The Great American Farce: Education by Legislation and Conflation
Anesthesiology(Keck/USC):
The past 2-3 weeks have been active on Twitter regarding the toxic presence of private equity and corporate medicine in health care. One of the most significant symptoms of this infestation is the perpetuation of the myth that nurse practitioners(NPs) and physician assistants(PAs) are comparable to physicians. Yep. Some amoral creature(s) somewhere in this corrupted medical universe decided that non-physician practitioners(NPPs) were equivalent to physicians. For business purposes, of course. This fable has become fact due to extensive, repetitive, effective propaganda generated by these vermin and their predatory cohorts. Not to be outdone and in simpatico with the enemy, unprincipled NPs and PAs, in their delicious delirium, decided arbitrarily that their years of experience were also commensurate with medical education. Fallacious presumption, but who gives a s**t? It sounds good and makes them feel important. It is beyond me to understand the psychological maneuvers in which one will engage to justify why NPPs are not only qualified to practice as independently as physicians, but also get paid for “doing the same work”. Who determined their work was the same? Why, they did. NPPs and corporate medicine. Not anyone actually trained in medicine(well, a few virtue-signaling, lap-dog licking, toadying, uninformed docs).The NPPs basis of “fact”? Shi**y studies purporting this nonsense and the NPPs gullibility in believing the hype insinuated by PE and corporate medicine. Cretinous executives and imbecilic legislators then enabled NPPs to bypass the normal path of medical education–by legislation and conflation. And avaricious NPPs jumped on that mimetic joystick with glee–ethics be damned.
NPPs continue to practice medicine without a medical license, sanctioned by statesmen and women who have no desire to be enlightened. If they did, they would do the work to stop this insanity. Unfortunately, they are too lazy and unmotivated to do anything but pass these absurd laws and wait for inexorable damage to the public to occur. It’s just easier than actually deliberating, processing and concluding that nothing about FPA and OTP is a good idea; however, that requires one to have fully functioning brain cells. How difficult is it to review the NPPs so-called studies that “prove” their care is equivalent? Just one study? One that NPs/PAs claim as their “gold standard”? These slothful lawmakers can barely muster the energy to focus, let alone actually review the documents. How f***ing hard can it be to compare the educational curriculums of NPs, PAs and physicians? It’s right at their lethargic fingertips. But nope, they just take the words of these agenda-driven, self-serving individuals because dammit, it’s just easier. Below are curriculum comparisons of various specialties in medicine and their so-called “equivalents” in NP programs.
Emergency Medicine(Vanderbilt):
Psychiatry(Drexel):
Family Medicine(Duke):
It should now be apparent after perusing these figures that these professions are not equivalent. Family Medicine is the specialty in which NPs claim the most equivalency and which other medical specialists assume is so easy. Anyone who believes FM is easy is a fool. Family Nurse Practitioners are not Family Medicine physicians; therefore, they cannot practice Family Medicine. That specialty does not exist in their group of “specialties”. Here is what does exist: Family Nurse Practitioner(FNP), Adult/Geriatric Nurse Practitioner(AGNP), Acute Care Nurse Practitioner(ACNP), Pediatric Nurse Practitioner(PNP), Psychiatric/Mental Health Nurse Practitioner(PMHNP), Women’s Health Nurse Practitioner(WHNP), Clinical Nurse Practitioner(CNP), Neonatal Nurse Practitioner(NNP), Certified Nurse Midwife(CNM) and Certified Registered Nurse Anesthetists(CRNA). That is it. There is no Family Medicine Nurse Practitioner curriculum-again, IT DOES NOT EXIST. It is important to understand that NP “specialties” are based on a population focus, thus their scope of practice is narrow, unlike medicine which is not based only on a particular demographic and therefore has a very broad SOP. It is indeed why we possess licenses that state we are physicians AND surgeons. However, physicians tend to remain within the specialty areas in which they have been trained and are the most comfortable. But were it necessary for a doctor to step outside of their SOP within a practice setting, he/she could(ie: Orthopedist in a rural clinic delivering a baby or a pediatrician treating an elderly patient with pneumonia). It is legal as our licenses permit it and so does each state Medical Act. Not so with NPs. NPs are nurses with advanced academic degrees(master’s) that permit them to do more than RNs. However, it does not enable them to practice medicine or to flit from one medical specialty to another. But they do because legislators authorized that idiocy. Inappropriately. To conflate NPs with Family Medicine physicians is not only incorrect, it is deceitful and insulting for both professions. As an example, the Duke FNP program is, by all accounts, a good program and is ranked #1 in the nation by U.S. News and World Report. It is a hybrid online program that requires a minimum of 728 clinical hours to graduate. How the hell does that, by any stretch of the imagination, equate to Duke’s FM residency which mandates thousands of hours before the residents can graduate? No matter how stellar any NP program is, it can never be equivalent to medical residency programs for one reason: nursing and medicine are, and remain, completely separate disciplines. Period.
