CRNA salaries surpass those of primary care doctors

I received several requests asking me to comment on this CNN story, “Some nurses paid more than family doctors.”

This isn’t really news, as CNRA salaries have been on a trajectory surpassing primary care physicians’ for a few years now. In fact, I wrote about it back in June of 2008.

According to the latest numbers, “Primary care doctors were offered an average base salary of $173,000 in 2009 compared to an average base salary of $189,000 offered to certified nurse anesthetists, or CRNAs, according to the latest numbers from Merritt Hawkins & Associates, a physician recruiting and consulting firm.”

And this isn’t something that happened overnight. According to Merritt, “It’s the fourth year in a row that CRNAs were recruited at a higher pay than a family doctor.”

It isn’t just the money, folks. A CRNA has a more manageable lifestyle, primarily consisting of shift work, as well as less administrative burdens compared to a primary care physician.

Correct me if I’m wrong, but I believe their malpractice premiums are lower too.

So, in summary: better lifestyle, less bureaucracy, and possibly lower malpractice expense. All for higher pay.

What’s there not to like? As long as primary care continues to be grossly underpaid, relatively speaking, I’m sure that some prospective medical students considering primary care may reconsider their career choice and go the CRNA route.

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  • http://www.ohiosurgery.blogspot.com buckeye surgeon

    Primary care? It’s not just them. Check out starting gen surg salaries in places like chicago and NYC. (Less than 170) Why would anyone want to invest $150,000 in a medical school education when you can just go to school for 2 yrs, earn 180k and go home every day by 3pm? Plus all the responsibility ultimately falls on the suprevising anesthesiologist. That CRNA lobby must have somebody by the balls….

    • Anonymous

      CRNA’s go to school longer than 2 years.

      • http://medicalpastiche.blogspot.com Peter

        CRNA training is around 27 months (2 years and 3 months months).

        To enter CRNA training, 1 year of work as a nurse in a critical care atmosphere is required, as well as a bachelor’s of science in nursing.

        • primaryMD

          so you can get bachelors in nursing in 4 years, work as an ICU nurse for a year, then do 2 years of CRNA training (plus an extra 3 months to be exact, apparently) and then make more than an FP/Internist who did 4 years after college in med school, and 3 years in residency?

          4 fewer years of training? With however many tens of thousands less in debt? To make more money with less responsibility and better hours?

          hmmmm…..tough choice here. And we wonder why primary care is dying.

          • Anonymous

            Malpractice is no small deal in anesthesia. And many CRNAs practice independently in rural areas, check your facts before you spout. We work very hard and often long shifts. Jealousy isn’t flattering, get over it.

    • unc-crna

      CRNA’s deal, literally, with the shit MD’s will not. A CRNA gets a 4 year BSN, works for a minimum of 1 year (the average experience is 3-5 years of ICU nursing) cleaning up shit and correcting dumbass residents, then it’s 2 1/2 years of anesthesia school. I think it’s properly compensable for the amount training and the work. PA’s on the other hand…..BS in some kind of science(no clinical experience) then 2 years of PA schooling and then they’re seeing/diagnosing you in the clinical setting. I know one thing when I go in the hospital/office I don’t want them seeing me!

      • student

        I know you are irritated by comments you find disparaging of your training. However, you are making the same mistake in your response by insulting resident physicians and PAs. Perhaps a touch of humility is in order when you claim to be essentially running the hospital in spite of the physicians. Further, I have to defend the clinical experience of PAs prior to schooling as equal if not greater than the average of NPs. Above all, however, the take away point of this piece has to be that specialties in general, whether practiced by MDs/NPs/PAs/shamans, are being prioritized at the expense of primary care. The perceived zero sum atmosphere of relative compensation is likely contributing to the divisiveness amongst practitioners you are contributing here.

  • primaryMD

    less school, less debt, less responsibility, fewer hours, more money? What’s not to like?

    It’s a wonder even 2% of med students are going into primary care.

  • Doc99

    To be fair, CRNA involves first receiving a Nursing degree. The PG CRNA education involves either a 2 or 3 yr program. However, the level of indebtedness is considerably less than that of today’s med school graduates. Personally, I’m advising seeking a career in Veterinary Medicine.

  • Happy Hospitalist
  • dud

    Let me get this straight. We need to have the government subsidize physician salaries because why?
    Where are the defenders of letting the marketplace set the pay scale?
    If the shortage in primary care results in demand for more primary care doctors then the market will rectify the situation. As it is, people would rather get rapid treatment at an acute care center or Wal Mart. Good luck changing the public demand for easy, prompt care even if it is very poor.

    Buckeye, my neighbor is a gen surg, in Chi area and brings in a lot more than $170. He works his arse off and earns every penny, just saying.

    Our society (financially at least) rewards risk. Always has, always will.

