Mid level creep in Internal Medicine Subspecialties?

[762513]

RN license is meaningless, if the NP isn’t the masters degree then it’s in something like “nursing theory” lol so that is also meaningless, and the NP can be gotten online with 600 added hours of shadowing....

I’m not really seeing much of a difference here.

That’s because you have no idea what you’re talking about. @Matthew9Thirtyfive is either lying or delusional. I’m a war vet who has treated patients in combat and functioned as was described above. I’m also an NP. Some of you are just doubling down on stupid. If I had behaved that way I would be on probationary status in a second. You guys can break TOS all you want @UnoMas. Funny how that works.

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[UnoMas]

What did I do?
You, on the other hand, used words like 'stupid,' '*****ic' to describe other people while haven't made any substantive post at all. Not much of an argument going on, just name calling

 

[AnatomyGrey12]

That’s because you have no idea what you’re talking about. @Matthew9Thirtyfive is either lying or delusional. I’m a war vet who has treated patients in combat and functioned as was described above. I’m also an NP. Some of you are just doubling down on stupid. If I had behaved that way I would be on probationary status in a second. You guys can break TOS all you want @UnoMas. Funny how that works.

I’m going to tell you the same thing I told @Goro , if you don’t like what I said then go point by point and refute it like an adult. Instead you come back with vague comments that don’t actually address anything.

 

[762513]

I mean at the cost of sounding like an elitist dingus, just look at this NP student and our average pre-allo/allo troll, there's a stark difference in the level of wit, comprehension and argumentation. Obviously it's hard to project their level of 'smart' off of this observation alone but It's absolutely horse**** that student like this can do a short course of online school and claim equivalency.

See above.

 

[AnatomyGrey12]

See above.

None of that breaks the TOS. The only name calling in this discussion has come from you.

 

[762513]

I’m going to tell you the same thing I told @Goro , if you don’t like what I said then go point by point and refute it like an adult. Instead you come back with vague comments that don’t actually address anything.

I made a poignant statement about some physicians behavior. It was ignored. If you want to go point by point let’s do it. Start with responding to what I said. I’m sure you can scroll up and find it. Practice what you preach.

 

[762513]

None of that breaks the TOS. The only name calling in this discussion has come from you.

I never once called anyone stupid or *****ic. I called their statements and positions such.

 

[UnoMas]

I made a poignant statement about some physicians behavior. It was ignored. If you want to go point by point let’s do it. Start with responding to what I said. I’m sure you can scroll up and find it. Practice what you preach.

Matthew already did. There are bad apples everywhere, in medicine or in mid level. Are you saying all NPs are angelic, nonjudgemental beings? It doesn’t account for all the mid-level problem
Not much of a point there dude.


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[Matthew9Thirtyfive]

I did the exact same thing. It’s nothimg even close to being a trained NP. I’m sure most of these posters don’t know the difference and will agree with you as a way of antagonizing me, but what you said is pretty *****ic. You guys can go back to trolling goro now, I’m out.

Again, you're not addressing my point. My point wasn't that the training was the same as an NP or a PA. My point was that I've practiced in a setting where there is a knowledge gap, and yet I'm the primary provider. So I empathize with mid-levels who want to prove that they are capable. The point was that I don't automatically assume an NP or a PA is incompetent because I've been in that position with less training and have provided quality care within my training and comfort.

But you continue to ignore that point in an attempt to troll and antagonize. Do me a favor and don't mention you're a vet on here. I'd prefer not to have them think of your type of behavior when they see I'm military.

 

[762513]

Again, you're not addressing my point. My point wasn't that the training was the same as an NP or a PA. My point was that I've practiced in a setting where there is a knowledge gap, and yet I'm the primary provider. So I empathize with mid-levels who want to prove that they are capable. The point was that I don't automatically assume an NP or a PA is incompetent because I've been in that position with less training and have provided quality care within my training and comfort.

