Expansion of Residency Positions

[Postictal Raiden]

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As many of you have noticed, it didn't take much for EM to go from a very lucrative field with abundance of job opportunities to situation where grads are not able to find jobs. This is mainly an unprecedented expansion rate of their residency programs/position combined with a competing force of midlevels invasion.

So I looked at the latest NRMP data and realized that neurology is undergoing a very fast rate of expansion as well.

As you see, the number of categorical spots has grown by 33 positions and the advanced positions by 10 positions from 2020 to 2021. That's a total of 43 positions, or about 4% growth in a single year. In a five year period, the expansion is 183 positions or 23%.

How concerning is this trend?

 

[MedDoc305]

I have no idea about how the job market is for neurologists, but didn’t EM almost double their slots in 5 years? It’s quite a big difference compared to the 4% increase every year of an already lower number of spots

 

[stevresidentp]

Actually it’s very concerning. Neurology had an increase of 45.3% in the last five years. More than any other speciality.

 

[Chibucks15]

Actually it’s very concerning. Neurology had an increase of 45.3% in the last five years. More than any other speciality.

But at the same time I feel like there's more long term demand for neurology. In the middle of the country it takes almost 6 months in some places to see an outpatient doc. EM can't work outpatient so there is a finite amount of opportunity for them. With the ability to do outpatient, inpatient, or both I feel like sets up neuro to be able to handle a degree of expansion better. If there aren't jobs in the "desirable" places for people, they will funnel to where they are needed. With an aging population and rapidly expanding neuro diagnoses and treatments I think we're a long way off from the trouble EM finds themselves in. But that's what was explained to me by one of my mentors so it may be a different viewpoint when you have trouble getting docs out to smaller cities

 

[BoneWizard]

It's actually a lot worse when you compare it to the overall residency growth.

If you look at the NRMP match report, in terms of pipeline programs (non-prelim/transitional), there were 27,586 positions in 2017 and 33,622 in 2021. This comes out to an increase of 21.9%.

This makes it seem like neurology is keeping pace with residency positions overall, but only because the data presented in the NRMP match report is not an accurate reflection of overall GME training.

In order to have a accurate picture of GME training you'd need to look at the ACGME Data Resource Books which are released annually in September, the AOA match figures (as these aren't included in the data book) and compare the true number of residents entering training.

A couple notes:

• The data book snapshots are taken at the end of the academic year so the 2019-2020 data book is used for the 2020 match.
• The data book does not take into account positions offered in the AOA match or PGY-2 (R) positions.
• The data book defines "pipeline" as specialties that lead to primary board certification (categorical and advanced programs).
• The ACGME/AOA merger started in 2015 and ended in 2020 with 2019 being the last year of the AOA match.
• AOA programs were only allowed to apply for ACGME accreditation after July 1st, 2015. This means the 2015 match occurred pre-transition.
• 2015 and 2020 were used as 2015 was the year immediately preceding the AOA/ACGME merger and 2020 was the first year post-merger.

Here is the overall number of ACGME pipeline residents:

Looking at 2015-2020 ACGME match years (2014-2015 vs 2019-2020) we can see an overall increase of 33,594-27,534= 6,060 pipeline residents. This is a 22.0% increase from 2015-2020 or a 4.06% increase year over year in ACGME . For reference if we were to only look at the NRMP report and tallied the filled pipeline positions (match + soap) for 2015 and 2020, we'd see 31,338 for 2020 and 25,787 for 2015.

In the same time period the AOA match recorded 1,988 filled pipeline positions in 2015. An additional 387 positions were filled in the AOA scramble but no delineation is made regarding which type of programs these were. About half the SOAP matches every year in the NRMP match are to 1-year programs so I'll estimate 194 in the AOA scramble are pipeline programs which gives a total of 2,182 pipeline matches for 2015.

The height of the AOA match didn't actually occur until 2016 where a total of 2,099 pipeline matches occurred and 535 scrambled for a total estimate of 2,367 entering pipeline programs. But, as all AOA programs either transitioned or closed by 2020, so we can still use the 2,182 number for 2015 and 0 for 2020 in order to estimate net change.

If we sum the total change from ACGME and AOA programs combined we get the following:
2015- 27,534+2,182 = 29,716 pipeline residents.
2020- 33,594+0 = 33,594 pipeline residents.
This equals an actual increase of 3,878 pipeline residents which is a 13.05% overall net increase from 2015-2020 or 2.48% year over year.


Now we can look at neurology. The AOA match for 2015 recorded 22 available neurology positions with 15 being filled. As 100% or almost 100% of all neurology spots fill either through match or SOAP for NRMP, I'll assume all 22 positions were filled for AOA.

ACGME 2015 table:

ACGME 2020 table:

So neurology growth from 2015 to 2020 was from 679+22=701 to 868 which is an increase of 23.8% or 4.36% year over year.

If we look at total number of programs, neurology had 133 ACGME and 10 AOA programs in 2015 which increased to 160 ACGME programs in 2020 A 11.9% increase. This suggests the net increase in positions is occurring primarily due to existing program expansion.

If you look at the number of residents by specialty on the ACGME tables from 2015-2020, neurology has a listed 26.9% 5 year increase in total number of residents. The only two specialties with a greater increase are FM at 27.5% and EM at 32.8%.
AOA matched 549 to FM in 2015, ACGME lists 3,578 for a total of 4,127 FM residents entering in 2015. ACGME lists 4,737 entering for 2020. So the actual FM increase is only 14.8%.
AOA matched 289 to EM in 2015. ACGME lists 1,877 for a total of 2,166 EM residents entering in 2015. ACGME lists 2,666 entering for 2020. So the actual EM increase is only 23.1%.

This means that when adjusted for the loss of AOA programs, neurology has had the greatest net increase in positions out of all specialties (including EM) from 2015-2020.




Here's the data books: ACGME Data Resource Book
AOA match: 2015 Summary by Program Type
AOA match report: https://www.aacom.org/docs/default-...trends/2015-matchreport.pdf?sfvrsn=493c5297_8

 

[xenotype]

EM's problem is more about midlevels and CMGs than excess residents. The midlevel issue impacts us, but not to the same extent at least presently. Will there be a major issue 10 years from now? Quite possibly. My program expanded while I was in it, and the expansion was terribly needed. With most patients facing 3-9 month waits to see even a general neurologist in many areas it would be a bit unconscionable to not expand programs, particularly when the volumes and call burden at academic centers are very high for existing residents at many programs. Worry about midlevels more than the expansion of programs. I think less of a threat to us than EM, but who knows what quality of care people will settle for.

 

[A Mysterious Stranger]

Someone made a really good point on these forums a couple weeks ago: that if we don’t fill the demand with physicians then the market will fill the demand with midlevels. At that point, we will have to compete with not only each other, but people who are willing to work for a third of the income.

I’d rather compete for a fair wage in a slightly more crowded market.

 

[sharkbaitwhohaha]

I've been thinking about this occasionally for the past several months since hearing about EMs troubling situation.

One positive point, it's not that lucrative or not much incentive for CMGs to independently create neurology residencies. And there are more greater barriers for neuro residency creation than EM I think.

But we should not be advocating for mass neurology residency expansion. We need to actively get involved with AAN to stop future efforts.

 

[Postictal Raiden]

Midlevels in neurology, for the most part, don’t function nearly as autonomous as they do in EM, for obvious reasons.

