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Transcript to podcast: "JAMA Neurology's solution to neurologist shortage: Just substitute NPs/ PAs"

On May 24, 2021, JAMA, or the Journal of the American Medical Association, published a viewpoint entitled: “Advanced Practice Clinicians—Neurology’s Underused Resource.” The article was authored by nurse practitioner Calli Cook and Dr Heidi Schwarz, a neurologist with the University of Rochester and argued that due to a shortage of neurologists across the country, non-physician practitioners should be used more widely to provide neurology care to patients. Physicians for Patient Protection submitted a letter to the editor expressing concerns about these viewpoints, however, JAMA Neurology declined to print our letter, citing space concerns and "your letter did not receive a high enough priority rating for publication."

Neurologist/ psychiatrist Dr. Alyson Maloy and neurologist Dr. Carol Nelson join me to discuss the replacement of neurologists by nonphysician practitioners. Link to JAMA Neurology article: Get the book! Join

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Rebekah Bernard MD 0:07

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, Dr. Rebekah Bernard and I am joined by my guest co host tonight, Dr. Alyson Maloy. She is a fellow board member with Physicians for Patient Protection. On May 24, 2021, JAMA Neurology, the Journal of the American Medical Association published a viewpoint entitled "Advanced practice clinicians: Neurology's underused resource." The article was authored by nurse practitioner Calli Cook and Dr. Heidi Schwarz, a neurologist with the University of Rochester. And the article argued that due to a shortage of neurologists across the country, that non physician practitioners should be used more widely to provide neurology care to patients. Today I am joined by two experts to discuss this article, my co host who I introduced - Dr. Alyson Malloy is a Board Certified neurologist and psychiatrist in Maine. And on the phone we have joining us, Dr. Carol Nelson. She is a neurologist practicing in South Dakota. Welcome to the show. Dr. Nelson, can you start us out by sharing a little bit about your background and the training of a neurologist?

Carol Nelson MD 1:20

Sure. I'm a little older. I've been in practice for coming up on 26 years now. I started in 1982 with a four year bachelor's degree at the University of South Dakota and I majored in biology and minored in Chemistry, which is, I think, a pretty typical route for somebody that's pre med. I then took my MCAT. And then in 1986, I started at the University of South Dakota School of Medicine. So I did my four years there, and then I did what's called a transitional year. And it's a year of kind of like a preliminary medicine year where you do a lot of, you know, kind of month by month, different specialties to kind of get a feel for the different specialties. And then I went to University of Vermont for three years of Neurology training. So by the time I finished all of that I was 30. And then I came to Sioux Falls. And for the last 26 years I've been practicing here in Sioux Falls, practicing neurology. I started with an independent group and then became hospital owned, I think it was in about 2007. So I've seen over all these years, lots of changes in medicine.

Rebekah Bernard MD 2:32

It sounds like you're going to be able to speak to a lot of the evolution of Neurology especially. But just to recap, you did your transitional year, and then how many years was your neurology residency?

Carol Nelson MD 2:43

My transitional year was was one full year and then neurology is three years.

Rebekah Bernard MD 2:51

Does everyone have to do a transitional or an intern year in general medicine before they go into neurology?

Carol Nelson MD 2:57

Yes. You could either choose transitional year or at that time preliminary medicine.

Rebekah Bernard MD 3:01

Okay, so just to be clear, to become a Board Certified neurologist, as a physician, you have to complete four years of college, four years of medical school, a transitional or an intern year, which is one year, and then an additional three years, so a total of four years of residency training. Now, Alyson, what about you? Tell us about your story and your background.

Alyson Maloy MD 3:20

I did a four year degree at Columbia undergrad. I did four years of medical school at the University of Vermont. And then I did a double residency in neurology and psychiatry. There's only a few of them in the country. And you do the same eight years of residency in six. And so I had an internship year in medicine. And then I did three years of Neurology residency. Well, two and a half years of Neurology residency, and then two and a half years of psychiatry residency for a total of six, and then I did a one year neurology fellowship in autonomic disorders.

