I have an emergency! Five o'clock okay?

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I just had a patient yell at me, "You work for me! I'm your boss!" He, of course, was on medicaid.

 

[Daiphon]

I really wonder what motivated some of you to go into medicine since you can't seem to think beyond yourselves and your own income. And then you wonder why the profession doesn't get the respect that it used to or why you have become just a cog in the machine.

You're missing the point, or at least not seeing the whole point.

Everyone here, if they have 2 neurons to rub together, is in this to help patients. One doesn't absorb 10 years of loans & diminished income (with its compounding downstream effects) without having a modicum of altruism or masochism.

That being said, helping others & wishing to be fairly compensated for our efforts (both in the actual encounter, as well as to recoup the opportunity costs of getting there) are not mutually exclusive. Furthermore, when you have an unfunded federal mandate that effectively dictates our services are meaningless and without true value, it is little wonder people abuse the system like they had to call 7-11 instead of 9-11.

Convenience room we're not, but that's how we're treated.

So, if the feds want to push people into the ED (Obamacare) and make sure we can't fairly ask for payment up front for services rendered (EMTALA) while simultaneously making it illegal to *not* bill the patient (CMS rules - we used to be able to write off our services) but artificially setting the costs of those services (new CMS rules allowing insurers to pay whatever they want in lieu of "usual & customary"), and at the same time provide no feasible loan forgiveness... then yeah, the money is important.

But I don't question my patients. They come see me, I take care of them - as will everyone on this board. I just want to be paid for it, which is fair & appropriate; you are interchanging the macro & micro issues here.

Not my job to be a steward until I have real tort protections and loan forgiveness to make it worthwhile. Otherwise that population-level MACE of 1.7%, while great in theory means nothing for the little solitary tree in exam 3.

Semper Brunneis Pallium

 

[Siggy]

I should have clarified myself. I should have said Most Hospital Based EDs are money losing. I know that most FSED are money cows. Trust me, I know.

Assuming that most EDs lose money, most patients comes in through the ED, thus providing the patients for the profit centers.

 

[emergentmd]

Assuming that most EDs lose money, most patients comes in through the ED, thus providing the patients for the profit centers.

I know the hospital need the ED to make money. But by itself, its a money losing part of the hospital. That is a big reason why its so difficult to get any upgrades in the ED while the orthopods can say jump and admin asks where they should jump.

 

[Arcan57]

I know the hospital need the ED to make money. But by itself, its a money losing part of the hospital. That is a big reason why its so difficult to get any upgrades in the ED while the orthopods can say jump and admin asks where they should jump.

It's a matter of where the ED is located. I've never been an attending at an HBED that lost money (and that's exclusive of indirect revenue from admits). If you're a critical access hospital or located in an inner city with 60% Medicaid then you're going to lose money. But if you have a HBED that has a similar demographic base as a FSED
then it's supporting itself with the admits being a bonus.

 

[GeneralVeers]

I really wonder what motivated some of you to go into medicine since you can't seem to think beyond yourselves and your own income. And then you wonder why the profession doesn't get the respect that it used to or why you have become just a cog in the machine.

Because to do otherwise would drive most of us insane. If you're not in charge of your own income, someone else will be.

 

[coachB]

.

 

[Brahnold Bloodaxe]

I don't know how it is in FSEDs or low acuity community shops... But at the bigger centers and inner city ED's, the "worried well" are very stressful to take care of. In those places, it's not $200 for your kids college, it's a huge malpractice case because you are taking away time from other patients who may have real problems. It's a "I'm dealing with this high maintenance patient who wants a sandwich, instead of the low risk chest pain who MAY have ACS." In this respect, resource allocation is important because it can affect outcomes.

You are completely right that these low acuity patients are the ones we need to be most vigilant about because they are the ones who will crunk when you least expected them to. And those patients can be challenging, and they are $200 well earned. But there are clearly patients who have no business being there. While in the short term it may seem like taking care of these patients equals "cha-ching", in the long term I wonder if EM docs are going to get pushed aside because we cost so much for a job that someone else who is less qualified can do for half the cost.

People in this thread are talking about America and the profit incentive, and how profit is great and we should all want to get paid. I agree with that premise. But a big part of making profit when you are talking about business is cutting costs. EM docs spending a huge chunk of their time taking care of patients who are straight forward, who want some Tylenol, who just need to "metabolize to freedom" etc. Why are hospitals/groups going to keep paying EM docs top dollar when as someone else stated, you could train a med student to do most of this in 6 months?

