Least Vulnerable Specialties To Midlevel Encroachment?

[Jack Donaghy]

So just to clarify, you are saying at your institution that the intensivist or the neurologist are not supervising these midlevels and they are working independently? That's definitely an outlier, if so.

If you told me they are being "supervised" but not really then I would say it's typical morally bankrupt behavior from some boomer attending at play here.

Neuro and rheum are typically "we have no idea what to do with this patient" destinations so I still maintain that PAs aren't going to be taking over the movement disorder clinic, epilepsy clinic etc etc.

I have a pretty pessimistic view of midlevels and their path of destruction on medicine but I'm more bullish regarding their ability to fake it in the neuro clinic than in the pulm clinic for example. I need to expand on this post more when I have some time.

I will say this: Pcps order mri and emg and whatever all the time and neurologists didn't disappear due to that. They aren't gonna disappear from midlevels who don't even know most neuro diseases.

My man... if you think any "collaborating" or "supervising" physician is actually doing anything to sway the independent practice of whatever midlevel they're "supervising", then I'm afraid I have bad news.

I once asked a neurologist which physician is the liability sponge for all the PAs I see running around and being the final read on MRIs before the patient leaves the hospital. The answer was: "I dunno, but it ain't me" until I asked the last physician. Apparently no one "supervises" these people out there in the real world.

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[dohopeful13]

Right. Like picking a specialty that midlevels won't ruin. Which is the point of this thread................

unless you have a crystal ball it's hard to pick with certainty. . I'm justing cautioning against using mid-level encroachment as your major determinant of residency choice. The inevitable move to a public option is only going to spur more mid level involvement across the board, and I'm not going exhaust myself about trying to figure out which specialty is "safest", whatever that means.

I only even post this because this topic comes up so frequently here, and I used to be guilty of stressing out over it too.

 

[Neopolymath]

My man... if you think any "collaborating" or "supervising" physician is actually doing anything to sway the independent practice of whatever midlevel they're "supervising", then I'm afraid I have bad news.

I once asked a neurologist which physician is the liability sponge for all the PAs I see running around and being the final read on MRIs before the patient leaves the hospital. The answer was: "I dunno, but it ain't me" until I asked the last physician. Apparently no one "supervises" these people out there in the real world.

There are people out there doing it "the right way." Well, the right way would be not at all but I digress lol.

I have worked in hospitals where attendings do their job and midlevels toe the line.

Also, no midlevel is doing the final read on an MRI. Maybe you meant that differently? By policy, a radiologist is doing the final read if nothing else but to get paid. Like in the ER, people look at the x-ray and act on obvious findings but they don't put a read in and put their name on a radiology report for all aspects of that x ray for eternity liability-wise.

 

[MICKY MANTLE]

Until they start creating PA/NP surgical "residencies" and forcing surgeons to train them at academic centers while pumping funds into forcing these independent practice bills through.

I would have said surgery in the past, but I've seen that there is truly no limit to the greed of these independent midlevels, the physicians training them, and the hospitals employing them. They just can't be underestimated.

My man... if you think any "collaborating" or "supervising" physician is actually doing anything to sway the independent practice of whatever midlevel they're "supervising", then I'm afraid I have bad news.

I once asked a neurologist which physician is the liability sponge for all the PAs I see running around and being the final read on MRIs before the patient leaves the hospital. The answer was: "I dunno, but it ain't me" until I asked the last physician. Apparently no one "supervises" these people out there in the real world.

No way are PAs having the final word on MRI reads.

 

[Jack Donaghy]

There are people out there doing it "the right way." Well, the right way would be not at all but I digress lol.

I have worked in hospitals where attendings do their job and midlevels toe the line.

Also, no midlevel is doing the final read on an MRI. Maybe you meant that differently? By policy, a radiologist is doing the final read if nothing else but to get paid. Like in the ER, people look at the x-ray and act on obvious findings but they don't put a read in and put their name on a radiology report for all aspects of that x ray for eternity liability-wise.

I meant it in a functional way. As in, read this MRI and determine the immediate next steps, including the possible discharge of this patient, before rads does the over-read.

Which would be perfectly acceptable for a neurologist to do, but these are PAs I'm talking about.

