Are mid-level providers allowed to be 'attendings' for MS3/MS4?

This forum made possible through the generous support of SDN members, donors, and sponsors. Thank you.
wonderdog

wonderdog

Senior Member
10+ Year Member
Joined
Dec 28, 2011
Messages
374
Reaction score
57
Members do not see this ad.
Does the LCME allow for med students to have their proctor be a midlevel provider?

I'm on ambulatory service and today I had a mid level provider that:
  1. Can't sign my skills log.
  2. Doesn't want to teach (something i'll mention in my eval)
 
wonderdog said:
Does the LCME allow for med students to have their proctor be a midlevel provider?

I'm on ambulatory service and today I had a mid level provider that:
  1. Can't sign my skills log.
  2. Doesn't want to teach (something i'll mention in my eval)
Click to expand...
Midlevel providers should not be in charge of med students' education. You went to med school to become a physician, not a midlevel, therefore your education should come from a physician. The LCME should not allow it.
 
wonderdog said:
Does the LCME allow for med students to have their proctor be a midlevel provider?

I'm on ambulatory service and today I had a mid level provider that:
  1. Can't sign my skills log.
  2. Doesn't want to teach (something i'll mention in my eval)
Click to expand...

It's not their job to teach you just as it won't be your job to teach midlevels although many doctors do for those sweet tuition dollars. The mid level is in the right. They are not attendings and they cannot precept you.

Your school is failing you and they should be ashamed of themselves. But what can you do when your tuition dollars get shunted to ever expanding administrative pockets at the expense of your education? Sorry that your school sucks op, best you can do is to post on your school specific thread to save others from a crappy education.
 
the issue to me here has more to do with the faculty in particular and not the fact that they are a midlevel

interest in teaching isn't an automatic when it comes to having an MD

in any case, the majority of your ed should come from MD/DOs, but that isn't to say there aren't rotations were you would have a ridealong day with EMT, or a psych rotation where you spent a night in the ED with a psychologist, a peds rotation where you spent a day with PT, etc etc

you can have midlevels in your ed, they have things to teach the MS

if you eval this person, you should mention what made them an ineffective and uninterested instructor
 
chipwhitley said:
Midlevel providers should not be in charge of med students' education. You went to med school to become a physician, not a midlevel, therefore your education should come from a physician. The LCME should not allow it.
Click to expand...

Maybe you didn't mean this sentence so generally, but, if you did, it's just dogma.

Best lecture I ever got on gas exchange was from a perfusionist. Best learning experience for managing a normal vaginal delivery was from a midwife. Best practical teaching on assessing air flow limitation was from a PhD respiratory specialist--not a physician. By contrast, I've received some very dumb "wisdom" from more than a few attendings. And not every attending is inclined to teach either.

Part of becoming a doctor is learning how to evaluate sources of knowledge. And non-doctors can be great sources of knowledge.

But still, I don't think it's appropriate for non-physicians to be proctoring clinical encounters (which is different from teaching). "Proctor" means to assess, and your clinical knowledge should be assessed with respect to the knowledge, competency, and perspective of a physician. Who more appropriate to do that than an actual physician?

But this is a very specific question about a very crappy day. Just give the appropriate feedback and move on. What else are you going to do? Pick your battles...
 
Last edited:
lymphocyte said:
Maybe you didn't mean this sentence so generally, but, if you did, it's just dogma.

Best lecture I ever got on gas exchange was from a perfusionist. Best learning experience for managing a normal vaginal delivery was from a midwife (who are very highly trained in Australia). Best practical teaching on assessing air flow limitation was from a PhD respiratory specialist--not a physician. By contrast, I've received some very dumb "wisdom" from more than a few attendings. And not every attending is inclined to teach either.

Part of becoming a doctor is learning how to evaluate sources of knowledge. And non-physicians can be great sources of knowledge.

