The world of medicine is like a bubble. A lot of people THINK they know what goes on there, but unless you're down in the trenches it's unlikely you do. So here is my semi-anonymous blog, here to tell you what really goes on in the life of a medical resident.

Tuesday, January 09, 2007

Knock, knock... who's there?

Who is staffing our emergency rooms these days? Around these parts, it's a hot topic. When I first moved to this town to start my residency training in emergency medicine, one of the teaching hospitals affiliated with the university had undergone a pretty dramatic upheaval. For some reason not fully understood, the hospital emergency room was being staffed by Med-Emerg, a medical staffing agency. Basically, they take over responsibility for staffing the emergency room. This was significant as it required pulling all residents out of this hospital, as Med-Emerg staff were not affiliated with the university and therefore not able to teach residents. Word around the Valium fountain in the Emergency Department was that they staffed ED's with fresh grads, most of whom didn't have any emerg training. Family doctors who got paid handsomely to drop in and staff a shift with no commitment to the hospital or the community. I'm not entirely sure why docs affiliated with this agency are instantly deemed inferior, but it definitely had an impact on the residency training in our academic centre. After the Med-Emerg one year contract with the hospital expired, the hospital was again staffed by university-affiliated staff docs. And now, residents are back in the ED there.

The Med-Emerg solution is costly, but probably better than the other alternative to EDs facing severe staffing shortages. Another ED in the region facing closure due to staff shortages managed to stay open by recruiting a CCFP-EM resident (a resident who has finished training in family medicine and is currently doing an additional year of training to specialize in emergency medicine) to cover its weekend shifts. This was widely reported in the news at the time, trumpeted as a 'partnership' between medical academia and the government to meed the regions needs.

Crazy. This wasn't a success! This was a clear failure of the system. The ED had to reach into the pool of medical trainees for staff-- while I'm impressed that the resident in question had the cojones to work without backup in a busy emergency department just two months after finishing her family medicine residency, I wouldn't have felt comfortable in that situation. Why would I be doing a third year in emergency medicine if I could just walk into an ED with nothing but my family medicine certification and an 'interest' in emergency medicine and work without concern?

This is likely to happen more and more often in a system where supply is clearly falling short of meeting demand. In Canada, there are 27 spots in FRCP Emergency Medicine each year. Twenty-seven. For ALL of CANADA. The year I matched there were about 75 applicants for these positions. Granted, these are the spots intended for academic positions in emergency medicine, but it still seems like a ridiculously small number. In the stream that I'm in, the CCFP-EM program, there are about 6 spots for each academic centre. In spite of that, there is still considerable competition for these training spots. So my point is that the lack of qualified staff to man emergency departments is certainly not from lack of interest on behalf of residents.

Now things seem to be going one step further. Out east, one politician believes that the solution lies in staffing emergency departments with nurse practitioners and paramedics. I'm not sure how, in the words of Kevin, M.D., NP + paramedic = ER doc. Paramedics are not trained in any way to diagnose disease. The paramedics scope of practice pretty much ends at assessment. Treatment is only given insofar as it fits into one of numerous protocols set forth by the BLS Manual. Advanced Care Paramedics do have an extended scope of practice, but again are not trained to diagnose disease. I do not understand the role that they are intended to play in replacing physicians at the helm of the emergency department.

I'm not putting doctors on a pedestal here. In fact, I've never really understood the difference between a primary care nurse practitioner and a primary care physician. Both may assess and examine the patient, both may order diagnostic tests, both may diagnose disease, both may prescribe and/or administer treatment. So if nurses can do all this, why have primary care physicians at all? What can they do that NP's can't?

My exposure to NP's has been restricted to academic centres. I've worked with them in the dialysis unit, in the NICU and in the PICU. Their role in those places seems to be similar to that of the Physician Assistant in the U.S. (we don't have PA's in Canada)-- but they work as members of a team, not independently from the physician. So you can understand my confusion when it comes to the role of NP's practicing independently in the community. I know this happens in remote places, but I've never had first-hand experience.

When I think about it, though, it's kind of frustrating for the primary care physician. NP's are trained in just 12 months (if they hold a university B.Sc.N) or 24 months (if they held a college nursing RN) according to this journal article. It's no wonder doctors are worried. Compare that to the university degree (4 years), medical school (4 years) and residency (2 years minimum) completed by a primary care physician and it's easy to understand why there might be resistance to declaring the two equivalent. If a NP can do a family doctor's job, why would a wanna-be family doctor bother doing medical school at all? Not when the same end may be accomplished with half the years of training and a fraction of the debt load.