 

[TwistedTea]

Anything outpatient. Before you think I’m nuts....Patients are paying the same for midlevel and physician care. They have more choice in the outpatient setting whom to choose. Inpatient the lines are often blurred and they have less choice.
And surgical stuff and rads. And everything else of value based care comes into play.
Not worried much about midlevels. Unless I was anesthesia or palliative or psych maybe lol

 

[TwistedTea]

Let them. Won’t matter. Learning surgery is not an issue with credentials or length of training, it’s actual time in the operating room and your own proficiency with learning the skills. It’s why you can’t really shave off more years from surgical training. At best we could get gen surg down to four and fold the other specialties into an I6 sort of model but it will never get shorter than that, and you’ll still need 800+ operations and 70 hour work weeks for 52+ weeks to accomplish it. Your credentials will never change that no matter how hard you try.

Besides, AG is right. The next time you’re in the OR count how many cases the surgeon *doesn’t* say “this is harder than normal” “this is stickier than normal” “this is more inflamed than normal” “this is really oozy, is this guy on Coumadin and we forgot to hold it (for a 40 y/o athlete)” “this anatomy is not right” “why is this one so fat compared to normal”

I can count on one hand how many times in a month someone says “that was straightforward”. The normal routine case is the unicorn and normal is a lie we tell ourselves to justify it taking the extra hour it always does.

Patients are getting sicker and more difficult to care for and more and more treatments and dx keep coming out in general. I don’t think many of us need to worry about mid levels

 

[7331poas]

I'm in the minority but I don't think it's a particularly fruitful topic and all it seems to do is generate frustration.

Great, then close your browser window and stop complaining.

 

[Cath Up]

Anything outpatient. Before you think I’m nuts....Patients are paying the same for midlevel and physician care. They have more choice in the outpatient setting whom to choose. Inpatient the lines are often blurred and they have less choice.
And surgical stuff and rads. And everything else of value based care comes into play.
Not worried much about midlevels. Unless I was anesthesia or palliative or psych maybe lol

Dude you need to stay on probationary status. It's the theme colors of twisted tea that way

 

[Cath Up]

Anything outpatient. Before you think I’m nuts....Patients are paying the same for midlevel and physician care. They have more choice in the outpatient setting whom to choose. Inpatient the lines are often blurred and they have less choice.
And surgical stuff and rads. And everything else of value based care comes into play.
Not worried much about midlevels. Unless I was anesthesia or palliative or psych maybe lol

Agree anesthesia appears to be poorly positioned given the continued expansion of CRNAs. That would be great if a 3:1 or 4:1 oversight is as bad as it will get and the field could stabilize. I don't know if that will happen though. Anesthesia is fascinating and I love what they do but overseeing midlevels and fighting fires is not why I pursued medicine.

In an actual palliative team at a place with reasonable resources, there will always be a physician at the top. There are midlevels by design in a palliative team.

Psych is one of the mostly outpatient specialties where I hear patients can more often vote with their feet, compared to other specialties.

 

[Chibucks15]

Seems vulnerable to me. You see a neurologist you are getting an MRI and possibly an EMG. A midlevel could do that.

Not a chance. Sure you can do stroke (because it’s basically an algorithm, but even then I’ve seen tPA given for things that are definitely not strokes...6% death rate ain’t nothing to mess with) but literally everything else is super subtle on physical exam that other physicians miss.

Neuro midlevels manage epilepsy follow ups where they’re fine, peripheral neuropathy, and other basic things that don’t change. That’s their role and honestly from what I’ve seen they are utilized more appropriately in neuro than others

 

[TwistedTea]

[/QUOTE]

In an actual palliative team at a place with reasonable resources, there will always be a physician at the top. There are midlevels by design in a palliative team.

Psych is one of the mostly outpatient specialties where I hear patients can more often vote with their feet, compared to other specialties.

Any patient with decent insurance can vote with their feet in most areas in most specialties. Hence why I believe outpatient is safer against mids than inpatient stuff. Midlevels don’t save patients any money so why buy a chevy when you can get a Lexus for the same price ?

I dislike mids as much as the next person but they aren’t gonna take all our jobs lol. Have you wait till you work with them and see their limitations.

