NEJM article on scope of practice

[SXMMD]

It's out in print, the upcoming issue Feb 13th, there is an article in the perspective section written by folks with backgrounds in public health/policy and an RN (not 1 physician on authorship) arguing for expansion of scope of practice across the spectrum of health care, e.g. psychiatric pharmacist doing medication management services in areas underserved by psychiatrists, dental therapists providing routine preventive and restorative oral health care services like preparation and filling cavities. While they did not outright advocate for increased scope of practice for midlevels in the primary care setting, the piece seems to be setting the stage for a push for expanded scope of practice of allied health professions into fields where there is practical experience of sorts without any real formal education and training in actual clinical care.

Anecdotally, where I am training (unopposed family medicine in the midwest) we have a PA program that the local hospital system invests in far more heavily than the residents in our residency program. PAs on the specialty services get better training- dibs on procedures and cases, specialists make time out of their schedule to lecture for their didactics (getting a specialist to work with our program is like pulling teeth) and so on.

In my recent job search I have found that a majority of hospital systems are making a strong push for "APC or APP" supervision as part of standard contracts.

I know there are plenty of threads on "zomg midlevel takeover" and I'm not trying to re-create that hysteria, but based on my admittedly limited anecdotal experience it really does appear that the minimum standard of skill/knowledge in medical practice that is considered acceptable by social/political opinion is precipitously dropping (or the marketing for "equivalent outcomes" for midlevels in primary care and other "non acute" fields seems to be picking up anyway). Is this also the experience of other new grads ? For those of you who have been in the game for a while, do you see this as a passing trend? What does this mean for the new grad in FM in the long term, how do we distinguish ourselves from "advanced practice providers" who "do the same thing" as a specialty short of losing our identity as generalists by specializing (I mean beside providing superior primary care, which can subjectively be un/under appreciated when the marketing for APPs is strong enough in an area)?


Of note, the market for FM seems to be great, so I'm not so much worried about being able to get a job as much as seeing, at least on the surface, the specialty of fm being marketed as essentially obsolete.

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[deleted941485]

It's out in print, the upcoming issue Feb 13th, there is an article in the perspective section written by folks with backgrounds in public health/policy and an RN (not 1 physician on authorship) arguing for expansion of scope of practice across the spectrum of health care, e.g. psychiatric pharmacist doing medication management services in areas underserved by psychiatrists, dental therapists providing routine preventive and restorative oral health care services like preparation and filling cavities. While they did not outright advocate for increased scope of practice for midlevels in the primary care setting, the piece seems to be setting the stage for a push for expanded scope of practice of allied health professions into fields where there is practical experience of sorts without any real formal education and training in actual clinical care.

Anecdotally, where I am training (unopposed family medicine in the midwest) we have a PA program that the local hospital system invests in far more heavily than the residents in our residency program. PAs on the specialty services get better training- dibs on procedures and cases, specialists make time out of their schedule to lecture for their didactics (getting a specialist to work with our program is like pulling teeth) and so on.

In my recent job search I have found that a majority of hospital systems are making a strong push for "APC or APP" supervision as part of standard contracts.

I know there are plenty of threads on "zomg midlevel takeover" and I'm not trying to re-create that hysteria, but based on my admittedly limited anecdotal experience it really does appear that the minimum standard of skill/knowledge in medical practice that is considered acceptable by social/political opinion is precipitously dropping (or the marketing for "equivalent outcomes" for midlevels in primary care and other "non acute" fields seems to be picking up anyway). Is this also the experience of other new grads ? For those of you who have been in the game for a while, do you see this as a passing trend? What does this mean for the new grad in FM in the long term, how do we distinguish ourselves from "advanced practice providers" who "do the same thing" as a specialty short of losing our identity as generalists by specializing (I mean beside providing superior primary care, which can subjectively be un/under appreciated when the marketing for APPs is strong enough in an area)?


Of note, the market for FM seems to be great, so I'm not so much worried about being able to get a job as much as seeing, at least on the surface, the specialty of fm being marketed as essentially obsolete.

Did you want a physician to endorse it?

 

[SXMMD]

Did you want a physician to endorse it?

No, definitely happy on that point, but our profession does have a habit of shooting itself in the foot

 

[deleted941485]

No, definitely happy on that point, but our profession does have a habit of shooting itself in the foot

Oh I agree. It’s really a tie between the academic physician and the really shady/greedy private docs that will ultimately do everyone else in.

