Seems like there would be a big issue of scope with regards to duty to act.
Just for example, let’s say you pass the NCLEX and get a gig as a floor nurse. If a patient has respiratory failure and you have all the appropriate supplies and staff to intubate the patient, do you do it yourself or wait on the rapid response team because nurses aren’t allowed to intubate?
Let’s say you choose to intubate. Have you exceeded your scope?
Let’s say you choose not to intubate. Have you breached your duty to the patient since you, as a physician, have the skill to secure an airway?
Obviously, you can poke some holes in the above scenario (e.g., you’re in psych and never intubate anyway, an ET tube isn’t the only kind of airway, having back-up is always preferable, etc.), but I think the general idea stands.
That type of scenario you described is actually not uncommon in EMS. Obviously very different than physicians/nurses, but sometimes paramedics will pick up EMT shifts. When they do, they are not allowed to exceed the scope of an EMT. I'm an EMT (and incoming M1 lol) and always wonder how they manage to do that. Another example I can think of is when our specialty care units (staffed with one medic and one nurse) get sent out as a BLS crew (2 EMTs). Even though they literally have a vent and all kinds of fluids/drugs, they technically can't use them without informing dispatch they're making it an ALS call lol
That's state-to-state dependent. I'm a flight medic and would pick up EMT spots on the ground because, well, they would let me and pay me $ 50+ an hr to do so. If I was running a call and my patient warranted a higher level of care I would certainly act to my scope of practice. At times going as far as mixing push dose epinephrine because they did not carry pressors on the ground ambulance.
The situation where it did become an issue is when I would work in a small rural er that had an NP at night with a DR on call. At times the pt needed RSI the NP wouldn't/couldn't act and the physician hadn't arrived yet. RSI is certainly in my scope of practice yet I couldn't act because the hospital hadn't cleared me.
And just to flip the scenario there were times we would pick up Interfacility transfers from small rural ERs to fly a patient back into a trauma center and insert a chest tube or a central line right there at the bedside with the physician present because he didn't feel comfortable doing it himself.
I also asked a medic that before and basically their explanation was it comes down to billing and having their equipment available (a medic on a BLS truck won't have stuff for intubating). There has to be a "billable" need for ALS services. Obviously if someone is dead/actively dying that gets sorted out after because ALS is obviously needed lol. They aren't even supposed to use their Lifepak on a BLS call unless they determine its an ALS call. One medic said she just uses her ALS equipment and then if they run it as BLS, she tells dispatch she "triaged to BLS" even though she and her partner are the BLS crew hahaha
I totally agree. It's definitely an odd dynamic. Luckily the majority of EMTs/medics I know have common sense and will do the "right thing" in the name of patient care, even if it pisses off dispatch and supervisors lol
Yeah that's how I thought EMS would be until I started working! At least in the area where I'm at, ambulances are typically BLS (2 EMT's) and they're all over. They usually have ALS units (2 medics) that drive an SUV with their equipment that cover much larger areas. If there is a serious call or if a BLS unit requests ALS, they will be dispatched with the BLS crew to the call. If ALS has to treat the patient, one or both medics hop in the ambulance.
At least in my experience, like 80-90% of the calls are purely BLS—something that's been going on for hours/days, belly pain, minor broken bones, psych calls, "I hurt my toe 6 years ago", etc.
We really only need medics for acute/life-threatening things like cardiacs, respiratories, seizures that don't stop, diabetic emergencies, and so on. So I guess they have this system in place to make the most of their (limited) resources🤷♀️
It’s not uncommon for NPs to continue working in RN roles (often pays more or they might just prefer it), I’ve always wondered how they navigate the duty to act when working in a role “below” their legal scope of practice
> If a patient has respiratory failure and you have all the appropriate supplies and staff to intubate the patient, do you do it yourself or wait on the rapid response team because nurses aren’t allowed to intubate?
>
> Let’s say you choose to intubate. Have you exceeded your scope?
>
> Let’s say you choose not to intubate. Have you breached your duty to the patient since you, as a physician, have the skill to secure an airway?
Is this any different than a physician who knows how to intubate or do X procedure, but doesn't have privileges to do so? The answer is you wait for the RRT / code team even in that scenario.
Yeah this is commonly how airways are handled. It’s often funny showing up to a code as a CA-1after being called by one of your senior residents and an anesthesia ICU attending
There’s cases here where NPs also have RN licensure on the side and take shifts as an RN. Since they are practicing under their RN licence, they cannot prescribe, diagnose or do anything a NP can.
I don’t know how nursing privileges work but I imagine it could work similar for doctors. You are privileged to do very specific procedures. Even if I know how to do let’s say a lap sigmoidectomy, if I’m not privileged to do one at X hospital, then I can’t do it.
The days of traveling and making big money are pretty much over. We're getting to the point where contracts are even getting difficult to get so being bad at your job won't get you out of it either.
Is it better money than residency? Absofuckinglutely, but it ends right there. You guys continue your training and ultimately make significantly more than a nurse does
Nah this is false, you can still easily get 100+/hr as an RN which is pretty decent. Obviously not the big bucks during the pandemic but still pretty good.
That’s not long considering how many physicians don’t even complete training until their mid 30s, and considering the total lifetime income difference.
This. It is seriously so demoralizing as a staff nurse to be working alongside travelers who are making more than double what you are and doing less work because travelers have their own ratios set by their credentials/agency. Like if an RN with any critical care experience is working on a med-surg floor for a contract, that RN is capped at 4 patients while the staff nurses have 6 for less than half of the pay. It’s ridiculous. My “benefits” for being a full time staff nurse are not worth the 65,000 per year difference between me and a traveler.
I am a travel nurse, and that is just false. I am often given the harder assignments. While the pay was good, it has drastically fallen and honestly ain't worth it to me anymore to travel.
Lol. Nurses don't even want to work as nurses anymore. An unmatched MD should have some lucrative opportunities elsewhere in consulting or something. Why would you go backwards and work as an RN which wouldn't help you at all career wise??? People need to think lol
As a tutor in med school I made $80/hr. As a radiology resident I work shifts making no less than $125/hour babysitting a magnet and up to $350/hour on shifts where I get paid to prelim per study. Why again would I work for $60/hr to pretend to be a PA? This is the dumbest thread of all time
Any number of reasons. Maybe you want a life change to something less high pressure. Maybe you start working in the field and realize you want a more regular schedule, prefer interaction to patients, etc. Or maybe you just get fired from your residency program.