Rebekah Bernard MD 4:08

Wow. So again, four years of college, four years of medical school, six years to become double board certified in neurology and psychiatry, and then an additional fellowship year to sub specialize. Just for contrast, tell us what you know about the requirements to become a nurse practitioner or a physician assistant in neurology. Do you have any experience with that, Carol?

Carol Nelson MD 4:34

Well, I I have worked with some nurse practitioners and some PAs, but most of my experience is with a nurse practitioner because I've had the same nurse practitioner. I think we've been together about eight years. And she comes a little bit more from the old school time when nurse practitioners graduated from nursing school and practiced nursing for - I don't know the number of years - but there was a set amount of time they had to practice nursing before they could go back to school. She then got her master's in nurse practitioner and then she worked in orthopedics, I think it was for a year. So very little clinical experience before she came to me. So all of the neurology she learned was through myself and through our office, which it seems like a lot of what a good physician extender does is learn how your office works so that they can make the neurologist in this case more efficient. So she I think, nurse practitioners at that time, was also just a year after nursing school, and I believe they are still one or there might be some two year programs if you're getting your doctorate as a nurse practitioner.

Rebekah Bernard MD 5:49

Well, I really like what you say about acting as as a physician extender, and helping you to do your job more efficiently. We know that not all nurse practitioners nowadays do go through that brick and mortar training and have experience as nurses before they become nurse practitioners. In fact, many can go directly to become a nurse practitioner without even having worked as a nurse. And then the requirement is 500 clinical hours to be certified. For physician assistants. It's about 2000 clinical hours. So I guess the point I'm just trying to make as we lead into this discussion of this JAMA article is just that you and Dr. Maloy went through years and years and years, and I'd say it has to be 25-30,000 hours of training, because as a family physician, my training was about 15,000 hours. And that was a three year program. So I have to imagine you guys might may have even doubled that. And so to compare that to like a 500 hours or even 2000 hours, there's really no comparison.

Carol Nelson MD 6:47

But you know, I remember - again, I've done this for a long time - but I started practice before the time they put that 80 hour work week - I think it's 80 Hour work weeks - for residents, which is crazy when you think about it. 80 hours a week is a lot, but I remember working 110 one time,

Rebekah Bernard MD 7:06

Me too.

Alyson Maloy MD 7:06

Me, too.

Rebekah Bernard MD 7:08

Yeah, we're all three of us are old school here. We're all pre residency hour restrictions.

Alyson Maloy MD 7:13

That's where the term residency comes from. We live at the hospital. It's just not a generic word used for it, and it was our lives.

Rebekah Bernard MD 7:24

So why don't we start out by talking about this article that was written and published in JAMA? Alyson, can you tell us a little bit about what that article said?

Alyson Maloy MD 7:33

The title of the article, "advanced practice clinicians, neurology's underused resource" really examined why, when compared to other specialties, as they worded, neurology, quote unquote, 'struggles to integrate non physician practitioners' - meaning physician assistants and nurse practitioners. And the article really argues several points that we will all discuss here. But one of the biggest ones that stuck out at me was this concern for the lack of the number of neurologists and the hope that non physician practitioners can fill that deficiency of neurologists in the country. And it's a great idea. I really liked the idea. I don't happen to think it's possible. But that was really the premise. And then the article went through just ways that neurology can better integrate non physician practitioners and a lot of it was about how to improve the morale of the NPPs in practice, saying that many times they feel marginalized or undervalued in a neurology setting. And that ways to retain NPP should involve letting them practice, quote, unquote, 'at the top of their license.'

Rebekah Bernard MD 8:49

Right, so I'll just read from the beginning of the article, it says, quote, 'we have a supply and demand issue in neurology. Currently, the supply of neurology clinicians is inadequate to meet the demands of patients. And the distribution of neurologists in the US highlights inequitable access to care. This is not news to neurologists, where the mean wait time for a new patient is 32 to 35 days.' Now, first of all, let me ask you both of you this question. I'm a primary care doctor, so I don't know the correct answer, but is thirty days too long for the average patient to wait for a neurology visit?

