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What specialties can least be done by mid-levels?

Discussion in 'Allopathic' started by SchroedingrsCat, 04.17.12.

  1. mjl1717

    mjl1717 Senior Member

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    SDN Members don't see this ad. (About Ads)
    Yes I agree with you docshop:

    A gastoenterologist was telling me that the only doctors who will survive the current healthcare quagmire .. Will be those who efficiently utilize P.A.s and N.P.s End of story. :thumbup:


    Addendum: My answer to the O.P.s original question is: none..

    Also from what I understand P.A. is a physician dependent position. So they are the least likely threat to the doc!
    Last edited: 04.22.12
  2. CuriousGeorge2

    CuriousGeorge2

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  3. valkener

    valkener

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  4. Shnurek

    Shnurek

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  5. auburnO5

    auburnO5

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    Oh great not this kid. He is the stereotypical OD student who couldn't get in to medical school.

    As a disclaimer: I don't feel this way about all OD students, but this guy gives the other ones a bad name.
  6. Shnurek

    Shnurek

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    Never applied.
    [​IMG]
  7. Droopy Snoopy

    Droopy Snoopy Previously Tic

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    Right now mid-levels are being best utilized by the surgical subspecialties. A neurosurgeon with a PA can spend more time in the OR and less time dealing with post-op constipation, all without worrying that their employee will supplant them in 10 years doing anterior spinal fusions. Fields like pathology, radonc, and radiology don't exactly have a natural pathway for midlevels to get in the door and are thus somewhat protected, however can you imagine a near future where routine CXRs are nighthawked by a specially trained PA sitting in their underwear at home? I sure can. Fields like cardiology and heme/onc for example are also somewhat protected, since the depth and breadth of knowledge required to do the job well is just immense. And, like the surgical fields, their business practice models can actually be more efficient with mid-levels doing the med checks and routine follow-ups.

    FP, peds, anesthesia, ob/gyn, Occ/Prev Med, ER, PM&R, public health, even hospitalist-type work -- that's where midlevels are actively competing with physicians for business/jobs and where the fight will be for most of our careers at least. Derm also has a real need for providers that makes it susceptible. Also paraprofessionals; don't discount the evolution of say optometry on the field of ophthalmology or clinical psych/social work on psychiatry.
  8. NeuralNetwork

    NeuralNetwork Pass the BDNF

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    The question I have is...is the competition very pronounced, validating a concern for entering said fields, or is it more of a subtle issue that shouldn't deter?
  9. mTOR

    mTOR | veritas.vos.liberabit |

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    All specialties can be taken over by mid levels. Formal medical education is, for the most part, not sufficient nor necessary. Experience is. Ergo, the only thing that separates a mid level from a physician aside from elitist credentialism is the access to opportunities to gain experience (itself, determined by elitist credentialism).

    Since experience (and the skill and knowledge gained from it) is the critical driver here -- restricted access to experience is the name of the game in the labor market, and has always been.


    Enable access, and even this guy

    [​IMG]

    can do the job that you suffered 6 years of mostly irrelevant nonclinical schooling for:

  10. Droopy Snoopy

    Droopy Snoopy Previously Tic

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    Most of these are primary care fields that have a tremendous need for providers no matter what the stripe, so theoretically there is room for everyone. In reality though the distribution of MDs is skewed toward more preferable areas and populations. Expect midlevels to continue to do the same and compete.

    How this should affect your career decision-making I can't say... go through that progression of surgery vs medicine, kids or adults, primary care or referral base, academics or clinical, etc. Whatever you're interested in just try to control your own destiny. Make great grades, test well, publish, and secure a good residency. That way you won't have to worry about the mid-level boogeyman taking your job.
  11. johnnydrama

    johnnydrama I'm no Superman

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    It's too late, he's already found a way in...

