Nurses doing colonoscopies on black patients

[efle]

Condescension aside, I’m not necessarily against that kind of a model in certain situations. I am against midlevels doing these things because they aren’t trying to just do these things. They are doing the procedures and then trying to manage the patient completely, which they just don’t have the knowledge base to do.

Didnt realize the NPs were trying to read the path on their biopsies, read cross sectional imaging, or prescribe chemo or do resections

Those would all be a problem for me too

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[Lawpy]

I knew i was remembering something:

Yale merging physician residency with PA residency

https://escholarship.org/uc/item/0th2j7k3 From their abstract: Physician assistants (PA) are an important part of emergency department healthcare delivery and are increasingly seeking specialty-specific postgraduate training. Our goal was to pilot the implementation of a PA postgraduate...

forums.studentdoctor.net

 

[Lem0nz]

I was an endo tech and did hundreds of scopes. Your opinion is not based in reality. It doesn’t matter if you get hundreds of reps if you don’t have the education to know what your looking for and why.

I'll take the endo tech. Residency doesn't magically impart any unicorn knowledge that absolves the need of experience. What the numbers are to be credentialed and privileged and signed off or whatever you want to call it are a joke.

 

[Lawpy]

I'll take the endo tech. Residency doesn't magically impart any unicorn knowledge that absolves the need of experience. What the numbers are to be credentialed and privileged and signed off or whatever you want to call it are a joke.

What about a PA? The more i'm thinking/reading, i'm becoming convinced that PAs are the answer to this discussion.

PA education is at least standardized and of good quality

 

[Lem0nz]

What about a PA? The more i'm thinking/reading, i'm becoming convinced that PAs are the answer to this discussion.

PA education is at least standardized and of good quality

There is literally no difference between an endo tech who has to do 300 scopes to get trained or a PA who has to do 300 scopes or an NP who has to do 300 scopes or an MD who has to do 300 scopes if you're talking about screening endoscopies. Its a trade skill. You don't need an MD to be a plumber. This is not taking a **** on our GI docs but this is not rocket science.

Its *useful* for a GI doc to do it because they can often do advanced interventions or deal with the aftermath of "ok, found a bad thing, wut next?" and advance the care of the patient without an additional referral. But this is what efle is trying to say - there is no reason 4 endo techs can't be under one GI doc who's managing all of that and moving an entire group forward doing things at economy of scale instead of having 2 GI docs billing and being more expensive than the 4+1 endo techs.

 

[Lawpy]

There is literally no difference between an endo tech who has to do 300 scopes to get trained or a PA who has to do 300 scopes or an NP who has to do 300 scopes or an MD who has to do 300 scopes if you're talking about screening endoscopies. Its a trade skill. You don't need an MD to be a plumber. This is not taking a **** on our GI docs but this is not rocket science.

Its *useful* for a GI doc to do it because they can often do advanced interventions or deal with the aftermath of "ok, found a bad thing, wut next?" and advance the care of the patient without an additional referral. But this is what efle is trying to say - there is no reason 4 endo techs can't be under one GI doc who's managing all of that and moving an entire group forward doing things at economy of scale instead of having 2 GI docs billing and being more expensive than the 4+1 endo techs.

No i get that and i agree but i was also trying to address the generality and educational background in some of the responses that favored NPs over techs. I think for that, the PAs are the best of the both worlds

But i mean, i'm ok with delegating procedures to nonphysicians. That makes it more efficient and less costly but it requires having at least some strict training to be credentialed

 

[Lawpy]

Wait that reminds me on that one point

Why won't the IRB approve a prospective study comparing outcomes in NP-only vs PA-only vs physician-only care in states where midlevels can practice independently? I think i saw this earlier from @efle @Matthew9Thirtyfive discussions and a study like this will resolve this debate effectively

 

[VA Hopeful Dr]

Condescension aside, I’m not necessarily against that kind of a model in certain situations. I am against midlevels doing these things because they aren’t trying to just do these things. They are doing the procedures and then trying to manage the patient completely, which they just don’t have the knowledge base to do.

You know, I'm starting to warm to this idea.

If we train not doctors to do a bunch of the low risk very common procedures (with the inevitable reimbursement cuts), maybe all those procedure heavy specialists will join us non-procedure heavy specialists in trying to get insurance to reimburse more for office visits.

Let's start an endoscopic tech screening colonoscopy program. 5 years from now I will enjoy the GI doctors complaining like the rest of us that we don't get paid enough for office visits.

