NP/PA “neurology” fellowship

[stevresidentp]

What do you think about the few dozen programs creating one year APP fellowship for Neurology? Like Duke, Darmouth, USC.. etc. How is that going to impact the field, jobs and residents training/experience?

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[sharkbaitwhohaha]

Might be best to avoid those programs. Cant predict how those midlevel "training" programs with impair your learning. Also, don't support programs that are trying to train our replacements.

 

[Telamir]

I've met plenty of NPs who are doing neuro either outpatient or inpatient. So far not impressed with any of them, regardless of "experience".

 

[sharkbaitwhohaha]

I've met plenty of NPs who are doing neuro either outpatient or inpatient. So far not impressed with any of them, regardless of "experience".

Agree. But patients won't know the difference and will just be seeing the "provider"

 

[deathmerchant]

Yea this is a slippery slope. Right now it might not change much but slowly these "providers" will be everywhere!!

 

[neglect]

The bottom line is that these people want titles like intern/resident/fellow, but couldn't get into med school. It is just so sad to see these academic places churning out NPs/PAs with woeful under training and less intellectual ability, work-ability, and even interpersonal skills. Their interest is transparent: they need cheaper worker bees to do the clinical heavy lifting. But extenders get scared, over-utilize, over-consult, fail to come to correct diagnoses, fail to disclose the diagnosis, so end up creating a ton of waste. Many are susceptible to quackery and pharma marketing. It is also so sad to see the AAN being steadily infiltrated by extenders, since the one thing they do well is organize to try to legislate independent practice.

 

[neglect]

Highly recommend watching this to see the NP mindset, practice creep, and the damage they cause.

And if you think your patients are safe as a neurologist, you're delusional.

 

[DrSatan]

Nothing like a quiet sob at 10 AM

 

[xenotype]

Agree with everything said however for a reality check I think our field is at low direct risk for serious encroachment compared to most non-surgical fields. The risk is much lower in neurology due to complex procedures NPs will never credibly learn (EEG, EMG) and the risk of severe harm in the case of misdiagnosis (tPA or no, status or PNES, encephalitis or just another toxic metabolic)- these things can kill or completely disable patients if you are gravely wrong. Big misses carry direct liability to hospitals as well, and punting on the diagnosis means an urgent transfer somewhere else with loss of revenue. Much of neurology residency as everyone knows is getting over the fear factor and learning a rational approach with stroke and seizure. No one is going to take an NPs word alone on big questions regarding these and you'll find ED/hospitalists much more skeptical on recommendations as they are liable too.

This isn't to say there is no risk, but for future neurology applicants I don't see AI, NPs, or even too many graduates being an issue anytime soon. There just aren't that many residents graduating per year, and the demand for general neurologist time is almost inelastic- the easier to consult the more opinions one is asked to render. Most NPs you see in neurology only do stroke, or only do headache, or only do movement/NM and can't really go outside that box without getting scared as they should.

 

[deathmerchant]

Agree with everything said however for a reality check I think our field is at low direct risk for serious encroachment compared to most non-surgical fields. The risk is much lower in neurology due to complex procedures NPs will never credibly learn (EEG, EMG) and the risk of severe harm in the case of misdiagnosis (tPA or no, status or PNES, encephalitis or just another toxic metabolic)- these things can kill or completely disable patients if you are gravely wrong. Big misses carry direct liability to hospitals as well, and punting on the diagnosis means an urgent transfer somewhere else with loss of revenue. Much of neurology residency as everyone knows is getting over the fear factor and learning a rational approach with stroke and seizure. No one is going to take an NPs word alone on big questions regarding these and you'll find ED/hospitalists much more skeptical on recommendations as they are liable too.

This isn't to say there is no risk, but for future neurology applicants I don't see AI, NPs, or even too many graduates being an issue anytime soon. There just aren't that many residents graduating per year, and the demand for general neurologist time is almost inelastic- the easier to consult the more opinions one is asked to render. Most NPs you see in neurology only do stroke, or only do headache, or only do movement/NM and can't really go outside that box without getting scared as they should.

Im sorry to say that is very naive; or you haven't encountered the reality of what's going on. I have seen NPs take consults independently in almost every field now including Neurosurgery. As you know, they pretty much work like a full Anesthesiologist. I personally know of neuro clinics that are run by NPs independently (and an attending is just required to sign off on 10% or so of their notes).
In many residency programs, where there are no fellows, they have NPs take stroke call and residents (including PG4s!) have to call the NP after hours.
Even if we assume that they will never be accepted for high acuity stuff, there is still a lot of bread and butter neurology that they can and are doing. It can't be good for Neurologists in any way. This thing has to be nipped in the bud.

 

[neglect]

Agree with everything said however for a reality check I think our field is at low direct risk for serious encroachment compared to most non-surgical fields. The risk is much lower in neurology due to complex procedures NPs will never credibly learn (EEG, EMG) and the risk of severe harm in the case of misdiagnosis (tPA or no, status or PNES, encephalitis or just another toxic metabolic)- these things can kill or completely disable patients if you are gravely wrong. Big misses carry direct liability to hospitals as well, and punting on the diagnosis means an urgent transfer somewhere else with loss of revenue. Much of neurology residency as everyone knows is getting over the fear factor and learning a rational approach with stroke and seizure. No one is going to take an NPs word alone on big questions regarding these and you'll find ED/hospitalists much more skeptical on recommendations as they are liable too.

