Is "Midlevel Creep" becoming an important thing to watch out for?

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goofball

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I've seen posts on reddit.com/r/medicine where people argue that some specialties are better choices than others because they are less vulnerable to "Midlevel Creep," or NPs/PAs encroaching on a physician's work. For example, one person argued that Urology would be a better choice than Anesthesia because the former was relatively immune to midlevel creep.

Would you select a specialty based in part on this?

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PAs/NPs practice in EVERY field.
Just do what you love. don't make a career choice based on if you think it will be safe from PA/NP encroachment or you will end up as the proctologist with the best job security and least happiness.
 
PAs/NPs practice in EVERY field.
Just do what you love. don't make a career choice based on if you think it will be safe from PA/NP encroachment or you will end up as the proctologist with the best job security and least happiness.

Yes, I know that they're everywhere. I'm talking specifically about problems like CRNAs encroaching on work previously reserved for Anesthesiologists, or NPs trying to replace FM Docs.
 
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Yes, I know that they're everywhere. I'm talking specifically about problems like CRNAs encroaching on work previously reserved for Anesthesiologists, or NPs trying to replace FM Docs.
my point was that if PA/NP folks encroach on every field then no field is "safe" and you should not use it as a criteria.
what if you chose nephrology for example and the next yr NPs developed a nephrology residency and began to flood the market? it can happen to any field and do so on short notice. do what you enjoy. as a doc you will always be at the top of the food chain and you will always be employable.
 
I've seen posts on reddit.com/r/medicine where people argue that some specialties are better choices than others because they are less vulnerable to "Midlevel Creep," or NPs/PAs encroaching on a physician's work. For example, one person argued that Urology would be a better choice than Anesthesia because the former was relatively immune to midlevel creep.

Would you select a specialty based in part on this?

If you are in the top 10% of your field and one of the best at your craft then you will always be in need.

I would include it in my decision but it wouldn't make the decision for me.

Surgery is the most safe, but like I said, being the best in your field is your best security.
 
On this message board it is, in every ****ing thread apparently
 
what's up with all this paranoia lately?

Nothing is guarantee. From having a successful marriage to worshiping the right God to buying a cheap car on Craig's list. Pursuing a career in medicine is no exception.

Life is too short. Pursue your happiness. Excel at what you do. Believe in yourself.
 
what's up with all this paranoia lately?

Nothing is guarantee. From having a successful marriage to worshiping the right God to buying a cheap car on Craig's list. Pursuing a career in medicine is no exception.

Life is too short. Pursue your happiness. Excel at what you do. Believe in yourself.

that was my point.
maybe they will accept it from someone with MD after their name.
 
As someone that is both a PA and now a med student it appears that even the attendings have been voicing this lately. I had one last month even say midlevels have it better due to less liabilities, benefits etc...(but IMHO this person limited their sop too tightly as a physician)

I had another one here recently that voiced similar concerns but it was not for himself but future docs. I asked him about what he thought about the DNP movement and he literally said- Son we have lost that battle and midlevels salaries will go up but ours will remain stagnant or drop. It won't affect him he can retire whenever he pleases but loves patient care.

Personally, I couldn't face my kid and expect her to do her best when she gets older when her father didn't do his(IMO remaining a PA would have been settling when I think I might be capable of more. That is just my personal feelings but its a good career for others) and if I was in it for money solely,I could have stayed at my last job and rode into the sunset but I (like many of my medical student colleagues) want to be the head nothing less will satisfy our drive.

Tons of typos typing this in the cafeteria on my phone.
 
As someone that is both a PA and now a med student it appears that even the attendings have been voicing this lately. I had one last month even say midlevels have it better due to less liabilities, benefits etc...(but IMHO this person limited their sop too tightly as a physician)

I had another one here recently that voiced similar concerns but it was not for himself but future docs. I asked him about what he thought about the DNP movement and he literally said- Son we have lost that battle and midlevels salaries will go up but ours will remain stagnant or drop. It won't affect him he can retire whenever he pleases but loves patient care.

