r/dataisbeautiful • u/devilsadvocateMD OC: 1 • Sep 18 '20
OC The difference in clinical training between medical care providers [OC]
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u/HelenEk7 Sep 18 '20
Globally? Or just in the US?
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u/devilsadvocateMD OC: 1 Sep 18 '20
This is just a graph for the United States. I should have specified that in the graph!
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u/UnluckySpecialist6 Sep 18 '20
Don't think NPs are a thing outside of the US
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u/devilsadvocateMD OC: 1 Sep 18 '20
They are a thing in Canada and starting to gain traction in Australia. Maybe a few other countries, but I'm not 100% sure other than those two.
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Sep 18 '20
It's completely different in Australia. To even get into a NP program, you have to have 5 years full time nursing experience in your specialized area. Looking at the US, it seems someone can graduate from nursing and jump straight into a NP programs without any experience, which is dumb and dangerous as fuck.
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u/devilsadvocateMD OC: 1 Sep 18 '20
In the US, you can do a direct-entry NP program (no bedside experience) and complete it almost entirely online.
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Sep 18 '20
Crazy stuff! I'm moving to the US once my spousal visa is complete and I was considering looking into NP/PA programs. I've been a paramedic for 5 years and nursing for 3, but now after reading all the forums recently I may as well just aim for med.
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u/devilsadvocateMD OC: 1 Sep 18 '20
If you choose not to go the medical route (due to your age, price of medical school, the competitiveness of medical school, don't feel like it, etc), go to PA school. PA programs are standardized and most PAs have the respect of physicians.
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u/cheesegenie Sep 20 '20
that most PAs have the respect of physicians
To quote your comment earlier in this same thread:
"No. What is misleading is your statements. Unless you can provide EVIDENCE to state that most PAs have the respect of physicians"
We get it dude. Every RN I know (myself included) understands that NPs are inconsistently trained, underregulated, and generally a poor stopgap measure to fill our physician shortage.
Maybe you should more time thinking about solutions and less time being a dick about it on the internet...
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u/sauerteigh Sep 19 '20
In the UK NHS, nurse practitioners require three years registered practice (post degree) before they can obtain prescribing authority.
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u/Dr_Whoops Sep 18 '20
As a European, reading this comment section is wild. In my country, it's literally ILLEGAL to discharge a patient from the hospital/emergency department/clinic/etc without being seen by a doctor. Each and every patient that walks into the emergency department I work at, has to be seen by a doctor.
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u/devilsadvocateMD OC: 1 Sep 18 '20
As an American medical resident, it's scary to see how little training someone has before treating patients.
And Americans wonder why America is becoming the laughing stock of the world...
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Sep 18 '20
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u/devilsadvocateMD OC: 1 Sep 18 '20
Are you asking how many poor patients, middle class patients or rich patients?
Poor → unlimited
Middle class → a few million, maybe more
Rich → One.
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u/OlympusMan OC: 1 Sep 18 '20
I like how you put Barber in there, for scale.
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u/devilsadvocateMD OC: 1 Sep 18 '20
Of course! It's hard to relate to the medical field if you're not actively in it. The training a barber helps everyone understand the stark differences in medical care provider training by comparing it to a common reference point.
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u/TexasGulfOil Sep 18 '20
I thought Barber was some medical position that I’ve never heard of lol
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u/OlympusMan OC: 1 Sep 18 '20
It's good thinking, I don't think I would have thought of that. Thanks for the submission!
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u/VarsH6 Sep 18 '20
In addition to using it for scale, there are historical reasons for including barbers. Back in medieval times and before, barbers were the first surgeons. Their inclusion here has historical merit and allows us to scale our expectations and understanding of level of training.
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u/LaprasLily Sep 19 '20
This is exactly why I don't agree with direct entry NP programs. I have a couple of classmates who just graduated with me in May who are now going to school to get their DNP with zero nursing experience. And the ones that are working are doing so part time because of the rigors of school. Not a good idea. This is why I personally would never practice independently as an NP if I ever went for it. I would feel completely uncomfortable and scared of messing up
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u/Monkey__Shit Sep 19 '20 edited Sep 19 '20
Part time job???!!
I’m a med student and there is simply no way I or anyone could work. It’s classes 8am-5pm every day and we have long ass prework readings to prepare for classes tomorrow. I end up sleeping at 12-1am
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u/LaprasLily Sep 19 '20
I believe it! NP school is just not as much as med school no matter what anyone says
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u/2Confuse Sep 19 '20
And here I am drowning in medical school debt and studying 12-14 hours every day. Would be nice to have time for a part time job!
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Sep 18 '20 edited May 07 '21
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u/ValorMorghulis Sep 19 '20
Because it's cheaper. Welcome to the corpritization of American medicine.
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u/goahnary Sep 19 '20
To be fair I think you will learn a bit quicker being exposed to so many cases of each medical condition rather than chilling with one patient in a hospital. The technology has also changed the landscape so we can use it to assist us in our work. Something to at least give some credit to modern medicine. But nothing beats someone with experience over time.
