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Hospitalist vs ID vs Nephrology

blue.jay

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Which amongst these non-procedural field have a better job outlook?
1. Stable salary
2. Better lifestyle and job satisfaction
3. Less midlevel encroachment
4. Easier path to CCM (NephCCM vs ID-CCM)

I like hospital medicine but don't like collaborating with midlevels. I'm hearing over the next few years hospitalist will be replaced by NP/PA. Will ID/Nephrology be easier for midlevels to encroach? I'm fine with 200-230k pay if my skill set is unique from midlevels.
 

IMGASMD

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If you want ccm? I’d just bit the bullet and do pulm/ccm?

You’d have bronch that shields you from mid level. No need for pulm consult. If I’d have to pick one I’d do nephrology than ID. It’s always is the patient dry or wet.

Good luck.
 
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CCM-MD

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If you want ccm? I’d just bit the bullet and do pulm/ccm?

You’d have bronch that shields you from mid level. No need for pulm consult. If I’d have to pick one I’d do nephrology than ID. It’s always is the patient dry or wet.

Good luck.

CCM does bronchs, it’s a core competency. Most programs also train for perc trachs. ICU procedures are easy target for midlevels. There is an Ivy League institution that lets midlevels do ICU bronchs in the presence of an attending. The number of idiots selling out medicine is unbelievable.

I think from a midlevel encroachment “safety” point of view, any consult based organ specific specialty is probably safest among IM subspecialties. In fact, if midlevels truly “take over” hospital medicine, critical care is probably next, and the number of consults to ID, nephro etc. will be enormous.
 
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IMGASMD

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CCM does bronchs, it’s a core competency. Most programs also train for perc trachs. ICU procedures are easy target for midlevels. There is an Ivy League institution that lets midlevels do ICU bronchs in the presence of an attending. The number of idiots selling out medicine is unbelievable.

I think from a midlevel encroachment “safety” point of view, any consult based organ specific specialty is probably safest among IM subspecialties. In fact, if midlevels truly “take over” hospital medicine, critical care is probably next, and the number of consults to ID, nephro etc. will be enormous.

Sure. But with pulm and one more year, you may get more options. Worked at a place, CCM would defer any bronch to pulm, because of whatever arrangement they had at the time.

I think when midlevel takes over ccm, you might as well call it game over. You allow midlevel to take care of your sickest of the sick. What else can’t they really do then?
 
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blue.jay

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Sure. But with pulm and one more year, you may get more options. Worked at a place, CCM would defer any bronch to pulm, because of whatever arrangement they had at the time.

I think when midlevel takes over ccm, you might as well call it game over. You allow midlevel to take care of your sickest of the sick. What else can’t they really do then?

During my residency, one of our intensivist used to say he can even train a monkey to do procedures, but to think like a doctor needs hard
work, knowledge and experience. They are having NPs do lines these days, CRNAs are intubating in many places. Unlike endoscopies and cardiac cath there aren't many pulm procedures to get away from midlevels completely.
I don't ever think CCM MD will be replaced by NPs but it's highly likely they will have one day MD and eICU at night and hire more NPs for other roles (in places which needs staffing by 2 docs). There are so many PA/NPs in pulm clinic these days.
But like you suggested, I would prefer PulmCCM but it has gotten very competitive over the last few years hence debating ID-CCM route
 
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CCM-MD

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During my residency, one of our intensivist used to say he can even train a monkey to do procedures, but to think like a doctor needs hard
work, knowledge and experience. They are having NPs do lines these days, CRNAs are intubating in many places. Unlike endoscopies and cardiac cath there aren't many pulm procedures to get away from midlevels completely.
I don't ever think CCM MD will be replaced by NPs but it's highly likely they will have one day MD and eICU at night and hire more NPs for other roles (in places which needs staffing by 2 docs). There are so many PA/NPs in pulm clinic these days.
But like you suggested, I would prefer PulmCCM but it has gotten very competitive over the last few years hence debating ID-CCM route

If you can get a combined ID program that formally has a CCM year integrated, that’s good. But there are only a handful of those. Going the route of an ID fellowship and subsequently applying separately for a CCM year may not be easy. There are ~40 IM-CCM programs. I personally know that many specifically prefer 2 year fellows. In addition, think about your work prospects after completion. I have several friends who are nephro-CCM and one ID CCM. All of them are doing full time ICU work because combined jobs are very rare for those specialties. There are pulm CC folk that do full time intensivist work also, without practicing any pulm simultaneously. Transitioning back to practicing pulm, nephro, ID etc. after years of not practicing it would be challenging to say the least.
 
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blue.jay

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If you can get a combined ID program that formally has a CCM year integrated, that’s good. But there are only a handful of those. Going the route of an ID fellowship and subsequently applying separately for a CCM year may not be easy. There are ~40 IM-CCM programs. I personally know that many specifically prefer 2 year fellows. In addition, think about your work prospects after completion. I have several friends who are nephro-CCM and one ID CCM. All of them are doing full time ICU work because combined jobs are very rare for those specialties. There are pulm CC folk that do full time intensivist work also, without practicing any pulm simultaneously. Transitioning back to practicing pulm, nephro, ID etc. after years of not practicing it would be challenging to say the least.

Thanks for your opinion. I can only find a handful of combined ID-CCM programs, and that seems be very competitive as well. I was thinking if I get burnt out in ICU after few years I can fall back to doing inpatient ID consults without clinic for low pay. Probably that's more easier than trying to practice out-patient Pulm or Nephrology after 10 years as intensivist?
More than $ I'm trying to figure out what speciality will have less burnout when I'm in my 60s (when ICU is probably too stressful)
 

CCM-MD

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Thanks for your opinion. I can only find a handful of combined ID-CCM programs, and that seems be very competitive as well. I was thinking if I get burnt out in ICU after few years I can fall back to doing inpatient ID consults without clinic for low pay. Probably that's more easier than trying to practice out-patient Pulm or Nephrology after 10 years as intensivist?
More than $ I'm trying to figure out what speciality will have less burnout when I'm in my 60s (when ICU is probably too stressful)

I can tell you that burnout is real. So you are definitely thinking along the right lines. And the biggest way to burnout is to do something you don’t enjoy. Your best bet is doing Pulm/CCM. You have the ability to transition to less ICU work or entirely out of it as you age. I don’t know if your ID plan is a good one - almost sounds like you want to do something like 2 years on (ccm)/2 years off (on ID). Too many variables, is there gonna be an available ID job? Are you gonna move every time?
 

grt398

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I like hospital medicine but don't like collaborating with midlevels. I'm hearing over the next few years hospitalist will be replaced by NP/PA. Will ID/Nephrology be easier for midlevels to encroach? I'm fine with 200-230k pay if my skill set is unique from midlevels.