This isn't to say there is no risk, but for future neurology applicants I don't see AI, NPs, or even too many graduates being an issue anytime soon. There just aren't that many residents graduating per year, and the demand for general neurologist time is almost inelastic- the easier to consult the more opinions one is asked to render. Most NPs you see in neurology only do stroke, or only do headache, or only do movement/NM and can't really go outside that box without getting scared as they should.

With kindness: NPs are actually encroaching in reality, despite what you believe. But then again, your post is contradictory and illogical, so it appears you believe two things. 1. There’s no risk of encroachment, but 2. NP’s in neuro “only do stroke, or only do headache.” Pick 1 or 2.

Most newly minted neurologists are scared of anything outside their expertise. And how are NPs not a threat to patients when they are acting like neurologists, even if they stick to a single sub-specialty?

I’m all for extenders operating as physician extenders within a team. That team needs to be led by a neurologist who graduated med school and residency.

NPs should be terrified of neurology. Even headache. The fact they think they can do it is Duning Kruger exhibit A.

 

[neglect]

Im sorry to say that is very naive; or you haven't encountered the reality of what's going on. I have seen NPs take consults independently in almost every field now including Neurosurgery. As you know, they pretty much work like a full Anesthesiologist. I personally know of neuro clinics that are run by NPs independently (and an attending is just required to sign off on 10% or so of their notes).
In many residency programs, where there are no fellows, they have NPs take stroke call and residents (including PG4s!) have to call the NP after hours.
Even if we assume that they will never be accepted for high acuity stuff, there is still a lot of bread and butter neurology that they can and are doing. It can't be good for Neurologists in any way. This thing has to be nipped in the bud.

Everyone should write to the AAN with their concerns. NPs highjacked the AAN and try to get leadership positions. Now, I can’t tolerate the AAN on a good day, and here as in everywhere they suck. But at least they could try to stick up for their doctor members the way the Family Practice associations have. Instead, I fear they just see dollars and dues.

Still, the more people who get upset about this, even quit the AAN over it, perhaps the more they’ll listen.

 

[PikminOC]

In private practice I will refer a patient to a neurologist. And they end up seeing the np. Smh

 

[Thama]

In private practice I will refer a patient to a neurologist. And they end up seeing the np. Smh

Same thing happens when I refer to a neurosurgeon half the time.

In our group all new visits are MDs and we use NPs only for follow-ups in between MD visits. It's the only safe way in our field, IMO. Too much can get missed and the breadth of knowledge required to avoid the "never miss" diagnoses is too large.

 

[sharkbaitwhohaha]

Everyone should write to the AAN with their concerns. NPs highjacked the AAN and try to get leadership positions. Now, I can’t tolerate the AAN on a good day, and here as in everywhere they suck. But at least they could try to stick up for their doctor members the way the Family Practice associations have. Instead, I fear they just see dollars and dues.

Still, the more people who get upset about this, even quit the AAN over it, perhaps the more they’ll listen.

Curious. What has the AAN done to give you this view? Any specific examples?

 

[PikminOC]

Same thing happens when I refer to a neurosurgeon half the time.

In our group all new visits are MDs and we use NPs only for follow-ups in between MD visits. It's the only safe way in our field, IMO. Too much can get missed and the breadth of knowledge required to avoid the "never miss" diagnoses is too large.

I don't think mid-level are ok even for in between. Too many things can even happen in between. I don't use them at all in my practice.

 

[Thama]

I don't think mid-level are ok even for in between. Too many things can even happen in between. I don't use them at all in my practice.

For many in our practice it's see a mid-level between visits or go for a year or more between visits. Too many patients, not enough neurologists. We have NPs that we trust and we don't turn them loose until we've seen first hand that they can be trusted.

 

[neglect]

Curious. What has the AAN done to give you this view? Any specific examples?

Here. AAN Video: Extenders are Doctors, "We’re the Same"

If this doesn’t make you sick, you don’t have a pulse. This is the AAN position paper which reads like it was written by the AANP and the type of academics Without a shred of self-awareness. I hope they get exactly the care they want for others. Key quotes, my emphasis.

APPs may assume the leadership of straightforward cases, allowing more time for the physician to dedicate to the treatment of complex or difficult case.

What is a straightforward case? A headache is straightforward, but how many cases have started straightforward and ended up with morbidity and mortality?

Advanced practice providers can conduct evaluations, prescribe medications, order and interpret testing, and perform some procedures independent of direct physician supervision.

So no need for physician oversight per the AAN. This is also called practicing medicine without a license.

 

[stevresidentp]

Agree with everything said however for a reality check I think our field is at low direct risk for serious encroachment compared to most non-surgical fields. The risk is much lower in neurology due to complex procedures NPs will never credibly learn (EEG, EMG) and the risk of severe harm in the case of misdiagnosis (tPA or no, status or PNES, encephalitis or just another toxic metabolic)- these things can kill or completely disable patients if you are gravely wrong. Big misses carry direct liability to hospitals as well, and punting on the diagnosis means an urgent transfer somewhere else with loss of revenue. Much of neurology residency as everyone knows is getting over the fear factor and learning a rational approach with stroke and seizure. No one is going to take an NPs word alone on big questions regarding these and you'll find ED/hospitalists much more skeptical on recommendations as they are liable too.

