Least Vulnerable Specialties To Midlevel Encroachment?

[Detective SnowBucket]

Maybe I'm spending too much time on reddit, but who cares, I'm on spring break.
Anyways, I'm really getting spooked by the amount of bills popping up in state legislatures for independent practice and the amount of state that actually pass them! I'd like to hear your thoughts on the least vulnerable specialties, as specific as you can be. I have a specialty I'm most interested in but I want to see if you'll list it as (non-)vulnerable without prompting.

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[The Last Ankibender]

I think this has been discus before. But I will start

least
1. Rads
2. Path
3. Most Surgical Specialties

Anything take requires a lot of knowledge and pays is low may also be save nepro, endo, rheumatoid

 

[The Last Ankibender]

1. Integrated interventional radiology
2. Orthopedic surgery
3. Integrated plastic surgery
4. Neurological surgery
5. Otolaryngology
6. Dermatology
7. Thoracic surgery

I think midlevels are getting derm

 

[M&L]

I think this has been discus before. But I will start

least
1. Rads
2. Path
3. Most Surgical Specialties

Anything take requires a lot of knowledge and pays is low may also be save nepro, endo, rheumatoid

Pathology assistants are pretty busy in a lot of places ....

 

[odyssey2]

Radiology for sure since you need a ton of knowledge to even pass a scan off as “normal.” No such thing as bread and butter which can be siphoned off.

 

[Detective SnowBucket]

I admittedly don’t know very much about this topic as a first year med student but I personally wouldn’t pick a specialty based on my perception of how much NP and PAs are involved. At this point they’re involved in every specialty of medicine and although we should fight independent practice laws, the laws will not change that many practices and academic centers will rely on NPs and PAs to increase productivity. I’m in the camp of pick something that you want to wake up and do everyday. In that sense the “most protected” specialties are actually quite different aside from the surgical specialties.

You're exactly right. I went about this the other way. I know what I'm interested in and I specifically don't say what it is in this post to see what people's opinions are before they know what I'm going for to see if they mention it.

 

[Detective SnowBucket]

I think this has been discus before. But I will start

least
1. Rads
2. Path
3. Most Surgical Specialties

Anything take requires a lot of knowledge and pays is low may also be save nepro, endo, rheumatoid

For the surgical specialties, what makes one more/less vulnerable compared to others? For path is it because of the difficulty of the subject, the lack of "b.llsh.t-ability" in that you can't pass off lack of knowledge like DR or that it's not sexy? For rads, are you saying IR or DR or no difference?

 

[DrSpine]

Hey you guys - Pain Doctor here, was scrolling by and saw this post, and figured I knew what the question was about.

This is absolutely a legitimate worry to have. Also, look for specialties where you still have a shot of private practice, so you're not basically forced into an employment model by hospitals or private equity employment. Sounds convenient to just collect a paycheck, but its miserable when you're basically seeing your pay constantly threatened, go down, or see midlevel encroachment for cheaper value.

I got super lucky in retrospect, and didn't even think of this through. Looking back now, I am lucky. I did PM&R and then Interventional Pain. Midlevels can't do our procedures, especially minimally invasive procedures like Spinal Cord Stimulators, SI Joint Fusions, Vertiflex, DRG, Radiofrequency Ablation, etc. On top of that, we're one of the few specialties where most are still private practice and we have a great opportunity to still own our own practice (probably with a partner). So I would definitely look into that.

 

[paki20]

1. Integrated interventional radiology
2. Orthopedic surgery
3. Integrated plastic surgery
4. Neurological surgery
5. Otolaryngology
6. Dermatology
7. Thoracic surgery

Mid levels have been doing some of the simpler IR cases.

Interventional cardiology should be added to that list.

 

[Cath Up]

orthopedic surgery
ENT
surgical oncology
IR
colorectal surgery
neurosurgery
ophthalmology
urology
OBGYN
plastic surgery
trauma surgery
vascular surgery
rocket surgery
general surgery
pediatric surgery anything

 

[Cath Up]

I admittedly don’t know very much about this topic as a first year med student but I personally wouldn’t pick a specialty based on my perception of how much NP and PAs are involved. At this point they’re involved in every specialty of medicine and although we should fight independent practice laws, the laws will not change that many practices and academic centers will rely on NPs and PAs to increase productivity. I’m in the camp of pick something that you want to wake up and do everyday. In that sense the “most protected” specialties are actually quite different aside from the surgical specialties.

What has pushed me away from multiple specialties even though I would love to wake up and do the actual specialty- is that I would not love to wake up and watch others do the specialty, forcibly oversee them to make my overlord some money, be their liability sponge, and do certain/complex cases of the specialty.