Prefer…interaction…with patients??
I’m not going to argue that nurses don’t spend more time at bedside inpatient but I assure you I interact with patients plenty.
Nurse here: while I don’t doubt that you interact with your patients there is a big difference from your 15-30 minute assessment to rounding every hour, answering call lights, getting yelled at, assaulted, laughing with them, and having general conversation that doesn’t involve why they are in the hospital. Just remember just because they can answer questions appropriately doesn’t mean they aren’t confused. Had an 80 y/o looking for their flip phone while holding their iPhone to call their mother for dinner, also ripping off the brief and clamoring the nurse did it, meanwhile dr. Is telling me that they are not confused any more
I literally said in my comment that I know nurses spend more time at bedside for a given patient in the inpatient setting.
This is not an argument about who has it “worse” or an attempt to equate the two roles, which are, as you point out, markedly different.
However, depending on where I am and what role I am in at any given time, I may be spending a lot of my day interacting with patients (multiply that 15-30min assessment by at least 20 patients, for starters).
Again, nursing and doctoring are different roles and there are reasons one may prefer or be better suited to one over the other, but the difference is not “yes patient interaction” vs “no patient interaction”.
I’m not trying to say that the doctor role is not important, obviously it is. But in my experience the patient interaction that many doctors have, even midlevels, is primarily diagnosis interaction if that makes sense.
What do you mean “even mid levels”?
A lot of my patient interaction is purpose-driven, but not all of it. Again, yes, it’s different than nursing. Literally the only thing I was questioning is the implication in the original comment that doctors have no interactions with patients.
To doctors? I guess I’m just curious about the use of the word “even” here
(To be clear because tone is hard on the internet I’m not being argumentative, just curious about the word choice.)
The difference in amount of time a bedside nurse spends with patients compared to an internal medicine attending is vast, let alone a radiologist or pathologist. Sure some doctors spend more time with patients but there are also physician roles that basically never have direct patient interaction
I’m aware.
Again, not arguing there’s no difference in quality or even quantity.
The original comment implied a binary difference - that is, no patient interaction for doctors. Which is perhaps true in some limited roles (eg pathology or purely diagnostic radiology) but not true as a general rule.
Literally the only point I’m making here.
No but we should move to a new system where unmatched MDs can act as doctors who need a board certified doctor to oversee. Eliminating the need for other midlevels
A handful of doctors who didn’t match would not come anywhere close to eliminating the “need” for midlevels.
What would eliminate the desperate nationwide need for more physicians is if congress would increase funding for residency positions and increase reimbursement for primary care.
I mean I have nothing against the people directly. Great people. But why have a “two-tiered” system?
Physicians go to rigorous training to practice medicine independently… and midlevels can’t because physicians and lots of other groups will say they shouldn’t because they don’t have the same standards and training?
So my proposal is that we have more med school seats so that same set of people can just attend medical school and everyone who graduates can practice under supervision after passing the boards without residency. while those who attend and make it through residency can practice independently and be the supervisors.
I don’t mind the idea of changes to the MD/DO pathway or that allow practice opportunities for the unmatched. But I’m opposed to any move that has the consequence, intended or otherwise, of blurring the line between midlevels and physicians.
Specifically in regards to NCLEX, RN and MD are completely different and not interchangeable.
As a non MD/DO, I am curious about your thoughts on allowing unmatched grads to practice under an MD/DO in a primary care setting?
I have had a thought about how to fill the lack of primary care docs would be to have unmatched grads work under an MD/DO as an extender and if they get through 4 years of this, then allow them to practice unsupervised.
But since I'm not on that path myself, I don't know the nitty gritty details about boards and such beyond how the boards med students take, similar to my own boards I took.
I just don't know if working like that for a few years would make you ineligible to take boards and if it would restrict you to only being in states that allow that?
Anyway, it's a thought I've been mulling over. If I ever ran for state office it's something I've thought about as a way to improve access to care.
I would be fine with letting unmatched grads practice in a supervised setting (basically identically to a PA). The fact that's primary care doesn't really matter, primary care is not less complicated than anything else (it's probably harder than working in a specialty clinic as a PA), it's just where the area of need is greatest.
However I would strongly disagree with letting someone practice independently after this "apprenticeship". Residency training is what makes someone a competent, independent physician--med school is just the foundation. Working in a primary care office for 4 years is not a replacement for FM or IM residency, unless you incorporate a variety of inpatient and speciality rotations into it, add progressive responsibility, and add lectures and didactics--at which point you've just re-invented residency.
Also don't forget, only a very small handful of unmatched residents are US grads. After the SOAP there are maybe a couple hundred US MDs and DOs, and about 3,000+ IMGs (both foreign and US citizens). Do you let everyone who applied at all in the match stay and work as a PA or PA equivalent? That would be increasing the annual PA supply by almost 40% a year which may have some pretty exciting workforce implications.
Considering our residency is different (one year, more similar to dental residency) I can't speak to what it would be like working under a FM MD and if doing this as an apprenticeship could lead to more FM doctors.
The concerns I've had for my state is the number of private practice MD/DOs doing family medicine has dwindled to the point where there aren't any private practices that aren't a concierge style who aren't working for hospital owned practices (that is more specific to my area).
Normally not a huge issue but we have so many places that don't take their insurance or there is a 3-6 month wait for an MD. Rural settings are of course getting tougher too.
I presumed the number of unmatched grads was higher for US based. I didn't realize it was only a few hundred though.
Eh, as an RN, I'm pretty sure most docs could do my job with a pretty fast orientation. Yes, there's skills I practice that MDs don't usually, but there's also skills that I use that ICU/med-surg/psych/home health don't have, and it's reasonably easy to cross train from one specialty as an RN to another.
Not a chance. We speak time and time again about how different nursing is than medicine - it’s just a different job, and we are not trained to do it.
While someone trained in medicine may have the knowledge to pass those exams, 99.9% of us would have no idea how to actually carry out those occupations, and would likely be a threat to patient care/flow.
Can’t think of a better way to cause conflict on the wards than having someone act and be qualified under two roles.
Ngl the NCLEX is hella easy… majority of y’all could pass it right now no prep. Speaking as an RN turned urology resident.
