Medicine is taking a nosedive...

[Splenda88]

Right? Like...

Got any pets?

Any family member that is a midlevel?

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[Lawpy]

I'm all good with bashing private equity if we're tired with midlevel stuff

I hate private equity

 

[Lem0nz]

Any family member that is a midlevel?

Exhibit B on dogmatic people.

 

[Lawpy]

Any family member that is a midlevel?

I have a crush on some hot PAs but even then i'm still anti midlevel... at least on SDN

i really am i swear!

 

[Matthew9Thirtyfive]

I have a crush on some hot PAs but even then i'm still anti midlevel... at least on SDN

i really am i swear!

You don’t have to be anti midlevel. Most of us who advocate for physician-led care aren’t. We are just against midlevel independence.

 

[Lawpy]

Look, I have zero problem with midlevels being utilized to see more patients and make more money. My problem is when those midlevels are not appropriately supervised, which happens a LOT. Probably less in surgery, but it is so common in primary care, derm, etc. And don’t even get me started on psych NPs.

Oh crap, we disagree on this topic too

I'm supporting independent practice rights over supervision just because i want midlevels to face liability and malpractice lawsuits if things go wrong

That said, i don't want to endanger patient care but the problem is less midlevel and more access to care.

 

[Captain_Falcon]

I have a crush on some hot PAs but even then i'm still anti midlevel... at least on SDN

i really am i swear!

pics or they don't exist


kidding, kidding

 

[BorntobeDO?]

I can explain that. As we all know, M1-4 students are mainly in the books and there is no formal (required) clinical training where medical students are required to interact with the practical components of healthcare. Some students counter that they're Rock Star Medical Student who knows all that stuff...but the majority don't. For example, ask a nurse (and hence NP) what the indications for XYZ line is and things to watch out for and they will know and be able to remove/replace the line whereas many medical students are clueless until they start residency.

That's why I think there should be earlier clinical integration into the medical student's education with practical components...but no, some people want more biochem and anatomy because that's what differentiates the doctor's education from a midlevel's. Nurses (and hence NPs) learn this early in their education. The sooner you teach these practice components, the more a student will understand and be able to act on.

Your kidding yourself if you think biochem is the difference between a doctor and a nurse. And you are way overselling nurses. NPs don’t understand almost anything that they are doing, they hit symptoms with drugs and that’s it. It’s funny how attendings who think nurses are so compentent and trustworthy paint all students/resident with the ‘untrustworthy’ brush solely due to their familiarity with a nurse or NP and how well those workers follow their preferences, rather than any actual medical knowledge base.

Quite frankly, as someone who was a nurse for years and went back to medical school because it was more rigorous I find it quite insulting when someone insinuates that a RN or NP is more knowledgeable. It seems this an extension of some sort of psuedo-pc mindset that has been cleverly ingrained into medicine, where it is okay to be super harsh and judgmental on students and residents but concurrently have no standards for the supporting staff. None of the NPs/PAs working would hold up well to the scrutiny that an intern/medical student gets when presenting in the classic academic setting.

 

[Lawpy]

pics or they don't exist


kidding, kidding

Lol i wish but i'd be the most strongly pro midlevel propaganda SDNer on the forums

I'm already pro midlevel independence and believe midlevels are professionals in their own right, which is a major break from my earlier posts on the topic.

 

[Splenda88]

I have a crush on some hot PAs but even then i'm still anti midlevel... at least on SDN

i really am i swear!

Sleeping with the enemy...

 

[Redpancreas]

Your kidding yourself if you think biochem is the difference between a doctor and a nurse. And you are way overselling nurses. NPs don’t understand almost anything that they are doing, they hit symptoms with drugs and that’s it. It’s funny how attendings who think nurses are so compentent and trustworthy paint all students/resident with the ‘untrustworthy’ brush solely due to their familiarity with a nurse or NP and how well those workers follow their preferences, rather than any actual medical knowledge base.

Quite frankly, as someone who was a nurse for years and went back to medical school because it was more rigorous I find it quite insulting when someone insinuates that a RN or NP is more knowledgeable. It seems this an extension of some sort of psuedo-pc mindset that has been cleverly ingrained into medicine, where it is okay to be super harsh and judgmental on students and residents but concurrently have no standards for the supporting staff. None of the NPs/PAs working would hold up well to the scrutiny that an intern/medical student gets when presenting in the classic academic setting.

