Is being replaced by mid levels a legitimate concern in peds?

[zeppelinpage4]

So I’m a year into my first gen peds job and noticed 90% of my visits are standard sick visits like URI’s, UTI’s, stomach bugs, eczema etc, and the rest are well visits. I’m mostly providing reassurance and preventative care. Once in a while I get something odd, like a Kawasaki case or pneumothorax but it’s rare and often times I have to refer anything more complex because of limited time (we only have 10-15 minutes per patient) or it’s truly beyond my scope.

We also have three experienced NP’s who see all the same patients and visits we do. They’re not supervised by the docs, and work along side us. However the NP’s are paid less and don’t get RVU bonuses like the doctors. Thus, I am wondering, what is stopping my employer from one day replacing me with an NP to save money?

I know my training is more rigorous but for a strictly outpatient gen peds job like mine where most complex cases go to the specialist and the hospitalist does all the inpatient care, is there a future for a physician? Or am I likely to be replaced by an NP? I keep hearing physicians will get replaced my mid levels, especially in primary care and I don’t know if this is overblown or if I should genuinely be concerned and look for career alternatives now. I don’t mind working alongside NPs but would like to keep my outpatient only peds job and salary as it is.

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[SurfingDoctor]

So I’m a year into my first gen peds job and noticed 90% of my visits are standard sick visits like URI’s, UTI’s, stomach bugs, eczema etc, and the rest are well visits. I’m mostly providing reassurance and preventative care. Once in a while I get something odd, like a Kawasaki case or pneumothorax but it’s rare and often times I have to refer anything more complex because of limited time (we only have 10-15 minutes per patient) or it’s truly beyond my scope.

We also have three experienced NP’s who see all the same patients and visits we do. They’re not supervised by the docs, and work along side us. However the NP’s are paid less and don’t get RVU bonuses like the doctors. Thus, I am wondering, what is stopping my employer from one day replacing me with an NP to save money?

I know my training is more rigorous but for a strictly outpatient gen peds job like mine where most complex cases go to the specialist and the hospitalist does all the inpatient care, is there a future for a physician? Or am I likely to be replaced by an NP? I keep hearing physicians will get replaced my mid levels, especially in primary care and I don’t know if this is overblown or if I should genuinely be concerned and look for career alternatives now. I don’t mind working alongside NPs but would like to keep my outpatient only peds job and salary as it is.

Your knowledge base is higher. The patients pay for that expertise.

The actual question is do patients want expertise or someone to give them the drugs they want? Based on my time in the PICU with COVID, they want the latter. That’s the rub.

 

[Putkernerinthehall]

So I’m a year into my first gen peds job and noticed 90% of my visits are standard sick visits like URI’s, UTI’s, stomach bugs, eczema etc, and the rest are well visits. I’m mostly providing reassurance and preventative care. Once in a while I get something odd, like a Kawasaki case or pneumothorax but it’s rare and often times I have to refer anything more complex because of limited time (we only have 10-15 minutes per patient) or it’s truly beyond my scope.

We also have three experienced NP’s who see all the same patients and visits we do. They’re not supervised by the docs, and work along side us. However the NP’s are paid less and don’t get RVU bonuses like the doctors. Thus, I am wondering, what is stopping my employer from one day replacing me with an NP to save money?

I know my training is more rigorous but for a strictly outpatient gen peds job like mine where most complex cases go to the specialist and the hospitalist does all the inpatient care, is there a future for a physician? Or am I likely to be replaced by an NP? I keep hearing physicians will get replaced my mid levels, especially in primary care and I don’t know if this is overblown or if I should genuinely be concerned and look for career alternatives now. I don’t mind working alongside NPs but would like to keep my outpatient only peds job and salary as it is.

I think it's a valid concern. I'm surprised that docs with lots of experience haven't responded. As a parent, my first choice in having my kid evaluated would be the pediatrician --- every time. Is the patient cost (charge) for an NP the same as MD ? In a competitive world, it shouldn't be. If I call to get my kid seen and they want to assign the visit to a NP, my first question would be "how much cheaper is that than seeing the doctor?"

