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NP/Physician assistant EM "Residents" in USA to make more than medical residents


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Just a sign of how things are trending in USA and what to beware of and prepare for up here in Canada. They now have their own "residencies" and are training midlevels to go out into underserved areas and work solo. Even the "supervision" models are nonsense and no physician ever checks their work. And to add insult to injury, these guys are training (aka stealing procedures from actual residents) and getting paid more for it. 

 

 

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17 hours ago, ZBL said:

I don’t know what the resident physician organizations are doing in Canada. “Great news, we negotiated an extra 2K in salary this year!” Failure in my opinion. To continue to pay residents 50-60K per year is atrocious. R5s should be over 100K at least. 

Not gonna happen, even if that may approach fair compensation. Things are moving in the opposite direction pay wise for many fully fledged attending MDs let alone residents. Just look at the situation in Alberta. 
 

For several years now EM has been booming. A lot more candidates than residency spots, and now this is trickling down into attending EM jobs. Things are becoming saturated. They are not yet saturated but I think we will see this happen this decade. The situation down south is similar.  If Canada follows the path of the US, it will become even more saturated job wise. If this occurs, I think those first hit might be the newly trained CCFP-EM folks, something to consider if pondering this route. What emergency medicine physicians do will also fundamentally change. Over the long term, the job could become more of a department management / supervisor type role (this opens a bunch of other issues), with a lot less EM docs being needed or hired. Also raises a lot of questions around training. It gets complicated in a jiffy. 
 

I don’t think this is generally in the interest of patient care. But it seems like where the political and economic winds might be blowing. Hopefully we chart a different more patient centered course here in Canada. 

 

 

Edited by rogerroger
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13 hours ago, rogerroger said:

Not gonna happen, even if that may approach fair compensation. Things are moving in the opposite direction pay wise for many fully fledged attending MDs let alone residents. Just look at the situation in Alberta. 
 

For several years now EM has been booming. A lot more candidates than residency spots, and now this is trickling down into attending EM jobs. Things are becoming saturated. They are not yet saturated but I think we will see this happen this decade. The situation down south is similar.  If Canada follows the path of the US, it will become even more saturated job wise. If this occurs, I think those first hit might be the newly trained CCFP-EM folks, something to consider if pondering this route. What emergency medicine physicians do will also fundamentally change. Over the long term, the job could become more of a department management / supervisor type role (this opens a bunch of other issues), with a lot less EM docs being needed or hired. Also raises a lot of questions around training. It gets complicated in a jiffy. 
 

I don’t think this is generally in the interest of patient care. But it seems like where the political and economic winds might be blowing. Hopefully we chart a different more patient centered course here in Canada. 

 

 

Haven't EM residency spots been very stable for years? The job market is still excellent for EM and there's a large number of old docs retiring very soon and actively retiring at the moment. So not sure how we'll get saturated...

 

Nonetheless, my post was primarily a warning about midlevels. Need to take notes and learn lessons from the American side and not let it happen here. In USA, ICUs, inpatient services, almost all urgent cares/walk ins and even a huge chunk of specialty services are run by NPs/PAs. Let that sentence sink in for a minute.

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There's nothing wrong with mid levels, if they are appropriately used/distributed. They're basically perma-residents, and there's lots of scenarios where that's a good thing. Lets say I'm a family doc in an undeserved city. I can see X patients a day, and I have a week long wait list. If I hire a NP to do routine health maintenance visits (well baby/woman, warfarin titrating, immunizations/injections etc), which I review and sign off on, I can then see X+Y patients a day (although less due to extra paperwork of quick review of NPs visits/signing prescriptions/forms etc), and focus on more interesting diagnostics/patients etc. If the billings from Y is at least equal to the NP's salary than it's a benefit (even if just equal, reduces your wait list to increase patient satisfaction), and perhaps you enjoy your job more focusing on what you're interested in.

In my domain, very common to have NPs or CAs cover NICUs in-house while neonatologist is on home call (+residents in house) which keeps the unit covered while allowing continuous neonatologist coverage.