So I'm not sure replaced is the right word, but I would not be surprised if there was more "supervisory" type practice like anesthesia these days. I can't remember where I read it, probably these boards over the years, but I believe multiple institutions including Mayo have tried stretching the mid-level to physician ratio for hospitalist work and found that it was doable on a 2:1 supervisory ratio (2 mid-levels per physician) but more than that and the mid-levels cost the hospital too much with excessive testing/consulting etc. Keep in mind for many hospital admissions, patients are admitted under some type of DRG code and at least for many of the common ones, there's a payment amount associated with "COPD exacerbation" so if the mid-level runs up $500k in expenses, the hospital is still getting the standard DRG payment of $X, whatever that is. Here's an example of such a model if you're interested, looking at COPD and a trial program at UAB:


As someone starting a CCM fellowship, I do worry about this as I'd prefer to practice independently, and I've seen mid-levels in the ICU in residency do things that were inappropriate and had some bad outcomes, which would never have occurred had an attending been there. I'm not sure yet how to manage this issue because my inclination would be to require them to run every single treatment decision by me as if they were a PGY1. And at that point it would be more efficient to do the work myself, which is why I'd prefer to practice independently.
 

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CCM does bronchs, it’s a core competency. Most programs also train for perc trachs. ICU procedures are easy target for midlevels. There is an Ivy League institution that lets midlevels do ICU bronchs in the presence of an attending. The number of idiots selling out medicine is unbelievable.

I think from a midlevel encroachment “safety” point of view, any consult based organ specific specialty is probably safest among IM subspecialties. In fact, if midlevels truly “take over” hospital medicine, critical care is probably next, and the number of consults to ID, nephro etc. will be enormous.
Nice to see you came around hard on this issue.
 

shouldigomd

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I think what you feel is common early on in training. I felt the same way especially as an intern in the MICU. The reality is that critical care medicine really has very few high skill procedures. Intubating, lines and even bronch's are generally very easy low skill procedures (obviously anything can become difficult).

Your skillset in the fields you mentioned isn't really procedures but your knowledge and problem solving. Thats why you get paid and thats why midlevels can't work without you.

I personally feel the field most "threatened" by midlevels is anesthesiologists.
 
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grt398

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I realize this is going to fan the flames a bit, but even procedural fields that people think are safer probably are not. Sure no one is yet talking about letting a non-MD do neurosurgery, but things like colonoscopies and cardiac caths....

Comparisons of Screening Colonoscopy Performed by a Nurse Practitioner and Gastroenterologists: A Single-Center Randomized Controlled Trial - PubMed (UC-Davis study, conclusion: "Cecal intubation rates, duration of procedure, sedative, and analgesic use, and patient reported procedural pain scores were equivalent among the groups. The GI-NP group had a higher adenoma detection rate compared with the combined GI-MD groups (42% and 17%, respectively, p = .0001) and a higher satisfaction score when compared with the combined GI-MD groups (mean 5.9 ± 13.81 and 8.6 ± 16.11, respectively, p = .042; visual analog scale 0-100 mm, "0" = completely satisfied, "100" = completely dissatisfied). There were no immediate complications reported in any group. The properly trained GI-NP in our study performed screening colonoscopy as safely, accurately, and satisfactorily as the GI-MDs.")

Here's a blog post from a Professor of Internal Medicine at OSU and medical director of one of their hospital discussing how he would "theoretically" implement a training program to create NP/PA endoscopists that would be much cheaper than a GI doc:


Here's the meta-analysis he cites as evidence for the safety of it out of UCSF: Non-Physicians Performing Lower and Upper Endoscopy: A Systematic Review and Meta-Analysis

I suspect the real answer for most fields is: (1) Splenda88's suggestions above of putting yourself in position to FIRE ASAP and (2) get involved with the admin side to advocate against the things noted above. It seems highly likely medicine in the US is going to change dramatically over the next 10-15 years.
 
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CCM-MD

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I realize this is going to fan the flames a bit, but even procedural fields that people think are safer probably are not. Sure no one is yet talking about letting a non-MD do neurosurgery, but things like colonoscopies and cardiac caths....

Comparisons of Screening Colonoscopy Performed by a Nurse Practitioner and Gastroenterologists: A Single-Center Randomized Controlled Trial - PubMed (UC-Davis study, conclusion: "Cecal intubation rates, duration of procedure, sedative, and analgesic use, and patient reported procedural pain scores were equivalent among the groups. The GI-NP group had a higher adenoma detection rate compared with the combined GI-MD groups (42% and 17%, respectively, p = .0001) and a higher satisfaction score when compared with the combined GI-MD groups (mean 5.9 ± 13.81 and 8.6 ± 16.11, respectively, p = .042; visual analog scale 0-100 mm, "0" = completely satisfied, "100" = completely dissatisfied). There were no immediate complications reported in any group. The properly trained GI-NP in our study performed screening colonoscopy as safely, accurately, and satisfactorily as the GI-MDs.")

Here's a blog post from a Professor of Internal Medicine at OSU and medical director of one of their hospital discussing how he would "theoretically" implement a training program to create NP/PA endoscopists that would be much cheaper than a GI doc:


Here's the meta-analysis he cites as evidence for the safety of it out of UCSF: Non-Physicians Performing Lower and Upper Endoscopy: A Systematic Review and Meta-Analysis

I suspect the real answer for most fields is: (1) Splenda88's suggestions above of putting yourself in position to FIRE ASAP and (2) get involved with the admin side to advocate against the things noted above. It seems highly likely medicine in the US is going to change dramatically over the next 10-15 years.


