Medicine is taking a nosedive...

[Splenda88]

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[slowthai]

This post surprisingly made it to the front page of reddit. Interestingly, a lot of laypeople thought the comments on the post were d-baggish and elitist. All I can say is, ignorance kills, in more ways than one.

 

[Lem0nz]

I lol'ed when I dug this out of the downvoted posts.

"I know I’m gonna get downvotes for this, but what this picture fails to convey is the med student lounge downstairs, the resident lounge rooms downstairs, the surgical lounge with free food on 2, the OB resident lounge/kitchen on 3, the anesthesia “library/lounge” on 2, and that the IM residents have catered lunches every day at conference. But sure, if the lounge UHS and MFA pay for their employees let’s you complain more that SMHS employed residents don’t have access, or that the chiefs don’t let all their coresidents in the same way I did when I was there, go ahead."

Reality. Complete the narrative. They're such horrible people at GW for giving residents their own lounges, how dare they. Shame them for giving them their own spaces for each discipline.

Oof. People advocating to quash midlevels are up there with Qanon fanatics on that Reddit.

 

[slowthai]

I lol'ed when I dug this out of the downvoted posts.

"I know I’m gonna get downvotes for this, but what this picture fails to convey is the med student lounge downstairs, the resident lounge rooms downstairs, the surgical lounge with free food on 2, the OB resident lounge/kitchen on 3, the anesthesia “library/lounge” on 2, and that the IM residents have catered lunches every day at conference. But sure, if the lounge UHS and MFA pay for their employees let’s you complain more that SMHS employed residents don’t have access, or that the chiefs don’t let all their coresidents in the same way I did when I was there, go ahead."

Reality. Complete the narrative. They're such horrible people at GW for giving residents their own lounges, how dare they. Shame them for giving them their own spaces for each discipline.

Oof. People advocating to quash midlevels are up there with Qanon fanatics on that Reddit.

Thanks, gonna rush back to reddit to downvote you some more. I'm joking, lol. But taken in isolation, that sign makes zero sense whatsoever. Why are attendings, fellows, chief residents, and midlevels grouped together? Like what? Lol

 

[Lem0nz]

Thanks, gonna rush back to reddit to downvote you some more. I'm joking, lol. But taken in isolation, that sign makes zero sense whatsoever. Why are attendings, fellows, chief residents, and midlevels grouped together? Like what? Lol

Wasn’t my post. I learned my lesson on Reddit. But it sheds light into what I feel is a huge problem with this counter movement by doctors - taking facts out of context and putting them in isolation. Not good friends.

 

[FrkyBgStok]

Thanks, gonna rush back to reddit to downvote you some more. I'm joking, lol. But taken in isolation, that sign makes zero sense whatsoever. Why are attendings, fellows, chief residents, and midlevels grouped together? Like what? Lol

That’s how it is in my hospital. Attendings, fellows, and advanced level practitioners. The main reason is that attendings and advanced level practitioners pay for privilege. Most hospitals wrap up the physician lounge in their med staff dues. So it isn’t the hospital being nice to advanced level practitioners. They are paying. The fellows they say “hey you could be an attending so we will throw in the benefits.” And in the physician lounge there is free food and drinks.

There is a separate resident lounge that the residents have as a private space. Attendings don’t go in there and there is no free food, but the hospital essentially pays for that area.

So I imagine the most accurate sign would say it for fellows and whoever else pays for the privilege.

 

[Lawpy]

Wasn’t my post. I learned my lesson on Reddit. But it sheds light into what I feel is a huge problem with this counter movement by doctors - taking facts out of context and putting them in isolation. Not good friends.

While i disagree with your pro midlevel stance, i agree reddit is a toxic dumpster fire

 

[slowthai]

Wasn’t my post. I learned my lesson on Reddit. But it sheds light into what I feel is a huge problem with this counter movement by doctors - taking facts out of context and putting them in isolation. Not good friends.

It's a huge problem? Do you mind elaborating?

 

[FalconSlice]

This post surprisingly made it to the front page of reddit. Interestingly, a lot of laypeople thought the comments on the post were d-baggish and elitist. All I can say is, ignorance kills, in more ways than one.

Saw this picture earlier and thought "what whiny babies..." because our institution has "attending lounges" where it is literally what it is. No residents, fellows, students, etc. Then... I reread it and realized that NPs/PAs were allowed too

 

[operaman]

Oh good lord, someone on Twitter or Reddit trying to win more fake outrage points. Looking forward to the 12+ tweet long threads from all the Twitterati about how residents are physicians too. Extra outrage points to the first tweeter who says Med students should be allowed in too because they’re basically physicians already.

