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medigeek

Ontario to fund new residency spots with return of service requirements

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51 minutes ago, crysally said:

Our school has given us a list of internal spots. Sounds like the plan is to match available spots internally first, then open it up provincially.

The lack of transparency and secrecy with different students/ schools giving different information seems like it could be quite nerve-wracking. 

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37 minutes ago, JohnGrisham said:

The lack of transparency and secrecy with different students/ schools giving different information seems like it could be quite nerve-wracking. 

Yup! Havent heard from my school. 

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2 hours ago, LittleDaisy said:

I have seen a few NPs working independently in GTA with no physician supervision, billing FFS and sending referrals and <<rostering>> patients under their names. The majority of newly grad NPs want to work in urban area or work in academic FHT or academic hospitals, which is oversaturated with physicians regardless.

The underserved population in rural area, represents the aging and medically complex patients, who have far too many medical comorbidities, and in my humble opinion, would truly benefit from a physician to advocate and manage them holistically. In my humble opinion, NPs with undergrad mainly focused on taking care of patients with basic pathophysiology, with 2 years of master which is far less rigorous and in-depth as family medicine residency,

Having NPs taking care of medically complex patients often result in over-referrals to specialisits, which in long run, cost much more to our health system, or inappropriate care of medically complex aging patients. In short term, the government seems to like the idea of training NPs to cater the population <<needs>> and cut down costs (costs  less than a GP). In long term, the majority of NPs leave the underserved areas and want to practice in urban areas or practice in a very specific field, which do not meet the objective of serving underserved population.

In my humble opinion, qualifying NP to work independently as a family physician with 2 year of master is an oversimpliciation of primary care, I am surprised that the College of Family Physicians hasn;t acted upon the qualification of NPs. In long term, no one predicts that the government would allocate more fundings to train NPs who act as GP with less costs?

So, that first part is just not true. NPs can't bill FFS, they don't have the right to bill OHIP directly. They can send referrals, they can roster patients (depending on their set-up), and like many physicians it wouldn't surprise me if they had to shadow bill, but they cannot bill FFS as an FP would in Ontario. NPs can't work in downtown Toronto unless a position is provided for them, they can't just move there and set up shop. The Ontario government has far more say over where NPs work than they do over where FPs work.

I'm not aware of any data to back up your assertion that the majority of NPs leave underserviced areas. At best, I can find NP statistics by LHIN, which appear to show a relatively stable distribution across the province. And while I'd also prefer to have FPs available for all patients who need one, especially in underserviced areas, that clearly hasn't been happening and I haven't seen much enthusiasm from physician groups to push for changes that would make this more likely to happen. If anything, in Ontario at least, we've clearly seen the opposite.

You've used the phrase "in my humble opinion" three times in your response, but it's at odds with best available evidence - flawed evidence, no doubt, but still best available - for the sake of personal anecdotes, and to be blunt, is an opinion that isn't particularly humble. FPs are not as good as we like to think, even when it comes to medically complex patients, our training is not that rigorous, nor is it that deep. Believing that we're better than NPs just because we have an MD behind our names, in spite of evidence to the contrary, is not a humble opinion - rather, it's one that is, at best, full of pride, at worst, representative of the long-standing arrogance of our profession.

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49 minutes ago, ralk said:

So, that first part is just not true. NPs can't bill FFS, they don't have the right to bill OHIP directly. They can send referrals, they can roster patients (depending on their set-up), and like many physicians it wouldn't surprise me if they had to shadow bill, but they cannot bill FFS as an FP would in Ontario. NPs can't work in downtown Toronto unless a position is provided for them, they can't just move there and set up shop. The Ontario government has far more say over where NPs work than they do over where FPs work.

I'm not aware of any data to back up your assertion that the majority of NPs leave underserviced areas. At best, I can find NP statistics by LHIN, which appear to show a relatively stable distribution across the province. And while I'd also prefer to have FPs available for all patients who need one, especially in underserviced areas, that clearly hasn't been happening and I haven't seen much enthusiasm from physician groups to push for changes that would make this more likely to happen. If anything, in Ontario at least, we've clearly seen the opposite.