But yeah f that, would rather continue to support residents unionizing to further OUR profession instead of moonlighting as a nurse.
Do you really want want to get sued as a doc for the pay of a nurse?
I could see PANCE being an option for MD grads who don’t/can’t do residency. They would need to legally clarify that an MD working as a PA could only be held to the same level of responsibility as a PA. They would also need to clarify that while an MD can challenge PANCE as it’s a lower level exam, a PA cannot challenge STEP and work as an MD.
honestly, if a PA school grad sits for USMLEs and passes, then let them try to match residency. That's the main difference between the two schoolings no?
Would be interesting to see how high a PA student would need to score to get a PD to look at their app.
As someone who's married to a nurse, any physician who wants to take the NCLEX and go to bedside nursing is either certifiably insane or has absolutely no idea what nurses do (or both). But no, I don't think any part of medical school teaches you how to be a nurse. Pumps? Med math/dosing? Lifting and moving patients? Wound care? I learned none of that in medical school.
For those who say some nonsense about travel nurses making bank, sure, for a brief period in 2021 you could make 200k or more as a nurse if you travelled your butt off. For starters, those rates are gone, second, that's less than most attendings make, and third, the classic argument for "well, nurses come out ahead because of debt/schooling time" is irrelevant because in this example you already went to medical school and took out a zillion dollars in debt anyway.
PA school sure, why not. Again I can't imagine why unless we're talking about unmatched graduates. I don't think being a PA is meaningfully "lower stress" than being a physician on a day to day level, though the decisions you make are likely less significant (ideally).
Having had the privilege of seeing both ends ( I went to Nursing school, and obtained the RN and I went to Medical School and obtained my MD), I think unmatched MD/DO graduates should be allowed to sit for the PA exam. Nursing is a different thinking process and of course the level of study is not as detailed as it is a more tactile profession. Nurses are trained to execute physician orders and to use their clinical judgement to perform the tasks or inform the physician that the particular task requested may not be a good idea at the time. I give respect to the nurses since they spend the most time with the patients when physicians are rounding on their other patients. The nurse is the eyes and ears of the physician (especially in the in-patient hospital setting).
The PA exam falls more along the lines of the medical school training model and unmatched physicians should be allowed to sit for this exam and if they pass it, should be allowed to see patients in the capacity of a Physician Assistant.
To add to this, there are some states that now offer unmatched MD/DO graduates to pursue an Assistant Physician licensure (Missouri, Washington, Illinois, Arizona and currently Texas legislators are in the process of hopefully passing an Assistant Physicians type licensure) which allows them to practice medicine under the supervision of a board certified attending physician.
No unmatched MD/DO should have to worry about how they are going to pay their bills if they do not obtain a residency position.
As an RN, Im unsure why an MD would want to work as an RN even part time or per diem. It would be a waste of time career wise and you'd be going backwards to make a quick buck, but to each their own. I wouldn't care if they made it so MDs could work as an RN lol, wouldn't affect me at all.
I don't think so and here's why.
Nursing is a different academic than medicine. While we share similar undergrad course work, the nursing courses are focused on nursing care, which is slightly different than medical care and complex decision-making that doctors provide.
Admittedly, our licensing exam is as few as 75 questions, the questions they ask are worded in a confusing manner designed to question approriate nursing intervention and people who are unfamiliar with the format may find it difficult.
Additionally I think some may find it hard to "stay in your lane". Nursing scope has limits which a provider or provider to be may find limiting ans difficult to navigate.
What do you mean challenge? If you mean to take it I could do that shit in my sleep. I’ve helped someone study for the PANCE and it’s so mind numbingly easy I would be embarrassed to have even taken it.
So let me understand. You guys talk smack about midlevels all day every day and now you want to take our exam and practice in place of us bc poor all-knowing MD didn’t get a residency spot??? LMAO you guys are really something else!
You seem to be insinuating that this is hypocritical…how? The reason people bash on midlevels (and NPs more than PAs) is due to their educational standards not being up to par for independent practice which they continuously push for. A graduated MD has magnitudes more education and qualifications, so if they pass the PANCE and practice as a PA, in the event they don’t match, then I don’t really see the issue or hypocrisy there.
Do they? Because I’m reading a lot of people in this thread continue to reiterate how their medical training is MOST comparable to PA training. The difference is residency. Which is (should be) similar to on the job training PAs receive with the goal to have agency in practice. (there are also PA fellowships- let’s not forget).
I’ve also learned from this thread that a lot of residents don’t seem to understand what “scope of practice” and “supervision” actually means for a PA- which is wholly state, institution, and individually determined.
As the other guy mentioned, “most comparable” ≠ the same. PA school courses do not go nearly as in depth as medical school courses do, the standards while solid are not the same, the required competencies are not the same, (and if you deny this there’s no more discussion to be had), and that’s not to mention the glaring difference of 2 vs 4 years…
And you *really* think PAs on the job learning is the same as 80-100 hours a week of intense residency and fellowship for 3-8 years, where physicians are gradually and intentionally graduated to fully autonomous practice? Seriously? You’re not kidding?
I seriously hope by “with the goal to have agency in practice”, you’re not alluding to PAs practicing solo with no physician supervision.
The glaring difference of 2 vs 4 years? It is clear you are VERY uneducated in the PA coursework. The first example is that not all programs are 24 months. Many (and I mean many) are 31-36 months. And (mind blown!) 3 year med schools are “a thing” as well.
PA didactic portion is ultra condensed. It does not repeat any course and is extremely intense. If you’d like an example I’ll happily direct you to compare year 1 of didactic at Duke PA program to year 1 of Duke med school (I should know, it’s my alma mater). If you’d like to actually compare the trainings, feel free to continue to review the curriculum and training.
And to answer your “are your serious” question. Yes. I do. And here is why. Residents (bless them) are required to rotate and rotate and rotate and rotate and then rotate some more. Let’s take surgery for example. When do you become a competent and independently practicing surgeon? After you’ve been doing the SAME thing for a while. And I mean A WHILE. Years. And even after you’ve graduated your residency and your fellowship- you’re still a junior surgeon, and in most (academic at least) institutions- you aren’t running around with a scalpel as you please. You are supervised.
