AN UNSEEMLY TUG OF WAR–THE RECLAMATION OF MEDICINE
Let me say clearly and unequivocally, I thoroughly DESPISE the corporate practice of medicine(CPOM). By its very nature, it is the complete antithesis to quality health care–it’s hell care. It is crucial, I daresay a requirement, that patients under the corporate system not be prioritized. Instead, they MUST BE commoditized. It is the only way the corporate executives can satisfy the insatiable appetite of their shareholders. The modus operandi of these private equity-backed conglomerates is to swoop in, under the guise of a White Knight savior, to rescue an already depleted hospital organization, create chaos, destruction and yes, even death, pilfer and gut, then exit left, absconding happily with the proceeds they have plundered. Left behind is a barely recognizable carcass where a functional health care institution once existed. These pillagers then slither their way across the nation like serpents, seeking out their next victim.
Unfortunately, there are opportunistic traitors within our health care system who act as Trojan Horses and willingly assist these villains because they benefit from their repulsive behavior. The intent of any business is to profit. It is no great secret that one way of increasing profits is to decrease expenses. Physicians are the source of some of the highest expenditures for employers…for good reason. Expertise costs. However, these business people don’t want to pay for expertise. Remember, patients are not a priority to these heathens. Therefore, in order to make bank, they must find some way around utilizing physicians. Enter the non-physician providers(NPPs), the nurse practitioners(NPs) and physician assistants(PAs). They appear functionally equivalent to physicians because they can mimic. Well. In addition, NPPs are pliable, obedient and question nothing. They love guidelines/protocols/criteria because they don’t have to think or process. Makes no difference to them that those guidelines/protocols/criteria may be written by non-medical corporate flunkies; thereby violating CPOM laws. They just do what they are told, to the delight of the C-suite. Who cares that the cognitive knowledge necessary to manage complex human beings with various common and uncommon ailments and disorders is lacking in these NPPs? No one will be the wiser, including patients, if there is no physician around to check them. What with the NPs and PAs striving to obtain legislative approval for the unsupervised practice of medicine(UPOM or UPM) and the CPOM displacing and replacing physicians, it is a mutually beneficial win-win situation for these conniving bottom-feeders. Huge loss for the patient-physician relationship, but they don’t care about that either. It’s all about the Benjamins with these pimps and ho’s. They hopped in bed together and there the fun began.
NPP supporters of the UPM movement, giddy and gullible with the loving attention showered on them by their corporate paramours and legislative sycophants, believe their own hype. They confidently recite buzzwords and phrases so often that fiction becomes fact inside their Dunning-Kruger infested minds. What does “We want to practice to the full extent of our education and training…” mean? Translated: “We want to practice medicine without the proper education, accountability or legal restriction so we can get the same respect, prestige and pay physicians do.” NPs, enabled by their corporate daddies, legislative fans and uninvolved “collaborative” physicians providing notional supervision, now do whatever the f**k they want, however they want in 26 states. PAs are attempting to follow suit with their absurd Optimal Team Practice(OTP) concept. Neither NP nor PA education was designed for either to have independent practice. To meet the exceptional, educational standards essential to become proficient enough to practice medicine independently and competently would entail a major overhaul of both academic systems. That is unlikely to occur as the costs would be prohibitive. It would also necessitate the involvement of physicians who most likely would not donate their time when there are future medical students and physicians-in-training they must prioritize. It would also be redundant, considering that an exceptional, academic model already exists. One cannot develop a program that is equivalent to physician training without physicians being involved at some level. Those involved in the UPM movement knew this, so they went another route, education by legislation. And with that they began burning bridges with physicians, whom they did not want on the team anyway.
