[NPInfo] Blogs

[David Mittman]

Stephen:
Two things. What's the old expression about getting in the mud to  
wrestle with pigs? You get dirty and it makes them feel great. Same  
here. Individual docs who say stupid things will always be there  
(hate to admit it but so will there be stupid NPs and PAs). If these  
docs are in your town or city or hold any official position, I say  
take out their livers. If they are just a person who says stupid  
things, their colleagues usually think the same thing we do.
Don't get in the mud.

That is different from places like the web site for the physicians  
where they will not let us on. Where thhey take pride in excluding us.

We will start our own!!!!!
Dave

On Mar 8, 2008, at 7:43 PM, SGrtWhite at aol.com wrote:

> Because I have so much free time (like I all know we have so much  
> of!), I
> peruse the physician-written blogs. While I do enjoy reading the  
> vast majority
> of them, it really gets me when they start ranting about NP's/PA's  
> -- and
> believe me, a good number of them find a way to. See the post below  
> and feel
> free to comment back to Panda Bear, MD and his diatribe on "Mid- 
> Levels."
>
> Happy Reading -- -NOT!
> Stephen, FNP
>
> _http://pandabearmd.com/blog/2008/03/07/from-excessive-knowledge- 
> good-lord-del
> iver-us/_
> (http://pandabearmd.com/blog/2008/03/07/from-excessive-knowledge- 
> good-lord-deliver-us/)
>
>
> Cry Me a Friggin’ River, Why Dontcha’?
> It seems that I can’t mention mid-level providers, even in an  
> offhand way as
> I did in my previous article where I compared Physician Assistants to
> brand-new  interns, without the usual scolding from assorted mid- 
> levels who are
> quick,  mostly politely I hasten to add, to rehash the usual half- 
> truths and
> agitprop  about their profession vis-a-vis physicians. It is not  
> enough, apparently,
> for  me to be generally highly complementary to mid-levels in many  
> of my
> articles but  I must instead roll over and submissively urinate,  
> crying Uncle and
> admitting  that the only difference between a physician and mid- 
> level is some
> inconsequential and medically irrelevant minutia that we had forced  
> on us in
> medical school and residency but from whose wasteful tyranny the  
> mid-levels
> have  been spared.
> This is not the case however and the credence one gives to the  
> theory that
> Less is Better depends on how much knowledge, the currency of  
> medicine, one has
>  in their possession. Since it is, barring some warping of space-time,
> impossible  to cram the same amount of teaching into a typical two- 
> year-and-change
> Physician  Assistant or Nurse Practitioner curriculum as is crammed  
> into a
> four-year  medical degree, a graduating medical student on his  
> first day of intern
> year  starts out with an advantage in medical knowledge and it’s  
> not an
> inconsequential one either despite the usual protestation from mid- 
> levels that
> their shortened curriculum is just as rigorous as the medical  
> school curriculum
> (but it’s not ’cause they don’t learn any of the useless stuff… 
> see?). Is
> this  extra knowledge important? Of course it is. I am not exactly  
> medical
> training’s  biggest fan but there is not a single thing I learned  
> in medical
> school, from  the structure of cardiac ion channels to neurolation  
> in the embryo
> that does  not, in some way, make me a better physician strictly by  
> virtue of
> being a more  knowledgeable one. It’s easy to stand on the low  
> ground and insist
> that all of  this knowledge is useless but, and maybe I’m missing  
> something,
> we have not yet  arrived at a time where we admire and seek to  
> emulate those
> physicians who make  an effort to limit their knowledge,  
> judiciously deciding
> that they can do  without this or that, and adopting the attitude  
> of one of my
> fellow students in  a now-distant pre-med anatomy class who,  
> exasperated by the
> depth of the subject  matter, said, “This would be a much better  
> class if
> their weren’t so many  word.”
> It also should be noted that upon graduation, a mid-level’s mandatory
> education is at an end while an intern’s is just beginning.  
> Strictly speaking,
> medical school is a minimum of seven years for all physicians as  
> residency
> training, although not legally necessary, is a de facto requirement  
> to  practice
> medicine. I will have had eight years of medical training before I  
> feel  barely
> comfortable to practice on my own which is typical. Residency  
> training  lasts
> anywhere from three to seven years (and even more if we count  
> fellowships)
> which is something that many mid-levels forget or ignore when they  
> assert the
> equivalence of their training. Additionally, training is not the  
> same thing as
> punching the clock. In other words, a mid-level can graduate from  
> his program,
>  secure a position, say as an extender for a busy cardiology group,  
> and after
> a  little on-the-job training get into his groove as a paid  
