Interesting Ideas concerning PA evolution....

FROM a PA who went back to the Medical School, and became a physician. I don't see it happening, but interesting nonetheless.

PA’s are as diverse in personality, background and desires as the sands of the sea. A young PA will have differing opinions on various subjects than an older PA. Times change, exams change,people change but human beings are basically competative by nature. Anyone ever run a race to come in second place? My comments to you all are very contemporary, political but with “YOU” in mind. I recently spoke at a conference where a group of NP’s addressed a fellow DNP by the title Doctor. I was recently at a rural clinic where an older PA and a younger PA apparently had issues with a Doctorally trained PA using the titile “Dr.Jones the associate Physician” I didn’t have a problem with that but the two PA’s apparently did. My goodness the PA had a Doctorate degree in Public Health and 18 months of residency training under his belt and I as an MD would not insult this man, brush aside his skills and great bedside manner to consider him my assistant but rather my associate.

To the gentleman who erroneously states PA’s are not considered second class medical citizens check this out and then tell me what you think, then I will answer Daves question as to what the profession needs to do. I propose a scheme for PA’s that would answer the question of why some people got into the medical field and not the PA profession particularly. I think outside of the box so my proposals take into account the group that loves the assistant role and being supervised versus the group which recognizes the practice of medicine boils down to good training and a lot of experience, not a “HAZING” process of brutal medical school training with 3 years of inhumane residency slavery.

Proof that the medical community sees you as second class citizens.

The Michigan state medical board without letting you all know, listed podiatrists as supervising physicians of PA’s. How respected is the PA profession when foreign-trained doctors working in Federal facilities can get a PA license without any didactic or clinical training in a PA program? see

http://www.aapa.org/policy/unlicensed-med-grads.html
http://www.bop.gov/jobs/job_descriptions/physician_assistant.jsp

When a medical organization accepts a model of licensure that designates its practitioners as lifelong “interns/residents” needing supervision,(Post Graduate year 1/2 medical students). That profession is doomed to accept practice guidelines involving supervision by “any” independant healthcare professional, (podiatrist).

Statement by AMA to increase medical student seats to increase the primary care force. PA’s are not even considered a viable option. Physician workforce shortage: Yes, no, or maybe? e-mail story | print story In the March 2005 issue of the GME E-letter, we wrote, “It appears we are facing a national shortage of doctors. This shortage is currently confined to some regions and specialties, but the bulge of aging baby boomers threatens to widen the gap. “The Association of American Medical Colleges (AAMC) has called for a 15 percent increase in the number of medical school graduates by 2015--but that won’t solve the whole problem. We will need more GME positions as well. “To be feasible, this expansion will require removing the current caps on the number of federally funded residency positions as well as finding additional funding sources for GME. But how should these residency slots be distributed geographically and among the specialties? And how should we develop national policy on medical workforce issues such as these?”
http://www.ama-assn.org/ama/pub/category/14908.html

So when a Doctor gets disciplined or has his/her license revoked and the state medical board publishes this statement;

“Dr. John doe was placed on 2 years probabtion and is prohibited from SUPERVISING PA’s and NP’s”

So when those PA’s/NP’s just lost their job because of the MD’s incompetence and the underlying tone of such statements imply that a PA/NP can’t function without the valid,unrestricted license of an MD I have 2 questions;

a) Why then do you have PA/NP licensing agencies?
B) Why take exams,do clinical rotations,take CME’s or even have conferences?

Dave it was a Doctor who created the P.A profession now the PA’s should move the profession forward by doing the following;

1) Change your title to “Associate Physician”. The word Assistant in 33 standard dictionaries means “Clerical”.

2) Create a Doctorate Associate Physician (DAP). Read the history of DO’s then you will see that this just follows an already established precedent. A DO colleague of mine once said that “MD’s may look down upon me because I am a DO but at least I’m not a PA” the DAP degree needs to be created and granted with completion of accredited postgraduate clinical residency training programs. This should be a clinical degree, and you should use a doctoral title. Optometrist,opthomologist,psychologist and psychiatrist don’t have a problem with an established precedent of “Degrees”. I suggest the following licensing scheme to keep all Associates and Assistants happy;

4 year degree, Bachelors, Associate Physician. (BAP)

7-8 Year degree,(bachelors and 3 years of additional
training) Masters, Associate Physician(MAP)

7-8 Year degree, with Post-Graduate training,
Doctorate, Associate Physician (DAP)

This would be the key in a licensing system as defined;

Distinction/educational level is clear in this scheme.BAP, MAP and DAP. The bachelors trained professionals
are the only ones that need to follow the current PA-Physician supervisory model. This would keep all the assistants happy. If you want to be an assistant then stay here. The MAP and DAP should be independant practitoners however. In this scheme a seasoned, experienced Associate Physician could actually move up the career chain after many years of practice if they choose, or 26-30 year olds fresh out of medical school residency training will become supervising Physicians of a 30 year practicing PA. Doesn’t make sense to me. I had to put a 1 year out of residency training Board certified 30 year old FP in his place because the 50 Year old PA of whom he was the supervising Physician was correct regarding the use of basal -vs- bolus insulin in a Diabetic patient. It was quite obvious this board certified rookie learned all this detail about Lantus but didn’t understand you don’t use basal insulin for Bolus random blood sugar elevations, the 50 year old PA his “assistant” knew however.