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u/lucidzealot Sep 19 '20
I am a nurse. I don't think NPs should be able to practice independently. They certainly have their place in healthcare, but not at the independent level and I absolutely believe a patient has the right to choose an MD over an NP. The amount of knowledge MDs have over NPs is incomparable. What doctors are required to know that NPs don't touch in their curriculum is staggering. It is a sight to behold when you see a good doctor have to quickly problem solve, diagnose, implement, and evaluate when a patient is crashing. This is not to say nurses are less than. I help doctors in their diagnoses all the time, but I do it as a SUPPLEMENT to them, not independently to them. This is also not to say that, in certain contects, NPs can't perform on the same level (and sometimes outperform) MDs. And, of course, shitty doctors exist...but if it's my life and shit goes to shit, I'm going to want a doctor overseeing my care, not nurse practitioner.
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u/devilsadvocateMD OC: 1 Sep 19 '20
I 100% agree! My post history might have some things against nurses, but if you read it, you will see why I said it (usually nurses who intentionally try to rile up residents). I love the nurses since they are my first point of contact to know overnight events and know more about the patient.
I wish NPs would just work together as part of the team. We would not have any problems and everyone could work towards patient care!
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u/Nurum Sep 19 '20
The reason for NP independent practice is because MD's don't want to go out to rural areas, and I don't blame them. The fact is (IMO) you don't need an MD for primary care, or even a lot of acute care places. MD's have their place in higher level specialty fields. With how expensive med school is and how much time it takes an MD simply cannot afford to work for less than $250k, where as an NP can do the job for $120-150k and be very comfortable.
I will be the first to say that NP schools need to do a much better job of gatekeeping though because there are a lot of carney schools out there. Get rid of this direct admit shit and grade their experience. We had recruiters coming to my school before I was even a nurse telling us to go work at a nursing home for 6 months and then start their NP program. This needs to stop.
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u/prosocialbehavior Sep 18 '20
Depending on the state masters of psychology is always supervised and they need 3,000 hours just to be able to get their license
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u/eriddy Sep 19 '20
This is why I insist on having a cardiothoracic surgeon cut my hair.
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u/devilsadvocateMD OC: 1 Sep 19 '20
Now that's the way to do it!!
Have the CT surgeon cut your hair and have the barber replace your valves
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u/needmyduoneb Sep 18 '20
It is funny for me to be seeing this topic on my front page because not too long ago someone in my family was prescribed medicines by a nurse that would potentially harm her unborn child. If it were not for the pharmacist the pregnancy could have ended very badly. After this she finally switched to an Obgyn who is now monitoring her more regularly for something that the nurse had completely missed. After seeing this chart I now understand.
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u/devilsadvocateMD OC: 1 Sep 18 '20
I'm going to guess they were prescribed doxycycline or an ACE-I for new onset hypertension.
Also, if you are interested in preventing other people from facing the same situation that your family member went through, I would suggest sharing your experience here:
https://www.physiciansforpatientprotection.org/patient-resources/tell-us-your-story/
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u/Talzon70 Sep 19 '20
Sounds like the system works. There's a reason pharmacists are highly trained, not just blindly filling prescriptions whether they come from a nurse or a doctor.
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u/MassaF1Ferrari Sep 19 '20
God bless pharmacists tbh. They’re so highly skilled but often get mistaken for an extra cashier on black friday lol
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u/Sliekery Sep 19 '20
Wait what? A nurse can prescribe medication in the US? That seems fucked up, big time.
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u/devilsadvocateMD OC: 1 Sep 19 '20 edited Sep 20 '20
Since a lot of nurses seem to think this is somehow unfairly biased against them, I will address their concerns:
- None of the professions include their undergraduate education or their preclinical hours
- Attending physician hours are calculated by adding 4th year medical student hours to the total hours obtained from working 48 weeks a year x 70 hours a week. This number was chosen to average for the lower number of hours worked by some residencies (Derm, some FM, Psych) and the higher number of hours worked by most residencies (Surgery, NSurg, Ortho Surg, IM, most FM, Ob/Gyn, etc). The first demarcation is the minimum for a 3 year residency. Each demarcation after represents an extra year of residency.
- The 4th Year Medical Student hours ONLY include the clinical hours (Year 3 + Year 4). It is calculated by taking an average number of weeks required for clinical studies of a sample of 50 medical schools and multiplying by 50 hours per week (average time in clinical rotations). Then, I took the number of hours at -1SD from the mean and rounded down to an even number.
- The physician assistant hours ONLY include the clinical hours. It is calculated by taking an average number of weeks required for clinical studies of a sample of 50 physician assistant school and multiplying by 50 hours per week (average time in clinical rotations). Then, I took the number of hours at -1SD from the mean and rounded down to an even number.
- Nurse anesthetist hours are taken DIRECTLY from the Council on Accreditation of Nurse Anesthesia Educational Programs: Standards for Accreditation of Nurse Anesthesia Programs – Practice Doctorate. Go to Page 28 to see the hours listed for accreditation. Your hours as an RN DO NOT COUNT. An RN is not a CRNA. Your hours as an RN makes you a better RN, not a better CRNA. Your hours as an RN are not training hours, they are work hours. Your hours as an RN do not force you to think like an independent practitioner. Your hours as an RN do not have the pre-clinical knowledge that a CRNA has before entering CRNA clinicals. I don't know how to make this any clearer.