But still, I don't think it's appropriate for non-physicians to be proctering clinical encounters (which is different from teaching). "Proctor" means to assess, and your clinical knowledge should be assessed with respect to the knowledge, competency, and perspective of a physician. Who more appropriate to do that than an actual physician?

But this is a very specific question about a very crappy day. Just give the appropriate feedback and move on. What else are you going to do? Pick your battles...
Click to expand...

this isn't a pick your battles kind of thing. His school is failing hard at the main service it is supposed to provide. With tuition as high as it is I would be pissed
 
lymphocyte said:
Maybe you didn't mean this sentence so generally, but, if you did, it's just dogma.

Best lecture I ever got on gas exchange was from a perfusionist. Best learning experience for managing a normal vaginal delivery was from a midwife (who are very highly trained in Australia). Best practical teaching on assessing air flow limitation was from a PhD respiratory specialist--not a physician. By contrast, I've received some very dumb "wisdom" from more than a few attendings. And not every attending is inclined to teach either.

Part of becoming a doctor is learning how to evaluate sources of knowledge. And non-physicians can be great sources of knowledge.

But still, I don't think it's appropriate for non-physicians to be proctering clinical encounters (which is different from teaching). "Proctor" means to assess, and your clinical knowledge should be assessed with respect to the knowledge, competency, and perspective of a physician. Who more appropriate to do that than an actual physician?

But this is a very specific question about a very crappy day. Just give the appropriate feedback and move on. What else are you going to do? Pick your battles...
Click to expand...
You can learn medical science from anyone or anything, including textbooks, apps, random people on the internet. But you go to medical school specifically to become a physician, so your training in medical school should be led by physicians, and you should be evaluated/assessed by physicians, only.
 
chipwhitley said:
You can learn medical science from anyone or anything, including textbooks, apps, random people on the internet. But you go to medical school specifically to become a physician, so your training in medical school should be led by physicians, and you should be evaluated/assessed by physicians, only.
Click to expand...

How do we disagree?
 
Last edited:
wonderdog said:
Does the LCME allow for med students to have their proctor be a midlevel provider?

I'm on ambulatory service and today I had a mid level provider that:
  1. Can't sign my skills log.
  2. Doesn't want to teach (something i'll mention in my eval)
Click to expand...

The LCME doesn't specify that preceptors must be physicians.

If this only happened today or only happens once in a while, don't worry about it. If you're going through the majority of a rotation and not working with an attending physician, then you should address it with your school.

I had several rotations during which there were a few days I worked with a mid-level, like a midwife or NP or CRNA. I don't consider it that big of a deal, in fact I learned more from them and from residents than I did from some of the attendings.
 
Ismet, how do you have a verified physician tag already? I signed up for one 2 months ago and no response at all.
 
Ismet said:
The LCME doesn't specify that preceptors must be physicians.

If this only happened today or only happens once in a while, don't worry about it. If you're going through the majority of a rotation and not working with an attending physician, then you should address it with your school.

I had several rotations during which there were a few days I worked with a mid-level, like a midwife or NP or CRNA. I don't consider it that big of a deal, in fact I learned more from them and from residents than I did from some of the attendings.
Click to expand...
Look, I know there are good midlevel providers and that you can learn from them. But this is a political issue. They've already gained a lot of ground on us. Allowing them to officially teach us in medical school just gives their organizations far more "evidence" to argue in front of the govt and the public that they are just as qualified as us. After all, they teach us! We have to be really careful about this. The LCME really should specify that preceptors for MD/DO students should be MD/DOs.
 
NP practice cookbook medicine, so LCME should make it clear to schools that they should not use NP as preceptors...
 
wonderdog said:
Half of my shifts next week are mid-levels.
Click to expand...

Yeah, no, if half of your shifts are under a midlevel, that's crazy. You absolutely can learn from Nurses, techs, midwives, NPs and PAs, and I've learned some valuable things that the attending didn't/couldn't teach. That said, those were people sharing knowledge because they liked to and obviously had more than me, not because they were my preceptor.

