Least Vulnerable Specialties To Midlevel Encroachment?

[Lem0nz]

Surgery is not as protected as everyone thinks. APCs may not be able to do surgery, but they can do everything else clinic based/hospital rounds. So a surgeon who in the past may have hired another surgical partner, now just hires 2 APCs so he/she can operate more.

So eventhough they may not be cutting, they are taking away surgical jobs.

Radiology may be the last frontier. All specialities with clinics will have a need for less docs b/c of the above.

I don't know that many people are hiring surgeons to increase throughput for rounds and clinic. That's just not the underlying premise of hiring a partner to me.

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[7331poas]

To free up time from clerical scut work to do the thing you were actually designed to do: cut.

That's funny, because I remember on my surgical rotation the surgeons were constantly preaching about how surgery is more than just cutting. they were constantly preaching about how surgeons need to understand medical management pre-op and post-op care.

I guess in the end those things don't really matter when their wallet is affected.

I happen to disagree with you, I personally hate it when you're in the ER and you consult neurosurgery and a PA comes down to evaluate the patient instead of a neurosurgeon

 

[AnatomyGrey12]

That's funny, because I remember on my surgical rotation the surgeons were constantly preaching about how surgery is more than just cutting. they were constantly preaching about how surgeons need to understand medical management pre-op and post-op care.

I guess in the end those things don't really matter when their wallet is affected.

I happen to disagree with you, I personally hate it when you're in the ER and you consult neurosurgery and a PA comes down to evaluate the patient instead of a neurosurgeon

I agree with you that consults should be seen by the surgeon. After the initial consult though?

You can argue semantics if you want, and I never said surgeons should just become technicians. I’ll ask you my question again, what is an appropriate role for a surgery midlevel then? To hear some of you talk it’s like you don’t think they should exist at all.

I just can’t get riled up about midlevels rounding on patients in the hospital and post ops in the clinic. There are plenty of examples of scope creep, this isn’t one of them.

 

[Jack Donaghy]

it’s like you don’t think they should exist at all.

Nailed it.

 

[Lem0nz]

That's funny, because I remember on my surgical rotation the surgeons were constantly preaching about how surgery is more than just cutting. they were constantly preaching about how surgeons need to understand medical management pre-op and post-op care.

I guess in the end those things don't really matter when their wallet is affected.

I happen to disagree with you, I personally hate it when you're in the ER and you consult neurosurgery and a PA comes down to evaluate the patient instead of a neurosurgeon

Seeing a new consult and seeing a post op in the clinic are not the same thing at all though. Nor are morning rounds. And a PA or NP doing those things (and even seeing consults) does not suddenly mean surgeons are not ever seeing their patients. With the exception of post op clinics, we're still seeing them. Just not RIGHT AWAY. Instead of having to round at 6am we can round at 9am between our first and second operation. And instead of seeing a consult to say "well, I can't tell you what the plan is because we need this test and this test and this test first" we can just send a midlevel to see the patient and order those tests and then come back and say "Hi, so we have everything we need, and this is the plan and this is the surgery you do or do not need."

Unless its truly emergent which most consults in surgery aren't it gets seen in 24 hours. Which is the same standard that we hold literally every other consulting doctor in the country to. Why should surgery be different and come down to the ER up front? How is that a good use of time or resources? And if it is an emergency, we are going to go see them with or without our midlevel.

I can understand your frustration and annoyance with seeing a midlevel first because I've been on the receiving end from NSG when I was doing trauma, but it doesn't change that the NSG isn't going to do anything differently other than say "yes, we do in fact need that MRI before we make decisions". The surgeon seeing someone up front doesn't speed up the care in most cases.

 

[slowthai]

Nailed it.

Yeah, the problem with all the arguments I've seen for the existence of midlevels is that once you give them an inch, they inevitably take a mile. Well, outside of surgery/DR, at least.

Midlevels are a solution for a problem that was manufactured by worthless administrators, as usual. Force doctors to see more patients at all costs, and then throw midlevels at them when they can't keep up or meet your completely unreasonable demands, devaluing doctors in the process. It's a win-win for these people.

Alas, that ship has sailed, so we can only do what we can to stop them from harming/killing patients.