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grt398

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Thank you! I remembered reading those studies but hadn't taken the time to look them up. Also, from the Anesthesia forum, here's the california public salary database listing nurses (Clinical Nurse III, which I can't verify but the Anesthesia forum said was an ICU nurse) making >$300k/year just for some perspective, as well as Clinical Nurse II where you have to go 3 pages in to get to someone making <$150k/year:


It's unfortunate that people with certain agendas like to point to our salaries as an "issue" without accounting for the amount of training we do, nor mentioning that there are a substantial number of individuals making similar or greater salaries with less training, working less hours, with less responsibility, and requiring less ongoing continuing medical education etc. All that said, I do actually love the field I'm going into, I'm just planning to put myself in the FIRE position as soon as possible so that if I find myself in a work situation I no longer enjoy, I have the freedom to find one I do, whether that takes a month or a year, or I've even considered doing overseas work etc. I've never forgotten a surgeon I met at a career day at my med school, who told me (and I'm paraphrasing): "I still love performing surgery, but I hate working as a surgeon in the US, and if I didn't have a family, I'd go spend the rest of my career doing mission work overseas." That said a lot to me about the state of healthcare, even for an attending.
 

blue.jay

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I realize this is going to fan the flames a bit, but even procedural fields that people think are safer probably are not. Sure no one is yet talking about letting a non-MD do neurosurgery, but things like colonoscopies and cardiac caths....

Comparisons of Screening Colonoscopy Performed by a Nurse Practitioner and Gastroenterologists: A Single-Center Randomized Controlled Trial - PubMed (UC-Davis study, conclusion: "Cecal intubation rates, duration of procedure, sedative, and analgesic use, and patient reported procedural pain scores were equivalent among the groups. The GI-NP group had a higher adenoma detection rate compared with the combined GI-MD groups (42% and 17%, respectively, p = .0001) and a higher satisfaction score when compared with the combined GI-MD groups (mean 5.9 ± 13.81 and 8.6 ± 16.11, respectively, p = .042; visual analog scale 0-100 mm, "0" = completely satisfied, "100" = completely dissatisfied). There were no immediate complications reported in any group. The properly trained GI-NP in our study performed screening colonoscopy as safely, accurately, and satisfactorily as the GI-MDs.")

Here's a blog post from a Professor of Internal Medicine at OSU and medical director of one of their hospital discussing how he would "theoretically" implement a training program to create NP/PA endoscopists that would be much cheaper than a GI doc:


Here's the meta-analysis he cites as evidence for the safety of it out of UCSF: Non-Physicians Performing Lower and Upper Endoscopy: A Systematic Review and Meta-Analysis

I suspect the real answer for most fields is: (1) Splenda88's suggestions above of putting yourself in position to FIRE ASAP and (2) get involved with the admin side to advocate against the things noted above. It seems highly likely medicine in the US is going to change dramatically over the next 10-15 years.

Who knows this could really happen. They can train monkeys to do simple procedures. The training we get is when is it better to not test, treat and just watch. Even fresh grads are not good at it; only with time we learn the art of medicine. Unfortunately this country doesn't value quality more than quantity. To me it seems they want these half-assed midlevels consult everyone and order every test to keep feeding the system.
I am actually fine with them doing procedures but I don't like them getting free on the job residency training and later tell they are better than internist, pediatricians, obstetrician, anaesthesiologist, neurologist etc.

I'm fine working for a lower pay if I don't have to collaborate with a midlevel and take on their liability. Sadly those jobs in clinical setting are slowly going away. They are everywhere (floors, clinics, ICU, OR)
 
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Chemist0157

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I wouldn’t worry about PAs/NPs encroaching on nephrology. The ones we use take a lot of training to get them where they need to be. Seems like ID would be safe as well. Subspecialty work is not “plug and play” enough so to speak. Too much knowledge necessary.

A previous co-fellow of mine did a critical care year after his 2 years of nephrology fellowship at the same institution so it was very straightforward for him.
 

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Do something you like. No one knows what will happen in 10-20 years. Focus on now, sure you can plan and speculate at the same time.

Remember why you entered medicine, don’t get too bitter or scared along the way.

(Talking to myself as myself 15 years ago).

If you find yourself hating going to work or can’t wake up early enough for work.... maybe it’s not the right field for you.

Good luck.
 
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grt398

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I wouldn’t worry about PAs/NPs encroaching on nephrology. The ones we use take a lot of training to get them where they need to be. Seems like ID would be safe as well. Subspecialty work is not “plug and play” enough so to speak. Too much knowledge necessary.

A previous co-fellow of mine did a critical care year after his 2 years of nephrology fellowship at the same institution so it was very straightforward for him.

Just playing devil's advocate today, but neurology is one of those fields you'd also think would be difficult for midlevels to encroach, and yet the American Academy of Neurology, which is the national organization for neurologists, put out the following:


Here's some key quotes:

"The ultimate goal of integration of non-physician care providers is to add value by both improving access and enhancing quality of care for patients with neurologic disease. Advanced practice providers can conduct evaluations, prescribe medications, order and interpret testing, and perform some procedures independent of direct physician supervision."

"The AAN needs to gain a better understanding of what APPs desire from the AAN, and to fill gaps in resources that APPs need to be successful in neurologic practice. In particular, the AAN needs to:
  • Accurately identify what membership benefits are valuable to APPs
  • Accurately identify what educational gaps can be filled by our programs
  • Address and advertise the Continuing Certification (CC) requirements for APPs that can be met by AAN offerings
  • Incorporate APPs into the committee structure of the AAN to allow for their perspectives to be effectively communicated and for the AAN to better understand new models of value based care
  • Develop a Fellow of the AAN status, similar in requirement of the Fellow statuses for physicians and research scientists, for APPs"
Their leadership seems a lot more interested in allowing non-physicians to practice than advocating for neurologists themselves. And there are many people in academic leadership in many fields with similar views.
 
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Splenda88

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Just playing devil's advocate today, but neurology is one of those fields you'd also think would be difficult for midlevels to encroach, and yet the American Academy of Neurology, which is the national organization for neurologists, put out the following:


Here's some key quotes:

"The ultimate goal of integration of non-physician care providers is to add value by both improving access and enhancing quality of care for patients with neurologic disease. Advanced practice providers can conduct evaluations, prescribe medications, order and interpret testing, and perform some procedures independent of direct physician supervision."

