APCs and Testing

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This is the conclusion from a JAMA study in January:

Advanced practice clinicians are associated with more imaging services than PCPs for similar patients during E&M office visits. Expanding the use of APCs may alleviate PCP shortages. While increased use of imaging appears modest for individual patients, this increase may have ramifications on care and overall costs at the population level.

I am aware that the same people will send me hate mail claiming that this study is somehow irrelevant.   I am only being fair.  We get studies thrown at us all the time from the powers that be or from the NPs/PAs that claim that they can do the same job as family docs.  They cannot and here is another study proving it.  This is why education and training matter.  Interestingly, that is why NPs/PAs are paid more than nurses. There is a difference.  In fact, I highly recommend you look at something called the Dunning-Kruger effect.  In essence it says that:

The most competent individuals tend to underestimate their relative ability a little, but for most people (the bottom 75%) they increasingly overestimate their ability, and everyone thinks they are above average. There are several possible causes of the effect. One is simple ego – no one wants to think of themselves as below average, so they inflate their self-assessment. People also have an easier time recognizing ignorance in others than in themselves, and this will create the illusion that they are above average, even when they are in the single digits of percentile.

Dunning said that, “Incompetent people do not recognize—scratch that, cannot recognize—just how incompetent they are.  What’s curious is that, in many cases, incompetence does not leave people disoriented, perplexed, or cautious. Instead, the incompetent are often blessed with an inappropriate confidence, buoyed by something that feels to them like knowledge.”

This is NOT to say that NPs or PAs are incompetent or not needed.  It says that the less we know the more we can sometimes fake it to make it which is VERY dangerous in the field of healthcare.  When a PA on a recent blog here stated he did gold standard care I was shocked and aghast. What the hell is gold standard care?  I am a good doc because I still know how little I know.  A fellow resident I worked with during my residency was a former PA.  He often said that once he became a doctor he was amazed at how little he actually knew when he was a PA.   This is not a knock against PAs or NPs.  This is just a pat on the back for higher education.

Now, let the hate mail begin. Keep it civil and cordial and respectful.  If it is too aggressive then I will not let it be published.  Been there.  Done that.

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] 

  8 comments for “APCs and Testing

  1. Lady A of Gomerland
    March 13, 2015 at 12:30 am

    I’ve got an even crazier story for you. I am a CMIO at a large southern health system. MD trained and boarded in both Family Medicine and Clinical Informatics (and if you think ABFM MOC is crazy, let me tell you it has nothing on ABPM which does my CI certificate). I report to the CMO and our IT department likes turf battles, so they hired their own MD. She washed out of a surgical residency after a couple of years and got an MBA so they think she’s credible. Today in the physician lounge she was talking about how she’s working at an indigent clinic doing primary care. Another colleague called her on it, and said how in good conscience can you practice in a specialty when you’re not trained or certified, and her response was “it’s not that hard, I mean it’s only primary care.” I guess my three year residency and my cert exam and a recert after 7 years and now a ton of MOC means nothing. I should have just flunked out and hung out my own shingle, eh? Another colleague said that the state of Missouri passed an asinine “Assistant Physician” law that would allow people that didn’t even do an internship to practice in underserved areas. I guess rural people don’t deserve quality care? What a crock. I didn’t believe it until I saw it myself. Here is a link. I think any physicians that agree to supervise these people should be shunned by their peers and by patients. I hope the medical liability carriers charge them out the wazoo for coverage. That may be the only thing that would stop this.
    http://www.sciencebasedmedicine.org/missouri-tackles-primary-care-shortage-with-assistant-physicians/

  2. March 12, 2015 at 8:55 am

    I was also a “victim” of the Dunning-Kruger effect as a young intern in Internal Medicine. I remember meeting with a patient (whom I had been assigned to care for on a daily basis) during a bedside exam on teaching rounds with a group of more senior residents and attendings. After everyone else had left his room, the patient asked me to explain who they all were. I reviewed their names, credentials, and role in his care. Then he asked me what MY role was… and I said, “My job is to protect you from all those other doctors.” It was kind of funny, but also reflected the same kind of attitude that I see in some NPs and PAs. The less we know, the more confident we seem to be in our ability to assess a situation…