I would argue the nosedive is a result of students and trainees trying to leverage fake outrage and oppression for social media clout. It takes 5 seconds and fewer brain cells to understand why this sign is a non issue.

 

[littlecow]

Mid-levels need to learn their place. They are not attendings.

 

[Lem0nz]

It's a huge problem? Do you mind elaborating?

I did, ad nauseam, in the post below (above?) this one called Future or something like that. I don’t need to again.

 

[slowthai]

I did, ad nauseam, in the post below (above?) this one called Future or something like that. I don’t need to again.

I see. I wasn't 100% sure that's what you meant, so I just wanted to make sure.

 

[ohmanwaddup]

I'm surprised that the midlevels were nice enough to let the physicians in, since midlevels provide better care and actually care about patients /s

 

[slowthai]

I guess if it's based on paying dues or whatever, my question is, why don't the midlevels have their own lounge just like the attendings, residents, and med students do? It just looks like false equivalency if you're looking at this as an outsider with no context, which 99% of people are. It just makes GW look like an institution that devalues residents even more than usual.

A number of people are low ranking, DNR'ing, or not applying to this place now. According to people in the know, it's apparently kind of malignant, or at least, not a good place to train. So even though they've got lounges for residents and students too, it's not a place you wanna be for 3+ years. I'm glad this was uncovered, at least. Makes our lives a little easier come match season.

 

[Matthew9Thirtyfive]

Oh good lord, someone on Twitter or Reddit trying to win more fake outrage points. Looking forward to the 12+ tweet long threads from all the Twitterati about how residents are physicians too. Extra outrage points to the first tweeter who says Med students should be allowed in too because they’re basically physicians already.

I would argue the nosedive is a result of students and trainees trying to leverage fake outrage and oppression for social media clout. It takes 5 seconds and fewer brain cells to understand why this sign is a non issue.

Have you been on medtwitter lately? They’re all falling over themselves to say how midlevels are just as good or better than they are.

 

[slowthai]

Mid-levels need to learn their place. They are not attendings.

That is true, but the problem is, many places treat them like they are, at least on a cultural level. All these ivory tower sellouts treat them like they're God's gift to medicine. It's ridiculous and completely insane. I'm talking, from attendings down to med students, they have bought in to the idea of midlevels being equal or even better at doing medicine than actual doctors. They should just let a midlevel operate on them when they need a CABG.

 

[Matthew9Thirtyfive]

That is true, but the problem is, many places treat them like they are, at least on a cultural level. All these ivory tower sellouts treat them like they're God's gift to medicine. It's ridiculous and completely insane. I'm talking, from attendings down to med students, they have bought in to the idea of midlevels being equal or even better at doing medicine than actual doctors. They should just let a midlevel operate on them when they need a CABG.

Lol yeah right. You think those hypocrites have anyone but an attending take care of them?

 

[Lem0nz]

They should just let a midlevel operate on them when they need a CABG.

lol who do you think does the vein harvest?

 

[slowthai]

Lol yeah right. You think those hypocrites have anyone but an attending take care of them?

Yeah, I was being sarcastic haha. It's incredible how great of a motivator social media popularity is for throwing all integrity and common sense in the trash.

 

[slowthai]

lol who do you think does the vein harvest?

But that's nothing new. I'm talking skin to skin, not parts of a case. I guarantee you they wouldn't knowingly allow that mess.

 

[Redpancreas]

"what this picture fails to convey is the med student lounge downstairs, the resident lounge rooms downstairs, the surgical lounge with free food on 2, the OB resident lounge/kitchen on 3, the anesthesia “library/lounge” on 2, and that the IM residents have catered lunches every day at conference. But sure, if the lounge UHS and MFA pay for their employees let’s you complain more..."
Reality. Complete the narrative. They're such horrible people at GW for giving residents their own lounges, how dare they. Shame them for giving them their own spaces for each discipline.

I agree. We're all in this together but let's not waste getting outraged about things like this

People advocating to quash midlevels are up there with Qanon fanatics

I think there's a lot of concern I have for midlevels but agree that it's turned into a cult. If I wanted more of this content I'd go to Reddit. I'm willing to bet OP found it on r/noctor.

 

[Matthew9Thirtyfive]

I agree. We're all in this together but let's not waste getting outraged about things like this


If I wanted more of this content I'd go to Reddit. I'm willing to bet OP found it on r/noctor.

Pretending it doesn’t exist only helps them.

 

[Redpancreas]

Pretending it doesn’t exist only helps them.