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7 hours ago, bearded frog said:

There's nothing wrong with mid levels, if they are appropriately used/distributed. They're basically perma-residents, and there's lots of scenarios where that's a good thing. Lets say I'm a family doc in an undeserved city. I can see X patients a day, and I have a week long wait list. If I hire a NP to do routine health maintenance visits (well baby/woman, warfarin titrating, immunizations/injections etc), which I review and sign off on, I can then see X+Y patients a day (although less due to extra paperwork of quick review of NPs visits/signing prescriptions/forms etc), and focus on more interesting diagnostics/patients etc. If the billings from Y is at least equal to the NP's salary than it's a benefit (even if just equal, reduces your wait list to increase patient satisfaction), and perhaps you enjoy your job more focusing on what you're interested in.

In my domain, very common to have NPs or CAs cover NICUs in-house while neonatologist is on home call (+residents in house) which keeps the unit covered while allowing continuous neonatologist coverage.

Yeah.... no. You're dead wrong on this and are another sell out physician who led to the issue in the US in the first place. 

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22 hours ago, medigeek said:

Yeah.... no. You're dead wrong on this and are another sell out physician who led to the issue in the US in the first place. 

What an eloquent and well researched response... I have personally worked with many NPs and CAs and have all been great at what they do, and fill a niche that is needed for an effective system. Medicine is changing for the better and being more team based is part of that. You seem to have a chip on your shoulder when it comes to mid level HCPs, and while there is some places in the US where perhaps the wrong ratio of MDs to mid levels has the chance to affect patient care, that is not the situation in Canada, and I'm optimistic that our highly regulated system wouldn't allow that.

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4 hours ago, bearded frog said:

What an eloquent and well researched response... I have personally worked with many NPs and CAs and have all been great at what they do, and fill a niche that is needed for an effective system. Medicine is changing for the better and being more team based is part of that. You seem to have a chip on your shoulder when it comes to mid level HCPs, and while there is some places in the US where perhaps the wrong ratio of MDs to mid levels has the chance to affect patient care, that is not the situation in Canada, and I'm optimistic that our highly regulated system wouldn't allow that.

And rewind the clock to a decade ago in the US where it wasn't that bad and another decade prior when it was even better. Your view is very shortsighted and delusional. Looking at how things are at the present time and ignoring all the other variables (legislation for independent practice, increased midlevel practice rights, increased training of midlevels, etc.) is honestly either a lack in common sense or typical Ivory tower screaming. 

And our "highly regulated system" also gave NPs independent rights on top of letting RNs prescribe birth control and pharmacists prescribe antibiotics. The only thing stopping them, literally, is a smaller work force than the US and being unable to bill for services. Otherwise, we'd have all walk ins staffed with only midlevels like the US. CRNAs doing half of surgeries virtually alone. ICUs run by midlevels like in the US. Hospitalists being half midlevel half physician. And new consults being seen by midlevels alone. 

That's the reality of the US system and there's 0 reason it can't happen here.

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Recently met a PA in Winnipeg who works in Cardiology 5 days a week, minimal call shifts and makes 170k. Didn't believe it until I saw the hospital salary disclosure documents. It's a similar trend to the US where PAs are making really good money for the education/cost. And there is more regulation for NPs/PAs on the way in the near future so midline expansion is happening just like it did in the US.

 

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Really don't need personal attacks.

I don't understand where the vitriol is coming from. Are you worried that you will be paid less if there are more NPs? Are you worried that patient care will be affected? My example above is a scenario where billing and patient satisfaction are increased by having a NP. Having midlevels fill in the gaps in our health care system should not affect you in a negative way...

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7 hours ago, bearded frog said:

Really don't need personal attacks.

I don't understand where the vitriol is coming from. Are you worried that you will be paid less if there are more NPs? Are you worried that patient care will be affected? My example above is a scenario where billing and patient satisfaction are increased by having a NP. Having midlevels fill in the gaps in our health care system should not affect you in a negative way...

agreed, no need for personal attacks.
 

Currently no, but the their scope keeps expanding. So to think that it won’t eventually is incorrect IMO (pay, and affect care). UK nurses will now be providing surgery (including hernias). Sure it sounds small, but one forgets that over time, scope increases instead of looking at one single point in time. So it’s fair to say that eventually, midlevels will continue to do higher level things and eventually it may push physicians to either adapt and think of new things to do, or If that doesn’t happen at a fast enough pace, physicians will be pushed out for actually less training and affect care potentially. I know they definitely fill a gap, and it definitely helps streamline faster care for patients in a supervised setting, but solo practice is a different matter entirely when their entire training model is to be supervised. Also there are now online NP degrees in the states. More research to be done in the near future one would hope to see what occurs. There is a reason we are trained for such long periods of time after all.

