(Writing this blog can be difficult. While I am interested in many subjects, developing coherent ideas and putting them down in a logical and entertaining manner does not always come easy. In other words, most of my articles do not just fall effortlessly from my brain. On the other hand, there are some subjects about which I am so interested and have such well-developed ideas that I almost want to avoid writing about them because it feels too much like “phoning it in.” Some run home to their mommies at the first sign of trouble. When I have trouble coming up with anything new I, too, metaphorically run home to the comforting bosom of my mother, revisiting subjects like futile care and the abuse of residents. Precisely because these things are easy to write about and I take great pleasure in doing it, sometimes I feel like a fraud, one who is just repeating himself with only slight variation, and throwing to you, my loyal readers, easy-to-obtain red meat instead of coming up with something original.
With this in mind, please accept the following article as more red meat. I hadn’t planned on writing it but I received so many private emails about what was really just a throwaway line in my last article that I felt compelled to fire up the old easy-writing machine to shoot ducks in a barrel and pluck the low-hanging fruit. You get my drift. I’m not proud of it but there it is. -PB)
Cry Me a Friggin’ River, Why Dontcha’?
It seems that I can’t mention mid-level providers, even in an offhand way as I did in my previous article where I compared Physician Assistants to brand-new interns, without the usual scolding from assorted mid-levels who are quick to rehash the usual half-truths and agitprop about their profession vis-a-vis physicians. It is not enough, apparently, for me to be generally highly complementary to mid-levels in many of my articles but I must instead roll over and submissively urinate, crying Uncle and admitting that the only difference between a physician and mid-level is some inconsequential and medically irrelevant minutia that we had forced on us in medical school and residency but from whose wasteful tyranny the mid-levels have been spared.
This is not the case however and the credence one gives to the theory that Less is Better depends on how much knowledge, the currency of medicine, one has in their possession. Since it is, barring some warping of space-time, impossible to cram the same amount of teaching into a typical two-year-and-change Physician Assistant or Nurse Practitioner curriculum as is crammed into a four-year medical degree, a graduating medical student on his first day of intern year starts out with an advantage in medical knowledge and it’s not an inconsequential one either despite the usual protestation from mid-levels that their shortened curriculum is just as rigorous as the medical school curriculum (but it’s not ’cause they don’t learn any of the useless stuff…see?). Is this extra knowledge important? Of course it is. I am not exactly medical training’s biggest fan but there is not a single thing I learned in medical school, from the structure of cardiac ion channels to neurolation in the embryo that does not, in some way, make me a better physician strictly by virtue of being a more knowledgeable one. It’s easy to stand on the low ground and insist that all of this knowledge is useless but, and maybe I’m missing something, we have not yet arrived at a time where we admire and seek to emulate those physicians who make an effort to limit their knowledge, judiciously deciding that they can do without this or that, and adopting the attitude of one of my fellow students in a now-distant pre-med anatomy class who, exasperated by the depth of the subject matter, said, “This would be a much better class if their weren’t so many word.”
It also should be noted that upon graduation, a mid-level’s mandatory education is at an end while an intern’s is just beginning. Strictly speaking, medical school is a minimum of seven years for all physicians as residency training, although not legally necessary, is a de facto requirement to practice medicine. I will have had eight years of medical training before I feel barely comfortable to practice on my own which is typical. Residency training lasts anywhere from three to seven years (and even more if we count fellowships) which is something that many mid-levels forget or ignore when they assert the equivalence of their training. Additionally, training is not the same thing as punching the clock. In other words, a mid-level can graduate from his program, secure a position, say as an extender for a busy cardiology group, and after a little on-the-job training get into his groove as a paid professional, keeping up with his continuing education requirements of course, but essentially having arrived at a point in his career where he can decide to sit around watching American Idol after he punches out. This is not the case with residency training. Every rotation is training and every day is an exploration of the dark continent of our ignorance, a vast territory whose boundaries no man can see and in which no sooner is one hill crested than we are presented with the prospect of still more hills in the distance. So it goes for eight years and it is the background acquired in medical school and residency, the useless minutia, that provides the foundation for understanding and the ability to synthesize original thinking on medical problems and not to just regurgitate contextless facts.
Now, as to the assertion that because most of medicine is fairly routine a mid-level can handle 90 percent or some arbitrarily high percentage of a physician’s job, the first thing you have to realize is that for those of us in the generalist specialties, even Emergency Medicine, it should surprise no one that fifty percent of what we see is absolute bullshit (if I may be allowed to create statistics from whole cloth, I mean). Far from requiring the skill of an expensive mid-level, most of these presentations could be easily sorted and sent home by a reasonably competent school nurse who has learned even less of that bothersome and useless knowledge. We don’t even need a well-trained registered nurse either because although their focus is patient care and not diagnosis and treatment, registered nurses particularly Emergency Department and ICU nurses, are extremely sharp cookies and they are probably over-trained to assess and send home many of the patients we see.