    CRNA’s are instrumental in allowing more surgical procedures to occur hence more money to hospitals, out patient surg centers and physicians offices. More surg = more money for the principal so the “value” of the CRNA is increasing.

    Seems fair to me.

    • http://thehappyhospitalist.blogspot.com Happy Hospitalist

      If the shortage in primary care results in demand for more primary care doctors then the market will rectify the situation.

      LOL. You don’t know much about how doctors are paid, do you.

      http://thehappyhospitalist.blogspot.com/2007/11/what-is-99223-worth.html

      And you’ll understand why the market for primary care care doesn’t exist.

  • docguy

    most of the time at least in my life, obgyn, the anesthesia provider, either crna or md, makes more than the surgeon.

  • docguy

    also only when you have open markets will demand cause increases in prices and then more supply, we don’t have a open market in healthcare and it’s only likely to get worse.

  • H

    On the open market, I don’t really care about someones debt or workload. I only care about the product. I decide if the product is worth the price.

    One of our local clinics is laying off a large number of their staff because of the recession. People are waiting longer to make an appointment and are going without elective procedures. I pay 20 % and chose a nurse practitioner for my care partly because it’s cheaper for me. I already skip most of the preventative stuff-it’s expensive and it’s focused on people with unhealthy lifestyles. For something more complicated, I go to a specialist-which doesn’t cost anymore than a primary care doctor and probably avoids a second appointment. There are many internet tools that indicate the severity of a group of symptoms and give possible diagnoses-and they are free. I often use them to decide which path I chose.

    In an open market, are primary care doctors going to provide better quality products?

    • http://thehappyhospitalist.blogspot.com Happy Hospitalist

      What you seem to be saying is there is no role for a patient with complicated medical issues or even a single new complicated issue between an extender and a subspecialist.

      You have fallen into the trap of believing that simple things belong to the NP and the complicated things belong with a subspecialist. No one can change your mind for your faulty thinking except to say that what internists and family medicine doctors offer is nothing like what an NP offers. These MDs are trained in a scope vastly superior to the less intense extender training. They are specialists of the entire body, with training that is far superior in scope and depth than what you believe capable.

      Just don’t be surprised when you a specialist who only looks at one organ system 50 times a day, every day starts recommending thousands of dollars, tens of thousands of dollars worth of testing that are neither indicated nor necessary. I see it every single day I request records from offices.

      In an open market, are primary care doctors going to provide better quality products? A resounding yes to your answer.

      • H

        You assume my health is not complicated. I have 5 chronic diseases and I never had a primary care doctor consider all of these at the same time. In addition to my medical history, I do not have a typical lifestyle and have never had a primary care doctor consider my priorities when recommending care. I never felt well. It was a nightmare. It wasn’t the primary care doctor who stepped in when I was spiralling down into despair. When primary symptoms lead to secondary symptoms, it wasn’t primary care doctor that cared.

        Regarding specialists, many I have seen have looked at the big picture, not just that single organ. Four of the five chronic conditions were diagnosed by specialist after referral. The one diagnosed by my primary care doctor was erroneously thought to be simple and I ended up consulting a specialist anyway.

        Clearly, you feel that these faults with the care I have received would go away in a free market system-for how much? Twice what I pay now? Half of what I pay now? So what more am I going to get? I often do I have to feel ripped off by the care I receive?

  • rezmed09

    The free market is PCP’s requiring a $500 – 1000 retainer fee for seeing each patient for a year. Sure if you want capitalism and to be able to see the same doc year after year, be prepared.

    • http://fertilityfile.com IVF-MD

      Not exactly. Remember that what we have today (even with the concierge practices) is nowhere near being free market. There is a government-imposed oligopoly on who can render the nebulous area known as healthcare. In a true free market, if someone is charging 500-1000 per year retainer, some smarter, more innovative person will come along and figure out how to give them comparable quality and service for $200-400, all the way driving the price further downwards until it hits the limit of what is reasonably possible.

      • H

        And pretty soon, an office visit will cost $19.95 with a coupon for free coffee.

        Of course the way to reduce prices is to hire nurse practitioners so you can collect more retainer fees and scrunch everybody into 10 minute appointments.

        Hospitals and surgical centers seem to have already figured that out.

        • http://fertilityfile.com IVF-MD

          Let’s not insult the intelligence of the patients. If their choice is to pay $50 for a rushed 10 minutes with a NP vs paying $280 for 55 minutes with an experienced physician, there are many who will choose to pay the higher amount. I’m sure of that no matter HOW GOOD the coffee is.

          • H

            Right now I get the 55 minutes with the NP for $50 and the rushed 10 minutes for $280 with the experienced physician.

            What if I have a problem and I am not sure it requires medical attention…do I pay the $50 or the $280 to find out?

            What if it’s a follow-up for a long standing problem that hasn’t changed and I just need a presciption…do I pay the $50 or the $280?

