Future of midlevels in neurology?

[WalkingOnTheSun]

As we know midlevels are increasing in every specialty, and there are threats to physicians as a whole due to various factors, including the recent executive order that includes a mandate for establishing pay parity for physicians and other providers as well as reducing "burdensome supervision requirements" for midlevels (Executive Order on Protecting and Improving Medicare for Our Nation's Seniors | The White House).

Obviously no one knows the future, but to me the writing seems to be on the wall that sooner rather than later, midlevels in medical fields will be able to make as much money as the physicians, and this will most likely drive physician compensation down (since I doubt hospitals will want to pay NPs 200-300K+). As someone trying to decide a field to go into for the next 35-40 years, this is a huge concern for me.

So the question is, with this looming threat, how serious is it for neurology specifically? I imagine things will be much worse off for internal medicine, family medicine, psychiatry, etc. But the small number of NPs I have met in neurology during my third year rotations were only comfortable seeing a couple disease processes that they felt knowledgeable about and never saw undifferentiated patients. I'm curious if anyone sees their scope increasing over time, or if their role will continue to be fairly limited compared to in internal medicine and supportive (seeing stable follow-up patients, etc.). I'm currently interested in stroke or epilepsy specifically.

Also, how are NPs incorporated into your current practice, and do you think having them actually helps you, or was it something that the hospital or group you work with forced upon you?

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[Thama]

I've never met an NP that wanted to practice independently in neurology. Even the best ones I've worked with get very nervous if they are being asked to see something not routine or with a firm diagnosis, and want to be able to discuss with an MD regularly.

 

[Telamir]

I don't see NPs becoming a serious "threat" to neurology. Most of the time they see the more "algorithmic" processes such as stroke and headache or assist in epilepsy clinic (and there I feel like their role is more limited). They typically tend to focus on 1-2 things as mentioned above. I work with an excellent NP inpatient. She's been doing it for over 10 yrs at this point and her limitations are obvious when she sees a case that deviates from those types of cases. Neurology is by definition quite "vague" and it's not a field people come into in droves let alone NPs. There are "easier" fields if that makes sense.

In my limited experience I've found their training focuses more on algorithmic thinking (if this then order XYZ etc) and very few aspects of neurology lend itself well to this sort of process. All in all I'm not concerned.

 

[deathmerchant]

As we know midlevels are increasing in every specialty, and there are threats to physicians as a whole due to various factors, including the recent executive order that includes a mandate for establishing pay parity for physicians and other providers as well as reducing "burdensome supervision requirements" for midlevels (Executive Order on Protecting and Improving Medicare for Our Nation's Seniors | The White House).

Obviously no one knows the future, but to me the writing seems to be on the wall that sooner rather than later, midlevels in medical fields will be able to make as much money as the physicians, and this will most likely drive physician compensation down (since I doubt hospitals will want to pay NPs 200-300K+). As someone trying to decide a field to go into for the next 35-40 years, this is a huge concern for me.

So the question is, with this looming threat, how serious is it for neurology specifically? I imagine things will be much worse off for internal medicine, family medicine, psychiatry, etc. But the small number of NPs I have met in neurology during my third year rotations were only comfortable seeing a couple disease processes that they felt knowledgeable about and never saw undifferentiated patients. I'm curious if anyone sees their scope increasing over time, or if their role will continue to be fairly limited compared to in internal medicine and supportive (seeing stable follow-up patients, etc.). I'm currently interested in stroke or epilepsy specifically.

Also, how are NPs incorporated into your current practice, and do you think having them actually helps you, or was it something that the hospital or group you work with forced upon you?

In my hospital I have NPs in training rotate with me for few weeks(and it’s usually at the end of their training)- The gap in knowledge is just too much, esp when I compare them to MS3. They have limited knowledge of neuro anatomy/basic sciences and how to apply them. And most of them admit themselves neuro is the subject they know/understand the least.
I think it’s about a certain thinking process that comes with going through med school and residency. And like mentioned above neuro is not very algorithmic and objective. We also don’t have many good labs/tests like other fields.
On the other hand, they are probably better at taking care of patients in a different way, which as a physician we probably can’t do as well.
Having worked with them and trained them, I would not be comfortable with an NP working independently in neuro. I mean why would an IM/FM/ER trained physician want a Neuro NP to see a patient, they can probably diagnose, manage them better themselves.

 

[GuillainMollaret]

I've never met an NP that wanted to practice independently in neurology. Even the best ones I've worked with get very nervous if they are being asked to see something not routine or with a firm diagnosis, and want to be able to discuss with an MD regularly.

