Full Practice Authority

[Sailor Senshi Dermystify]

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Recently, Cali approved the full practice authority bill. Is this an issue in dermatology? If so, what is the AAD doing to combat this and how will this effect future derm hopefuls?

Thanks!

 

[asmallchild]

Recently, Cali approved the full practice authority bill. Is this an issue in dermatology? If so, what is the AAD doing to combat this and how will this effect future derm hopefuls?

Thanks!

Is this an issue in dermatology?

Yes and no. It is never a good thing to grant a mid level the ability to practice medicine independently. That being said, this is nothing new. There are 22 states that already have this in place. If you practice in one of those states, it should not be difficult to be significantly better than those competitors if you are a board certified dermatologist. Or practice in a state that doesn’t allow mid levels to practice independently.

what is the AAD doing to combat this

I don’t know what the AAD is doing to fight this. Historically they have been very good fighting off encroachment. That being said, the landscape in dermatology and AAD leadership is rapidly changing so it is something we all need to keep an eye on.

- Sign the Petition
- Sign the Petition

how will this effect future derm hopefuls?

It won't. Dermatology will still be very competitive. I would not count on this as a way to "lessen" the competition. If anything, it should inspire derm hopefuls (and hopefully, current dermatologists) to work hard, be good at what they do, and fight hard for what is best for our patients and what is best for our specialty (it's interesting how those 2 are typically well - aligned and it's very obvious why people veer away)

 

[avidrapper]

I strongly counter the above statement.

Expanding midlevel practice authority doesn’t hurt the old guard of dermatology (those who entered into practice 50-5 years ago). But it is really hurting dermatologists entering the field now.

In the past five years there has been a flood of midlevels in the market who can practice (at least in the eyes of corporate entities) the same as a physician.

For new dermatology attendings entering into practice, good jobs are really hard to find. Salaries have been stagnant, partnership opportunities are nonexistent, and the role of a dermatologist is very focused on how many RVU’s you can generate. It makes sense, why hire a derm when you can hire an NP to do the same work for less?

It’s affecting every field of medicine. Derm is still a great field, but the lifestyle value is trending downward and mid levels are a strong factor in that.

 

[asmallchild]

I strongly counter the above statement.

Expanding midlevel practice authority doesn’t hurt the old guard of dermatology (those who entered into practice 50-5 years ago). But it is really hurting dermatologists entering the field now.

In the past five years there has been a flood of midlevels in the market who can practice (at least in the eyes of corporate entities) the same as a physician.

For new dermatology attendings entering into practice, good jobs are really hard to find. Salaries have been stagnant, partnership opportunities are nonexistent, and the role of a dermatologist is very focused on how many RVU’s you can generate. It makes sense, why hire a derm when you can hire an NP to do the same work for less?

It’s affecting every field of medicine. Derm is still a great field, but the lifestyle value is trending downward and mid levels are a strong factor in that.

It is amusing to be considered part of the old guard now 🙂

Admittedly, I have not been on a job hunt in > 5 years (and maybe that gap in time blinds me) but many of the issues you've mentioned were issues back then.

"Back in my day":
- good jobs were still hard to find. We were taught even as residents that the best jobs are found by word of mouth. Because they don't need to be otherwise advertised.
- I was taught to view salaried positions (particularly high salaried positions) with caution. The fairest setup in an employer / employee situation is ultimately one based off of productivity with a salary perhaps to buy time for both sides to get to know each other. I can't speak to whether or not salaries have stagnated but I have noticed that when we interview graduating residents ; they keep floating higher and higher salary numbers that are simply not realistic when compared against their anticipated productivity.
- good partnership opportunities were still rare, I can see this one being more pronounced with the proliferation of PE but not sure what mid-levels have to do with this
- how "good" you were, particularly in a private practice environment, focused more on how productive you were as opposed to the quality of care rendered. This has always been the case in private practice.

In the end, I do not think we are disagreeing. I do think expanding midlevel practice authority is a mistake. I do think it will hurt the field (and in particular, patients) in the long run. I think it will hurt medicine in general in the long run. But as you said, this is a problem almost every other field faces. Where we may differ is that I do not think the damage to dermatology specifically is as catastrophic as others make it out to be. I certainly do not think it will make applying for a dermatology residency less competitive.