"The AAN needs to gain a better understanding of what APPs desire from the AAN, and to fill gaps in resources that APPs need to be successful in neurologic practice. In particular, the AAN needs to:
  • Accurately identify what membership benefits are valuable to APPs
  • Accurately identify what educational gaps can be filled by our programs
  • Address and advertise the Continuing Certification (CC) requirements for APPs that can be met by AAN offerings
  • Incorporate APPs into the committee structure of the AAN to allow for their perspectives to be effectively communicated and for the AAN to better understand new models of value based care
  • Develop a Fellow of the AAN status, similar in requirement of the Fellow statuses for physicians and research scientists, for APPs"
Their leadership seems a lot more interested in allowing non-physicians to practice than advocating for neurologists themselves. And there are many people in academic leadership in many fields with similar views.
What a bunch of bs! If I was a neurologist and member of the AAN, my membership would be terminated today.
 
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blue.jay

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Just playing devil's advocate today, but neurology is one of those fields you'd also think would be difficult for midlevels to encroach, and yet the American Academy of Neurology, which is the national organization for neurologists, put out the following:


Here's some key quotes:

"The ultimate goal of integration of non-physician care providers is to add value by both improving access and enhancing quality of care for patients with neurologic disease. Advanced practice providers can conduct evaluations, prescribe medications, order and interpret testing, and perform some procedures independent of direct physician supervision."

"The AAN needs to gain a better understanding of what APPs desire from the AAN, and to fill gaps in resources that APPs need to be successful in neurologic practice. In particular, the AAN needs to:
  • Accurately identify what membership benefits are valuable to APPs
  • Accurately identify what educational gaps can be filled by our programs
  • Address and advertise the Continuing Certification (CC) requirements for APPs that can be met by AAN offerings
  • Incorporate APPs into the committee structure of the AAN to allow for their perspectives to be effectively communicated and for the AAN to better understand new models of value based care
  • Develop a Fellow of the AAN status, similar in requirement of the Fellow statuses for physicians and research scientists, for APPs"
Their leadership seems a lot more interested in allowing non-physicians to practice than advocating for neurologists themselves. And there are many people in academic leadership in many fields with similar views.

Traditionally neurology is supposedly the most difficult by subject matter. Lots of rare diseases, weird presentations, complex anatomy and physiology. AAN lost my respect for selling out their profession. One of the few specialities which requires a sound basic science knowledge which we learn in medical school is given away to those so called advanced nurses.
 
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Chemist0157

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Just playing devil's advocate today, but neurology is one of those fields you'd also think would be difficult for midlevels to encroach, and yet the American Academy of Neurology, which is the national organization for neurologists, put out the following:


Here's some key quotes:

"The ultimate goal of integration of non-physician care providers is to add value by both improving access and enhancing quality of care for patients with neurologic disease. Advanced practice providers can conduct evaluations, prescribe medications, order and interpret testing, and perform some procedures independent of direct physician supervision."

"The AAN needs to gain a better understanding of what APPs desire from the AAN, and to fill gaps in resources that APPs need to be successful in neurologic practice. In particular, the AAN needs to:
  • Accurately identify what membership benefits are valuable to APPs
  • Accurately identify what educational gaps can be filled by our programs
  • Address and advertise the Continuing Certification (CC) requirements for APPs that can be met by AAN offerings
  • Incorporate APPs into the committee structure of the AAN to allow for their perspectives to be effectively communicated and for the AAN to better understand new models of value based care
  • Develop a Fellow of the AAN status, similar in requirement of the Fellow statuses for physicians and research scientists, for APPs"
Their leadership seems a lot more interested in allowing non-physicians to practice than advocating for neurologists themselves. And there are many people in academic leadership in many fields with similar views.

That’s quite the helping hand.
 

Chemist0157

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Just playing devil's advocate today, but neurology is one of those fields you'd also think would be difficult for midlevels to encroach, and yet the American Academy of Neurology, which is the national organization for neurologists, put out the following:


Here's some key quotes:

"The ultimate goal of integration of non-physician care providers is to add value by both improving access and enhancing quality of care for patients with neurologic disease. Advanced practice providers can conduct evaluations, prescribe medications, order and interpret testing, and perform some procedures independent of direct physician supervision."

"The AAN needs to gain a better understanding of what APPs desire from the AAN, and to fill gaps in resources that APPs need to be successful in neurologic practice. In particular, the AAN needs to:
  • Accurately identify what membership benefits are valuable to APPs
  • Accurately identify what educational gaps can be filled by our programs
  • Address and advertise the Continuing Certification (CC) requirements for APPs that can be met by AAN offerings
  • Incorporate APPs into the committee structure of the AAN to allow for their perspectives to be effectively communicated and for the AAN to better understand new models of value based care
  • Develop a Fellow of the AAN status, similar in requirement of the Fellow statuses for physicians and research scientists, for APPs"
Their leadership seems a lot more interested in allowing non-physicians to practice than advocating for neurologists themselves. And there are many people in academic leadership in many fields with similar views.

But to my previous point, midlevels aren’t ready to do these things right out the gate. They have to receive additional training to be useful. It would be very weird for an NP to set up shop just to see CKD patients when the money is in seeing dialysis patients. So for NPs to be a threat 1) they would need the training 2) the government would have to be okay with them independently seeing some of the sickest patients in the country and 3) the dialysis companies would have to be on board with it as well. Not impossible as I can appreciate the power of lobbyists, but these are massive, massive hurdles.
 
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blue.jay

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But to my previous point, midlevels aren’t ready to do these things right out the gate. They have to receive additional training to be useful. It would be very weird for an NP to set up shop just to see CKD patients when the money is in seeing dialysis patients. So for NPs to be a threat 1) they would need the training 2) the government would have to be okay with them independently seeing some of the sickest patients in the country and 3) the dialysis companies would have to be on board with it as well. Not impossible as I can appreciate the power of lobbyists, but these are massive, massive hurdles.