Carol Nelson MD 9:24

You know, I think, for the most part, 30 days is probably a bit long. There's a lot of the different issues in neurology that can wait. Thinking of myself as a patient - when I've been a patient before - even waiting a week if I think I have some problem is a long time, especially when you're trying to get in with with something that requires a specialist. In my group, we've ranged anywhere from about five to nine partners, and I think the least amount of time we've ever had is a three week wait. We've gone up to three months. I do primarily headaches. So I can get booked out a little bit further, because I'm one of the only ones in the area that really does that primarily. I also take my job very seriously and my passion as a neurologist, and as a headache specialist very seriously. And if anybody messages me or calls me, one of the other primary physicians, or other specialists, I'm going to go out of my way to work them in. I work a lot of noon hours. So I think for the most part, a lot of neurologic conditions can wait 30 days from a physical standpoint, from the psychiatric standpoint, Dr. Maloy, you can probably answer this even better. From the psychiatric standpoint, it's hard to wait.

Alyson Maloy MD 10:42

To me, that 30 days sounds like a dream. Because here in Maine, I think most patients wait probably two months. And if something is more urgent, they will either go to the emergency room, or as Dr. Nelson said, as neurologists, we will just work late or we have urgent spots in our schedule are ready for something urgent. And also, what I will often do is work with their primary care physician to get the workup going before I see them. And I find that to be a very efficient and effective way to get people treated.

Rebekah Bernard MD 11:18

That makes sense. In my community, when I make a referral to a neurologist, usually they will review the records and the referral and then prioritize the patient based on what the issue is. Of course, you know, they're getting a lot of referrals for things like chronic back pain. And, of course, 30 days is a long time when you have back pain. But often we're talking about people who have been having this for possibly years. So they're going to prioritize people that have more acute problems, at least in my community. So I mean, I guess it's pretty clear that we do need more neurologists. I know we do in my community. But the answer to that may not be what this article suggested. And in fact, the truth is that there are more applicants for neurology residency training than there are slots. And according to the National Residency Match data, there were 1,441 applicants for just 701 PGY-1 first year neurology positions. So the first thing that I would say to this is, if we have a shortage of neurologists, why don't we train more neurologists? What do you think about that, Carol?

Carol Nelson MD 12:22

I think this has been just such a long term chronic shortage. As you know, whenever you try to fix a shortage, it takes a few years to catch up. Not only to catch up, to get them through training, but then to get them out into the communities and working full force. And this has just been such a chronic issue. And I know there's a cap on residency spots in general, and medicine has changed so much - it requires more doctors and more specialists. And it just hasn't kept up with the demand. And also with the aging population. Just medicine in general, getting physicians out into practice is just falling short.

Rebekah Bernard MD 13:04

Right. But I mean, I would argue based on the number of years that you had to go through training that just to replace neurologists with lesser trained - I don't know - and in fact, even the article says that. They say that there is a lack of Neurology qualifications for nurse practitioners and physician assistants. In fact, the article says, quote, 'there is little or no exposure to neurology in training for either of those professions.' Alyson, what do you think when you hear that?

Alyson Maloy MD 13:34

You know, I have been in medicine a long time and I moved to the state of Maine and didn't know a lot about nurse practitioners. And Maine is FPA - full practice authority -state. And it's quite disturbing to look around me and see what is proposed in this article has has in many ways already happened. And it doesn't work. I was shocked. That is Dr. Nelson alluded to. The only reason we are in this crisis is because of the 1997 Balanced Budget Act. The only reason all patients are scrambling, everybody's stressed, people can't see a doctor when they want to see a doctor, and we have all these convoluted, quote unquote, 'solutions.' The solution is simple. You need more neurologists, you train more neurologists. What's the confusion? You know, when we need more pilots, we don't train more mechanics, we train more pilots. And to suggest that you could have someone with no training move into a spot and then want to see patients independently? When Dr. Nelson and I had to go through the wringer for over a decade to prove our competency. Not only just prove it, but to actually gain it. You know, neurologic disorders are very complicated and takes seeing a lot of patients To see what's out there and to become competent and taking care of people, and I can give examples. Do we have time?