In other words, in their zeal to devalue medical knowledge, mid-levels are, perhaps unwittingly, bringing into the question not only the justification for having physicians but also for spending money training so many mid-levels to the extent they are trained today. Far better to just allow reasonably motivated high school graduates to take a year or two of basic coursework at their local junior college, give them a white coat and a stethoscope, and let ’em at all of those routine patients. Why not? My undergraduate degree is in Civil Engineering, for example, and any sharp witted, smooth-talking village idiot could make a good case that this contributes nothing to my ability to diagnose and treat disease. The same fellow could also make the case that eight years of medical school and residency training is not necessary to recognize the flu, treat garden-variety diabetes, or write a couple of prescriptions for blood pressure medications. Hell, as long everything goes smoothly and all we expects is low-level primary care then everything is going to be fine. Unfortunately, as we push the boundaries of medicine and reap a bumper crop of increasingly elderly and multiply comorbid patients, most of whom expect to survive their visit to the doctor, the trend nowadays is towards more complex patients, albeit mixed in with some undetermined proportion of sublimely ridiculous chief complaints or cookie-cutter cases that can be handled by our intrepid Junior college graduate.
Mid-levels are quick to note however that the trend even in their professions is towards more, not less education. Obviously some of that useless minutia is of value.
Let me relate a parable. As many of you know I was once an engineer and after graduating with my engineering degree found myself in an engineering firm where I was in charge of a stable of young design-draftsmen, the “mid-level” providers of the engineering world. Most of these design-draftsmen had Associate degrees in Engineering Technology from reputable junior colleges where their curriculum was heavy on drafting with a smattering of low-level engineering design courses. Good guys, for the most part, and I picked their brains for tips on computer-aided design and drafting as many of them had been using AutoCAD for years and were fairly good at it. (Junior engineers nowadays are expected to do a lot of their own drafting, probably because it is easier to do it yourself than prepare a sketch for a draftsman to translate into a finished drawing). The useful thing about well-trained design-draftstmen is that you can send them, for example, the design drawing for a piece of process equipment (a roll cage, conveyor, etc.) and they have the knowledge to produce detail drawings and parts lists without having to bug you all day about it. Same with detail drawings for structural or foundation work. Very few structural engineers, for example, produce detailed drawings of structural steel connections but instead pass the design drawings to a “mid-level” steel detailer who produces cut lists and all of the drawings need to fabricate and assemble the structure. The details are based on the engineers specifications and if, for example, I were to specify a shear-only connection to resist a certain load the detailer would produce the drawings from which the actual pieces could be fabricated. It’s not rocket science and, as a structural engineer, I am quite capable of designing and drawing my own connections but didn’t, habitually, except for the difficult ones that did not fit the cookie-cutter examples in the two major steel design manuals (that would be the AISC ASD and LRFD manuals for those of you who are interested and still following along).
Naturally, when I finished my five years as an “Engineer in Training” (interestingly enough also called an “intern” in the Civil Engineering world) and passed the licensing exam to become a Registered Professional Engineer I was completely responsible for all aspects of the design, drafting, and detailing of everything that passed through my hands including the detail drawing produced by the detailer, himself usually an independent contractor. Did I check every single connection on a large structure, burning the proverbial midnight oil for weeks at a time with a red pen in hand? Of course not. My detailer had been in the business since before I was born and knew a thing or two about steel fabrication. But that was his thing, you see. My thing was design and management and I don’t recall ever taking a detailer or a design-draftsman aside and asking their help for a particularly thorny foundation design problem. That was my thing.
One day, one of the more crusty design-draftsmen let on to me that he didn’t think it was fair that engineers made more money, especially as he believed he could do ninety percent of what an engineer did.
“Well,” I replied, “seeing as ninety percent of my job involves standing around drinking coffee making sure that you’re doing your job I don’t doubt it.”
But you see, the devil is in that left-over ten percent (or fifteen or twenty or whatever percentage makes you comfortable with your career choice). Most of every career is routine, repetitive, and can be handled on autopilot. The difference between medicine and other careers is that one never knows what patient is suddenly going to become one of the ten percent. Consequently we want to avoid the autopilot as much as possible. Emergency Medicine in particular is all about not just treating the ten percent but accurately determining who is part of this dangerous minority and until such a time as we can determine which of the ninety percent only need the school nurse and which need an attending physician, prudence dictates that we have the physician standing by even if many of his cases turn out to be nothing…keeping in mind of course that your definition of “nothing” depends on your training. Many of what I once thought were incredibly complicated patients are now just another boring case of sepsis or meningitis.
In reality the practice of medicine is a team effort, not unlike a symphony orchestra where everyone has a part and an instrument they are expected to play. If any individual from the conductor to the third flute doesn’t do his job well the entire ensemble is going to sound like a high school marching band. While it is true that a good symphony can produce ethereal musical magic from the great composers, they also spend a lot of their time sawing out The Nutcracker to keep the proles interested.
On another note, many of the critical emails I receive about the difference between mid-level providers and residents start out with some variation of, “I have been a PA for twenty years,” and then proceed to expound on the uselessness of an intern. Well, God bless you. I’m willing to allow that a new Emergency Medicine intern on his first day in the department can probably have circles run around him by a Physician Assistant who has been practicing for twenty years. But we’re comparing apples to oranges here. There is a steep learning curve for a resident and I would not presume to say I am even near to cresting it. That’s why we call it it “training.” On the other hand, a typical Emergency Medicine attending with twenty years of experience can run circles around a twenty-year mid-level and their little dog too. They didn’t get that way by stopping their ears against useless medical knowledge.