Having previously worked for a PE-owned group, I can also say that while the group obviously makes more money off the mid level than a physician, a well-qualified physician (particularly one willing to oversee midlevels) is also worth its weight in gold to the practice. Our strongest recruitment pitches were geared towards these physicians. Perhaps location played a role but I also found we had very well-educated patients. The patients themselves had a very good handle on what they would allow the midlevel to see and what they insisted the physician would see. I supervised 4 midlevels and when it came down to complex medical derm, excisions, Mohs (obviously), and cosmetics, most patients ended up insisting on seeing me. I'd like to think being a well-trained dermatologist made a difference. But the point is, even if my state allowed for independent midlevel practice, even a ruthlessly number focused PE-owned group couldn't have simply replaced me with a midlevel. There will always be a place for good physicians.

 

[avidrapper]

It is amusing to be considered part of the old guard now 🙂

Admittedly, I have not been on a job hunt in > 5 years (and maybe that gap in time blinds me) but many of the issues you've mentioned were issues back then.

"Back in my day":
- good jobs were still hard to find. We were taught even as residents that the best jobs are found by word of mouth. Because they don't need to be otherwise advertised.
- I was taught to view salaried positions (particularly high salaried positions) with caution. The fairest setup in an employer / employee situation is ultimately one based off of productivity with a salary perhaps to buy time for both sides to get to know each other. I can't speak to whether or not salaries have stagnated but I have noticed that when we interview graduating residents ; they keep floating higher and higher salary numbers that are simply not realistic when compared against their anticipated productivity.
- good partnership opportunities were still rare, I can see this one being more pronounced with the proliferation of PE but not sure what mid-levels have to do with this
- how "good" you were, particularly in a private practice environment, focused more on how productive you were as opposed to the quality of care rendered. This has always been the case in private practice.

In the end, I do not think we are disagreeing. I do think expanding midlevel practice authority is a mistake. I do think it will hurt the field (and in particular, patients) in the long run. I think it will hurt medicine in general in the long run. But as you said, this is a problem almost every other field faces. Where we may differ is that I do not think the damage to dermatology specifically is as catastrophic as others make it out to be. I certainly do not think it will make applying for a dermatology residency less competitive.

Having previously worked for a PE-owned group, I can also say that while the group obviously makes more money off the mid level than a physician, a well-qualified physician (particularly one willing to oversee midlevels) is also worth its weight in gold to the practice. Our strongest recruitment pitches were geared towards these physicians. Perhaps location played a role but I also found we had very well-educated patients. The patients themselves had a very good handle on what they would allow the midlevel to see and what they insisted the physician would see. I supervised 4 midlevels and when it came down to complex medical derm, excisions, Mohs (obviously), and cosmetics, most patients ended up insisting on seeing me. I'd like to think being a well-trained dermatologist made a difference. But the point is, even if my state allowed for independent midlevel practice, even a ruthlessly number focused PE-owned group couldn't have simply replaced me with a midlevel. There will always be a place for good physicians.

I appreciate you writing this out. We are on the same page that expansion of midlevel practice hurts medicine as a whole and dermatology as a field isn't hurt more or less than any other field.

That being said, as a physician entering into the market soon, mid levels have directly impacted my ability to negotiate salary. My maximum production is simply the number of patients I can see, not the quality of care I provide or the number of years of training I have. Obviously, I have an eye for providing high quality care but doing less biopsies and spending more time on complicated patients is the opposite of what gets me paid.

It's easy for me to hit 500k in production when I am seeing simple biopsies and followups that can take 5-10 minutes. The issue is that midlevels have taken the easy cases, leaving physicians with more complicated, time intensive patients. If I go to a practice with midlevels and say I want to see 30 patients in a half day they would laugh because the easy 5 minute patients are taken by the midevels.

It's a problem with our entire healthcare system. But we still live in a production based world. The more people who can produce RVUS (PA's, NP's, etc.) the greater the supply and the reduction in demand for everyone else, dermatologists included.