You've used the phrase "in my humble opinion" three times in your response, but it's at odds with best available evidence - flawed evidence, no doubt, but still best available - for the sake of personal anecdotes, and to be blunt, is an opinion that isn't particularly humble. FPs are not as good as we like to think, even when it comes to medically complex patients, our training is not that rigorous, nor is it that deep. Believing that we're better than NPs just because we have an MD behind our names, in spite of evidence to the contrary, is not a humble opinion - rather, it's one that is, at best, full of pride, at worst, representative of the long-standing arrogance of our profession.

Thanks for clarifying ralk! I just think that there might be a trend of Canadian government to increase training for more NPs in the future, as it saves  money over training for family physicians. Who knows what the future beholds? 

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2602652/

Here is a good read from College of Family Physician Journal in 2008. 

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18 hours ago, ralk said:

Sure, there are NPs that work in academic FHTs, but these are not taking the place of physicians, they're supporting a team designed specifically to train residents. My home site's FHT has NPs, but they're functioning exactly as you say you want NPs to function - under a physician-led team. Where the more independent ones exist tend to be in underserviced areas, and that's a very much a function of need.

I think you give the average FP more credit than they're due. There are plenty of FPs who over-refer or inappropriately refer, or send their patients for excessive work-ups. There's so much bias in these standpoints that I have to defer - at least in part - to available studies, which indicate that for primary care, the difference in outcomes is minimal. Inappropriate referrals should be addressed - but until we start holding physicians accountable for bad referrals, of which there are plenty, I'm not inclined to throw too many stones at NPs.

What's happening in the US is concerning, but the situation is significantly different. There are far, far more NPs in the US than in Canada - after accounting for population differences, there's at least 5 times as many NPs in the US. It would take decades of significant growth of NPs to match that number here. Meanwhile, there continues to be enthusiasm for training more - not less - FPs in Canada (though currently through training fewer specialists). Second, NPs and FPs in the US are compensated in very similar ways - usually both as employees of a hospital or healthcare group. In Canada, FPs are independent, essentially decentralized, with the ability to bill for services without prior approval so long as they stay within the billing rules. NPs have no such ability and require dedicated funding. This is why most NPs work in FHTs or hospitals in Canada, it's the only way they can get funded. An FP can't get forced out of their work by a new NP, because the FP can simply continue to bill as they would before. That's true even for new grads, who can bill with impunity once their license is established. It's not as though the job market for FPs is bad these days either.

As someone who chose not to do Family Medicine partially related to discussions like this, I think that these sentiments devalue the work of our Family Physician colleagues.  If someone was a medical student, knowing that NPs were encroaching on Family Medicine territory would make it seem much less attractive.  Why bother going through so many years of training if NPs are advertised as equivalent care.  One might as well specialize so that you're not just doing what a nurse can be allowed to do.  Hiring more NPs will not improve the lack of family physicians.  Promotion of midlevels just provides lower quality care.  There are great NPs out there and horrible Family physicians, but the I am sure the distribution of quality is different.

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2 hours ago, LittleDaisy said:

Thanks for clarifying ralk! I just think that there might be a trend of Canadian government to increase training for more NPs in the future, as it saves  money over training for family physicians. Who knows what the future beholds? 

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2602652/

Here is a good read from College of Family Physician Journal in 2008. 

If we're going to speculate about what could happen based on irrational decisions from the government, I think there are some bigger issues to address... That article linked is 10 years old and the situation hasn't appreciably changed since then. While some NP-led clinics have arisen, they continue to be the exception, not the rule, and most NPs work in collaborative settings with FPs. That alone is reason not to panic. I do believe that NPs are best employed when used in conjunction with FPs, especially since the better studies on NP quality come from such practice set-ups. For that reason, and to preserve better role definition between providers, I'd narrowly agree with physician groups pushing back against NP-led clinics - but only if it came in conjunction with a feasible plan to address the reason NP-led clinics got established in the first place, namely inadequate access to primary care services.