Disagree (edit) *I dont think this is* an issue. The residents/students have their own lounges and get catered lunches. I just don't like the meme this is becoming. I think it's cherry picked. When an NP sends an HIV patient home with sumatriptan when they had cryptococcal meningitis that's a different story.

 

[Matthew9Thirtyfive]

Disagree that it's an issue. The residents/students have their own lounges and get catered lunches. I just don't like the meme this is becoming. I think it's cherry picked. When an NP sends an HIV patient home with sumatriptan when they had cryptococcal meningitis that's a different story.

Oh, you specifically meant this one situation. I thought you meant in general.

 

[Redpancreas]

Oh, you specifically meant this one situation. I thought you meant in general.

I just don't like that what people (or even us as physicians) see when they think "midlevel critics" are people who care about stupid stuff like this. I'm glad @Lem0nz 's posted early and exposed the meme so hopefully the thread doesn't devolve to the lowest common denominator.

 

[ohmanwaddup]

Assuming there are other lounges (Never seen a med student lounge before but I'm also a third year at a tiny community hospital), this sign seems stupidly petty unless there was a constant issue of all the chairs/food being taken by med students or non attendings being disruptive.

Maybe I just don't know how things are at academic places though.

 

[Matthew9Thirtyfive]

I just don't like that what people (or even us as physicians) see when they think "midlevel critics" are people who care about stupid stuff like this. I'm glad @Lem0nz 's posted early and exposed the meme so hopefully the thread doesn't devolve to the lowest common denominator.

I think the anti-midlevel sentiment goes too far on Reddit. Midlevel scope creep is a problem. A real problem. There are literally midlevels practicing independently in half the states in this country, and it’s terrifying. They are harming patients and costing the healthcare system more money. And saying “wElL rEsIdEnTs MaKe MiStAkEs ToO” is a terrible argument because even though they are doctors, they are learning their specialties—midlevels are very often treated like staff and not like trainees, and in a lot of places they are working without a real safety net. It’s completely different.

BUT. That doesn’t describe all midlevels, and there is a real place for them. Surgical specialties is a great example, as they can keep surgeons in the operating room and be a first assist. Surgeons just have to keep in the assist role. Another great example is the NICU. NICU nurses who go back and become NPs and work in the NICU working with physician oversight are the perfect example of what a midlevel should be: someone with years of experience in a niche subspecialty who goes into that field as a midlevel with real physician supervision.

That is what they should be doing. Not being loosed on the public in primary care when they have nowhere near the knowledge to be able to adequately care for primary care patients.

 

[Redpancreas]

I think the anti-midlevel sentiment goes too far on Reddit. Midlevel scope creep is a problem. A real problem. There are literally midlevels practicing independently in half the states in this country, and it’s terrifying. They are harming patients and costing the healthcare system more money. And saying “wElL rEsIdEnTs MaKe MiStAkEs ToO” is a terrible argument because even though they are doctors, they are learning their specialties—midlevels are very often treated like staff and not like trainees, and in a lot of places they are working without a real safety net. It’s completely different.

BUT. That doesn’t describe all midlevels, and there is a real place for them. Surgical specialties is a great example, as they can keep surgeons in the operating room and be a first assist. Surgeons just have to keep in the assist role. Another great example is the NICU. NICU nurses who go back and become NPs and work in the NICU working with physician oversight are the perfect example of what a midlevel should be: someone with years of experience in a niche subspecialty who goes into that field as a midlevel with real physician supervision.

That is what they should be doing. Not being loosed on the public in primary care when they have nowhere near the knowledge to be able to adequately care for primary care patients.

Exactly. I'm not in surgery, but I don't think some understand how hard surgeons work. They do the cases/pre-op, patient interaction, and attempt their best medical management but there's no way they have time to manage patients medically per guidelines. That said, the issues these perioperative patients have are minimal and you don't need to have a patient admitted under a hospitalist either because they "have a medical issue-i.e. SLE stable of HCQ 200mg for years". The solution in place I think is already good - Having a veteran NPs who's worked on that floor or similar ones for 20 years along with resident-interns managing the patient. If medical complexities arise, consult Internal Medicine to manage an acute medical issue. Agreed that NPs should not be providing independent primary care. Yes, the best well-intentioned NP may stack up better than the burnt out Caribbean grad in FM who doesn't care about medicine anymore, but the NP training is not meant for independent practice. If they want to become equivalent, require equivalent certifications (Step 3, board certification) and watch them drop like flies.