This isn't to say there is no risk, but for future neurology applicants I don't see AI, NPs, or even too many graduates being an issue anytime soon. There just aren't that many residents graduating per year, and the demand for general neurologist time is almost inelastic- the easier to consult the more opinions one is asked to render. Most NPs you see in neurology only do stroke, or only do headache, or only do movement/NM and can't really go outside that box without getting scared as they should.

Optimism is good but it’s far from reality, I’m not sure if you have noticed, but almost every single neurocritical care unit has NPs, sometimes covering nights. I don’t think anyone consider NCC low liability or low risk!

 

[chocomorsel]

For many in our practice it's see a mid-level between visits or go for a year or more between visits. Too many patients, not enough neurologists. We have NPs that we trust and we don't turn them loose until we've seen first hand that they can be trusted.

And this is how it all begins. Those NPs are learning trade secrets directly from you and will one day quit and and open up shop right across the street.
So what if it takes a year to get a follow up? Maybe we need to priorities higher acuity patients to be seen sooner and lower acuity to wait.
What happens in Europe?
When I hear stories like this I wonder how in the world people survive with the long wait times in Canada and Europe.
We feed into too much of this “patient must be seen now” mentality and patients are all about I want to be seen now and in the process create our own monsters.
I am of course speaking as someone who works with NPs sometimes as a locums doc. I prefer not to, but we are on the middle of a pandemic and I work in the ICU.
The work can obviously be too much, I get it. But we need a better solution. I am all for direct market forces. Don’t train them. Let them sink or swim. Americans want “now” healthcare they are gonna pay for it.

In PP I prefer to do my own cases, see my own patients. And in non pandemic times as well while in the ICU.

 

[Thama]

And this is how it all begins. Those NPs are learning trade secrets directly from you and will one day quit and and open up shop right across the street.
So what if it takes a year to get a follow up? Maybe we need to priorities higher acuity patients to be seen sooner and lower acuity to wait.
What happens in Europe?
When I hear stories like this I wonder how in the world people survive with the long wait times in Canada and Europe.
We feed into too much of this “patient must be seen now” mentality and patients are all about I want to be seen now and in the process create our own monsters.
I am of course speaking as someone who works with NPs sometimes as a locums doc. I prefer not to, but we are on the middle of a pandemic and I work in the ICU.
The work can obviously be too much, I get it. But we need a better solution. I am all for direct market forces. Don’t train them. Let them sink or swim. Americans want “now” healthcare they are gonna pay for it.

In PP I prefer to do my own cases, see my own patients. And in non pandemic times as well while in the ICU.

No, I don't think they will. We are a subspecialty-specific clinic, and they've been with us for decades in some cases. They still come to us for help for anything even remotely not routine within our subspecialty and anything that is even completely routine outside of it.

We also have RNs that see patients under our supervision in specific situations, should we be afraid that they too will take our jobs if we dare to teach them? My MA is getting pretty good at anticipating my orders, should I cut her loose before she learns too much and sets up an MA-only practice across the street? How insecure does one have to be about their value-add to think this way in a market where there is already a vast, overwhelming shortage of your skillset?

 

[chocomorsel]

No, I don't think they will. We are a subspecialty-specific clinic, and they've been with us for decades in some cases. They still come to us for help for anything even remotely not routine within our subspecialty and anything that is even completely routine outside of it.

We also have RNs that see patients under our supervision in specific situations, should we be afraid that they too will take our jobs if we dare to teach them? My MA is getting pretty good at anticipating my orders, should I cut her loose before she learns too much and sets up an MA-only practice across the street? How insecure does one have to be about their value-add to think this way in a market where there is already a vast, overwhelming shortage of your skillset?

I think you are naive or living under a rock.
Ask yourself why this is not a problem in other countries.
And keep ignoring what is really happening.
I am secure. And I give a crap about not losing my job to a mid level who’s trained by people like you who keep making excuses. And maybe not me directly, but the junior generation.

 

[Thama]

I think you are naive or living under a rock.
Ask yourself why this is not a problem in other countries.
And keep ignoring what is really happening.
I am secure. And I give a crap about not losing my job to a mid level who’s trained by people like you who keep making excuses. And maybe not me directly, but the junior generation.

It's not a problem in other countries because the rest of the developed world has a (more) rational approach to medical education and economics. My family in Canada has been able to get in to see a subspecialist faster than my family in the US can in most situations, and their primary care model is unquestionably superior. At my center a neurology appointment within 3-4 months is a miracle, and some subspecialties take 8-12 months to get you in. It's generally harder to land a job as a physician in Canada because the physician supply through their educational system has more closely approximated their demand.