Personally, I couldn't face my kid and expect her to do her best when she gets older when her father didn't do his(IMO remaining a PA would have been settling when I think I might be capable of more. That is just my personal feelings but its a good career for others) and if I was in it for money solely,I could have stayed at my last job and rode into the sunset but I (like many of my medical student colleagues) want to be the head nothing less will satisfy our drive.

Tons of typos typing this in the cafeteria on my phone.

If you don't mind me asking, what specialty was that Attending in? I've seen the reimbursement changes, and while they look bad, not every field is stagnant or dropping. Just most of them, haha.
 
I have sort of a related question. How is it that midlevel providers are able to acquire training in specialized areas of medicine (e.g. cardiology, neurology, etc)? I understand that educational programs exist, but I'm curious how these programs are structured and who is behind them. For example, is it other nurse practitioners who teach coursework in cardiology? How would they themselves have become qualified to practice or teach in these areas in the first place? I realize these questions might come off as pointed, but that's not my intent. I truly am curious to know and would appreciate if anyone had any insight.
 
My mother is a DNP and she has no desire to "overtake" the physicians role. Or, creep, or whatever. She wants to be respected for being great practitioner and be seen as a integral team member. If she is disrespected she fires back and if she is commended she reciprocates. Every field and specialty has idiots in it and mid levels suffer from this affliction just like CNA's and Physicians. The sky is far from falling.

in case you wondered: She introduces herself to patients as First name Last name your nurse practitioner.
 
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My mother is a DNP and she has no desire to "overtake" the physicians role. Or, creep, or whatever. She wants to be respected for being great practitioner and be seen as a integral team member. If she is disrespected she fires back and if she is commended she reciprocates. Every field and specialty has idiots in it and mid levels suffer from this affliction just like CNA's and Physicians. The sky is far from falling.

So let me ask does she refer to herself as doctor in clinical practice? Why did she get a DNP instead of just becoming a NP with a MS?
 
I have sort of a related question. How is it that midlevel providers are able to acquire training in specialized areas of medicine (e.g. cardiology, neurology, etc)? I understand that educational programs exist, but I'm curious how these programs are structured and who is behind them. For example, is it other nurse practitioners who teach coursework in cardiology? How would they themselves have become qualified to practice or teach in these areas in the first place? I realize these questions might come off as pointed, but that's not my intent. I truly am curious to know and would appreciate if anyone had any insight.
I can only answer for PAs. we have optional structured postgrad programs run by physicians alongside traditional md residencies. generally the program is based on a pgy-1 yr in the same specialty. for em there are currently 19 of these with many more in the works. docs know they will have to work with PAs in the future so they want the PAs to function at a high level. in em the main drive for these is ACEP, the physician em organization. if they can set up PAs as the non-physician provider of choice in em then the "independent" NPs will be less of a threat.
www.appap.org for a list of residencies with links. click on "programs" from the main page. many have been around for 30+ years.
 
Midlevel salaries will only go so far. If they go anywhere near physician salaries there is no point in hiring them. Plus, once they get similar pay they have to work similar hours. That equation won't work. There is a CAP to encroachment but it remains to be seen how far it goes. State lawyers and judges will play a crucial role.
 
. Plus, once they get similar pay they have to work similar hours.
many of us already work as many, or more, hrs than the docs we work with.
docs in my group: 120-130 hrs/mo
PAs in my group 180 hrs/mo.
most surgical PAs I know do the early morning rounds, take 1st call to the er, etc while the docs they work with are at home.
docs hire PAs to do the work they don't want to do at the times and places they don't want to do it.
 
So let me ask does she refer to herself as doctor in clinical practice? Why did she get a DNP instead of just becoming a NP with a MS?

I addressed this in my post please read the last statement. She was asked by her employer and the classes were paid for by her employer to become a DNP. In order to become a ARNP in the future you will be required to be a DNP. Some may get grandfathered in but the state of Florida is paying for my mother to get hers to be compliant.
 