> professional,
> keeping  up with his continuing education requirements of course,  
> but essentially
> having  arrived at a point in his career where he can decide to sit  
> around
> watching  American Idol after he punches out. This is not the case  
> with
> residency  training. Every rotation is training and every day is an  
> exploration of the
> dark  continent of our ignorance, a vast territory whose boundaries  
> no man
> can see and  in which no sooner is one hill crested than we are  
> presented with
> the prospect  of still more hills in the distance. So it goes for  
> eight years
> and it is the  background acquired in medical school and residency,  
> the useless
> minutia, that  provides the foundation for understanding and the  
> ability to
> synthesize original  thinking on medical problems and not to just  
> regurgitate
> contextless facts.
> Now, as to the assertion that because most of medicine is fairly  
> routine a
> mid-level can handle 90 percent or some arbitrarily high percentage  
> of a
> physician’s job, the first thing you have to realize is that for  
> those of us in
> the generalist specialties, even Emergency Medicine, it should  
> surprise no one
> that fifty percent of what we see is absolute bullshit (if I may be  
> allowed to
>  create statistics from whole cloth, I mean). Far from requiring  
> the skill of
> an  expensive mid-level, most of these presentations could be  
> easily sorted
> and sent  home by a reasonably competent school nurse who has  
> learned even less
> of that  bothersome and useless knowledge. We don’t even need a  
> well-trained
> registered  nurse either because although their focus is patient  
> care and not
> diagnosis and  treatment, registered nurses particularly Emergency  
> Department
> and ICU nurses,  are extremely sharp cookies and they are probably
> over-trained to assess and  send home many of the patients we see.
> In other words, in their zeal to devalue medical knowledge, mid- 
> levels are,
> perhaps unwittingly, bringing into the question not only the  
> justification for
>  having physicians but also for spending money training so many mid- 
> levels to
> the  extent they are trained today. Far better to just allow  
> reasonably
> motivated  high school graduates to take a year or two of basic  
> coursework at their
> local  junior college, give them a white coat and a stethoscope,  
> and let ‘em
> at all of  those routine patients. Why not? My undergraduate degree  
> is in
> Civil  Engineering, for example, and any sharp witted, smooth- 
> talking village
> idiot  could make a good case that this contributes nothing to my  
> ability to
> diagnose  and treat disease. The same fellow could also make the  
> case that eight
> years of  medical school and residency training is not necessary to  
> recognize
> the flu,  treat garden-variety diabetes, or write a couple of  
> prescriptions for
> blood  pressure medications. Hell, as long everything goes smoothly  
> and all we
> expects  is low-level primary care then everything is going to be  
> fine.
> Unfortunately, as  we push the boundaries of medicine and reap a  
> bumper crop of
> increasingly  elderly and multiply comorbid patients, most of whom  
> expect to
> survive their  visit to the doctor, the trend nowadays is towards  
> more complex
> patients, albeit  mixed in with some undetermined proportion of  
> sublimely
> ridiculous chief  complaints or cookie-cutter cases that can be  
> handled by our
> intrepid Junior  college graduate.
> Mid-levels are quick to note however that the trend even in their  
> professions
>  is towards more, not less education. Obviously some of that  
> useless minutia
> is  of value.
> Let me relate a parable. As many of you know I was once an engineer  
> and after
>  graduating with my engineering degree found myself in an  
> engineering firm
> where  I was in charge of a stable of young design-draftsmen, the  
> “mid-level”
> providers  of the engineering world. Most of these design-draftsmen  
> had
> Associate degrees  in Engineering Technology from reputable junior  
> colleges where
> their curriculum  was heavy on drafting with a smattering of low-level
> engineering design courses.  Good guys, for the most part, and I  
> picked their brains for
> tips on  computer-aided design and drafting as many of them had  
> been using
> AutoCAD for  years and were fairly good at it. (Junior engineers  
> nowadays are
> expected to do  a lot of their own drafting, probably because it is  
> easier to do
> it yourself  than prepare a sketch for a draftsman to translate into a
> finished drawing). The  useful thing about well-trained design- 
> draftstmen is that
> you can send them, for  example, the design drawing for a piece of  
> process
> equipment (a roll cage,  conveyor, etc.) and they have the  
> knowledge to produce
> detail drawings and parts  lists without having to bug you all day  
> about it. Same
> with detail drawings for  structural or foundation work. Very few  