 

[Dr. Trafalgar Law]

So then, knowing that the current midlevel situation is only going to continue to grow, as NPs/PAs are graduated by the tens of thousands each year, would doing a fellowship (be it in Mohs surgery or dermpath) be a good way for a new dermatologist to insulate themselves from this growing encroachment by midlevels?

 

[asmallchild]

I appreciate you writing this out. We are on the same page that expansion of midlevel practice hurts medicine as a whole and dermatology as a field isn't hurt more or less than any other field.

That being said, as a physician entering into the market soon, mid levels have directly impacted my ability to negotiate salary. My maximum production is simply the number of patients I can see, not the quality of care I provide or the number of years of training I have. Obviously, I have an eye for providing high quality care but doing less biopsies and spending more time on complicated patients is the opposite of what gets me paid.

It's easy for me to hit 500k in production when I am seeing simple biopsies and followups that can take 5-10 minutes. The issue is that midlevels have taken the easy cases, leaving physicians with more complicated, time intensive patients. If I go to a practice with midlevels and say I want to see 30 patients in a half day they would laugh because the easy 5 minute patients are taken by the midevels.

It's a problem with our entire healthcare system. But we still live in a production based world. The more people who can produce RVUS (PA's, NP's, etc.) the greater the supply and the reduction in demand for everyone else, dermatologists included.

I'm sorry to hear that. Is this a theoretical difficulty in negotiating salary? Or are you in the midst of the process and having significant difficulty?

I had plenty of difficulties during my job search (and quite a few stories to retell from the process) but mid-level encroachment really did not pose a problem (again, this is 5+ years ago. Or maybe, I just didn't know of a hidden role it may have played with my job search difficulties)

 

[asmallchild]

So then, knowing that the current midlevel situation is only going to continue to grow, as NPs/PAs are graduated by the tens of thousands each year, would doing a fellowship (be it in Mohs surgery or dermpath) be a good way for a new dermatologist to insulate themselves from this growing encroachment by midlevels?

Sure, the more things you can do, the better equipped you will be to insulate from encroachment.

That factor alone would not me enough to push me into a fellowship and give up a year of attending salary. I think it is more important that you have genuine interest in the fellowship and ideally, an idea of how you will include that fellowship training into your future practice.

I think one of the frustrations with mid level encroachment is that it obviously has nothing to do with qualifications and everything to do with financial benefit. So a year of fellowship will make you that much more qualified than a mid level but may do nothing to give you a leg up for a group that is hellbent on extracting every last dollar of benefit out of a healthcare provider (ie. the less qualified mid level will still win out because the group doesn't have to pay the mid level as much)

 

[PhillyMed777]

The issue is that midlevels have taken the easy cases, leaving physicians with more complicated, time intensive patients.

This is so true.

PA/NP schedule vs our resident/attending schedules look like completely different fields.
ALL easy stuff goes to the NP/PA schedules and we are left with complex med derm patients failing multiple immunosuppressive meds, and when it's finally a skin check, it's someone who has a complex and long list of skin cancers. I can only speak for myself, but this kind of program/set-up strongly discourages residents to stick to clinical derm, much so academic derm. It pushes people into fellowships or into private practice.

 

[yungspleen]

I'm sorry to hear that. Is this a theoretical difficulty in negotiating salary? Or are you in the midst of the process and having significant difficulty?

I had plenty of difficulties during my job search (and quite a few stories to retell from the process) but mid-level encroachment really did not pose a problem (again, this is 5+ years ago. Or maybe, I just didn't know of a hidden role it may have played with my job search difficulties)

Can you discuss the difficulties? Finding jobs in a desired area? Or just low salary offers?

 

[ddcg]

 

[avidrapper]

I'm sorry to hear that. Is this a theoretical difficulty in negotiating salary? Or are you in the midst of the process and having significant difficulty?

