades, away from them.

    Last one out of the Medical Staff, please remember to turn off the lights.

    ps: Mr. Gilles, when you say that you don’t want a physician’s salary, I call bullshit on that, unless you are Jesus Christ or Mahatma Ghandi. You’d love a physician’s salary. Heck, I’d love a neurosurgeon’s salary. The fact is, though, that you’re never going to get it, because now that you’re in the market, your lower salary is going to push everybody else’s salaries down to the lowest common denominator, the same as having scabs break a strike, or Chinese make steel. It may seem fine to you to eat the food off of someone else’s plate, but in the end, everyone involved will suffer, even those who are willing to do “the same job” for half the pay, and the quality of medical care will suffer as well.

    • Steven Gilles
      November 7, 2013 at 9:47 pm

      Sir Lance – A – Lot

      Fair enough – I would love a physician’s salary, but as you stated, I won’t get it.

      So, I should rephrase my statements . . in choosing to be a PA, I took on the role with the understanding that I would not get physician pay. I took on the role understanding I was not a doctor. I took on the role not for the purpose of ever wanting to take over a physician’s role or undermine their training, expertise or the role they play in medicine.

      I chose to be a PA because I truly, sincerely believed that I would be respected for wanting to provide access to care. I chose to be a PA because I truly, sincerely believed that I would be respected for being cost effective. I chose to be a PA without knowing that there were physicians who truly do not respect us. My experience is that the disrespect is one based in fear. Most disrespect is based in fear. Fear we are upstarts, fear we intend to dissolve away the importance of the MD role, fear that we feel we are “equal” to a physician.

      What many of the people writing on here keep trying to imply is that there is some kind of movement within the PA/NP groups to undermine physicians and attempt to be on equal ground. That just isn’t the case. Certainly not for PAs, maybe NPs. We are taught from day one of PA school that the physician is our colleague, or partner and better or worse, our supervisor.

      I think that when PAs ask for respect and ask be included and ask to be seen as quality members of a team that gets translated as attempts to be equal. It is physicians who support and maintain the caste system in medicine, so it only makes sense that the PAs would be seen as “less than” adequate by physicians.

      I think PAs get frustrated because most of us come to the table with an open hand and say “How can we help?” and the response is “Stop trying to be our equal!!” or “How can we be cost effective?” and the response is “Stop trying to take our jobs!” or “How can I provide patient care with you?” and the response is “Stop trying to take away our role providing care for patients!”

      I respect your comments and feelings – you have worked with PAs and I think you value us on some level.

      • Sir Lance-a-lot
        November 7, 2013 at 10:14 pm

        Mr. Gilles, I value you guys just fine, and I respect you and your work, too, but that’s not really the important issue, either for you or for me. I work with ass-kickin’ PAs and I enjoy working with them.

        None of that is the point. The point is that administrators, MBAs, people who know nothing but money, combined with the inexorable pressures of economics, will inevitably force this to a conclusion that will be very bad for us, and not really that great for you, just as soon as they can figure out how to do so without triggering any alarm bells.

        You never wanted to do anything other than the things that you’ve mentioned, and you didn’t suspect that this game would play out in the direction that it’s going, any more than I did, but the forces are pulling us along whether you or I like it or not. As I say, it’s neither your fault nor mine, because the die was cast decades ago, in a very different medical world, and none of us was involved when that happened.

        Look at it this way: You’ve gone through your career with most things being basically the same from year to year, and if anything has changed with regard to respect, scope of practice, or authority, it has changed slowly and for the better, and changes like that are not the sort that most of us notice too easily.
        On the other hand, the same changes, and the ones to come, have stripped us of power, authority, respect, latitude of action, and income, with each incremental change coming as a new slap in the face.
        We can’t help but notice it, and can’t help but react to it, sooner or later.
        It may not be apparent from the outside, but most of us are ticking timebombs of rage. You guys did nothing to create this situation, but, unfortunately, will be the occasional target of those of us who are not as discriminating as we should be in directing our helpless flailing as we are melted away like the Wicked Witch of the West.

        • Steven Gilles
          November 7, 2013 at 10:56 pm

          Thanks Sir Lance-a-Lot. These are good clarifying points for me. Pat had similar feelings in something he wrote . . clearly we all somewhat agree that the administrators, MBAs, the insurers, the business leaders, the government influences, the drug companies are the real root of the problem.