They are serving the purpose of filling the shortage gap at the moment.

I’m hoping once our supply meets the demand, the reliance on midlevels starts to diminish.

Wishful thinking?

 

[Wisco12]

One of the many reasons I'm aiming to specialize in Neurology is because out of all my interests it seems pretty secure up to mid-career in regard to positions available, minimal mid-level encroachment (compared to EM, FM, Anesthesia, at least in terms of autonomy), etc. Don't get me wrong, I'm interested because I like working with the patient population, diagnoses, etc, but it seems like not many med students even think about the future trajectory of their specialty (as much as anybody can really try and predict medicine in 20 years). In regard I'm somewhat concerned, but not enough to outweigh all the other things I really enjoy about it.

I'm curious who is filling these expanding spot? Is it more and more IMGs, more AMGs, or the same proportion? I have a pretty large class size and can count on my hands the number of people truly interested in Neuro, whereas there are still loads of people wanting to go into EM even with what is happening now. Neuro seems to be pretty self-selective in that regard, so I wonder whether the increasing slots will be filled with people who actually want to do Neuro or who use it as a backup/soap into it?

 

[BoneWizard]

Oh, I absolutely agree with the need for an increase in neurology residency spots in the immediate future.
I'm just worried the specialty will overcorrect like RO did and leave a rough job market.

This is the AAN estimate from 2013: Supply and demand analysis of the current and future US neurology workforce

We'd essentially need to output a net 3,380 increase between 2012 and 2025 to meet demand. The report used a figure of 729 new neurologists per year between 2012 and 2025 as their supply model or a total of 13*729 = 9,477 new neurologists.

Assuming a 4 year neurology residency, we'd need to look at positions from 2008 to 2021 to estimate 2012 and 2025.
Here's the number of positions offered in the NRMP match from 2008 to 2021:

2009- 581
2010- 585
2011- 605
2012- 638
2013- 670
2014- 700
2015- 717
2016- 747
2017- 786
2018- 839
2019- 898
2020- 926
2021- 969

Which gives a total of 9,661. Based on a 2.8% rate of attrition from 2005-2009, we'd have 9,390 neurologists entering which results in a net shortage of 3,380 + 87 = 3,467. So they were fairly accurate with this model.

If we extrapolate the supply and demand from AAN's projection (it looks like they estimated a 0.76% increase in supply and a 1.28% increase in demand per year) for another 10 years we would get a supply of 19,480 and a demand of 24,348 or a gap of 4,868. If we assume a consistent 4.4% increase in residency positions we would end up with a total 22,031 positions or 21,414 after attrition.

2022- 1,011
2023- 1,056
2024- 1,102
2025- 1,151
2026- 1,201
2027- 1,254
2028- 1,309
2029- 1,367
2030- 1,427
2031- 1,490

Their supply model for this period would be 729*23 = 16,767 which is a difference of 21,414-16,767 = 4,647 which narrows the gap to 221. So the gap will disappear by 2036 if this model stays consistent. In summary, it looks like we're able to absorb a 4.4% per year increase for the next 2 decades or so before it becomes a problem.

 

[Postictal Raiden]

Interesting analysis.

I just want the field to remain the way it is for just another 10 years haha. That is enough for me to payoff my debt and buy a small house.

I’m very happy I chose a field that I immensely enjoy and take pride of. Money and job security are very important factors though.

 

[stevresidentp]

Midlevels in neurology, for the most part, don’t function nearly as autonomous as they do in EM, for obvious reasons.

They are serving the purpose of filling the shortage gap at the moment.

I’m hoping once our supply meets the demand, the reliance on midlevels starts to diminish.

Wishful thinking?

Yes. All the big academic centers currently have Midlevels. Becoming more common in private settings too. Some places even creating NP neurology “fellowships”. They are cheaper and they won’t go anywhere.
Neurology is not a lucrative speciality for hospitals, but rather a necessity, so if they can hire cheaper people that can do the job regardless of quality, they will.
You can see the armies of Midlevels in neurocritical care and stroke units.

 

[CargoPants]

I think we need to use a lot of the information that we have learned from the EM situation and apply it to neurology. I was just looking for my first post-training job this season, so I will share my thoughts on how things are going and how they’re might compare to ED.

I'll start with the bad news:

When we compare our residency situation with EM, we can see our Residency training is also expanding rapidly. We see the numbers from the other posters above. HCA already has a number of neurology residencies, and existing programs are looking to expand further. With the additional med schools being built and the unending pool of willing foreign doctors, these positions will fill.

Residency training for Neurology is 4 years (as opposed to 3-4 years for EM), and it is mostly followed by a one year fellowship. Out of the last 35 graduates from my home program in the last 4 years, only 2 went into practice straight after residency. EM residents are now starting to talk about using fellowships to offer more, but a lot of their fellowships do not broaden their employment significantly (ultrasound, toxicology). Avoid similar ones in neurology.

The mid level situation will also get worse. Neurology training is already heavily fragmented into inpatient and outpatient responsibilities. The large majority of neurology programs are inpatient heavy, which comes at the cost of outpatient exposure. Tasking a midlevel to address a specific component of either world, especially one that it protocolized, will be increasingly common. We are seeing that already. This is further exacerbated by increasing reliance on imaging. Making a decision based on an MRI read allows for less thinking and more "defensible" decisions, both of which benefit midlevels.

The good news is that there are fundamental differences in the practice between ED and neurology.

Fortunately, at this time, there still remains a good number of private practice groups. As of right now, practice opportunities are plentiful in private, hospital employed, and academic scenarios. Hopefully this can continue as the competition between the groups will be to our benefit.

We have more ownership of our patients, and most prefer to see the same person for their care.

Our fellowships tend to extend our expertise in a significant way.

The fundamentals of neurology haven't changed that much. EM faced a rapid expansion and demand from Urgent Cares and small ERs popping up over the last 10 years. Then, when many of them folded, it caused a precipitous drop of employment opportunities. Radiation Oncology faces decreasing utilizations/indications for radiation, which is compounding their oversupply issue. Our closest analog may be the advancement of imaging?



Takeaways we can apply from the ED situation:
- It seems unlikely that residency program expansion will reverse, or even stabilize in the next couple of years. The projections above and from other professional organizations don't paint a grim picture in the IMMEDIATE future, but it is likely that eventually ALL specialties will be facing a parity between supply and demand.
- Employed compensation will face a downward pressure in the future. Preparing for this is important, and can vary from maximizing current income opportunities while salaries are still good, to going academic and advancing in that path, to pursing partnership opportunities. Staying in a hospital employed position runs the risk of the same fate as ED.
- Offer a niche, but stay broad overall. The mid-level encroachment will likely start to chip away at specific areas of neurology practice, but it's hard to be sure which one at this moment in time. Will it be on the inpatient side/neurohospitalist vs basic general neurology and triaging role vs sub-specialized procedure monkeys doing botox or other procedures all day?

 

[curiousneuro]

The mid level situation will also get worse. Neurology training is already heavily fragmented into inpatient and outpatient responsibilities. The large majority of neurology programs are inpatient heavy, which comes at the cost of outpatient exposure. Tasking a midlevel to address a specific component of either world, especially one that it protocolized, will be increasingly common. We are seeing that already. This is further exacerbated by increasing reliance on imaging. Making a decision based on an MRI read allows for less thinking and more "defensible" decisions, both of which benefit midlevels.