For interest, here's the concurrently-published opposing viewpoint to that piece in the CFPJ - http://www.cfp.ca/content/54/12/1669

To take a step back, I do get the fear here. Nurses in general constitute a powerful lobbying group in Canada and they definitely have not been shy about pushing the boundaries of their practice, at times without good justification for patient care. And I'm a strong believer both that we need good role definitions between healthcare providers, rather than having multiple groups trying to do the same thing, and that we don't have those good role definitions currently. Yet, those fears should be founded based on what's happening rather than what could happen, and that we shouldn't disparage other healthcare providers' ability without good reason. When it comes to NPs, I don't see enough of an active threat to makes those fears justified, and I definitely don't see enough reason to disparage their abilities as a group based on current available evidence.

1 hour ago, regular said:

As someone who chose not to do Family Medicine partially related to discussions like this, I think that these sentiments devalue the work of our Family Physician colleagues.  If someone was a medical student, knowing that NPs were encroaching on Family Medicine territory would make it seem much less attractive.  Why bother going through so many years of training if NPs are advertised as equivalent care.  One might as well specialize so that you're not just doing what a nurse can be allowed to do.  Hiring more NPs will not improve the lack of family physicians.  Promotion of midlevels just provides lower quality care.  There are great NPs out there and horrible Family physicians, but the I am sure the distribution of quality is different.

As someone who chose to do Family Medicine, I don't think these sentiments devalue my work in the slightest. I'm not sure why what I do would be in any way lessened by what others do. Does my care worsen because there's an NP also working in primary care? And why should acknowledging research that says that their care, on average, no worse than that of a typical family physician, change the value of my work? You say that you are "sure the distribution of quality is different" - based on what?! Where's the evidence to support that statement? Because I'm looking, and I'm finding more than a few RCTs and systemic reviews against that statement.

You ask a good question though - why bother going through so many years of training if NPs are advertised as equivalent care? I'd love to get an answer from medical schools on that front, because I don't have a good one. Compared with my healthcare training prior to medical school, I've found my medical training to be uncoordinated, unfocused, and shockingly inefficient, with surprisingly low standards for advancement. It boggles the mind that training programs like NPs can reasonably approximate the 5-6 years it takes to be an FP, but only when starting with the assumption that medical training is the optimal approach - considering current medical training is based on century-old models that haven't been appreciably altered in that entire time, that's not a safe assumption to make.

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As someone who chose to do Family Medicine, I don't think these sentiments devalue my work in the slightest. I'm not sure why what I do would be in any way lessened by what others do. Does my care worsen because there's an NP also working in primary care? And why should acknowledging research that says that their care, on average, no worse than that of a typical family physician, change the value of my work? You say that you are "sure the distribution of quality is different" - based on what?! Where's the evidence to support that statement? Because I'm looking, and I'm finding more than a few RCTs and systemic reviews against that statement.

Based on the fact that the process to enter medicine is much more difficult than nursing school.  I don't think it's even debatable to say the average physician has proven they can learn and adapt better than the average RN (again outliers exist in both).

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2 hours ago, ralk said:

To take a step back, I do get the fear here. Nurses in general constitute a powerful lobbying group in Canada and they definitely have not been shy about pushing the boundaries of their practice, at times without good justification for patient care.

And there is the fact that the population actually is sympathetic to their demands because they are seen as devoted while physicians are often percieved as being greedy.

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13 minutes ago, Snowmen said:

And there is the fact that the population actually is sympathetic to their demands because they are seen as devoted while physicians are often percieved as being greedy.

I still hear though that some patients prefer to see the family doctor over a NP. 

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1 minute ago, Edict said:

I still hear though that some patients prefer to see the family doctor over a NP. 