I agree with Ismet that once in a blue moon is fine, but it being any sort of regular thing doesn't seem right.
 
wonderdog said:
Not a big deal. Just curious.
Click to expand...

It's actually a huge deal, you're getting cheated. I've never had a midlevel as my preceptor for any day. The only time I worked with them in any capacity is when I was on anesthesiology, one of them let me do a bunch of intubations in their room.

Having any of your shifts under a midlevel is completely inappropriate. I can't believe that any medical school has a student that is doing half of their shifts under a midlevel. That's unimaginable at my school and there's no way you should feel okay about it unless you're paying np level tuition.
 
hallowmann said:
Yeah, no, if half of your shifts are under a midlevel, that's crazy. You absolutely can learn from Nurses, techs, midwives, NPs and PAs, and I've learned some valuable things that the attending didn't/couldn't teach. That said, those were people sharing knowledge because they liked to and obviously had more than me, not because they were my preceptor.

I agree with Ismet that once in a blue moon is fine, but it being any sort of regular thing doesn't seem right.
Click to expand...
Be careful though, people will try to teach you things that aren't in their area of expertise and you'll know no better as an inexperienced MS3 (not you personally, hallowman, I mean in general, as I have no idea where you are in your education). This applies to attendings and residents as well, but I've had the worst from NPs. Many of them I worked with suffered greatly from the Dunning Kruger Effect. If something seems fishy definitely confirm with someone more qualified.
 
chipwhitley said:
Be careful though, people will try to teach you things that aren't in their area of expertise and you'll know no better as an inexperienced MS3 (not you personally, hallowman, I mean in general, as I have no idea where you are in your education). This applies to attendings and residents as well, but I've had the worst from NPs. Many of them I worked with suffered greatly from the Dunning Kruger Effect. If something seems fishy definitely confirm with someone more qualified.
Click to expand...

Midlevels be telling me that haldol is an atypical and that ph of 7.34 is alkalemia. They consult ct surg for "tortuous aorta" on x-ray and order stat ct stroke study and mri for possible stroke in a 60 year old vasculopath who is post op from lower extremity bypass surgery with several month history of diminished vision. Please don't learn medicine from a midlevel.
 
I had a midlevel consult surgery for suture removal. Dent the third year medical student to do it. (No eval, just to take out staples.)
 
Psai said:
Midlevels be telling me that haldol is an atypical and that ph of 7.34 is alkalemia. They consult ct surg for "tortuous aorta" on x-ray and order stat ct stroke study and mri for possible stroke in a 60 year old vasculopath who is post op from lower extremity bypass surgery with several month history of diminished vision. Please don't learn medicine from a midlevel.
Click to expand...

That's not a fair generalisation. Let's trade stories. There was an ED attending who placed an ICU consult for shock with metabolic acidosis refractory to fluid challenge after many liters of normal saline (and yes, it was a NAGMA). This same attending used to joke, "What does DNP stand for? Definitely not a physician"! Very droll. (I've noticed the ones most vociferous about the incompetence of their "lessers" were the ones who also seemed least secure about their own abilities.)

Maybe he was a bad attending. Maybe he wasn't. Who am I judge? That's not the point. As medical students, we should be open to learning wherever possible. And then always try to double-check it ourselves. That's part and parcel of learning how to critically evaluate knowledge--the only skill that will probably matter 20 years from now when half of the received wisdom will either be wrong or inapplicable. (Respectful) skepticism is good, even of our seniors. That's how medical knowledge advances. But skepticism also includes humility: the humility to think that others with less formal education might still have wisdom to impart (like the midwife, or the perfusionist, or whatever).

But I feel like the OP has a very specific concern and this is devolving into a very broad discussion that's been rehashed over and over again... (that's why I like @Crayola227's questions).

