mid-level encroachment

[DrOwnage]

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Wow this makes me feel awesome being set on applying to Anesthesia in September... Are my prospects really that horrible? I have a crapload of debt

 

[postbacpremed87]

Wow this makes me feel awesome being set on applying to Anesthesia in September... Are my prospects really that horrible? I have a crapload of debt

Do a fellowship to help insulate yourself and work hard/take a fair amount of call. Do these things and you will be well remunerated (350-400k+). You can pay off a crapload of debt with that kind of money.

 

[Psai]

This is the line of thinking in all specialties using mid-levels though... yet mid levels always end up doing a little more every year. Urology PA's are doing cystoscopy now. GI NPs are doing colonoscopies at Johns Hopkins. The slope is slippery. Sure, they will never replace MDs in any (most?) fields, but they will impact the job market.

Regarding ED physicians, sure the market is still good-- but at many places the MD:mid-level ratio is changing. At our main hospital, they recently expanded the ED and changed the ratio from 1 MD per 1 mid-level to 1 MD per 2 mid-levels. In this case, when the ED exapanded they opted for more mid-levels instead of more ED docs. The sky isn't falling, but we shouldn't ignore that these changes are happening.

Greed is the bane of american medicine. Doctors found out that they could have mid-levels do their work and bill for that work while skimming off of the top. So now we have all of these mid levels that are basically partially trained people doing the same things without the same knowledge base. A little knowledge is a very dangerous thing, especially when you don't realize the limitations of your education. But mid-levels aren't stupid, they know that the docs are making money off of them and so they push for more autonomy so that they can get a bigger piece of the pie. Now we have an alphabet soup of "doctorates" parading through hospitals and medical centers pretending to be doctors and every passing year leads to more restrictions leading to crappier medical training as mid-levels slowly expand their scope of practice. It's a shame that mid-levels are being given the amount of responsibility that they are through a shortcut and that this is being exploited by large corporations who are skimming even more off mid-levels and doing it to the doctors themselves as well, much of the time by other docs.

 

[Jabbed]

Eh, I wouldn't be so sure. I agree with doxy, everything you mention can be learned by immersion. Plus the rad onc job market will likely always be tight, so any mid level movement will probably have more of an impact.

No..

 

[Baller MD]

Do a fellowship to help insulate yourself and work hard/take a fair amount of call. Do these things and you will be well remunerated (350-400k+). You can pay off a crapload of debt with that kind of money.

CRNAs have been doing cardiac anesthesia bro. It's only going to become more widespread. It's a race to the bottom like in any other field.

 

[KinasePro]

No..

A thoughtful MS-1 retort..

 

[Jabbed]

A thoughtful MS-1 retort..

Spare the "I am two steps ahead of you in your educational pathway so I know everything and you know nothing" airs. It didn't warrant a more thoughtful reply because it's completely preposterous. Radiation oncologists are specialists' specialists and virtually every aspect of their job involves arranging and directing complex treatment modalities. The only room for mid-levels is in the actual delivery of therapy, and that is the one aspect of care that most rad onc physicians do not engage in in the first place. There is absolutely no room for mid-levels to encroach upon other than the auxiliary role that they are already filling.

This says nothing of the idea that "learning by immersion" in this particular field is completely ridiculous.

 

[Jabbed]

CRNAs have been doing cardiac anesthesia bro. It's only going to become more widespread. It's a race to the bottom like in any other field.

That is crazy. I'm amazed that any practice is willing to assume that liability.

 

[postbacpremed87]

Other than surgery, what fields are naturally insulated from mid-level encroachment? Specialties where the scope of material is just too vast to even try and practice it...

 

[giantswing]

Other than surgery, what fields are naturally insulated from mid-level encroachment? Specialties where the scope of material is just too vast to even try and practice it...

Like primary care, where anything can walk thru the door.

Wait...

 

[studentdoct69]

Hm. This is an interesting forum and is something that should be of concern for all people in MD or DO.