1. "Your kidding yourself if you think biochem is the difference between a doctor and a nurse"

No dude, I didn't say that. This is a outdated argument I've heard from Ph.Ds retort when I've advocated for curriculum changes long ago at my institution as a student rep. It's also what some people on here have said. I was parodying that viewpoint.

2. "NPs don’t understand almost anything that they are doing, they hit symptoms with drugs and that’s it. It’s funny how attendings who think nurses are so compentent and trustworthy paint all students/resident with the ‘untrustworthy’ brush solely due to their familiarity with a nurse or NP and how well those workers follow their preferences, rather than any actual medical knowledge base."

I have been there. I really have. It was 7am after I admitted 6 CICU patients and put out fires all night and I was presenting a new patient that hit the floor at 630am and I didn't have a coherent story and was stuttering because I was sleep deprived and the peppy AM nurse just starting her shift who had report from like 5 different people chimes in and the attending tells her "well, why don't you just come and take his place"...the whole team laughed it off...so I get your sentiment and I'm not disputing it happens.

Also, the NP Dunning Kruger effect is an established thing too. They pick up on mind-numbingly obvious patterns like elevated WBC-> abx and some have egos too and have attitudes against medical students which is f'ed up. That is why they should be supervised because at the end of the day they should never be in charge of the big picture.

3. "Quite frankly, as someone who was a nurse for years and went back to medical school because it was more rigorous I find it quite insulting when someone insinuates that a RN or NP is more knowledgeable. It seems this an extension of some sort of psuedo-pc mindset that has been cleverly ingrained into medicine, where it is okay to be super harsh and judgmental on students and residents but concurrently have no standards for the supporting staff. None of the NPs/PAs working would hold up well to the scrutiny that an intern/medical student gets when presenting in the classic academic setting"/

What I said was that there are practical elements that NPs know from their nursing education. Something so simple as what a midline vs. a PICC line is and how that differs from a tunneled subclavian is something medical students should ideally know. These are not just things nurses touch (the viewpoint of some medical students). Being able to identify a line immediately gives you insight into what care a patient received or did not receive at another institution and knowing these things are essential for patient care when it comes to transitions of care. Some medical students know this stuff but the fact is most don't because this is not something formally taught. So yes, NPs are more knowledgeable in these areas than many interns given their experience and prior nursing background and this what allows them to report certain facts that a medical student may not fully grasp yet because it has not been told to them.

 

[Matthew9Thirtyfive]

Oh crap, we disagree on this topic too

I'm supporting independent practice rights over supervision just because i want midlevels to face liability and malpractice lawsuits if things go wrong

That said, i don't want to endanger patient care but the problem is less midlevel and more access to care.

No, the whole “let them have independent practice and their own liability” isn’t the solution. It’s the reaction to them getting independent practice. But the goal should be to prevent that in the first place.

 

[Lawpy]

No, the whole “let them have independent practice and their own liability” isn’t the solution. It’s the reaction to them getting independent practice. But the goal should be to prevent that in the first place.

They shouldn't be viewed as trainees requiring supervision forever though. Their roles should be defined in such a way they can act as independent professionals in their own right

 

[DrNotaDr]

I was a nurse... I look into NP before making the decision to go to med school--so I know.

Then you’re purposefully misleading others when you say she got her education in 3 years, knowing the standard education is 2 semesters a year, instead of 3. So in reality it took her 4 “years” to do all her work, if she took more traditional courses. Who cares. Can we talk about how you changed the name of your entire thread just to make it even more incendiary and anti nurse? I’d really like to hear your explanation there.

 

[Splenda88]

That is FL for ya. Taking from my spouse's friend family/psych NP license

Qualifications
Autonomous Practice APRN
Nurse Practitioner
Psychiatric Nurse


Our system sucks...

 

[Redpancreas]

That is FL for ya. Taking from my spouse's friend family/psych NP license

Qualifications
Autonomous Practice APRN
Nurse Practitioner Psychiatric Nurse


Our system sucks...

Yeah, so I'll grab my pitchfork and protest against this.

 

[DrNotaDr]

Yeah, so I'll grab my pitchfork and protest against this.

Good luck. Don’t forget to attack the PA’s too, they are also now independent in Florida.

 

[Redpancreas]

Good luck. Don’t forget to attack the PA’s too, they are also now independent in Florida.

Who is this guy?

 

[DrNotaDr]

Who is this guy?

