Is a mid-level creep a problem in Canada?

[MasterDoc]

Recently the subreddits of r/medicalschool and r/medicine have been flooded by frustrated med students and attendings complaning about mid-levels. They are taking about how the increasing autonomy of NPs and PAs is endangering patient safety. People have mentioned how mid-levels are on med school admission boards and they have began taking on the roll of teaching new residents. Also med schools have been telling their students propaganda about how all positions in healthcare are equal and nurses should be paid the same as doctors. 

All of this is horrifying to listen to and I am wondering if some of you can comment how the situation is up here? From what I understand the CMA is considered a better lobbying group than the AMA. Are we headed down the path of the US where mid-levels are continuing to creep into physician territory?

[Vons]

I've been watching those discussions and wondering the same thing as well. I'm not really sure what factors are causing this in the states though, so I'm not really sure how it would map onto Canada. If I were to speculate, I'd say that lobbying/regulation/healthcare funding is different enough in Canada that it's unlikely that we would see the exact same situation. But what do I know lol.

[CGreens]

One protective factor in Canada is that we do not have the "degree mill" programs like they do in America. We have a limited number of PA and NP programs, and for our NP programs, the RN needs clinical experience before being accepted (e.g., 2-years nursing experience). Frustration on those forums seems, in part, to stem from the degree mills that are flooding the market with clinicians, who those forums would argue are undertrained. Discussing this issue with clinicians in Canada, it seems that our version of NPs/PAs are well trained and competent. Scope issues and fights will always be a thing, but that is just part of being in self-regulated professions which want to protect their monopolies on certain aspects of care. Perhaps we should focus our efforts on prescribing efforts and scope expansion of naturopaths and other CAM providers. 

Another aspect is the corporate nature of healthcare in America. Note that more and more physicians are employed by healthcare systems now in America (rather than being the employer themselves). It seems that insurance companies pay the healthcare organization the same amount of money, whether seen by a NP, PA, or MD. As a MD costs more money, the healthcare organization makes more money when patients are seen by the PA/NP. Alternatively, MDs can employee NP/PAs so that they can see more patients which makes them more money. I don't see Canada going down a route prioritizing midlevels, often it is more cost efficient to have a MD see patients (e.g., many can see more patients per day than a NP, NPs order more tests/imaging, etc.). We also have a much more comprehensive primary care system which emphasizes family medicine as a gate keeper. I think somewhere around 40-50% of Canadian medical grads become family physicians, where as something like less than 10% (fact check me here!) in America become family physicians. In America, it is not uncommon to have IM, peds, or OBGYN as your primary care provider. Basically, I am getting at that we have a system that is different than the American system, and that our system has certain insulations to this particular issue. One could argue that we could train more PAs to go rural, but NOSM has proven that training individuals from rural communities are more likely to go back and provide. In a publicly funded system, I think cost will be a deciding factor, and ultimately, as long as a MD is more cost efficient per patient, I think we will be fine. 

[1D7]

The situation reminds me of medical school where we'd regularly have mandatory small group discussions on the roles of allied health (incl. NPs) and "interprofessional days". Literally everyone was the self-described "quarterback"/essential of the medical team. Everyone but the docs basically spent hours patting themselves on the back. I don't believe unsafe expansion in scope of practice will be as severe for reasons CGreens described.

But to some extent it will happen because these professions regulate themselves and many do not understand the level of training it takes to be safe. As to your point regarding the AMA/CMA, physicians do a very bad job claiming credit where it's due. Historically with homeopaths (i.e. complete incompetents), physicians have been politically passive. Even when they directly interfere with care on an individual level, physicians generally avoid direct confrontation.

[MasterDoc]

On 11/22/2020 at 10:36 AM, CGreens said:

as long as a MD is more cost efficient per patient

Won't NP and PAs be more cost efficient? If anything when budgets cuts come, the NPs would be at an advantage cause they don't charge as much as physicians. 

[JohnGrisham]

9 minutes ago, MasterDoc said:

Won't NP and PAs be more cost efficient? If anything when budgets cuts come, the NPs would be at an advantage cause they don't charge as much as physicians. 

You need to understand what cost efficient means. Your argument has validity but not for the reason you are stating. They are attractive due to the illusion of providing care, and the govt's game is to cut costs and contain cost. Physicians that treat patients, aka provide care, are a cost on the govt.  

[JohnGrisham]

On 11/22/2020 at 8:36 AM, CGreens said:

One protective factor in Canada is that we do not have the "degree mill" programs like they do in America. We have a limited number of PA and NP programs, and for our NP programs, the RN needs clinical experience before being accepted (e.g., 2-years nursing experience). Frustration on those forums seems, in part, to stem from the degree mills that are flooding the market with clinicians, who those forums would argue are undertrained. Discussing this issue with clinicians in Canada, it seems that our version of NPs/PAs are well trained and competent. Scope issues and fights will always be a thing, but that is just part of being in self-regulated professions which want to protect their monopolies on certain aspects of care. Perhaps we should focus our efforts on prescribing efforts and scope expansion of naturopaths and other CAM providers. 