 

[deleted1076141]

Assuming there are other lounges (Never seen a med student lounge before but I'm also a third year at a tiny community hospital), this sign seems stupidly petty unless there was a constant issue of all the chairs/food being taken by med students or non attendings being disruptive.

Maybe I just don't know how things are at academic places though.

We have a pretty nice med student exclusive lounge at Minnesota

 

[operaman]

Have you been on medtwitter lately? They’re all falling over themselves to say how midlevels are just as good or better than they are.

I peek occasionally, but the nausea and vomiting eventually win out and I have to turn it off and pop a zofran.

 

[Matthew9Thirtyfive]

I peek occasionally, but the nausea and vomiting eventually win out and I have to turn it off and pop a zofran.

I prefer promethazine so I can sleep it off and forget I ever read it.

 

[Matthew9Thirtyfive]

Exactly. I'm not in surgery, but I don't think some understand how hard surgeons work. They do the cases/pre-op, patient interaction, and attempt their best medical management but there's no way they have time to manage patients medically per guidelines. That said, the issues these perioperative patients have are minimal and you don't need to have a patient admitted under a hospitalist either because they "have a medical issue-i.e. SLE stable of HCQ 200mg for years". The solution in place I think is already good - Having a veteran NPs who's worked on that floor or similar ones for 20 years along with resident-interns managing the patient. If medical complexities arise, consult Internal Medicine to manage an acute medical issue. Agreed that NPs should not be providing independent primary care. Yes, the best well-intentioned NP may stack up better than the burnt out Caribbean grad in FM who doesn't care about medicine anymore, but the NP training is not meant for independent practice. If they want to become equivalent, require equivalent certifications (Step 3, board certification) and watch them drop like flies.

They actually did take step 3. They did an experiment where selected volunteer NPs took a watered down version of step 3 that was geared toward midlevels. The average pass rate ranged from 33-50% so they stopped the program.

 

[Redpancreas]

They actually did take step 3. They did an experiment where selected volunteer NPs took a watered down version of step 3 that was geared toward midlevels. The average pass rate ranged from 33-50% so they stopped the program.

That's actually quite impressive depending on how watered down their version was. Maybe I'm biased because I took it recently, but Step 3 is not a joke. It requires a solid amount of clinical reasoning. If it actually meant something and people were looking to get 230s/240s, it would generate far more angst than it currently does.

 

[Matthew9Thirtyfive]

That's actually quite impressive depending on how watered down their version was. Maybe I'm biased because I took it recently, but Step 3 is not a joke. It requires a solid amount of clinical reasoning.

The pass rate for physicians on the real thing is 97%. The watered down version was specifically not intended to look at independent practice. It was all first order questions. A sub-50% pass rate is what I expected, but it’s not impressive. These are NPs who were handpicked to take this exam and still less than half could pass it. And yet they are out there practicing independently.

 

[Redpancreas]

The pass rate for physicians on the real thing is 97%. The watered down version was specifically not intended to look at independent practice. It was all first order questions.

Quite embarrassing in that case. 97% on a difficult test vs. 33-50% on test simply designed to test what they're already supposed to know XD.

 

[Lawpy]

Whether midlevels are important or not doesn't change the fact that they should be held mainly, if not completely, liable for any harms done under their watch without falling back on physicians' license.

 

[Lem0nz]

There are literally midlevels practicing independently in half the states in this country. In a lot of places they are working without a real safety net. It’s completely different.

Are there statistics for this? I feel like the anti-midlevel crowd dramatically overinflates the problem because I have never been into a hospital at any point in ten years where midlevels are independently practicing medicine, at least in the inpatient realm. None of the major hospital systems I have worked for (6 or 7 of them at this point) employ them this way. The 28 states who have passed laws or whatever, I'm curious how many APPs are utilizing them and what their distribution is? Genuinely interested. Not in the 9 NPs working under 1 anesthesia doc and calling that independent practice; I don't think that is true independent practice. I mean like actual, no physician oversight what-so-ever, independent practice. What are the real numbers? How many places are a lot of places?

 

[Matthew9Thirtyfive]

Are there statistics for this? I feel like the anti-midlevel crowd dramatically overinflates the problem because I have never been into a hospital at any point in ten years where midlevels are independently practicing medicine, at least in the inpatient realm. None of the major hospital systems I have worked for (6 or 7 of them at this point) employ them this way. The 28 states who have passed laws or whatever, I'm curious how many APPs are utilizing them and what their distribution is? Genuinely interested. Not in the 9 NPs working under 1 anesthesia doc and calling that independent practice; I don't think that is true independent practice. I mean like actual, no physician oversight what-so-ever, independent practice. What are the real numbers? How many places are a lot of places?