 

[7331poas]

Not a chance. Sure you can do stroke (because it’s basically an algorithm, but even then I’ve seen tPA given for things that are definitely not strokes...6% death rate ain’t nothing to mess with) but literally everything else is super subtle on physical exam that other physicians miss.

I mean the abdominal exam is also subtle. but the solution thus far has been reflex ordering abdominal CTs. In neuro it will just be the MRI. Why try and localize when the radiologist can tell you where the lesion is.

 

[TwistedTea]

I mean the abdominal exam is also subtle. but the solution thus far has been reflex ordering abdominal CTs. In neuro it will just be the MRI. Why try and localize when the radiologist can tell you where the lesion is.

probably harder to localize on abdominal exam than neuro even since eh, pretty much anything can hurt anywhere contrary to what the text says lol

 

[RangerBob]

Any patient with decent insurance can vote with their feet in most areas in most specialties. Hence why I believe outpatient is safer against mids than inpatient stuff. Midlevels don’t save patients any money so why buy a chevy when you can get a Lexus for the same price ?

I dislike mids as much as the next person but they aren’t gonna take all our jobs lol. Have you wait till you work with them and see their limitations.
[/QUOTE]

I agree. I am surprised at how many patients do know they’re seeing a mid level, and they notice the difference. Midlevels have a lot of limitations and ultimately that will be their rate-limiting step. Or rather, the rate limiting step insurance will likely eventually apply.

Insurance dictates so much. I was talking with an Australian construction worker-he said over there if they’re working on a roof, you have to have a harness, net (to catch you if you fall and harness fails) and scaffolding (so EMS can get up to the roof quickly). All because insurance has required that to be covered.

Unfortunately we’re still in the “working it out” phase. Who knows where the balance ends. Or maybe I’m wrong and corporate greed takes over. That would be most unfortunate given the respect and prestige our profession still commands, despite many saying otherwise. Still-look at any survey and we’re the most respected profession typically (though nursing is the most trusted, which doesn’t bode well for us if they have the title nurse practitioner...)

I personally wouldn’t shy away from any specialty just because of midlevel concerns. I would factor in job market a bit more (rad inc and EM having a tougher time, grass has been super green for FM, IM, peds and psych for a while.) Still, it could be as many as 7+ years till you have to apply for a job in that job market, and the tables could flip entirely in that time.

 

[fldoctorgirl]

Any patient with decent insurance can vote with their feet in most areas in most specialties. Hence why I believe outpatient is safer against mids than inpatient stuff. Midlevels don’t save patients any money so why buy a chevy when you can get a Lexus for the same price ?

I dislike mids as much as the next person but they aren’t gonna take all our jobs lol. Have you wait till you work with them and see their limitations.

I think what will likely happen is a shift to a more two-tier system. I have lots of family/friends who have told me they refuse to see a midlevel because they are paying the same co-pay, so they want the physician. My SO saw a PA for an emergent appointment since the doc had nothing available but just demanded that the doc come in and see him after the PAs plan was basically to do nothing; the doctor's plan was completely different from the PAs, and now his whole family refuses to see PAs lol. Unfortunately, I think those with less health literacy will end up being stuck with midlevels as their PCPs. The fact that you can't get an appointment with an IM/FM doc for 2-3 months but can see an NP/PA same day is pretty telling imo (although it kind of sucks because if I had an urgent issue I'd want to see the MD/DO, but I digress).

 

[Jack Donaghy]

I think what will likely happen is a shift to a more two-tier system. I have lots of family/friends who have told me they refuse to see a midlevel because they are paying the same co-pay, so they want the physician. My SO saw a PA for an emergent appointment since the doc had nothing available but just demanded that the doc come in and see him after the PAs plan was basically to do nothing; the doctor's plan was completely different from the PAs, and now his whole family refuses to see PAs lol. Unfortunately, I think those with less health literacy will end up being stuck with midlevels as their PCPs. The fact that you can't get an appointment with an IM/FM doc for 2-3 months but can see an NP/PA same day is pretty telling imo (although it kind of sucks because if I had an urgent issue I'd want to see the MD/DO, but I digress).

I agree. 20 years from now it will be those with good insurance and / or ability to use a cash-pay practice = MD or DO. Those with medicaid or no insurance / bad insurance = NP or PA. Which will only exacerbate the existing health disparities in this country.

