Is neurology safe from mid-level encroachment for the foreseeable future?

[sice4]

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After seeing what's going on with CRNAs and anesthesiology recently I am interested in future proofing from mid-level encroachment. Is neurology safe?

 

[Postictal Raiden]

No specialty is safe from mid-level encroachment. However, some specialties are more prone than others. I'd like to think of it as a spectrum, 1 to 5, with 1 being least midlevel friendly and 5 being most.

Fields like neurosurgery/transplant sx/medical genetics would be 1. On the other hand, primary care/anesthesia/EM would be 5. Neurology would be 2-3 depending on subspecialization.

 

[sice4]

Thanks for the response. What subspecializations of neurology do you think are most protected from encoarchment? Least?

 

[Postictal Raiden]

I’d say the more subspecialized you are the more likely to be shielded from said encroachment. Neuro-onc, neuro-ophth, neuro-immun, etc come to mind.

With that said, I don’t think you should pursue a field totally based on projected supply/demand and job security. The situation is much more complex that simple math and looking at trends.

 

[Telamir]

Neurology has a lot of nuance, and it's not a very popular field among doctors, much less NPs. Clinic can be lifestyle friendly, but the hospital is very unpredictable with strokes, bleeds, seizures etc. It's a discipline that's hard to do well, in my opinion. FWIW I don't see it being much of a problem.

 

[GuillainMollaret]

Neurology has a lot of nuance, and it's not a very popular field among doctors, much less NPs. Clinic can be lifestyle friendly, but the hospital is very unpredictable with strokes, bleeds, seizures etc. It's a discipline that's hard to do well, in my opinion. FWIW I don't see it being much of a problem.

Yes, it's a discipline that's hard to do well, but that doesn't mean people won't try.

Neurology midlevels are definitely out there. We have quite a few at my residency program (large academic center).

 

[Telamir]

I don't see it being a big problem. You'll find anything at "large academic centers", and indeed there were a few where I trained. That being said they did ONE thing. I.E. epilepsy followups, headache management, P.D. followup clinics, etc. Like I said, neurology isn't super popular even among MDs we're overall quite rare. In the hospital I work with an excellent NP who has ONLY done Neurology for 10 ish years and I'm fresh out of training. She's great, but let's just say I don't fear being replaced any time soon.

 

[Dr. Bruce Banner]

very safe from mid-level encroachment

 

[neglect]

I'd confirm what others have said and add a few thoughts. Extenders do best with very well defined algorithms or VERY low stake problems. See post-op hernia (or cath or hip or PNA hospital day #2) patient, write note, if they look bad, then call for help. Start induction for anesthesia. See 8 year old with ear pain in an urgent care.

Neurology has neither well defined algorithms nor low stakes. Diagnose ANY neuro problem? Diagnose stroke? Start an MS med? Neuro is also very high stakes. Fail to appreciate that the wrist drop involves finger flexion, fail to diagnose stroke, fail to get carotid imaging, and very real damage results. We're totally safe. Very few doctors are comfortable with neurology, and no extender should be.

I used to think this was going to be more of an issue globally. I used to think that NP/PAs were essentially going to offer cheaper alternatives and at least perform at resident levels. But then I met a few, I've read their notes. They NEED attending supervision. I would NEVER go to an NP or PA without attending supervision for any problem.

There's a reason they didn't get into med school and at every turn their education, expectation, performance was less than a doctor. But the fact is that this is a battle we need to fight. For some reason, the NP degree also grants an inflated sense of worth, while degree mills and decreasing quality (even more). We are seeing the Duning Kruger effect in real time: more idiocy, more perceived competence. So they very much want to practice independently. This will kill and maim patients.

 

[Neurologo]

Instead of creating a new thread, I will just post this case here:

There is a hospital where 2 NPs are used for inpatient follow ups. This means a neurologist sees the initial consult and makes recommendations but the follow up visits thereafter are all done by NPs independently with no supervision. This has been done so far because for 2 weeks a month the inpatient service has been covered by tele-neuro with the support of these NPs. Now that the NPs has been sort of working "independently" without supervision, they enjoyed the "autonomy" and want to continue doing the same even when there will be a live neurologist in-house.