I agree NPs can never become nephrologist, endocrinologist or neurologist. But nothing is going to stop the employers from hiring plenty of midlevels under the guise of supervision by 1-2 doctors (on paper).
That's my dilemma. Claiming team based approach they are replacing some doctor roles with midlevels. This is inevitable but I really don't like working with midlevels I would rather not sign their charts and work alone. I realize that's an unreasonable ask these days. Though I love being an internist I can't wait for retirement though I'm in my early 30s :(
 
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Chemist0157

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I agree NPs can never become nephrologist, endocrinologist or neurologist. But nothing is going to stop the employers from hiring plenty of midlevels under the guise of supervision by 1-2 doctors (on paper).
That's my dilemma. Claiming team based approach they are replacing some doctor roles with midlevels. This is inevitable but I really don't like working with midlevels I would rather not sign their charts and work alone. I realize that's an unreasonable ask these days. Though I love being an internist I can't wait for retirement though I'm in my early 30s :(

Ideally then, you would join a private practice group run by physicians. It’s the best :) At least then, you can help call the shots and not have a hospital system over your head. It’s not bad having PAs/NPs when they work for you. I would try to look into something like that because, as you said, it may be very challenging to find a job where there is 0 midlevel interaction, especially if you are an employee yourself with minimal control.
 

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But to my previous point, midlevels aren’t ready to do these things right out the gate. They have to receive additional training to be useful. It would be very weird for an NP to set up shop just to see CKD patients when the money is in seeing dialysis patients. So for NPs to be a threat 1) they would need the training 2) the government would have to be okay with them independently seeing some of the sickest patients in the country and 3) the dialysis companies would have to be on board with it as well. Not impossible as I can appreciate the power of lobbyists, but these are massive, massive hurdles.

So I agree with you on much of this, but what worries me is that many times the govt and other entities are more concerned with the appearance of providing healthcare, rather than the meaningful content of providing healthcare. Metrics have been designed to measure pointless things like door-to-doctor times in the ED, or compliance with various numbers for various tests (% of pts w/A1c < X for example) as "quality" measures, when in reality they don't represent any type of true quality measure for the physicians on the ground who are actually providing care or anything meaningful for patients. This is one of my favorite JAMA studies showing an inverse correlation b/w patient satisfaction and mortality:


And the large organizations are really just concerned, at the top level at least, with meeting whatever metrics are required for their bonuses/stock vesting/future elevation of their stock price etc. I'm a bit cynical, but having worked for several years at a large investment bank prior to med school and having friends who still work in the healthcare finance field with many companies often cited on these message boards, to put it politely, there is a gap between the C-suite's concerns and the concerns of physicians on the ground. One group (and unfortunately sometimes both) is often more focused on maximizing efficiency so long as it doesn't run afoul of any official govt regulations. What that means for patients....
 
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Chemist0157

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So I agree with you on much of this, but what worries me is that many times the govt and other entities are more concerned with the appearance of providing healthcare, rather than the meaningful content of providing healthcare. Metrics have been designed to measure pointless things like door-to-doctor times in the ED, or compliance with various numbers for various tests (% of pts w/A1c < X for example) as "quality" measures, when in reality they don't represent any type of true quality measure for the physicians on the ground who are actually providing care or anything meaningful for patients. This is one of my favorite JAMA studies showing an inverse correlation b/w patient satisfaction and mortality:


And the large organizations are really just concerned, at the top level at least, with meeting whatever metrics are required for their bonuses/stock vesting/future elevation of their stock price etc. I'm a bit cynical, but having worked for several years at a large investment bank prior to med school and having friends who still work in the healthcare finance field with many companies often cited on these message boards, to put it politely, there is a gap between the C-suite's concerns and the concerns of physicians on the ground. One group (and unfortunately sometimes both) is often more focused on maximizing efficiency so long as it doesn't run afoul of any official govt regulations. What that means for patients....

I’m not really interested in derailing the OP’S thread. I have answered his question the best I can. Yes, there are different priorities at play. Yes, the risk of midlevels encroaching on nephrology is not zero, but it is virtually zero now, and I suspect it will be as such for a long time.
 

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I realize this is going to fan the flames a bit, but even procedural fields that people think are safer probably are not. Sure no one is yet talking about letting a non-MD do neurosurgery, but things like colonoscopies and cardiac caths....

Comparisons of Screening Colonoscopy Performed by a Nurse Practitioner and Gastroenterologists: A Single-Center Randomized Controlled Trial - PubMed (UC-Davis study, conclusion: "Cecal intubation rates, duration of procedure, sedative, and analgesic use, and patient reported procedural pain scores were equivalent among the groups. The GI-NP group had a higher adenoma detection rate compared with the combined GI-MD groups (42% and 17%, respectively, p = .0001) and a higher satisfaction score when compared with the combined GI-MD groups (mean 5.9 ± 13.81 and 8.6 ± 16.11, respectively, p = .042; visual analog scale 0-100 mm, "0" = completely satisfied, "100" = completely dissatisfied). There were no immediate complications reported in any group. The properly trained GI-NP in our study performed screening colonoscopy as safely, accurately, and satisfactorily as the GI-MDs.")

Here's a blog post from a Professor of Internal Medicine at OSU and medical director of one of their hospital discussing how he would "theoretically" implement a training program to create NP/PA endoscopists that would be much cheaper than a GI doc:


Here's the meta-analysis he cites as evidence for the safety of it out of UCSF: Non-Physicians Performing Lower and Upper Endoscopy: A Systematic Review and Meta-Analysis

I suspect the real answer for most fields is: (1) Splenda88's suggestions above of putting yourself in position to FIRE ASAP and (2) get involved with the admin side to advocate against the things noted above. It seems highly likely medicine in the US is going to change dramatically over the next 10-15 years.

From what I've seen and heard, the GI folks are close-knit. There is a deliberate bottle neck to keep fellowship spots low so they always have good demand, unlike cardiology which now has almost 1000 spots. I'm pretty sure they won't let midlevels touch their scopes. They are the ones who use midlevels the way they are supposed to function; scribe, boring clinic and consults while they make $$$ spending their time on endoscopies.

In the hospital where I work, GI NPs work very hard they see about 10-15 patients each, discuss with attending and write good notes. Our hospitalists NP/PA see 4-6 pts, never discuss and cringe if they have to do one extra admission. I recently asked them to help us out with admissions alone (because they don't like working 7/7off and instead scheduled themselves to work 3on/4 off) during the daytime instead of seeing f/u they threatened to quit if that's made a requirement. I guess they like playing doctor, independently managing patients during the whole hospital course and sporadically discussing if we keep nagging them about their patients.
 
