What specialties will have the most and least midlevel encroachment?

[Astra]

As someone who is wanting to do primary care, boy is it scary

---

Members don't see this ad.

 

[libertyyne]

Most if not all proceduralists will have little to no midlevel encroachment.

 

[jqueb29]

If you don't suck, you'll be just fine. Midlevels are pretty bad at anything more advanced than the easiest stuff and should pose no threat to most folks. They may scream and holler for more autonomy and ability to do more things, but they aren't actually capable of doing pretty much any of the things they ask for. Midlevels are a toothless lion.

 

[libertyyne]

If you don't suck, you'll be just fine. Midlevels are pretty bad at anything more advanced than the easiest stuff and should pose no threat to most folks. They may scream and holler for more autonomy and ability to do more things, but they aren't actually capable of doing pretty much any of the things they ask for. Midlevels are a toothless lion.

The problem is John q public doesn't care and just wants to see a medical professional. If they get autonomy via state legislature there will be some encroachment, but most just for simple stuff as you said.

 

[Astra]

The problem is John q public doesn't care and just wants to see a medical professional. If they get autonomy via state legislature there will be some encroachment, but most just for simple stuff as you said.

That's the scary part. I have no problem with PA's or DNP's but when the public starts equating their knowledge/responsibilities to MD's/DO's, its scary.

 

[Lawpy]

If you don't suck, you'll be just fine. Midlevels are pretty bad at anything more advanced than the easiest stuff and should pose no threat to most folks. They may scream and holler for more autonomy and ability to do more things, but they aren't actually capable of doing pretty much any of the things they ask for. Midlevels are a toothless lion.

The problem is John q public doesn't care and just wants to see a medical professional. If they get autonomy via state legislature there will be some encroachment, but most just for simple stuff as you said.

Then midlevels will get sued for malpractice and lose their licenses.

 

[AnatomyGrey12]

Don't doublebpost. You will also get better, more informed responses in the allo thread you made.

 

[libertyyne]

Then midlevels will get sued for malpractice and lose their licenses.

Good luck with that. That assumes there is logic behind initiation of lawsuits or all instances of negligence or error result in lawsuits. They lawsuits do not necessarily result from less competent people making mistakes.

Also getting sued does not equate to loosing license.

 

[Lawpy]

Good luck with that. That assumes there is logic behind initiation of lawsuits or all instances of negligence or error result in lawsuits. They lawsuits do not necessarily result from less competent people making mistakes.

Also getting sued does not equate to loosing license.

If midlevels become autonomous and independent providers, they will likely be held to same standards as physicians (because patient care matters). Since midlevels lack the knowledge, expertise and experience that physicians have, their diagnosis, management and treatment plans will be limited, which would compromise and endanger patient care. This will result in more lawsuits filed against them, and they will lose their credibility and their license to practice.

I think that's a fundamental problem inherent to midlevel care. And yeah lawsuits arise from various reasons, but it's a compelling argument against midlevel autonomy and encroachment. If they want to enjoy the prestige and privilege of being called a doctor, they should be subjected to comparable responsibilities. But given their significantly limited background, their impact on patient outcomes would be dangerous and harmful in the long term.

 

[libertyyne]

If midlevels become autonomous and independent providers, they will likely be held to same standards as physicians (because patient care matters). Since midlevels lack the knowledge, expertise and experience that physicians have, their diagnosis, management and treatment plans will be limited, which would compromise and endanger patient care. This will result in more lawsuits filed against them, and they will lose their credibility and their license to practice.

I think that's a fundamental problem inherent to midlevel care. And yeah lawsuits arise from various reasons, but it's a compelling argument against midlevel autonomy and encroachment. If they want to enjoy the prestige and privilege of being called a doctor, they should be subjected to comparable responsibilities. But given their significantly limited background, their impact on patient outcomes would be dangerous and harmful in the long term.

Although your argument makes sense but it based on the idea that incompetence = more lawsuits. This simply is not the case in the real world.

Your assertion is also demonstratively proven incorrect by looking at states that have granted full autonomy to NPs for practice. NPs have not been sued out of existence in those states, I am even willing to venture they probably get sued less or equal to physican counterparts in those states.

 

[Lawpy]

Although your argument makes sense but it based on the idea that incompetence = more lawsuits. This simply is not the case in the real world.

That's true but it presents a significantly greater danger to patient outcomes and long-term public health. Thst's why i don't think midlevel autonomy (if it happens) won't survive for long, unless dramatic overhauls happened in midlevel education. But this would make it too similar to medical education, and the costs of labor for hiring midlevels would drastically increase.

