Can I moonlight in a specialty not related to my residency field as a PGY2?

[ThoracicGuy]

IMO, thats inappropriate behavior on your consultants sake. I wouldn't want an NP seeing initial outpatient consults, just helping with follow-ups. Maybe that's just me though.

In my practice, my NP sees followup patients in the clinic. She may see new inpatient consults, but thats about all of the new contacts that she would be the first person the patient saw from our group.

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[Brahnold Bloodaxe]

They're not the first point of contact, they're the subspecialty appointment. I guess you can argue that the neurosurgery PA fills a diagnostic role to free the neurosurgeon to be in the OR (though I still don' t need the PA's help for diagnosis) but for Derm, Psych, Endo, or whatever else they just manage the patients. I have no idea how sick you need to be to merit seeing an actual physician, but apparently none of my patients have ever been sick enough.

We have't seen nothing yet. Today, there are roughly 230,000 midlevels. That's a lot in absolute terms but relatively very few compared to how many are coming out the pipeline. There are over 25,000 of them being churned out every year which means that over our careers their number will exceed 800,000 even with no additional growth in their training slots.

Somebody please tell me how increasing today's midlevel numbers threefold will not result in a cataclysmic disaster for the medical profession. They're already taking over our turf when there are only 230,000 of them, what are the next 500,000 gonna be doing if not taking over our jobs, or at the very least destroying our salaries to the point where it doesn't make financial sense to hire them?

 

[VA Hopeful Dr]

They're not the first point of contact, they're the subspecialty appointment. I guess you can argue that the neurosurgery PA fills a diagnostic role to free the neurosurgeon to be in the OR (though I still don' t need the PA's help for diagnosis) but for Derm, Psych, Endo, or whatever else they just manage the patients. I have no idea how sick you need to be to merit seeing an actual physician, but apparently none of my patients have ever been sick enough.

This must be location dependent, because none of my subspecialists with mid-levels operate this way. The first appointment is always with a physician. Follow-ups may be with the mid-level, but that's a different story.

 

[mimelim]

They're not the first point of contact, they're the subspecialty appointment. I guess you can argue that the neurosurgery PA fills a diagnostic role to free the neurosurgeon to be in the OR (though I still don' t need the PA's help for diagnosis) but for Derm, Psych, Endo, or whatever else they just manage the patients. I have no idea how sick you need to be to merit seeing an actual physician, but apparently none of my patients have ever been sick enough.

I won't get into whether or not that is appropriate given that everyone's practices are different. I haven't seen that where I am. Things are generally done as @ThoracicGuy and @VA Hopeful Dr describe where I am. Were your patients harmed by seeing a mid-level only? If there was delay in care or harm done, I would be pretty pissed at my consultants and would be unlikely to use them in the future if I had other options.

Now, that having been said, when I call some of our consultant services, I'm not really interested in what the residents have to say. I want to know what the attending says or what the NP or PA says. Frankly, they are more reliable and accurate. Far from universal, but not particularly rare.

 

[Perrotfish]

Now, that having been said, when I call some of our consultant services, I'm not really interested in what the residents have to say. I want to know what the attending says or what the NP or PA says. Frankly, they are more reliable and accurate. Far from universal, but not particularly rare.

I don't really want to know what the resident or the midlevel has to say, if its a pediatric subspecialty. I feel I know more than either a resident or a midlevel about those subjects, and I don't trust their diagnoses or plan of treatment more than one I could come up with myself. That's not saying midlevels are incompetent, just that I'm not either and I don't feel that they have a lot more expertise than I do. That being said with residents I know that this is part of the process of making a physician, and also that their opinion will ultimately be vetted by the attending, so I deal with it in the spirt of fairness and charity and wait for them to call me back with the 'new idea' about their plan in three hours, after they've talked to their attending. With midlevels odds are the attending will never even hear about my patient, and its not part of any training process, so I just end up crossing another consultant off of my list and pick up another skill set.

It does make outpatient medicine more interesting.

 

[Raryn]

Now, that having been said, when I call some of our consultant services, I'm not really interested in what the residents have to say. I want to know what the attending says or what the NP or PA says. Frankly, they are more reliable and accurate. Far from universal, but not particularly rare.

Depends on the resident.

I don't particularly care what the intern (any intern. except my wife.) has to say, but if it's the PGY7 Neurosurgery resident, he probably at least has some clue.

 

[VA Hopeful Dr]

Shockingly rare for people to get that

Signed,
PGY-1000000

Psh, I'll care about your opinion when you're a PGY-1000001

 

[cbrons]

you must be a med student if you think the 4 years in medical school gives you any proficiency in clinical practice...

And NP school is? I think thats the point he was trying to make.

 

[cbrons]

I won't get into whether or not that is appropriate given that everyone's practices are different. I haven't seen that where I am. Things are generally done as @ThoracicGuy and @VA Hopeful Dr describe where I am. Were your patients harmed by seeing a mid-level only? If there was delay in care or harm done, I would be pretty pissed at my consultants and would be unlikely to use them in the future if I had other options.