Rebekah Bernard MD 15:07

Yes, go ahead, Alyson.

Alyson Maloy MD 15:08

I specialize in complicated patients who have not gotten a solution, you know, going through the typical system. And I'll never forget a few of my patients. Most of them have been seeing physician extenders as a primary clinician, because in Maine, it's legal for a nurse practitioner to function independently. And PAs just got passed for that. Also, I had one woman come to me for depression and anxiety because again, I'm a psychiatrist. I said, Well, you know, What are you here for? And she's like, well, it's hard for me to really say, but I guess depression, anxiety. And as we started talking, she had migraines since age four, she had vertigo, she had this weird event after which she was disabled. Long story short, she had Thoracic Outlet Syndrome. And a nurse practitioner - first of all, as a physician, I'm thinking okay, a woman, a person who's had migraine headaches, since they're four, that's something structural, that's not a migraine. And she was being seen by a nurse practitioner in a headache clinic. And I asked her, so what physician ever diagnosed you with migraines? And you know, she had never really had a real formal evaluation for migraines. It just sort of kind of met the criteria and just always carried that diagnosis from when she was younger, but she had never seen a neurologist for headaches. And so long story short, you know, two surgeries later,she has no migraines. She has no depression and anxiety.

Rebekah Bernard MD 16:37

Alyson, for our listeners who don't know, can you explain what Thoracic Outlet Syndrome is?

Alyson Maloy MD 16:42

Thoracic Outlet Syndrome is when either the nerves or their blood vessels, they might get compressed - under your arm or somewhere up in your neck area. And so you don't have normal blood flow, neurologic function, you can get adhesions, and so you have a lot of pressure problems. And so her vertigo was from the abnormal pressure, and also on physical exam, you know, she had blanching on her chest, well, and then I had reviewed - she'd seen a chiropractor as well. And they'd reported some saccades, which also could be seen in Thoracic Outlet Syndrome. So, point being, this is a poor woman who had her life ruined, was on disability, had gone to see a million and one clinicians, was being managed by a neurology NP, whatever that means, because there's no real training in it. And she just needed to be seen by a physician.

Rebekah Bernard MD 17:36

Wow, well, it's not just a physician, it's a physician with your expertise. Because I'm a primary care physician, I'm a family doctor. And there's a good chance, I might not have been able to make that diagnosis. But of course, as you mentioned, I rely on my neurologist colleagues to help me with those tough cases. And in fact, that's one of the counter points that as part of our group Physicians for Patient Protection, we actually wrote a response to this viewpoint. And we pointed out that when primary care doctors or other specialists refer our patients to a neurologist, we're counting that that patient is going to be seen by an expert who knows more than we do. And that would not be a nurse practitioner or physician assistant; they have not trained longer than a family physician or an internal medicine physician. So just as you've mentioned, if you are the expert in that type of care, you need to know all of these rare conditions and how to make these diagnoses. And thank God, you were able to see her. It sounds like she may be on her the road to having a more normal life now,

Alyson Maloy MD 18:35

Definitely. She's a nurse, and she I fully expect to make a full recovery and go back to working.

Rebekah Bernard MD 18:41

Wow. Well, thanks for sharing that story.

