Ontario to fund new residency spots with return of service requirements

[ralk]

31 minutes ago, medigeek said:

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. 

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.

[medigeek]

5 minutes ago, ralk said:

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.

You're not understanding what I'm saying. NPs by definition manage only basic patients. Outcomes in those patients are only loosely tied to health care intervention at best. So it's easy to compare anything vs doctors and get similar outcomes when the physician isn't doing much for the patient any way. The reason NPs get the outcomes they do is simply being able to spend more time with the patient (due to their model) to get better compliance etc. 

 

And you can't be telling me that having a 6th author who's an MD justifies a study, right? They're done in USA where MD/DOs have a strong interest (some of them) in midlevels because it doubles their income while ruining it for the others. 

My point is that garbage studies don't mean much. I could pull up 10 studies right now (with much better methodology and far less bias) showing how turmeric lowers X disease or whatever or how garlic cures the common cold. 

[ralk]

3 hours ago, medigeek said:

You're not understanding what I'm saying. NPs by definition manage only basic patients. Outcomes in those patients are only loosely tied to health care intervention at best. So it's easy to compare anything vs doctors and get similar outcomes when the physician isn't doing much for the patient any way. The reason NPs get the outcomes they do is simply being able to spend more time with the patient (due to their model) to get better compliance etc. 

 

And you can't be telling me that having a 6th author who's an MD justifies a study, right? They're done in USA where MD/DOs have a strong interest (some of them) in midlevels because it doubles their income while ruining it for the others. 

My point is that garbage studies don't mean much. I could pull up 10 studies right now (with much better methodology and far less bias) showing how turmeric lowers X disease or whatever or how garlic cures the common cold. 

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.

[A-Stark]

Can’t view things through UWO’s proxy!

[ralk]

11 minutes ago, A-Stark said:

Can’t view things through UWO’s proxy!

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.

[GrouchoMarx]

9 hours ago, ralk said:

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.

focusing on the 'greater good' ideal of how medical care should be delivered always ends in frustration and creates more problems than it solves.

supporting NPs will only weaken MDs.

i recall a study that showed that fewer than half of NPs could pass a dumbed down version of the USMLE step 3. in contrast, basically all doctors who take it pass. there is certainly the argument that NPs cannot practice medicine as they do not have the theoretical underpinnings required for it.

the studies quoted by ralk may be biased, either through involvement by nursing organizations, large facilities that want to cheap out, or doctors that profit from running multiple NPs at once. its hard for me to trust those studies, even in tandem, and even with their clinical trial structure.

even if you do believe that an NP can run easy cases, and even if you do believe that the above studies are legitimate, the definite possibility of the unexpected complex case being misdiagnosed or mismanaged by NPs is still possible, given the stochastic nature of these events.

in those cases, and I cannot think of a study design that could answer the question, one has to assume which professional would be more likely to get it right. The MD or the NP. 10 times out of 10 I would bet on the MD.

From a policy analysis point of view, sure, that one case is worth the potential cost savings of having NPs. But from that one patient's point of view it is not. 

we have a duty to uphold the standards of our profession. allowing NPs to practice our profession, which is what they are doing despite them calling it something different, is our failure.

[LittleDaisy]

23 minutes ago, GrouchoMarx said:

focusing on the 'greater good' ideal of how medical care should be delivered always ends in frustration and creates more problems than it solves.

supporting NPs will only weaken MDs.

i recall a study that showed that fewer than half of NPs could pass a dumbed down version of the USMLE step 3. in contrast, basically all doctors who take it pass. there is certainly the argument that NPs cannot practice medicine as they do not have the theoretical underpinnings required for it.

the studies quoted by ralk may be biased, either through involvement by nursing organizations, large facilities that want to cheap out, or doctors that profit from running multiple NPs at once. its hard for me to trust those studies, even in tandem, and even with their clinical trial structure.

even if you do believe that an NP can run easy cases, and even if you do believe that the above studies are legitimate, the definite possibility of the unexpected complex case being misdiagnosed or mismanaged by NPs is still possible, given the stochastic nature of these events.

in those cases, and I cannot think of a study design that could answer the question, one has to assume which professional would be more likely to get it right. The MD or the NP. 10 times out of 10 I would bet on the MD.