Midlevel salaries will only go so far. If they go anywhere near physician salaries there is no point in hiring them. Plus, once they get similar pay they have to work similar hours. That equation won't work. There is a CAP to encroachment but it remains to be seen how far it goes. State lawyers and judges will play a crucial role.

Another thing is that DNPs can't demand anywhere near the salaries that physician's demand. If a nurse demands a similar salary, they've lost the battle. Because then, why would anyone hire the nurse instead of a vastly better-trained physician?
 
I don't want to comment on salaries and the economics behind this, they are out of my scope. However, how is it possible for PAs and nurses to fill physicians shoes, and all of our training as medical students will just all go down the drain or what?

Also, hypothetically if a PA is experienced enough clinically could his/her clinical knowledge base and skillset match a physician's?
 
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Also, hypothetically if a PA is experienced enough clinically could his/her clinical knowledge base and skillset match a physician's?
depends on the PA and depends on the physician. I know A LOT more about emergency medicine than a typical fp residency grad. they know more about the rest of medicine.
an em boarded doc KNOWS a lot more medicine than I do but in practice that probably makes a difference 1% of the time. a lot of this is pocedures that almost never happen. I've never done burr holes or put in an ICP monitor. all em docs do this in training. I have never done a solo thoracotomy(have first assisted.) I could do a perimortem c-section if required. I have put in chest tubes and done paracentesis, etc.
Like I said, probably 1%.
I've been doing this enough that I run codes, tx chest pain and cva's, etc with similar outcomes to my physician partners. 2 of my current 3 jobs involve solo night coverage without a doc in house. if my outcomes were not similar to the docs who work on day shift they would replace me with a doc.
 
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I don't want to comment on salaries and the economics behind this, they are out of my scope. However, how is it possible for PAs and nurses to fill physicians shoes, and all of our training as medical students will just all go down the drain or what?

Also, hypothetically if a PA is experienced enough clinically could his/her clinical knowledge base and skillset match a physician's?

Hypothetically, why wouldn't they be able to do the same work? Well, a janitor who "dropped in on surgery" for 20 years could learn from the world's best surgeon and with proper training by this guy, the janitor could end up as one of the world's best, too. In practice, it's kinda unlikely and that's why there are licenses out there that you have to earn. It's the best predictor if you're capable or not. That's why encroachment is unfair in many ways, but such is life.
 
depends on the PA and depends on the physician. I know A LOT more about emergency medicine than a typical fp residency grad. they know more about the rest of medicine.
an em boarded doc KNOWS a lot more medicine than I do but in practice that probably makes a difference 1% of the time. I've been doing this enough that I run codes, tx chest pain and cva's, etc with similar outcomes to my physician partners. 2 of my current 3 jobs involve solo night coverage without a doc in house. if my outcomes were not similar to the docs who work on day shift they would replace me with a doc.

So what you are saying is that experienced PA's are just as effective as doctors by getting less pay? If that's the case why wouldn't we want this midlevel creep, from a patient's perspective?
 
depends on the PA and depends on the physician. I know A LOT more about emergency medicine than a typical fp residency grad. they know more about the rest of medicine.
an em boarded doc KNOWS a lot more medicine than I do but in practice that probably makes a difference 1% of the time. I've been doing this enough that I run codes, tx chest pain and cva's, etc with similar outcomes to my physician partners. 2 of my current 3 jobs involve solo night coverage without a doc in house. if my outcomes were not similar to the docs who work on day shift they would replace me with a doc.

I, personally, would like to see the data that shows your outcomes are similar to the physicians. This data does not exist to my knowledge. And i doubt you could present us any.
 
depends on the PA and depends on the physician. I know A LOT more about emergency medicine than a typical fp residency grad. they know more about the rest of medicine.
an em boarded doc KNOWS a lot more medicine than I do but in practice that probably makes a difference 1% of the time. I've been doing this enough that I run codes, tx chest pain and cva's, etc with similar outcomes to my physician partners. 2 of my current 3 jobs involve solo night coverage without a doc in house. if my outcomes were not similar to the docs who work on day shift they would replace me with a doc.