 

[Putkernerinthehall]

For a patient? It’s the same. Why would they charge you less lol. Literally the only people who gain from this situation are the suits who pocket the difference and the noctors who get to play make believe

I know it's the same. That's my point. But patients shouldn't settle for seeing a NP unless it's really routine. If the patient and their employer / insurance are paying the same freight for NP or physician, demand to see the physician.

Part of the reason there are so many mid-levels is that in many places patients are too stupid, lazy, impatient, etc. to demand a doctor. And the healthcare organizations are all too willing to provide PAs and NP's.

Just like with anything else --- patients have to demand maximum value for their dollar. When I want to see a doctor, I ask for one. When I need an attorney, I don't settle for a paralegal.

 

[PikminOC]

So I’m a year into my first gen peds job and noticed 90% of my visits are standard sick visits like URI’s, UTI’s, stomach bugs, eczema etc, and the rest are well visits. I’m mostly providing reassurance and preventative care. Once in a while I get something odd, like a Kawasaki case or pneumothorax but it’s rare and often times I have to refer anything more complex because of limited time (we only have 10-15 minutes per patient) or it’s truly beyond my scope.

We also have three experienced NP’s who see all the same patients and visits we do. They’re not supervised by the docs, and work along side us. However the NP’s are paid less and don’t get RVU bonuses like the doctors. Thus, I am wondering, what is stopping my employer from one day replacing me with an NP to save money?

I know my training is more rigorous but for a strictly outpatient gen peds job like mine where most complex cases go to the specialist and the hospitalist does all the inpatient care, is there a future for a physician? Or am I likely to be replaced by an NP? I keep hearing physicians will get replaced my mid levels, especially in primary care and I don’t know if this is overblown or if I should genuinely be concerned and look for career alternatives now. I don’t mind working alongside NPs but would like to keep my outpatient only peds job and salary as it is.

Usually the MD is somewhere in the chart as a collaborative physician. That's the only reason they keep physicians around. To take the hit it malpractice suits. Otherwise they can get three np for the price of one physician!

 

[zeppelinpage4]

Your knowledge base is higher. The patients pay for that expertise.

The actual question is do patients want expertise or someone to give them the drugs they want? Based on my time in the PICU with COVID, they want the latter. That’s the rub.

Sad but so true. I think there’s also a lack of transparency and understanding. I often overhear patients calling their NP doctor and they probably don’t even realize there’s a difference. We’re all “providers” under my employer.

I think it's a valid concern. I'm surprised that docs with lots of experience haven't responded. As a parent, my first choice in having my kid evaluated would be the pediatrician --- every time. Is the patient cost (charge) for an NP the same as MD ? In a competitive world, it shouldn't be. If I call to get my kid seen and they want to assign the visit to a NP, my first question would be "how much cheaper is that than seeing the doctor?"

Same here. If it’s my own loved one, I absolutely push for the doctor when I can. And that’s a good point. I know the NP’s are paid less, but they are billing the same levels as us so I assume the hospital pockets more money from the NP visits. Or some of the senior docs get some of the RVUs from the NP visits.

Usually the MD is somewhere in the chart as a collaborative physician. That's the only reason they keep physicians around. To take the hit it malpractice suits. Otherwise they can get three np for the price of one physician!

So true. I think one of the senior docs who gets paid for some of the NP RVUs is probably carrying that risk, though I’ve never seen them supervise or sign off on any NP charts.

 

[zeppelinpage4]

Appreciate all the responses! It’s nice to hear from others dealing with this first hand. I guess my initial concerns are’t fully off base. I don’t know if I have the energy to do more training but I’m debating if a fellowship and sub-specializing more may protect me from this? Though I see NP’s working in the speciality offices too now. Just sucks, after a decade in school and all the boards, a career in gen peds may not have the same security it once did.

 

[Putkernerinthehall]

Appreciate all the responses! It’s nice to hear from others dealing with this first hand. I guess my initial concerns are’t fully off base. I don’t know if I have the energy to do more training but I’m debating if a fellowship and sub-specializing more may protect me from this? Though I see NP’s working in the speciality offices too now. Just sucks, after a decade in school and all the boards, a career in gen peds may not have the same security it once did.

Eh, I don't know. Not an expert here but my sense is new mothers and fathers want the best care for their kid. And they like the idea of establishing a long-term relationship with a pediatrician until kid the hits 18. In my family, our pediatricians were revered, almost extended family. And they were not NP's or PA's.