            When my health conditions require me to see a provider 5-6 times a year…do I pay $250-$300 a year or $1400-$1680 per year?

          • http://fertilityfile.com IVF-MD

            So H, it’s not just the QUANTITY of time, but the QUALITY as well. So during your 55 min with the NP, it is the job of you and the NP to figure out whether your problem is best handled by them or by upgrading your care to that of the physician.

            For the Rx renewal, it would presumably be a short visit that just requires a review of how you’re doing and checking the appropriate liver test or whatever so the $50 would be more appropriate UNLESS you have a new problem or the old problem is not being resolved to your satisfaction.

            For repeated visits, you would pay accordingly depending on whether it’s a maintenance visit for a satisfactory resolution of your problem (less expensive) or one that requires complex attention to deal with your new issues or unsatisfactory address of your old issues (more expensive). You decide.

            Remember also that with healthy competition and little or no bureaucracy, the economy would be booming and you would be earning more in whatever you do, so you’d be able to afford a lot more discretionary spending. Also, the $50 or $280 fees would come down to their minimum as all the NPs and MDs work hard to come up with a superior product value in order to compete for your healthcare dollars. The key difference is that YOU decide where your money goes instead of having some bureaucrat hundreds of miles away who has never even met you (and frankly might not really care about you other than for your tax money and your vote) making the decision.

          • H

            So IVF-MD, if a open market on health care is going to result in cheap, quality care, great. I would guess that a nurse practitioner in this market will be cheaper than the MD.

            If the value of what I place on certain services doesn’t pay for medical education, then what? What if I think that CRNA are just fine if they keep costs of surgery down? What if I think that service is more valuable than the services provided by primary care?

            Since when do I decide charges. One of my last visits to my primary doctor before I made the switch to the NP, the doctor’s PA spent 5 minutes with me for a worsening condition that had already been diagnosed. I received no new information from this person, only a new prescription. Level 4-$290. So much for the expertise of a doctor.

            Do I get to come into your office and say I want a level 1 with a side of fries? What if I say I only have $50 this month to spend on medical care and I only want a $50 medical visit even though my problem might be a $100 problem?

          • http://fertilityfile.com IVF-MD

            H, you are correct that in our CURRENT system, you DON’T really get to decide. The point is that opening things up to more competitors all working hard to earn your voluntarily spent dollar will give you a lot more power and options than the way it’s set up now. This applies both to providers AND to insurance plans.

  • dud

    Rezmed,

    If that is what the market bears, so be it.

    Some people will choose cheaper (Walgreens, etc…) care for their medical needs. I’m quite sure this is not good but it is the way we are headed. Public clinics with long lines for some and a “concierge” practice for others. Probably not too much in between.

    Unless the public believes they are placing their health at risk by not seeing an MD or having a anesthesiologist manage their sedation they will be okay paying less or wait less time to see/utilize an “extender” (man is that an odd term).

  • rod

    SHAME!!!!!!!!!!!!!!!!!!
    What are AMA , ACP, AAFP doing, sleeping at the wheel???? How can they treat their doctors like this.
    How can our system ignore cognitive skills needing complex decision making and value just monotous procedures more ? HOw can all all the medical school training, residency training be ignored so blatantly.

    • R Watkins

      The AMA, with its specialist dominated RUV committee, is the primary cause of the intentional and ongoing devaluing of cognitive services.

    • Anonymous

      Welcome to protocol driven medicine. How much training do you need to evaluate a patient as fitting a confined set of parameters and then following the instructions? NPs, CRNAs, etc, by the definition of their role (I think), handle low liability patients that fit set parameters. Anything more complicated than that is supposed to be referred to someone who can develop more personalized treatment. I’m not surprised at how much the CRNA is making. I’m just unsettled that the person who takes the higher risk, more complicated patients are not rewarded. It’s like paying the technician who fixes things out of the manual more than the engineers who write the manual.

      • Anonymous

        I’m going to help you out here…..today i started and finished a difficult CABG without MDA guidance and the use a manual. Now if you know where I can find this “manual” and the pt’s that fit it’s parameters please let me know.

        • Anonymous

          What I wrote was my understanding of the scope of practice for advanced nurses and was not an attempt to be rude. Judging from your comment, you are a CRNA, and also from your comment, the answer to my question “how much training is needed…” is 2 years and 3 months. Which would also imply that anesthesiologists are grossly over qualified for what they do. My heart goes out for them, and for all physicians, as advanced nurses everywhere claim that they can do the same job as a physician with less training, which I hope they can back up because with this attitude, the physician deficit will continue to grow and grow…

          • Pat

            Just like to point out that Anesthesiologists make far more money on average than CRNAs hence making the CRNA a more cost effective solution for smaller and rural hospitals. Comparing the salaries between CRNAs and family practice doctors should not be the argument here. It should be about the inequality of pay between medical specialties. Seeing as that is what is truly driving the rise in CRNA salaries.