Now, that having been said, when I call some of our consultant services, I'm not really interested in what the residents have to say. I want to know what the attending says or what the NP or PA says. Frankly, they are more reliable and accurate. Far from universal, but not particularly rare.

Mid-levels are a scourge and you’ll soon be seeing them taking on surgical cases by themselves. It gets somewhat tiring reading you constantly harp on about how smart and more useful mid-levels are than everyone else, and repeating the obvious falsehood that “its just a med student issue.” Med students are more pissed about mid levels because mid levels jumped the queue all the way to full independent practice without any kind of med school or residency, and make 3x more than residents do without anywhere near the kind of debt. Youre daily experience in the vascular surgery world where NPs havent inveigled their way in to doing your entire job isnt how it is everywhere else in medicine. What’s more, it’s not how its going to remain in your specialty either. While a lot of surgeons think they are irreplaceable the fact of the matter is that the powers that be along with the various midlevel lobbies will be getting their “surgical provider” autonomy a lot sooner than you think.

 

[mimelim]

Mid-levels are a scourge and you’ll soon be seeing them taking on surgical cases by themselves. It gets somewhat tiring reading you constantly harp on about how smart and more useful mid-levels are than everyone else, and repeating the obvious falsehood that “its just a med student issue.” Med students are more pissed about mid levels because mid levels jumped the queue all the way to full independent practice without any kind of med school or residency, and make 3x more than residents do without anywhere near the kind of debt. Youre daily experience in the vascular surgery world where NPs havent inveigled their way in to doing your entire job isnt how it is everywhere else in medicine. What’s more, it’s not how its going to remain in your specialty either. While a lot of surgeons think they are irreplaceable the fact of the matter is that the powers that be along with the various midlevel lobbies will be getting their “surgical provider” autonomy a lot sooner than you think.

You are under some delusion that I am offended if an NP can do aspects of my job safely and cheaply, even when it comes to procedures. We offload our vein cases and a lot of our catheter work to mid-levels already. Most of our cardiac guys have PAs that open the chest, get the vein out and after doing the anastamoses, leave the OR. If there are protocolized procedures that can be performed at a lower cost by employing mid-levels, then it should be done by them. Obviously, if there is a different level of service, that is a completely different ball game.

By far my biggest objection to the NP/PA trashing is that medical students and physicians feel as though they are entitled to a certain job because of what they have sacrificed and how long they have been in school, just by virtue of having gone through it. The entitlement when looked at through the lens of anyone outside of medicine borders on the absurd.

 

[Psai]

You are under some delusion that I am offended if an NP can do aspects of my job safely and cheaply, even when it comes to procedures. We offload our vein cases and a lot of our catheter work to mid-levels already. Most of our cardiac guys have PAs that open the chest, get the vein out and after doing the anastamoses, leave the OR. If there are protocolized procedures that can be performed at a lower cost by employing mid-levels, then it should be done by them. Obviously, if there is a different level of service, that is a completely different ball game.

By far my biggest objection to the NP/PA trashing is that medical students and physicians feel as though they are entitled to a certain job because of what they have sacrificed and how long they have been in school, just by virtue of having gone through it. The entitlement when looked at through the lens of anyone outside of medicine borders on the absurd.

Of course it's absurd when you're paying huge amounts of money to be taught, just to be passed over for someone who sacrificed less time and effort than you did by the people who should be looking out for your interests. Training midlevels to do your job without them understanding why they're doing something just because you're lazy and want to work fewer hours is pathetic. I always go out of my way to educate medical students. I don't mind answering questions from nurses and ancillary staff but it's not my job to train people who think they are just as good as me and can replace me. There are just way too many midlevels online and in real life who disparage the physicians that trained them and try to discount what we do to get where we are.

 

[rokshana]

Of course it's absurd when you're paying huge amounts of money to be taught, just to be passed over for someone who sacrificed less time and effort than you did by the people who should be looking out for your interests. Training midlevels to do your job without them understanding why they're doing something just because you're lazy and want to work fewer hours is pathetic. I always go out of my way to educate medical students. I don't mind answering questions from nurses and ancillary staff but it's not my job to train people who think they are just as good as me and can replace me. There are just way too many midlevels online and in real life who disparage the physicians that trained them and try to discount what we do to get where we are.

why would a doctor train a midlevel student?

 

[Raryn]

why would a doctor train a midlevel student?

You never had PA students rotating around?

Plus, who do you want teaching say, student CRNAs to intubate?

 

[Psai]

I'm not like others who steal procedures from another specialty just to train an advanced care provider to do it

You never had PA students rotating around?

Plus, who do you want teaching say, student CRNAs to intubate?

They can train themselves as far as I'm concerned. I see the nonsense that they post online and the official statements posted by their leadership that go out of their way to disparage doctors at every opportunity.

 

[rokshana]

You never had PA students rotating around?

