Post AShx4zsjR60EtnP5CS by MadMadMadMadRN@mastodon.social
(DIR) More posts by MadMadMadMadRN@mastodon.social
(DIR) Post #AShx4s0wgfosUxBWtM by MadMadMadMadRN@mastodon.social
2023-02-15T14:24:09Z
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Many physicians have issues with mid-level providers (Nurse Practitioners and Physician Assistants) having independent practice authority (IPA). Many of these criticisms center on the relative lack of education and on-the-job training mid-levels have relative to physicians and the safety issues that can arise from this relative inexperience. And there's something to these claims.However, there is an important point that the physicians who voice the concerns often neglect.
(DIR) Post #AShx4soZi9WCysPAFU by MadMadMadMadRN@mastodon.social
2023-02-15T14:40:41Z
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America has one of the lowest ratios of physicians to population among wealthy countries. According to the OECD, among member states only Japan, Korea, Mexico, and Türkiye have a lower ratio of practicing doctors per 1,000 population.https://data.oecd.org/healthres/doctors.htm
(DIR) Post #AShx4tKTnX2UZpKdyi by MadMadMadMadRN@mastodon.social
2023-02-15T14:42:48Z
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There are many reasons for America's relatively low number of physicians, but as @DeanBaker13@econtwitter.ne has extensively documented, a large factor was an extensive lobbying campaign in the early 1980s by the AMA and other members of the "Doctor Lobby" to restrict the number of med school and residency spots. This campaign was successful and throughout the 80s, the number of new med school and residency spots grew much slower than the population.
(DIR) Post #AShx4u0JI0V2fYu3BA by MadMadMadMadRN@mastodon.social
2023-02-15T14:45:51Z
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The AMA and others who lobbied for these restrictions argued that they were necessary to prevent a physician "glut" that would hold down physician wages. The restrictions were lifted in the late 80s and early 90s, but America has never caught up with this lost decade.
(DIR) Post #AShx4uPTmQdHvcg9PU by MadMadMadMadRN@mastodon.social
2023-02-15T14:48:04Z
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In many ways, the rise of NPs and PAs tracks the drop in the number of physicians American med schools and residency programs were creating every year – especially in critical but relatively low-paying and low-prestige specialties like family medicine, psychiatry, and pediatrics.And the number and autonomy of NPs and PAs grew first in those areas were physicians were already scarce, particularly rural areas and states in the mountain west.
(DIR) Post #AShx4v1PVOyRpGQRX6 by MadMadMadMadRN@mastodon.social
2023-02-15T14:52:28Z
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Of course, much of the shortage in the number of physicians created by the "Doctor Lobby" in the early 80s could be filled by foreign-trained physicians. After all, American physicians command very high salaries compared to other nations, even other wealthy nations. This should make America a natural magnet for top physicians from other countries the way we are a magnet for top software engineers or scientists.
(DIR) Post #AShx4vZnRYTnXuVu88 by MadMadMadMadRN@mastodon.social
2023-02-15T14:55:17Z
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There's just one problem: it is all but impossible to practice medicine in the United States if you have not completed your residency here. As a result, any foreign-trained physician who wishes to practice in the US almost always must repeat their entire residency. This is true even if a physician was trained in a wealthy "advanced" country with better health outcomes than the US (e.g. Germany).
(DIR) Post #AShx4w0NqhkMsMx8ZU by MadMadMadMadRN@mastodon.social
2023-02-15T14:58:43Z
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I have personally worked with several "residents" in my career that were licensed attending physicians in their home countries, but were repeating their entire training because there was no other way to practice medicine in the US. Some of these physicians were highly experienced and accomplished and regularly taught things not just to their fellow residents but their "supervising" attendings as well.
(DIR) Post #AShx4wUA3zZAMisuzA by MadMadMadMadRN@mastodon.social
2023-02-15T15:01:16Z
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The reason it is so difficult for foreign-trained doctors to practice in the US without repeating their residencies is, of course, because that's how the AMA and the "Doctor Lobby" want things. Just like restricting med school and residency spots grew physician salaries by preventing a "doctor glut" restricting foreign-trained physicians from practicing in the US boosts salaries for domestically-trained physicians by preventing an "immigrant doctor glut".
(DIR) Post #AShx4xFfDNZ0k36r1k by MadMadMadMadRN@mastodon.social
2023-02-15T15:04:13Z
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Of course, the "Doctor Lobby" no longer wears its more mercantile motivations so openly. Instead, the reason foreign-trained physicians cannot practice in the US without repeating their residencies, the public is told, is that there is no way to assure the quality, scope, and content of foreign physician training programs.
