NP Encroachment

[Patellaboy]

Hi Everyone,

I have noticed more and more NPs essentially running their own full-scope practice. Some are even completely running an emergency department in the rural settings without supervision. I'm genuinely curious as to why we are allowing this to happen? Anyone who has ever spent a significant amount of time with NPs know that their level of knowledge is not even close to canadian-graduated MDs. This is a slippery slope as once you start granting people decision-making capabilities, it is hard to retract these powers. We've seen the outcome of this in the US... with CRNAs, PAs, NPs, etc essentially mimicking the job of MDs.

I would like a discussion that goes beyond the fact that we have lack of physicians such as in BC and rural communities to justify these actions. Why are we allowing someone with half the amount of medical training as our own family doctors, without the same vigour, depth, and quality of training, have the same kind of practice as our MDs? Why go through 4 years of medical school and at minimum 2 years of residency when one could have just became a nurse instead? What's the point of our licensing exams? Why go into +$100,000 in debt when the nurse next door who can barely interpret an ECG just open up his/her own clinic next door and practice the same level of medicine??

This is a serious issue and I think we need a hard look at the direction of our healthcare system here. We've become far too complacent in these manners without anyone really questioning what is going on. 

[medigeek]

How are they running ERs solo?

[Patellaboy]

16 minutes ago, medigeek said:

How are they running ERs solo?

In a small rural town in BC, there was an NP that was covering the whole ED. Granted there was an MD who was in a clinic nearby, but the NP was essentially running the ED by herself. There was actually two unstable patients who came in that day, one of which was an upper GI bleed and she had absolutely zero clue what to do. 

[shikimate]

Because this saves the government money. Imagine the additional cost of all those IMG who want to work in Canada, let alone training more CMGs. 

The government still wants to provide medical service because "free" healthcare has become the sacred cow of Canadian identity and politics. But how do you give people something when they don't want to pay for it? Given them less for the same price tag, aka shrinkflation. Just like you'll notice in grocery stores the price is same but quantity of food in a package has decreased.

It's very hard to tell the difference in quality of care provided when you are not an insider. Somebody with UGIB the NP could say with a sympathetic tone "I am sorry but your loved one was too ill and succumbed" and 99% of the population wouldn't know better about what could have been done. It's just like when I take my car to a mechanic, 99% of the time I really don't have the expertise to say whether they did a lackluster job, mediocre job, good job, or superb job.

So it's all about the money my friend, follow the money.

[Bobthebuilder]

''allowing this to happen?''

''level of knowledge is not even close''

''once you start granting people decision-making capabilities''

''without the same vigour, depth, and quality of training''

''one could have just became a nurse instead?''

''nurse next door who can barely interpret an ECG''

''far too complacent in these manners''

 

So...beside being ridiculously offensive towards your colleagues. Are you bringing any new evidence to the table ?

I was working with a cardio-NP this morning and she could read ECG quite alright...

Healthcare is a team sport. Not everything need a MD doing it. There is probably discussions to be had. But clearly not comign with this mindset.

Also, once canadian MDs accept being paid the same as their european counterparts and that money being reinvested in med schools spots and residency spots then we can talk about relying less on other healthcare providers. It is however, not happening anytime soon, so unless we want to spend 20% of our GDP on MD alone we need to think about other means to provide care. One of these is realizing not everything needs an MD in to provide quality care. There is plenty of evidence for this in physical therapy, OT, and pharmacy as well. 

 

[Patellaboy]

3 hours ago, Bobthebuilder said:

''allowing this to happen?''

''level of knowledge is not even close''

''once you start granting people decision-making capabilities''

''without the same vigour, depth, and quality of training''

''one could have just became a nurse instead?''

''nurse next door who can barely interpret an ECG''

''far too complacent in these manners''

 

So...beside being ridiculously offensive towards your colleagues. Are you bringing any new evidence to the table ?

I was working with a cardio-NP this morning and she could read ECG quite alright...

Healthcare is a team sport. Not everything need a MD doing it. There is probably discussions to be had. But clearly not comign with this mindset.

Also, once canadian MDs accept being paid the same as their european counterparts and that money being reinvested in med schools spots and residency spots then we can talk about relying less on other healthcare providers. It is however, not happening anytime soon, so unless we want to spend 20% of our GDP on MD alone we need to think about other means to provide care. One of these is realizing not everything needs an MD in to provide quality care. There is plenty of evidence for this in physical therapy, OT, and pharmacy as well. 