Yes I should have clarified. I did not mean inpatient. I meant outpatient. There are places where midlevels are practicing unsupervised inpatient, but I don’t think that is super common.

 

[Splenda88]

Yes I should have clarified. I did not mean inpatient. I meant outpatient. There are places where midlevels are practicing unsupervised inpatient, but I don’t think that is super common.

It's pretty common, at least at my ivory tower.

 

[Prehealth1011]

They actually did take step 3. They did an experiment where selected volunteer NPs took a watered down version of step 3 that was geared toward midlevels. The average pass rate ranged from 33-50% so they stopped the program.

I can only imagine the horror in their faces when they see "what is the next step" in a question and can't find "refer to MD/DO" in the answer choices

 

[Matthew9Thirtyfive]

It's pretty common, at least at my ivory tower.

It might be common, I just don’t know. I think it’s probably more common at critical access hospitals. I know at the one I worked at, CRNAs were independent without any anesthesiologist oversight.

 

[Redpancreas]

It's pretty common, at least at my ivory tower.

You mean there's an NP or midlevel workflow you know where daily table rounds with physicians are not a thing? I don't even think that's allowed anywhere. Please provide an example if you can without compromising anonymity as that's something I'd be firmly against.

 

[Redpancreas]

Thanks, gonna rush back to reddit to downvote you some more. I'm joking, lol. But taken in isolation, that sign makes zero sense whatsoever. Why are attendings, fellows, chief residents, and midlevels grouped together? Like what? Lol

Totally agree and was trying to make sense of it as well. I think you can draw a pattern from it which is that everyone with a full practice license (and perhaps employed under whatever UHA/MFA means) refers to the former whereas not fully licensed is SMHS.

Edit: Googled the terms. SMHS is simply an abbreviation for the medical school. MFA means Medical Faculty Associates.

 

[Matthew9Thirtyfive]

You mean there's an NP or midlevel workflow you know where daily table rounds with physicians are not a thing? I don't even think that's allowed anywhere. Please provide an example if you can without compromising anonymity as that's something I'd be firmly against.

I know for a fact there are at least some hospitals where all the care is provided by NPs and either the physicians don’t exist or are just completely absent for huge chunks of time (like most of the day). They have been involved in lawsuits after bad outcomes.

 

[Redpancreas]

I know for a fact there are at least some hospitals where all the care is provided by NPs and either the physicians don’t exist or are just completely absent for huge chunks of time (like most of the day). They have been involved in lawsuits after bad outcomes.

I mean at centers I have worked at with lists >10 per team, usually a hospitalist goes and sees everyone in the AM but PA/NP covers half the patients and deals with their stuff until sign out. The way this factors into the EMR is usually the PA/NP have placed orders and the MD/DO have the ability to review them and will call their mid levels if concerns arise. Many allow for notifications every time an order is placed. It allows for convenient remote work and I think that counts as supervision.

I think people get the wrong idea because they don't see the full picture behind the scenes. Many of these anti-NP/PA people are students who are plenty intelligent but lack the vantage point in the hospital system and get false impressions.

 

[sunshinefl]

You mean there's an NP or midlevel workflow you know where daily table rounds with physicians are not a thing? I don't even think that's allowed anywhere. Please provide an example if you can without compromising anonymity as that's something I'd be firmly against.

I’ve seen NP daily table rounds with a physician for an entire panel of inpatients be as short as 30 seconds total.

 

[Splenda88]

You mean there's an NP or midlevel workflow you know where daily table rounds with physicians are not a thing? I don't even think that's allowed anywhere. Please provide an example if you can without compromising anonymity as that's something I'd be firmly against.

Where I am, NP manage their OWN patients in the MICU/CVICU. Their notes are final (aka not attested by MD/DO). It's an 1000+ beds hospital--the main site of my IM residency program.

 

[Redpancreas]

I’ve seen NP daily table rounds with a physician for an entire panel of inpatients be as short as 30 seconds total.

It's the physician's role to set a standard and is on them if they're not supervising carefully enough. If the MD/DO is willing to do that, maybe they're reviewing orders behind the scenes which with EMRs/telemonitoring is actually close supervision. If they're not, that's partly on physicians enabling that.

 

[Lem0nz]

physicians are just completely absent for huge chunks of time (like most of the day)

This is normal inpatient medicine all across our country. Your attending doc sees you for ten minutes once a day, the end. The only place and service I have ever seen anything different is the ICU where you were seen twice a day, once in AM once in PM (sometimes depending on the attending). So an NP or PA being present in this model honestly provides more coverage and service, not less.