  • Castro

    Does the healthcare reform bill help balance responsibilities and pay between nurses and doctors?
    -i have a career decision to make….

  • http://www.kevinmd.com/blog/2010/03/mammogram-screening-divides-doctors-patients.html DrLemmon

    I’m not sure anyone wants a truly free market (except me).

    There are many types of providers that can provide the care that RNs do without being licensed RNs. Same for NPs, and MDs of various specialties.

    To some extent, licensing requirements and government regulations keep others out of the market place. This is how MDs cornered the market. RNs have done the same thing. Even cosmetologist’s (wonder why general chemistry is on their licensing exam?). Why are people not allowed to read for the bar exam anymore?

    In 1949 a family doctor made $8,835 / year. Adjusted for inflation that would be $78,660 in 2009 dollars. FNPs clear more than that. Other specialties have beat inflation by even more. It’s not a free market that caused this either.

    We have the highest paid doctors in the world here in the US. What is less well know is that we have the highest paid nurses in the world too. We also have the highest paid school teachers. Don’t believe it, browse world.salaries.org.

    • http://fertilityfile.com IVF-MD

      I’m with you on this. There is talk now of the bureaucrats and politicians wanting Yoga Instructors to be certified and licensed for the “safety and protection” of the public who would otherwise be gravely harmed by those poorly trained mid-level Yoga-Instruction Assistants.

  • IVF-MD

    In reference to some of the previous comments, pay scale should be based on what the people receiving the services choose to pay, not based on whether primary care doctors or CNRA’s are better at paying lobbyists to bribe politicians. That’s a big component of why our system is such a mess.

  • Surgical Resident

    IVF-MD hit it on the mark. People complain about PCP’s and other MD’s having long wait times, etc all the time without realizing that PCP’s have to see people quickly just to make it.

    Then you hear people say that they will just go see a specialist bypassing the PCP. That really bugs me for several reasons. The insurance company or government is picking up more than 50% of the tab. Why should I pay for you seeing someone that costs more without an obvious benefit. Now you may say that you are smart enough to figure out the specialist that you need. I say good for you, because there are times that I get confused and I’m a chief resident in general surgery. Also, we have a saying that if you are holding a hammer; everything looks like a nail. This is why I don’t see everyone with abdominal pain, because everyone would have surgery.

    Sorry for the rambling, but it is clear that people outside of the medical system really have no clue what each component does.

    • H

      RE: Why should I pay for you seeing someone that costs more without an obvious benefit.

      Office visits cost the same for primary and specialist care. I have found the specialists don’t think everything is a nail and try to hit it with a hammer. They are quite knowledgable about medicine outside their specialty. Hopefully, when you are done with your training, you will be more thoughtful and not just operate on someone with abdominal pain.

      • anon

        H: You are quite condescending to people who have dedicated quite a bit of their lives to what they do. If Surgical Resident is a chief resident, in his fifth year of surgical training, I would at least give him the benefit of hyperbole. The maxim “When all you have is a hammer, everything looks like a nail” has wisdom to it, and his greater point should be taken.

        • PCP

          As a resident in internal medicine, one of the reasons I don’t plan to specialize is that during rotations with various specialties I have seen the way they only address their one system and indeed the way that everything to these hammers is a nail. Don’t get me wrong-they are a VITAL part of the system…for when something is seen less often, when a test (eg cardiac cath) needs to be done, for when expertise is needed…which in today’s medical system is quite often. However, I just know that I couldn’t wake up everyday and go into work knowing that the problem with the patient was going to be somewhere between the mouth and the anus (or the liver or pancreas) and that’s all…or that the problem with the kidneys for which I’m being consulted as an inpatient is either pre-renal, renal, or post-renal and that my job is to recommend the standard battery of tests for the same conditions over and over. It seems boring to me but does highlight the fact that specialists by definition specialize and that many patients with chronic diseases would benefit from having their condition as a whole person addressed, by someone who understands the pathophysiology behind all of those conditions, at least a few times a year.

  • joe

    ” Office visits cost the same for primary and specialist care. I have found the specialists don’t think everything is a nail and try to hit it with a hammer. They are quite knowledgable about medicine outside their specialty….”
    Actually H the reverse is true. A specialist deals with his/her area and orders/evaluates based on what they know. Yes a cardiologist may have done IM 20 years ago, but you and certainly do want him managing your diabetes. I am medical subspecialist. I see NP c/s all the time that I never used anything more than my IM training in my clinical decision making. It’s easy money. But it sure is not cheaper to the patient. I also consider myself a pretty fair internist, but I certainly don’t consider my IM knowledge/experience as broad as someone who does it all the time. Why, because I spend my time dealing with my subspecialty.
    Just why do you an NP=IM I am not sure. The training experience certainly is not the same. Don’t get me wrong. NP’s have a role, it just that NP does not equal residency trained IM.

