# Paramedic Practitioners



## Vetitas86 (Mar 23, 2012)

Doing a little skimming through some articles on different models of EMS, so on. I think the idea of a paramedic practitioner is a great idea, honestly. Especially in cutting down BS hospital trips/admissions and in critical care flight settings as a chief crewmember in the absence of a physician. 

Thoughts on this and how to.implement it (just bench racing as it were)?

My thought is this. Something along the lines of PA training, but with an integrated emergency med training and clinical set from day one.


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## bstone (Mar 23, 2012)

I think it would be a fantastic idea. I envision this to be a PA/NP level with an extra year of EMS education.


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## Vetitas86 (Mar 23, 2012)

ASAP, the American Society for the Advancement of Paramedicine, is really pushing for it. Still in its infancy even as an organization, but I truly think this is going to be something to watch. I think there is a distinction between how NPs and PAs are trained vs. medics. 

NPs and PAs focus on clinical settings. There's a void left in field settings, especially in prehospital care. Sure, groups push for MDs all the way to PAs to crew ambulances and flights, but to me, their training isn't as suitable to the field as it would be for medics. 

And since the EMS system does need an overhaul, why not start from the top? Roll out PPs, increase the skills of the medics and push the increased preclinical skills down to EMT-Bs and it'd be a good start.


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## bstone (Mar 23, 2012)

http://www.asap51.com/American_Society_for_the_Advancement_of_Paramedicine/FAQs.html

Fascinating. I had no idea there was a group pushing for this. I liked them on FB.


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## Miscusi (Mar 23, 2012)

Oh the street practitioner ? 

I dont know... I think alot of what it takes to be a practioner ( pardon the lack of spellcheck ) is the network of resources available to the pracitioner.

The MDs I go to for my own medical needs mostly rely on lab work, and the slew of specialists out there..  

I went in to a MD last month for my plantar facisitis that I got on my Clinical Rotation,  MD suspects it is plantar facisiitis, but refers me to a podiatrist, so I go, and the podiatrist suspects, but then sent me for an X ray...  on the X ray form, it asks the X ray company to evaluate the X ray for him...

I just cant imagine how much better medicine can be with Paramedic Practioners vs standard Paramedics...  I mean like, how much can one do on the back of a truck ?  Even if you staff an ALS ambulance with MDs it would still be very limited because all the resources would still be at the hospital anyway.

Just IMHO..


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## bstone (Mar 23, 2012)

I think the point of a paramedic practitioner would be to initiate *very* advanced interventions in the field. What would those be? I imagine things like starting central lines, general anesthesia, cracking a chest, chest tubes, thrombolytics, antibiotics, etc etc. In the cases where someone is too sick to get out of bed but doesn't need an ER workup they would be able to examine, diagnose, and prescribe treatment independently of an ER physician (or NP/PA).


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## Miscusi (Mar 23, 2012)

one thing ...  ppl sare saying NP/PA ..  I was wondering if that meant:  Nurse practionioner / Physician Assistant...

because I think the PA is not a practionier , they work under a MD's direction and authorization like the rest of us,

that being said in the post above, about the VERY VERY VERY special interventions...  I somehow think that if there is such a need, it would be around 0.03 % of the total call volume,  

They say that 99% of the calls are Bull S**... and 1% of the calls are OH Sh**

and out of that 1 % oh sh**  how many is gonna need their chest cracked open right then and there? and in the patients home that is not sterile ? Mr Lister would turn in his grave. ( if that is what you meant by chest cracking, I dunno, Im new )

The hospital would be the best place for any serious patient, I honestly believe that, due to the superior resource levels and hosts of specialists and supplies and etc...

Just IMHO... That instead of practioner on wheels, they should just expand the scope of existing regular paramedics to include those more advanced interventions as being outdoors allow.. then you wouldnt need to be your own pracitonioner if the protocols already allow you to do the maximun anyway...

( really just IMHO )


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## bstone (Mar 23, 2012)

Miscusi said:


> one thing ...  ppl sare saying NP/PA ..  I was wondering if that meant:  Nurse practionioner / Physician Assistant...



Yup.



> because I think the PA is not a practionier , they work under a MD's direction and authorization like the rest of us,



Your thinking is incorrect. PAs act at the same level as NPs. Their licenses are from different state boards but their function is identical. NPs are also required to have a Supervising Physician, tho this MD/DO might be thousands of miles away and only available via carrier pigeon.


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## Vetitas86 (Mar 23, 2012)

I think expanding scope is what this is about. You can only take prehospital so far. 

From my (limited) understanding, the idea of a paramedic prac. is to be able to more effectively diagnose and treat in situations that wouldn't be "hospital worthy." 

Having a clinician in the field, the PP could write (limited and under view of a superior) scripts, use advanced therapy, and act as de facto field supervisor. Supervision in the role of at least knowing how to stabilize in OS moments vs treading water. 

And in some areas, paramedics do supervise. But having someone who could act as a catch all and hands on supervisor could free up paramedics to have more field time, letting the EMT-Bs have more time at their level of training.

It would lessen the amount of ridiculous calls being shipped to the ED, provide better quality care, and let the guys and girls do what they're trained to do vs being glorified taxi drivers. (Not my analogy, btw)

Do I think this is ideal in every setting? Hard to say. But in areas where there is a lot of lesser action in the ED, it could very well be a godsend. Even in flight settings, having essentially an advanced paramedic to care for and stabilize critical patients would take the load off flight nurses. 

It has the potential for keeping criticals alive and expanding the scope of paramedicine where it needs to be. Again, its still not off the ground yet, but it definitely is something to watch that could change the face of American EMS.


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## bstone (Mar 23, 2012)

I don't know if this sort of paramedic would find a strong enough demand in order to make it a reality. I would strongly support an EMS "residency" for NPs and PAs.


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## Miscusi (Mar 23, 2012)

Oh, I guess it must be a NY thing. here, a nurse practioner can rent an office, open her own practice and have customers...

meanwhile our PAs here in NY cannot do so.


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## Vetitas86 (Mar 23, 2012)

But then the issue is finding malpractice coverage for nonclinical work, to say nothing of ones that would work part time or full time EMS. They're out there, just have a feeling they're few and far between. 

As far as the residencies, I know there's EM for PAs, and they're officially rolling out board certs for docs this year in EMS. I think its possible that residencies could filter down to NPs and PAs, but would the demand for those be strong enough? And would they just want to be in an admin position? 

Having dedicated personnel for prehospital care would solve that, I think. And demand isn't high, but I think if it worked as well as it looked on paper in the States, I genuinely believe there would be. 

Think about it. Even training possibilities for Paramedic pracs would open up. Tox, advanced trauma, advanced transport...

Specialization is a problem in health care in general, yeah. But, keeping the NPs and PAs in a clinical setting assisting the MDs is a good thing to me. That's more what they're trained for. Tacking on a residency, to me...its not going to make that much difference when it comes down to it.


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## bstone (Mar 23, 2012)

Miscusi said:


> Oh, I guess it must be a NY thing. here, a nurse practioner can rent an office, open her own practice and have customers...
> 
> meanwhile our PAs here in NY cannot do so.



Sure they can. I know many PAs who run their own practices in NY and all over.


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## Miscusi (Mar 23, 2012)

thats sounds very reasonable, I guess I have met NPs who had businesses, but never a PA. All the PAs I have met work in hospitals..  But I'll look it up to see what NY has to say.. I think IIRC that the PA can have the MD DO be far away and the NP needs no MDDO at all... but I'll look..


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## Miscusi (Mar 23, 2012)

ok so far:  http://www.health.ny.gov/professionals/doctors/conduct/physician_assistant.htm

So in NYS,  PAs cannot practice medicine. I'll find the NP and post back...


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## bstone (Mar 23, 2012)

> A physician assistant is considered a dependent practitioner working under the supervision of a licensed physician responsible for the actions of the physician assistant. The supervising physician may delegate to the physician assistant any medical procedures or tasks for which the physician assistant is appropriately trained and qualified to perform and that are routinely performed within the normal scope of the physician's practice.



Do know the requirements for the supervising physician? The doc can be thousands of miles away and only available via phone but that is considered legal supervision.



> Countersignature of such orders may be required if deemed necessary and appropriate by the supervising physician or the hospital, but in no event shall countersignatures be required prior to execution.


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## Miscusi (Mar 23, 2012)

So as far as I can understand, the NP is a real practicing professional.  they only need a Collaborative Agreement with a MD who does a few things with the NP once every 3 months or something like that...  Whereas the PA needs MD supervision directly and is an extension of an MD rather than an independent practionioner himself...

Nurse Link:

http://www.op.nysed.gov/prof/nurse/np.htm

but that is just New york State.. im sure its different in all 52 states !


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## Miscusi (Mar 23, 2012)

*Thousands of miles by phone...*

_"D. Supervision

A physician assistant works under the supervision of a licensed physician who is responsible for the physician assistant's performance as well as the overall care of the patient. The physician assistant may have more than one supervising physician; however, there must be one clearly designated supervising physician who is available at any one time.

In New York State, a physician in private practice may supervise no more than two PAs at one time; in a correctional facility, no more than four PAs at one time; and, in a facility licensed pursuant to PHL Article 28, no more than six PAs at one time. Physicians are not required by law to notify the State Education Department which PAs they employ or supervise.

The supervising physician may delegate to the PA any clinical functions within that physician's scope of practice providing the PA is appropriately trained and experienced to perform those functions. The physician assistant is subject to the limitations set by the supervising physician and to the policies of the employing institution, in addition to state laws, rules, and regulations."_

OK I see that there is no distance requirements mentioned, but it does offer a limit on how many PAs a doc can sponsor...

I just cannot see how if a doc can only sponsor 2 PAs, they would do so in a manner where they are thousands of miles away.  That is borderline very immoral.  

I think the doc should ( and usually as I have seen ) work in the same hospital as the PA they sponsor.

I think any DOc who sponsors a PA thousands of miles away is not an ethical person, so maybe these docs are driven by the loophole and wants a part of the money, but by the state limiting the amount of PAS per doc, that removes alot of the money making these less than ethical docs can make...

but though no countersignature is needed before the treatment, I still think the counter signature is needed afterwards, or eventually.

but I'll be sure to ask the next PA I meet about the countersigs as the website is not too clear on that..


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## Vetitas86 (Mar 23, 2012)

And the nonsupervision of NPs is less "immoral" because...?


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## Miscusi (Mar 23, 2012)

Vetitas86 said:


> And the nonsupervision of NPs is less "immoral" because...?



but the NPs are practioners, they are not supposed to be supervised. hence the term Nurse "Practioner".  They are only required to have a collabration. 

Supervision and Collabration is not the same thing..


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## Vetitas86 (Mar 23, 2012)

You can't really use semantics as the prime backing behind your reasoning. Based purely upon training and education required, your logic is fallacious. They're both midlevels, they both have prescribing rights, and they're both trained to act within their scope of practice. The only difference is the letter of the law and the determination thereof.

To me, PA training is as tough or tougher than nurse prac training, due to being based on the allopathic and osteopathic methods. It's up for interpretation, but that's just me.

At the end of the day, both are midlevel providers who should be able to act within a collaborative relationship with a supervising physician. Just because the letter of the law states things one way, doesn't mean its necessarily the way it should be. If that were the case, we'd still be having tea time and flying the Union Jack.


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## Miscusi (Mar 23, 2012)

with all due respect, Please read the links I have provided, I said things may differ from state to state, and in new york state, the information is clearly there. the education is different, the work is different, homeo or whatever is not what its about here in NYS, which was what I was talking about, but dont take it from me, go ahead and read it for yourself... the links are to the goverment websites.


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## Vetitas86 (Mar 23, 2012)

Again, semantics. 

I've read your links. The primary difference in scope of practice is minimal. The only difference is the wording. 

In a practical sense, they do the same thing. Educationally, PAs are trained in a medical model, not a nursing model. Both are however, abbreviated forms of what MDs and DOs do. 

Homeopathy has nothing to do with it. 

Point is. They're both licensed midlevel healthcare providers who act under supervision of a physician. The difference is how much supervision is legally required, and I'm not disputing that.


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## Miscusi (Mar 23, 2012)

OK, I have taken some text and put it here...

PA:  A physician assistant is considered a *dependent *practitioner *working under the supervision* of a licensed physician responsible for the actions of the physician assistant. 

So you can see, the PA's doctor is RESPONSIBLE for the PA's actions, the PA does as the MD orders him to do.

whereas: 

NP: have a collabration. It really isnt like Supervisor / underling.

see here. 

http://www.op.nysed.gov/prof/nurse/np-sample-collaborative-agreement.pdf


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## Vetitas86 (Mar 23, 2012)

So basically what you're saying is...

A) PAs are not professionals.

B) Due to the wording of laws created at different times, the amount of supervision required of each is a major factor in how they practice in clinical settings.


First of all, a PA is a licensed professional, trained to provide care to patients. Supervision is irrelevant. That's what they do, functionally.