This may be ok for mild cases such as migraines but for critical cases like acute stroke, hemorrhages, status epilepticus...neurologists should be following until final recommendations are made. Also legal ramifications is huge. If there is a lawsuit due to mismanagement by one of these NPs, neurologist that "signed off" to them will still be responsible. Unfortunately the two neurologists there are actually supporting the NPs' desire. Any tips on how to tactfully steer these two NPs to agree to be supervised or be ok with seeing only the noncomplex cases? I mean this would be what the patients and their families want! As previously mentioned by others, I've worked with several neuro-NPs with "20-30 years experiences" who still struggle mightily with subtle nuances in neuro care beyond the "protocol" box.

 

[Telamir]

Instead of creating a new thread, I will just post this case here:

There is a hospital where 2 NPs are used for inpatient follow ups. This means a neurologist sees the initial consult and makes recommendations but the follow up visits thereafter are all done by NPs independently with no supervision. This has been done so far because for 2 weeks a month the inpatient service has been covered by tele-neuro with the support of these NPs. Now that the NPs has been sort of working "independently" without supervision, they enjoyed the "autonomy" and want to continue doing the same even when there will be a live neurologist in-house.

This may be ok for mild cases such as migraines but for critical cases like acute stroke, hemorrhages, status epilepticus...neurologists should be following until final recommendations are made. Also legal ramifications is huge. If there is a lawsuit due to mismanagement by one of these NPs, neurologist that "signed off" to them will still be responsible. Unfortunately the two neurologists there are actually supporting the NPs' desire. Any tips on how to tactfully steer these two NPs to agree to be supervised or be ok with seeing only the noncomplex cases? I mean this would be what the patients and their families want! As previously mentioned by others, I've worked with several neuro-NPs with "20-30 years experiences" who still struggle mightily with subtle nuances in neuro care beyond the "protocol" box.

No idea how to help with that. That being said, I think the original solution of 2 independent NPs with a tele-neuro seems quite inadequate if the hospital has any sort of real acuity/complexity. The fact that they skated by on this sort of sub-optimal coverage in the past is no argument to continue in the future, especially if now there are adequate resources and neurologists in house. If I was in your shoes (let's say 2 neurologists think this is fine, you're neurologist #3, and you don't) I'd probably request them to staff with me regardless of the hurt feelings. Fact of the matter is like you said it's your license you're putting on the line because they "like the autonomy", or for their feelings. Sorry but that's not a trade-off I'd make. You're the physician and the buck stops with you.

Hope this helps somehow.

 

[Postictal Raiden]

And that's why I'm not a fan of telemedicine. Now with the proliferation of residency spots, hopefully there will be enough neurologists to physically staff every hospital.

 

[deathmerchant]

Instead of creating a new thread, I will just post this case here:

There is a hospital where 2 NPs are used for inpatient follow ups. This means a neurologist sees the initial consult and makes recommendations but the follow up visits thereafter are all done by NPs independently with no supervision. This has been done so far because for 2 weeks a month the inpatient service has been covered by tele-neuro with the support of these NPs. Now that the NPs has been sort of working "independently" without supervision, they enjoyed the "autonomy" and want to continue doing the same even when there will be a live neurologist in-house.

This may be ok for mild cases such as migraines but for critical cases like acute stroke, hemorrhages, status epilepticus...neurologists should be following until final recommendations are made. Also legal ramifications is huge. If there is a lawsuit due to mismanagement by one of these NPs, neurologist that "signed off" to them will still be responsible. Unfortunately the two neurologists there are actually supporting the NPs' desire. Any tips on how to tactfully steer these two NPs to agree to be supervised or be ok with seeing only the noncomplex cases? I mean this would be what the patients and their families want! As previously mentioned by others, I've worked with several neuro-NPs with "20-30 years experiences" who still struggle mightily with subtle nuances in neuro care beyond the "protocol" box.