  • H

    “Yes a cardiologist may have done IM 20 years ago, but you and certainly do want him managing your diabetes.”

    The cardiologist has broad enough knowledge to know he isn’t the right person for the job. My point being that a good practitioner would consider possibilities outside their speciality instead of cutting someone with abdominal pain open.

    Are you saying that if something was outside your subspecialty, you wouldn’t recognize it as such?

  • IndiePsychNP

    As a psychiatric nurse practitioner, I would like to make three points. First, MDs can call NPs “mid-levels” and lament our short length of training. I propose, then, that nurse practitioners get access to the same federal moneys that fund the internships and residencies of MDs. I came out of Columbia University with $150K of debt. I could not, then, pay for 3 years of a residency out of my own pocket. Second, NPs work in the toughest environments that MDs will not work in: jails, rural areas, homeless shelters etc. with the sickest of the sick. Psychiatric NPs in all settings see exactly who a psychiatrist would see with no prescreening for acuity of illness. Third, I find it interesting that in all of this conversation, no MD has brought up any negative outcome studies regarding the care provided by NPs. Amazing how people aren’t dropping dead left and right without a doctor in the room!!! I think MDs need to become more like NPs: listening and thinking aloud with patients about what they are reporting doesn’t take that long if you listen in the first place. There aren’t very many of us. We’re taking over, but you won’t even notice it by the time it has already happened.

    • student

      the arrogance and overreach of your post should hopefully moderate your thoughts once you read it out loud to yourself. or even try reading the stuff you cite critically for that matter–you make conclusions and assumptions that are not fitting for someone claiming clinical acumen.
      regarding residency, i think you would find many physicians would support an outpatient residency for np’s, but it is hard to argue np school prepares students adequately for most md residencies as they currently exist ie: acuity of inpatient setting, etc. i honestly think appropriately structured post-grad training would be a great thing for np’s and a way to homogenize their training so they could easier apply for jobs. how a graduating np student without further training is supposed to be independently competent is beyond me; given the trouble my friends in np school have finding jobs, i think employers agree.

  • resident

    Anybody who has spent a lot of time in the OR knows that there is a constant turn over “behind the drape”. Breaks, shift changes, and emergencies may lead to 3-4+ different anesthesia practicers over the course of a long case. During this time the situation is checked and rechecked by more senior providers and the responsible (liable) anesthesiologist. Also, it is not uncommon for a surgeon to demand the presence of the supervising anesthesiologist for whatever reason. I’m not saying that CRNA’s should get paid less, honestly I don’t care as long as it makes financial sense to the hiring institution or supervising anesthesiologist.
    What I am saying is that CRNA’s should not try to over-play their hand. Most parts of medicine are team sports, and CRNA’s should resist the temptation of believing that they are working independently.

  • IndiePsychNP

    I think it is ironic you urge me to read my post out loud to myself when the grammar, punctuation and syntax of your post makes it simply hard to understand. I was not suggesting that NPs would want to do the residency programs of MDs. I made the point that NP’s are not substitute MDs. A key difference between MDs and NPs is that we have experience as RNs (which, for example, prevents interns from killing patients in their intern year) before becoming NPs. MDs don’t start getting clinical experience until after they do their academics. Simply because some MDs do not respect what RNs do, does not mean the role does not involve the acquiring a large body of knowledge of pathological conditions, assessment of patients, and critical thinking regarding the mistakes of defensive residents. But I do appreciate your support for federal funding for residencies for NPs. I have to say that I find it fascinating that my opinions expressed on this blog would have anything to do with my clinical acumen regardless of whether you agree with them or not. I could draw the same conclusion from your written expression, but I would not make a personal attack on you in an intellectual discourse.

    • Roy S

      “MDs don’t start getting clinical experience until after they do their academics.”
      I did two years of clinical training in my third and fourth year of medical school. In fact it is the BSN degree which greatly reduced nurses’ clinical experience before they graduated nursing school. I have seen a change in the nursing profession where many are in it just for the money.
      Your statement that your debt from Columbia did not allow you to do a residency demonstrates that you do not put your patients first because you were not willing to sacrifice to get more training as many physicians have. When my family enters a hospital as a patient I demand the order “no mid levels allowed” because I can not trust their opinion is not biased as it is more important for them to prove a point than to care for a patient.

    • student

      Calling out grammar and syntax, really? Look, while you have some valid points, you are intermixing them with some rather inflammatory statements (ie: we’re taking over, MDs need to be more like NPs, etc.). For the sake of rejoining the post’s discussion, I apologize for any offense I have caused in responding to such comments. I certainly don’t want to insinuate any judgment of your clinical capacity.
      With that said, though I would also agree the RN background helps NPs, I think you are a) overreaching in claiming this exempts them from getting post-grad training vs. MDs and b) underestimating how many NPs do not have substantial RN experience ie: direct entry. Though you say you are not suggesting NPs replace MDs, you write as if the RN experience somehow grants NPs knowledge that it takes several intense years of residency training to acquire. Whether in the setting of CNRAs or other practitioners, I don’t know that everyone would agree with that.