It sounds like you work with good NPs who are able to recognize their limitations.

The problem is that not all NPs are going to be like that and there are ones that dont know what they dont know and may take a more cavalier approach. I have no complaints about the NPs I've worked with, but it's often shocking how little neurology they actually know.

I've seen dramatic growth in the use of neurology NPs over the last few years, at least where I'm at. This is clearly profitable for health systems, so their role will continue to expand.

 

[neurologist]

Nothing and nobody is a threat to neurology because everyone except neurologists hate and/or fear it.

 

[Telamir]

They have limited knowledge of neuro anatomy/basic sciences and how to apply them. And most of them admit themselves neuro is the subject they know/understand the least.
I think it’s about a certain thinking process that comes with going through med school and residency. And like mentioned above neuro is not very algorithmic and objective. We also don’t have many good labs/tests like other fields.

Actually, to be honest I hear this from EVERYONE. Neurology is always the subject people know/understand the least. This goes from MS1 all the way to EM/IM/ICU docs. In that regard job security is there, haha.

 

[WalkingOnTheSun]

Having worked with them and trained them, I would not be comfortable with an NP working independently in neuro. I mean why would an IM/FM/ER trained physician want a Neuro NP to see a patient, they can probably diagnose, manage them better themselves.

I hear what you're saying but this is already the reality right now. My dad is in IM and he's told me before about being unpleasantly surprised after sending a patient to an endocrinologist for management of some complicated endocrine disorder and the patient only got seen by a PA, and he thought, "well I could have managed the patient myself then."

 

[WalkingOnTheSun]

It sounds like you work with good NPs who are able to recognize their limitations.

The problem is that not all NPs are going to be like that and there are ones that dont know what they dont know and may take a more cavalier approach. I have no complaints about the NPs I've worked with, but it's often shocking how little neurology they actually know.

I've seen dramatic growth in the use of neurology NPs over the last few years, at least where I'm at. This is clearly profitable for health systems, so their role will continue to expand.

I agree with that sentiment. I'm curious what the dramatic growth has been in your healthcare setting -- has it been inpatient, outpatient, or both? Are the NPs seeing new referrals or follow-ups only?

 

[GuillainMollaret]

I agree with that sentiment. I'm curious what the dramatic growth has been in your healthcare setting -- has it been inpatient, outpatient, or both? Are the NPs seeing new referrals or follow-ups only?

Outpatient mainly.

Historically, they have only seen returns (including some pretty complicated patients), but now at least some of them are seeing new patients also for things like neuropathy and headache.

 

[Thama]

Outpatient mainly.

Historically, they have only seen returns (including some pretty complicated patients), but now at least some of them are seeing new patients also for things like neuropathy and headache.

In other words the kind of neurology that a PCP can practice after 3 weeks of a neurology elective.

I'm not worried.

 

[Postictal Raiden]

As a neurology resident, my exposure to NPs has only been limited to the inpatient ones. Primarily stroke. They do excellent job I gotta say. Perhaps that’s because stroke is very algorithmic, at least 90% of it.

Regarding general neurology, or other neurology subspecialties like movement and epilepsy, the clinical presentations can be extremely vague and unsettling that no one without formal residency/fellowship training could get a good grasp of. In our movement clinic for example, the specialist sees half a dozen patients daily who had been misdiagnosed by not NPs or PCPs, but by general community neurologists.

 

[deathmerchant]

I hear what you're saying but this is already the reality right now. My dad is in IM and he's told me before about being unpleasantly surprised after sending a patient to an endocrinologist for management of some complicated endocrine disorder and the patient only got seen by a PA, and he thought, "well I could have managed the patient myself then."

That being said, there is no doubt number of NPs and PAs are increasing in every field including neuro. They usually work in inpatient stroke units, seeing stroke follow ups and making sure all the work up is done and then taking care of discharge paper work and other quality measures. I actually think that helped me a lot in residency.
We also had NPs in almost every other subspecialty. They see routine follow ups like MS, PD, AD, Stroke, Headache etc. I think the good ones do a decent job taking care of and talking to patients with chronic neurological disorders, where we are not changing much medically- like ALzheimers.

I think the number is gonna increase further but for the few NPs interested in neuro, it still would need lots of supervision.

 

[GuillainMollaret]

In other words the kind of neurology that a PCP can practice after 3 weeks of a neurology elective.

I'm not worried.

Sure, but headache alone makes up a huge chunk of most outpatient general neuro practices.

Most NPs and PCPs for that matter can probably do just fine taking care of uncomplicated migraine patients, but how many of them are going to get unnecessary MRIs? Or conversely, how many secondary headaches are going to be missed? Even something as common as headache can be incredibly nuanced.

