MD/DO "Mini-Residency" Idea

[deleted128562]

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I'm dead serious about this and wondering if it would be feasible. (The question is, would anyone implement this?) To set this all up:

1) There's been a lot of talk lately about NP's doing specialty "residencies" and then going into specialty practice. These "residencies" are 1000 hours, or about the equivalent of 3 months of an MD's intern year.

2) At the same time this is happening, more MD's and DO's were shut out of the match this year than ever before. This is especially true for foreign grads, but is now becoming a reality for US grads as well.

3) Many people get through medical school and find themselves beat down, worn out, and regretting all the work they've put in when the only thing they have to look immediately forward to is years of a grueling residency. Others regret going to school completely and wish there were some path other than a full residency to use their hard earned MD/DO.

With these things in mind, what about starting "Mini-Residencies" in several fields? An MD or DO would go through, say, an intense 4 month mini-residency in some specialty and then be licensed to practice essentially as an extender under the practice of an MD/DO who has done a full residency/fellowship in that field. (Essentially equivalent to a mid-level provider). This MD would have more schooling hours than, and equal "residency" time to an NP (or PA) and would thus be just as qualified to practice in this capacity.

The derm thread had some mention about an NP making $180K in derm. I know that many PA's and NP's who work in specialties can make nice 6 figure sums. As many people as med school burns out, I would be willing to bet good money that many MD's and DO's would elect to go the mini-residency route, leaving more match spots open for grads who wanted to do a full residency. This would help solve provider shortages since currently those doctors kept out of the match aren't able to practice in any capacity. It might also have the effect of pushing NP's back into primary care which is what they argued they were needed for in the first place. (Why hire an NP for 180K a year when you can hire a mid-level MD for 180K per year?).

The NP's have played the game and played it well. Now maybe it's our turn to figure out how to get a piece of their pie. If you think this is a decent idea, do you have any thoughts on who this should be suggested to? As I said, I'm dead serious about this. I think it could be very good for our profession and our communities.

 

[Shinken]

The NP's have played the game and played it well. Now maybe it's our turn to figure out how to get a piece of their pie.

Let me see if I got this right. Since NP's have been successful at enhancing their scope of practice, you suggest going to medical school to become a mid-level provider?

Genius idea.

 

[deleted128562]

Let me see if I got this right. Since NP's have been successful at enhancing their scope of practice, you suggest going to medical school to become a mid-level provider?

Genius idea.

Apparently you lack reading comprehension. I'm saying MAKE IT AN OPTION as some people who finish medical school don't really want to go on to a full residency. I've read many such posts just on these forums, and know people personally who wanted to do the whole shabang, but after finishing medical school regretted going that route and would have readily jumped on an option such as this rather than going through another 3-7 years of pain. I'd also be willing to bet that the many IMG's unable to match would love the option.

 

[JaggerPlate]

I'm going to have to agree with Shrinken on this one ... it just doesn't make sense. Go through 4 years of hell to practice under someone??? There's absolutely no point. You can just become a NP or a PA.

Plus, this already exists ... it's called just doing an internship and then doing whatever the hell you want. I know an uber successful hair transplant surgeon who did an internship, then a preceptorship and makes 7 figures doing hair restoration in New York. I also know a doc in So Cal who just did an internship, got a MBA afterward, and now does vein treatment ... makes a killing.

If you're entertaining the idea of doing a mini-residency, just go full blown ... eff a residency, do an internship, and wing it. However, if you want to practice clinical medicine or do something not cosmetic err whatever, just do a residency. But going 200k in debt, doing a few months in residency, then working under someone like a mid-level makes no sense in my opinion.

 

[Maybeknot]

This MD would have more schooling hours than, and equal "residency" time to an NP (or PA) and would thus be just as qualified to practice in this capacity.

By doing so, wouldn't the medical community be essentially agreeing with the DNP proponents who think that their training is sufficient?

We need to be making the argument that, as skilled providers of health care, more training is good, not less. This is a political battle, and one that we are losing as of now.

 

[Speculatrix]

I'm dead serious about this and wondering if it would be feasible. (The question is, would anyone implement this?) To set this all up:

1) There's been a lot of talk lately about NP's doing specialty "residencies" and then going into specialty practice. These "residencies" are 1000 hours, or about the equivalent of 3 months of an MD's intern year.

2) At the same time this is happening, more MD's and DO's were shut out of the match this year than ever before. This is especially true for foreign grads, but is now becoming a reality for US grads as well.

3) Many people get through medical school and find themselves beat down, worn out, and regretting all the work they've put in when the only thing they have to look immediately forward to is years of a grueling residency. Others regret going to school completely and wish there were some path other than a full residency to use their hard earned MD/DO.