Physicians who insist that FNPs and FM docs are comparable and that NPPs can work in primary care unsupervised also never take the time to review these curriculums. They assume they are familiar not only with the NPPs education, but their scope of practice because they have “trained” them. Most have never heard of the Nursing Act which actually determines NP SOP and is completely separate from the Medical Act; thus violations of NP SOP occur time and time again under physician “supervision”. These physicians’ egos are so enlarged that they presume their subjective abilities to train NPPs is comparable to the nationally standardized and accredited programs which they completed and which prepared them to perform for the very roles in which they currently practice. No physician exists who is so spectacular that he/she can compensate for the NPPs lack of didactic and clinical knowledge that all physicians obtain in medical school. No matter what one does, one cannot condense 4 years of medical school into 6 weeks or even one year. But these docs convince themselves they can achieve the impossible. In reality, what they do is teach NPPs to mimic, so well that some NPPs now believe they are equivalent to physicians. I’ve long stated that all physicians have to do is pimp NPPs the way they pimp medical students, residents and fellows. Their knowledge deficits will quickly become apparent. But physicians don’t. Then these same doctors ensure their families have physicians, especially for their children. Some physicians believe that NPPs are being taken advantage of by big business and the degree mills and are helpless, hapless victims in this whole mess. I would have agreed with this early on, but not today. The information about these profit-driven degree mills is well-known–they are sub-standard. They only remain open because NPs keep providing the funds. It is a shame that NPs refuse to demand more of their education by withholding their money. I would argue that there is no education actually being obtained from these shoddy programs. Yet, NPs choose to invest their time and capital into these facilities that do not provide them with an adequate return on their contributions. And they do so by choice. That is not a victim. That is a willing participant. Those seeking the path of least resistance to attain “success” are the least motivated and the worst educated.
The consequences of allowing people who are unqualified to practice medicine to do so is now becoming evident. This is indeed how Physicians for Patient Protection(PPP) came to be, as patients being mismanaged by NPPs sought help and made their way to physicians in unprecedented numbers. A few physicians took notice and decided to follow the trail which subsequently led to NPs practicing as physicians, FPA/OTP and the corporate practice of medicine. Patients, in general, are not stupid and possess an inherent ability to assess whether the care they receive is sufficient….or not. In my opinion, their intelligence is underestimated. It is impossible to hide detrimental practices that result in harm to human beings from a lack of fundamental medical knowledge because what is in the dark will always come to light. Always. There are now law practices that subspecialize in malpractice against NPPs. Insurance conglomerates are refusing to reimburse for NPPs practicing outside their scope. Eugene Stead, MD, the physician who created the first PA program, understood the limitations of the PAs he trained. NP can be substituted for PA in his quote.
“The PA can have independence at a low level of performance or he can accept dependence and achieve a high level of performance.”–Eugene Stead, MD
This quote remains relevant today. Physicians have a responsibility to understand the limitations of the NPPs they choose to train and all need to respect the differences in education, practice and discipline. NPs, PAs and physicians are not and never will be equivalent. It is impracticable.