 

[Matthew9Thirtyfive]

Didnt realize the NPs were trying to read the path on their biopsies, read cross sectional imaging, or prescribe chemo or do resections

Those would all be a problem for me too

Are you really this ignorant? Is it intentional? I can’t tell anymore.

 

[Matthew9Thirtyfive]

There is literally no difference between an endo tech who has to do 300 scopes to get trained or a PA who has to do 300 scopes or an NP who has to do 300 scopes or an MD who has to do 300 scopes if you're talking about screening endoscopies. Its a trade skill. You don't need an MD to be a plumber. This is not taking a **** on our GI docs but this is not rocket science.

Well I’ve been an endo tech. And now I’m a med student. As an endo tech I pushed scope hundreds of times. With the education I got, I could easily do the procedure, but I had very little idea of what was likely benign, what was concerning, etc. And God forbid there was a complication. Even just being an MS3 has shown me how much I didn’t know.

Now if you gave me a year of didactics and training in which things to biopsy, how, the most common complications and how to deal with them and then what to do for bad things like perfs, I’m sure I could have been just as good as an MD at that screening procedure.

The difference so many of you don’t seem to understand is that NPs and PAs aren’t stopping at just doing this screening procedure. They are trying take over as much as possible. They aren’t just really trained endo techs doing a screening and then having the patient follow up with a physician.

I feel like some of you just have dollar signs in your eyes or something. Some of the mental gymnastics in this thread are wild.

 

[Lawpy]

Well I’ve been an endo tech. And now I’m a med student. As an endo tech I pushed scope hundreds of times. With the education I got, I could easily do the procedure, but I had very little idea of what was likely benign, what was concerning, etc. And God forbid there was a complication. Even just being an MS3 has shown me how much I didn’t know.

Now if you gave me a year of didactics and training in which things to biopsy, how, the most common complications and how to deal with them and then what to do for bad things like perfs, I’m sure I could have been just as good as an MD at that screening procedure.

The difference so many of you don’t seem to understand is that NPs and PAs aren’t stopping at just doing this screening procedure. They are trying take over as much as possible. They aren’t just really trained endo techs doing a screening and then having the patient follow up with a physician.

I feel like some of you just have dollar signs in your eyes or something. Some of the mental gymnastics in this thread are wild.

I think that scope creep is a bigger problem for NPs than PAs or even specialized techs though

 

[Matthew9Thirtyfive]

You know, I'm starting to warm to this idea.

If we train not doctors to do a bunch of the low risk very common procedures (with the inevitable reimbursement cuts), maybe all those procedure heavy specialists will join us non-procedure heavy specialists in trying to get insurance to reimburse more for office visits.

Let's start an endoscopic tech screening colonoscopy program. 5 years from now I will enjoy the GI doctors complaining like the rest of us that we don't get paid enough for office visits.

When the nurses start doing surgery here like they’re starting to do in the UK, I will laugh at the sudden change of opinions of some of these surgeons.

 

[Matthew9Thirtyfive]

I think that scope creep is a bigger problem for NPs than PAs or even specialized techs though

It’s not really a problem for hypothetical specialized techs because they can’t do anything but that one or two things. They really just are extenders. PAs are absolutely trying to scope creep just as much as NPs. They just haven’t been as successful.

 

[Matthew9Thirtyfive]

Wait that reminds me on that one point

Why won't the IRB approve a prospective study comparing outcomes in NP-only vs PA-only vs physician-only care in states where midlevels can practice independently? I think i saw this earlier from @efle @Matthew9Thirtyfive discussions and a study like this will resolve this debate effectively

It’s not ethical to compare something that is by definition below the standard of care to standard of care. You can’t randomize someone to a treatment arm made up of people with significantly less training and say we’re going to see if they can do as good a job as the standard when we know they don’t have the same education.

Maybe someone can do some sort of retrospective study, but you’d have to really work hard to control for the NPs having access to physicians to bail them out.

 

[efle]

Are you really this ignorant? Is it intentional? I can’t tell anymore.

I'm joking dude FMs doing screenings dont do any of that themselves either.

 

[Lem0nz]

When the nurses start doing surgery here like they’re starting to do in the UK, I will laugh at the sudden change of opinions of some of these surgeons.

Let them! God I wish it would happen already so people would stop pretending like its some sort of magic bullet and surgeons are all of the sudden going to go 'omg midlevels we were wrrrrroooonnngggggg so sorry fam!'

This is America. If they can do it as well as us for a fraction of the cost then they ought to be doing it. If they can't then we'll figure it out and deal with the aftermath and keep on doing surgery.