 

[Dr. Doctor MD]

Path
Rads
Surgical anything
IR
Rad-Onc
Ophtho (unless you consider ODs midlevels)

Pretty much everything else is midlevel overrun or at least mid-level friendly

 

[Neopolymath]

Pathology assistants are pretty busy in a lot of places ....

They function differently than other midlevels so it's not a concern.

 

[Detective SnowBucket]

orthopedic surgery
ENT
surgical oncology
IR
colorectal surgery
neurosurgery
ophthalmology
urology
OBGYN
plastic surgery
trauma surgery
vascular surgery
rocket surgery
general surgery
pediatric surgery anything

what are your thoughts on the post above yours? Saying that midlevel's have been witnessed in the wild performing some IR procedures

 

[Cath Up]

I have no informed opinion! I don't think I have ever seen an IR doctor in my life.

 

[The Last Ankibender]

Hey you guys - Pain Doctor here, was scrolling by and saw this post, and figured I knew what the question was about.

This is absolutely a legitimate worry to have. Also, look for specialties where you still have a shot of private practice, so you're not basically forced into an employment model by hospitals or private equity employment. Sounds convenient to just collect a paycheck, but its miserable when you're basically seeing your pay constantly threatened, go down, or see midlevel encroachment for cheaper value.

I got super lucky in retrospect, and didn't even think of this through. Looking back now, I am lucky. I did PM&R and then Interventional Pain. Midlevels can't do our procedures, especially minimally invasive procedures like Spinal Cord Stimulators, SI Joint Fusions, Vertiflex, DRG, Radiofrequency Ablation, etc. On top of that, we're one of the few specialties where most are still private practice and we have a great opportunity to still own our own practice (probably with a partner). So I would definitely look into that

Isn’t pain pretty saturated market?

 

[aldol16]

Yeah, most surgical specialties are not gonna see midlevel encroachment. From a regulatory perspective, it's a hard case to sell and most patients probably would not want a surgery performed by a midlevel anyway. Midlevels can be first assists even now, but an MD has to be scrubbed.

 

[Neopolymath]

what are your thoughts on the post above yours? Saying that midlevel's have been witnessed in the wild performing some IR procedures

I have seen midlevels doing piccs, paras, thoras, chest tubes in IR and some other stuff like that. This is all stuff that I did as a 3rd year med student as well. Many hospitals have a picc line team that is RNs so I'm not worried about an IR midlevel doing this. At least the rads department can bill and claim rvus instead of the hospital taking the whole pie.

 

[Neopolymath]

Isn’t pain pretty saturated market?

Geography dependent and business savy dependent from what I have seen.

 

[MissRibeye]

What about neurology?

 

[Neopolymath]

What about neurology?

It's protected and will be even more protected in the future with all the exciting new treatments coming out all the time. It's like a less accessible rheumatology to midlevels.

These are just too tedious and pedantic for midlevels. You can't monkey see, monkey do something easily that confuses even other physicians.

 

[Dave1980]

What about neurology?

Seems vulnerable to me. You see a neurologist you are getting an MRI and possibly an EMG. A midlevel could do that.

 

[SweetBurger]

everyone mentioning rads is safe... yeah safe from NP/PA not from A.I. lmao

 

[The Last Ankibender]

everyone mentioning rads is safe... yeah safe from NP/PA not from A.I. lmao

Rads more difficult that it appears. It will a long time until AI can read a MRI as good as a physician. but sure AI is a threat. But the threat is in the future.

NP/PA are a threat now. And it will only get worse

 

[cal75]

Path
Rads
Surgical anything
IR
Rad-Onc
Ophtho (unless you consider ODs midlevels)

Pretty much everything else is midlevel overrun or at least mid-level friendly

Optometrists have been lobbying for more procedures

 

[Pinocytosis]

everyone mentioning rads is safe... yeah safe from NP/PA not from A.I. lmao

 

[SweetBurger]

Rads more difficult that it appears. It will a long time until AI can read a MRI as good as a physician. but sure AI is a threat. But the threat is in the future.

NP/PA are a threat now. And it will only get worse

i agree.
was meme'ing

 

[Jack Donaghy]

It's protected and will be even more protected in the future with all the exciting new treatments coming out all the time. It's like a less accessible rheumatology to midlevels.

These are just too tedious and pedantic for midlevels. You can't monkey see, monkey do something easily that confuses even other physicians.

I thought this as well until I did my neuro rotation during 4th year. At least at my hospital, there are PLENTY of PAs running around pretending to be neurologists. Including reading MRIs and dictating orders IN THE NEURO ICU without any physician oversight.

 

[AnatomyGrey12]

Anything surgical.

