PAs vote for no supervision, own medical boards

[d2305]

I just looked up my heart block, left anterior hemiblock, prognosis. Not as benign as I thought.

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[Fox800]

Taking ATLS now. Three NPs in the class with us. When we went through the radiology station, the NP in my group says "I don't read chest x-rays" when it's her turn. It was a GIANT pneumothorax.

 

[MSmentor018]

Taking ATLS now. Three NPs in the class with us. When we went through the radiology station, the NP in my group says "I don't read chest x-rays" when it's her turn. It was a GIANT pneumothorax.

well she was right, she doesn't know how to read them at all

 

[Fox800]

well she was right, she doesn't know how to read them at all

"It ain't right, but it ain't wrong..."

 

[Brahnold Bloodaxe]

Did you guys realize that the NP workforce is going to swell to a staggering 700,000+ in the next few decades? (currently at 130k) They are graduating over 20,000 new NPs a year and that number is growing exponentially.

I know this thread is about the PAs, but Mary mother of god, the midlevels are going to be fighting for jobs, any jobs, including EM jobs, like a dozen cats trapped in a burlap bag. Surely the CMGs will be more than happy to exploit the staggering number of midlevels and see just how far they can get by staffing EDs with them at rock bottom prices.

 

[WilcoWorld]

well she was right, she doesn't know how to read them at all

That's a very good point, but nowhere in the original post did it say the NP was a she.

 

[northernpsy]

Surely the CMGs will be more than happy to exploit the staggering number of midlevels and see just how far they can get by staffing EDs with them at rock bottom prices.

Yes, I think this kind of thing is exactly the plan behind the push to make NPs and PAs independent and crank out as many as possible as quickly as possible.
I have become very militant on this issue as I have looked around at what's happening. I refuse to train midlevels. I refuse to supervise or "collaborate" with them. I refuse to call them "Advanced Practice Providers". This is turning into a monster and patients are suffering from it.

 

[Fox800]

Yes, I think this kind of thing is exactly the plan behind the push to make NPs and PAs independent and crank out as many as possible as quickly as possible.
I have become very militant on this issue as I have looked around at what's happening. I refuse to train midlevels. I refuse to supervise or "collaborate" with them. I refuse to call them "Advanced Practice Providers". This is turning into a monster and patients are suffering from it.

We need more like you.

 

[Boatswain2PA]

Instead of becoming militant about not teaching/supervising midlevels, which WILL hurt patients, why don't you work within physician organizations to DEFINE what the PRACTICE OF MEDICINE is and ensure that anyone who does so is under the BOM.

Or, you could continue being "militant" about not working with midlevels. That will cost you $20-$50K a year as you continue watching the psychiatric NP take over your field of expertise.

 

[shoal007]

Instead of becoming militant about not teaching/supervising midlevels, which WILL hurt patients, why don't you work within physician organizations to DEFINE what the PRACTICE OF MEDICINE is and ensure that anyone who does so is under the BOM.

Or, you could continue being "militant" about not working with midlevels. That will cost you $20-$50K a year as you continue watching the psychiatric NP take over your field of expertise.

as a medical director covering many NPs/PAs, the chart reviews i do seem appropriate and reasonable. They do an excellent job for the most part but there are subtle things that sill get past an unseasoned ones. (ie a good NP told me that she was shocked my chest pain pt ruled in that i admitted to our EDOU with burping and burning CP -- I was not shocked)

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[sonofva]

That's a very good point, but nowhere in the original post did it say the NP was a she.

Did you just assume that gender? Check yur priv bruh!

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[Fox800]

Instead of becoming militant about not teaching/supervising midlevels, which WILL hurt patients, why don't you work within physician organizations to DEFINE what the PRACTICE OF MEDICINE is and ensure that anyone who does so is under the BOM.

Or, you could continue being "militant" about not working with midlevels. That will cost you $20-$50K a year as you continue watching the psychiatric NP take over your field of expertise.

I'm in favor of that. However, I continue to have beef with the AAPA's recent push for independent practice...and only a fool would train someone that aims to take their job.

NPs can train other NPs. That's how it should be. Don't lean on physicians for clinical education and then claim equivalence.

 

[doctalaughs]

Instead of becoming militant about not teaching/supervising midlevels, which WILL hurt patients, why don't you work within physician organizations to DEFINE what the PRACTICE OF MEDICINE is and ensure that anyone who does so is under the BOM.

Or, you could continue being "militant" about not working with midlevels. That will cost you $20-$50K a year as you continue watching the psychiatric NP take over your field of expertise.

