# What constitues a "Mid-level Provider"



## VFlutter (Feb 10, 2013)

The term mid-level provider or practitioner has been frequently used, somewhat loosely, on the forum over the past few days and I think it would be good to have a discussion as to what makes a mid level provider. 

Currently the DEA only recognizes two groups as mid level providers, NP and PA. 

Is the title something granted based on the position you are in or does it suggest a higher status and authority? 

For example, is anyone who functions in a position in-between that of a Physician and lower professional a mid-level provider or are there some criteria that must be met? 


Here are some criteria that I think are required for a group to be considered mid-level providers:


Graduate level education
Prescriptive authority
Ability to assess, diagnose, and treat
Ability to bill for services
Ability to perform advanced procedures? This is questionable


So where do we set the bar or what are the minimum requirements?


Lets not turn this into a debate comparing professions.


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## ExpatMedic0 (Feb 10, 2013)

Certified athletic trainer?


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## Veneficus (Feb 10, 2013)

"mid level" sounds better than "band-aid."

Basically a provider requiring an advanced degree, like physical therapy, PA, NP, etc, that is not a physician but desperately wants to call themselves one.


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## EpiEMS (Feb 10, 2013)

Chase said:


> The term mid-level provider or practitioner has been frequently used, somewhat loosely, on the forum over the past few days and I think it would be good to have a discussion as to what makes a mid level provider.



This is a fascinating question -- I'm gonna review some literature to try and formulate more intelligent opinion.

Quickly, though, it's an efficient solution, in many cases, to a problem of physician supply (including the willingness of physicians to practice in certain areas, fields, etc.)


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## Bullets (Feb 10, 2013)

Veneficus said:


> "mid level" sounds better than "band-aid."
> 
> Basically a provider requiring an advanced degree, like physical therapy, PA, NP, etc, that is not a physician but desperately wants to call themselves one.



What about those that have no desire to be an MD? Around these parts we are seeing more PAs and students who openly state they have no desire to attend the full medical school. My girlfriend is in PA school and she feels it is a better deal then being an MD. The ER is run by PAs at night with a MD on call, and there are usually just 2 MDs during the day with 5-6 PAs. They do 99% of the work, they run the trauma team, and they get paid a very similar amount of money. Since they work under the doctor, he carries all the malpractice insurance and they carry very little. "Mid level" seems to be the endgame for more students then ever before


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## abckidsmom (Feb 10, 2013)

Bullets said:


> What about those that have no desire to be an MD? Around these parts we are seeing more PAs and students who openly state they have no desire to attend the full medical school. My girlfriend is in PA school and she feels it is a better deal then being an MD. The ER is run by PAs at night with a MD on call, and there are usually just 2 MDs during the day with 5-6 PAs. They do 99% of the work, they run the trauma team, and they get paid a very similar amount of money. Since they work under the doctor, he carries all the malpractice insurance and they carry very little. "Mid level" seems to be the endgame for more students then ever before



Yeah, the ability to function as a physician without all that pesky medical school and buck-stops-here liability is nice.  

I like the idea of mid-level providers but I think the idea was never meant to fully staff an ER, or a hospital, with PAs or NPs as things have progressed.


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## Veneficus (Feb 10, 2013)

Bullets said:


> What about those that have no desire to be an MD? Around these parts we are seeing more PAs and students who openly state they have no desire to attend the full medical school. My girlfriend is in PA school and she feels it is a better deal then being an MD. The ER is run by PAs at night with a MD on call, and there are usually just 2 MDs during the day with 5-6 PAs. They do 99% of the work, they run the trauma team, and they get paid a very similar amount of money. Since they work under the doctor, he carries all the malpractice insurance and they carry very little. "Mid level" seems to be the endgame for more students then ever before



Yep, it's a great idea.

Lesser educated, lesser dedicated, and less capable providers running around pretending and representing themselves as something they are not and taking money for it.

We have a word for that, we call them "quacks."

Undoubtably it is easier to be a quack then to be legitimate.


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## NYMedic828 (Feb 10, 2013)

Bullets said:


> *What about those that have no desire to be an MD? Around these parts we are seeing more PAs and students who openly state they have no desire to attend the full medical school.* My girlfriend is in PA school and she feels it is a better deal then being an MD. The ER is run by PAs at night with a MD on call, and there are usually just 2 MDs during the day with 5-6 PAs. They do 99% of the work, they run the trauma team, and they get paid a very similar amount of money. Since they work under the doctor, he carries all the malpractice insurance and they carry very little. "Mid level" seems to be the endgame for more students then ever before



I don't think there is a lack of desire to be an MD. Everyone in healthcare wants to be a physician whether they admit it or not. The lack of ambition/desire/perserverence to attend medical school is what they are not willing to commit to. But that lack of ambition/desire does not mean they don't want to be an MD. It simply means they want to take a short-cut.

ERs may be run by PAs/NPs and nurses with a doctor on call but does that make it right, or does it just express the further lowering of standards to facilitate costs and profit over providing the highest medical care possible?

When I go to my IM doctor, I expect to see the doctor that I am paying to see. I don't expect to see someone with arguably half the education and dedication of the physician.


Edit: Dammit I was trying to beat Vene to responding. You suck.


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## mycrofft (Feb 10, 2013)

About 5'6", 160 lbs...


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## Bullets (Feb 10, 2013)

I guess the question that is asked is, Why spend more time in school, more money on education, and take on greater liability for similar pay, workload and more hands on patients? I also do see the PAs representing themselves as doctors. They are always honest about their roles when asked. As with the EMT-Paramedic relationships, the Docs know who can be relied on and who cant. We know which EMTs and Medics are good and which arent. Same in the hospital. Every profession has its sand baggers and its superstars

I dont think a higher cert results in a higher level of dedication.


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## NYMedic828 (Feb 10, 2013)

Bullets said:


> I guess the question that is asked is, Why spend more time in school, more money on education, and take on greater liability for similar pay, workload and more hands on patients?



Because being a physician is not all about making money. Some actually believe in making a difference and curing disease instead of just treating it.

Physicians do that. Not NP/PAs/Nurses. (99% of the time anyway)

(Mind you I hope to be an NP someday, but only because I refuse to give up my dream job to be an MD like some around here did)


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## CodeBru1984 (Feb 10, 2013)

Bullets said:


> I guess the question that is asked is, Why spend more time in school, more money on education, and take on greater liability for similar pay, workload and more hands on patients?



Not to side track this thread, but I have had the pleasure of interacting with some mid level providers that are more educated than the MD who's license they practice under.


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## ExpatMedic0 (Feb 10, 2013)

mycrofft said:


> About 5'6", 160 lbs...



Haha ok I laughed at this


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## Veneficus (Feb 10, 2013)

http://www.youtube.com/watch?v=57yjSmX4Wlw

http://www.youtube.com/watch?v=xxQB1R8AF4A

This sums it up perfectly.


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## VFlutter (Feb 10, 2013)

Veneficus said:


> http://www.youtube.com/watch?v=xxQB1R8AF4A
> 
> This sums it up perfectly.



I would not say it sums it up perfectly, there is some inaccurate information, but I understand the main point. 

Not every NP is militant and claiming to be equivalent to MDs even though that is what the nursing lobbies make it seem like


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## Summit (Feb 10, 2013)

CodeBru1984 said:


> Not to side track this thread, but I have had the pleasure of interacting with some mid level providers that are more educated than the MD who's license they practice under.



So are they the exception that proves the rule than physicians are better educated? C'mon! :lol::blink:


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## ExpatMedic0 (Feb 10, 2013)

The American Academy of Nurse Practitioners (AANP) released a position statement in 2009 denouncing the use of several relegating terminology. Terms such as "mid-level provider," "physician extender," "limited license provider," "non-physician provider," and "allied health provider" when referring to nurse practitioners are discouraged by the AANP.[6] The American Academy of Nurse Practitioners prefers that nurse practitioners are referred to as "independently licensed providers," "primary-care providers," "health-care professionals," and "clinicians..... interesting


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## CodeBru1984 (Feb 10, 2013)

Summit said:


> So are they the exception that proves the rule than physicians are better educated? C'mon! :lol::blink:



I'm not saying mid level providers are better educated than MD's at all, however as you have stated there are exceptions to that rule.


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## Clare (Feb 10, 2013)

Here is how it works in New Zealand 

There are about 20 professions regulated under what is called HPCA or Health Practitioner Competency Act; Doctors, Nurses, Dentists, Optometrists, Anaesthetic Technicians, Chiropractors etc. 

These groups have protection of title, can perform acts within their scope of practice, must have an annual practicing certificate and are held responsible to their professional council be it Medical, Nursing, Dental etc.

Each group may have different levels; e.g. there is dental therapist, dental hygenist, dentist etc and each has a specific scope of practice which limits what they can do.  They are defined in broad terms and not specific interventions although going outside the bounds of their limits of knowledge etc is professionally unacceptable and you can get in a lot of trouble for it.  

Prescribing is a different matter: Doctors can prescribe generally and within their specific vocational scope e.g. only an oncologist can prescribe cancer drugs, only a dermatologist can prescribe dermatology drugs, but all can prescribe general medicines like antibiotics.  

NP can prescribe within their specific scope and even then it is tricky e.g. a diabetes NP can only prescribe certain drugs and cannot prescribe ACE inhibitors, it all depends who you are and where you work.

Dentists and Midwives can prescribe but only those drugs immediately related to the specific reason the person is consulting them, e.g. antibiotics can only be prescribed by a Dentist for something to do with teeth/mouth and a Midwife cannot prescribe abx as far as I know.

From next year Paramedic and Intensive Care Paramedic will be registered so they will have recognised legal ability as a healthcare provider but they won't be able to prescribe, in the future perhaps Extended Care Paramedic will be able to when they are introduced formally.


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## Bullets (Feb 10, 2013)

NYMedic828 said:


> Because being a physician is not all about making money. Some actually believe in making a difference and curing disease instead of just treating it.
> 
> Physicians do that. Not NP/PAs/Nurses. (99% of the time anyway)
> 
> (Mind you I hope to be an NP someday, but only because I refuse to give up my dream job to be an MD like some around here did)



I dont understand what your trying to say? That only physicians can cure diseases? I think you sell the medical profession short when you suggest that 99% of healthcare workers only do so for the money. I doubt thats why most of us work in EMS

How about you get called what you are? Why is there this desire invent labels for everything beyond what they are? It seems specific to the medical field. i dont see cops, or lawyers or teachers worrying about this stuff


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## VFlutter (Feb 10, 2013)

The intention of this thread was not to get opinions as to the motivations or usefulness of mid level providers. 

This was more about outlining what should be required to work in the mid level role.


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## medicsb (Feb 10, 2013)

Chase said:


> Here are some criteria that I think are required for a group to be considered mid-level providers:
> 
> Graduate level education
> Prescriptive authority
> ...


A decent general criteria, though I'd add physician supervision (direct or indirect), and then I'd add "limited" to the beginning of 2, 3, 4, and 5.



Veneficus said:


> "mid level" sounds better than "band-aid."
> 
> Basically a provider requiring an advanced degree, like physical therapy, PA, NP, etc, that is not a physician but desperately wants to call themselves one.



I'd more likely apply this to NPs.  I find that more PAs are fine with just being mid-levels and do not want to undermine physicians.

I think NPs and PAs can be helpful.  THe NPs on the surgical service on which I am rotating seem to fill a role that I find to be appropriate.  They do not do any procedures and their job is meant to assist the attendings and residents with data gathering, patient discharges, med recs, and post-op checks.  They report to residents and attendings.  They prescribe under the guidance of the team and there is little they will prescribe without consulting a physician.  They are only on duty during the day.  

There are PAs working in the ED under physician supervision and for sure most of the more silly consults tend to come from the PAs, but they do consult appropriately more often than not.  Occasionally, the EM physician will get on the phone and cancel the consult and apologize.  

The expansion of PAs and NPs has flourished since the 60s because of artificial limitations in the number of physicians trained, which started in the early half of the 1900s.  Right now, there is something like 20 new medical schools slated to open in the US.  Medicine is slowly but surely responding to the increased demand for physicians.  I expect medical training to change in order to produce more primary care physicians (e.g having tracks for med students that is more primary care focused) As more physicians are trained and as more get pushed towards primary care, I expect NPs and PAs may have a more questionable future.


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## Veneficus (Feb 10, 2013)

2 of the NPs I know fill a very useful role without trying to undermine the doc. 

They spend an extended period delving into pt history, medications, medication reactions, and eliciting side effect profiles. 

They then either modify the treatment for better tolerance or present pertinant info to the MD prior to her exam and planning.


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## platon20 (Feb 10, 2013)

medicsb said:


> The expansion of PAs and NPs has flourished since the 60s because of artificial limitations in the number of physicians trained, which started in the early half of the 1900s.  Right now, there is something like 20 new medical schools slated to open in the US.  Medicine is slowly but surely responding to the increased demand for physicians.  I expect medical training to change in order to produce more primary care physicians (e.g having tracks for med students that is more primary care focused) As more physicians are trained and as more get pushed towards primary care, I expect NPs and PAs may have a more questionable future.



Actually its more like 50 new med schools.  Plus the existing med schools are expanding like crazy.  Its pretty easy to get accepted into med school these days -- I expect the quality of doctors to drop off quite a bit.

I agree with you about MDs being pushed by force into primary care.  They will have no choice.  Specialties like plastics, ENT, derm are going to be nearly impossible to get and you'll have to get super high USMLE scores adn near perfect grades.