I do agree that neurology is more insulated from midlevel encroachment than other fields like primary care, emergency med, derm, etc. but with 30,000 new NPs graduating every year, if even 2% of them choose to do neurology, that's going to be more new NPs than graduating neuro residents per year. There's no way that doesn't lead to decrease demand/salary for neurologists.

 

[Thama]

I do agree that neurology is more insulated from midlevel encroachment than other fields like primary care, emergency med, derm, etc. but with 30,000 new NPs graduating every year, if even 2% of them choose to do neurology, that's going to be more new NPs than graduating neuro residents per year. There's no way that doesn't lead to decrease demand/salary for neurologists.

I think this touches on something important - the fact that rising salaries in neurology are driven largely by the incredible shortage of qualified neurologists and lack of ability of other MDs to cover for that. There's nothing wrong with wanting to be fairly compensated, and we absolutely should fight for adequate compensation for E&M and procedures.

However, if we are going to protect our income by trying to maintain shortage demand to protect the most absurd of the locums/PP offers posted here on occasion, then we are doing harm to those suffering from neurological disease throughout the nation, doing something objectively evil, and the public would be right to lose trust in our profession.

 

[GuillainMollaret]

However, if we are going to protect our income by trying to maintain shortage demand to protect the most absurd of the locums/PP offers posted here on occasion, then we are doing harm to those suffering from neurological disease throughout the nation, doing something objectively evil, and the public would be right to lose trust in our profession.

Definitely not advocating for maintaining a shortage of neurologists. Improved access to neurological care is incredibly important and I wish more med students were interested in neurology. I think it's great that NPs are playing a role in improving access to neurological care.

I was just pointing out that salaries have the potential to decrease in a field where its members have historically felt undervalued. Additionally, this may further disincentivize future med students from picking what has always been an unpopular field and as a consequence lead to even less neurologists.

 

[Thama]

Frankly I'm pretty OK with not having the ortho/uro bros trying to figure out how to make neurology compatible with 3 vacation homes, a Bentley and a regular parking spot at the local strip club. The fact that neurology isn't the path of least resistance or most glamour adds to the field rather than subtracting from it.

However, one of the biggest issues with the field is just how incredible the volume can be. If we can figure out how to coexist with NPs so they can handle braindead cases like migraine and neuropathy, that frees us up to do what we came here to do. I don't know if it will save cost in the end (for reasons stated above - a lot of unnecessary MRIs for migraine, etc), but it could improve access if done right.

 

[WalkingOnTheSun]

Frankly I'm pretty OK with not having the ortho/uro bros trying to figure out how to make neurology compatible with 3 vacation homes, a Bentley and a regular parking spot at the local strip club. The fact that neurology isn't the path of least resistance or most glamour adds to the field rather than subtracting from it.

I think wanting to be fairly compensated is not something that can be equated with wanting extreme luxury. For many students who are juggling their own debt and the debt of their medical spouse and have spent much of their 20s and 30s in delayed gratification mode, wanting to graduate and actually make some money is not unreasonable. But if instead, you graduate in 4-5 years and because of an inundation of NPs in the field and federally mandated pay parity, you realize you're only making 100k, that would be frustrating to say the least. I do agree that the fact that neurology doesn't attract people who just want to make a ton of money easily is a good thing, it makes for a great culture with great people, but fair compensation is also important.

 

[neglect]

As we know midlevels are increasing in every specialty, and there are threats to physicians as a whole due to various factors, including the recent executive order that includes a mandate for establishing pay parity for physicians and other providers as well as reducing "burdensome supervision requirements" for midlevels (Executive Order on Protecting and Improving Medicare for Our Nation's Seniors | The White House).

Obviously no one knows the future, but to me the writing seems to be on the wall that sooner rather than later, midlevels in medical fields will be able to make as much money as the physicians, and this will most likely drive physician compensation down (since I doubt hospitals will want to pay NPs 200-300K+). As someone trying to decide a field to go into for the next 35-40 years, this is a huge concern for me.

So the question is, with this looming threat, how serious is it for neurology specifically? I imagine things will be much worse off for internal medicine, family medicine, psychiatry, etc. But the small number of NPs I have met in neurology during my third year rotations were only comfortable seeing a couple disease processes that they felt knowledgeable about and never saw undifferentiated patients. I'm curious if anyone sees their scope increasing over time, or if their role will continue to be fairly limited compared to in internal medicine and supportive (seeing stable follow-up patients, etc.). I'm currently interested in stroke or epilepsy specifically.