With these things in mind, what about starting "Mini-Residencies" in several fields? An MD or DO would go through, say, an intense 4 month mini-residency in some specialty and then be licensed to practice essentially as an extender under the practice of an MD/DO who has done a full residency/fellowship in that field. (Essentially equivalent to a mid-level provider). This MD would have more schooling hours than, and equal "residency" time to an NP (or PA) and would thus be just as qualified to practice in this capacity.

The derm thread had some mention about an NP making $180K in derm. I know that many PA's and NP's who work in specialties can make nice 6 figure sums. As many people as med school burns out, I would be willing to bet good money that many MD's and DO's would elect to go the mini-residency route, leaving more match spots open for grads who wanted to do a full residency. This would help solve provider shortages since currently those doctors kept out of the match aren't able to practice in any capacity. It might also have the effect of pushing NP's back into primary care which is what they argued they were needed for in the first place. (Why hire an NP for 180K a year when you can hire a mid-level MD for 180K per year?).

The NP's have played the game and played it well. Now maybe it's our turn to figure out how to get a piece of their pie. If you think this is a decent idea, do you have any thoughts on who this should be suggested to? As I said, I'm dead serious about this. I think it could be very good for our profession and our communities.

This is an colossally terrible idea. First of all, the people who are getting "shut out" of residencies are terrible candidates in the first place [I am not talking about the advanced year non-matches, like non-match to derm or radiology, but those who couldn't swing a less competitive specialty - the people who could not match into an advanced specialty are all highly competitive enough to match/scramble into prelims]. Therefore, this would create an option simply for those who are lazy, not cut out for a full residency, or washouts in general. Who would want to hire those people, let alone pay them that much money?? A partial fix would be a judicious increase in the number of residency slots, correlating with increased AAMC school enrollment.

I also echo the sentiments about the inadequacy of training. Stooping down to that level would only create more confusion and water everyone else's training down.

 

[deleted128562]

I'm going to have to agree with Shrinken on this one ... it just doesn't make sense. Go through 4 years of hell to practice under someone??? There's absolutely no point. You can just become a NP or a PA.

Plus, this already exists ... it's called just doing an internship and then doing whatever the hell you want. I know an uber successful hair transplant surgeon who did an internship, then a preceptorship and makes 7 figures doing hair restoration in New York. I also know a doc in So Cal who just did an internship, got a MBA afterward, and now does vein treatment ... makes a killing.

If you're entertaining the idea of doing a mini-residency, just go full blown ... eff a residency, do an internship, and wing it. However, if you want to practice clinical medicine or do something not cosmetic err whatever, just do a residency. But going 200k in debt, doing a few months in residency, then working under someone like a mid-level makes no sense in my opinion.

Sigh. I don't think you're understanding me. I'm not saying anyone should go to medical school with the goal of becoming a mid-level. That would in fact be colossally stupid. I'm saying that in 4 years a lot can happen. Let's consider some examples:

1) Bob gets a 194 on his STEP 1 and struggles to pass med school. His options are now pretty much limited to FM residency in rural Iowa or FM residency in rural North Dakota. Give him a chance to do a "mid-level" residency in cards or derm and he just may take it. You may say, "Well that's dumb because Bob is obviously less competent than his classmates". I'd ask how that's any different than allowing an NP who has done far less schooling to do such a residency. As an added bonus it keeps Bob supervised since he's a "mid-level", rather than practicing on his own as a sub-par PCP.

2) Mary goes to medical school excited and starry-eyed, gets married and has a kid, and graduates deciding she doesn't want to spend the next 4 years of her life away from her kid. That wasn't what she thought life would bring four years ago, but life happens. A mid-level type residency might be very appealing to her.

3) Steve goes to medical school in the Caribbean. He tries for two years to match into a residency and can't. The mid-level thing might start to look pretty appealing.

My point is this: With rare exception (those couple of people who make 7 figures with just an internship), the MD or DO degree is worth zilch without a residency. 4 years undergrad plus 4 years intense training is worthless in the job market, whereas 4 years undergrad plus 2 years of not quite as intense training (NP or PA) can get you a 6-figure job. This doesn't make any sense. Why can't we open the door to MD's and DO's to put their degree to use if they go to med school planning to go the full distance, but have something happen in their lives which makes them reconsider wanting to do so?

 

[JaggerPlate]

1) Bob gets a 194 on his STEP 1 and struggles to pass med school. His options are now pretty much limited to FM residency in rural Iowa or FM residency in rural North Dakota. Give him a chance to do a "mid-level" residency in cards or derm and he just may take it. You may say, "Well that's dumb because Bob is obviously less competent than his classmates". I'd ask how that's any different than allowing an NP who has done far less schooling to do such a residency. As an added bonus it keeps Bob supervised since he's a "mid-level", rather than practicing on his own as a sub-par PCP.

Okay, I'll bite ...