I’m just a doctor who isn’t a doctor. 😜

 

[notretired]

What I said was that there are practical elements that NPs know from their nursing education. Something so simple as what a midline vs. a PICC line is and how that differs from a tunneled subclavian is something medical students should ideally know. These are not just things nurses touch (the viewpoint of some medical students). Being able to identify a line immediately gives you insight into what care a patient received or did not receive at another institution and knowing these things are essential for patient care when it comes to transitions of care. Some medical students know this stuff but the fact is most don't because this is not something formally taught. So yes, NPs are more knowledgeable in these areas than many interns given their experience and prior nursing background and this what allows them to report certain facts that a medical student may not fully grasp yet because it has not been told to them.

I mean this seems like a fairly simple thing to teach a student on rotations no? In which case they will leave your rotation having learned it, since you know, they are there to learn and all.

 

[DrNotaDr]

I mean this seems like a fairly simple thing to teach a student on rotations no? In which case they will leave your rotation having learned it, since you know, they are there to learn and all.

I’ve never seen an intern who knew the difference between a mahukar and a trialysis line and what that may mean for the morning working flow if that patient is decompensating, and frankly, sometimes there isn’t time to teach all of that.

 

[Redpancreas]

I mean this seems like a fairly simple thing to teach a student on rotations no? In which case they will leave your rotation having learned it, since you know, they are there to learn and all.

I mean...of course...but this isn't the only thing to teach them lol. It would be nice if there was some way to provide this information to them in a formalized way because who learns something and who doesn't shouldn't depend on the attending's proclivity to teach that morning.

Also this notion that they're supposed to learn these things on the fly. Well...clearly medical students are not retaining it. Expecting an attending to teach medical students what they need to know is the equivalent of expecting your teenage baby sitter to teach your toddler long division and serve them home cooked meals when they really are just going to Facetime their significant other for two hours. It's nice if they do it, but there's no real incentive for them to do so.

 

[notretired]

I mean...of course...but this isn't the only thing to teach them lol. It would be nice if there was some way to provide this information to them in a formalized way because who learns something and who doesn't shouldn't depend on the attending's proclivity to teach that morning.

Also this notion that they're supposed to learn these things on the fly. Well...clearly medical students are not retaining it. Expecting an attending to teach medical students what they need to know is the equivalent of expecting your teenage baby sitter to teach your toddler long division and serve them home cooked meals when they really are just going to Facetime their significant other for two hours. It's nice if they do it, but there's no real incentive for them to do so.

That's basically why we have boards. I'm not saying they are the end all and be all, but if you ask 5 different attendings to describe what vital knowledge students must posses, you'd get 5 different answers. The system isn't perfect, but students come out of preclinical with a base, and the clinical years and residency/fellowship sharpen that base into a pyramid. NP's start out at the top of pyramid with nothing underneath ~ to compare the two when med students still have 4-5yrs of additional training to go seems a bit shortsighted.

 

[VA Hopeful Dr]

It’s not just in BFE. And the UK is the sixth fattest nation with obesity rates that rival or exceed the US. Midlevels certainly aren’t the only factor in our worse outcomes, but that doesn’t mean it isn’t a problem that needs to be addressed.

Not so much.

The UK is 6th among OECD countries. Using that qualifier the US is #1 by a pretty large margin (we're roughly 40% higher: 36% v 27%).

I have seen zero data that tried to blame midlevels for our outcomes (which aren't actually that bad). If you have it I'd love to see it.

 

[sunshinefl]

Please tell me why you want midlevels to forever be under the liability of attendings as opposed to practicing independently

Also your comparison doesn't make sense. You're comparing junior doctors that eventually become senior to midlevels who are forever stuck in liability under an attending

This was all I needed to downvote this post. Comparing physicians advocating for patients to Qanon is a complete fallacy and false equivalency. At this point with both PAs and NPs advocating for complete independence, I don’t see a clear role for them in healthcare that doesn’t jeopardize patient care. Whatever they were originally designed to do, they aren’t doing. You can say you like mid levels cause they are cheap and can generate profit for a practice, but your interest is clearly not patients receiving adequate care.

Mid levels should only be used in a 1:1 hire/fire/train/follow the doctors protocol/true physician extender/ supervised by that doctor type of role.

 

[Mad Jack]

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.

Ugh, Reddit

 

[Redpancreas]

That's basically why we have boards. I'm not saying they are the end all and be all, but if you ask 5 different attendings to describe what vital knowledge students must posses, you'd get 5 different answers. The system isn't perfect, but students come out of preclinical with a base, and the clinical years and residency/fellowship sharpen that base into a pyramid. NP's start out at the top of pyramid with nothing underneath ~ to compare the two when med students still have 4-5yrs of additional training to go seems a bit shortsighted.

