Ask Yer’ Uncle Panda: More on Mid-Level Providers and other Topics

(In which I answer several random questions submitted to me by readers. -PB)

Hey, Panda, I’m not sure what specialty I would like to do and am considering going to PA school because Physician Assistants can easily move between specialties.  Your thoughts?

I often hear the ease of movement between specialties touted as a benefit of being a Physician Assistant or other mid-level provider. The theory is that if you find yourself bored in, say, primary care you can easily find a job in a different, more interesting, or more lucrative specialty.  By contrast, changing specialties as a physician is a long, incredibly arduous undertaking. The only way, for example, an internist can credibly practice as a cardiologist is to complete an additional three year fellowship on top of his first three years of residency.  If, as another example, I wanted to practice as a surgeon I would have to apply for and complete an additional four years of residency training assuming any surgery residency program would take me which, because of the way medical training is funded, they probably wouldn’t.   A Physician Assistant, on the other hand, can get a job with a cardiology group and a few days later, mutatis mutandis, he is a cardiology PA.

Nothing wrong with this of course. The role of a Physician Assistant in many specialties does not require the depth of knowledge of a physician and I repeat, as many Physician Assistants are hired to do the relatively low-skilled grunt work of a practice this depth of knowledge is not required. But unless we’re going to revisit that magical world where two is bigger than four, five years of residency is no different than a little on-the-job-training, and superior knowledge can be had without learning all of that useless stuff, the ease of moving into different specialties should only indicate that a certain…how can I put it…comprehensiveness is not required of a Physician Assistant.

Which is not exactly a ringing endorsement of the depth of Physician Assistant training although if that’s your thing, go for it.

But Panda, can’t Physicians Assistants do 90 percent of what a doctor does?

No.  Although to be fair they can do 90 percent of the paperwork so, since fifty percent of my job consists of useless bureaucratic tasks, ipso facto they can do a large part of my job.  The conceptual difficulty many of you have is your lack of understanding about the structure of the goat-rodeo-cum-cluster-fuck known as American medicine in which there are three broad specialties.  The first is actual, honest-to-Jehovah Medicine of the kind we all imagined we would be practicing long ago before we actually started wrestling the proverbial pig.  You know, things like diagnosing and treating diseases using good clinical judgment and appropriate testing and consults.

The second specialty is Tort Medicine which is something we do continuously in an effort to minimize the perceived risk of being named in a lawsuit for a bad outcome that may or may not have been our fault.  As this primarily involves throwing vast quantities of money at our patients in the form of useless, unnecessary, or only marginally helpful studies and procedures in an attempt to uncover every single thing that could possibly be wrong with the patient (no matter how unlikely), I see no reason to doubt that Physician Assistants can handle these tasks admirably, the number of boxes you check on the order sheet being often inversely proportional to your knowledge of real medicine.

The third and largest specialty is Boilerplate Medicine in whose service we devote countless hours charting, documenting, and filling out reams of redundant forms, the main purposes of which are to legitimize billing and keep millions of low-level administrators gainfully employed.  It is in this specialty where mid-level providers particularly excel and for which most are hired.  What are most History and Physicals for routine admissions and procedures, after all, but loads of useless information, grimly documented for the insurance company, surrounding a kernel of important facts?  Unfortunately, since you can’t bill insurance companies or the government with a concise paragraph describing everything important about the patient, we have developed check boxes and forms that codify useless information and organize it for easier parsing by bureaucrats; even though for strictly medical communication all most doctors need and would prefer is a brief paragraph.

Or, to look at it another way, I am now after eight years of medical training capable of writing a brief, elegant, and succinct paragraph describing everything you need to know about the patient as well as my assessment and plan which any other doctor can read and understand completely.  If this was all I had to do I could probably see twice as many patients but unfortunately, the government and private insurance companies (not to mention the lawyers as there is considerable overlap between Tort and Boilerplate Medicine) need their medical prose like a sailor needs a happy ending and if I can hire a relatively cheap mid-level to crank it out then so much the better.

The real question should be whether someone needs a two-year Masters degree (in the case of Physician Assistants) or one year of fluffy smugness (in the case of Nurse Practitioners or Doctor Nurses or whatever the hell they want to be called) to essentially fill out a bunch of mostly useless paperwork?  Surely if clinical skills are not that important, and that’s exactly what a mid-level is really telling you when he insists that his two years of training is equivalent to your seven or more, then we could probably save a heap o’ wampum by training motivated Community College students for an exciting career that we can call “Physician Assistant Assistant” (or PAA) and eliminate the expensive mid-level middleman.

But what about Primary Care?  Surely mid-level providers are suited for primary care?

You only say that because you don’t understand primary care or are confusing it with something else.  Primary care physicians should and ought to have the highest level of medical knowledge and clinical instincts because they are not specialists and therefore have to be fluent or at least conversant in all of the medical specialties.  To the extent that they aren’t is only a reflection on the nature of American Goat Rodeodery where reimbursement and the predatory legal environment makes referring to specialists a de facto requirement for a primary care physician’s financial survival.   With this in mind, most specialists are used not in their intended role as sage consultants for particularly difficult cases but as extenders for over-worked primary care physicians, meaning that they primarily see nothing but fairly routine patients with bread-and-butter conditions that the patient’s family doctor simply did not have the time or the legal gonads to address.  In this respect mid-level providers are probably better suited to the specialist trade, and the more specialized the better, because it is easier to acquire a superficial knowledge of a highly specialized field than of a broad, non-specialized one.  I know, for example, a Pulmonary Medicine Nurse Practitioner whose entire job is to set patients up for bronchoscopy, the pulmonologist’s signature procedure and biggest money-maker.  Realistically, however, I could train a high school student to do most of her job.

Now, it is true that primary care physicians see a lot of minor complaints.  Hell, I’m an Emergency Physician and I see plenty of them too, some so trivial that it would drive one crazy if it weren’t for a sense of humor or plentiful, cheap whiskey.  In fact, a substantial subset of the patients I see have complaints that are not only minor but only twenty years ago wouldn’t even have been considered the kind of medical problem for which someone would legitimately seek medical attention.  Can a mid-level provider handle these?  Of course.  But are they sure they want to make the motto of their profession, “Mid-Level Providers: Wrangling Patients that Don’t Really Need to Be Seen So You Don’t have To?”

Primary Care, in other words, is not just about minor complaints and it is not urgent care either.

What About Urgent Care?

