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Everything posted by ralk

  1. Didn't see that the CaRMS stats were out until now, a few weeks after the fact, but wanted to get a competitiveness breakdown out there, particularly given the difficulties experienced with this year's match. I've attached the full data set, but wanted to highlight the larger specialties directly here as well as offer a few comments. As always, my preferred metric for competitiveness is the percentage of individuals who rank a specialty first overall who match to that specialty. Those matching to an alternative discipline are also listed, as it provides a sense of how easy it is to back-up to another specialty when shooting for a particular first choice specialty. This metric is not a perfect representation of competitiveness, nor is it the only one available, but given available stats I believe it has the most value to those approaching the match and deciding on their CaRMS strategies. All stats are for the 1st iteration and for CMGs only. First Choice Discipline Percent Matching to Discipline Percent Match to Alternative Discipline Percent Unmatched Family Medicine 96.4% 1.0% 2.6% Internal Medicine 88.9% 9.1% 1.9% Diagnostic Radiology 88.9% 6.2% 4.9% Psychiatry 85.8% 9.0% 5.3% Anatomical Pathology 84.2% 7.9% 7.9% Physical Medicine & Rehabilitation 83.9% 12.9% 3.2% Orthopedic Surgery 80.4% 3.6% 16.1% Radiation Oncology 77.8% 14.8% 7.4% Pediatrics 77.6% 19.9% 2.6% Neurology 76.4% 16.4% 7.3% Neurosurgery 69.2% 11.5% 19.2% Anesthesiology 68.5% 21.2% 10.3% General Surgery 63.6% 10.8% 25.6% Obstetrics and Gynecology 63.4% 28.6% 8.0% Urology 58.3% 25.0% 16.7% Ophthalmology 52.1% 29.6% 18.3% Emergency Medicine 50.4% 37.4% 12.2% Otolaryngology 47.2% 22.6% 30.2% Dermatology 43.3% 48.3% 8.3% Plastic Surgery 34.6% 23.1% 42.3% A few thoughts on these numbers: 1) Across the board, a competitive year for surgical disciplines. These specialties have slowly been losing residency spots due to their generally poor job markets, but demand seems to have largely stayed put despite this, driving competition up. With over a quarter of people applying to Gen Sx, ENT, and Plastics going outright unmatched in the first round, and over 15% in pretty much all other surgical disciplines speaks to the risks involved going down that career path. To be a surgeon these days, you've got to really want it, and fight for your spot. 2) By contrast, certain moderate and high competitiveness specialties can be rather safe with an appropriate back-up plan. Derm and OBGYN have overall combined match rates (first choice + alternative) close to the weighted average of all specialties. More people who picked Derm first ended up in a back-up specialty than in Derm itself, a figure fairly consistent with previous years. Part of this may be driven by those with weak interest in the field - say a person who is essentially going for FM but taking a long-shot on a Derm program on the off-chance it works out - but considering that obtaining a Derm interview in the first place isn't a guarantee, I think there's something to be taken away by those specific numbers. 3) Likewise, two specialties this year had a combined match rate better than FM, generally considered the safe specialty to apply to - namely, IM and Peds. Here I do think individual circumstances play a role that prevents a simple interpretation of these numbers, as those who pick FM first tend to apply less broadly than those going for specialties, and most of those backing up from IM and Peds will end up in FM. Still, there was a growing inclination that Peds and increasingly IM were competitive enough that you had to gun for them like you would a surgical specialty, ignoring a back-up entirely, and I don't think that's true at all. Back-ups remain viable, especially in these specialties, if approached correctly. 4) Rads continues on the pathway towards non-competitiveness, a journey it's been on in fits and spurts for half a decade now. As someone who gave Rads a good hard look in pre-clerkship without ever really coming around to the field, I'd be very interested in exploring what's driving this trend. My guess is a combination of increasing work requirements, slowly declining incomes (though still exceptionally high, even by doctor standards), and a growing medical student preference for patient contact are the main drivers, but even that seems like it's missing something. 