I think we all agree that the only ones suitable to evaluate student doctors on their knowledge, skills, and abilities as future doctors are actual doctors. Sure, maybe there's a place for non-physicians to comment on collegiality, professionalism, empathy, etc., because that's within their scope of expertise as colleagues in the broader medical care setting. But who better understands the appropriate perspective, thought process, fund of knowledge with respect to current level of training, etc.? The bulk of training and evaluation should be coming from doctors. Also, WTF are you paying for?
 
Last edited:
Midwives teach on OB all the time. There's nothing wrong with that. However, if they're going to be over-seeing your education, they need to be able to sign your skills log (not that I know what that is...lowly accepted student). That's just common sense. If they can't confirm what you're doing/sign your log, then they shouldn't be responsible for your education. I think the fault is not the mid-level aspect, rather it's an administrative issue with what your school says is ok.

Also, midwives teaching SVD's are probably the only situation where I would feel comfortable being trained by a mid-level. Any other aspect, and I'd probably be a tad PO'd that my thousands of tuition dollars to become a physician went to being trained by NOT-a-doctor.
wonderdog said:
Does the LCME allow for med students to have their proctor be a midlevel provider?

I'm on ambulatory service and today I had a mid level provider that:
  1. Can't sign my skills log.
  2. Doesn't want to teach (something i'll mention in my eval)
Click to expand...
 
chipwhitley said:
It actually is a fair generalization. We need to stop acting like discriminating between levels of education and training is like discriminating between races. Your n=1 doesn't mean much.
Click to expand...

My N=1 is what's known as an illustrative example. This example was meant to segue into a broader argument about the topic. Your response quoted my first sentence, spouted a truism that nobody actually takes seriously, and then disregarded the rest of the argument with a cliché. But, as you point out, this is a political issue for you. It's a practical issue for me. Don't let my reasons get in the way of your ideology.

Speaking of politics, I take a libertarian stance on this issue. If anybody thinks they can replace me for less pay and less training, they're welcome to try. After working with NPs/PAs and doing healthcare consulting and watching how painfully time-consuming and costly it is to expand allied health scope of privilege, I have absolutely zero concerns. I should also note that compensation for family medicine specialists in the US is rising, not falling, despite expanding scope of practice for NPs/PAs.

Now, back to the issue of whether they should be proctoring the bulk of your medical education...
 
Last edited:
wonderdog said:
Does the LCME allow for med students to have their proctor be a midlevel provider?

I'm on ambulatory service and today I had a mid level provider that:
  1. Can't sign my skills log.
  2. Doesn't want to teach (something i'll mention in my eval)
Click to expand...

1.) The fact they can't sign your log should be brought up to admin, especially if you are not meeting requirements because of it. I would avoid bringing up the fact you are paired with a mid-level. I know, this sounds like admitting defeat, but hear me out. Your administrators probably already know this is a problem. I mean, if it is obvious to us then I assume they know it is a shortcoming to not pair medical students with physicians for every shift.


2.) Honestly, if you are with a midlevel and they don't teach you anything, it is just like being with a physician who doesn't teach you anything. You are taught nothing by them regardless. Tolerating these circumstances shows that you have respect for mid-level providers. Complaining openly to your preceptors and peers could potentially be taken poorly and affect your perceived professionalism (I know, this sucks, you just have to play the game here). Third year is 90% theatrics.


If it were me in your situation, I would just get through the rotation without causing too many waves, and write your concerns about mid-levels in the course evaluation. Chances are your schedule is already established, so the odds of it being dramatically changed to have all shifts with physicians sounds abysmal.
 
chipwhitley said:
Be careful though, people will try to teach you things that aren't in their area of expertise and you'll know no better as an inexperienced MS3 (not you personally, hallowman, I mean in general, as I have no idea where you are in your education). This applies to attendings and residents as well, but I've had the worst from NPs. Many of them I worked with suffered greatly from the Dunning Kruger Effect. If something seems fishy definitely confirm with someone more qualified.
Click to expand...