Second, the amount of supervision has no bearing in how each practices. They both diagnose, both prescribe, and both do procedures within their scope of practice. 


To reiterate. The wording of the law, while relevant in theory, is irrelevant in practice. Scope of practice and functional duty are what matter outside of law school and the courts. 

Yes. You are right when it comes to how it is worded. That doesn't make up for the functional.similarities both in duty and scope of practice. 

My point is, the PA is as much of a professional as a nurse practitioner IN PRACTICE. No more, no less. Nurse practitioners and PAs should operate under the same level of supervision, as midlevel providers. 

I am aware this is not how it works, but how it should be. And hopefully, at some point it will change. Until then, as trained and licensed midlevel practitioners, PAs demand the same level of respect as NPs. Again, no more, no less.


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## Miscusi (Mar 23, 2012)

sir. 

PAs are professionals yes.

EMT Basics are professionals too 

NP are also professionals, and so is my hooker down the street. 

_"Second, the amount of supervision has no bearing in how each practices. They both diagnose, both prescribe, and both do procedures within their scope of practice. _"


I said the PA is not a practitioner the way a MD, DO, or NP or DDS is.  the PA is the Physican's Assistant.  He does what the MD authorizes him to do.

Yes the MD can authorize him to do everything a MD can do, or nothing more than to get a cup of coffee every day at 4.

Whereas the Nurse practionioner has certification as a practitioner.  She works under no one else's authority.  the MD collabrator just does as you have read in the PDF link,  he is available when the NP is not there so the patient/customers of the NP has a place to go.  And he is required to look at SOME the NPs patient records every 3 months to see if things are going smoothly.... If the Collbrator do not like what the NP is doing, he can end the collabratopn ( he should ) and the NP is out of business. but he cannot reduce what she does to getting coffee at 4.

IMHO !!


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## firecoins (Mar 23, 2012)

Miscusi said:


> ok so far:  http://www.health.ny.gov/professionals/doctors/conduct/physician_assistant.htm
> 
> So in NYS,  PAs cannot practice medicine. I'll find the NP and post back...



NY PAs cans start their own practise provided they hire an MD as an employee to supervise them otherwise your right.


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## Vetitas86 (Mar 23, 2012)

Your argument lost it's charm when you brought up your hooker.



Back to the topic at hand...

How would you go about implementing a program for paramedic practitioners?

What kind of educational requirements and practical training?


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## firecoins (Mar 23, 2012)

Why mot PA traning with an EMS/prehospital residency?


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## Vetitas86 (Mar 23, 2012)

Actually not a horrible idea. Just don't know how easy it would be getting a PA on the bus, salary and insurance wise.


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## Vetitas86 (Mar 23, 2012)

Double post but Tapatalk won't let me edit.

Thinking about it, too. As far as prehospital PAs, it goes into residency requirements. 

You'd have to train the PA as a paramedic along with advanced procedures. Why do 2-3 years PA school and a 2-3 year residency just to do it?


Edit (worked that time): What would you change about the way EMS education works in general?


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## ExpatMedic0 (Mar 23, 2012)

Just something to think about for those of you that are shooting down the mid level practitioner model. Parts of the UK and Australia already use this model.

Also for those of you who do not know I travel to Denmark  twice a month. I have done some ALS ride along time there and also seen there system as a by stander quite a bit. Every priority ALS call gets a BLS ambulance an ALS chase car that contains an M.D. and a Paramedic duo.


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## jwk (Mar 23, 2012)

bstone said:


> Yup.
> 
> 
> 
> Your thinking is incorrect. PAs act at the same level as NPs. Their licenses are from different state boards but *their function is identical*. NPs are also required to have a Supervising Physician, tho this MD/DO might be thousands of miles away and only available via carrier pigeon.



Their function is FAR from identical.  NP is a very generalist concept.  There are no national standards, and in fact, there are online programs for them meaning NO clinical education past what they might have received in their ASN program.  DNP programs in particular are loaded with far more nursing theory and political indoctrination than they are clinically oriented subjects.  

PA's can be generalists as well, but many specialize, with some doing residency-type programs after they get their degree.  Both their didactic and clinical education is far superior to NP's, and the vast majority of it is clinically relevant.  While it's true they have sponsoring physicians, their scope of practice and clinical accumen far exceeds that of 99% of nurse practitioners.  PA's have had educational standards and national certification in place for decades.  Not so for NP's.


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## Vetitas86 (Mar 23, 2012)

Here's a thought. 

Train a paramedic to the bachelors level (BAAS). Call them something like an interventional paramedic. 

They could perform minor invasive and clinical tasks under standing orders from a physician medical director. They'd act as the primary lead in transport duties, since they'd be trained to the same level as RN, but with specialization in emergency and transport care.

They wouldn't have prescribing rights per se. This would keep the ambulance as transport to care rather than a mobile clinic and wouldn't infringe on other specialties. They could however administer selective medications under either the standing orders or consultation with the medical director. 

Just brainstorming, but thoughts are welcome.

I'd advocate this because
A) there's not always going to be a midlevel who wants to ride the truck.
B) it allows medics to advance their careers and education.
C) the ambulance performs as an ambulance, not as a mobile outpatient clinic.


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## WTEngel (Mar 23, 2012)

Require a 2 year associates degree at a MINIMUM to become a paramedic.

Offer a 4 year bachelor's degree in pre-hospital emergency medical science. This should include the following courses, in addition to core curriculum:

8 hours of biology including lab
8 hours general chemistry including a lab
8 hours of organic chemistry including lab
8 hours of physics with lab
Anatomy and Physiology I & II with lab

Paramedics who have completed the 4 year bachelor's program, will then take the GRE with biology, cell and molecular biology, and math subject tests added. Students who meet the minimum science and overall GPA threshold (3.25 and 3.5 respectively) and have satisfactory scores on the GRE, may then apply for a competitive specialized Physician Assistant program that is offered at an existing medical school with affiliated PA program.

Entrance requirements should also include a minimum experience criteria, somewhere around 3 years at the advanced level.

The terminal degree would be called something along the lines of:

Master of Physician Assistant Studies with an emphasis on Pre-Hospital Emergency Medicine.

Basically it is the standard MPAS training, with previous experience as a paramedic required and additional emphasis (maybe one additional semester) solely focused on prehospital integration with definitive care.

Also, I'll add, the true value of having a mid level in the field does not necessarily lie with the ability to perform advanced interventions. In fact, show me a paramedic who can load up and get the critical patient to the hospital quickly and alive (hopefully better than they found them), and I am generally happy. 

The REAL value lies in the ability to treat and work up non critical patients and avoid them going to the hospital all together. Taking the strain off of the ED and EMS system by doing general work ups for non emergent conditions in the field is highly valuable in my opinion. 

EMS and the ED have become a safety net for primary care. The faster we can wrap our heads around that fact, and find an efficient way of dealing with the issue, and hopefully plugging patients with limited resources into a primary care system where they are followed, the faster we can begin to fix this current convolution of primary care and emergency treatment we call the ER.


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## Vetitas86 (Mar 23, 2012)

There are already PA residencies that focus on prehospital care/EMS. And they can cross train for EMT-P. 

I do think there should be a medic-PA fast track though. And what you've got looks killer for that.

Thing is though, it turns into mostly academic training from BS on. That's my reasoning behind a BAAS. You can do didactics as well as clinical time, in theory (someone correct me if I'm wrong. I'm not up to date on academia these days). 

The BAAS could effectively operate aa field chief then, and would be trained with a combination of book smarts and hands on skills. Maybe an associates + experience or cert requirement (CCP comes to mind)?

And on the subject, I'm very much in favor of all medics being trained to associate level. Improves quality of care (There are plenty of good medics out there that don't have the AAS, not saying that) as well as academic respectability for EMS like what nursing got with the BSN. What's not to like?


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## WTEngel (Mar 23, 2012)

I'm not advocating a paramedic to PA fast track at all. In fact, the opposite. 

The post graduate training should be around 28 months at a minimum after receiving your bachelor's degree. 

Also, PA school is not exclusively academic. They have a large number of clinical hours and rotations that must be completed. The clinicals are broad, and intended to give a general survey of the wide array of specialties in the medical community.

Simply having a bachelor's degree, some experience, and a few months of additional training isn't going to cut it. 

If medics want prescribing authority, the ability to do advanced procedures and complex work ups on patients, etc. then the education should be comprehensive and include extensive upper level science electives and comprehensive post graduate training, based on a medical school education model, not some sort of hybrid academic/vocational situation (which we currently have....) 

Anything short of that and I fear the program will not come close to meeting the educational minimums required of practitioners intending to perform the aforementioned tasks.


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## Vetitas86 (Mar 23, 2012)

The issue with giving medics prescribing rights in practice would be backlash from the existing prescribers. Even with limited rights, it gets into how much is enough and how much is too much.

At the end of the day, medics still operate primarily in the field, either as responders or transport. There's only so much that can be done in the field, and the additional academic training that you propose I can see the point of, but how many medics in practice would want to do masters level work?

As far as complex procedures, there's only so much that a medic can do without a hospital or advanced transport. Doing workups and diagnostics in a field setting without physician oversight brings up all kinds of issues, both with the medical establishment and insurance issues. 

I really do see where you're coming from though. I just believe that medics operate in a similar capacity to RNs, just in a different setting with different levels of expertise. 

I see medics operating on a midlevel provider level opening up all kinds of opposition. It would be too much too quick. Starting at a bachelors level (I would actually advocate a 5 year bachelors honestly, similar to other professional degrees, like architecture), it would set a standard of operating procedure and a clear scope of practice that EMS doesn't currently have and produce medics trained to lead clinically in the field.

Edit: The five year bachelor would include the two years of medic training plus upper level training in field and clinical specific sciences. Medics wanting to do that could skip the first two years and take on the sciences and clinicals. To make a poor analogy, medics are field and clinical operators, not lab junkies. I'd venture few of us have the attention span for the sheer volume of science and math needed to operate in transport and response settings.


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## Veneficus (Mar 24, 2012)

*thank you*



WTEngel said:


> Require a 2 year associates degree at a MINIMUM to become a paramedic.
> 
> Offer a 4 year bachelor's degree in pre-hospital emergency medical science. This should include the following courses, in addition to core curriculum:
> 
> ...



This looks like the only intelligent post in this whole thread.

But I have to say, with all of those requirements it is probably easier to just become a doctor.

Maybe we just need more of them rather than all of this pseudo-practicioner midlevel stuff?


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## Pneumothorax (Mar 24, 2012)

Veneficus said:


> This looks like the only intelligent post in this whole thread.
> 
> But I have to say, with all of those requirements it is probably easier to just become a doctor.
> 
> Maybe we just need more of them rather than all of this pseudo-practicioner midlevel stuff?



I agree, but mid level providers are cheaper right? At least that's what we've been told in school. In terms of NP vs MD/DO



bstone said:


> I don't know if this sort of paramedic would find a strong enough demand in order to make it a reality. I would strongly support an EMS "residency" for NPs and PAs.



I think this would be awesome!


bstone said:


> I think the point of a paramedic practitioner would be to initiate *very* advanced interventions in the field. What would those be? I imagine things like starting central lines, general anesthesia, cracking a chest, chest tubes, thrombolytics, antibiotics, etc etc. In the cases where someone is too sick to get out of bed but doesn't need an ER workup they would be able to examine, diagnose, and prescribe treatment independently of an ER physician (or NP/PA).



Omg my skin crawled just thinking about doing a CVC in some of the filthy houses I've stepped foot in. I do however think that for the 99% of bs calls or at least seem like bs at first having a PP/PA whatever doing assessments like say the people who call 911 for a tooth abscess x 2 weeks , 2months whatever... The PP could assess them and say either ya you need serious medical intervention or go to a dentist in the morning or here's an rx for norco for pain/ abx for the infection, & be done with it.


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## Arovetli (Mar 24, 2012)

Pneumothorax said:


> here's an rx for norco for pain/ abx for the infection, & be done with it.



Narcotic scripts delivered right to your door? I can only imagine how much the call volume would increase if folks knew they could get written for narcs and not have to leave their own couch. 

One of the big problems with this paramedic practitioner/EMS 2.0 stuff is that there is simply no good way to finance it. Most viable ambulance services are large private companies or one's who derive the majority of their revenue from non-emergent transports or ones attached to city's or large hospitals who can sustain the ambulance with other revenue sources. You would have to completely overhaul the current insurance system or charge up front payment to sustain an advanced practitioner. Besides there are already plenty of mobile NP/PA's that offer home health services already out there, but these are only utilized by folks who can afford it.

In 7 years of EMS I can't think of any situation where an expanded scope of practice or prescribing rights would have significantly affected patient outcome. The utility of a midlevel provider staffing a routine 911 truck would be so limited that it would  be financially untenable. Unnecessary transports are a problem and a financial drain but I seriously doubt an advanced provider will solve this problem. No amount of advanced procedures or years in training is going to reduce abuse of the system. It is simply cheaper and more efficient in our current system to take the patient to the provider than to take the provider to the patient. If you want to do home health as a midlevel then become a midlevel and do home health.