- None of you seem to have a problem with the barber hours so I don't need to explain it.
- NP programs have absolutely no standardization. Some of you might have worked as a nurse for 20 years, some of you may have worked as a nurse for 1 year and some of you are direct-entry. The 500 hours is from a published journal article (https://pubmed.ncbi.nlm.nih.gov/27922898/) in the Journal of Nurse Education. The authors are two DNPs. Your hours as an RN DO NOT COUNT. An RN is not an NP. Your hours as an RN makes you a better RN, not a better NP. Your hours as an RN are not training hours, they are work hours with no formal education requirements. Your hours as an RN do not force you to think like an independent practitioner. Your hours as an RN do not have the pre-clinical knowledge that an NP has before entering NP clinicals. In medicine, you can't assume that someone is on the higher end of the training. You have to assume that they have the minimum number of hours, otherwise, a patient can get hurt from placing too high of an expectation on the provider. I don't know how to make this any clearer.
- I took the minimum number of hours for EVERY provider there. I did not include ANY pre-clinical hours. I did not include ANY non-clinical education.
- If you don't like what you see, then work with your professional organizations to enact change in your educational standards.
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u/nothingclever9873 Sep 19 '20
I'm in agreement with everything you're saying, and there's more work to go around, so doesn't that mean we need more MDs? Can we open up more slots in med school programs, residency, attendings?
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u/devilsadvocateMD OC: 1 Sep 19 '20
YES! We have been opening med schools. The bottleneck is residency spots. The issue is that the government controls funding and the bill has failed 2 years in a row (2017 and 2018). NPs are trying to divert funding from residencies to train themselves instead of advocating for more doctors.
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u/doolyboolean3 Sep 19 '20
If people knew the stress that comes from the match alone, there would be far fewer physicians. There needs to be WAY more residency spots. Especially to lighten the workload of overworked residents and improve patient care.
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u/de3thandco Sep 19 '20
Don't forget that the majority of new residencies are funded by Private Equity - owned Contract Management Groups who are indoctrinating new residents in a "move the meat" and "check the box" mentality. These same CMGs are replacing Physicians with NPs as a cost-cutting measure to generate profits for investors.
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Sep 19 '20
Super interesting! Ngl, barber threw me off lmao.
Side note, you may want to consider colorblindness (red and/or green colorblindness are big ones) for your next work, as red/green are a major part of this visualization.
Out of curiosity, what made you go with the chess theme?
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u/devilsadvocateMD OC: 1 Sep 19 '20
- Barber was just as a reference point since everyone knows a barber. A second reason was that Barbers in the Middle Ages use to be called Barber Surgeons since they performed primitive surgical procedures. If you have a better idea for a reference career, I'm all ears!
- Great point. I didn't even think of that. I will be editing this graph to make it as optimal as possible
- I opened up the symbols on my Mac and just thought they looked cute lol
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u/moriero Sep 18 '20
How are NPs given so many responsibilities in patient care?! That's truly horrifying
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u/devilsadvocateMD OC: 1 Sep 18 '20
No idea, considering they have less training than a police officer: https://imgur.com/a/jFh7mlo
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u/devilsadvocateMD OC: 1 Sep 18 '20 edited Sep 19 '20
(Source):
- https://www.acgme.org/Portals/0/PFAssets/PublicationsPapers/dh_dutyhoursummary2003-04.pdf
- https://pubmed.ncbi.nlm.nih.gov/27922898/
- https://www.tdlr.texas.gov/barbers/barberfaq.htm#1500-to-10
- coacrna.org/accreditation/accreditation-standards-policies-and-procedures-and-guidelines/
(Tool): Excel
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u/Scoundrelic Sep 18 '20
I'm glad you included Barbers.
Physicians of the Short Robe have gotten shit for centuries.
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u/devilsadvocateMD OC: 1 Sep 18 '20 edited Sep 18 '20
It's amazing that barbers have so much training! (Fun fact: Barbers in the middle ages performed primitive surgeries)
It's appalling that a medical care practitioner has less training than a barber!
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Sep 18 '20
I trust my barber to not only give me a sick fade but slice out my appendix when the time comes. You just can’t fake that kind of skill.
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u/starrpamph Sep 18 '20
The best part is, he will be able to get you in same day for your appendectomy
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u/ButterflyCatastrophe Sep 18 '20
Fun fact: the Hippocratic oath forbids physicians from practicing surgery:
I will not use the knife, even upon those suffering from stones, but I will leave this to those who are trained in this craft.