Plus, who do you want teaching say, student CRNAs to intubate?

nope
as a resident i had medical students on the service and don't recall ever seeing any. We had pharmacy residents on the service at the university hospital, but the pharmacist on the team was responsible for them.
as a fellow, had med students and medical residents on the service. We had one NP taking some of the inpt diabetes follow ups (with eventual goal of taking on most of the diabetes follow ups, but they did not do the initial consults).

I have seen mid levels utilized in an appropriate way...inpt to follow up glucose control in the hospital...i would probably bill, at best a level II, though most often a level I and using NP to follow them allows the attending to better utilize their time to to see more clinic pts(which we all know bill higher) or new consults in the inpt setting.

Where I am now, we have 2 mid levels that see the diabetes pts, for fairly straight forward diabetes, they may see them for the 1st visit and most follow ups (where i am, i believe they can run fairly independently, but the hospital has then "supervised" by the medical director. The policy is for the MD to see these pts 1-2 time a year) and the more complicated pts will see the MD initially and may continue to follow wit the MD or the NP at the MD's discretion. This does free up my schedule to see primarily endocrine pts...which i prefer...in the geographic area i am currently in, there is a significant lack of physicians in general and endocrinologists in particular, midlevels here are utilized in the best way...allowing for more care for the pts that need them.

 

[mvenus929]

nope
as a resident i had medical students on the service and don't recall ever seeing any. We had pharmacy residents on the service at the university hospital, but the pharmacist on the team was responsible for them.
as a fellow, had med students and medical residents on the service.

We have PA students/PA Fellows rotating on our hospitalist service and in the ED (though they don't take the place of a med student/resident, they just function as another body, which is fine in some ways and frustrating in others).

But yeah, for endo, the NPs primarily see diabetes follow-ups and simple hypothyroidism. The NPs/PAs on the surgery services basically function as eternal residents--they do all the floor work and assist in the OR, but still have to run plans by the attending. Our Cardiology PAs have years and years of experience, so the cardiologists trust them more than just about anyone else, thus they usually help run rounds and give plans to the residents when the attending gets held up somewhere else.

 

[rokshana]

We have PA students/PA Fellows rotating on our hospitalist service and in the ED (though they don't take the place of a med student/resident, they just function as another body, which is fine in some ways and frustrating in others).

But yeah, for endo, the NPs primarily see diabetes follow-ups and simple hypothyroidism. The NPs/PAs on the surgery services basically function as eternal residents--they do all the floor work and assist in the OR, but still have to run plans by the attending. Our Cardiology PAs have years and years of experience, so the cardiologists trust them more than just about anyone else, thus they usually help run rounds and give plans to the residents when the attending gets held up somewhere else.

what the heck is a PA fellow??

 

[Rendar5]

what the heck is a PA fellow??

I assume a PA training to be used in a specific setting/specialty

 

[rokshana]

I assume a PA training to be used in a specific setting/specialty

then why would that not be a PA resident? A fellow is someone who has done a core residency then seeks further sub specialized training.

 

[Psai]

then why would that not be a PA resident? A fellow is someone who has done a core residency then seeks further sub specialized training.

I'm just surprised that they don't try to call themselves PA attendings while they're attempting to gain more training

 

[sugarangelcake]

I'm just surprised that they don't try to call themselves PA attendings while they're attempting to gain more training

They're already trying to change it from physician assistant to physician associate, who knows what they will push for later on?

 

[mvenus929]

what the heck is a PA fellow??

I didn't make the term, I have no idea why it was coined, but at our institution, they are people who have a PA degree and license who are going through more training in a specific field (usually urgent care, in our case).

 

[AdmiralChz]

what the heck is a PA fellow??

At my residency institution, we had "surgical critical care fellowships" open to PAs and NPs. Very frequently when we, as residents, rotated in SICUs we would be preparing for a procedure (bronch, intubation, CVL) only to be pulled aside by the "fellow" so they could get more experience. The surgeons in charge of the unit didn't seem to give a crap, I finally had it by my last year and refused to allow them to take procedures from interns/junior residents on service. Almost earned me a "failure" in professionalism for the rotation, but was totally worth it.

If you don't see these graduates believing they can function independently in a critical care setting then you don't have your eyes open. We also had a EM fellowship for midlevels - EM and CC are the next frontier of independent practice for them.

There was recently a great discussion about this over in the critical care subforum, check it out here for more insight from others: What is the midlevel situation in CC?

 

[Brahnold Bloodaxe]

You are under some delusion that I am offended if an NP can do aspects of my job safely and cheaply, even when it comes to procedures. We offload our vein cases and a lot of our catheter work to mid-levels already. Most of our cardiac guys have PAs that open the chest, get the vein out and after doing the anastamoses, leave the OR. If there are protocolized procedures that can be performed at a lower cost by employing mid-levels, then it should be done by them. Obviously, if there is a different level of service, that is a completely different ball game.