Now if there is a need in your particular system for expanded scope then you need to sit down with your medical director and ask to have whichever procedure or drug permitted and then train your personnel sufficiently on said procedure/drug.

Now I'll agree that the current state of paramedic education is weak at best and could stand to be improved. More basic science, clinical exposure and an increased emphasis on caring for chronic care pt.'s is needed. However there's already EMT-B's, EMT-IV's, AEMT's, EMT-I's, and paramedics. The last thing we need is to add another level of prehospital provider to the mix.

It makes for interesting conversation and is nice to think about but I seriously doubt that a paramedic practitioner is practical in the US. It may be a pessimistic approach but being a medic means accepting the limitations that go along with it. There are plenty of ways already in existence to advance yourself professionally.


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## Veneficus (Mar 24, 2012)

Pneumothorax said:


> I agree, but mid level providers are cheaper right? At least that's what we've been told in school. In terms of NP vs MD/DO



Bold faced lie.

Most hospitals now have MDs who bill people (for seeing them) to act as a supervisor to a midlevel provider who also creates a bill for service to follow a mindless protocol that some guy off the street could do.

Which means you are getting billed twice for the same thing. Which in almost every case is inferior.  

Since they are only taught to handle "common" problems, you run the risk of them missing something uncommon and delaying treatment. 

If they actually identify a problem over their head, which in my experience with PAs or DNPs is everything or nothing, then you are going to pay a doctor anyway.

The real solution isn't to increase midlevel providers, it is to increase doctors. Simple economics, if there is abundance of supply, then value goes down. AKA price goes down.

I would never consent to being seen by a PA or NP. If I am paying for a doctor, I want a doctor, not her protocol lackey. If you are already seeing a doctor, why would you pay again for something less?

Healthcare management is not a part of medical school. It is all about patient care.

Any doctor who sees their patients less than their lackey is not worthy to be called a doctor and certainly shouldn't be paid for that nonsense.

No PA or NP should operate where there is a doctor. I was once told the purpose of them was to act where there was none. Like out in the sticks not in a medical center.


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## abckidsmom (Mar 24, 2012)

Veneficus said:


> Bold faced lie.
> 
> Most hospitals now have MDs who bill people (for seeing them) to act as a supervisor to a midlevel provider who also creates a bill for service to follow a mindless protocol that some guy off the street could do.
> 
> ...



As an educated end-user, I love seeing a NP. I get a provider who is not rushed to see 8-10 patients an hour, who has delved deeply into a specialty and is extremely practiced and interested in just the "boring" day to day office visits. Especially in the peds setting, where people are learning how to care for their children, it is excellent to have a NP to be able to take the time to do the teaching. It is not the same role as a physician, but a different and (arguably) necessary role in this culture where everyone expects needed information to be handed to them. 

In the clinic setting, NPs fill a needed role. For standard primary care, I don't see any other type of provider.


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## Veneficus (Mar 24, 2012)

Veneficus said:


> Any doctor who sees their patients less than their lackey is not worthy to be called a doctor and certainly shouldn't be paid for that nonsense.
> 
> No PA or NP should operate where there is a doctor. I was once told the purpose of them was to act where there was none. Like out in the sticks not in a medical center.



The role is needed because the doctor is not doing his/her job.

Care and education is the role of the physician. If the physician is too busy, it is the failure of the physician.

No person in any system should be paying more or getting lesser care because their doctor is not doing what they are supposed to.

I can think of no other industry that hires and paysa second person to do the job the first person they hired was responsible for.

Nobody can spend 8-10 minutes with a patient and do them any good.I wouldn't pay a doctor for crappy care either, and it is ashame the American healthcare consumers do not hold their medical providers to task for poor care.


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## Vetitas86 (Mar 24, 2012)

Pneumothorax said:


> I agree, but mid level providers are cheaper right? At least that's what we've been told in school. In terms of NP vs MD/DO
> 
> 
> 
> ...



The idea as the the PP could act as a field triage. If its legit, take them in, if not, have the director clear them via radio or something and take the next call. 

I honestly don't believe we absolutely NEED a midlevel in the field. It'd be nice, but from a logistical standpoint, it'd be terrible. 
What I'm saying is starting small. Put medics on par with BSNs. This would give them more opportunities for ER work as well as supervisory positions in the field.

Going into graduate level territory isn't something a lot of medics who just want to practice are going to do. And masters programs for midlevels are already in place. Why add another?

From an academic standpoint, it also seems to me that the grad level and beyond for medicial specialties gets into more esoterica and more advanced procedure that wouldn't have much practical place in the field.


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## ExpatMedic0 (Mar 24, 2012)

I am surprised to hear that some of you that are so against the mid level practitioner level paramedics.

 In case you have not noticed the USA has the lowest educational requirements for normal ALS Paramedics as it is(compared to most other major western country's that use them) Not only would this help us advance as a profession... 
We also are the only modern western country I know of that uses the death penalty, has an embarrassingly extraordinarily high percentage of over weight people, under educated people, and does not provide basic health care of our citizens.
As an american working abroad  and a Paramedic, I am embarrassed  from not only the country I come from but the educational requirements behind my profession compared to my international colleagues. 

I really encourage you guys to open your eyes and do some research on google or something about how these higher educated Paramedics practitioner are working so well in Aus and UK and maybe even some hard data/study's that show some facts regarding it.


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## Arovetli (Mar 24, 2012)

schulz said:


> I really encourage you guys to open your eyes and do some research on google or something about how these higher educated Paramedics practitioner are working so well in Aus and UK and maybe even some hard data/study's that show some facts regarding it.



There are a multitude of differences between the US health care system and that of other countries. Just because something works well there doesn't mean it will work here. 

Speaking of hard data/studies, there are several out there that call into question the abilities of paramedics to perform at the current level, saying nothing of the ability to perform as a midlevel.

It's supply and demand...if there was sufficient demand for a midlevel paramedic I would have no problem with supplying one. However there is no feasible way to fund them without a massive infusion of tax dollars or charging  patients up front out of pocket.

Where I work the ER midlevels make about 2.5x as much as a medic for 1/3rd less of the hours. If my service were to sink that much money into hiring a field midlevel, not counting the cost of liability coverage or finding an insurance carrier willing to write coverage for a treat and release program, I'd much rather they spend it on hiring more medics so we could run more trucks, reduce response times, ease the workload on the current crews, increased training opportunities, etc.


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## wildmed (Apr 5, 2012)

There is a lengthly thread on the PA forum currently about this very topic. http://www.PhysicianAssistantForum.Com/forums/showthread.php/25974-To-PAs-in-pre-hospital-EMS

There are several pilot programs already seeking to address some of these problems. IE wake's advanced paramedic, king county's ICU (?) medic, and our " community" paramedic program being used by several agencies here in rural CO.
EMS is growing quickly, even though some people can not/ refuse to see it. Bachelors level paramedic certification will eventually become standard, just like it has in nursing, hopefully this will come with an increase in scope of practice. In my opinion it is much more important to grow the standard training and scope of practice of paramedicine as a whole. It does not make sense to add an extra level of practice, especially if an already existing profession could easily be modified to meet these demands.

On that token, I do think that there should be an EMS/remote medical residency for PAs. It would train PAs to not only be functional in EMS, but also extremely competent to work solo coverage in critical access ED's as well as oil rig/ expedition/ remote site practice. These residencies would emphasize more advanced procedures, and emergent thinking skills under austere conditions. Maybe these PA's need to be dual certed as medics, maybe they don't. 
I could see PA's working in two ways for EMS agencies, possibly in a referral system where a EMT/Medic 911 crew arrives on scene with a pt that could be released, calls a regional PA in a fly car who sees the PT on scene and releases the rig. This PA could respond emergent for extended extrication, mass casualty or field amputation. 
I also think EMS PA's would be fantastic in a HEMS setting with high acuity patients.  Where Nurses excel at transporting and maintaining ICU pts, admittedly some are not the best choice to be on a scene flight. An EMS PA with medic experience could perform very advanced life saving procedures that are out of the scope of an RN. The flight PA could begin semi-definitive medical treatment en route, especially with the advent of smaller and smaller medical devices along+ advanced training in the medical model.
Financially this could be feasible, especially because you are now billing PTs for definitive treatment through there insurance. This becomes even more realistic with the advent of socialized healthcare, which you will notice, every country with a really advanced EMS system has. 
As someone going the medic--->PA route I really do foresee something like this becoming reality in the not so distant future.


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## Arovetli (Apr 7, 2012)

Might I remind everyone that the evidence is not indicating the need for widespread midlevel super-ALS, and that the need for the current level of paramedic is only useful in very limited situations.

http://www.ncbi.nlm.nih.gov/pubmed/21092256


If you are dreaming that American EMS as a whole will evolve into some kind of preventative/primary care entity...well, you are dreaming. However everyone is entitled to their own dreams and opinions...


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## Tigger (Apr 8, 2012)

Arovetli said:


> Might I remind everyone that the evidence is not indicating the need for widespread midlevel super-ALS, and that the need for the current level of paramedic is only useful in very limited situations.
> 
> http://www.ncbi.nlm.nih.gov/pubmed/21092256
> 
> ...



It's a good study and I agree, but the study does not really address EMS as a whole, it address a fairly small subset of injuries and illnesses. The absence of a study confirming something as "best practice" does not automatically discredit an action, it just means that more research needs to be done.

Look at EMS use of pain control--surely giving pain control for an isolated extremity fracture will not do anything to improve the patient's mortality (or even any degree of outcome for that matter). It is going to be difficult to quantify the mitigation of pain and suffering, but it is surely something that EMS should be doing, right? Surely EMS should not adopt the view that since pain control is not empirically proven to improve outcomes in the prehospital setting, we should simply not bother?


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## Arovetli (Apr 8, 2012)

Tigger said:


> it address a fairly small subset of injuries and illnesses.



There is only a fairly small subset of injuries and illnesses where paramedic level makes a difference.

Not sure what your getting at with the pain management issue, it is a well established practice.


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## Tigger (Apr 8, 2012)

Arovetli said:


> There is only a fairly small subset of injuries and illnesses where paramedic level makes a difference.
> 
> Not sure what your getting at with the pain management issue, it is a well established practice.



Exactly, it's a well established practice with no empirical evidence backing it. My point is that not everything we do will be evidence based, but it will still be the best practice.


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## Veneficus (Apr 8, 2012)

Arovetli said:


> Might I remind everyone that the evidence is not indicating the need for widespread midlevel super-ALS, and that the need for the current level of paramedic is only useful in very limited situations.
> 
> http://www.ncbi.nlm.nih.gov/pubmed/21092256
> 
> ...



Actually, I consider it a required step if EMS is going to remain a viable industry. 

For what it does not it is really overreimbursed and if it is to maintain feasability, EMS is going to have to add something of value.

No different from the advancement of the fire service really.


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## Arovetli (Apr 8, 2012)

Forgive my cynicism......

Its not going change any time soon. It's simply not economically feasible to staff 911 trucks with midlevels. EMS is viable as it is. It is not viable, however, as a high paid private advanced profession. The economics of the market will keep thing were they are..unless you get some kind of massive intervention from the government. Someone has to move people to and from the hospital. As the population ages the demand for EMS will increase. More trucks, lower response times, better training...all of these things are better uses of our limited healthcare dollars than placing a whole bunch of midlevels in the field. 

Besides, there are already midlevels in the field...google and you'll find np's doing house calls. And the market for them is extremely limited. These folks actually have reimbursement systems  in place for the care they provide and the market barely sustains them. So, without massive infusions of cash from  the government, it's a pretty safe bet that you'll never be an working on an ambulance as an advanced home health prescription writing super provider.


Tigger you've lost me. Are you now suggesting that pain management has no grounding in the literature?


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## Arovetli (Apr 8, 2012)

The reason we have midlevels now, and the reason why they proliferate is because they make people money. The reason why there are no midlevels on the ambulance is because they make nobody money.


It's as simple as that.


Now, if it were economically feasible...it would be totally cool.


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## Arovetli (Apr 9, 2012)

http://www.jems.com/article/news/new-community-paramedicine-law-maine-loo

Relevant to this discussion.


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## Veneficus (Apr 9, 2012)

Arovetli said:


> Forgive my cynicism......
> 
> Its not going change any time soon. It's simply not economically feasible to staff 911 trucks with midlevels. EMS is viable as it is. It is not viable, however, as a high paid private advanced profession.?



$300+ is not a viable taxi ride.

Fielding enough units to answer increasing 911 calls because of both an aging population and ultraspecialization of society is not feasable.

The economics are that it is not worth paying what is paid now, and as healthcare becomes less affordable, EMS will have to demonstrate some value.

I don't see the need of some "midlevel" super provider, in fact I see all mid levels as a complete drain on the system. The idea was for them to operate where there were no physicians, not to add a redundant level in established facilities, so said facility can add that service to the bill, where most of them find employ. 