Best to hear from some practicing general peds doctors.

 

[zeppelinpage4]

Eh, I don't know. Not an expert here but my sense is new mothers and fathers want the best care for their kid. And they like the idea of establishing a long-term relationship with a pediatrician until kid the hits 18. In my family, our pediatricians were revered, almost extended family. And they were not NP's or PA's.

Best to hear from some practicing general peds doctors.

Those are very comforting words. Thank you. I am very curious to hear from general pediatricians actively in practice. I can see patients wanting to see their established doctor and stick to them and hopefully that will help keep us relevant. Though there are a few patients at our office that regularly see the same NP and seem to be developing a similar bond with them as well. But hopefully parents are educated on the differences and aware of that.

 

[FrustratedFamDoc]

Everyone knows what a patient's parents prefer (physician), but unfortunately that is becoming less relevant. I don't exactly see the public picketing hospitals and congress over this issue.

The lines are blurred between us and them, purposely. The doctor shortage drum continues to be beaten, despite the fact that we have a distribution problem, not a quantity problem (I'll take Tampa over Detroit all day long, regardless of the $$). Doctor shortage!!! naturally implies that we need to have more 'providers'. Mills keep pumping out mid levels and suits laugh all the way to their yachts. There is a reason for check box medicine that we have become.

I'm Family Medicine. The concerns are the same.

I'll be called an alarmist, I'm sure, but the momentum isn't exactly on our side. Many contracts now mandate mid level supervision for a very nominal compensation.

Midlevels are more prone to imaging and labs. Suits don't exactly mind if the CT $canner never gets a chance to cool down.

 

[Putkernerinthehall]

Everyone knows what a patient's parents prefer (physician), but unfortunately that is becoming less relevant. I don't exactly see the public picketing hospitals and congress over this issue.

The lines are blurred between us and them, purposely. The doctor shortage drum continues to be beaten, despite the fact that we have a distribution problem, not a quantity problem (I'll take Tampa over Detroit all day long, regardless of the $$). Doctor shortage!!! naturally implies that we need to have more 'providers'. Mills keep pumping out mid levels and suits laugh all the way to their yachts. There is a reason for check box medicine that we have become.

I'm Family Medicine. The concerns are the same.

I'll be called an alarmist, I'm sure, but the momentum isn't exactly on our side. Many contracts now mandate mid level supervision for a very nominal compensation.

Midlevels are more prone to imaging and labs. Suits don't exactly mind if the CT $canner never gets a chance to cool down.

Do you docs push back on contracts that mandate mid-level supervision for what you perceive to be low/nominal compensation ? Do you docs push back on the volume / numbers of mid-levels you agree to supervise ?

 

[FrustratedFamDoc]

Sure, but with student loan debt, many are worried about rocking the boat. Also with consolidation of the health care system, these contracts are largely standardized, take it or leave it. Supply (more residency/mid level grads) and demand is not on our side.

 

[Putkernerinthehall]

Sure, but with student loan debt, many are worried about rocking the boat. Also with consolidation of the health care system, these contracts are largely standardized, take it or leave it. Supply (more residency/mid level grads) and demand is not on our side.

Yeah, I get that. Does the AMA or other body get involved and try to influence what is happening with more and more midlevels with less than half the training of MDs? The public is generally ignorant so agree grass roots is probably not a big part of the solution.

 

[FrustratedFamDoc]

I can't recall the last meaningful pro-physician anything the AMA lobbied for. Last thing I do remember was them endorsing the ACA.

 

[Putkernerinthehall]

Is the AMA not made up of a bunch of doctors ? If not, can't you all vote them out and put doctors in there ? Naive questions I'm sure but from the outside looking in it seems like the docs who have all the brains, training, and talent are not collectively working together to improve their profession by pushing back on ownership / PE. Maybe it's that the old guys feel like they got theirs and are too tired to fight it and the young ones have loans and are too afraid to fight.

 

[HemeOncHopeful19]

Is the AMA not made up of a bunch of doctors ? If not, can't you all vote them out and put doctors in there ? Naive questions I'm sure but from the outside looking in it seems like the docs who have all the brains, training, and talent are not collectively working together to improve their profession by pushing back on ownership / PE. Maybe it's that the old guys feel like they got theirs and are too tired to fight it and the young ones have loans and are too afraid to fight.