The board exams are so different from clinical work that it's become a caricature. The fact of the matter is current formal clinical education is poor and many US medical students do not meet their full potential as a result. Forget the NP/PA comparison then if it rubs some people the wrong way. Just focus on the fact that at some US medical schools, a student can go through a medicine clerkship by just giving formulaic presentations daily and doing some busy work residents gave them without any instruction on practical clinical skills or assessment of their clinical reasoning. They'll appease enough to get passing evaluations and have enough time to do UWorld when they're off. Sure maybe some blame falls on the student for lack of proactivity, but blame should also be put on the system in place where it's really not in line with an attending's/resident's incentives to teach medical students this stuff. If we want medical students to be more useful, we have to teach them and that culture is not in place across the board at all medical schools.

The only reason I push for this is because students seem to have an issue with why midlevels (licensed professionals) have more autonomy than medical students. We can fix that. The missing practical components EARLY in medical school training are a major reason medical students are lost. How can we expect medical students to perform well on clerkships if they don't even know what all the instruments at the patient's bedside mean/do? They should be taught earlier (not to displace MD material) but to allow for complementary learning. I have given examples with pulmonary physiology- ventilators, infectious disease-catheters, etc. in other threads.

 

[Lawpy]

Mid levels should only be used in a 1:1 hire/fire/train/follow the doctors protocol/true physician extender/ supervised by that doctor type of role.

Ehh that's where i disagree. Midlevels are not trainees forever demanding supervision. Midlevels are professionals in their own right and should be treated as such. I oppose supervising midlevels

 

[Steve_Zissou]

Ehh that's where i disagree. Midlevels are not trainees forever demanding supervision. Midlevels are professionals in their own right and should be treated as such. I oppose supervising midlevels

Lawpy flip floppy

 

[sunshinefl]

Ehh that's where i disagree. Midlevels are not trainees forever demanding supervision. Midlevels are professionals in their own right and should be treated as such. I oppose supervising midlevels

They don't have the education and training necessary for independence. But I agree that physicians shouldn't be forced liability shields for an army of midlevels either. Hence why I said it should be a 1:1 relationship only if the physician wants to have a "right hand man/woman", with hiring/firing/training selection and authority.

 

[Lawpy]

Lawpy flip floppy

there may or may not be a conflict of interest

no but for real, the problem with midlevel encroachment arose because of supervision, whether because physicians want to maximize profits/efficiency or because of hospitals wanting to do the same. Residents and students have far more value because their education is far more standardized and their role is by definition trainees.

 

[Lawpy]

They don't have the education and training necessary for independence. But I agree that physicians shouldn't be forced liability shields for an army of midlevels either. Hence why I said it should be a 1:1 relationship only if the physician wants to have a "right hand man/woman", with hiring/firing/training selection and authority.

Then the solution is to force higher standards for midlevel education. I'm pushing for independence just because i want midlevels to face the full brunt of liability and malpractice lawsuits. Hospitals should also be sued if they force physicians to accept/supervise midlevels

We need to define clearly what a midlevel is and isn't. NPs are more of a nursing role than medical role so NPs streamlining nursing practice is better suited. PAs are more similar to being residents for life but that's a disturbing problem in itself if a career fundamentally depends on being a forever trainee.

 

[Redpancreas]

Then the solution is to force higher standards for midlevel education. I'm pushing for independence just because i want midlevels to face the full brunt of liability and malpractice lawsuits. Hospitals should also be sued if they force physicians to accept/supervise midlevels

We need to define clearly what a midlevel is and isn't. NPs are more of a nursing role than medical role so NPs streamlining nursing practice is better suited. PAs are more similar to being residents for life but that's a disturbing problem in itself if a career fundamentally depends on being a forever trainee.

Medical education could use some reforms too, but agreed. I think there needs to be healthcare policies in place so that lawyers can not chase the money (as they often do - ive seen it with industry experience in lawsuits against the auto industry) but the one who is actually responsible. There's an easy way to track that. Who wrote the order? The NP? Then it's on them? Did the physician cosign it? Then it's on the attending. Their actions should carry some weight too.

Yeah, I'm grouping PAs/NPs on here a lot for the sake of completeness but I don't really know the difference which is probably not a good thing.