    Because of our desire to see ourselves as having equal knowledge/skills, we will exaggerate peer flaws and make excuses for our own. As we grow more mature, our self-confidence no longer depends on creating superior self comparisons to others – instead, we admire those who are smarter or more experienced and surround ourselves with them. I’ve grown a lot over the years, and I’m a better doctor now because I respect my peers and learn as much as I can from them – I don’t project that old “presumption of incompetence” attitude. Mature NPs and PAs feel the same way about physicians – those who don’t are probably still stuck in the immature stage of development, requiring false beliefs in MD/NP knowledge/skills equivalency to shore up personal insecurities.

  3. Marlan
    March 11, 2015 at 8:10 pm

    I agree with you. When I was a PA, I thought I knew a lot but when I went to medical school, I realized what was meant by ” A little Knowledge is a dangerous thing” and how little I actually knew. Arrogance is a physician’s worst enemy.

  4. Perry
    March 11, 2015 at 9:52 am

    I also found this interesting piece on how much training NPs get. I found some of the comments in here interesting:
    http://www.healthecareers.com/article/how-many-years-does-it-take-to-become-nurse-practitioner/172021
    “The extensive educational requirements can resemble the requirements for medical physicians. This is because nurse practitioners can have many of the same duties as physicians, including the administering of primary care.”
    And,
    ” However, medical doctors can have very competitive natures, which they often need to make it through medical school, and can sometimes make efforts to let it be known that nurse practitioners are not on the same level that they are on. ”

    I agree with the other posters that NPs and PAs can add greatly to the care of the patient within the scope of their education and training. I do find it unnerving that in many states NPs can practice unsupervised, and I have to undergo testing every 10 years in addition to MOC to maintain my Family Practice board certification.

  5. Perry
    March 11, 2015 at 9:44 am

    It’s interesting you post this when this has come out in Medscape:
    http://www.medscape.com/viewarticle/841190

  6. JoAnn white
    March 11, 2015 at 9:00 am

    Dear Dr Farrago, I was a nurse for forty years, and I could not agree with you more. Physicians examine and evaluate patients, while NP’s and PA’s order MRI’s, which, I am sure, keeps the hospital system very happy!

  7. MItch Moreau
    March 11, 2015 at 7:42 am

    How true!
    NPs and PAs only know what they are being taught: little about little, with very limited academic scope since they only have to know certain things well. By not acknowledging this fact they have no clue about how much they don’t know and are under the illusion that they know as much as family docs.
    As we progress in age we know that…we don’t know much at all. It’s called humility.
    MM

    • Steve O'
      March 13, 2015 at 8:12 am

      “As we progress in age we know that…we don’t know much at all. It’s called humility.” But humility requires insight, not arrogance – and arrogance is the great force that closes off knowledge. Many people believe that they can retrieve the essence of something by searching for it on the web. They can perhaps achieve a recognizable image of something, but not much more. Just because I can obtain an image of Mt. Denali in Alaska does not mean that I am a mountaineering expert.
      I see the understanding of medical practice completely slipping away in the community’s mind. The perception seems not much different than that of children. You listen, you take their temperature – you look in their ears, and give them a prescription. What could be simpler?
      Since that is what so many want, that is what so many get. We do not see through our technological haze that we are slipping back into the primitive days of medicine, when people died of the unexpected and misunderstood, and such things were merely acts of nature. Who is to expect more than this, if nothing else is known?
      The Dark Ages is not about hovels and torches and plague – merely about the loss of understanding and ability. In twenty years, it will be the PA’s griping about the licensure of the Doctors of Witchcraft (DW). As long as they maintain their Certification of Enchantment every few years from their Boards, they’re cool…who is to say otherwise?

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