You gotta fight fire with fire or it doesn't work. If someone punches you in the face you don't just meekly agree to talk it out while continuing to "work with them."

If doctors were smart (and unfortunately we aren't) we would introduce a BOM rules saying no MD/DO is allowed to work with, train, supervise or employ any PA that is licensed or regulated outside the BOM. Any doctor violating that rule gets their license pulled. I guarantee PAs would instantly drop their militant push for complete independence.

Imagine if paralegals suddenly decided they could practice law independently based on a few outliers in their profession? It would be immediately shut down.


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[Boatswain2PA]

...If doctors were smart (and unfortunately we aren't) we would introduce a BOM rules saying no MD/DO is allowed to work with, train, supervise or employ any PA that is licensed or regulated outside the BOM. Any doctor violating that rule gets their license pulled. I guarantee PAs would instantly drop their militant push for complete independence.

Imagine if paralegals suddenly decided they could practice law independently based on a few outliers in their profession? It would be immediately shut down.

Better yet - define what it means to PRACTICE MEDICINE, and then get the BOM to oversee ANYONE who does that. Then you get the Noctors as well.

 

[Brahnold Bloodaxe]

You gotta fight fire with fire or it doesn't work. If someone punches you in the face you don't just meekly agree to talk it out while continuing to "work with them."

If doctors were smart (and unfortunately we aren't) we would introduce a BOM rules saying no MD/DO is allowed to work with, train, supervise or employ any PA that is licensed or regulated outside the BOM. Any doctor violating that rule gets their license pulled. I guarantee PAs would instantly drop their militant push for complete independence.

Imagine if paralegals suddenly decided they could practice law independently based on a few outliers in their profession? It would be immediately shut down.


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Would it even matter though? CMGs run this racket now, they'll easily find enough sellouts to "supervise" the midlevels at whatever ratio is needed to meet that quarter's earnings projections. From the perspective of "our jobs," this battle isn't being waged in the legislatures but in hospitals and clinics as the midlevels are slowly and steadily integrated into roles traditionally reserved for physicians. When you come in to work a shift and notice that instead of working with 1 other doc and 1 supervised PA you're now working with 2 supervised PAs, that is a worse sign than if they had merely kept the 2:1 ratio but made the PA independent.

 

[Fox800]

well she was right, she doesn't know how to read them at all

The more I think about this, the more it chaps my hide. This lady was an "acute care" nurse practitioner that works at a large community Hospital in my area. She just basically skates by and doesn't even try to read a chest x-ray, when any medical student or psychiatry intern would notice this huge pneumothorax.

 

[Dred Pirate]

The more I think about this, the more it chaps my hide. This lady was an "acute care" nurse practitioner that works at a large community Hospital in my area. She just basically skates by and doesn't even try to read a chest x-ray, when any medical student or psychiatry intern would notice this huge pneumothorax.

I am going to contribute to this thread as a pharmacist.
My profession has been trying to fight for provider status for years - and honestly - it is complete BS head in the clouds crap.
We all are trained to do certain things - and when we try to do items outside out scope or training, we often only do it half a$$.

A couple of points. I have never understood why NP's and PA's (well NPs for now) are allowed to be independent practitioners. Not saying they aren't competent for most of what they do, or if doing their job with the proper supervision, they can't be beneficial. Our ED staffs PA's to do much of the urgent care type of stuff for lack of a better term. And at least from what I see, them and the MD's do a good job of delinting responsibilities appropriately. (I sit right next to them as they have their conversations every day)

One thing I am completely surprised at is how a mid level can do cardiology work for 2 years, then go work in a surgical office, then decide to go work with neurology. I have seen several who do this. A MD with much more education can't just decide to change specialties, so why can someone with less education?

I catch so many basic drug dosing errors - that it emphasizes the issues with the above paragraph. I understand why a cardiology specialist may not know a lot about ID and vice versa. But I cannot count the number of times where I have seen a cardiology NP dose lovenox incorrectly. Multiple times I have called to verify if they want prophy dosing or treatment dosing (in the world of afib it is not always clear cut), and they don't even know how to answer that question. Just the other day a cardiology NP didn't have a clue what rate to start a lidocaine drip at - I would expect that from a surgeon (not their area of specialty) - but if you claim to be a cardiology NP - shouldn't you know cardiology drug doses? (she had worked in cards for at least 3-4 years)

 

[northernpsy]

Instead of becoming militant about not teaching/supervising midlevels, which WILL hurt patients, why don't you work within physician organizations to DEFINE what the PRACTICE OF MEDICINE is and ensure that anyone who does so is under the BOM.