  • ninguem

    The libertarian in me says let all the midlevels practice. What I resent is having to clean up the mess when they screw up.

  • http://fertilityfile.com IVF-MD

    Let’s take this theoretical idea of letting all midlevels practice as they choose and run with it to an even greater degree. What if we give full responsibility and freedom back to the consumer? Let’s do this. Patients are free to choose an MD, a PA, a NP, a chiropractor, a Traditional Chinese Medicine doc, a witch doctor, a psychic or whomever to entrust their care to. But if they choose a dangerous quack, that is their own responsibility.

    Word-of-mouth will quickly spread via friends, social media networks, independent internet rating systems, etc as to which of them provided better outcomes, worse outcomes or disastrous outcomes. There can even be formal agencies such as Underwriter’s Laboratories, etc that will actively inspect and research providers and make that information available to prospective patients who desire it. Of course, you could still have the AMA giving their seal of approval. The difference would be that patients could choose to respect the AMA rating and choose to only see MD’s or they could choose to take their chances and see the psychic and witch doctor instead. The burden is on the patient to do their research. If they DON’T want to do their research, they could just “play it safe” (arguably) and see the MD’s the way it is today.

    Wouldn’t this make MD’s work harder to provide better service?
    Wouldn’t this allow the good NP’s to provide excellent inexpensive care and be free to practice medicine to the degree that they can actually deliver, and not just based on arbitrary accreditation?
    Wouldn’t this allow the emergence of innovative medical-education systems that are super-efficient at imbuing students with SKILLS and KNOWLEDGE, rather than touchy-feely politically-correct nonsense? Oh, but of course, for those patients who value that kind of stuff, they are free to restrict their choices of providers to those who graduated from the traditional medical schools that emphasize those things.

    The upside possibilities are mind-boggling. My opinion is that the quality of care would go up as providers are greatly greatly motivated to do their best rather than rely on protectionist perks to keep the competition away. The cost of care would go down as market pressures drive providers to compete. Of course the top 1% of providers could probably charge what they want, but in order to command those fees, they better get darn good at what they do. The role, power (and salaries and perks) of bureaucrats, insurance company middlemen and politicians would plummet.

    By the way, I am a board-certified MD, but I personally would much rather have patients CHOOSE me because I WORK HARD TO PROVIDE THE BEST SERVICE rather than they see me out of having no other options because I’m in the minority that has the papers and licenses and accreditation to count on the coercive might of the government to lock out any competitors.

  • Surgical Resident

    Wow lots of posts….

    H, thanks for having so little disregard for my profession. I certainly wouldn’t operate on everyone with abdominal pain, but that isn’t the point. The point is that we bring biases to everything and that a PCP is better equipped to take care of “minor” things while sending out more “major” things. (Please note that I don’t like the word minor/major for describing this but can’t think of better words). For example, my friend’s 5 year old had belly pain and asked what I thought it could be. Being a surgeon I worried about an appendicitis, but said he should see his PCP or ED doc. Since 95% of my ped’s patients with abdominal pain have an appendicitis, I have a jaded view of the world. Hence my analogy. I do think that my analogy applies to other specialties as well.

    I do think there is a purpose for mid level providers. My major complaint is that PCP’s do NOT operate in a free market. They don’t set prices. Medicare/medicaid does. Now you may say that you can go see an NP at Walgreens for much cheaper and get the abx you need, but that’s because Walgreens makes money on the prescription. Going to an acute care center is also great for minor thinks like coughs, colds, etc. in healthy people. They make it work and should be used more.

    IVF hit it on the mark. We don’t have a free market. If we did then all this would balance out. We don’t pay PCP’s enough so no one goes into those fields. Heck, I can only think of about 5% of my class that went into primary care. I think we should pay them more, period. This by the way would result in a pay cut for me!

    Finally, one thing that no one has mentioned is this. I like having an MD behind the drape or at least supervising/available because you never know what is going to happen. I can illustrate this better in my field. I can teach anyone to take out an easy gallbladder in probably a couple of weeks, but that doesn’t mean they should.

    Now let’s say you have a hospital that lets family practice docs take these out (some do) without a general surgeon in the hospital. Now you have a bad trauma/peritonitis/etc come through the door. This hospital is now ill equipped to manage this. In other words, it costs money to keep people around that can deal with these emergencies and the free market may not be the best place for this to work. Think of fire protection being handled by the free market. It wouldn’t work.