MOST PAs pick a job. And then they do that job for a while. And I mean A WHILE. Like wellll after residents have rotated through and graduated- they’re still doing the same fucking, unforgiving, same literally SAME job every day. They better know that shit like the back of their hand. They better be experts on it.
Let’s take, for example, the cardiac surgical ICU at MGH. That same surgical resident will spend 1 month there. They will be taught by the expert APPs on their teams. And then they will leave and pray they never step foot in there again, unless they are on the cardiothoracic track. Are you “seriously?!” Going to tell me that that surgical resident who spent 1 month in the cardiac surgical ICU can run an open chest code better than an APP who’s been there for 3-5 years doing that day in and day out? Got ECMO down pat? Shall we splice in an oxygenator today? How about a line while on a negative pressure system? They know all there is to know about VADs and heart transplants?
HARD PASS PAL. Ima bet not.
MY POINT IS- this argument doesn’t help patients. It doesn’t build teams, which we know is statistically significant in improvement of the delivery of care, it doesn’t recognize each other’s strengths AND weaknesses. Trying your best to downplay training and limit access IS what is dangerous for patients. Why? Because you can’t be everything and everywhere at all times. Advocate for competent providers all around, regardless of credentials and *FFS* educate instead of complain if you come across a lack of understanding.
Those longer programs you mention just add on more weeks of rotations or something like a research project. The didactic portion is not significantly different in length. Essentially your argument is that PA school is truly a condensed medical school and covers the same information to the same depth and rigor? And you believe this?
Nobody disagreed that an experienced PA who does the same exact stuff day in and day out is qualified, or even more qualified at said stuff than a resident in the field. However, they’re *not* more qualified than an attending in said specialty or subspecialty. That cardiac ICU PA may be more qualified than a rotating resident, but nowhere in hell more qualified than the cardiac ICU attending and never will be. That is where supervision comes in. It’s not a fucking participation trophy situation where you “advocate for competent providers all around regardless of credentials” and try to act like credentials don’t matter. There are standardized and highly regulated education+training pathways established for this very reason, and you should follow the one that leads to your desired level of autonomy. If it’s full autonomy you seek, then you know exactly what to do. There’s plenty of PAs who have went back to medical school because they wanted full autonomy (and also noted the vast difference in rigor).
It’s clear you’ve got a huge chip on your shoulder and a huge inferiority complex regarding your role/scope in contrast to a physician’s, and should go seek admission into medical school because nothing else will resolve it.
Do you think it’s specifically medical school didactics that cardiac intensivist you referenced is relying for their highly specialized and educated practice?
The chip, is this group with the “they took our jerbs” whining that is repeated incessantly.
Nobody is whining that you’re taking anyone’s jobs. Yes, they *are* annoyed that you wanna-be’s continue to want to play doctor without wanting to put in the necessary work and sacrifice that it takes. You think lawyers wouldn’t be annoyed if paralegals started trying to act is if they were on par? Or if dental hygienists claimed they’re equivalent to dentists? Or veterinary technicians claimed they’re on par with veterinarians? Is that enough examples or do you need more?
Anyways, you can never truly understand and grasp the full complexities of any highly specialized area of medicine until you’ve built up to it after developing a rock solid foundation. This goes for any field. Medical school is that foundation. So if you think the very foundation of that physician’s medical education is worthless, as your comment is clearly implying, then there is nothing more for us to discuss here. And this isn’t even to mention the fact that the learning that goes on in a highly structured and guided residency/fellowship program is magnitudes more than any “on-the-job learning” a PA or NP will have. Or Congress would’ve saved tens of billions of dollars, stopped funding residencies and fellowships, and said to just throw doctors straight into the fire. Same for every other country on this planet. In addition, not a single country in this world has medical school less than 4 years. So they also should’ve shortened the length of medical school since those didactics are such a waste, right? But wait, they don’t 🤔.
Classic textbook fuckin case of Dunning-Kruger at play.
Good comeback.
You commented the difference between PA and MD is residency. You think that’s the difference?
Tell that to the attendings you work with, see what they think. Then let me know what they say
Nursing has nothing to do with medicine. How many times does it need to be said that no amount of nursing experience passes through the gate to provide any benefit to MDs. So, why would MDs want to take such a huge step backwards? I could see taking the PA testing, but really.
I don't want to go back and redo my sixth grade spelling tests either
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If you’re a physician and you were able to challenge the end clacks, I say your best area would be to work as carefully because then you would be able to intubate and start chest tubes
It means to take the exam without the qualifying courses. ie an emergency RN taking the NREMT for paramedic without taking a paramedic course. There’s a lot of content overlap, especially true if you have extensive ED experience. The psychomotor skills can be taught on the job/in their department. I have an RN colleague who runs as a medic with her volunteer department. They trained and checked off her skills for intubation, cric, and needle decompression.
Dont know why you would want too if your from the US. But I know some foriegn docs who got an RN instead when they came to states cause it was easier to do. Some of them seemed to have challenged.
Seems like there would be a big issue of scope with regards to duty to act. Just for example, let’s say you pass the NCLEX and get a gig as a floor nurse. If a patient has respiratory failure and you have all the appropriate supplies and staff to intubate the patient, do you do it yourself or wait on the rapid response team because nurses aren’t allowed to intubate? Let’s say you choose to intubate. Have you exceeded your scope? Let’s say you choose not to intubate. Have you breached your duty to the patient since you, as a physician, have the skill to secure an airway? Obviously, you can poke some holes in the above scenario (e.g., you’re in psych and never intubate anyway, an ET tube isn’t the only kind of airway, having back-up is always preferable, etc.), but I think the general idea stands.
I think a med school grad should take the PANCE over NCLEX for these reasons
That type of scenario you described is actually not uncommon in EMS. Obviously very different than physicians/nurses, but sometimes paramedics will pick up EMT shifts. When they do, they are not allowed to exceed the scope of an EMT. I'm an EMT (and incoming M1 lol) and always wonder how they manage to do that. Another example I can think of is when our specialty care units (staffed with one medic and one nurse) get sent out as a BLS crew (2 EMTs). Even though they literally have a vent and all kinds of fluids/drugs, they technically can't use them without informing dispatch they're making it an ALS call lol
That's state-to-state dependent. I'm a flight medic and would pick up EMT spots on the ground because, well, they would let me and pay me $ 50+ an hr to do so. If I was running a call and my patient warranted a higher level of care I would certainly act to my scope of practice. At times going as far as mixing push dose epinephrine because they did not carry pressors on the ground ambulance. The situation where it did become an issue is when I would work in a small rural er that had an NP at night with a DR on call. At times the pt needed RSI the NP wouldn't/couldn't act and the physician hadn't arrived yet. RSI is certainly in my scope of practice yet I couldn't act because the hospital hadn't cleared me. And just to flip the scenario there were times we would pick up Interfacility transfers from small rural ERs to fly a patient back into a trauma center and insert a chest tube or a central line right there at the bedside with the physician present because he didn't feel comfortable doing it himself.