 

[Sushirolls]

1) Don't supervise or train ARNP
2) End CMS funding for GME - this reliance on funds is choking our GME system with the concept of 'golden handcuffs', a greater equilibrium will arise once programs lose the short sighted nature of having only 'funded' GME slots
3) Petition states to reduce licensure requirements from PGY 1 (or 2), to that of Medical school graduates, and to drop step/level III
4) Ramp up MD/DO schools and/or class sizes, flood the market with fresh MD/DO grads to then become the new mid levels
5) Join the only organization that actually gives a darn: Home - Physicians for Patient Protection
6) Create medical groups or private practices that advertise they are physician only

 

[SLC]

Just straight up refuse to sign any agreement to supervise mid-level providers. That’s what I did.

 

[MedicineZ0Z]

It's out in print, the upcoming issue Feb 13th, there is an article in the perspective section written by folks with backgrounds in public health/policy and an RN (not 1 physician on authorship) arguing for expansion of scope of practice across the spectrum of health care, e.g. psychiatric pharmacist doing medication management services in areas underserved by psychiatrists, dental therapists providing routine preventive and restorative oral health care services like preparation and filling cavities. While they did not outright advocate for increased scope of practice for midlevels in the primary care setting, the piece seems to be setting the stage for a push for expanded scope of practice of allied health professions into fields where there is practical experience of sorts without any real formal education and training in actual clinical care.

Anecdotally, where I am training (unopposed family medicine in the midwest) we have a PA program that the local hospital system invests in far more heavily than the residents in our residency program. PAs on the specialty services get better training- dibs on procedures and cases, specialists make time out of their schedule to lecture for their didactics (getting a specialist to work with our program is like pulling teeth) and so on.

In my recent job search I have found that a majority of hospital systems are making a strong push for "APC or APP" supervision as part of standard contracts.

I know there are plenty of threads on "zomg midlevel takeover" and I'm not trying to re-create that hysteria, but based on my admittedly limited anecdotal experience it really does appear that the minimum standard of skill/knowledge in medical practice that is considered acceptable by social/political opinion is precipitously dropping (or the marketing for "equivalent outcomes" for midlevels in primary care and other "non acute" fields seems to be picking up anyway). Is this also the experience of other new grads ? For those of you who have been in the game for a while, do you see this as a passing trend? What does this mean for the new grad in FM in the long term, how do we distinguish ourselves from "advanced practice providers" who "do the same thing" as a specialty short of losing our identity as generalists by specializing (I mean beside providing superior primary care, which can subjectively be un/under appreciated when the marketing for APPs is strong enough in an area)?


Of note, the market for FM seems to be great, so I'm not so much worried about being able to get a job as much as seeing, at least on the surface, the specialty of fm being marketed as essentially obsolete.

I've heard of these midlevel "residencies." You say they get first dibs on procedures and cases? Dude that's insanity. Your residency should be flipping ****.

Anyway...

Stop calling them "advanced practice providers." Call them midlevels. That's literally what they are. Nothing advanced about them.

 

[deleted941485]

I've heard of these midlevel "residencies." You say they get first dibs on procedures and cases? Dude that's insanity. Your residency should be flipping ****.

Anyway...

Stop calling them "advanced practice providers." Call them midlevels. That's literally what they are. Nothing advanced about them.

Drop a dime to the ACGME. The admin will tell you not to and hat you aren’t a team player and that it’s not good to have a program on probation. But you know what? Do it anyway

 

[CCM-MD]

Terrible.

Join Physicians for Patient Protection. Only organization actively doing something about this.

 

[MedicineZ0Z]

Terrible.

Join Physicians for Patient Protection. Only organization actively doing something about this.

Nice to see you've come around (not the PPP organization, but stance against midlevels). Did you observe anything new in the past while in your ICU/hospital?

 

[CCM-MD]

Nice to see you've come around (not the PPP organization, but stance against midlevels). Did you observe anything new in the past while in your ICU/hospital?

I disagree with a lot of your posts but I have never been and will never be a proponent of the ever expanding role of midlevels. Any physician advocating for independent practice of midlevels is short sighted and a total *****.

 

[67552931811]

Terrible.

Join Physicians for Patient Protection. Only organization actively doing something about this.

Why does your link go to a diff webpage (physicians for patients NOT physicians for patient protection).

Home - Physicians for Patient Protection

35

www.physiciansforpatientprotection.org

Is this the group you meant? I’ve never heard of the group in your original link before (would be nice to have another group actively involved, though!).

 

[CCM-MD]

Why does your link go to diff webpage (physicians for patients NOT physicians for patient protection).

Home - Physicians for Patient Protection

35

www.physiciansforpatientprotection.org

Is this the group you meant? I’ve never heard of your original link before...

I put the wrong website. Yours is the correct one.

 

[Sardonix]

Just straight up refuse to sign any agreement to supervise mid-level providers. That’s what I did.