We in medicine have been sitting on the sidelines of a medical shortage in needed specialties and geographic regions for decades. As outcomes and access to care worsened everywhere except for in the most lucrative specialties and the most desirable metro areas, our lobbying organizations continued to fixate on squeezing every cent out of the RVU conversion factors and mostly ignored creating enough residency positions to keep up with demand. We were tacitly OK with the massive mismatch between supply and demand because it meant both job security for even the most wildly incompetent members of our profession and often extra income from desperate areas.

Now the business side is taking matters into their own hands to match supply to demand in a way that benefits them because we were too short-sighted to actually steer the solution while we still had some control. I plan to work within the inevitable solution in a way that continues to be safe and physician directed. You are welcome to fight the tide with your shovel - let us know how that goes for you.

 

[stevresidentp]

No, I don't think they will. We are a subspecialty-specific clinic, and they've been with us for decades in some cases. They still come to us for help for anything even remotely not routine within our subspecialty and anything that is even completely routine outside of it.

We also have RNs that see patients under our supervision in specific situations, should we be afraid that they too will take our jobs if we dare to teach them? My MA is getting pretty good at anticipating my orders, should I cut her loose before she learns too much and sets up an MA-only practice across the street? How insecure does one have to be about their value-add to think this way in a market where there is already a vast, overwhelming shortage of your skillset?

MAs are not fighting for independent practice to see patients alone and creating faux studies saying they are “equal or even better” at a cheaper cost. Also neurology residencies have been increasing! Look at the acgme data for the last 5 years, almost double in number of spots!
Also waiting an extra month for an outpatient referral is better than providing low quality care that can create more damage(serious damage in some situations) than good.

 

[Thama]

MAs are not fighting for independent practice to see patients alone and creating faux studies saying they are “equal or even better” at a cheaper cost.

When you really dig down, neither are NPs in general. Corporate medicine is fighting that fight with the NPs as their proxies. There aren't enough qualified physicians to fill the jobs they want filled, so they're going to take the Dollar Tree version over an empty chair.

Also neurology residencies have been increasing! Look at the acgme data for the last 5 years, almost double in number of spots!

Too little, too late. Increasing residency spots now is like instituting cap and trade after Manhattan is under 10 feet of ocean.

Also waiting an extra month for an outpatient referral is better than providing low quality care that can create more damage(serious damage in some situations) than good.

Waiting a month, sure. That's not real life in many places though. Try waiting 8-12 months to see someone that can make a diagnosis of a disease that may have been treatable. If my NP is taking care of more followups to adjust medications for patients I've already diagnosed (and sending me their notes with alerts for concerning changes), that means I can get to more people that need me.

 

[Postictal Raiden]

Sorry but any doctor who agrees to train and allow midlevels to see pts independently to boost their income and/or improve their lifestyle is in one way or another admitting that NPs/PAs = physicians. I blame them for the destruction of this profession.

 

[DrSatan]

When you really dig down, neither are NPs in general. Corporate medicine is fighting that fight with the NPs as their proxies. There aren't enough qualified physicians to fill the jobs they want filled, so they're going to take the Dollar Tree version over an empty chair.

Sure, but their governing body is adamantly pushing for independent practice & 22 states already allow for independent practice. They are also being allowed to interpret imaging without need for a radiologist. There is not a physician shortage, but a distribution problem. If corporations want rural physicians, they need to spend more money attracting physicians. And NPs do not try to fill the rural gap regardless.

Too little, too late. Increasing residency spots now is like instituting cap and trade after Manhattan is under 10 feet of ocean.

A step in the right direction is always a good thing.

Waiting a month, sure. That's not real life in many places though. Try waiting 8-12 months to see someone that can make a diagnosis of a disease that may have been treatable. If my NP is taking care of more followups to adjust medications for patients I've already diagnosed (and sending me their notes with alerts for concerning changes), that means I can get to more people that need me.

Primary care NPs inappropriately consult other services more than family physicians. More NPs could theoretically lead to longer waiting times. I'd also better trust a family physician to at least perform the basic workup, & if wait time for referral is too long, figure out how to best manage the patient in the interim. My trust in a family physician far exceeds that of a NP. But yes, I get bad consults from both parties.

I should say, I think NPs are extremely valuable in the right circumstances (ie, being supervised for follow ups or straight forward initial consults). I also think it's very reasonable to have NPs see follow ups as you do, at least once you've established a level of trust with them. That said, you should probably see the patient briefly & do a quick neurologic exam yourself (which is required, no?). I also strongly believe that NPs (& PAs, PTs, etc) should absolutely not be allowed to refer to themselves as doctors to patients in a clinical setting & should explain their role to all patients. Patients have a right to know when they are seeing a doctor vs an NP or PA, especially given that it (from what I've heard) saves them no money anyway. I oppose NP independence & I find the false equivalency of NP = MD/DO to be frankly ignorant more than offensive.

 

[Thama]

Primary care NPs inappropriately consult other services more than family physicians. More NPs could theoretically lead to longer waiting times. I'd also better trust a family physician to at least perform the basic workup, & if wait time for referral is too long, figure out how to best manage the patient in the interim. My trust in a family physician far exceeds that of a NP. But yes, I get bad consults from both parties.