 

NP degrees in Canada, are not that significantly more competency based than the US. The 2 year experience requirement, doesn't really change much under the surface. Nursing is a broad field, and nursing experiences vary alot. An ICU or ED nurse has a very different skillset than a community outreach RN. I work with multiple decent quality NPs, so no angst, but in general the ones I know are fairly upfront about the lack of actual clinical experience in NP programs -and confusion of how the local govts often want to make them seem "equivalent" or an alternative to MDs, rather than working alongside/under supervision from them.

[ArchEnemy]

Over the years, I have noticed that this is becoming a problem in Canada too, although not as rampant for the reasons mentioned above. I believe a physician cannot bill for the work of a PA unless they physically lay eyes on the patient themselves. NPs, on the other hand, do not need to be supervised by a physician. I have seen large Telehealth Organizations take advantage of this.

[medigeek]

On 11/22/2020 at 8:51 AM, Vons said:

I've been watching those discussions and wondering the same thing as well. I'm not really sure what factors are causing this in the states though, so I'm not really sure how it would map onto Canada. If I were to speculate, I'd say that lobbying/regulation/healthcare funding is different enough in Canada that it's unlikely that we would see the exact same situation. But what do I know lol.

It is very likely we will have the same issues in Canada. 

 

On 11/22/2020 at 10:36 AM, CGreens said:

One protective factor in Canada is that we do not have the "degree mill" programs like they do in America. We have a limited number of PA and NP programs, and for our NP programs, the RN needs clinical experience before being accepted (e.g., 2-years nursing experience). Frustration on those forums seems, in part, to stem from the degree mills that are flooding the market with clinicians, who those forums would argue are undertrained. Discussing this issue with clinicians in Canada, it seems that our version of NPs/PAs are well trained and competent. Scope issues and fights will always be a thing, but that is just part of being in self-regulated professions which want to protect their monopolies on certain aspects of care. Perhaps we should focus our efforts on prescribing efforts and scope expansion of naturopaths and other CAM providers. 

Another aspect is the corporate nature of healthcare in America. Note that more and more physicians are employed by healthcare systems now in America (rather than being the employer themselves). It seems that insurance companies pay the healthcare organization the same amount of money, whether seen by a NP, PA, or MD. As a MD costs more money, the healthcare organization makes more money when patients are seen by the PA/NP. Alternatively, MDs can employee NP/PAs so that they can see more patients which makes them more money. I don't see Canada going down a route prioritizing midlevels, often it is more cost efficient to have a MD see patients (e.g., many can see more patients per day than a NP, NPs order more tests/imaging, etc.). We also have a much more comprehensive primary care system which emphasizes family medicine as a gate keeper. I think somewhere around 40-50% of Canadian medical grads become family physicians, where as something like less than 10% (fact check me here!) in America become family physicians. In America, it is not uncommon to have IM, peds, or OBGYN as your primary care provider. Basically, I am getting at that we have a system that is different than the American system, and that our system has certain insulations to this particular issue. One could argue that we could train more PAs to go rural, but NOSM has proven that training individuals from rural communities are more likely to go back and provide. In a publicly funded system, I think cost will be a deciding factor, and ultimately, as long as a MD is more cost efficient per patient, I think we will be fine. 

Biggest mistake in your post is training midlevels to go rural. The US is concrete proof that it does the opposite. 

A lot of rural ERs in USA are staffed by just a midlevel and no one else. CRNAs delivery anesthesia all alone too, 0 supervision. And this is for stuff like ex laps etc. 

ICUs are run by midlevels all alone overnight all over USA. Even in academic centers. PA and NP "hospitalists" are also rampant everywhere.

[Vons]

28 minutes ago, medigeek said:

It is very likely we will have the same issues in Canada.

Any ideas for how to head it off before it becomes impossible? What should medical students/residents/physicians in a Canadian context be doing? What changes should happen on a structural/organizational level that we can influence?

[medigeek]

3 minutes ago, Vons said:

Any ideas for how to head it off before it becomes impossible? What should medical students/residents/physicians in a Canadian context be doing? What changes should happen on a structural/organizational level that we can influence?

1. Don't train them. By far the most important part. At the beginning, they're just learning. 5 years later, they're lobbying for independent practice and will claim to be at minimum equal to you or better. 

2. Don't hire them. Sure they'll work for you initially and do as told. Then go down the street and become a direct competitor. 

3. Raise awareness. So many people in the field are barely aware of this issue or think superficially it's a good thing. 

4. Aggressively lobby against proliferation. 

[Vons]

53 minutes ago, medigeek said:

1. Don't train them. By far the most important part. At the beginning, they're just learning. 5 years later, they're lobbying for independent practice and will claim to be at minimum equal to you or better. 

2. Don't hire them. Sure they'll work for you initially and do as told. Then go down the street and become a direct competitor. 