But far more likely than any of that is that absolutely no one will notice because there's enough work to go around. Anesthesia docs aren't scrounging for jobs. Psychiatrists can walk into any practice in the country. Family med docs have been 'competing' with midlevels longer than any other profession and we have seen over and over and over again our FM attendings here posting how their salaries are north of 350k and they would love to hire more attending level physicians but can't find as many and that they're stuck either just being happy with what they have or expanding with midlevels.

 

[VA Hopeful Dr]

It’s not really a problem for hypothetical specialized techs because they can’t do anything but that one or two things. They really just are extenders. PAs are absolutely trying to scope creep just as much as NPs. They just haven’t been as successful.

Side effect of being under the jurisdiction of the medical board

 

[efle]

It’s not ethical to compare something that is by definition below the standard of care to standard of care. You can’t randomize someone to a treatment arm made up of people with significantly less training and say we’re going to see if they can do as good a job as the standard when we know they don’t have the same education.

Maybe someone can do some sort of retrospective study, but you’d have to really work hard to control for the NPs having access to physicians to bail them out.

Gonna put out the reality check again that there are already independent NPs acting as PCPs in many states, and all we would have to do is gather data from them and the DO/MDs in the same areas

 

[Matthew9Thirtyfive]

I'm joking dude FMs doing screenings dont do any of that themselves either.

Woosh.

 

[Matthew9Thirtyfive]

Gonna put out the reality check again that there are already independent NPs acting as PCPs in many states, and all we would have to do is gather data from them and the DO/MDs in the same areas

You keep saying this, but you keep completely ignoring the part where most of them still work with physicians and have complete access to consult with physicians. That completely eliminates your ability to compare.

 

[efle]

You keep saying this, but you keep completely ignoring the part where most of them still work with physicians and have complete access to consult with physicians. That completely eliminates your ability to compare.

10% of NPs are entirely independent of a practice agreement per the US health dept NP survey and that was nearly a decade ago. I know you dont want it to exist but it does.

 

[Matthew9Thirtyfive]

Let them! God I wish it would happen already so people would stop pretending like its some sort of magic bullet and surgeons are all of the sudden going to go 'omg midlevels we were wrrrrroooonnngggggg so sorry fam!'

This is America. If they can do it as well as us for a fraction of the cost then they ought to be doing it. If they can't then we'll figure it out and deal with the aftermath and keep on doing surgery.

But far more likely than any of that is that absolutely no one will notice because there's enough work to go around. Anesthesia docs aren't scrounging for jobs. Psychiatrists can walk into any practice in the country. Family med docs have been 'competing' with midlevels longer than any other profession and we have seen over and over and over again our FM attendings here posting how their salaries are north of 350k and they would love to hire more attending level physicians but can't find as many and that they're stuck either just being happy with what they have or expanding with midlevels.

This is so completely missing the point, I don’t even know where to begin.

 

[Matthew9Thirtyfive]

10% of NPs are entirely independent of a practice agreement per the US health dept NP survey and that was nearly a decade ago. I know you dont want it to exist but it does.

Lol dude you keep saying this and yet you keep failing to demonstrate that these magical independent NPs are working completely without physician help available and in a practice setting that is comparable to a physician practice (ie, not minute clinic or medspa settings) in enough numbers to get data from.

Please show me, because I really want it to exist. I would love to go through the data.

 

[Lem0nz]

You keep saying this, but you keep completely ignoring the part where most of them still work with physicians and have complete access to consult with physicians. That completely eliminates your ability to compare.

This is so completely missing the point, I don’t even know where to begin.

Start somewhere. Physicians also have complete access to consult with physicians and work with other physicians.

Surgeons KNEW radical surgery would cure cancer and you had to cut everything out for any chance. Surgeons KNEW that laparoscopy would never work and was too dangerous. Surgeons KNEW robotic surgery would never be cost effective and wouldn't take off.

What surgeons will know tomorrow, who can say?

 

[efle]

Lol dude you keep saying this and yet you keep failing to demonstrate that these magical independent NPs are working completely without physician help available and in a practice setting that is comparable to a physician practice (ie, not minute clinic or medspa settings) in enough numbers to get data from.

Please show me, because I really want it to exist. I would love to go through the data.

Sure let me send you a couple googles when im on a PC

I'll try starting with Maryland since this was kicked off by a hopkins paper in honor

 

[Matthew9Thirtyfive]

Start somewhere. Physicians also have complete access to consult with physicians and work with other physicians.