In my residency/fellowship training, I've had a very different experience with midlevels in neurology. Unlike on other services, none of our midlevels would EVER provide independent neurological expertise on literally anything, especially something as high-risk as acute ischemic stroke. Would they help with rounding and following-up on these patients, making sure orders are in, rehab placement, etc.? Sure. Routine migraine/epilepsy follow-ups? Sure. But I really haven't come across midlevels in neurology actually seeing consults independently and providing neurological expertise without the backup of an attending.

Is this different at other centers? I just can't imagine our midlevels really independently providing neurological expertise; I've honestly have not even been impressed with their ability to do basic neuro exams. And our midlevels on our stroke service have been with us for years....

 

[xenotype]

Midlevels in neurology, for the most part, don’t function nearly as autonomous as they do in EM, for obvious reasons.

They are serving the purpose of filling the shortage gap at the moment.

I’m hoping once our supply meets the demand, the reliance on midlevels starts to diminish.

Wishful thinking?

Agree. There are very few truly autonomous midlevels. Most are in headache because it is easy, fomulaic, and misdiagnosis in headache rarely results in a bad outcome especially with liberal use of imaging and LPs. There is no MRI that will diagnose a seizure versus PNES, and MRI is finicky even for stroke where there are rare cases one can get badly burned without clinical gestalt and caution. Neuromuscular disease, even serious acute things like GBS, MG crisis mostly has no imaging findings at all, and is easily missed by inexperienced midlevels.

Yes. All the big academic centers currently have Midlevels. Becoming more common in private settings too. Some places even creating NP neurology “fellowships”. They are cheaper and they won’t go anywhere.
Neurology is not a lucrative speciality for hospitals, but rather a necessity, so if they can hire cheaper people that can do the job regardless of quality, they will.
You can see the armies of Midlevels in neurocritical care and stroke units.

The midlevels in stroke units aren't making any independent decisions on tPA, and if they were the ED and their malpractice provider would balk.

In my residency/fellowship training, I've had a very different experience with midlevels in neurology. Unlike on other services, none of our midlevels would EVER provide independent neurological expertise on literally anything, especially something as high-risk as acute ischemic stroke. Would they help with rounding and following-up on these patients, making sure orders are in, rehab placement, etc.? Sure. Routine migraine/epilepsy follow-ups? Sure. But I really haven't come across midlevels in neurology actually seeing consults independently and providing neurological expertise without the backup of an attending.

Is this different at other centers? I just can't imagine our midlevels really independently providing neurological expertise; I've honestly have not even been impressed with their ability to do basic neuro exams. And our midlevels on our stroke service have been with us for years....

Agree. Midlevels in neurology rarely provide independent, final recommendations and usually exam skills are poor compared to even a PG4 resident. There are rare exceptions- ex an NP doing ALS clinic for 10+ years. With that said, no guarantee there won't be NPs with significant experience competing for jobs in the future, without the background of med school or certifications.

 

[Postictal Raiden]

I agree with all of the above.

Neurology is tough. Not only the complex science of it, but also the art side. Even as a PGY3 about to become PGY4, I still feel I haven’t scratched the surface of clinical competence in the field. I’m not even sure I’ll be ready after my fellowship.

Hospital MBAs don’t care tho. They’ll continue to push for a cheap, but dangerously incompetent, care. Many of these efforts are unfortunately aided by the glut of RVU chasing neurologists.

The inpatient side will face the pressure first, I predict. Unlike outpatient, the demand for inpatient neurology is finite. Most neurological processes are chronic and managed on the outpatient side. Plus there’s a surge of interest among neuro residents for inpatient neurology. The lure of 7 on/7 off lifestyle is strong. Combine this with a residency experience heavily catering for inpatient neurology and a horrible outpatient experience in the residency continuity clinic. Not hard to see why everyone wants to do inpatient.

Outpatient will remain somewhat safer IMO. For all the reason above and because as an outpatient neurologist, you are a brand. Once patients develop a good, trusting relationship with their doctor, they’ll follow them to the end of the earth and back. I recently did an elective in movement disorder. The neurologists I worked with functioned as PCP for their patients. They didn’t only focus on addressing the neurological aspect of neuro degenerative diseases, but also managed all of the systemic complications these conditions entail. From orthostatic hypotension, to siahorrhea, to psychosis, to intractable nausea. Such neurologists can NEVER be replaced.

 

[CargoPants]

In my residency/fellowship training, I've had a very different experience with midlevels in neurology. Unlike on other services, none of our midlevels would EVER provide independent neurological expertise on literally anything, especially something as high-risk as acute ischemic stroke. Would they help with rounding and following-up on these patients, making sure orders are in, rehab placement, etc.? Sure. Routine migraine/epilepsy follow-ups? Sure. But I really haven't come across midlevels in neurology actually seeing consults independently and providing neurological expertise without the backup of an attending.

Is this different at other centers? I just can't imagine our midlevels really independently providing neurological expertise; I've honestly have not even been impressed with their ability to do basic neuro exams. And our midlevels on our stroke service have been with us for years....

That’s not for lack of trying from many academic centers. Let’s remind ourselves of what Duke is alrwdy

The Duke neurology advanced practice provider residency: Its time has come - PMC

The acknowledgment that specialization in neurology based on a clinician's extensive background in neuroscience contributes to expertise in patient care was a motivating factor in developing neurology residency programs. The increasing demand for ...

www.ncbi.nlm.nih.gov

Regarding the APP role:
“On the inpatient side, APPs work alongside resident house staff, with faculty, or independently depending on the service model.”

Regarding their APP neurology residency:
“Unlike medical postgraduate training, no trainee license was available from our state medical board. Therefore, we had to credential our neurology APP residents as providers, which created some confusion among faculty and administrative personnel. Although some APP residencies in other areas have used billing capabilities of APPs to offset their salary/benefit costs, we felt strongly that our APP residents should not bill because they would always be supervised by a faculty neurologist or supervising senior APP. We felt it was appropriate to pay them at a PGY1 level because an NP or PA graduate degree was the prerequisite for application... Our neurology APP residents are paid for by resources from both our department and our hospital... Ultimately, we believe that other institutions will see the merit of this approach to the development of APP neurology clinicians. The American Academy of Neurology is embracing the participation of APPs in neurology, and this will further the graduates' ability for lifelong learning.”

Instead of paying the same money to train a physician, they are paying to train APPs out of their own pocket. You can bet that they look at this as a form of investment when they hire them onto their staff

You sure they aren’t gonna prove some equivalency to physicians on some esoteric quality measure? I can see them being better at keeping MS patients compliant on their medications compared to physicians.

By that time, if APPs have independent practice rights across the nation, we will be in the same boat anesthesia is in where people are calling us “physician neurologists” and APPs “nurse neurologists”.

 

[xenotype]

That’s not for lack of trying from many academic centers. Let’s remind ourselves of what Duke is alrwdy

The Duke neurology advanced practice provider residency: Its time has come - PMC

The acknowledgment that specialization in neurology based on a clinician's extensive background in neuroscience contributes to expertise in patient care was a motivating factor in developing neurology residency programs. The increasing demand for ...

www.ncbi.nlm.nih.gov

Regarding the APP role:
“On the inpatient side, APPs work alongside resident house staff, with faculty, or independently depending on the service model.”

