Where does medicine begin and where does it end?

[chbare]

Good evening, I suspect this will be a controversial topic, and people may develop hurt feelings or revert to an us versus them mentality. However, this is not my intent. With all of the talk about improved education, where exactly does the role of physician begin and end?

As many are aware, the new doctor nurse practitioner is causing a stir among both the medical and nursing community. A thread on a nursing site I frequent disappeared before I felt we could have any type of intelligent conversation on the topic of midlevel providers and how this relates to practicing medicine and the bigger health care picture.

In EMS we often argue about diagnosis and the line that exists between a health care provider and a physician. It seems this line is becoming quite blurry and much confusion and drawing of lines in the sand appears to be occurring.

I would like to see if any type of intelligent productive conversation can occur on this topic as many people have discussed the future possibility of EMS providers who provide midlevel type care.

Obviously, I find this topic quite interesting because of my nursing background. However, I will make my stance quite clear: I do not think there is any way to get around or replace the intense amount of education and experience physicians receive. In addition, the exact role of midlevel providers is something that confuses me, specifically NP's who technically provide "advanced nursing," is even more confusing in light of this DNP concept.

Hopefully, people will see I have no agenda other than productive and thoughtful conversation. In light of my nursing background, I remain absolutely supportive of the bottom line. That being, the delivery of effective patient care. Therefore, I am not poised to take anything personally and hope to gain an appreciation for other people's views. Especially the midlevel clinicians and physicians who frequent this site.

While not directly related to EMS specifically, perhaps we all could learn from this conversation. I hope for the best and understand that this could turn ugly. If the later occurs, I will apologize in advance.

Take care,

chbare.

[itku2er]

I can only speak from my expirence here Ch but honestly here in my area the NP's are 100 times better than the MD themselves. They are more apt to find out what is wrong with you by your signs and symptoms than the MD is. But of course most of the Docs here came over on the ark with Noah. Some aren't really up to date on the newest trends they have the "Well I have been a Doctor for years" mentality. But I think Doctors like every other profession if you dont continue your education you can't stay up to date and be effective in the long run to your patients.

[ERDoc]

Good topic ch. I would like to address a few things in your post. First, I do feel that EMS providers are making a diagnosis, at least a very basic one. You cannot treat someone if you do not have an idea what is going on. Do you have the equipment to confirm the diagnosis? No, of course not, but that doesn't mean you don't have the tools to form a differential and to aim your treatment at the most likely suspect. There will be times when the clinical picture is not clear and you will hold on giving a certain treatment, but this happens in the hospital too and is resolved by performing tests which help make the picture clearer (sometimes). To say the prehospital providers don't make a diagnosis is just silly.

You asked about EMS providers being midlevel care. As you can see from some of my recent posts, I feel that prehospital care should be a midlevel level of care. There are so many calls that could be taken care of in the field by people with the proper education. This could ease a large burden on the ER so that the sickest of the pts could get more attention. There would be drawbacks to this however. I can see an abuse of the system develop that would be even worse than it is now. I don't have all of the answers, but I'm sure there is a way to work things out for the better.

As for the DNPs, I have no problem with the idea behind them but it is the practical application that I have many problems with. I think having independent practitions who would be willing to serve the underserved would be a welcomed idea. Look through the cirriculum of most of the programs and you see very little in the way of pathophysiology/pharmacology/medical care. Most of these can be completed online (do you want a doctor who has gotten their degree online to take care of you?). I have many other concerns but I think the discussion can be found here on SDN. There are egos of both sides of the arguement but if you wade through the facts you get a good idea of the concerns.

[RatPack]

Mid level providers dont practice medicine.

EMTs dont practice medicine and assuming a paramedic does is quite a stretch. To practice medicine one needs to be self sufficient. The diagnose starts and ends with you, their is no oversight.

We are technicians, extensions of the ones who truly practice medicine. Why does everyone have such a problem with that? Requiring a bachelors or associates degree will not changes this fact. Yes we will have more true education which I believe is necessary, it however is not going to change our role. We are pre-hospital providers. We provide treatment and transportation. Nothing besides a medical degree should change that.

[ERDoc]

Mid level providers dont practice medicine.

EMTs dont practice medicine and assuming a paramedic does is quite a stretch. To practice medicine one needs to be self sufficient. The diagnose starts and ends with you, their is no oversight.