By far my biggest objection to the NP/PA trashing is that medical students and physicians feel as though they are entitled to a certain job because of what they have sacrificed and how long they have been in school, just by virtue of having gone through it. The entitlement when looked at through the lens of anyone outside of medicine borders on the absurd.

The mentality you are espousing is what is absurd. Might as well tell people to be happy and accepting of another man coming into your house and banging out your wife. After all, if this other dude can do the job better than you can you'd have to be an "entitled" pig to oppose the notion, amirite?

The presence of people with this mentality in my chosen profession disgusts and depresses me. I simply cannot envision a lawyer glibly accepting being made redundant by a paralegal "so long as the service is equal." Or in any other profession. But according to you, by going to medical school I have forfeited my very humanity: I cannot care about my own future or well being nor do I have a right to respond to threats the way human nature dictates.

Of course that's all bullsheit. You merely feel insulated in your chosen specialty and think you can smugly pontificate because you believe you have no skin in the game. If you woke up one day and felt that everything you worked for over the previous decade of your life was under serious threat you'd surely be singing a whole different tune.

 

[VA Hopeful Dr]

The mentality you are espousing is what is absurd. Might as well tell people to be happy and accepting of another man coming into your house and banging out your wife. After all, if this other dude can do the job better than you can you'd have to be an "entitled" pig to oppose the notion, amirite?

The presence of people with this mentality in my chosen profession disgusts and depresses me. I simply cannot envision a lawyer glibly accepting being made redundant by a paralegal "so long as the service is equal." Or in any other profession. But according to you, by going to medical school I have forfeited my very humanity: I cannot care about my own future or well being nor do I have a right to respond to threats the way human nature dictates.

Of course that's all bullsheit. You merely feel insulated in your chosen specialty and think you can smugly pontificate because you believe you have no skin in the game.

You can care as much as you want. Just don't expect those of us out in the world who are actually dealing with mid-levels to agree with you.

 

[Brahnold Bloodaxe]

You can care as much as you want. Just don't expect those of us out in the world who are actually dealing with mid-levels to agree with you.

I don't expect anyone to agree with me and I never said anything to that effect in the post you quoted. This is what I object to:

"By far my biggest objection to the NP/PA trashing is that medical students and physicians feel as though they are entitled to a certain job because of what they have sacrificed and how long they have been in school, just by virtue of having gone through it. The entitlement when looked at through the lens of anyone outside of medicine borders on the absurd."

He's literally saying that after going 300k into debt and devoting 7 to 10 years of my life in a single-minded pursuit of a medical career it would be "absurd" for me to be upset if it all went to waste and I ended up without a job or with the salary I had at 22 straight out of college. This kind of mentality is sheer insanity.

 

[VA Hopeful Dr]

I don't expect anyone to agree with me and I never said anything to that effect in the post you quoted. This is what I object to:

"By far my biggest objection to the NP/PA trashing is that medical students and physicians feel as though they are entitled to a certain job because of what they have sacrificed and how long they have been in school, just by virtue of having gone through it. The entitlement when looked at through the lens of anyone outside of medicine borders on the absurd."

He's literally saying that after going 300k into debt and devoting 7 to 10 years of my life in a single-minded pursuit of a medical career it would be "absurd" for me to be upset if it all went to waste and I ended up without a job or with the salary I had at 22 straight out of college. This kind of mentality is sheer insanity.

I don't think he was saying you can't be ticked off in that scenario, only that you aren't entitled to a job just because you're a doctor.

 

[mimelim]

I don't expect anyone to agree with me and I never said anything to that effect in the post you quoted. This is what I object to:

"By far my biggest objection to the NP/PA trashing is that medical students and physicians feel as though they are entitled to a certain job because of what they have sacrificed and how long they have been in school, just by virtue of having gone through it. The entitlement when looked at through the lens of anyone outside of medicine borders on the absurd."

He's literally saying that after going 300k into debt and devoting 7 to 10 years of my life in a single-minded pursuit of a medical career it would be "absurd" for me to be upset if it all went to waste and I ended up without a job or with the salary I had at 22 straight out of college. This kind of mentality is sheer insanity.

Welcome to the real world. If someone can do a part of your job for a fraction of the cost with a fraction of the headache to the bosses, you bet that you are going to get priced out of the market. It doesn't matter how much schooling you have had or how much you have sacrificed. If someone with less training, shorter training or whatever it is can do something, hospitals are going to utilize them. In no way am I saying that NPs = MDs or that NPs can function as 1 to 1 doctor replacements.

And yes, I consider your position to be absurd. You want to have guaranteed employment with a salary in the top 3% of Americans by virtue of you going to school for a certain amount of time. Not based on your value to to the healthcare system, not based on your relative capabilities both economical and healthcare delivery wise. But, just because you spent the time. In a capitalistic society, no other industry does it work like that. That is the textbook definition of entitlement. You feel like you are owed something based on who you are, not your actual value to others.

The mentality you are espousing is what is absurd. Might as well tell people to be happy and accepting of another man coming into your house and banging out your wife. After all, if this other dude can do the job better than you can you'd have to be an "entitled" pig to oppose the notion, amirite?