5) As was already apparent, this was a rough match overall. Too many left without a residency position after the first round and as is now being exposed, medical schools and provincial governments had no real plan to address this. Now that the dust has settled, the last-minute efforts to provide emergency residency spots in Ontario, plus the military opening up additional spots after the match, have helped improve the immediate crisis. Yet, the underlying math of the situation has yet to really change. As we approach the time when the final residency numbers get set, here's hoping some more wiggle room enters the system. While the vast majority of graduating CMGs will have a good outcome, even if nothing changes, that bad outcomes for a small subset are now virtually assured is very concerning. For all those reading, please remember that unmatched CMGs are more than ever victims of circumstance and should not automatically be considered weaker or flawed candidates. One mildly frustrating change with the reported stats this year is that CaRMS has not provided the numbers for people who match to a given specialty when it is not their first choice. That makes it harder to identify specialties that are good options to back-up into, though I strongly suspect this continues to be FM and IM. Lastly, a few caveats on the data above. First, this works off of first choice rankings, which are not always straight-forward. Some individuals will put a single program in one specialty followed by a ton in a second. Some will want a particular specialty but get no interviews and be left with only their back-up options to rank first. Many will apply in a limited geographic area, or generally utilize a bad match strategy which results in them going unmatched for reasons that have little to do with their chosen specialty's competitiveness. Second, while I have listed all specialties in the excel spreadsheet attached, please interpret the smaller ones with caution. Lots of variability in these specialties year-to-year that make definitive conclusions almost impossible. Finally, some specialties have chosen to offer streams with slight differences from the standard program - such as those with an academic or research focus - that appear as a completely separate CaRMS discipline in the stats. This makes interpretation of these specialties much more complex, as these slightly different streams undoubtedly share the main applicant pool as their main streams. This means if someone wants, say, a Clinician Investigator Program as their first choice but would be perfectly happy with just the normal stream, if they end up matching to that normal stream, they're automatically shown as falling into a "second choice" program, even when they really didn't. This is particularly bothersome for the Public Health programs, which are split between "Public Health and Preventive Medicine" and "Public Health and Preventive Medicine including Family Medicine", but are essentially the same specialty. Same could be said of the lab-based programs, which are shades of the same thing under different names. There's not nearly enough transparency in residency matching and these shenanigans make what little data we have even worse. If I've gotten anything wrong with the numbers, please let me know and I'll correct it ASAP. I try to double-check things but something can always slip through and sometimes the source material gets things wrong too. CaRMS stats 2018 First Round.xlsx
  2. Match rate's below 90%. These days I'd call pretty much every specialty besides FM and a few smaller unique specialties moderately competitive or worse.
  3. Absolutely. Being geography-constrained and going for competitive specialties still means a risky match overall, but by focusing heavily on only a few programs (especially if it's at the home school), it opens up some back-up options that might not be as feasible when applying cross-country for the 1st choice specialty.
  4. Quick update - when I first made this post, CaRMS data on specialties that applicants back up into was essentially missed. CaRMS has since updated the numbers, so I think a quick dig into those is worthwhile. About 360 people backed up into a specialty - that is, they matched to a specialty that wasn't the one they ranked the highest. Over those, 290 backed up into either FM (228 applicants) or IM (62 applicants). Another handful backed up into the larger, moderately competitive specialties (11 to Psych, 10 to Peds), with scattered numbers elsewhere. The highly competitive specialties like Derm essentially have no one backing up into them, as could be expected. Split specialties that are essentially the same once again skew the numbers here a bit, such as with the research track programs, likely account for about 10 of the remaining slots and I'd call these backing up in name only. All told, the situation is essentially the same as it has been for years - if you want to back up, chances are you'll be backing up with FM or IM. There's always a shot at backing-up to some other specialties - even relatively competitive specialties like Gen Sx and OBGYN get a few every year - but it's a riskier option and personal circumstances are likely major factors in walking that tightrope that public data just can't reveal. Overall, backing up remains a viable option for a lot of people who would be comfortable with something like FM or IM as a 2nd or 3rd choice option, so long as they approach their electives planning and CaRMS match strategically.
  5. Na, you're fine. Practice good gun safety and tell your patients to do the same when it's relevant, otherwise it shouldn't have any impact on your career.