We are technicians, extensions of the ones who truly practice medicine. Why does everyone have such a problem with that? Requiring a bachelors or associates degree will not changes this fact. Yes we will have more true education which I believe is necessary, it however is not going to change our role. We are pre-hospital providers. We provide treatment and transportation. Nothing besides a medical degree should change that.

I have to respectfully disagree with you Rat. The midlevels (mostly PAs) I work with practice medicine. Sure, I have to sign off on the charts and I am the one that is ultimately responsible but they work pretty independently. The only caveat is that they have to present the pt before they are discharged. There are very few times that I would do something differently. You don't need to be a doctor to make a diagnosis. Nurses do it all the time. Like I said before, in order to give a drug, you have to make a diagnosis, otherwise, how do you know what drug to give. If you look at a monitor and say, "Hey, that's SVT." You have just made the diganosis. You can now give the proper medication to treat the problem. Can you look at an ankle and (in most cases) say, "That ankle is broken."? No, and neither can I. We can both say, "It's either broken or sprained." We have developed a differential diagnosis. I just happen to have the equipment to narrow down the differential.

There are plenty of medical issues that don't require an MD/DO and can be treated by someone who is properly educated. The example I keep using is a laceration. This can be treated in the field and does not need a physician. There are some hospitals that has a nurse who takes care of the laceration. The education part is knowing when the laceration is not just a simple laceration and needs to be taken to the hospital. Another example would be strep throat or ear infections. These people could be evaluated and treated by someone in the field with no physician input.

[tniuqs]

Conceptually a great idea (midlevel Dx and Treatment)

The Government in Alberta believes that this will take the strain out of system, the end all and be all, but without very clear guidelines this could be akin to opening a Pandoras box.

Motivation for the Independant Practitioner so what is the reward system, as one has to have incentive to take on more resposibility just why should I take on more responsibility and cost of independant malpractice insurance ?

In some remote deployments "off shore" this concept is old hat, and the London Service and the NHS has had a lot of positive success.

That Said:

Implimentation in the US with Ambulance chasing Lawyers ... hmm?

cheers interesting topic.

There are plenty of medical issues that don't require an MD/DO and can be treated by someone who is properly educated. The example I keep using is a laceration. This can be treated in the field and does not need a physician. There are some hospitals that has a nurse who takes care of the laceration. The education part is knowing when the laceration is not just a simple laceration and needs to be taken to the hospital. Another example would be strep throat or ear infections. These people could be evaluated and treated by someone in the field with no physician input.

Ah the old treat in the field suture senario ... we know that this enviroment is far more "unsanitary" the risk of infection increases, so just who takes it on the wrist when the patient developes infection and then becomes septic ?

Edited April 26, 2009 by tniuqs

[RatPack]

I have to respectfully disagree with you Rat. The midlevels (mostly PAs) I work with practice medicine. Sure, I have to sign off on the charts and I am the one that is ultimately responsible but they work pretty independently. The only caveat is that they have to present the pt before they are discharged. There are very few times that I would do something differently. You don't need to be a doctor to make a diagnosis. Nurses do it all the time. Like I said before, in order to give a drug, you have to make a diagnosis, otherwise, how do you know what drug to give. If you look at a monitor and say, "Hey, that's SVT." You have just made the diganosis. You can now give the proper medication to treat the problem. Can you look at an ankle and (in most cases) say, "That ankle is broken."? No, and neither can I. We can both say, "It's either broken or sprained." We have developed a differential diagnosis. I just happen to have the equipment to narrow down the differential.

There are plenty of medical issues that don't require an MD/DO and can be treated by someone who is properly educated. The example I keep using is a laceration. This can be treated in the field and does not need a physician. There are some hospitals that has a nurse who takes care of the laceration. The education part is knowing when the laceration is not just a simple laceration and needs to be taken to the hospital. Another example would be strep throat or ear infections. These people could be evaluated and treated by someone in the field with no physician input.

I was referring to middle level providers in EMS, my mistake. I agree with you for the most part on diagnosis, however I believe most pre-hospital providers treat symptoms of an underlying cause in which pre-hospitably we have no way of diagnostically determining or correcting. With the example of SVT we are treating the consequences of the underlying issue. Practicing medicine would be for example the ablation needed to correct the cause.