Seems like a shortsighted solution to the physician staffing problem.



Anonymous Andy said...

But what alternative is there?

12:02 AM

Blogger DrShroom said...

Interesting to see the same solutions being thrown up all over. In the UK, the Government has very much the same idea. Emergency Physicians are letting them get away with it, too, mostly by relinquishing their interest in 'minors' - which make up around 60% of the case load - in favour of the more acute medical emergencies. My experience of specialist nurse practitioners is that their training, and so their perspective, is very narrow. They lack the broader scope that a doctor brings to a diagnostic problem. While they may be a cheap alternative to doctors, they certainly aren't an equivalent.

5:27 AM

Anonymous Anonymous said...

At my doctor's office, there are 3 FPs and 4 NPs. You can request to see your doc instead of an NP but I have a feeling they'd rather you see an NP most of the time, especially for annual physicals and stuff like that. I'm always worried that by requesting to see a doc instead, that I'm being a nuisance. Do FPs not want to see patients anymore for minor things? Finding out that NPs only train for 24 extra months is making me even more leary of replacing my FP with an NP.

8:23 AM

Blogger Couz said...

That's just how it works in Ontario-- I really have no idea how it works in the rest of Canada, let alone in the U.S.

If it makes you feel any better, nurses require a certain number of years experience before they do their NP training.

9:40 AM

Anonymous Anonymous said...

So really then, what is the difference between the two? If family doctors want to use NPs for the routine and minor stuff, won't they lose a good chunk of their clients? (Mybe that's the aim hehe) Isn't family medicine generally more of the routine, minor stuff and then if patients have a serious problem they see a different specialist?

Is it because the reimbursement for doing the routine and more minor stuff sucks and isn't worth the FPs time anymore?

3:30 PM

Blogger Patient Anonymous said...

anonymous, I don't know how things work in your clinic. I find it interesting that you do actually have a choice, however. I know someone who can't even find a FP so he and his family see a NP. They are quite happy with the choice.

We have major doctor shortages in this country within FP medicine.

In my opinion, yes, ideally if you are having more *complicated* issues, your FP physician should refer you to a specialist but that is not always the case. I have had problems in the past with getting referrals as my ex-FP wanted to treat me for all of my issues.

Not a good sign.

As far as the billing and division of labour? That's between the parties that work in the clinic?

couz: Glad to have found your blog. We were both "Grand Rounder's" from the last series. I think I'm going to blogroll you...I need more Can-Con haha. Come to think of it, I don't have any so you'll be my first!

Nice to meet you.

4:26 PM

Anonymous Jen said...

Here's a website with up-to-date info: (Cdn Nurse Practitioner initiative).

I know it's your blog, but please don't continue the nurse = doctor wanna be stereotype, NP or not.


8:29 PM

Anonymous Anonymous said...

Patient anonymous - I didn't mean to give you the impression that I wanted detailed billing info from my clinic...I was simply wondering if the low rate of reimbursement could be a factor, which kind of is a public issue since it's our health care system that's suffering.

Jen - whenever I have had an NP for my appointments, the quality has been exceptional, so I don't want to give the impression that I don't think NPs are qualified. It's just that every other year or so I feel like I should see my doctor. Afterall, they've had at least a decade of schooling and that's what they're there for.

11:06 AM

Blogger Couz said...

Why would I think that an NP is a 'wannabe doc'? All I want to know is what the differences are in the scope of practice between a family doc and a NP.

4:37 PM

Blogger Patient Anonymous said...

Hi anonymous: I apologize for misintrepreting. Sometimes I take things in a very literal sense.

If (I think) what you are suggesting is that FPs are "handing off" lower billed procedures to NPs simply because they want the higher billed items for themselves then I would certainly hope not! And if I were the NP in that circumstance I certainly wouldn't want to work there!

I would *assume* (but you know what happens when you do that: ass, u, me) that under "normal" circumstances the doctors do what they are allowed to do and bill appropriately and the NPs do the same. I don't know exactly what specifically a FP can do that a NP can not do.

But I am neither a physician, nor a NP and I may be misinterpreting what you are saying again so I may be really making a mess of this comment section. Apologies to couz if that is the case.

Maybe we(I?) need a NP in here to help out?

Leaving before I say more to confuse the issue...

4:44 PM

Anonymous Jen said...

Sorry Couz, I totally mis-read this portion yesterday:

"...why would a wanna-be family doctor bother doing medical school at all? Not when the same end may be accomplished with half the years of training... "

That and being sensitive to the feedback I heard in clinical just yesterday: "You are so smart, why are you not in med school?" Er, do you not want smart nurses (yes, preferably ones that can read blogs properly... >>blush<<)

Anyways, the FAQ's at that website still address your question re: scope of practice.


