An Inconvenient Truth…Or A Convenient Lie?
I’ve written multiple articles on the deception that is oh so prevalent in the scope creep issue. From the misappropriation of medical titles to the misuse of the term “collaboration” to the strategic “spinning” rampant in the Full Practice Authority(FPA) movement to fabrications so profound they rise to serious violations of the law. Lying is intrinsic to the medical culture over this topic. The deceit is enabled and endorsed by academic medical centers, community hospitals, medical clinics and even medical schools. Online medical directories exist with nurse practitioners, physician assistants and other non-physician practitioners(NPPs) listed under “physician” categories. Despite them not actually being physicians AND enjoying special days/weeks/months specifically dedicated to each of their unique disciplines, NPPs are also included, by the aforementioned entities, in the celebration of days supposedly devoted to honoring physicians. The most recent example of this nonsense is the University of Kansas-St. Francis campus who, on 2/3/22, promoted an entire video and Facebook page to celebrate National Women Physician’s Day–to anybody with an XX-chromosome providing health care. In this written promotion, note how the insidious, but not so subtle segué from “female physicians” to “female providers” immediately diminishes the significant accomplishment of Dr. Elizabeth Blackwell by merging “physician” with “provider”.
This conflation also appears as if U of K has more female physicians than it actually has. Their ad is misleading…..but what’s a little fib when distorting the truth is the name of the game? In addition, no honorable mention of the first Black female physician in the United States, Dr. Rebecca Crumpler–this being Black History month and all….one would think someone in their marketing department would have noticed. Still, U of K sure as hell managed to name all of the female non-physician practitioners in their midst. But I digress. U of K, St. Francis campus, had one day to get this s**t right and honor female physicians exclusively. ONE DAY out of the entire year–and they still f**ked it up.
What irks me most is the ease with which the purposeful disinformation in scope creep occurs. So casual as to be considered acceptable. Normalization of deviance at its best–and worst. It’s wrong and distasteful; yet, the offenders will not acknowledge this because it means accepting the utter repugnance of their behavior. Denial is much more preferable. The copious use of euphemisms permit the offenders to remain in denial about their despicable conduct. Lying has such a bad connotation. Although lying suggests purposeful intent to deceive and therefore potentially cause harm, to concede that fact is not an option(nor is telling the truth) for the wrongdoers, for they would be considered…well…liars. No one likes being called a liar, even when they are.
Fraudulence is the modus operandi for professionals intent on practicing medicine without a license. In fact, the entire scope creep matter in medicine is predicated, and I daresay completely dependent upon, duplicitous behavior by non-physician practitioners, physicians, corporate executives, politicians and even the public. Scope creep would almost certainly fail without the assistance of these human catalysts. So the connivers proceed….their lack of a moral compass securely intact.
“No legacy is so rich as honesty.”
―William Shakespeare, All’s Well That Ends Well
I have always agreed with you as my specialty is in a persistent war with lesser trained optometrists who are forever fighting to enlarge their scope of practice, claim they are more available, claim they are more efficient, have a very effective lobby, have changed their title to include eye doctor and optometric physician, are trying to be gatekeepers to ophthalmologists, have demanded referral fees/kickbacks (and have legally had CMS approve comanagement fees which have become a joke since Medicare fees are so low that 20% of peanuts is just a few shells. Their other basic business model is accept all vision plans and their “$100 (?)” allowance for new glasses each year as a chance to upcharge patients hundreds of dollars so those free glasses are now $500. Add the classic models of the mid-levels: extensive testing for whatever and overdiagnose and overtreat. And tell alll the older patients they have a lutein deficiency and require te $80/month eye vitamins which they sell onsite.
UNFORTUNATELY YOU ARE VENTING TO THE CHOIR HERE ABSENT THE COMMENT ABOVE.
There is a shortage of doctors. Can you blame the public when there is someone else with a white coat who says they can help alleviate the physician shortage? Oh and don’t forget as per CPT codes, whoever is allowed by the state to perform certain medical duties shall be reimbursed the same. Sort of like paying that new quarterback on your local team the same as Tom Brady or vice versa. Excuse me, I forgot the NFL is so important ad so powerful it will never be commoditized.