Supporting them politically doesn't mean they'll then actually accept to be treated by one instead of a FP. People are weird! :rolleyes:

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8 hours ago, crysally said:

Our school has given us a list of internal spots. Sounds like the plan is to match available spots internally first, then open it up provincially.

Wow. Talk about red carpet treatment! Are there numerically enough spots for everyone who's unmatched at your school?

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6 minutes ago, shematoma said:

Wow. Talk about red carpet treatment! Are there numerically enough spots for everyone who's unmatched at your school?

Very interesting. Is there any internal application process or do you just indicate which spots you would be interested in? 

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28 minutes ago, polarbear89 said:

Very interesting. Is there any internal application process or do you just indicate which spots you would be interested in? 

So far no clear process has been communicated, and no definite number of funded spots. We have relatively few people unmatched though, so hopefully it won't be too bad.

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1 hour ago, Snowmen said:

And there is the fact that the population actually is sympathetic to their demands because they are seen as devoted while physicians are often percieved as being greedy.

Exactly! I agree with you that some patients would prefer to see a family physician over NPs..I have a few patients transferred under my care, as they become too medically complex to be managed by the NPs in our FHT (accepted by my preceptors)! 

In general, the population perceives nurses as compassionate and caring, physicians as patriarchs and greedy for money $$$

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3 hours ago, LittleDaisy said:

Exactly! I agree with you that some patients would prefer to see a family physician over NPs..I have a few patients transferred under my care, as they become too medically complex to be managed by the NPs in our FHT (accepted by my preceptors)! 

In general, the population perceives nurses as compassionate and caring, physicians as patriarchs and greedy for money $$$

But as others mentioned, when push comes to shove many if not most would probably rather see a physician... NP's don't have nearly as much actual medical knowledge or training and people know it.

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On 4/24/2018 at 7:59 AM, ralk said:

Honestly, I don't find NPs, or other mid-levels, to be much of a threat. For one, there's not many of them, even as they grow more popular, and they're pretty heavily constrained by the current funding set-up. FPs can essentially make their own jobs - even if it means billing less through a FFS model - while NPs have to secure specific government-created positions.

Even in primary care, most NPs are still working closer to the level of a senior resident than a fully-qualified FP, seeing fewer patients and with a restricted scope of practice. Their pay per day may be less, but their pay per action is similar to that of FPs, especially once you account for benefits and overhead. And NPs are filling a legitimate need in the community - at least where I do my residency, NPs in primary care are either working exactly as you describe and seeing patients rostered to an FP in conjunction with that FP, or they're working in heavily underserviced areas. Where I'm doing a rotation now has a number of NPs seeing patients (though many are also dual-rostered to an FP) in no small part because there's such a shortage of FPs. Hard for the CFPC to object to NPs when they're doing what FPs aren't willing to do in sufficient numbers.

Additionally, while it's true that NPs have less in-depth, rigorous training than physicians, including FPs, current research on outcomes shows comparable results between FPs and NPs, at least on major outcomes. That seems to come with some over-ordering of tests, as well as I suspect a higher rate of referral to specialists. With that in mind, the question I have isn't "why do we let NPs practice with so much less training than MDs?" but "why isn't supposedly superior MD training seeing better outcomes?" Frankly, the quality of education in MDs is laughably poor, going for an ineffective shotgun approach that leaves a lot of information transmitted but far less retained, and residency thus far seems to be more about putting in time than it is about any directed learning.

To the extent I am concerned about NPs taking over positions that used to go to FPs, it's because of flaws in our training regimen, not flaws in their's.

This is nonsense. Measuring "outcomes" aka patient satisfaction ratings because they got the drugs they wanted and got 10 extra mins of chitchat or outcomes across basic uncomplicated patients when looking at things like BP... is bs. Most NPs do not have any sort of extensive knowledge base, period. Pointing out doctors negatives as an argument for midlevels makes no sense because for every bad doctor there are 20 good ones and 30 bad NPs. 