I had plenty of difficulties during my job search (and quite a few stories to retell from the process) but mid-level encroachment really did not pose a problem (again, this is 5+ years ago. Or maybe, I just didn't know of a hidden role it may have played with my job search difficulties)

Im in the midst of the process. I wouldn't say it's "significant difficulty" but it is a noticeable difference than my friends who entered the field several years ago. The starting salaries are mostly the same (350k starting + production giving an average 5 day work week 450k annually in an urban area), but no partnership opportunity, more call required (yes, home call answering the phone, but still), and generally more complicated patients.

Derm is still an amazing lifestyle but I'm more concerned about the trend. Medicine as a whole is trending downwards for physicians and upwards for midlevels - derm is not insulated from this trend. Ten years from now, when the PE firms have bought up all the practices and midlevels have their own cosmetic and biopsy clinics, what will be left for those coming into the field?

We're already seeing that in Mohs - oversaturation making a "full-time" Mohs position after fellowship nonexistent (granted, this isn't a midlevel issue but more to demonstrate that supply and demand play huge roles in any area of practice).

 

[yungspleen]

We're already seeing that in Mohs - oversaturation making a "full-time" Mohs position after fellowship nonexistent (granted, this isn't a midlevel issue but more to demonstrate that supply and demand play huge roles in any area of practice).

So what would you say is a better career just in terms of outlook for physicians in 25 years...rads or derm

 

[avidrapper]

So what would you say is a better career just in terms of outlook for physicians in 25 years...rads or derm

No idea. Pick the one you wouldn't mind doing for half the salary and you'll be fine either way.

 

[reno911]

That being said, as a physician entering into the market soon, mid levels have directly impacted my ability to negotiate salary. My maximum production is simply the number of patients I can see, not the quality of care I provide or the number of years of training I have.

I was actually going to post something about this point a few days ago, but I never got around to it.

Here's the thing. This has nothing to do with midlevels.

One thing that has always been true and likely will be is that the quality of care you provide is of very little concern to most employers. Sure, they would prefer someone who is better, but it's next to impossible to judge how good someone is based on some interviews and references. Especially for someone who is just coming out of residency.

What really matters (to employers) is how productive you can be, if you get along with everyone else, and if your patients like you and are satisfied (and you have to have at least some level of competence to do that). Your clinical acumen and technical skill are a lot farther down on the list of the priorities for employers. That's just the way it is and it was always like that even before the mid-level explosion. It's unfortunate, but we can't really blame midlevels for that.

 

[Private_MD]

Yes and no. It is never a good thing to grant a mid level the ability to practice medicine independently. That being said, this is nothing new. There are 22 states that already have this in place. If you practice in one of those states, it should not be difficult to be significantly better than those competitors if you are a board certified dermatologist. Or practice in a state that doesn’t allow mid levels to practice independently.



I don’t know what the AAD is doing to fight this. Historically they have been very good fighting off encroachment. That being said, the landscape in dermatology and AAD leadership is rapidly changing so it is something we all need to keep an eye on.

- Sign the Petition
- Sign the Petition



It won't. Dermatology will still be very competitive. I would not count on this as a way to "lessen" the competition. If anything, it should inspire derm hopefuls (and hopefully, current dermatologists) to work hard, be good at what they do, and fight hard for what is best for our patients and what is best for our specialty (it's interesting how those 2 are typically well - aligned and it's very obvious why people veer away)

So I don't get this. Why are we allowing non doctors to practice as doctors? I'm not a dermatologist but same issue across specialties. Why are we as physicians going through all these hoops to then have nurses essentially practice as doctors with 1/4 of the training? Why are we taking steps, and MCAt, and going to med school, and boards? Why not cut down on a bunch of all this nonsense then? why are we having a double standard?

 

[asmallchild]

Can you discuss the difficulties? Finding jobs in a desired area? Or just low salary offers?

It is very similar to what has already been mentioned.

Finding a job is fortunately fairly easy in dermatology, finding a good job can be more challenging.

In general, the more desirable the area, the worse a group can treat you (I interviewed at a group that had churned through 5 first year attendings in 5 years)

I don't know how common this is now but when I was first looking for positions, numerous PE groups in less desirable areas were floating astronomical salaries. They would reel you in with those salaries and then switch to a productivity based contract 1-2 years down the road. If you didn't practice medicine they way they envisioned (full schedules, everyone gets multiple biopsies, etc), you would see a huge dropoff in income.