But I do think that EMS will have to become more involved with things such as healthcare education, public health initiatives, and illness prevention.

I don't think it will require a greatly advanced clinical practicioner, and definately won't require handing out prescriptions.

As many of our collegues from AU and NZ point out regularly, sometimes help navigating the system is what is needed, or perhaps some minor care and attention at home. 

I cannot recall the number of times I went on a 911 call to be asked if the person was sick enough merit spending the money on a doctor. These consumers are absolutely right. There is definately not a need to transport everyone to the ED. The price is simply outrageous. Both for the transport and the facility.

As it has become, once you confine medicine to ivory towers where the most important question is "how much can you afford" a provider for the masses will be needed. While some cultures actually have to use something like a shamen for this, I think that modern civilizations could use a healthcare provider who has at least some basic knowledge other that the handful of tricks for the sickest patients, which make up a minority of all volume.

If you were operating a business, would you want to spend more effort on 5% or 95% of your customers?

The current US EMS system was created for a different time, with different challenges. It is easy to bury a head in the sand and pretend the world doesn't change, but it does. There are many vocations that have been lost to history.    




Arovetli said:


> The economics of the market will keep thing were they are..unless you get some kind of massive intervention from the government. Someone has to move people to and from the hospital. As the population ages the demand for EMS will increase. More trucks, lower response times, better training...all of these things are better uses of our limited healthcare dollars than placing a whole bunch of midlevels in the field.



I do not think the economics will support the constantly advancing standard of prehospital medicine on the reimbursement schedule it has now.

I don't think controlling healthcare costs is conducive to spending hundreds of dollars per person per dialysis trip.

I also think that EMS is such a minor stakeholder in healthcare, that when reform is forced by the economic realities, that its interests will be completely overshadowed by more major players.

I have said many times, totally eliminating mid level providers and techs, forcing doctors and nurses back to the bedside and out of managing healthcare will save lots and lots of money.


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## Arovetli (Apr 11, 2012)

Veneficus said:


> The current US EMS system was created for a different time, with different challenges. It is easy to bury a head in the sand and pretend the world doesn't change, but it does. There are many vocations that have been lost to history.



This is solid gold. 

EMS, Emergency Medicine even, is a hot sloppy mess, with no easy fix. I don't think there is anyone who even knows how to begin to fix it. Physicians and medics have little involvement in politics and politics=power.

Now what EMS does not need to do is start accumulating more and more primary care responsibility, which alot of people advocate doing and in my opinion is wishful thinking at best and lunacy at worst.


Honestly (at the risk of being flamed), I often think it would work better if we went back to the olden days with ambulances being staffed with basic first aid technicians and a ride to the hospital. Paramedics should still exist, but they need not be deployed on every ambulance. A waste, as it currently is. I often got frustrated at the conditions of my employment as an ambulance medic, but then I realized I was doing a job that probably shouldn't exist in the first place.

I have been watching old Emergency! episodes. They represent a much more logical approach to EMS response. They also represent a much more logical patient population....

Ambulances will always exist because everyone has a right to a free ride to the hospital and free medical service at the ER right?? I mean, this is American after all. As far as the transports...yes it is absolutely ridiculous to send paramedics to do the granny shuffle/renal roundup/(whatever you call it) but this is where the money lies so services will bill away.

+1 to your views on midlevels and +1 to the fact that there is too much provider inflation in healthcare driving up the cost.


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## Veneficus (Apr 11, 2012)

Arovetli said:


> Now what EMS does not need to do is start accumulating more and more primary care responsibility, which alot of people advocate doing and in my opinion is wishful thinking at best and lunacy at worst.
> 
> I have been watching old Emergency! episodes. They represent a much more logical approach to EMS response. They also represent a much more logical patient population....



Actually, I don't think it is wishful thinking or lunacy at all.

One of the things I have studies in my career is paleopathology, which  explores the historical progression of human disease.

As we progress as a modern society, the types of patients seen on "Emergency" and in the minds of many providers, worthy of an ambulance, will become less and less. 

The golden days of major trauma from car accidents has been replaced by the acute MI, and a majority of patients will end up calling EMS not for this, but for acute exacerbations of chronic diseases.

In the future, more likely because of the later. There simply won't be a need for paramedics as they exist today. 

So you are left with only 2 possibilities, you (collective you) will retool to perform a need, or you will be gone.

If you consider the growing number of CCT transports, that is really where signs point to the paramedic being most needed. Those are transports of serious illness for one reason or another.

As we have seen studies, as well as revise our treatment of emergencies, even today the roles performed by US medics is largely ineffective and insufficent.

As we have seen with the professional fire service, with the exception of major cities, changes in building construction and frequency of fire has all but eliminated most of what they do as fire suppresion and rescuing people from fire. 

A majority of the country is volunteer because they cannot economically support what a professional fire service does today or simply do not have the need.

As I stated in my above post, EMS will have to add value by performing a service needed by modern society, or the combination of technology and economic value will reduce it to a low level tech plugging you into some stuff on your way to the hospital and perhaps administering meds by protocol. (Which honestly does not take a medic now, it only takes a medic when a decision has to be made, which in protocol medicine is often a decision to withold)

As the shift towards chronic disease continues in modern societies, paramedics will have to shift towards primary care to have a viable job. It won't matter if there is 1 on every block or 1 for every 100 blocks. The current skill set and treatments will simply not be needed.

As evident by todays standards, of paramedics neededing less training than a barber to take you to the hospital and provide treatment, as a vocation, this will not be feasable as a living in the near future. Look at how difficult of a living it can be now in a majority of places. 2 to 3 jobs to live in the lower middle class.

Personally, I would rather help morph EMS into something relevant and sustainable in the modern world, but that is just my lunacy.(I call it giving back)  

In all logical prediction the future of prehospital EMS will probably look nothing like we see today, and even less like  the days of Johnny and Roy, which I grew up with, and providers of that generation barely could have imagined EMS as it is today.   



Arovetli said:


> Ambulances will always exist because everyone has a right to a free ride to the hospital and free medical service at the ER right?? I mean, this is American after all.



While many Modern societies actually have embodied in law of providing fire and ambulance service, the US is not one of those societies. (in fact the US is falling behind many modern societies on a number of levels, but watching Rome burn is a topic for a different forum)

In no modern society is that ambulance ride free. It is just a question of how it is paid for. 



Arovetli said:


> As far as the transports...yes it is absolutely ridiculous to send paramedics to do the granny shuffle/renal roundup/(whatever you call it) but this is where the money lies so services will bill away.



Today.

But do you honestly believe with the current problems (read crisis) in US healthcare spending that it will be even possible to spend the money that is being spent on this for long?

As the current reforms underway unfold, those groups with political power will protect thier money at the cost of others. Hospitals have political power, nurses do, doctors do, pharm does, as you accurately pointed out, EMS doesn't.

Logically that means EMS will take the cut first and it will likely be the deepest. The days of IFT getting what it does are limited, and I expect the bottoming out of it will come in my carrer.

I think most if not every EMS provider would love to only be handling emergencies as we have come to define them, but reality is, soon those days will be romanticized like knights on horseback. There are even groups playing (competing) EMS games which strongly resemble renaissance festivals. Dressing up with props to relive the by gone days of real emergencies and archaeic treatments.

Remember the days when there were numerous cases of scury and iodine deficency?

Me neither...

Change will come. Whether we agree on how or not.


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## Arovetli (Apr 11, 2012)

Veneficus said:


> Change will come. Whether we agree on how or not.



 A fitting end to our exchange. The future will certainly be interesting.


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## firecoins (Apr 11, 2012)

Veneficus said:


> Any doctor who sees their patients less than their lackey is not worthy to be called a doctor and certainly shouldn't be paid for that nonsense.
> 
> No PA or NP should operate where there is a doctor. I was once told the purpose of them was to act where there was none. Like out in the sticks not in a medical center.



agree with this....alot.


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## wildmed (Apr 11, 2012)

firecoins said:


> agree with this....alot.



 I also agree with this statement. There are a lot of services/specialities that PAs could bring to rural areas if there was a push in that direction. Unfortunately, just like for physicians, the money and comfort is in urban areas. 

   My main goal in perusing PA school is to provide high quality rural emergency/ trauma care. Most rural EDs, at least where im from, are staffed with Family Practice docs. However from my prospective, it would probably be to the benefit of the patient to have at least one medic/PA with a year of EM/trauma residency in each ED. From what I have seen a lot of FP docs, even if they are seasoned in their ED, tend to struggle with the really sick/ high acuity trauma PTs. I personally would rather have a PA with alot of EM( training ( residency, ATLS,ACLS,PALS, difficult airway ect.) take care of me in a critical situation than an FP doc. This seems to be the thinking with the development of the ECP in england and hopefully the US will follow suite.

On another note... correct me if im wrong, but it seems to be the opinion of some people on this thread that EMS is a dying profession? First, thats really disappointing. Secondly, I don't agree. As long as people are getting hurt, or sick in places outside of the hospital, there will be a need for EMS. It is too ingrained into the system that it could just go away. I do think its evolving both for better and for worse, but all professions do.


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## Arovetli (Apr 11, 2012)

wildmed said:


> However from my prospective, it would probably be to the benefit of the patient to have at least one medic/PA with a year of EM/trauma residency in each ED. From what I have seen a lot of FP docs, even if they are seasoned in their ED, tend to struggle with the really sick/ _*high acuity trauma*_ PTs. I personally would rather have a PA with alot of EM( training ( residency, ATLS,ACLS,PALS, difficult airway ect.) take care of me in a critical situation than an FP doc.



For high acuity trauma, I'll take the surgical intensivist. There is a reason why the training is 10+ years. PA's with 3 years don't belong here. Preop/Postop rounding, clinic and buffering the night call...maybe...from what I've seen (anecdote alert) of surgical PA's they do alot of scut. It is also highly dependent on how far the attending lets them off the leash.

Also no amount of watered down alphabet courses supplant a proper medical education. The "residency" of a PA does not compare to a true medical residency. I will take the physician who dedicated many many years to their field over the assistant who did not.

There are some very intelligent midlevels, and midlevels have a place in medicine.  A trained physician, however, they do not make.



wildmed said:


> On another note... correct me if im wrong, but it seems to be the opinion of some people on this thread that EMS is a dying profession? First, thats really disappointing. Secondly, I don't agree. As long as people are getting hurt, or sick in places outside of the hospital, there will be a need for EMS. It is too ingrained into the system that it could just go away. I do think its evolving both for better and for worse, but all professions do.



Not a dying profession, but as Vene says, it exists for a world that no longer does. Medicine as a whole is facing some very huge challenges in the coming years. Things will change.


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## EpiEMS (Apr 11, 2012)

firecoins said:


> agree with this....alot.



Where's the data to back up the argument that a PA shouldn't be attending patients when an MD/DO is present? All the research I've seen demonstrates equivalency in outcomes. Then again, I haven't seen anything about, say, multiple trauma victims.


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## Arovetli (Apr 12, 2012)

EpiEMS said:


> Where's the data to back up the argument that a PA shouldn't be attending patients when an MD/DO is present? All the research I've seen demonstrates equivalency in outcomes. Then again, I haven't seen anything about, say, multiple trauma victims.



Studies have compared midlevel care to resident/house staff care of lower acuity patients and found equivalency. Or the literature will compare midlevel care to physician care and find equivalency in outcomes yet the patients will still be low acuity. I am unaware of any studies showing full equivalency in outcomes of midlevels in treating any and all who present. 

I feel there is a paucity of evidence in general on the utilization of midlevels. 

If you have data to the contrary please present it. It may very well exist, yet I am unaware of it.

I see the utility in midlevels in certain circumstances but I share Veneficus' frustration with the situation.

As a consumer I would not want to pay the same for seeing a midlevel as I would a physician and as a clinician it is a matter of professional pride to take ownership of your patients rather than pawn them off on a lesser provider for the sake of making money.


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## Veneficus (Apr 12, 2012)

Arovetli said:


> For high acuity trauma, I'll take the surgical intensivist. There is a reason why the training is 10+ years. PA's with 3 years don't belong here. Preop/Postop rounding, clinic and buffering the night call...maybe...from what I've seen (anecdote alert) of surgical PA's they do alot of scut. It is also highly dependent on how far the attending lets them off the leash.



10+ is a nice understatement, mine will be closer to 20, from undergrad through residency.



Arovetli said:


> Also no amount of watered down alphabet courses supplant a proper medical education. The "residency" of a PA does not compare to a true medical residency. I will take the physician who dedicated many many years to their field over the assistant who did not.
> 
> There are some very intelligent midlevels, and midlevels have a place in medicine.  A trained physician, however, they do not make.



Finally, somebody gets it...

I like you.

I also like the idea of taking ownership of patients. A mid level operating where there is a physician is just an extra middleman that needs paying. From the consumer point of view, it is waste.