To clarify, I know the importance of having EM docs for ruling out ACS in patients with low risk chest pain, for making sure that one HA is not a SAH etc. We are needed for those cases and you can't train your average person to manage those cases.

What you're proposing is essentially that EM docs don't wait around to get their paycut from third parties, but proactively go in search of said paycut. I don't really see the logic of throwing away 80% of your patient base out of fear that 80% of your patient base will be taken away from you by someone else. Either way the outcome is the same, and all you're doing is losing money in the interim at best or creating a self fulfilling prophecy at worst.


The truth is, there are now over 2000 PGY1 EM slots. The field is clearly designed around high volume emergency-non emergency patient mix at this point. If you cut the patient base of this field by 80% then this field is dead, worse than pathology. You need the patient volume to find jobs, any jobs with the number of EM docs floating around and entering the workforce each year. Sure, it's possible they'll crack down on ED use and kill your jobs anyway, but why would you proactively work to make it a certainty?

 

[TheComebacKid]

What you're proposing is essentially that EM docs don't wait around to get their paycut from third parties, but proactively go in search of said paycut. I don't really see the logic of throwing away 80% of your patient base out of fear that 80% of your patient base will be taken away from you by someone else. Either way the outcome is the same, and all you're doing is losing money in the interim at best or creating a self fulfilling prophecy at worst.


The truth is, there are now over 2000 PGY1 EM slots. The field is clearly designed around high volume emergency-non emergency patient mix at this point. If you cut the patient base of this field by 80% then this field is dead, worse than pathology. You need the patient volume to find jobs, any jobs with the number of EM docs floating around and entering the workforce each year. Sure, it's possible they'll crack down on ED use and kill your jobs anyway, but why would you proactively work to make it a certainty?

I never proposed anything. I am merely pointing out that I think the current system whereby EM docs are getting reimbursed buttloads of money for doing mindless work that can be done by someone else for a fraction of the cost, is unsustainable. Bubbles will inevitably burst. People are talking about how EM is a commodity precisely because they take care of these patients who want sandwiches or med refills and probably generate RVUs in the process. Do you really think in the cut throat world of hospital administration that they are going to continue shelling out $200/hour to a board certified EM doc, when the task at hand may be so straightforward that a medical student could do it?

Aren't there lessons to be learned from anesthesia? Anesthesiologists made an absolute killing doing straight forward cases while day trading simultaneously. Employers realized that there were these people called CRNAs, who were able to do the same job for a lower price. Now anesthesiology residencies go unfilled, compensation goes down, job prospects are worse. Now look at the anesthesiologists who are doing liver transplants (real problem), cardiac cases (real problem) etc. They are still putting their kids through college without much difficulty, because a CRNA can't run the liver transplant room. The doctors who are taking care of real patients and putting their training to use are the ones that are getting paid.

 

[Brahnold Bloodaxe]

I never proposed anything. I am merely pointing out that I think the current system whereby EM docs are getting reimbursed buttloads of money for doing mindless work that can be done by someone else for a fraction of the cost, is unsustainable. Bubbles will inevitably burst. People are talking about how EM is a commodity precisely because they take care of these patients who want sandwiches or med refills and probably generate RVUs in the process. Do you really think in the cut throat world of hospital administration that they are going to continue shelling out $200/hour to a board certified EM doc, when the task at hand may be so straightforward that a medical student could do it?

Aren't there lessons to be learned from anesthesia? Anesthesiologists made an absolute killing doing straight forward cases while day trading simultaneously. Employers realized that there were these people called CRNAs, who were able to do the same job for a lower price. Now anesthesiology residencies go unfilled, compensation goes down, job prospects are worse. Now look at the anesthesiologists who are doing liver transplants (real problem), cardiac cases (real problem) etc. They are still putting their kids through college without much difficulty, because a CRNA can't run the liver transplant room. The doctors who are taking care of real patients and putting their training to use are the ones that are getting paid.

Sure, I agree. I am probably more afraid of the midlevel threat than anyone. If they can replace EM docs with midlevels, then they will.