Where I think most people seem to disagree with me on is that physicians also bear some brunt of accountability in this. A majority of physician groups across the nation utilize PA/NPs in their practice and it creates a significant lessened work burden. That's why I think it's disingenuous to be like this is all NP/PA propaganda. Physicians have enabled the expanded scope as a majority of hospital groups are using the services and benefiting. At some places, I can understand if one individual is hellbent on doing his own work but then the model makes it unsustainable to not have a PA but then this isn't one institution. This is across the board.

 

[notretired]

The board exams are so different from clinical work that it's become a caricature. The fact of the matter is current formal clinical education is poor and many US medical students do not meet their full potential as a result. Forget the NP/PA comparison then if it rubs some people the wrong way. Just focus on the fact that at some US medical schools, a student can go through a medicine clerkship by just giving formulaic presentations daily and doing some busy work residents gave them without any instruction on practical clinical skills or assessment of their clinical reasoning. They'll appease enough to get passing evaluations and have enough time to do UWorld when they're off. Sure maybe some blame falls on the student for lack of proactivity, but blame should also be put on the system in place where it's really not in line with an attending's/resident's incentives to teach medical students this stuff. If we want medical students to be more useful, we have to teach them and that culture is not in place across the board at all medical schools.

The only reason I push for this is because students seem to have an issue with why midlevels (licensed professionals) have more autonomy than medical students. We can fix that. The missing practical components in medical school training are a major reason medical students are lost. How can we expect medical students to perform well on clerkships if they don't even know what all the instruments at the patient's bedside mean/do? They should be taught earlier (not to displace MD material) but to allow for complementary learning. I have given examples with pulmonary physiology- ventilators, infectious disease-catheters, etc. in other threads.

I agree with you there, a lot of the reasons for this extend well beyond the control of the student - and the onus falls on the system AND the physicians (who chose to work in academics I might add) to teach students. There's a mismatch with the incentives though. Train a midlevel and you have someone to do your busy work for years to come. Train a student and they're gone in the next month. In a world without midlevels and excessive litigation, I imagine students would be freed up to work much like they did in the 80's/90's. It's not the students fault that they choose to do uworld in lieu of what effectively amounts to shadowing on some rotations.

 

[Lawpy]

Medical education could use some reforms too, but agreed. I think there needs to be healthcare policies in place so that lawyers can not chase the money (as they often do - ive seen it with industry experience in lawsuits against the auto industry) but the one who is actually responsible. There's an easy way to track that. Who wrote the order? The NP? Then it's on them? Did the physician cosign it? Then it's on the attending. Their actions should carry some weight too.

Yeah, I'm grouping PAs/NPs on here a lot for the sake of completeness but I don't really know the difference.

Where I think most people seem to disagree with me on is that physicians also bear some brunt of accountability in this. A majority of physician groups across the nation utilize PA/NPs in their practice and it creates a significant lessened work burden. That's why I think it's disingenuous to be like this is all NP/PA propaganda. Physicians have enabled the expanded scope as a majority of hospital groups are using the services and benefiting. At some places, I can understand if one individual is hellbent on doing his own work but then the model makes it unsustainable to not have a PA but then this isn't one institution. This is across the board.

That's a major reason for pro independence midlevel propaganda. They're claiming they're underpaid because greedy physicians are exploiting them combined with their arrogance they're comparable to physicians.

 

[Lawpy]

Also medical education is getting diluted by aggressive DO expansion with little to no clinical sites and worsening quality by COCA, so medical leaders cannot claim they're truly flawless with regards to education quality

We need a regulatory body like LCME but for midlevels

 

[Redpancreas]

I agree with you there, a lot of the reasons for this extend well beyond the control of the student - and the onus falls on the system AND the physicians (who chose to work in academics I might add) to teach students. There's a mismatch with the incentives though. Train a midlevel and you have someone to do your busy work for years to come. Train a student and they're gone in the next month. In a world without midlevels and excessive litigation, I imagine students would be freed up to work much like they did in the 80's/90's. It's not the students fault that they choose to do uworld in lieu of what effectively amounts to shadowing on some rotations.

Yeah we're on the same exact same wavelength here. The student's incentive to be proactive is just not there because of the momentum of past expectations and how things work. The attending's incentive to teach is always there either. I am not old enough to comment on the 80s/90s but I would love for students to have a greater role in overall care as it promotes complementary learning. I do not think (like lem0nz pointed out) there's not enough residents to eliminate PA/NP roles but maybe more can be displaced by medical students and medical students who do not match if we incorporate this practical material.