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## Veneficus (Apr 12, 2012)

wildmed said:


> On another note... correct me if im wrong, but it seems to be the opinion of some people on this thread that EMS is a dying profession? First, thats really disappointing. Secondly, I don't agree. As long as people are getting hurt, or sick in places outside of the hospital, there will be a need for EMS. It is too ingrained into the system that it could just go away. I do think its evolving both for better and for worse, but all professions do.



It is important to understand EMS in the US is not a profession, it is a vocation.

The question is not about the elimination of EMS, it is a question of becomming a profession or remaining a vocation.

That is the fundamental principle underlying to everything from curriculum, to increased educational standards, autonomy, and ultimately pay.


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## EpiEMS (Apr 12, 2012)

Arovetli said:


> I am unaware of any studies showing full equivalency in outcomes of midlevels in treating any and all who present.



Agreed, I haven't found anything about anything beyond moderate acuity patients. Though I'd wager that even with severe acuity patients, no matter whether you've got an ED PA or an ED MD/DO, they're gonna do the same thing –:censored:whether it is move them to surgery ASAP or get them to a ICU ASAP, right?



Arovetli said:


> I feel there is a paucity of evidence in general on the utilization of midlevels.



I disagree: there's been good research coming out on PAs and NPs since the 1970s.



Arovetli said:


> As a consumer I would not want to pay the same for seeing a midlevel as I would a physician and as a clinician it is a matter of professional pride to take ownership of your patients rather than pawn them off on a lesser provider for the sake of making money.



That's certainly your choice – but they're, as I've presented above, not inferior providers by any means. The midlevels are designed to speed treatment, treat lower-acuity patients, and, when an MD/DO is not available on site, to serve as a physician extender, as far as I can tell. Midlevels also bill at lower rates, so if cost is a factor, as a hospital administrator, I might very well choose to hire 1 MD at $160k and 2 PAs at $80k each rather than 2 MDs at $160k each. That is quite possibly a better thing for patients, both higher acuity and lower acuity. Think about it this way:

Say your ED has 8 low/moderate acuity rooms and 2 beds for high acuity patients. You've got 8 filled regular beds, which the PAs can attend to, and 2 high acuity patients can be dealt with by the MD. You've got some RNs to do other tasks and a couple techs too. A 1:5 ratio is not nearly as good as a 3:10 ratio, right? And I might even go as far as to say that the high acuity beds, if filled, should be attended to by 1 MD, giving 1:2 and giving the 8 moderate acuity beds to either 2 PAs or 1 MD. I'd rather have 2 PAs covering, 'cause 1:4 is WAY better than 1:8.


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## EpiEMS (Apr 12, 2012)

Veneficus said:


> . A mid level operating where there is a physician is just an extra middleman that needs paying. From the consumer point of view, it is waste.



This just isn't true. The PA or ED NP operates at lower cost to the consumer. He or she also operates at essentially the same level as the MD, at least, as far as outcomes go. And, don't forget, since PAs and NPs are cheaper than MDs, you have a better patient/staff ratio, so patients are seen more and given quicker attention.


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## Veneficus (Apr 13, 2012)

EpiEMS said:


> This just isn't true. The PA or ED NP operates at lower cost to the consumer. He or she also operates at essentially the same level as the MD, at least, as far as outcomes go. And, don't forget, since PAs and NPs are cheaper than MDs, you have a better patient/staff ratio, so patients are seen more and given quicker attention.



I am not sure you are understanding how this operates.

These people are rounding in facilities which submit a bill for their services.

The facility also have physicians that "oversee" the same patients who submit a bill as if they saw the patient.

That is 2 bills for the same service. One for the doctor and one playing doctor.

When I saw it in action, I witnessed mid level providers simply following algorithms on each patient, which is quite something the nurse can do.

There is no reason these same patients cannot be seen daily by the doctor who is billing. If the doctor is too busy, then perhaps the doctor shouldn't get to bill?

Fat chance of that happening though. It is just an additional layer. If there was no physician billing, I could support the use of a midlevel. 

But that is not the case.


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## EpiEMS (Apr 13, 2012)

Veneficus said:


> These people are rounding in facilities which submit a bill for their services.
> 
> The facility also have physicians that "oversee" the same patients who submit a bill as if they saw the patient.



I was under the impression that midlevels bill at 85% of physician billing rates, at least for many times they're providing care for Medicaid patients. And billing rates vary for private insurers, Tricare, etc. 
I'm sure billing and payment varies at many places, much like how ER docs are employees of the hospital in some places and independent contractors in others.
I admit that I'm neither a PA/NP nor MD/DO, and certainly not even close to any of those levels of education, but from a purely business and health policy perspective, midlevels make extremely good sense.


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## Veneficus (Apr 13, 2012)

EpiEMS said:


> I was under the impression that midlevels bill at 85% of physician billing rates, at least for many times they're providing care for Medicaid patients. And billing rates vary for private insurers, Tricare, etc.
> I'm sure billing and payment varies at many places, much like how ER docs are employees of the hospital in some places and independent contractors in others.
> I admit that I'm neither a PA/NP nor MD/DO, and certainly not even close to any of those levels of education, but from a purely business and health policy perspective, midlevels make extremely good sense.



If only the midlevel was getting paid.

But on an inpatient ward, if a midevel sees you 4 days a week and the physician sees you once, you pay 85% of what the physician would get for the midlevel, then you pay 100% of what the physician gets to the physician.

It is a business strategy used by hospital not because of the level of care provided or care access, but because now they are getting 185% instead of 85%for just the midlevel or 100% for the physician.

Consider something for just a moment. The US spends the highest amounts of any nation many times over for some of the worst healthcare in the world among its populous.

Salary in any business is a major expense. 

Midlevels are almost non existant outside of North America, low level tech positions are almost nonexistant outside of North America.

Explain to me how generating 2 bills for the same service, saves money?

That is like paying to have your lawn mowed by the guy doing it, then paying a higher price to have what that guy did inspected.


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## EpiEMS (Apr 13, 2012)

Veneficus said:


> If only the midlevel was getting paid.
> 
> But on an inpatient ward, if a midevel sees you 4 days a week and the physician sees you once, you pay 85% of what the physician would get for the midlevel, then you pay 100% of what the physician gets to the physician.
> 
> It is a business strategy used by hospital not because of the level of care provided or care access, but because now they are getting 185% instead of 85%for just the midlevel or 100% for the physician.



So, say the MD bills $100 and the PA bills at $85 (obviously way low, but for convenience). 4 PA visits = $340. 1 MD visit = $100. 5 practitioner visits = $440. That's cheaper than 5 MD visits for the patient, and since you can train 2+ PAs for the price and time of training 1 MD, it makes good business sense to have the PAs, both from the employer perspective and the patient (i.e. customer) perspective



Veneficus said:


> Midlevels are almost non existant outside of North America, low level tech positions are almost nonexistant outside of North America.
> 
> Explain to me how generating 2 bills for the same service, saves money?



There are 2 bills for the same service all the time. If you've got a radiology clinic owned by a hospital and serviced by physicians who are in their own practice, you get a bill from the hospital and a bill from the docs. Pretty common setup, happens for ERs too.

But, aside from being common, generating 2 bills with the PA-MD team gets the patient seen more often by a trained provider. The patient is seen more, seen faster, and treated effectively at lower cost per visit and at a lower total cost.

I'm by no means qualified to speak on the medical component of PA vs MD care quality, except insofar as I've never seen large scale studies showing that PA care quality is any less than that provided by physicians. I am only trying to speak to the business and policy side, so I apologize for any errors I've made.


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## wildmed (Apr 13, 2012)

venificus, 
first of all, the way your projecting your opinions on midlevels is mildly offensive. I don't know where your interacting with NP/PA, So I am in no place to judge, but they definitely  deserve more credit than you give.  I know PAs that work solo coverage in EDs, who do multitudes of fully independent, highly invasive procedures in IR, cary their own patient loads in FP offices and even run level 1 trauma alerts in hospitals where all of the 1st responders on the trauma team are midlevels. There are even PAs that very successfully have a there own practice, cary there own patient load and pay a retired doc to look over a certain percent of their charts and sign them.These people sure as heck do not run off of any "algorithm" and are fully competent providers.

I've been around in hospital healthcare for almost my entire career and have worked with countless midlevels.The billing your are talking about does happen however i've been told its not exactly legal and obviously is wholly immoral. What happens more often is that the patient gets billed at 100% instead of the 85% because the doc meets with the pt once and then is attended to by the midlevel for the remainder of their care but is still under the " physicians care". There is a pretty big backlash against even this right now. I do however think that this gets tricky with surgical PAs when the doc and the PA are both "Providers" in the OR.  Honestly, this is all just perpetuated by a healthcare system that is driven by profit and unfortunately by greed. 
Ill reiterate this, PAs really were not men't to work in urban areas, they where supposed to work in places with dire healthcare need.  Those that do, make a HUGE difference in the level of competent healthcare that is available in those communities.

Lets get this thread back on track and talk about the furtherance of EMS why don't we?

I think many agree that making a midlevel EMS provider is not a great idea, How ever expanding the scope of practice and required education of our top level of EMS provider to include treat and street protocols, more advanced field protocols ect would probably alleviate any need for one anyway. I honestly think going back to a system with maybe a higher level EMT as an initial first responder and then a high level ALS backup, similar to what is used in australia is the way to move forward.

Random thought:
Does anyone else find it odd that in this country people leave EMS to go to nursing, and in other countries people leave nursing to go to EMS? In most cases nurses are not ALS providers per-sey ( flight nurses/AP nurses excluded) but paramedics are? Pay for paramedics tends to be much higher than nursing as well in those countries as well. kinda backwards right?


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## EpiEMS (Apr 13, 2012)

wildmed said:


> Random thought:
> Does anyone else find it odd that in this country people leave EMS to go to nursing, and in other countries people leave nursing to go to EMS? In most cases nurses are not ALS providers per-sey ( flight nurses/AP nurses excluded) but paramedics are? Pay for paramedics tends to be much higher than nursing as well in those countries as well. kinda backwards right?



It seems backwards to me, frankly, because I perceive paramedics as having more clinical autonomy than any RN short of an NP. In terms of compensation, EMT-P education is shorter than RN education. But EMT-P working conditions are more dangerous. I'm not sure how many paramedics there are in the US, but I can say with fair certainty that there are about 2.7 million RN jobs and 227,000 EMS jobs at all levels of providers. One would think that EMT-Ps would be making as much or more than RNs, but it could be the union factor. Or the "nursing is a profession, EMS is 'just a technician.'"


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## Medic Tim (Apr 13, 2012)

EpiEMS said:


> It seems backwards to me, frankly, because I perceive paramedics as having more clinical autonomy than any RN short of an NP. In terms of compensation, EMT-P education is shorter than RN education. But EMT-P working conditions are more dangerous. I'm not sure how many paramedics there are in the US, but I can say with fair certainty that there are about 2.7 million RN jobs and 227,000 EMS jobs at all levels of providers. One would think that EMT-Ps would be making as much or more than RNs, but it could be the union factor. Or the "nursing is a profession, EMS is 'just a technician.'"



I have an AAS degree in ems. All the pre rec and general classes are the same as the nursing program. THe only difference is that we do Medic classes and they do nursing. Same degree different concentration.
The program I went through is starting a community paramedics program next semester as Maine is beginning a pilot project. I am thinking I might go for it.


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## EpiEMS (Apr 13, 2012)

Medic Tim said:


> I have an AAS degree in ems. All the pre rec and general classes are the same as the nursing program. THe only difference is that we do Medic classes and they do nursing. Same degree different concentration.
> The program I went through is starting a community paramedics program next semester as Maine is beginning a pilot project. I am thinking I might go for it.



Understood, and your compensation should most certainly reflect it. If EMS were to become a profession as we recognize professions (e.g. medicine, law, divinity, etc.), it would be most preferable. Ideally, that'd be the standard: Associates degree in EMS as entry level for medics, and bachelors as an upgrade, ending up with graduate degrees. Nursing has done a good job at making itself into a profession:censored:– this is recent change, I feel, considering the history of the field.


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## Medic Tim (Apr 13, 2012)

EpiEMS said:


> Understood, and your compensation should most certainly reflect it. If EMS were to become a profession as we recognize professions (e.g. medicine, law, divinity, etc.), it would be most preferable. Ideally, that'd be the standard: Associates degree in EMS as entry level for medics, and bachelors as an upgrade, ending up with graduate degrees. Nursing has done a good job at making itself into a profession:censored:– this is recent change, I feel, considering the history of the field.



Where I went in ME the starting wage for a medic is 10 an hour. Where I work in Canada  a Primary Care Paramedic (the equivalent of an EMT-Intermediate) makes more than double that. It is also the minimum level on the trucks. The PCP course here is 9 months didactic m-f 9-5 then 2-3 months in the hospital and on the trucks. For Advanced Care Paramedic it is another 1-2 years with at least a couple years experience as a PCP. There are also a few BS Paramedicine programs out west. With my 2 year EMS Degree there was still an education gap I needed to fill on my own.