With that said, this thread was on a tangent discussing whether EM docs should engage in "resource stewardship" and I still think the answer to that is a loud "hell no." If you are correct in proposing that the majority of ED patients can be treated by midlevels, then that is that. We will eventually end up with a midlevel takeover of the field, regardless of whether docs practice "resource stewardship" in the interim. If they need you for only 20% of the patient base then when all is said and done you will have that 20% and not a penny more. So in the end, being altruistic and working to save "the system" money won't prevent you from being a victim of midlevel encroachment, just make you have less $$$ in the bank when you're made redundant. There is simply no way that acting as a resource steward can benefit any EM doctor: you just lose money and gain nothing in return.

Edit: lol, just realized you're still a med student. For some reason I had you pegged as an attending and was surprised about you speaking so brazenly about how any monkey could do 80% of the work in the ED. Had me scared there for a second

 

[Arcan57]

Sure, I agree. I am probably more afraid of the midlevel threat than anyone. If they can replace EM docs with midlevels, then they will.

With that said, this thread was on a tangent discussing whether EM docs should engage in "resource stewardship" and I still think the answer to that is a loud "hell no." If you are correct in proposing that the majority of ED patients can be treated by midlevels, then that is that. We will eventually end up with a midlevel takeover of the field, regardless of whether docs practice "resource stewardship" in the interim. If they need you for only 20% of the patient base then when all is said and done you will have that 20% and not a penny more. So in the end, being altruistic and working to save "the system" money won't prevent you from being a victim of midlevel encroachment, just make you have less $$$ in the bank when you're made redundant. There is simply no way that acting as a resource steward can benefit any EM doctor: you just lose money and gain nothing in return.

The smugness of that last line is matched only by it's inaccuracy. This is best illustrated in list form:

1) All EM docs act as resource stewards. The demand for healthcare is essentially infinite and we deal with choosing when to truncate workups all shift, every shift. The epigastric abdominal pain you sent home after a neg CT scan, nl "belly" labs, and two sets of serial cardiac markers could still need a EGD or a stress test. You're choosing to end the work-up when you feel that an emergency condition has been excluded. Or to put it another way, you're being a resource steward. Every time you don't order an MRI on a knee pain... resource steward. Every time you send home a URI without drawing labs or ordering CXR... resource steward. If you wanted to make a point that there are downsides to being an outlier in terms of resource utilization, that's obvious (and not the point you made).

2) In order for a specialty to thrive in the current medical environment it has to offer value to the system. You're advocating actively reducing our value to the system by increasing the spending of system resources for little or no return. An example to consider would be the success of anesthesia groups that have taken on the mantle of peri-operative specialists and saved millions on unneeded pre-op testing. Your approach would actively lower job security.

3) "Can be treated by" is a sort of minimal standard. If every belly pain gets a CT, if every cough gets "strep/flu/CXR", if every HA gets CT then it doesn't really matter if you're seen by a MLP or a physician. If, on the other hand, a physician uses their training and experience and utilizes less resources while achieving the same outcome? Value. Fewer tests means shorter LOSs which means that you can see more patients in the same number of rooms. This means better metrics. Better metrics mean larger C-suite bonuses. Larger C-suite bonuses mean happier administrators. Happier administrators = increased job security.

4) Increased resource utilization has a neutral to negative effect on EM doc salary. Unless you're the owner of a FSED, you're not making money off of unnecessary CTs or labs. Your billing is going to be determined by the complexity of your documentation of which test interpretation is only an (optional) part. It's quite possible to bill critical care time without doing any tests (anaphylaxis for example) and it's possible to spend thousands of dollars on a workup that ultimately yields a level 3 chart. If you are in an RVU system and your resource stewardship allows you to see more patients due to faster cycle times then you may actually make more money by not tying up a bed for 2-3 hrs with unnecessary tests.

 

[Brahnold Bloodaxe]

The smugness of that last line is matched only by it's inaccuracy. This is best illustrated in list form:

1) All EM docs act as resource stewards. The demand for healthcare is essentially infinite and we deal with choosing when to truncate workups all shift, every shift. The epigastric abdominal pain you sent home after a neg CT scan, nl "belly" labs, and two sets of serial cardiac markers could still need a EGD or a stress test. You're choosing to end the work-up when you feel that an emergency condition has been excluded. Or to put it another way, you're being a resource steward. Every time you don't order an MRI on a knee pain... resource steward. Every time you send home a URI without drawing labs or ordering CXR... resource steward. If you wanted to make a point that there are downsides to being an outlier in terms of resource utilization, that's obvious (and not the point you made).