Regarding their APP neurology residency:
“Unlike medical postgraduate training, no trainee license was available from our state medical board. Therefore, we had to credential our neurology APP residents as providers, which created some confusion among faculty and administrative personnel. Although some APP residencies in other areas have used billing capabilities of APPs to offset their salary/benefit costs, we felt strongly that our APP residents should not bill because they would always be supervised by a faculty neurologist or supervising senior APP. We felt it was appropriate to pay them at a PGY1 level because an NP or PA graduate degree was the prerequisite for application... Our neurology APP residents are paid for by resources from both our department and our hospital... Ultimately, we believe that other institutions will see the merit of this approach to the development of APP neurology clinicians. The American Academy of Neurology is embracing the participation of APPs in neurology, and this will further the graduates' ability for lifelong learning.”

Instead of paying the same money to train a physician, they are paying to train APPs out of their own pocket. You can bet that they look at this as a form of investment when they hire them onto their staff

You sure they aren’t gonna prove some equivalency to physicians on some esoteric quality measure? I can see them being better at keeping MS patients compliant on their medications compared to physicians.

By that time, if APPs have independent practice rights across the nation, we will be in the same boat anesthesia is in where people are calling us “physician neurologists” and APPs “nurse neurologists”.

Sure. But what is anyone here going to do about it? People are not refusing to train at Duke due to this, or refusing to be AAN members and being vocal about it. Many NPs can't find a job at all in many markets without experience, let alone one in an outpatient specialty practice with no relevant experience. Everyone here knows the pain of training a new midlevel who can't even do a neuro exam with halfway reliable findings. It is a major problem, but I do believe it impacts neurology a little less than FM, EM, and IM as we have to make difficult final calls on the diagnosis. Either midlevels mostly won't be comfortable putting the chips down on the table, or will be dead wrong on things like epilepsy vs PNES where it really matters and is obvious to the patient/family and outside providers they were clueless.

 

[scoopdaboop]

That’s not for lack of trying from many academic centers. Let’s remind ourselves of what Duke is alrwdy

The Duke neurology advanced practice provider residency: Its time has come - PMC

The acknowledgment that specialization in neurology based on a clinician's extensive background in neuroscience contributes to expertise in patient care was a motivating factor in developing neurology residency programs. The increasing demand for ...

www.ncbi.nlm.nih.gov

Regarding the APP role:
“On the inpatient side, APPs work alongside resident house staff, with faculty, or independently depending on the service model.”

Regarding their APP neurology residency:
“Unlike medical postgraduate training, no trainee license was available from our state medical board. Therefore, we had to credential our neurology APP residents as providers, which created some confusion among faculty and administrative personnel. Although some APP residencies in other areas have used billing capabilities of APPs to offset their salary/benefit costs, we felt strongly that our APP residents should not bill because they would always be supervised by a faculty neurologist or supervising senior APP. We felt it was appropriate to pay them at a PGY1 level because an NP or PA graduate degree was the prerequisite for application... Our neurology APP residents are paid for by resources from both our department and our hospital... Ultimately, we believe that other institutions will see the merit of this approach to the development of APP neurology clinicians. The American Academy of Neurology is embracing the participation of APPs in neurology, and this will further the graduates' ability for lifelong learning.”

Instead of paying the same money to train a physician, they are paying to train APPs out of their own pocket. You can bet that they look at this as a form of investment when they hire them onto their staff

You sure they aren’t gonna prove some equivalency to physicians on some esoteric quality measure? I can see them being better at keeping MS patients compliant on their medications compared to physicians.

By that time, if APPs have independent practice rights across the nation, we will be in the same boat anesthesia is in where people are calling us “physician neurologists” and APPs “nurse neurologists”.

A lot of the big name medical centers have stuff like this for mid-levels. You would think these places have physicians who obviously value merit and "name-brand" when selecting residents etc. won't allow stuff like this... but maybe they're less scared about midlevels ever being a threat so they train them anyways... or they just don't care, because it's more money for them now.

 

[CargoPants]

Sure. But what is anyone here going to do about it? People are not refusing to train at Duke due to this, or refusing to be AAN members and being vocal about it. Many NPs can't find a job at all in many markets without experience, let alone one in an outpatient specialty practice with no relevant experience. Everyone here knows the pain of training a new midlevel who can't even do a neuro exam with halfway reliable findings. It is a major problem, but I do believe it impacts neurology a little less than FM, EM, and IM as we have to make difficult final calls on the diagnosis. Either midlevels mostly won't be comfortable putting the chips down on the table, or will be dead wrong on things like epilepsy vs PNES where it really matters and is obvious to the patient/family and outside providers they were clueless.

In my above post, I had some realistic recommendations about what people should consider doing right now to help insulate from the changing landscape. This may not be comforting for incoming residents (or worse, medical students), but knowing about these and monitoring the shifting dynamics of each specialty can help them land in the best position possible.

People are not going to avoid Duke because of their actions, nor would I expect them to. With a near infinite pool of increasing MD/DO/IMG/FMG candidates, it would be silly to judge someone for matching/SOAPing Duke versus unmatched. See below on why it may actually spur them into actively seeking these types of programs.

As for the qualms about mid levels, the easiest rebuttal would be, “that’s why an APP neurology residency is offered. If anything, we need more!”

Also, I'm not sure why you think epilepsy vs PNES is a make-or-break differentiator for a good clinician. I'm guessing you are imagining a scenario in the inpatient setting for an acute, initial presentation? If there is one thing that I would expect an APP to do, would be to give benzos/keppra to "stabilize" either presentation and call for an EEG.

A lot of the big name medical centers have stuff like this for mid-levels. You would think these places have physicians who obviously value merit and "name-brand" when selecting residents etc. won't allow stuff like this... but maybe they're less scared about midlevels ever being a threat so they train them anyways... or they just don't care, because it's more money for them now.

If a glut of midlevels and residents start to hit the market, it's the graduates from smaller programs that get hit the hardest. For the big programs, it actually STRENGTHENS their name brand.

When competing against others for academic jobs or legitimate partnership-track positions, those Duke grads are gonna look much more attractive than the HCA grads.

 

[xenotype]

Also, I'm not sure why you think epilepsy vs PNES is a make-or-break differentiator for a good clinician. I'm guessing you are imagining a scenario in the inpatient setting for an acute, initial presentation? If there is one thing that I would expect an APP to do, would be to give benzos/keppra to "stabilize" either presentation and call for an EEG.

If you are following the guidelines correctly, convulsive seizures should rapidly be treated with intubation and sedation long before an EEG can be connected which is quite dangerous in the case of misdiagnosis. I'm sure you've seen at least one PNES patient with tracheomalacia from multiple intubations. It isn't benign at all, and PNES needs to be clinically recognized in the acute setting long before EEG connection- not just have benzos thrown at it. At my center, even connecting an EEG stat for obvious ongoing psychogenic events can result in a department wide email at one's expense on unnecessary abuse of EEG. Cell phone video can of course mitigate much of this, but not to the same degree for an independent midlevel that lacks support.

This is just one example. There's plenty of ways to get burned in neurology from inexperience or lack of training. I think my point stands unless you think misdiagnosis in neurology really has no consequences. Plenty of PGY2 residents would discharge acute stroke from the ER with no work up if there wasn't anyone asking them questions about it- I've seen it happen.

 

[Telamir]

I hook them up to EEG so I see their PNES on video.