    [​IMG]
  12. mjl1717

    mjl1717 Senior Member

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    I like this last paragraph:

    So in summary...Become Oslerian- like, or damn near "best of the best"..Not necessarily greedy-greedy..Then one does not have to look over there shoulder sweating and worrying, saying to themself.."who is going to take my job now?" :oops:
  13. JackShephard MD

    JackShephard MD

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    It's very dangerous to make career decision based upon things like this.

    My recommendation would be to be well informed and then to find a career you are passionate about. If there are many you equally enjoy, then I would let these extraneous factors play a bigger role.

    You can always find a way if you're doing what you love, you'll be better at what you do and you'll make a bigger impact.
  14. D elegans

    D elegans 2 1 5

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    I'm going to drop out of med school, then get a DNP, so that I can get the choicest spots
  15. badasshairday

    badasshairday Account on Hold

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    Here is a little secret guys. A lot of doctors don't know the functions and scope of many mid-levels. So medical students are even more uninformed. My significant other is finishing PA school as are her classmates whom I know very well. The difference in their training is that they learn a significant amount about coding and dictating, which help docs see more patients and make more money. Their medical knowledge is less than a 4th year medical student. How do I know? Because I am a 4th year med student and help them study etc.

    These newly minted PA's are getting jobs in ER, GI, IM, ortho, Cardiology and getting paid 65-85K starting.

    Do you know what they do in GI? They do H and P's and most of the time after the H and P is done the orders are already put in by the attending. They see follow up patients in the clinic. They round on patients in the morning who are in house, but sometimes the attendings see the patients very quickly on their own leaving the PA's with less to do. For this they get paid 75K starting. Don't you guys think you can do that by the time you are done with med school? Of course you can! We are damn under paid as interns and residents!

    Another example is a brand new ortho PA i know. She does the post op checks and hold retractors for 90K a year. The attending sees all the new patients, but she earns her keep by allowing him to see more patients and do some of the inpatient work like removing staples/sutures.

    Of course over the years in the same specialty they develop a better foundation of knowledge. But the fact is, a fresh faced PA is making way more for way less hours than the average medical graduate. One of my friends finishing PA school is doing a job with an internist and pulmonologist and she does clinic, urgent care, and some inpatient work. Probably going to work a good number of hours (~55-60) including weekends like an intern would. All for a cool 85 K. She made me feel sad, because I felt like I was getting paid a lot, 54K, which is a lot for internship.

    But in the end. As and MD you have MUCH higher earning potential. As they say, "It is the cost to be the boss."
  16. Ibn Alnafis MD

    Ibn Alnafis MD

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    My thoughts exactly.

    Many people here on SDN, from pre-meds to attendings, whine about losing grounds to midlevels. I don't buy it. The reason we, in the US, have such professionals is simply because we don't have enough doctors. If you look at the physicians-to-population ratio of all countries, the US ranks somewhere in the 50's. Other industrialized countries, such as France, have a much higher ratio.

    I believe it's far better to have less doctors and more midlevels (aka assistants) than flooding the nation with physicians.

    Yes, many midlevels are pushing for more independence, but that doesn't threaten me as a future physician. Physician will never have to compete with midlevels for the same positions, because physicians will always win.
  17. SCHMITTIE120

    SCHMITTIE120

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    Interesting. I have learned nothing about coding or dictating in class (as a PA student). I have learned those things on rotation out of necessity in order to help out the residents and interns that I am working with. What area of the country are you in? It is interesting to see how different areas utilize PAs. Where I am at PAs are essentially like residents for the first 5 or so years out of school then as we learn more and develop our knowledge base responsibility and scope of practice grows.
  18. badasshairday

    badasshairday Account on Hold

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    Of course they learn how to put in orders and everything as well like a medical student. Even as a medical student I dictated on one of my rotations. They learn how to code because they use a program called Typhon to log their patient encounters. I wouldn't be surprised if some medical school in the nation uses Typhon as well, but my school using something that doesn't require ICD-9 codes for us to log our patient encounters. I am in the midwest at a highly reputed PA school. My fiancee is doing ER and during her rotation as a student the nurses took her orders as they would a late 3rd year or 4th year med student would on some of their rotations. I am mostly just commenting on the fact that a medical graduate can and do do similar work and then some as a newly minted PA does but gets paid a whole lot less. This is not me being a hater (on the contrary I am benefiting as my signicant other who is a PA will be my sugar mama), it is just commenting on how it is.