 

I think there is a definitely a role for allied health professionals in our healthcare system. Particularly, as you mentioned, when they have well-defined roles. Case in point the NP cardiologist you worked with, who has significant exposure to cardiology patients and likely can take a good cardiology HPI and come up with an impression and plan. Would you be comfortable with this NP cannulating you patient's left main coronary? Probably not. Are they reading echos and stress tests? Are they managing patients with cardiogenic shock and on dialysis by themselves? No. What makes you comfortable in them managing a whole ED by themselves? Even family medicine, where arguably the breadth of knowledge is much more vast than a cardiology clinic that has strict limitations on what an NP can do and cannot do.

My main point is that we are allowing people with two vastly different training perform the same kind of work. How does that make any sense? The previous user mentioned financial savings and while I think this is quite a complex issue, I think theres a point to be made there. It's not about whether you know an NP Cardiologists that can read ECGs well, its about the fact that we are giving people who are not trained in FAMILY or EMERGENCY MEDICINE to work as family or emerg doctors.

[bearded frog]

NPs are working solo in mostly places where MDs do not want to work. They could hire 10000 more doctors but someone who has gone through the extensive education you describe does not want to live in the middle of nowhere, they want amenities in their life. Some places in northern BC only have nurses and there's a doc somewhere central available by phone and that's it.

[Let'sGo1990]

13 hours ago, Bobthebuilder said:

''allowing this to happen?''

''level of knowledge is not even close''

''once you start granting people decision-making capabilities''

''without the same vigour, depth, and quality of training''

''one could have just became a nurse instead?''

''nurse next door who can barely interpret an ECG''

''far too complacent in these manners''

 

So...beside being ridiculously offensive towards your colleagues. Are you bringing any new evidence to the table ?

I was working with a cardio-NP this morning and she could read ECG quite alright...

Healthcare is a team sport. Not everything need a MD doing it. There is probably discussions to be had. But clearly not comign with this mindset.

Also, once canadian MDs accept being paid the same as their european counterparts and that money being reinvested in med schools spots and residency spots then we can talk about relying less on other healthcare providers. It is however, not happening anytime soon, so unless we want to spend 20% of our GDP on MD alone we need to think about other means to provide care. One of these is realizing not everything needs an MD in to provide quality care. There is plenty of evidence for this in physical therapy, OT, and pharmacy as well. 

 

Some of that is true though?

Are you really going to argue that the level of knowledge is close? That the vigour, depth, and quality off training is comparable? That some aspects of medicine couldn't just be practiced by becoming a nurse given the current rules?

Regarding payments - sure, maybe once our tuition, opportunity cost, schooling path, residency hour requirements, etc. match our European counterparts, along with a pension, benefits, fixed hour work week, etc. we can chat. Oh, and the government can cover overhead too, and spend 100k a year on a clinic manager responsible for finding clinic space, hiring staff, sorting out the EMR, internet, chairs, equipment, patient complaints, finding staff replacements when your nurse or secretary calls in sick or quit without notice, etc., ALL of which is an unpaid managerial headache assumed by Canadian physicians for "free" that the government would otherwise be paying for.

[Patellaboy]

16 hours ago, bearded frog said:

NPs are working solo in mostly places where MDs do not want to work. They could hire 10000 more doctors but someone who has gone through the extensive education you describe does not want to live in the middle of nowhere, they want amenities in their life. Some places in northern BC only have nurses and there's a doc somewhere central available by phone and that's it.

There's NPs practicing in major cities now... My point also goes beyond rural communities though, which I completely agree have their own challenges. It's more about level of training, credentials, competency. Would you let an electrical engineer build a bridge in north Ontario if no civil engineer wants to work there? Would you let an ICU-trained nurse stent your patient's coronaries? 

There are lack of family doctors. There is a lack of funding. I get these points, but we are literally letting people who do not have the qualifications have the same role as our own MDs.

To anyone who is still questioning my line of thinking, would you be comfortable with an NP acting as your GP/emerg doc/internist? 