I should say, I think NPs are extremely valuable in the right circumstances (ie, being supervised for follow ups or straight forward initial consults). I also think it's very reasonable to have NPs see follow ups as you do, at least once you've established a level of trust with them. That said, you should probably see the patient briefly & do a quick neurologic exam yourself (which is required, no?). I also strongly believe that NPs (& PAs, PTs, etc) should absolutely not be allowed to refer to themselves as doctors to patients in a clinical setting & should explain their role to all patients. Patients have a right to know when they are seeing a doctor vs an NP or PA, especially given that it (from what I've heard) saves them no money anyway. I oppose NP independence & I find the false equivalency of NP = MD/DO to be frankly ignorant more than offensive.

To be clear - I'm in no way advocating NPs operating independently. That's the worst case scenario, and is IMO in part the result of physicians not taking the lead in finding safe models to use them in. Some fight against the very existence of midlevels, and others are happy to just rubber-stamp an NP operating de facto independently - is it any wonder they think they can be safely independent when this is how we behave? The NPs I know that operate the most cautiously are those that have worked closely with a real expert MD - they quickly become aware of the gap between their knowledge and the MD's knowledge and how much work it would take to close that gap, and tend to welcome close supervision thereafter. I also get terrible referrals from PCP NPs (but also from MDs - just a little less I think).

Re: seeing the patient briefly - no that's not required. I'm not billing off their visits, they bill for themselves. They're going to see me in the amount of time that I can see them again in, but I offer an intermediate NP followup if they want it for those that I think will need more hand-holding or where closer followup really needs to happen and I just don't have the availability.

 

[Postictal Raiden]

In many occasions the follow up visit is more crucial than the initial visit

 

[DrSatan]

In many occasions the follow up visit is more crucial than the initial visit

I think it's fair to assume s/he is seeing these important follow ups rather than an APP though.

 

[Thama]

I think it's fair to assume s/he is seeing these important follow ups rather than an APP though.

Or I speak to them by phone about important results, etc.

But in most cases, the decision isn't "Do you see me every 4 months, or do you see me every year and my NP every 4 months between that?"

The decision is "Do you see me every year and nobody in between, or do you see me every year and my NP between that?"

The other alternative is that we could just stop taking new patients altogether and let our entire metro area flounder. And that would really create an environment where an NP-only practice could step into.

 

[Postictal Raiden]

I think it's fair to assume s/he is seeing these important follow ups rather than an APP though.

Except many times you can’t anticipate the type of stuff your patient would surprise you with

 

[cbrons]

Agree with everything said however for a reality check I think our field is at low direct risk for serious encroachment compared to most non-surgical fields.

delusion: the post

I saw a mid level practicing independently in electrophysiology recently. You aren't safe at all.

 

[deathmerchant]

Or I speak to them by phone about important results, etc.

But in most cases, the decision isn't "Do you see me every 4 months, or do you see me every year and my NP every 4 months between that?"

The decision is "Do you see me every year and nobody in between, or do you see me every year and my NP between that?"

The other alternative is that we could just stop taking new patients altogether and let our entire metro area flounder. And that would really create an environment where an NP-only practice could step into.

I think everyone agrees that NPs/PAs have Some role in our messed-up, current medical system. Your setup sounds pretty good- where you have reliable, experienced NPs who sorta know what they know and what they don't. And they mostly see bread and butter follow ups.

What is concerning is how fast it is going from 'Nurses/assistants' to 'Midlevels' to 'Physician equivalents'. In fact, some NPs honestly believe that they provide better "healthcare" than physicians who just practice "medicine". And they say this to patients and administrators and politicians who believe it.
The other issue is obviously that the stakes are so high in medicine. Even 1 preventable mistake can lead to someone's death! There shouldn't be a place for a 'Dollar general' provider.

Where should we draw the line, that is the question? I personally believe they should have to briefly present every case to an attending, like we did in our continuity clinics in residency. (Although I'm not sure its in our hands anymore)

 

[neglect]

No, I don't think they will. We are a subspecialty-specific clinic, and they've been with us for decades in some cases. They still come to us for help for anything even remotely not routine within our subspecialty and anything that is even completely routine outside of it.

We also have RNs that see patients under our supervision in specific situations, should we be afraid that they too will take our jobs if we dare to teach them? My MA is getting pretty good at anticipating my orders, should I cut her loose before she learns too much and sets up an MA-only practice across the street? How insecure does one have to be about their value-add to think this way in a market where there is already a vast, overwhelming shortage of your skillset?

Right, so a true market place where there is a A “vast, overwhelming shortage of your skillset” would thus make that skillset very valuable, like being able to hit 99% home runs on 100 PMH pitches. A free market would increase the price for rare skills, then others would gain those skills (because the market rewards them), and prices would fall. Tell me we live in that world, because when I looked at my clinical income it wasn’t exactly near baseball superstar levels. And I tell people they have a horrible disease and are going to die nearly every day.

Let’s agree that we don’t live in a strict market-place. Let’s agree that NPs want to legislate themselves as doctor equivalents. Many actually call themselves doctors! Let’s agree that any personal experience is very biased, yours is very good with your staff, congratulations. Let’s agree that independent practice is what these NPs want, the AAN and many legislatures want to give it to them.