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## platon20 (Feb 10, 2013)

CodeBru1984 said:


> Not to side track this thread, but I have had the pleasure of interacting with some mid level providers that are more educated than the MD who's license they practice under.



More educated?  No.  More common sense and work better wtih people?  Absolutely.

On the other hand, I have seen EMTs in training run circles around paramedics.  That kind of stuff happens in all fields.

However, on average the physician will be superior to the midlevel, just as the AVERAGE paramedic will be superior to the new EMT trainee


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## platon20 (Feb 10, 2013)

Bullets said:


> What about those that have no desire to be an MD? Around these parts we are seeing more PAs and students who openly state they have no desire to attend the full medical school. My girlfriend is in PA school and she feels it is a better deal then being an MD. The ER is run by PAs at night with a MD on call, and there are usually just 2 MDs during the day with 5-6 PAs. They do 99% of the work, they run the trauma team, and they get paid a very similar amount of money. Since they work under the doctor, he carries all the malpractice insurance and they carry very little. "Mid level" seems to be the endgame for more students then ever before



I disagree that PAs get paid a very similar amount of money.  They get paid about half of what an MD in their field gets.

Example:

emergency physician = 300k
emergency room PA = 120k

primary care physician = 150k
primary care PA = 80k

This is why midlevels wont solve the access problem in medicine.  They will run off to the high paying specialties just like the MDs do.  Why would a PA choose to do primary care and take a 50% paycut when they can work in ER with ZERO extra training and make more money?  Doesnt make any sense.


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## VFlutter (Feb 10, 2013)

At my hospital we have House PA/NP who work with the hospitalists. They put in central lines, PICCs, and respond to all RRTs and codes. Some can intubate if necessary. We can also call them for simple orders if the attending can't be reached. For example if the attending never put in PRN orders we can call and get them from the PA/NP. During the night they provide house coverage, the only MDs in house are the CCPs and ER physicians. 

Each MD group usually has their own PA/NP who will round for them and provide coverage while they are in surgery or the CCL. They are the ones who usually handle discharge paperwork. 

We also have a few CRNA that round as pain management specialists.

Then each ICU has their own ACNPs who are very involved in patient care and will do various procedures like A lines and chest tubes. 

There is a small group of surigcal NP/PA. 

None of the providers are independent, outside of the CRNAs, and fully collaborate with MDs



platon20 said:


> Why would a PA choose to do primary care and take a 50% paycut when they can work in ER with ZERO extra training and make more money?



I could be wrong but I am pretty sure PAs have to go through extra schooling and a residency to work in the ER.


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## medicsb (Feb 10, 2013)

platon20 said:


> Actually its more like 50 new med schools.  Plus the existing med schools are expanding like crazy.  Its pretty easy to get accepted into med school these days -- I expect the quality of doctors to drop off quite a bit.
> 
> I agree with you about MDs being pushed by force into primary care.  They will have no choice.  Specialties like plastics, ENT, derm are going to be nearly impossible to get and you'll have to get super high USMLE scores adn near perfect grades.



No, its actually closer to 20.   Unless there are 30 schools in the very very early stages.  (http://www.lcme.org/newschoolprocess.htm)

Also, it is still pretty hard to get in to medical school.  Not to say that won't change once all schools are up and running.  I doubt quality will be much different, instead of some students going to the Caribbean or over-seas, they'll be able to stay in the US.  

Right now, something like 60% of family med residencies are made up of IMGs; that will likely shrink in the future.


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## platon20 (Feb 10, 2013)

medicsb said:


> No, its actually closer to 20.   Unless there are 30 schools in the very very early stages.  (http://www.lcme.org/newschoolprocess.htm)
> 
> Also, it is still pretty hard to get in to medical school.  Not to say that won't change once all schools are up and running.  I doubt quality will be much different, instead of some students going to the Caribbean or over-seas, they'll be able to stay in the US.
> 
> Right now, something like 60% of family med residencies are made up of IMGs; that will likely shrink in the future.



You are ignoring all the DO programs.  LCME only licenses MD schools.  DO is a completely separate ballgame.

http://forums.studentdoctor.net/showthread.php?t=825147


1. MD - University of Hawaii-Kakaako - 2006

2. DO - Touro/Las Vegas - 2005

3. DO - PCOM/Atlanta - 2005

4. MD - University of Miami/FAU joint program - 2004

5. MD - Cleveland Clinic/Lerner - 2004

6. DO - LECOM/Bradenton - 2004

7. MD - Florida State University - 2002

8. DO - VCOM - 2002

9. DO - Rocky Vista University COM - 2008 

10. MD - Florida International Univ - 2008

11. MD - Univ Central Florida - 2008

12. DO - Wisconsin College of Osteopathic Medicine, Wasau WI (http://wisccom.org/, http://www.wausaudailyherald.com/art...-school-Wausau)

13. DO - Touro (Harlem NY) - 2008

14. DO - Pacific Northwest (Yakima WA) - 2007

15. MD - Michigan State University (Grand Rapids MI) - 2008

16. MD - University of Arizona (Phoenix AZ) - 2007

17. DO - AT Still University (Mesa AZ) - 2007

18. DO - Lincoln Memorial/Debusk (Harrogate TN) - 2007

19. DO - William Carey Univ (Hattiesburg, MS, http://www.wmcarey.edu/asp/viewpr.asp?item=430) - 2009

20. MD - Commonwealth/Scranton (Scranton, PA, http://physiciansnews.com/spotlight/1006.html)

21. MD - MCG-UGA/Athens (http://www.uga.edu/news/artman/publi...Building.shtml)

22. MD - University of Cal Merced (Merced CA)

23. MD - University of Cal Riverside (Riverside CA)

24. MD - Texas Tech - El Paso (El Paso TX)

26. DO - MSUCOM (Detroit MI)

27. DO - Barry University (Miami FL)

28. DO - Center for Allied Health Nursing (FL), http://www.osteopathic.org/inside-ao...d-campuses.pdf

29. MD - Virginia Tech/Carilion (private, Roanoke VA) 
http://www.carilion.com/ContentStore... Release.pdf

30. MD - Central Michigan University (http://www.mlive.com/news/sanews/ind...660.xml&coll=9)

31. MD - Oakland University (Michigan) http://www4.oakland.edu/view_news.aspx?sid=34&id=3803

32. MD/DO - St Thomas (St Paul MN) http://www.stthomas.edu/bulletin/new...ool5_11_07.cfm

33. MD - Temple/West Penn Allegheny, Pittsburgh PA (http://www.wpahs.org/medical-school)

34. MD - Hofstra Univ (http://www.hofstra.edu/home/News/Pre...medschool.html)

35. MD - Mercer/Savannah (http://www2.mercer.edu/News/Articles...hMedSchool.htm)

36. DO - WesternU COM/Lebanon OR (http://www.gazettetimes.com/articles...1_hospital.txt)

37. MD - Univ Washington/Spokane (http://depts.washington.edu/mediarel/spokane1.html)

38. DO - LECOM, Greenburg PA, Seton Hill Univ (http://www.osteopathic.org/index.cfm?PageID=acc_predoc)

39. DO - MSUCOM, Clinton Township MI, Macomb College (http://www.osteopathic.org/index.cfm?PageID=acc_predoc)

40. DO - Indiana Wesleyan University (http://www.osteopathic.org/inside-ao...d-campuses.pdf)

41. DO - Campbell University (NC) (http://www.osteopathic.org/inside-ao...d-campuses.pdf)

42. DO - Homer G Phillips (St Louis) (http://www.osteopathic.org/inside-ao...d-campuses.pdf)

43. DO - Marian University (Indiana) (http://www.osteopathic.org/inside-ao...d-campuses.pdf)

44. DO - Missouri Southern State Univ (Joplin MO) (http://www.osteopathic.org/inside-ao...d-campuses.pdf)

45. DO - Southwestern Penn (Beaver PA) (http://www.osteopathic.org/inside-ao...d-campuses.pdf)

46. DO - Univ Southern Nevada (http://www.osteopathic.org/inside-ao...d-campuses.pdf)

47. DO - Univ St Augustine (St Augustine FL) (http://www.osteopathic.org/inside-ao...d-campuses.pdf)

48. MD - Scripps Research Institute (La Jolla CA) (http://legacy.signonsandiego.com/new...n25school.html)

49. MD - California NorthState Univ COM (Elk Grove CA) (http://www.egcitizen.com/articles/20...4445565512.txt)

50. MD - Quinnipiac University (North Haven CT) (http://www.quinnipiac.edu/x4877.xml)

51. MD - Florida Atlantic Univ (Boca Raton FL) (http://articles.sun-sentinel.com/201...final-approval)

52. MD - Palm Beach Medical College (http://en.wikipedia.org/wiki/List_of...s#cite_note-48)

53. MD - Western Michigan Univ (Kalamazoo MI) (http://www.wmich.edu/wmu/news/2011/03/066.shtml)

54. MD - Cooper/Rowan (Camden NJ) (http://www.cooperhealth.org/content/...university.htm)

55. MD - Bataan/Univ New Mexico (Las Cruces NM) (http://en.wikipedia.org/wiki /List_of_medical _schools_in_the_United_States #cite_note-53)

56. MD - Univ of Oklahoma/Tulsa Univ (Tulsa OK) (http://www.tulsaworld.com/news/artic...1_Univer322000)

57. DO - VCOM Carolinas Campus (Spartanburg SC) (http://www.vcom.vt.edu/news/groundbreaking.html)

58. MD - Univ of Houston (Houston TX) (http://en.wikipedia.org/wiki/List_of...s#cite_note-58)

59. DO - Marian University (http://www.marian.edu/medicalschool/Pages/FAQ.aspx)

60. DO - Southeast Alabama Medical Center (http://www2.dothaneagle.com/news/201...ool-ar-348324/)

61. MD - King School of Medicine, Abingdon VA (http://www.lcme.org/newschoolprocess.htm)

62. MD - Mayo/Arizona State, Scottsdale AZ (http://www.azcentral.com/business/ar...cottsdale.html)

63. DO - Monmouth College, NJ (http://www.osteopathic.org/inside-ao...d-campuses.pdf)

64. DO - Southern California COM, Los Angeles (http://www.osteopathic.org/inside-ao...d-campuses.pdf)

65. DO - Southern Univ of Utah COM, Cedar City UT (http://www.osteopathic.org/inside-ao...d-campuses.pdf)

66. DO - Liberty University, Roanoke VA (http://www.roanoke.com/business/wb/298456)


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## medicsb (Feb 10, 2013)

platon20 said:


> You are ignoring all the DO programs.  LCME only licenses MD schools.  DO is a completely separate ballgame.
> 
> http://forums.studentdoctor.net/showthread.php?t=825147



Well, I stand corrected.  I had read elsewhere that even including DO schools in the works, the number was 22ish.


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## Bullets (Feb 10, 2013)

Mid level providers should be able to manage things like PromptCare so basic treatments like suturing, splinting and casting, prescribing things like analgesics for bone breaks, arthritics, and antibiotics for influenzas and other colds, basic diabetic emergencies, simple allergic reactions

The main ER, supervised by multiple MDs, should treat cardiac, neuro, multi system traumas, major allergic reactions, major pulmonary illnesses

I do not think a hospital visit requires a patient to be seen by a doctor simply because you walked into the door. 

Mid level providers should be at least a Masters Degree education and have the ability to make independent treatments and prescriptions.


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## JPINFV (Feb 10, 2013)

platon20 said:


> Its pretty easy to get accepted into med school these days -- I expect the quality of doctors to drop off quite a bit.




Under which metric? Percent accepted continues to either be stable or decrease while MCAT and GPA continues to trend upwards. When a field has a 50%+ *rejection* rate, it's hard to call it "easy" to get accepted (not counting FMG schools like Ross or St. George).


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## JPINFV (Feb 10, 2013)

medicsb said:


> platon20 said:
> 
> 
> > You are ignoring all the DO programs.  LCME only licenses MD schools.  DO is a completely separate ballgame.
> ...



To be fair, the list is partially out of date (the independent University of California Riverside plan has been scrapped) and a lot of those are just announcements. It takes more than an announcement in a newspaper to open up a new medical school.


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## WTEngel (Feb 10, 2013)

Chase said:


> Here are some criteria that I think are required for a group to be considered mid-level providers:
> 
> 
> Graduate level education
> ...



I would agree with this list, and add to it:

Working under the supervision of a licensed physician (direct or indirect depending on the circumstances)

Ability to prescribe medications and obtain a DEA #

Also, in response to the previous poster who was stating how easy it was to get into medical school...please, in your spare time, go through the app process for kicks, and report back to us just how easy it is to get into medical school.

As someone who is currently in the process of trying to get into medical school, I find it pretty insulting that, with your apparent lack of knowledge on the matter, you decide to come around and profess to everyone how simple it is. As soon as you are accepted, you have every right to tell us how easy it is. Until then, your opinion carries the weight of Weekly World News and their latest Batboy story.


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## Carlos Danger (Feb 10, 2013)

Chase said:


> The term mid-level provider or practitioner has been frequently used, somewhat loosely, on the forum over the past few days and I think it would be good to have a discussion as to what makes a mid level provider.
> 
> Currently the DEA only recognizes two groups as mid level providers, NP and PA.
> 
> ...


I think your list there makes for a pretty good definition. CRNA's and (I think) CNM's have prescriptive authority in some states, as well.



Veneficus said:


> "mid level" sounds better than "band-aid."
> Basically a provider requiring an advanced degree, like physical therapy, PA, NP, etc, that is not a physician but desperately wants to call themselves one.