 

[killrforehand]

orthopedic surgery
ENT
surgical oncology
IR
colorectal surgery
neurosurgery
ophthalmology
urology
OBGYN
plastic surgery
trauma surgery
vascular surgery
rocket surgery
general surgery
pediatric surgery anything

Can you enlighten me what rocket surgery is? Sounds like such an uplifting field

 

[Rusino]

Soooo FM is basically screwed? RIP my rural medicine primary care dreams.

 

[Black_Taurean]

What about emergency pediatrics?

 

[2thDoc11]

I think midlevels are getting derm

I worked in a Derm clinic and although they can do biopsies, acne, cosmetics and simple diagnoses, their education doesn’t even scratch the surface compared to what the doctors are introduced to during residency.. or so I heard from our MOHS surgeon. Midlevels only know as much as they see while practicing which is on the backs of the doctors to explain what’s happening with the patient.. I saw many of our mid levels having to constantly pull the doctors from their exam rooms into the mid levels due to lack of knowledge. We‘ll see what happens

 

[toastedbutter]

Any thoughts on ID? At first glance it seems like it can easily get overrun but I've also heard ID be called a very intellectually demanding field. Might as well switch to interventional cardiology while I have the chance if my ID career dreams are down the sinkhole.

 

[SmallChanges]

Ah, surgical subspecialties. Idk. I think they may be mostly safe, but in my n=1 anecdotal experience, PA's and NP's have been doing ortho surgeries and other procedures (OB, cardio, etc) in my area since I was an undergraduate (4 years ago). As such, I don't really consider any specialty to be safe from encroachment.

Edit: I can tell you which institution this is in DM

 

[Slappin' glass]

They function differently than other midlevels so it's not a concern.

Pathology assistants are pretty busy in a lot of places ....

Pathology assistants only gross. They do not interpret cases.

 

[AnatomyGrey12]

Ah, surgical subspecialties. Idk. I think they may be mostly safe, but in my n=1 anecdotal experience, PA's and NP's have been doing ortho surgeries and other procedures (OB, cardio, etc) in my area since I was an undergraduate (4 years ago). As such, I don't really consider any specialty to be safe from encroachment.

What classifies as an “ortho surgery”

 

[InternistDO]

Soooo FM is basically screwed? RIP my rural medicine primary care dreams.

Adult primary care will be fine. There are many issues a PCP faces but midlevel displacement will not be one of them. Rural primary care even more so.


And for everyone in the thread, many specialties will have challenges over the next few decades. For some specialties it will be midlevels. Others will be oversaturation, or changes in standard of care. Rad-onc, for example, managed to destroy itself without involving a single nurse practitioner. If you try and base your career off of a single theoretical risk you are likely be wrong, as doctors have historically been truly awful at predicting trends in medicine.

 

[armytrainingsir]

I don't disagree with the cause. I think it's a systemic problem that needs to be pointed out. It's not just a few bad actors. I just feel like it's the similar to MD v. DO in pre-allo in that everyone's said their bit and we just keep rehashing things. A dedicated subforum, sticky, etc. would probably create a more focused discussion. I'd rather see threads for people who're looking for advice in training, etc. It seems like all anyone wants to talk about on SDN-Medical Students is midlevel encroachment or some version of which field offers XYZ. Maybe I'm biased because I'd rather talk about medical education policy, clinical reasoning, clinical ward tips, etc. and those are starting to disappear.

I think this has been discus before. But I will start

least
1. Rads
2. Path
3. Most Surgical Specialties

Anything take requires a lot of knowledge and pays is low may also be save nepro, endo, rheumatoid

Path and Radiology are gonna get hit by AI

 

[IDPathDoc]

Pathology assistants are pretty busy in a lot of places ....

Pathology assistants (not physician assistants) require a separate and intense training program than physician assistants, and there is a massive shortage of them. They gross specimens and assist with autopsies and frozen sections but they do not make any diagnosis. Pathology assistants will not supplant pathologist because they cannot push glass. As opposed to physician assistants and NPs who do diagnosis. Some physician assistants are employed at centers under busy apheresis services, but they will not supplant pathologists either, they cannot run a blood bank.