I would argue it is actually more dangerous to patients when doctors give NPs delusions of adequacy by trying to help them. Let the NPs struggle with the simple things, so that maybe they will recognize how poorly trained they were by their NP school and understand that they shouldn't even attempt handling the complicated patients.

I would totally support it if you have a plan for how to require NPs to answer to the BOM. So far, it appears that when people have complained to nursing boards about NP malpractice that nobody seems to care all that much.

 

[doctalaughs]

Would it even matter though? CMGs run this racket now, they'll easily find enough sellouts to "supervise" the midlevels at whatever ratio is needed to meet that quarter's earnings projections. From the perspective of "our jobs," this battle isn't being waged in the legislatures but in hospitals and clinics as the midlevels are slowly and steadily integrated into roles traditionally reserved for physicians. When you come in to work a shift and notice that instead of working with 1 other doc and 1 supervised PA you're now working with 2 supervised PAs, that is a worse sign than if they had merely kept the 2:1 ratio but made the PA independent.

You cant "sell out" if your license has been revoked because you can't legally practice medicine. Now clearly this would be lobbied hard against by interests like CMGs, but if the doctors running the BOMs had any balls this is exactly what they would do.

No one would risk their license supervising if these rules were invoked. It's really the only way to take a stand against the erosion of practicing medicine.


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[Status Sciaticus]

Taking ATLS now. Three NPs in the class with us. When we went through the radiology station, the NP in my group says "I don't read chest x-rays" when it's her turn. It was a GIANT pneumothorax.

I would argue it is actually more dangerous to patients when doctors give NPs delusions of adequacy by trying to help them. Let the NPs struggle with the simple things, so that maybe they will recognize how poorly trained they were by their NP school and understand that they shouldn't even attempt handling the complicated patients.

I would totally support it if you have a plan for how to require NPs to answer to the BOM. So far, it appears that when people have complained to nursing boards about NP malpractice that nobody seems to care all that much.

Well if they're independently practicing, then I'm sure once the lawsuits start piling up, itll become obvious soon enough. If supervising MDs refuse to sign their charts, and they realize that theyre on the hook for liability, then they will change their tune soon enough.

You cant "sell out" if your license has been revoked because you can't legally practice medicine. Now clearly this would be lobbied hard against by interests like CMGs, but if the doctors running the BOMs had any balls this is exactly what they would do.

No one would risk their license supervising if these rules were invoked. It's really the only way to take a stand against the erosion of practicing medicine.


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This is never going to happen. No BOM is going to have revocation of their license just for teaching someone who wants to learn. As my point above, even on the off chance they get independence (which they wont), the step forward is to refuse signing their charts. Its not in your contract to do so, and if it is, then either re-negotiate it or see the actual patient as you would a new patient (thereby slowing down the flow to where it is not cost effective for them).

 

[deleted109597]

I just looked up my heart block, left anterior hemiblock, prognosis. Not as benign as I thought.

Everybody dies mang

 

[doctalaughs]

Well if they're independently practicing, then I'm sure once the lawsuits start piling up, itll become obvious soon enough. If supervising MDs refuse to sign their charts, and they realize that theyre on the hook for liability, then they will change their tune soon enough.



This is never going to happen. No BOM is going to have revocation of their license just for teaching someone who wants to learn. As my point above, even on the off chance they get independence (which they wont), the step forward is to refuse signing their charts. Its not in your contract to do so, and if it is, then either re-negotiate it or see the actual patient as you would a new patient (thereby slowing down the flow to where it is not cost effective for them).

Thats the attitude which makes you probably right.

However if the BOMs took the hard line that the practice of MEDICINE need to be regulated by boards of MEDICINE not outside entities, they could logically sanction doctors who enable those violating this tenant.

If I started teaching a janitor how to do medical procedures, and he went on to injure patients then I'm pretty sure my license would be in trouble. Obviously that is an extreme example but there is no reason the BOM can't sanction docs who enable the practice of medicine outside their purview. After all, NPs are supposedly practicing "advanced nursing" so we technically have nothing to teach them. And if PAs decide to setup their own boards practicing some sort of pseudo-assistant-medicine then there's zero reason for us to work with them any longer. We can continue to work with the ones under the actual boards of medicine.


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[deleted109597]

Thats the attitude which makes you probably right.