Yeah, I agree. Personally, I would say that virtually all had to do with more procedural things, like "what happens in the hospital when X" or if they were actually showing me how to do certain things.

Obviously have a high level of suspicion when you learn anything from an individual. This is true about anyone you interact with on rotations. I've had attendings try to tell me some ridiculous things, and I even had an anti-vaxxer MD as a preceptor for a bit. Weird experience.
 
So I usually just lurk here since I'm not a med student yet. But I'd just like to throw in that an RN student at a community college would lose his/her mind if they had to precept an LPN. The difference in their education is like two semesters. Why do docs have to put up with so much abuse?


Sent from my iPhone using Tapatalk
 
Ho0v-man said:
So I usually just lurk here since I'm not a med student yet. But I'd just like to throw in that an RN student at a community college would lose his/her mind if they had to precept an LPN. The difference in their education is like two semesters. Why do docs have to put up with so much abuse?


Sent from my iPhone using Tapatalk
Click to expand...
Because we have a bunch of physicians that are idiots , as evidenced by some med students and residents in this thread that think NP are (or will be) their 'equal' colleagues... These people(NP) have been indoctrinated from day 1 in nursing school to think they know as much as physicians and most physicians only care about the mighty $$$. What I am saying is not an exaggeration, and you don't believe me, ask anyone who attended nursing school.
 
Ho0v-man said:
So I usually just lurk here since I'm not a med student yet. But I'd just like to throw in that an RN student at a community college would lose his/her mind if they had to precept an LPN. The difference in their education is like two semesters. Why do docs have to put up with so much abuse?


Sent from my iPhone using Tapatalk
Click to expand...

Because society is at a place now where if you're seen as entitled in any way then people think they're allowed to **** on you. If you are smart, hard working, or white then people try to use that as a weapon against you to make you feel bad about yourself. "Hey you can't complain because you're skinny. You can't complain because you're a man. You can't complain because you're white. You can't complain because you're heterosexual. You can't complain because you make more money than me. Listen to me and my story because I'm unique and you're oppressing me."

And the people in power are laughing all the way to their bank.
 
W19 said:
Because we have a bunch of physicians that are idiots , as evidenced by some med students and residents in this thread that think NP are (or will be) their colleagues... These people(NP) have been indoctrinated from day 1 in nursing school to think they know as much as physicians and most physicians only care about the mighty $$$. What I am saying is not an exaggeration, and you don't believe me, ask anyone who attended nursing school.
Click to expand...

Oh trust me, I know. I've been a CT tech for eight years and nursing at every hospital I've ever worked at treats every other department like second-class citizens. My mom (a nurse) talked me out of nursing because "it's basically med school in two years for way less money. It'd be easier to just go to med school."

The indoctrination starts day one of nursing school. They really do tell them that the only reason patients survive hospital admissions is because nurses keep greedy lazy doctors from killing patients due to their own stupidity and arrogance.

The older, more experienced nurses seem to know what's up. In fact, nurses with >10 years experience will routinely say don't go NP because it's a BS degree and advocate for MD/DO or PA.

Just the rigors of premed are more intense than the entire process of becoming an NP. But they're going to legislate independence despite their entire education being nothing more than a degree in nursing awesomeness. Never mind that unimportant science nonsense. Blind confidence will make up for it.

I consider myself lucky that a friend of mine who just finished his online DNP said he'd let me work for him when I get out of residency.

*steps off soapbox *




Sent from my iPhone using Tapatalk
 
username456789 said:
Because people like lymphocyte will gladly ask for a second helping before they've even swallowed their first bite.
Click to expand...
W19 said:
Because we have a bunch of physicians that are idiots , as evidenced by some med students and residents in this thread that think NP are (or will be) their 'equal' colleagues... These people(NP) have been indoctrinated from day 1 in nursing school to think they know as much as physicians and most physicians only care about the mighty $$$. What I am saying is not an exaggeration, and you don't believe me, ask anyone who attended nursing school.
Click to expand...
Psai said:
Because society is at a place now where if you're seen as entitled in any way then people think they're allowed to **** on you. If you are smart, hard working, or white then people try to use that as a weapon against you to make you feel bad about yourself.
Click to expand...