  • H

    “Now you may say that you can go see an NP at Walgreens for much cheaper and get the abx you need, but that’s because Walgreens makes money on the prescription. ”

    To clarify, I see a indepently practicing Advanced Registered Nurse Practitioner. The state I live in allows them to practice without supervision. She owns her own practice and works in the same market as the physicians do. She accepts insurance, takes care of the billing, is part of my insurance companies network. So my NP doesn’t practice in a free market either. She handles my basic care-those bumps and bruises that come along-as well as managing some of my chronic conditions. I have 5 chronic conditions, 4 of them were diagnosed by specialists-3 of which I was referred by a primary MD-one of the referrals came from a specialist. I continue to see one of the specialists for follow up. At one time I felt that my primary MD could handle care for this problem and I was horribly wrong so I continue to see this specialist-sorry if your premiums go up because of this.

    I started to see the NP because the appointments offered at my primary MD’s office were increasingly with a physician’s assistant. Granted these individuals was under the umbrella of the doctor, but I never knew who was taking care of me. At my last appointment at that office, the PA looked at my chart and said I needed to come back for an additional appointment because I hadn’t seen “my doctor” in two years, even though I had been in the office a dozen times. I did get a phone call from my absent doctor, the first phone conversation in the five years I had been her patient, referring me to a specialist-sorry about your premiums again.

  • Surgical resident

    H.

    It is clear that you had a bad experienece with your pcp, and I’m sorry. Sounds like you have a good np which is great!

    My major complaint is that using pcp’s should save money for the system and improve patient care. However they are grossly underpaid and undervalued. Lumping a mid level provider in with them is simply unfair. For example, i doubt a np /pa is going to question what a specialist is doing if e/she thinks it is wrong. Now I think they can handle most thinkgs fine, but I do think supervision is important.

    The problem that a lot of people have is that they try to apply a single story (often tines their story) to a particular problem. Of course in medicine wr consider that pretty weak evidence.

    Sorry for the mia spellings. I’m on the iPhone and can barely see what I’m writting!!!!

    • H

      Of course my experiences are anecdotal.

      BMJ 2002;324:819-823 ( 6 April )

      Primary care

      Systematic review of whether nurse practitioners working in primary care can provide equivalent care to doctors

      Objective: To determine whether nurse practitioners can provide care at first point of contact equivalent to doctors in a primary care setting.

      Results: 11 trials and 23 observational studies met all the inclusion criteria. Patients were more satisfied with care by a nurse practitioner (standardised mean difference 0.27, 95% confidence interval 0.07 to 0.47). No differences in health status were found. Nurse practitioners had longer consultations (weighted mean difference 3.67 minutes, 2.05 to 5.29) and made more investigations (odds ratio 1.22, 1.02 to 1.46) than did doctors. No differences were found in prescriptions, return consultations, or referrals. Quality of care was in some ways better for nurse practitioner consultations.

      • H

        Evaluation of a nurse practitioner-staffed preventive medicine program in a fee-for-service multispecialty clinic

        James D. Brown*, , Maureen I. Brown† and Frank Jones‡

        Abstract
        Patient satisfaction with the physical assessment services offered by the preventive medicine department of a large, multispecialty clinic was evaluated by a questionnaire forwarded to 492 randomly selected from patients voluntarily choosing to be examined by physicians or nurse practitioners. …Patients seen by nurse practitioners had significantly less waiting time and more new health problems detected than those seen by physicians. No differences occurred between the groups concerning patient compliance, existing health problems undetected, confidence in the examination, and cost of the examination.

        • Roy S

          These studies were funded by United Health Care and the primary NP on these studies is on their Board of Directors. The question is why isn’t that disclosed in the article?

  • H

    Primary Care Outcomes in Patients Treated by Nurse Practitioners or Physicians
    A Randomized Trial

    Mary O. Mundinger, DrPH; Robert L. Kane, MD; Elizabeth R. Lenz, PhD; Annette M. Totten, MPA; Wei-Yann Tsai, PhD; Paul D. Cleary, PhD; William T. Friedewald, MD; Albert L. Siu, MD, MSPH; Michael L. Shelanski, MD, PhD

    JAMA. 2000;283:59-68.

    Context Studies have suggested that the quality of primary care delivered by nurse practitioners is equal to that of physicians. However, these studies did not measure nurse practitioner practices that had the same degree of independence as the comparison physician practices, nor did previous studies provide direct comparison of outcomes for patients with nurse practitioner or physician providers.

    Objective To compare outcomes for patients randomly assigned to nurse practitioners or physicians for primary care follow-up and ongoing care after an emergency department or urgent care visit.

    Conclusions In an ambulatory care situation in which patients were randomly assigned to either nurse practitioners or physicians, and where nurse practitioners had the same authority, responsibilities, productivity and administrative requirements, and patient population as primary care physicians, patients’ outcomes were comparable.