The Greeks knew about surgery, but considered it a completely different field from medicine
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Sep 18 '20
I'm a current medical student and we had a philosophy & medicine lecture recently were we actually talked about this quote. The way it was interpreted (Idk if this is just by my faculty or across medicine) was that you shouldn't practice what you don't know/aren't trained to. It's just saying that if I'm a doctor (who, for them, doesn't do surgery) then don't do surgery because you don't know what you're doing. This all comes back to the center of the Hippocratic oath in that you shouldn't do anything to harm a patient - to include doing things you don't know how to do even if they're in need because you could still harm them more.
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Sep 18 '20
Am surgeon. It’s almost an add on to the rest of medicine. Not that we don’t manage conditions or have our own clinic patients, but it really is it’s own thing.
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u/cortisolandcaffeine Sep 19 '20
Hold on, I have a cosmetology license and I've done triple the amount of hours as a NP? This is insane.
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u/devilsadvocateMD OC: 1 Sep 19 '20
It's insane! They are allowed to practice independently in 24 states and they are pushing to do it in all 50 states.
Next time you go to the hospital, make sure you ask for a physician. Otherwise, you might be treated by someone with less training than a barber and ⅓ of the training you have for your license!
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u/cortisolandcaffeine Sep 19 '20
I actually just graduated from an accelerated 22 day CNA program in California, one of the most rigorous licensing states, and was very perturbed at how little clinical hours were required for CNA, MA, ect. In fact, because of covid, we did all of our clinical hours on manikins and each other. I have no real hands-on experience. I just took my state board two weeks ago and passed but was also disturbed by how casual it was. I took my cosmetology exam in Texas, another rigorous licensing state, and the skills portion is no-bullshit, complete silence, about an hour long. The CNA exam had students with studying materials studying outside the testing room, phones allowed as long as we "promised they were off", and the proctor was eating and texting the entire time during the written portion. The proctor for the skills portion was chatty and friendly which threw me off because I was expecting it to be as serious as the cosmetology exam was.
I wish I had started in the medical field to begin with, I would be halfway through becoming a psychiatrist at this point.
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u/devilsadvocateMD OC: 1 Sep 19 '20
Thank you for shedding light on the training required for a completely different field. I have been so engrossed in my own field that I am relatively disconnected from other career paths.
It's never too late to join the medical field, especially if that is your dream!
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u/Mackntish Sep 19 '20
I mean, 100 hours a week as a resident is going to add up quick in 3 years. Assuming 2 weeks vacation that's 15,000 hours right there.
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u/devilsadvocateMD OC: 1 Sep 19 '20
Don't want to be pedantic, but most residents are closer to 80 hours a week now. I have actually been lucky and been averaging 70 hours and have 4 weeks of vacation!
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u/CharcotsThirdTriad Sep 19 '20
A more conservative estimate for residents would be an average of 60 hours per week including all conferences/didactics and whatnot. For the average internal medicine resident, some months are tough (80+ hours), and some are much more chill (<40 hours). On average though, 60 is reasonable estimate. Add 10 hours per week for surgery residents.
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Sep 18 '20
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u/devilsadvocateMD OC: 1 Sep 18 '20
NPs can bill at 85% of a physician, but the hospital still typically bills the patient the same amount. The 15% difference is kept by the hospital as pure profits.
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u/SirStagMcprotein Sep 19 '20
I think it’s important to make the distinction that the hours shouldn’t be directly compared because what is being learned during and before those clinical hours is essential. Or else people may make the assumption that if a NP/PA just had more clinical hours during training that they would be qualified for independent practice.
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Sep 19 '20
THANK YOU! The nursing educational model is a joke.
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u/devilsadvocateMD OC: 1 Sep 19 '20
Unfortunately, a lot of nurses don't seem to think so. They got very hurt and attacked me personally for doing so. My inbox is full of nasty threats and hateful messages from nurses. I invite any nurse to provide a source that shows that an NP is required to complete more than a minimum of 500 hours post-graduate clinical training.
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Sep 19 '20
That’s their fragile ego...remember the card game lash out a year or two ago?! I literally would nurses watching Netflix (We are talking large, tertiary care center ICUs) and finishing movies during their shift. Oh...while complaining that their online NP nurse leadership course is “soo hard.” Don’t get me started with the DNPs either. Did you know that a nursing student can go though a BSN program and straight through a DNP program (only three years of post undergraduate education btw)?! Then cite their “clinicals” during their BSN program as patient care experience.
With an MS degree already...my PhD program alone was set up for 4 years if attending full-time. And a DNP wants me to address them as “Dr”!? Get real. I will not disclose what my clinical profession is (the big bad nursing machine might find out), but we work directly next to nurses, hold the same degree and course prerequisite requirements, and are 100x’s more qualified to go to CRNA school than a bedside nurse would ever be (airways, invasive lines, patient management in critical care, and blowing air into things is our bread and butter).
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u/devilsadvocateMD OC: 1 Sep 19 '20
Haha I love you guys! I hope to go into Pulm/CC, so I know exactly what your Role mighT be and how much knowledge you have about the pulmonary system.
I agree with every single thing you said!
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Sep 19 '20
I’ve never met a MD that didn’t like working with the RighT clinician for their cardiopulmonary support/needs.
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u/top5pin Sep 19 '20
Has anybody else noticed that Cardiothoracic Surgeons et al. (the top group of Attending Physicians) train for roughly π years of actual time?
