Welcome to patients at risk a discussion of the dangers that patients face when physicians are replaced with non physician practitioners. I'm your host and the co author of the book patients at risk, the rise of the nurse practitioner and physician assistant in health care, Dr. Rebekah Bernard. Thank you for joining us for part two of my discussion with Dr. John Lafferty regarding the Flexner Report, which occurred in
medicine in 1910. The question that we're discussing is whether or not it's time for a similar Flexner style report for nurse practitioners and physician assistants based on some of the decline that we're seeing in the quality of education. Dr. Lafferty was just talking about his experience in precepting PA students.
I can tell you what it was like in the PA program that I was a preceptor at, they were having so much trouble that I was willing to do it because I love to teach. But I was at that point not doing any obstetrics. And I wasn't doing any major surgery. And they said, No problem, we'll make it work. And so my PA students basically were in a low environment practice of looking at folks that need a birth control and women that were
pregnant. And they had cut the rotation, which they clearly advertised 200 hours of clinical experience in women's health, and 200 hours of surgery and 200 hours of psychiatry and of the other clinical rotations. But my obviously, my role was in women's health the last year. And I think this is important for the public to know. And this is just the truth. They were in my office for a total of not 200
hours, but about 30. And of those 30 - Since we had some patients that didn't want them to participate, their actual face to face with patients for their entire womens health was under 15 hours. And the other what did they do with the rest of their time? Well, the school had online lectures and things of this nature. That sounds an awful lot like the proprietary Medical School of the 19th century.
What I'm hearing is a couple things. First of all, the apprentice model that was not good enough for physicians is what the training standard is in many cases for NPs and PAs. They get assigned to someone either they are lucky enough to have a school help them find a preceptor or they find them themselves. And then that preceptor is basically the extent of their education and
their experience. So for example, and I've precepted Of course many NPS and PAs In the past, now, I only take physicians, medical students or residents. But you know, I'm a family doctor. And I work in southwest Florida. So what that means is I take care of a lot of senior citizens, and I love it. And it's great. But if you are hoping to get a full spectrum Family Medicine experience, you're not going to see a lot of babies or small children in my
practice. And so the challenge is that these apprentices basically, are only getting trained on what their preceptor sees. And in many cases, that's
just not going to be enough. And I think you are actually sharing with me, in a very core skill that PA and nurse practitioners and physicians, of course need if they're doing primary care, is the ability to do basic preventative women's services like pap tests, and I believe you told me that they only got to do just a few paps when they worked with you.
I had PA students not from their lack of wanting to do it. It was It wasn't their fault, right. But they probably got one or two. And, and that's, you know, that's certainly and I have called a call for the directors and I was a preceptor and want to do a good job. And I said, What problems are you having? he said, we have this problem across the board, and so does, all the other programs across
the country. It's also was true I had, and again, this is second hand, but I being so interested in this, I quizzed my students, my PA students, and they said, In one instance, their pediatric rotation, they could not find a rotation for them. And so they put them in with a family practitioner, who did, as you say, very little pediatrics. And they basically saw three or four children, and that counted as their rotation.
Yeah, and now that's why we're seeing these posts from new graduates saying, 'Hey, can you give me some advice? Because I can't seem to figure out how to find a cervix, or where do I learn how to dose medications for children'. And these are people that have already graduated, and basically, they're trying to learn on the fly. And that's just not going to cut it. You know, one of the things that you mentioned that Flexner recommended was that there be a
teaching hospital. And when I think back to my medical school days, and my preceptorships, one of the ways that we gained so much experience was that we worked at these large tertiary centers that had a large catchment of patients that were coming from all around the state, to this center. And it was a wonderful opportunity as a student and as a resident, you just had so much exposure to
patients and to pathology. And when you're out in the community, you may not just have that same volume, or those same, that same degree of pathology,
well, and, you know, to the lay public, and maybe to some physicians, the one of the big differences in medical training and training of non physician practitioners is that they do not have a residency and we have both previously said that I'm not 100% agree with you, I learned how to practice medicine in my residency, not in medical school. And even in med school, we have far more contact with patients than a lot of these
folks have. And I hate to say it, but I don't think that you could run into a single physician that had been has been practicing for a long time that has run across instances where not only have PAs and NPs that have seen people that are urgent care center or an ER made mistakes, but they've made mistakes that no physician would have made. Now, not all of them, you had a spectacular case in your book where someone died.
