Monday, January 29, 2007

Medical Licensing: Quackery, Financing, and Mixed Market Economics - Part II: The Midlevel Proliferation

As I mentioned in my last post, quality has become the major reason for the preservation of medical licensing. According to this logic, we have placed a medical license at the end of a nine year slog of servitude that exists in order to ensure the quality of the providers. However, physicians are not the only providers. Ignoring everything from chiropracters to naturopaths, who all have their own alphabet soup of practice scopes and licensing authorities, I am going to focus on midlevels. The same thing can be said about many of these other practicioners that I will say about midlevels, but they are the model that proves the point most effectively.

I am going to preface this by saying that I am NOT anti-midlevel. On the contrary, I believe that midlevels may end up being part of the solution to affordable healthcare in some places. However, their existance proves a point.

There is no longer a mandatory nine year training period in pursuit of a medical license. A physicians assistant (PA) can be trained in just three. A nurse practicioner (NP) can also be trained in just three. Variations in state law place these practicioners in positions varying from bound service to MD or DO practicioners to virtual independent practice. Unlike those who seek the traditional medical degree, NPs and PAs are supposed to "learn on the job." This is the understood function of their license.

Anyone who works with these practicioners can tell you that there is VAST variation in both knowledge and skill. There are some midlevels that have advanced to a position where they are perfectly capable (and comfortable) with independent practice in a certain field of medicine. Others are not. New PAs and NPs have spent fewer hours in a hospital than a fourth year medical student.

So what is my point? Getting a license as a midlevel DOES NOT even pretend to imply competence. This doesn't mean that all midlevels are incompetent. In fact, the license means nothing at all, save for the completion of some classroom and clinical work that the same governments and licensing authorities said was inadequate for the granting of a medical license. Some midlevels will then learn with the license and become competent, and some will not. Some will learn to a level where they can operate only under supervision, and some will learn to a point where they can operate alone in many cases. The license is nothing but a tax. Of course, tuition at PA and MSN programs has soared in recent years, as the gatekeepers to the licensing monopoly have gained power to stand between the PA or NP and the clinical training that is supposed to make them competent "on the job."

Recent proposals in government for containing healthcare costs have included expanded practice rights for midlevels in states from Ohio to California. These governments are creating a dual system, in which the two different medical licenses with vastly different training requirements are progressively leading to similar scopes of practice. These governments are giving up the "quality" mandate in exchange for cheaper service. If the government can do this, why can't private individuals choose to do the same thing? If preparation for independent practice isn't a requirement for a medical license, should a license exist at all?

Stay tuned for part III


Anonymous Anonymous said...

Not sure where you learned that it only takes 3 years to be an NP.
These days, it takes first a BSN and RN licensure followed by a MSN and NP program. So at least 6 years of education.
Historically NPs were RNs who had many years of experience. Unfortunately, now many programs are accepting young/inexperienced RNs into NP programs. It may be the downfall of the profession.

My own path was quite circuitous - was a dietitian and did a year of clinical internship at MCV in dietetics. Then worked for 5 years as an RD in a couple hospitals and dialysis units. Went back for my BSN/RN. Worked for 7 years as an MICU, then cathlab/EP lab RN in a large tertiary care med ctr. Then completed an acute care cardiac NP program.
As a "new" NP I had a whole lot more clinical knowledge than a new medicine intern given my background in the trenches.
But, just as an intern learns on the job, so does an NP.
At the present time I know my limitations and practice within them. But I have seen many an NP who did not recognize their limitations.


1:23 AM  
Blogger MiamiMed said...

Thanks for your reply,

I based my three years statement on the program my wife considered enrolling in. I've always argued that anyone should be able to practice to his capability, regardless of licensing. My only point was that there is a vast difference in training amongst midlevels, and the varying standards create a very heterogenous product. You sound as though you have done a lot, and I'm sure that you are good at what you do. I would be the last person to say that you shouldn't have every right to do it.

I am utterly opposed to government protection. At the end of the day, our work should speak for itself. I chose to seek a medical degree in order to have the background and skill to perform my work well. I do not look down on those who choose a different path. Best of luck in your endeavors.

2:27 PM  

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