1. What cardiologist or dermatologist in their right mind is going to pay Bob, the less than competent doc, a nice salary because of his mini-residency? Who assumes the risk when Bob screws up on a cards patient because he only trained for 6 months in cardiology??? Does the doc get sued? Does Bob have his own mal-practice? What are Bobs independent rights??

How is it different than a NP??? Because they have their own rules, regulations, restrictions, etc. Bob doesn't. Technically, Bob is a doctor, and unless the rules are re-written on state laws, board certification, mal-practice, etc, Bob is just a huge risk to anyone.

Furthermore, Bob could be making more money as the rural FP. Actually, way more ... rural guys do far better. Plus, he wouldn't be 200k in debt and making 80k (if even) in someone's practice.

Listen, I get the point of your argument ... but even if no one goes in planning for it, or there are special circumstances, it just doesn't play out for various, various reasons.

2) Mary goes to medical school excited and starry-eyed, gets married and has a kid, and graduates deciding she doesn't want to spend the next 4 years of her life away from her kid. That wasn't what she thought life would bring four years ago, but life happens. A mid-level type residency might be very appealing to her.

So she still spends 2 years away, then goes off and practices and is away every year??? Doesn't pan out again. Again, dude ... I get what you are reaching for here, but it just doesn't pan out.

My point is this: With rare exception (those couple of people who make 7 figures with just an internship), the MD or DO degree is worth zilch without a residency. 4 years undergrad plus 4 years intense training is worthless in the job market, whereas 4 years undergrad plus 2 years of not quite as intense training (NP or PA) can get you a 6-figure job. This doesn't make any sense. Why can't we open the door to MD's and DO's to put their degree to use if they go to med school planning to go the full distance, but have something happen in their lives which makes them reconsider wanting to do so?

1. I can't comment on how rare these exceptions are, because people who enter medicine are, for the most part, extremely risk adverse ... hence why they have no issue letting the ANA walk all over them AND why we even have to entertain the idea of 'mini-residencies.'

2. My biggest issues are the fact that a. Let's face it, the bottom line is that you're training for the marathon, sprinting your heart out, and then stopping 1/4 mile from the finish line and saying ... screw it, I'll take 5th place with all the slackers who trained half as hard as me. I mean, it's better than not competing, right??? This is a hard sell, even if people like DNPs start getting more for working less. b. You'd seriously have to re-write state laws, the definition of board certification, scope, practice rights, mal-practice, etc.

 

[deleted128562]

Fine, stupid idea. Knee-jerk on my part. Unfortunately these mini-residencies are going to happen anyway. NP's are going to do them, and they will be employed by unwitting physicians and even on their own as states allow them more and more independent practice rights.

 

[deleted87716]

NP's are going to do them, and they will be employed by unwitting physicians and even on their own as states allow them more and more independent practice rights.

That remains to be seen.

 

[deleted128562]

That remains to be seen.

Care to make a wager?

 

[deleted87716]

Care to make a wager?

I've already bet my career. What have you got?

 

[NotAProgDirector]

A mini residency as you describe it sounds like a bad idea. As others have mentioned, 3 months (or 1000 hours) is really nowhere near enough to get competent at medicine. NP's have started a very dangerous precedent, and physicians shouldn't follow it.

However, your idea has some merit. We used to have a system where you could be a GP -- finish an internship and hang up a shingle. Those days are mostly gone. However, we could consider creating "Outpatient Medicine" residencies. These would be based in an outpatient clinic. There would be little or no inpatient experience at all -- certainly no ICU, Heme/Onc, or inpatient cards training. Call would only be "outpatient call" -- i.e. answering phone calls (perhaps in some supervised way). I could imagine such a residency being 2 years long -- 1 year seems too short -- but would be much less intense than a standard residency. The ABIM (or ABFP) would need to create a specific pathway for this, and states might have to change their licensing laws to accomodate it.

Is this a good idea? I'm not sure. I think a physician can learn to practice the majority of outpatient medicine in 2 years -- certainly to be comfortable with routine exams, diabetes, HTN, chol, osteoporosis, etc -- the bread and butter. The problem is that rarely someone will present with something strange, and if all you've been trained in is the bread and butter, you'll most likely miss it. But, 2 years of 100% outpatient training might make you much better at counseling patients on tobacco cessation, or weight loss, etc, and that might have a greater positive societal impact overall.

 

[Sneezing]

Isn't that kind of what a preventive medicine residency is?

I tried advocating this in a different thread that we should support the GP movement but some other poster tore me apart. It should still be a viable option for a few rare souls like the hair transplant person, but not an endorsed policy change.

If a person must... do an intern year. Otherwise, tough it out through a residency.

Besides, Obamacare is going to ruin things to the point no one will want this job anyways.