Carol Nelson MD 18:45

Add one other thing with what Alyson is saying. So what what Alyson is describing, I'm sure that took her 30 or 45 minutes to take that history. But if you don't have the training, you can't take the appropriate history to sort out the different systems that were involved, and then bring that back together to how it's connected, because you're talking about headaches and vertigo and Thoracic Outlet Syndrome. So you've got to know what each of those are, you've got to be able to take the history. And then you have to be able to assimilate all that while you're sitting there and come up with the diagnosis. And then you have to examine them and see if that fits. And then you order the testing, not willy-nilly. But testing specific to either prove or disprove that, and then come up with the treatment and then sit there with the patient and go through prognosis. You simply cannot do that without the training that Alyson has. She kind of talks through it like it's easy, because it's what she does, and that's what we do. You can't just walk in and do that. You got to know the physiology and the anatomy in order to figure out the pathology.

Rebekah Bernard MD 19:54

To even think about that diagnosis because it's not super common. It's certainly wouldn't be on top of my list of differential diagnosis, but that's what you guys do. And you have that expertise. And that's why we rely on you to take care of our patients.

Alyson Maloy MD 20:07

And you know, that's the other thing, too, is one of the workups for that was a venogram, and it came back normal. But because I was so convinced that she had this based on the history, and based on the clinical exam, I called the neuroradiologist to reread it. And she said, actually, you're right, there is some narrowing here. And it's bilateral and etc. And so, you know, again, this is why medicine is an art and a science because you have to put the clinical and the studies together. I tried to get my clinical history to the neuroradiologist but it didn't make it there. And so when I saw she didn't have it, and I called her up to discuss the case, it was actually not a normal venogram. So you know, these things could never be done by a non physician practitioner.

Rebekah Bernard MD 20:54

No, it doesn't sound like it. And, you know, one of the things that we talk a lot about is concerning is health inequities. And in fact, the article pointed out, they say, they're concerned that not having enough neurologists leads to health inequities. But the question is, are some patients going to be asked to see a non physician practitioner, while other patients who have more knowledge or privilege are going to be allowed to see neurologists? You're in a rural area, Carol, what's your take on that?

Carol Nelson MD 21:22

I think it's actually been proven that the amount of testing that's ordered by a physician extender compared to an MD or a DO is astronomical. And so it's certainly not saving the system, or certainly the patient, money. And so getting in with an advanced practice provider or physician extender, or whatever term we want to use, it's not necessarily getting you closer to an answer - it is sort of just like buying some time and having them float through the system. But I think it's going to create a lot of unfairness for the poor, for the people that can't advocate for themselves, or people that are in the jail system. You know, I think there's a lot of people that are going to fall through the cracks and think they're - a lot of these people think they're seeing a neurologist. There's not a lot of transparency in who they're seeing. So the patient might think they're walking down the right path, and they're not.

Rebekah Bernard MD 22:19

Yeah, you're so right. I mean, it's not always transparent. Patients don't always know the difference. They just see someone in a white coat or someone with a lot of initials after their name. And they don't know. And that's really unfair, I think, to patients. They lose their ability to make a choice if they don't have that information. So one of the things that the article did was, it said that, again, their argument is that we need more non physician practitioners in neurology. And so in admitting that they don't have training in their actual programs, they suggest that these non physician practitioners should attend and participate in medical student and resident educational offerings. When we addressed that [in PPP] there was a lot of concerns because first of all, to get into medical school and residency, you have to have a really strong background and foundational understanding of medicine, and specifically neurology and neuro anatomy. And also you have to really have honed your critical thinking skills and problem solving skills. What do you think about the idea of putting a nurse practitioner or physician assistant in with medical students or with residents to enhance their training?

Carol Nelson MD 23:29

I think what happens then is it dilutes the learning of the resident, or the medical student, both, because you speak to people differently based upon their level of education. So if I'm speaking to the level of the lowest educated, I'm not speaking to the level of the medical student or the resident. If I'm backing up and teaching basic physiology, anatomy, and whatever, to try to get this nurse practitioner or a PA educated, I'm going down below the level of education that the resident and medical students already have. And it's also going to take away some of the procedures from the medical students.