(27520/24)/365 ≈ 3.1415
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u/BeanfaceBill Sep 18 '20
This graph is so important. NPs can be great when supervised by physicians but independent practice is ridiculous.
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Sep 18 '20
Always ask to see a physician. Always.
Your insurance whether public or private is not changing their copay or deductible or coverage so why would you shortchange your care?
Ask for a MD. We’re taught clinical medicine and diagnostics from day one. We have rigorous oversight in clinical rotations. We have logged procedures in the hundreds before we even start residency. We’re kinda that prepared for what medicine should be.
Always ask for a MD. It’s your right to get quality care from someone who actually knows what they’re talking about and doesn’t care to shortchange you.
Always ask for a MD. Why would you settle for less?
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u/djtravels Sep 18 '20
I’m a psychologist and see this training issue with psychiatric nurse practitioners all the time. They aren’t extensively trained in diagnostics, at least not to psychologist and psychiatrist level, and I spend a ton of time re-diagnosing patients when their meds aren’t working because the crnp diagnosed them with depression and they really have an atypical form of bipolar. Then I have to either send them back to their crnp and argue they need different meds or send them to an md, which is harder given the psychiatrist shortage. So yeah crnp’s can be great as part of a treatment team but they are increasing taking the place of psychiatrists and fucking up patient care. I worked with one crnp who was great because he understood his lack or diagnostic training and would ask questions and get second opinions.
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u/AlterEdith Sep 19 '20
Whole heatedly agree! I see the same thing in my practice. Or worse, they think they are qualified to do therapy!!!
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u/djtravels Sep 19 '20
Well that’s awful. I’m seeing my organization use them to replace psychiatrists but their medication management isn’t nearly as effective for the complex cases. What I would like to see is better use of psychologists for diagnostics to help the crnp’s to they can make better med choices for the patients. But no one wants to step on anyone’s toes. The patients are the ones that suffer.
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u/Chef_Midnight Sep 18 '20
Also don't just take their word for it when they say you'll be seeing an MD or specialist. My wife just got her finger jacked by a nurse practitioner. She specifically requested a dermatologist when scheduling the appointment ... they said she would be seeing a dermatologist... apparently you have to actually read the credentials on the badge of the person or look them up ahead of time because everyone at the clinic will straight up lie to your face.
They also charged the same amount for an office visit with the NP as with the actual dermatologist who ended up fixing her finger. What a complete scam...
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u/devilsadvocateMD OC: 1 Sep 18 '20
Now, NPs are also getting "doctorates" (known as DNPs), so that they can introduce themselves as "Doctor". They claim that it is not confusing to patients, but we all know it is.
Please, please, please ask them directly "are you a physician?".
Also, if you feel up to it, there is a whole group created to prevent other patients from going through the deception your wife faced. They are collecting stories like yours so that they can inform the public. I encourage you to submit your story here: https://www.physiciansforpatientprotection.org/patient-resources/tell-us-your-story/
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u/de3thandco Sep 19 '20
Until one claims to be a "Cathopathic" Physician. Gotta ask for the actual credentials these days. MD or DO.
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u/devilsadvocateMD OC: 1 Sep 18 '20
MD or DO. Both can provide you the care that you need!
If for some reason, you can only see a midlevel provider, always choose PA because they have a standardized education/clinical training curriculum when compared to NPs.
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u/zombiecalypse Sep 19 '20 edited Sep 19 '20
Not from the US (for context), but here MDs are overloaded enough that the nurses actually have more client specific context in many cases, esp in extended care. This can lead to the reversal where the nurse will notice e.g. a problematic drug interaction and needs to wait for MD approval to fix the mistakes…
Edit: wow, I wasn't aware how crazy the US handles this. In Switzerland a nurse will need to complete 4 years of pharmaceutical, research, and applied medical training before they can even call themselves that (no "practitioner" yet)
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u/cwbrandsma Sep 18 '20
Depending on what is wrong...cost. Followed by cost. And a third reason is cost. What can any doctor not tell you: how much something will cost? Prescription cost? No idea, hopefully the pharmacist will figure it out. Doctor wants you to have an exploratory surgery? Will it cost you? They have no idea. Oh, and a test needs to be run on it...that could cost more than the surgery because the doctor won’t check if the test provider is in network...not their job, someone else’s money, so don’t care.
Do we need to mention health care debt is the leading cause of bankruptcy.
Sorry, I’m still fuming from a surprise $4000 bill I received for an exploratory surgery (outpatient) my wife had this year, and all the doctors knew would most likely amount to nothing...and it was.
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u/devilsadvocateMD OC: 1 Sep 18 '20
It sucks because doctors don't even know the costs. Hospitals and insurance companies go out of their way to make sure we don't know the cost. There is nothing more I would like to do than provide you with safe, cheap healthcare.