Even basic bread and butter cases are simple, until they aren’t.

 

[Redpancreas]

@Lawpy

Why can't we just have a "midlevel" thread? This topic's the origin of a third of SDN Medical Student Threads.

 

[slowthai]

Anything surgical.

Even basic bread and butter cases are simple, until they aren’t.

Until they start creating PA/NP surgical "residencies" and forcing surgeons to train them at academic centers while pumping funds into forcing these independent practice bills through.

I would have said surgery in the past, but I've seen that there is truly no limit to the greed of these independent midlevels, the physicians training them, and the hospitals employing them. They just can't be underestimated.

 

[Captain_Falcon]

@Lawpy

Why can't we just have a "midlevel" thread? This topic's the origin of a third of SDN Medical Student Threads.

Because just like medicine midlevels are taking over SDN without any oversight


Jk. Kinda

 

[Redpancreas]

Because just like medicine midlevels are taking over SDN without any oversight


Jk. Kinda

I don't disagree with the cause. I think it's a systemic problem that needs to be pointed out. It's not just a few bad actors. I just feel like it's the similar to MD v. DO in pre-allo in that everyone's said their bit and we just keep rehashing things. A dedicated subforum, sticky, etc. would probably create a more focused discussion. I'd rather see threads for people who're looking for advice in training, etc. It seems like all anyone wants to talk about on SDN-Medical Students is midlevel encroachment or some version of which field offers XYZ. Maybe I'm biased because I'd rather talk about medical education policy, clinical reasoning, clinical ward tips, etc. and those are starting to disappear.

 

[Captain_Falcon]

I don't disagree with the cause. I think it's a systemic problem that needs to be pointed out. It's not just a few bad actors. I just feel like it's the same as MD v. DO in pre-allo. Everyone's said their bit and we just keep rehashing things. A dedicated subforum, sticky, etc. would probably create a more focused discussion. I'd rather see threads for people who're looking for advice in training, etc. It seems like all anyone wants to talk about on SDN-Medical Students is midlevel encroachment or some version of which field offers XYZ. Maybe I'm biased because I'd rather talk about medical education policy, clinical reasoning, clinical ward tips, etc.

I agree, and that's with me wanting to go into a field that is very susceptible to midlevel scope creep

 

[Neopolymath]

I thought this as well until I did my neuro rotation during 4th year. At least at my hospital, there are PLENTY of PAs running around pretending to be neurologists. Including reading MRIs and dictating orders IN THE NEURO ICU without any physician oversight.

So just to clarify, you are saying at your institution that the intensivist or the neurologist are not supervising these midlevels and they are working independently? That's definitely an outlier, if so.

If you told me they are being "supervised" but not really then I would say it's typical morally bankrupt behavior from some boomer attending at play here.

Neuro and rheum are typically "we have no idea what to do with this patient" destinations so I still maintain that PAs aren't going to be taking over the movement disorder clinic, epilepsy clinic etc etc.

I have a pretty pessimistic view of midlevels and their path of destruction on medicine but I'm more bullish regarding their ability to fake it in the neuro clinic than in the pulm clinic for example. I need to expand on this post more when I have some time.

I will say this: Pcps order mri and emg and whatever all the time and neurologists didn't disappear due to that. They aren't gonna disappear from midlevels who don't even know most neuro diseases.

 

[AnatomyGrey12]

Until they start creating PA/NP surgical "residencies" and forcing surgeons to train them at academic centers while pumping funds into forcing these independent practice bills through.

I would have said surgery in the past, but I've seen that there is truly no limit to the greed of these independent midlevels, the physicians training them, and the hospitals employing them. They just can't be underestimated.

I’m sure they think they can pull it off, but I have zero concerns. The first time they get into bleeding will be the last time they think they can do what a surgeon does.

 

[slowthai]

I’m sure they think they can pull it off, but I have zero concerns. The first time they get into bleeding will be the last time they think they can do what a surgeon does.

I hope you're right.

 

[Redpancreas]

I’m sure they think they can pull it off, but I have zero concerns. The first time they get into bleeding will be the last time they think they can do what a surgeon does.

What do you mean? Just close them up, transfuse them to keep them hemoglobin up, and rely on hemostasis.

 

[Lem0nz]

Until they start creating PA/NP surgical "residencies" and forcing surgeons to train them at academic centers while pumping funds into forcing these independent practice bills through.

I would have said surgery in the past, but I've seen that there is truly no limit to the greed of these independent midlevels, the physicians training them, and the hospitals employing them. They just can't be underestimated.