  6. Yeah, that's a tough spot. Polite persistence is what I would recommend. Be direct in asking what you're looking for, whether that's a chance to get further into the research project or clinical opportunities. Often these preceptors won't say "no" to any requests, but will try to string you along with vague promises or by saying they'd like to but can't for whatever reason. They want you to keep working for them. Just keep asking. They can't take you along with them in clinic? That's fine, do they have a colleague who would be willing? They'd love to go over your research questions but never sit down to do it? Ask when, provide times. None of those times work? Give a bunch more. Get them to set timelines and firm commitments. When they go past their timelines to get back to you, send them another message reminding them of your earlier discussion. Do it politely, do it respectfully, and don't do it excessively (for example, if they ask for a week to get back to you, give them at least that week), but do it persistently. Don't avoid being a nuisance, just be a reasonable nuisance. My first real research supervisor was an incredibly busy person who was upfront about telling me to annoy them. Best research advice I ever got. It is a bit of a balancing act, as it's possible to go to far, but doing nothing gets you ignored. Keep holding up your half of the deal (do the scut work and do it well) while gently pushing them do hold up their implicit end of it. If in doubt, start slow and ramp up as necessary.
  7. Even if your main role is scut work, that doesn't eliminate other opportunities with this group, but you'll likely have to show additional initiative. Approach the group that you're working for and tell them what your goals are - namely, that you'd like to learn more about the field and that you'd like to learn more about all parts of research, not just the part that you're currently assigned. Depending on their receptiveness, offering to help with analysis and/or manuscript writing could be worthwhile as well. At the early stages, most research opportunities unfortunately involve a lot of scut work. That's a big part of what research is these days. Most preceptors should be willing to trade that scut work for opportunities to learn though, especially for those that show interest. There are those that don't, who just take advantage of students for free labour, and all you can do in that situation is learn that lesson, get out of working for those people ASAP and pick future opportunities more carefully.
  8. If someone applied to both Derm and FM (and wanted Derm first), but didn't get any Derm interviews, they're not likely to rank any Derm programs (even though there's no downside to doing so). Rather, I'd expect most students in this position to start their rankings with FM. In this case, their "first choice" would be considered FM, not Derm, and while I don't think this is an overly common situation, it would skew the stats somewhat to make Derm look less competitive than it actually is.
  9. FM has some specific mental health/therapy billing codes. Don't think they're anywhere near as lucrative as the psych codes though, they just help bridge the gap caused by the fact that mental health visits often take quite a bit of time and so would be a major cost if we could only bill the same as a regular visit (which are much, much faster).
  10. I think that rationale works for residency, but not for medical school. Larger centres have more responsibility for rarer or more unique cases, but these cases aren't high-yield learning cases at the medical student level, where the focus is still rightfully on the bread-and-butter cases. Furthermore, at larger centres, there are far more learners ahead of you in the form of residents and fellows for those unique cases. To the extent a medical student might get more variety of cases in a larger centre, it's by sitting in a corner behind the 4 other people in the room. Meanwhile the student at the smaller centre is learning the important day-to-day cases directly with a staff person, maybe with a single resident ahead of them at worst. To the extent getting into those rarer cases matters, it's during electives, which can be done anywhere regardless of home site. Clerkship is about getting the basics down. No one cares if you can correctly identify a rare genetic disorder that a sub-specialist sees once in their career if you can't read an ECG, or have a good differential for abdominal pain, or treat a COPD exacerbation. The weird stuff is for residency and fellowships.
  11. I've done "MD Candidate". Don't think it's ever been a problem, even in professional communications. "Medical Student" just seems weird to me as a professional sign-off.
  12. ralk

    Switching out of Rural Fm

    If acute care has been of interest and you've enjoyed your time in emerg, why not try for the +1 in EM? Transferring may be an option, but if you're just coming to the end of PGY-1, you may running out of time for that to happen. Not saying you shouldn't explore that option, especially with what seems to be a decent interest in IM, but for FM residents the main time for that to happen is at the end of the PGY-1 year.