I cannot tell you how many patients in my rural area respond to the question of who their PCP is with a PA or NP. IT IS TRAGIC. They say they go to Dr Smith but they never see him, they only get to see Susan, These are typically private family practices that have been “bought out” by the hospital system. Here is an example. I have a patient who needs glaucoma surgery lest she will go blind, (I neglected to say how eager the optometrists are to get their hands on lasers for the eye…….are you all aware that the laser can be used repeatedly to treat glaucoma and the reimbursal is quite good although the results are mixed- so if you are a patient with borderline glaucoma , perhaps overdiagnosed, just laser them every 3 months and collect the insurance and you do not even have to put the patient through the hassle of using eyedrops). (And the laser companies cannot wait to have a machine installed in EVERY eye clinic). Borderlinee glaucoma means they do not really have glaucoma in which case any treatment at all or no treatment at all will yield the same results (unless you actually aimed the laser with enough power to actually damage something The glaucomatologist I have referred the patient to says it is too risky until her BP is controlled. So the patient is due to see Susan the PA every 3 months as usual. I hit the ceiling and tell her she needs to see the real doctor. She calls their office and is told Susan will decide if she needs the real doctor. I call their office and demand patient is scheduled with real doctor and then turn around and relay this info to her. SCARY!!!
THIS IS THE FUTURE OF MEDICINE.
Most all patients can be stabilized and transferred to a lower level provider until they start to go bad. CPT reimbursal rates were originally intended for physicians (I think). So let’s have this ever decreasing reimbursal rate serve to generate revenue while the administrators get someone for less to perform the billable services. Makes sense? Physicians themselves have done this to clear backlogs of patients. Physician oversight……are their strict rules about that?
Another convenient lie is that there is a shortage of physicians. THERE IS NOT. There is a shortage of medical residencies. Med schools continued to open despite the 1997 residency cap by CMS. This subsequently led to a bottleneck of unmatched grads, currently 8-10,000/year. In addition, FMGs who have practiced in their country for several years as physicians should have an alternative pathway in the U.S. They are a viable option should not have to go to med school and residency again. The good news is that on 12/21/20, Congress approved CMS funding for 1000 residencies to address the shortage. First time in 25 years. It’s small but it is a start. In addition, the Resident Physician Shortage Reduction Act of 2021 has progressed further than any other bill preceding it. If passed, 14,000 residencies in 7 years will open up. Approximately 6 states have Assistant Physician(AP) programs(not to be confused with PAs) which permit unmatched grads, supervised by PC physicians, to work in underserved areas until they can re-apply and get into residency. Patients in those areas actually get doctors caring for them. AP programs allow these grads to maintain their skills as well. Bottom line, there are options in which physicians can be utilized and our numbers elevated. Don’t believe the hype that the only option is NPPs. It’s bulls**t. They cannot replace physicians. Period.
I share my commentary in AM on Twitter, where I have a decent following. My followers then re-tweet. Many of my followers are laypeople–they are being educated. They are very much aware and do not like what is happening. My commentary is shared in many FB groups as well. In practice, many of our PPP members working in PC are getting more patients demanding to see a “real” doctor. I think we underestimate the public and their intelligence. If physicians were not having an impact, there would be no need for some NPPs and their umbrella organizations to lie about their credentials or misrepresent themselves. Hence, the purpose of my current article.
You keep advocating for your patients as you do. It is frustrating, but the patients get the message that the care they are being forced to accept is not the best care nor is it always in their best interest. When you advocate, they learn.
Indeed! My SIL was a physician in a foreign country – went to medical school, residency, and practiced there for a couple of decades. She married my brother, came to the US, “sure” that she could get a medical license “without much trouble”. The only option she seemed to have was to return to medical school and go through residency – complete with all of the costs. Meanwhile, I went to an “eye doctor” to update my glasses prescription. She gave me some great advice on exercises to help my strabismus – seemed to be more than an optometrist could do. I talked to her, and it turns out she was an ophthalmologist trained in the same country my SIL was from. She found that she could go through a course in optometry, and get her license to practice. I got her to talk with my SIL. The end result: My SIL is now a manager at McDonalds! Meanwhile, she keeps hearing of the “physician shortage”.
“bottleneck of unmatched grads, currently 8-10,000/year.”
Is that USA MD/DO graduates in schools within the USA? As opposed to foreign nationals in other countries, or American citizens in foreign schools.