Also, food for thought...It is naive for students (not you) to assume academic physicians all choose academia because they're so passionate about teaching medical students. Even though salaries are not high, there are many benefits like having your institution settle aggressively if your group makes a mistake, healthcare at your institution, significantly lessened work burden, opportunities for travel/publication, and prestige which make academics appealing to some. Like there is no check to ensure attendings cover what needs to be taught. You pointed out earlier that you take 5 attendings and each one will want to teach something different. Let's just say that you just randomly pick what one attending wants to teach. Even then, there are no checks/standards to ensure that material will make its way to all clerkship students and get assessed appropriately in the system medical students work in today.

 

[Lawpy]

With CS gone, why can't we just let more IMGs/FMGs do residency in US + residency expansion in FM/IM/peds to crowd out the midlevels?

 

[jambro]

With CS gone, why can't we just let more IMGs/FMGs do residency in US + residency expansion in FM/IM/peds to crowd out the midlevels?

Theoretically I agree that everyone would be better off if we had more IMGs/FMGs and less midlevels. Unfortunately, the reality is that what would happen would be the same amount of midlevels (continually increasing) + more IMGs/FMGs which would cause a big job market issue for the physician jobs that are left. The midlevel ship has sailed.

 

[Redpancreas]

With CS gone, why can't we just let more IMGs/FMGs do residency in US + residency expansion in FM/IM/peds to crowd out the midlevels?

There would have to be some level of assessment. Midlevels have a certain amount of practical training that makes them useful. They come out of midlevel school. I remember starting in the ICU, the midlevel reported the vent settings and full presentation very well and knew how to change settings, etc. because those practical elements are part of their training especially since they work 1-on-1 (their version of residency for like a year) in the hospital with a pro-midlevel who drills this into them before they start on their own.

The stereotype of an IMG is that they're super book-smart with tons of clinical experience from their country where they had more hands on experience. That's not always the case. I suppose passage of Step 3 would at least ensure the medical knowledge for independent practice is there, but there are still practical components and knowledge of how the US system works many are lacking so they'll need some further guidance (i.e. residency here). Not something that can't be fixed but those are the barriers to your proposal.

 

[Lawpy]

There would have to be some level of assessment. Midlevels have a certain amount of practical training that makes them useful. The stereotype of an IMG is that they're super book-smart with tons of clinical experience from their country where they had more hands on experience. That's not always the case. You would have to separate out the two. I suppose passage of Step 3 would at least ensure the medical knowledge is there, but there is still practical components and knowledge of how the system works many are lacking so they'll need some further guidance. Not something that can't be fixed but those are the barriers to your proposal.

They still have to take all Steps + passing the boards and completing residency?

Theoretically I agree that everyone would be better off if we had more IMGs/FMGs and less midlevels. Unfortunately, the reality is that what would happen would be the same amount of midlevels (continually increasing) + more IMGs/FMGs which would cause a big job market issue for the physician jobs that are left. The midlevel ship has sailed.

Why would # of midlevels keep increasing?

 

[Lawpy]

Theoretically I agree that everyone would be better off if we had more IMGs/FMGs and less midlevels. Unfortunately, the reality is that what would happen would be the same amount of midlevels (continually increasing) + more IMGs/FMGs which would cause a big job market issue for the physician jobs that are left. The midlevel ship has sailed.

Also is there really a shortage of jobs? We need to make this issue clear because more physicians can help resolve the distribution issue, which is the reason for midlevel threat to exist in first place

 

[Redpancreas]

They still have to take all Steps + passing the boards and completing residency?

Ahhh. I see, I misunderstood you. You're proposing IMG do PA/NP level work AFTER their residency. I was assuming you were proposing before residency.

That's even more unrealistic. IMGs will not accept that and will stop coming here. They're not coming here to settle for PA/NP level work or pay. They're coming here to match Internal Medicine (one of the fields open to them) so they can match its flagship fellowship (Cardiology) and put stents in people for a living. Now, if they go unmatched in that or are not coming here for that, they're going to go the hospitalist/specialist route and have midlevels working for them just like any other physician here. If they're offered asked to do what you're proposing they're going to be like hell no...and go back to their country where they get to be a physician and earn more. No one (like literally 0 people) would settle for that after they've completed residency and have the qualifications to be the hospitalist that employs midlevels. The IMGs you see here out of work are those who did not complete residency.