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18 hours ago, ralk said:

If all the government does with NPs is to have more of them help academic FHTs and work in underserviced areas, I'd call that a solid win. In academic FHTs they provide continuity residents simply can't (and can be decent sources of learning for those residents too). Underserviced communities need any providers they can get and while it would be ideal if FPs stepped into that void, we haven't, and neither physician groups nor governments have come up with reliable methods to get adequate FPs to those locations long-term, especially not without significant cash incentives.

I agree about midwives, but that's also a bit of a complicated situation. Midwifery, as a concept, I think makes a lot of sense. Low-risk OB is rather simple, and have dedicated providers (rather than, say, FPs doing OB only as an adjunct to their main office-based practice) has logistical and safety advantages that are hard to ignore. Some countries, like the UK, use midwives as a mainstay of obstetrical care and their outcomes are quite good. The problem in Canada is the midwifery standards are far too low, and midwives as a whole have bought into too many non-evidence-based practices like home delivery. They're very slowly moving in the right direction, but don't have the training or skills yet to do so effectively, resulting in high rates of transfers to OBs. Better than the alternative of hanging onto patients they shouldn't, but not an efficient or effective system in the slightest.

When it comes to public perceptions of physicians, we are definitely losing ground, but as I've said on this forum many times in the past, we have only ourselves to blame. A big part of that is our profession's collective over-estimation of its own importance and capabilities. It's a strain of arrogance that every patient has seen from a physician. That's why we're not going to get anywhere in improving our public standing by going after other health care professionals, especially NPs who are essentially filling gaps in our own coverage. Doing so only reinforces the perception of physician egotism.

Not true. Stop training these midlevels - fixes a chunk of the problem. Oh and don't hire them. Look at the US for the damage (ex. anesthesia group booted because it didn't want a 1:7 CRNA ratio....) that can be done and learn from it. 

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3 hours ago, medigeek said:

This is nonsense. Measuring "outcomes" aka patient satisfaction ratings because they got the drugs they wanted and got 10 extra mins of chitchat or outcomes across basic uncomplicated patients when looking at things like BP... is bs. Most NPs do not have any sort of extensive knowledge base, period. Pointing out doctors negatives as an argument for midlevels makes no sense because for every bad doctor there are 20 good ones and 30 bad NPs. 

Yeah, we're not just talking about patient satisfaction. While all studies I've seen come with caveats, some outcomes noted include no difference in overall patient visits to healthcare providers (including primary care, specialists, and ER), diabetes care, HIV care, asthma care, and yes, management of hypertension (for which available evidence is actually in favour of NPs, rather than simply showing non-inferiority).

And, yes, there are caveats to these studies, and I'm wary for potential bias here, but there's enough studies out there and I still have yet to find one with clearly worse outcomes for NPs. I'm starting to run in circles in this thread against anecdotal expressions of disdain, so I'm just going to start repeating this question - where's the evidence for your statements!?

Also, are you so blinded by your dislike of NPs that you can't do basic math anymore? "for every bad doctor there are 20 good ones and 30 bad NPs"... even assuming less than 5% of physicians suck at their job, having 30 bad NPs for every bad doctor means not only that every NP in the country is apparently bad at their jobs, but their numbers have exploded by a factor of 10 overnight and they're still all apparently bad! This is beyond hyperbole into the realm of sheer ridiculousness.

3 hours ago, medigeek said:

Not true. Stop training these midlevels - fixes a chunk of the problem. Oh and don't hire them. Look at the US for the damage (ex. anesthesia group booted because it didn't want a 1:7 CRNA ratio....) that can be done and learn from it. 