The presence of people with this mentality in my chosen profession disgusts and depresses me. I simply cannot envision a lawyer glibly accepting being made redundant by a paralegal "so long as the service is equal." Or in any other profession. But according to you, by going to medical school I have forfeited my very humanity: I cannot care about my own future or well being nor do I have a right to respond to threats the way human nature dictates.

Of course that's all bullsheit. You merely feel insulated in your chosen specialty and think you can smugly pontificate because you believe you have no skin in the game. If you woke up one day and felt that everything you worked for over the previous decade of your life was under serious threat you'd surely be singing a whole different tune.

I think I can safely be rather blunt here based on this post. You are most certainly are entitled to your opinion. You literally have no ****ing clue what you are talking about. Never mind the medical stuff...

#1 For starters, I think that your attempted comparison of my position on mid-level providers and sexual assault of my spouse to be rather misguided and offensive.
#2 Further, you clearly know nothing about the legal profession. Ask recent law graduates about the job market. Suggest that they should be guaranteed employment with a salary in the top 5% of earners in the US and watch them laugh at you. That isn't how the real world works. If you graduate from a top school, if you graduate in the top of your class, you will have job offers and opportunities, but the majority struggle to find 'good' legal jobs. And yes, many of them are turned away from firms because frankly a lot of the legal work CAN be done by paralegals and paralegals are cheaper, less hassle and once they gain experience in a particular area infinitely better than a fresh associate. Not terribly unlike the situation with mid-level providers.
#3 I don't know how I have implied anywhere that you "forfeited your humanity". Sounds rather melodramatic for my tastes. You can absolutely respond however the **** you want. Just realize that you come across as a spoiled little brat when you whine about what you are entitled to rather than what your actual value is.

I feel "merely insulated"? Some of us live this every ****ing day. How many mid-level providers have you interacted with in the last 2 weeks. Or better yet, how many physicians have you interacted with in the last 2 weeks? How much time have you spent away from academic practices, ie. where the vast majority of healthcare in the United States is delivered? I interface daily with dozens of physicians, the vast majority who employ mid-level providers. We certainly all have our gripes about mid-levels, the same way we do about different specialties, or residents or really anyone. But, I see physicians in every specialty utilizing mid-level providers and happily so, whether it be primary care or surgical subspecialties. @Perrotfish 's point is well taken. There are plenty of NPs or PAs that are employed in ways that will confound or piss off consultants. That is bad business practice. But, that is hardly what you and others are arguing.


In short, there are extremely good reasons why hospitals and private physicians hire mid-level providers and in general it is with the blessing of or strong encouragement of physicians. I have yet to hear in person a physician gripe about mid-level encroachment as a threat to their practice. I have heard ad nauseum from pre-meds and medical students about the evils of mid-levels because they get to practice sooner than them and make more money than them while they are residents. You can be ticked off all you want. You can be upset by it all you want. I know that my professional life will be improved by having mid-level providers in the work place. I know that this in no way is limited to my specialty or surgical subspecialties. I can see the massive limitations of our healthcare system as it is right now. I certainly acknowledge that most of those limitations were not made by physicians, but by the same token, weren't solved by them either and are in no way going away. More Americans will be helped healthcare wise with mid-level proliferation. Some will invariably be hurt by it. And I can sleep at night knowing that.

 

[Perrotfish]

Welcome to the real world. If someone can do a part of your job for a fraction of the cost with a fraction of the headache to the bosses, you bet that you are going to get priced out of the market.

The issue is that this is a licensed profession. Physicians went through their minimum of 11 years of training with the understanding that the practice of our profession would be protected from people who had less training. Because the government said you need 11 years of training to practice safely, and even then you can only practice a small subset of medicine without going back to train more. The promise that ALL medical providers would be held to those standards was an implied contract with the government.

However, while this generation of physicians were racking up hundreds of thousands in non dischargable debt, we somehow decided that it was OK for a mid-level to do anything at all with a minimum of 6 years of online part time coursework. The government broke their end of the contract.

Worse yet, we kept the training and licensing requirements for phyicians. In fact we are making them worse: more MOC, more states denying licenses to providers without multiple years of GME, and more regulation of students' ability to contribute to the team that devalues medical education .

This is unfair to our profession. We are being shacked by rules that everyone else no longer needs to play by. This is also unfair to our patients: they should be able to assume that either the quality of care they are receiving is regulated, or that it isn't and that they need to distrust every provider until they have done a background check. A model where some providers go through a tightly regulated and expensive training pathway pathway while others can do basically anything with almost not training is not sustainable..

 

[Rendar5]

That’s assuming that mid levels do the equivalent of physicians which they don’t. I haven’t yet found jobs to be lacking in my field despite having seen and worked alongside midlevels in my field since residency (And I’m talking mid levels with at least a decade of experience which means they were working in my field for 20 years at this point). They’re not providing the same overall level of care as me and they’re not taking any of the jobs that I want so I don’t expect them to have to do the same education or jump through the same hoops as I do. I can’t speak on behalf of other parts of medicine, but I can speak on behalf of emergency medicine.