 

[curiousfox]

Can any anesthesiologists speak on this?

 

[chicandtoughness]

Right. Like picking a specialty that midlevels won't ruin.

I'm not a med student (so maybe that makes my opinion worth ****), but I would like to point out that midlevel encroachment isn't necessarily something you can predict, especially over a lifetime. Ask psychiatrists from the 60s - did they expect that 30 years later the field of mental health would be completely overrun by LPCs/LMHCs/LMFTs/LCSWs/whatever other poorly trained masters level clinicians there are? (Some of whom were never intended to provide psychiatric services to begin with?) Psych is a good example of a field whose original intent has been completely swallowed by the midlevels and it is sad to see. I am one of said midlevels and I'm so pissed off about it I'm leaving the field entirely.

 

[xenotype]

I mean the abdominal exam is also subtle. but the solution thus far has been reflex ordering abdominal CTs. In neuro it will just be the MRI. Why try and localize when the radiologist can tell you where the lesion is.

I rarely venture into this part of SDN these days, but obviously you know nothing about neurology. Order all the MRIs you want, they won't diagnose the patient in myasthenic crisis or GBS about to crash in the ED or the inpatient ward when no one is looking. The pulse-ox and the ABG/VBG from 30 minutes ago also won't save you (or the patient) from misdiagnosis either. An MRI also may not show any evidence of an acute stroke until it is far too late to do anything about it, especially a brainstem or posterior circulation infarct. ALS, parkinson's disease won't pop up on your MRIs either. You'll also miss serious but entirely treatable adult onset inherited conditions like Pompe's, Fabry's, Wilson's with generally no imaging findings at all early on that are irreversible when a diagnosis is made too late. Regardless, many patients with health problems cannot even get MRIs anyways due to implanted devices (AICD, DBS, bladder stimulators, spinal cord stimulators, prior high velocity lead exposure).

 

[T-burglar]

Cardiothoracic anesthesia is relatively safe in my biased opinion. Pediatric anesthesia too if you work in a reputable children's hospital and enjoy being one of the volunteers to take care of the extremely alien malformed children.

But tons of routine anesthetics are simple enough that a fleet of nurses can do them with outcomes that will be "satisfactory" to anyone in hospital administration. In my opinion if you don't want to do sick cardiothoracic or jacked up kids then anesthesia may be kind of miserable in the near future.

 

[Man o War]

Can any anesthesiologists speak on this?

Me.
I’m old. I’ve seen the evolution of the specialty over time.
Anesthesia has the most established midlevels of all the specialties- they’ve been around for a long time. Our compensation is still excellent despite that.
What I see happening is even in states that allow them independent practice, most of the hospitals still opt to have them supervised.
Now, having said that....there are some crappy jobs out there that essentially make you a liability sponge. However, you can choose not to work in that type of arrangement. I work in a doc only group. We have no CRNAs or AAs. I also did a cardiac fellowship. The cases we do really do not lend themselves to midlevels; they would be really out of their depth and our surgeons have made it very clear they refuse to operate without doctors at the head of bed.
The other reality is CRNAs are expensive. In some ways they are pricing themselves out of the market which is going to prevent a takeover of the speciality as I see people predict sometimes- they don’t take call in ACT models, and generally work 40 hours a week; anything after that you’re paying time and half...which gets pricy at their rate. They are unique amongst midlevels in that they are more expensive in general for the amount of work you get out of them.
You usually see them working independently in rural areas at critical access hospitals for a couple reasons. 1) the acuity is lower and 2) Medicare literally pays these hospitals to hire them vs an anesthesiologist. It’s called pass through. They get paid if they hire CRNAs, but not anesthesiologists. So in rural hospitals where the financial margin is razor thin, they have a tough choice to make.
They’ve also started getting in on the diploma mill phenomenon. Used to be you could count on them to be competent, education was good, requirements were stringent. It’s more hit or miss these days for sure.

 

[Slappin' glass]

Path and Radiology are gonna get hit by AI

Love to see a clinician call a bot to explain their diagnosis.

 

[TheOther]

With the DPC movement, primary care's outlook is solid. You just can't replace a good primary doc, the backbone of healthcare. This value will continue to be recognized with time.