          I would rather I was seen as a mutual partner in insuring as clinicians we have a voice as opposed to being seen as part of what is wrong with the system.

          • Sir Lance-a-lot
            November 7, 2013 at 11:19 pm

            It’s all a question of who is with whom, though, unfortunately, based on what I know of doctor behavior, it’s a moot question at this point.

            Waaaay back when I worked on coastwise boats, our union understood the importance of solidarity, and valued the fact that everyone on the boat, from below deck to the wheelhouse, was together in the same union.

            If there was a beef, the boat didn’t move.

            Fighting among ourselves is what the administrators want us to do.
            If we are all together, they have a much harder time screwing us.

            The problem is, getting doctors to stick together, or to in any way practice intentional resistance, is essentially impossible, so it’s all academic.

            Sadly, there’s some sort of “professional gene” that means that when push comes to shove in the medical world, you can never trust that any doctor has got your back.
            It saddens me, but I don’t think it’s surmountable.

    • Pat
      November 7, 2013 at 10:27 pm

      Excellent post Lance.

      • Sir Lance-a-lot
        November 7, 2013 at 10:36 pm

        Why, thank you, Pat.

        I don’t know what part of the country you’re from, but I think one day you and I ought to get together with Doug and tie one on.

        • Pat
          November 8, 2013 at 1:30 am

          First round’s on me.

  3. Aaron Levine
    November 7, 2013 at 12:57 pm

    I did not want to mean that I am against NP or PAs. I have seen good ones at work. I worked with some in the military who knew more of some topics than I did. That holds true today. I am concerned of the decisions being made purely on economic basis and not on quality issues. I just saw a headline that the use of NP and PA means there is no longer a shortage of FPs. I am actually a subspecialist and not a FP. I am actually close to retirement, so this is not an economic threat to me. I am, however, looking at the long term situation. I remember when there were few superspecialists. By that, I mean there were general surgeons, but few with specialized other general surgical skills. There were orthopedic surgeons. A few did hands or scoliosis or pediatric ortho, but there were no knee, or hip or sports medicine specialists. Now there are invasive cardiologists, and medication cardiologists. While specialization can bring efficiency and improved safety, there are costs never discussed. I recently had a discussion with a general surgeon (GS1), a couple of years younger than myself. He got a call from another, Board Certified GS I will label GS2, who had a patient needing a mastectomy. The GS 2 said he never saw or did a mastectomy, and needed help to do one!!!! this is not alone. Another GS told me that another GS told him that he never treated an anal fissure and needed help. I did these as an intern. I fear that the this will extend in a generation to FPs who will be extinct. While I am not against embracing the new, I worry that we are ignoring our past. FPs were the ones who knew the patient, the family, and other intangibles. I may have been trained during the Marcus Whelby era, but they cared for generations of the same family. They cemented the relationships that gave meaning to medicine. We had comments in the 60s of doctors running in and out. Those who never paid attention to the patient. (Watch the movies Hospital and Doctors to see what I mean). We now enter a factory system, where each doctor is an interchangeable part. I know, because I was a spent time as a salaried physician in one system. There was lip service to quality, patient care, etc. But the fact was the bottom line ran the show. Craftsman in cottage industries gave way to the assembly line worker, who in turn was replaced by robots. I fear that this is rapidly happening to a profession that I dearly love. I know I ramble on, but I am hoping that I clarify not a hostility to PAs and NPs, but rather they are being used not for care, but for discount care. I read, but can not confirm, where one hospital replaced their ER physicians with a single new grad (meaning just finished his residency) and he was to supervised 4 PAs and NPs. All were direct employees (and not independent contractors) of the system. Again, I can not confirm this, but allegedly this was done to control costs in the ACO model. It was not a quality decision.

  4. Madelyn Sieraski
    November 6, 2013 at 1:58 pm

    I have worked with NP’s and PA’s for 20 years. They do a great job with the routine and well care. They only time I was concerned were the really sick patients. Especially the children. They come in with a simple problem and had a bad diagnosis. It was like working with a resident who had not had their hospital training. Its also hard to determine what is a simple medicine change or something else. How does the person scheduling know who to schedule with. In our clinic the PA/NP were not responsible for the quality indicators. Each visit was one less for us to “get” our indicators done. The extenders have really been helpful but it is hard to get things right.