 

[cbrons]

The issue is that this is a licensed profession. Physicians went through their minimum of 11 years of training with the understanding that the practice of our profession would be protected from people who had less training. Because the government said you need 11 years of training to practice safely, and even then you can only practice a small subset of medicine without going back to train more. The promise that ALL medical providers would be held to those standards was an implied contract with the government.

However, while this generation of physicians were racking up hundreds of thousands in non dischargable debt, we somehow decided that it was OK for a mid-level to do anything at all with a minimum of 6 years of online part time coursework. The government broke their end of the contract.

Worse yet, we kept the training and licensing requirements for phyicians. In fact we are making them worse: more MOC, more states denying licenses to providers without multiple years of GME, and more regulation of students' ability to contribute to the team

This is unfair to our profession. We are being shacked by rules that everyone else no longer needs to play by. This is also unfair to our patients: they should be able to assume that either the quality of care they are receiving is regulated, or that it isn't and that they need to distrust every provider until they have done a background check. A model where some providers go through a tightly regulated and expensive training pathway pathway while others can do basically anything with almost not training is not sustainable..

Well stated as always.

Idk if you are aware but there is now a 5-year option to becoming an “attending” straight out of high school: Accelerated BSN (1-year) plus DNP online (4-years). I know of one person doing this who is a real prize and thinks he’ll be a surgeon someday. I can guarentee he will, too.

Also, know many admins/staffers from medical schools up to the hospital level who buy into the mid-level racket. There is one in particular on here who despite having no medical degree herself makes it a point to tell stories about her kid’s “pediatrician” who isnt actually a pediatrician, but a PA - using the term specifically to troll people.

 

[Perrotfish]

Idk if you are aware but there is now a 5-year option to becoming an “attending” straight out of high school: Accelerated BSN (1-year) plus DNP online (4-years).

Honestly I don't even know what the right answer is. Maybe 5 years is enough. Or maybe 8 is. Or maybe surgeons need all the training but PCPs don't. I have seen a lot of horrifyingly bad midlevels, but I have also seen a lot of really bad doctors. Clearly neither system is perfect and I don't know what the benefit is for those extra years of training.

I'm just sure that ONE of these systems need to go. If 11 years of being trapped in medical education is what we need to practice safely then we can't let some providers skirt the rules. On the other hand if six much less abusive years are enough then we need to say that and shut down the residencies. One or the other.

 

[mimelim]

The issue is that this is a licensed profession. Physicians went through their minimum of 11 years of training with the understanding that the practice of our profession would be protected from people who had less training. Because the government said you need 11 years of training to practice safely, and even then you can only practice a small subset of medicine without going back to train more. The promise that ALL medical providers would be held to those standards was an implied contract with the government.

However, while this generation of physicians were racking up hundreds of thousands in non dischargable debt, we somehow decided that it was OK for a mid-level to do anything at all with a minimum of 6 years of online part time coursework. The government broke their end of the contract.

Worse yet, we kept the training and licensing requirements for phyicians. In fact we are making them worse: more MOC, more states denying licenses to providers without multiple years of GME, and more regulation of students' ability to contribute to the team that devalues medical education .

This is unfair to our profession. We are being shacked by rules that everyone else no longer needs to play by. This is also unfair to our patients: they should be able to assume that either the quality of care they are receiving is regulated, or that it isn't and that they need to distrust every provider until they have done a background check. A model where some providers go through a tightly regulated and expensive training pathway pathway while others can do basically anything with almost not training is not sustainable..

I'm not following the "implied contract with the government" which is what this all seems to be hinging on. Which government are you talking about? Do you mean the state licensing board? If you mean the federal government, which part of it? If there is an obvious breach of contract where is the lawsuit? Does anyone agree that there was an implied contract outside of physicians? While I can follow this line of reasoning somewhat, it is hard to see it beyond an extremely limited scope unless you bring in emotional appeals of, "they are taking our jobs!"

For starters, it is disingenuous to say "minimum of 11 years of training". I know MDs who had 7 years of post-high school education and are practicing medicine in the US. They are not board certified. They only did a year of residency. But, they have unrestricted state medical licenses and practice medicine. There are a variety of pathways that can lead you to practicing medicine with an MD in the US that do not take 11 years. We can argue about whether or not that is safe or right to do, and while they are a small minority of MDs, so are NPs that are 5-6 years out of high school. If we are going to call undergrad "training", it is hard to discount working as an RN. The government does not mandate the number of years of training, it simply has requirements that you must fulfill in order to practice. Which is no different than any other profession, in medicine and out.

I can understand being against people calling for NP and MD equivalency. I am most certainly for that. But, the concept that everything that physicians have historically provided can ONLY be provided by physicians is absurd and people are calling us on it. We have a practical problem in this country of providing healthcare for our population. Physicians are not capable or are unwilling to providing that comprehensive coverage. It should hardly be surprising that people come up with other solutions.