Surgeons KNEW radical surgery would cure cancer and you had to cut everything out for any chance. Surgeons KNEW that laparoscopy would never work and was too dangerous. Surgeons KNEW robotic surgery would never be cost effective and wouldn't take off.

What surgeons will know tomorrow, who can say?

So to the first point, I’m not saying midlevels shouldn’t be allowed to consult physicians in real life. What I’m saying is you can’t compare outcomes between NPs and physicians when the NPs are getting help from physicians in managing their patients. That sort of defeats the purpose and is an enormous confounder that makes any sort of independence comparison impossible.

As for surgery, I have a couple questions. Who is going to manage the complications from these midlevels doing surgery? If they have a complication, who will bail them out? A surgeon or another midlevel? And if it is a surgeon, who do you think will hold the liability?

Your “surgeons KNEW” argument is a logical fallacy, so I’ll ignore that.

 

[Matthew9Thirtyfive]

Sure let me send you a couple googles when im on a PC

I'll try starting with Maryland since this was kicked off by a hopkins paper in honor

Awesome. Looking forward to it.

 

[Lem0nz]

So to the first point, I’m not saying midlevels shouldn’t be allowed to consult physicians in real life. What I’m saying is you can’t compare outcomes between NPs and physicians when the NPs are getting help from physicians in managing their patients. That sort of defeats the purpose and is an enormous confounder that makes any sort of independence comparison impossible.

As for surgery, I have a couple questions. Who is going to manage the complications from these midlevels doing surgery? If they have a complication, who will bail them out? A surgeon or another midlevel? And if it is a surgeon, who do you think will hold the liability?

Your “surgeons KNEW” argument is a logical fallacy, so I’ll ignore that.

If they're operating independently as you say - they can bail themselves out or they can send it to another surgeon not affiliated with their practice, in which case, just like surgery in real life for the rest of us - surprise, they can get sued for malpractice and the surgeon that has to do a re-operation for the complication is not suddenly magically liable for a midlevel that decided to operate.

If they're operating under supervision of a surgeon, of course it will be the surgeons job to bail them out and they'll be liable, the same as if a surgeon let's a resident do the operation and sits in the corner or goes to get coffee and pokes their head in every now and then.

Alternatively, maybe they just have the same complication rates as us after being trained by a surgeon to do surgery after 2-3 years and we were all wrong. I really doubt it. But its possible.

Which point in there suddenly makes me change my mind? Because if its #1 - no. My mind is not changed. Those midlevels doing that and hurting people will not survive with a practice very long, malpractice costs will be prohibitive, surgery centers and hospitals will not credential them or hire them. Point #2 then? No, my mind is not changed. If you choose as a surgeon to train someone and accept the responsibility and manage the risk and fallout appropriately, that is your choice. That whole "well what if corporate medicine forces you to use them" argument holds no sway with me. Physicians have enough options that they can choose what terms are in their contract or find another contract. It might really suck to have to do that, but that's real life.

So then its got to be #3 right? I'll be upset when they take my job because they could do it just as well and we should protect my job because I'm a doctor and I deserve it? I'm sorry but no. If they CAN do my job as well as me, for a quarter of the cost and in half the time, then I shouldn't exist. That's improving healthcare. But again, I really doubt #3 is going to be the case.

#s 1 and 2 will never ever put me out of a job.

Which brings me to my point, #4 - they can't do it as well, it will become apparent given enough time, and they will fall into small niches that do not destroy the job market but it certainly will take away parts of the physician job market. And we as physicians will have to learn to work with and adapt to that.

 

[Matthew9Thirtyfive]

If they're operating independently as you say - they can bail themselves out or they can send it to another surgeon not affiliated with their practice, in which case, just like surgery in real life for the rest of us - surprise, they can get sued for malpractice and the surgeon that has to do a re-operation for the complication is not suddenly magically liable for a midlevel that decided to operate.

If they're operating under supervision of a surgeon, of course it will be the surgeons job to bail them out and they'll be liable, the same as if a surgeon let's a resident do the operation and sits in the corner or goes to get coffee and pokes their head in every now and then.

Alternatively, maybe they just have the same complication rates as us after being trained by a surgeon to do surgery after 2-3 years and we were all wrong. I really doubt it. But its possible.