Here's the key question though...how independent were you right after you graduated from pa school? This is the issue that is frequently ignored in discussions of midlevel autonomy. Physicians, on completion of residency, are expected to function independently, which is why the training is so extensive. I would venture to say that very few PAs or NPs fresh out of school could function independently.

Also, that "1%" of patients can be a significant number of patients over the course of 30 years. I wouldn't summarily dismiss it in favor of autonomy for midlevel providers. Many people could be harmed by a several decade career of mismanaging this subset of patients.
 
Here's the key question though...how independent were you right after you graduated from pa school? This is the issue that is frequently ignored in discussions of midlevel autonomy. Physicians, on completion of residency, are expected to function independently, which is why the training is so extensive. I would venture to say that very few PAs or NPs fresh out of school could function independently.

Also, that "1%" of patients can be a significant number of patients over the course of 30 years. I wouldn't summarily dismiss it in favor of autonomy for midlevel providers. Many people could be harmed by a several decade career of mismanaging this subset of patients.

good points. right out of school I was not ready to practice at the level I do now, not even close.
that 1% of folks are pts I get consults on. if I don't clearly know the answer to something I go looking for an answer.
 
I, personally, would like to see the data that shows your outcomes are similar to the physicians. This data does not exist to my knowledge. And i doubt you could present us any.
I was talking about bounce backs, missed dx, missed fxs, etc
our practice does keep #s for that sort of stuff and the PAs who work solo in the group(only a few of us) have equivalent #s to the docs.
 
Here's the key question though...how independent were you right after you graduated from pa school? This is the issue that is frequently ignored in discussions of midlevel autonomy. Physicians, on completion of residency, are expected to function independently, which is why the training is so extensive. I would venture to say that very few PAs or NPs fresh out of school could function independently.

but again, fresh residents right out of med school are not ready for practice either. (disclaimer, im a med student)
 
1) DNP's are seeking equal pay... "we do same work, why should we get 85% of the pay rate?"

2) The surgeon analogy... surgery is not just or even mostly about cutting and sewing. my program director famously says "I can teach a monkey to sew the common bile duct"... The question is, do you want the person caring for you to have the deeper understanding of the disease state or just to know the correct steps to take if the diagnosis is correct?

3) Any data out there that says there are comparable outcomes is from the DNP/PA literature, studies run by DNP's and PA's and are very limited on the scope of their coverage. Most measures on the "quality" of a doctor are bull anyway. The fact that over 50% of DNP graduates failed a dumbed down version of step 3, a test with something like a 95% pass rate for MD's who largely don't study or care about the test, should be all you need to know about the knowledge base.

4) The average attending physician works 60+ hrs a week. The average PA/DNP has a 40hr work week.

5) Your freshly graduated DNP requires the clinical training related to about 6-7 weeks of a residency (500hrs). That's without having the basic science background of medical school either.
 
3) Any data out there that says there are comparable outcomes is from the DNP/PA literature, studies run by DNP's and PA's and are very limited on the scope of their coverage. Most measures on the "quality" of a doctor are bull anyway. The fact that over 50% of DNP graduates failed a dumbed down version of step 3, a test with something like a 95% pass rate for MD's who largely don't study or care about the test, should be all you need to know about the knowledge base.

is there link to the literature of this claim? I'd like to read thanks
 
but again, fresh residents right out of med school are not ready for practice either. (disclaimer, im a med student)

that's why they have to complete a residency, at least 1 year (and an MD 1 year from residency is much more prepared clinically than a DNP/PA after any of their "residencies").

and most MD's have completed 3-7 years of post-graduate training before they practice independently. If DNP's get granted what they want, a high school student could enter college for a nursing degree (4years for BS in nursing and 2.5 years for DNP in a shorter time than a graduating MD can finish residency/fellowship in many cases...)
 