I am in no way arguing that we should scrap regulations on the practice of medicine. But, I think that the vast majority of complaints about NPs/PAs are born out of ignorance and emotional, us vs them mentalities. Are there people within the NP community that are fanatical and argue for more than what I would consider as safe? Absolutely. But, I would argue that the opinions of many pre-meds, medical students, residents and practicing physicians are equally fanatical (see comparison of sexual assault of my wife to NPs practicing in limited scope earlier this thread as a recent example). Talks of "unfair" or "we paid lots of tuition" gets laughed at by virtually everyone outside of medicine and frankly by the general public. It is hard to defend, "But I should be guaranteed top 3% earner salary and a job."

 

[Perrotfish]

I am in no way arguing that we should scrap regulations on the pracice of medicine.

See I think that, basically, you are. If you are arguing that people should be allowed to 'find other solutions' for providing care, rather than forcing everyone to go through a regulated training pathway that we created through mutual consensus, you are arguing for deregulation. If you believe an NP or PA should be allowed to practice you are arguing that medical education is not necessary.

That can be a reasonable argument. You might argue that we need to keep regulations, but set a lower bar for who is and is not allowed to practice.. Maybe medical school alone is enough to practice and residency is a waste. Maybe a 2 year degree is enough to practice and we should scrap MDs and switch to all DNP degrees. Maybe an undergraduate degree is enough and anything more than an RN is a waste. You might argue (many surgeons do) that some parts of medicine (surgery) needs an MD and a long residency but other subsets of medicine (primary care) could be handled by pretty much anyone. You might even argue that medicine should be deregulated completely: anyone should be allowed to set up shop as a physician if they want to, we should get rid of licensing, and anyone should be able to buy any medication they want without getting permission from an expert.

Whatever you think is appropriate, though, it doesn't make sense for us to have different pathways to the same job, that involve wildly different commitments of time and money. If 6 years is enough for primary care, then we need to shut down every primary care residency in this country as unnecessary and abusive. If 11 years is the minimum for competence, we need to shut down every 5 year high school to DNP program as a danger to the public.

 

[VA Hopeful Dr]

See I think that, basically, you are. If you are arguing that people should be allowed to 'find other solutions' for providing care, rather than forcing everyone to go through a regulated training pathway that we created through mutual consensus, you are arguing for deregulation. If you believe an NP or PA should be allowed to practice you are arguing that medical education is not necessary.

That can be a reasonable argument. You might argue that we need to keep regulations, but set a lower bar for who is and is not allowed to practice.. Maybe medical school alone is enough to practice and residency is a waste. Maybe a 2 year degree is enough to practice and we should scrap MDs and switch to all DNP degrees. Maybe an undergraduate degree is enough and anything more than an RN is a waste. You might argue (many surgeons do) that some parts of medicine (surgery) needs an MD and a long residency but other subsets of medicine (primary care) could be handled by pretty much anyone. You might even argue that medicine should be deregulated completely: anyone should be allowed to set up shop as a physician if they want to, we should get rid of licensing, and anyone should be able to buy any medication they want without getting permission from an expert.

Whatever you think is appropriate, though, it doesn't make sense for us to have different pathways to the same job, that involve wildly different commitments of time and money. If 6 years is enough for primary care, then we need to shut down every primary care residency in this country as unnecessary and abusive. If 11 years is the minimum for competence, we need to shut down every 5 year high school to DNP program as a danger to the public.

Except he's not arguing for midlevel independence. As long as they are legally required to be supervised, its not really deregulation of who can practice medicine.

 

[cbrons]

Except he's not arguing for midlevel independence. As long as they are legally required to be supervised, its not really deregulation of who can practice medicine.

They're not in most states now.

 

[Winged Scapula]

"Fraction of the cost" is the key here.

Midlevels, especially NPs are pushing to be paid the same as physicians. The same physicians they say make too much money. They want to be paid the same because they think they offer the same service. They stuff they write on their websites and FB pages is ugly and full of ignorance and self-importance. They believe that because they thread angiocatheters, that the next logical step is to be privileged to perform angioplasty and thrombectomy.

What MLP fail to realize is that they were hired because they were cheaper.

We cannot bury our heads in the sand and think it won't affect us. A group of physicians just returned from DC attempting to educate politicians on the differences in education and training; they felt it was beneficial but noted that right in front on them and right behind them were a very strident strong nursing lobby attempting to curry favor for independent practice and equal reimbursement and privileges.

 

[Perrotfish]

"They want to be paid the same because they think they offer the same service.

The thing is that I actually agree with them. In medicine, it's either the standard of care or it isn't. We would never allow a pharmacist to dispense a medicine that's 'kinda' pure or 'sorta' safe to save money, it's all or none.

If NPs providing unsupervised care is the standard of care then they should be paid the same as anyone else providing that service. That might mean increasing their salary, decreasing reimbursement for physicians, or (most likely) some midway point between the two. On the other hand if it's not the standard of care then it needs to be illegal. Not lower cost. Illegal.

