Half the notes are written by NPs?

[TexasMed22]

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I'm a resident at a large, well funded academic hospital system, and >50% of the heme onc notes I read are written by NPs. Do you all have concerns about midlevel encroachment in this field and its impact on future oncologist demand? I know this has been discussed in previous threads, but it seems to be progressing substantially from when it was last discussed.

 

[gutonc]

I'm a resident at a large, well funded academic hospital system, and >50% of the heme onc notes I read are written by NPs. Do you all have concerns about midlevel encroachment in this field and its impact on future oncologist demand? I know this has been discussed in previous threads, but it seems to be progressing substantially from when it was last discussed.

My concern is mostly that 95% of those notes are complete s***t and totally useless.

Inpatient hem/onc is mostly intellectually vapid and the work could be done by a modestly competent M4 on their sub-I (which is the level at which most APPs I know are able to practice). If your goal is to be a hem-onc hospitalist, then yes, you should be concerned. If you just want a job in Hem/Onc, you'll be fine.

 

[HemeOncHopeful19]

It is definitely a concern (imo anything that might be a threat should be on people’s radar) but lower on the list than the Inflation Reduction Act and 340B programs in general.

If you are an IM resident then there is no reason to be more concerned about midlevel encroachment in Heme/Onc than any other field except *MAYBE* GI and even then I’m sure it has it’s own threats (scope reimbursement)

 

[checkpointinhibitor]

Inpatient - I agree with APPs. Most of the solid tumor issues are social support/dispo management. PGY1 resident can do that, APPs are very capable of doing that. For any complex patients TTP etc, consultants should see the patients and should be directly supervising. Even seasoned APPs won't be able to reliably help on those patients. Utilizing APPs for inpatient services to free outpatient work is the way to go in community.

Outpatient - is a whole another issue. APPs should not and could not do a consult. Oncology is complex as it is and hematology except for some stuff (sent by APPs) which can be easily handled by PCPs (but choose not to) can be done? except for rare cases in which they will clearly miss non-secretory myeloma, HES etc. Grip of foundational sciences is a must. For chemo follow ups, some practices use APPs. IMO if you are productivity based, there is no reason to have APP in oncology. They would take easy cases and leave hard cases to you. For salaried academic positions, they usually like to deflect a lot to APPs (which I hold grudge against).

In short, oncology is proliferating so rapidly, that APPs won't be able to handle outpatient (cerebral things). As someone else mentioned, IRA and 340B may create a larger problem but pharma lobby and hospital lobby (for better or worse) is strong with deep pockets. In that case, there will be eventual pendulum swing to private practices.

 

[ShuperNewbie]

You know, when I was a resident / hospitalist, I used to ask this same question (whether it was being replaced by NPs or in the modern era - AI) all the time to onc attendings, and they used to shrug at me and laugh and I didn't get why

I also used to ask whether oncology was just following NCCN guidelines day in and day out with no creative thought, and onc attendings used to shrug at me and laugh and I didn't get why.

Now as an onc attending, I kinda get why.

It's one of those things where - once you experience it, you kind of get it but until then, it's really hard to put into words. It's kind of like when a random tech bro chats you up at a party and pitches you their "n"th idea of how to improve the healthcare ecosystem with automation (like AI replacing hospitalists) and your mind immediately jumps to some things it can do well (recognize sepsis and auto enter sepsis protocol orders) and some things it can't do well (find dispo for the 80 year old man with vascular dementia whose family abandoned him and figure out a way to calm him down when he starts charging the staff at 2am because he's sundowning really hard) and you immediately realize that an algorithm probably won't replace the work in its entirety but it's really hard to explain why because your brain is just full of a bunch of anecdotes and a million reasons why his idea won't work but you're just trying to get another Old Fashioned at the bar. It's like that feeling. Tough to explain til you're there.

 

[checkpointinhibitor]

You know, when I was a resident / hospitalist, I used to ask this same question (whether it was being replaced by NPs or in the modern era - AI) all the time to onc attendings, and they used to shrug at me and laugh and I didn't get why

I also used to ask whether oncology was just following NCCN guidelines day in and day out with no creative thought, and onc attendings used to shrug at me and laugh and I didn't get why.

Now as an onc attending, I kinda get why.

It's one of those things where - once you experience it, you kind of get it but until then, it's really hard to put into words. It's kind of like when a random tech bro chats you up at a party and pitches you their "n"th idea of how to improve the healthcare ecosystem with automation (like AI replacing hospitalists) and your mind immediately jumps to some things it can do well (recognize sepsis and auto enter sepsis protocol orders) and some things it can't do well (find dispo for the 80 year old man with vascular dementia whose family abandoned him and figure out a way to calm him down when he starts charging the staff at 2am because he's sundowning really hard) and you immediately realize that an algorithm probably won't replace the work in its entirety but it's really hard to explain why because your brain is just full of a bunch of anecdotes and a million reasons why his idea won't work but you're just trying to get another Old Fashioned at the bar. It's like that feeling. Tough to explain til you're there.