 

[Beedoc]

Believe it or not, psych and any PCP cause they are desperately needed, especially if healthcare access is expanded. Pay on those specialties might be a different story though. Here's a list: The 15 most in-demand specialties in 2019 and their base salaries

 

[sylvester500]

I have a separate worry. For context, I will begin medical school next year. For 5 years, I have worked at an urgent care (throughout college + some). We're almost all mid-level. Like literally 80% of patients are seen by midlevels without a physician onsite. The "provider administration" is all mid-levels, with a few docs in the C-suite. So, it's a huge trend in less-established/up-and-coming healthcare organizations. You can see where the trend is going.

With this being said, I also worry that internet-based obsession with the problem is going to "speak the problem into existence." What I mean is that it may be a problem now, but it will only be worse if the majority of medical students are getting all tied up online worrying about whether their chosen specialty will be "secure" in the future.

The more we worry online, the more our medical student colleagues will see the worry see thus drum up fear that specialty X is going down the toilet. Fewer students will go into specialty X, thus creating an even larger gap between supply of physicians in the specialty and patients' needs for the specialty. This gap will in turn be filled by the glut of midlevels being produced in this country and further perpetuate the problem, thus feeding into a vicious cycle.

I'm concerned. But, I want action. Anybody have any ideas about what actions can be taken?

 

[machete fred]

Ah, surgical subspecialties. Idk. I think they may be mostly safe, but in my n=1 anecdotal experience, PA's and NP's have been doing ortho surgeries and other procedures (OB, cardio, etc) in my area since I was an undergraduate (4 years ago). As such, I don't really consider any specialty to be safe from encroachment.

Edit: I can tell you which institution this is in DM

Doing a steroid injection and first assisting on a hip replacement is not "doing ortho surgery"

 

[SpliceOfLife]

Until they start creating PA/NP surgical "residencies" and forcing surgeons to train them at academic centers while pumping funds into forcing these independent practice bills through.

I would have said surgery in the past, but I've seen that there is truly no limit to the greed of these independent midlevels, the physicians training them, and the hospitals employing them. They just can't be underestimated.

This won't happen.

In addition to what's already been said, remember that PA/NPs are most interested in 3 things:
1. Responsibility (they're pushing full-practice authority)
2. Remuneration (they are already gunning for equal pay)
3. Recreation (they wont sacrifice this)

Point number 3 means you're not going to find PAs/NPs trying to supplant surgeons. They may get #1 and #2, but if they have to sacrifice their off-work time they're not interested. After all, that's the whole reason they went into PA/NP anyway - so they can do healthcare stuff without having to think and work like physicians.

Remember that there will always be surgical emergencies off some kind in almost every specialty. PAs/NPs don't want to deal with that. And what happens when your 8-hour case pushes past 5pm? What, are they going to sign out the OR patient to the next on-call PA/NP to finish the surgery lol?

Even cardiologists couldn't fully supplant cardiac surgeons. And cardiologists are some of the most hard-working ppl in the hospital. How much more PAs/NPs??

 

[TwistedTea]

This won't happen.

In addition to what's already been said, remember that PA/NPs are most interested in 3 things:
1. Responsibility (they're pushing full-practice authority)
2. Remuneration (they are already gunning for equal pay)
3. Recreation (they wont sacrifice this)

Point number 3 means you're not going to find PAs/NPs trying to supplant surgeons. They may get #1 and #2, but if they have to sacrifice their off-work time they're not interested. After all, that's the whole reason they went into PA/NP anyway - so they can do healthcare stuff without having to think and work like physicians.

Remember that there will always be surgical emergencies off some kind in almost every specialty. PAs/NPs don't want to deal with that. And what happens when your 8-hour case pushes past 5pm? What, are they going to sign out the OR patient to the next on-call PA/NP to finish the surgery lol?

Even cardiologists couldn't fully supplant cardiac surgeons. And cardiologists are some of the most hard-working ppl in the hospital. How much more PAs/NPs??