Which point in there suddenly makes me change my mind? Because if its #1 - no. My mind is not changed. Those midlevels doing that and hurting people will not survive with a practice very long, malpractice costs will be prohibitive, surgery centers and hospitals will not credential them or hire them. Point #2 then? No, my mind is not changed. If you choose as a surgeon to train someone and accept the responsibility and manage the risk and fallout appropriately, that is your choice. That whole "well what if corporate medicine forces you to use them" argument holds no sway with me. Physicians have enough options that they can choose what terms are in their contract or find another contract. It might really suck to have to do that, but that's real life.

So then its got to be #3 right? I'll be upset when they take my job because they could do it just as well and we should protect my job because I'm a doctor and I deserve it? I'm sorry but no. If they CAN do my job as well as me, for a quarter of the cost and in half the time, then I shouldn't exist. That's improving healthcare. But again, I really doubt #3 is going to be the case.

#s 1 and 2 will never ever put me out of a job.

Which brings me to my point, #4 - they can't do it as well, it will become apparent given enough time, and they will fall into small niches that do not destroy the job market but it certainly will take away parts of the physician job market. And we as physicians will have to learn to work with and adapt to that.

This is a well reasoned post I can agree with.

 

[Lem0nz]

Err. Wasn't expecting that. ****. What are we going to talk about for the rest of the weekend now?

 

[Matthew9Thirtyfive]

Err. Wasn't expecting that. ****. What are we going to talk about for the rest of the weekend now?

I mean, when you make good points, I’m not going to say you’re wrong lol. I thought that was very well said.

 

[efle]

Awesome. Looking forward to it.

Ok here ya are

Adult Primary Care Services

COVID Updates: We are now offering both In-office and video visits. Masks are required for all inpatient appointments.

adultprimarycareservices.com

Staff — South Mountain Community Health

www.southmountainhealth.com

Our Staff

Affordable Medical Clinic LLC provides clinical services to the residents of Hyattsville, Maryland.

www.affordablemedclinic.com

Here's a few hits in MD that appear to be marketing themselves as primary care services with only midlevels on staff

 

[Matthew9Thirtyfive]

Ok here ya are

Adult Primary Care Services

COVID Updates: We are now offering both In-office and video visits. Masks are required for all inpatient appointments.

adultprimarycareservices.com

Staff — South Mountain Community Health

www.southmountainhealth.com

Our Staff

Affordable Medical Clinic LLC provides clinical services to the residents of Hyattsville, Maryland.

www.affordablemedclinic.com

Here's a few hits in MD that appear to be marketing themselves as primary care services with only midlevels on staff

Hmm. Now to start on an IRB.

 

[Lawpy]

It’s not ethical to compare something that is by definition below the standard of care to standard of care. You can’t randomize someone to a treatment arm made up of people with significantly less training and say we’re going to see if they can do as good a job as the standard when we know they don’t have the same education.

Maybe someone can do some sort of retrospective study, but you’d have to really work hard to control for the NPs having access to physicians to bail them out.

I'm trying to keep logical fallacies straight since isn't that begging the question? The idea of the study is to test whether it's really below the standard of care

 

[Matthew9Thirtyfive]

I'm trying to keep logical fallacies straight since isn't that begging the question? The idea of the study is to test whether it's really below the standard of care

Yeah I’m just telling you what an irb would probably say. The standard of care is physician level (or at least it’s supposed to be despite what greedy corps want). They have much less education than a physician and therefore are by definition not the standard of care.

 

[paki20]

APRNs do vein harvesting in OR for bypass grafts in patients undergoing CABG. They do C sections. APRNs do IR work. Procedural and surgical work is not off limits. UK is already training nurses to do surgery. Only time before they push for more privileges because they think they can do what doctors do and hospital administrators will agree.

The holy grail for hospital administration is when midlevels can bill at same rate as doctors. Game over then.

 

[Jack Donaghy]

I can't do another back and forth with @Lemonz. It's clear that he isn't concerned with the future of medicine and whatever downfall might be consequence of his obsession with expanded midlevel scopes of practice.

I'll just keep stealing his $$ as an FM doing scopes while he advocates for midlevel-led medical care in the US.

 

[Lem0nz]

I can't do another back and forth with @Lemonz. It's clear that he isn't concerned with the future of medicine and whatever downfall might be consequence of his obsession with expanded midlevel scopes of practice.

I'll just keep stealing his $$ as an FM doing scopes while he advocates for midlevel-led medical care in the US.

That’s nice. I wasn’t particularly interested in your opinion anyway so thank you for sparing us all.

 

[paki20]

Nurses did a masterful job of infiltrating administrative positions and for mounting an impressive PR campaign. Doctors are too scared to do speak up at the risk of being fired and losing their $300,000+ yearly income.