But you continue to ignore that point in an attempt to troll and antagonize. Do me a favor and don't mention you're a vet on here. I'd prefer not to have them think of your type of behavior when they see I'm military.

I’d prefer them not think you are as well. When you equate someone with 16 weeks of military training to a NP with a masters degree thats just as offensive as when a NP claims to be the equal of a MD. It’s just as offensive. A little reflection on what you’re saying may help, because I don’t believe you’re purposefully trying to be offensive.

 

[Matthew9Thirtyfive]

That’s because you have no idea what you’re talking about. @Matthew9Thirtyfive is either lying or delusional. I’m a war vet who has treated patients in combat and functioned as was described above. I’m also an NP. Some of you are just doubling down on stupid. If I had behaved that way I would be on probationary status in a second. You guys can break TOS all you want @UnoMas. Funny how that works.

You're a war vet? The only people I have served with or vets I know who talk like that are people who never did anything. No one is breaking the TOS except for you. We're addressing points and providing an argument. You're ignoring all the points and just insulting people.

And I question how much you actually did when you were in if you really think what you're posting. I'm in class with a number of Army medics, all of whom have deployed at least once. Not one of them acts like you do, and all of them have been in situations where they had more autonomy. You're conflating saying I practiced with autonomy with saying I have the education of a PA. Not the same thing.

And you'd be on probationary status because you're just insulting people. You've responded to my posts with the word stupid multiple times now, and my responses have all been logical.

 

[Matthew9Thirtyfive]

I’d prefer them not think you are as well. When you equate someone with 16 weeks of military training to a NO with a masters degree thats just as offensive as when a NP claims to be the equal of a MD. It’s just as offensive. A little reflection on what you’re saying may help, because I don’t believe you’re purposefully trying to be offensive.

Again, you completely ignore the point and the several instances where I clarify that I don't think a corpsman has the education of a PA. You are either a really dedicated troll, or the standards for entry into NP programs are really low.

 

[AnatomyGrey12]

It was ignored.

What? That was already addressed. Now go address my comments you disagree with (I’m assuming you disagree with something I said as you quoted me) and present specific rebuttals.

 

[VA Hopeful Dr]

What? That was already addressed. Now go address my comments you disagree with (I’m assuming you disagree with something I said as you quoted me) and present specific rebuttals.

And addressed by at least 3 people that I noticed...

 

[762513]

What? That was already addressed. Now go address my comments you disagree with (I’m assuming you disagree with something I said as you quoted me) and present specific rebuttals.

Much of the critism of NP education is accurate. It needs to be longer and more rigorous. That’s why I didn’t respond.

 

[762513]

Again, you completely ignore the point and the several instances where I clarify that I don't think a corpsman has the education of a PA. You are either a really dedicated troll, or the standards for entry into NP programs are really low.

So when an NP says they practice very similarly to a physician but without the same education SDN says the sky is falling. How is that different from saying a enlisted healthcare MOS does the same as an NP. If we each examine our unconscious bias and debate intellectually honestly I think this conversation (with you) could be useful.

 

[Matthew9Thirtyfive]

So when an NP says they practice very similarly to a physician but without the same education SDN says the sky is falling. How is that different from saying a enlisted healthcare MOS does the same as an NP. If we each examine our unconscious bias and debate intellectually honestly I think this conversation (with you) could be useful.

So are you asking me what I think or what SDN thinks? If a mid-level is practicing independently, they are practicing in a position similar to a physician without the same level of knowledge. Where in my post did I imply they are different? In fact, I have said several times that they are similar, which is why I don’t jump to conclusions about a given midlevel’s competence. That was the whole point, which you so deftly missed so many times.

 

[AnatomyGrey12]

Much of the critism of NP education is accurate. It needs to be longer and more rigorous. That’s why I didn’t respond.

Then I guess I'm confused as to what your point is.

 

[762513]

So are you asking me what I think or what SDN thinks? If a mid-level is practicing independently, they are practicing in a position similar to a physician without the same level of knowledge. Where in my post did I imply they are different? In fact, I have said several times that they are similar, which is why I don’t jump to conclusions about a given midlevel’s competence. That was the whole point, which you so deftly missed so many times.