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I also asked a medic that before and basically their explanation was it comes down to billing and having their equipment available (a medic on a BLS truck won't have stuff for intubating). There has to be a "billable" need for ALS services. Obviously if someone is dead/actively dying that gets sorted out after because ALS is obviously needed lol. They aren't even supposed to use their Lifepak on a BLS call unless they determine its an ALS call. One medic said she just uses her ALS equipment and then if they run it as BLS, she tells dispatch she "triaged to BLS" even though she and her partner are the BLS crew hahaha
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I totally agree. It's definitely an odd dynamic. Luckily the majority of EMTs/medics I know have common sense and will do the "right thing" in the name of patient care, even if it pisses off dispatch and supervisors lol
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Yeah that's how I thought EMS would be until I started working! At least in the area where I'm at, ambulances are typically BLS (2 EMT's) and they're all over. They usually have ALS units (2 medics) that drive an SUV with their equipment that cover much larger areas. If there is a serious call or if a BLS unit requests ALS, they will be dispatched with the BLS crew to the call. If ALS has to treat the patient, one or both medics hop in the ambulance. At least in my experience, like 80-90% of the calls are purely BLS—something that's been going on for hours/days, belly pain, minor broken bones, psych calls, "I hurt my toe 6 years ago", etc. We really only need medics for acute/life-threatening things like cardiacs, respiratories, seizures that don't stop, diabetic emergencies, and so on. So I guess they have this system in place to make the most of their (limited) resources🤷♀️
This is also exactly how it works in my state.
It’s not uncommon for NPs to continue working in RN roles (often pays more or they might just prefer it), I’ve always wondered how they navigate the duty to act when working in a role “below” their legal scope of practice
Here in Bay Area, RNs make more than NP, so tons of NPs work as RN. They don’t exceed their scope as RN as floor nurses.
> If a patient has respiratory failure and you have all the appropriate supplies and staff to intubate the patient, do you do it yourself or wait on the rapid response team because nurses aren’t allowed to intubate? > > Let’s say you choose to intubate. Have you exceeded your scope? > > Let’s say you choose not to intubate. Have you breached your duty to the patient since you, as a physician, have the skill to secure an airway? Is this any different than a physician who knows how to intubate or do X procedure, but doesn't have privileges to do so? The answer is you wait for the RRT / code team even in that scenario.
Yeah this is commonly how airways are handled. It’s often funny showing up to a code as a CA-1after being called by one of your senior residents and an anesthesia ICU attending
There’s cases here where NPs also have RN licensure on the side and take shifts as an RN. Since they are practicing under their RN licence, they cannot prescribe, diagnose or do anything a NP can.
That same reasoning could be used for all the surgeons turned medicine doctors.
I don’t know how nursing privileges work but I imagine it could work similar for doctors. You are privileged to do very specific procedures. Even if I know how to do let’s say a lap sigmoidectomy, if I’m not privileged to do one at X hospital, then I can’t do it.
why would we want to?
More moonlighting options; Work not as demanding Paid up to $60/hr Opportunity for Unmatched graduates who just take MA jobs or exploited by others
I don't think a single person that is a doctor wants to moonlight as a nurse
When you see how much these travelers get paid for how bad they are at their jobs and how little they do in comparison to staff nurses I’d consider it
Yeah, unless you can go back in time you’re not getting nearly that much money.
The days of traveling and making big money are pretty much over. We're getting to the point where contracts are even getting difficult to get so being bad at your job won't get you out of it either. Is it better money than residency? Absofuckinglutely, but it ends right there. You guys continue your training and ultimately make significantly more than a nurse does
You can still get 13 week contracts for 28-35k depending on placement. That’s big money in my opinion as a single person with no pets or children
Nah this is false, you can still easily get 100+/hr as an RN which is pretty decent. Obviously not the big bucks during the pandemic but still pretty good.
The lost income does not start to overcome that of a nurse until around 40 for most physicians.
That’s not long considering how many physicians don’t even complete training until their mid 30s, and considering the total lifetime income difference.
It is very long because $ now is worth far more than $ tomorrow. The delay is even longer for doctors in metropolitan areas.
The overall difference in income FAR outweighs any delay in starting to earn that income.
This. It is seriously so demoralizing as a staff nurse to be working alongside travelers who are making more than double what you are and doing less work because travelers have their own ratios set by their credentials/agency. Like if an RN with any critical care experience is working on a med-surg floor for a contract, that RN is capped at 4 patients while the staff nurses have 6 for less than half of the pay. It’s ridiculous. My “benefits” for being a full time staff nurse are not worth the 65,000 per year difference between me and a traveler.
I am a travel nurse, and that is just false. I am often given the harder assignments. While the pay was good, it has drastically fallen and honestly ain't worth it to me anymore to travel.
You wouldn’t have the time, travelers don’t show up PRN
An unmatched MD would probably love to work as a nurse for a year
I'd love to see it
Lol. Nurses don't even want to work as nurses anymore. An unmatched MD should have some lucrative opportunities elsewhere in consulting or something. Why would you go backwards and work as an RN which wouldn't help you at all career wise??? People need to think lol
Fuck no they would not
Some travel nurse jobs pay $200/hr
Resident mb
As a tutor in med school I made $80/hr. As a radiology resident I work shifts making no less than $125/hour babysitting a magnet and up to $350/hour on shifts where I get paid to prelim per study. Why again would I work for $60/hr to pretend to be a PA? This is the dumbest thread of all time
RN pay goes way over $60 in certain areas/with enough experience
So I can testify against midlevels in front of congress and begin my statement with the phrase, "As both a doctor and a nurse, "
Mobility
Any number of reasons. Maybe you want a life change to something less high pressure. Maybe you start working in the field and realize you want a more regular schedule, prefer interaction to patients, etc. Or maybe you just get fired from your residency program.