2) In order for a specialty to thrive in the current medical environment it has to offer value to the system. You're advocating actively reducing our value to the system by increasing the spending of system resources for little or no return. An example to consider would be the success of anesthesia groups that have taken on the mantle of peri-operative specialists and saved millions on unneeded pre-op testing. Your approach would actively lower job security.

3) "Can be treated by" is a sort of minimal standard. If every belly pain gets a CT, if every cough gets "strep/flu/CXR", if every HA gets CT then it doesn't really matter if you're seen by a MLP or a physician. If, on the other hand, a physician uses their training and experience and utilizes less resources while achieving the same outcome? Value. Fewer tests means shorter LOSs which means that you can see more patients in the same number of rooms. This means better metrics. Better metrics mean larger C-suite bonuses. Larger C-suite bonuses mean happier administrators. Happier administrators = increased job security.

4) Increased resource utilization has a neutral to negative effect on EM doc salary. Unless you're the owner of a FSED, you're not making money off of unnecessary CTs or labs. Your billing is going to be determined by the complexity of your documentation of which test interpretation is only an (optional) part. It's quite possible to bill critical care time without doing any tests (anaphylaxis for example) and it's possible to spend thousands of dollars on a workup that ultimately yields a level 3 chart. If you are in an RVU system and your resource stewardship allows you to see more patients due to faster cycle times then you may actually make more money by not tying up a bed for 2-3 hrs with unnecessary tests.

With all due respect to your lengthy and informative post, what you are describing is far closer to being simply "good medicine" than the type of "resource stewardship" I was ridiculing in my posts, which seemed to mean purposefully limiting the number and types of patients EM docs see and apply good medicine to because those patients could be seen in less expensive settings. In other words, ceding turf.

As I've said earlier in the thread, I consider the job of a physician is to perform the best medical care he is capable of, and treating patients efficiently and with the minimum use of tests and interventions to still be effective certainly falls under the definition of good medical care. Worrying about and actively working against your self interest in the arena of healthcare policy as a guy working in the trenches is however something I consider outside the job description and completely foolish. That is the sort of "resource stewardship" I was criticizing and it has little to do with the sorts of things you wrote about above.

 

[emergentmd]

This Thread has definitely gone in way too many directions. I will part this to all docs (EM alike) who thinks that going into medicine must mean that you are the utmost noble person. That you go into medicine as a sacrifice for the good of the world, while sacrificing your own good - No different than going into priesthood.

This is the mentality that has screwed up medicine and has allowed the government to take over our control of what we practice. We are one of the few fields that has allowed the government to dictate how we practice medicine just because the country feels we need to be saintly.

Even down to not being able to take a small gift from Drug reps while the people making laws are getting gifts left and right.

Its great that some are happy to sacrifice their own good so they can uphold the man made morality when they stepped into medical school. I am happy to help pts and "do the right thing" along the way, but when it comes down to it, I am here to make a better life for myself and family. If the hospital gave me bonuses for practicing "appropriate medicine" and the gov protect me while practicing "appropriate medicine", then I would be the first to be in line.

But when it comes down to it, NO one including the government or Hospital conglomerate want me to practice "appropriate medicine". If they did, they would fix tort reform and get rid of all the crazy hospital metrics that impede care.

The government on one hand can't say how doctors are creating all of these heroin junkies while on the other hand saying that we need to treat pain quickly. Hospitals can't say we need to order less tests and use clinical judgement when we then get complaints on the missed Appy b/c we used our clinical judgement. Hospitals can't say we need to see pts quicker and then throw outdated dos based ordering/charting systems at us. Hospitals can't say they want to decreased needless testing and then put midlevels in triage who pan labs everyone and order a CT on everything that hurts.

If you really think you will change any of this as a doctor, you will be burnt out in no time.
I work within the system constraints, make my $$$, and do the best I can for patients. If you think the hospital conglomerate are making changes in the best interests of the pt you are kidding yourself.... All they care about is money. If you think the gov is making changes in the bets interests of the pts you are kidding yourself.... All they care about is getting Votes and staying in Office.

 

[WilcoWorld]

Hospitals can't say we need to order less tests and use clinical judgement when we then get complaints on the missed Appy b/c we used our clinical judgement.