There can be difficulties with non-PE-affiliated groups. I was particularly disappointed with one group that was recommended to me by a friend (also a dermatologist). The route to partnership was via sweat equity and that meant being drastically underpaid for the first three years. I didn't bother investigating to see how many actually made it to partnership given how low the proposed salary was.

Again, mid level encroachment is not a good thing, but it was not the biggest problem I encountered during my job search.

 

[asmallchild]

So I don't get this. Why are we allowing non doctors to practice as doctors? I'm not a dermatologist but same issue across specialties. Why are we as physicians going through all these hoops to then have nurses essentially practice as doctors with 1/4 of the training? Why are we taking steps, and MCAt, and going to med school, and boards? Why not cut down on a bunch of all this nonsense then? why are we having a double standard?

Doctors are notoriously bad at protecting their own territory.

Nurses / mid-levels / etc are great at playing this political game.

I don't have the answer to this one.

 

[Skindoc83]

So I don't get this. Why are we allowing non doctors to practice as doctors? I'm not a dermatologist but same issue across specialties. Why are we as physicians going through all these hoops to then have nurses essentially practice as doctors with 1/4 of the training? Why are we taking steps, and MCAt, and going to med school, and boards? Why not cut down on a bunch of all this nonsense then? why are we having a double standard?

Because the baby boomers. They saw a way to leverage their productivity and they just so happened to set medicine on the path to ruination in the process. So greed coupled with the dumbing down of society and general distrust for “elites” and “experts” means people with a fraction of a physicians knowledge have been empowered to take the reins and start practicing on their own.

 

[Private_MD]

Because the baby boomers. They saw a way to leverage their productivity and they just so happened to set medicine on the path to ruination in the process. So greed coupled with the dumbing down of society and general distrust for “elites” and “experts” means people with a fraction of a physicians knowledge have been empowered to take the reins and start practicing on their own.

then why are we still taking "boards" and "Steps" and "oral boards" and "mock exams"? ridiculous

 

[Sailor Senshi Dermystify]

It is very similar to what has already been mentioned.

Finding a job is fortunately fairly easy in dermatology, finding a good job can be more challenging.

In general, the more desirable the area, the worse a group can treat you (I interviewed at a group that had churned through 5 first year attendings in 5 years)

I don't know how common this is now but when I was first looking for positions, numerous PE groups in less desirable areas were floating astronomical salaries. They would reel you in with those salaries and then switch to a productivity based contract 1-2 years down the road. If you didn't practice medicine they way they envisioned (full schedules, everyone gets multiple biopsies, etc), you would see a huge dropoff in income.

There can be difficulties with non-PE-affiliated groups. I was particularly disappointed with one group that was recommended to me by a friend (also a dermatologist). The route to partnership was via sweat equity and that meant being drastically underpaid for the first three years. I didn't bother investigating to see how many actually made it to partnership given how low the proposed salary was.

Again, mid level encroachment is not a good thing, but it was not the biggest problem I encountered during my job search.

What are PE-firms and are these firms good for doctors?

Doctors are notoriously bad at protecting their own territory.

Nurses / mid-levels / etc are great at playing this political game.

I don't have the answer to this one.

What can we do to lobby more especially on the medical student and resident level? I feel like we do not lobby enough and we take this too lightly.

 

[sore eye asses]

PE = Private equity

Tons of threads on this one, take a look back and read. Be careful not to go too far down the rabbit hole.

The general take is that PE is probably not good for dermatology. It has benefited a fraction of dermatologists (those nearing retirement) in an outsize way.

Not sure what residents can do...probably better to simply focus on learning medicine. Once an attending you can crusade for whatever you choose, as your voice will be more meaningful once you’ve reached a certain level of education and experience.

 

[Skindoc83]

What are PE-firms and are these firms good for doctors?



What can we do to lobby more especially on the medical student and resident level? I feel like we do not lobby enough and we take this too lightly.