And we have to say that we're not saying that that is happening a huge amount of time every day. But less than that people are not getting properly diagnosed. And it has nothing to do with the motivation of these folks. It has to do with the fact that they're being put out there in situations where they're under trained, in my opinion
in my opinion, the NPS and PAs are actually just as much of a victim as anyone in this because their institutions, their leadership, is telling them that they can go out and practice and in some cases, they're being put by corporations or academic centers, even into positions that they really are not prepared for. And they're just, you know, they don't know any better. They're just winging it. And that is really dangerous.
How about Rebecca, page 15 of the Flexner Report. 'A heavy sympathy for the American youth who too often to the prey of commercial advertising methods is steered into the practice of medicine. With an almost no opportunity to learn the difference between an efficient Medical School and a hopelessly inadequate one. '
Wow. I mean, that's exactly what we're seeing now. So what I'm hearing from you, and what I'm seeing here is, it's time for a Flexner Report for these professions. Well, how does something like that come about? What do we need to do?
Well, I think that, and we may have to take another half an hour to, to deal with this. And I think that your organization that I have joined, may have to do some, some heavy thinking about this, because it is political. You are swimming against some currents that are very, very difficult. I know that no, I don't know at this point where I can enumerate all of them. But certainly, there is a push because of COVID. To say, well, let's just let them all
practice. There is a push because of general lack of physicians and of which we know. But we also feel that some of that has been generated by Congress and not having enough residency positions, not being as efficient and getting those folks through. But we're going to have to look at all this. But I do know one thing. I don't think the solution to the problem is to substitute well trained folks for lesser trained
folks. And when I say training, again, I, if I get phone calls from the nurse practitioners that don't agree with me, I am not talking about your sense of worth or your ability to potentially do things, I would hope. And I have talked to some of the older nurse practitioners and physician's assistant that did train in the 60s. And Rebekah, they also quietly are appalled of what's going on. But they will not speak up. In some cases,
well, a lot of times they're being told not to by their leadership. And you may recall that back in the end of 2019, the American Association of nurse practitioners had their annual conference. And in their final lecture, which was given by Margaret Fitzgerald, a nurse practitioner educator, she put up a slide and it had a smiley face with a zipper for the mouth. And it said, sometimes the strongest voice is silent.
And her message was if you do not agree with full practice authority, if you do not if you have concerns about nurse practitioner education, you need to stay quiet, you take this to, to keep it on the inside, don't air our dirty laundry, we don't need to talk about these things. And nurse practitioners are aware that if they voice anything they are you know, they're potentially getting themselves in a lot of trouble.
I have no doubt that there are nurse practitioners and physician assistants that everyday competently and accurately take care of folks. My issue is that because of their training, if there's something unusual, they are more likely to miss it or not diagnose it properly. And it has everything to do with training. So let me say in terms of reform. Sure. I think that your attorney of the I think this would be a radical proposal that would get pushed back against
quite a bit. But I think that in the states where nurse practitioners are practicing independently, I think we have to redefine that as essentially the practice of medicine. And I think they should come on to the medical board. If they are working under the license of a physician, then? Probably not. And I think that that would be
one thing. I certainly think we have to point the fingers Also at physicians in the supervisory states, this one being one, I have seen examples where they are supposed to be supervised. And I have seen practices out there where the non physician practitioners are not being supervised at all. There's no charts being reviewed, there are no phone calls happening. And I think that we need to look at that and at least be honest about what we're doing or not
doing. And so that's something else that we really do need to look at.