"Desperately want to call themselves one"? Keep stroking your own ego, dude. 

I've known or worked with many PT's, OT's, SLP's, RD's, PharmD's, NP's, CRNA's, and engineers with doctoral degrees and I don't think I've ever once heard one refer to themselves as "doctor". It's always "Hi, I'm Julie - I'm a physical therapist" or "Hi, I'm John from anesthesia".

You might not like it, but mid-levels are being utilized more and more, precisely because they are more cost-effective than physicians. 



abckidsmom said:


> Yeah, the ability to function as a physician without all that pesky medical school and buck-stops-here liability is nice.



You really don't know what you are talking about, on either count.

Medicine is a crappy field to be in these days. There was a large survey of physicians (5,000 I think) done last year where 90% of respondents said they would not recommend medicine as a profession.  For all sorts of good reasons.

I've had several docs tell me things like "if I had it to do over again, I'd be a career firefighter", or "I should have been a PA/CRNA/NP".

And as for liability, there are many states where NP's and CRNA's practice with 100% autonomy, and are solely liable for their actions. Even in states where MD supervision is required, courts typically hold responsible the person that made the mistake, not the supervising physician, who may be 20 miles away at the time of the incident. Claims and MP premiums tend to be only slightly higher for doctors in primary care than they are for NP's and it's because the doctors make more money and are thus more often the target of lawsuits, not because they are "more liable" for their actions.

That doctors are "ultimately liable" for the actions of clinicians working "under them" is an absolute myth. 

Even an EMS medical director faces little risk for being found responsible for faulty actions by paramedics, unless the paramedic's action can be shown to be a result of the MD's direct orders or failure to ensure proper training.



NYMedic828 said:


> I don't think there is a lack of desire to be an MD. Everyone in healthcare wants to be a physician whether they admit it or not. The lack of ambition/desire/perserverence to attend medical school is what they are not willing to commit to. But that lack of ambition/desire does not mean they don't want to be an MD. It simply means they want to take a short-cut.



So you are personally aware of the motivations of millions of people you've never met? Fascinating. 

Over the years I've known or talked to many ANP's and PA's who considered medical school and certainly had the intelligence, the grades, and the drive to succeed there.

Some of them chose another route because it was "easier", but many simply felt it made more sense to become and NP or PA. See above.


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## platon20 (Feb 10, 2013)

old school said:


> IEven in states where MD supervision is required, courts typically hold responsible the person that made the mistake,* not the supervising physician*




You just lost all credibility with this statement.


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## platon20 (Feb 10, 2013)

old school said:


> I've had several docs tell me things like "if I had it to do over again, I'd be a career firefighter",




LOL, just LOL

You seriously believe this BS?  Yeah I'm gonna give up my job as a PCP (average salary is 190k by the way) to work as a fireman and make 50k at best  

LMAO


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## NomadicMedic (Feb 10, 2013)

Folks. Lets keep this on topic and avoid any personal attacks or conjecture. 

I'm watching this.


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## platon20 (Feb 10, 2013)

what oldschool and some others dont realize about midlevels is that doctors make a TON of $$$ off of them.

Even in areas with independent scope of practice for midlevels, almost zero choose to actually do it.

New Mexico gave full independence to NPs in 1994.  The claim at the time was that NPs would flood rural new mexico with their own clinics and treat the underserved.

15 years later, guess how many independent NP-run clinics are in New Mexico?  ONE.  They all went to work for doctors offices instead of starting thier own clinics.  The doctors are making a ton of $$$ billing for their services.

NPs are NOT entrepreneurs -- they are "my job is 9 to 5" nurse nonsense which is why it is EXTREMELY RARE for them to attempt to open their own clinic, even in a state that allows them to do so.


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## Summit (Feb 10, 2013)

Chase said:


> At my hospital we have House PA/NP who work with the hospitalists. They put in central lines, PICCs, and respond to all RRTs and codes. Some can intubate if necessary. We can also call them for simple orders if the attending can't be reached. For example if the attending never put in PRN orders we can call and get them from the PA/NP. During the night they provide house coverage, the only MDs in house are the CCPs and ER physicians.
> 
> Each MD group usually has their own PA/NP who will round for them and provide coverage while they are in surgery or the CCL. They are the ones who usually handle discharge paperwork.
> 
> ...



I'd find that very fulfilling.


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## rescue1 (Feb 10, 2013)

Unless you've found a doctor who just lost a huge malpractice battle, I find it very unlikely there exist physicians who dream of the healthy and high paying job of firefighter.


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## JPINFV (Feb 10, 2013)

old school said:


> "Desperately want to call themselves one"? Keep stroking your own ego, dude.
> 
> I've known or worked with many PT's, OT's, SLP's, RD's, PharmD's, NP's, CRNA's, and engineers with doctoral degrees and I don't think I've ever once heard one refer to themselves as "doctor". It's always "Hi, I'm Julie - I'm a physical therapist" or "Hi, I'm John from anesthesia".



I can find some awesome, "But I'm a doctor too!" threads over at Allnurses.com that I can link for you. 



> Even in states where MD supervision is required, courts typically hold responsible the person that made the mistake, not the supervising physician, who may be 20 miles away at the time of the incident.
> ...
> That doctors are "ultimately liable" for the actions of clinicians working "under them" is an absolute myth.



I believe the term you're looking for is "vicarious liability."


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## Summit (Feb 10, 2013)

rescue1 said:


> Unless you've found a doctor who just lost a huge malpractice battle, I find it very unlikely there exist physicians who dream of the healthy and high paying job of firefighter.



I've had more than a few docs tell me that they would have gone a different path or poo-poo any of my occasional regrets of not going their path (including one immediate family member). IMHO I think a lot of it comes from docs who got into the field in one type of medical and business environment, buying into that, and then finding the world had changed all around them so that it isn't what they expected/wanted/whatever making them feel less fulfilled or like they got the short end of the stick. I think there are plenty who are very happy and plenty who are entering now with no preconceptions that their world may change. [/babbling]


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## VFlutter (Feb 10, 2013)

platon20 said:


> NPs are NOT entrepreneurs -- they are "my job is 9 to 5" nurse nonsense .



That is a pretty bold generalization to make. Maybe it is like that in your particular area but that is not representative of NPs in general. The majority of NPs I have met work long crappy hours, holidays, and are frequently on call.


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## rescue1 (Feb 10, 2013)

Oh I've met doctors like that too. But usually those doctors wish they'd become lawyers or investment bankers. Not firemen. 
Heck, in any career on the planet you're going to find people who wish they had done something else.


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## EgyptianMedic (Feb 11, 2013)

I have no desire to call myself a physician. Ill be completed with my PA program shortly. What confuses me is all the statements on here saying PAs are limited. It seems to me that most of those on here that have posted really have no idea about the fundamentals regarding the PA profession and its origins. 

The profession, as are much of the programs mission statements, are designed to help serve rural or under served populations. The field was created to extend access to healthcare services that otherwise would not be accessible. Go to the physicianassistantforum.com and scroll through there a little bit and educate yourself rather than assuming. Many PAs work autonomously without a physician on site. That being said most programs are primary care based (not to be confused with family practice).

A PA can own their own clinic, holds a DEA C-II-V license, in some states (like CA) has to only have 10% of their chart reviewed and often times trains physicians during clinical rotations and residency. There is no exemption from liability, they can be sued independently without the doctor carrying any liability. Often times they DO carry THIER OWN mal practice insurance. 

Most people I know who are PAs like myself found this career as a second calling. The love of being a business executive faded and i wanted more job reward. I am, in my own opinion, too old to go through med school and loved the level of autonomy and depth of knowledge / scope of practice I'd get as a PA so I chose this field over being a RN after being in business for over 10 years.

What most of you should recognize is that PAs are highly skilled and trained healthcare professionals that complete the same curriculum as a physician in an accelerated format and instead of doing a residency they receive on the job training. Although residency and CAQs are becoming more common place in certain specialties such as EM. 

So please... Stop throwing BS out there and ASSuming. Go do your homework before you start making false statements.


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## platon20 (Feb 11, 2013)

EgyptianMedic said:


> I have no desire to call myself a physician. Ill be completed with my PA program shortly. What confuses me is all the statements on here saying PAs are limited. It seems to me that most of those on here that have posted really have no idea about the fundamentals regarding the PA profession and its origins.
> 
> The profession, as are much of the programs mission statements, are designed to help serve rural or under served populations. The field was created to extend access to healthcare services that otherwise would not be accessible. Go to the physicianassistantforum.com and scroll through there a little bit and educate yourself rather than assuming. Many PAs work autonomously without a physician on site. That being said most programs are primary care based (not to be confused with family practice).
> 
> ...




1.  You do NOT complete the "same curriculum" as MDs do.  Yes you get a sample of it but you dont go thru nearly the same number of clinical rotations they do, nor do you get the same exposure to subjects such as histology, embryology, etc.  

2.  Residency is NOT the same as "on the job" training.  How many thoracotomies does an surgeon-MD in residency get vs an on the job PA?  Residency training exposes you to areas of practice that you dont get "on the job" as a PA.

3.  Although PAs do carry their own malpractice and it is POSSIBLE for them to be sued independent of the MD, in practice this never happens.  All lawsuits involving PAs also involve their supervising physician.

4.  Training physicians during residency?  Thats a real laugh.  I'll let you in on a little secret.  Phlebotomists train physicians during residency to do blood draws too.  Does that mean that they are equivalents?  Of course not.  Hell regular floor RNs "train" residents too.  Does that mean that all floor RNs have the same capabilities as MDs?

5.  This whole BS about PAs/NPs treating underserved populations is a farce.  Look at the statistics -- PAs love the big cities just as much as the MDs do.  Thats why New Mexico's little experiment to give NPs complete autonomy failed.  It turns out the NPs wanted to live in Santa Fe and Albuquerque and work for physicians.  They did NOT want to open up their own solo clinic in Portales, Roswell, or New Laguna.

6.  You will never be a doctor, period.  Hell you dont even get to call yourself "doctor" like the NPs do.  Does it make you sad that patients will think an NP is a doctor but you cant claim it?


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## WTEngel (Feb 11, 2013)

EgyptianMedic said:


> that complete the same curriculum as a physician



While the course titles may be similar, I think you saying PA school is just a condensed form of medical school is an extreme over simplification.

If this was in fact true, then you would expect PAs to be able to score comparatively on the USMLE step exams, which I have seen no proof of.


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## Rialaigh (Feb 11, 2013)

I think, like anything else, there are wonderful really great PA's and NP and there are those who barely scratched through a second rate program. I know a girl who finished her PA at 22, Didn't do a single clinical hour in a hospital setting, and works laser hair removal 36 hours a week no weekends no holidays and makes 85k+ a year. Scary thing is she can write for controlled substances and do lots of other stuff that she was "trained" to do....

Then there are nurse practitioners who were critical care nurses or ER nurses (and damn good ones at that) for 15 years before getting their NP and I think some of them are every bit as good as most ER docs or IM docs. 


They have their place in healthcare, and I do see them replacing docs in many many many fields over the next 10 years.


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## EgyptianMedic (Feb 11, 2013)

platon20 said:


> 1.  You do NOT complete the "same curriculum" as MDs do.  Yes you get a sample of it but you dont go thru nearly the same number of clinical rotations they do, nor do you get the same exposure to subjects such as histology, embryology, etc.



Enough that the government allows for us to diagnose, treat, and continue with care of patients while being able to prescribe drugs including narcotics. And when PAs are working in the field they're not exposed to the same patients? Not sure what bubble you're living in.



platon20 said:


> 2.  Residency is NOT the same as "on the job" training.  How many thoracotomies does an surgeon-MD in residency get vs an on the job PA?  Residency training exposes you to areas of practice that you dont get "on the job" as a PA.



And you're speaking from first hand experience? And of course you do realize you're choosing the one specialty that PAs can only first assist in... How about all the others?



platon20 said:


> 3.  Although PAs do carry their own malpractice and it is POSSIBLE for them to be sued independent of the MD, in practice this never happens.  All lawsuits involving PAs also involve their supervising physician.



Here's an article for you to read.
hgexperts.com/article.asp?id=5878



platon20 said:


> 4.  Training physicians during residency?  Thats a real laugh.  I'll let you in on a little secret.  Phlebotomists train physicians during residency to do blood draws too.  Does that mean that they are equivalents?  Of course not.  Hell regular floor RNs "train" residents too.  Does that mean that all floor RNs have the same capabilities as MDs?



Here's an interesting read if you got the time. content.healthaffairs.org/content/14/2/181.full.pdf



platon20 said:


> 5.  This whole BS about PAs/NPs treating underserved populations is a farce.  Look at the statistics -- PAs love the big cities just as much as the MDs do.  Thats why New Mexico's little experiment to give NPs complete autonomy failed.  It turns out the NPs wanted to live in Santa Fe and Albuquerque and work for physicians.  They did NOT want to open up their own solo clinic in Portales, Roswell, or New Laguna.



I plan on working in a rural area so I guess I'm the exception right?



platon20 said:


> 6.  You will never be a doctor, period.  Hell you dont even get to call yourself "doctor" like the NPs do.  Does it make you sad that patients will think an NP is a doctor but you cant claim it?



You would need to lack self confidence to require to be addressed as Dr in order to help those in need. I could care less... Ill introduce myself by my first name and correct those who call me Doctor. I don't care for a title.. I never went around with the degree creep or title creep in my previous endeavors.