3. Raise awareness. So many people in the field are barely aware of this issue or think superficially it's a good thing. 

4. Aggressively lobby against proliferation. 

That seems reasonable. Those points seem to be geared towards reducing the supply of midlevels, rather than (perceived) demand. In the states, one of the main arguments seems to be that PAs/NPs/etc. will make up for primary care physician shortage, particularly in rural areas. Evidence seems to indicate that they're not really doing that, and that's not even to address the issues of training/safety. In Canada the topic of primary care physician shortages comes up frequently as well (both rural and urban), but iirc ~50% of Canadian MDs go into Family Med, while in the US it is closer to ~15% (though I get that primary care is different there so these numbers may not have exactly the same significance). My point is that it seems like unless we can simultaneously address primary care physician access in Canada (and reduce the demand for PAs/NPs), the physician rhetoric/action against PAs/NPs (even if it is well-founded) will be seen by the public as "protectionist" and not truly in the interest of Canadians broadly.

[Pakoon]

On 12/12/2020 at 2:34 PM, Vons said:

That seems reasonable. Those points seem to be geared towards reducing the supply of midlevels, rather than (perceived) demand. In the states, one of the main arguments seems to be that PAs/NPs/etc. will make up for primary care physician shortage, particularly in rural areas. Evidence seems to indicate that they're not really doing that, and that's not even to address the issues of training/safety. In Canada the topic of primary care physician shortages comes up frequently as well (both rural and urban), but iirc ~50% of Canadian MDs go into Family Med, while in the US it is closer to ~15% (though I get that primary care is different there so these numbers may not have exactly the same significance). My point is that it seems like unless we can simultaneously address primary care physician access in Canada (and reduce the demand for PAs/NPs), the physician rhetoric/action against PAs/NPs (even if it is well-founded) will be seen by the public as "protectionist" and not truly in the interest of Canadians broadly.

If we have a physician shortage then we should train more physicians. From what I could gather mid-levels are not cheaper on a system of shared resources like our healthcare system. It may seem cheaper to hire them at first, but unsupervised it seems mid-levels cost the system more in areas such as unnecessary tests and missed diagnoses. Looking at the situation in the states this is most likely the case. 

[Snowmen]

On 12/15/2020 at 12:01 AM, Pakoon said:

If we have a physician shortage then we should train more physicians. From what I could gather mid-levels are not cheaper on a system of shared resources like our healthcare system. It may seem cheaper to hire them at first, but unsupervised it seems mid-levels cost the system more in areas such as unnecessary tests and missed diagnoses. Looking at the situation in the states this is most likely the case. 

And the fact that an NP working in primary care ends up costing more per patient than a GP in the first place when you consider overhead and benefits.

[Vons]

It seems like the Ontario Pharmacists Association is trying to get in on it as well: https://www.readyforwhatsnext.ca/

[Intrepid86]

5 hours ago, Vons said:

It seems like the Ontario Pharmacists Association is trying to get in on it as well: https://www.readyforwhatsnext.ca/

It is a clear conflict of interest for pharmacists to be both the prescriber and dispenser. Also, what they assess and assume is a "minor illness" may in fact turn out to be something more significant.

[JohnGrisham]

37 minutes ago, Intrepid86 said:

It is a clear conflict of interest for pharmacists to be both the prescriber and dispenser. Also, what they assess and assume is a "minor illness" may in fact turn out to be something more significant.

Another clear conflict of interest is physician clinics with sweetheart rents(i.e. free) attached to pharmacies, but no one is putting a stop to these at all. Even if you aren't directly telling your patients to go there, it is still a source of bias etc.

[ArchEnemy]

  

2 hours ago, Intrepid86 said:

It is a clear conflict of interest for pharmacists to be both the prescriber and dispenser. Also, what they assess and assume is a "minor illness" may in fact turn out to be something more significant.

In several countries, the physician is both the prescriber and dispenser.

So imagine if physicians were allowed to dispense medications from their offices, I wonder how would pharmacists and pharmacy chains feel about that?

[gogogo]

4 hours ago, JohnGrisham said:

Another clear conflict of interest is physician clinics with sweetheart rents(i.e. free) attached to pharmacies, but no one is putting a stop to these at all. Even if you aren't directly telling your patients to go there, it is still a source of bias etc.

Why is it considered a conflict of interest rather than just convenience? As a patient, I'd be happier to pick up my prescription right next door to my doctor's, rather than drive to an unaffiliated pharmacy. Or is it thought that the physician will be more inclined to prescribe (even if not medically necessary) because of the free rent? Do doctors actually feel that pressure from attached pharmacies?

[JohnGrisham]

34 minutes ago, gogogo said:

Why is it considered a conflict of interest rather than just convenience? As a patient, I'd be happier to pick up my prescription right next door to my doctor's, rather than drive to an unaffiliated pharmacy. Or is it thought that the physician will be more inclined to prescribe (even if not medically necessary) because of the free rent? Do doctors actually feel that pressure from attached pharmacies?

In some scenarios there is definitely conflict by stating "go to the pharmacy right there", don't forget all pharmacies have different filling fees and costs to the patient.   As well with certain "hi, how come you're not prescribing as much drug X". 

Sure its not the most audacious COI, but there is something to think about in general.