Urgent Care is mostly a scam, at least in cities that have functioning Emergency Departments and I would advise most of my patients to avoid them as an unnecessary and costly middleman.  With a few exceptions, if your complaint is minor enough where it can be addressed in an Urgent Care Clinic you probably didn’t need to be seen at all and whatever treatment was prescribed is just a placebo, something to show that we care or to keep you amused while nature takes it course.  If your complaint is legitimate or even the slightest bit threatening the practitioner running the place will default to his legal protection mode and refer you to the Emergency Department, off-site Emergency Department triage actually being the only legitimate medical function of Urgent Care clinics.

Can you get a school sports physical at an Urgent Care or a note from your doctor as an excuse when you miss work?  Sure you can.  But these things are worth what they are worth.  The work note is worth nothing medically and the cursory sports physical as it will never pick up any but the most obvious reasons why you might drop dead while playing basketball, fulfills what is mostly a bureaucratic requirement and not a medical one.   This is why, by the way, residents love moonlighting at Urgent Care Clinics.  Namely because it pays pretty well, the stakes are low, nobody is really sick, and if they are you can easily punt to a higher level of care.

What about Complementary and Alternative Medicine?  Can’t I go to Chiropractic School or something like that if all I want to do is primary care?  My Chiropractor advertises himself as “Primary Care” so I was just wondering.

Complementary and Alternative Medicine is mostly modern superstitious drivel marketed to people who are, in their knowledge of science and reason, no better than seventh century peasants except that Dark Age peasants had an excuse to be ignorant as they had marauding Norsemen competing for their attention.   On the other hand most people don’t think about medicine that much and have no reason to distrust their chiropractor so allow me clear something up for you: Chiropractors, naturopaths and other Alternative Medicine practitioners do not have the same training and education as medical doctors, not in quality and not in quantity, not by a long shot, and therefore they are not qualified to serve as primary care physicians, a job that requires more than some haphazard study of herb lore or a cursory knowledge of the spine. If they had the same training including residency training they would be qualified…but they don’t so they’re not.

Take your typical chiropractor, for example.  He has a four-year degree at an institution that was probably nothing but a federal student loan processing mill in which the odds are he never saw a really sick patient, at least not one that wasn’t immediately taken to the nearest Emergency Department.  Unlike your Family Physician who has four years of medical school followed by an intensive three year residency, your chiropractor has never rotated on a pediatric ward, in the Intensive Care Unit, on an internal medicine service, a surgery service, or any other of the medical services in which the core knowledge of every physician is developed.  He has done no call, been responsible for exactly nothing during his brief pseudo-medical training and has never had to make a decision that mattered to anybody.  More than likely he slithered through chiropractic school making a mental list of the many, many things he would never have to worry about (I mean, assuming he was introspective enough for this) and that he would defer to real doctors.  He is, therefore along with his naturopath cousins eminently unsuited to recognize, diagnose, and treat general medical complaints.

The funny thing is that I would never try to pass myself off as a surgeon, an obstetrician, an internist, or a neurologists because I lack the training and knowledge to honestly represent myself to the public as something I am not…and yet naturopaths, chiropractors, and the whole pack of Snake Oil Salesmen with a fraction of the training required for the job lack the humility, the self-awareness that comes with an appreciation of their own limitations, to consider that maybe, just maybe, they don’t know enough to be primary care physicians.

No doubt your Chiropractor can fill out forms with the best of them and correctly bill your insurance company but if you have a medical problem serious enough to warrant treatment you should see a real doctor and eliminate the useless middleman.   Likewise if you really care about your long-term health.

Not to mention that the primary treatment modalities of practioners of Complementary and Alternative Medicine are extremely ridiculous on a fifth grade biology level.  To believe in them, things like subluxations and Reiki, is to place yourself in the company of drooling cretins.

47 thoughts on “Ask Yer’ Uncle Panda: More on Mid-Level Providers and other Topics

  1. Fantastic writing. I am a newcomer to your blog, but I am already a fan. Keep up the good work.

  2. Panda, you are incredibly arrogant. And arrogance sells…witness Rush, Michael J. Savage and many others. It’s fun to hear them talk and equally fun to read your well crafted diatribes.Unfortunately there is only a grain of truth in what you say…about the same grain as in the naturopath’s nostrums. You are almost unbelievably uninformed as to the nature and intensity of Physician Assistant training and skill. If YOU ever had to lie behind a discarded oil barrel while some PA stuck a chest tube into your thorax so you didn’t die after that road-side bomb in the desert exploded, you’d have more respect. If YOU had multiple facial lacs repaired with the great skill of even an average PA, you’d realize how misinformed you’ve been.
    And if you ever sat in a remote urgent care, gasping for breath as a PA set up a nebulizer treatment and gave you some steroids, you’d realize how much more than an off-site ER triage an urgent care is. Stop patting yourself on your arrogant residency-trained back and get out into the real world. You need a “dose” of reality!!

    (Hang on, what you mean to say is that there is a lot of truth. not just a grain, in what I say although, like most generalizations, there are exceptions. As for chest tubes, as a former United States Marine Infantryman I have nothing but respect for corpsmen, medics and anybody else in a similar capacity. On the other hand, I learned how to do chest tubes, central lines, intubation, and all that other stuff as an intern…and yet I still didn’t know what I was doing if you get my drift. -PB)

  3. It is incredibly refreshing that someone is brave enough to speak the truth, not the canned, politically correct answers we are all trained to recite. Great post.

  4. Sure, Stephen, PA’s have their place. I am only a few months from being a residency trained EM doctor and the stuff I don’t know scares the @#$% out of me. And that’s after 7 years of post-graduation training. I suppose you crammed that into two years while I sipped scotch on my back porch. If I had to choose a PA or John Doe, sure I would pick a PA. If I had my choice of a PA or a EM residency trained doc I would choose an EM doc. If I had my choice between a 10 year veteran EM residency trained doctor and a new grad I would choose the experience. Is it truly arrogant to believe that additional education and training provides greater depth and breadth of knowledge. The greater sin is to assume one knows more than one actually knows. As they say “Ignorance is bliss” I am sure you must truly be a great PA, thus your spirited defense. Don’t get me wrong – I love to have the PA suture the lacerations so I can move the rest of the department but our educations are not equal even after accounting for ‘experience’. If you want to be a doctor (and God bless you if you do) then go to medical school.

  5. Fourth year med student, graduating in May.

    1. I’ve put in a chest tube. I then taught somebody else to do it. It’s not hard, it just takes exposure.

    2. Suturing up lacerations. Again, this is easy. There’s a reason surgeons let med students close their incisions.

    3. Setting up a nebulizer. The nurses do that.

    PA’s are best used as ASSISTANTS. They help the doctor do their job more quickly or lend a hand when it’s needed.

    As for urgent care, its only real utility is to dispense antibiotics for simple bacterial URI. And even that they do too often.