If you compare IMGs and AMGs overall, more AMGs are willing to do true primary/underserved care. IMGs (again the aggregate) have different goals.

 

[jambro]

They still have to take all Steps + passing the boards and completing residency?



Why would # of midlevels keep increasing?

It'll keep increasing because prospective midlevels see it was an easy pathway to be like a doc, and schools want more customers.

Also is there really a shortage of jobs? We need to make this issue clear because more physicians can help resolve the distribution issue, which is the reason for midlevel threat to exist in first place

I have to imagine that most would agree that if there were no midlevels, there would be more job opportunities for physicians. Imagine if you needed an anesthesiologist to sit every case?

My argument for the distribution issue was a special license that is only valid in a particular area. It's a big ask so most people probably won't go for it, but we know how competitive medicine is. i am confident we can find some people from rural areas who are willing to have a fulfilling job living like a king serving the area they grew up in. and they can't move to a coastal area unless they want to give up their job. I dont see how were going to solve the maldistribution issue otherwise.

 

[Lem0nz]

Physician reimbursement is also not going to go up. Like, ever. Its going to go down. Anyone in hospital admin can show you the graphs with the trajectory and the planned CMS cuts and the additional quality cuts that are in the pipe. That is not going to reverse. Perhaps be postponed like it was this year, but not forever.

You don't have to like it but it would do all of us well to accept it because to maintain a salary of 300k+ in many fields of medicine you are going to have to see more volume, become hospital employed, or often some combination of the two of those things while increasing the quality of your care. Someone in this thread posted how they don't want to be a business manager of a bunch of midlevels and see half as many patients who are only complex - that's probably fine for the next 20 years or so, but I personally doubt that will be the future of medicine for MDs past that. That's just not the direction we are headed and I don't see an act of god coming to course correct it. In the era of student loan burdens on graduation being 250-500k for an MD, there is a lot of pressure to try to inflate your salary past that 300 mark to address the lost income potential and tackle the student loans. Fighting and not using midlevels to augment yourself is going to make that harder. I *do* respect and understand all of the docs who don't like it, don't want it, and don't agree with it. But I fear for them because the midlevel issue is a small piece of the much bigger pie and we have very little control over the rest of that pie.

Also doesn't mean you have to use/manage midlevels as the only solution. Its just one of them. Being hospital employed is another great solution. Alternative revenue streams, administrative roles, there's lots of stuff. But for the people who just want to do clinical stuff which I think is probably over half of us, it can be a tough thing to fix.

 

[Steve_Zissou]

Physician reimbursement is also not going to go up. Like, ever. Its going to go down. Anyone in hospital admin can show you the graphs with the trajectory and the planned CMS cuts and the additional quality cuts that are in the pipe. That is not going to reverse. Perhaps be postponed like it was this year, but not forever.

You don't have to like it but it would do all of us well to accept it because to maintain a salary of 300k+ in many fields of medicine you are going to have to see more volume, become hospital employed, or often some combination of the two of those things while increasing the quality of your care. Someone in this thread posted how they don't want to be a business manager of a bunch of midlevels and see half as many patients who are only complex - that's probably fine for the next 20 years or so, but I personally doubt that will be the future of medicine for MDs past that. That's just not the direction we are headed and I don't see an act of god coming to course correct it. In the era of student loan burdens on graduation being 250-500k for an MD, there is a lot of pressure to try to inflate your salary past that 300 mark to address the lost income potential and tackle the student loans. Fighting and not using midlevels to augment yourself is going to make that harder. I *do* respect and understand all of the docs who don't like it, don't want it, and don't agree with it. But I fear for them because the midlevel issue is a small piece of the much bigger pie and we have very little control over the rest of that pie.

Also doesn't mean you have to use/manage midlevels as the only solution. Its just one of them. Being hospital employed is another great solution. Alternative revenue streams, administrative roles, there's lots of stuff. But for the people who just want to do clinical stuff which I think is probably over half of us, it can be a tough thing to fix.

I don’t have to accept ****. Fortunately, I’m not going to go into a field that is particularly affected by midlevels, but I will use every bit of influence to fight the admin/midlevels on this sort of BS.

You’re right about one thing, there are many interest groups out there looking to take our slice of the pie and devalue our education as much possible so they can rake in the cash. You’re defeatist attitude is what’s wrong, but you’re also in a field that isn’t particularly affected by midlevel expansion YET.

Serious question, if you could spend your days overseeing 4 PAs that did surgery while doing very few surgeries yourself, would you be happy? Would you go into medicine again if that was the work?