I’ve already seen what this looks like. My father was hospitalized for 5 days with pneumonia and failure to thrive (mostly due to isolation at his ALF). In those 5 days after he was admitted through the ER he was never seen by any physician other than a pulmonologist who visited 3 times (I know, I have the EOBs). The “hospitalist” NP was unable to give me any cogent assessment of his prognosis (which I thought was dire). When I asked her what the admitting doctor (supposedly her supervisor) thought she ADMITTED to me that the doctor “doesn’t see my patients, she just signs my notes” A palliative care consult was answered by yet another NP who spent 10 minutes telling me he was not hospice appropriate at age 89 and weighing 120 pounds. It dawned on me about day 4 that the person with the most training and experience seeing the poor man was ME. We took him home and cared for him there until he passed the following week (‘not hospice appropriate’ per the NP, remember?) I was on the staff at that hospital for over 30 years and took care of inpatients for 25 of those years, and I thought it was a good institution. This private for profit hospital has apparently decided that hospitalized inpatients do not deserve to be cared for by a physician. I’m sure it’s far more cost effective for them. Needless to say, none of my family will ever go near that facility again. Take a good look, folks. This is what the future looks like.
May I share this story?
My sincere condolences on the loss of your father. I agree with Doug, this story needs to be shared.
https://twitter.com/Your_Pal_Billy/status/1391755321979326469/photo/1
Surely you see the same in physician hiring.
Then after doing their best to drive applicant physicians away, turning down qualified physicians, looking for some unicorn, a brain surgeon willing to accept minimum wage, the osition remaining open for months with dozens and dozens of qualified applications……….
You know what they do — scream “PHYSICIAN SHORTAGE” and expand practice rights for anyone with a pulse.
https://southseattleemerald.com/2021/07/27/photo-essay-family-and-community-remember-12-year-old-kaloni-bolton-demand-justice/
https://www.redmond-reporter.com/northwest/lawsuit-filed-for-girl-who-died-while-waiting-for-care/
12-year-old asthmatic dies of sthma at a suburban Seattle urgent care run by a big box with million-dollar CEO salary of course. By the time they got a real doctor into the picture it was time to run a code.
The sad fact is that they are all equivalent because they can all generate CPT based charges. As long as the state authorizes them to perform a certain function (a CPT coded procedure), they are the same!!!! I know this. I am an ophthalmologist. I perform eye examinations. The optometrist down the street gets paid the same as I do for any given CPT. Heck I could allow a tech to to perform a test and bill it under my NPI number. Guess what, we all get paid the same. So if I were a businessman trying to generate charges, I would look for the lowest overhead provider of said service, no? It all comes down to the bottom line. Quality of care is some esoteric dream. Flip the coin around. If you were the patient and the cost was the same if the anesthetist, anesthesia tech, or real anesthesiologist OR the optometrist, ophthalmologist, or one of their techs, or dental hygienist or dentist did a service on you……WHO WOULD YOU PICK? I do not like to generalize but the system is broken. But medicine has become commoditized. The service provided by the medical student (supposedly under the attendings eye) is reimbursed just the same as the doc with 40 years experience who may be the best doc for that problem in the world. Hey, why don’t we pay all the players on the YANKEES team the same salary- the are all doing the same job, right?
Until physicians start suing the State Legislatures for violating their own medical licensing requirements, ie, USMLE, which is REQUIRED in every State in the US; I don’t think you’ll stand an icebergs chance in Hell of changing anything.
Benjamin, I have to say again that the absurdity of us launching a defense of our overwhelming superiority to nurses is just cra-cra.
Before the dilution of medical training, I would have to say I was far advanced over a nurse practitioner at the end of medical school.
I would be considered higher intelligence with a higher problem solving aptitude
I had an extensive high school science curriculum that I mastered with all A”s in a system where only 10% got As
I had a Biology and Science college curriculum that I mastered with all A”s in a system where only 10% got As
I had a medical school with 80 hours a week of lectures and study in medical science and disease.
Starting third year, I took care of patients and managed their care to be reviewed with 300 clinical hours per month. On anesthesia I intubated and managed.
In 4th year I did rotations where I was the intern, essentially managing patients. I was the ER in house officer up north for 2 months. I had another 3000 clinical hours.
Then surgical residency with 35,000 clinical hours without overtime
How can that possibly compare to someone, who did not have the same academic prowness or ability other than to pay tuition that spends 500 hours without full responsibility to someone who had over 40,000 clinical hours. That is only 1% of the training and the ability would be like comparing a high school swimmer that makes the team to an Olympic level swimmer, not even in the same pool
It is patently insane that we even have to have this discussion. My God…
“a hybrid online program that requires a minimum of 728 clinical hours to graduate.”
I think we spent longer than that just reading ECG’s in my program!