The best thing a resident can do is not join a PE backed group when they finish training

 

[yungspleen]

Dermatology Practitioner

I guess it really is Mohs or bust. Every NP wants to do derm rn.

 

[Skindoc83]

I guess it really is Mohs or bust. Every NP wants to do derm rn.

mohs is over trained and starting next year with the mohs board exam, every derm will be a “board certified mohs surgeon.” Plus there will be an approximate 10 percent reimbursement cut starting January 1 and mohs is always a favorite target of the RUC. There are no fields in medicine that can’t be partially lost to mid levels. Truthfully, most mid levels want to do cosmetics, not rashes. With that said, I can’t imagine many board certified dermatologists would allow themselves to work for a nurse

 

[Slack3r]

mohs is over trained and starting next year with the mohs board exam, every derm will be a “board certified mohs surgeon.” Plus there will be an approximate 10 percent reimbursement cut starting January 1 and mohs is always a favorite target of the RUC. There are no fields in medicine that can’t be partially lost to mid levels. Truthfully, most mid levels want to do cosmetics, not rashes. With that said, I can’t imagine many board certified dermatologists would allow themselves to work for a nurse

Except Paul Rose, apparently.

 

[Vandalia]

I guess it really is Mohs or bust. Every NP wants to do derm rn.

If a nurse practitioner can do dermatology as well as a dermatologist - which you appear to have conceded - why should a patient want to see a dermatologist?

That is what I have never understood about this mid-level paranoia, they are only a threat if they are as good as physicians. If they can handle a heart failure patient as well as a cardiologist, then I guess we don't need cardiologists.

Do you really think anyone in primary care - nurse practitioner or physician - is going to send any patient to someone who botches the case? Or "sure, I love Judy the NP, she hasn't done a thing about this horrible rash for two years, but I love her." Nope.

But if someone can do the job as well for less cost, then I guess that is something we need to move towards to reign in healthcare spending.

 

[PhillyMed777]

If a nurse practitioner can do dermatology as well as a dermatologist - which you appear to have conceded - why should a patient want to see a dermatologist?

They can’t, no where close. The difference is so vast I cannot begin to explain.

they can pretend however. And the lesser informed can listen and believe.

 

[Vandalia]

They can’t, no where close. The difference is so vast I cannot begin to explain.

they can pretend however. And the lesser informed can listen and believe.

But at the end of the day people want results. Particularly when it comes to dermatology. If they don't get results, they are not happy. Yes there are people who may believe that the OTC wart remover may help their melanoma.... but not for long.

 

[avidrapper]

But at the end of the day people want results. Particularly when it comes to dermatology. If they don't get results, they are not happy. Yes there are people who may believe that the OTC wart remover may help their melanoma.... but not for long.

Sure, people want results. But for 90% of routine cases, an NP can deliver the same "results" as a physician. For the 10% of cases they cant, dealing with the harm, or settling the lawsuit, or dumping the case on a physician somewhere else creates an environment that overvalues NP's and undervalues physicians.

Physicians are staying stagnant. And in a world where there is inflation and midlevel encroachment that means physicians are trending heavily downward.

Case in point: A derm making $350,000 in the year 2000 would be equal to around $530,000 today from inflation alone. But derm starting salaries have remained stagnant.

NP salaries on the other hand have grown with inflation and will continue to do so.

Will things even out? Who knows. But right now the job of a physician dermatologist is on a downward trend from where it was before.

 

[yungspleen]

If a nurse practitioner can do dermatology as well as a dermatologist - which you appear to have conceded - why should a patient want to see a dermatologist?