 

[libertyyne]

That's true but it presents a significantly greater danger to patient outcomes and long-term public health. Thst's why i don't think midlevel autonomy (if it happens) won't survive for long, unless dramatic overhauls happened in midlevel education. But this would make it too similar to medical education, and the costs of labor for hiring midlevels would drastically increase.

Cat is already out of the bag in rural Western states. They haven't been sued out of existence there.
I would also like to see the data for the difference in outcomes and increased adverse outcomes for primary care under midlevels. I am on your side but I prefer concrete evidence.

 

[Lawpy]

Cat is already out of the bag in rural Western states. They haven't been sued out of existence there.

that's not good. although i think the reason why that happened is not many physicians are available to work in the rural regions. that and the cheaper costs of labor for hiring midlevels could explain midlevel independence in those areas.

i think the best way to deal with this is for residencies to somehow subsidize primary care residents to work in rural regions. or maybe give incoming med students a full ride provided they spend a few years in residency working in these areas. some ways to combat and reduce physician maldistribution will help

 

[libertyyne]

that's not good. although i think the reason why that happened is not many physicians are available to work in the rural regions. that and the cheaper costs of labor for hiring midlevels could explain midlevel independence in those areas.

i think the best way to deal with this is for residencies to somehow subsidize primary care residents to work in rural regions. or maybe give incoming med students a full ride provided they spend a few years in residency working in these areas. some ways to combat and reduce physician maldistribution will help

State level lobbying is required to fix this and perhaps an honest conversation about medical education and duration of medical education.
But the map disproves your argument that lawsuits would prevent this spread.

 

[freak7]

to loosing license.

That's the second time you've made that typo in two days. Not that I'm counting or anything

 

[libertyyne]

@freak7
ESL slips through some times.

 

[freak7]

Tbh I had a difficult time correcting it and I copied @lawpers spelling that I was quoting.

I'm just salty this morning. Ignore me

 

[Jim Hopper]

that's not good. although i think the reason why that happened is not many physicians are available to work in the rural regions. that and the cheaper costs of labor for hiring midlevels could explain midlevel independence in those areas.

i think the best way to deal with this is for residencies to somehow subsidize primary care residents to work in rural regions. or maybe give incoming med students a full ride provided they spend a few years in residency working in these areas. some ways to combat and reduce physician maldistribution will help

So if you browse some of the primary care forums, the consensus seems to be that rural areas offer some pretty lucrative pay to physicians since they know the location isn't ideal.

On the other hand, DNPs are being provided with more and more autonomy as they're seen as a way to meet rural needs. However, DNPs aren't staying rural, and have been vying for jobs near/in cities.

Do you think DNPs with full autonomy will drive down the higher salary offers for rural physicians, or are DNPs flocking to cities to the extent where they're no longer providing rural relief?


Sent from my iPhone using SDN mobile

 

[Astra]

Don't doublebpost. You will also get better, more informed responses in the allo thread you made.

This forum has more traffic and some users that only browse here. Wanted to get more points of view

 

[efle]

You know I have yet to see true midlevel encroachment. Where I work the CRNAs in the procedure rooms all clearly defer to the floor Anesthesiologist. When I shadowed a private practice neuro there were a bunch of PAs handling straightforward return visits that would give the neurologist an update and he'd say yup looks good, and sign off.

Is that encroachment? Did it use to be anesthesiologists in every room just for 30 mins of MAC? Or did it used to be four neurologists doing the work this one + assistants does?

Though, my experience comes from living in states that are Restricted on that map above. Is it the case out in the northwest that your town doc is actually a PA all on their own?

 

[Matthew9Thirtyfive]

You know I have yet to see true midlevel encroachment. Where I work the CRNAs in the procedure rooms all clearly defer to the floor Anesthesiologist. When I shadowed a private practice neuro there were a bunch of PAs handling straightforward return visits that would give the neurologist an update and he'd say yup looks good, and sign off.

Is that encroachment? Did it use to be anesthesiologists in every room just for 30 mins of MAC? Or did it used to be four neurologists doing the work this one + assistants does?

Though, my experience comes from living in states that are Restricted on that map above. Is it the case out in the northwest that your town doc is actually a PA all on their own?

I worked at a rural hospital in Texas that had no anesthesiologist. The entire anesthesia staff was CRNAs. Is that encroachment? I dunno, but they'd probably say yes on the anesthesiology forum.

As far as outcomes go @libertyyne, the only studies I have seen were focused on primary care, in which case the outcomes were similar. In one study though (1), they found that NPs were less likely to change blood pressure management in diabetes patients with hypertension. What that means, I don't know. Another study (2) found that while outcomes in primary care are similar, midlevels tend to take longer for visits and performed more tests. And yet a third (3) found that outcomes were similar, but that physicians tended to take care of sicker patients and work longer hours, while midlevels took care of less complex patients and consulted re nursing staff more.

1. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3903431/

2. http://www.bmj.com/content/320/7241/1048.full.pdf+html

3. http://search.proquest.com/openview/24277706fa09c024d2f2364dfb59775c/1?pq-origsite=gscholar

I just did a really quick Google Scholar search though.

 

[libertyyne]

I worked at a rural hospital in Texas that had no anesthesiologist. The entire anesthesia staff was CRNAs. Is that encroachment? I dunno, but they'd probably say yes on the anesthesiology forum.

As far as outcomes go @libertyyne, the only studies I have seen were focused on primary care, in which case the outcomes were similar. In one study though (1), they found that NPs were less likely to change blood pressure management in diabetes patients with hypertension. What that means, I don't know. Another study (2) found that while outcomes in primary care are similar, midlevels tend to take longer for visits and performed more tests. And yet a third (3) found that outcomes were similar, but that physicians tended to take care of sicker patients and work longer hours, while midlevels took care of less complex patients and consulted re nursing staff more.

1. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3903431/

2. http://www.bmj.com/content/320/7241/1048.full.pdf+html

3. http://search.proquest.com/openview/24277706fa09c024d2f2364dfb59775c/1?pq-origsite=gscholar

I just did a really quick Google Scholar search though.

It was really a rhetorical question to temper some of @lawpers claims of "significant danger to public health and outcomes" . Thankyou for doing the legwork.

 

[Astra]

I think a good solution is to open primary care only med schools. That would alleviate the lack of primary care docs in rural areas and maintain the level of practice without having to empower PA's/DNP's

 

[libertyyne]

You know I have yet to see true midlevel encroachment. Where I work the CRNAs in the procedure rooms all clearly defer to the floor Anesthesiologist. When I shadowed a private practice neuro there were a bunch of PAs handling straightforward return visits that would give the neurologist an update and he'd say yup looks good, and sign off.

Is that encroachment? Did it use to be anesthesiologists in every room just for 30 mins of MAC? Or did it used to be four neurologists doing the work this one + assistants does?

Though, my experience comes from living in states that are Restricted on that map above. Is it the case out in the northwest that your town doc is actually a PA all on their own?

I have only worked in the reduced autonomy states and the crnas have only had the very simple low risk short duration procedures. IIRC PAs don't have the same autonomy that NPs have due to the lobbying efforts by NPs for NP access and not catch-all midlevels access.
Full access states they don't need an MD to sign off. I mean even in restricted access states all you need is an MD signature at the end. So you could have an NP all by themselves sending electronic notes to the MD 100 miles away who is just signing off. Talk about scary, I would have to really trust that mid level.

 

[libertyyne]

I think a good solution is to open primary care only med schools. That would alleviate the lack of primary care docs in rural areas and maintain the level of practice without having to empower PA's/DNP's

You still couldn't force them to move to undesirable locales you might just have more pcps in cities and the coasts.

 

[efle]

I think a good solution is to open primary care only med schools. That would alleviate the lack of primary care docs in rural areas and maintain the level of practice without having to empower PA's/DNP's

Man, that would be tough though, would you have to transfer out if you fell in love with a specific subject area or became disillusioned with your original intentions (like rural care)? I hear so often that people change their mind about what they want during medical school...

@libertyyne wow I hadn't even considered that there might be infighting between midlevel types. Pretty funny to think that some states might be restricting what a PA can do whilst licensing Naturopathic Docs and letting them practice

 

[Astra]

You still couldn't force them to move to undesirable locales you might just have more pcps in cities and the coasts.

sure but after a certain level of saturation, it would be worse to practice in urban areas than rural. eventually, people WILL have to go to rural areas to pay back student loans.

 

[Astra]

Man, that would be tough though, would you have to transfer out if you fell in love with a specific subject area or became disillusioned with your original intentions (like rural care)? I hear so often that people change their mind about what they want during medical school...

@libertyyne wow I hadn't even considered that there might be infighting between midlevel types. Pretty funny to think that some states might be restricting what a PA can do whilst licensing Naturopathic Docs and letting them practice

That's true but the med schools that are primary care focused could have lower admissions stats. That way we get more people into medicine who would've otherwise stopped and we fix primary care shortages.

 

[AnatomyGrey12]

That's true but the med schools that are primary care focused could have lower admissions stats. That way we get more people into medicine who would've otherwise stopped and we fix primary care shortages.

Schools that are primary care focused with lower admissions stats? Hmm I wonder where we can find some of those...

 

[Astra]

Schools that are primary care focused with lower admissions stats? Hmm I wonder where we can find some of those...