(DIR) Post #AShx4xvqgXJ8qsqXmS by MadMadMadMadRN@mastodon.social
2023-02-15T15:05:52Z
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While this *may* be true of poorer nations with less robust regulation and government oversight, in regards to countries such as the UK, Canada, Germany, Japan, etc., this concern is laughable and an obvious fig leaf for the true purpose of restricting foreign-physicians from practicing in the US: more physicians would mean more competition and lower salaries.
(DIR) Post #AShx4ygHtsSFAuZdAG by MadMadMadMadRN@mastodon.social
2023-02-15T15:08:41Z
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So, how does this relate to mid-level providers (NPs and PAs). Well, mid-levels are filling a provider gap that was created by the Doctor Lobby successfully arguing to restrict the number of med school and residency spots decades ago and is perpetuated by the Doctor Lobby successfully arguing to keep out foreign competition today.
(DIR) Post #AShx4z90B7QIby0YvA by MadMadMadMadRN@mastodon.social
2023-02-15T15:12:26Z
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In addition, many physicians did not seem to have concerns with NPs and PAs until these groups won IPA and were no longer legally required to work under a physician. Again, while there is a legitimate safety concern, there is also a strong financial motive for physicians to boost their own incomes by limiting competition from mid-levels.
(DIR) Post #AShx4zsjR60EtnP5CS by MadMadMadMadRN@mastodon.social
2023-02-15T15:13:48Z
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Given the history of the Doctor Lobby in restricting med school and residency spots and keeping out foreign-trained physicians (even today), it's difficult to take these safety concerns at face value and assume they are being made in total good faith.But, as I said before, many of these safety concerns are valid. Especially given the changes to NP programs over the last decade.
(DIR) Post #AShx50Q3RCeqZ8zh8i by MadMadMadMadRN@mastodon.social
2023-02-15T15:15:48Z
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There was a time when even being admitted to an NP program required several years of clinical experience in the field one wished to study. If you wanted to be a Psych NP, for example, you had to have several years of clinical experience working as a psych nurse.Over the last decade there has been an explosion in NP programs, particularly online programs offered by for-profit schools such as Walden and Chamberlain.
(DIR) Post #AShx50tTfoC42OlC08 by MadMadMadMadRN@mastodon.social
2023-02-15T15:18:22Z
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There are legitimate concerns about the quality of these programs and the NPs they are producing. Moreover, many of these programs no longer require years of clinical experience in the area of study. I have met several psych NPs who never worked in psych at all before starting NP school. These schools have a strong incentive to admit and graduate as many students as possible. In online programs, cheating is also a real and growing concern (ChatGPT will, I imagine, make this even worse).
(DIR) Post #AShx51MXvjRhUYMPJI by MadMadMadMadRN@mastodon.social
2023-02-15T15:23:11Z
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There are even some NP programs that are direct-entry in which students complete a BSN, obtain a nursing license, and are directly admitted to the NP program without ever having to have worked as a nurse. I expect Direct Entry NP programs to continue to grow if only to counter the competition from PA programs which do not require students to first be an RN or even to work in healthcare at all.
(DIR) Post #AShx51vdpFWDFOmR0q by MadMadMadMadRN@mastodon.social
2023-02-15T15:25:48Z
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In short, the whole mid-level situation is a big hot mess rife with conflicts of interest and self-dealing disguised as concern for public safety.To get out of this mess, a few things have to happen:
(DIR) Post #AShx52QpxGTKo9NLdY by MadMadMadMadRN@mastodon.social
2023-02-15T15:27:34Z
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1) The Doctor Lobby needs to stop fighting to keep out foreign-trained physicians. Physicians from peer nations should be allowed to practice in the US after, say, 1-2 years of supervision under an American attending (mostly to allow time for foreign-trained physicians to adapt to the US system).2) The US needs to drastically increase the number of med school and residency spots, opening many new med schools if necessary.
(DIR) Post #AShx532PhYWuggxMCu by MadMadMadMadRN@mastodon.social
2023-02-15T15:30:49Z
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3) NP programs need to have strict requirements for years of clinical experience in specialty for all students.4) NPs and PAs should be required to practice under the supervision of a physician or a more senior NP or PA for several years before obtaining FPA.5) NP and PA supervision should be meaningful and not just consist of a mid-level being required to work for and give a percentage of their earnings to another provider.
(DIR) Post #AShx53ZjhfBWM2Xy9A by MadMadMadMadRN@mastodon.social
2023-02-15T15:34:09Z
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One issue I didn't address above is that many US physicians say they need to earn more than peers in other countries because US med school is so expensive. This is a valid concern. But it's also the end result of a vicious cycle that started with restricting med school and residency spots to boost physician incomes. Fewer med-school and residency spots mean more income for fewer physicians.