You put is very succinctly.
Just waiting for an Old Fashioned as well 🙂

 

[MD46]

Inpatient - I agree with APPs. Most of the solid tumor issues are social support/dispo management. PGY1 resident can do that, APPs are very capable of doing that. For any complex patients TTP etc, consultants should see the patients and should be directly supervising. Even seasoned APPs won't be able to reliably help on those patients. Utilizing APPs for inpatient services to free outpatient work is the way to go in community.

Outpatient - is a whole another issue. APPs should not and could not do a consult. Oncology is complex as it is and hematology except for some stuff (sent by APPs) which can be easily handled by PCPs (but choose not to) can be done? except for rare cases in which they will clearly miss non-secretory myeloma, HES etc. Grip of foundational sciences is a must. For chemo follow ups, some practices use APPs. IMO if you are productivity based, there is no reason to have APP in oncology. They would take easy cases and leave hard cases to you. For salaried academic positions, they usually like to deflect a lot to APPs (which I hold grudge against).

In short, oncology is proliferating so rapidly, that APPs won't be able to handle outpatient (cerebral things). As someone else mentioned, IRA and 340B may create a larger problem but pharma lobby and hospital lobby (for better or worse) is strong with deep pockets. In that case, there will be eventual pendulum swing to private practices.

Agree with most of what you are saying but in collection based outpatient private model, one can utilize NPs to their fullest in terms of being profitable. Ideally see 10-12 patients in am clinic with mostly chemo followups and some other anemia like 3-6m followups if needed. This is where you have your weekly carbo/taxol with rads and you see them every other time. Also you can have your FOLFOX every 2 weeks and alternate, FLOT, opdivo etc. If incidence to billing is allowed and properly done. After that they round in the hospital and see followups which will generate a good number of RVUs/collection daily for on average a Level 2 service. example: Neutropenic fever from chemotherapy, patient admitted with low ANC

For new patients unless urgent need, you should probably do the initial inpatient visit.

 

[whoknows2012]

I'm a resident at a large, well funded academic hospital system, and >50% of the heme onc notes I read are written by NPs. Do you all have concerns about midlevel encroachment in this field and its impact on future oncologist demand? I know this has been discussed in previous threads, but it seems to be progressing substantially from when it was last discussed.

Short answer is, no

I will not throw APPs under the bus as there are several things they do well. Relying on them for anything cerebral, as you guys have mentioned above, is not apart of any future I can imagine.

I am mostly inpatient mal heme and we have significant help from APPs on inpatient services, including for procedures (which is incredibly helpful for improving efficiency!) Yet the diseases we treat, day to day decisions on response assessments, treatment decision making, and evaluation of complications are incredibly complex and take even junior faculty YEARS to feel confident in. I don’t worry about APP encroachment personally

 

[MifflinDunder]

Inpatient oncology in 2025 is mostly CYA consults (history of cancer at any point in their life = consult heme onc), GOC, and social visits. There’s zero critical thinking and limited educational value overall. NP/PAs and unfortunately fellows, are perfect for this level of scutwork.

 

[checkpointinhibitor]

Agree with most of what you are saying but in collection based outpatient private model, one can utilize NPs to their fullest in terms of being profitable. Ideally see 10-12 patients in am clinic with mostly chemo followups and some other anemia like 3-6m followups if needed. This is where you have your weekly carbo/taxol with rads and you see them every other time. Also you can have your FOLFOX every 2 weeks and alternate, FLOT, opdivo etc. If incidence to billing is allowed and properly done. After that they round in the hospital and see followups which will generate a good number of RVUs/collection daily for on average a Level 2 service. example: Neutropenic fever from chemotherapy, patient admitted with low ANC

For new patients unless urgent need, you should probably do the initial inpatient visit.

This makes perfect sense for a private practice or even in employed settings where you have an APP under your supervision. You have direct say in hiring the APP, training them and in return, you get a fixed portion of collections or $/wRVU. Unfortunately, the corporate overlords want to hire the APPs (under MD) and have them work independently. They then give a measly annual stipend which is typically a rounding error on our taxes or tell you that 'you have support' from APPs. Non-finance savvy (gullible) MDs fall for that trap.

I agree with above for someone who practices inpatient predominant oncology (BMT, cellular therapy, leukemia etc) where APPs are extremely essential to improve efficiency. But in such cases, those are salaried academic appointments (typically).

APPs do have a role but don't let the corporate overlords whitewash you with the term 'providers'. We are physicians, much above any mid levels.