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grt398

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In the hospital where I work, GI NPs work very hard they see about 10-15 patients each, discuss with attending and write good notes. Our hospitalists NP/PA see 4-6 pts, never discuss and cringe if they have to do one extra admission. I recently asked them to help us out with admissions alone (because they don't like working 7/7off and instead scheduled themselves to work 3on/4 off) during the daytime instead of seeing f/u they threatened to quit if that's made a requirement. I guess they like playing doctor, independently managing patients during the whole hospital course and sporadically discussing if we keep nagging them about their patients.

This sounds incredibly painful, sorry to hear it, though not tremendously surprised based on some of my residency experiences.
 

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Ironically, I don't think NP/PA can replace hospitalists for some reasons mentioned above. You may find some to cover the basic BS stuff like social work cases and simple cellulitis that ED can assign to a midlevel service. More medically complicated cases will still need an MD who is willing to provide continuity of the hospital stay for 7 days straight.
 

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Someone explain to me why some attendings of ALL ages who make NO money off midlevels still support them ?? I swear a big chunk of society lives in some delusional bubble. And it includes people from all walks of life (janitor, doctor, president, etc.)
 

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Someone explain to me why some attendings of ALL ages who make NO money off midlevels still support them ?? I swear a big chunk of society lives in some delusional bubble. And it includes people from all walks of life (janitor, doctor, president, etc.)

Vast majority of us are employed these days, we have no say in midlevel hiring decisions. Some physicians are nice to midlevels but personally like working alone without having to collaborate. I thought I was only one who hated working with midlevels but I asked others in my group and they all felt the same (but were not vocal about it) so rounding with midlevel team is evenly distributed over the year. I presume our GI docs appreciate them because they can spend more time doing profitable procedures and private practice physicians who employ midlevels earn more $$$ from the revenue generate by them.

I would say we dug our own grave by encouraging midlevel expansion. They earn 3 figure salary and learn on the job; their numbers are exploding and they are lobbying hard for independent practice. It will really suck to work with midlevels who have diluted knowledge and follow cook book medicine; which seems to be the desire of American healthcare system
 
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Vast majority of us are employed these days, we have no say in midlevel hiring decisions. Some physicians are nice to midlevels but personally like working alone without having to collaborate. I thought I was only one who hated working with midlevels but I asked others in my group and they all felt the same (but were not vocal about it) so rounding with midlevel team is evenly distributed over the year. I presume our GI docs appreciate them because they can spend more time doing profitable procedures and private practice physicians who employ midlevels earn more $$$ from the revenue generate by them.

I would say we dug our own grave by encouraging midlevel expansion. They earn 3 figure salary and learn on the job; their numbers are exploding and they are lobbying hard for independent practice. It will really suck to work with midlevels who have diluted knowledge and follow cook book medicine; which seems to be the desire of American healthcare system

My partners love our midlevels since they write all the notes, put orders in, filter calls etc. Its all fine now... but once you get enough midlevels who want to work at the "top of their license" and they organize, it will quickly become a lot like anesthesia in the OR. All of our consulting services have midlevels. Interestingly the hospitalists have the least number. ICU expansion is definitely a real possibility in the next 10-15 years.

1593198509002.png

Get ready for the NP Intensivists.
 
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Vast majority of us are employed these days, we have no say in midlevel hiring decisions. Some physicians are nice to midlevels but personally like working alone without having to collaborate. I thought I was only one who hated working with midlevels but I asked others in my group and they all felt the same (but were not vocal about it) so rounding with midlevel team is evenly distributed over the year. I presume our GI docs appreciate them because they can spend more time doing profitable procedures and private practice physicians who employ midlevels earn more $$$ from the revenue generate by them.

I would say we dug our own grave by encouraging midlevel expansion. They earn 3 figure salary and learn on the job; their numbers are exploding and they are lobbying hard for independent practice. It will really suck to work with midlevels who have diluted knowledge and follow cook book medicine; which seems to be the desire of American healthcare system
Many still display verbal support though and advocate for them, when there'$ no reason to. That's my issue.
 

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My partners love our midlevels since they write all the notes, put orders in, filter calls etc. Its all fine now... but once you get enough midlevels who want to work at the "top of their license" and they organize, it will quickly become a lot like anesthesia in the OR. All of our consulting services have midlevels. Interestingly the hospitalists have the least number. ICU expansion is definitely a real possibility in the next 10-15 years.

View attachment 311134

Get ready for the NP Intensivists.

I could imagine in few years, ER midlevel will triage patients to the floor, the midlevel hospitalist will transfer the patient to a midlevel intensivist, who will consult a midlevel cardiologist to get a midlevel level expert opinion while the physician sits in a bunker and sign their charts. :rofl:
 
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I could imagine in few years, ER midlevel will triage patients to the floor, the midlevel hospitalist will transfer the patient to a midlevel intensivist, who will consult a midlevel cardiologist to get a midlevel level expert opinion while the physician sits in a bunker and sign their charts. :rofl:

In a few years? Its already happening. No matter who you consult, you get a midlevel. Most consultants are pretty good and stay on top of things but some are barely involved and know just enough to cosign the damn notes while they scope/cath/operate all day.
 
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Ideally then, you would join a private practice group run by physicians. It’s the best :) At least then, you can help call the shots and not have a hospital system over your head. It’s not bad having PAs/NPs when they work for you. I would try to look into something like that because, as you said, it may be very challenging to find a job where there is 0 midlevel interaction, especially if you are an employee yourself with minimal control.

I’m not really interested in derailing the OP’S thread. I have answered his question the best I can. Yes, there are different priorities at play. Yes, the risk of midlevels encroaching on nephrology is not zero, but it is virtually zero now, and I suspect it will be as such for a long time.

Given how bad it is for physicians in nephrology right now, there really isn't much for midlevels to encroach upon. Don't worry though, it will change quickly if nephrology ever becomes financially attractive again. There are more than enough corporate players in nephrology so you better believe midlevel incursion will be rapid. You are probably an aspiring nephrologist, so I can understand your consistent defensive posts about the field but lets be real here. This is a time where the trend is towards physicians becoming hospital employed, not away from it. The first step in solving the problem is recognizing it and accepting it. Ignoring the problem and pretending everything is/will be ok is the wrong strategy here.