[jb24]

6 hours ago, Patellaboy said:

There's NPs practicing in major cities now... My point also goes beyond rural communities though, which I completely agree have their own challenges. It's more about level of training, credentials, competency. Would you let an electrical engineer build a bridge in north Ontario if no civil engineer wants to work there? Would you let an ICU-trained nurse stent your patient's coronaries? 

There are lack of family doctors. There is a lack of funding. I get these points, but we are literally letting people who do not have the qualifications have the same role as our own MDs.

To anyone who is still questioning my line of thinking, would you be comfortable with an NP acting as your GP/emerg doc/internist? 

If you read US forums, that is the case. NP schools popping up almost like diploma mills. Especially ER medicine has been affected, because in the US there is incentive to admit patients for hospitals (generate revenue). It's easy to just admit everyone or consult every service available.

 

[zoxy]

On 11/29/2022 at 12:02 PM, Bobthebuilder said:

Also, once canadian MDs accept being paid the same as their european counterparts and that money being reinvested in med schools spots and residency spots then we can talk about relying less on other healthcare providers. It is however, not happening anytime soon, so unless we want to spend 20% of our GDP on MD alone we need to think about other means to provide care.

Ahh, the classic all of our money goes towards paying greedy Canadian MDs argument rears its head again. I would expect the clueless public and the foul politicians in power to make arguments like yours, but I don't want such arguments to go unchallenged by factual reality on this forum.

Physician compensation is 13.6 percent of healthcare spending in Canada in 2022, according to the CIHI. With overall healthcare spending being 12.2 percent of total GDP, that would make physician compensation 1.66 percent of total GDP.

Total government spending across all levels in Canada is between 40-44% of total GDP. Using the more conservative 40% number, that would mean that spending on physicians accounts for 4.15% of total government spending in Canada. So out of every dollar the governments spends, 4 cents go to doctors. I don't know about you, but this data doesn't point to our fiscal problems being caused by greedy doctors.

Additionally, even when comparing Canadian physician earnings to European physicians, you'd see that Canadian physicians earn broadly in line with the OECD average when compared to the median domestic earnings. In fact Canadian doctors earn LESS when compared to Canada's median wage than German and French doctors earn compared to the median wage in France or Germany. OECD data is linked below. The notion that Canadian doctors grossly out earn their European counterparts is a myth.

As for comparing Canadian MDs compensation to European compensation levels, you should also compare things like tuition paid, length of training, hours worked, clinical burden, benefits, and pension as well. In fact, due to the low number of physicians per capita, our aging population, and our inefficient system, Canadian physicians are some of the most overworked in the world.

Sources:

https://www.cihi.ca/en/where-is-most-of-the-money-being-spent-in-2022

https://www.cihi.ca/en/national-health-expenditure-trends-2022-snapshot

https://www.oecd-ilibrary.org/remuneration-of-doctors-general-practitioners-and-specialists_5jfksz1wnbjb.pdf?itemId=%2Fcontent%2Fcomponent%2Fhealth_glance-2017-55-en&mimeType=pdf

https://macdonaldlaurier.ca/size-of-government-in-canada/

https://www.fraserinstitute.org/sites/default/files/size-of-government-in-canada-in-2019.pdf

[Let'sGo1990]

One more comment - complacency in this regard is exactly the sort of attitude which has led to the current problem in the United States regarding nurse practitioners and physician assistants. What sounded like a good idea in principle marred by politics and ultimately resulting in worse care for patients.

It is not uncommon for people to refer to a specialist now, and to receive a consultation note back from a nurse practitioner, with little to no physician oversight in the United States. You are receiving (often poor) advice from somebody less qualified than you. Twisted.

[who_knows]

Provincial physician colleges across Canada are granting more privileges to NPs. I was reading last news from the CMA and those people, who are supposed to represent and fight for doctors, are welcoming NP's scope creep. They also advocate for inviting more IMGs. Seriously, physicians need better representation and organization in this country.

[LoquaciousLoquat]

There is no longer encroachment in the sense that NPs now have full medicolegal scope to do the work of family physicians (at least in primary care). They are equivalent.

As for your initial question of: "why go into debt and training from medical school?", it's so you can have an opportunity to access careers still exclusive to MDs: medical specialists, surgeons, etc... If you decide against those paths and solely wish to focus on primary care, well, then that's your choice.