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I guess I philosophically don't have a problem with disruptions and trying new things in health care. We have a traditional doctor - nurse - patient relationship for decades that works great for most things but as just as technology has changed the practice of medicine in the last 20 years, there are room for other major changes. Certainly there are is a lot of unhappiness in the current system, ie wait times, access, physicians feeling underpaid/appreciated, undeserved rural areas, health care costs in a public system. I think it's fine to try new things including new roles for non-classically trained physicians to try and close these gaps. Do I think that may mean that the role of an MD will change over time? Yes. And that's medicine. And medicine is going to change regardless. If you hate change you're going to have a bad time.

Medical school trains you to have a wide array of knowledge/skills that means you can do a lot, even though many non-family doc MDs have a focused practice. I have my own opinions about if it makes sense for pathologists to attend traditional medical school, but for instance procedures that an PGY2 resident could do unassisted are pretty safe territory for PAs/NPs to do if they have the relevant focused training, as long as there were an MD available if needed, much like supervising residents.

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On 2/25/2020 at 7:24 PM, bearded frog said:

What an eloquent and well researched response... I have personally worked with many NPs and CAs and have all been great at what they do, and fill a niche that is needed for an effective system. Medicine is changing for the better and being more team based is part of that. You seem to have a chip on your shoulder when it comes to mid level HCPs, and while there is some places in the US where perhaps the wrong ratio of MDs to mid levels has the chance to affect patient care, that is not the situation in Canada, and I'm optimistic that our highly regulated system wouldn't allow that.

You assume they will have adequate training or that things will change towards improving the system.

The reality in America is that this current change is driven by costs and the ability to cut corners where the layperson is unable to tell the difference. In America it is possible to become a NP via direct entry without ever practicing as a RN. During direct entry training they only need 500 clinical hours, meaning M3s half way through clerkship will have more experience than some of these new autonomously practicing NPs. Would you be comfortable with a halfway M3 seeing your loved one and making independent decisions about serious health conditions? Doctors do not naturally unite together unfortunately. Just look at the forum and the monthly topics. We are much more likely to target those amongst us who have better lifestyles, or are paid more, or have less training than unite to make changes for the better.

I do not think any of this is an imminent threat and like you, I have positive working experiences with NPs. But we have elements in Canada similar to the American situation: disorganized physician groups prone to internecine infighting, mounting cost pressures, midlevel organizations eager to expand their scope, legislators who listen to lobby $$$ over medicine, etc. Without any vigilance and pushback we will eventually go down the path the American system has where profit and cost savings are valued over patients.

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17 hours ago, IMislove said:

Also there are now online NP degrees in the states.

Even in Canada, the amount of education that an NP receives is shockingly low from a clinical perspective. I see some of the nurses in our hospital working on becoming NPs and it seems like it's some online theoretical course work and then a very short "clerkship" equivilent. That's it. I was very surprised when one of them explained the program for me. 

If you have never looked at how little is involved to become an NP, here are a few programs that people I know have done. It's not many courses and a lot of them are clinically irrelevant crap:

https://catalogue.uottawa.ca/en/graduate/graduate-diploma-primary-health-care-masters-nursing/#programrequirementstext

https://www.mun.ca/nursing/grad/master/Practicumsequence.php

https://www.dal.ca/academics/programs/graduate/nursing/program-details/master-program.html

My experience with NPs has been the ones in primary care tend to send/call for poorer consults and display worse clinical judgement/knowledge than the family docs in my region. Anecdotal, but a common refrain among most of our specialists. 

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7 hours ago, NLengr said:

Even in Canada, the amount of education that an NP receives is shockingly low from a clinical perspective. I see some of the nurses in our hospital working on becoming NPs and it seems like it's some online theoretical course work and then a very short "clerkship" equivilent. That's it. I was very surprised when one of them explained the program for me. 

If you have never looked at how little is involved to become an NP, here are a few programs that people I know have done. It's not many courses and a lot of them are clinically irrelevant crap:

https://catalogue.uottawa.ca/en/graduate/graduate-diploma-primary-health-care-masters-nursing/#programrequirementstext

https://www.mun.ca/nursing/grad/master/Practicumsequence.php

https://www.dal.ca/academics/programs/graduate/nursing/program-details/master-program.html

My experience with NPs has been the ones in primary care tend to send/call for poorer consults and display worse clinical judgement/knowledge than the family docs in my region. Anecdotal, but a common refrain among most of our specialists. 