  6. I sorta feel like there’s a connection that’s not being made here with mid level care. You complain in this blog about the enormous amount of ‘tort’ medicine practiced in primary care: testing or punting at the slightest suspicion of anything and often when there isn’t even a suspicion of anything. Then you continue to maintain that PAs are in no way capable of working as Priimary Care docs. Now I’m not saying that PAs could pass as primary care docs in a reasonable, sane system of primary care, but you work with the world that you have and considering how the system is actually set up now does it really make sense to pay for the extra training a physician requires? The legal side of medicine basically prohibits the clinician from using the sort of medical judgement that would constitute a return on that investment. I think the PAs make a reasonable argument that the scope of primary care has, thanks to the lawyers, now shurnk to the point where a much less extensive course of training now covers everything required of a general practicioner in all but the most rural settings.

    (I thought that was my point. However, your professional career should not depend on institutional insanity. -PB)

    100% with you on CAM, though. F-ing voodoo. I remember one of the most disgusting presentations I’ve ever seen was a certified anesthesiologist that had started doing that acupuncture thing where he stuck needles in peoples ears to cure them of everything that they didn’t actually have in the first place. I really do think we need to move to take licences from people who trade their professions’ integrity for a slightly higher profit margin.

  7. CAM has its place. If it’s interfering with proper medical treatment, eg cancer, then it can be dangerous. Naturopaths need to know when to send their patients to MDs, absolutely.

    Hypochondriacs and those with good health that want to achieve “optimal health” are big suscribers to CAM. Perhaps taking antioxidant supplements and/or St. John’s Wort or the like can help those with their psychosocial conditions become more fully fuctional in their lives. Whether the supplements work as placebo or have some minimal benefit, it keeps them from utilizing resources in the medical sector of health care.

    I guess what I support is CM rather than CAM. Complementary medicine has its place, but alternative medicine like Reiki have no place in health care.

    (I really have no objection to CAM except that government money (mine, I mean, taken by force) as well as private insurance can be used to pay for it. If that wasn’t the case, I wouldn’t give rat’s ass about it as I am a firm believer in letting people be as stupid as they want to be. The solution is not to distract the public with pretty lights and whistles but to shut them down when they want to waste medical resources.-PB)

  8. Panda, I agree that if there were a choice between an EM trained physician and a PA, it might be reasonable to choose the physician…if the problem required a physician’s skill and knowledge. But that’s the whole point…PAs were created to free up physicians to do what only they can do. No one (except you) is suggesting that PAs are equal to MDs in education, and training. Again, the whole point is that it doesn’t require a physician’s training to do everything that needs to be done. Remember, PAs do only what is delegated to them by their supervising MDs, they are not acting independently. Many studies have shown that the outcomes of MD vs.PA treated patients are equivalent (for the types of problems that PAs are trained to care for.) To make it simple enough for all who read this, remember that PAs practice only what is delegated to them by the MD, based on mutual trust and respect. In this world of paucity of medical services, and overspending at every turn, there is a place for practitioners who are neither physicians, wannabees or snake-oil-salesmen.They are highly trained professionals who do what they were trained to do and delegated to do by physicians who are hopefully more open minded and less “full of themselves” than some of your bloggers.

    (Bullshit. Now you’re back-peddling from your initial observation that “A PA is just like a doctor because I was there, Man! Crouchin’ behind a burning oil barrel doin’ the doctor thang puttin’ in one of them thar’ extremely tricky chest tubes,” to the sanitized official position of the PA establishment, a position that is not reflected by many in the rank and file. Like I said, since some large portion of my job is utter bullshit, and since most of this bullshit could be handled by a motivated high school student with a year or two of community college level medical transcriptionist-type training, if this is your claim to utility then knock yourself out.

    American Goat Rodeodery (Medicine I mean) is mostly a big fucking scam and a waste of money which is why people like Nurse Practitioners who, even you will agree, have highly variable but mostly extremely inadequate training would even be considered to fill the role of Primary Care Provider. -PB)

  9. Panda, you mentioned earlier that academic positions are of a lower salary usually. Obviously many people want that job, so they can afford to pay less – but the question is why? What is the advantage of practicing in an academic center? Research? Other career benefits? More support staff? I’d be interested in your opinion on the matter.

  10. Whew! You really explained it well! Now I understand why the surgeons I work for pay me 160k a year to see the patients they don’t want to see: the bawlers, the whiners, the uninsured, the ER patients the EM docs demand be evaluated by ortho but are nonsurgical….

    I’ve worked along side smart talented physians and scary incompetent (despite medical school, residency, and specialty training)physicians. Scarier than providers, whether nurses, PAs or docs, who do not know what they do not know, is being in a life-threatening situation with a provider who SHOULD know and is incapable or falls to pieces. You describe mid-level’s in pretty derisive terms. Have you never ever met an incompetent MD? Don’t know how far into your career as an EM physician you are but if you have not encountered one of these you will and maybe, just maybe you will look at all the roles around you and recognize the value of collegiality. Gee, if you are this happy-go-lucky in your work place then you may find the rest of the staff “sticking it” to you when you are up to your elbows in alligators trying to save the life of a patient along side the scary incompetent surgeon.

    (Now hang on, there are incompetant people in every profession. So what? Because language is generalization, we have to occasionally generalize and set aside the outliers. I could just as easily point to the many scary and dangerous mid-levels out there. Instead, I reiterate that all other things being equal and ignoring the few individuals in either profession at the good and bad ends of the bell curve, a physician has much more training than a mid-level provider. This is a simple concept. Don’t tie yourself in knots about it. I’m not that deep. -PB)

  11. Whoa there Phil,

    Pretty arrogant for someone who hasn’t even started internship yet. I know plenty board-certified (some in EM) docs who do a bang up job manning the local urgent care. Is it an ED attached to a level one trauma center? Hell no. But urgent care is a fine place to go for medical care that doesn’t require the facilities of an er, and, I predict, will become an ever larger part of our health-care system in the coming years.

    Urgent care is certainly not a glorified minute-clinic.

    Hell, I go there myself whenever I have an urgent, but not emergent, medical issue, which I’d like to be seen for within the hour, any day of the week, by a board-certified physician, often one with >15 years experience in em.

    (I repeat, most (but not all, of course) of Urgent Care visits are for self-limiting things that need no medical attention whatsoever and if they did, would respond to over-the-counter remedies without the need to involve the expensive and inefficient apparatus of American Goat Rodeodery. I know, for example, that our local Urgent Care clinics give away antibiotics like they were candy, mostly with neither a good indication or any thought to side effects. Hell, a large portion of the visits to my Emergency Department are, likewise, for things that are so trivial and so self-limiting that it is mystifying why anybody would waste half a day seeking medical attention. American Medicine is expensive because we have thrown common sense out the door. -PB)

  12. 97% of all illnesses get better without treatment. Even most bacterial infections will resolve without intervention; otherwise humans would never have survived until the accidental discovery of the potency of bread mold.