    You are most definitely correct the scope of a PA changes with experience, as it should. For example the new ortho PA I mentioned in my previous post who does what I can do as an intern, I can give you an example of an ortho PA with 10 years of experience. The ortho PA I know with 10 years of experience isn't just seeing post-op check patients in clinic nor is she just holding retractors. She sees new patients while the surgeon is also seeing patients. She will present them to him, which allows him to focus more on whether the patient is a surgical candidate as well as ask a few more clarifying questions without having to weed through BS that new patients often bring. In the OR she does pretty much a full exposure for the surgeon while he is doing crucial parts in another OR with one of the residents/fellows. After the crucial part is done he moves onto the room with his PA who has a beautiful exposure for him to do his foot/ankle surgery. Then she closes. So yea, in this case she functions more like a more experienced resident.

    But let us not fool ourselves, a newly minted PA and a newly minted intern have a huge income gap despite doing similar work, as do residents and experienced PA's. I am saying that PA's do function like interns/residents basically but are paid significantly more. That is just the way it is. Just want people to know that they should not be hating the players, just hating the game. I just want to know who I should be petitioning to get intern pay average up to a median of 70K. :)
    Last edited: 04.23.12
  19. Frank Nutter

    Frank Nutter

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    This is on point imo. :thumbup:

    $65k at age 26? Sweet. How about at age 56? Nothing like having a boss half your age, with half your experience. It's sad the experienced midlevels aren't allowed to put their expertise to use or to be rewarded for it.
  20. badasshairday

    badasshairday Account on Hold

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    Actually they are. Pay grade raises with experience. Start at 65K at 26 and make 130K at 56.
  21. Dranger

    Dranger

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    Haha at the hospital I was at today "mere" staff med surg RNs and specialist RNs were being called in to work overtime at around ~$100 an hour (and they still couldn't get people to come in). Unless someone is really into OB I have no clue why someone would drop being a staff RN to pursue CNM, but meh . Oh and you also have to take into account that the South's cost of living is pretty damn low compared to the coasts. 60k goes a lot further down there.

    The highest paid nursing sub specialty is probably anesthesia. CRNAs is my area hover around a median of 170k (bottom low end is 150k) a year.

    Keep in mind a blue collar factory worker at Boeing observing composite machines can make around 150k with overtime and a HS diploma.
  22. Druggernaut

    Druggernaut Lifetime Donor

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    Uh, my parents never pulled down that much individually, and we were very comfortably middle class, with a 3,000 square foot house in the suburbs with a 1.5 acre lot, a car for each of them, and one to split between myself and my brother.

    If a PA/NP is pulling down less than 80K, it's because they chose to work in a market that doesn't pay well. ED PAs in some sizeable cities can make $125K or more with minimal experience. But even the veterans chose to staff their sicker patients with the fresh out of residency attendings, so I'm not sure where the notion that "experience is everything" is coming from. Still, it's a good gig if you're comfortable with the limitations.
  23. Slack3r

    Slack3r Sicker than your average

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    Well, since the median household income in the US is just under $50k, I'd say plenty of people support families on $60k. Guess you must have been asleep for those cultural competency lectures, eh?
  24. Megatron2016

