Mid level creep in Internal Medicine Subspecialties?

[Matthew9Thirtyfive]

But what if they're practicing primary care autonomously in a State that allows it. That's technically within their scope of practice.

I think better phrasing would be their scope of knowledge. They are not prepared to handle more than sick call type stuff—minute clinic type medicine—but are attempting to practice at the level of physicians.

---

Members don't see this ad.

 

[Goro]

Midlevels R taking R jobs!!!

 

[VA Hopeful Dr]

Midlevels R taking R jobs!!!

 

[Windians16]

They literally paid those people to say that. At the end of the video "real patients were compensated for their participation."

 

[W19]

Pretty soon we will all be NPs



Jokes Jokes, but for real this video seems like a glaring middle finger to MDs

Saw this commercial on a pretty busy channel

Lol...

 

[radsisrad]

Midlevels R taking R jobs!!!

It's true when blue-collar workers say it, and it's true for doctors.

Not so funny anymore.

 

[VA Hopeful Dr]

It's true when blue-collar workers say it, and it's true for doctors.

Not so funny anymore.

Sure it is

 

[Goro]

It's true when blue-collar workers say it, and it's true for doctors.

Not so funny anymore.

Most of the midlevel hate you see on SDN is not motivated by the fear of loss of earnings, nor of patient safety, but of the mindset of "how dare those peasants move beyond their station!"

People who think that they're God's anointed have trouble dealing with threats to their egos.

 

[Lawpy]

Most of the midlevel hate you see on SDN is not motivated by the fear of loss of earnings, nor of patient safety, but of the mindset of "how dare those peasants move beyond their station!"

People who think that they're God's anointed have trouble dealing with threats to their egos.

Idk the midlevel outrage I see has to do with their irrational demands of independent practice and their arrogance that they are as good if not better than physicians. Personal experiences basically show that midlevel care actually poses a significantly greater danger to patient safety than physician care (because midlevels have a smaller knowledge base and have this irrational tendency to overprescribe medications and tests).

 

[radsisrad]

Most of the midlevel hate you see on SDN is not motivated by the fear of loss of earnings, nor of patient safety, but of the mindset of "how dare those peasants move beyond their station!"

People who think that they're God's anointed have trouble dealing with threats to their egos.

That's a problem, but as the video above demonstrates, there is a certain attitude not uncommonly found among the more "ambitious" midlevels that's downright obnoxious. And regarding the "they took our jobs" punchline (which has never been funny to anyone sensitive to the concerns of the working class) - yes, many of us are protectionist. Why shouldn't we be?

 

[The Knife & Gun Club]

That's a problem, but as the video above demonstrates, there is a certain attitude not uncommonly found among the more "ambitious" midlevels that's downright obnoxious. And regarding the "they took our jobs" punchline (which has never been funny to anyone sensitive to the concerns of the working class) - yes, many of us are protectionist. Why shouldn't we be?

There’s being protectionist then there’s being irrationally scared of something that is just not a major problem.

There is virtually no hard data (im talking published in serious journals, not dinner-napkin calculations) that mid level providers pose a significant threat to the employment or earnings of most physicians. There may be niches - urgent care, well child visits, follow-ups for uncomplicated chronic medical conditions - where midlevels will one day dominate, but medicine as a whole? Nope.

At least for the foreseeable future the US is at risk for a shortage of healthcare providers - not a surplus.

 

[radsisrad]

There’s being protectionist then there’s being irrationally scared of something that is just not a major problem.

There is virtually no hard data (im talking published in serious journals, not dinner-napkin calculations) that mid level providers pose a significant threat to the employment or earnings of most physicians. There may be niches - urgent care, well child visits, follow-ups for uncomplicated chronic medical conditions - where midlevels will one day dominate, but medicine as a whole? Nope.

At least for the foreseeable future the US is at risk for a shortage of healthcare providers - not a surplus.