I got your point and I do appreciate you are a moderate on this topic. There’s good and bad midlevels just as there are good and bad physicians.

I very strongly disagree that you have “midlevel experience.” A midlevel, as you know, is a civilian prescriber other than a physician with DEA privileges. As a medic I functioned independent in a small unit occasionally suturing and even “prescribing” keflex and other antibiotics to healthy young 20 year olds without comorbidities. I did not function as a midlevel, nor did you. You have military medical experience, which is awesome, but it’s not “midlevel” experience.

 

[Psai]

Yeah actually sounds like he was an advanced practice provider

 

[Select All That Apply]

@Matthew9Thirtyfive The entry requirements to a NP school are ridiculously low. I'm sure your partner agrees. There are students in my cohort who direct transitioned into an NP program after finishing nursing school with one such student stating, "I never wanted to wash a butt. That job is for CNAs."

 

[AnatomyGrey12]

I got your point and I do appreciate you are a moderate on this topic. There’s good and bad midlevels just as there are good and bad physicians.

I very strongly disagree that you have “midlevel experience.” A midlevel, as you know, is a civilian prescriber other than a physician with DEA privileges. As a medic I functioned independent in a small unit occasionally suturing and even “prescribing” keflex and other antibiotics to healthy young 20 year olds without comorbidities. I did not function as a midlevel, nor did you. You have military medical experience, which is awesome, but it’s not “midlevel” experience.

I'm genuinely curious, I'd love to hear your arguments as to what a mid-level does that is so different than what he was doing.

 

[762513]

I'm genuinely curious, I'd love to hear your arguments as to what a mid-level does that is so different than what he was doing.

The same reason for why a NP isn’t a physician. Much shorter training. Different (for the medic no) DEA license. Depth of training. Acuity and comorbidities of their patients, the parallels are endless. I’ll end this with what you’d all call the fallacy of an appeal to authority, but for those one or two of you who aren’t trolling, I know what I’m talking about. I’ve been in both worlds and had both the educations.

 

[UnoMas]

The same reason for why a NP isn’t a physician. Much shorter training. Different (for the medic no) DEA license. Depth of training. Acuity and comorbidities of their patients, the parallels are endless. I’ll end this with what you’d all call the fallacy of an appeal to authority, but for those one or two of you who aren’t trolling, I know what I’m talking about. I’ve been in both worlds and had both the educations.

So if I am reading this right, you are basically clearly delineated a lower limit- what differentiates what he did and a mid level- but conveniently left out ‘the top of your license.’ Cant have it both way brother.




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[Black Coffee 24/7]

Want to share some news to you guys from a recent occurrence in my life.

One of the RNs at our clinic thought that my resident is a medical student, and tried to pick on him by challenging his ddx and plans.

Got put in her place nicely with thoughtful explanations. She then realized that he’s a senior resident from one of the top IM programs.

It made my day. She kept her mouth shut for the rest of the week.

 

[Matthew9Thirtyfive]

I got your point and I do appreciate you are a moderate on this topic. There’s good and bad midlevels just as there are good and bad physicians.

I very strongly disagree that you have “midlevel experience.” A midlevel, as you know, is a civilian prescriber other than a physician with DEA privileges. As a medic I functioned independent in a small unit occasionally suturing and even “prescribing” keflex and other antibiotics to healthy young 20 year olds without comorbidities. I did not function as a midlevel, nor did you. You have military medical experience, which is awesome, but it’s not “midlevel” experience.

I don’t claim to be a mid level. I use my experience to demonstrate that I have an idea of what it’s like to practice at a mid-level...level. But from what I’ve heard from Army medics, we have a bit more autonomy. I don’t have to ask any physicians or PAs before I give or put in a script for abx or before I order labs or imaging. If my supervising doc thinks my practice is inappropriate, she’ll tell me. I always tried to practice ebm when appropriate.