 

[Neopolymath]

Surgery is not as protected as everyone thinks. APCs may not be able to do surgery, but they can do everything else clinic based/hospital rounds. So a surgeon who in the past may have hired another surgical partner, now just hires 2 APCs so he/she can operate more.

So eventhough they may not be cutting, they are taking away surgical jobs.

Radiology may be the last frontier. All specialities with clinics will have a need for less docs b/c of the above.

In my OR, there was a trend toward using less midlevels by PP surgical attendings. While BSing on call many of them said that they realized the value wasn't there for their situation. The hospital employed surgeons used them though. I noticed this in two separate places over about 10 years. These were busy, busy community hospitals so it wasn't a volume issue.

 

[Lem0nz]

In my OR, there was a trend toward using less midlevels by PP surgical attendings. While BSing on call many of them said that they realized the value wasn't there for their situation. The hospital employed surgeons used them though. I noticed this in two separate places over about 10 years. These were busy, busy community hospitals so it wasn't a volume issue.

I think it is going to vary wildly by discipline too, right? Things like surg-onc or transplant there's massive utility. Those operations are long, complex, maybe you need/want a dedicated bedside robot person for complex robotics cases and you don't want to subject your partners to do that and that is quite frankly incredibly boring and cruel to put a resident through. Plastics gets a lot of use out of them as they can harvest skin grafts, close one side (or even do one side for some advanced midlevels) while the attending is starting the other side, be very particular with retractors and exposure, etc.

General surgery won't benefit from that at all. You don't need someone special to hold the camera and the retracting arm for a gallbladder. You can honestly probably balance the camera on your wrist for an appendix (kidding, but the scrub can hold it). Open surgery either needs a second surgeon or no one at all for most laparotomies it feels like.

Some of that you can do with an RNFA but some can't. There's a difference between an RNFA, a dedicated midlevel, and a second surgeon in the OR for sure. Most ORs you also can't guarantee you'll get the same team every time. Every place tries their best but its not a sure fire thing pretty much anywhere I've been to.

Out of the OR, same thing. Depends on the complexity. Most general surgery stuff is very monotone and can be copy/pasted/macroed and doesn't vary much based on pathology. I think general surgeons have less (but no zero) use of a midlevel. And some of it just varies with the institutional practice and patient population. A major urban trauma center might not really need a midlevel at all and the residents can and do handle it just fine because those patients tend to be young and discharge needs are minimal. A suburban level two trauma center may benefit massively from a PA because those patients are all medical cripples who need mounds of paperwork and home planning/case management stuff to keep them from bouncing back. That isn't gratifying work or a good use of a surgeon (or a resident's) time but is perfect for a midlevel and vital.

 

[emergentmd]

I see PA/NP utilized in many surgical subspecialty in all varying degrees. Ortho seems to love them. GS not as much. Most other like ENT, CV, NGS all seem to use them.

Bottom line is in the past, it was a surgeon who hired/partnered with another surgeon when they got too busy. Now they just hire a PA/NP to do all the rounding/paperwork so they can be more efficient.

So APCs are not technically operating but they are reducing the needs for more surgeons which at the end of the day, they are essentially doing part of the surgeon's job.

We all are creatures of wanting to make money. If hiring 2 APC saves a surgeon from hiring another surgeon at 500K, he gets to pocket 300K while doing what he really likes. So he does less rounding, discharging, follow up, charting, clinics, overnight calls.... Win win in his eyes.

Really no different than what is happening in EM where APCs get hired to do simple stuff.

 

[Lem0nz]

You aren't wrong, but I see it as a welcome evolution to our field to get all of us in the operating room more often. It isn't just more money, it makes us happier. Maybe it will create problems down the road for our job market too, but that seems at least ten years (or more) off, and if it concentrates operations into a smaller surgeon cluster in the long run that could have benefits for our patients on the outcomes side. I think its a more complex discussion than more APCs less surgeons jobs = bad. Have to account for more of us being employed models and gradually trying to get off of productivity.

I think there's a lot to be said from our FM/IM attending colleagues who frequently comment that the job market cries of fear are overhyped and they have no trouble finding jobs.

 

[Espressso]

Yeah, the problem with all the arguments I've seen for the existence of midlevels is that once you give them an inch, they inevitably take a mile. Well, outside of surgery/DR, at least.