Maybe we will start seeing this too: 

 

 

 

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NPs function well in certain circumstances and often at a permanent r1-2 level in that specific focus. NP in an oncology follow up service or surgery post-op service is great use of resources so that residents can spend more time scrubbed in or doing new consults for example. But very few indications should they be solo.  Unlike an r1-2 medical resident that has lateral skills and background to rely upon from experience outside of a specific service, NPs just dont have that lateral knowledge.  Thats the big difference. 

The US is a case where hospital $ and efficiencies have led to a lot of terrible decision making by MHAs and MBAs to cut costs and make more profit.

 

Bias: 3 friends are NPs. 1 in canada, 2 in the US(after working as RNs in canada). We get into friendly arguments but in general they agree that in the US things have gotten out of hand with mid level providers.  Fortunately they all worked for 6-8yrs before jumping ship to NP and they constantly complain about their colleagues who are so inexperienced. 

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3 hours ago, JohnGrisham said:

NPs function well in certain circumstances and often at a permanent r1-2 level in that specific focus. NP in an oncology follow up service or surgery post-op service is great use of resources so that residents can spend more time scrubbed in or doing new consults for example. But very few indications should they be solo.  Unlike an r1-2 medical resident that has lateral skills and background to rely upon from experience outside of a specific service, NPs just dont have that lateral knowledge.  Thats the big difference. 

The US is a case where hospital $ and efficiencies have led to a lot of terrible decision making by MHAs and MBAs to cut costs and make more profit.

just to add - because this really is an important topic, and one that will have an impact in the future. Only natural people might get a bit "heated" about it but again collectively everyone should remain civil. 

Our current model is ancient and I think it is worth questioning its structure (even if it just stays the same). We have an incredibly complex system for training doctors with a lot of inefficiency built in. Everyone is trained for years to do things in the end they will never do - and then probably promptly forgets most of it going forward. I think you really could ask some basic questions - like do we really need to do all of that (and at least an undergrad prior) to become skilled? I always use the analogy that we train doctors like they are going to fix formula 1 race cars and every other possible type of vehicle and then have the vast majority of us just fix the breaks on family vans. In my own speciality there is a question to whether it would possible to much faster train someone to ONLY read on particular imaging study (mammography comes up a lot for this but also specific procedures, ) and if you did that would be be faster/cheaper/and yes better as you are a highly focused expert etc. Truth is I am not sure but usually you do get better results in systems if people are more specialized 

Now you can argue for the particular tasks/jobs that alternative models are worse - NP/PA are less experienced etc, may miss things because they don't have the broader perspective/experience or more training. You probably could also argue they may be better at some areas if they are able to spend the time doing it that doctors due to cost constraints cannot do.  It can go both ways in particular examples. For R1-R2 may have lateral skills but the number of times the nurse ha stops the junior resident for overdosing a patient is bit too common to be comfortable as well (you only get lateral experience by doing things you aren't good at).

Lastly and one way or the other this important to manage - you cannot EVER leave an unfilled need and expect someone/some system to fill it. For tons of well known reasons doctors haven't been willing to do things that NP/PAs have been willing to do. Things like rural practises constantly come to mind. Either we as a profession figure that out (step up and take a leading role) or someone else will. More over someone SHOULD step up - because it impacts patient care. I really believe that and it goes for my field of radiology as well (ahem 24/7 care ha - whether we like it or not for acutely ill patients etc). 

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16 hours ago, rmorelan said:

 

Lastly and one way or the other this important to manage - you cannot EVER leave an unfilled need and expect someone/some system to fill it. For tons of well known reasons doctors haven't been willing to do things that NP/PAs have been willing to do. Things like rural practises constantly come to mind. Either we as a profession figure that out (step up and take a leading role) or someone else will. More over someone SHOULD step up - because it impacts patient care. I really believe that and it goes for my field of radiology as well (ahem 24/7 care ha - whether we like it or not for acutely ill patients etc). 

Not to go off topic but just a side comment: in this country we have way too many small rural ERs and hospitals that are essentially money pits (Atlantic Canada is really bad for this) and provide worse quality services (good evidence exists that centralization improves quality). Centralization of services needs to occur to control costs if public healthcare is to survive in Canada. Unfortunately, centralization and reducing rural services is political suicide so the needed actions are never undertaken, and when they are, they are quickly reversed (look at NB recently). 