I agree that there needs to be a shift in EMS education. A min of 2 years for medic would be a good start. I would also like to see Basic done away with and the EMT level turn into what an Intermediate or AEMT Currently is. I would love to see EMS in the US move from a vocation to a profession.


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## wildmed (Apr 13, 2012)

I fully agree with the above. I think EMS is moving in that direction, abet slowly, but eventually we will get there. I had a good conversation with a long time medic the other day that suggested that EMS try to move in alignment the AMA to advance itself. This idea had never occurred to me but it would make sense due to the fact that EMS professionals are trained within the medical model, even if it is extremely paired down version of it. It would definitely  give some weight where it would count politically. I would guess that this could bring EMS to the level of nursing and beyond rather quickly. Ideally this would make the Medic the equivalent of the nurse, but trained within  the medical model.
     The community paramedic idea seems to be catching on rather quickly, eagle county EMS here in CO was one of the first to establish a community medic program. So far its been pretty effective. I personally think its a great idea, especially if you could mix being a community medic with traditional 911 EMS. I think it would help with burnout and job satisfaction because your A. making an attempt to decrease BS calls. B. making an attempt to help people STAY healthy C. Shifting the majority of real emergent calls to people who really, actually need your assistance.  However, then we come back to the idea of a "community paramedic" being advance practice and the argument has come full circle as to if this is a good idea or not.


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## Veneficus (Apr 13, 2012)

EpiEMS said:


> I'm by no means qualified to speak on the medical component of PA vs MD care quality, except insofar as I've never seen large scale studies showing that PA care quality is any less than that provided by physicians.



If that were the case, there would be no need for a physician at all.

I have never seen such studies, but the very idea that somebody with considerably lesser education performs care as well as somebody with more, is either terribly flawed research or the research is set up to demonstrate the outcome specifically.

I am really not concerned about offending mid level providers, if they want to play doctor they should go to medical school.


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## EpiEMS (Apr 14, 2012)

Medic Tim said:


> With my 2 year EMS Degree there was still an education gap I needed to fill on my own.


Wow! That's very interesting –:censored:I guess I've gotta do some more reading on the Canadian system, it sounds very cool!



Medic Tim said:


> I agree that there needs to be a shift in EMS education. A min of 2 years for medic would be a good start. I would also like to see Basic done away with and the EMT level turn into what an Intermediate or AEMT Currently is. I would love to see EMS in the US move from a vocation to a profession.



I would tend to agree, but my only concern is whether that would actually improve patient outcomes. Lots of calls can be handled BLS, and by BLS I mean very, very basic. How often, after all, are people just using EMS as a taxi with O2 and a SAED? If we were to reduce the volume of calls that are BS, then maybe it would be worthwhile to start considering upping the educational requirements. But short of that, I dunno how much you'd see care really improve. I'd wager that it's not cost effective, but I'm just a basic and I'm not an academic researcher on the subject by any means.


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## EpiEMS (Apr 14, 2012)

Veneficus said:


> If that were the case, there would be no need for a physician at all.
> 
> 
> 
> ...


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## Arovetli (Apr 14, 2012)

EpiEMS said:


> I'm only withholding judgement one way or the other until I see good data or serious problems, one or both (preferably just good data). I tend to think that for most patients, a PA or NP will provide good care, and probably equivalent care to the MD/DO. I can say with a fair amount of surety that more patients can be seen, and they can be seen quicker (and often cheaper) if we have more PAs and NPs.
> 
> Understood, but it does need to be acknowledged that PAs and NPs are qualified to perform services as physician extenders. They are both legally and educationally capable of doing so, right?





What I find most irritating from a consumer standpoint is that often I do not have the choice whether I see a physician or a midlevel. We have a shortage of physicians. Instead of educating more assistant physicians I believe we should educate more real physicians.

For my money, I want the best. I want the physician. I want the person who took the long road and learned all the minutiae along the way. There is far too much subtlety in medicine to learn it in 26 months with a watered down residency optional. 

If you have never been to medical school or delved deeply into the nuts and bolts of medicine you might not understand Veneficus' position, or mine for that matter. It is often said that midlevels don't know what they don't know. If you are really interested in the topic I would encourage you to visit SDN (studentdoctor.net) as there are a few former midlevels who went back to medical school and are happy to share the differences between the two.

There is a lack of scientific data on the subject. We can do nothing but exchange opinions and ideas.

For me as a patient, a midlevel will *never* be good enough. Some physicians aren't good enough either. Like I said I want the best.

For you, I encourage you to be treated by whomever you wish. I believe in free choice. You as a consumer are free to see whomever you please. If that is a midlevel, and you are happy with their performance, then I am happy for you.


Now that that is out of the way, we should probably steer the thread back to EMS topics as you suggested.


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## Arovetli (Apr 14, 2012)

wildmed said:


> I honestly think going back to a system with maybe a higher level EMT as an initial first responder and then a high level ALS backup,



I agree with this. The majority of callers want a medi-taxi. Give it to them.


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## Veneficus (Apr 14, 2012)

EpiEMS said:


> [Understood, but it does need to be acknowledged that PAs and NPs are qualified to perform services as physician extenders. They are both legally and educationally capable of doing so, right?



legally, yes.

capable? I have my doubts.


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## wildmed (Apr 14, 2012)

Ok I know this tangent needs to stop but, Veinificus and arovetli , have you both gone through Med school? Residency? It seems that that is both what your implying, just wanted to clarify.


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## Arovetli (Apr 14, 2012)

wildmed said:


> Ok I know this tangent needs to stop but, Veinificus and arovetli , have you both gone through Med school? Residency? It seems that that is both what your implying, just wanted to clarify.



I apologize, I wasn't trying to make an argument to authority. It's just the higher you go or try to go in healthcare the more you find yourself having to whack people with a stick to protect both yourself and your patients. That was the point I was trying to make, not that Vene and I are somehow better than anyone else. 

Too much care is sacrificed for the sake of profit as it is.

But I do believe midlevels have a role, just maybe not a big of a role as they have now or are trying to obtain.

How 'bout this for a bit better argument: During my education, and probably for alot of you guys' too, I got taught sometimes by TA's. Just because the graduate TA could get a bunch of freshman to pass a survey course or help some with the upper division coursework doesn't mean the graduate TA should replace the Ph.D. At typical State U lecture halls are jammed with hundreds of students to one professor and TA's are used as cheap labor to fill in the gaps. We should utilize more Ph.D.'s. instead of a student to teacher ratio of a bazillion to one. If you went through all the horrors of academics to get that Ph.D. and to get tenure tracked wouldn't you be frustrated if TA's tried to edge you out or were used to maximize profit over of education? Or, in the case of the DNP, created a phoney baloney degree just so they could call themselves Dr.? As a student I was extremely frustrated that I was having to pay obscene sums for a professor that was just some dude who stood down front and you had to squint really hard to try and see him.

Medicine need not be the land of OZ that it is becoming. The doctor - patient relationship is supposed to be sacred. Now alot of the time its just about $$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$

But I am really starting to digress now.


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## EpiEMS (Apr 14, 2012)

Arovetli said:


> As a student I was extremely frustrated that I was having to pay obscene sums for a professor that was just some dude who stood down front and you had to squint really hard to try and see him.



The comparison to TAs is appropriate, but I disagree with how you put it. I would say that:
NPs and PAs often see lower acuity patients – just like TAs often teach intro courses. But NPs and PAs can also see critical patients –:censored:just like TAs can teach upper level courses. And, they've always got professors for supervision – just like PAs (not so much NPs).



Arovetli said:


> Medicine need not be the land of OZ that it is becoming. The doctor - patient relationship is supposed to be sacred. Now alot of the time its just about $$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$



Dude, it's always been about $ etc. But, and I stress this, there were never as many disincentives for people to take care of themselves or third party payer problems than there have ever been. Not to mention, medical education has never been more expensive, nor has malpractice coverage or overhead costs been so high as they are today.


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## Arovetli (Apr 14, 2012)

EpiEMS said:


> The comparison to TAs is appropriate, but I disagree with how you put it. I would say that:
> NPs and PAs often see lower acuity patients – just like TAs often teach intro courses. But NPs and PAs can also see critical patients –:censored:just like TAs can teach upper level courses. And, they've always got professors for supervision – just like PAs (not so much NPs).




Now I would counter why the need for a subpar provider who needs constant supervision? As veneficus pointed out for inpatients access to a physician should be readily available. I just can't find the overall use for a midlevel besides paying them less than what they can bill for and pocketing the difference. It's basically like employing a career resident except you will never advance to the top and just be at the mercy of your attending all career long. 

Less assistants and more of the real deal I say.

Its getting late and I think my thoughts are starting to run together so I will call it a night.

But before I go, why don't PA's challenge the USMLE if they want to prove their mettle? Go big or go home I say.


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## Veneficus (Apr 14, 2012)

EpiEMS said:


> Dude, it's always been about $ etc..



While this is certainly true, there is an important distinction.

The purpose of medicine is to preserve wealth. (That of the individual and society) 

Somewhere in US history, nearest I can pinpopint is immediately post WWII, US society started to use healthcare to generate wealth.

Since then, everyone has put their hand in the pot. As is the natural order, when you are trying to generate wealth, you create inflation. 

Now it is so out of control it is heading for imminent collapse. 

Right now, every interested party is just milking it for the most until it does.

(sort of off topic) but it is my opinion that the current healthcare reform is really sort of a bailout to soften the landing a bit.

(back on topic) Which is why in the future, I see the value and need of paramedics in particular, providing more community and primary care service. 

Not only as the way to advance the profession, but in order to be economically sustainable as modern disease and treatment evolves.


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## Arovetli (Apr 14, 2012)

EpiEMS said:


> Dude, it's always been about $ etc. But, and I stress this, there were never as many disincentives for people to take care of themselves or third party payer problems than there have ever been. Not to mention, medical education has never been more expensive, nor has malpractice coverage or overhead costs been so high as they are today.



You can only rip a system off so much before it rips back.....eh Wall Street??


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## Arovetli (Apr 14, 2012)

EpiEMS said:


> Not to mention, medical education has never been more expensive, nor has malpractice coverage or overhead costs been so high as they are today.



Also to hit on this real quick you will find a growing sentiment in the halls of US medical schools to trade that big payday down the road for lower tuition loans and malpractice protection. Believe it or not most medical students aren't in this for $$$. An idealistic bunch at the outset.

In full disclosure there do exist these things called gunners and ROAD warriors.
Grrrrr.


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## Arovetli (Apr 14, 2012)

Hypothetical question.

If there is such equivalency between a midlevel and a physician, why can they not take the MCAT and prove it? Why can they not take the USMLE and prove it? 

These are two commonly used metrics to establish physician level knowledge.


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## kindofafireguy (Apr 14, 2012)

I could be wrong, but don't PA's take the MCAT?


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## Arovetli (Apr 14, 2012)

kindofafireguy said:


> I could be wrong, but don't PA's take the MCAT?



GRE for entry and PANCE for exit.

That would be the same GRE required by darn near every graduate program regardless of field.

I think some can substitute MCAT for GRE, but GRE is still the standard.


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## kindofafireguy (Apr 14, 2012)

Ah, that's what I couldn't remember. Guess it's up to the school.


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## medicsb (Apr 15, 2012)

Apparently, an organization, American Board of Comprehensive Care, has been administering a watered down version of the USMLE Step 3 to DNP graduates.  As far as I know, step 3 is supposed to be the easiest of the steps (I'm currently preparing for step 1, I know step 2 is considered to be much easier).  So far, about half of the DNPs can't pass it on their first attempt.  Telling.


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## EpiEMS (Apr 15, 2012)

Arovetli said:


> You can only rip a system off so much before it rips back.....eh Wall Street??



The system is the problem –:censoredeople "ripping it off" in a legal manner are only acting rationally in a system with perverse incentives.

Regarding lowering income in return for lower overhead and lower cost education, I could see that as a reasonable trade-off.


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## wildmed (Apr 15, 2012)

medicsb said:


> Apparently, an organization, American Board of Comprehensive Care, has been administering a watered down version of the USMLE Step 3 to DNP graduates.  As far as I know, step 3 is supposed to be the easiest of the steps (I'm currently preparing for step 1, I know step 2 is considered to be much easier).  So far, about half of the DNPs can't pass it on their first attempt.  Telling.



  Not to rip on the nursing profession, because it is both the backbone and heart of healthcare, but NPs are pushing things way too far in general in there quest for power. Nps do a great job in certain parts of healthcare, however due to being trained in the NURSING model they do a great job performing advanced NURSING not MEDICINE. 
   I think APNs seem to do very well in family practice, as non critical/ and occasionally critical care hospitalists, anesthesia and outpatient maintenance of chronic illness. However in the most basic sense nursing is about general patient maintenance ,not clinical diagnoses, treatment or intervention.  NPs should stay within that roll in healthcare if they really want to be accepted. Don't even get me started on the whole DNP=Doc argument. Unfortunately many DNP programs are a joke clinically and could not even hold a candle to PA education, although there are some exceptions.
   PAs are a much better fit within specialities ie EM/trauma,IR,Cards,CritCare, nonsurgical ortho, pulm, GI ect, however PA's also do very well in primary care. I don't think midlevels should be in the OR at all, it further perpetuates the "assistant" image and is usually a vast underuse of education and skills.