I think maybe you just feel a little insulted that someone without your schooling is saying they did the same job. Funny, that’s how a lot of physicians feel about mid-levels.

But I’m not saying I was a mid-level. I was in that setting, but because we have less training, my threshold for referral was very low (likely lower than most PAs).

 

[Matthew9Thirtyfive]

The same reason for why a NP isn’t a physician. Much shorter training. Different (for the medic no) DEA license. Depth of training. Acuity and comorbidities of their patients, the parallels are endless. I’ll end this with what you’d all call the fallacy of an appeal to authority, but for those one or two of you who aren’t trolling, I know what I’m talking about. I’ve been in both worlds and had both the educations.

Mid-levels tend to see lower acuity patients with few or no comorbidities except in fully independent practice settings. As I said, our patient population was generally very healthy and we referred our for things like even diabetes (because they can’t be on a ship). I wouldn’t try to manage someone’s diabetes because I don’t feel I have the training even if I am sure I could learn it and do it safely.

 

[762513]

I don’t claim to be a mid level. I use my experience to demonstrate that I have an idea of what it’s like to practice at a mid-level...level. But from what I’ve heard from Army medics, we have a bit more autonomy. I don’t have to ask any physicians or PAs before I give or put in a script for abx or before I order labs or imaging. If my supervising doc thinks my practice is inappropriate, she’ll tell me. I always tried to practice ebm when appropriate.

I think maybe you just feel a little insulted that someone without your schooling is saying they did the same job. Funny, that’s how a lot of physicians feel about mid-levels.

But I’m not saying I was a mid-level. I was in that setting, but because we have less training, my threshold for referral was very low (likely lower than most PAs).

Thank you for your service, sir. Have a good semester if you’re a student.

 

[AnatomyGrey12]

The same reason for why a NP isn’t a physician. Much shorter training. Different (for the medic no) DEA license. Depth of training. Acuity and comorbidities of their patients, the parallels are endless. I’ll end this with what you’d all call the fallacy of an appeal to authority, but for those one or two of you who aren’t trolling, I know what I’m talking about. I’ve been in both worlds and had both the educations.

Ok, I can understand that reasoning. In that same vein, I know you said this yourself but need to point it out, you can see that those same reasons are the very reasons we are all so opposed to independent mid-level providers right? And why we take such offense to NP's telling everyone they are "as good" or even "better" than physicians? There is definitely a ceiling to what an NP can, and should, do and yet here we are where the leadership is very militantly pushing their agenda of "brain of a doctor and heart of a nurse" schpiel. The even bigger problem is that the new generation of nurses has a growing cohort of individuals that actually believes it. My wife went to a very good BSN program and even there was taught very frequently how they will save patients from doctors. She would come home and laugh but many of her classmates adopted that mentality. Many of those same individuals were open about the fact that they went to the program because they were going straight into NP school after that because, "why would I go to medical school when I will be just as good as an NP in much less time."

There is often an "us vs. them" mentality in medicine, and my experience so far (4 years working in a directly clinical environment and now 2 years of medical school) is that it very much originates from the nursing side. I have been taught nothing except how important nurses are to my role as the physician, but the that sentiment does not go the other way. I do however, believe that the majority of working nurses and NPs do not have that mentality, but unfortunately the loudest are the ones that are driving the movement.

Now yes there are doctors who are complete ***hats, and that is unacceptable and we need to change some of our behaviors, but to pretend like we are the ones that started the culture war is disingenuous.

 

[W19]

PA is legit guys...

 

[762513]

PA is legit guys...

God what a troll. Is it possible to end a SDN conversation on a good note for once?

 

[MrMe123]

I've heard so many med students and doctors make snide remarks about nurses from a place of narcissism and having a holier than thou attitude. It's not so wild that a profession held so sacred and as the leaders of medicine can often let it get to their heads. And nurses know it happens.