  13. If you come across a relevant question where bringing up what you went through would be a meaningful part of honest and thorough answer, I'd say you shouldn't feel the need to shy away from telling this part of your personal journey towards a career in medicine. Especially considering the growth you've shown in response to it, I would be very surprised (and deeply disappointed) if it were in any way held against you. By the same token, however, don't feel that not talking about this part of your life is somehow deceptive towards interviewers. I'd go even further and suggest that you not go out of your way to disclose what you went through, not because I think it'll stigmatize you, but rather because doing so can land you into a bit of classic trap interviewees frequently fall into - drawing attention to aspects of your story important to you, rather than the aspects important to their interviewers. The key part of your story to sell is that you proactively took on an advocacy role and provided support for a group of victims. As an interviewer, while I do care about the motivation behind those actions, it's by far a secondary consideration - I would still think highly of what you've done if you hadn't been assaulted, even while acknowledging the strength it takes to turn such a negative experience into positive action.
  14. Dr. McInnes has been beating this drum for a while, to the point of asking for undergrad marks from applicants as part of their assessment. I think importantly, they've had the power to make positive changes and haven't. He's rallied against subjective or vague criteria, but has never provided transparency as to how they select their residents, especially specifics on how they select one candidate over another, despite clearly having a formalized metric for doing so. There's also nothing against programs testing their applicants' knowledge base, which they could do if it is of such paramount importance. There are good reasons we moved to a pass/fail system - it meant a heavy focus on information of limited clinical value, emphasized short-term knowledge acquisition, and contributed to student stress and burnout as result. I'm sympathetic to the idea of standardized testing, which at least means less-frequent stressors in evaluating knowledge, but I'd argue we need something a lot better than the LMCC, which functions reasonably well as a pass/fail test, but tests a lot of extraneous or useless knowledge. There's also an issue of stratifying physicians by specialty on the basis of a single test result, as is done in the US - we've made a lot of progress to get strong medical students into traditionally lower-competitive specialties like FM, IM, and Psychiatry, and pushing applicants with weaker test scores into those professions by barring them from more competitive ones works against those efforts. Overall, such testing may allow program directors to better identify the best students, but may be counterproductive to producing the best students.
  15. So... your response to a study in the Journal of the American Medical Association is a non-peer reviewed website... saying that garlic supplements work... that just happens to sell products related to supplement use. When we talk about levels of evidence and likelihood for bias, pretty sure peer reviewed RCT in high-impact journal trumps non-peer reviewed summaries in an unaffiliated website with profit motive. Even the individual citations are not overly impressive. One of the RCTs used in their "high evidence" conclusions says in the abstract "Since Allicor [the garlic product being studied] is the remedy of natural origin, it is safe with the respect to adverse effects and allows even perpetual administration". One of their citations is to Scientific American, not a scientific journal, but a popular science magazine. (As an aside for those simply reading along, I don't want to demonize Examine.com too harshly. Compared to similar sites, it certainly is closer to an evidence-based framework and to its credit, does not seem to be directly selling the products they're recommending. Still, being better is not the same as being good, and they're making many recommendations that I would strongly argue are not in keeping with best available evidence. Be careful what you read on the internet folks, including here!) There's also a reason I asked for tumeric articles rather than garlic. Despite my criticisms above, there is some evidence for garlic as an intervention. It's far too weak and inconsistent to recommend on a regular basis for any medical conditions, and side-effect profiles are still suspect, so it shouldn't be recommended in clinical practice. Most of these studies are against placebos too, rather than against gold-standard medications with proven clinical efficacy. I can also point to studies that more directly back-up such my assertion that garlic shouldn't be recommended based on current available evidence - here's a Cochrane review that looked at the topic, for example. This is why I've asked people to provide studies showing that NPs are worse than FPs - I'm looking for contrasting literature. The best argument against poor studies is good studies, not no studies. I guess I won't be asking you for a reference then? If you're going to join the discussion, is it too much to ask that you contribute constructively, rather than post a personal attack in isolation? If this is your opinion, please, explain why you think I'm undermining my specialty, because that's the opposite of what I'm trying to do. I want strong primary care and especially strong family physicians. I just think we're on the wrong path to get there.