You have to realize that health-care IS a business. We provide a service and expertise (and this is why health-care is NOT a "right" for all citizens....*since when did the LABOR of one man become the RIGHT of another?!* this should make all medical students/professionals furious).

Like anything else, supply-demand concepts will dictate if our profession becomes diluted.

If you had a serious health problem, and you have enough money, would you see a PA or an MD/DO? Probably MD/DO. For more serious health issues there will always be a higher demand for the more expert titles and people who specialize/know more.

As for general coughs and congestion. PAs will increasingly become more popular in that field b/c those problems aren't too worrisome and they charge less.

I would say yes, the field of health-care is evolving. But MDs/DOs will always have more leverage in the market because they have more expertise.

Why are PAs and NPs increasing? B/C there's a demand for it. If MDs/DOs could alleviate this demand, then they would and the PAs and NPs wouldn't increase. So, when the demand slows down....PAs/NPs will be the first to lose their jobs or at least they will have the most fluctuation in terms of pay.

The real problem with a health-care career right now is the government getting in the way and destroying the "free market" of it all (if that ever even existed). If you are worried about anything in this profession it should be this. Also, a PA is just that, a physician ASSISSTANT. They work for a physician. Just like an accountant works for a CEO. There will most likely always be a space for the physician to be the leader in health-care and to be the one making most of the money and making most decisions.

Sure it might SLOWLY be getting diluted. But, what profession isn't getting diluted? My bet is more and more people are becoming educated in every field across the nation (hence applicants to universities and MBA programs rising).

 

[studentdoct69]

And, this might be a little extreme but....if health-care was totally a free market how cool would it be for doctors. Patients could buy there surgeries based on reviews and what-not; and the best doctors (best reviews, best results etc.) would be able to charge the most and make the most.

Right now it seems like one doctor MD may be a wayyyyyyy better surgeon and get miraculous results whereas another doctor at the same hospital doesn't get the best results and reviews for patient care, yet both doctors make essentially the same or have comparable positions in terms of lucrativeness--this must frustrate the great surgeons who have better ideas. This is kind of indirectly harming the quality of health-care b/c it takes away some of the incentive for doctors to keep getting better at what they do. Idk now i'm rambling but think about it

 

[DeucesHigh3]

Other than surgery, what fields are naturally insulated from mid-level encroachment? Specialties where the scope of material is just too vast to even try and practice it...

Radiology. Pathology. Anybody who throws around notions of mid-levels or "teh computorz" replacing those specialties is delusional.

 

[Jimmy Jones]

Good question. Besides midlevel providers, medicine is be affronted by technology as well. It's not as important to have a highly trained physician who know the "art" of practicing medicine anymore. We have algorithms for that now. We even have data that shows when we try to get "artsy" with our practices, our outcomes are probably worse than if we had just used the algorithm some PhD whipped up in their free time with an excel sheet and some stats work. The idea that more education makes you more useful is only valid if you can prove there is some added value to that education. The medicine system is built like a guild, where all the training is a rite of passage in which you "buy in" and gain the RIGHT to treat patients. AMA is one of the most successful groups at maintaining high barriers to entry (in this case entry is lawful ability to treat humans for medical diseases).

I would love it if someone here could show some data that clearly demonstrates increased mortality when patients are treated by NP instead of physician, but I'm not aware of it. I have noticed in my own experience that MLP's seem to "over workup" patients. Perhaps due to their inferior training. This would increase the cost of care/diagnosis per patient, but the hospitals (who employ MLP and physicians) also make money of this stuff, so they have no incentive there to slow that down do they?

I agree surgeons will be the final line in the battle. You have a highly trained person intellectually, but you also have a carefully learned technical skill. An NP may be able to work through the pre-surgical diagnosis and treatment, but they are a LOOOONG ways away from being able to supplant a surgeon in the operating room with any level of facility. Also, a patient is probably fine with an NP ordering a chest X-ray and giving them antibiotics, but I'm thinking they will not be so eager to sign up for the craniotomy, whipple, hip replacement etc done by a MLP.