The short version is that we are all too busy doing our actual jobs to lobby Congress unlike hospital executives and insurance companies whose entire jobs EXIST because they take the time to lobby said Congress.

 

[voxveritatisetlucis]

The short version is that we are all too busy doing our actual jobs to lobby Congress unlike hospital executives and insurance companies whose entire jobs EXIST because they take the time to lobby said Congress.

Why don’t doctors collectively hire lobbying firms that will advocate for their interests then? Perhaps even throwing in some exorbitant performance bonuses (ie. For every successful state effort to ban independent mid level practice, you get a 1m dollar bonus). If resources were pooled, it would hardly cost anything.

 

[VA Hopeful Dr]

Why don’t doctors collectively hire lobbying firms that will advocate for their interests then? Perhaps even throwing in some exorbitant performance bonuses (ie. For every successful state effort to ban independent mid level practice, you get a 1m dollar bonus). If resources were pooled, it would hardly cost anything.

Because we are notoriously cheap.

 

[Putkernerinthehall]

Because we are notoriously cheap.

Or more likely simply disorganized and apathetic

 

[voxveritatisetlucis]

Or more likely simply disorganized and apathetic

I also think that it has to do with the fact that physicians with entrenched organizational and or economic power have incentives to use midlevels.

 

[SurfingDoctor]

Is the AMA not made up of a bunch of doctors ? If not, can't you all vote them out and put doctors in there ? Naive questions I'm sure but from the outside looking in it seems like the docs who have all the brains, training, and talent are not collectively working together to improve their profession by pushing back on ownership / PE. Maybe it's that the old guys feel like they got theirs and are too tired to fight it and the young ones have loans and are too afraid to fight.

Ha. The AMA has been and will be always be a terrible organization.

 

[Putkernerinthehall]

Ha. The AMA has been and will be always be a terrible organization.

Why do you doctors have it representing you then ? Why don't doctors replace it with a lobby group that actually helps their profession ?

 

[HemeOncHopeful19]

Why do you doctors have it representing you then ? Why don't doctors replace it with a lobby group that actually helps their profession ?

It doesn’t represent us. I don’t feel like googling it but I think less than 15% of physicians are actually members of the AMA.

I would wager it probably gets its funding from hospitals or pharma if you really dive deep enough.

 

[VA Hopeful Dr]

It doesn’t represent us. I don’t feel like googling it but I think less than 15% of physicians are actually members of the AMA.

I would wager it probably gets its funding from hospitals or pharma if you really dive deep enough.

CPT coding

 

[zeppelinpage4]

Everyone knows what a patient's parents prefer (physician), but unfortunately that is becoming less relevant. I don't exactly see the public picketing hospitals and congress over this issue.

The lines are blurred between us and them, purposely. The doctor shortage drum continues to be beaten, despite the fact that we have a distribution problem, not a quantity problem (I'll take Tampa over Detroit all day long, regardless of the $$). Doctor shortage!!! naturally implies that we need to have more 'providers'. Mills keep pumping out mid levels and suits laugh all the way to their yachts. There is a reason for check box medicine that we have become.

I'm Family Medicine. The concerns are the same.

I'll be called an alarmist, I'm sure, but the momentum isn't exactly on our side. Many contracts now mandate mid level supervision for a very nominal compensation.

Midlevels are more prone to imaging and labs. Suits don't exactly mind if the CT $canner never gets a chance to cool down.

I would agree. I seem to be the only doctor concerned at my practice. Granted the other doctors are nearing retirement and know this won’t affect them.

So is there any reasonable plan B for those of us who may be competing or losing jobs to NPs in the coming years? I’ve thought of going non-clinical entirely but it’s not so easy or straight forward to break into those roles without prior experience and I don’t know if it’s really even better.

I would be all for trying to lobby and push for change. But agree getting doctors to organize and unite is much like herding cats and most of us are overwhelmed and occupied with high volumes and paper work burdens.

 

[qwerty89]

Dozens Of Pediatricians Losing Jobs As Children's Health Clinics Change Management

Families all over North Texas are learning they're about to lose their trusted family doctors. Dozens of pediatricians are losing their jobs as Children's Health gives up management of most of its clinics -- with two of them set to close.

www.cbsnews.com

From Dec 2018.