 

[AnatomyGrey12]

I've heard so many med students and doctors make snide remarks about nurses from a place of narcissism and having a holier than thou attitude. It's not so wild that a profession held so sacred and as the leaders of medicine can often let it get to their heads. And nurses know it happens.

I’m not even sure what your point is here...

 

[Matthew9Thirtyfive]

I’m not even sure what your point is here...

Just trying to start more ****.

 

[W19]

Vanderbilt has all kind of **** fellowships for MLP

Office of Advanced Practice - VUMC Advanced Practice Fellowship - Vanderbilt Health Nashville, TN

 

[libertyyne]

Vanderbilt has all kind of **** fellowships for MLP

Office of Advanced Practice - VUMC Advanced Practice Fellowship - Vanderbilt Health Nashville, TN

First eugene gu, now this, where will it stop vandy? Is there even a governing body or can I just open up an APP Fellowship in my garage?

 

[W19]

Wait,
"leadership" classes and "nursing theory" do not hel

First eugene gu, now this, where will it stop vandy? Is there even a governing body or can I just open up an APP Fellowship in my garage?

I dont know too much about Eugene case, so I can't comment on it. But I think the medical community needs to start boycotting VB because of these *** fellowships...

 

[VA Hopeful Dr]

First eugene gu, now this, where will it stop vandy? Is there even a governing body or can I just open up an APP Fellowship in my garage?

That asshat made his own bed, Vandy just had the bad luck to have hired his narcissistic self

 

[W19]

I thought fellowship had a meaning... Geez!

 

[AnatomyGrey12]

First eugene gu, now this, where will it stop vandy? Is there even a governing body or can I just open up an APP Fellowship in my garage?

Bro I’ll come be your governing body, we’ll tag team it and make some serious $$$

That asshat made his own bed, Vandy just had the bad luck to have hired his narcissistic self

Beat me to it lol. Eugene is insane.

 

[libertyyne]

That asshat made his own bed, Vandy just had the bad luck to have hired his narcissistic self

The mistake was the poor judgement in hiring him in the first place.

 

[Instatewaiter]

On the other hand, my kid's pediatrician (on look, I'm using a word meant for the anointed!) is an NP and she gets in over her head when things her more complicated than the run of the mill kid's stuff.

No, you're using the term for someone who has completed the necessary training and board exams to categorize themselves as a pediatrician . An NP will never be a pediatrician. This is not an ego thing. I have no dog in the pediatrics fight.

Look I fall on your side of the tracks that the sky is NOT falling. It is rare that midlevels do not realize their place. When I was younger I was more worried about midlevels than I am now. In the vast majority of specialties, primary care included, there is such a volume of patients to be seen that it won't matter. My practice for instance employs 11 or 12 PAs or NPs. We literally couldn't see all the patients we need to without them. Note we have hired 4 new docs as well in the last year.

Now i am in a specialty that is unlikely to be taken over by midlevels and takes a lot of training. Right out of training I knew more than the midlevels that had been a midlevels in the field for over a decade. They know that. It is only the young NPs without much experience who think they have what it takes to be completely independent.

 

[LutGholein]

Vanderbilt has all kind of **** fellowships for MLP

Office of Advanced Practice - VUMC Advanced Practice Fellowship - Vanderbilt Health Nashville, TN

They have “colorectal surgery fellows”....
Dilution is real.

 

[Cryc_to_the_point]

Vandy seems like a mid-level creep hot spot...

 

[libertyyne]

They have “colorectal surgery fellows”....
Dilution is real.

probably doing post op visits, and screens pre-procedure.

 

[Psai]

probably doing post op visits, and screens pre-procedure.

You would think so until you read about the nurse that performs caths or Mt Sinai training nurses to do colonoscopies for the underserved rural community of Manhattan's upper East side

 

[lemurcatta]

Yea but.. who trains these nurses? Who writes the textbooks and UpToDate articles they use, and the guidelines they follow? Who credentials medical staff at hospitals? Physicians. I don't think any of you will be out of a job anytime soon. NPs may say they can practice independently but they would be hamstrung immediately without the accumulated knowledge and expertise of physicians.

