Paramedic Practitioners

[EpiEMS]

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

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

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

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

 

[EpiEMS]

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

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

I'm only withholding judgement one way or the other until I see good data or serious problems, one or both (preferably just good data). I tend to think that for most patients, a PA or NP will provide good care, and probably equivalent care to the MD/DO. I can say with a fair amount of surety that more patients can be seen, and they can be seen quicker (and often cheaper) if we have more PAs and NPs.

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

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

 

[Arovetli]

I'm only withholding judgement one way or the other until I see good data or serious problems, one or both (preferably just good data). I tend to think that for most patients, a PA or NP will provide good care, and probably equivalent care to the MD/DO. I can say with a fair amount of surety that more patients can be seen, and they can be seen quicker (and often cheaper) if we have more PAs and NPs.

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

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

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

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

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

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

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


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

 

[Arovetli]

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

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

 

[Veneficus]

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

legally, yes.

capable? I have my doubts.

 

[wildmed]

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

 

[Arovetli]

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

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

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

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

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

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

But I am really starting to digress now.

 

[EpiEMS]

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

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

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

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

 

[Arovetli]

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

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

Less assistants and more of the real deal I say.

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

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

 

[Veneficus]

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

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

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

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

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

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

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

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

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

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

 

[Arovetli]

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

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

 

[Arovetli]

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

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

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

 

[Arovetli]

Hypothetical question.

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

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

 

[kindofafireguy]

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

 

[Arovetli]

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

GRE for entry and PANCE for exit.

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

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

 

[kindofafireguy]

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

 

[medicsb]

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

 

[EpiEMS]

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

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

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

 

[wildmed]

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

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

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

 

[fma08]

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