Oh look, one of these threads again
 
that's why they have to complete a residency, at least 1 year (and an MD 1 year from residency is much more prepared clinically than a DNP/PA after any of their "residencies").

and most MD's have completed 3-7 years of post-graduate training before they practice independently. If DNP's get granted what they want, a high school student could enter college for a nursing degree (4years for BS in nursing and 2.5 years for DNP in a shorter time than a graduating MD can finish residency/fellowship in many cases...)

I understand that. A lot of people on sdn argue that nurses do not have the same basic science knowledge, i guess my question is, how can the basic science knowledge be taught differently apart from what we learn in medical school? shouldn't they be learning the same science that we learn
 
I understand that. A lot of people on sdn argue that nurses do not have the same basic science knowledge, i guess my question is, how can the basic science knowledge be taught differently apart from what we learn in medical school? shouldn't they be learning the same science that we learn

they aren't... take a look at a BSN or a DNP/Master in Nursing cirriculum

PA's take the same basic coursework as MD's... often rotate with them in clinical rotations too...
 
they aren't... take a look at a BSN or a DNP/Master in Nursing cirriculum

PA's take the same basic coursework as MD's... often rotate with them in clinical rotations too...

So what's the difference between PA and MD aside from residency then?????? That way wouldn't PA with tons of experience=MD? I think im getting more and more confused
 
🙄

PA's have two years of professional school. I have a very good friend who is a PA. She talks about medicine like a lay person. I can't have complex discussions about medicine with her.

I have a few friends who are nurses. I truly think they're dumb people. Love them to death, but if they were the primary health provider, I would under no circumstances send me family to them. On second thought, I know a lot of dumb people in my med school, but at least I can talk about medicine with them without losing them completely.
 
🙄

PA's have two years of professional school. I have a very good friend who is a PA. She talks about medicine like a lay person. I can't have complex discussions about medicine with her.

I have a few friends who are nurses. I truly think they're dumb people. Love them to death, but if they were the primary health provider, I would under no circumstances send me family to them. On second thought, I know a lot of dumb people in my med school, but at least I can talk about medicine with them without losing them completely.

Agreed on the nurses - in general they are very good at what they do and the critical care nurses and ER nurses I've met have been great. But their education is different from ours in many ways, and it's based primarily around procedure and guideline, not around science.
 
Did anyone hear the Diane Rehm show the other day? The following guests were on there discussing this very issue. You can listen to it at the following link: http://thedianerehmshow.org/audio-player?nid=17498 (I highly recommend that everyone interested listen, it was pretty good)


Dr. Reid Blackwelder - family physician and president-elect of the American Academy of Family Physicians.

Mary Agnes Carey - senior correspondent for Kaiser Health News.

Ken Miller - nurse practitioner, associate dean at The Catholic University of America School of Nursing, and president-elect of the American Association of Nurse Practitioners.

Sandra Nattina - nurse practitioner at Columbia Medical Practice in Columbia, Md., and past president of Nurse Practitioner Association of Maryland.

Ken Miller, pushing the NP agenda, went so far as to say that NPs not only match physicians in numerous studies, but even exceed them in some things... Of course, he was sure to dismiss any study contrary to his propaganda as having been published by physicians a long time ago.

Web link is here: http://thedianerehmshow.org/shows/2013-03-26/role-nurse-practitioners
 
So what's the difference between PA and MD aside from residency then?????? That way wouldn't PA with tons of experience=MD? I think im getting more and more confused

Pa school is typically 3years,1.5basic science and 1.5clinical...not as in depth as MD's, but as I said, classes like biochem and physio are taught side by side med students. And clinical rotations typically are also along side medical students.