 

[Redpancreas]

I can't do another back and forth with @Lemonz. It's clear that he isn't concerned with the future of medicine and whatever downfall might be consequence of his obsession with expanded midlevel scopes of practice.

I'll just keep stealing his $$ as an FM doing scopes while he advocates for midlevel-led medical care in the US.

It's not a zero-sum game. I find your pride in your FM training program's ability to teach you colonoscopies FM quite odd. If I'm not mistaken you're still in residency so you don't even know the logistics of how this will work (volume, workflow, etc.) yet you say you're going to steal other physician's money as if this is some sort of inter-specialty competition. I highly doubt that is what your FM programs's goal is...to train residents to do colonoscopies so they can make $. I would imagine the point is to help target underserved populations in need of CRC screening. Maybe you said that in jest to make a point...but not sure what that point is...?

 

[Neopolymath]

So to the first point, I’m not saying midlevels shouldn’t be allowed to consult physicians in real life. What I’m saying is you can’t compare outcomes between NPs and physicians when the NPs are getting help from physicians in managing their patients. That sort of defeats the purpose and is an enormous confounder that makes any sort of independence comparison impossible.

As for surgery, I have a couple questions. Who is going to manage the complications from these midlevels doing surgery? If they have a complication, who will bail them out? A surgeon or another midlevel? And if it is a surgeon, who do you think will hold the liability?

Your “surgeons KNEW” argument is a logical fallacy, so I’ll ignore that.

One of surgery's favorite arguments against anyone doing anything surgery likes to do in the hospital is that they shouldn't because they can't manage every single possible complication with the procedure.

I, like you, will be absolutely glued to SDN to see the schadenfreude when this stupid chicken comes home to roost during our careers. Misery does love company LOL.

 

[efle]

One of surgery's favorite arguments against anyone doing anything surgery likes to do in the hospital is that they shouldn't because they can't manage every single possible complication with the procedure.

I, like you, will be absolutely glued to SDN to see the schadenfreude when this stupid chicken comes home to roost during our careers. Misery does love company LOL.

Lol everyone needs rescuing sometimes that's such a lame argument. I've been in OB cases that had to call urology and it doesnt make the OB any less of an expert at hysterectomies

 

[Lem0nz]

One of surgery's favorite arguments against anyone doing anything surgery likes to do in the hospital is that they shouldn't because they can't manage every single possible complication with the procedure.

I, like you, will be absolutely glued to SDN to see the schadenfreude when this stupid chicken comes home to roost during our careers. Misery does love company LOL.

My favorite underpinning against every argument that involves the words midlevel and surgeon. That you somehow think we are for independent practice, that you assume we think midlevels should be practicing without supervision, that you think we don't give a **** about the other specialties.

Most of us believe literally none of that ****. But we are grounded in reality. You are not going to undo the midlevel pandora's box. They are here to stay. So you can either adapt, accept, and learn to work with them in some capacity that maximizes your reimbursements, maximizes your job security, and minimizes harm to your patients, or you can bury your head in the sand and say "WE HAVE TO FIGHT THEM MIDLEVEL BAD".

We will be right there next to you complaining about the referral and re-operation from the midlevel who tried a lap chole and hit the CBD. ****, I'm there now listening to the attendings complaining in the vent thread about midlevel referrals in the attending sub. It sucks. But it also is not going away or being reversed. So we have to adapt and manage and deal with it in a constructive way.

 

[Redpancreas]

One of surgery's favorite arguments against anyone doing anything surgery likes to do in the hospital is that they shouldn't because they can't manage every single possible complication with the procedure.

I, like you, will be absolutely glued to SDN to see the schadenfreude when this stupid chicken comes home to roost during our careers. Misery does love company LOL.

But who else can? Just because an argument is used a lot doesn't make it a bad argument.

 

[Matthew9Thirtyfive]

My favorite underpinning against every argument that involves the words midlevel and surgeon. That you somehow think we are for independent practice, that you assume we think midlevels should be practicing without supervision, that you think we don't give a **** about the other specialties.

Most of us believe literally none of that ****. But we are grounded in reality. You are not going to undo the midlevel pandora's box. They are here to stay. So you can either adapt, accept, and learn to work with them in some capacity that maximizes your reimbursements, maximizes your job security, and minimizes harm to your patients, or you can bury your head in the sand and say "WE HAVE TO FIGHT THEM MIDLEVEL BAD".