  5. Doug
    November 6, 2013 at 1:43 pm

    The fact is that education and experience can sometimes mean the difference between life an death or between getting it right the first time and getting the run around. A well educated experienced PA, FNP, CNM, CRNA can focused like a laser and get things done faster than any general MD bumbling around an issue that he or she has had little interest in or experience with. The opposite of that is sometimes an MD’s breadth of knowledge and experience is what’s needed to see through the weeds. Collaborative practice works and each professional has a role to play. That physicians will get displaced by lower cost providers is a matter of economic realities you simply can’t fight. Docs must compete, get relevent, get lean, get specialized or get something else to do. That’s just how it is.

    • Doug Farrago
      November 6, 2013 at 2:01 pm

      Oh, we can fight. That is what this blog is all about.

  6. Steven Gilles
    November 6, 2013 at 9:46 am

    The unnecessary belittling comments by MD clinicians in regards to NPs and PAs is discouraging. It is also based on no actual data. I see blog posts and comments like these all the time with statements about sub-par care by PA/NP providers, missed diagnoses, poor quality of care and ‘gasp!’ PA/NP providers being allowed to practice medicine. None of these comments is ever backed by hard data and fails to acknowledge that physicians are equally fallible.

    I can only speak for PAs, but the reality is, we practice good medicine. We are trained in a medical model. We know our skills, strengths, limits and weaknesses.

    These disparaging comments by Physicians are proof that you are scared. I don’t blame you. Patients say we do a good job, employers like us because we are cost effective and based on the data, our outcomes are as good as a physician’s.

    So, I’m sorry for you that you are scared my physician colleagues. I want to collaborate, work with and learn from you. I want to provide patient care and help be a co-solution to the shortage of clinicians our nation faces. I want to be a portal of access for patients. I am fortunate to work with physicians and physician leaders that get that.

    So, grow up. The attitude looks ugly on you and it isn’t helping patient care. Feel free to publish a study or two stating I provide sub par care and your argument will be valid. Until that happens, I don’t want to hear from you.

    • Doug Farrago
      November 6, 2013 at 10:12 am

      Part of your comment were appropriate. The part where you say, “I don’t want to hear from you” is interesting. Then DON’T READ THIS BLOG. As far as a study, here you go:

      http://medicaleconomics.modernmedicine.com/medical-economics/RC/national-library-medicine/pcps-outshine-peers-when-it-comes-to-diabetes-care

      Now what?

      • Dave Mittman, PA, DFAAPA
        November 6, 2013 at 10:59 am

        The study was positive and done by a PA. I think at one institution. Maybe they used PAs and NPs poorly there. It at best it showed we are good generally in diabetes management .

        There are many studies saying otherwise. You are still into putting us down. That will not get any of us to a better place.
        Sorry you have not learned that.
        Dave

        • Doug Farrago
          November 6, 2013 at 11:08 am

          Not really. When a study comes out (see Equal Quality Using Low Quality) and it favors midlevels, is that not putting MDs down? When I bring up another study that shows a different light then I am am a bad guy? Give me a break.

      • Steven Gilles
        November 6, 2013 at 2:02 pm

        Doug,
        With respect, did you read the study? It was comparing PCPs to Covering Physicians/Midlevel providers. So, it is comparing the PCP level of care against “not PCP” level of care. It is not asking the question: “Are Physicians better than non physicians at providing care?”

        So you asked me “What Now?” I will answer you. The study says that PCPs are better at providing care for their own patients than non PCPs. I happen to be a PCP to a 2000 patient panel. I provide better care for my panel than non PCPs do.

        Steve

        • Doug Farrago
          November 6, 2013 at 2:13 pm

          You are of the belief that doctors and midlevels are equal. You are wrong. Get more education. Get more training. Go to medical school and come back and talk to me. See response by Pat Conrad MD.

          • Steven Gilles
            November 6, 2013 at 2:40 pm

            Doug,

            Define “equal” as you see it. I don’t want physician level pay. I don’t want to be called doctor. I don’t want physician benefits.

            So asking to be respected by physicians for the care I provide is asking for equality? Asking for disrespectful comments based on non-facts is asking for equality? I don’t think so.

            Your comments make it crystal clear where you stand on things. You cannot respect anyone who doesn’t have an MD behind their name. You assume anyone that doesn’t have an MD wants to be an MD. You assume that anyone practicing medicine who doesn’t have an MD behind their name wants to be “equal” to an MD. These things just aren’t true.