    Megatron2016

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    +1

    Talk about out of touch with reality
  25. Slack3r

    Slack3r Sicker than your average

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    I'm not saying its an ideal situation or that I ever plan to work for a penny below several hundred thousand dollars (at least not as a physician, anyway), but to paint a salary well above what most American families live off of as an impossible feat is ridiculous.
  26. sportsperson

    sportsperson

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    It's all about what you're used to. Some people are used to having the ideal lifestyle you explained as well as nice vacations annually and being able to buy most of the things they want. Some others are used to the annual lifestyle. So satisfaction will be dependent on one's personal standards.
  27. sportsperson

    sportsperson

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    Very good post. Although I'm only 24, most people in their 20s and even more so just under 20s/teenage years, dont care much about money and think it's just there. They would also pick a career they "like" that pays 40k/year for years n years with glim hopes of making more over something that can pay 300k ... just cause they like it less (trust me I knew people who liked medicine but liked some random crap a bit more so they went in the pursuit of that...).
  28. mjl1717

    mjl1717 Senior Member

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    Single person without heavy loans!!
  29. johnnydrama

    johnnydrama I'm no Superman

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    Haha, you should visit the anesthesiology forums.

    One of the most vocal guys there doesn't believe in poor people and insists the median wage is closer to $80k and people are just lying to surveys/the IRS.

    It's amazing how out of touch some people are.
  30. JackShephard MD

    JackShephard MD

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    +1.

    It's ridiculous to say you can't survive above the median income in the richest country the world has ever known with the most disposable income any civilization has ever had.

    Try telling that to people outside America or to people who lived anytime in history before a few decades ago.
  31. johnnydrama

    johnnydrama I'm no Superman

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    To be fair, there are definitely places you can't survive on the national median income.

    As long as you're earning the local median though, you should be fine.
  32. Megatron2016

    Megatron2016

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    Very fair. It does annoy me a bit, however, when people feel entitled (or just feel like they have to) to live in places like New York City and complain about being poor. If that's what someone wants to do, great, but they should man (or woman) up and accept trade-offs of their choice .
  33. johnnydrama

    johnnydrama I'm no Superman

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    I won't complain about being poor in NYC at 50K, but I'll reserve the right to complain about housing...

    It's insane, and out of proportion to the other increased costs of living in the city.
  34. phltz

    phltz

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    What's so great about retirement? I mean, if you're a fireman, or a construction worker, it may be pretty necessary, because at some point it's just not feasible to do the work anymore. But being an old doctor seems like a pretty sweet gig. One of our pathology professors is probably in his late 70s. I think he works part time. He gives some lectures, pimps some students, looks at some slides, and heads home early. He's pretty freakin' awesome, and he seems to love hanging around the med school. Even if they're paying him a fraction of a full salary, I'm sure it's still enough to stretch whatever savings he has tremendously.

    Why would I retire and play gold and sit on the couch, when I could keep having fun and hanging out at the hospital?
  35. JackShephard MD

    JackShephard MD

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    First off, I don't even like the idea of retirement unless you are physically unable to work. I'd rather find something I love to do until I die. Joe Paterno just died at 85 and was working as a head coach at the same age. There are many other examples.

    Also, do you understand what a privilege retirement is? Being able to stop working and have the high standard of living Americans have. I've read on the attending forums of individuals goals to retire at 50. 50! To keep our Joe Paterno example going, he had 35 seasons remaining at 50.

    I don't think you realize how much higher the standard of living is even at 60k than the rest of the world.
    I don't think you realize how much of this is discretionary and how good you have it to be able to complain about these costs. Many people around the world live on a few dollars a day, half the world lives in poverty. They aren't talking about when they get to stop working, how much their cars costs, how much their nice home in the suburbs costs, how much music lessons cost. They are struggling to survive. Be grateful for what you have.

    #firstworldproblems


    :thumbup: Do what you love, then you never have to work.
  36. Slack3r

    Slack3r Sicker than your average

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    Just keep digging deeper, eh?
  37. Shnurek

    Shnurek

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    Exactly. You want to live in a crowded city then accept the trade offs or get on some government housing programs. Its all supply and demand. More demand for living in NYC than there is supply of dwellings. That is why a windowless studio near times square will cost you $2000 a month or so. What I tell everyone that bitches here: "If you don't like it then get out." Any other place in the country has a lower cost of living and lower taxes.