 

[JaggerPlate]

Mr Hat, you were talking a minute ago about docs hiring NPs ... but I had a general question:

If this DNP thing gets out of hand and they really do start seeing patients, why wouldn't all MD/DOs just refuse to accept referrals from DNPs? It's really not debatable that they won't handle the complex cases, so their rates of referrals to docs are going to be huge. If docs start rejecting these in droves, patients are going to catch on, and their entire volume will probably go to crap, or they will stop referring and essentially be a runny nose clinic???

 

[deleted128562]

I've already bet my career. What have you got?

$3.50 and a half-eaten roll of certs. Pretty much not exaggerating.

 

[deleted128562]

A mini residency as you describe it sounds like a bad idea. As others have mentioned, 3 months (or 1000 hours) is really nowhere near enough to get competent at medicine. NP's have started a very dangerous precedent, and physicians shouldn't follow it.

However, your idea has some merit. We used to have a system where you could be a GP -- finish an internship and hang up a shingle. Those days are mostly gone. However, we could consider creating "Outpatient Medicine" residencies. These would be based in an outpatient clinic. There would be little or no inpatient experience at all -- certainly no ICU, Heme/Onc, or inpatient cards training. Call would only be "outpatient call" -- i.e. answering phone calls (perhaps in some supervised way). I could imagine such a residency being 2 years long -- 1 year seems too short -- but would be much less intense than a standard residency. The ABIM (or ABFP) would need to create a specific pathway for this, and states might have to change their licensing laws to accomodate it.

Is this a good idea? I'm not sure. I think a physician can learn to practice the majority of outpatient medicine in 2 years -- certainly to be comfortable with routine exams, diabetes, HTN, chol, osteoporosis, etc -- the bread and butter. The problem is that rarely someone will present with something strange, and if all you've been trained in is the bread and butter, you'll most likely miss it. But, 2 years of 100% outpatient training might make you much better at counseling patients on tobacco cessation, or weight loss, etc, and that might have a greater positive societal impact overall.

That's actually a pretty interesting idea. Would this be for primary care only I assume?

 

[dragonfly99]

3 or 4 months isn't long enough in "residency" to practice anything.
I think that MD/DO should be able to get a job, some kind of job, without a residency. I think this because PA and NPs can go straight out and get a job after they are done with school; the difference is that many of them had prior clinical experience (particularly the NP's). However, it's still stupid that someone can get a MD from an accredited US med school and be basically non-employable. I'm with the OP on that. Right now the ONLY option is 3-7 years of residency, and I think it is true that sometimes people's lives change, or they just aren't as successful as they'd expected to be in med school.

 

[deleted128562]

Mr Hat, you were talking a minute ago about docs hiring NPs ... but I had a general question:

If this DNP thing gets out of hand and they really do start seeing patients, why wouldn't all MD/DOs just refuse to accept referrals from DNPs? It's really not debatable that they won't handle the complex cases, so their rates of referrals to docs are going to be huge. If docs start rejecting these in droves, patients are going to catch on, and their entire volume will probably go to crap, or they will stop referring and essentially be a runny nose clinic???

It seems like a very good idea in theory, but I think there are a few practical problems. For one, if NP's do start doing these specialty "residencies", they can just refer to one another (God help us all). For another thing, this would require the vast majority of physicians to come together. From what I've seen, there are still a ton of doctors who are willing to bend over and take it. If you get another group in your town (and the 10 NP's working with them) who are willing to take on the referral base, then all you'll accomplish is going out of business.

Add to this the fact that hospitals are increasingly hiring physicians on as employees. In my home town a few years ago, the hospital got fed up of bargaining with the local cardiology group and just hired in 5 cardiologists. The local group lost their hospital privileges and ended up closing their doors quickly. Look for something like this to happen if you try to implement this plan. All it takes is for the hospital to hire a couple of physicians in your specialty (and their army of mid-level providers), and you are done.

Finally, even if this plan works and NP's are left operating runny nose clinics, it leaves the problem of MD's getting all the complex problems while NP's cherry pick the easy 5 minute patients (whose insurance might pay not all that much less than for the 30 minutes of complex care you're providing). From what I understand, a big part of what keeps primary care offices profitable is the quick visits from patients with simple problems.

 

[deleted87716]

From what I understand, a big part of what keeps primary care offices profitable is the quick visits from patients with simple problems.

Not true. Most offices schedule patients in standard-length appointment blocks regardless of their chief complaint.

Unless you choose to schedule these marginal visits in very brief appointment slots, you're much better off financially spending the equivalent amount of time seeing more complex patients.

The big trouble with doing it that way, however, is that you're counting on your front desk people (who are generally non-clinical) to know whether the "cough" that they're putting into a five-minute slot isn't really congestive heart failure. This can quickly lead to schedule backups and long wait times when something that was thought to be simple really isn't. This happens more often than you might think.