Here’s what those supporting the CPOM and UPM also never consider…who will treat the complications of their actions once they are independent? Physicians do not have to take referrals from unsupervised NPPs if they don’t want to. So the NPPs will have three choices if that occurs: they have to refer to each other, inundate emergency departments(with no guarantee a physician will be present) or the patients are just up s**t creek. The more independent-minded millennials are graduating with no desire to work for “the man”. Many want to be their own bosses and are less fearful than those of my generation who gave up their autonomy, believing “that ship has already sailed”, as if they had no choice but to become employed. Offended by NPPs behaving as if they are equivalent to and who have no interest in working with physicians anyway, these younger docs are less inclined to work with NPPs in their own practices.
Do not be discouraged about the future of medicine, for the superficial, happy marriage between the CPOM and UPM movement is destined to fail. The NPPs don’t understand that their usefulness to the CPOM is only temporary, until those pimps can find a cheaper ho that’s better in bed….and more naive. Then there will be no more sweet talk in their ear, telling them how they are just as good as those egotistical physicians. Their favored role usurped by yet another jump-off, courted and manipulated by the CPOM. At some point, NPPs will also be forced to acknowledge that the UPM movement will not succeed in the long run. Why? Again, because their fundamental educational foundation is not stable enough to carry the practice of medicine indefinitely. To reiterate, they simply do not possess the requisite knowledge that is imperative to practice medicine competently and without supervision. Diagnosing patients isn’t always about what one sees, it is about what is unseen and obtained by in-depth, skilled, history-taking. It is about understanding complicated pathophysiological processes and convoluted pharmacological management–both of which take years to learn didactically and clinically. One cannot assimilate such detailed information by simply practicing for years as a NP or PA. This kind of education must be taught at a fundamental level and ingrained, which is why medical training is so extensive and arduous. Their inability to recognize their limited apperception will be their downfall. With NPs in particular, the degree mill graduates will expose their ineptitude which unavoidably will become apparent by the inadequate management of their patients.The “education” provided by these mills is a farce and ultimately results in little to no education for NPs pursuing additional schooling. And to add fuel to the fire, they are giving rise to a slew of people unqualified to work as RNs, let alone NPs. So tell me, how can they then fill a “physician gap” when they are not qualified to even fill the nursing gap, which is much greater? They can’t. It’s just a matter of time, because you can’t fake it until you make it in medicine.
With all of this precariousness, the romance between the CPOM and UPM will inexorably crumble because, much like their professional practices, the relationship is shallow, co-dependent and based on a mutual desire to take over medicine. While making no attempt to become intimately familiar with or understand her. They have decided that authentic medicine doesn’t warrant the respect or the time to get to know her–not the makings for a cohesive, stable, long-term love affair such as she has had with deferential physicians. The tug-of-war between doctors and the CPOM/UPM will ultimately end in our favor, because their power does not inherently impart the medical knowledge needed to ultimately succeed in the practice of medicine. Therefore, they will never possess her. Never. Because we physicians are taking her back.
Power concedes nothing without a demand; it never has and it never will.–Frederick Douglass
Dr. Newman wrote that NPPs have the following choices when their patients get too complex for them to manage:
…the NPPs will have three choices if that occurs: they have to refer to each other, inundate emergency departments(with no guarantee a physician will be present) or the patients are just up s**t creek. The more independent-minded millennials are graduating with no desire to work for “the man”.
I suspect they will have at least one more option, which is to propose legislation that mandates every licensed physician to accept referrals from NPPs to transfer care of their “too complex” patients. Don’t laugh because: 1) It’s not funny; and 2) It could easily happen in states like California (where I’m licensed).
Natalie, as usual, you knocked it too far out of the park for the LELT’s to see where it landed. I hope you are right and I am wrong, but I am well past discouraged all the way to chronic sarcasm. I think the CPOM has created, but also reflects a dumb, greedy, fearful society that wants it fast+perfect+cheap. Of course they’ll get none of the above, but these are the herds that call a NP “doc”, and are just as happy to run to the ER for “free” care, or sue over any bad outcome. I think the majority of society values a physician when they are in actual extremis, and the rest of the time view us as little better than waiters with extra technical training and fancy words. Yeah, I’m discouraged, and have no idea why anyone would go into this profession, only to be devalued by the likes of those pushing garbage like OTP, and wanting the job without going to all that trouble and expense to earn the position.