 

[Lem0nz]

I don’t have to accept ****. Fortunately, I’m not going to go into a field that is particularly affected by midlevels, but I will use every bit of influence to fight the admin/midlevels on this sort of BS.

You’re right about one thing, there are many interest groups out there looking to take our slice of the pie and devalue our education as much possible so they can rake in the cash. You’re defeatist attitude is what’s wrong, but you’re also in a field that isn’t particularly affected by midlevel expansion YET.

Serious question, if you could spend your days overseeing 4 PAs that did surgery while doing very few surgeries yourself, would you be happy? Would you go into medicine again if that was the work?

Yes. I would actually just go into teaching full time probably and let residents operate independently where I could focus my time letting them go turtle slow through a case because there aren't financial repercussions and other obligations pulling me away and I really, really enjoy teaching. And I would never ever do a small case, I would focus solely on the insanely complex ones that require a lot more thought and planning and try to become a specialist at the absolute disasters. That's my true passion. You can do that in academics but there are generally research obligations that I have *ZERO* interest in being a part of so that pathway is not for me. I would rather do lots of surgery as a clinical surgeon.

 

[Steve_Zissou]

Yes. I would actually just go into teaching full time probably and let residents operate independently where I could focus my time letting them go turtle slow through a case because there aren't financial repercussions and other obligations pulling me away and I really, really enjoy teaching. And I would never ever do a small case, I would focus solely on the insanely complex ones that require a lot more thought and planning and try to become a specialist at the absolute disasters. That's my true passion. You can do that in academics but there are generally research obligations that I have *ZERO* interest in being a part of so that pathway is not for me. I would rather do lots of surgery as a clinical surgeon.

Ufff, yeah, maybe you and I just want really different things out of medicine. I did not go into medicine to be a manager, and the idea of managing midlevels is not appealing to me at all. I’ll just chock this one under “irreconcilable differences due to differences in values” and leave it at that.

 

[Lem0nz]

Ufff, yeah, maybe you and I just want really different things out of medicine. I did not go into medicine to be a manager, and the idea of managing midlevels is not appealing to me at all. I’ll just chock this one under “irreconcilable differences due to differences in values” and leave it at that.

That's totally fair. I really enjoy the business and administrative side of medicine. I think there is a ton that can be done in that realm that can really benefit our patients. Take my world for example - cancer care. You may see a bunch of semi-autonomous NPs or PAs managing chemotherapy as dangerous and greedy. But I see it that if you can have one medical oncologist overseeing three NPs who are doing routine cases for breast cancer which is generally very formulaic, than you can afford to hire another medical oncologist who specializes only in sarcoma. Sarcoma is such a complicated topic that patients who have it and are managed by super specialists like that really really benefit because sarcoma is like 70 histologies wrapped into one thing. But that doesn't make a cancer center any money because there's 1 sarcoma patient to every 350 breast cancer patients. But as long as you keep the cancer center very profitable and in the black you can afford to expand into those niche things that don't make money but really benefit some of our cancer patients.

Certainly not for everyone.

 

[Steve_Zissou]

That's totally fair. I really enjoy the business and administrative side of medicine. I think there is a ton that can be done in that realm that can really benefit our patients. Take my world for example - cancer care. You may see a bunch of semi-autonomous NPs or PAs managing chemotherapy as dangerous and greedy. But I see it that if you can have one medical oncologist overseeing three NPs who are doing routine cases for breast cancer which is generally very formulaic, than you can afford to hire another medical oncologist who specializes only in sarcoma. Sarcoma is such a complicated topic that patients who have it and are managed by super specialists like that really really benefit because sarcoma is like 70 histologies wrapped into one thing. But that doesn't make a cancer center any money because there's 1 sarcoma patient to every 350 breast cancer patients. But as long as you keep the cancer center very profitable and in the black you can afford to expand into those niche things that don't make money but really benefit some of our cancer patients.

Certainly not for everyone.

**** like this is why the younger generation is saying “f*ck midlevels” and have a strong disdain for older physicians who advocate for midlevels. They’re devaluing our education and spreading propaganda that is being bought by politicians and our admin overlords. They’re getting more and more rights, and when they finally have the same rights as a physician, what will be the point of medical school? **** if I can just get my bachelors in nursing, turn around and get my FNP or DNP as soon as I finish my bachelors then I can pretend to be a doctor and make decent money with far less debt and headache.