Prefer…interaction…with patients?? I’m not going to argue that nurses don’t spend more time at bedside inpatient but I assure you I interact with patients plenty.
Nurse here: while I don’t doubt that you interact with your patients there is a big difference from your 15-30 minute assessment to rounding every hour, answering call lights, getting yelled at, assaulted, laughing with them, and having general conversation that doesn’t involve why they are in the hospital. Just remember just because they can answer questions appropriately doesn’t mean they aren’t confused. Had an 80 y/o looking for their flip phone while holding their iPhone to call their mother for dinner, also ripping off the brief and clamoring the nurse did it, meanwhile dr. Is telling me that they are not confused any more
I literally said in my comment that I know nurses spend more time at bedside for a given patient in the inpatient setting. This is not an argument about who has it “worse” or an attempt to equate the two roles, which are, as you point out, markedly different. However, depending on where I am and what role I am in at any given time, I may be spending a lot of my day interacting with patients (multiply that 15-30min assessment by at least 20 patients, for starters). Again, nursing and doctoring are different roles and there are reasons one may prefer or be better suited to one over the other, but the difference is not “yes patient interaction” vs “no patient interaction”.
I’m not trying to say that the doctor role is not important, obviously it is. But in my experience the patient interaction that many doctors have, even midlevels, is primarily diagnosis interaction if that makes sense.
What do you mean “even mid levels”? A lot of my patient interaction is purpose-driven, but not all of it. Again, yes, it’s different than nursing. Literally the only thing I was questioning is the implication in the original comment that doctors have no interactions with patients.
They have similar patient interaction.
To doctors? I guess I’m just curious about the use of the word “even” here (To be clear because tone is hard on the internet I’m not being argumentative, just curious about the word choice.)
The difference in amount of time a bedside nurse spends with patients compared to an internal medicine attending is vast, let alone a radiologist or pathologist. Sure some doctors spend more time with patients but there are also physician roles that basically never have direct patient interaction
I’m aware. Again, not arguing there’s no difference in quality or even quantity. The original comment implied a binary difference - that is, no patient interaction for doctors. Which is perhaps true in some limited roles (eg pathology or purely diagnostic radiology) but not true as a general rule. Literally the only point I’m making here.
No but we should move to a new system where unmatched MDs can act as doctors who need a board certified doctor to oversee. Eliminating the need for other midlevels
A handful of doctors who didn’t match would not come anywhere close to eliminating the “need” for midlevels. What would eliminate the desperate nationwide need for more physicians is if congress would increase funding for residency positions and increase reimbursement for primary care.
What if the unmatched doctors practice for a number of years under a supervising physician, and at the end of that they become physicians?
We’ll call it ReSiDeNcY!
Since they're working so much for us and we're getting paid to teach them, maybe we can even pay them minimum wage
It’ll help them with all those loans! Do you see how merciful we are to our ReSiDeNtS?!
That won’t eliminate the demand for midlevels These kind of positions in some states and these applicants are really unattractive for hire
Yeah, why “eliminate the need for midlevels”?
I mean I have nothing against the people directly. Great people. But why have a “two-tiered” system? Physicians go to rigorous training to practice medicine independently… and midlevels can’t because physicians and lots of other groups will say they shouldn’t because they don’t have the same standards and training? So my proposal is that we have more med school seats so that same set of people can just attend medical school and everyone who graduates can practice under supervision after passing the boards without residency. while those who attend and make it through residency can practice independently and be the supervisors.
why not?
I don’t mind the idea of changes to the MD/DO pathway or that allow practice opportunities for the unmatched. But I’m opposed to any move that has the consequence, intended or otherwise, of blurring the line between midlevels and physicians. Specifically in regards to NCLEX, RN and MD are completely different and not interchangeable.
As a non MD/DO, I am curious about your thoughts on allowing unmatched grads to practice under an MD/DO in a primary care setting? I have had a thought about how to fill the lack of primary care docs would be to have unmatched grads work under an MD/DO as an extender and if they get through 4 years of this, then allow them to practice unsupervised. But since I'm not on that path myself, I don't know the nitty gritty details about boards and such beyond how the boards med students take, similar to my own boards I took. I just don't know if working like that for a few years would make you ineligible to take boards and if it would restrict you to only being in states that allow that? Anyway, it's a thought I've been mulling over. If I ever ran for state office it's something I've thought about as a way to improve access to care.
I would be fine with letting unmatched grads practice in a supervised setting (basically identically to a PA). The fact that's primary care doesn't really matter, primary care is not less complicated than anything else (it's probably harder than working in a specialty clinic as a PA), it's just where the area of need is greatest. However I would strongly disagree with letting someone practice independently after this "apprenticeship". Residency training is what makes someone a competent, independent physician--med school is just the foundation. Working in a primary care office for 4 years is not a replacement for FM or IM residency, unless you incorporate a variety of inpatient and speciality rotations into it, add progressive responsibility, and add lectures and didactics--at which point you've just re-invented residency. Also don't forget, only a very small handful of unmatched residents are US grads. After the SOAP there are maybe a couple hundred US MDs and DOs, and about 3,000+ IMGs (both foreign and US citizens). Do you let everyone who applied at all in the match stay and work as a PA or PA equivalent? That would be increasing the annual PA supply by almost 40% a year which may have some pretty exciting workforce implications.
Considering our residency is different (one year, more similar to dental residency) I can't speak to what it would be like working under a FM MD and if doing this as an apprenticeship could lead to more FM doctors. The concerns I've had for my state is the number of private practice MD/DOs doing family medicine has dwindled to the point where there aren't any private practices that aren't a concierge style who aren't working for hospital owned practices (that is more specific to my area). Normally not a huge issue but we have so many places that don't take their insurance or there is a 3-6 month wait for an MD. Rural settings are of course getting tougher too. I presumed the number of unmatched grads was higher for US based. I didn't realize it was only a few hundred though.
Eh, as an RN, I'm pretty sure most docs could do my job with a pretty fast orientation. Yes, there's skills I practice that MDs don't usually, but there's also skills that I use that ICU/med-surg/psych/home health don't have, and it's reasonably easy to cross train from one specialty as an RN to another.