I was about to get in a similar situation recently. My hospital wanted to hire NPs to help with outpatient and do clinic independently, including new patients. I refused.
We all know how tricky neuro can be. I even worry about something not commonly life threatening like Psychogenic disorders where a non-neurologist will surely order bunch of unnecessary testing. Then there are all the zebras we have to include or exclude everyday.

Inpatient is even trickier where a small mistake means life or death or lifelong disability. May be Im still inexperienced and bit cautious but I would never be comfortable with an NP seeing any new inpatient independently including migraines!

May be you could start with having them see follow up, stable patients and once you know their skill level you can delegate more responsibility.

 

[neglect]

Instead of creating a new thread, I will just post this case here:

There is a hospital where 2 NPs are used for inpatient follow ups. This means a neurologist sees the initial consult and makes recommendations but the follow up visits thereafter are all done by NPs independently with no supervision. This has been done so far because for 2 weeks a month the inpatient service has been covered by tele-neuro with the support of these NPs. Now that the NPs has been sort of working "independently" without supervision, they enjoyed the "autonomy" and want to continue doing the same even when there will be a live neurologist in-house.

This may be ok for mild cases such as migraines but for critical cases like acute stroke, hemorrhages, status epilepticus...neurologists should be following until final recommendations are made. Also legal ramifications is huge. If there is a lawsuit due to mismanagement by one of these NPs, neurologist that "signed off" to them will still be responsible. Unfortunately the two neurologists there are actually supporting the NPs' desire. Any tips on how to tactfully steer these two NPs to agree to be supervised or be ok with seeing only the noncomplex cases? I mean this would be what the patients and their families want! As previously mentioned by others, I've worked with several neuro-NPs with "20-30 years experiences" who still struggle mightily with subtle nuances in neuro care beyond the "protocol" box.

If these NPs are working independently without ANY oversight, you're just described a serious safety problem (IMO, and that opinion might change if you're living in rural Nebraska 3 hours away from a local neurologist).

A few thoughts:

1. FU's are where the rubber hits the road. The first shot at the diagnosis is just that. Sometimes neurologic diseases take time to fully declare themselves. We don't LP or image all headaches. But the next day if associated with fever or focal symptoms, then you need to adjust. In a very big way, follow up visits are MORE prone to danger due to diagnostic inertia/closure, which biases you against new symptoms that overturn the first diagnosis. So I say this to highlight the concern. After all, most "easy cases" are easy because the neurologist thought there was nothing concerning.

2. There are VASTLY different levels of independence. Make SURE these NPs are operating independently, which I would define as operating without oversight or backup. An attending might be, for example, reviewing their notes or available for questions. The latter is a safety issue. The former is not.

3. What to do next. I abide by see-something-say-something policy. This is a dangerous situation, patients could be harmed, and you are morally obligated to share your well founded concerns. I'd start with the director of inpatient medicine. Put NOTHING in writing. Just make a meeting. If the director is a worthless admin, and odds are good that's exactly what they are (what makes a bad doctor, makes a bad admin, but the positions tend to attract yes-men.), then nothing will come of it. Then could escalate to chief of staff. Then get the hell out of there and never go back.

I was about to get in a similar situation recently. My hospital wanted to hire NPs to help with outpatient and do clinic independently, including new patients. I refused.
We all know how tricky neuro can be. I even worry about something not commonly life threatening like Psychogenic disorders where a non-neurologist will surely order bunch of unnecessary testing. Then there are all the zebras we have to include or exclude everyday.

Inpatient is even trickier where a small mistake means life or death or lifelong disability. May be Im still inexperienced and bit cautious but I would never be comfortable with an NP seeing any new inpatient independently including migraines!

May be you could start with having them see follow up, stable patients and once you know their skill level you can delegate more responsibility.

Seen with timely oversight is totally different than unsupervised.

 

[Postictal Raiden]

As always, very insightful post by @neglect