From a policy analysis point of view, sure, that one case is worth the potential cost savings of having NPs. But from that one patient's point of view it is not. 

we have a duty to uphold the standards of our profession. allowing NPs to practice our profession, which is what they are doing despite them calling it something different, is our failure.

I agree, it really disheartens me that the College of Family Physicians allows NPs to practice independently as basically <<family physicians>>, what scares me the most is the complex  medical patients being misdiagnosed and mismanaged by NPs, and end up referring to family physicians for second opinion and as MDs we assume the full responsibility medico-legally for our second opinion. 

[regular]

As with all midlevels, first they are happy being supervised but after a while they will push for more autonomy.  After a while, they may even become your boss

Meet the NP that hires family docs to run her clinic

.

[ralk]

9 hours ago, GrouchoMarx said:

focusing on the 'greater good' ideal of how medical care should be delivered always ends in frustration and creates more problems than it solves.

supporting NPs will only weaken MDs.

i recall a study that showed that fewer than half of NPs could pass a dumbed down version of the USMLE step 3. in contrast, basically all doctors who take it pass. there is certainly the argument that NPs cannot practice medicine as they do not have the theoretical underpinnings required for it.

the studies quoted by ralk may be biased, either through involvement by nursing organizations, large facilities that want to cheap out, or doctors that profit from running multiple NPs at once. its hard for me to trust those studies, even in tandem, and even with their clinical trial structure.

even if you do believe that an NP can run easy cases, and even if you do believe that the above studies are legitimate, the definite possibility of the unexpected complex case being misdiagnosed or mismanaged by NPs is still possible, given the stochastic nature of these events.

in those cases, and I cannot think of a study design that could answer the question, one has to assume which professional would be more likely to get it right. The MD or the NP. 10 times out of 10 I would bet on the MD.

From a policy analysis point of view, sure, that one case is worth the potential cost savings of having NPs. But from that one patient's point of view it is not. 

we have a duty to uphold the standards of our profession. allowing NPs to practice our profession, which is what they are doing despite them calling it something different, is our failure.

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...

8 hours ago, LittleDaisy said:

I agree, it really disheartens me that the College of Family Physicians allows NPs to practice independently as basically <<family physicians>>, what scares me the most is the complex  medical patients being misdiagnosed and mismanaged by NPs, and end up referring to family physicians for second opinion and as MDs we assume the full responsibility medico-legally for our second opinion. 

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. 

[blingbling]

https://www.thestar.com/vancouver/2018/04/12/doctors-without-jobs.html

That's me... PGY1 FM now. 

[rmorelan]

17 minutes ago, blingbling said:

https://www.thestar.com/vancouver/2018/04/12/doctors-without-jobs.html

That's me... PGY1 FM now. 

Glad in the end you got something you wanted!

 

[shematoma]

6 hours ago, blingbling said:

https://www.thestar.com/vancouver/2018/04/12/doctors-without-jobs.html

That's me... PGY1 FM now. 

Congratulations, and nice to see a success story... I can totally relate to not wanting to do medicine again if I could start over. You're 1/2 through your residency, so there's a bright light at the end of the tunnel. And you still get to work with kids. I think the stats for this year are a foregone conclusion... more unmatched grads than ever. But luckily the Ontario government is coming to the rescue...

[medigeek]

On 4/26/2018 at 2:49 PM, ralk said:

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.

The physician FFS model gives inventive to see patients faster. NPs have more time for their very easy to manage patients and hence can cheer lead them more effectively to take their meds. 

Also these studies simply cannot control for patient complexity because midlevels do not see complex patients. Why don't we take med students and hand them easy patients with 30 minute time slots and see what happens? Guarantee they get better outcomes than everyone discussed. 

 

[ralk]

6 hours ago, medigeek said:

The physician FFS model gives inventive to see patients faster. NPs have more time for their very easy to manage patients and hence can cheer lead them more effectively to take their meds. 