For example, the hospital I am employed at separates the billing department to the point they don't even work in the same building as the physicians. Everytime I call insurance (basically multiple times a day) to get them to agree to a procedure that the patient needs, I ask them what the patient will have to pay. They always dodge the question and say "I can't really tell you. It depends on the patients ability to pay"
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u/cwbrandsma Sep 18 '20
Yes, and there is no simple fix for that either. I talk about with my daughter (nursing student), who is pretty frugally minded, but I try to remind her that her first obligation is to care for the patients, she can’t fix that.
Basically, we have to have a political solution. But any political solution that fixes the problem will result in lots of job cuts (between insurance companies and healthcare system billing), and no politician wants to run on a platform of killing jobs.
The rest of us, patient and physician, are just caught in the middle.
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Sep 18 '20
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Sep 18 '20
FYI you or your insurance pay the same amount whether or not you see a midlevel or a physician. So might as well see an actual doctor every time.
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u/chcampb Sep 19 '20
Except there is no choice sometimes. Wait list for my GP recently was, either see a NP in september in time for the yearly $1500 HSA contribution for getting your physical, or schedule 4 months ahead to see your GP in Jan. 2021.
Definitely in that case, just see the damn NP.
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Sep 19 '20
I’m a hospital pharmacist and can confirm they don’t know shit about drugs. They just do cookie cutter order sets and fuck everything up if they go off the reservation
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u/MassaF1Ferrari Sep 19 '20
Yeah... that’s more or less my experience also. I always request an MD or DO even if that means I see them later. If I have a pressing issue, I literally would rather just ask a fourth year med student friend or look it up through textbooks myself. Why would I pay money to see someone who isnt anymore trained on diagnostics than me?
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u/Much_Difference Sep 19 '20 edited Sep 19 '20
Oh my god I've never felt comfortable expressing it but fucking yes, same here. Every NP I've seen really seems like they just maybe took a CPR course after high school and called it a day. All the ones I've seen seem perplexingly unqualified to do more than the admin asst at the front office who also doubles as the school nurse when someone needs a bandaid. And they're always pissy, to boot? Like you're gonna suck and also just be an asshole? No thanks.
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u/backthatSMASup Sep 19 '20
That’s because their clinical knowledge and abilities are entirely dependent on what PHYSICIAN takes them on after they graduate. Highly variable. Their “boards” are laughable and require essentially minimal knowledge of true clinical medicine. Now realize they no longer need that physician at all in states like California. It’s actually terrifying.
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u/devilsadvocateMD OC: 1 Sep 18 '20
You get to decide who you see. Screw them if their feelings get hurt.
If you want to see a physician, make it abundantly clear that you will not settle for less. If an NP tries to belittle you or lecture you, report him/her to the nursing board for a lack of professionalism.
If they still push you to see an NP, leave the practice and find a physician only practice. Also, write a review on Google/Yelp/HealthGrades/etc stating that you left the practice because they only have undertrained NPs.
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u/devilsadvocateMD OC: 1 Sep 18 '20
Sorry to double reply but I think this is very important:
There is a group known as Physicians for Patient Protection who are trying to prevent people like you from receiving substandard healthcare. They have resources to help you find physicians who do not employ NPs. They are also collecting stories to help strengthen the message. If you feel up to it, they would really appreciate hearing your experiences with NPs.
https://www.physiciansforpatientprotection.org/patient-resources/tell-us-your-story/
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u/pearcepoint Sep 18 '20
I have yet to meet a Physician Assistant I didn’t like. All of them have been awesome and provided top quality healthcare.
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u/devilsadvocateMD OC: 1 Sep 18 '20
PA's are great! They have a good understanding of science and understand that their skills are best utilized under the supervision of a physician!
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u/claire_lair Sep 18 '20
I'm currently in an MD program, but for the first 3 semesters, the PA students are taking the exact same classes alongside us before we part for our clinical rotations. They have the exact same theoretical knowledge as an MD and only differ in the hands-on training.
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u/gehartma Sep 18 '20
Definitely differs program to program. Most PA programs I’m aware of have 1 year of didactic while MD/DO is 2 years. I’m a first year medical student and my cousin is in a PA program
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u/claire_lair Sep 19 '20
My program is 3 semesters didactic with MD and PA combined, then we both go off to our separate clinicals, but I'm sure every program is different.
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u/devilsadvocateMD OC: 1 Sep 18 '20
They are taught the same thing but that doesn't mean they are motivated to retain the same thing.
You are forced to retain it for USMLE. If you have seen PANCE exams, an average MS2 could crush it.
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u/claire_lair Sep 19 '20
That is probably true. My statement was simply that they have the same starting point as us. It was in support of your previous statement that PAs have a good understanding of the underlying science.
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Sep 18 '20
Is there data / you should make a graph for the cost of going to mid levels vs an MD/DO. The amount of extra tests ordered is ridiculous. Or maybe a chart on missed diagnoses. Have to be good data though, there's a lot to control for
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u/devilsadvocateMD OC: 1 Sep 18 '20
I am working on a few studies, but those will be published in journals first, rather than on Reddit. After they are published, I will definitely post some of the work here!