I think for you as a medical student, the bigger challenge isn't the NP supplanting your role as a physician (you will always be needed in some manner), but the reality that it is getting harder for medical students to find residency spots. This is because medical school is shifting toward the "for profit" mentality (like law schools), and they are increasing enrollment far quicker than residency positions are growing. More and more american grads are now holding an MD, but not matching in their desired specialty, or not even matching at all. This is the problem that needs to be addressed.

Increasing residency positions will make it easier to match, but will shift the supply/demand curve that helps keep physician pay high.....

this is one of the best posts i ver read

 

[W19]

Radiology. Pathology. Anybody who throws around notions of mid-levels or "teh computorz" replacing those specialties is delusional.

I agree with you because most MD/DO would be terrified to carry out a treatment plan based on NP radiology/pathology report... The level of expertise that these field required is beyond what most NP can handle...

 

[Psai]

Since when do mid levels charge less? You need to learn about how physicians are actually paid.

But I don't need data to know that mid level care is inferior. I see it everyday. The real question is whether the government is willing to pay for the best care or merely good enough care. I'm not holding out hope

 

[studentdoct69]

I guess physicians have more ability to specialize in treatments whereas PAs are....*assisstants* they don't have the leverage the docs do...you're right the mid-levels don't "charge less".

And yup. that's what i'm saying about how there is no free-market in health-care. Medicine is basically driving into becoming socialized.

Unfortunately, my guess is it will only get harder to make money and get rewarded for being a better physician b/c of this.

 

[KinasePro]

Spare the "I am two steps ahead of you in your educational pathway so I know everything and you know nothing" airs. It didn't warrant a more thoughtful reply because it's completely preposterous. Radiation oncologists are specialists' specialists and virtually every aspect of their job involves arranging and directing complex treatment modalities. The only room for mid-levels is in the actual delivery of therapy, and that is the one aspect of care that most rad onc physicians do not engage in in the first place. There is absolutely no room for mid-levels to encroach upon other than the auxiliary role that they are already filling.

This says nothing of the idea that "learning by immersion" in this particular field is completely ridiculous.

lol sounds like you're hoping to go into rad onc and are pretty butt hurt by this discussion. ICU docs were saying the same thing about their field 10 years ago... They were the doctor's doctors, a specialist's specialist, no room for mid-levels etc... Now look at their field and how many ICUs are stacked full of mid levels functioning with too much autonomy. There's no use in keeping your head in the sand, the same thing can happen to Rad Onc. I sure hope it doesn't, but it absolutely could. Good luck with the indignant MS-1 act... that will carry you far I'm sure.

 

[Psai]

lol sounds like you're hoping to go into rad onc and are pretty butt hurt by this discussion. ICU docs were saying the same thing about their field 10 years ago... They were the doctor's doctors, a specialist's specialist, no room for mid-levels etc... Now look at their field and how many ICUs are stacked full of mid levels functioning with too much autonomy. There's no use in keeping your head in the sand, the same thing can happen to Rad Onc. I sure hope it doesn't, but it absolutely could. Good luck with the indignant MS-1 act... that will carry you far I'm sure.

this is not a good thing. i'm waiting for the pendulum to swing back as patient care is compromised
if that doesn't happen, then all medical schools should be shut down and we should have mid levels run everything

 

[Kaustikos]

this is not a good thing. i'm waiting for the pendulum to swing back as patient care is compromised
if that doesn't happen, then all medical schools should be shut down and we should have mid levels run everything

Will med students be able to transfer credits to mid level schools? Can you substitute your step 1 score for whatever entrance exam?
More importantly: what does one do with their white coat????

 

[W19]

Will med students be able to transfer credits to mid level schools? Can you substitute your step 1 score for whatever entrance exam?
More importantly: what does one do with their white coat????