Also, how are NPs incorporated into your current practice, and do you think having them actually helps you, or was it something that the hospital or group you work with forced upon you?

We have always had 1-3 NP/PAs within our practice. I'd never worked with PAs in the past, so I thought they were like residents. I was quickly disabused. There's a chasm in training, ethos, intelligence, knowledge, and ability. The worst resident I've ever seen is about the same as an above average NP/PA. And that resident is going to have massive value added. The extender is stuck in first gear.

And yet, yes, this IS a threat. It was pointed out above that people hate neurology, so our jobs are safe. True enough. Also, because primary care NP/PA's know NOTHING, we will get more referrals. Prices for clinical care will go down, and that's concerning. But nothing is concerning as much as the danger for patients. Neurology is one of those things where you can get in over your head very quickly. People present with vague problems, exam signs are sometimes subtle, but the underlying cause is deadly or disabling if not caught early. Spinal abscess and carpal tunnel can both present with hand numbness.

Extenders are trying to legislate their way to independent practice with no physician oversight. This will kill patients. Oppose all legislation that gives extenders ability to practice independently. If they want to practice, they can go to med school.

In my hospital I have NPs in training rotate with me for few weeks(and it’s usually at the end of their training)- The gap in knowledge is just too much, esp when I compare them to MS3. They have limited knowledge of neuro anatomy/basic sciences and how to apply them. And most of them admit themselves neuro is the subject they know/understand the least.
I think it’s about a certain thinking process that comes with going through med school and residency. And like mentioned above neuro is not very algorithmic and objective. We also don’t have many good labs/tests like other fields.
On the other hand, they are probably better at taking care of patients in a different way, which as a physician we probably can’t do as well.
Having worked with them and trained them, I would not be comfortable with an NP working independently in neuro. I mean why would an IM/FM/ER trained physician want a Neuro NP to see a patient, they can probably diagnose, manage them better themselves.

Exactly.

I hear what you're saying but this is already the reality right now. My dad is in IM and he's told me before about being unpleasantly surprised after sending a patient to an endocrinologist for management of some complicated endocrine disorder and the patient only got seen by a PA, and he thought, "well I could have managed the patient myself then."

That's disgusting. I hope he called the practice and told them that he will no longer send them patients. A PA doing a new outpatient consult? That's crazy already. And to be unsupervised?

 

[Telamir]

Your mention of ethos/work ethic brought me flashbacks from residency. Neurology only employed NPs in the outpatient setting doing very specific things (headache, PD followups, stable epilepsy patients) and whenever the patient got complex you could tell their limitations as their management would not be "typical" (ugly med-med interactions, un-necessary imaging, etc) however one thing that stood out to me is how "sacred" they were. They only did X condition, they could never take Y. They only saw X amount of patients per day and not a single one more.

Neurosurgery employed them in the hospital and they only worked 8-4 (or whatever their shift length was) and not a minute longer or there would be complaints. Someone in the E.D. with a neurosurgical problem, but getting close to end of shift? No problem, admit to neuro residents. Their catering to was unreal. It pissed me off so much back then and to add insult to injury they'd make 2-3x what you'd make as a resident and often times (regardless of specialty) they would wait for the resident's note to go into the chart, and then copy + paste, change 2 things in the plan "discuss with attending XYZ in the am" and done.

Anyway, rant over.

 

[Thama]

I worked with several on the inpatient service during residency. One was pretty much how neglect says - equivalent to a bad junior resident that never improves, but good enough to be helpful doing scheduled admissions and other routine work. Another was amazingly lazy with little desire to improve. Another was unbelievably good - not one of us would have batted an eye if someone told us they would be allowed to just skip med school and join our residency program at about the PGY3 level.

The surgical PAs I've interacted with are very much like Telamir says and it was a constant battle with neurosurgery to admit even the most obvious neurosurgical problem to them for this reason. Literally not capable of figuring out what to do with someone on aspirin and a single antihypertensive.

 

[WalkingOnTheSun]

Your mention of ethos/work ethic brought me flashbacks from residency. Neurology only employed NPs in the outpatient setting doing very specific things (headache, PD followups, stable epilepsy patients) and whenever the patient got complex you could tell their limitations as their management would not be "typical" (ugly med-med interactions, un-necessary imaging, etc) however one thing that stood out to me is how "sacred" they were. They only did X condition, they could never take Y. They only saw X amount of patients per day and not a single one more.