 

[neglect]

Our fellowships tend to extend our expertise in a significant way.

Takeaways we can apply from the ED situation:
- It seems unlikely that residency program expansion will reverse, or even stabilize in the next couple of years. The projections above and from other professional organizations don't paint a grim picture in the IMMEDIATE future, but it is likely that eventually ALL specialties will be facing a parity between supply and demand.
- Employed compensation will face a downward pressure in the future. Preparing for this is important, and can vary from maximizing current income opportunities while salaries are still good, to going academic and advancing in that path, to pursing partnership opportunities. Staying in a hospital employed position runs the risk of the same fate as ED.
- Offer a niche, but stay broad overall. The mid-level encroachment will likely start to chip away at specific areas of neurology practice, but it's hard to be sure which one at this moment in time. Will it be on the inpatient side/neurohospitalist vs basic general neurology and triaging role vs sub-specialized procedure monkeys doing botox or other procedures all day?

Think we're comparing apples and pinecones here. As you pointed out, neurology and ER are non-analogous and while we should be wary, there's less to worry about than ER, which got totally saturated with young residents looking for a rush.

On fellowships: I used to think that it was regrettable when neurologists would forsake general training to go into sub-specialties. I still think one should stay general. At the same time, consider that 20 years ago getting a neuro-interventional job was impossible, like literally impossible. There was no neuromonitoring. Neuro-ICUs were barely a thing, mostly under ICU-pulm with neuro consults. My job (running clinical trials) was very rare. Pain mgmt, with neurologists doing mostly injections was very rare. VERY few PD patients got implants. So new jobs are actually being created within the field, extending and deepening neurologic services. Imagine if an Alzheimer's disease modifying drug gets approved or if brain-machine interface takes off for stroke/SCI.

I also think that neuro patient needs are basically infinite. If you're a HA doctor, you could book those folks Qweek for a year and most would show up. The ER has fairly static supply. Although it feels to you, when you need an ER, that this is a weird one time break/cut/fall/admit, on a population level it is the same % bad events per day. Neurology patients are always underserved. Our diseases are common and distressing.

In terms of takeaways: either get protected in academics/research, or get private. Hospitals will want to replace you with a compliant NP tomorrow. I also think neurologists in the future MUST adapt. This means that you have to start adopting things that make you indispensable and cannot be done by an NP. If you do peripheral, for example, you must learn to do US and skin bx, and personally I'd even try to learn how to do CTS surg.

 

[deleted941485]

After reading the reasons why Neuro can't go the way of EM, I am now more convinced it can and will go the way of EM.

When you're employed by the hospital and rest assured most of you will be: Nobody cares about your brand or where you went to school especially if the C-suite is actively contemplating replacing you with an NP.

 

[neglect]

After reading the reasons why Neuro can't go the way of EM, I am now more convinced it can and will go the way of EM.

When you're employed by the hospital and rest assured most of you will be: Nobody cares about your brand or where you went to school especially if the C-suite is actively contemplating replacing you with an NP.

1. I'm private. I've been this way since graduating fellowship. Tell me how I'm going to end up employed. Or admit you know nothing.
2. Hospital admins want to replace everyone with cheap, compliant NPs/PAs. Then they get ill and, like everyone else, want to see a doctor. Even for the most trivial back pain, migraine, tingling. Nothing will change here.
3. At least try to make a case. I'm not aware of all the challenges ED docs face. How are they akin to neurology, with it's mix of inpatient, outpatient, minor procedures, diagnostic reads?

Or are you just trolling?

 

[deleted941485]

1. I'm private. I've been this way since graduating fellowship. Tell me how I'm going to end up employed. Or admit you know nothing.
2. Hospital admins want to replace everyone with cheap, compliant NPs/PAs. Then they get ill and, like everyone else, want to see a doctor. Even for the most trivial back pain, migraine, tingling. Nothing will change here.
3. At least try to make a case. I'm not aware of all the challenges ED docs face. How are they akin to neurology, with it's mix of inpatient, outpatient, minor procedures, diagnostic reads?

Or are you just trolling?

1. "I'm Private" - sure for now
2. Admins - thanks for making my point - They'll roll the dice if it means a bigger bonus. I don't think you fully understand the pure singular focus on bottom line that exists in admin world. Everything else is about what they can get away with. Even if it means sacrificing a family member or two to save a buck.
3. Make a case: Do you just lurk the neuro forums? The bottom line is over training...every other argument made on here regarding the reasons neuro would be safer compared to EM are completely irrelevant (We do complicated procedures, we read images, we make complicated treatment plans, its non-algorithmic etc, we have BRAND NAMES!! TOTAL NONSENSE). If you generate more bodies than there is demand all other things constant you will face either unemployment falling salaries or both and mid levels are basically marketing themselves as your equal and govts are buying what they're selling.

20 years ago MDs would have had a conniption if an NP was seen doing cardiac caths or colonoscopy or giving radiographers a crack at cross sectional imaging= but guess what they are training them at places like Duke, Yale, and Penn.

I really hope your house is paid off and your kids 529s are nice and fat and that you have enough in the retirement kiddy

 

[xenotype]

Think we're comparing apples and pinecones here. As you pointed out, neurology and ER are non-analogous and while we should be wary, there's less to worry about than ER, which got totally saturated with young residents looking for a rush.

On fellowships: I used to think that it was regrettable when neurologists would forsake general training to go into sub-specialties. I still think one should stay general. At the same time, consider that 20 years ago getting a neuro-interventional job was impossible, like literally impossible. There was no neuromonitoring. Neuro-ICUs were barely a thing, mostly under ICU-pulm with neuro consults. My job (running clinical trials) was very rare. Pain mgmt, with neurologists doing mostly injections was very rare. VERY few PD patients got implants. So new jobs are actually being created within the field, extending and deepening neurologic services. Imagine if an Alzheimer's disease modifying drug gets approved or if brain-machine interface takes off for stroke/SCI.

I also think that neuro patient needs are basically infinite. If you're a HA doctor, you could book those folks Qweek for a year and most would show up. The ER has fairly static supply. Although it feels to you, when you need an ER, that this is a weird one time break/cut/fall/admit, on a population level it is the same % bad events per day. Neurology patients are always underserved. Our diseases are common and distressing.

In terms of takeaways: either get protected in academics/research, or get private. Hospitals will want to replace you with a compliant NP tomorrow. I also think neurologists in the future MUST adapt. This means that you have to start adopting things that make you indispensable and cannot be done by an NP. If you do peripheral, for example, you must learn to do US and skin bx, and personally I'd even try to learn how to do CTS surg.

Academics is in no way protected. Research is, and is highly specialized. Hospitals cannot at this time replace that many neurologists. I've never heard of a single hospital having an independent midlevel signing off on initial consults (even for silly stuff) by themselves with no attending input. Any hospital that did take such an approach opens themselves up to liability via their credentialing committee should anyone sue, and we are not a low liability specialty. Follow-ups sure they can bill independently. Of course this could change over time, but we don't do the same job as the PA in the fast track in the ED, or the CRNA in the OR that the patient barely remembers. Family absolutely care about grandpa's neurologist when it comes time to weigh in on prognosis on a consult.

As for demand- entirely agree. Almost everyone will need a neurologist at some point in their life unlike many specialties, and many conditions are chronic with patients preferring to see us much more frequently than our schedules permit.