Was this an obstacle for you? Even though it's off in the distance for me, I can't help but predict this will mean something like sacrificing my "ideal" practice when they demand midlevel supervision.

 

[MedicineZ0Z]

Was this an obstacle for you? Even though it's off in the distance for me, I can't help but predict this will mean something like sacrificing my "ideal" practice when they demand midlevel supervision.

Then 3 years later you're in court over signing off on a patient's chart who you never saw yourself who went home and died.

 

[Sardonix]

Then 3 years later you're in court over signing off on a patient's chart who you never saw yourself who went home and died.

You're stating the obvious. I'm trying to find to what extent this will complicate job searches so that when I eventually get there I can mentally prepare myself to walk away rather than even entertain the idea for the exact reason you mention.

 

[SLC]

Was this an obstacle for you? Even though it's off in the distance for me, I can't help but predict this will mean something like sacrificing my "ideal" practice when they demand midlevel supervision.

Nope, but I’d already signed my employment contract. I got multiple separate contracts afterward: for PA supervision, hospital coverage, ER coverage, etc. I just sent the PA one back and said I was uncomfortable doing it. Nobody seemed to mind; and I ran it by my physician supervisor and he said “I wish I’d refused to sign mine too”.

It’s been 18months and there’s been no pushback at all.

 

[VA Hopeful Dr]

Nope, but I’d already signed my employment contract. I got multiple separate contracts afterward: for PA supervision, hospital coverage, ER coverage, etc. I just sent the PA one back and said I was uncomfortable doing it. Nobody seemed to mind; and I ran it by my physician supervisor and he said “I wish I’d refused to sign mine too”.

It’s been 18months and there’s been no pushback at all.

Most places if you don't want to supervise, you don't have to and it's fine.

One of my partners used to supervise an NP, had a falling out with the NP and stopped supervising her. That doctor still has a job and it wasn't a big deal at all.

 

[Sardonix]

I am very happy to hear this. Was afraid of stories like contracts failing to be renewed after refusing midlevels etc.

 

[septoplasty]

This thread is refreshing.

OP, if its interfering with your training, and your program isn't doing anything about it (midlevels), than time to take it up a notch and talk to the ACGME. That'll light a fire under some ass.

Hopefully one day, there can be two "tiers" of medicine in the system that is embracing the "same quality/cheaper" BS.
One mode of healthcare, completely with MD/DO, and another where patient can see all the mid-levels they want. Happy to facilitate this.

 

[septoplasty]

I am very happy to hear this. Was afraid of stories like contracts failing to be renewed after refusing midlevels etc.

Really a catch 22, if all MD/DO refuse to sign, whom will they get to supervise?
The trouble here is, many of us feel like we aren't significant enough to do anything.
Unfortunately the mid level society has recognized this, and is fighting actively for independent "rights", as to avoid supervision.

 

[septoplasty]

Most places if you don't want to supervise, you don't have to and it's fine.

One of my partners used to supervise an NP, had a falling out with the NP and stopped supervising her. That doctor still has a job and it wasn't a big deal at all.

Anecdotal somewhat, there is a well known example of the opposite happening in Illinois with a chain of urgent cares..

 

[VA Hopeful Dr]

Anecdotal somewhat, there is a well known example of the opposite happening in Illinois with a chain of urgent cares..

Yeah but that's Urgent Care (also known to happen in EM). I haven't heard of it happening in Primary Care in any appreciable volume.

 

[hallowmann]

I'm seeing this as more and more of an issue in healthcare systems/academic institutions. Just over the last few years, I have seen a significant expansion in the NPs and PAs in all the different specialties at my institution. There are more of those 1-year "residencies" (where they get paid the same they would starting in practice, which is more than the average resident, and do less work than the average resident). In one categorical program, the PA "residents" are now consistently scheduled in procedure clinic and end up edging out residents for all procedures. It's under the guise that the PAs are only there a year, but there's a new one every year, so in the end the residents just simply get less procedural training.

It sure feels like healthcare systems are just finding another way to screw over physicians, and in all honesty, they're probably going to screw over the PAs and NPs too.

 

[KeikoTanaka]

I'm seeing this as more and more of an issue in healthcare systems/academic institutions. Just over the last few years, I have seen a significant expansion in the NPs and PAs in all the different specialties at my institution. There are more of those 1-year "residencies" (where they get paid the same they would starting in practice, which is more than the average resident, and do less work than the average resident). In one categorical program, the PA "residents" are now consistently scheduled in procedure clinic and end up edging out residents for all procedures. It's under the guise that the PAs are only there a year, but there's a new one every year, so in the end the residents just simply get less procedural training.

It sure feels like healthcare systems are just finding another way to screw over physicians, and in all honesty, they're probably going to screw over the PAs and NPs too.