A credit to your profession. Keep it classy guys.
 
Last edited:
Now I'm supposed to feel bad about the things that other people do and say? Yeah thanks but no thanks
 
chipwhitley said:
You're the one complicit in destroying your own profession.
Click to expand...

That's a bit Chicken Little. Do you have any evidence or reasons to support your claim? Or is this just politics again?

It's interesting to hear the ones most degrading of non-physicians being the ones most worried about their encroachment. Based on your own logic, why should you be worried? But in the immortal words of @Blue Dog: if you're that worried about being replaced, then maybe you should be replaced.

Again, I've worked with NPs/PAs, I've done healthcare consulting nationally and internationally, I've seen who holds the reigns of power (it ain't the midlevels), and I have absolutely zero concerns.

This is a forum for preclinical students. My advice to preclinical students is this: learn what you can from whomever, double-check for yourself, and non-doctors shouldn't be evaluating you but be careful making waves if you don't have to.

Also, yeah. Nothing new has been added to this timeless debate.
 
Last edited:
username456789 said:
I should hope not.

Substance > style.

You're floundering here. Badly.
Click to expand...

Your "substance" has now expanded to four sentences and yet you've only managed two additional words, for a grand total of ten.

Look, I'm not going to engage further because nobody has presented evidence or reasons to engage. I feel like everybody can read what's been argued and come to their own conclusions. I'd rather just reroute this conversation back to @wonderdog's concerns.
 
Last edited:
Psai said:
Because society is at a place now where if you're seen as entitled in any way then people think they're allowed to **** on you. If you are smart, hard working, or white then people try to use that as a weapon against you to make you feel bad about yourself. "Hey you can't complain because you're skinny. You can't complain because you're a man. You can't complain because you're white. You can't complain because you're heterosexual. You can't complain because you make more money than me. Listen to me and my story because I'm unique and you're oppressing me."

And the people in power are laughing all the way to their bank.
Click to expand...

This is sadly too close to the truth. Thankfully, we should expect the pendulum to shift back toward sensibility and at least slightly further away from the absurdity that is the Oppression Olympics. It just might take a while.
 
Ho0v-man said:
Why do future docs have to put up with so much abuse?
Click to expand...

Fixed that for you. And the answer is that doctors are lazy and greedy and will gladly foist all of their work onto somebody else as long as they can still get paid for it.
 
Señor S said:
Fixed that for you. And the answer is that doctors are lazy and greedy and will gladly foist all of their work onto somebody else as long as they can still get paid for it.
Click to expand...

My point was that in other fields where the educational difference is only marginal, this would still be considered completely unacceptable, yet (future) docs are supposed to embrace it because we all need to be team players.

And you're answer is not exclusive to docs. Everybody in every field is like that. I personally know a nurse who went NP just to "not get my hands dirty" anymore.


Sent from my iPhone using Tapatalk
 
You must log in or register to reply here.

Similar threads

J
Are there any mid levels worse than mid levels worse than trauma surg mid levels??
Replies
25
Views
2K
LucidSplash
LucidSplash
U
Advices needed for Signaling - IMG, Mid YOG, Mid scores, no research
Replies
1
Views
303
Dral
Dral
S
Vacation time during MS3/MS4 (reflect poorly for competitive specialty?)
Replies
4
Views
1K
GoSpursGo
GoSpursGo
V
Why are some residents/attendings like this??
Replies
46
Views
4K
Lost in Translation
Lost in Translation
S
Divorce Advice MS4
Replies
7
Views
2K
VA Hopeful Dr
VA Hopeful Dr
Top