After reading the reasons why Neuro can't go the way of EM, I am now more convinced it can and will go the way of EM.

When you're employed by the hospital and rest assured most of you will be: Nobody cares about your brand or where you went to school especially if the C-suite is actively contemplating replacing you with an NP.

You aren't a neurologist and thus don't understand the specialty. Someone has to sign on the dotted line for tPA, write the EEG reports, and tell the family whether Grandpa might ever wake up. Someone has to say yes, it is ALS. These things carry significant legal liability just like radiology reports do, and the hospital themselves face liability for whomever they credential to do these things accurately. People are already suspicious of the 'local neurologist' compared to the nearest Miracle Whip offshoot. Second, third opinions are very common in our specialty and people will drive 3 hours to get them, or have Grandpa transferred to another hospital to get it. It isn't radiology where no patient knows your name, or ever even meets you.

 

[deleted941485]

Academics is in no way protected. Research is, and is highly specialized. Hospitals cannot at this time replace that many neurologists. I've never heard of a single hospital having an independent midlevel signing off on initial consults (even for silly stuff) by themselves with no attending input. Any hospital that did take such an approach opens themselves up to liability via their credentialing committee should anyone sue, and we are not a low liability specialty. Follow-ups sure they can bill independently. Of course this could change over time, but we don't do the same job as the PA in the fast track in the ED, or the CRNA in the OR that the patient barely remembers. Family absolutely care about grandpa's neurologist when it comes time to weigh in on prognosis on a consult.

As for demand- entirely agree. Almost everyone will need a neurologist at some point in their life unlike many specialties, and many conditions are chronic with patients preferring to see us much more frequently than our schedules permit.


You aren't a neurologist and thus don't understand the specialty. Someone has to sign on the dotted line for tPA, write the EEG reports, and tell the family whether Grandpa might ever wake up. Someone has to say yes, it is ALS. These things carry significant legal liability just like radiology reports do, and the hospital themselves face liability for whomever they credential to do these things accurately. People are already suspicious of the 'local neurologist' compared to the nearest Miracle Whip offshoot. Second, third opinions are very common in our specialty and people will drive 3 hours to get them, or have Grandpa transferred to another hospital to get it. It isn't radiology where no patient knows your name, or ever even meets you.

No you do not understand, I have heard all of this before and the arguments are not all that convincing. The best that neurologist can hope for in the future is becoming a liability sponge while the multiple MLPs while they push the tPa, do the consults, place the orders, and "collaborate" on cases with you.

As for the driving 3 hours for a consultation maybe that will fly in the real remote parts of this wonderful country but seriously telehealth is here to stay and expertise that was largely confined to the academia can now be available to the dark corners of the country.

You're right its not radiology and trust me they, its a clinic based patient facing specialty that carries many of the same risks that other fields where MLPs have taken the reins.

 

[neglect]

1. "I'm Private" - sure for now
2. Admins - thanks for making my point - They'll roll the dice if it means a bigger bonus. I don't think you fully understand the pure singular focus on bottom line that exists in admin world. Everything else is about what they can get away with. Even if it means sacrificing a family member or two to save a buck.
3. Make a case: Do you just lurk the neuro forums? The bottom line is over training...every other argument made on here regarding the reasons neuro would be safer compared to EM are completely irrelevant (We do complicated procedures, we read images, we make complicated treatment plans, its non-algorithmic etc, we have BRAND NAMES!! TOTAL NONSENSE). If you generate more bodies than there is demand all other things constant you will face either unemployment falling salaries or both and mid levels are basically marketing themselves as your equal and govts are buying what they're selling.

20 years ago MDs would have had a conniption if an NP was seen doing cardiac caths or colonoscopy or giving radiographers a crack at cross sectional imaging= but guess what they are training them at places like Duke, Yale, and Penn.

I really hope your house is paid off and your kids 529s are nice and fat and that you have enough in the retirement kiddy

1. Seriously try to back up your statement. Your claim must be that 100% of neurologists will join hospitals in order to include someone you don't know. How? Our practice HIRES extenders BTW. So I know a bit about their limitations from an admin level.

2. My opinion of hospital admins is very low, but I think you perhaps need to get off this forum if you think they will sacrifice 'a family member or two to save a buck.' Seriously chill out and stop being hard on yourself. Life might be hard for you. Perhaps your expectations didn't mesh with reality very well. Adapt and overcome, but first go for a walk and take stock of your life. Personal note: I fully support you. I might not know your situation, but you're a doc, which means you have a combination of smarts, hard work, diligence and ability that puts you in the 99th%ile. We all face professional challenges, and perhaps a pair of ears from outside your field could help. DM me here.

3. I TOTALLY agree that extenders are horrible for physicians. We are on the same page here. What the AAN and academic institutions permit is nothing short of abomination. That said, and remember that as part of private practice I AM an admin: when we hire a NP/PA they cannot fill as an outpatient to do general neuro. They only fill for headache, where the need appears infinite.

For anyone listening, sadly RadsWFA1900 has a point: the extenders are coming for neurology (and psych, and FM, and peds, and caths and rads). Aside from lowering employed physician salaries (due to cheaper labor) and insurance payments (increased supply, ease of performing task), this is devastating for patients, including vulnerable populations neurologists care for: mentally impaired with seizures, dementia, and those suffering with mental illness.

It is also horrible for the system, since data shows that extenders overutilize and overprescribe, so their personal cost savings are offset by ordering an MRI on all migraine patients (and if they just have the J&J shot, then MRVs!). This actually helps hospital systems, so they don't care. But we should, because, again, it causes financial hardship for patients.

The AAN is having their mess of a conference now. And I'm happy to report that I quit the AAN based on their statement that extenders are 'pretty much the same' as doctors. I encourage everyone reading this to fight this extender creep. Since it came up, personally I live well below my income, the 529s are good. I'm going to be fine, but the next generation will NOT be.

Academics is in no way protected. Research is, and is highly specialized. Hospitals cannot at this time replace that many neurologists. I've never heard of a single hospital having an independent midlevel signing off on initial consults (even for silly stuff) by themselves with no attending input. Any hospital that did take such an approach opens themselves up to liability via their credentialing committee should anyone sue, and we are not a low liability specialty. Follow-ups sure they can bill independently. Of course this could change over time, but we don't do the same job as the PA in the fast track in the ED, or the CRNA in the OR that the patient barely remembers. Family absolutely care about grandpa's neurologist when it comes time to weigh in on prognosis on a consult.

As for demand- entirely agree. Almost everyone will need a neurologist at some point in their life unlike many specialties, and many conditions are chronic with patients preferring to see us much more frequently than our schedules permit.


You aren't a neurologist and thus don't understand the specialty. Someone has to sign on the dotted line for tPA, write the EEG reports, and tell the family whether Grandpa might ever wake up. Someone has to say yes, it is ALS. These things carry significant legal liability just like radiology reports do, and the hospital themselves face liability for whomever they credential to do these things accurately. People are already suspicious of the 'local neurologist' compared to the nearest Miracle Whip offshoot. Second, third opinions are very common in our specialty and people will drive 3 hours to get them, or have Grandpa transferred to another hospital to get it. It isn't radiology where no patient knows your name, or ever even meets you.

Yeah, I should have been clear about what I meant by academics: in a research setting, salary protected with funding from grant/charity or in an admin position like program director. If you're in 'academics' and see patients all day, then you might as well work for a huge hospital system. There's essentially no difference. In fact, it is probably worse.