Here's DaVita drooling over midlevels:
1593203107182.png
 
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Given how bad it is for physicians in nephrology right now, there really isn't much for midlevels to encroach upon. Don't worry though, it will change quickly if nephrology ever becomes financially attractive again. There are more than enough corporate players in nephrology so you better believe midlevel incursion will be rapid. You are probably an aspiring nephrologist, so I can understand your consistent defensive posts about the field but lets be real here. This is a time where the trend is towards physicians becoming hospital employed, not away from it. The first step in solving the problem is recognizing it and accepting it. Ignoring the problem and pretending everything is/will be ok is the wrong strategy here.

Here's DaVita drooling over midlevels:
View attachment 311141


Screenshot_2020-06-21-08-58-40-730_com.android.browser.jpg

Even midlevels don't get paid well in Nephrology. If these organizations (ASN) are worried about shrinking workforce either they should make it a 1 yr fellowship or work on making policy changes to improve nephrologist reimbursement or lifestyle. The answer these days is hire midlevels for all our worries.
 

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Given how bad it is for physicians in nephrology right now, there really isn't much for midlevels to encroach upon. Don't worry though, it will change quickly if nephrology ever becomes financially attractive again. There are more than enough corporate players in nephrology so you better believe midlevel incursion will be rapid. You are probably an aspiring nephrologist, so I can understand your consistent defensive posts about the field but lets be real here. This is a time where the trend is towards physicians becoming hospital employed, not away from it. The first step in solving the problem is recognizing it and accepting it. Ignoring the problem and pretending everything is/will be ok is the wrong strategy here.

Here's DaVita drooling over midlevels:
View attachment 311141

Dialysis rounding would potentially be a target for midlevels, but there are too many barriers for that to happen at the moment.

I’m not an aspiring nephrologist. I have been private practice at a physician owned practice for about two years now. We have a partnership with Davita and are medical directors for their units as well as seeing our patients there. This is my job everyday, and I know the situation very well.

If you know anything about nephrology, then you should know the money is at dialysis. Physicians are trending towards larger practices and hospital employed no doubt, but nephrology will likely lag behind the rest as the above is true. It would not be the best, but nephrology can run along without a hospital system as long as one has CKD clinic and outpatient dialysis. That is not true of most specialties at this point given the cost prohibition of equipment for example. Think cardiology, surgery of course, among others. Heme/onc can get sucked in due to cost of chemotherapy drugs. GI could be okay with outpatient procedures.

I have said what I said here because I found a good job very easily. My cofellows did. The fellows before me did. The fellows after me have. The programs I have connections to have no problems. The data is the data so I cannot dispute it with anecdotes alone. However, there is a huge disconnect between how things are in my region compared to elsewhere. I suspect (and know to some degree for that matter) that some programs just are not very successful. They would do well to shrink number of spots. I also suspect most of what we have seen is from the well being poisoned by number of spots and subsequent influx of IMGs who may have been poorer candidates overall, had visa restrictions that led to limited options for jobs, etc. That does not affect AMGs.

My final point. Now I’m no sucker. If the government or companies like davita feel like they can pay less for midlevels and without at least an appreciable change in outcomes (there would be unless they are very highly trained and experienced, NPs/PAs right out the door hardly know how to even treat hypertension patients referred to us), they will do it. But your article is not in the spirit of that at all. They are recommending hiring PA/NP/MA to make sure the more menial work is done so nephrologist remain available for the more comprehensive care, medical directorships, etc. It is to Davita’s advantage for physicians to be readily available.
 
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Chemist0157

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View attachment 311142

Even midlevels don't get paid well in Nephrology. If these organizations (ASN) are worried about shrinking workforce either they should make it a 1 yr fellowship or work on making policy changes to improve nephrologist reimbursement or lifestyle. The answer these days is hire midlevels for all our worries.

:shrug: I guess I don’t read too much into that. It just seems like a bad job listing. We pay better than that. Also doesn’t mention hours worked among other details.

The future will go one of two ways. We need X number of physicians to take care of the hundreds of thousands of dialysis and transplant patients at the very least. Either the graduates will find themselves more and more in demand because retiring physicians need to be replaced or they will be replaced by midlevels. I suspect private practice will continue to use physicians because a midlevel will not 1:1 the workload a physician does. If a midlevel was picked up, the rest of the practice would have to pick up the slack. Not likely, but this could happen if there are no grads available.
 

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Listen, I am not trying to shi*t on nephrology. Thinking your field is safe is a mistake. If you really think DaVita wants to get midlevels to "help the nephrologist with menial work", you need to wake up. Read between the lines and put it into the context of what is happening in other areas of medicine.
 
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Chemist0157

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Listen, I am not trying to shi*t on nephrology. Thinking your field is safe is a mistake. If you really think DaVita wants to get midlevels to "help the nephrologist with menial work", you need to wake up. Read between the lines and put it into the context of what is happening in other areas of medicine.

You should go back and actually read what I wrote if you think I need to “wake up” when I myself acknowledge that if there is an opportunity to save money, Davita will take it. At the same time, your example webpage was trash and did not make the point you wanted. Midlevels are going to intrude on some specialties more quickly and some more slowly. I think nephrology is going to be more slowly. Time will tell.

@blue.jay Back to the OP, I think if you already could see yourself doing hospital medicine, just do that. You can find a job that does not involve midlevels but understand that a hospital employer, of which you have no control, can always hire midlevels to fill in the gaps, save money, etc. For nephrology/ID, if they are groups employed by a hospital system, the case may be the same. If you join an ID or nephrology private practice, then it can be a minimal issue as the midlevels are not encroaching but only there at the service of the physicians. I have tried to make my case why I think we will not see midlevels working independently in nephrology for at least a while.

I really enjoy being in a physician owned practice. We have a lot of control of our destiny. It was a very welcome breakaway after the years of training.
 
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You should go back and actually read what I wrote if you think I need to “wake up” when I myself acknowledge that if there is an opportunity to save money, Davita will take it. At the same time, your example webpage was trash and did not make the point you wanted. Midlevels are going to intrude on some specialties more quickly and some more slowly. I think nephrology is going to be more slowly. Time will tell.

@blue.jay Back to the OP, I think if you already could see yourself doing hospital medicine, just do that. You can find a job that does not involve midlevels but understand that a hospital employer, of which you have no control, can always hire midlevels to fill in the gaps, save money, etc. For nephrology/ID, if they are groups employed by a hospital system, the case may be the same. If you join an ID or nephrology private practice, then it can be a minimal issue as the midlevels are not encroaching but only there at the service of the physicians. I have tried to make my case why I think we will not see midlevels working independently in nephrology for at least a while.