> structural
> engineers, for example,  produce detailed drawings of structural steel
> connections but instead pass the  design drawings to a “mid-level”  
> steel detailer
> who produces cut lists and all  of the drawings need to fabricate  
> and assemble
> the structure. The details are  based on the engineers  
> specifications and if,
> for example, I were to specify a  shear-only connection to resist a  
> certain
> load the detailer would produce the  drawings from which the actual  
> pieces could
> be fabricated. It’s not rocket  science and, as a structural  
> engineer, I am
> quite capable of designing and  drawing my own connections but didn’t,
> habitually, except for the difficult ones  that did not fit the  
> cookie-cutter examples
> in the two major steel design  manuals (that would be the AISC ASD  
> and LRFD
> manuals for those of you who are  interested and still following  
> along).
> Naturally, when I finished my five years as an “Engineer in Training”
> (interestingly enough also called an “intern” in the Civil  
> Engineering world)  and
> passed the licensing exam to become a Registered Professional  
> Engineer I was
> completely responsible for all aspects of the design, drafting, and  
> detailing
> of  everything that passed through my hands including the detail  
> drawing
> produced by  the detailer, himself usually an independent  
> contractor. Did I check
> every  single connection on a large structure, burning the  
> proverbial midnight
> oil for  weeks at a time with a red pen in hand? Of course not. My  
> detailer
> had been in  the business since before I was born and knew a thing  
> or two about
> steel  fabrication. But that was his thing, you see. My thing was  
> design and
> management  and I don’t recall ever taking a detailer or a design- 
> draftsman
> aside and asking  their help for a particularly thorny foundation  
> design
> problem. That was my  thing.
> One day, one of the more crusty design-draftsmen let on to me that  
> he didn’t
> think it was fair that engineers made more money, especially as he  
> believed
> he  could do ninety percent of what an engineer did.
> “Well,” I replied, “seeing as ninety percent of my job involves  
> standing
> around drinking coffee making sure that you’re doing your job I  
> don’t doubt  it.
> ”
> But you see, the devil is in that left-over ten percent (or fifteen  
> or twenty
>  or whatever percentage makes you comfortable with your career  
> choice). Most
> of  every career is routine, repetitive, and can be handled on  
> autopilot. The
> difference between medicine and other careers is that one never  
> knows what
> patient is suddenly going to become one of the ten percent.  
> Consequently we
> want  to avoid the autopilot as much as possible. Emergency  
> Medicine in
> particular is  all about not just treating the ten percent but  
> accurately determining
> who is  part of this dangerous minority and until such a time as we  
> can
> determine which  of the ninety percent only need the school nurse  
> and which need an
> attending  physician, prudence dictates that we have the physician  
> standing by
> even if many  of his cases turn out to be nothing…keeping in mind  
> of course
> that your  definition of “nothing” depends on your training. Many  
> of what I
> once thought  were incredibly complicated patients are now just  
> another boring
> case of sepsis  or meningitis.
> In reality the practice of medicine is a team effort, not unlike a  
> symphony
> orchestra where everyone has a part and an instrument they are  
> expected to
> play.  If any individual from the conductor to the third flute  
> doesn’t do his job
> well  the entire ensemble is going to sound like a high school  
> marching band.
> While it  is true that a good symphony can produce ethereal musical  
> magic
> from the great  composers, they also spend a lot of their time  
> sawing out The
> Nutcracker to keep  the proles interested.
> .
> On another note, many of the critical emails I  receive about the  
> difference
> between mid-level providers and residents start out  with some  
> variation of, “
> I have been a PA for twenty years,” and then proceed to  expound on  
> the
> uselessness of an intern. Well, God bless you. I’m willing to   
> allow that a new
> Emergency Medicine intern on his first day in the department  can  
> probably have
> circles run around him by a Physician Assistant who has been   
> practicing for
> twenty years. But we’re comparing apples to oranges here. There  is  
> a steep
> learning curve for a resident and I would not presume to say I am   
> even near to
> cresting it. That’s why we call it it “training.” On the other   
> hand, a typical
> Emergency Medicine attending with twenty years of experience can   
> run circles
> around a twenty-year mid-level and their little dog too. They  
> didn’t  get that
> way by stopping their ears against useless medical knowledge.
>
>
>
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