    If people that complain don't move to somewhere cheaper they will end up like this guy:
    [YOUTUBE]http://www.youtube.com/watch?v=x4o-TeMHys0[/YOUTUBE]
  38. Morsetlis

    Morsetlis SGU MS-4

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    :love:
  39. oldbearprofessor

    oldbearprofessor Camp Kesem Advisor Bear Administrator SDN Senior Moderator SDN Advisor

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    I'm more than 3 decades beyond the early 20's and have no plans for retirement ever unless/until forced to by health. I don't see what's so great about it either.

    Perhaps some folks, dedicated to their profession, enjoy what they do and don't see the idea of sitting at home as the way they want to spend their later years. I recognize that I'll need to slow down, cut back on in-house night call, and maybe eventually do less work, but I don't plan to retire at any magic age in the 55-75 year bracket.

    YMMV, but not everyone who plans to keep working into their 60s and (gasp) 70's is a young idealist.
  40. phltz

    phltz

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    Nice attempt at being condescending, but I'm already in my early 30s. And no, I don't want to go into primary care. I'm more interested in research and teaching. Both of which are things that you can easily keep doing (albeit probably at a lower intensity) well into old age.
  41. phltz

    phltz

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    Working in a career that I can't wait to get out of is not a goal of mine. In fact, my goals are to work in a career that I find interesting and exciting enough that I won't want to stop unless circumstances force me to. Good luck counting down the days until you can finally get out of a job that you are apparently already planning on disliking before you've even started.
  42. phltz

    phltz

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    You may have noticed my post is carefully constructed to mirror yours. I take issue with your condescending tone, and either insufferably smarmy or sarcastic manner. As you are evidently annoyed by my post, it seems you should be able to recognize how annoying yours was.
  43. aphenomenon

    aphenomenon

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    agreed
  44. ToldYouSo

    ToldYouSo Student

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    For those actually in the trenches of medical school/attending... is it wrong to think that a good primary care provider is actually safer from mid-level encroachment? I feel like the breadth of knowledge needed to be competent in all the aspects of FP/IM/Peds makes it harder to take away from. Except for the routine and "simple" BB cases, but every field has those right? Also emergency medicine. Regarding FP, I've heard bluedog say a few times "if you're afraid of being replaced by a midlevel, then you probably should be" or something along those lines.
  45. Oxer45

    Oxer45

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    Doctors have become more managers these days. Best way to describe it is: imagine a academic hospital with one attending and two residents who see pts and do what the attending directs them to do. Now imagine the resident is replaced by a NP or PA. That is how the future of medicine/surgery is starting to look like.
  46. badasshairday

    badasshairday Account on Hold

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    A little bit more envious today. Had a gathering and went out with my significant other and her friends who all are finishing up PA school. Jobs lined up. One of them, at the ripe old age of 24 obtained his first job in the ER with a starting salary of 100 grand. Stung a little, considering I'm 27 getting my MD in one week and have had a more extensive clinical training, but will be starting with a salary that is literally half of these PAs.

    :laugh:
  47. auburnO5

    auburnO5

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    Yeah that kind of sucks. But at the end of the day you'll be a MD and they are still just PA's (no offense to PA's at all). Maybe it doesn't mean as much as it used to, but I don't think I could ever be satisfied with myself knowing that I'm not living up to my full potential.

    That takes the sting out just a little bit for me.
  48. duckie99

    duckie99

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    except his max salary is probably 125k. Your max in radiology could easily >500k. There is no comparison. Also even in residency you'll be getting close to 50k. I honestly would be unhappy making less than 350k when all is said and done.
  49. johnnydrama

    johnnydrama I'm no Superman

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    >500k is not at all common in radiology anymore.
  50. duckie99

    duckie99

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    ok well he'll still make way more than 125k. Medscape 2012 I think put radiology around 350k average.

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