Above all else, let's agree that extenders have a role in healthcare when directly supervised in a timely manner by a physician. I've personally seen an NP who had physician oversight. The objection is only for independent practice.

 

[stevresidentp]

Or I speak to them by phone about important results, etc.

But in most cases, the decision isn't "Do you see me every 4 months, or do you see me every year and my NP every 4 months between that?"

The decision is "Do you see me every year and nobody in between, or do you see me every year and my NP between that?"

The other alternative is that we could just stop taking new patients altogether and let our entire metro area flounder. And that would really create an environment where an NP-only practice could step into.

Hm no. NP should be supervised for every single patient visit. If patient needs a sooner follow up appointment, then they need it for a reason. We are specialists not primary care. Why is the patient seeing someone with less education than their PCP? You are making the assumption that the NP has capability of recognizing when they don’t know something rather than thinking what they know is correct. Just because the situation is working for you well and probably largely financially, does not make it a standard.

On a side note: AAN has many advocacy groups, we need to join and voice our concerns!

 

[Thama]

Right, so a true market place where there is a A “vast, overwhelming shortage of your skillset” would thus make that skillset very valuable, like being able to hit 99% home runs on 100 PMH pitches. A free market would increase the price for rare skills, then others would gain those skills (because the market rewards them), and prices would fall. Tell me we live in that world, because when I looked at my clinical income it wasn’t exactly near baseball superstar levels. And I tell people they have a horrible disease and are going to die nearly every day.

Our skillset being in shortage doesn't make it as rare as a .350 hitter. There are maybe a dozen people on the planet that have a snowball's chance in hell at doing that, while there are many orders of magnitude more trained neurologists. Furthermore, the number of posts on the neurology sub on SDN or reddit compared with your average baseball forum should tell you where the public interest and thus money lies.

An MGMA-average neurologist makes well into the 98th percentile of US income, and is generally well above the average IM or FM MD. Let's not pretend like we aren't very well compensated for our in-demand skillset. We don't need to make our point via persecution complex.

Let’s agree that we don’t live in a strict market-place. Let’s agree that NPs want to legislate themselves as doctor equivalents. Many actually call themselves doctors! Let’s agree that any personal experience is very biased, yours is very good with your staff, congratulations. Let’s agree that independent practice is what these NPs want, the AAN and many legislatures want to give it to them.

I'd argue that this is mostly a function of NP organizations that represent NPs about as well as the AAN represents neurologists. But sure, as a matter of public policy there's not much difference.

Above all else, let's agree that extenders have a role in healthcare when directly supervised in a timely manner by a physician. I've personally seen an NP who had physician oversight. The objection is only for independent practice.

Completely agree with this. That's not the opinion of many in this thread who seem threatened by the very existence of midlevels.

 

[Thama]

Hm no. NP should be supervised for every single patient visit.

Sure, but how? The way that NP shops practice where an MD "chart reviews" a small fraction of a large number of NPs that really have no oversight counts as supervision, but we all know that's not ideal. Treating an NP as a junior resident and having the attending spend 15 minutes in the room with each visit would be nice, but literally nobody practices that way because it's logistically impossible.

If patient needs a sooner follow up appointment, then they need it for a reason. We are specialists not primary care. Why is the patient seeing someone with less education than their PCP? You are making the assumption that the NP has capability of recognizing when they don’t know something rather than thinking what they know is correct.

This would carry more weight if the standard for neurological knowledge among generalists wasn't so gobstoppingly embarassing. Yes, I will trust my well-trained NP over the PCPs that refer to us 100 times out of 100 to recognize a problem in our field.

Just because the situation is working for you well and probably largely financially, does not make it a standard.

I'm in an academic practice, and my salary varies exactly 0% by the degree to which I work with NPs. There is no standard for how to do this, we all have to find ways to do our best within the realities of modern medicine in our local environments. The reality of my local environment is that not using NPs would immediately result in closing our practice (and thus pretty much our entire sub-specialty in a very large geographical radius) to new patients.

 

[sharkbaitwhohaha]

I'm an aggressive physician led proponent. And I intend to use midlevels in my future practice to expand my patient base and increase practice revenue.

Let's say I diagnose a patient with chronic migraine, complete neuro exam is normal and start an abortive and preventative. Theres clearly no need for me to physically see that patient with the NP at a follow up visit.

 

[Telamir]

Until they’re on Fioricet q8H that is.

I keed I keed.

 

[neglect]

Our skillset being in shortage doesn't make it as rare as a .350 hitter. There are maybe a dozen people on the planet that have a snowball's chance in hell at doing that, while there are many orders of magnitude more trained neurologists. Furthermore, the number of posts on the neurology sub on SDN or reddit compared with your average baseball forum should tell you where the public interest and thus money lies.

[/QUOTE]

Wait until this Joe Public gets ALS, their mom gets Alzheimer's, their kid has a stroke. Then it is pretty amazing how quickly they take an interest and pay vast sums for any shot towards health.

Let's agree not to devalue what we do.

An MGMA-average neurologist makes well into the 98th percentile of US income, and is generally well above the average IM or FM MD. Let's not pretend like we aren't very well compensated for our in-demand skillset. We don't need to make our point via persecution complex.