Why am I on here? I don’t want my fellow hardworking, intelligent and innovative colleagues to go through the “Hell” I went through to move away from the clinical handcuffing I went through as a PA, going through medical school, residency training only to end up doing the same thing I did day in and out but now with a title change. Now with a better income and incentive pay. With hospitalist, I don’t need to manage patients in the hospital etc.....Wake up my friends and move forward. The grass is green on your side please water it properly.

Interesting, and timely discussion....

Example of Cost Increases.....

So, some time ago, I had a younger, obese female patient present to the ED. She came with a complaint of a breast lump with skin discoloration. At first, I thought of potential mastitis, could she have a ductal abcess, something bad...right? Nope. This had been present for 2 months duration, and she had done a "lot of research on the internet". That is not usually a good statement to hear from your patient, primarily because there is just so much BAD information out there, and you often spend a great deal of time correcting misinformation, or even more often, MISINTERPRETATION of information. Anyway, she saw her local MD, who referred her to a breast physician locally. She was extremely concerned that she had Invasive Ductal Carcinoma. In fact, she had already staged herself, and was concerned that she had already progressed to stage II. Mind you, she had not seen a breast physician yet. She had been concerned, and had already called our breast clinic, for which she had an appointment in 2 days.

This was unacceptable apparently. The patient wanted an MRI (which we rarely ever do in the ED, and only in the instance of a severe emergency), or to have it biopsied in the ED. I explained to her calmly that I could not offer her either of those options. I explained some alternative ways that she could potentially move up her appointment.

A completely unnecessary visit, which cost hundreds of dollars, and added nothing to her care. I don't blame her. I blame the system in which this is encouraged. This is not even an unusual story, as there are dozens of patients who present every day with complaints that should have likely been seen in an outpatient clinic.

Wellpoint CEO....

Well, those of you who follow this blog, know that I don't have a lot of empathy for insurance companies, and some of their practices.

THAT being said, I agree with the CEO of Wellpoint Angela Braly's recent stance. She's right, while some of the insurance industries practices are a bit distasteful, such as recission, and denial of claims. The insurance industry is not the main reason costs are increasing. Hospitals, physicians, and other providers are raising rates. Add in a tumbling economy, and you get a risk selection bias as healthier individuals forego insurance, and an increase in COBRA enrollment, which is almost universally full of sick individuals. This creates a problem for the insurance company. While I am not going to say I feel sorry for Wellpoint, I believe that most people are missing the point of Ms Braly's comments.

She's right, we need more than simple health insurance reform. We need DELIVERY system reform, and right now, we're not getting it.

How about this idea. If we are going to mandate that all patients have insurance, and we are going to mandate that all insurance companies cannot deny pre-existing conditions, or cancel policies, and must have higher MLR ratios, then how about MANDATING that all providers accept Medicare patients. Tie it to their DEA number. If they refuse to see new Medicare patients, they lose their DEA number.

Providers need to have some skin in the game too.

More HERE

Free Markets and Healthcare

I seem to be having this recurrent conversation lately....."Government can't run healthcare, let the free market do it". To which I reply "Well, so you're saying that you want to get rid of Medicare, Medicaid, and SCHIP?"...to which the usual answer is "NO, just let the private market function as a free one"....my reply is. "you've never studied economics, have you?"..."No, why?"..."Thought so".

Free market principles DO NOT work in healthcare. It's a great news soundbite, and sounds like a great libertarian fantasy....in fact, John Galt would be proud, but it's simply not factual. There are any number of reasons, including the resultant distribution inequity that would result, but a large part of it is inelasticity. Market forces tend to work well when a commodity or service is elastic. That is, if prices rise by x percentage, then demand falls by an equal precentage. When there is inelasticity, that falls apart. Deflationary pressure isn't applied to prices, and they continue to rise unabated. Sound familiar?

Paul Krugman had a great opinion about this last summer.

HERE

He's right, and essentially he is talking about a resultant inequity in distribution, but he never comes out and says it exactly. In other words, the richest people would benefit from reduced prices and increased competition. The upper middle class would see some benefit, but not much, and everyone would else would suffer with decreased access, an inability to afford anything more than a throat culture, and our society would be much worse off.

But sure, the market can solve everything....talk about an "invisible" hand...