  16. I fully agree, if the outcomes were patient life expectancy, then there's no way a study can be sufficiently powered to address such an outcome. Likewise, I agree that if an outcome is patient satisfaction, especially in isolation, that's not a particularly meaningful outcome - patient satisfaction is a complex issue and I have rather mixed opinions on it, but to save myself from writing yet another essay, I'll simply say that I too would largely ignore any study simply showing equivalent patient satisfaction scores. However, to repeat myself, I would encourage everyone reading this thread to actually read the studies, or at least skim them over. Many of the metrics investigated are clinically-relevant process measures. Outcomes like ER visits matter to me, as I spend a fair bit of my time trying to keep patients out of the ER. And I agree, there's nuance here that's tough to sort out, but that's why I think it's important to dig into that nuance rather than paint in broad strokes, especially when it comes to dismissing an entire profession outright. Like, when I see a JAMA article, I don't expect the research to be anywhere close to perfect or a final evaluation of a subject, but it's usually a safe bet that they at least investigated a clinically-meaningful outcome and that their study is appropriately powered to support any conclusions made, which speaks to the two concerns you've expressed. And looking through the article I can't find fault on those issues at least - they looked at outcomes I think are important, and the sample size on first glance appears sufficiently large to draw some tentative conclusions from.
  17. I apologize, I wanted to respond to this earlier but didn't have the time. You bring up some good points. I do think it's fair to say that criticisms within the profession will be used by outside bodies with ulterior motives to further agendas against the profession. However, I think that's always going to be the case - there's always going to be some sort of publicly-relevant negotiation, or legal battle, or funding issue - and if we never engage in any self-criticism within the profession or reign in our worst impulses, we're going to aid those with ulterior motives even further. There's historical precedent for this and it's part of what makes me very wary of the path we're going down, particularly in Ontario. Right now physicians in Ontario are facing government actions at the provincial and federal level that will hurt physician finances, potentially impact autonomy, in the context of poor overall public support for physicians, and as a result Ontario physicians are considering job actions. This isn't a new script. In the 1980's, Canada eliminated extra-billing for publicly insured services, and Ontario's physicians eventually went on strike as a result, perceiving the cut as an affront to their autonomy and financially unjustified. Physicians lost, hard. Public opinion, which was never in the corner of physicians, worsened further, and eventually the strike ended with virtually no meaningful concessions to physicians. The decade that followed was not good for physicians - incomes were low by historical standards, a lot of people left for the US, even medical school spots were cut and held down until the turn of the millennium. The resulting overwork and gaps in care that that caused eventually led to incomes rising again, as well as a rapid expansion in medical school positions since 2000 until about 2010 when both income and number of medical spots stalled. The shortages of the 1990's led to openings for groups like NPs to come in, as their entrance into the mainstream of medical care coincides with that expansion of medical school spots in the early 2000's. It's far from a direct line from one action to another - I wouldn't claim full causation here, which is tricky with any historical example - but it's hard not to spot the correlation between these events that seriously weakened physician public opinion and a period where physicians appeared powerless to fight major changes to the medical system that negatively impacted both us and patients. It wasn't internal criticism that has brought the profession's power down in the past, it was an over-willingness to fight unpopular battles. I'd like to avoid a repeat of history here, and that means reigning in our worst impulses, presenting a positive story of change and improvement within the profession to the public, and picking our battles carefully. To the extent there should be a fight between us and other professions, I have to note that as they are now on issues like taxation benefits, nursing associations came out against the 1986 physician strike. When nurses feel comfortable enough to actively come out against physicians, it should tell us how weak our position actually is - they smell blood in the water. And they're pressing that advantage too, with RNs (not NPs, RNs) now on the edge of getting the right to prescribe medications, something that absolutely should concern every physician.
  18. I'd counter that several of the studies do include complex patients within their investigated populations. They don't look exclusively at complex patients, but that's because no primary care provider has only complex patients - rather, most patients in any primary care setting are not particularly complex, including those under the care of FPs, and the health outcomes of non-complex patients are still very important measures. Again, these studies have their flaws, as most studies do. As I've said, the best evidence is for NPs working in collaboration with physicians. If it is the case that FPs can handle complex patients that NPs can't, this provides cover for that while still employing NPs to expand access. But having flawed evidence, and understanding those flaws to add nuance to conclusions, is a far cry above rejecting any evidence that contradicts a viewpoint because that rejection of the evidence is more convenient than changing that viewpoint. And that's what some posters here have done. When medigeek proclaims that they can find better studies on tumeric than on the value of NPs, then failing to provide them, it shows that the criticism of these studies is reflective of their bias, meant as a smokescreen to confuse the issue and allow them to maintain their previously-held beliefs.