Regarding NPs doing caths or colonoscopy, Jesus Christ. I will soon be a PA, and I wouldn't want a PA doing a heart cath or full colonoscopy alone on me or anyone I know. Let alone an NP- who have inferior training generally, and exactly 0 hours of anatomy education beyond their lower division undergraduate introductory anatomy course for their BSN. Who lets these people near a procedure room?

 

[762513]

Yea but.. who trains these nurses? Who writes the textbooks and UpToDate articles they use, and the guidelines they follow? Who credentials medical staff at hospitals? Physicians. I don't think any of you will be out of a job anytime soon. NPs may say they can practice independently but they would be hamstrung immediately without the accumulated knowledge and expertise of physicians.

Regarding NPs doing caths or colonoscopy, Jesus Christ. I will soon be a PA, and I wouldn't want a PA doing a heart cath or full colonoscopy alone on me or anyone I know. Let alone an NP- who have inferior training generally, and exactly 0 hours of anatomy education beyond their lower division undergraduate introductory anatomy course for their BSN. Who lets these people near a procedure room?

Looks like there's some recent evidence the PA's "superior education" doesn't translate into any better outcomes.

A Comparison of Nurse Practitioners, Physician Assistants, and Primary Care Physicians' Patterns of Practice and Quality of Care in Health Centers. - PubMed - NCBI

 

[lemurcatta]

Looks like there's some recent evidence the PA's "superior education" doesn't translate into any better outcomes.

A Comparison of Nurse Practitioners, Physician Assistants, and Primary Care Physicians' Patterns of Practice and Quality of Care in Health Centers. - PubMed - NCBI

Ok hold up. You know the outcomes measured in your cited paper are: smoking cessation, number of statin prescriptions divided by cases of "hyperlipidemia", "total number of preventive/counseling services offered", and a grab bag of other exceptionally strange "outcomes" (was a physical exam provided...haha)? Also, you do know that my post was referring to competency to independently perform certain procedures such as colonoscopy?

Edit: a few additional thoughts. You cannot measure PAs, NPs, or physicians by the number of statins we prescribe, or the number of "physical exams" provided, and then claim that because they are similar, that the education or global clinical outcomes of NPs, PAs, and MDs are all mutually non-inferior. That's absurd. You can cite a million replicates of this gem until the cows come home, but MD education is vastly more comprehensive than either NP or PA education, and also, on average PA education is far more standardized and rigorous than NP education. You are welcome to take a look at ARC-PA accreditation standards which are publicly available online (by the way, we only have one accreditation body, not 2+ where programs can pick and choose the more lax standards). (also you might want to look at the applicant pools of all three programs and see where nursing stacks up).

 

[762513]

Ok hold up. You know the outcomes measured in your cited paper are: smoking cessation, number of statin prescriptions divided by cases of "hyperlipidemia", "total number of preventive/counseling services offered", and a grab bag of other exceptionally strange "outcomes" (was a physical exam provided...haha)? Also, you do know that my post was referring to competency to independently perform certain procedures such as colonoscopy?

Edit: a few additional thoughts. You cannot measure PAs, NPs, or physicians by the number of statins we prescribe, or the number of "physical exams" provided, and then claim that because they are similar, that the education or global clinical outcomes of NPs, PAs, and MDs are all mutually non-inferior. That's absurd. You can cite a million replicates of this gem until the cows come home, but MD education is vastly more comprehensive than either NP or PA education, and also, on average PA education is far more standardized and rigorous than NP education. You are welcome to take a look at ARC-PA accreditation standards which are publicly available online (by the way, we only have one accreditation body, not 2+ where programs can pick and choose the more lax standards). (also you might want to look at the applicant pools of all three programs and see where nursing stacks up).

I was talking about NP compared to PA. Thanks for telling me physicians are better clinicians. On a side note, the pope is catholic.