          • Doug Farrago
            November 6, 2013 at 3:01 pm

            Your interpretation of my comments is what is crystal clear to you. You see what you believe instead of believing what you see. I have made my feelings about midlevels here known on this blog for years. I do not hide this like my wimpy peers at the AAFP. What are my feelings? There is a role for midlevels. We can work together collaboratively. That being said, there are third parties as well as the NPs pushing for competition. And I am supposed to just sit back like the AAFP and say fine? Nope. I mention fact – Lesser Education, Lesser Training and I get pushback. Why? It’s the truth. Others can take potshots at me and I can’t respond with facts? I really don’t care about what you want to do, be called, or want you want to get paid. Once midlevels (and this is more NPs) claimed they want to compete because they are “as good” as me on making a strep dx then game on. Sorry if you don’t like it. I don’t care. Why is that disrespectful? Because you don’t like it, that’s why.

    • Pat
      November 6, 2013 at 11:44 am

      You are not my “colleague”, however much you may aspire to be. And your not blaming actual physicians for “being scared” shows your support for the economic competition that government has awarded you.

      Your submission reads that you want to be equal and acknowledged as an equal to physicians. No matter how much money you save or make, how many patients you save, or how many expanded capabilities are granted you, you will never, can never be MY equal without first taking the time and trouble to finish medical school and residency. Your statement is arrogant and dishonest, camouflaged in the rhetoric of patient care.

      • Steven Gilles
        November 6, 2013 at 2:27 pm

        Pat,

        I am not your colleague specifically, and based on your comments today, this makes me glad. The true definition of colleague is not dependent on the degree that one brings to the group one works with. I am privileged to work with many fantastic physicians, NPs, PAs, MAs, RNs as my colleagues who wish to provide high quality care to patients.

        I never stated I wanted to be a physician’s equal. I simply asked to be respected for what I do. I also asked that the belittling and disrespect of non physician clinicians stop. I was the first to state that I respect and admire and learn from, lean on and need my physician colleagues, I don’t believe any of my comments disrespected you as a physician but I am sorry if I hurt your feelings Pat.

        I am not clear on why you felt my post was arrogant and dishonest. I don’t believe anything I stated was arrogant or dishonest. I could sum it up for you and anyone else so they don’t have to read my entire post.

        1. MDs who bad mouth non physician clinicians are disrespectful
        2. Please stop being disrespectful
        3. I want to work with everyone I work with to insure that patients receive adequate care
        4. MD clinicians are sometimes scared of non MD clinicians because we provide good care (that is based on fact)
        5. I respect and trust my physician colleagues so that I can learn from them, lean on them and collaborate with them to provide patient care
        6. Please publish studies that provide me with solid data on my inadequacy if any such data exists.

        I don’t want to be your equal Pat. I don’t want to get paid like a physician. I don’t want to be called doctor. I DO want to be respected. I DO want to know I can go to a physician supervisor or colleague when I have a question and know they will be there to help. I DO want conjecture based comments on blogs like these to stop because it isn’t helping anyone in the long run.

        Thanks.
        Steve

        • Dave Mittman, PA, DFAAPA
          November 6, 2013 at 2:33 pm

          I echo what Steve said.
          And truly can not understand the attitudes of physicians who post on this and many sites.
          The “if you don’t like it, go to medical school” answer is not going to make it for either of us.
          There has to be an opportunity for listening. Something it seems either we PAs are unable to message adequately or that physicians are unable to understand.
          In either case, stop the negative badmouthing.
          Dave

  7. Dave Mittman, PA
    November 6, 2013 at 9:10 am

    Stop blaming NPs and PAs.
    I’ll tell you right now we are not the enemy. And if we are, it’s time for a peace treaty.
    Yes, as time goes on PAs will be able to do more, because like so many others we will have earned it. We, as all professions do, need to grow and evolve and NOTHING shows our care is inferior in any way. We are still part of a team and want to be that. At the end of the day, if we were the bad guys, why are all of us busy making almost every practice we work with money and the quality is not going down?
    Yet, we are one of the few professions that can’t become a partner even a 5% partner in a practice we build for you. Almost any other American can. Hell, after 45 years, we can’t even give flu shots without a supervising physician. Fair is fair, and that is because organized medicine lobbies even against that (OK, tell me I am a menace when I give shots, or do a physical) and it is a poor use of health manpower and resources.
    I don’t want to get into a pissing contest about this. We all have a place. I don’t think you see or have ever considered our side, you just look at us as the bad guys and we are not. Same goes for NPs but I understand your reaction to some of their rhetoric at times. Most work hard for the physicians they work with and we re all in this together.
    We are the good guys. Sad but it’s so much more easy to blame us than accept accountability.
    Dave

    • Pat
      November 6, 2013 at 11:50 am

      Dave, by “peace treaty” I assume you mean for physicians to suck it up and acquiesce just as our profession has on literally every other major health care issue. It’s funny, whenever I hear a nurse, PA, administrator, IT tech, or administrative drone tell me that we are “all part of a team”, I’ve learned to interpret that as “do as you are told.”