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## EgyptianMedic (Feb 11, 2013)

Rialaigh said:


> I think, like anything else, there are wonderful really great PA's and NP and there are those who barely scratched through a second rate program. I know a girl who finished her PA at 22, Didn't do a single clinical hour in a hospital setting, and works laser hair removal 36 hours a week no weekends no holidays and makes 85k+ a year. Scary thing is she can write for controlled substances and do lots of other stuff that she was "trained" to do....
> 
> Then there are nurse practitioners who were critical care nurses or ER nurses (and damn good ones at that) for 15 years before getting their NP and I think some of them are every bit as good as most ER docs or IM docs.
> 
> ...



Most PA programs require paid healthcare experience with direct patient contact. Unfortunately some schools focus more on high grades and don't require HCE like western university and USC. This trend is something that erks PAs today.


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## JPINFV (Feb 11, 2013)

EgyptianMedic said:


> What most of you should recognize is that PAs are highly skilled and trained healthcare professionals that complete the same curriculum as a physician in an accelerated format and instead of doing a residency they receive on the job training. Although residency and CAQs are becoming more common place in certain specialties such as EM.




While I'll often find myself on rotation with other PA students, the difference between the depth and breadth of the fund of knowledge between the 2nd year PA students and 3rd year medical students is rather staggering. It's not the same curriculum, just in an accelerated format. If it was, then all of medical school would be 2 years with no need for a residency. There's a reason residency (and don't compare PA residencies to medical residencies, they're not the same) and 4 years of medical school are required to practice independently, it's because medicine isn't easy and there aren't any shortcuts.


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## JPINFV (Feb 11, 2013)

EgyptianMedic said:


> Enough that the government allows for us to diagnose, treat, and continue with care of patients while being able to prescribe drugs including narcotics. And when PAs are working in the field they're not exposed to the same patients? Not sure what bubble you're living in.



Go over to the specialty forums at forums.studentdoctor.net and post in one of the specialties that you treat the same patients as the physicians. I'm sure the attendings will get a rather good laugh at that. The more complex patients are going to be treated by the physicians, not the mid-levels. Furthermore, for the surgical PAs, how often are they the primary surgeon? First assist? Sure (heck, interns and medicals students can first assist). Primary surgeon doing operations from open to close? Nope. 





> And you're speaking from first hand experience? And of course you do realize you're choosing the one specialty that PAs can only first assist in... How about all the others?



Ok... Emergency medicine then. EM residencies are 3-4 years. Here's an 18 month residency for PAs. Are you telling me that PAs can master all of emergency medicine in half the time as physicians? 

http://www.uihealthcare.org/GME/ResProgHome.aspx?pageid=231957&taxid=226453

Some how I doubt the emergency PAs are treating the severe sepsis or the undifferentiated respiratory failure or altered mental status patients unless they're in a single coverage spot in the middle of no where that can't attract emergency physicians.


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## JPINFV (Feb 11, 2013)

EgyptianMedic said:


> Most PA programs require paid healthcare experience with direct patient contact. Unfortunately some schools focus more on high grades and don't require HCE like western university and USC. This trend is something that erks PAs today.




Go Western U! 


HCE isn't going to make up for the lack of preclinical education that physicians go through.


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## EgyptianMedic (Feb 11, 2013)

JPINFV said:


> While I'll often find myself on rotation with other PA students, the difference between the depth and breadth of the fund of knowledge between the 2nd year PA students and 3rd year medical students is rather staggering. It's not the same curriculum, just in an accelerated format. If it was, then all of medical school would be 2 years with no need for a residency. There's a reason residency (and don't compare PA residencies to medical residencies, they're not the same) and 4 years of medical school are required to practice independently, it's because medicine isn't easy and there aren't any shortcuts.



Correct me if I'm wrong, but a physician technically only has to complete a 1 year residency to practice (specifically primary care). Additionally don't PAs who do residencies do so along side of their MD/DO counterparts?

Times are changing. You can complete medical school in 3 years.

usatoday30.usatoday.com/news/education/2010-03-25-medical-school-early_N.htm

physiciansnews.com/2009/11/05/lecom-develops-a-3-year-medical-school-curriculum-to-encourage-primary-care-careers/


Don't get me wrong MDs/DOs get paid the big bucks for a reason but given time and experience I would expect the margin for being able to handle the same patient cases and complexity to level out or at least narrow to a point that it would be negligible.


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## JPINFV (Feb 11, 2013)

EgyptianMedic said:


> Correct me if I'm wrong, but a physician technically only has to complete a 1 year residency to practice. Additionally don't PAs who do resudencies do so along side of their MD/DO counterparts?


Good luck getting insurance companies to reimburse you, med mal coverage, or hospital practice rights without completing a residency. It's like saying you can drive with a drivers license, but that doesn't mean you automatically get a car to drive around in either. 

Again, 1.5 year residency does not equal a 3-4 year residency. 



> Times are changing. You can complete medical school in 3 years.
> 
> usatoday30.usatoday.com/news/education/2010-03-25-medical-school-early_N.htm
> 
> physiciansnews.com/2009/11/05/lecom-develops-a-3-year-medical-school-curriculum-to-encourage-primary-care-careers/


Ah, LECOM. Read the fine print there. Primary care only, linked match, very little electives, and essentially no vacation. It's not a model that's going to gain traction outside of very specific areas with very specific residency linkages. There's a reason there's no special line of people jumping at the chance of a 3 year track.


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## EgyptianMedic (Feb 11, 2013)

JPINFV said:


> Go Western U!



LOL! :lol:


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## Brandon O (Feb 11, 2013)

EgyptianMedic said:


> You would need to lack self confidence to require to be addressed as Dr in order to help those in need. I could care less... Ill introduce myself by my first name and correct those who call me Doctor. I don't care for a title.. I never went around with the degree creep or title creep in my previous endeavors.



I think this is a bigger part of the issue than most people will admit. Many people who become an MD, DO, or PA are as interested in the resulting letters as in the resulting care or education.


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## Veneficus (Feb 12, 2013)

EgyptianMedic said:


> Don't get me wrong MDs/DOs get paid the big bucks for a reason but given time and experience I would expect the margin for being able to handle the same patient cases and complexity to level out or at least narrow to a point that it would be negligible.



This is what a lot of PAs I have encountered think. But it is seriously flawed. 

A PA will never be able to handle the complex cases of a physician specialist. 

I'll explain it like this:

A PA basically is like a musician that learns to play an instrument without knowing how to read music or music theory. They can play some tunes, they may even be very good at playing those tunes, but it doesn't mean they will be able to understand, and therefore play the most complex music. They will never be the conductor, and they will never be recognized as capable as a doctor by the international community of medicine. 

Which means all they really are is a master of a more advanced protocol set with an absentee medical director. 

Whether you like titles or not. Whether you agree with titles or not, they demonstrate that you have met the minimum standards required to do certain things. 

You find a shortcut in PA school, good for you. Make your money. But don't expect equaity from those who did do it from the ground up, put forth the sacrifces of medical school, and earned that title.

Nobody who is part of medicine will ever see you as capable as a doctor. The only people who do are other PAs and patients who wouldn't know a good doctor from a bad one anyway. 

Legal quackery is all it is. Only the people in the military and North Americaare dumb enough to not see it for what it is. It is like taking pride in being a snake oil salesman. 




Brandon Oto said:


> I think this is a bigger part of the issue than most people will admit. Many people who become an MD, DO, or PA are as interested in the resulting letters as in the resulting care or education.



There are many. Many more who do it for the money. But if you really have dedication to medicine, you become a doctor. Though the way recognized for centuries. With all the associated costs. A shortcut isn't going to make you an expert. That shortcut will never make you a player on the world stage. Which means you will be relegated to being a lesser player in the worst medical system in the entire developed world. Operating under direction or in a place where you are simply better than nothing that wishes they had a doctor.

You can disagree, you can tell me I'm wrong, you can present your biased and flawed research and tell me how PAs tricked somebody into paying the same as a doctor, but in the end, maybe in 5 years, maybe in 10, you will hit the cieling. It will not be glass. 

Fair warning.


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## EgyptianMedic (Feb 12, 2013)

Thank you for sharing your opinion. Your presentation of the field backed by facts and sources for us to review has completely changed my view of the profession. I tip my hat to you sir. Best of luck to your future. Ill leave you with this: http://m.californiahealthline.org/a...hanging-non-physicians-scope-of-practice.aspx


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## JPINFV (Feb 12, 2013)

EgyptianMedic said:


> Thank you for sharing your opinion. Your presentation of the field backed by facts and sources for us to review has completely changed my view of the profession. I tip my hat to you sir. Best of luck to your future. Ill leave you with this: http://m.californiahealthline.org/a...hanging-non-physicians-scope-of-practice.aspx




Just because the State of Fruits and Nuts thinks about doing something doesn't mean it will automatically happen.


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## jrm818 (Feb 12, 2013)

State runs out of money to pay employees?  simple! issue placeholder to keep people quiet: IOU

State runs out of doctors to provide medical care?  simple........


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## Veneficus (Feb 12, 2013)

I think US doctors, based soley on greed, are to blame for the shortages of US doctors.

It is the fault of such groups as the AMA that midlevels were ever permitted to exist, and in the near future there will be a fight over jobs.

As I said somewhere, I think it was PM, when the system eventually rights itself, midlevels will be on the block. They simply bloat an already overtaxed system, they do not provide the underserved care they clamed to be for in any great number. 

I also stand by my statement that it is only through greed and political maneuvering that mid-levels have what they do. It is certainly not for their incredible medical knowledge and outstanding patient care.

In order to recieve a license and practice medicine, the WHO developed a world accepted minimum education. Those who meet this *minimum* standard, enjoy the social and professional benefits of being a doctor. Along with the responsibilities. 

Mid levels *do not meet* this *minimum* but instead claim to be *cheaper* and *easier* to produce.

Then following the same "evidence based" epidemiological guidlines as all techs,* they demonstrate that they can follow them *just as well as doctors from a hands on perspective.

But me wrenching on a car doesn't make me a mechanic. Even though I did take a cheaper and shorter vocational class in highschool for it, rather than pay a community or votech and spend longer in school and supervised practice. I might even wrench as good as somebody that did and I certainly am cheaper than taking your car to a *real* mechanic.

Keep telling yourself how good you are and how equal to the world wide minimum you are despite not meeting that requirement. Tell your parents you are as good as a doctor even though doctors in 3rd world countries have more education and training than you do. 

Don't forget to tell those politicians in California, which incidentally amplifies an already shortage of doctors with its crazy licensing and recognition requirements, that with 1/2 the training, you can do the same thing a doctor can and you want paid the same. Because you are just as good and worth it.

Tell your patients too. About the same time you tell them you are treating them like a number despite the desire and scientific advances towards individual care. 

But f course they told you in PA school that you didn't need all that molecular biology, biochemistry, work because you are going to perform the guidline treatment and if it doesn't work refer them to somebody who really can help them.

Also make sure to tell them that you are billing for your "treatment" and if they had gone to see a doctor to begin with, she could have helped whether they fell into the guidline or not.

That is why you keep citing simple studies. Anyone who understands medical research is not fooled. Direct cause and effect in human body can onl be discovered by selective experimentation. 

The body is an electrical current in a water medium, a very large interconnected soup each with different ingedients. You must be far smarter and more capable than I am to figure out all the things I have about medicine in your 2 year PA program. Perhaps it is my retardation that has kept me in school so long? I did put forth considerable effort to be just as good as a PA.

But then again, I did meet the world recognized minimum standards for my position. PAs, NPs, CRNAs?

Nope.


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## ExpatMedic0 (Feb 12, 2013)

haha you guys crack me up, can we bring back the nurses and paramedic argument into this? Lets just create a variable cornucopia of penile measuring and ego stroking across a larger spectrum ;-)


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## Veneficus (Feb 12, 2013)

schulz said:


> haha you guys crack me up, can we bring back the nurses and paramedic argument into this? Lets just create a variable cornucopia of penile measuring and ego stroking across a larger spectrum ;-)



Yea, it is strangely reminiscent of PAs telling paramedics how undereducated and incapable they are isn't it?

In a "just because you see a skill performed doesn't mean you have the knowledge it takes to safely, efficently, do it" sort of way.

They like to dish it out but don't take it very well.


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## Agent Cooper (Feb 12, 2013)

I have to say I'm surprised by some of the responses on this thread. I had no idea there was so much animosity towards PAs. :unsure:
As someone considering PA school, it never occurred to me to want to be called a doctor or mistaken for a doctor. In my mind, PAs have a scope of practice like everyone else in the healthcare profession. They are not doctors, and cannot do everything a doctor can do.  

That said, I think they have their place. For example, I had to see a specialist. The wait time to see him was several months. But, they did have a PA appointment available in a few days. I knew it wasn't the same as seeing a doctor, but I was able to see her, get some basic tests ordered, and know that if there was something blatantly and seriously wrong with me she would tell the doctor and I could see him sooner. I appreciated that system because I got access to basic care much faster. I thought that was the point of PAs? :blink:

I guess I'm naive.


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## JPINFV (Feb 12, 2013)

AOx4 said:


> I have to say I'm surprised by some of the responses on this thread. I had no idea there was so much animosity towards PAs. :unsure:
> 
> ...
> 
> ...



The problem is not when mid-levels assist physicians. The problem is when mid-levels advocate that they are equal to physicians and deserve unrestricted practice rights, including independent practice.


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## Veneficus (Feb 12, 2013)

JPINFV said:


> The problem is not when mid-levels assist physicians. The problem is when mid-levels advocate that they are equal to physicians and deserve unrestricted practice rights, including independent practice.



and bill the same.