I share in your disillusionment regarding the future of medicine. My daughter is about to start her medical training, and I told her it was a waste of her talents. I fear for her future in her chosen career as I do for the life of my tiny granddaughter. I don’t recognize the current practice of medicine, further, I don’t recognize this country which I love and served in uniform for many years. Despair doesn’t fully cover my emotion right now.
I would feel secondhand embarrassment working alongside someone who expresses themself in such a vituperative manner. She must be hurting or something. I’ll pray for her mental wellbeing while at the same time advocating for all members of the healthcare field.
This will be the last comment by any militant midlevels on this post. All others will be deleted because that’s what I do. Don’t even waste your time.
As a PA, I’ve had the great honor and privilege of being trained by and worked with many amazing physicians that value our clinical training and skill set. Clearly, Dr. Newman is not one of those physicians. Sad, because as a military physician, she’s worked with plenty of excellent PAs that she knows are capable of independent medical decision making and command level decisions. As an ER doc, she also knows that because she’s seen PAs save lives. She is refusing to acknowledge the objective truths before her.
The article suggests we are pliable, obedient, and question nothing. That opinion is untrue. We LOVE questioning things. Especially when it is something the physician is getting wrong. It also suggests we LOVE guidelines and protocols because we don’t have to think. Also untrue. We dislike corporate guidelines as much as physicians. (We could partner with physicians on this challenge, just saying…)
There are so many corporate shills out there and so many sell outs and so many “bad guys” that are in insurance and corporate medicine. Don’t lump PAs and NPs in with them simply because you’re feeling upset. A small subset of physicians (MD leaders) have marginalized non MDs for 100++ years. Where has that gotten you? A fractured system where everyone has to get a doctorate and develop their own boards because MD groups refuse to allow anyone at the table.
Good job guys. The monster you hate, you created.
It is unusual for any EM physician to never have worked or trained PAs in EM, particularly in the military. Nor would I have lasted 27 years in EM with no ability to do so. It should be evident to anyone with intellect reading my commentary to understand that some qualifications don’t have to be made, they can be presumed. If the shoe does not apply to you then you need not be offended. If you were actually familiar with my mounds of commentary, you would have noted that I have given PAs where credit is due and that it is actually my preference to work with them if NPPs where NPPs are a necessity. I also acknowledged that had PAs not been pushed out of the medical landscape by FPA, OTP most likely would not have come to fruition, but it did.
As much as PAs such as yourself like to lay the blame for the enmity at the feet of physicians, it was the Optimal Team Practice agenda promoted by your umbrella organization that initiated that mess. Before then, most EPs did not have any issue with PAs. Those of you against OTP say nothing publicly to denounce that stance. No organized body of PAs against OTP, just whining about physicians who criticize the PAs who support this idiocy and play victim. In 2017, in Washington and Tennessee, some PAs tried to get the legislature to approve the unsupervised practice of medicine in primary care by those PAs possessing the fraudulent, online Doctor of Medical Science. It was not successful because in addition to physicians, the state chapters of the AAPA vigorously and loudly opposed that move because they understood that the curriculum for PAs was not designed for independent practice. Today with OTP? Crickets. Docs do not support OTP anymore than they support FPA for NPs. The AAPA lumped PAs with NPs when they decided to jump on their bandwagon by a different name. By doing so, your leadership also hopped in bed with the corporate practice of medicine who seeks to replace physicians with NPPs. Physicians had nothing to do with the AAPA whoring themselves out to the CPOM. You have no one to blame but yourselves for that s**t.
You’re on crack if you think that physicians have to allow anyone to sit at the table of medicine as an expert without going through the established education to become an expert in medicine. You really expect physicians to agree to that s**t when they have put in the work and you haven’t? Your lazy a** leadership, like the NPs before them, decided that the long-established standard was too much work and that using the same exact PA curriculum that has existed for years, suddenly claim that PAs can practice the same as physicians. I’m disgusted that both the AANP and AAPA attempted to get carte blanche approval by the Trump administration to seek unsupervised practice in all 50 states when the pandemic began. Talk about opportunists. Where was your f***ing voice opposing that s**t then? And by being silent, you and your co-horts who may not support OTP complied. If PAs were in fact aligned with physicians, that s**t never would have happened. Nothing about any of the actions initiated by the AAPA screams respect for physicians. None of it.