I'm not in a field that's at very high risk of encroachment by midlevels, so it's not personal for me. But I empathize with the FM, primary care, and anesthesiology guys out there.

 

[Psai]

Most of the midlevel hate you see on SDN is not motivated by the fear of loss of earnings, nor of patient safety, but of the mindset of "how dare those peasants move beyond their station!"

People who think that they're God's anointed have trouble dealing with threats to their egos.

Look I work in clinical settings at least sixty hours a week on the regular. I deal with these people all the time. Let me know when you can say the same.

You don't even come close to knowing what you're talking about here. Stick to medical education.

 

[Iz_FtB]

Most of the midlevel hate you see on SDN is not motivated by the fear of loss of earnings, nor of patient safety, but of the mindset of "how dare those peasants move beyond their station!"

People who think that they're God's anointed have trouble dealing with threats to their egos.

To what degree is "ego" a factor in the motivation of midlevels lobbying for independence?

 

[VA Hopeful Dr]

I'm not in a field that's at very high risk of encroachment by midlevels, so it's not personal for me. But I empathize with the FM, primary care, and anesthesiology guys out there.

FM here. Not worried about midlevels in the slightest.

 

[ortnakas]

Absolutely anecdotally- the only physicians I’ve talked to who seem threatened by mid-levels are anesthesiologists. There’s more than enough work to go around for hospitalists and PCPs, and the other specialties I’ve worked with/been exposed to are grateful to have a midlevel to help with an otherwise almost-impossible patient load.

 

[Goro]

To what degree is "ego" a factor in the motivation of midlevels lobbying for independence?

I don't know and don't care. I do care about the mindset that "I'm a doctor and I'm God's chosen" mentality. Just look at some of the bile posted in these fora.

 

[Goro]

Idk the midlevel outrage I see has to do with their irrational demands of independent practice and their arrogance that they are as good if not better than physicians. Personal experiences basically show that midlevel care actually poses a significantly greater danger to patient safety than physician care (because midlevels have a smaller knowledge base and have this irrational tendency to overprescribe medications and tests).

This is a far more pertinent issue, but sadly gets the least amount of press here on SDN.

I would like to see some published data. For every dangerous midlevel anecdata, someone can throw right back a dangerous doctor story.

 

[VA Hopeful Dr]

This is a far more pertinent issue, but sadly gets the least amount of press here on SDN.

I would like to see some published data. For every dangerous midlevel anecdata, someone can throw right back a dangerous doctor story.

The problem is, we can't ethically do such a study and the nurses can math up any studies they do to show whatever they want.

 

[Goro]

The problem is, we can't ethically do such a study.

Really??? How come?

 

[Matthew9Thirtyfive]

I don't know and don't care. I do care about the mindset that "I'm a doctor and I'm God's chosen" mentality. Just look at some of the bile posted in these fora.

So you only care about ego insofar as it lets you bash physicians and med students. Gotcha.

 

[Goro]

So you only care about ego insofar as it lets you bash physicians and med students. Gotcha.

Triggered?

The peasants trying to move beyond their station doesn't bother me, unless patient safety is at issue.

 

[Matthew9Thirtyfive]

Triggered?

The peasants trying to move beyond their station doesn't bother me, unless patient safety is at issue.

lol I'm not triggered. It's just a little hypocritical that you don't seem to care that masses of significantly lesser-trained NPs are fighting for independent practice under the guise of providing care to the underserved and then promptly flocking to overserved urban centers to make more money.

 

[VA Hopeful Dr]

Really??? How come?

When's the last time you ever heard of an inferiority study?

 

[radsisrad]

FM here. Not worried about midlevels in the slightest.

You're not in training.

 

[VA Hopeful Dr]

You're not in training.

OK, and?

 

[evilbooyaa]

When's the last time you ever heard of an inferiority study?

Wonder if we could do a real, by the books, non-inferiority study, with the conclusion that "NP care is not deemed non-inferior to physician care"?