Midlevels are a solution for a problem that was manufactured by worthless administrators, as usual. Force doctors to see more patients at all costs, and then throw midlevels at them when they can't keep up or meet your completely unreasonable demands, devaluing doctors in the process. It's a win-win for these people.

Alas, that ship has sailed, so we can only do what we can to stop them from harming/killing patients.

this x500. the problem is that doctors are too nice for this complex issue. LIke you said, you give them an inch and the powerful nursing lobby takes a imle.

 

[LatentStudying]

There’s currently no clear path for AI to sign out a synoptic case report of major 88309 (mastectomies, colectomies, lung resections, etc) resections with margins and lymph nodes. PA’s and NP’s are already here, and they’re significantly encroaching on residents work in most all fields except for a very rare few like path.

The above is spot on. Nobody on your side is going to push to get AI better incorporated despite it already being capable, and we (ML researchers) really don't care enough to fight for it as we get most of our funding from other sources. On the other hand, PA's and NP's self advocate and it's their entire focus.

 

[Spikebd]

Surgery is not as protected as everyone thinks. APCs may not be able to do surgery, but they can do everything else clinic based/hospital rounds. So a surgeon who in the past may have hired another surgical partner, now just hires 2 APCs so he/she can operate more.

So eventhough they may not be cutting, they are taking away surgical jobs.

Radiology may be the last frontier. All specialities with clinics will have a need for less docs b/c of the above.

And path 😊

 

[MICKY MANTLE]

At the end of the day, I doubt that any state would ever allow, by law/regulation, anyone other than a "qualified surgeon" (licensed medical doctor -MD, DO, DPM) to perform any major surgical procedures. Sure, PAs, NPs, etc may be a first assistant, but that is as far as that will go. Midlevels or CNMs can assist in cesareans, but again, cannot be the one performing them.

The practices that employ PAs, NPs, etc. are doing so all because of the financial incentive to pay them less than a qualified physician.

 

[9blade]

My guess is that surgery is probably the least vulnerable to encroachment

 

[longhaul3]

That's funny, because I remember on my surgical rotation the surgeons were constantly preaching about how surgery is more than just cutting. they were constantly preaching about how surgeons need to understand medical management pre-op and post-op care.

I guess in the end those things don't really matter when their wallet is affected.

I happen to disagree with you, I personally hate it when you're in the ER and you consult neurosurgery and a PA comes down to evaluate the patient instead of a neurosurgeon

Three things about PAs seeing ED consults (although we do not have any midlevels seeing consults where I work)

1. Most ED consults to neurosurgery are CYA garbage based entirely on a radiology report. The ED PA (or worse, MD) can usually not provide a meaningful neurologic exam when asked. Reason for consult is always something like "concern for cauda equina syndrome," "mass effect" or my personal favorite "herniation" of any kind. I may see 10-15 inpatient consults in a day of which often zero are urgently operative.
2. Most neurosurgical decision making, especially in non-critically ill patients, is based primarily on imaging, which qualified neurosurgeons are reviewing when we are consulted, whether an MD sees the patient in the ED or not.
3. PAs are trained medical professionals. I think people overlook this in the anti-midlevel frenzy. They are not physicians but not uneducated stooges. They are perfectly capable of performing a routine H&P and neurologic exam especially for a trash back pain or ICH consult.

If there is a critically ill patient who needs immediate neurosurgical attention, anywhere I have been, a qualified MD will be available or the patient will be transferred.

Either way, in the end the recs are the recs, backed by the service, regardless of who saw the consult.

 

[xenotype]

That same argument could be made for the abdominal exam as well and yet that has not changed practice patterns.

I don't think you understood 'the argument' at all. The pathology you reference on 'subtle abdominal exams' is detectable on abdominal CT or ultrasound. The neuromuscular pathology I reference in my previous post is completely undetectable on MRI of the entire neuroaxis. I don't think you know 'practice patterns' at all either. The practice pattern is patient here with neuro problem -> consult neurology. And if you think MG, GBS are 'rare' diseases you'll likely never encounter in a PCP office or the ED your Dunning-Krueger curve is truly maximized. See the above neurosurgery post- most generalists have no idea how to do a halfway reliable neurologic exam, much less recognize what the exam means. In the real world nobody in the ED or PCP office takes a chance on neuro patients- they always, always consult often frantically out of fear of the unknown. Hence the post above me about dumb/low value neurosurgery consults for imaging findings.