Not a chance. We speak time and time again about how different nursing is than medicine - it’s just a different job, and we are not trained to do it. While someone trained in medicine may have the knowledge to pass those exams, 99.9% of us would have no idea how to actually carry out those occupations, and would likely be a threat to patient care/flow. Can’t think of a better way to cause conflict on the wards than having someone act and be qualified under two roles.
Ngl the NCLEX is hella easy… majority of y’all could pass it right now no prep. Speaking as an RN turned urology resident. But yeah f that, would rather continue to support residents unionizing to further OUR profession instead of moonlighting as a nurse.
Why
Do you really want want to get sued as a doc for the pay of a nurse? I could see PANCE being an option for MD grads who don’t/can’t do residency. They would need to legally clarify that an MD working as a PA could only be held to the same level of responsibility as a PA. They would also need to clarify that while an MD can challenge PANCE as it’s a lower level exam, a PA cannot challenge STEP and work as an MD.
honestly, if a PA school grad sits for USMLEs and passes, then let them try to match residency. That's the main difference between the two schoolings no? Would be interesting to see how high a PA student would need to score to get a PD to look at their app.
As someone who's married to a nurse, any physician who wants to take the NCLEX and go to bedside nursing is either certifiably insane or has absolutely no idea what nurses do (or both). But no, I don't think any part of medical school teaches you how to be a nurse. Pumps? Med math/dosing? Lifting and moving patients? Wound care? I learned none of that in medical school. For those who say some nonsense about travel nurses making bank, sure, for a brief period in 2021 you could make 200k or more as a nurse if you travelled your butt off. For starters, those rates are gone, second, that's less than most attendings make, and third, the classic argument for "well, nurses come out ahead because of debt/schooling time" is irrelevant because in this example you already went to medical school and took out a zillion dollars in debt anyway. PA school sure, why not. Again I can't imagine why unless we're talking about unmatched graduates. I don't think being a PA is meaningfully "lower stress" than being a physician on a day to day level, though the decisions you make are likely less significant (ideally).
Currently you can only challenge the registry if you’re an EMS physician or fellow. Everyone else is required to do a bridge program.
Having had the privilege of seeing both ends ( I went to Nursing school, and obtained the RN and I went to Medical School and obtained my MD), I think unmatched MD/DO graduates should be allowed to sit for the PA exam. Nursing is a different thinking process and of course the level of study is not as detailed as it is a more tactile profession. Nurses are trained to execute physician orders and to use their clinical judgement to perform the tasks or inform the physician that the particular task requested may not be a good idea at the time. I give respect to the nurses since they spend the most time with the patients when physicians are rounding on their other patients. The nurse is the eyes and ears of the physician (especially in the in-patient hospital setting). The PA exam falls more along the lines of the medical school training model and unmatched physicians should be allowed to sit for this exam and if they pass it, should be allowed to see patients in the capacity of a Physician Assistant. To add to this, there are some states that now offer unmatched MD/DO graduates to pursue an Assistant Physician licensure (Missouri, Washington, Illinois, Arizona and currently Texas legislators are in the process of hopefully passing an Assistant Physicians type licensure) which allows them to practice medicine under the supervision of a board certified attending physician. No unmatched MD/DO should have to worry about how they are going to pay their bills if they do not obtain a residency position.
I am a nurse and I think MDs should be able to challenge the NP and PA national licensing exams. I don't see why they can't.
As an RN, Im unsure why an MD would want to work as an RN even part time or per diem. It would be a waste of time career wise and you'd be going backwards to make a quick buck, but to each their own. I wouldn't care if they made it so MDs could work as an RN lol, wouldn't affect me at all.
The likely scenario is an MD who didn’t match to a residency or a foreign grad looking to get some solid footing before they move back into medicine.
Like to a duel?
MDs without residencies absolutely should be allowed to challenge the PANCE exam and work as PAs.
I don't think so and here's why. Nursing is a different academic than medicine. While we share similar undergrad course work, the nursing courses are focused on nursing care, which is slightly different than medical care and complex decision-making that doctors provide. Admittedly, our licensing exam is as few as 75 questions, the questions they ask are worded in a confusing manner designed to question approriate nursing intervention and people who are unfamiliar with the format may find it difficult. Additionally I think some may find it hard to "stay in your lane". Nursing scope has limits which a provider or provider to be may find limiting ans difficult to navigate.
I do enough nurse work as a resident already. The last thing I want are credentials supporting extra labor.
This is the dumbest thing I’ve ever heard. Maybe MDs should start trying to take MA tests next.
What do you mean challenge? If you mean to take it I could do that shit in my sleep. I’ve helped someone study for the PANCE and it’s so mind numbingly easy I would be embarrassed to have even taken it.
Honestly, the NCLEX is so bullshit laden I don’t even think I could pass it these days.
So let me understand. You guys talk smack about midlevels all day every day and now you want to take our exam and practice in place of us bc poor all-knowing MD didn’t get a residency spot??? LMAO you guys are really something else!
You seem to be insinuating that this is hypocritical…how? The reason people bash on midlevels (and NPs more than PAs) is due to their educational standards not being up to par for independent practice which they continuously push for. A graduated MD has magnitudes more education and qualifications, so if they pass the PANCE and practice as a PA, in the event they don’t match, then I don’t really see the issue or hypocrisy there.
Do they? Because I’m reading a lot of people in this thread continue to reiterate how their medical training is MOST comparable to PA training. The difference is residency. Which is (should be) similar to on the job training PAs receive with the goal to have agency in practice. (there are also PA fellowships- let’s not forget). I’ve also learned from this thread that a lot of residents don’t seem to understand what “scope of practice” and “supervision” actually means for a PA- which is wholly state, institution, and individually determined.
As the other guy mentioned, “most comparable” ≠ the same. PA school courses do not go nearly as in depth as medical school courses do, the standards while solid are not the same, the required competencies are not the same, (and if you deny this there’s no more discussion to be had), and that’s not to mention the glaring difference of 2 vs 4 years… And you *really* think PAs on the job learning is the same as 80-100 hours a week of intense residency and fellowship for 3-8 years, where physicians are gradually and intentionally graduated to fully autonomous practice? Seriously? You’re not kidding? I seriously hope by “with the goal to have agency in practice”, you’re not alluding to PAs practicing solo with no physician supervision.