 

[bronx43]

For clinical medicine, midlevels are closer to an existential threat than just a shadowy boogeyman hiding in the corner. The bottom line is that the true skills of clinical medicine is catching rare diseases or rare manifestations of common diseases. This means that superficial competence is easy to feign and the mistakes are hidden, because… well, rare things are rare. This also means that the vast majority of patients can’t tell or don’t care about the depth of medical knowledge or skills of the clinician. They only care if you’re nice and sociable. These are not things one needs medical school for.

I don’t recommend any med student go into clinical specialties. Do either a procedural specialty or radiology.

 

[Putkernerinthehall]

For clinical medicine, midlevels are closer to an existential threat than just a shadowy boogeyman hiding in the corner. The bottom line is that the true skills of clinical medicine is catching rare diseases or rare manifestations of common diseases. This means that superficial competence is easy to feign and the mistakes are hidden, because… well, rare things are rare. This also means that the vast majority of patients can’t tell or don’t care about the depth of medical knowledge or skills of the clinician. They only care if you’re nice and sociable. These are not things one needs medical school for.

I don’t recommend any med student go into clinical specialties. Do either a procedural specialty or radiology.

What about clinical specialties? Pediatric hem/onc, pediatric cardiology, neonatal, PICU, etc. ?

 

[bronx43]

What about clinical specialties? Pediatric hem/onc, pediatric cardiology, neonatal, PICU, etc. ?

I'm not peds, so I don't have deep insight into these subspecialties. What I can say is this.

As a rheumatologist, there has been frightening incursion by midlevels into what should be a specialty totally off limits to non-physicians. But here we are. At the "desirable" metro area by me, almost half the rheumatology "providers" are midlevels. It destroys the job market for young grads. Even though rheumatologists as a whole aren't replaced by midlevels, new grads are functionally replaced in major markets. Every rheumatic disease patient seen by a midlevel and loosely "supervised" by a doctor is a patient that wouldn't see a fellowship trained rheumatologist.

 

[dantt]

So I’m a year into my first gen peds job and noticed 90% of my visits are standard sick visits like URI’s, UTI’s, stomach bugs, eczema etc, and the rest are well visits. I’m mostly providing reassurance and preventative care. Once in a while I get something odd, like a Kawasaki case or pneumothorax but it’s rare and often times I have to refer anything more complex because of limited time (we only have 10-15 minutes per patient) or it’s truly beyond my scope.

We also have three experienced NP’s who see all the same patients and visits we do. They’re not supervised by the docs, and work along side us. However the NP’s are paid less and don’t get RVU bonuses like the doctors. Thus, I am wondering, what is stopping my employer from one day replacing me with an NP to save money?

I know my training is more rigorous but for a strictly outpatient gen peds job like mine where most complex cases go to the specialist and the hospitalist does all the inpatient care, is there a future for a physician? Or am I likely to be replaced by an NP? I keep hearing physicians will get replaced my mid levels, especially in primary care and I don’t know if this is overblown or if I should genuinely be concerned and look for career alternatives now. I don’t mind working alongside NPs but would like to keep my outpatient only peds job and salary as it is.

Legitimate concern. The saving grace is when all is said and done the compensation is probably very similar...you'll probably get paid a little bit more for doing more work 😞

 

[dantt]

Your knowledge base is higher. The patients pay for that expertise.

The actual question is do patients want expertise or someone to give them the drugs they want? Based on my time in the PICU with COVID, they want the latter. That’s the rub.

I'm not peds but no, patients do not pay for the expertise. Patients pay for insurance and insurance pays for a provider. Lowest bidder gets the contract.

 

[FrustratedFamDoc]

I see the trend going in the direction of:

History:

Old school: knowing what to ask, what not ask, how to ask it and when to ask it and then reading their body language, what they say, what they don't say and how they say it.. you know, a typical garden variety, get to the point physician encounter that is carefully honed after years of clinical practice.

New school: Read off the list of questions that correlates to the presenting chief complaint.

Physical exam:

Old school: Not necessarily comprehensive, but certainly guided by clinical experience and knowing what variations of normal are.... guided by years of clinical experience.

New school: go over the physical exam points guided by the EMR. Document any irregular findings.