    This is also how chiropractors stay in business–taking credit for curing back pain with “adjustments” while muscles recover spontaneously.

    Urgent care centers have very little use, except to take advantage of a system that disables patients by keeping them uniformed about their medical problems.

  13. I’d like to clarify that I can suture and put in a chest tube, and have taught other people to do the same things.

    As for urgent care, I used it when I needed antibiotics for strep or an ear infection. Anything sicker than that took me to my doctor. I guess people without a PCP use urgent care more often.

    Having confidence in my ability to close a wound and put in a chest tube isn’t arrogance, it’s competence. As for nebs, nurses set them up everywhere I’ve trained. This guy was talking about how awesome PA’s are when the skill set he was bragging on combines the skills of an average 4th year med student and a nurse.

  14. You’re right, it is a simple concept. A physician has much more training than a mid-level provider. I’m untying the knots because there is other stuff to get worked up about. I would not presume to know as much as a physician. It is a shame you are running into a problem with mid levels presuming to know as much as a physician.

    In my community the issue is not about knowledge….it is only about money. If there is a revenue source available everyone wants it. The greater area has a population of about 135,000 and there are five MRI machines, that many or more CT machines, and yes, my mother went to the urgent care affiliated with her provider and got an antibiotic for a sore throat she had had for HALF A DAY! The doc told her she had sinusitis and “pus running down the back of her throat.” Non-smoker, no fever chills or feeling unwell. I wanted to rip my eyeballs out of my head when she told me that! Her reply was “you never seem to approve of what my doctors do for me” agghhh

    Interestingly, I did a trauma fellowship in England in 2005 (my nursing background is ortho trauma and total joints) and was amazed at the high tech implants and equipment available. The care was good, and all traumas were triaged exactly the same because ability to pay is not consideration in the treatment plan. They collect stats on EVERYTHING so they can evaluate outcomes. It breaks my heart to see a twenty-five-year-old uninsured male splinted in the ER and sent to our office for closed treatment of a fracture that would be better managed with an ORIF and allow him to return to work quicker instead of spending three to four months in a long leg cast. American medicine IS expensive because we HAVE thrown common sense out the window.

  15. Welcome back Panda and congrats on finishing your residency and your new job. 🙂

    I appreciated what you wrote in a previous post about Obama and your neighbor, etc.

    Personally, I have found this last political week to be a very difficult pill to swallow. The European trip -aplogy for America, in Turkey trying to say we aren’t anything but a secular country. Stating we aren’t a Christian or Jewish country, etc., but then staring that Islam shaped America.


    I’ll stop here or will turn into a rant.

    Oh and then Barney Frank being obnoxious and disingenuous with the Harvard law student. (THAT was unbelievable!)

    I apologize for being off topic..but am curious for your take on all of this.

  16. I just found your blog, and I’m hooked – it’s brilliant! Glad that you’re posting again.

  17. “The second specialty is Tort Medicine which is something we do continuously in an effort to minimize the perceived risk of being named in a lawsuit for a bad outcome that may or may not have been our fault.”

    Does it work? I mean, doctors always say they do all this stuff solely to avoid lawsuits, but how do they know if it works to actually, you know, avoid lawsuits? Is it just an article of faith, or is there a study somewhere that shows it works?

  18. I’m a PA. Been one for 12 years after serving 20 yrs as a military officer. I work from 8 – 5; see about 30 patients a day; don’t take call; am home by 6 pm every night; have weekends off; make about $90K / yr. and work with a good doc.
    Why would any one want to be a physician: you come outta med school ass deep in debt; your pay is a little better but you spend 15 hrs+ at work; you have all the “bullshit” to deal with…nah, I’m happy just being a lowly mid-level PA 🙂 he he he

  19. I have read several times that becoming a MD requires 8 years of schooling and then specialized training. (I have no problem with that because it = the truth/facts)

    What I do have a problem with, is just giving the amount of time PA schooling encompasses a 2 yr sticker.

    My take on things:

    Road to become a MD- 4 yrs undergrad + 4 yrs medical school +/- years of residency
    (3-6 avg)

    Road to become a PA (over 80% of PAs)- 4 yrs undergrad + 2 yrs PA school + many years of OJT

    That would give you an equation that equals 8 yrs to become an MD vs 6 yrs to become a PA with specialized training tacked on dependent upon specialization for MD’s.

    (Tacked on? Good Lord. Residency training is not just an afterthought and it is not casually added to the end of medical school as a lark. It is an integral part of being a physician and is more rigorous than medical school. The vast majority of medical students complete a residency. Those who don’t usually either quit medicine entirely or go into research. I might as well say that two years of PA training is just tacked on to the end of your undergraduate training. -PB)

    But the simple equation to just get the MD behind your name is simply 4+4 = 8

    PA is predominately 4+2 = 6

    So please no more of this 2 yr tag stuff, if that’s how you want to look at things then simply say MD’s have 4 years of medical school compared to PA’s 2 years of medical education.

    NOT 8 vs 2…….that’s not an appropriate comparison

    Take it for what its worth

    (It is worth nothing. You see, PAs can’t do math. Physicians have four years for an undergraduate degree plus four years for medical school plus four years for residency: 4+4+4=12, at least by your irrelevant mathematical theory. 12 is greater than 6. 2:1.

    I repeat: a PA can practice with 2 years of medical training. A board certified physician needs anywhere from seven to twelve years of formal medical training.

    I repeat, your major malfunction is your obliviousness to the importance of residency training, a de facto requirement for practice as a physician. -PB)

  20. 4+4+4 would not be correct either….it’s ok everyone understands that to become a MD in the US and to practice you need lots and lots of training, no one is disputing that fact.

    Your equation would make more sense if it were 4+4+3 = 11 not 12 (to practice)

    (Uh…Okay. You seem desperate to prove that you have almost, but not quite, a third of the formal medical training that even the least well-trained physician has, that is, two years of PA school compared to seven years for a Family Physician. Yee hah! -PB)

    As I understand it there are at least 4 specialties that only require 3 yrs of residency NOT 4 and EM can be done in a minimum of 3 yrs however some are 4 yrs

    I do understand the importance of residency training that was never my intention to downplay that importance.

    One other thing, I can not for the life of me understand why people assume (A LOT of people on your blog) that people who choose medical school over PA school are so much brighter individuals than people who choose PA school.

    The fact is there are smart people in medical school and smart people in PA school, and not so smart people in medical school and not so smart people in PA school.