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## RocketMedic (Feb 12, 2013)

Schulz, I think that a PA is, on its face, an answer to a half-asked question. 

Doctors have worked themselves into a shortage here in the US due to the sheer expense of becoming one and the selectiveness of their educational process. Realistically, to become a doctor now, as a married, white, 24-year old male just starting college, I need to defer raising a family and be prepared to give up 4-6 years for medical school after I earn an undergraduate degree. Most importantly, I either go far in debt or rejoin the active military. Heck, look at Veneficus- he had to move overseas and attend medical school in Europe at least in part due to the expense of American medical schools.

A PA is what a paramedic should be- it is literally the same job. We are extensions of a physician, and a PA is essentially a technician, following the same guidelines that we follow as paramedics. Valuable, yes, but a self-imposed and ultimately false distinction between the levels of care. Simply put, there are Doctors and there is Everyone Else. 'Mid-level provider' is like being half-pregnant. 

Nurse Practicioners fall into this same category, although I'm perfectly willing to let them be autonomous in terms of nursing care (does a doctor really need to detail how to bathe someone?)

My belief, however, is that doctors and the American medical educational system will have to come to reality in the not-so-distant future and make medical school a more realistic prospect for American students. Costs are simply astronomical, even with loans. A proper government-funded nonmilitary medical-school accessions program would be helpful here.

Me? Lawyer, baby. I really do enjoy it, and that's my current long-term goal. That or some sort of something...astronaut? Mars's first paramedic would be cool.


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## ExpatMedic0 (Feb 12, 2013)

I just like watching the doctors, PA's, and medical students fight. Wish we could put them all in thunder dome.

I have no problems with PA's in fact, its a great option for many Paramedics with undergraduate degree's who decide to move on to something else. Now a PA billing the same as an MD and claiming to be equal to an MD is kind of funny. Don't get me wrong I love PA's, a lot of my previous co workers went on to that and I know its always an open door for me in the future should I decide. Its not a doctor though, period. same as NP


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## WTEngel (Feb 12, 2013)

Making medical school more obtainable is not necessarily the answer. More affordable and more opportunities for loan forgiveness when choosing to pursue specialties where there is a shortage I can definitely support.

The main issue I have with making medical school "easier" to get into is that the primary public education system for the most part is very flawed, and produces students who are not ready to pursue higher academia. By proxy, universities are succumbing to the same fate, and getting a bachelors degree in the USA is not real crowning achievement anymore. The American university system is turning out a generation of "rapid access to information" students, with very little ability for synthesis and higher order reasoning. Because the answers are so easily accessible for most questions, the pursuit of scholastic excellence has been turned into little more than a quest to easily learn the material for an exam and get an A, regardless of actual retention of information.

I would say the MCAT is the great equalizer, but it too is flawed. It is flawed primarily in the fact that exam prep companies have figured out the formula for scoring well on it, and any applicant with a reasonable amount of time on their hands can train hard and break 30. 30 is the new 25, and the scores are still trending upward.

The 2015 MCAT will likely suffer he same fate after it has been around for a few years. Test prep companies make a living on training people to take an exam well, and if the MCAT proves anything about an applicant, it would be that they can score decent on an exam for which they have been given the formula to.

So, what does all this have to do with the price of tea in China? Making medical school more accessible is not the answer. Not from an admissions standpoint anyway. If the applicants being produced are on the whole underprepared, we will not see an increase in people flunking out, we will see an decrease in overall quality of medical education. 

I am all for a newly graduated doctor having some chance of receiving their degree with zero debt. I am not for allowing a generation of "is this going to be on the exam" type students into higher education.


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## WTEngel (Feb 12, 2013)

schulz said:


> I just like watching the doctors, PA's, and medical students fight. Wish we could put them all in thunder dome.
> 
> I have no problems with PA's in fact, its a great option for many Paramedics with undergraduate degree's who decide to move on to something else. Now a PA billing the same as an MD and claiming to be equal to an MD is kind of funny. Don't get me wrong I love PA's, a lot of my previous co workers went on to that and I know its always an open door for me in the future should I decide. Its not a doctor though, period. same as NP



Remember Saudi Schulzenstein? Everyone and their brother claimed to be a doctor of some sort!

Now there's an example of a place where respect was based on the alphabet soup after your name. It didn't matter what the degree was in or where you got it, as long as it came with a pretty certificate and a good foil seal!


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## Simplify (Feb 12, 2013)

Veneficus said:


> I think US doctors, based soley on greed, are to blame for the shortages of US doctors.
> 
> It is the fault of such groups as the AMA that midlevels were ever permitted to exist, and in the near future there will be a fight over jobs.
> 
> ...



No.  Generalizing about an entire profession based on your own limited personal experiences is ignorant and speaks more about your own hangups and biases than it does about the state of midlevels in this country.  Believe it or not, the average PA school student currently enrolled today, CHOSE PA SCHOOL OVER MEDICAL SCHOOL.  Blasphemy?  Impossible you say!?  Hardly.  Most programs receive in excess of 2,000 applications for 30 or 40 coveted spots.  If you think the people who make the cut with stakes this high are anything short of brilliant you are delusional. These students have near perfect GPA's, backgrounds in genetics, cellular biology, biochemistry, research, etc and they only get better every year.  These are people who could of gotten into a multitude of medical programs, but again, they CHOSE PA school.

I have worked with many phenomenal PAs who don't just follow algorithms- they are competent, respected members of the team with a very solid, conceptual understanding of medicine.  They teach residents and collaborate with other providers, yes MD and non-MD!  There is actually very little "doc envy" within the profession as you see it.  Rather, there is a growing movement amongst PAs to be utilized up to one's actual level of training and potential.  Much of this actually stems from bitter MD's who are realizing all too late that those two weeks spent studying the histology of teeth has done squat to make them a better provider.  You can reduce the profession down to fit your preconceived notion of MD=GOD/ Non-MD=HACK, but as they say, opinions are like :censored::censored::censored::censored::censored::censored::censored:s. A concept you are surely familiar with.


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## ExpatMedic0 (Feb 12, 2013)

WTEngel said:


> Remember Saudi Schulzenstein? Everyone and their brother claimed to be a doctor of some sort!
> !



Aaron even would say he was a doctor sometimes because no one knew what a paramedic was haha. One of the guys with an undergraduate degree had "Doctor" on his licence


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## WTEngel (Feb 12, 2013)

Simplify said:


> No.  Generalizing about an entire profession based on your own limited personal experiences is ignorant and speaks more about your own hangups and biases than it does about the state of midlevels in this country.  Believe it or not, the average PA school student currently enrolled today, CHOSE PA SCHOOL OVER MEDICAL SCHOOL.  Blasphemy?  Impossible you say!?  Hardly.  Most programs receive in excess of 2,000 applications for 30 or 40 coveted spots.  If you think the people who make the cut with stakes this high are anything short of brilliant you are delusional. These students have near perfect GPA's, backgrounds in genetics, cellular biology, biochemistry, research, etc and they only get better every year.  These are people who could of gotten into a multitude of medical programs, but again, they CHOSE PA school.
> 
> I have worked with many phenomenal PAs who don't just follow algorithms- they are competent, respected members of the team with a very solid, conceptual understanding of medicine.  They teach residents and collaborate with other providers, yes MD and non-MD!  There is actually very little "doc envy" within the profession as you see it.  Rather, there is a growing movement amongst PAs to be utilized up to one's actual level of training and potential.  Much of this actually stems from bitter MD's who are realizing all too late that those two weeks spent studying the histology of teeth has done squat to make them a better provider.  You can reduce the profession down to fit your preconceived notion of MD=GOD/ Non-MD=HACK, but as they say, opinions are like :censored::censored::censored::censored::censored::censored::censored:s. A concept you are surely familiar with.



Then why is medical school longer, and why is a residency still required if you intend to specialize?

Surely they could shave a few months or a year or two off of medical school and give the newly graduated doctors some OJT, and it would be just as good, right?


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## WTEngel (Feb 12, 2013)

schulz said:


> Aaron even would say he was a doctor sometimes because no one knew what a paramedic was haha. One of the guys with an undergraduate degree had "Doctor" on his licence



Probably Hale...and I am sure he lived up to every letter in the word "doctor" :rofl:

Oh my, how did we get to this place old friend? I am pretty sure all expats in KSA for any duration of time contract some sort of prion disease...

I loved that place, I made a ton of Saudi friends, and I would love to go back someday...but sometimes there was nothing to do other than just shake your head...


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## RocketMedic (Feb 12, 2013)

Simplify said:


> No.  Generalizing about an entire profession based on your own limited personal experiences is ignorant and speaks more about your own hangups and biases than it does about the state of midlevels in this country.  Believe it or not, the average PA school student currently enrolled today, CHOSE PA SCHOOL OVER MEDICAL SCHOOL.  Blasphemy?  Impossible you say!?  Hardly.  Most programs receive in excess of 2,000 applications for 30 or 40 coveted spots.  If you think the people who make the cut with stakes this high are anything short of brilliant you are delusional. These students have near perfect GPA's, backgrounds in genetics, cellular biology, biochemistry, research, etc and they only get better every year.  These are people who could of gotten into a multitude of medical programs, but again, they CHOSE PA school.
> 
> I have worked with many phenomenal PAs who don't just follow algorithms- they are competent, respected members of the team with a very solid, conceptual understanding of medicine.  They teach residents and collaborate with other providers, yes MD and non-MD!  There is actually very little "doc envy" within the profession as you see it.  Rather, there is a growing movement amongst PAs to be utilized up to one's actual level of training and potential.  Much of this actually stems from bitter MD's who are realizing all too late that those two weeks spent studying the histology of teeth has done squat to make them a better provider.  You can reduce the profession down to fit your preconceived notion of MD=GOD/ Non-MD=HACK, but as they say, opinions are like :censored::censored::censored::censored::censored::censored::censored:s. A concept you are surely familiar with.




Howdy, welcome to the forum. Please be a bit more respectful when talking to others on our boards, we try not to use too many exclamation points or vulgarity. 

Would you like to introduce yourself? I'm a paramedic from Oklahoma.

Lastly...*popcorn*.


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## WTEngel (Feb 12, 2013)

Rocketmedic40 said:


> Howdy, welcome to the forum. Please be a bit more respectful when talking to others on our boards, we try not to use too many exclamation points or vulgarity.
> 
> Would you like to introduce yourself? I'm a paramedic from Oklahoma.
> 
> Lastly...*popcorn*.



Yes...popcorn indeed!

Plenty of 1-10 post count contributors around these threads in the past few days. 

Coincidence, I think not...


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## ffemt8978 (Feb 12, 2013)

Play nice, or become the focus of my complete and undivided attention.


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## Simplify (Feb 12, 2013)

WTEngel said:


> Then why is medical school longer, and why is a residency still required if you intend to specialize?
> 
> Surely they could shave a few months or a year or two off of medical school and give the newly graduated doctors some OJT, and it would be just as good, right?



I agree wholeheartedly.  Medical school should be shorter.  The healthcare crisis in this country and lack of providers which is slated to reach critical mass within the next decade seems to corroborate this notion as well.  Longer does not always mean better, and I would argue that many med programs could trim the fat and consolidate their curriculum.  The antiquated model of provider education in this country is analogous to gun fanatics claiming that the 2nd amendment is somehow still applicable in the 21'st century. Times, as they say are a changin.


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## WTEngel (Feb 12, 2013)

Well, I guess I should point out that I was using a rhetorical device.

We do not agree, because I do not believe that medical education should be shorter.

No disrespect, but I think you are off base. Medical education in the US is not getting shorter anytime soon.


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## silver (Feb 12, 2013)

WTEngel said:


> Well, I guess I should point out that I was using a rhetorical device.
> 
> We do not agree, because I do not believe that medical education should be shorter.
> 
> No disrespect, but I think you are off base. Medical education in the US is not getting shorter anytime soon.



A few schools are trialling 3 years (specifically I know NYU is for this application cycle) for some of their top performing students. Basically they are looking to integrate more basic science over the entire time and add in classes before fall of first year and summer between first and second. I also believe that the students are to go into an NYU residency so that there is a continuum of clinical training in place of part of the 4th year. As this is medicine, it is important to note that the curriculum is examined like a science. So they will be tracking the performance very closely to see if this model could be expanded.


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## BSE (Feb 12, 2013)

Wow, I joined here to maybe get some info on state license issues....but maybe I won't.

Explanation, I am a long time military medic/Paramedic and I will be starting PA school soon in another state.  I would like to maintain my cert.

Many of you guys really have no clue as to what a PA does and how they are educated/utilized.  Which I find odd being that EMS is one of the main feeders of the profession.  

Honestly, I haven't seen this level hostility and blatant ego boosting since the last time I checked out SDN.  Sorry admin, not an attack....just an observation.

This would like me completing PA school and starting a thread bashing paramedics.  I mean...how can you teach a guy with only high school to do advanced airways....sheesh....wannabes.  *I heard this statement said about my guys by an anesthesiologist.  

PA's are not MD's.....they know and understand that.  PA's have been around since the 60's....nothing new here.  I couple of bitter medics and med student with an over-sized sense of self are not good sources of information.  There are better sources for those who would really like to know.  Search and you will find.

Bye.


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## usalsfyre (Feb 12, 2013)

Simplify said:


> I agree wholeheartedly.  Medical school should be shorter.  The healthcare crisis in this country and lack of providers which is slated to reach critical mass within the next decade seems to corroborate this notion as well.  Longer does not always mean better, and I would argue that many med programs could trim the fat and consolidate their curriculum.  The antiquated model of provider education in this country is analogous to gun fanatics claiming that the 2nd amendment is somehow still applicable in the 21'st century. Times, as they say are a changin.