 

[xenotype]

No you do not understand, I have heard all of this before and the arguments are not all that convincing. The best that neurologist can hope for in the future is becoming a liability sponge while the multiple MLPs while they push the tPa, do the consults, place the orders, and "collaborate" on cases with you.

As for the driving 3 hours for a consultation maybe that will fly in the real remote parts of this wonderful country but seriously telehealth is here to stay and expertise that was largely confined to the academia can now be available to the dark corners of the country.

You're right its not radiology and trust me they, its a clinic based patient facing specialty that carries many of the same risks that other fields where MLPs have taken the reins.

I'll ask you one question. Why do people consult neurologists? Our entire specialty only exists for hand holding other physicians, patients, and serving as a liability sponge. They don't need to consult us, but they do. If midlevels themselves, hospital credentialing committees, patients and families, and their malpractice lawyers believe our 'overtraining' adds nothing then that's fine. Neurology scares the hell out of people, and often they want second opinions, reassurance, or other options. Often we don't know exactly what is going on, but have a better clue than anyone else. I just provide opinions, if people don't want my opinion they can pay someone else less, or not pay anyone at all. I'll adapt or find something else to do, but for now I enjoy neurology. Radiology will face some of the same pressures and has already suffered from a really terrible job market and declining reimbursements- there is no non-surgical specialty that is completely safe.

 

[deleted941485]

I'll ask you one question. Why do people consult neurologists? Our entire specialty only exists for hand holding other physicians, patients, and serving as a liability sponge. They don't need to consult us, but they do. If midlevels themselves, hospital credentialing committees, patients and families, and their malpractice lawyers believe our 'overtraining' adds nothing then that's fine. Neurology scares the hell out of people, and often they want second opinions, reassurance, or other options. Often we don't know exactly what is going on, but have a better clue than anyone else. I just provide opinions, if people don't want my opinion they can pay someone else less, or not pay anyone at all. I'll adapt or find something else to do, but for now I enjoy neurology. Radiology will face some of the same pressures and has already suffered from a really terrible job market and declining reimbursements- there is no non-surgical specialty that is completely safe.

Why do people consult neurologists? Why does anyone consult for anything? So that Providers (Yes providers because in this day and age it doesn't even matter if the patient is admitted by an DNP, MD or PA) to cover their ass and they don't have time or expertise to sit there and manage the problem themselves. Its not that hard to imagine a world where a neurology MLP hand holds the admitting MLP and an MD who never saw the patient signs off on the whole thing. This is not the future this is happening right now. Admins are gonna push this concept as far as they can get away with it.

I really hope you have as good a gig lined up. Id hate for someone to be like 50 years old and jump ship for another career. Lots of ageism out there to say nothing of the fact that you'll be starting at the bottom.

 

[Telamir]

Hey man, I gave you the benefit of the doubt but you do nothing but be contrarian on every single post, and there's nothing but doom-porn to your posts. People here have tried to debate/discuss with you but you're just being a little bitch about it.

I guess what I'm trying to say is...**** off.

 

[deleted941485]

Hey man, I gave you the benefit of the doubt but you do nothing but be contrarian on every single post, and there's nothing but doom-porn to your posts. People here have tried to debate/discuss with you but you're just being a little bitch about it.

I guess what I'm trying to say is...**** off.

Hey man. Sorry if you're feelings were hurt. Wake me up when you have an actual point to make that refutes my argument.

 

[Postictal Raiden]

Hey man, I gave you the benefit of the doubt but you do nothing but be contrarian on every single post, and there's nothing but doom-porn to your posts. People here have tried to debate/discuss with you but you're just being a little bitch about it.

I guess what I'm trying to say is...**** off.

Just take a look at his/her post history and you’ll get the picture.

 

[neglect]

Hey man. Sorry if you're feelings were hurt. Wake me up when you have an actual point to make that refutes my argument.

You have less of an argument than an outlook, a prediction where you come off as an angry and depressive troll. I don’t want to insult, but your posts make me think you’d benefit from a career change and even professional help. Please take care of yourself. And again, despite any differences here, as a doctor you have my respect and I’d be happy to talk to you in real life. But your catastrophic Cassandra certainty just doesn’t square with the reality.

You’re taking a very real problem: extenders taking jobs, and pretending that current trends will continue, so you can wallow in a post-apocalypse fiction. Your supportive “argument” is that admins want their hospital systems to make money and will replace doctors with extenders. Forgive me for not agreeing with you, giving up now, and going back to PA school. I’ve been hearing about the end of medicine for over 20 years, this is just a new wrinkle.

So the reality is that yes, this is a problem. But why should we suppose current trends will continue? Because, in part, extenders are terrible. If neurologists are over trained (I’m a sub specialist, not even sure I agree), then extenders are woefully undertrained. As they make more and more mistakes, they will kill and maim more and more people. Some of these people will be connected to the politicians who legislated allowing unsupervised extenders, we will realize that medicine is hard, pendulum will swing back. Practicing medicine without a license is and should be illegal, now and always.

As far as admins, yes, most are terrible. But doctors are not terrible. We are some of the brightest minds and we hold the reins.

 

[scoopdaboop]

Look at family medicine. It's interesting because a lot of doom and gloom is about ER/CRNA but in family medicine, NP/PA have probably even more leeway. They can open their own practice etc, but Family medicine physicians are still very much in demand... Why is this the case for FM but not ER docs and anesthesiologists? Hospitals don't care if ER midlevels are referral monkeys, and anesthesia adverse outcomes are super low. I think specialties like cardio, GI, Heme-onc, neuro are pretty safe, because there's a whole lot of experience to be learned that drive decisions.

 

[neglect]

Look at family medicine. It's interesting because a lot of doom and gloom is about ER/CRNA but in family medicine, NP/PA have probably even more leeway. They can open their own practice etc, but Family medicine physicians are still very much in demand... Why is this the case for FM but not ER docs and anesthesiologists? Hospitals don't care if ER midlevels are referral monkeys, and anesthesia adverse outcomes are super low. I think specialties like cardio, GI, Heme-onc, neuro are pretty safe, because there's a whole lot of experience to be learned that drive decisions.

Good point, if a neurologist doc cannot compete with an NP or PA, they need to look inward.

Docs are likely top of class in college, then 4 years med school, then an internship, then 3 years residency and likely a fellowship. NP's are NOT top of class, 2 year weak school, no residency.

 

[curiousneuro]

At the end of the day - it seems that NP/PAs don't even learn really anything about neuro in school, and are very unlikely to make a push for independent practice in neurology without a SIGNIFICANT amount of post-school experience. And these midlevels seem to very few and far between.

Contrast that with EM/FM - midlevels feel (wrongly, but still) that they can independently practice in these areas because they can just shotgun tests and consults. And that's the general medicine to which they are exposed to...unlike neurology.

 

[sharkbaitwhohaha]

Good discussion. Likely, midlevels won't be the end of neurologists. The rapid expansion of neurology residencies might. (AANP and AAN need to be controlled)

 

[xenotype]

Why do people consult neurologists? Why does anyone consult for anything? So that Providers (Yes providers because in this day and age it doesn't even matter if the patient is admitted by an DNP, MD or PA) to cover their ass and they don't have time or expertise to sit there and manage the problem themselves. Its not that hard to imagine a world where a neurology MLP hand holds the admitting MLP and an MD who never saw the patient signs off on the whole thing. This is not the future this is happening right now. Admins are gonna push this concept as far as they can get away with it.