I'd argue that this is mostly a function of NP organizations that represent NPs about as well as the AAN represents neurologists. But sure, as a matter of public policy there's not much difference.



Completely agree with this. That's not the opinion of many in this thread who seem threatened by the very existence of midlevels.

Totally agree with this. But among those in the 98th percentile, neurologists (and doctors in general) are incredibly well trained, hard working, and intelligent. I took a decade of training after college with 0 salary, then trivial salary into my late 20s and early 30s. I now work very hard, routinely leave the office after 10 hour days, take home call, have come in in the middle of the night hundreds of times in the past decade. I'm s-m-r-t. I've also devoted my life to conducting clinical trials to not just help the people in front of me, but the many thousands who could benefit from better therapies in stroke, MS, AD and PD. You're the same. Your work matters - not just your paycheck.

Compare with finance, lawyers, sports figures, and lottery winners who make up many among the top 1-2% of earnings (wealth is different). Not only are some of these people occupying bull**** jobs, some of them are paid to make things worse! This isn't entirely fair. But MANY finance people spend their day on schemes that endanger our economy (many others fund worthy causes). Of those who work at insurance companies and make bonuses for NOT delivering health care, most lawyers. Many do not cure, heal, help, invent, or create.

I'm an aggressive physician led proponent. And I intend to use midlevels in my future practice to expand my patient base and increase practice revenue.

Let's say I diagnose a patient with chronic migraine, complete neuro exam is normal and start an abortive and preventative. Theres clearly no need for me to physically see that patient with the NP at a follow up visit.

Yes. But you MUST oversee the visit and sign off on the impression and plan. Plenty can go wrong.

 

[deathmerchant]

I'm an aggressive physician led proponent. And I intend to use midlevels in my future practice to expand my patient base and increase practice revenue.

Let's say I diagnose a patient with chronic migraine, complete neuro exam is normal and start an abortive and preventative. Theres clearly no need for me to physically see that patient with the NP at a follow up visit.

For an aggressive NP/PA proponent "There is clearly no need for a physician to diagnose a migraine". I mean why are you drawing a line at -they can't 'Diagnose' a migraine but can 'Treat' and 'prescribe' dangerous medicines or at least not be able to give comfort sooner to a patient. If you believe they can do the latter, then why can't they do the former. And why can't they diagnose or treat PD or MS or anything. Its just an arbitrary "feel good" thing that physicians have developed.

Eventually they can have enough 'follow-up' patients and they can practice independently and cut you off and find someone to sign off (which is super easy- see attachment). I also know this because I was offered a deal like that (that too for a neurosurgery/ortho PA!! who saw mostly back pain/spinal issues or chronic post op follow ups after his NES attending retired.)

This is a recent statement from PA association (Attachment). Like I keep saying- slippery slope.

 

[deathmerchant]

Sure, but how? The way that NP shops practice where an MD "chart reviews" a small fraction of a large number of NPs that really have no oversight counts as supervision, but we all know that's not ideal. Treating an NP as a junior resident and having the attending spend 15 minutes in the room with each visit would be nice, but literally nobody practices that way because it's logistically impossible.



This would carry more weight if the standard for neurological knowledge among generalists wasn't so gobstoppingly embarassing. Yes, I will trust my well-trained NP over the PCPs that refer to us 100 times out of 100 to recognize a problem in our field.


I'm in an academic practice, and my salary varies exactly 0% by the degree to which I work with NPs. There is no standard for how to do this, we all have to find ways to do our best within the realities of modern medicine in our local environments. The reality of my local environment is that not using NPs would immediately result in closing our practice (and thus pretty much our entire sub-specialty in a very large geographical radius) to new patients.

I mean like we do for residents in continuity clinics.
I personally would have a trainee/or midlevel go and see the patient. Then come out and give me a 30 sec Impression and plan. I would confirm and only go in/examine or change plan if I feel it was needed. I think it will be extra 3-5 minutes per patient at most.

 

[WhereMyLiberalsAt]

For an aggressive NP/PA proponent "There is clearly no need for a physician to diagnose a migraine". I mean why are you drawing a line at -they can't 'Diagnose' a migraine but can 'Treat' and 'prescribe' dangerous medicines or at least not be able to give comfort sooner to a patient. If you believe they can do the latter, then why can't they do the former. And why can't they diagnose or treat PD or MS or anything. Its just an arbitrary "feel good" thing that physicians have developed.

Eventually they can have enough 'follow-up' patients and they can practice independently and cut you off and find someone to sign off (which is super easy- see attachment). I also know this because I was offered a deal like that (that too for a neurosurgery/ortho PA!! who saw mostly back pain/spinal issues or chronic post op follow ups after his NES attending retired.)

This is a recent statement from PA association (Attachment). Like I keep saying- slippery slope.

That second attachment... My jaw is still on the floor.

 

[xenotype]

Im sorry to say that is very naive; or you haven't encountered the reality of what's going on. I have seen NPs take consults independently in almost every field now including Neurosurgery. As you know, they pretty much work like a full Anesthesiologist. I personally know of neuro clinics that are run by NPs independently (and an attending is just required to sign off on 10% or so of their notes).
In many residency programs, where there are no fellows, they have NPs take stroke call and residents (including PG4s!) have to call the NP after hours.
Even if we assume that they will never be accepted for high acuity stuff, there is still a lot of bread and butter neurology that they can and are doing. It can't be good for Neurologists in any way. This thing has to be nipped in the bud.