4:45 PM

Blogger Couz said...

Jen: On the other side of the fence, family med residents get "But you're so smart? Why would you want to waste that in family medicine?"

I shit you not.

4:52 PM

Blogger Patient Anonymous said...

couz: That's extremely distressing. No wonder it's so hard to find a good FP? Ouch.

7:35 PM

Anonymous Anonymous said...

I'm don't know what it's like in Canada but as far as U.S.-trained NP's go, you all are grossly misinformed. A nurse practitioner in the U.S. has to have a Bachelor of Science in Nursing (4 year degree) and then must obtain a Master's Degree (two years +) with over 800 clinical hours in the case of my program. NP's are highly trained,competent professionals. Multiple studies, including one in JAMA have demonstrated that NP's provide equal or superior care to physicians. No, NP's are not and do not want to be physicians.. Unless they are specialists, they do not treat patients with unusual or very complicated illnesses.

3:12 PM

Anonymous Anonymous said...

Hello, I have been a PA for several years and have worked both in IM/FP and EM. Let me tell you from my perspective, that being a PA sucks. You get little respect from the doctors and they patients are angry that they are not seeing the doctor. Don't get me wrong, I have been very lucky were I have worked (actually running the ER in the absence of the attending---not that I agree with that, and haveing a patient following that follows me where ever I work). However, job security is yet to be foumd. Here in NY it is not uncommon to have 5 obs in 5 years. Trust me if I new then what I know now I would have taken the MD/DO route. Now I am thinking of going back to the ER, for what maybe some security that I can provide my family.

8:07 PM

Blogger klassenk said...


You counted up the years of education for a doc wrong. The 4 years of undergrad are NOT related to medicine. So in reality, you get
4 years NURSING school, 1-2 years Nurse Practitioner school = NP

4 years MEDICAL school, 2 years family medicine residency = MD(CCFP)

Now, the medical education is obviously much more broad and demanding than nursing, but really, the differences aren't that great. When it comes down to it, an NP will be able to handle 95% of the stuff an FP will be able to cover. The bulk of that comes down to experience, in my opinion. The remaining 5% are unfortuante, but I'm guessing NPs have a physician they can consult with?

4:42 PM

Anonymous Anonymous said...

FP and NP's prolly don't differ much. In med school, you can choose to specalize (dermatology being the most coveted) or you can be a FP...BOOOO. Almost no one wants to be an FP. There is an extreme shortage of FP's. Many schools will pay your way through med school if you would just be an FP... They don't want to be FP's you can't make 'em, they won't do it. HOWEVER, MD's can perform surgery, stitch ppl up, etc. Nurses at any level will prolly NEVER be able to cut anybody. That is strictly reserved for Doc's. That's the difference. an MD can be a neurosurgen, GI surgen, plastic surgen, cardiac...etc etc. Get it?! Nurses have always basically done the same things as doc's outside of the OR. Insurance companies are just catching on because it's cheaper, and half the doctors don't care because they wanna do the superstar stuff and cut you. They don't give a crap about curing your yeast infection.

BTW nurses are just as educated. As already stated, and as a nursing student, let me tell you, I've had Medical student's laugh at me because I was required to take classes that they didn't have to. Most younger doc's understand that our education is very similar. And they give us that respect. Anyways we're all looking at the same patient charting on the same disease, after a while you kind of know what strep throat looks like... you know what I mean?

5:46 PM

Anonymous Anonymous said...

I am in the U.S. and my first experience with seeing an NP instead of a doctor was at the large university research hospital where I was treated and am followed at the cancer center for Stage III melanoma.

For initial work up I saw the NP, resident doc, patient counselor, and the surgical ONC who is my primary doc in terms of the cancer. After my sentinel node biopsy and following lymph node dissection, I saw the surgical ONC for the first post ops. Since then when the ONC has done minor surgery, I see the NP for wound check.

For routine follow-up, it alternates between the NP and ONC. When I needed pain meds after initial recovery due to nerve issue (groin dissection), the NP wrote the scripts. The advantage to my NP appointments is I only see the admitting nurse and the NP. When I see the ONC, I often see the admitting nurse, NP, a resident doc, and by the time the ONC comes in, if the others haven't told him what I said, he's out of luck because I'm weary and don't say as much. Hmmmmmm, maybe that's the whole point. Just kidding, sort of.

10:43 PM

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