However if the BOMs took the hard line that the practice of MEDICINE need to be regulated by boards of MEDICINE not outside entities, they could logically sanction doctors who enable those violating this tenant.

If I started teaching a janitor how to do medical procedures, and he went on to injure patients then I'm pretty sure my license would be in trouble. Obviously that is an extreme example but there is no reason the BOM can't sanction docs who enable the practice of medicine outside their purview. After all, NPs are supposedly practicing "advanced nursing" so we technically have nothing to teach them.

A loophole is delegated orders, especially in the prehospital realm. I can have paramedics do thoracotomies if I wrote it in the protocols. I don't, but they are viewed as an extension of me and my license (and my malpractice).

 

[Status Sciaticus]

Thats the attitude which makes you probably right.

However if the BOMs took the hard line that the practice of MEDICINE need to be regulated by boards of MEDICINE not outside entities, they could logically sanction doctors who enable those violating this tenant.

If I started teaching a janitor how to do medical procedures, and he went on to injure patients then I'm pretty sure my license would be in trouble. Obviously that is an extreme example but there is no reason the BOM can't sanction docs who enable the practice of medicine outside their purview. After all, NPs are supposedly practicing "advanced nursing" so we technically have nothing to teach them. And if PAs decide to setup their own boards practicing some sort of pseudo-assistant-medicine then there's zero reason for us to work with them any longer. We can continue to work with the ones under the actual boards of medicine.


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I actually agree with you. However, given that doctors are barred from unionizing, and the AMA is woefully inadequate in providing a unified lobbying voice to the entire profession, how do you suggest this gets accomplished? You think that hospitals that employ physicians or insurance providers will just let you do it without any repercussion? Do you think ACEP will advocate for this, knowing its going to hurt their sponsors (CMGs, hospital groups, etc..)?

 

[d2305]

Everybody dies mang

When I develop a 3 degree block, the death board will deny a pacemaker.

 

[anbuitachi]

I actually agree with you. However, given that doctors are barred from unionizing, and the AMA is woefully inadequate in providing a unified lobbying voice to the entire profession, how do you suggest this gets accomplished? You think that hospitals that employ physicians or insurance providers will just let you do it without any repercussion? Do you think ACEP will advocate for this, knowing its going to hurt their sponsors (CMGs, hospital groups, etc..)?

It's ******ed that doctors replacements are heavily unionized and doctors cant unionize. someone should be fighting this

 

[MSmentor018]

It's ******ed that doctors replacements are heavily unionized and doctors cant unionize. someone should be fighting this

I simply can't understand why our association is so limp when compared to the rest. it makes no damn sense

 

[xClashx]

I simply can't understand why our association is so limp when compared to the rest. it makes no damn sense

They are too busy doing research on the effectiveness of Standardized videos interviews for EM residency applications

 

[Status Sciaticus]

It's ******ed that doctors replacements are heavily unionized and doctors cant unionize. someone should be fighting this

I simply can't understand why our association is so limp when compared to the rest. it makes no damn sense

Apparently, if doctors went on strike, patients that would die as a result would be tantamount to murder..
But the lack of being able to unionize effectively bars out ability to effectively bargain the way nursing unions can.
Regarding why our association, both the AMA and ACEP are so limp, it's simply that they dont want to say anything that will affect their sponsors/donors. And while I can understand it to an extent, physicians complaining about paying annual memberships are a reason why alternative revenue streams are sought out, which inherently muddies the priorities of the organization.

They are too busy doing research on the effectiveness of Standardized videos interviews for EM residency applications

I see what you did there..

 

[shoal007]

Apparently, if doctors went on strike, patients that would die as a result would be tantamount to murder..
But the lack of being able to unionize effectively bars out ability to effectively bargain the way nursing unions can.
Regarding why our association, both the AMA and ACEP are so limp, it's simply that they dont want to say anything that will affect their sponsors/donors. And while I can understand it to an extent, physicians complaining about paying annual memberships are a reason why alternative revenue streams are sought out, which inherently muddies the priorities of the organization.


I see what you did there..

~$1000/yr should be enough. wtf they doing with my donation. **** went on auto pay too and no way to cancel without a call. Time to cancel my sub.

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[Status Sciaticus]

~$1000/yr should be enough. wtf they doing with my donation. **** went on auto pay too and no way to cancel without a call. Time to cancel my sub.

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there are about 45,000 EM docs in the US currently. That puts the total at 45M. And NEMPAC only gets a portion of it. Do you think that holds a candle next to how much other groups can lobby with?