Also these studies simply cannot control for patient complexity because midlevels do not see complex patients. Why don't we take med students and hand them easy patients with 30 minute time slots and see what happens? Guarantee they get better outcomes than everyone discussed. 

 

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.

[indefatigable]

On 27 avril 2018 at 9:30 AM, ralk said:

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. 

To summarize, it seems as if you're suggesting that the NP issue has partly arisen because of manifestations of bigger issues - deficiencies in educational quality and systemic "hubris".  Unfortunately, given the lack of stability in physicians’ constant ongoing negotiations and vulnerability in the public eye, one can imagine that this kind of engaged self-criticism where imperfections are possibly exposed to be hopefully corrected, no matter how well-intentioned, could easily lead to further criticism in the general public and be exploited by the government during negotiations leading to the irk of colleagues.  Perhaps the solution is partly through greater vigilance of the colleges (Royal & CCFP) as well as the licensing bodies CACMS/LCME, through input from physicians.  In the recent past at least, CACMS/LCME hasn't hesitated to put schools on probation if deficiencies were found.  At the residency level, hopefully, the transition to competency based medical education can also correct some of these short-comings for the Royal college specialties.  Although, I personally prefer a more transparent approach, rather than everything behind closed doors.

Now it seems as if within the Canadian context especially, part of the issue is the FFS model itself.  It seems as if it's a double-edged sword - it does incentivize productivity but on the other hand, quality care and time with patients are not directly rewarded.  Some have even suggested that FFS can lead to some of the issues that you identified like overprescription  and over-referral.  So within the NP vs physician debate within Canada, physicians could have an advantage on the cost/volume side, but I don't think that is the winning argument.  

However, I do think it's possible there are residual differences between Canada & US, especially with regards to more recent FPs.  I speculated that Canadian medical education may better prepare CMGs for clinical practice based on the general educational model- and it turns out that this is at least partially the case.  One recent study suggests that for FM, PGY-1 CMGs significantly outperformed PGY-1 USMGs but by PGY-2/PGY-3, the differences had disappeared (link) or even partially reversed.  In other words, the extra year in the US made a big difference.  Nonetheless, I do wonder if there is further comparative work to be done - I would speculate that the overall Canadian outcomes are still possibly stronger than in the US.  It could be however, that the volume-oriented FFS model does mask some of the quality, unfortunately.    

Finally, I tend to favour regionalism, like NOSM, on admissions for the under-serviced areas problem.  Neither "drawing lots" nor RoS seem to work well.  In the link above, there were anecdotes of NOSM students who turned down offers of other medical school to go to NOSM and work in smaller communities in the North - this contrasts with anecdotes on this site for instance, where people have expressed deep dissatisfaction with having to work in rural regions with no ties or history.  The NOSM model is imperfect, but it does seem to be effective.  I'm not sure how effective SWOMEN is for the especially rural communities in the region.  

 

[Edict]

31 minutes ago, marrakech said:

 

Finally, I tend to favour regionalism, like NOSM, on admissions for the under-serviced areas problem.  Neither "drawing lots" nor RoS seem to work well.  In the link above, there were anecdotes of NOSM students who turned down offers of other medical school to go to NOSM and work in smaller communities in the North - this contrasts with anecdotes on this site for instance, where people have expressed deep dissatisfaction with having to work in rural regions with no ties or history.  The NOSM model is imperfect, but it does seem to be effective.  I'm not sure how effective SWOMEN is for the especially rural communities in the region.  

 

I agree with you that NOSM does serve a great purpose. The location and mission of the school really do make a difference in ensuring that people from the region are able to stay. Additionally, NOSM is not a large enough school that it would comparatively disadvantage urban applicants. I

However the concept of IP admissions in all provinces except Ontario is an issue that has yet to be addressed. As shown in a previous thread, Ontario residents are shown to be at a comparative disadvantage to other province's residents. Medical schools in Ontario barring McMaster are not IP schools, allowing equal opportunity for both in province and out of province residents. Western itself does have a SWOMEN program but still includes Ontario residents and non-Ontario residents in the same pool. Considering that other provinces seem more than happy to protect their medical school spots for their own residents, I don't see why Ontario has to be so generous with our own, to the detriment of Ontario's own residents. 