 As Ive said earlier, both PAs and NPs really are just $$$ makers for someone higher on the food chain if they work in an urban area, and in that way they are a drain on the healthcare system. However if they are utilized as they should be,independently, under a limited scope, in medically underserved areas, they are of great benefit to healthcare. Midlevels will never be doctors, no contesting that, but a healthcare provider that can do at least 80% of what a doctor can do is definitely better than no healthcare provider. Especially if the PA has had strong educational background within their specialty.
   Ill reiterate my original point again.. If i was to get severely injured in the sticks, Id MUCH rather have a highly trained EMPA take care of me than a FP trained doc while I was waiting for transport to a higher level of care.


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## fma08 (Apr 16, 2012)

I apologize if this has been mentioned before as I just skimmed the posts, but to all interested check out the Community Paramedic program that Minnesota is working on putting together. I know our service is very interested in it as it would fill a gap in the preventative/supportive care and medical access that is somewhat lacking in our community.


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## systemet (Apr 16, 2012)

Arovetli said:


> At typical State U lecture halls are jammed with hundreds of students to one professor and TA's are used as cheap labor to fill in the gaps. We should utilize more Ph.D.'s. instead of a student to teacher ratio of a bazillion to one.



I would argue that the universities should focus more on the educational part of their role.  Because, let's face it, right now teaching isn't very important to the career of an average postdoctoral fellow or tenured researcher.  It's largely seen as an inconvenience, and something that distracts them from their "real" work.  This is a terrible attitude, but very pervasive.



> If you went through all the horrors of academics to get that Ph.D. and to get tenure tracked wouldn't you be frustrated if TA's tried to edge you out or were used to maximize profit over of education?



Honestly, I think most PhD's would be very happy if their teaching and administrative loads were reduced so that they could do more lab work, spend more time designing experiments, and less time interacting with undergraduate students and filling in grant applications.  I think they'd be more than happy to have more graduate students teaching.

I'd also argue that there's almost no development of teaching skill within the university system, and that lecturers are often left to sink or swim as graduate TAs, then postdocs, and any skill they develop by the time they are tenured is simply a result of having spent more hours in the classroom than of any structured commitment to building better teachers.

I'd also suggest that the graduate TAs may be the people most driven and interested in the education of the undergraduate students, because they haven't yet been contaminated with the attitude that teaching =/= real work, and is a distraction from more important matters.



> Or, in the case of the DNP, created a phoney baloney degree just so they could call themselves Dr.?



I doubt most PhDs are that informed about DNPs, unless they're dual trained, and also working or conducting research in a clinical environment and having to work with them.  I assume here we're talking about the relatively narrow field of PhDs doing biomedical research who might be interacting with undergraduate biology students or teaching in professional medical or dental programs.

If there's anything I've seen from people with PhDs it's been a sense of confusion with the way clinicians insist on being called "Dr. Blank" all the time.  This seems to be much less important in an academic environment.



> As a student I was extremely frustrated that I was having to pay obscene sums for a professor that was just some dude who stood down front and you had to squint really hard to try and see him.



As was I, and I think it's a fair complaint.  Undergraduate students money is used to subsidise administration and research programs.  The same programs that are already being funded (however inadequately) through other sources.  To a certain point, getting an undergraduate degree is as much about branding yourself by association with a (hopefully) famous / prestigious institution, than it is about obtaining knowledge.  And for many students "knowledge" is roughly defined as "any combination of required courses and ridiculously easy electives that will be acceptable for preparation for the MCAT, and used in calculating a cGPA".  It's far from a perfect system.


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## jjesusfreak01 (Apr 16, 2012)

systemet said:


> If there's anything I've seen from people with PhDs it's been a sense of confusion with the way clinicians insist on being called "Dr. Blank" all the time.  This seems to be much less important in an academic environment.



I have to disagree here. While they may not insist on constantly being called "Doctor", the letters of their official title are the only things that matter in an academic environment. If you don't have a PhD, you are considered useless in many academic circles.


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## Veneficus (Apr 16, 2012)

wildmed said:


> PAs are a much better fit within specialities ie EM/trauma,IR,Cards,CritCare, nonsurgical ortho, pulm, GI ect, however PA's also do very well in primary care. I don't think midlevels should be in the OR at all, it further perpetuates the "assistant" image and is usually a vast underuse of education and skills.



Thanks for that, I really needed a laugh today.

A PA cannot even come close to the ability of a physician in these categories.

PAs are just assistants who think because they have a rudementary medical education they are worth more than they really are.

The only thing they are good for is routine care of noncritical conditions. There are way too many exceptions, deviations, and balances required in critical care than any PA I have ever met or heard of is capable of performing at an acceptable level.

I wouldn't let a PA treat a dog I didn't like. I certainly wouldn't pay for one.


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## systemet (Apr 16, 2012)

jjesusfreak01 said:


> I have to disagree here. While they may not insist on constantly being called "Doctor", the letters of their official title are the only things that matter in an academic environment. If you don't have a PhD, you are considered useless in many academic circles.



I don't think we're actually disagreeing here.  A PhD is the entry-level qualification to be considered a researcher, or an academic.  A lot of people within the academic community wouldn't consider someone fully trained until after completing a postdoctoral fellowship or two, and even then, that person might be considered a very junior member of the community.

I'm not trying to suggest that academia isn't also very hierarchical, or that there's no prestige associated with getting a PhD, just that the title of "Dr." seems a lot less important to the people I've met in that particular environment.  This may also be a cultural thing.  It may also be a form of passive aggression that's formed after hearing "Oh, PhD.. so you're not a real doctor?" too many times 

[* I'm not a PhD.  I just have a few friends who are.]


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## jjesusfreak01 (Apr 16, 2012)

systemet said:


> I don't think we're actually disagreeing here.  A PhD is the entry-level qualification to be considered a researcher, or an academic.  A lot of people within the academic community wouldn't consider someone fully trained until after completing a postdoctoral fellowship or two, and even then, that person might be considered a very junior member of the community.
> 
> I'm not trying to suggest that academia isn't also very hierarchical, or that there's no prestige associated with getting a PhD, just that the title of "Dr." seems a lot less important to the people I've met in that particular environment.  This may also be a cultural thing.  It may also be a form of passive aggression that's formed after hearing "Oh, PhD.. so you're not a real doctor?" too many times
> 
> [* I'm not a PhD.  I just have a few friends who are.]



I don't think the problem is in needing a PhD to be a researcher or academic, but that in academia there is little respect for those who are excellent teachers but who lack a PhD, or who have acquired practical knowledge in a field far above the PhDs (say a CEO vs a PhD in business). What annoys me is that we have tenured PhDs teaching in universities who have no business in a classroom while staff instructors are being cut from budgets because they don't bring in research dollars. The hierarchy of academia is slowly eating away at the quality of our educational system.


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## Arovetli (Apr 16, 2012)

@wildmed, bro I don't mean to pick on you but Veneficus is right..and your post is pretty funny. You named some of the most intensive and nuanced subspecialites in medicine...PA's running diagnostic/interventional rads??? Nice.

Honestly dude, I'm not trying to be rude to ya. I respect you in that you have your opinion and doubt I can change it. 

Where are you coming up with this midlevels doing 80% of what a physician can? It is an oft repeated party line with no basis in fact. A political slogan. 

Heck I drive an ambulance fast...does that mean I do 80% of what a Nascar driver can? I mean its just a couple pedals and a steering wheel. The only thing missing is the shifter and clutch...


@epiEMS: I agree we have created a system that encourages abuse. "Emergency" providers can complain all day long about routine use of the ER but when Hospital admins are erecting billboards all over town and broadcasting the wait times and use programs like inquicker.com and primary physicians are extremely inaccessible why not go to the ER? The doc is there, the lab is there, the imaging is there...we have created an inefficient unsustainable system, but one that is highly profitable to the right people. It is out of touch with reality and will change or collapse or be propped up by the government more than it is now to survive....like Wall St.


@everyone else: I guess I opened a can of worms with the academia analogy and now spawned a whole other side discussion. I was trying for a simple comparison but I guess I was a little off. Yes, the current higher education system deemphasizes teaching over research prestige and funding dollars...and sports I might add. Research is important and a academician must generate it, but the academician has his duty to educate as well. Anyways, sorry to open that tangent up, I guess it wasn't the best analogy.

However just as alot of PhD's would rather deal less with undergrad students alot of physicians rather deal less with uncomplicated patients. Personal preferences are fine and vary from person to person but anyone who prioritizes one and neglects the other or delegates it to a lesser qualified person wholesale is a farce, has little professional pride, and should be booted swiftly out the door.

I understand that for Dr. Internist switching John Public from Avapro to Micardis because it gives him a headache is probably boring but get over it. You chose primary care and following people for most of their lives through their cool diseases and their boring diseases is what you signed up for and what they are paying you for. Spend time with John because he is paying for your expertise and advice and most importantly he is your patient. He is yours. Take ownership. In another life I was a beat cop. The streets in my zone were my MF'ing streets and nobody messed with them or the people who lived on them without answering to me. Ownership and professional pride. That HTN patient is your patient, no matter if you think his HTN is boring or not. Nothing should make him sick without answering to you. It infuriates me to see the physicians walk around high and mighty because they make large sums of money and understand what a carboxylation reaction is. The ability to be a physician is a gift, an honor, and privilege and is to be used for the benefit of you patient. Be accessible to that patient. Not that there is anything wrong with being compensated, but do precisely what you are being compensated to do.

Back in the day there were alot of pioneering and innovative physicians who saw all these guys coming back from war with alot of advanced training and came up with a way to put all that knowledge to use to fill a gap in rural/austere/low physician saturation environments. PA's are great for what they were designed for on the drawing board but in reality they have proved to be just like doctors, not wanting to go to the far to reach environments, following the money and the gravy train, and physician and hospitals hire them for the sole fact that they increase the money and pour more gravy on the train. Now we have this weird Master's level half educated no residency provider and we are letting this person be a primary provider to patients when the physician is a few feet away. It makes as much sense as assigning an ambulance to roam the halls of the hospital. We don't need field providers in an environment where there is no field.


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## systemet (Apr 17, 2012)

jjesusfreak01 said:


> I don't think the problem is in needing a PhD to be a researcher or academic, but that in academia there is little respect for those who are excellent teachers but who lack a PhD, or who have acquired practical knowledge in a field far above the PhDs (say a CEO vs a PhD in business).



I agree, to a point.  I think when you start getting into higher level courses you need someone who can evaluate the current literature critically, and teach someone how to be a researcher.  For biosci or physics, or most science disciplines, it's going to be hard to find people without a PhD who are going to be able to do that.

On the other hand, when you consider introductory courses, where you're presenting material that's mostly already in the textbooks, and you're not really evaluating that information critically, then it's easy to think that someone without a PhD could be excellent -- and may be a far superior student.

When you start looking at applied fields like business or nursing, then I think the line gets blurrier.  If you're teaching someone how to do research into business methodology, etc., then you probably need an instructor with a PhD -- if you're teaching someone to be an entreprenour, or act as a CEO to a large company, then I'm sure that no one would turn down the opportunity to get lectures from someone like Bill Gates.

Business schools are interesting to me.  I have a friend who took an MBA, and was considering going for a DBA.  He took a bit of step back, and started asking himself what the point was --- could he really be an expert on how to run a business, without having ever done it himself?  At what point was his lack of personal business experience going to hurt his ability to teach business related courses to other people.  The old, "a bunch of virgins teaching someone about sex" analogy.




> What annoys me is that we have tenured PhDs teaching in universities who have no business in a classroom while staff instructors are being cut from budgets because they don't bring in research dollars. The hierarchy of academia is slowly eating away at the quality of our educational system.



I agree wholeheartedly.  And even in the technical colleges and lesser university colleges, there seems to be a push to have more and more PhDs teaching, award more advanced degrees, and even run small research programs.  

Part of this problem is also a market saturation of qualified PhDs, not unlike what we see in EMS.  You can go to school for 10 years, get a PhD in genetics, and yet most entry-level postdoctoral positions are paying less than $40,000, and you're working 70-80 hour weeks.  You have a large pool of people chasing an increasingly smaller number of jobs, and at some point a lot of them either can't progress in their chosen career path, or no longer want to.  A lot of these people look for instructional jobs that were traditional held by people without PhD degrees.  The smaller institutions salivate at the idea of having more PhDs on staff, and expanding their degree-granting status.

There's also a lack of consumer awareness when it comes to university education.  People in the 18-22 demographic that makes up the bulk of undergraduate students aren't good at getting their voices heard by anyone other than market retailers, and often don't recognise that they're paying a ridiculous amount of money to get an increasingly poorer product.