If we are going to start saying it's ok for poor patients to get kind of unsafe care because, you know.... poor, then we are moving medical ethics back to where it was in the 19th century. That is NOT ok.

 

[VA Hopeful Dr]

They're not in most states now.

Not mine, and I wouldn't move to a state where they were.

 

[VA Hopeful Dr]

The thing is that I actually agree with them. In medicine, it's either the standard of care or it isn't. We would never allow a pharmacist to dispense a medicine that's 'kinda' pure or 'sorta' safe to save money, it's all or none.

If NPs providing unsupervised care is the standard of care then they should be paid the same as anyone else providing that service. That might mean increasing their salary, decreasing reimbursement for physicians, or (most likely) some midway point between the two. On the other hand if it's not the standard of care then it needs to be illegal. Not lower cost. Illegal.

If we are going to start saying it's ok for poor patients to get kind of unsafe care because, you know.... poor, then we are moving medical ethics back to where it was in the 19th century. That is NOT ok.

And that's the rub. Once they are paid the same as us, why would anyone hire them over a doctor. Answer: they won't.

 

[Perrotfish]

And that's the rub. Once they are paid the same as us, why would anyone hire them over a doctor. Answer: they won't.

To be clear, when they say they want to be 'paid' the same, they mean they want to receive the same reimbursement per unit of service from insurance companies, first and foremost from Medicare.. They are selling this to insurance companies as a win:win. They can decrease overall costs by decreasing the price per unit of service while still increasing the reimbursement for mid-level. So only doctors lose.

The people who actually hire midlevels, and us, calculate their value as revenue minus overhead. If the revenue was the same per unit of service they would not hire them 'over' us, they also wouldn't hire us over them. From the admin side we would be equivalent: same number of RVUs generated, same reimbursement per RVU, same overhead, same salary. They become more desirable hires when they are 'paid' more, because they generate more revenue against a static overhead cost.

You might feel you are more valuable to your employer because you provide better care. Unless you work for an HMO that isn't true. You are more valuable to your PATIENTS if you provide better care, but you are more valuable to your employer because most insurance policies currently say that a check up from a physician is worth 1.5x the value of a checkup from a mid-level. If they change that rule, your relative value to your employer disappears.

 

[VA Hopeful Dr]

To be clear, when they say they want to be 'paid' the same, they mean they want to receive the same reimbursement per unit of service from insurance companies, first and foremost from Medicare.. They are selling this to insurance companies as a win:win. They can decrease overall costs by decreasing the price per unit of service while still increasing the reimbursement for mid-level. So only doctors lose.

The people who actually hire midlevels, and us, calculate their value as revenue minus overhead. If the revenue was the same per unit of service they would not hire them 'over' us, they also wouldn't hire us over them. From the admin side we would be equivalent: same number of RVUs generated, same reimbursement per RVU, same overhead, same salary. They become more desirable hires when they are 'paid' more, because they generate more revenue against a static overhead cost.

You might feel you are more valuable to your employer because you provide better care. Unless you work for an HMO that isn't true. You are more valuable to your PATIENTS if you provide better care, but you are more valuable to your employer because most insurance policies currently say that a check up from a physician is worth 1.5x the value of a checkup from a mid-level. If they change that rule, your relative value to your employer disappears.

That's true if we take out patient preference. My experience has been that, if cost to them is the same, they want to see a doctor. That's also often the case even if cost to them isn't the same.

 

[Señor S]

Not mine

...not yet

 

[DrfluffyMD]

You are under some delusion that I am offended if an NP can do aspects of my job safely and cheaply, even when it comes to procedures. We offload our vein cases and a lot of our catheter work to mid-levels already. Most of our cardiac guys have PAs that open the chest, get the vein out and after doing the anastamoses, leave the OR. If there are protocolized procedures that can be performed at a lower cost by employing mid-levels, then it should be done by them. Obviously, if there is a different level of service, that is a completely different ball game.

By far my biggest objection to the NP/PA trashing is that medical students and physicians feel as though they are entitled to a certain job because of what they have sacrificed and how long they have been in school, just by virtue of having gone through it. The entitlement when looked at through the lens of anyone outside of medicine borders on the absurd.

So let me get this right, you offload “a lot of” vein and angio work to your mid levels. The same mid levels who are often already clinically adapt at seeing patients independently (whether you agree or not).

Isn’t that mst of your specialty outside of the open surgical work which are diminishing?

Fact is, utilization of mid level is always a way to cure your thirst by drinking poison. As someone who is soon to be a junior attending I am more than happy to have them around because they make my job easier, but it doesn’t change how midlevels threaten everyone involved.

There honestly isn’t anything special about angioplasty past a steep learning curve. If your precedessors can learn it, so can your NP and PAs, and yes, they will learn it whether you teach it to them or not.

Sounds like they are fairly ready to go into your house and eat your cake.