    People choose PA school over medical school for a lot of different reasons (not because they couldn’t cut the mustard in medical school) trust me you don’t need to be a rocket scientist to go to medical school and perform under the bell curve, nor PA school.

    (I never said PAs weren’t smart or that they didn’t have good reasons to pick the PA route…number one being that you only need one third of the training to start practicing. -PB)

    Here are a few numbers for you-

    Cost of private PA school Master’s level (2yrs) (2009)- $95,668

    Cost of private Medical School (4rs) (2009)- $237,294

    Time till PA can make a decent salary (directly after graduation)

    Time till MD can make a decent salary (after completion of residency)

    So here we go again back to the numbers-

    PA Potential = 85K (avg) salary right after graduation x 5 years(2 yrs MD is still in medical school + 3 yrs of residency = 5 yr pay period for PA before MD can reap full monetary benefits of schooling) = $425,000 (earnings)

    MD Potential = 45K (avg)yearly stipend for 3 yrs of residency = $135,000

    Back to school costs-

    PA (95,668)
    MD (237,294)

    Salary potential for Family Medicine MD =

    Salary potential for Family Medicine PA =

    Let’s just hope we don’t have a motivated PA who wants to work a part-time job during that 5 yrs. The potential would look more like this-

    PA part time job working every other weekend (4 days/month) in EM 12 hr shift at $50 an hour-

    $50 x 48 hrs = $2400/month x 12 = extra $28,800/yr

    That would be 85K + 28.8K = 113.8K x 5 yrs = 569K vs 135K for a(MD resident)

    I know residents can moonlight so just to be fair lets give the resident 28.8K too for 3 yrs that = 135K + 28.8 x(3)= 221.4K vs 569K (PA)

    With math being math I guess you could now tell me how long it would take for a MD in Family Medicine right out of residency to break even with a PA in Family Medicine considering they started PA and Medical School at the same time?

    Hmm not a bad comparison when you are trying to decide between PA and Med school.

    The numbers stated will vary by institution I simply chose figures from my institution for purposes of calculations.

    I also chose family medicine because it’s a 3yr residency and the salary statistics are pretty straightfoward for PA and MD.

    (Uh uh. That’s why very few American Medical School graduates go into Family Practice. I betcha’ a lot of PAs run screaming from it too. -PB)

  21. I forgot to end with my point, with the numbers I mean!

    Sometimes we make decisions to choose one thing over another based on finances, and for someone interested in medicine needing a decent steady income now instead of later PA school is an ideal option.

    But that only applies to people who don’t have an EGO as big as Jupiter, for PAs by design will always work for (tha man) and rely on tha man..tha man being Mr. or Ms. MD/DO.

    (I assure you that unless I was a physician, this career would so not be worth it. I can think of a lot of things I’d rather do for a living and could do if I only wanted a typical PA salary. -PB)

  22. Congrats on being so honest! Your very last paragraph pretty much sums up your raison d’etre….MONEY! But please realize that some of us went into medicine for other, perhaps more idealistic reasons. Ten years from now, if you are still a physician, (which I doubt), you will be so embarassed by the drivel you have espoused in your posts this last couple of weeks.Be sure and copy them to CD for posterity.

    (So let me get this straight: One of the chief appeals to being a PA, and almost every PA will tell me this, is that you can make a decent income much sooner than a physician who, in my case as an example, has had to defer this for eight years, racking up debt all the while and losing the advantage of the time value of money. In other words, you went to PA school instead of medical school because a) you wanted to start making good money with minimal effort, and b) you didn’t want to sacrifice so much of your life in service to the Goat Rodeo.

    And I’m the one who’s a mercenary? Face it, although you are smart enough to be a physician, you decided for strictly mercenary reasons to eschew the longer, more difficult training. Fair enough but don’t make a virtue out of it and pat yourself on the back too hard. Every mid-level would rather be a physician because that’s the image in which you are made and think of yourselves. It’s different for nurses and other allied health people because a Respiratory Therapist, for example, is firmly in the allied health camp with no ambiguity whatsoever. Do you get that it’s the ambiguity that drives you crazy?

    I also assure you that you can be cavalier about money because you don’t have the structural problems that physicians have vis-a-vis money. While residency pay is decent, at least on a yearly basis (but not an hourly one), it is only enough to live and not even that if you have a family, therefore most residents physicians just tool along for the better part of a decade while they train building no assets, equity, or financial security. Some of us have a huge debt that must be paid. You have no idea how badly I need to kill a mammoth or two and quickly once I graduate residency because the vultures are circling our cave.

    So spout your drivel. I happen to inhabit the real world, a world in which you would not work for free and would resent mightily a pay cut. -PB)

  23. I know one thing that every medical school teaches that you failed to learn:
    “Don’t ASSUME…it makes an ASS out of YOU,
    not ME!”

    Happy Easter, Panda, sincerely, and I hope you’re not on call. 😉

  24. Quick quesetion: do you think it’s possible to create a program to train midlevels up to the point where they’re ready to provide primary care, other than just starting at the begining by enrolling in medical school? Let’s take a best case scenario: an NP who has 4 years undergraduate medical training, 2 years experience as an RN, a 1-2 year Masters degree to be an NP, and has worked in EM, primary care, ICU, and surgery for at least 1 year each. If this person isn’t able to deliver primary care quite yet, how much additional training do they need? Are they really no closer to being a medical doctor that a 21 year old with 1 year of premedical science prereqs and a major in Irish cuisine?

    (Only if you view primary care as nothing but minor complaints with a big red panic button to push for anything over your head. Then of course your hypothetical nurse can handle it. If that’s all you want out of primary care then, like I said, eliminate mid-levels and make Primary Care a two-year associates degress right out of high school. A 21 year-old with a degree in Irish Cuisine is not a trained physician until he graduates medical school and residency which is kind of the important step that mid-levels forget while they thump their chests. -PB)

  25. I don’t think you’re reading my question. I’m asking: is it possible to create a program to give NPs the additional experience/education they need to provide primary care, and how long do you think that extra education would take? Could a nurses working experience substitute for some of the hours of residency training? Of medical student rotations?

    (No. Nursing is different than medical practice. -PB)

    See, that’s what the idea of the new Doctor of Nurse Practicioner degree is. Doctors said NPs weren’t educated enough to provide primary care, so the nurses created an additional layer of medical education to try to bridge the gap. Now, if the MDs then said ‘sorry that’s not enough, we would like program that looks more like this’ or ‘you should only admit nurses with x number of years of experience’ I think they would get a positive response, but when they brush that idea off with ‘if you want to be a doctor you should apply to medical school’ I can see how the nurses unions decide to throw up their hands in disgust and legislate around the docs, rather than working with them. Maybe it’s reasonable to say that nurses are’t yet ready to provide primary care, but to say that, to get there, they need no more or less additional education than a 21 year old with a major in basket weaving is insulting and seems a little bit ignorant as well.