Neurosurgery employed them in the hospital and they only worked 8-4 (or whatever their shift length was) and not a minute longer or there would be complaints. Someone in the E.D. with a neurosurgical problem, but getting close to end of shift? No problem, admit to neuro residents. Their catering to was unreal. It pissed me off so much back then and to add insult to injury they'd make 2-3x what you'd make as a resident and often times (regardless of specialty) they would wait for the resident's note to go into the chart, and then copy + paste, change 2 things in the plan "discuss with attending XYZ in the am" and done.

Anyway, rant over.

Even though I'm only a medical student I have also noticed that difference in work ethic and that definitely sounds frustrating to have them dump on you as a resident.

Despite this work ethic difference, it doesn't stop them from lobbying for more and more independence. I mean take a look at this recently published open letter by the AANP:

An Open Letter to Medicine: Shame on the PPP

Recently an organization called the “Physicians for Patient Protection” (PPP) put out yet another attack on the American Association of Nurse Practitioners® (AANP) and the nurse practitioner (NP) profession (“A Tragic Comedy of Errors”, January 5, 2020). In it, PPP-backed physicians make a series…

www.aanp.org

"...In the remaining states, NPs are required to contract with a physician under the guise of “supervision” or “collaboration” and, in many cases, must pay a fee to the physician. This is not a health benefit to patients. It is an economic incentive for physicians to boost their incomes while squeezing the supply of providers available to patients."

Makes it really clear what they see supervision as: something completely unnecessary and only for the physician's benefit.

 

[neglect]

Your mention of ethos/work ethic brought me flashbacks from residency. Neurology only employed NPs in the outpatient setting doing very specific things (headache, PD followups, stable epilepsy patients) and whenever the patient got complex you could tell their limitations as their management would not be "typical" (ugly med-med interactions, un-necessary imaging, etc) however one thing that stood out to me is how "sacred" they were. They only did X condition, they could never take Y. They only saw X amount of patients per day and not a single one more.

Neurosurgery employed them in the hospital and they only worked 8-4 (or whatever their shift length was) and not a minute longer or there would be complaints. Someone in the E.D. with a neurosurgical problem, but getting close to end of shift? No problem, admit to neuro residents. Their catering to was unreal. It pissed me off so much back then and to add insult to injury they'd make 2-3x what you'd make as a resident and often times (regardless of specialty) they would wait for the resident's note to go into the chart, and then copy + paste, change 2 things in the plan "discuss with attending XYZ in the am" and done.

Anyway, rant over.

Yes, extenders are best with ONE thing, like a migraine follow up. Diagnosis made, care plan made, now add a TCA or change the triptan and consider botox or biologic. It'll take them 3-6 months to learn how to do that (not throwing stones, it took me a year or so to figure out migraine and then a decade to decide I never wanted to see another chronic migraine patient ever again).

But it is the self-entitled nonsense that really gets me. All these doctors talk about self care and burnout because they spend 40-60 hours seeing patients, on the phone with patients/families, which is really the hardest thing ever, then have to document everything AND have to come up with impressions and action plan. It looks easy, so NPs think they can do it as well. I kinda home they get what they ask for: all that stress, liability, and work - and they are totally unprepared for it by training, intelligence, and knowledge.

The surgical PAs I've interacted with are very much like Telamir says and it was a constant battle with neurosurgery to admit even the most obvious neurosurgical problem to them for this reason. Literally not capable of figuring out what to do with someone on aspirin and a single antihypertensive.

How can you even see ataxia if you never learned how the cerebellum works (a big on/off learning circuit)? You see fatiguable weakness without knowing the basics of the NM jxn? When you know nothing, you're not capable of figuring our anything.

Remember that we think of the Duning Kruger curve as applying to people who are poor at a task, but assume they are good at it. But that curve tells another story: those with exceptional competence believe what they do is easy.

Even though I'm only a medical student I have also noticed that difference in work ethic and that definitely sounds frustrating to have them dump on you as a resident.

Despite this work ethic difference, it doesn't stop them from lobbying for more and more independence. I mean take a look at this recently published open letter by the AANP:

An Open Letter to Medicine: Shame on the PPP

Recently an organization called the “Physicians for Patient Protection” (PPP) put out yet another attack on the American Association of Nurse Practitioners® (AANP) and the nurse practitioner (NP) profession (“A Tragic Comedy of Errors”, January 5, 2020). In it, PPP-backed physicians make a series…

www.aanp.org

"...In the remaining states, NPs are required to contract with a physician under the guise of “supervision” or “collaboration” and, in many cases, must pay a fee to the physician. This is not a health benefit to patients. It is an economic incentive for physicians to boost their incomes while squeezing the supply of providers available to patients."

Makes it really clear what they see supervision as: something completely unnecessary and only for the physician's benefit.

This is just mind boggling.