    • Pat

      This study does not seem to be relevant with respect to CRNAs. This study is observing the comparisons between nurse practitioners and Primary care doctors as opposed to nurse anesthetists and anesthesiologists. CRNAs and FNPs are two very distinct Nursing specialties.

      • H

        The discussion with “medical resident” regarding my relationship with a nurse practitioner lead to the belief that I could not get competent care from a nurse practitioner. Since my anecdotal evidence was not sufficient, I found some peer reviewed studies to show the value of the NP’s.

  • http://www.kevinmd.com/blog/2010/03/mammogram-screening-divides-doctors-patients.html DrLemmon

    Look at P values and look at what was measured:
    http://jama.ama-assn.org/cgi/content/full/283/1/59/TABLEJOC90696T3

  • Shantanu

    Why is NOTHING being done to prevent this obvious ENCROACHMENT of an allied health field into what has traditionally been MEDICAL DOCTOR territory? As long as you physicians idly sit by and shrug your shoulders this will continue to happen.

  • MTCRNA

    First of all the comparison here is apples and oranges.

    CRNA salary $180,000
    Anesthesiologist salary $350,000-$500,000
    Not equal but ok, anesthesiologists bring valued knowledge and experience to the OR.
    *************************************************************************
    ARNP salary $70,000-$80,000
    PCP salary $175,000
    Not equal but PCP do manage some more difficult patients and chronic health conditions.

    These are where the comparisons should be, within your own area of specialty. It seems PCP’s are upset because someone with NURSE in their title is making more than them. We are in different areas of healthcare that provide different services, so the pay is different.

  • IndiePsychNP

    I have heard that 15 to 20 years ago it was thought by “established” anesthesiologists that too many foreign medical graduates were pursuing anesthesia as a specialty and moves were taken to limit this influx. These literal foreigners were felt to be unqualified. And, so CRNAs are now felt to make too much money when they make less than three-fifths the pay of anesthesiologists simply because it is more money than a primary care MD makes to engage in a much different, much less risky, non-specialist practice. Restraint of trade? Ring a bell? Those are all of the laws insurance companies are exempt from but we, as health care providers are not. Why not work together and get off the high horses because at the rate things are going the high horses are going to run over us if we don’t work together.

    • student

      I agree with you taking issue with calls to reduce CNRA pay, however few they may be. Nonetheless, many would separately argue that pcp pay, whether to md’s or np’s, is unfairly undervalued in comparison to specialist pay such as that of CNRAs. Yes, the flash point here seems to be cnra’s making more than pcp md’s, but i don’t see why that isn’t a bit alarming. You argue as if you truly believe these rates are backed by some sort of market or clear rationale (ie: risk as you put it) when the evidence suggest the RVUs dictating higher payments to specialists are anything but market driven. Further, I think it’s a bit much to claim the compensation difference is driven by a tougher job by the CNRA or anesthesiologist; I think you will find many PCPs arguing the responsibilities, hours, and non-acute risks present in their setting is just as taxing and worthwhile of reimbursement, especially when you are sharing risk exposure and responsibilities with a surgeon.
      I agree again that the focus shouldn’t be on reducing anyone’s pay on grounds of jealousy or title, but I will also point out that working together here necessarily means re-valuing pcp’s, md’s or otherwise, who are being left behind unfairly. I myself am not going into primary care, but I surely can appreciate their woes and their bases for occasional catharsis and thus cut them some slack.

      • tgottsdo

        I agree… well put. But I hate it when someone says, “I myself”… its redundent. just a pet peeve and something I’m trying to eliminate from the english language.

  • H

    “Money and Happiness: Rank of Income, Not Income, Affects Life Satisfaction”-Psychological Science

    “Earning a million pounds a year appears to be not enough to make you happy if you know your friends all earn 2 million a year.”

    “Our study found that the ranked position of an individual’s income best predicted general life satisfaction, while the actual amount of income and the average income of others appear to have no significant effect.”

  • tgottsdo

    H:

    It sounds like you are the special one off patient that doesn’t quite fit into any catagory. I think you’ve figured out a system that works for you and thats fine. I don’t think it works for the average person. In the long run you will be spending a lot more money going to a different physician for every body part. Many times, once a condition is stable, a primary care doctor can follow it just as well as a specialist. Now of course you will say that in your case you need constant care and adjustment in treatment by the specialist… and thats fine for you… I’m talking about the average patient. I’m wondering, since this is anonymous, what the 5 chronic conditions are that you mentioned before… just curious. I’m an Internist and see patients with over 5 chronic conditions everyday… the vast majority I manage without any specialists on the case.

    BTW, I never get $280 for any office visit no matter how long I spend with a patient… I might bill $280 but my average reimbursement per patient is $54 (all patients all levels, new and established). Every NP that I’ve ever worked with was on an hourly wage.