I really enjoy being in a physician owned practice. We have a lot of control of our destiny. It was a very welcome breakaway after the years of training.

Talk about shifting goal posts, damn. You’ve said a lot of things in here, sorry I couldn’t keep up (I’m not a nephrologist, just a dumb ICU doc). You said in this very thread: “risk of midlevels encroaching on nephrology is virtually zero”. You’ve toned that down quite a bit to say the least.

I’m glad you like your physician owned practice. Most of us probably would. Enjoy it while it lasts.
 

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I sort of lost track of this thread, op.

I just wanted to circle back and say, do whatever you want and you like. Trying to predict job market? If anyone here can do that with any regularity, we wouldn’t be here.

Don’t base your future on some kind of prediction. If you enjoy doing a sub speciality, do that. Same thing has been happening in anesthesia for years. Do a fellowship, only if you like it. If you do one “for the wrong reason” (whatever that means for you), you’d still be a miserable duck
 
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Chemist0157

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Talk about shifting goal posts, damn. You’ve said a lot of things in here, sorry I couldn’t keep up (I’m not a nephrologist, just a dumb ICU doc). You said in this very thread: “risk of midlevels encroaching on nephrology is virtually zero”. You’ve toned that down quite a bit to say the least.

Don’t do that. I doubt you are dumb. I suspect you are quite smart. However, you use quotation marks when that is not what I said. You are probably pulling from post #27. I feel very confident that midlevels are not in a position “now.” If you take issue with “a long time,” agree to disagree then. I am fairly confident midlevels are not taking over dialysis in the next few years. Also note this was in the context of comparing to hospital medicine where 1) they are already there and 2) docs have no control over the hospital system.

We can see what happens in the next 1, 2, 5, 10 years. I will be the first to know. I’m happy to admit if my prediction is wrong.

I’m glad you like your physician owned practice. Most of us probably would. Enjoy it while it lasts.

Unnecessarily ominous, but yes I will, thank you.
 

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I sort of lost track of this thread, op.

I just wanted to circle back and say, do whatever you want and you like. Trying to predict job market? If anyone here can do that with any regularity, we wouldn’t be here.

Don’t base your future on some kind of prediction. If you enjoy doing a sub speciality, do that. Same thing has been happening in anesthesia for years. Do a fellowship, only if you like it. If you do one “for the wrong reason” (whatever that means for you), you’d still be a miserable duck

I agree. I want to do something which I enjoy even if it pays low. I don't want a job where I dread driving to work, that's not fair to my colleagues and patients.
I love being a generalist, knowing all disease processes, skilled in basic procedures and doing point of care ultrasound. I like looking at the bigger picture, talking to patients, avoiding unnecessary consults, imaging and labs.

During residency I used to think generalist job won't be suitable for midlevels. During my residency we had midlevels in cardiology, onc, neuro, ID, GI, pulm but not in hospital medicine and ICU. There are so many physiologic changes and pathology happening which I assumed would be hard for midlevels to manage. But we have midlevels almost everywhere in my current job (which is one of top 5 ranked hospital in the nation). They have low threshold for consults, imaging, vanc-zosyn etc. I would like to manage certain conditions before I involve a specialist, but midlevels end up consulting even before the patient is seen by me.

I agree with @Chemist0157 most happy doctors are private practice physicians. I think a physician only group would fit me, but that's slowly going away. I started looking for other jobs. I know it's not wise to predict the future. Though my heart says be a generalist/hospitalist; my mind is nagging me to apply for fellowship (and take the pay cut for some job security). I still can't believe this country will trust midlevels to perform broad based specialities unsupervised when they should be functioning under supervision to take away mundane tasks from specialist.
 

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I agree. I want to do something which I enjoy even if it pays low. I don't want a job where I dread driving to work, that's not fair to my colleagues and patients.
I love being a generalist, knowing all disease processes, skilled in basic procedures and doing point of care ultrasound. I like looking at the bigger picture, talking to patients, avoiding unnecessary consults, imaging and labs.

During residency I used to think generalist job won't be suitable for midlevels. During my residency we had midlevels in cardiology, onc, neuro, ID, GI, pulm but not in hospital medicine and ICU. There are so many physiologic changes and pathology happening which I assumed would be hard for midlevels to manage. But we have midlevels almost everywhere in my current job (which is one of top 5 ranked hospital in the nation). They have low threshold for consults, imaging, vanc-zosyn etc. I would like to manage certain conditions before I involve a specialist, but midlevels end up consulting even before the patient is seen by me.

I agree with @Chemist0157 most happy doctors are private practice physicians. I think a physician only group would fit me, but that's slowly going away. I started looking for other jobs. I know it's not wise to predict the future. Though my heart says be a generalist/hospitalist; my mind is nagging me to apply for fellowship (and take the pay cut for some job security). I still can't believe this country will trust midlevels to perform broad based specialities unsupervised when they should be functioning under supervision to take away mundane tasks from specialist.

How we are reimbursed has a lot to do with it.... procedures.
 

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I’m not really interested in derailing the OP’S thread. I have answered his question the best I can. Yes, there are different priorities at play. Yes, the risk of midlevels encroaching on nephrology is not zero, but it is virtually zero now, and I suspect it will be as such for a long time.


Complete BS. 80% of what a nephrologist do can be replaced by a midlevel. Majority of dialysis rounds are done by NP/PA now a days so that physician can cut down on driving.
 
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Chemist0157

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Complete BS. 80% of what a nephrologist do can be replaced by a midlevel. Majority of dialysis rounds are done by NP/PA now a days so that physician can cut down on driving.

Not sure how you read what I wrote here and boiled it down to the above. My prediction does not live or die by whether midlevels could be taught to do some nephrology work though that is one hurdle they need to cross. I made points above and will not make repeat them here.

We’ll see I guess?:shrug:

A lot of dialysis rounds are done by midlevels, but thinking it is just about cutting back driving is a pretty shallow way to think about it.
 
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  3. Your reply is very long and likely does not add anything to the thread.
  4. It is very likely that it does not need any further discussion and thus bumping it serves no purpose.
  5. Your message is mostly quotes or spoilers.
  6. Your reply has occurred very quickly after a previous reply and likely does not add anything to the thread.
  7. This thread is locked.