Assessment/Plan:

Old school: What you have is a variation of normal that I don't see a lot, but is perfectly ok. This is nothing worrisome, but let me know if things change. Or... Something just seems a bit off, and I do think we need to be a bit more aggressive in our workup, even though I'm not finding much on exam. I don't like some of the answers that you gave me.

New school: There are some things not normal on your exam. I suggest we need to do some tests, and probably refer you to one of the system affiliated specialists. Or... I didn't find anything abnormal on your physical exam. I'll see you back in 4 months.

We cost more, run few studies, and refer less frequently. Systems will gladly accept the risk of missed diagnoses from lesser trained providers as the payoff in terms of total overhead is a no brainer.

 

[Putkernerinthehall]

I see the trend going in the direction of:

History:

Old school: knowing what to ask, what not ask, how to ask it and when to ask it and then reading their body language, what they say, what they don't say and how they say it.. you know, a typical garden variety, get to the point physician encounter that is carefully honed after years of clinical practice.

New school: Read off the list of questions that correlates to the presenting chief complaint.

Physical exam:

Old school: Not necessarily comprehensive, but certainly guided by clinical experience and knowing what variations of normal are.... guided by years of clinical experience.

New school: go over the physical exam points guided by the EMR. Document any irregular findings.

Assessment/Plan:

Old school: What you have is a variation of normal that I don't see a lot, but is perfectly ok. This is nothing worrisome, but let me know if things change. Or... Something just seems a bit off, and I do think we need to be a bit more aggressive in our workup, even though I'm not finding much on exam. I don't like some of the answers that you gave me.

New school: There are some things not normal on your exam. I suggest we need to do some tests, and probably refer you to one of the system affiliated specialists. Or... I didn't find anything abnormal on your physical exam. I'll see you back in 4 months.

We cost more, run few studies, and refer less frequently. Systems will gladly accept the risk of missed diagnoses from lesser trained providers as the payoff in terms of total overhead is a no brainer.

I only see this changing if patients (parents in the case of Peds) demand change. If parents demand a fully trained MD pediatrician maybe that will start to make a difference. When the local Peds office has NP's standing around because all the parents only want their kids to see the real pediatrician --- that would induce some changes. Hard to see that happening but doctors have to do a much better job communicating to the public about the value the MD brings.

I can take my car to the cheap shop on the corner that uses re-manufactured / used parts. Or I can go to the high end shop with very experienced mechanics who specialize in my car model. The high end shop has to convince me of the value.

 

[Staphylococcus Aureus]

Functional replacement is all too real. Every shift taken by a midlevel is one less shift demanding a physician. What was a market of three full time pediatric cardiologists is now a market of one cardiologist and three Midlevels etc. this Constricts the market for docs out of residency/fellowship to the point of having to move states to change jobs. Kills demand and bargaining power. Eliminates patient access to expert care. Unfortunately all too real in peds.

 

[Putkernerinthehall]

Functional replacement is all too real. Every shift taken by a midlevel is one less shift demanding a physician. What was a market of three full time pediatric cardiologists is now a market of one cardiologist and three Midlevels etc. this Constricts the market for docs out of residency/fellowship to the point of having to move states to change jobs. Kills demand and bargaining power. Eliminates patient access to expert care. Unfortunately all too real in peds.

Somehow docs have to convince patients of the value of that expert care so the patients are unwilling to see midlevels except for the most simple/benign situations. Need to have midlevels standing around while the docs are loaded with patients. I don't know how else the docs can reverse this. And the more senior docs who have the nice jobs with the midlevels under them won't want to drive this change.

 

[PikminOC]

I see the trend going in the direction of:

History:

Old school: knowing what to ask, what not ask, how to ask it and when to ask it and then reading their body language, what they say, what they don't say and how they say it.. you know, a typical garden variety, get to the point physician encounter that is carefully honed after years of clinical practice.

New school: Read off the list of questions that correlates to the presenting chief complaint.

Physical exam:

Old school: Not necessarily comprehensive, but certainly guided by clinical experience and knowing what variations of normal are.... guided by years of clinical experience.

New school: go over the physical exam points guided by the EMR. Document any irregular findings.