I've become more and more cynical, and I want somebody to take a NP-hospitalist team and MD-hospitalist team, randomize all non-ICU admissions (or even a common diagnosis, like pneumonia/COPD/CHF exacerbations) between the two, and not allow NPs to ask the MDs for help. If the hospitalist MD is consulted for management because the NP can't figure it out, that's an 'event' and the patient's outcome is censored. Wonder what the event rate would be. Evaluate average number of consultations per patient (which can be MDs), do a cost analysis.

 

[Matthew9Thirtyfive]

Wonder if we could do a real, by the books, non-inferiority study, with the conclusion that "NP care is not deemed non-inferior to physician care"?

I've become more and more cynical, and I want somebody to take a NP-hospitalist team and MD-hospitalist team, randomize all non-ICU admissions (or even a common diagnosis, like pneumonia/COPD/CHF exacerbations) between the two, and not allow NPs to ask the MDs for help. If the hospitalist MD is consulted for management because the NP can't figure it out, that's an 'event' and the patient's outcome is censored. Wonder what the event rate would be. Evaluate average number of consultations per patient (which can be MDs), do a cost analysis.

That will never happen, because you already know what the results would be and so do they.

 

[Goro]

When's the last time you ever heard of an inferiority study?

But one can look at negative outcomes, right?

 

[W19]

Absolutely anecdotally- the only physicians I’ve talked to who seem threatened by mid-levels are anesthesiologists. There’s more than enough work to go around for hospitalists and PCPs, and the other specialties I’ve worked with/been exposed to are grateful to have a midlevel to help with an otherwise almost-impossible patient load.

I dont think you should have that kind of mindset... If it's affecting anesthesiologists, it's affecting the profession.

 

[radsisrad]

OK, and?

You have less to lose than those who've got more work-years ahead of them.

 

[Moose A Moose]

I’ve worked with plenty of “cardio NPs”... they’re essentially eternal intern year residents.

 

[NicMouse64]

I’ve worked with plenty of “cardio NPs”... they’re essentially eternal intern year residents.

I was shadowing this cardiologist at the end of his career as a premed a couple years ago who was nearing retirement. He basically said he took on a np because it made his life easier and he got more reimbursement because he could see more patients. His daughter was becoming a cardio NP. He talked about his colleagues and how some of them were intolerant of the NPs and were "behind the times". To some extent it made me sad, as he saw things as so black and white, and refused to say anything remotely critical of the profession. I don't know what to think sometimes. NPs from my experience are very pleasant people to work around, and it's hard to tell someone who is super nice "you don't know what you are talking about." People naturally get upset when pleasant people are attacked.

 

[AnatomyGrey12]

Really??? How come?

But one can look at negative outcomes, right?

Part of the problem is that it would be completely unethical to run a study on patients where the NPs truly had no physician back up. If you look at the "studies" the NPs push they are taking more time to see less patients, the patients have less comorbidities, and simply are different populations. A true comparison would require complete randomization of patients, regardless of acuity, standardize the time per visit, and leave the NPs completely to their own devices. Patients would have to suffer significant medical outcomes simply to prove an outcome that is obvious to anyone in medicine, it's unethical. Such a study will never be run because we already know what it would show and so do they, part of the problem is they know that such a study won't be run so they trot out BS garbage studies (I mean studies so bad they make OMM studies look like perfect, high quality medical research) that the administrations and politicians eat up because mid-levels are cheaper.