I could not agree more. In fact, one of the things that I'm concerned about is I'm seeing these online, do you need a physician collaborater websites where basically, you know, doctors are signing up just to basically get a check to quote, you know, supervise or collaborate but are they really doing that? Or are they just basically taking advantage of this broken system? And I think that we definitely need to hold our own
accountable. If you are going to collaborate in my life to say supervise, then you need to take that seriously for for patients. I mean, that's a huge responsibility.
Well, I have talked to someone on the north Carolina medical board who does agree that a nurse practitioner who is hasn't practice in western North Carolina, who's supervising physician is on the coast, the Atlantic coast 300 miles away, does not constitute supervision in his view. And so I'm hoping that, at least in North Carolina, we will start to look at that. If we're going to be a supervisory state, we really need to we need to in everything
we do, we need to be honest. And there's a lot of dishonesty in what the problem to offering. There's obviously not the subject of this podcast, but there's a lot of dishonesty in how non physician practitioners present themselves in a clinic setting. You have had other podcast about that. And I think that the public deserves that much. And that's what we're all about.
Absolutely. It's really all about patient safety. And that's what our organization positions for patient protection is really about simply ensuring that patients have access to physician led care, and truth and transparency, we just believe that patients should know who is taking care of them. What are their credentials, we do not oppose nurse practitioners or physician assistants at all. In fact, we think they're really important members of the clinical team.
But they really should be practicing under supervision of a physician, if they want to practice independently, that would be something I would encourage, but that would require going to medical school and doing a residency. And we've interviewed many doctors on this program who have done exactly that they were PA or they were NPS. And they decided they wanted more, they wanted to know more, they wanted to put in the time, and they did it. And that is a path and it's an option.
And that group of people, which I think are very valuable to a person looking back on their nurse practitioner education of their pa education and their physician education were astounded at the depth and, and links of what physicians have to do. These are the these other groups.
We hear it every time and they always say, I had no idea what I didn't know. And I guess it's that whole Dunning Kruger effect where you know, as the more you know, the more you realize, you don't know, it's really quite
frightening, actually. And I think it's one of the reasons why a lot of doctors, when you talk to them, no matter how many years they've been practicing, they will still tell you and I will to that we're all we're still a little scared every single day because we realize that there are always going to be some gaps in our knowledge. And there's always more that we can learn and need to know. And it's it's a great responsibility to be in this position.
And the good nurse practitioners and PAs that are out there do know their limitations. But if you don't, and you're in a situation where you haven't been properly trained, because that's when it
gets dangerous. I ran across a quote, and I'm going to finish up by quoting people but the great physicist that had Lou Gehrig's disease, Stephen Hawking from Britain, he said, 'the enemy of knowledge is not ignorance, the enemy of knowledge is the illusion of knowledge.' I would also like to quote for those of us that love history, and hopefully got something out of this foray back into Flexner and realize the phenomenal parallels between what was going on in medical education, what the, in the
medical profession did to correct it, how it elevated the profession, it would be such a great thing for nurse practitioners and PAs, if they also add a Flexner report and streamline their education. And, in some cases, went back to the way that they originally were trained to start with the famous quote of George Santyana, the philosopher said, 'those of us who cannot remember the past are condemned to repeat it.' And I'm afraid in some cases we are
doing that. The great novelist in Mississippi William Faulkner said 'the past is not dead. It's not even past.'And then my favorite philosopher of all time, Yogi Berra, the catcher for the New York Yankees said 'it's deja vu all over again.'
Well, thank you so much. I really want to thank Dr. John Lafferty for joining me for such an interesting discussion. If you'd like to learn more about this topic I encourage you to get our book is called patients at risk the rise of the nurse practitioner and physician assistant in healthcare. It's available@amazon.com and at Barnes and Noble, and if you're a physician and you'd like to learn more about getting involved in promoting Physician led care. I would encourage you
to join our group. It's called physicians for patient protection. Oh, thank you for showing the book John. Join our group physicians for patient protection. Our website is physicians for patient protection.org Thank you so much and we'll see you on the next podcast.