Assessment/Plan:

Old school: What you have is a variation of normal that I don't see a lot, but is perfectly ok. This is nothing worrisome, but let me know if things change. Or... Something just seems a bit off, and I do think we need to be a bit more aggressive in our workup, even though I'm not finding much on exam. I don't like some of the answers that you gave me.

New school: There are some things not normal on your exam. I suggest we need to do some tests, and probably refer you to one of the system affiliated specialists. Or... I didn't find anything abnormal on your physical exam. I'll see you back in 4 months.

We cost more, run few studies, and refer less frequently. Systems will gladly accept the risk of missed diagnoses from lesser trained providers as the payoff in terms of total overhead is a no brainer.

They like the midlevels to order more tests are refer more. More money generated.

 

[PikminOC]

Somehow docs have to convince patients of the value of that expert care so the patients are unwilling to see midlevels except for the most simple/benign situations. Need to have midlevels standing around while the docs are loaded with patients. I don't know how else the docs can reverse this. And the more senior docs who have the nice jobs with the midlevels under them won't want to drive this change.

Patients like the midlevels. They dole out the candy

 

[Putkernerinthehall]

Patients like the midlevels. They dole out the candy

Seriously, as an attending, what's your approach to the encroachment? Do you endorse it because it makes your job easier and/or more lucrative? Do you despise it ? Are you apathetic about it since maybe your own position is not threatened? I'm genuinely curious why doctors don't seem to be collectively united to protect their profession.

 

[HemeOncHopeful19]

Seriously, as an attending, what's your approach to the encroachment? Do you endorse it because it makes your job easier and/or more lucrative? Do you despise it ? Are you apathetic about it since maybe your own position is not threatened? I'm genuinely curious why doctors don't seem to be collectively united to protect their profession.

I'm genuinely curious what would you suggest we do?

 

[PikminOC]

Seriously, as an attending, what's your approach to the encroachment? Do you endorse it because it makes your job easier and/or more lucrative? Do you despise it ? Are you apathetic about it since maybe your own position is not threatened? I'm genuinely curious why doctors don't seem to be collectively united to protect their profession.

I refuse to supervise or collaborate with them. I work solo and don't want to pimp out my license

 

[Putkernerinthehall]

I'm genuinely curious what would you suggest we do?

Some approaches come to mind. My sense is that the senior docs are the only ones that can move the needle on this. They may not have a lot of clout but the top dogs have more than everyone else. I've heard the excuses, too cheap, too busy, etc. I think it's apathy and lack of organization.

1) Attendings should specifically document when midlevels mis-manage patients. Docs need to make sure to write in their notes that the PCP is a NP or PA. And due to the CARES Act, patients can see doctors' notes which will help educate patients. Docs are also obligated to tell their patients why a screw-up happened. Eventually the risk management department will start to get the message.

2) Docs could push back on contracts that mandate mid-level supervision for what they perceive as low/nominal compensation. Docs should push back on the volume / numbers of mid-levels they agree to supervise.

3) ED attendings, when discharging patients and you're asked about locating a good doctor -- you need to take the opportunity to educate. Give them a list of doctors and say something like "for your next appointment, ask to be seen by a physician." Many patients have no idea they are being seen by a PA or a nurse and assume the man/woman walking into the room with a long white coat is a physician.

4) If the situation is as dire as it sounds, physician groups need to bargain collectively. Maybe this isn't unionization but there needs to be some level of pushback on the MBAs that are running the show. Residents and recently minted attendings with $300k debt aren't going to lead this. Has to be the senior, strongest docs leading the charge. Make demands, negotiate, challenge. This is where the problem lies, IMO. The docs who have all the brains, training, and talent are not collectively working together to improve their profession by pushing back on ownership / PE. The senior docs are probably too comfortable to rock the boat.

5) Public shaming - utilize the all too willing world of journalism to "out" the excessive use of mid-levels, the mismanaged care from mid-levels when it happens, and the money grubbing MBAs who are taking an enormous cut from your salaries and don't respect your training. Big healthcare systems "HATE" bad press.

6) Professional lobbying ---- if the AMA sucks, why don't the senior docs get together and do something about it ? Why don’t doctors collectively hire lobbying firms that will advocate for their interests? Again, the senior, most powerful docs have to lead the way here. If you don't have time, hire firms to do this. As someone noted upthread, perhaps even throwing in some exorbitant performance bonuses (ie. for every successful state effort to ban independent mid level practice, you get a 1m dollar bonus). If resources were pooled, it would cost little.