Have you looked at NP curriculums? Many of them don't even go into further pathophysiology than what is taught in BSN courses. They are full of "nursing theory" classes that don't touch on diagnosis or management, and then they have "clinicals" that are simply about 600 hours of shadowing, a 3rd year medical student has more clinical experience by their 4th rotation. It's laughable, and terrifying at the same time. Many of them will counter with "but NPs generally have worked as a floor nurse for year" but that argument is crap because 1. many NPs these days are going directly into graduate programs without true working experience, and 2. I don't care if you've been a practicing nurse for 50 years because nursing is fundamentally different than medicine and it doesn't teach you how to develop a differential, diagnose, and treat no matter how long you do it. It is based largely on following protocols, which is fine for run of the mill stuff but the problem is that many patients that appear as run of the mill could have lots of hidden problems, and only physician training teaches you how to keep a wary eye out for these issues.

Personally I have met good NPs, but I've also seen enough terrifying ones that I will never hire one. I will hire PAs because at least with them I have a general idea what they should know because their curriculum is standardized.

The issue is not, "they rose above their station and are taking our jobs," the issue is that they are simply not qualified and are dangerous without significant supervision to be independent providers.

 

[Goro]

Personally I have met good NPs, but I've also seen enough terrifying ones that I will never hire one. I will hire PAs because at least with them I have a general idea what they should know because their curriculum is standardized.

The issue is not, "they rose above their station and are taking our jobs," the issue is that they are simply not qualified and are dangerous without significant supervision to be independent providers.

But these are the points that really matter! Yet they are raised far too infrequently.

Yet the more common vitriol (I am using that word very carefully) comes from the ego issues I have described.

 

[Matthew9Thirtyfive]

But these are the points that really matter! Yet they are raised far too infrequently.

Yet the more common vitriol (I am using that word very carefully) comes from the ego issues I have described.

Is it though? Or are the ones that do come from that perspective just the loudest?

 

[Goro]

Is it though? Or are the ones that do come from that perspective just the loudest?

Loudest. The most common are "they're taking R jobs!!"

To which the attendings here try to tell you isn't happening, yet they are always ignored.

 

[Psai]

Loudest. The most common are "they're taking R jobs!!"

To which the attendings here try to tell you isn't happening, yet they are always ignored.

Remember when you were in the market for a physician job? Yeah me neither.

 

[VA Hopeful Dr]

You have less to lose than those who've got more work-years ahead of them.

Ah, so facts are relative. Good to know.

I'm also only 5 years out, so its not like I'm going to retire in 10 years.

 

[VA Hopeful Dr]

But one can look at negative outcomes, right?

But its unethical to do a study where you know that one arm is likely to result in harm.

Its why our studies always use the current best practice as the control and what we hope will be a BETTER treatment as the experimental arm. The instant that the experimental arm is suggested to worsen outcomes compared to the control, the trial gets stopped because of course it does.


Its why the NPs are the only ones that do these studies, because they think it will show that they are equal to us. You can't do it the other way around.

 

[Matthew9Thirtyfive]

Its why the NPs are the only ones that do these “studies”

FTFY

 

[Goro]

But its unethical to do a study where you know that one arm is likely to result in harm.

Its why our studies always use the current best practice as the control and what we hope will be a BETTER treatment as the experimental arm. The instant that the experimental arm is suggested to worsen outcomes compared to the control, the trial gets stopped because of course it does.

But do you actually know that? Or turning things around, wouldn't you expect to see better outcomes where care is provided by an MD/DO?

 

[Goro]

Remember when you were in the market for a physician job? Yeah me neither.

Does this mean that you won't be able to get a job in NYC, Miami or Chicago, and will instead have to settle for, say, Pomona, Des Moines or Indy? Or God forbid, Kirksville or Pikesville? Poor baby! Welcome to the world of Faculty job hunting. You at least don't have to bring a grant with you to find a job.

 

[VA Hopeful Dr]

But do you actually know that? Or turning things around, wouldn't you expect to see better outcomes where care is provided by an MD/DO?

That's just semantics though.

It would be like me designing a trial comparing metformin to Coke in diabetes. Yes I could say I'm trying to prove that metformin is better for glucose control than Coke, but that's still an unethical trial that any IRB worth their salt will reject.