  19. I'll repeat myself - where's your evidence? You keep making assertions, but not backing them up with anything besides your own viewpoint. These articles did attempt to control for complexity, despite your statements to the contrary. I'm still waiting for your tumeric articles.
  20. Let's talk about bias. Many in this thread are quick to call out the published studies for potential bias. That's fair, and as I said earlier, it's important to take these studies with a grain of salt, as well as to recognize their limitations. As most of these studies address NP performance in collaboration with physicians, I do think it's reasonable to push back against things like NP-led clinics in favour of those better-studied collaborative models, again with the caveat that we as physicians make a concerted effort to address the underlying reason for those NP-led clinics coming to be created in the first place, which is a lack of availability to adequate primary care. But bias runs both ways. In completely dismissing peer-reviewed literature, you and other posters in this thread have put anecdotes and personal observations as the basis for your opinion. So when talking about the "standards of our profession", let me ask you - in the hierarchy of evidence, where to systematic reviews and RCTs stand in comparison to anecdotes or expert opinion? Which is more prone to bias? That's part of my point here. Physicians are quick to blame, attack, denigrate, or malign other actors in the healthcare system for lowering the standards of medical care, but we don't hold ourselves accountable. FPs (and specialists) order unnecessary tests, over-prescribe, misdiagnose, and over-refer all the time and we as physicians don't lift a finger to stop that. But when an NP does it suddenly we should take swift and decisive action not just to correct that behaviour, but to limit the very notion of NPs. I've seen physicians bill inappropriately, practice outside of their training, prescribe medications that they shouldn't to people they shouldn't in non-clinical settings when they shouldn't. And when any group try to address these problems - the CPSO, the Ministry of Health, local hospitals, even patient advocacy groups - sure enough physicians rise up in anger at this horrible affront to their autonomy to enforce what should be basic ethical principles of our profession. I see medical students and residents get promoted through various stages of training and eventually graduating despite struggling to manage those complex patients everyone here seems to be worried about landing in an NP's lap, and I've been told that I'm qualified to do a procedure independently that I've seen - not done, seen - once, because that's considered acceptable for some reason. We do have a duty to uphold the standards of our profession, but that starts with us. And on that front, we have been failing, and failing for quite some time. All the ways in which the profession has been degraded - the loss of admiration from our patients, the loss of respect from the public, the loss of clout within the healthcare system - all this stems from our profession's own actions. I agree, allowing NPs to do what physicians do is our failure. It's our failure because we held ourselves as the ultimate authority in medical care, and when medical care stopped living up to expectations, we failed to close that gap. That opened the door for others to fill it for us. Yet, by attacking NPs, all we'd be proposing to do is open that gap back up. That's not going to work. If the goal really is to push NPs or other mid-levels out, we need to close those gaps ourselves. We can do this by strengthening both our standards as well as physicians' adherence to those standards. We can do it by making much more of an effort to get physicians into the communities that are lacking appropriate care, even if that means getting physicians to work in settings they'd prefer not to. We can do it by raising our education standards to take better advantage of our longer training times, so that we someone goes to study the differences between physician competency and those of other providers, there's no ambiguity - we would be clearly superior. But these actions take a degree of humility, a willingness to admit fault, and an acceptance of certain sacrifices to improve the profession. I have yet to see that sentiment from anything but a small minority of physicians. Instead, we get vocal physician groups proclaiming that our profession is under siege by countless external forces. This misdiagnosis the problem, and so gets the solution wrong. The problems of the physician profession are internal. The external stressors on medicine as a profession are simply reactions to those internal problems - to be sure, some of those stressors are opportunistic, some are malicious, but all are reactions to our own failings. We can knock down groups like NPs, but that's just going to open the door for other changes we don't like to be enforced upon us - and those other changes might not be as benign as accepting a group of practitioners that at least have some evidence to support their merits to practice... You can't be held liable for another independent practitioner's actions. If an NP refers to you for a second opinion, you're responsible for that second opinion, but not for the actions of the NP unless there is a previously agreed upon supervisory role. This is no different than if another FP referred to you for a second opinion. This is a major part of the reason I'm much more comfortable with NPs than PAs. NPs work off their own license, while PAs work off their supervising physician's license.