 

[Snowmen]

3 hours ago, ralk said:

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.

Regardless of whether or not they control for complexity, it doesn't matter since they compare at a level of complexity where it is unlikely a FPs would be able to pull away. Show a study where they handle moderate to complex patients and then we can talk.

[ralk]

9 minutes ago, Snowmen said:

Regardless of whether or not they control for complexity, it doesn't matter since they compare at a level of complexity where it is unlikely a FPs would be able to pull away. Show a study where they handle moderate to complex patients and then we can talk.

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.

[goleafsgochris]

51 minutes ago, ralk said:

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.

I'm not saying dismiss the studies...but studies showing "no difference" are complicated to take a message away from.  The problem for me is that the measures used are not sufficiently sensitive to detect change.  Like if the end result is "patient life expectancy is unchanged", it would take a huge number of patients to create a meaningful difference at a family physician level.  I bet you could find "no difference" between a 2nd year med student and either group.  Secondly, if the metric is "patient satisfaction", I truly consider that meaningless. Its well known that patients say they are satisfied if doctors are nice to them and spend a long time with them, regardless of quality.  Again, 2nd year med student would likely show "no difference" here.  Its the subtleties that make a difference--has the dr chosen the available med that will work best with the best side effect profile?  Difficult to study (because of difficulty of outcome measures), but I bet MDs would perform better here.  

[medigeek]

1 hour ago, ralk said:

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.

I mean, really.. here's like 100+ studies on herbal treatment https://examine.com/supplements/garlic/ which trumps any of the crap NP studies you provided. You have to be very biased as the reader to not detect a flaw when the bulk of these studies are NP-driven in some fashion whether it's MDs profiting, NP funded, non-practicing MDs etc. 

[regular]

I really hope Ralk isn't on any positions of significant authority because family doctors with his/her attitude are helping to undermine their own specialty.  

[medigeek]

3 hours ago, regular said:

I really hope Ralk isn't on any positions of significant authority because family doctors with his/her attitude are helping to undermine their own specialty.  

Right! I really reallyy hope people like him/her do not ever gain any sort of power when dealing with this issue. 

Like suddenly in 2018 we have a platform of debate between midlevels and physicians? It's insane! This is false equivalency to the max. There shouldn't even be any sort of debate. The gap in knowledge between the two is like comparing a fresh family doc to an MD/PhD in X subspecialty and seeing who does better in that field.

Like why do we need to train anyone extensively? Almost every job out there can be done by a 20 year old with a month of training. Why then, do these jobs need university degrees? We don't see this equivalency debate in other sectors but for some reason one of the most critical professions is able to be challenged by a nurse who studied (increasingly online in USA) ethics and epidemiology for 2 years. Then we get doctors bowing down to them. It's ridiculous and the medical profession on every level (from med school to residencies to the college) needs to take a very strong stance on this. 

[A-Stark]

13 hours ago, Edict said:

However the concept of IP admissions in all provinces except Ontario is an issue that has yet to be addressed. As shown in a previous thread, Ontario residents are shown to be at a comparative disadvantage to other province's residents. Medical schools in Ontario barring McMaster are not IP schools, allowing equal opportunity for both in province and out of province residents. Western itself does have a SWOMEN program but still includes Ontario residents and non-Ontario residents in the same pool. Considering that other provinces seem more than happy to protect their medical school spots for their own residents, I don't see why Ontario has to be so generous with our own, to the detriment of Ontario's own residents. 

Doesn't Ottawa have lower GPA cutoffs for Ottawa-area residents? They did back when I was applying (~10 years ago!!!).

[rmorelan]

11 hours ago, A-Stark said:

Doesn't Ottawa have lower GPA cutoffs for Ottawa-area residents? They did back when I was applying (~10 years ago!!!).

I believe they dropped that

[NLengr]

13 hours ago, A-Stark said:

Doesn't Ottawa have lower GPA cutoffs for Ottawa-area residents? They did back when I was applying (~10 years ago!!!).

You old!