 

 

[shikimate]

3 points:

- in many places the hospital/government stipulates you join the provincial medical association, so their modus operandi is to get more $ by increasing physician numbers. Kind of like cash grab LMCC. Fee is main purpose, others are secondary (aka advocating or testing). Kind of like how these days anyone can get into some "no name university", same idea, get $ first, education is a by-product.

- there are many other fields with over-qualified people being underpaid for jobs. For example in US there are excessive # of lawyers. Engineering grads doing jobs that doesn't require engineering degree. People with Masters of Arts degree working barista jobs etc. So medical students shouldn't be complacent and just expect job security and $$$$$, those are the 80s and 90s bygone days. You gotta hustle hustle and HUSTLE for $.

- there are still very lucrative and/or cushy jobs being a FMD. Just like there are lucrative dental practices even though competitive is fierce in some markets. FMD grads aren't taught on how to be shrewd for this, which is unfortunate. Actually I dare someone name ANY residency that teaches their grads to be shrewd when it comes to finding good lucrative positions!

[LoquaciousLoquat]

 

2 hours ago, shikimate said:

- there are still very lucrative and/or cushy jobs being a FMD. Just like there are lucrative dental practices even though competitive is fierce in some markets. FMD grads aren't taught on how to be shrewd for this, which is unfortunate. Actually I dare someone name ANY residency that teaches their grads to be shrewd when it comes to finding good lucrative positions!

The real issue here is that primary care family medicine has lost exclusivity of practice (not just to NPs, but eventually to clinical pharmacists and other midlevels that will slice away key parts of the practice).

Being shrewd won't bring back the sunk cost of medical school (time and money).

Being shrewd won't help you when more midlevels get prescribing rights, and directly compete with you for parallel care.

Being shrewd won't stop the unending flow of paperwork, letters, forms... all of which are only set to increase in a more bureaucratic / liability-averse culture.

Being shrewd won't reverse the normalized disrespect and devaluation of primary care family physicians in the eyes of the public and politicians.

It all comes back to exclusivity of practice. In fact, the only real way "to be shrewd" in family medicine... is to also do specialized work that only an MD-qualified physician can do (i.e. ER, hospitalist, etc...). Unsurprisingly, the specialized work nearly often will pay far more than office-based primary care practice.

[bearded frog]

On 11/30/2022 at 1:16 PM, Patellaboy said:

Would you let an electrical engineer build a bridge in north Ontario if no civil engineer wants to work there? Would you let an ICU-trained nurse stent your patient's coronaries?

NPs are not leading cardiac bypass surgeries though? They are doing routine medicine either under the supervision of an MD or doing heavily guide-lined/standardized primary care...

[hero147]

27 minutes ago, bearded frog said:

NPs are not leading cardiac bypass surgeries though? They are doing routine medicine either under the supervision of an MD or doing heavily guide-lined/standardized primary care...

For now....But I already see NPs taking over most fields in medicine in time. Look at how much NPs have gained in terms of scope of practice compared to family docs over the past 10 years. They were originally suppose to be under the supervision of an MD and now can practice independently...

You think it's just primary care? There are NPs being trained (and later staffing) ICU at tertiary care hospitals in Canada right now with the idea that they would be able to manage the unit at night because some physicians don't want to do inhouse call anymore. If ICU isn't safe, other than surgery, what is? 

[bearded frog]

4 hours ago, hero147 said:

For now....But I already see NPs taking over most fields in medicine in time. Look at how much NPs have gained in terms of scope of practice compared to family docs over the past 10 years. They were originally suppose to be under the supervision of an MD and now can practice independently...

You think it's just primary care? There are NPs being trained (and later staffing) ICU at tertiary care hospitals in Canada right now with the idea that they would be able to manage the unit at night because some physicians don't want to do inhouse call anymore. If ICU isn't safe, other than surgery, what is? 

This already happens in ICUs. NPs are basically equivalent to fellows, and the ones I have seen have ++ years of ICU experience compared to 3-5 years of clinical experience (and much less in ICU) for fellows. If you're cool with an R3/R4 being inhouse while the staff is at home, you should be cool with a (properly trained and experienced) NP doing the same.