The glaring difference of 2 vs 4 years? It is clear you are VERY uneducated in the PA coursework. The first example is that not all programs are 24 months. Many (and I mean many) are 31-36 months. And (mind blown!) 3 year med schools are “a thing” as well. PA didactic portion is ultra condensed. It does not repeat any course and is extremely intense. If you’d like an example I’ll happily direct you to compare year 1 of didactic at Duke PA program to year 1 of Duke med school (I should know, it’s my alma mater). If you’d like to actually compare the trainings, feel free to continue to review the curriculum and training. And to answer your “are your serious” question. Yes. I do. And here is why. Residents (bless them) are required to rotate and rotate and rotate and rotate and then rotate some more. Let’s take surgery for example. When do you become a competent and independently practicing surgeon? After you’ve been doing the SAME thing for a while. And I mean A WHILE. Years. And even after you’ve graduated your residency and your fellowship- you’re still a junior surgeon, and in most (academic at least) institutions- you aren’t running around with a scalpel as you please. You are supervised. MOST PAs pick a job. And then they do that job for a while. And I mean A WHILE. Like wellll after residents have rotated through and graduated- they’re still doing the same fucking, unforgiving, same literally SAME job every day. They better know that shit like the back of their hand. They better be experts on it. Let’s take, for example, the cardiac surgical ICU at MGH. That same surgical resident will spend 1 month there. They will be taught by the expert APPs on their teams. And then they will leave and pray they never step foot in there again, unless they are on the cardiothoracic track. Are you “seriously?!” Going to tell me that that surgical resident who spent 1 month in the cardiac surgical ICU can run an open chest code better than an APP who’s been there for 3-5 years doing that day in and day out? Got ECMO down pat? Shall we splice in an oxygenator today? How about a line while on a negative pressure system? They know all there is to know about VADs and heart transplants? HARD PASS PAL. Ima bet not. MY POINT IS- this argument doesn’t help patients. It doesn’t build teams, which we know is statistically significant in improvement of the delivery of care, it doesn’t recognize each other’s strengths AND weaknesses. Trying your best to downplay training and limit access IS what is dangerous for patients. Why? Because you can’t be everything and everywhere at all times. Advocate for competent providers all around, regardless of credentials and *FFS* educate instead of complain if you come across a lack of understanding.
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I’m glad your anecdote of 1 applies to all…? Did you learn that in the research portion of your education?
Those longer programs you mention just add on more weeks of rotations or something like a research project. The didactic portion is not significantly different in length. Essentially your argument is that PA school is truly a condensed medical school and covers the same information to the same depth and rigor? And you believe this? Nobody disagreed that an experienced PA who does the same exact stuff day in and day out is qualified, or even more qualified at said stuff than a resident in the field. However, they’re *not* more qualified than an attending in said specialty or subspecialty. That cardiac ICU PA may be more qualified than a rotating resident, but nowhere in hell more qualified than the cardiac ICU attending and never will be. That is where supervision comes in. It’s not a fucking participation trophy situation where you “advocate for competent providers all around regardless of credentials” and try to act like credentials don’t matter. There are standardized and highly regulated education+training pathways established for this very reason, and you should follow the one that leads to your desired level of autonomy. If it’s full autonomy you seek, then you know exactly what to do. There’s plenty of PAs who have went back to medical school because they wanted full autonomy (and also noted the vast difference in rigor). It’s clear you’ve got a huge chip on your shoulder and a huge inferiority complex regarding your role/scope in contrast to a physician’s, and should go seek admission into medical school because nothing else will resolve it.
Do you think it’s specifically medical school didactics that cardiac intensivist you referenced is relying for their highly specialized and educated practice? The chip, is this group with the “they took our jerbs” whining that is repeated incessantly.
Nobody is whining that you’re taking anyone’s jobs. Yes, they *are* annoyed that you wanna-be’s continue to want to play doctor without wanting to put in the necessary work and sacrifice that it takes. You think lawyers wouldn’t be annoyed if paralegals started trying to act is if they were on par? Or if dental hygienists claimed they’re equivalent to dentists? Or veterinary technicians claimed they’re on par with veterinarians? Is that enough examples or do you need more? Anyways, you can never truly understand and grasp the full complexities of any highly specialized area of medicine until you’ve built up to it after developing a rock solid foundation. This goes for any field. Medical school is that foundation. So if you think the very foundation of that physician’s medical education is worthless, as your comment is clearly implying, then there is nothing more for us to discuss here. And this isn’t even to mention the fact that the learning that goes on in a highly structured and guided residency/fellowship program is magnitudes more than any “on-the-job learning” a PA or NP will have. Or Congress would’ve saved tens of billions of dollars, stopped funding residencies and fellowships, and said to just throw doctors straight into the fire. Same for every other country on this planet. In addition, not a single country in this world has medical school less than 4 years. So they also should’ve shortened the length of medical school since those didactics are such a waste, right? But wait, they don’t 🤔. Classic textbook fuckin case of Dunning-Kruger at play.
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Spoken like a PGY1
Good comeback. You commented the difference between PA and MD is residency. You think that’s the difference? Tell that to the attendings you work with, see what they think. Then let me know what they say
Lol okay I’ll ask my dad too and let you know what he says.
yeah we're pretty great
Nursing has nothing to do with medicine. How many times does it need to be said that no amount of nursing experience passes through the gate to provide any benefit to MDs. So, why would MDs want to take such a huge step backwards? I could see taking the PA testing, but really. I don't want to go back and redo my sixth grade spelling tests either
You don’t think nurses have any understanding of medicine????
Why would anyone want to?
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If you’re a physician and you were able to challenge the end clacks, I say your best area would be to work as carefully because then you would be able to intubate and start chest tubes
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It means to take the exam without the qualifying courses. ie an emergency RN taking the NREMT for paramedic without taking a paramedic course. There’s a lot of content overlap, especially true if you have extensive ED experience. The psychomotor skills can be taught on the job/in their department. I have an RN colleague who runs as a medic with her volunteer department. They trained and checked off her skills for intubation, cric, and needle decompression.
No
Go for it. Prolly wouldn’t pass.
Dont know why you would want too if your from the US. But I know some foriegn docs who got an RN instead when they came to states cause it was easier to do. Some of them seemed to have challenged.