    (I am not responsible for the bad decisions and missteps of the medical establishment. A four-year nursing degree is not remotely equivalent to medical school, the NP curriculum is slipshod and highly variable, and working as a nurse is not the same as residency. Different focus. However, NPs are more than qualified to function in the Goat Rodeo because, as I think you agree (?) most of American medicine is borderline ridiculous, ineffectual, and, as the stakes are low so long as primary care is just going to be about sniffles and colds and referrals anybody can do it. But, when I think of primary care, I think of Internists managing the many chronic conditions of their patients without referring every thing and without playing “Chicken” medicine like we all do.

    But, the bottom line is, NPs and PAs are not qualified to be physicians…unless we define “physician” differently which is, I think, your most excellent point.

    By the way, I am always looking for guest authors so if you’d like to put together your take on the issue I’d be happy to post it. -PB)

  26. Let me speak up for a moment in defense of Urgent Care, by which I am assuming you are referring to those clinics sometimes derisively referred to as Doc-In-The-Box. I think Urgent Care has its place for those of us who are among the great unwashed/uninsured. Well, uninsured anyway. We do shower every day. 🙂

    My guy Ron and I are self-employed and have yet to find an insurance plan we can really afford, so we just try to take care of ourselves and hope for the best. Neither one of us has a primary care physician and we very rarely avail ourselves of medical care. (Even when we had real jobs with real insurance, we rarely used it.)

    A few years ago, though, I received a pretty bad dog bite that required immediate attention. It was bleeding profusely, it hurt badly, and I hadn’t had a tetanus shot in many years. I could have gone to the Emergency Department at one of the many hospitals in the big city we were living in at the time (Houston). Had I done that, I most likely would have had to wait hours on end, and then would have been faced with a bill of hundreds if not thousands of dollars — which we would not have been able to pay — to get this wound taken care of. Or I could have just stayed home and hoped my arm wouldn’t fall off.

    Ron had medic training in the Navy and he can do a suture as well as anyone, but we didn’t have the proper equipment on hand, and besides, there was that tetanus shot issue. So off we went to the local Doc-In-The Box, waited maybe fifteen minutes, and I got the care I needed, including the tetanus shot.

    Later that same year I contracted a UTI that turned very bad very quickly. I was in bad pain and had a fairly high fever. This was on New Years Eve, so I can only imagine what the Emergency Department would have been like. Once again I was off to the Doc In The Box, where I got the tests I needed and a strong antibiotic.

    Ron has used the Doc-In-The-Box himself on a few occasions too when he had bad bronchitis or pneumonia and needed an antibiotic. In all cases we’ve received excellent care from doctors (M.D.’s in most cases, a D.O. in one case) who actually did seem to care about our well-being. And the fees have been very affordable for us.

    I understand the criticisms about Urgent Care but I also think the Doc-In-The-Boxes have their place, especially for uninsured folks who DON’T make a habit of running to the doctor every time they have a sniffle. The Doc-In-The-Boxes sure have been a blessing to Ron and me on more than one occasion.

  27. Panda,
    I have enjoyed reading your blog and forum. While I don’t value your degrading remarks regarding PAs and NP’s. I appreciate your profound insight into Medical Training. Before you tear into your thesaurus to rip me a new one, I will give you my credentials.
    I’m 23, I’m an emt (medicare taxi driver in all honesty) My clinical experience is working in a ER is limited to making sure the overhead light is on before the md/pa enters the suture room (god forbid it doesn’t turn on), phlebotomy, wiping ass, and crushing dead people’s chests, and whatever other people don’t want to do. All for 13 dollars an hour. I went to a $47k a year because of the name on the degree. I did Pre-Med because I wanted to make the big bucks as a Doc (little did I know as a freshman, there are better ways of making it). I never read the text, I wrote my papers the night before the due date and I still managed a 3.9. Come graduation, I took a break and to make the big decision PA or MD school. I chose PA school because of exactly what you say sucks about being an MD. The amount of training, the accrued debt, liability. I understand you don’t want to deal with patients with paper cuts and knee scrapes but I frankly don’t want to deal with patients who require 8 hours of work ups, arguments with the lab, hospitalists, nursing supervisors, families, etc, etc. As a PA I will only need to do things the way you would do them. THAT’S THE ROLE. However, my education will teach me when you are being insane and when I should get the incident report ready. Oh sure, I will still be master skills on my own patients, If you honestly think after all the training you are ready for any situation well.. Stephen is right, you will not survive as a physician. To think 300k+ in debt, 15% of life lost trainging, Working at a hotdog stand because you spent too much time behind a keyboard with a thesaurus making witty remarks. What a shame.
    I’m kidding, I’m sure you’ll do fine.

    (But what do your really know about it? Medical school, residency, or even PA school I mean? You have training commensurate with being an EMT. I was an EMT. In hindsight, I knew nothing of real value compared to PAs and physicians…so how are you so sure you have it all figured out? You may not, you know. -PB)

    (I assure you that unless I was a physician, this career would so not be worth it. I can think of a lot of things I’d rather do for a living and could do if I only wanted a typical PA salary. -PB)
    You said it yourself. Medicine is not worth it without proper compensation. This is exactly why you aren’t about to work at a community health center.
    (Surely if clinical skills are not that important, and that’s exactly what a mid-level is really telling you when he insists that his two years of training is equivalent to your seven or more )
    Who said that? I think your bitter toward your classmate in college who chose PA school. He probably spent the majority of his 20s driving a BMW and taking doctor-like vacations on private beaches reading medical journals. All the while getting the same appreciation you will receive someday by the same type of useless patients.

    (I didn’t know what a PA was and had never heard of them until my first year of medical school. They had a PA school there and, about the only thing I remember about them is that they had a high proportion of hot-looking chicks. Also, you will not get the same level of appreciation. You will get the same level of contempt from the minority of patients who are so entitled that the welfare state has made them blind to the distinction between nurses, doctors, mid-levels and janitors (as we are all just their servants) but as far as respect, well, the idea that the public holds mid-levels in the same esteem it holds doctors is just some more agitprop. -PB)

    Nearly All Physician Assistant programs have mission statements which state “training based on the medical model to prepare competent clinicians,” not “expert physician equals”.
    But, the bottom line is, NPs and PAs are not qualified to be physicians…unless we define “physician” differently) As for your thought process on PAs thinking they are physicians? The title is physician ASSISTANT, can they get any clear than that? Should they stop wearing white coats so patients aren’t confused? Personally I don’t want to wear the white Coat, it makes me look shorter. Maybe we should wear t-shirts that say “I’m not a physician, but I know what an infection looks like, maybe.”
    You Have your nearly endless residencies and high profile internships. I surely will need an experience MD to work with. Also one to refer my patients to. One to look at my x-rays, One to interpret complicated things. I’ll just take the PA licensing requirement of 100 hours of CME per every 2 years and a re-cert test which skims minor points off the top of every topic in medicine.
    Lets see… 50h x 10 years, 500 hours. That’s about .25 years of residency + the 10 years working with my own patients… It will be only around give or take 40 years to be as smart as you coming out of residency. Perfect timing, I’ll be 65. Ready for a retirement! Am I just looking for an easy way to become a physician? No, I’m just taking the shorter route to waking up every morning knowing I’ll be making people who are concerned but really should be, feel better.