 

[MSmentor018]

Apparently, if doctors went on strike, patients that would die as a result would be tantamount to murder..
But the lack of being able to unionize effectively bars out ability to effectively bargain the way nursing unions can.

if nurses went on strike (I've done that as a RN in my past career), the same result happens. doctors orders just stay in the rack and people die.
so what's the difference?
and yes the ANA is very powerful lobby. so why does the crew of the ship have more power than the captain? they have lower dues but more constituents. similar commercials in their magazines, rely on ads, donations....etc.

 

[Status Sciaticus]

if nurses went on strike (I've done that as a RN in my past career), the same result happens. doctors orders just stay in the rack and people die.
so what's the difference?
and yes the ANA is very powerful lobby. so why does the crew of the ship have more power than the captain? they have lower dues but more constituents. similar commercials in their magazines, rely on ads, donations....etc.

nurses dont make medical decisions on patients...
Realistically however, its possible to have a strike and leave a few physicians 'to cover' the sickest patients while still slowing work down in a hospital. You could do that without a union as well. Literally slow it down to 0.5-1 pph.

The crew of any ship has more power because they can overpower you.. in this case, with lobbying dollars.
Hopefully there are more physicians in the future who run for office, so we can atleast get some semblance of representation.

 

[Birdstrike]

Like I've always said, if PAs and NPs want independence, give it to them!

And along with it they will be given a fortune cookie that says, "Be careful what you wish for, because you just might get it."


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[NP 2 DPM]

Instead of becoming militant about not teaching/supervising midlevels, which WILL hurt patients, why don't you work within physician organizations to DEFINE what the PRACTICE OF MEDICINE is and ensure that anyone who does so is under the BOM.

Or, you could continue being "militant" about not working with midlevels. That will cost you $20-$50K a year as you continue watching the psychiatric NP take over your field of expertise.

A very well said point, @Boatswain2PA

 

[Arcan57]

Regarding why our association, both the AMA and ACEP are so limp, it's simply that they dont want to say anything that will affect their sponsors/donors. And while I can understand it to an extent, physicians complaining about paying annual memberships are a reason why alternative revenue streams are sought out, which inherently muddies the priorities of the organization.

Physicians used to hold the line. It's why we have Medicare instead of single-payer. Was that what was good for the nation? I think that's debatable but it sure as hell was good for the docs. Incomes and reimbursement soared. Specialists especially saw their income soar as new and lucrative techniques began receiving mainstream acceptance. We were basically fleecing the government and private payers and after about 20 years they started pushing back. By the time payers pushed back, most of the practitioners decided it was easier just to work a little more than to fight the pushback. Additionally, the AMA had pivoted from being funded by physicians to being funded by the government/private insurers for CPT codes and by pharm for the physician Masterfile.

The fight now is to preserve the income that we've been used to. In order to do that (which I think is important given the debt our newest physicians are drowning in), we've tried working longer hours, figuring out the most efficient way of extracting $$$ from our time (5 min visits, concurrent surgeries, etc), and finally delegating some of our authority to non physicians. If ED docs were ok with dropping to $150k/yr, we'd have all kinds of leverage in terms of who we let play in our space (ignoring CMG just skimming the money off the top). With the prevailing attitude that it's not worth getting out of bed for less than $225k and anything less than $300k is being treated like chattel, mid-levels are going to be a fact of life. There are too many hospitals were there aren't enough patients to toss in another doctor at the current pay scale but there are too many to let walk out the door. If everyone in the group says fine, hire another doc, we'll take the $25-50/hr cut to fund it you don't see midlevels in that department. What generally happens though is everyone just tries to stretch (pay goes up for docs but job satisfaction and metrics start dropping) or they hire a midlevel. Once the docs see that they can plugin a midlevel and the sky doesn't fall, they get used to supervising as well as seeing their own patients, and they get the income boost from the midlevel it makes hiring that second or third midlevel shift an even easier decision.

 

[Status Sciaticus]

Physicians used to hold the line. It's why we have Medicare instead of single-payer. Was that what was good for the nation? I think that's debatable but it sure as hell was good for the docs. Incomes and reimbursement soared. Specialists especially saw their income soar as new and lucrative techniques began receiving mainstream acceptance. We were basically fleecing the government and private payers and after about 20 years they started pushing back. By the time payers pushed back, most of the practitioners decided it was easier just to work a little more than to fight the pushback. Additionally, the AMA had pivoted from being funded by physicians to being funded by the government/private insurers for CPT codes and by pharm for the physician Masterfile.