It was obvious there would soon be more USA graduates than residency positions, leaving perfectly good yeoman graduates with worthless and expensive degrees. Didn’t know it was getting that bad.
I am sorry but you are barking up the wrong tree. If you have specific problems voice them. As a PA I was not involved with writing this, nor do I care much about how or what was written. There are real problems within our healthcare system, insurance companies dictate everything, Rx drugs are so high that patients cant afford them. Covid and access to care. Real problems. And you will soon be blaming us for those too. I think you see things where there is noting to see. We can work together on these problems but you rail against there only friends you have left. Such is life I guess…Go after the real culprits.
It is apparent you are not familiar with my writing or you would be aware of my activities involving the issues of which you speak. I am quite capable of multitasking which should be apparent considering I am an EM doc. In addition, I am not one who minces words. I am succinct and specific. If you missed my points in multiple articles then you are deaf, dumb and blind.
If PAs wanted to work with physicians, they would not be supporting OTP or the asinine lie that PAs can do what physicians do. The overt disrespect has not gone unnoticed.
You don’t get to decide what I believe to be important and what battles I fight–I decide. It is no secret that I do not and never will support FPA or OTP. NPPs have no business practicing medicine w/o a medical license. You have determined that issue is unimportant to you. So be it. You can pontificate all you like about the vileness of CPOM, insurance companies and the like, but PAs jumped on that bandwagon when they decided to become opportunists(and hypocrites) and use those same platforms to propagate OTP. When they did that, they became part of the problem. If you gave one damn about access to care, you would support ALL populations having access to physicians, not a two-tiered system that leads to those with no choice being treated like lab rats. You would support the Resident Physicians Shortage Reduction Act. You would support AP programs. You would support Graduate Medical Education funding for more medical residencies. You don’t because you have your own agenda. PAs are not victims and your attempt to play one does not resonate with me. You have no influence over here. Try holding your own organization accountable for the enmity between physicians and PAs. They stopped being our “friends” the moment they introduced OTP.
This!
My biggest dispute is none of these providers are obligated for emergency room call. At the same time many hospitals, under the legal loophole of medical staff bylaws require non employed physicians to provide call coverage as an obligation for privileges. Since it is an obligation they don’t have to pay and exploit the doctors.
At the same time the ER is full of newly minted NPs calling the specialist to bail them out.
Where I worked before retirement, the N.P.s had collaborating physicians and didn’t do hospital work. None worked independently. I can see the point that Benjamin Van Raalte makes of N.P.s calling to be bailed out by specialists if they are operating independently.
I was the filter my N.P. came to when she picked up on a difficult case. In our group practice, the N.P.s were supposed to be given the straight forward cases to free up the doc to see other patients. As it turned out, they sometimes got patients that were very difficult to sort out and mine always came to me for help. She was actually quite experienced. Did R.N. work for a few years after graduating then went to work as an oncology nurse for 6 years. Got tired of that and got her Masters and F.N.P. credentials. Came to work at the group clinic where I was at and the administrator came up and asked me if I’d mind being a collaborating physician with an N.P. I’m pretty free spirited and loose and said, “Sure.”
We worked for 22 years together and she was a good clinician. Knew when to come to me and some times the patient was so sick I’d have to direct admit them to the hospital. She always made good calls.
I do remember a stupid P.A. who removed a nevus from a patient and the path report came back melanoma. He went to one of our group’s veteran surgeons (cardio-thoracic but he didn’t want to live that life so did vascular-thoracic in our rural area. Lucky us.) He asked the doctor, “How much more tissue should I remove? ” My surgeon colleague told me his eyes bugged out and told the P.A. guy he’ll handle the patient from there. Extremely dangerous when one doesn’t realize they are out of their realm of practice! That P. A. was let go shortly thereafter.
This occurred over 35 years ago.
N.P.s can be a helpful adjunct as long as they have a good working relationship with a supervising doc. Anything otherwise, the malpractice attorneys will nip the independent practice of N.P.s in the bud once there are a few large settlements. Too bad some patients will get hurt if that is allowed.
Kurt Savegnago M.D.(retired)
The model you had at your clinic is the appropriate model. It works well. But now NPPs want more freedom w/o taking on the entire liability themselves. Malpractice attorneys are taking notice. However, as you said, it will take a few large settlements or a VIP case before “independent” practice for NPPs receives the scrutiny it should.