    Advanced Practice High school Graduate

    (Let me shock you. Apples on apples and allowing for the vagaries of the bell curve upon whose slope must we all toil, you will never be as educated as a physician or as well-trained. It’s not as if, after residency, Physicians remain stagnant while those wiley PAs are constantly edumafuckingcating themselves. Also, On-the-job-training is not the same thing as residency. I have said this about a hundred times but many of the PAs are dismissive of residency training because they don’t know what’s involved. A PA working in our Emergency Department might say, “Hey, other than the fact that the residents take all of the traumas and critical patients, our jobs aren’t too much different.” On the other hand the PAs didn’t have to do six months of rotations in the Intensive Care Unit, three months of surgery, inpatient internal medicine, or OB/Gyn. And no, a few weeks of it in PA school is not the same as months of it as a resident.

    You got some good reasons to be a PA instead of a doctor, Cochise. Let’s not get ridiculous about it. -PB

  28. Hey PB, if you’re this jaded and cynical just after finishing your residency, you’re gonna be a complete asshole in 10 years..assuming you survive that long 🙂
    PAs and NPs aren’t going away. Hope to God you learn to work with them.

    (I am not jaded. -PB)

  29. PB,

    Interesting thoughts. 7 > 2.5 and people should know there is a specific role we all have as members of the healthcare team. Midlevels by definition are not physicians nor should they have a complex about who they are not. I ran across this statement that we should not be judged by what we are not. So on that note, what’s your take on CRNA’s?

  30. Great site, just found it about a week ago.

    My question is potentialy simple, do you feel that there is any place in the current medical system for mid-levelers at all?

    Would you work with a mid-level?


  31. “What about Complementary and Alternative Medicine? Can’t I go to Chiropractic School or something like that if all I want to do is primary care? My Chiropractor advertises himself as “Primary Care” so I was just wondering.”

    PB’s reply: “Complementary and Alternative Medicine is mostly modern superstitious drivel marketed to people who are, in their knowledge of science and reason, no better than seventh century peasants except that Dark Age peasants had an excuse to be ignorant as they had marauding Norsemen competing for their attention.”

    I see you have returned to blogging, PB. That must mean you passed your ER Boards. Congratulations. Our healthcare system needs all the well trained dedicated ER physicians it can get.

    From the above quote your thinking remains unevolved intellectually as well as factually challenged. Or as I like to think of you as blindly opinionated and wrong per usual.

    Today I offer yet another link to an article showing the patented and proven dishonesty of those you consider ‘the smartest in the room’, the medical researchers and their research.

    Once again you will in all probability reply idiotically and disingenuously “So what’s your point?” b/c you have more spleen than brains and no clue what is important unless someone points it out to you.

    “How Many Scientists Fabricate And Falsify Research?”

    “ScienceDaily (May 29, 2009) — It’s a long-standing and crucial question that, as yet, remains unanswered: just how common is scientific misconduct? In the online, open-access journal PLoS ONE, Daniele Fanelli of the University of Edinburgh reports the first meta-analysis of surveys questioning scientists about their misbehaviours. The results suggest that altering or making up data is more frequent than previously estimated and might be particularly high in medical research…”

    …skipping…”In both kinds of surveys, misconduct was reported most frequently by medical and pharmacological researchers.”

    The point is to show that what you think you know, trust and rely upon may be and probably is wrong of many areas and on many levels.

    For example a few months ago it was reported that in the field of cardiology fully 90% of what is considered standard practice is not supported by science.

    That came up in the “evidence based medicine” debates.

    Cardiology was by far the worse field for evidence based care and other fields had 90% levels of evidence by comparison.

    And the point of bringing that to your attention is to equate you, Panda Bear, with the “mostly modern superstitious drivel marketed to people who are, in their knowledge of science and reason, no better than seventh century peasants.”

    So PB while you believe modern medicine has come a long way from Phrenology and Leeches it really hasn’t, it just changed PR firms.

    (Let me repeat something that is so fundamental as to be axiomatic: Mistakes made by real physicians and therapies that we eventually discover to be ineffectual in no way justify or prove Homeopathy, Chiropractic, Reiki, or whatever is your snake-oil du jour. Even therapies that don’t work in modern medicine are generally based on plausible theories, the worst that can be said of which is that they didn’t pan out or that their application to a complex system like the human body was not exactly as clear-cut as expected. There is, on the other hand, no plausible theory that can explain snake oil and to propose one is to divorce oneself from science, reason, and common sense. I can adapt my therapies to take into account new discoveries or refutations of the old conventional wisdom. There is no evidence whatsoever that will cause you to be skeptical of any aspect of chiromancy as your belief in it is religious, not rational. -PB)

  32. Jay:

    PA education/training is not merely shorter than medicine education/training it is different. A PA or NP is not merely a doctor minus a couple of years of training, though many of them believe they are. This new “doctor nurse” role is a perfect example. The central idea behind it is that a NP is almost a doctor and with a few more months of education can provide the same level of care as a residency-trained physician.

    The difference between docs and mid-levels is this: physicians are trained as medical scientists. Medicine sometimes requires creative solutions to complex problems. Mid-levels are trained to apply algorithms.

    You’re a PA and can do some of the things a doctor can do? Congratulations. The system needs that and you’re providing a useful service. But remember, just because you can throw a baseball doesn’t mean you can pitch in the major leagues.

    I can diagnose otitis media in peds clinic, I’m sure you as a PA can as well. I can also run an ICU. Did you learn that in your OJT?

  33. When you are using college in your equation for medical education- there seems to be a problem. It doesn’t come across as bush league; it is bush league. Why not just include high school, junior high, and grade school. What is the difference

    @Panda: love the posts as usual. Best wishes

  34. The thing everyone is forgetting is that, originally, the PA was already an experienced professional before he (or more likely She, if you look at the statistics) ever attended PA school; the first PAs were career USN Corpsmen. That is -supposed- to be the way the PA profession goes. PAs are -supposed- to have spent years (if not decades) as nurses, EMTs/paramedics, respiratory therapists, armed forces medics, and similar allied health professional careers. I believe the original standard was 4000 hours (so, two years full-time experience). This was a minimum, of course; competitive applicants often had a decade or more prior experience.