I really hope you have as good a gig lined up. Id hate for someone to be like 50 years old and jump ship for another career. Lots of ageism out there to say nothing of the fact that you'll be starting at the bottom.

The MD signing off on the whole thing takes the liability. If this is a PD consult- continue meds, sure seeing the patient is a waste of the attending's time. An AMS consult without a readily apparent etiology? Totally different situation. There are hospitals now that function without neurologists and either provide substandard care or end up quickly transferring most of their patients that have any neurological issue. Putting a 'neurology' midlevel in with limited experience will result in the same outcome, or a lawsuit against the hospital and midlevel when the patient dies or the family figures out they weren't taken care of properly. Again, you haven't convinced anyone here the sky is falling. Inexperienced midlevels provide really awful care in neurology, and this becomes very apparent when patients inevitably are referred to larger/academic centers. A very experienced midlevel can be somewhat autonomous in a specific subspecialty, but they completely fall apart when covering general neurology issues and I haven't seen a single 'experienced' midlevel that wasn't terrified when dealing with a general neurology issue outside their sub-specialty. This isn't like CRNAs where the patient either wakes up or they don't. We deal with huge grey areas, and patients frequently get referred elsewhere later where if you've massively screwed up it's pretty obvious you were clueless.

At the end of the day - it seems that NP/PAs don't even learn really anything about neuro in school, and are very unlikely to make a push for independent practice in neurology without a SIGNIFICANT amount of post-school experience. And these midlevels seem to very few and far between.

Contrast that with EM/FM - midlevels feel (wrongly, but still) that they can independently practice in these areas because they can just shotgun tests and consults. And that's the general medicine to which they are exposed to...unlike neurology.

This. Fear of neurological problems is why we have a job, and for whatever reason the fear of neurology is quite high outside our specialty. They don't have to consult us, but they love the ability to do so. Anything weird goes into the 'maybe its neurological box'. Neurology midlevels follow protocols especially in subspecialties, but is very hard in neurology to only practice in a subspecialty and not face general neurology questions- especially if on call or in a small group. Any patient that deviates from the protocol they get scared. Or, they don't get scared and screw up the diagnosis and management, and it is painfully obvious after the fact to the pissed off family and the new neurologist. Patients that didn't read the textbook are very common in neurology as is misdiagnosis. Sometimes misdiagnosis is catastrophic, like Wilsons.

 

[Thama]

This. Fear of neurological problems is why we have a job, and for whatever reason the fear of neurology is quite high outside our specialty. They don't have to consult us, but they love the ability to do so. Anything weird goes into the 'maybe its neurological box'. Neurology midlevels follow protocols especially in subspecialties, but is very hard in neurology to only practice in a subspecialty and not face general neurology questions- especially if on call or in a small group. Any patient that deviates from the protocol they get scared. Or, they don't get scared and screw up the diagnosis and management, and it is painfully obvious after the fact to the pissed off family and the new neurologist. Patients that didn't read the textbook are very common in neurology as is misdiagnosis. Sometimes misdiagnosis is catastrophic, like Wilsons.

The more algorithmic a specialty, the more attractive it is to midlevels. A huge fractiion of the work in specialties like OB and cardiology can be reduced to a series of flowsheets, while very little of what we do outside of acute stroke works that way.

 

[deathmerchant]

Midlevels are here to stay. I think they do have a role in healthcare but it is not of an 'independent provider'.
We should come up with a list of things that every MS/Resident/Attending should do to make sure they are not doing things they shouldn't be doing like compromising student/resident learning and experience, affecting patient care, and try to compete with physicians for jobs!

I have worked with NPs and trained some. Needless to say the knowledge gap is dramatic and dangerous.
Did it for 6 months and have refused to take on any more NPs now. I told them- "I don't think I know how to train or evaluate Nurses"

I also make sure I tell all the med students rotating with me about these issues. Also talk to other physicians who are naive or too optimistic about this situation.
I try to enlighten any friends and family and sometimes on online forums like reddit about the dangers of MLPs.
Also try to only communicate with other physicians rather than MLPs about consults/referrals.

If you guys have more ideas let me know.

 

[deathmerchant]

One thing I've noticed with MLPs becoming more common in ER and Primary care is that it has actually increased neurology consults/referrals that I get for obvious reasons.

 

[stevresidentp]

Excellent discussion. Any thoughts on what sub speciality should be avoided in neurology due to the above issues ?

 

[Postictal Raiden]

Excellent discussion. Any thoughts on what sub speciality should be avoided in neurology due to the above issues ?

I’m in the mindset that the existence of midlevels is due to and fueled by shortage of physicians. Avoiding a field would only exacerbate this problem.

 

[stevresidentp]

I’m in the mindset that the existence of midlevels is due to and fueled by shortage of physicians. Avoiding a field would only exacerbate this problem.

I think the reason of the discussion is to provide information on the current outlook of the field. It’s up to the individual to decide if they want to “fight” or detour.

 

[Thama]

Midlevels in subspecialties are facilitated by algorithmic medicine. The more algorithmic you can make a field, the more you're likely to see midlevels there. Headache, epilepsy, and sleep are the areas in neurology most vulnerable to this (minimal physical exam required, only a few different well-defined pathways capture 99% of your referrals), while fields like movement and neuromuscle are likely to remain highly resistant though not impregnable.

 

[xenotype]

Midlevels in subspecialties are facilitated by algorithmic medicine. The more algorithmic you can make a field, the more you're likely to see midlevels there. Headache, epilepsy, and sleep are the areas in neurology most vulnerable to this (minimal physical exam required, only a few different well-defined pathways capture 99% of your referrals), while fields like movement and neuromuscle are likely to remain highly resistant though not impregnable.

Mostly agree with caveats which I suspect you'll agree with. My center has experienced midlevels in movement and NM that are somewhat autonomous- the midlevels involved have years of experience and only see patients with those problems. They also are quick to involve attendings when it isn't clear what is going on, which is frequent in NM and movement for obvious reasons. Agree that headache is very formulaic and very hard to harm a patient in. Sleep clinic is easy, and sleep studies are easy but I doubt midlevels have an easy way in to reading sleep studies. Epilepsy clinic is easy and very formulaic. Reading EEGs well is not easy at a level IV center. Deciding on surgical plans and really knowing seizure semiology, taking a careful enough history and EEG video review to find the onset zone is not easy at all. A miss on the high end of level IV epilepsy practice is an easy lawsuit when the family is incredibly devastated they still have seizures, and now have some new memory deficits too post-op. The clinic part a midlevel can easily do, but most epileptologists don't like clinic anyways. There's no real route into reading EEGs other than doing an neurology residency and either having the appropriate fellowship training or just making stuff up which plenty of neurologists get away with but very doubtful a midlevel could get paneled or credentialed to do.

 

[Thama]

I agree with your caveats - we have an NP that is semi-autonomous but with a decade plus of experience, and even still a) only sees follow-ups, routing notes to the MD to ensure we know what she did (and thus can make changes if needed), and b) has an extremely narrow clinical focus. Having mostly NPs rather than MDs would not be possible in movement - but having a couple that can help in a narrowly defined role can be useful.