I am reminded of a quote from James Buchanan...no NOT that one, James M Buchanan, a nobel prize winning economist, who said:

“Gross misperception, especially in the minds of noneconomists, often prompts the claim that ‘the market’ (or ‘capitalism’) either works or does not work without constraints, a claim that is demonstrably unsupportable, either in analytical logic or in empirical reality.”

Healthcare Summit....

So, it's over.

President Obama met with the Republicans today to discuss bipartisanship. Except it didn't happen. And that really wasn't the purpose of this meeting anyway. Obama has known from the outset, that obstructionsim is the republican goal, and it is their only goal.

This meeting was more about lining up moderate democrats for the reconciliation maneuver. The problem is, that there are portions of the bill that cannot pass through a reconciliation process. This will leave holes in the bill that will require future legislation.

Part of me hopes that they do it. The republicans have no real ideas regarding healthcare reform, and have no agenda, despite what they say publicly...(YES, that means you John McCain). Their only agenda is taking back seats in Congress in November, nothing else matters to them.

The Senate bill is "okay". There are a number of good provisions, and some bad ones in the bill, and you know what....that's okay. We are NEVER going to get a perfect piece of legislation, it simply ain't going to happen. What we need is a starting point, and this seems as good as any legislation to start with.

What the US public needs to know, is that reform is a process, not a destination. This is going to take YEARS to implement, and we are going to try things that aren't going to work, and things that are going to work. It needs to be built upon.

The other part of me rationalizes, that we need a complete teardown of the current delivery system. We need to hire a team of systems engineers to completely re-design it from the bottom up.

We owe it to our patients, and our future patients.

Obstructionism....and Republicans....

One of the best articles I have ever read regarding the current rather venomous climate in DC....From the article...

ARTICLE HERE


With these acts of legislative sabotage, Republicans tapped into a deep truth about the American people: they hate political squabbling, and they take out their anger on whoever is in charge. So when the Gingrich Republicans carried out a virtual sit-down strike during Clinton's first two years, the public mood turned nasty. By 1994, trust in government was at an all-time low, which suited the Republicans fine, since their major line of attack against Clinton's health care plan was that it would empower government. Clintoncare collapsed, Democrats lost Congress, and Republicans learned the secrets of vicious-circle politics: When the parties are polarized, it's easy to keep anything from getting done. When nothing gets done, people turn against government. When you're the party out of power and the party that reviles government, you win.

Greenspan earns dubious distinction....

The dynamite prize in economics.

Alan Greenspan, Milton Friedman, and Larry Summers, after over 18,000 votes have been awarded the dynamite prize, and have been proclaimed the economists most responsible for blowing up the global economy....

Can we now proclaim neo-classical economics dead on arrival....

See HERE

Funny photo

Okay, now this really made me laugh out loud....LOL......

Economic Rant.....

Paul Krugman has stated that the government stimulus was not enough. He is concerned about the possibility of a "liquidity trap", of the type that the Japanese fell into in the 90's. Their recession worsened, and lasted over a decade. He sees a lot of similarities with our current situation. Small stimuluses, just enough to avoid the brink, but not enough to turn it around. Strange that so many ignore history. Additionally, I don't think that Summers and crew have handled this well. Obama has been positive because, well, that's his job to increase consumer and investor confidence. Right now. GDP predictions for 09 were all over the place, for example, 3rd Q estimates were first at 3.5%, then revised to 2.8%, and finally revised to 2.2%. Additionally, the 3.5% estimates only represeted 0.5% of real growth once government spending was excluded. REAL GDP growth was still negative. There is no vector in the marketplace ready to really stimulate and grow the economy. Energy maybe, in 5 years or so, but the infrastructure is not there to do it currently. The excesses of spending and credit obligations of the last 30-40 years are not going to simply work their way through the system in 1-2 years.

I haven't even touched on jobs yet, but with minus GDP growth, it ain't gonna happen. Okun's Law states that you need 3% of growth in production to get a 1% growth in employment. However, this only represents a 0.5% decrease in unemployment, as the modeling suggests that at least 0.5% of that 1% is an increase in hours worked by those already employed. We're nowhere NEAR 3% yet.

I'm also stuck on the dollar because while it helps our export market, the combination of a weak dollar and prolonged low interest rates creates a real potential for severe inflation. Although right now, most economists think we will hit a deflationary period first. The IMF actually is calling for countries to raise interest rates, and to aim for a consistent 4% inflation goal. It won't help us now, but they are thinking of ways to try and prepare to deal with future events. Additionally, we import more than we export. We are a consumer nation, and while a weak dollar will help a few companies, many others who import components and pieces will only have to raise prices... and there's that pesky inflation again.

Anthem in California is raising ire..

Exhibit A....Anthem in California raises rates on 700,000 enrollees by an average of 25%, for roughly 25% of them, they will see a rise in premiums of between 33 and 39%. Even at 25%, this represents roughly 4 times medical inflation (average of 6.2% per annum over the past ten years). If you don't think that this is coming to your state soon, well, I want some of whatever you are smoking.

More HERE