Let them. Won’t matter. Learning surgery is not an issue with credentials or length of training, it’s actual time in the operating room and your own proficiency with learning the skills. It’s why you can’t really shave off more years from surgical training. At best we could get gen surg down to four and fold the other specialties into an I6 sort of model but it will never get shorter than that, and you’ll still need 800+ operations and 70 hour work weeks for 52+ weeks to accomplish it. Your credentials will never change that no matter how hard you try.

Besides, AG is right. The next time you’re in the OR count how many cases the surgeon *doesn’t* say “this is harder than normal” “this is stickier than normal” “this is more inflamed than normal” “this is really oozy, is this guy on Coumadin and we forgot to hold it (for a 40 y/o athlete)” “this anatomy is not right” “why is this one so fat compared to normal”

I can count on one hand how many times in a month someone says “that was straightforward”. The normal routine case is the unicorn and normal is a lie we tell ourselves to justify it taking the extra hour it always does.

 

[slowthai]

Let them. Won’t matter. Learning surgery is not an issue with credentials or length of training, it’s actual time in the operating room and your own proficiency with learning the skills. It’s why you can’t really shave off more years from surgical training. At best we could get gen surg down to four and fold the other specialties into an I6 sort of model but it will never get shorter than that, and you’ll still need 800+ operations and 70 hour work weeks for 52+ weeks to accomplish it. Your credentials will never change that no matter how hard you try.

Besides, AG is right. The next time you’re in the OR count how many cases the surgeon *doesn’t* say “this is harder than normal” “this is stickier than normal” “this is more inflamed than normal” “this is really oozy, is this guy on Coumadin and we forgot to hold it (for a 40 y/o athlete)” “this anatomy is not right” “why is this one so fat compared to normal”

I can count on one hand how many times in a month someone says “that was straightforward”. The normal routine case is the unicorn and normal is a lie we tell ourselves to justify it taking the extra hour it always does.

Are you saying that even if this training is available for them that they won't be willing to do it due to the sheer intensity of it?

 

[FutureSurgical]

Are you saying that even if this training is available for them that they won't be willing to do it due to the sheer intensity of it?

I don’t know if you’re using sarcasm at all (and if you are, then this comment is pretty pointless.) But ask every single PA or NP why they chose to go into their respective role. 95% of the time, it will be about not spending a ton of time in the hospital like the residents (and attendings.) Bonus if they bring up wanting a family.

 

[slowthai]

I don’t know if you’re using sarcasm at all (and if you are, then this comment is pretty pointless.) But ask every single PA or NP why they chose going into their respective role. 95% of the time, it will be about not spending a ton of time in the hospital like the residents (and attendings.) Bonus if they bring up wanting a family.

I wasn't being sarcastic. That's true.

 

[7331poas]

@Lawpy

Why can't we just have a "midlevel" thread? This topic's the origin of a third of SDN Medical Student Threads.

Or alternatively, you can close your eyes. Both stop you from engaging in this thread, but my option stops you from preventing our discussion.

 

[Neopolymath]

Are you saying that even if this training is available for them that they won't be willing to do it due to the sheer intensity of it?

Yes. It's a group of people defined by taking shortcuts or making career decisions to avoid the extra work and responsibility that is undesirable (for the ethical ones out there that do exist). Surgery goes against the point of being a midlevel.

 

[Lem0nz]

Are you saying that even if this training is available for them that they won't be willing to do it due to the sheer intensity of it?

Yes. What is the point of taking that route even if it existed? You'll get paid less than any general surgeon unless you're PP but I think the vast majority of new grads are gravitating towards employed models so a midlevel in that world would make less than a surgeon for the same amount of work, AND the same amount of education. There's zero reason to do any of that. They can make a very comfortable salary in the 150s, even low 200s, being a PA for a CT surgeon and harvesting veins and closing sternums with less hours, no malpractice, and its still a really cool exciting job.

 

[Redpancreas]

Or alternatively, you can close your eyes. Both stop you from engaging in this thread, but my option stops you from preventing our discussion.

I'm in the minority but I don't think it's a particularly fruitful topic and all it seems to do is generate frustration.

 

[NicMouse64]

I'm in the minority but I don't think it's a particularly fruitful topic and all it seems to do is generate frustration.

The midlevels are the ones generating the frustration that results in these threads........

 

[Redpancreas]

The midlevels are the ones generating the frustration that results in these threads........

Fair enough.

 

[dohopeful13]

I think it’s kind of pointless to try and project these things or to base a career choice of it.

Even if it’s not encroachment you could always worry about AI automation, poor job market (look at EM now), physician salary slashes.

I could worry sick about it or I could just do my best to focus on what I can control.

 

[Jack Donaghy]

or I could just do my best to focus on what I can control.

Right. Like picking a specialty that midlevels won't ruin. Which is the point of this thread................