If only the complaints were based on things as valid as missing an Appy! I get complaints about not doing an MRI on someone with 2 days of mild knee pain or not prescribing antibiotics for bronchitis - and what kills me is that the administrators take these complaints somewhat seriously. I don't get fired, but I do get emails that I have to reply to.

Whoops, looks like I just took this thread further afield.

 

[emergentmd]

If only the complaints were based on things as valid as missing an Appy! I get complaints about not doing an MRI on someone with 2 days of mild knee pain or not prescribing antibiotics for bronchitis - and what kills me is that the administrators take these complaints somewhat seriously. I don't get fired, but I do get emails that I have to reply to.

Whoops, looks like I just took this thread further afield.

If we start a "stupid admin/gov complaint" that I have to answer to, this would be an all star thread. Being a past director, I shudder at some of these complaints.

I have had a few Board complaints lodge against me that I had to respond to b/c I refused to give the pt meds and accusing them of drug seeking. Well Guess what Board, if you looked at their Pharmacy drug usage you would have thrown it right in the trash. If someone has 40 narc prescriptions from 8 different docs, ,filled at 4 different pharmacies some filled within 2 dys..... then guess what.

BUT no, it would take way too much time to just look at that and throw it in the trash. But I had to spend hours having a Paid lawyer write my response b./c that is what my insurance carrier wants. STUPID.

But I don't even get bothered by this anymore. Its just the extra steps I need to do to keep making 4-500K a yr. I have no problems sleeping at night raking in the cash if I have to jump through a few hoops. But don't tell me I am changing anything when No one above me really wants me to. They all like the status Quo where everyone complaints, nothing gets done, and everyone is making their $$$$$. Do you really think the hospitals want all of the non emergent stuff going to the clinic and cutting down on their income? Of course not, that is why we have the crazy billboards with wait times, and ERs across the country advertising and having LARGE ER signs pointing to the ER.

 

[MSmentor018]

Aren't there lessons to be learned from anesthesia? Anesthesiologists made an absolute killing doing straight forward cases while day trading simultaneously. Employers realized that there were these people called CRNAs, who were able to do the same job for a lower price. Now anesthesiology residencies go unfilled, compensation goes down, job prospects are worse.

there's definitely some truth to that. now they're wanting to work unsupervised at the VA with no physician oversight......until something bad happens then you gotta bail them out.

 

[link2swim06]

I never proposed anything. I am merely pointing out that I think the current system whereby EM docs are getting reimbursed buttloads of money for doing mindless work that can be done by someone else for a fraction of the cost, is unsustainable. Bubbles will inevitably burst. People are talking about how EM is a commodity precisely because they take care of these patients who want sandwiches or med refills and probably generate RVUs in the process. Do you really think in the cut throat world of hospital administration that they are going to continue shelling out $200/hour to a board certified EM doc, when the task at hand may be so straightforward that a medical student could do it?

Aren't there lessons to be learned from anesthesia? Anesthesiologists made an absolute killing doing straight forward cases while day trading simultaneously. Employers realized that there were these people called CRNAs, who were able to do the same job for a lower price. Now anesthesiology residencies go unfilled, compensation goes down, job prospects are worse. Now look at the anesthesiologists who are doing liver transplants (real problem), cardiac cases (real problem) etc. They are still putting their kids through college without much difficulty, because a CRNA can't run the liver transplant room. The doctors who are taking care of real patients and putting their training to use are the ones that are getting paid.

I am guessing you have never worked in an ER.

Hospital admins have nothing to do with most ER doctors salaries (in most practice arrangements). Medicare comes up with the billing codes/reimbursement. Most level 1 or 2 charts (mindless work), don't pay much at all. A lot of money is made from ER doctors billing procedures, critical care time, and level 4/5 charts. The system is already quite ****ed up because you as a doctor produce $300/hr but you work for a CMG and they take a $100/hr to pay the c-suite's salary.

My last shift I:
diagnosed a STEMI, activated heart alert, cordinated pts care to cath lab
placed a CVC, intubated, and started pressors on a septic shock patient
diagnosed GI bleed, initiated transfusion, ICU admission
diagnosed stroke, pushed tpa
treated a couple of patients that were sick enough for stepdown or floor admission
saw about 5-6 bull**** (ESI level 4/5 complaints)

Those 5 or 6 ESI level 4/5 complaints aren't billing for anything worthwhile. The homeless people aren't pay for crap. That's fine.