Residents reporting to NPs in a supervisory role is clearly against ACGME requirements, and these programs should be reported to the ACGME. Additionally, these residents have essentially zero protection against malpractice lawsuits under these conditions, which is a massive risk in acute stroke. I'm not questioning your story but the residents in these programs need to stand up for themselves as this is extremely legally questionable territory both from accreditation standpoint and malpractice. I doubt this is 'many' programs, and whatever program this has probably has no idea of the legal exposure they have created themselves and their residents.

Again, I agree with everyone here about the threat NPs pose, and that politically it needs to be opposed as strongly as possible (especially at the AAN). And, I did not stay there is zero risk of encroachment. Clearly there has already been encroachment, NPs doing headache completely independently, many NPs in subspecialties having no oversight. My point is that we are not in as terrible shape as FM, IM, anesthesia, and EM which are literally being wholesale replaced by corporate hospital groups in nearly a 1:1 fashion as fast as possible. I don't think we are that replaceable right now. NP 'fellowships' are certainly the big concern but I don't know how much power we have to stop them.

Staring into the future in 10-20 years, there will be a massive oversupply of midlevels of all stripes. They won't be able to get hired without direct experience in the field they wish to work, and MDs will always be preferred, but the economic hit to our salaries could be very large. The only major factors that could prevent this trend from accelerating would be 1) a major media event that brings to public consciousness how poor midlevel qualifications and training are (essentially a Libby Zion level event) or 2) cleverly crafted widespread legal action combined with jurisprudence across multiple states that makes it very expensive to insure midlevels. The issue with this currently is in most states only NPs can testify regarding NP 'standard of care' and it is hard to hold large organizations legally accountable for hiring poorly trained midlevels. Small scale political actions on our part are not going to be effective against the sheer profitability of using NPs and the huge delays in getting neurological care due to shortages. In fact you may risk getting the 'disruptive physician' label reported to NPDB by administration if you make a large fuss in your own system about getting NP consults or working with/near an NP.

 

[neglect]

Residents reporting to NPs in a supervisory role is clearly against ACGME requirements, and these programs should be reported to the ACGME. Additionally, these residents have essentially zero protection against malpractice lawsuits under these conditions, which is a massive risk in acute stroke. I'm not questioning your story but the residents in these programs need to stand up for themselves as this is extremely legally questionable territory both from accreditation standpoint and malpractice. I doubt this is 'many' programs, and whatever program this has probably has no idea of the legal exposure they have created themselves and their residents.

Again, I agree with everyone here about the threat NPs pose, and that politically it needs to be opposed as strongly as possible (especially at the AAN). And, I did not stay there is zero risk of encroachment. Clearly there has already been encroachment, NPs doing headache completely independently, many NPs in subspecialties having no oversight. My point is that we are not in as terrible shape as FM, IM, anesthesia, and EM which are literally being wholesale replaced by corporate hospital groups in nearly a 1:1 fashion as fast as possible. I don't think we are that replaceable right now. NP 'fellowships' are certainly the big concern but I don't know how much power we have to stop them.

Staring into the future in 10-20 years, there will be a massive oversupply of midlevels of all stripes. They won't be able to get hired without direct experience in the field they wish to work, and MDs will always be preferred, but the economic hit to our salaries could be very large. The only major factors that could prevent this trend from accelerating would be 1) a major media event that brings to public consciousness how poor midlevel qualifications and training are (essentially a Libby Zion level event) or 2) cleverly crafted widespread legal action combined with jurisprudence across multiple states that makes it very expensive to insure midlevels. The issue with this currently is in most states only NPs can testify regarding NP 'standard of care' and it is hard to hold large organizations legally accountable for hiring poorly trained midlevels. Small scale political actions on our part are not going to be effective against the sheer profitability of using NPs and the huge delays in getting neurological care due to shortages. In fact you may risk getting the 'disruptive physician' label reported to NPDB by administration if you make a large fuss in your own system about getting NP consults or working with/near an NP.

The 10 year plan here is scary. Think about all the patients with simple migraines who are safely handled by their primary care doctors. If there are red flags or failures on therapy, then these docs consult. Now imagine a world in which 1/3 of 'primarys' are extenders. Especially in states without phsician oversight requirements. You'll end up starting Imitrex as the patient's first abortive other than OTC.

This is legit scary and not just for neurologists. Patients are going to be harmed, given the run-a-round. Here's a place keeping track of just how incompetent https://www.reddit.com/r/Noctor/ This is really scary. They literally know nothing. Reading them floundering all over the place I'm reminded just how hard medicine is. Especially how hard it is when you know nothing.

 

[deathmerchant]

Just saw this. How crazy is this!?

Collaborating Docs - Connecting Practice Clinicians with Physicians

Collaborating Docs - Connecting Advanced Practice Clinicians with physicians for better patient care.

collaboratingdocs.com

Its a Teleservice by doctors to 'collaborate' with midlevels to help start their independent practice.