I dont consider a laceration or strep throat a life threatening condition, that would be more geared to educating the public on the proper use of the EMS system. I may be confusing the true essence of the original post, I am basing my opinions on EMS. Not in the hospital setting. I believe if the general public was educated on the correct use of the EMS system there would be no need for EMTs. In theory every activation of the EMS system would be life threatening and require an advanced level provider.

I would like to see in the future mobile treatment squad or clinic where a person would activate this system an ambulance or what have you would be dispatched to the scene and treatment would be performed. I have no idea what would be needed to bring this to fruition or how it would be staffed. This would cut down on the amount of ER visits and they would still have the ability to transport if deemed necessary.

[chbare]

Appreciate the replies. Here is my take on this whole movement:

I actually spent a fair amount of time working in a highly autonomous role when pulling remote clinic coverage. Ignorantly, I thought I was up to the task. However, it really hit me that I was making definitive decisions about the health and welfare of my patients. I remember having a rash/skin lesion day. It is actually humbling when you see six different people who have six different problems with similar but different characteristics.

I spent allot of time in an internal medicine and dermatology book. Unfortunately, much of this simply included looking at pictures and making a guess regarding the problem. Obviously, I did close follow up on many patients. So, here I am getting stumped by skin lesions in healthy people who will most likely recover without incident. However, if I screw up?

I actually was one of the only providers who would call one of our doctors every night and review every chart with that doctor. I would write their assessment into the records and any recommendations. In addition, I would revise the care plan of the patients based on the physician recommendations. In addition, I was not hesitant to have patients follow up with a physician at the main clinic. However, the security and logistical situation often did not support driving patients around Kabul at all hours of the day.

I feel I am a pretty smart guy. Perhaps not the sharpest tool in the shed; however, I do not look at my self as an idiot. However, I know what I do not know. My concern is that unless there is some highly intense education regarding "medicine" when I go on for my masters or to PA school, I do not see how I could possibly be in a position to consistently make these decisions without a physician backing me up.

Again, I am not here to cause any hurt feelings. This is just the observation of somebody who is not a midlevel provider. I admit my ignorance up front.

I did look at the SDN forums and some of the nursing specific forums. The problem I have, is many people are shooting from the hip and naturally lining up to protect their profession and personal interests. By coming to this forum, I am hoping for more productive discussion in a "neutral" environment. Not that this is totally possible.

Edited April 26, 2009 by chbare

[Richard B the EMT]

Chbare said

In EMS we often argue about diagnosis and the line that exists between a health care provider and a physician. It seems this line is becoming quite blurry and much confusion and drawing of lines in the sand appears to be occurring.

While I forget which medicine I keep seeing advertised on TV, I do note, they don't say "Doctor" or "Physician" to write the prescription. They only say "Health Care Provider".

I concur that some titles are, most definitely, getting blurred.

Edited April 26, 2009 by Richard B the EMT

[rock_shoes]

If you form a differential diagnosis based on S/S, and sound medical evidence, then treat a patient based on that diagnosis, you are in essence practicing medicine to a degree. Do Paramedics/EMT's/Nurses practice at the same level as a physician? Absolutely not. Nowhere even close.

The purpose of a mid-level provider such as a nurse practitioner or physician assistant is to provide a service closer (note I most certainly did not say equal) to that of a physician. Most PA programs I'm aware of are essentially masters degree programs which land them right in the middle between the educational requirements for a bachelors degree and a MD (not including fellowship or internship). Midlevel providers are a very new concept in Canada. Until recently the only place PA's have been used is in the armed forces. To the best of my knowledge only two provinces are in the process of putting PA's into use. Ontario and Manitoba if I recall correctly. The PA pilot program at Mcmaster University in Ontario indicates that the majority of students will come from the ranks of existing RN's and upper level paramedics (Advanced Care and Critical Care).

If we play our cards right PA's have the potential to revolutionize the delivery of out-of-hospital care. Note I said out-of-hospital care not EMS. There are many ailments that could be dealt with by a mid-level provider taking much of the strain off of emergency rooms. In addition PA's or Nurse Practitioners give us what we all really want and need; professionals with a higher level of education out on car. Can you think of a better way to kick fire out of the playground than to require a masters degree to provide ALS level care?