:nosoupfortroll:

Modern clinical medicine is far more complicated than it has been in the past. Shortening the curriculum is a ludicrous idea.


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## silver (Feb 12, 2013)

BSE said:


> Wow, I joined here to maybe get some info on state license issues....but maybe I won't.
> 
> Explanation, I am a long time military medic/Paramedic and I will be starting PA school soon in another state.  I would like to maintain my cert.
> 
> ...



Realistically there is a huge variation education and utilization of PAs depending on school, state and place of employment.


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## Simplify (Feb 12, 2013)

usalsfyre said:


> :nosoupfortroll:
> 
> Modern clinical medicine is far more complicated than it has been in the past. Shortening the curriculum is a ludicrous idea.



It's much more complicated, but more importantly, the *quantity* of information itself has increased.  In fact, medicine is the only field in existence where the entire "body of knowledge" doubles in 5 year increments.  Think about that... every five years everything there is to know about medicines doubles, and that rate is only increasing.  So the question is, is it even possible for a provider to grasp all of that information, even at a superficial level in 8 years?  12 years? 20 years?  Or, as the system seems to be dictating, does it make more sense to train more intensely, in narrower scopes of practice.  Honestly, why does the med student who KNOWS they want to be a hand surgeon spend all of that time learning which antibodies can cross the placental barrier?  Is it good to know? In an ideal world absolutely, but pragmatically, it's antiquated.  We need to refine the system and this is where "midlevels" come in.  As previously mentioned many med programs are experimenting with this concept as it becomes increasingly clear that the current model is woefully inept at producing providers in the numbers we need.  It's about thinking progressively and not getting entrenched in a dogmatic model of education that we are painfully outgrowing.


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## rujero (Feb 12, 2013)

platon20 said:


> Why would a PA choose to do primary care and take a 50% paycut when they can work in ER with ZERO extra training and make more money?  Doesnt make any sense.



If I need to see my doctor tomorrow for strep throat, or almost any other non emergency medical problem for that matter, I would 99% of the time be seeing an NP who would test, diagnose, and prescribe meds. And I have absolutely no problem with that.

My end goal at this point is to be either an NP or PA and work as a primary care provider in pediatrics under the primary MD. I have no problem making less money than a doctor because I would not be one. And I certainly would NOT go to mid-level status to present myself as a medical doctor to my peers. Even if I got my DNP and had the right to refer to myself as a Doctor, I would never present myself as a medical one. Being an NP or a PA is a pretty big accomplishment in that of itself.

I just feel like mid level providers are a more economical option in healthcare and the several I have spoken to are confident the profession will be in higher demand over the next 10-20 years. Would it be cool to be able to say, "I'm a Doctor (MD)"? Yes it would, but I'd rather avoid the extra schooling, the malpractice stress, and the divorce rates.

-r


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## VFlutter (Feb 12, 2013)

So this thread went downhill fast :glare: Can we please try to be a little more civil? This is not SDN. 

Just because I may choose to got to CRNA/PA/NP school does not mean that I am unintelligent or that I could never get into medical school. It is a personal choice based on my factors not a back up plan because I was rejected from med school. 

I understand the despise for midlevels who claim to be equivalent to MDs but do not let that create a despise for midlevels in general.


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## rujero (Feb 12, 2013)

Simplify said:


> It's much more complicated, but more importantly, the *quantity* of information itself has increased.  In fact, medicine is the only field in existence where the entire "body of knowledge" doubles in 5 year increments.  Think about that... every five years everything there is to know about medicines doubles, and that rate is only increasing.  So the question is, is it even possible for a provider to grasp all of that information, even at a superficial level in 8 years?  12 years? 20 years?  Or, as the system seems to be dictating, does it make more sense to train more intensely, in narrower scopes of practice.  Honestly, why does the med student who KNOWS they want to be a hand surgeon spend all of that time learning which antibodies can cross the placental barrier?  Is it good to know? In an ideal world absolutely, but pragmatically, it's antiquated.  We need to refine the system and this is where "midlevels" come in.  As previously mentioned many med programs are experimenting with this concept as it becomes increasingly clear that the current model is woefully inept at producing providers in the numbers we need.  It's about thinking progressively and not getting entrenched in a dogmatic model of education that we are painfully outgrowing.



+1 This is an excellent point.


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## rujero (Feb 12, 2013)

Chase said:


> So this thread went downhill fast :glare: Can we please try to be a little more civil? This is not SDN.
> 
> Just because I may choose to got to CRNA/PA/NP school does not mean that I am unintelligent or that I could never get into medical school. It is a personal choice based on my factors not a back up plan because I was rejected from med school.
> 
> I understand the despise for midlevels who claim to be equivalent to MDs but do not let that create a despise for midlevels in general.



See my post above. Not everyone thinks that way. A few people may have been in that exact situation, but it doesn't represent the majority. Specific field-focused mid levels are the future of general medicine.

-r


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## Tigger (Feb 12, 2013)

Chase said:


> So this thread went downhill fast :glare: Can we please try to be a little more civil? This is not SDN.
> 
> Just because I may choose to got to CRNA/PA/NP school does not mean that I am unintelligent or that I could never get into medical school. It is a personal choice based on my factors not a back up plan because I was rejected from med school.
> 
> I understand the despise for midlevels who claim to be equivalent to MDs but do not let that create a despise for midlevels in general.



This pretty much sums up my thoughts on the issue. 

I do not want to be a doctor. Does that mean I cannot practice medicine?

I am not looking at the PA/NP route as a shortcut to being on par with doctors. As I said, I simply have no interest in being a doctor, but I do have an interest in practicing medicine at a higher level than what I am doing now.


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## ExpatMedic0 (Feb 12, 2013)

Do other countries use mid level providers? They don't have them where I have been in Europe. I know Australia has masters and post graduate paramedics you could argue fit that bill


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## BSE (Feb 12, 2013)

silver said:


> Realistically there is a huge variation education and utilization of PAs depending on school, state and place of employment.



Interesting statement....based on?

There are some variances in the laws that govern PA in some states.  Mainly it has to do with the PA/MD relationship...supervision.  There aren't too many differences in scope, but there are some.  So yes, take out the word "huge" and you are correct.

There is only one governing body for PA education, the ARC-PA.  Like med schools, it takes years to establish a PA program.  The curriculum's all have to cover the same basic material...just the way med programs have to.  There are some differences in quality of faculty and clinical sites....just like med schools.  Remember, the PA profession was created by physicians....the model of school accreditation is very strict because the founding physicians (one being Dr. Eugene Steed) demanded it.  Not too much has changed in the accreditation process.  There really aren't any "fly-by-night" programs.  Some are better than others...sure.  There is no avoiding that.

One of the reasons I chose PA over NP was the standard curriculum.  Not bashing NP's, but their programs have three different ways to get accredited. Too much variance.


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## BSE (Feb 12, 2013)

schulz said:


> Do other countries use mid level providers? They don't have them where I have been in Europe. I know Australia has masters and post graduate paramedics you could argue fit that bill



NP's are used throughout Europe, especially in the UK.  The UK is starting 2 PA programs as a test project, but they are running into funding issues...last I heard.


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## ExpatMedic0 (Feb 12, 2013)

Only a doctor may practice medicine, correct? Practitioner is the act of unsupervised medical practice, but its not practicing medicine, correct? I am just a dumb paramedic but I remember something like that


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## ExpatMedic0 (Feb 12, 2013)

BSE said:


> NP's are used throughout Europe, especially in the UK.  The UK is starting 2 PA programs as a test project, but they are running into funding issues...last I heard.



Interesting, we only have doctors in Denmark


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## Tigger (Feb 12, 2013)

schulz said:


> Only a doctor may practice medicine, correct? Practitioner is the act of unsupervised medical practice, but its not practicing medicine, correct? I am just a dumb paramedic but I remember something like that



I don't know honestly.

When we come down hard here on people saying "don't forget, BLS before ALS!" the common response is "there is no distinction, medicine is medicine. It's a continuum." 

If EMS providers, physical therapists, athletic trainers, and midlevels are not practicing medicine, then what are they doing? Try to keep that response civil please.

It's an honest question, though I understand that "practicing medicine" likely has a specific legal connotation.


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## VFlutter (Feb 12, 2013)

BSE said:


> One of the reasons I chose PA over NP was the standard curriculum.  Not bashing NP's, but their programs have three different ways to get accredited. Too much variance.



I don't blame you. I would pick PA education over general NP. 

In my opionion it is 1. CRNA 2. ACNP and PA 3. NP 4. CNS


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## silver (Feb 12, 2013)

BSE said:


> Interesting statement....based on?
> 
> There are some variances in the laws that govern PA in some states.  Mainly it has to do with the PA/MD relationship...supervision.  There aren't too many differences in scope, but there are some.  So yes, take out the word "huge" and you are correct.
> 
> ...



Well at the most basic and non-contentious level considering there are residency programs for PAs in different specialities but it isn't a requirement, I would say a post-graduate educated PA has a huge difference in education than one who did not go through the same.

And yes scope is the same, but like I said utilization, which translated most directly into supervision (as you noted the difference).


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## JPINFV (Feb 12, 2013)

Simplify said:


> These are people who could of gotten into a multitude of medical programs, but again, they CHOSE PA school.



Then they need to live with the fact that their education is not the same as 4 years of medical school and 3+ years of residency (since the only place you'll find a non-specialized GP in the US is the military general medical officer), and does not prepare them for independent, non-restricted, autonomous practice. 




> There is actually very little "doc envy" within the profession as you see it.


Except the entire "we're just like physicians and want the same practice rights and ability to bill as physicians." Sentiments seen in this very thread. 



> but as they say, opinions are like :censored::censored::censored::censored::censored::censored::censored:s. A concept you are surely familiar with.



I've always found it extremely ironic when someone spouts this cliche while providing an opinion.


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## JPINFV (Feb 12, 2013)

Simplify said:


> .  Honestly, why does the med student who KNOWS they want to be a hand surgeon spend all of that time learning which antibodies can cross the placental barrier? Is it good to know? In an ideal world absolutely, but pragmatically, it's antiquated.


...because 20wk EGA pregnant females never need their hands reconstructed? 

...because it's rare for medical students to not change their minds, especially during 3rd or 4th year rotations? 

...because there's a certain level of knowledge that society and general medical practice expects out of all physicians?


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## jrm818 (Feb 12, 2013)

Tigger said:


> I don't know honestly.
> 
> When we come down hard here on people saying "don't forget, BLS before ALS!" the common response is "there is no distinction, medicine is medicine. It's a continuum."
> 
> ...



Not an expert, just did a quick google.  In MA, for instance, it looks like they "provide medical services"

http://www.malegislature.gov/Laws/GeneralLaws/PartI/TitleXVI/Chapter112/Section9E

by contrast, medical students "practice medicine" http://www.malegislature.gov/Laws/GeneralLaws/PartI/TitleXVI/Chapter112/Section9A

other states look like they do refer to PAs as "practicing medicine," but under the supervision of a physician



wikipedia agrees with schulz, for what it's worth
http://en.wikipedia.org/wiki/Medical_practice


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## Simplify (Feb 12, 2013)

JPINFV said:


> ...because 20wk EGA pregnant females never need their hands reconstructed?
> Are you suggesting we construct medical education around treating the outliers?
> 
> 
> ...



Following this rationale should all MD's be equally well versed in zero-g medicine so in the off chance they stumble across an astronaut in space they are capable of rendering care?  This is hyperbole, but my point is that medical education should reflect the bulk of the bell curve in terms of actual patient need.  We have to draw the line somewhere because the current model is failing.  Why not expedite the OB and the hand-surgeon's education, get them both out the door and working in half the time and treating patients.  A phone call between the two providers seems like an easier means of solving your hypothetical patient's problem than extra years of education tacked on of superficially studying material that neither is really interested in. 

Much in the same way that PA's are able to lateralize through different fields of medicine, shortened med tracks could also encourage providers to switch fields and prevent burnout. 

And lastly, societal expectations as you describe are a piss-poor means of evaluation.  
The proof should be in the pudding and evidence based medicine demands evidence based results, which at the moment are sorely lacking.  What good is it to have providers well versed in the minutia of medicine when you can't get in to see them until September of 2015?


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## rescue1 (Feb 12, 2013)

BSE said:


> Wow, I joined here to maybe get some info on state license issues....but maybe I won't.
> 
> Explanation, I am a long time military medic/Paramedic and I will be starting PA school soon in another state.  I would like to maintain my cert.
> 
> ...



I like to think most of the hate on this thread towards mid-levels is not hate towards mid-levels in general, but on the ones that claim equivalency of education and skill with physicians. 

In my experience, this is usually a Doctor of Nursing Practice vs. MD/DO debate, and PAs are usually left out of it.


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## rescue1 (Feb 12, 2013)

Simplify said:


> Following this rationale should all MD's be equally well versed in zero-g medicine so in the off chance they stumble across an astronaut in space they are capable of rendering care?  This is hyperbole, but my point is that medical education should reflect the bulk of the bell curve in terms of actual patient need.  We have to draw the line somewhere because the current model is failing.  Why not expedite the OB and the hand-surgeon's education, get them both out the door and working in half the time and treating patients.  A phone call between the two providers seems like an easier means of solving your hypothetical patient's problem than extra years of education tacked on of superficially studying material that neither is really interested in.