Pa's are perpetual interns/junior residents... They generally don't get the expertise or skills of that of the chief resident or attending... They get very good at the mid level job, which often the junior resident can perform independently, but as emepa said, they end up kicking it up and consulting out slightly more... The good ones know their limitations and are wonderful for MD's... When I practice I hope to have pas work my office for me (and as a hopeful transplant surgeon, that's no small task)... I won't be hiring dnp's to do that if I can help it...
 
I've yet to see a mid-level at my hospital break $150,000 (that was a pretty highly qualified individual as well) but there are literally dozens of MDs in the $500,000+ range. We have a handful of docs breaking $1 million annually... You will never see a mid-level in that range. Has anyone stopped to ask why a mid-level with 20 years of excellent experience should not be as well compensated as some physicians? Many levels of sergeant in the armed forces make more than lieutenants, and in some cases, even captains. That said, you'll never see a sergeant who out-earns a colonel or a general. Time commitment AND credentials should both be a factor and usually are in the real world; this is nothing new.
 
I've yet to see a mid-level at my hospital break $150,000 (that was a pretty highly qualified individual as well) but there are literally dozens of MDs in the $500,000+ range. We have a handful of docs breaking $1 million annually... You will never see a mid-level in that range. Has anyone stopped to ask why a mid-level with 20 years of excellent experience should not be as well compensated as some physicians? Many levels of sergeant in the armed forces make more than lieutenants, and in some cases, even captains. That said, you'll never see a sergeant who out-earns a colonel or a general. Time commitment AND credentials should both be a factor and usually are in the real world; this is nothing new.
there is the rare PA/NP who makes more than 150k. I made 150k for one year when I worked really crazy hrs.over a decade ago. I could do so again by working 20 days/mo but don't really want to.
The top PA in our group makes 200-250k/yr but has no life, multiple jobs, is also a Colonel in the army, etc
Andrew Rodican, PA(google him if you don't know the name) owns/manages a bunch of weight loss clinics and is a well known author. he makes 500+K/yr but is the only PA I know making this.
I know several PAs who are practice owners who make 200k+/yr but they have several employees making money for them and a lot of their income is from the practice ownership and their share of profits.
don't become a PA to make big money. it can be done but involves being a business owner as well. a typical PA makes 80-125k/yr and will for their entire career.
 
My mother is a DNP and she has no desire to "overtake" the physicians role. Or, creep, or whatever.

I'd imagine NPs like her are the majority. Unfortunately, the extremist beliefs of their leadership force our hand. Maybe my mindset will change when I'm out and practicing, but if I were in a position to hire midlevels for my practice or group, I'd hire PAs over them if at all possible. If their leaders are gunning for me and my job, I'll try to choke out the field as much as I can.

It's melodramatic, but it's like North Korea: I'm sure I'd have no problems with the average person there, but Kim Jong Un is a nut and has to be stopped. So we place economic sanctions to limit the progress they make, and start positioning ourselves for war as they ramp up their rhetoric.

The change from NP to DNP is not at all about patient care, it's about political maneuvering. I'm a little tired of having another thread about this, but hopefully it'll motivate the next generation of physicians to take back the ground we've been letting slip away to other hungrier, less qualified players.

I've yet to see a mid-level at my hospital break $150,000 (that was a pretty highly qualified individual as well) but there are literally dozens of MDs in the $500,000+ range. We have a handful of docs breaking $1 million annually... You will never see a mid-level in that range. Has anyone stopped to ask why a mid-level with 20 years of excellent experience should not be as well compensated as some physicians? Many levels of sergeant in the armed forces make more than lieutenants, and in some cases, even captains. That said, you'll never see a sergeant who out-earns a colonel or a general. Time commitment AND credentials should both be a factor and usually are in the real world; this is nothing new.

Many CRNAs are earning more than family practitioners and pediatricians. I even read a thread the other day where a psychiatrist hired a NP to replace a FM doctor after they left his practice, and did so at the same rate that the physician had been earning (drawing much outrage from his FM resident wife).