And how exactly is that a solution that can be implemented by physicians? For the most part, we don't train midlevels. For the most part, we don't hire midlevels. Those actions are largely out of our hands. And, let's say we could do that, and collectively refused to participate in the training or practice of any midlevels. What exactly do you think will happen in response? That they'll just throw in the towel and agree to go back to work as regular RNs or something? No, what we'll get is a series of media releases from nursing groups blasting physicians for being uncooperative, followed by articles in every major newspaper about physicians attacking NPs - almost sure to include multiple examples of NPs helping patients in various ways - and if we're really lucky, they won't include a long piece about patients with lack of access to healthcare providers right next to it. Declaring war on other healthcare providers, especially one with plenty of political clout and better public perception, will not help advance physician interests in the slightest.

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While I understand our concern, NPs do still provide a very valuable resource. They are working in rural areas, doing many of the more simple visits that previously family doctors had to do and allowing us to train family physicians who do not work full time. They are also working in hospitals acting as a permanent resident taking care of wards on services that do not have many residents. 

 

 

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7 hours ago, medigeek said:

This is nonsense. Measuring "outcomes" aka patient satisfaction ratings because they got the drugs they wanted and got 10 extra mins of chitchat or outcomes across basic uncomplicated patients when looking at things like BP... is bs. Most NPs do not have any sort of extensive knowledge base, period. Pointing out doctors negatives as an argument for midlevels makes no sense because for every bad doctor there are 20 good ones and 30 bad NPs. 

This is anecdotal, but this was my experience as a resident.  The 2 I encountered took forever, and were legitimately not intelligent--it was worse than poor medical knowledge, it was a failure to infer what a patient meant, or failure at not just knowledge but COMPREHENSION of basic guidelines, even when they had the knowledge.  They certainly functioned at a level below the junior residents.

There was one instance when a med student (thinking they were an authority and could answer questions) asked one about the pathophysiology of a medication they prescribed.  No shit, they told the student they have more practical training and didn't know the mechanism of the medication.  

 I work in the community and haven't encountered them (and likely never will the way I set up my practice), but it really left a bad taste in my mouth with respect to their competence.  

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There's understandably a lot of resistance, but it seems as if ralk is taking a lot of flak for a minority viewpoint, albeit one that seems more supported by evidence & research.  To go over some of the counter-arguments, regarding admission standards for instance,  SGU has lower GPA/MCAT compared to most other Canada/US med schools.  Yet according its website it's the fourth largest provider of physicians in the US and last year for example had over 70% match into primary care (with 20% in FM and 40% IM).  Which brings me to a second point - I imagine the studies that ralk is referring to were done in the US , and it could be that Canadian FM outcomes are significantly different - Canadian medical education is more geared clinically towards FM and FM is a relatively more selective and compensated role.  It's much less of a default choice than in the US, where pre-clerkship education is more oriented towards the basic sciences needed for Step 1 success, rather than the FM/GP model of education.  It could be stretch, since I haven't completed a full-clerkship, but it's possible that the NP practical training in some cases could have more clinical relevance than the basic science focus  which is more emphasized in the US, and thus help achieve good outcomes.  Nonetheless, US FPs need to complete three years of residency and go through more Steps which seem much more clinical, so I'm somewhat surprised at the research results ralk is referring to.  

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23 hours ago, LittleDaisy said:

Thanks for clarifying ralk! I just think that there might be a trend of Canadian government to increase training for more NPs in the future, as it saves  money over training for family physicians. Who knows what the future beholds? 

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2602652/

Here is a good read from College of Family Physician Journal in 2008. 

Thanks for this link; really interesting read.

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8 hours ago, ralk said:

Yeah, we're not just talking about patient satisfaction. While all studies I've seen come with caveats, some outcomes noted include no difference in overall patient visits to healthcare providers (including primary care, specialists, and ER), diabetes care, HIV care, asthma care, and yes, management of hypertension (for which available evidence is actually in favour of NPs, rather than simply showing non-inferiority).

And, yes, there are caveats to these studies, and I'm wary for potential bias here, but there's enough studies out there and I still have yet to find one with clearly worse outcomes for NPs. I'm starting to run in circles in this thread against anecdotal expressions of disdain, so I'm just going to start repeating this question - where's the evidence for your statements!?