I mean...I don’t think any of us have ever said we should get rid of midlevels as like an actual solution, so that’s a strawman. Our argument and fight is to stop their scope expansion and FPA to protect patients from being subjected to undertrained people providing crappy care. That may not yet be an issue in surgery, but if you’re saying no one should care about those things because you don’t have to worry about it, then you’re the one with your head in the sand.

 

[Lem0nz]

I mean...I don’t think any of us have ever said we should get rid of midlevels as like an actual solution, so that’s a strawman. Our argument and fight is to stop their scope expansion and FPA to protect patients from being subjected to undertrained people providing crappy care. That may not yet be an issue in surgery, but if you’re saying no one should care about those things because you don’t have to worry about it, then you’re the one with your head in the sand.

I am not saying you shouldn't care at all. I have never said that. I did say I personally don't care that much anymore but that's an entirely different issue from dealing with actual children who argue with me.

But you cannot be that blind that you haven't noticed in even the med student forums the gaggle of people who say midlevels shouldn't exist and that we must deliberately go out of our way to make their lives miserable and ignore them or shun them or refuse to work with them in the hospital. That group makes up about 1/3 of the anti-FPA crowd, at minimum.

You absolutely SHOULD care about them. I'm just encouraging you to be as constructive as possible about it. Finding ways to encourage them to be in a physician team, to maximize reimbursement for both the physician and the midlevel, to make sure their scope is defined in a way that doesn't encroach upon the physician job market but also addresses inefficiencies in healthcare are huge huge wins to me. Like... who gives rats butt if they're running med spas. If people want to waste their money getting IV B12 and a bunch of botox injections, whatever. But the psych NP rando prescribing crazy drugs - that's a real issue. What can we do to bring that psych NP back into the fold and educate him/her on the fact that she's crazy for changing drugs every four weeks and that there IS a defined role for her somehow, somewhere, with some specific patient population, and the ones that don't fit that should be seeing a psychiatrist? How do we get this person to get bought up by a larger hospital conglomerate that can plug him/her into a system that can escalate care?

These are issues I care deeply about. I wish more people would talk about that.

 

[Matthew9Thirtyfive]

I am not saying you shouldn't care at all. I have never said that. I did say I personally don't care that much anymore but that's an entirely different issue from dealing with actual children who argue with me.

Ad hominems aren’t really compelling arguments.

But you cannot be that blind that you haven't noticed in even the med student forums the gaggle of people who say midlevels shouldn't exist and that we must deliberately go out of our way to make their lives miserable and ignore them or shun them or refuse to work with them in the hospital. That group makes up about 1/3 of the anti-FPA crowd, at minimum.

No, and I don’t agree with that crowd either. Would it be nice if NPs and PAs didn’t exist? Yeah, but they do and we’re never going to get rid of them so focusing all your energy on talking about why they should go away is pointless.

You absolutely SHOULD care about them. I'm just encouraging you to be as constructive as possible about it. Finding ways to encourage them to be in a physician team, to maximize reimbursement for both the physician and the midlevel, to make sure their scope is defined in a way that doesn't encroach upon the physician job market but also addresses inefficiencies in healthcare are huge huge wins to me. Like... who gives rats butt if they're running med spas. If people want to waste their money getting IV B12 and a bunch of botox injections, whatever. But the psych NP rando prescribing crazy drugs - that's a real issue. What can we do to bring that psych NP back into the fold and educate him/her on the fact that she's crazy for changing drugs every four weeks and that there IS a defined role for her somehow, somewhere, with some specific patient population, and the ones that don't fit that should be seeing a psychiatrist? How do we get this person to get bought up by a larger hospital conglomerate that can plug him/her into a system that can escalate care?

I mean, this is exactly my point. This is what we are talking about. At least the people actually doing anything. The ones just screaming at clouds on the internet can do whatever they want since they aren’t helping anything anyway lol.

These are issues I care deeply about. I wish more people would talk about that.

Agreed. Me too. I wish we could all band together and work toward preventing scope expansion and prioritizing patient safety.

But tbh a lot of your posts seem to be saying you think midlevels aren’t a problem and that we should all be using them to line our pockets. Occasionally that doesn’t seem to be your thinking, but I think it seems like it is sometimes.

 

[efle]

I am not saying you shouldn't care at all. I have never said that. I did say I personally don't care that much anymore but that's an entirely different issue from dealing with actual children who argue with me.

But you cannot be that blind that you haven't noticed in even the med student forums the gaggle of people who say midlevels shouldn't exist and that we must deliberately go out of our way to make their lives miserable and ignore them or shun them or refuse to work with them in the hospital. That group makes up about 1/3 of the anti-FPA crowd, at minimum.