I like to think the chance of a medical student changing their mind about specialties is slightly higher than the chance to practice emergent Zero-G medicine.
The fact remains that if I have a medical condition that is more serious than basic primary care stuff, I want a provider taking care of me that has way more education than he knows what to do with, not one who has taken a "streamlined and efficient" path, which is usually code for "slightly worse and slightly cheaper".



Simplify said:


> Much in the same way that PA's are able to lateralize through different fields of medicine, shortened med tracks could also encourage providers to switch fields and prevent burnout.


Yes, but unlike PAs, a physician board certified in a specialty is assumed to be able to practice with total autonomy and handle most of what patients in that specialty throw at him. When PAs and residents don't know what to do with a patient, who they gonna call? The attending physician. Also, Ghostbusters.

You don't want to call an attending that has barely more experience then the first year interns.


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## WTEngel (Feb 12, 2013)

This whole thread has been trolled. 

Chase I appreciate the intentions, unfortunately this thing has run its course.

This thread needs to die... Probably two or three pages ago.


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## VFlutter (Feb 12, 2013)

WTEngel said:


> This whole thread has been trolled.
> 
> Chase I appreciate the intentions, unfortunately this thing has run its course.
> 
> This thread needs to die... Probably two or three pages ago.



I agree


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## Veneficus (Feb 12, 2013)

WTEngel said:


> Making medical school more obtainable is not necessarily the answer. More affordable and more opportunities for loan forgiveness when choosing to pursue specialties where there is a shortage I can definitely support.



In order for this to be accomplished, the entire billing system needs to be changed. Which sooner or later it will be, but not until it has been bleed to the point where doctors have to take a loss. Like most professions, in order to deal with less pay, work hours will be reduced, and when that happens, more providers will become mandatory.

*



			The main issue I have with making medical school "easier" to get into is that the primary public education system for the most part is very flawed, and produces students who are not ready to pursue higher academia. By proxy, universities are succumbing to the same fate, and getting a bachelors degree in the USA is not real crowning achievement anymore. The American university system is turning out a generation of "rapid access to information" students, with very little ability for synthesis and higher order reasoning. Because the answers are so easily accessible for most questions, the pursuit of scholastic excellence has been turned into little more than a quest to easily learn the material for an exam and get an A, regardless of actual retention of information.
		
Click to expand...

*
Too late, it is already like that and not just in the US.

*



			we will see an decrease in overall quality of medical education.
		
Click to expand...

*
and we are. 

*



			I am all for a newly graduated doctor having some chance of receiving their degree with zero debt. I am not for allowing a generation of "is this going to be on the exam" type students into higher education.
		
Click to expand...

*
That is what a majority of it is. Everywhere. In my opinion it has to do with the selection process. Too much focus academic selection, not enough focus on candidate selection.



Simplify said:


> The antiquated model of provider education in this country is analogous to gun fanatics claiming that the 2nd amendment is somehow still applicable in the 21'st century. Times, as they say are a changin.



Actually, I think the model works very well and I actually chose to go to a place with a more traditional bent. My goal was the oldest medical school in the world, but family always pulls my strings.

As WT eluded to, it is not the classical education that is the problem. It isthe inability for a majority of people to use it. Western societies are developing ultraspecialized knowledge requirements, anthropologists and taxonomists actually renamed the species to reflect this highly techno dependant and specialized lifestyle.

Consequently, The idea of a well rounded higher education loses its appeal, but not its effectiveness. 

Speaking specifically of medicine, it affects the mean level of providers by decreasing it over time. One of the things I have observed working in different medical systems, with doctors from all over the world, is that the US has a mean level, with relatively few excellent or poor providers. Whereas at least Europe and Africa have basically no mean level and providers end up in one extreme or the other. What is better is really a matter of personal choice, but it seems to be for the mean level when people are not sick and they quickly switch mindset when they or a loved one gets sick.

Just because you change something doesn't mean it changes for the better. Given the current decline of the US in all aspects of society I wouldn't consider the current change positive.   



silver said:


> A few schools are trialling 3 years (specifically I know NYU is for this application cycle) for some of their top performing students. Basically they are looking to integrate more basic science over the entire time and add in classes before fall of first year and summer between first and second. I also believe that the students are to go into an NYU residency so that there is a continuum of clinical training in place of part of the 4th year. As this is medicine, it is important to note that the curriculum is examined like a science. So they will be tracking the performance very closely to see if this model could be expanded.



This is actually happening all over the world to some degree. Several countries have included the intern year into the clinical education years with expanded responsibility and scope for the senior students. But it isn't done specifically to reduce medical school so much as it is to permit more providers entering specialty training. BUt it is much too political and convoluted to explain here.



Simplify said:


> It's much more complicated, but more importantly, the *quantity* of information itself has increased.  In fact, medicine is the only field in existence where the entire "body of knowledge" doubles in 5 year increments.  Think about that... every five years everything there is to know about medicines doubles, and that rate is only increasing.  So the question is, is it even possible for a provider to grasp all of that information, even at a superficial level in 8 years?  12 years? 20 years?  Or, as the system seems to be dictating, does it make more sense to train more intensely, in narrower scopes of practice.  Honestly, why does the med student who KNOWS they want to be a hand surgeon spend all of that time learning which antibodies can cross the placental barrier?  Is it good to know? In an ideal world absolutely, but pragmatically, it's antiquated.  We need to refine the system and this is where "midlevels" come in.  As previously mentioned many med programs are experimenting with this concept as it becomes increasingly clear that the current model is woefully inept at producing providers in the numbers we need.  It's about thinking progressively and not getting entrenched in a dogmatic model of education that we are painfully outgrowing.



With the first part I agree, there is a lot changing and being added to medicine. It does get to the point where it is impossible to know it all. But that does not mean there is benefit in hyperspecialization along traditional medical lines.

As knowledge of medicine grows it becomes apparent that drawing lines in the sand on antiquated specialties is a problem. Recently multiple new specialties which better address specific pathologies and common treatments have emerged. Such as acute care medicine and perinatology.

As for maintaining current, that is an individual choice. About 5 years ago now the NEJM published a piece on how doctors not specifically involved in academic medicine fell into a practice rut, where even if they read about newer treatment modalities are unwilling to embrace them. 3 published studies I have personally been involved in showed a lack of knowledge and change among the participants even as new information was widely disseminated.

The lack of ability to keep up seems directly tied to the motivation of the provider, not the expanding material. I think the solution is in more selection of personality traits in medical school admissions which fosters more of an apprentice type master/student relationship as opposed to the current quantatative assessments.   



Chase said:


> So this thread went downhill fast :glare: Can we please try to be a little more civil? This is not SDN.
> 
> Just because I may choose to got to CRNA/PA/NP school does not mean that I am unintelligent or that I could never get into medical school. It is a personal choice based on my factors not a back up plan because I was rejected from med school.
> 
> I understand the despise for midlevels who claim to be equivalent to MDs but do not let that create a despise for midlevels in general.



Too late, I despise them. Mostly for their lack of ambition and secondly for their ignorance of thinking they are equal and deserve to be. I submit when their attitude changes, so will mine.




rujero said:


> See my post above. Not everyone thinks that way. A few people may have been in that exact situation, but it doesn't represent the majority. Specific field-focused mid levels are the future of general medicine.



I don't really agree with this. Mostly because it is a contradiction in terms and ideas. General medicine is just that. in order to have field focused general medicine then patients would have to self refer. Which means they would have to know something about medicine. Which as demonstrated by more hyperspecialized societies in the western world is not the case. 

I think the future of general medcine is basically wha US EMs accel at. Quick fixes or accurate referral. Band-aids and antibiotics as I like to say. It seems a bit cyclical because I remember the days when the GP basically handled everything except the more complex cases. I see a definate shift back to that from systems all over the world. (and I get around) 



schulz said:


> Do other countries use mid level providers? They don't have them where I have been in Europe. I know Australia has masters and post graduate paramedics you could argue fit that bill



The UK uses NPs. From my experience there it does not seem to be working out. I heard about their pilot PA program, but I don't think it will be successful. Because of the EEA, wealthier countries like the UK have no problem picking up talent from the poorer ones. With consistent educational requirements throughout, there is no real shortage of doctors willing to work in general practice. The Swiss and the Swedish have seen the exact same.



JPINFV said:


> ...because 20wk EGA pregnant females never need their hands reconstructed?
> 
> ...because it's rare for medical students to not change their minds, especially during 3rd or 4th year rotations?
> 
> ...because there's a certain level of knowledge that society and general medical practice expects out of all physicians?



Because you cannot function as a provider unless you can recognize things out of your expertise.

The future of medical specialties is going to be driven by pathophys mechanisims, not by body area. There is already significant overlap in a number of specialties as evidence. 

Look at general surgery. It no longer exists as a group of procedures, it exists only as basic surgical training.


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## Brandon O (Feb 12, 2013)

schulz said:


> Only a doctor may practice medicine, correct? Practitioner is the act of unsupervised medical practice, but its not practicing medicine, correct? I am just a dumb paramedic but I remember something like that



A PA holds a license to practice medicine (you'd have to ask someone else about NPs), just not without restriction or without oversight. How exactly the latter apply depend on the state, your role, amount of experience, and so forth.

In terms of everyday function, the best comparison might be to a resident working under his attending.


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## Trashtruck (Feb 12, 2013)

Chase said:


> Lets not turn this into a debate comparing professions.



And that's EXACTLY what this turned out to be! To a five year old boy, 'Don't put your hand in there...whatever you do, don't put your hand in there'

You know exactly what's going to happen.


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## ffemt8978 (Feb 12, 2013)

The only reason the Community Leaders have allowed this thread to go on is that there have been attempts to avoid the profession vs profession debate by some of those participating, and there is some useful information in this thread.

However, we've reached the limit of what we're going to tolerate in this thread and if there is any more of the "my career is better than yours", it will go the way of the Dodo bird.


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## Amberlamps916 (Feb 12, 2013)

ffemt8978 said:


> The only reason the Community Leaders have allowed this thread to go on is that there have been attempts to avoid the profession vs profession debate by some of those participating, and there is some useful information in this thread.
> 
> However, we've reached the limit of what we're going to tolerate in this thread and if there is any more of the "my career is better than yours", it will go the way of the Dodo bird.




I'm sure the majority of us share the same sentiments.


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## ExpatMedic0 (Feb 13, 2013)

WTEngel said:


> This whole thread has been trolled.
> 
> Chase I appreciate the intentions, unfortunately this thing has run its course.
> 
> This thread needs to die... Probably two or three pages ago.



Its amazing how quickly a thread will be locked if its an EMS vs Nursing debate, but as soon as the "the big boys" step up to the plate everyone just steps back. :rofl:


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## ExpatMedic0 (Feb 13, 2013)

by the way this  thread is all over the PA forum and people are discussing everyone's replies. 
http://www.physicianassistantforum....ssion-about-midlevel-providers-at-EMTLife-com

It should also be noted some of them(the PA students) fail to realize many of them are arguing with medical students and doctors on this thread... not EMS personal.


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## Veneficus (Feb 13, 2013)

schulz said:


> by the way this  thread is all over the PA forum and people are discussing everyone's replies.
> http://www.physicianassistantforum....ssion-about-midlevel-providers-at-EMTLife-com
> 
> It should also be noted some of them(the PA students) fail to realize many of them are arguing with medical students and doctors on this thread... not EMS personal.



Well you know me, I am all about throwing around titles.


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## ExpatMedic0 (Feb 13, 2013)

Chase said:


> Here are some criteria that I think are required for a group to be considered mid-level providers:
> 
> 
> Graduate level education
> ...


Given that set of criteria I believe at this present time PA and Nurse Practitioners are the only ones who achieve all those things. I do not believe Athletic Trainers or Physical Thearpist (I could be wrong) have prescription authority.
 I believe there maybe other types of mid levels (specifically advanced care paramedics and community paramedics) in other countries, but I can find not any information on there abilities to write prescriptions at the moment, only rumors.


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## BSE (Feb 13, 2013)

schulz said:


> by the way this  thread is all over the PA forum and people are discussing everyone's replies.
> http://www.physicianassistantforum....ssion-about-midlevel-providers-at-EMTLife-com
> 
> It should also be noted some of them(the PA students) fail to realize many of them are arguing with medical students and doctors on this thread... not EMS personal.



I would dare say they do.  Being a physician or med student adds zero validity to the the ignorant statements that have been said. 

MD's bashing PA's because they have more education? Seriously....you want a prize?  Nowhere was it said that PA's are the same as MD's.  Ego......


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## NomadicMedic (Feb 13, 2013)

schulz said:


> Its amazing how quickly a thread will be locked if its an EMS vs Nursing debate, but as soon as the "the big boys" step up to the plate everyone just steps back. :rofl:



Trust me. As FF has stated, the mods are watching this thread closely. And if you have questions about moderation, please contact a member of the CL team via private message and we will address your concerns.


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## Veneficus (Feb 13, 2013)

*ego and delusions*



BSE said:


> I would dare say they do.  Being a physician or med student adds zero validity to the the ignorant statements that have been said.
> 
> MD's bashing PA's because they have more education? Seriously....you want a prize?  Nowhere was it said that PA's are the same as MD's.  Ego......



In my time on this board I have seen all manner of arguments for the mid level provider. Especially physician Assistants. (or arew they calling themselves associates now?) 

Some of the more respected members here who have chosen a mid level  path have valiently defended it posting studies from every nursing association, PA association, and all manner of biased sources.

We have had this discussion many times. 

But here are some of my observations. 