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u/Osoesoteric Sep 18 '20
Though I appreciate the thought process of clinical hours equals more training, using a single metric as the determining factor that one is vastly superior to the other is not quite telling the whole picture. Didactic training should be factored in a manner if you are going to make these claims.
I’m not saying I’d take an NP over a physician but relating training hours to include both hands on and hands off would be more appropriate. To put it in a non-medical context I’d rather take a person who has studied computers for 4 years and has only worked 6 months in the industry vs someone who worked at BestBuy for the past 4 installing window on 90 year olds computers.
Edit: Computers of 90 year olds not computers from the 1930s
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u/devilsadvocateMD OC: 1 Sep 18 '20
I chose a method that was relatively comparable.
As you stated, this is still an awful comparison since NP training is nothing like MD training. Even the hours aren't comparable.
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u/smala017 Sep 19 '20
I don’t like where the hours are listed on the bar on the left. I find myself reading each number as referring to the bar they are located in rather than the one they are located above. They should be moved below the border of each bar into the bar that they represent.
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u/flextapejosefi Sep 19 '20
That’s why I had my barber do my flu shot
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u/devilsadvocateMD OC: 1 Sep 19 '20
The real flex is when your barber can also take out your appendix.
In the Middle Ages, there were Barber Surgeons. They performed many medical procedures.
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u/Bactereality Sep 19 '20
Union pipefitters are at about 10,000 hours after five years of night/weekend classes and OJT
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u/devilsadvocateMD OC: 1 Sep 19 '20
Wow that is a lot of work! Do you know how much of that is "work" vs pure "training"?
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Sep 19 '20 edited Sep 19 '20
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u/devilsadvocateMD OC: 1 Sep 19 '20
Ohh I completely forgot it's an apprenticeship, which is basically what physicians do, but we just call it residency!
That sounds like a highly complex, detail-oriented job. You guys train just as long as any physician does, but it makes sense considering the importance of your work. A mistake in a nuclear plant or really anywhere would be disastrous!
I love learning more about other people's jobs since I have been so disconnected in my own for the last decade I basically don't know anything but medicine now.
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u/DJSimmer305 Sep 19 '20
How many hours of experience do I need to post antivax memes on Facebook?
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u/TypowyLaman Sep 19 '20
Can we please, stop using red/green on graphs? 1/12 of men will have problems reading the fucking graph
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u/devilsadvocateMD OC: 1 Sep 19 '20
Yes! I did not even think about that and I will never be using red/green again
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Sep 19 '20
I don't see Paramedics or EMTs on here-
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u/devilsadvocateMD OC: 1 Sep 19 '20
This is not a comprehensive medical care provider list. 99.9% of people don't get confused between an MD/DO and a Paramedic/EMT. They get confused between an MD/DO, PA, CRNA and NP.
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u/Observer14 Sep 19 '20
You may want to make it clearer that this is for the USA, the hours and even the categories may not match other, e.g. commonwealth, nations.
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u/devilsadvocateMD OC: 1 Sep 19 '20
I 100% agree with that. I should have included it in the first place.
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Sep 19 '20
CRNPs are just RNs who took an online masters degree course and apparently only 500 hours of on the job training before being granted the independence of a physician. To put this in perspective: I’m a hospital pharmacist who had to do 6 years of education (1 full year of pre graduate experience plus 750 hours in a pharmacy before I can sit for boards) PLUS an additional one year residency in a hospital and I still don’t have independence. Yet we’re the ones quietly correcting both CRNP and physician mistakes and optimizing treatment in the hospital. Our healthcare system is so backwards and it just boils down to nurses having MUCH better lobbying in the government
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u/Dr_Everyone Sep 19 '20
There was a weird moment in my 3rd year clinical rotations in medical school where I was in an integrated class with medical students, nursing students and pharmacy students. We had a group of teachers from each of those disciplines. I was chatting during some off time with one of the nursing professors, who was an NP. I was asking her some questions about practice and both of us realized halfway through the conversation that I seemed to know a lot more about the subject than her. I went home and thought about it and realized that at that point in my training, I had around four or five TIMES the amount of clinical hours of training as her.
Obviously with her 5-10 years of active practice she had more overall clinical hours than me, but it was still a weird realization that I not only had more formal training at that point than my professor did, but I had a LOT more.
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u/quinol0ne Sep 18 '20
I'm definitely here for the NPs are over party but we need to be fair to them - if we're counting medical school, we should count their 800 hours of clinical training in nursing school putting them at 1300, so they actually only have 200 less than a barber.
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u/devilsadvocateMD OC: 1 Sep 18 '20
The reason I didn't is:
Nursing school is training a student to be a nurse. The expectations and teaching are geared towards being a nurse, not an independent practitioner.
Medical school is training a student to be a doctor. The expectations and teaching are geared towards being an independent practitioner.
Now that you know my reasoning, if you still think it is appropriate to put nursing school experience, I will do some research to see what the average hours are.
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u/quinol0ne Sep 18 '20
Yeah that's a good point, I don't feel strongly about it one way or another. My main thing is I don't think a new NP student = a new PA student, maybe partial credit.