You absolutely SHOULD care about them. I'm just encouraging you to be as constructive as possible about it. Finding ways to encourage them to be in a physician team, to maximize reimbursement for both the physician and the midlevel, to make sure their scope is defined in a way that doesn't encroach upon the physician job market but also addresses inefficiencies in healthcare are huge huge wins to me. Like... who gives rats butt if they're running med spas. If people want to waste their money getting IV B12 and a bunch of botox injections, whatever. But the psych NP rando prescribing crazy drugs - that's a real issue. What can we do to bring that psych NP back into the fold and educate him/her on the fact that she's crazy for changing drugs every four weeks and that there IS a defined role for her somehow, somewhere, with some specific patient population, and the ones that don't fit that should be seeing a psychiatrist? How do we get this person to get bought up by a larger hospital conglomerate that can plug him/her into a system that can escalate care?

These are issues I care deeply about. I wish more people would talk about that.

Youd think malpractice lawyers would have a field day on out-of-bounds NPs

Anyone know how their medmal insurance costs compare?

 

[Lem0nz]

But tbh a lot of your posts seem to be saying you think midlevels aren’t a problem and that we should all be using them to line our pockets. Occasionally that doesn’t seem to be your thinking, but I think it seems like it is sometimes.

My passion in medical research actually happens to be in quality/safety. A massive part of that is efficiency. The big difference between you and I is that I don't think it would be nice if midlevels didn't exist at all. I do think there is an excellent place for them carved out in medicine, much like AAs in anesthesia. There's a lot of people who think that a physician should be managing every single part of a patient's care. That we're somehow doing a massive disservice by having midlevels round on post-op patients in surgery, or that an NP titrating glucose medications on a type two diabetic is somehow unsafe, unethical, or a money grab. Not you persay, but I would venture to say this is most of the anti-midlevel crowd. That the sentiment of "it would be better if a physician did it" is extremely prevalent.

I disagree with that. It wouldn't be better if a physician did it. It would be a waste of a physician's time that could be better spent in a more high-yield situation. For surgeons that is absolutely in the operating room. For the endocrinologist its managing some crazy disease of the adrenal that I can't pronounce with drugs I'd have to look up because there's a difference in types of steroids that I forgot long ago. For the family practice doc its the 70 year old with 5 medical co-morbids instead of the 14 year old high school physical.

I completely understand that not every doctor wants to just focus on the complicated stuff. That's fine. I firmly believe there is enough room in medicine that doctors can still more or less chart their own paths (EM the exception and at this point a different conversation which I believe we could both agree on). But I think the next phase of healthcare evolution for physicians is that we're going to have to accept that there are parts of our jobs that can be safely and efficiently done by a midlevel that are not optimal uses of our time. I think we should be talking to medical students about that reality and how they can incorporate that into their future practice plans. About what that's going to do to their job market and their paychecks in light of 500k student loan debt. That this isn't inherently a bad thing - it's simply the evolution of medical care in a corporate/capitalist medical system that is America, and that it is not likely to change in the next three decades. We may get a public option of health insurance in our lifetime, but it seems fairly unlikely that we'll be living under a Canandian, German, and certainly not a UK model of healthcare in the next thirty years.

In light of those many limitations - yes. YES. Money matters. To you, to me, to your peers, to your future employers as private practice continues to dwindle year after year, to your admins who are pulling the strings. So let's talk about it. Not because its what drives you as a physician, but its because its what drives the system. Find out how to make your SYSTEM more money and they'll hand you more control inside that system to drive change. To drive some of that profit back to your patients. To drive some of that profit to new medical technologies and equipment overhauls. To drive some of that profit to fix chronic staffing shortages or hire two more doctors AND eight more NPs to cut back on the specialist referrals because specialist referrals are not the answer.

I do think it is all about the money. But not because I want to make a ton of money. My next job is straight salary, zero productivity, zero RVU incentive and I could not be happier. Because it affords me the freedom to really dive into these big picture issues at no personal cost.

 

[Matthew9Thirtyfive]

Youd think malpractice lawyers would have a field day on out-of-bounds NPs

Anyone know how their medmal insurance costs compare?

There’s some research that hospitals are much more likely to pick up their malpractice because it’s cheaper to settle the suits and keep paying them less than doctors but bill the same than it is to just pay for a doctor. There has also been some difficulty getting experts because they have been able to successfully argue that a physician isn’t qualified to judge the quality of care provided by an NP since the NP practices “healthcare” and not medicine.