 

[Kuratz]

All I know is that NP schools and PA schools have been opening up like mad in my area. The NP schools can be done purely online for the didactic portion and then have between a measly 450-800 hours of clinical rotations. A third year med student on IM or Gen Surg for 8 weeks hits this number. I have less of a problem with their didactics since med school is largely online now; however NP schools actively advertise the ability to continue to work part-time which immediately questions the rigor of their program and the types of classes listed do not sound heavy on the clinical diagnostic/treatment aspects. The real crux is having such a limited amount of clinical experience is honestly dangerous. I studied my ass off for two years, including Step 1, and then had a full year of MS3 rotations with shelf exams and Step 2, multiple sub-Is and I feel nowhere near close to practicing independently. The fact that NP programs allow this is insane. It'll be interesting as the market in desirable areas continued to be further saturated by NPs. Something has to give: either they take a handsome paycut via supply and demand or they continue to encroach on MD domain. It should be the former but given how militant NPs act on a macro scale I wouldn't be surprised to see them continue chipping away and gaining more autonomy. Purely anecdotally the PAs I've worked with generally understand their role and perform it better, while NPs have a massive brick on their shoulder and are hellbent on being a "doctor". PAs coincidentally have a more standardized experience and greater clinical training. I'm sure there are fantastic NPs, but the lack of institutional standardization makes me scared ****less to see a younger one as a patient myself.

 

[Psai]

Does this mean that you won't be able to get a job in NYC, Miami or Chicago, and will instead have to settle for, say, Pomona, Des Moines or Indy? Or God forbid, Kirksville or Pikesville? Poor baby! Welcome to the world of Faculty job hunting. You at least don't have to bring a grant with you to find a job.

? It is easy to get a job in a big city. There are plenty of jobs, they just happen to pay like ****. No one wants to go to the middle of nowhere, USA. In any case, you are bringing up an irrelevant point to this discussion. Donny, you're outta your element.

 

[UnoMas]

It's so ****** ridiculous that physicians as a group who UNDENIABLY have longer, more rigorous training on paper is constantly being asked to prove their worth. You don't see this in any other industry.

 

[Goro]

? It is easy to get a job in a big city. There are plenty of jobs, they just happen to pay like ****. No one wants to go to the middle of nowhere, USA. In any case, you are bringing up an irrelevant point to this discussion. Donny, you're outta your element.

You're not getting any sympathy from me when the median salaries are at least 2x what I'm paid as a full professor, and I crack the six figure mark.

 

[SidNixon]

I am about to start my first year of medical school, and so naturally I am curious about this topic.

I recently heard from a member of my state congress, which approved NP's for independent practice a few years ago (she was in office at the time), about the reasoning behind their decision. She said that before her committee voted on the issue, both the House and the Senate held informational sessions. They sent invitations to the AAFP and to the AANP.

When she got to the session, the AANP went first. They had sent experienced lobbyists and the dean of a local NP program, who had prepared a nice presentation. The AAFP went next. They had sent a local family doc and two volunteer med students, who had obviously never even practiced running through the powerpoint. She said that there was almost no debate in her committee after that.

Could part of the problem (I am referring only to NP autonomy) be that NP's > doctors when it comes to organization and lobbying?

In addition, it seems like this problem will sort itself out eventually. If independent NP's are not able to handle patients on their own, there should eventually be data that shows this (in the form of pt outcomes), right?

 

[Psai]

You're not getting any sympathy from me when the median salaries are at least 2x what I'm paid as a full professor, and I crack the six figure mark.

It's unclear to me why you think you're supposed to compare with us in any shape way or form. It is clear that you're out of touch with your own students and don't have their best interests at heart. Why are you so pro mid-level when you're a professor working in medical education? Have you even worked a single day in a clinical setting or are you just holed up in your oak wood office surrounded by books that no one reads? Then again there are plenty of medical students here going rah rah for the demise of their future profession.