    The whole reason why PA school is two years is because the students were -supposed- to already know the basics. For instance, how to conduct a head-to-toe pt. exam or how to “set up a nebulizer” (as mentioned above). Additionally, many knew (or at least had exposure to) some advanced procedures: intubation (RSI or not) and vent management is a good example of something paramedics/military medics already know how to do.

    Another example: someone above said “I’ve put in a chest tube. I then taught somebody else to do it. It’s not hard, it just takes exposure”. Many nurses have assisted with a lot of central line and chest tube placements. No, it’s not the same as having the actual psychomotor skills, but I do think that an overall familiarity makes a big difference in how quickly one can acquire these skills.

    I say all this because up until now, the argument has been framed (by both sides, even the PAs!) as it being a matter of 4 years of undergrad plus 7 postgrad years for MD, and 4 years of undergrad plus 2 years of postgrad for a PA. It just isn’t that simple, and by the nature of the profession, was never supposed to be that way.

    Now, I am not saying that a year of nursing or medic experience is equivalent to a year of medical education, because it’s clearly not. There is a world of difference between someone who went to PA school straight out of college, and a “20 year man” (who was a corpsman for his entire hitch) who went to PA school because he didn’t want to go the >7 year MD track in his 40s. Neither of them will be equivalent to an MD, even after years of experience, but you can bet there will be a huge difference –between- them for their entire career.

    I say all this because, let’s face it, compared to an MD, two years is a pittance. Those two years become preposterously inadequate when you need to teach PA students the basics, which must be happening since a significant slice of PA schools no longer –require- past clinical experience!

    Yes, I’m sure the most competitive applicants all have prior clinical experience, but the fact that this is no longer a hard-and-fast requirement at some schools, speaks of a change in the overall philosophy being physician assistants (in my opinion, at least).

    This, to me, is further confirmed by PA/NP folks saying they find the terms “mid-level” and physician “assistant” demeaning, and will be lobbying to change them! Christ almighty.

    For the record, I’m a 2 year ER-tech with my EMT-B, in paramedic school. I plan on working for at least 5 or 6 years as a medic in Austin, TX (a very progressive, non-algorithmic/cookbook system) before I move on to MD/PA. Still not sure which one I’ll choose, but if I pick PA, I’ll go into it eyes open that PAs aren’t junior doctors.

  35. IDK what everyone else experienced here, but in undergrad (med student here) the kids who couldn’t make it into med/dent/vet/PA/PhD, hell even “Doctor” nursing school, went into chiropractic school ’cause they wanted to be a “doctor” but their 2 point whatever GPA and shitty MCAT score kept them out of any legitimate courses of study. Chiropractors are the dumbest group of health “professionals” around and the village idiot here proves it with every post.

    I don’t post much but I like reading the message boards and having someone that stupid post irrelevant crap constantly just screws up the flow. Panda, could you just ban him/her already?

  36. Enough with the pissing contests. There is a place for MDs, PAs and NPs on the team. I think we can all agree that there are shitty docs, horrible PAs, and quack-job NPs out there. At the same time, there are stellar providers in all three fields and the US vs. THEM mentality leads to one outcome: poor patient care. Quit your bitching and go see some patients.

  37. I am a “doctor” of homeopathic “medicine” and an acupuncurist. After nearly six years wasted in school learning total bunk, I have traded my needles and herbs for a brain and a broken heart. Your blog is like a salve that heals my delusions of grandeur and makes me believe that doctors are people too. I adore you. Keep up the good work, the world needs to hear your voice.

  38. I know that this particular post is elderly, but I feel like I must say something. For the midlevels who are asserting that they know how to put in lines, chest tubes, suture, run codes, etc – that’s great, but these are all technical skills that anybody could pick up after a few days/weeks of repetitive practice (e.g. a 1-month ICU rotation). The real challenge lies not in performing these technical skills, but rather in managing these patients before and after these procedures occur. This demands experience, as well as an incredible depth of knowledge in physiology and pharmacology. I can appreciate this, even as a medical student. The mid-levels that I have worked with may have competency in some limited procedures (e.g. the cardiac surgery PA who knows how to harvest a saphenous vein endoscopically; the NP who knows how to replete a surgical patient’s electrolytes without having to bug the attending), but these folks stick to their role. They can’t do what the residents and attendings do – manage complicated patients, both on the floor and in the ICU; operate in the OR; come up with a comprehensive assessment and plan – that’s the role that the physician has. The physician KNOWS HOW to do everything for his/her patients, from the basic nursing skills (how to turn patients, how to feed patients, how to clean patients, how to draw blood – even on a hard stick) to very complicated management like pressor dosing, ventilation, and renal replacement therapy – it’s just that the physician’s training is such that it is not cost-effective to have him/her performing menial tasks when he/she could be doing something more cost effective. Thus we delegate the more routine/menial tasks out to the nurses and midlevels.

    Why do midlevels get so defensive over this fact? Isn’t that why you become a midlevel – there’s something in actual “doctorhood” that doesn’t appeal to you, for one reason or another? I prefer to have the know-how to be able to manage my patient from A to Z if need be. This is not a personal attack on any profession, just a personal observation.

  39. Sound like dear old panda is suffering from liver qi stagnation

    anger injure liver not good not good

    tell me dear panda why do you think that only a MD is the authority? hmmmmm

    what is the hx of WM, what 300 years?

    medicine is always changing, Yes? So what you know today as fact, may not be in say 50 years.

    almost 400 years ago the worlds greatest scientific minds decided that the world was flat, Yes?

    one thing that has not changed and still works today is Traditional Chinese Medicine and TCM use of acupuncture

    I would make a visit to your local acupuncturist as liver qi stagnation can lead to other conditions

    I feel bad for you panda I really do, worst of all I feel bad for your patients, remember that bad energy travels, Yes

    Why not try smiling and saying nice things to people, make the world a better place, Yes

    When yin and yang are not in harmony this is very bad for body

    One day you will find a acupuncturist in the ER, Yes

    Anyway wish you best, but hope you learn to smile and be polite, angry liver very bad

  40. As someone who is going through the PA/MD debate right now, I found this post and the myriad of comments that followed to be good reading. So when I came upon TCM’s disjointed criticism of academic medicine and bizarre diagnosis of hepatic acrimony (all in what appears to be some kind of poorly constructed meter), I felt an obligation to write something solely for the purpose of denying TCM the final words on this page.

    And please save me some of whatever he is smoking.

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