Rebekah Bernard MD 24:13

Which is happening in a lot of fields right now, I understand. I think those are all really good points. And so the article says, in addition to that, or as an alternative, they say that neurologists should take the responsibility of training these practitioners and give them templates and onboarding materials. But isn't that kind of what you already do, Carol? You mentioned that you work with a nurse practitioner, and that sounds like kind of how you work with her.

Carol Nelson MD 24:41

I'm fortunate because I've got a very bright and very hardworking nurse practitioner who also enjoys her role as a physician extender and doesn't want more than that. She doesn't think she's more than that. And doesn't practice outside of her real scope, what her actual scope is, but we've had a lot of nurse practitioners and PAs go through our clinic where we fully train them and it takes months. So we fully, fully train them to be our extender. And we teach them some neurology, they can learn some of the like, okay for migraine, I'm going to do, you know, this preventive and this symptomatic therapy, or whatever. And then they quit and they go to the VA where they practice completely independently here. You take our our time - like, why should I train them? It's not my job. It's not my job. And I will train somebody who I'm trying to train to be my extender, who can do the prior authorizations, write the letters, you know, to the insurance companies, pull up the charts and get them ready for me, make calls to people, check my messages, things like that. Things that are helping me get to the patients that I need to be seeing, but we've seen several - they train and leave.

Rebekah Bernard MD 25:57

Well, neurology is a really tough field, I would say. I think it's one of the cognitive fields like endocrinology and rheumatology that, in my opinion, are undervalued because we tend to reward more procedures. But these are cognitive specialties. They require a lot of mental energy and time and investment. So I can see why people might come in and spend a few months and realize like this is not for me, I'm going on to something else.

Carol Nelson MD 26:23

Or they'll go and practice take what they learned from neurology and go and then they're considered a neurologist.

Rebekah Bernard MD 26:28

That doesn't seem fair at all. So you basically took the time to train them and now they are potentially competition I mean, not that they are real competition.

Alyson Maloy MD 26:36

But the problem is that they don't know enough. Three months of shadowing and being taught to be on a physician-led team gives one a false sense of mastery. And it is very, very dangerous because unless you have someone who is an expert in these fields at the bedside with you, guiding things and picking up things that a physician extender misses, these poor patients don't even know what has hit them. And I just briefly had another patient who saw an NP in psychiatry and an NP in neurology. She had known temporal lobe epilepsy. And she came to me again for depression, right this like, catch-all thing. And she said she was stumbling and this and that, and so the psych NP diagnosed her with bipolar and had her on dangerous class of medications called anti-psychotics because she was her mood was somewhat unstable. And the neuro NP again, whatever that means, diagnosed her with quote unquote, 'pseudo dementia,' which is when depression is so severe, it causes cognitive impairment. What she actually had was uncontrolled temporal lobe epilepsy. And it should not take - I mean, if this patient had been seeing an actual psychiatrist, she would not be on a dangerous class of medications of anti-psychotics mislabeled as bipolar. And if she'd seen an actual neurologist, they would have known that her temporal lobe epilepsy was not controlled, and she wouldn't have spent, you know, I think a year before she came to me to diagnose these basic things.

Carol Nelson MD 28:14

This spreads to a societal issue. Number one, this person is potentially disabled from this, her quality of life is poor. But if these people with epilepsy aren't controlled, they can seize and crash and kill somebody. So you don't just play as a doctor, you don't just play as a neurologist. It's a privilege to take care of patients. I mean, this is a human life, but that could also impact another human life and family. I mean, epilepsy, you don't just kind of do it. You do it. It's a huge responsibility. And actually, I think Alyson and Rebekah, I think you because we both agree with me when I was in my second and third year of residency - so I'm well into it, I remember sitting back and thinking, Oh, my gosh, I've only got a year left, how am I ever going to be ready? Am I going to feel ready? And I think the more you know, the more you realize what you don't know, and what you need to study more on. And you just realize how complex the human system is, and you just can't get that in a year and you can't get that in 2,000 hours. It's impossible.