The pay for ER doctors is representative of the combination of volume and acuity of patients. Nobody is making $200/hr just by handing out 30 sandwiches a shift.

I guess all of the above is mindless work. I would of been able to do that flawlessly as a third year med student.

 

[emergentmd]

OK,
working in a FSED. Saw some vague complaint pt via EMS. Labs drawn, treat, out the door in 28 minutes.

Tell me that FSEDs do not provide a needed service. Go to a hospital based ED and you are lucky to be out in 2 hrs.

 

[TheComebacKid]

I am guessing you have never worked in an ER.

Hospital admins have nothing to do with most ER doctors salaries (in most practice arrangements). Medicare comes up with the billing codes/reimbursement. Most level 1 or 2 charts (mindless work), don't pay much at all. A lot of money is made from ER doctors billing procedures, critical care time, and level 4/5 charts. The system is already quite ****ed up because you as a doctor produce $300/hr but you work for a CMG and they take a $100/hr to pay the c-suite's salary.

My last shift I:
diagnosed a STEMI, activated heart alert, cordinated pts care to cath lab
placed a CVC, intubated, and started pressors on a septic shock patient
diagnosed GI bleed, initiated transfusion, ICU admission
diagnosed stroke, pushed tpa
treated a couple of patients that were sick enough for stepdown or floor admission
saw about 5-6 bull**** (ESI level 4/5 complaints)

Those 5 or 6 ESI level 4/5 complaints aren't billing for anything worthwhile. The homeless people aren't pay for crap. That's fine.

The pay for ER doctors is representative of the combination of volume and acuity of patients. Nobody is making $200/hr just by handing out 30 sandwiches a shift.

I guess all of the above is mindless work. I would of been able to do that flawlessly as a third year med student.

If I offended you in any way, I genuinely apologize. I did say at multiple points throughout this thread that EM physicians take care of sick patients that have real medical problems. That's why they are there. That's why they are paid. The sentiment from other people in this thread (including attendings) was that EM is 80% "layups" and much of the procedural stuff is "so straightforward that I could teach a medical student to do in 6 months" (I am paraphrasing, but feel free to look at some of the other posts if you don't believe me. I was responding to those sentiments.)

I have been the one in this thread that has been saying that the real reason EM physicians are a valuable asset to healthcare is because they do the stuff that you did on your last shift. There are others in this thread who are saying "give me the ESI level 5 complaints all day! more money for my kids college education". I was merely saying that I didn't think we could sustain an environment where EM docs are getting paid competitive hourly wages by taking care of straight forward patients that require minimal clinical judgement and knowledge. If we create an environment where we encourage people with BS complaints to go to the ED (i.e. "check in online and continue shopping") we are devaluing the skills and the real work that providers like yourself are trained for. We are creating a system whereby we introduce so many new "customers" without real complaints to turn bigger profits. We are going to expand rapidly, and we are going to look to curtail costs. Cutting costs means paying people less, or finding others who will manage these ESI level 5 patients for pennies on the dollar. I'm not saying that's how it will pan out, but that's what I worry about. Maybe I'm just being Debbie Downer, but I do wonder about it.

I'm an MS4 that matched into EM. I don't deny the fact that I have a ton to learn and I literally know absolutely nothing right now regarding the business side of the field, reimbursements, medicare billing and so forth. I also couldn't do a single thing you did on your last shift at this stage in my training. I'm just speaking my mind and expressing my concerns as someone going into this field. At the end of the day, the more experienced folks on here are the ones who are going to make the big decisions on where this field is heading in the immediate future. I'm just voicing my thoughts on the matter because this discussion directly affects my career. Sorry again if my comments came off as rude.

 

[deleted109597]

You'd be surprised what an ESI 4 or 5 pays when you're getting the facility fee.

 

[link2swim06]

You'd be surprised what an ESI 4 or 5 pays when you're getting the facility fee.

Which is why I am moving to Texas when this whole residency thing is done....welcome free standing ER.

 

[NontradCA]

Layups for well trained EM docs are a free throw or three pointer for a midlevel. That is where the difference lies.

We all deal with 80% layups every shift, while a midlevel seeing the same would feel like playing Jordan's Bulls

But can Golden State beat a team of Nurse Practitioners?