PAs in particular like to claim they are just as effective as MDs. They tout their economic benefits ad generally denounce medical education as wasteful excess. 

But how many people see education as wasteful excess?

In this very thread, staunch supporters wonder about the history of teeth in modern medicine. Unfortunately they don't see the implications. HUman evolution is intrinsic to the practice of medicine. Unfortunately for them, they were never shown the importance.

In actual US medical practice, I often see PAs talk a tough game. But I have never seen one step up and be equal to an MD. The same talkers are the ones spouting how great the PA profession is, how they are independant, don't need oversight, fill a primary care role, etc.

I have seen the same thing on this discussion.

But I will just point out...

most of the PA propaganda is just that, kool-aid. Anyone who points out the flaws of the propaganda has an ego problem. Whether or not I have an ego problem is debatable, but I will honestly say when it comes to people who claim to be as good, who have not invested the time, money, and other sacrifices I have is a sure fire way to set me off.

When the kool-aid approach to convincing MDs of the value of PAs fails or is met with resistance, you never hear them speak of limitations or role on the team. You hear more entrenched delusions of grandeur. 

Tell me? How many PAs have walked into their hospital administration, touted the equivalency and economic benefit and suggested hiring only PAs and decreasing the physician staff?

How many PAs are employed by physician practice groups tell those group members they have useless and wasted education and were not smart enough to go to PA school because they can do the same things?

I will venture to guess none. 

I would offer the very same people and organizations spouting how great the PAs are, not coincidentally are the same ones that talked about how PAs would fill the primary care void in the US. But in a quick internet search today, even PA based websites are talking about how this didn't happen and the trend towards PA specialization is expected to continue.

Could it be that these same liars about PAs serving underserved community needs are the ones spouting the greatness of PAs?

When you look at the history of medicine, particularly that of the DO, they were first accepted by the military and the underserved populations. It is a true and tested way to break into the medical profession. But unlike PAs most DOs have more education than MDs, not less. They do not pretend they are serving some greater good that MDs are not. They get into the same specialty and high earning practices as everyone else, and are just as capable. (by the way they did meet the internationally recognized minimums) 

I am not suggesting DOs and PAs are the same, as DOs and MDs are the same, but their history is applicable to this conversation.

So let's just call a spade a spade. PAs tout themselves as a cost effective, mission specific solution to healthcare. Basically moving into direct competition for money that MDs are competing for. General system healthcare dollars. By their own admission they are not flocking to serve thier underserved targets. For profit healthcare embraces lesser paid "alternatives" that can bill for the same or similar rates. With even the largest academic centers filling their halls with them. 

But here is a question:

If a PAs equal to an MD, why do they accept less money?

Conversly, if a PA is not equal an MD, what gives them the right to bill equally?

What's reall vexing to me is if a healthcare organization, hospital or private practice group bills the same, why do PAs accept less salary?

It seems an aweful lot like scabs in a union shop to me.

But here is something else to think about.

When I defend my value and commitment, I am egotistical, arrogant, and ignorant. 

But many people who we have never seen here before get wind of my arguments against the PA kool-aid, they are compelled to come here and offer counter-point.

I have never posted on a PA forum. I don't even look at them. They might have PA vs MD vs garbage man vs street walker arguments all year. I would never know and certainly don't feel compelled to defend my profession there. 

It seems like that response is similar to religious zealots who have their faith questioned. 

Could it be I question your faith? Could it be that you feel threatened somebody might actually be persuaded by my arguments as to why PAs are not equal to doctors and might then decide they will not accept PAs? What if those people are politicians? Patients? Your game would be up.

I suggest you offer such passioned and spirited defense, because the PA profession might have to answer for some of its propaganda and it can't. 

Perhaps more policy makers should have this discussion?

Now I don't think I will convince my new detractors, but not everyone here is immune from rational or counter argument. 

The defense of my profession is no more egotistical, arrogant, and ignorant than yours. That is simply the pot calling the kettle black.

Rather than argue with me, why not simply surround yourself with people who make you feel better by drinking the koool-aid with you and call me an fool?

"And then He said, get this, that having more education makes you a better provider and people should not pay the same for less... arrogant fool."

"I am better than thou art now; I am a fool, thou art nothing"

Wise words from one of those useless literature classes.


----------



## JPINFV (Feb 13, 2013)

Veneficus said:


> When you look at the history of medicine, particularly that of the DO, they were first accepted by the military and the underserved populations. It is a true and tested way to break into the medical profession. But unlike PAs most DOs have more education than MDs, not less. They do not pretend they are serving some greater good that MDs are not. They get into the same specialty and high earning practices as everyone else, and are just as capable. (by the way they did meet the internationally recognized minimums)
> 
> I am not suggesting DOs and PAs are the same, as DOs and MDs are the same, but their history is applicable to this conversation.



I think what's even more important than the recent history is the reason for founding and early history. PAs were created specifically to help physicians. osteopathy (later "osteopathic medicine") was founded as an alternative to traditional medicine at a time when traditional medicine was almost as dangerous as what it was trying to cure. It would have been extremely easy for osteopathy to go down the same path as chiropractors (and arguably A.T. Still wanted us to go down that path). However, as medicine became more science based, we started to adopt and integrate it. In addition, yes, it wasn't just lip service we paid as a early profession to undeserved communities. Even now, just looking at where the DO schools are and where our residencies are shows a significant concentration outside of the big cities... where most MD schools are expected to show up.

It also helps when we put our money were our mouth is. It's hard to justify that DOs are significantly different when one state once changed all of their DOs to MDs for a fee and a Saturday class. It's hard to justify DOs are significantly different from MDs when plenty of DO students take and pass the USMLE.


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## Veneficus (Feb 13, 2013)

JPINFV said:


> In addition, yes, it wasn't just lip service we paid as a early profession to undeserved communities. Even now, just looking at where the DO schools are and where our residencies are shows a significant concentration outside of the big cities... where most MD schools are expected to show up.



While I support MD/DO as being entirely equal, and you are preaching to the choir, I am not so sure I buy the argument that DOs primarily serve underserved populations based on residency location. 

Several of the DO residencies I am familiar with are actually suburbs. Wealthy ones at that. While not specifically in the "big city" were it not for the signs telling you that you were in a different city, you would never know.

I will concede I have seen more DO practices in rural America, but not on a very massive scale. Probably only 1.5-2.0 : 1

I would say I have seen the lagest DO concentraions in the suburbs. With the largest MD concentrations in major cities. I would argue that inner city populations are just as underserved as rural communities, and certainly suburbs are not in danger of underservice. 

So while at one time DOs may have put their money where there mouth is, I don't find that compelling today.

But it doesn't mean I think any less of them. 

But if you were to base your entire value on that and justify lesser qualifications for the same level of practice and billing as a physician on altruisitc reasons when the sole motivation was education cost/time:income ratio, then we would have a quarrel.


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## BSE (Feb 13, 2013)

Veneficus said:


> In my time on this board I have seen all manner of arguments for the mid level provider. Especially physician Assistants. (or arew they calling themselves associates now?)
> 
> Some of the more respected members here who have chosen a mid level  path have valiently defended it posting studies from every nursing association, PA association, and all manner of biased sources.
> 
> ...




Brevity isn't your thing eh?  You have yet to state one fact.  Good luck to you in whatever you do.  Sorry you have such a bad opinion of PA's...guess I'll have to live with that.  Don't worry...I'm not crushed.


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## Veneficus (Feb 13, 2013)

*to those still following*

Really? Nobody on this tread stated that. It was implied that a PA (not MD) doesn't need the full course....you see, this is why PA's work with physicians. The Doc is the one who has full depth and can help the PA when they encounter something they are stumped on. It's called working together.

*Tell your colleagues, not me, do a youtube search and see some of the crap actually videoed by PA students and PAs on it. *

*I would have a much better opinion of them if this is what I was hearing from them instead of the constant BS. So far in my >20 years, the only one I have heard this from is you. *

There really isn't a movement for independent practice for PA's....NP's, not PA's. Opinions of the few shouldn't cloud you on this. The AAPA is adamant on this topic...PA's are not solely independent. Where are you getting your info....I have a feeling this is a very jaded speculation.

*Mostly from PA and CRNA students here. But there is usually an article or two in my medical news sources I run across every week.* 

What propaganda? The only one spewing propaganda is you...???

*Use the search function, turn on the TV, read the news. Again, I don't sit here wondering how I can pick on PAs. I hear the lies from somewhere. I can also call a spade a spade, so childish as you may see it, and certainly not flattering, it still is accurate.*

I've been in healthcare for 20 years, I have never heard of this happening. Speculation....again.

*That is my point. What is adverted to patients and policy makers is different from reality. At best it is 2 faced. That is not childish, it is a terrible thing known as the truth.*

Same as the MD's, most folks go where the money is. To humor you, according to the AAPA, approx 35% of PA's work rural/underserved.

*So about 1/3 I find that staggeringly low, especially based on their propaganda and how many I have encountered in academic medical institutions*. 

*But this is exaclty my point, the PA is a lesser trained, lesser skilled substitute chasing money over dedication to medicine. That mercenary attitude is exactly what leads to poor patient care and a bloated unsustainable medical system. Whether it is from a doctor or a PA. *

*I would find it a lot more palatable to just advert: "I am here for the money, patient care is secondary concern." I wouldn't like to hear it, but prefer the truth. *

Competing for money? You do realize most PA's are hired by MD's? Right? From the BLS, 70% of PA's directly for an MD. 

*Do you realize that every PA hired takes away the demand to train more doctors? To pay more doctors? Do you realize it directly takes away moonlighting spots for junior doctors? Who could follow guidlines just as well as you, consulting as necessary and getting paid more? Every PA spot is a residency spot. Every residency spot is a medical school spot. And all of those are fully trained doctors caring for patients.*

*Perhaps you realize it supports the postion of the very doctors who created a physician shortage in order to justify their outrageous and unsustainable salaries? Perhaps you  realize those are the same professors paid by medical school which cause student debt so high there is actually a tracked suicide rate for it specifically for those in medicine from student to attending?*

*Perhaps you realize that if given the choice, a patent might actually want to see the doctor? After all, didn't somebody in this thread state he would rather see the doctor but didn't want to wait? Do you think that is a lone sentiment?*

Here is where it gets sticky. If a patient sees me for a sore throat and I dx strep and give the appropriate abx...didn't I do the exact same thing as an MD? It's work paid for the work done. Doesn't matter though, PA's generally are billed at an 80% rate. This can be argued both ways.

*Work paid for work done. Outstanding. So should a paramedic be paid as an anesthesiologist everytime they intubate? RSI? How about as a cardiologist for interpreting 12 leads? Is is the argument of a labor mentality. I didn't lay any bricks today, I must have done no work.* 

Ummm, you're getting repetitive...PA's are not MD's...PA's seem to know this....why don't you?

*Hang around here, not too many of them seem to.*

Ummm, the high ground. I am a Paramedic transitioning to PA. Oh, you really won't find too many of those threads on a PA forum. PA's tend to know they are tied to MD's...and are ok with it.

*I am not claiming the highground, just introspection. I also must apologize because I am not wasting time searching out propaganda, I don't sit around making this stuff up, I hear it, and I acknowledge it as such. *

*I believe somebody here already posted a link about PA in CA claiming the right to more independance.*


Brevity isn't your thing eh? You have yet to state one fact. 

*I often repeat my thoughts because the format here coupled with my often having to leave and come back to what I am typing. Sorry, People don't seem to mind. I also find that I have to use a lot fo words to explain complex issues.*

*I also don't see things as disconnected. So when there are PA students who show up in one thread, they may not understand that my opinions are collective of my total experience, and not just here. *

*If you do a search I know Mr. Otto has posted studies on the outcomes associated with PAs, perhaps he might help you find them? I actually get a lot of my information from him (Though I am probably not interpreting it in a way he would like)*


----------



## BSE (Feb 13, 2013)

Again, not a single fact, that is verifiable.  Even your mention of the proposal in California is wrong.  I take it you didn't read it? *Hint, you should be nodding your head in agreement.  It was about independent practice for NP's....not PA's.  The only mention of PA's had to do with supervision rules....that are not going away.

Although you did make me laugh.....all those poor out of work MD's because of those "scab" PA's.:rofl:  I could say, you mean those poor MD's that didn't place in anything other than FM and are PO'ed that they aren't making $300K like their specialty friends...but that would be awfully cynical.

You are using youtube videos as your sources of information.  Really?  You are a man of science....you should know better.  :unsure:

No hard feeling...really.  You are entitled to your opinions.  Don't hire a PA if you are a Doc.  I won't lack for employers.


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## Brandon O (Feb 13, 2013)

Veneficus said:


> *If you do a search I know Mr. Otto has posted studies on the outcomes associated with PAs, perhaps he might help you find them? I actually get a lot of my information from him (Though I am probably not interpreting it in a way he would like)*



You must mean me, but I didn't. I try to stay out of this, since it's clearly about us and not about taking care of people. The only pertinent studies would be comparing the predictive value of post-nominal initials for genital size.


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## JPINFV (Feb 13, 2013)

Veneficus said:


> While I support MD/DO as being entirely equal, and you are preaching to the choir, I am not so sure I buy the argument that DOs primarily serve underserved populations based on residency location.



I was mentioning that from a historical stance, not from a current stance. As it is now, I'd argue that DOs, especially since a significant number of people go to DO because they weren't accepted at an MD school, are just as likely to go wherever they want than to specifically serve an underserved area.


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## ffemt8978 (Feb 13, 2013)




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