Rebekah Bernard MD 29:24

You're so right. And it speaks to that Dunning-Kruger syndrome in which people that have their low level of experience overrate their own expertise. And that was one of the things that I was very disappointed in this article about, because one of their big arguments and Alyson alluded to it earlier, is that they said while most NPs and PAs in neurology are currently utilized as physician extenders, and the authors note that this leads to quote, 'dissatisfaction about not being allowed to operate to the fullest extent of their license as clinicians'. And the point is, yeah, just because you can do something doesn't mean that you should do something. And especially if you don't have an accurate understanding of your own knowledge about a subject. So, I found very upsetting because the answer to a physician shortage or neurology shortage is not to give poor quality care or not to allow people to, as you said, Carol, so eloquently, 'play doctor,' because these are human lives at stake. And it's not a game and it needs to be taken seriously.

Carol Nelson MD 30:27

One of the main points that bothered me in this article is that they say these physician extenders are upset because they're not practicing to the full extent extent of their licensure. But in that same article, they say they have little or no exposure to neurology. That means they are practicing to the extent of their knowledge, because they don't have it.

Rebekah Bernard MD 30:52

That's a very good point. And you know, exactly what you're doing with your nurse practitioner sounds to me like an extremely perfect and appropriate use. And very collaborative. You have a person that you hand-selected, you trained, you work very closely with, supervise, and in return, that person helps you to take care of patients and give them the best quality of care. To me, that sounds like the perfect role for a good nurse practitioner or a physician assistant that I think anyone should be proud to do. Right?

Alyson Maloy MD 31:27

And you know, Rebekah, when you say, you know, quote, that line about 'supporting their role as a clinician,' that can be integrated, and later on in the paragraph, it says, 'neurologists also have to be mindful of our own insecurities and implicit biases stemming from the fear that we can be replaced or are no longer in charge, because such reactions are often unconscious. Comments, or actions that demean or marginalize APC colleagues can create an unwelcome culture.' You know, I agree with Dr. Nelson, this article was so disturbing because it made it seem like there's something wrong with a team, and that there is an expert on the team, and that the other people on the team play a very important role. When I think about myself as a resident, I was phlebotomist, I was EKG tech. I was social work. I was transport. I mean, I was whatever the patient needed in that moment; there was no job too silly or beneath me. And that's what medical training is. And so to have practitioners who train in school for a few years, and then have some clinical knowledge, really, be so insulted by not being - you know, they talk in this article about a culture of inclusiveness and shared leadership. I'm sorry, but there's one leader on a medical team, and it's the physician. And that's not because physicians are arrogant or any of that. It's just because of the expertise.

Rebekah Bernard MD 33:07

And it's not to say that anybody couldn't do the same thing. If you want to be a neurologist, there's a way to do that. You go to medical school, you go into residency, you pay your dues, you learn what you need to learn, and now you are a neurologist. There's really no shortcuts when it comes to patient lives. And Alyson, you've given us some great examples of exactly where expertise really matters. I want to thank both my guest, Dr. Alyson Maloy, and Dr. Carol Nelson, for joining me in this really important discussion.

As an addendum to the podcast, I'd like to let our listeners know that Physicians for Patient Protection did submit a letter to the editor expressing our concern about this article in JAMA neurology. Unfortunately, the editors declined to publish our response stating that quote, 'unfortunately, because of the many submissions we receive and our space limitations in the letter section, we are unable to publish your letter in JAMA neurology. After considering the opinions of our editorial staff, we determined your letter did not receive a high enough priority rating or publication in JAMA neurology.'

If you'd like to learn more about this topic, I encourage you to get our book it's called 'Patients at risk, the rise of the nurse practitioner and physician assistant in healthcare.' It's available at Amazon and at Barnes and Noble calm. And if you're a physician, we really encourage you to join our group. It's called Physicians for Patient Protection. Our website is physiciansfor Please like and subscribe to our podcast and our YouTube channel. It's called Patients at Risk. Thanks so much and we'll see you on the next show.

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