And experience only goes so far. When you're out in practice, you're not going to be pushing so hard to learn as when you were a medical student or resident. Four years of college covered a fraction of the material that four years of medical school does. As a medical student yourself, you know this, so apply that to the argument you're making.

And I don't care if a nurse has 30 years of experience as an ICU RN before going on for her NP. I'd take the critical care pulmonologist fresh out of his fellowship any time for caring for a sick person over her, because he trained to do the job he's being asked to do, unlike the nurse, who has lots of experience nursing. To a slightly lesser extent, the same goes if those 30 years of experience are as a critical care nurse practitioner.
 
My mother is a DNP and she has no desire to "overtake" the physicians role. Or, creep, or whatever. She wants to be respected for being great practitioner and be seen as a integral team member. If she is disrespected she fires back and if she is commended she reciprocates. Every field and specialty has idiots in it and mid levels suffer from this affliction just like CNA's and Physicians. The sky is far from falling.

in case you wondered: She introduces herself to patients as First name Last name your nurse practitioner.

doctors are concerned over the policies made by the midlevel lobbies
midlevels are part of the team and should be treated with respect

our current generation of doctors will enjoy less job security, prestige, and compensation than the previous generation. whether or not it will still be worth it is for the individual to decide
 
Like Confucius said, "If you know yourself and your enemy, you’ll never lose a battle", is there a nurses' or PAs' equivalent of sdn? i'd like to check out whatever is there as well. thanks!
 
Out of all these thread recently. I think the OP has put the issue just exactly how it should be for the best conversation for us. We should be thinking prognostics on what this phenomenon will mean for us and our posterity and the sustainability of our current model.

I'm rotating with a bachelor's level PA student who said today, unabashedly, that when she graduated with her bachelor's she will be able to do anything a physician can do. No flinch. Straight poker face. All those years in residency and fellowship--for suckers apparently.

So I think there's an obvious inculcation of these values across the board in the midlevel educational cultures. I suspect it's a recruiting tool. And parroting it seems to come effortlessly and uncritically to them. There's a brute force to it en masse. The effect of which is multiplicative with them being able to spend more face time with patients.

So we have a serious problem. In order to justify the salaries necessary to to pay down our tremendous sacrifice of time and money and years of life we have to roll through patients quicker. Nobody gets paid without moving the meat through our meat grinding system. If you've invested a fraction of what we have, you can take your time, work the straight 40, and be happy in those 20-30 minute encounters necessary to close the sale of your services in all these trainwreck unhealthy f'ers we're dealing with. You can't do that in the 10-15 we need to make what we're worth anymore.

And then there's all these basically dumb people that you simply cannot convince of the difference in training. They like the smiley talky person. Who doesn't?

They will expand rapidly under all these premises and circumstances and do very well. They'll chill through school. And get paid well to get a more protracted version of the residency training that we pay so dearly for. We'll give it to them for a blow out rate. Just a small cut of their salary. To cover our decade of lost wages. And then they'll replace us.

Prognostics are difficult. Some of us say we'll always do well so we just shut up and roll over. Some say the end is nigh. I don't know what to think. Other than I know the difference between demand of healthcare and the economic viability of servicing that demand. I didn't work with hundreds of Filipina nurses because they just loved america so much that they left everything that they knew behind or because Filipino people just hate health care. And I also know that just because things have been decent they can't get unrecognizably ****ty. Think Spain or Greece.

About all I think with any conviction is that anyone telling me not be concerned is someone I don't trust. Like that first guy that "wants to be friends and show you the ropes" when you end up in prison. I trust those guys about the same.
 
Like Confucius said, "If you know yourself and your enemy, you'll never lose a battle", is there a nurses' or PAs' equivalent of sdn? i'd like to check out whatever is there as well. thanks!

Doubt it, because people go to nursing school out of high school. It's much, MUCH easier to become a nurse than to become an MD, so there's no need for an SDN or TLS or WSO equivalent.
 
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