[Pakoon]

16 minutes ago, bearded frog said:

This already happens in ICUs. NPs are basically equivalent to fellows, and the ones I have seen have ++ years of ICU experience compared to 3-5 years of clinical experience (and much less in ICU) for fellows. If you're cool with an R3/R4 being inhouse while the staff is at home, you should be cool with a (properly trained and experienced) NP doing the same.

R3/R4s work under an attending physician, this is key. Also Fellows are fully trained physicians, every single time. where as for NPs its not standardized, I'm sure there are amazing NPs with 30+ years of ICU experience, but there are also those who can go to the US for an online degree.  Independent practice is what they continue to lobby for. Regarding the last point, and to reiterate, R3/R4s are supervised, and we should expect the same for NPs (Properly trained and experienced).

[Edict]

I think in some ways, this is inevitable. Technology has devalued the importance of book knowledge. 50 years ago, you had doctors discerning murmurs with their stethoscope, now you just order an echo. In its place, paperwork has increased, but paperwork isn't an exclusive skill of doctors. Add on to the fact that the modern generation values personal time over money, and you get doctors who would rather be employees and have flex hours and not work rurally and are willing to get paid less to do so. This leads to a shortage of doctors rurally and increased cost for the government (training time is the same but doctors don't work as many hours).

There is no way out, technology is coming for the medical profession. We certainly should fight this, but I see this as a losing battle. NPs offer value for money. They are the answer to the current modern day problem of the increased deskilling of primary care. As a PCP, think of how much of your day is actually spent using the doctor skills that are unique to your training versus how much of your day is spent doing things a NP can do just as well. 

The only argument I see doctors using is if NPs cost more to the healthcare system by ordering unnecessary tests, but that's a hard sell and you'll need plenty of evidence. Might be an interesting clinical research idea to be honest.

People are saying that physician leaders are selling the profession out. I think they see the writing on the wall, the government is slow but not stupid, physicians to them are just one stakeholder, not the authority, they want to see evidence. I haven't seen much good quality evidence to show the superiority of PCP over NP in terms of clinical outcomes and there is evidence that states that have allowed NPs independent practice rights have reduced emergency visits, increased PCP supply, no crowding out of family doctors etc. https://pubmed.ncbi.nlm.nih.gov/29475093/ Additionally, other studies have not shown any difference between NPs and physicians in primary care. https://pubmed.ncbi.nlm.nih.gov/10632281/

[hero147]

50 minutes ago, Edict said:

People are saying that physician leaders are selling the profession out. I think they see the writing on the wall, the government is slow but not stupid, physicians to them are just one stakeholder, not the authority, they want to see evidence. I haven't seen much good quality evidence to show the superiority of PCP over NP in terms of clinical outcomes and there is evidence that states that have allowed NPs independent practice rights have reduced emergency visits, increased PCP supply, no crowding out of family doctors etc. https://pubmed.ncbi.nlm.nih.gov/29475093/ Additionally, other studies have not shown any difference between NPs and physicians in primary care. https://pubmed.ncbi.nlm.nih.gov/10632281/

Honestly, from my opinion, a lot of physician leaders stick their head in the sand rather than maliciously selling the profession out. When I see pushes for longer family medicine residencies, I wonder what some people in some of these ivory towers are smoking. 

If longer training and residency times aren't translating to better care, then people need to start to take a better look at medical training and what can be removed from the curriculum. I remember in my first couple weeks of medical school, we were given an article that told us that learning glycolysis was still a necessary and beneficial part of medical education. I honestly wouldn't be as salty as I am today with regards to NP encroachment if training was shorter and wasn't filled with so much pointless fluff. 

[indefatigable]

It's really a turning point in family medicine.  Family doctors have experienced both erosion of scope (outside of rural especially) and loss of exclusivity from other providers performing the same function.  

The CFPC seems to believe that adding another year of training will fix all the issues.  Now, in theory, an extra year could be helpful in some situations since currently most +1s are competitive and there is a demand for practitioners with enhanced skills that exceeds supply.  So it's possible that further training could help both FPs that want to work in some practice areas but still unanswered questions in terms of equivalencies of qualifications for instance.  However, while more accessible training could be a growth area for FM to some extent, I don't think the clock will wind back to for example FPs doing low-risk obstetrics for multiple reasons including erosion of exposure/training, lifestyle preferences and push-back from gynecologists which has happened in some settings.  While more procedural & diagnositc skills could be within a FPs scope of practice with the right exposure/training fee codes and medico-legal climate can be disincentives - a practitioner may be incentivized to generate a systemwide costly consult rather than perform a said procedure or work-up due to unfavourable renumeration.  Perhaps the BC hourly-pay model may change things a little - but maybe the idea of a "generalist" doesn't exist anymore in the era of specialization.   