Because of politics, the system will never be fixed in any substantial way from a rural services point of view until it is collapsing and politicians are forced to make the correct decisions. 

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18 hours ago, NLengr said:

Not to go off topic but just a side comment: in this country we have way too many small rural ERs and hospitals that are essentially money pits (Atlantic Canada is really bad for this) and provide worse quality services (good evidence exists that centralization improves quality). Centralization of services needs to occur to control costs if public healthcare is to survive in Canada. Unfortunately, centralization and reducing rural services is political suicide so the needed actions are never undertaken, and when they are, they are quickly reversed (look at NB recently). 

Because of politics, the system will never be fixed in any substantial way from a rural services point of view until it is collapsing and politicians are forced to make the correct decisions. 

It also isn’t good for patients to have to drive several hours to be seen in an emergency department or have to deliver their baby on the side of the road. There are many good reasons closing rural hospitals is political suicide, and it’s not because people like wasting money.

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39 minutes ago, QuestionsAbound said:

It also isn’t good for patients to have to drive several hours to be seen in an emergency department or have to deliver their baby on the side of the road. There are many good reasons closing rural hospitals is political suicide, and it’s not because people like wasting money.

There is a balance for sure. You need to ensure core emergency services are avaliable within an acceptable distance. Nobody would argue that having to drive several hours to the nearest ER is acceptable. But generally we have too many services rurally and will need to look at how the system is structured with an eye to centralization. Easy example: Around here we have an "ER" in a health center that is 15 minutes from one of our regional referral centers. That small ER has no real capacity to do anything except initial triage and then ship any seriously ill patients to the bigger hospital. And we know most people who use it have category 5 issues (coughs and colds, back pain etc) and if you took it away they would simple stay home overnight and go to the family doc or the larger ER in the AM. The people who are seriously worried (chest pain, SOB etc.) Would still call an ambulance and go to the ER. It's pointless and a massive waste of money to keep it open but the minute the idea is floated to close it, people are in an uproar and politicians back down. Another example: we have a single ultrasonographer in a small rural health clinic about an hour from a regional referral center which has multiple US techs and radiologists. Centralization would increase efficiency, quality and reduce costs. 

Obviously nobody says "I'm gonna fight to have x, y and z service avaliable in my small town because I like wasting money". But the rural/urban demographics are changing rapidly, as well as the transportation system and the nature of healthcare (more tech, more specialized services/providers), so what worked in the 1960s when we set up all these tiny rural hospitals does not work effeciently or make sense economically anymore. If people want to continue to live rurally, increased travel to services will have to be the price they have to pay. It is harsh but needed if the system to survive.

I'm saying this as someone who is a rural physician and involved in admin of a rural health region. 

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On 2/26/2020 at 8:43 PM, VivaColombia said:

Recently met a PA in Winnipeg who works in Cardiology 5 days a week, minimal call shifts and makes 170k. Didn't believe it until I saw the hospital salary disclosure documents. It's a similar trend to the US where PAs are making really good money for the education/cost. And there is more regulation for NPs/PAs on the way in the near future so midline expansion is happening just like it did in the US.

 

PA (and specialized RNs/NPs) are the best bang for buck careers right now. Low opportunity cost, no overheard, short training, minimal personal liability, much better hours, all for a six-figure salary that is actually higher than some MDs (170k for example is more than a good chunk of FP, neuro, peds docs).

I enjoy medicine, but when kids ask me about going into the field, I ask them to make a serious cost-benefit analysis considering all of the above before they chose MD over PA/NP. The system/patients would benefit from more MDs, but it's probably in an individuals best interest to become a mid-level.

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We will be shielded somewhat since our system focuses more on cost savings rather than profit. In the American system someone ordering unnecessary tests and consults is encouraged because it generates more billings for the hospital. Administrators realize this which is why midlevel expansion has been much slower here.

My worry is that public opinion and politicians will be the ones who make the end decision, not the administrators who can see/understand the numbers. The general public doesn't care if a doctor works 80 hours/week after 8 years of training at 80-100 hours/week—all they see is that the doctor has a bigger dollar/year figure. The fact that a midlevel is less efficient is actually perceived positively by patients since they get more time with their medical provider.

And because nurses actually collaborate/unite instead of ripping each other up like doctors do, they can maintain a good PR machine while doctors are picked apart villified by the media.

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