 

[SurfingDoctor]

Seriously, as an attending, what's your approach to the encroachment? Do you endorse it because it makes your job easier and/or more lucrative? Do you despise it ? Are you apathetic about it since maybe your own position is not threatened? I'm genuinely curious why doctors don't seem to be collectively united to protect their profession.

In hospital-based professions, the answer to both is "yes".

 

[PikminOC]

In hospital-based professions, the answer to both is "yes".

They don't make your job easier. You have to go home and read the percentage of their charts too..

 

[PikminOC]

Some approaches come to mind. My sense is that the senior docs are the only ones that can move the needle on this. They may not have a lot of clout but the top dogs have more than everyone else. I've heard the excuses, too cheap, too busy, etc. I think it's apathy and lack of organization.

1) Attendings should specifically document when midlevels mis-manage patients. Docs need to make sure to write in their notes that the PCP is a NP or PA. And due to the CARES Act, patients can see doctors' notes which will help educate patients. Docs are also obligated to tell their patients why a screw-up happened. Eventually the risk management department will start to get the message.

2) Docs could push back on contracts that mandate mid-level supervision for what they perceive as low/nominal compensation. Docs should push back on the volume / numbers of mid-levels they agree to supervise.

3) ED attendings, when discharging patients and you're asked about locating a good doctor -- you need to take the opportunity to educate. Give them a list of doctors and say something like "for your next appointment, ask to be seen by a physician." Many patients have no idea they are being seen by a PA or a nurse and assume the man/woman walking into the room with a long white coat is a physician.

4) If the situation is as dire as it sounds, physician groups need to bargain collectively. Maybe this isn't unionization but there needs to be some level of pushback on the MBAs that are running the show. Residents and recently minted attendings with $300k debt aren't going to lead this. Has to be the senior, strongest docs leading the charge. Make demands, negotiate, challenge. This is where the problem lies, IMO. The docs who have all the brains, training, and talent are not collectively working together to improve their profession by pushing back on ownership / PE. The senior docs are probably too comfortable to rock the boat.

5) Public shaming - utilize the all too willing world of journalism to "out" the excessive use of mid-levels, the mismanaged care from mid-levels when it happens, and the money grubbing MBAs who are taking an enormous cut from your salaries and don't respect your training. Big healthcare systems "HATE" bad press.

6) Professional lobbying ---- if the AMA sucks, why don't the senior docs get together and do something about it ? Why don’t doctors collectively hire lobbying firms that will advocate for their interests? Again, the senior, most powerful docs have to lead the way here. If you don't have time, hire firms to do this. As someone noted upthread, perhaps even throwing in some exorbitant performance bonuses (ie. for every successful state effort to ban independent mid level practice, you get a 1m dollar bonus). If resources were pooled, it would cost little.

Old doctors don't care. You know they grandfathered themselves into moc and we have to recertify every seven to ten years right?

 

[VA Hopeful Dr]

They don't make your job easier. You have to go home and read the percentage of their charts too..

I'm not certain you understand how midlevels in the inpatient setting can be used

 

[SurfingDoctor]

They don't make your job easier. You have to go home and read the percentage of their charts too..

So you think attendings pre-round on their patients? Give updates to every family member about every irrelevant detail? Put in every order? Transport every patient for a study? Fill out every discharge instruction? In the procedural fields, they are the ones fielding all the calls while the surgeons are in the OR.

And, where I work, only attendings can provide billing documents so I don’t have to read any charts.

 

[VA Hopeful Dr]

Old doctors don't care. You know they grandfathered themselves into moc and we have to recertify every seven to ten years right?

You know that, at least for FM, no one is allowed to be grandfather in right?

 

[PikminOC]

You know that, at least for FM, no one is allowed to be grandfather in right?

In psych they are. Not sure about the other fields.

 

[PikminOC]

I'm not certain you understand how midlevels in the inpatient setting can be used

I was referring to my doctor friends in outpatient.

 

[PikminOC]

I'm not certain you understand how midlevels in the inpatient setting can be used

Makes sense to have midlevels with the sickest patients with no oversight?