In terms of other providers, surprisingly there doesn't seem to be a lot of evidence suggesting that NP care is any different - although the studies seem to be based on older data.  Now the floodgates to NPs certification in the US are wide open since there are literally online programs with 100% acceptance, etc..  Even supposing medical education is seriously flawed, I would be surprised that it's bad enough that a graduate from aa degree mill would broadly outperform a Canadian or US MG in a clinical setting.  I'd also suspect that most of the studies are coming from the US where more tests and referrals may generate revenue.   Here for example is a McMaster study commissioned by the BC government from 2019.  

https://www.mcmasterforum.org/docs/default-source/product-documents/rapid-responses/examining-the-effects-of-nurse-practitioners-on-the-quadruple-aim.pdf?sfvrsn=2

The debate for NP scope apparently is raging in Mississippi at the moment, where a 10 year retrospective study came out of a multi-center clinic suggesting that costs, referrals, ED visits were higher and other aspects were less favourable for NP - one feature was apparently the clinic lost money with extraneous tests unlike the standard set-up.  The editorial is interesting and points out that there are some parallels between the current state of NP education and MD education 100 years ago when there was a lack of standardization - this led to closure of many medical schools.  Another point seems to be medico-legal liability - NPs are apparently increasingly liable and named proportionally more for missed diagnosis as well as high-severity injury (with about half of claims in outpatient settings).  This could also slow the growth of the NP model.    

https://ejournal.msmaonline.com/publication/?m=63060&i=735364&view=articleBrowser&article_id=4196849&ver=html5

https://ejournal.msmaonline.com/publication/?m=63060&i=735364&view=articleBrowser&article_id=4196853&ver=html5

https://web.archive.org/web/20210623202406/https://www.rmf.harvard.edu/Clinician-Resources/Newsletter-and-Publication/2019/SPS-MPL-Risks-Associated-with-NPs

In terms of the medical student perspective, FM is obviously becoming less and less popular despite the fact that the education is nominally set up to favour GP development.  In QC for example, every specialty residency spot fills unlike FM even in mid-sized urban areas - although this may be partly due to less IMGs in the province.  

Still one wonders at what level the system is sustainable - sure the calculus of CaRMS guarantees that a large number of highly indebted graduates will end up in FM whether they want to or not - does it mean after jumping through the exact same hoops up to residency of a specialist colleague that they will now end up with an increasingly shorter end of the stick?  If so, I think that medical education and or residency allocation will have to change.  Ultimately though if things don't change it could lead to more of the same in multiple areas of medicine including Peds, IM..  surgery seems insulated though- the only threat to surgery turf are trained IMGs which the Royal College effectively acts as a gatekeeper.

 

[jb24]

2 hours ago, hero147 said:

Honestly, from my opinion, a lot of physician leaders stick their head in the sand rather than maliciously selling the profession out. When I see pushes for longer family medicine residencies, I wonder what some people in some of these ivory towers are smoking. 

If longer training and residency times aren't translating to better care, then people need to start to take a better look at medical training and what can be removed from the curriculum. I remember in my first couple weeks of medical school, we were given an article that told us that learning glycolysis was still a necessary and beneficial part of medical education. I honestly wouldn't be as salty as I am today with regards to NP encroachment if training was shorter and wasn't filled with so much pointless fluff. 

I think learning all that minutiae is important as it opens the door to niche specialties like medical biochemistry or pathology. Same with histology which forms the foundation of pathology. Also anatomy, with lab is an essential part of the medical curriculum. 

The last thing I want is our training to be watered down.  

[bearded frog]

23 hours ago, Pakoon said:

R3/R4s work under an attending physician, this is key.... Regarding the last point, and to reiterate, R3/R4s are supervised, and we should expect the same for NPs (Properly trained and experienced).

In house NPs covering ICUs would be "supervised" by the on-call attending at home... they work under physicians just like fellows or clinical associates (non-intensivist trained MDs who cover units under an intensest MRP).