The AAPA are the bad guys. You are either with them on OTP or against them. Many of us physicians have long been vocal about our lack of support for the AMA and we spoke with our feet and our pockets when they no longer represented our interests. They represent about 20% of physicians today. PAs could do the same. When you decide you want to stand up against OTP and the unsupervised practice of medicine and be supportive of physicians just as you expect us to be supportive of you and stop with your faux victimhood, then come back and we can have another conversation. Otherwise, you are dismissed.
Hi Dr. Newman. Thank you for your thoughtful response. It is always important to have a measured, respectful conversation with a colleague such as this. Thank you.
As a clinician, I have been trained in the medical model by physicians (some of whom are ex-military like yourself, thank you for your service!), people with PhDs, and experienced PAs. Because of this, I feel strongly that decisions need to be driven by evidence.
The evidence is that no PA has ever stated they want independent, unmonitored practice. OTP has been used as the boogeyman among a tiny sliver of physicians (of which I assume you are a member) to terrify physicians that PAs will go rogue, go completely independent, and start doing CABGs for funsies. Every PA program and every conversation around OTP has been about reducing burdens on physicians (who can’t get behind that idea, am I right?) and reducing insurers putting unnecessary burdens on PAs to “practice to the top of their license.” (Meaning, it is in our DNA to know our limits…much like an optometrist doesn’t do cataract surgery, we know where our training ends and a physician’s begins. That’s day 1 of PA school.)
Additionally, the evidence shows that every PA program and PA professional group invites physicians to guide them, be on our boards, teach in our programs, and be on our leadership groups. Also, many PAs sit on hospital governance boards by choice to enforce guidelines that push that PAs are held to a standard of quality. Finally, states that have enacted OTP have not seen any evidence of PAs going independent or rogue, and the sky has not fallen around the physicians that work there. Still plenty of patients. Still plenty of admin hurdles and bullshit. You can certainly keep screaming that OTP is an attempt by PAs for unmonitored, independent practice, but that is false and is not in line with any discussion among PAs. Come to our meetings. We invite physicians to our table all the time because we value your leadership, teaching, mentorship, and guidance.
Speaking of tables…I mentioned them not to suggest MD leaders and leadership groups need to allow non-physician clinicians in to debase themselves but purely for the purpose that PAs know where shared challenges are and want to champion the fight against them with physicians. The true bad guys: Payers, corporate medicine, administrators, the high clinician suicide rate, etc. are our common enemies. The energy wasted on screaming that PAs are going rogue could better be used to improve medicine and medical practice when the real problems are in front of us and not the pretend PA boogeyman doing CABGs in the back of a van.
We are not your enemy. We may seem like a symptom of the problems in medicine to you. But that is not true. The NPs decided long ago that physicians would try to end them at every turn and they developed their own boards, their own clinical doctorates and their own PhDs in response to MD leadership’s attempts. Dentistry did it also because the AMA edged them out. The chiropractors did it for the same reason. The DOs did it also. There’s an established pattern of evidence here.
Thank you for your calm, leveled response. Thank you for your service to our nation. Thank you for being a compassionate healer who saves lives.
Great post.
By turning a blind eye to the grotesque ethical and professional conflicts that are inevitable in the CPOM, our medical societies have covered themselves in shame – shame that is indelible and that cannot be rinsed out.
No one’s behavior has been more egregious than that of the AAFP, which sends out continuous praise for Iora/One Medical/Amazon and other profit-centered bordellos.
When the AAFP backed ObamaCare, I knew they were in it for themselves, that they didn’t represent our interest. I said bye-bye and never looked back. Same with the AMA and AARP.