I rotated through a derm office while the MD was on vacation and it was being run by 3 PA's. If even 10% of the patients we saw those 2 weeks knew that they weren't being seen by an MD i'd be surprised

mohs is over trained and starting next year with the mohs board exam, every derm will be a “board certified mohs surgeon.” Plus there will be an approximate 10 percent reimbursement cut starting January 1 and mohs is always a favorite target of the RUC. There are no fields in medicine that can’t be partially lost to mid levels. Truthfully, most mid levels want to do cosmetics, not rashes. With that said, I can’t imagine many board certified dermatologists would allow themselves to work for a nurse

So? I'm not talking about the salary cuts to a field. Nobody is going to let an NP/PA cut off half their nose, so Mohs is still a valuable fellowship. Patients don't care who is prescribing topical steroids as long as it works

 

[PhillyMed777]

I rotated through a derm office while the MD was on vacation and it was being run by 3 PA's. If even 10% of the patients we saw those 2 weeks knew that they weren't being seen by an MD i'd be surprised



So? I'm not talking about the salary cuts to a field. Nobody is going to let an NP/PA cut off half their nose, so Mohs is still a valuable fellowship. Patients don't care who is prescribing topical steroids as long as it works

Lol topicals?
What do think I’m doing all these years in residency?
People in other fields really need a reality check in the complexity of Derm.

 

[Skindoc83]

I rotated through a derm office while the MD was on vacation and it was being run by 3 PA's. If even 10% of the patients we saw those 2 weeks knew that they weren't being seen by an MD i'd be surprised



So? I'm not talking about the salary cuts to a field. Nobody is going to let an NP/PA cut off half their nose, so Mohs is still a valuable fellowship. Patients don't care who is prescribing topical steroids as long as it works

And when patients are undergoing CABG do you think that the patients know it’s a PA harvesting their vein? What about the patient having breast implants and the plastic surgeon lets the med student do the skin closure? To your point many patients don’t do any research on their provider or procedure and are wildly misinformed, they just google dermatologist near me, schedule, and assume that the person they’re scheduled to see is qualified. Many of my patients cant even identify their biopsy site. Nothing is protected from mid level creep.

 

[yungspleen]

And when patients are undergoing CABG do you think that the patients know it’s a PA harvesting their vein? What about the patient having breast implants and the plastic surgeon lets the med student do the skin closure? To your point many patients don’t do any research on their provider or procedure and are wildly misinformed, they just google dermatologist near me, schedule, and assume that the person they’re scheduled to see is qualified. Many of my patients cant even identify their biopsy site. Nothing is protected from mid level creep.

I agree with you, the patients are misinformed and have no idea. There are a few older patients who demanded to see the MD but besides that nobody cared. As far as your examples of the PA and med student, those still require an MD to be employed. It's not like a PA or med student is running the full case. The thing that worried me was seeing the attending not in the office at all for 2 weeks, and the PA's still seeing all of the patients like the attending normally would, which is vastly different from the examples you gave.

 

[Slack3r]

If you would’ve told the old timer MDs 20 years ago that NPs would be running their own clinics one day, they’d have called you crazy. Don’t think for a minute anything “surgical” is going to be safe from encroachment indefinitely.

 

[PhillyMed777]

dermpath is the most resistant to mid levels because it’s so complex and broad.

 

[yungspleen]

dermpath is the most resistant to mid levels because it’s so complex and broad.

True, although I think Mohs is still safe for a while. But like someone above mentioned, prob hard to find a full-time Mohs gig (and dermpath too for that matter unless you don't care where you live).

 

[Dr. Doctor MD]

True, although I think Mohs is still safe for a while. But like someone above mentioned, prob hard to find a full-time Mohs gig (and dermpath too for that matter unless you don't care where you live).

Agreed, Mohs and Dermpath may be resistant to midlevel encroachment, but the already high over-training in both fields has made it difficult to find anything close to full time in either field, and it's only going to get worse each year as they continue to pump out even more graduates. So if you're doing a fellowship to not compete with numerous unqualified midlevels, you'll instead be competing with numerous but qualified MDs. So not sure how much doing fellowship is going to insulate anyone from heavy competition.

 

[deleted314957]

So I don't get this. Why are we allowing non doctors to practice as doctors? I'm not a dermatologist but same issue across specialties. Why are we as physicians going through all these hoops to then have nurses essentially practice as doctors with 1/4 of the training? Why are we taking steps, and MCAt, and going to med school, and boards? Why not cut down on a bunch of all this nonsense then? why are we having a double standard?

Just 2 words explain it all. “ payors” and “ money “.