The fight now is to preserve the income that we've been used to. In order to do that (which I think is important given the debt our newest physicians are drowning in), we've tried working longer hours, figuring out the most efficient way of extracting $$$ from our time (5 min visits, concurrent surgeries, etc), and finally delegating some of our authority to non physicians. If ED docs were ok with dropping to $150k/yr, we'd have all kinds of leverage in terms of who we let play in our space (ignoring CMG just skimming the money off the top). With the prevailing attitude that it's not worth getting out of bed for less than $225k and anything less than $300k is being treated like chattel, mid-levels are going to be a fact of life. There are too many hospitals were there aren't enough patients to toss in another doctor at the current pay scale but there are too many to let walk out the door. If everyone in the group says fine, hire another doc, we'll take the $25-50/hr cut to fund it you don't see midlevels in that department. What generally happens though is everyone just tries to stretch (pay goes up for docs but job satisfaction and metrics start dropping) or they hire a midlevel. Once the docs see that they can plugin a midlevel and the sky doesn't fall, they get used to supervising as well as seeing their own patients, and they get the income boost from the midlevel it makes hiring that second or third midlevel shift an even easier decision.

So your solution to the MLP issue, after mentioning the overwhelming debt burden on new physicians, is to get paid less? barely above what an NP makes? The salaries, whether someone says 250K or ever 350K, is priced appropriately due to the service being provided from a highly skilled physician. Saying that accepting less money will provide us with leverage is very shortsighted, and it will infact do the opposite. Accepting a paycut will reinforce the already pervasive false belief that doctors are overpaid. I can understand that many hospitals in rural settings cant afford EM boarded physicians, and in those instances, having NPs or PAs with increased autonomy under supervision is acceptable. Rural shortages of care was the argument NPs used to get independence in many states. Ironically they now concentrate in cities rather than rural areas. The issue isnt with pay, its with not having proper representation, whether its due to conflicts of interest with the AMA or ACEP. We should look towards increased physician involvement and funding our own lobbying institutions rather than letting CMGs and other corporations do it.

 

[doctalaughs]

Physicians used to hold the line. It's why we have Medicare instead of single-payer. Was that what was good for the nation? I think that's debatable but it sure as hell was good for the docs. Incomes and reimbursement soared. Specialists especially saw their income soar as new and lucrative techniques began receiving mainstream acceptance. We were basically fleecing the government and private payers and after about 20 years they started pushing back. By the time payers pushed back, most of the practitioners decided it was easier just to work a little more than to fight the pushback. Additionally, the AMA had pivoted from being funded by physicians to being funded by the government/private insurers for CPT codes and by pharm for the physician Masterfile.

The fight now is to preserve the income that we've been used to. In order to do that (which I think is important given the debt our newest physicians are drowning in), we've tried working longer hours, figuring out the most efficient way of extracting $$$ from our time (5 min visits, concurrent surgeries, etc), and finally delegating some of our authority to non physicians. If ED docs were ok with dropping to $150k/yr, we'd have all kinds of leverage in terms of who we let play in our space (ignoring CMG just skimming the money off the top). With the prevailing attitude that it's not worth getting out of bed for less than $225k and anything less than $300k is being treated like chattel, mid-levels are going to be a fact of life. There are too many hospitals were there aren't enough patients to toss in another doctor at the current pay scale but there are too many to let walk out the door. If everyone in the group says fine, hire another doc, we'll take the $25-50/hr cut to fund it you don't see midlevels in that department. What generally happens though is everyone just tries to stretch (pay goes up for docs but job satisfaction and metrics start dropping) or they hire a midlevel. Once the docs see that they can plugin a midlevel and the sky doesn't fall, they get used to supervising as well as seeing their own patients, and they get the income boost from the midlevel it makes hiring that second or third midlevel shift an even easier decision.

Disagree. In other first-world countries midlevels have far less scope and encroachment on physicians. And despite common misperceptions docs get paid similarly to the US if you adjust for hours worked, malpractice, admin overhead and educational debt (zero in many countries).

The main problem in the USA is that 3rd parties (pharma, device, administration, venture capital etc) have taken an increasing percentage of the healthcare pie, leaving less and less for the doctors. At the same time, driven partly by culture, partly by fee-for-service, we've continued to increase the number of unnecessary/futile interventions which necessitates more "providers" - thus rise of the midlevels.

There are plenty of studies showing that the more "providers" you have, the more unnecessary interventions you get. In other words, beyond a certain supply, docs/midlevels are creating their own demand.

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