To be honest though, many procedures can be done without physician's direct guidance, especially if those procedures can be streamlined and made easier. As long as a Physician ordered it and knew it was the best thing, having someone else to do the procedure isn't the worst thing (Assuming it's not a potentially dangerous procedure - like intubating a complicated patient). PAs/NPs doing the "scut work" is just one step away from AI doing it in 20-30 years. This opens the physicians up to spending time doing what they were hired to do - the critical decision making (and obviously the more complex procedures). If someone else in the hospital can do the procedures and let the physicians do what they were hired for (medical management), that's just the future. Don't get me wrong, physicians in residency definitely need to learn these things in case it's too difficult or demanding for the PA/NP - But, I would argue procedures are the "muscle memory" things that don't require a huge amount of medical knowledge to do - in fact, are so little stressed in actual medical schooling, and therefore are more "on the job training" type of stuff.

It's weird because I see both sides. As a medical student I worry about my opportunities and debt in the future, but I also recognize we live in a world where the population is exponentially increasing. Physicians can't do it all. We really do rely on so many aspects of other healthcare workers working in the hospitals. So yes, physician opportunities and role may "lessen" (Which probably isn't super likely given how many are retiring and how many people our population is growing with) - and we may see a slight decline or stagnation in salary to make room for those others to come in - But, HOPEFULLY, the role of other providers/techs will truly allow physicians to not burn out so fast by decreasing their workload while allowing them to really focus on the important medical aspects of patient care that we trained for and not just a procedure that eventually a computer can do with the right technology anyways.

It's not fair necessarily to compare residents to PAs/NPs. They may make 85k in their "1 year residency" while a physician earns 55-70k for their 3 years of residency, but at the end of it all, they'll always be a NP/PA making ~100-115k. The resident will "graduate" and move on to making 225k+ (PCP) or 320k+ (ED) after 3 years, or more if its a longer residency/fellowship. If a PA/NP is truly spending 1 year out of school and their hospital is making them do procedures, but that frees up physicians and allows the physician to focus on staying up to do date on all other aspects of medical management that will make or break the patient's long term care, that may just be the future.

With all that being said, I 100% believe there shouldn't be any midlevel independence, and if a procedure has to be done, it must be first ordered and the patient cleared by a physician. So while I think its inevitable that others roles and scopes may expand, I believe improved telemedicine technology will allow for a more streamlined supervision approach for physicians and midlevels to work together to allow all of us to focus on our strengths.

I may get flamed for this, but as someone who sees the inevitability of midlevels in the future of a corporate-capitalistic driven healthcare system, I'm trying to rationalize these changes for my own sanity.

 

[TheOther]

But, HOPEFULLY, the role of other providers/techs will truly allow physicians to not burn out so fast by decreasing their workload while allowing them to really focus on the important medical aspects of patient care that we trained for and not just a procedure that eventually a computer can do with the right technology anyways.

Procedures are among the least of our worries when it comes to work burden. They hardly add to burnout. If anything, they add an extra dimension to our work that makes it more engaging.

In terms of family medicine docs, the issue with procedures during OUR training going to OTHER midlevels is that with our scope of practice, we should be as much of a "one stop shop" as possible -- especially in light of rural medicine and the growth of DPC practices. Taking procedures from residents diminishes the experience and preparedness for being the sole healthcare provider for many patients.

And to chalk it up to "AI can do it all in 20-30 years so might as well hand off the procedures now" -- sorry fam, that's just a silly argument. I work in a large urban city at a safety net community hospital. I'm training to care for my patients now and in the immediate future, they deserve that.

 

[Sardonix]

To be honest though, many procedures can be done without physician's direct guidance, especially if those procedures can be streamlined and made easier. As long as a Physician ordered it and knew it was the best thing, having someone else to do the procedure isn't the worst thing (Assuming it's not a potentially dangerous procedure - like intubating a complicated patient). PAs/NPs doing the "scut work" is just one step away from AI doing it in 20-30 years. This opens the physicians up to spending time doing what they were hired to do - the critical decision making (and obviously the more complex procedures). If someone else in the hospital can do the procedures and let the physicians do what they were hired for (medical management), that's just the future. Don't get me wrong, physicians in residency definitely need to learn these things in case it's too difficult or demanding for the PA/NP - But, I would argue procedures are the "muscle memory" things that don't require a huge amount of medical knowledge to do - in fact, are so little stressed in actual medical schooling, and therefore are more "on the job training" type of stuff.

This touches on an issue that is also very worrisome--NPs and PAs will get all the "easy" and "straightforward" cases while physicians will be required to see just as many patients as they did previously, except now they're all incredibly complex and don't have any of aforementioned simple visits to use as a breather.