  21. ralk

    FM + 1 EM ... where to start

    Can't say I've heard of that requirement, do you have a source for that? The linked CPSO document clearly states that it does not apply to rural FM residents with significant ED training, and makes no mention of a file review for such residents.
  22. ralk

    FM + 1 EM ... where to start

    Plenty of exceptions here, fortunately. Those who trained as residents in rural settings with a reasonable amount of ER experience, working in a similar setting with the same level of ER requirements, are exempted, for example. I think the idea is to prevent people training in urban centres with minimal ER training to simply jump into a rural ER for which they're really not qualified to work in. That makes sense to me and in many ways is already part of our guidelines (don't do things you're not qualified to do), this just removes the grey area for this specific circumstance.
  23. Haha, yeah that's fair Edited the post with pubmed links, should work now. That's what I get for posting in a rush on my way out the door.
  24. Can't say I'm aware of any physician model that demands the patients be cut off after a certain period of time. We choose to see patients faster because it pays us better. And please actually read the research before criticizing it... here's two studies that have more than half the authors as MDs - https://www.ncbi.nlm.nih.gov/pubmed/26480967 and https://www.ncbi.nlm.nih.gov/pubmed/28455091 - the first one's actually pretty interesting, showing some small deficiencies in NPs, though the authors conclude those differences are minor. And here's a JAMA article with the 2nd author being one of several MDs on the paper. https://www.ncbi.nlm.nih.gov/pubmed/10632281 - but then, JAMA's a pretty trash journal that only produces garbage articles, so I guess this doesn't count. I look forward to seeing your 10 articles on tumeric.
  25. So, the patient populations compared in the studies I've seen were identical. That's kind of the point of an RCT. Baseline characteristics were the same. And the points being looked at are typically the common conditions - HTN, diabetes, asthma - unless my medical training is a whole lot worse than I thought, I was under the impression that managing these well was kinda useful to a patient's long-term health. Also, is there something wrong with getting patients to exercise more and eat better, or that taking the time to make that happen is a bad thing? Getting someone to control their own health through lifestyle changes is pretty much the best win I can get with a patient... You're right, NPs do write a disproportionate number of these studies, and they can therefore be prone to bias. I wouldn't take any one of these studies as sacrosanct, especially in isolation. However, several of them were done with physicians as part of the investigating team, and published in journals that are run by physicians. And while NPs are certainly capable of doing such research, guess who else can do research and might have a vested interest in producing research that shows physicians are better than NPs? Doctors! And in other cases where potential competitors have produced flawed studies supporting their personal work, we've done just that, showing the relative non-benefits of a whole host of alternative medicine practitioners, including chiropractors, naturopaths, and accupuncturists. Midwifery was mentioned earlier in this thread, and that too can be taken down a peg, as we can clearly show research indicating that home births are not as safe as hospital births. Yet I can't find similar work for NPs. With as much antipathy towards them as seems to exist among physicians, you'd think someone would bother to run a study refuting the current research on NPs if it was believed to be that biased. I haven't found one - again, please, if you've got a decent study hiding somewhere, please share it. I base my views on the best available research and change my opinion accordingly when new research comes to light. The fact that I haven't found any tells me one of two things. Either no physician or physician group has done such research, despite being ready to take on NPs head on, or they have done the research and it hasn't shown what they were hoping for. As to the last point, how well is that working out? Have opinions of NPs on either side of the border fallen? Have those of physicians risen? Have NP numbers dropped? Again, unless you have data I haven't seen, it certainly doesn't seem like it. Putting aside the merits of NPs and whether their inclusion in the healthcare system should be supported or opposed by physicians, that in particular is a bad strategy.