To be fair most of us medicine people wouldn’t want to work surg hours either lol

 

[Steve_Zissou]

Path and Radiology are gonna get hit by AI

AI coming for radiologists like

But really, AI isn't going to replace radiologists, and likely isn't going to make a significant dent in their market. The more I learn about AI in radiology, the more I am convinced of 2 things, 1 being that people who say "radiology is going to be taken over by AI!!!!" know very little about both radiology and AI, and 2 being that it will be many more years before AI is able to do the job of a radiologist to any significant degree. Will it likely make radiologists more efficient? Yes, but there is so much work to be done that it likely won't affect the amount of radiologists needed.

 

[EMH Mark V]

Path and Radiology are gonna get hit by AI

Not Forensic Pathology

Agree surgical and clinical path will likely get adversely affected by AI, but by that time FP will probably be its own specialty like in Europe separate from path entirely

 

[cerebral edema]

Seems vulnerable to me. You see a neurologist you are getting an MRI and possibly an EMG. A midlevel could do that.

I’ve not seen any encroachment nor interest from mid levels with regards to neurology.

 

[nimbus]

I’m sure they think they can pull it off, but I have zero concerns. The first time they get into bleeding will be the last time they think they can do what a surgeon does.

Even some fellowship trained board certified surgeons are not very good at surgery.

 

[7331poas]

I rarely venture into this part of SDN these days, but obviously you know nothing about neurology. Order all the MRIs you want, they won't diagnose the patient in myasthenic crisis or GBS about to crash in the ED or the inpatient ward when no one is looking. The pulse-ox and the ABG/VBG from 30 minutes ago also won't save you (or the patient) from misdiagnosis either. An MRI also may not show any evidence of an acute stroke until it is far too late to do anything about it, especially a brainstem or posterior circulation infarct. ALS, parkinson's disease won't pop up on your MRIs either. You'll also miss serious but entirely treatable adult onset inherited conditions like Pompe's, Fabry's, Wilson's with generally no imaging findings at all early on that are irreversible when a diagnosis is made too late. Regardless, many patients with health problems cannot even get MRIs anyways due to implanted devices (AICD, DBS, bladder stimulators, spinal cord stimulators, prior high velocity lead exposure).

That same argument could be made for the abdominal exam as well and yet that has not changed practice patterns.

 

[nimbus]

Ah, surgical subspecialties. Idk. I think they may be mostly safe, but in my n=1 anecdotal experience, PA's and NP's have been doing ortho surgeries and other procedures (OB, cardio, etc) in my area since I was an undergraduate (4 years ago). As such, I don't really consider any specialty to be safe from encroachment.

Edit: I can tell you which institution this is in DM

Independently as primary? What procedures?

 

[Spikebd]

Not Forensic Pathology

Agree surgical and clinical path will likely get adversely affected by AI, but by that time FP will probably be its own specialty like in Europe separate from path entirely

There’s currently no clear path for AI to sign out a synoptic case report of major 88309 (mastectomies, colectomies, lung resections, etc) resections with margins and lymph nodes. PA’s and NP’s are already here, and they’re significantly encroaching on residents work in most all fields except for a very rare few like path.

 

[BronteR]

Hey you guys - Pain Doctor here, was scrolling by and saw this post, and figured I knew what the question was about.

This is absolutely a legitimate worry to have. Also, look for specialties where you still have a shot of private practice, so you're not basically forced into an employment model by hospitals or private equity employment. Sounds convenient to just collect a paycheck, but its miserable when you're basically seeing your pay constantly threatened, go down, or see midlevel encroachment for cheaper value.

I got super lucky in retrospect, and didn't even think of this through. Looking back now, I am lucky. I did PM&R and then Interventional Pain. Midlevels can't do our procedures, especially minimally invasive procedures like Spinal Cord Stimulators, SI Joint Fusions, Vertiflex, DRG, Radiofrequency Ablation, etc. On top of that, we're one of the few specialties where most are still private practice and we have a great opportunity to still own our own practice (probably with a partner). So I would definitely look into that.

Shhhh don't tell everyone

 

[nimbus]

Can any anesthesiologists speak on this?

I’ve been practicing in Southern California since 1996, MD only private practice. I personally haven’t seen a CRNA in 25 years and don’t see any on the horizon. But it’s regional.

 

[nimbus]

Are you saying that even if this training is available for them that they won't be willing to do it due to the sheer intensity of it?

Most medical school graduates won’t do it so why would midlevels?