Also, are you so blinded by your dislike of NPs that you can't do basic math anymore? "for every bad doctor there are 20 good ones and 30 bad NPs"... even assuming less than 5% of physicians suck at their job, having 30 bad NPs for every bad doctor means not only that every NP in the country is apparently bad at their jobs, but their numbers have exploded by a factor of 10 overnight and they're still all apparently bad! This is beyond hyperbole into the realm of sheer ridiculousness.

And how exactly is that a solution that can be implemented by physicians? For the most part, we don't train midlevels. For the most part, we don't hire midlevels. Those actions are largely out of our hands. And, let's say we could do that, and collectively refused to participate in the training or practice of any midlevels. What exactly do you think will happen in response? That they'll just throw in the towel and agree to go back to work as regular RNs or something? No, what we'll get is a series of media releases from nursing groups blasting physicians for being uncooperative, followed by articles in every major newspaper about physicians attacking NPs - almost sure to include multiple examples of NPs helping patients in various ways - and if we're really lucky, they won't include a long piece about patients with lack of access to healthcare providers right next to it. Declaring war on other healthcare providers, especially one with plenty of political clout and better public perception, will not help advance physician interests in the slightest.

You missed the points. The patient population NPs carry are always uncomplicated and basic. That's a severe limitation in any study. When it comes to the average joe off the street, health care doesn't do a whole lot for improving his outcome. If the NP has extra time to cheer him on to exercise more and eat better - of course they get a good outcome. 

Also you do know who funds and writes these studies, right? (Hint: NPs)

 

And I don't think you are aware but there are Drs in both Canada/USA who are pulling back from training/hiring midlevels for the reasons discussed. 

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5 hours ago, goleafsgochris said:

This is anecdotal, but this was my experience as a resident.  The 2 I encountered took forever, and were legitimately not intelligent--it was worse than poor medical knowledge, it was a failure to infer what a patient meant, or failure at not just knowledge but COMPREHENSION of basic guidelines, even when they had the knowledge.  They certainly functioned at a level below the junior residents.

There was one instance when a med student (thinking they were an authority and could answer questions) asked one about the pathophysiology of a medication they prescribed.  No shit, they told the student they have more practical training and didn't know the mechanism of the medication.  

 I work in the community and haven't encountered them (and likely never will the way I set up my practice), but it really left a bad taste in my mouth with respect to their competence.  

I've never seen or heard of a midlevel (except maybe critical care ones in USA) that's any different from what you described to be honest. 

 

4 hours ago, marrakech said:

There's understandably a lot of resistance, but it seems as if ralk is taking a lot of flak for a minority viewpoint, albeit one that seems more supported by evidence & research.  To go over some of the counter-arguments, regarding admission standards for instance,  SGU has lower GPA/MCAT compared to most other Canada/US med schools.  Yet according its website it's the fourth largest provider of physicians in the US and last year for example had over 70% match into primary care (with 20% in FM and 40% IM).  Which brings me to a second point - I imagine the studies that ralk is referring to were done in the US , and it could be that Canadian FM outcomes are significantly different - Canadian medical education is more geared clinically towards FM and FM is a relatively more selective and compensated role.  It's much less of a default choice than in the US, where pre-clerkship education is more oriented towards the basic sciences needed for Step 1 success, rather than the FM/GP model of education.  It could be stretch, since I haven't completed a full-clerkship, but it's possible that the NP practical training in some cases could have more clinical relevance than the basic science focus  which is more emphasized in the US, and thus help achieve good outcomes.  Nonetheless, US FPs need to complete three years of residency and go through more Steps which seem much more clinical, so I'm somewhat surprised at the research results ralk is referring to.  

 

It's easy to get the study outcomes you want when you compare outcomes in a healthy population vs a sick population and have a study funded by the nursing unions written by NPs. 

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