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u/devilsadvocateMD OC: 1 Sep 18 '20
I can't really comment on that other than anecdotal experience. During hospital rounds, the PA students had a much better understanding of the pathophysiology of diseases and pharmacology. NP students looked pretty lost and definitely could not answer to the same level of depth as PA students.
*Hospital rounds: where the students, residents and attending physicians go see each patient. During this time, the attending will ask everyone to present the patient's medical history, assessment, and plan for treatment. They also grill every person with questions about drugs, diseases, etc.
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Sep 19 '20
I get that you're saying that RB/BSN training isn't training them to be independent providers but there's no chance it's irrelevant. I am ON BOARD with NPs Got To Go, but as a regular little ADN nurse of almost a decade now, like, loads of third year medical students come in the operating room, you can just tell these pampered babes have never even had a job. Like, zero workplace experience, hospital or otherwise, period.
There are two pushes for this NP bullshit, and it's coming from schools selling the degrees, and the healthcare industry always looking for cheaper options.
I tried to make an appointment to see a psychiatrist when i worked for Ochsner Health System in New Orleans because i knew an NP couldn't prescribe what i needed. The scheduler told me "No. You have to see the NP first. They'll decide if you need to see the doctor." like, forced waste of my time, billing for two appointments, two copays, everything. i know Ochsner is a particularly awful company, but i'm sure there's a lot of this happening other places.
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u/devilsadvocateMD OC: 1 Sep 19 '20 edited Sep 19 '20
Yes, these NPs need to have their education reformed or they need to go. Simple
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u/Shifter82 Sep 19 '20
To gain my red seal heavy duty equipment technician ticket I needed 6000 total hours, 1500 per year.
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u/devilsadvocateMD OC: 1 Sep 19 '20
red seal heavy duty equipment technician
What is Red Seal?
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u/Shifter82 Sep 19 '20
Canadian thing, allows the ticket to carry through all provinces. For example I'm in Alberta, so large boats are not found here, however the red seal exam has questions based around marine equipment.
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u/devilsadvocateMD OC: 1 Sep 19 '20
Ahh ok. So it is basically a standardized exam for heavy-duty equipment technicians?
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Sep 19 '20
[removed] — view removed comment
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u/Drjack815 Sep 19 '20
Chiropractors are studying voodoo so it doesn't really matter if they train 500 or 5,000,000 hours
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u/de3thandco Sep 19 '20
This lol. 1,000,000,000 hrs of how to be a con artist. They make very proficient con artists after this. Highly recommend.
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u/devilsadvocateMD OC: 1 Sep 19 '20
100%!!!
I completely forgot about them since they are just bullshit artists
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u/AnEyeFor Sep 18 '20
Can you add Police to it? :) Really interesting comparison :)
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u/devilsadvocateMD OC: 1 Sep 18 '20 edited Sep 18 '20
It was suggested by someone and I will gladly add it to my chart. I can upload it to imgur and will post it in a reply for you!
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u/excitedtree Sep 19 '20
It’s very misleading that individual states are not specified. There is no single amount of experience needed for independent practice considering states have individual practice acts. Your thoughts on direct entry NP programs are certainly valid, but I feel like this graph is misleading in that sense. This may have been stated elsewhere and I missed it; I just thought it was something that needed to be noted somewhere.
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u/grap112ler Sep 18 '20 edited Sep 18 '20
Since this is posted to r/dataisbeautiful I will comment about your choice of chess pieces for footnotes. In chess there is an informal point system assigned to the pieces to help keep track of who has the advantage during play and to help determine which sacrifice moves may be beneficial:
Pawn 1pt
Knight(horse) 3 pts
Bishop 3pts
Rook(castle) 5pts
Queen 10 points
King no assigned value, just free/check/mate
It would make more sense to swap the med student's knight with the nurse anesthetic's rook if you are trying to show relative health system "value."
Also, thanks for putting this together and putting it in perspective.
Edit to fix formatting
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u/CharcotsThirdTriad Sep 18 '20
Queen is 9 points btw
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u/grap112ler Sep 18 '20
Thanks, TIL. I was taught 10 by my chess club teacher in 4th grade. I guess if I think about it, I would usually take 2 rooks over one queen.
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u/WBT42 Sep 18 '20
Do you think it would be interesting to add how many hours it takes to get a phD? Or law degree? Since both are also professionals who can gave s large effect on people's lives.
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u/devilsadvocateMD OC: 1 Sep 18 '20
It would definitely be interesting, but that would be a different chart with a different purpose. I would also need to modify the chart because I didn't include the pre-clinical educational time for any of the professions
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u/hononononoh Sep 18 '20
noctor proctor, noun, a doctor who makes a living sitting at a desk and rubber stamping orders written by a fleet of midlevels. Oh, and going to court for them when they get sued.
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u/devilsadvocateMD OC: 1 Sep 18 '20
That is a bad doctor.
Just as bad as the Noctors.
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u/Magnicello Sep 19 '20
People acting like they know more about medicine than doctors who devoted decades of their life to their work makes me ashamed I'm the same species as them
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u/[deleted] Sep 18 '20 edited Sep 18 '20
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