      • Dave Mittman, PA, DFAAPA
        November 6, 2013 at 12:51 pm

        Pat: Not at all. Just realize that if you keep saying nasty things and stay as ignorant as you seem to be, that you will push us away. If that is your intention-fine. If it is not, say something nice also. My point is we are not the enemy. SOME physicians think we are. If that keeps up it will not be good for either party. I don’t see how you can not see that. It feels to many of us (to me) that you want to bait us. I can’t see how you would want that to be intentional. If you are ready to lose so many who are not lost, it’s your gamble.
        And you have to realize times have changed. You can’t say nasty things about people who practice good medicine. If you go by an N of 20, we have our own Ns of 20 physicians, we all won’t get anywhere.
        I am not saying do as you are told. I am trying to say something nice.
        Maybe it’s the message?
        Dave

        • Pat
          November 6, 2013 at 2:36 pm

          Dave,

          Please note that I have not slammed mid-levels as a class of workers, and note also that I have known some genuinely excellent PA’s with whom I have very much enjoyed working.

          But that is not the point. You are correct, times have indeed changed. After making a huge life investment, many of us have been undercut by forces beyond our control, using others who made nowhere near as great an investment, and who stand to profit at our loss. None of what I have said is ignorant, but is based on common knowledge and personal experience. As for “nasty”, how exactly should physicians welcome their demise? Gratefully?

          • Dave Mittman, PA, DFAAPA
            November 6, 2013 at 2:46 pm

            But you are making me the bad guy. I did nothing for that except to join a profession before you joined yours I bet. Maybe you should have done your homework and realized that PAs and NPs would upset that huge life investment you made BEFORE you made it? I did not ever do anything to hurt you. I gave great care, loved family medicine and tried to forward my profession and all of medicine in general.
            After being a medic and college I graduated PA school in 1975. Started to prescribe in NY in 1976. We have 11,000 PAs in NY State most doing good things and helping people.
            Sorry if I stepped on your toes but I never planned to do that.
            Dave

          • Steven Gilles
            November 6, 2013 at 2:59 pm

            Pat,

            I like this comment. Thank you. This is the kind of conversation we should be having. I think that PA/NPs don’t understand where physician discomfort is coming from, but this certainly helps me understand it better. So thank you for that.

            If I can have that kind of honest conversation with physicians, I think it will help us to come to a better understanding. Please believe me when I say that most PAs want to play nice and have no intention on taking anything from the hard earned work that MDs have done.

            Thanks Pat.

  8. Mary Helen Morrow, MD
    November 6, 2013 at 8:43 am

    In Texas NP’s are only allowed to write triplicates in a hospice setting. In open practice, they need a collaborating physician… To your point however, understand that the direction all along by the government and the progressives was to move in this direction. I worked for a community health center 10-15 years ago, and the writing could be seen on the wall.
    MH

  9. Ellen Luse, RPh
    November 6, 2013 at 7:43 am

    Oh God, please let us keep our wonderful MDs and DOs! I’m sorry but FNPs don’t know what they are doing and some PAs scare the daylights out of me.

    Ellen

    • Steven Gilles
      November 6, 2013 at 9:49 am

      Ellen,
      I’m sorry that you have had a bad experience in the past with an NP or PA to have led you to believe this. As a PA in primary care for 7 years, I have had multiple patients thank me for providing top quality care better than they had ever had from a previous physician. I have also been privileged to have saved the lives of people who had a diagnosis missed by a physician. I’m not trying to bad mouth physicians. My point is, the degree certainly gets people to a point, but it isn’t the degree that defines the skill level or set of the clinician. It is the clinical acumen that this person has that defines them.

      I hope that in the future you will have the opportunity to meet and be treated by many good PA and NP providers.

      Kind regards,
      Steve

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