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## systemet (Apr 17, 2012)

Arovetli said:


> Research is important and a academician must generate it, but the academician has his duty to educate as well. Anyways, sorry to open that tangent up, I guess it wasn't the best analogy.



Sorry if I've derailed the thread a little.


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## Angel (Apr 17, 2012)

Veneficus said:


> Thanks for that, I really needed a laugh today.
> 
> A PA cannot even come close to the ability of a physician in these categories.
> 
> ...



HAHA this makes you sound jealous or bitter...maybe both. :rofl:
the ignorance is astonishing


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## Veneficus (Apr 17, 2012)

Angel said:


> HAHA this makes you sound jealous or bitter...maybe both. :rofl:
> the ignorance is astonishing



Jealous no...

Bitter? Perhaps. I have never had a positive or even neutral encounter with a PA in my life.

They talk a mean game between themselves and "lower" level providers. They are astonishingly quiet and humble in the presence of a physician.

They also don't seem to be so kind to providers they find "beneath" them.

I am also not impressed by why people become PAs.

"Medical school is too long, I am too old, the cost is too much, I don't want to work that hard" 

They are just excuses for not putting for the dedication and effort required for medicine.

The most credit for them I can muster is they are better than nothing. But not by much.

I stand by my position, I would not let one treat or even see a member of my family or close friends.

I would never consent to pay one.

"They have been measured and are found wanting."


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## Arovetli (Apr 17, 2012)

Angel said:


> HAHA this makes you sound jealous or bitter...maybe both. :rofl:
> the ignorance is astonishing



Nothing he said is inaccurate.

The truth is harsh at times.

Midlevels have limitations.

And who is ignorant and how?


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## Angel (Apr 17, 2012)

Veneficus said:


> Jealous no...
> 
> Bitter? Perhaps. I have never had a positive or even neutral encounter with a PA in my life.
> 
> ...



This coming from an EMT? Medic even? OK.


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## Arovetli (Apr 17, 2012)

Angel said:


> This coming from an EMT? Medic even? OK.



Just because this board is geared towards EMT's and medics doesn't mean all who post here are.

On a side note, Ad hominem much?


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## EpiEMS (Apr 17, 2012)

Veneficus said:


> "They have been measured and are found wanting."



The issue is: they haven't been measured sufficiently. However, where they have been measured, far as I can tell, they've been found to perform equivalently or even better.


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## terrible one (Apr 17, 2012)

Angel said:


> This coming from an EMT? Medic even? OK.



Pretty sure Veneficus has either completed or near completion of med school.


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## STXmedic (Apr 17, 2012)

Angel said:


> This coming from an EMT? Medic even? OK.



I think he's got a little more experience than you give him credit for.


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## EpiEMS (Apr 17, 2012)

PoeticInjustice said:


> I think he's got a little more experience than you give him credit for.



Anecdotes do not evidence make.


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## Arovetli (Apr 17, 2012)

EpiEMS said:


> Anecdotes do not evidence make.



As we covered some point earlier in the thread, there is a paucity in scientific evidence.

In light of that we just have to resort to hurling opinions at one another.


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## STXmedic (Apr 17, 2012)

EpiEMS said:


> Anecdotes do not evidence make.



Clarifying thanks for it.


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## EpiEMS (Apr 17, 2012)

Arovetli said:


> As we covered some point earlier in the thread, there is a paucity in scientific evidence.
> 
> In light of that we just have to resort to hurling opinions at one another.



I suppose so. I was just about to edit my post to say that I meant no offense in my statement. I'm just saying that we ought to withhold final judgement in the absence of evidence.


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## Veneficus (Apr 17, 2012)

EpiEMS said:


> Anecdotes do not evidence make.



Neither does studying what you are doing and calling it a measure of effectiveness. 

Most people can demonstrate they effectively do what they do very well. 

You can even generate good numbers when you compare when people above your level do the same thing.

But you cannot compare how well you do compared to people who operate above your level.

I have no doubt that a PA can follow a treatment guidline as well as any doctor that does. Because ay moron off the street can. 

Knowing when you are looking at the exception and modifying treatment accordingly or novel treatment in resistant patients is a much different matter.

Let me know when you find a study that shows PAs do that just as well as a doctor, so we can shut down every medical school in the world with it.

Edit: I am sure we could demonstrate car mechanics fix cars as well if not better than mechanical engineers.


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## EpiEMS (Apr 17, 2012)

Veneficus said:


> Neither does studying what you are doing and calling it a measure of effectiveness.



Most people can demonstrate they effectively do what they do very well. 

You can even generate good numbers when you compare when people above your level do the same thing.[/QUOTE]

There's not many unbiased studies, surely, and lots of them have been done by people with clear-cut incentives one way or another (i.e. DNPs studying efficacy of NPs vs MDs).



Veneficus said:


> But you cannot compare how well you do compared to people who operate above your level.



I'm hard pressed to think about how to study that. Though there's research on the topics of patient education, namely, where RNs do a much better job than MDs.



Veneficus said:


> Edit: I am sure we could demonstrate car mechanics fix cars as well if not better than mechanical engineers.



As a whole, yes, you're right. PAs are not a replacement for physicians, but they do serve a useful purpose – and I wouldn't advocate removing MDs from the loop, obviously, but I am trying to encourage the recognition of a place for midlevels, especially because of how cost-effective they are.


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## Arovetli (Apr 17, 2012)

EpiEMS said:


> because of how cost-effective they are.



You get what you pay for.


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## EpiEMS (Apr 17, 2012)

Arovetli said:


> You get what you pay for.



Yes and no. Medical care is a weird market - there's all kinds of perverse incentives and there's lots of asymmetric information. Plus, PAs aren't supplements for physicians, just a compliment for them.


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## Arovetli (Apr 18, 2012)

EpiEMS said:


> Yes and no. Medical care is a weird market - there's all kinds of perverse incentives and there's lots of asymmetric information. Plus, PAs aren't supplements for physicians, just a compliment for them.



The argument for inclusion of midlevels in healthcare generally revolves around midlevels billing at lower rates and quicker and cheaper to educate thus lending an economic advantage and consumer misinformation over the utility of the product. Oh I agree, there is alot of perverse things occurring in medicine, especially when it comes to misleading patients as to the abilities of the midlevel provider. 

The "economic advantage" is created by an inferior product and dubious marketing practices. Quantity and propaganda over quality.

Please clarify your last sentence so it can be properly addressed.


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## Veneficus (Apr 18, 2012)

EpiEMS said:


> Yes and no. Medical care is a weird market - there's all kinds of perverse incentives and there's lots of asymmetric information. Plus, PAs aren't supplements for physicians, just a compliment for them.



Actually, I blame doctors for this one.

If they did their job instead of worrying about how much money and how much vacation they got, then there wouldn't be a need of any midlevel outside of a remote or austere environment.

The next time I hear one of my EM friends complain about how hard they have it working (2) 12 hour clinical shifts and then an 8 hour office shift, I will remember to shed a tear.

Not because I don't have an appreciation for their efforts, but because a 32 hour work week for the money they get is rather light in my opinion, especially when the hospital has to then hire additional midlevels for coverage.

As I stated above, if an inpatient is being seen by a midlevel, either the physician or midlevel should forgo any compensation for repeating the same service. 

The place for a midlevel is where there is no doctor and they are better than nothing. Not working next to a doctor or "lightening" the load. If there are more patients then doctors, the solution is another doctor, not forcing lesser care on unsuspecting patients.


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## MichMedic1 (Apr 18, 2012)

Well I have read this entire discussion and it has been enlightening for many reasons. First of all, I must qualify my comments by saying that I am an EMT (Basic) with exactly one year of experience & a former medical coder with 7 years of experience, so my opinions might change in the future.  For now, I believe that NPs are not qualified to treat much more than common, chronic & acute conditions. I believe that PAs are a little better than NPs in terms of "medical" treatment. I do not believe we can compare them to each other because they are trained very differently from each other. The real problem is the shortage of qualified physicians due to the constraints of our medical schools.  Class sizes do not allow an influx of new students, which prevents us from having larger numbers of doctors in training. I don't think we can blame any other group for that issue. I became an EMT because I want to work in medicine but I don't personally want to be a doctor. Nursing classes have 3+ years of waitlists, PA school is accepting students that claim they want to work in areas of need- but then go the parts of the country that already have plenty of providers (liars), and medical school is ridiculously difficult to get into because of the limited number of students they are able to accept. So here I am wanting more education, but with limited options. Don't get me wrong-- I LOVE EMS!  It is fulfilling (even with the low pay), interesting, and my coworkers are awesome! But-- there needs to be more possibility in the future for our "profession" as a whole.  Nurses have demanded their roles & then used that leverage to create a terminal practice degree while "we" have submitted ourselves to the underling position. More education would definitely be a plus, but I know a lot of healthcare providers who have a B.S. or Masters and they know LESS about medicine than I do as an EMT.  More education is intended to teach students more information, but what we get are people who did well in their gen-ed classes and borderline in their healthcare classes. More years in college does not always equal more knowledge--- just more people who think they're important & who got into medicine for the power or the money or both. As far as Paramedic Practitioners go-- I say yes! But not for the reasons you might think. I believe that we are going to have to keep putting band aids on healthcare until we see some changes, and maybe allowing paramedics to fill the gap will, in itself, bolster the opinion of others about the professionalism of EMS. There are already some options in place in Alaska that are working well. There is a MICP (Mobile Intensive Care Paramedic) and a CHP (Community health Practitioner).  These are different in role and title and are specific to Alaska. MICPs are credentialed through EMS, while CHPs are licensed by the medical board to act in absence of a physician but supervised (long distance by a Dr.). I do not think this would work well in all states, but it is something to research and consider in other areas of the U.S. As far as billing issues go-- I can tell you that they are not double billing, but rather billing 2 halves. The hospital bills for use of equipment, supplies, and beds, while the providers bill for services. This means the radiologist bills for interpreting your x-ray & the hospital/clinic bills for the actual xrays & related equipment. If a PA sees a hospital patient M-Th & a Doc sees the pt. on Fri., then pt. is billed for 85% for the first four days & 100% for one day. You cannot bill both visits on the same day for the same patient (if you do-the men in little black suits WILL show up!). In closing, I respect all of the aforementioned opinions & look forward to future discussions. I am not sure what the answer is but I know with all of this wisdom that we will figure it out.


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## medicsb (Apr 18, 2012)

Many medical schools have increased enrollment and there will likely be around 20 new schools within the next 5 years.  Med school will become easier to get into as school will have to dig deeper into the applicant pool to fill spots.  And as it is, it isn't THAT hard to get into, it just takes a lot of hard work and dedication.


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## Veneficus (Apr 18, 2012)

I have noticed the bottleneck isn't in enrollment, it is in residency. 

It will be a complex problem to sort out because of the pay disparity between different specialties. 

While it may on the outside seem like increasing students will lead to hard to fill specialties having people in them (like family med) the real issue is nobody goes into those specialties because of the likelyhood of going bankrupt or working 100x more than say a dermatologist.

Which will of course lead to student loan default and in a few years, graduates who do not get into financially stable (nevermind financially enticing) spots will either leave the country or work in a field outside of clinical medicine. 

Everything will be right back where it started.

Some systems pay physicians for years out of school, with specialty specific performance bonuses. Such places do not have the earning potential of the US, but the lack of pay disparity does seem to help balance the needs of providers as well as consumers.

But as a very wise prson I know says:

"five is four" and the US system will inevitably collapse, in all likelyhood during my career. 

It is like standing across the river watching Rome burn while the citizens throw gas on the flames.


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## MichMedic1 (Apr 18, 2012)

I think that it will help to have more medical schools and spots available for med students. There is a medical school opening near me in 2014, so I think you might be right. I am not sure if it will make a big impact, but here's to hoping!


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## MichMedic1 (Apr 18, 2012)

I had not even considered the bottleneck in residency until I read your post. Interesting. I also love the Rome burning analogy-- sad but true.


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## Arovetli (Apr 19, 2012)

Veneficus said:


> I have noticed the bottleneck isn't in enrollment, it is in residency.




The bottleneck is absolutely at the Match. There's D.O. (ABSOLUTELY NOT an MD vs. DO statement) schools proliferating like bacteria with no GME to support them. Current schools are increasing seat size again no GME support. There are currently unfilled FM/peds/IM slots at Nowheresville Community Hospital but even these will fill up in the near future. 

Honestly, it is not that hard, an above average intelligence maybe, a propensity for science and superior work ethic, to get into or complete medical school. You just have to be dedicated to it and put in the time...a freaking lot of time.

It is incredibly hard, however, to match certain specialties due to the competition.

Taking a 250K+ debt load, it is hard to entice new doctors into primary care fields when they can pursue other fields with double, triple, quadruple or more the compensation.

And the midlevel assault on primary care is a huge headache new physicians want to avoid which further discourages selecting a primary care career.

P.S., I like your signature....lol


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## Veneficus (Apr 19, 2012)

Arovetli said:


> P.S., I like your signature....lol



I told you I was stealing it fair and square


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