I know there are some. But none have a mandate that forces you to do primary care after enrolling, which is what I am suggesting

 

[libertyyne]

That's true but the med schools that are primary care focused could have lower admissions stats. That way we get more people into medicine who would've otherwise stopped and we fix primary care shortages.

That pain point has yet to be seen. There is still a differential between rural and city pay scales. You underestimate the pay cuts young professionals will take to stay in cities.
Heck, they even have loan forgiveness programs.

 

[AnatomyGrey12]

I know there are some. But none have a mandate that forces you to do primary care after enrolling, which is what I am suggesting

There are primary care tracks at a number of schools. Have you ever looked at a DO match list? The majority (especially at the more rural schools) is in rural primary care. The "best" DO schools still put about 50% of there class in primary care. Don't underestimate how much people don't want to live in rural areas unless they are from there. The issue isn't an issue with education, jobs, or pay. The issue is at the medical school admissions level, the whole process selects for type A individuals who are driven to be as "successful" as they can and pursue the competitive fields and job markets. If you want someone to practice in rural Mississippi then go get a kid from rural Mississippi. Don't get the kid from the big school in the city with a 30+ MCAT who has no desire to all of a sudden become a country boy. And then when we get these guys in medical school we need to stop talking about primary care like it is career failure.

Some state schools do a good job of this, most do not.

 

[Matthew9Thirtyfive]

That pain point has yet to be seen. There is still a differential between rural and city pay scales. You underestimate the pay cuts young professionals will take to stay in cities.
Heck, they even have loan forgiveness programs.

A chief I work with has a girlfriend who finished a breast fellowship a couple years ago. She signed a $300k/year contract that also included significant loan repayment for three years working in rural North Carolina. Those things definitely exist, but so many people want to live in urban areas.

 

[Kgizzle]

A chief I work with has a girlfriend who finished a breast fellowship a couple years ago. She signed a $300k/year contract that also included significant loan repayment for three years working in rural North Carolina. Those things definitely exist, but so many people want to live in urban areas.

City folk just don't get it...

 

[Astra]

There are primary care tracks at a number of schools. Have you ever looked at a DO match list? The majority (especially at the more rural schools) is in rural primary care. The "best" DO schools still put about 50% of there class in primary care.

Once again, that is not the same as being forced to to primary care upon admission.

Don't underestimate how much people don't want to live in rural areas unless they are from there.

I'm not. I'm from a rural area and I can see why people would not want to live there.

The issue is at the medical school admissions level, the whole process selects for type A individuals who are driven to be as "successful" as they can and pursue the competitive fields and job markets.

I would disagree with you here but I can see where you're coming from. There are plenty of people in each medical class that are laid back and aren't focused on competing. Some with families who just wanna be a doctor and aren't concerned with competition, some with life experiences that makes them want to do less competitive specialties, etc. The fact that a good number of each class is like this shows that non Type A individuals do get accepted.

In addition, pursuing high paying specialties isn't necessarily due to being "successful" or having a Type A personality. For some, its out of necessity. They might have ONLY gotten accepted to a high COA school and will have to pay back 300k+ loans. Would you honestly tell me that pursuing a specialty that pays more makes you Type A in this scenario?

If you want someone to practice in rural Mississippi then go get a kid from rural Mississippi. Don't get the kid from the big school in the city with a 30+ MCAT who has no desire to all of a sudden become a country boy.

This is why I am saying we should have med schools with lower admission standards that only create primary care doctors. They could have sub 30 mcat and gpa requirements below 3.6. Place them in areas with large undeserved populations and only take IS students who want to practice in those areas.

And then when we get these guys in medical school we need to stop talking about primary care like it is career failure.

And they wouldn't be wrong if their only goal is to make tons of money. If their goal is to be a primary care doc, then its not career failure for them.

 

[Astra]

That pain point has yet to be seen

What point?

There is still a differential between rural and city pay scales

I know there is. If the market is flooded with primary care docs, then the salaries will drop in city areas. rural areas would then be more appealing. When you have tons of loans, money is important and I am confident more people would go to rural areas in this scenario.

You underestimate the pay cuts young professionals will take to stay in cities.

I don't. I get people will take a paycut to be in cities but after a certain point, it becomes very enticing to go to rural areas and that creates more rural doctors than we currently have. I'm not saying all the primary docs created this way will be in rural areas. Just more than our current system.

Heck, they even have loan forgiveness programs.

This is a sketchy issue currently. With Trump and Republicans controlling DC, loan forgiveness programs might not stick around

 

[Ismet]

Closing cross-posted thread. Discussion can be continued in the same thread over in the Allopathic forum: https://forums.studentdoctor.net/th...most-and-least-midlevel-encroachment.1232795/