Many of these NP schools don't have an entrance exam as long as you have a 3.0 GPA... I just wrote an LOR for a friend who will start NP school in August and she did not take any entrance exam. What was so strange about it was that the school emailed me to remind me to send the LOR because she gave the school my email address...

 

[Kaustikos]

Many of these NP schools don't have an entrance exam as long as you have a 3.0 GPA... I just wrote an LOR for a friend who will start NP school in August and she did not take any entrance exam. What was so strange about it was that the school emailed me to remind me to send the LOR because she gave the school my email address...

I was... Completely joking. Though I do appreciate the insight!

 

[W19]

I was... Completely joking. Though I do appreciate the insight!

I did not read your previous posts... However, after posting I realized that you were probably joking because I remember that you are a big NP fan.

 

[Kaustikos]

I did not read your previous posts... However, after posting I realized that you were probably joking because I remember that you are a big NP fan.

Too true lol

 

[W19]

The whole system is f... up. You have states that would not give a GP license to a physician after 1-year residency and yet NP have unlimited practice right in these states

 

[Psai]

The whole system is f... up. You have states that would not give a GP license to a physician after 1-year residency and yet NP have unlimited practice right in these states

Now we have all these sub specialty groups creating new boards with expensive exams to try to carve out a niche as nurses happily train themselves to do gi scopes and cardiac anesthesia

 

[FiveOClock]

Now we have all these sub specialty groups creating new boards with expensive exams to try to carve out a niche as nurses happily train themselves to do gi scopes and cardiac anesthesia

The idea that we have mid-levels doing these things is appalling. There is one culprit, one bad guy in this scenario (besides the govt, they are always bad for everything ever), and that would be the AMA.

 

[IlDestriero]

I'm not sure that there are many CRNAs independently providing cardiac anesthesia. There may be a few, but that is absolutely not widespread.
If you really live in fear, do peds cardiac. They'll never do that independently. Most peds anesthesia people don't even want anything to do with it.

 

[W19]

The idea that we have mid-levels doing these things is appalling. There is one culprit, one bad guy in this scenario (besides the govt, they are always bad for everything ever), and that would be the AMA.

What do you think the AMA could have done to stop that? Not defending the AMA here--just curious.

 

[Doctor Bob]

Other than surgery, what fields are naturally insulated from mid-level encroachment?

There is no field that is naturally insulated.

 

[Jabbed]

I'm not sure that there are many CRNAs independently providing cardiac anesthesia. There may be a few, but that is absolutely not widespread.
If you really live in fear, do peds cardiac. They'll never do that independently. Most peds anesthesia people don't even want anything to do with it.

10 years ago you could've said that there probably aren't that many CRNAs practicing independently, and that if you're worried about encroachment you could always stick to cardiac.

 

[qwerty89]

There's been basically no midlevel encroachment in any of those fields besides anesthesia.

The EM job market is as good as ever, which is why EM is getting more competitive every year. Do a lot of EDs use PAs/NPs? Sure, usually in a type of "fast track" role, they aren't exactly pushing EM physicians out of jobs.

Pathology and radiology caused their own problems, and it's really only pathology that seems to have the big problem with residents having to do multiple fellowships to get the kind of jobs they want. This has nothing to do with midlevels at all and more to do with overtraining residents in fields where attendings can easily work till they're 80. Even so, the radiology starting salaries are solidly in the high 200s to 300s...not exactly poverty on the streets.

Have you seen the massive increase in EM positions over the past few years?

2000: 1118 combined PGY1/2 positions
2005: 1332
2010: 1575
2015: 1821

In the short run this is acceptable. In the long run? TBD. Doesn't look good to me though.

 

[Makati2008]

Have you seen the massive increase in EM positions over the past few years?

2000: 1118 combined PGY1/2 positions
2005: 1332
2010: 1575
2015: 1821

In the short run this is acceptable. In the long run? TBD. Doesn't look good to me though.

Honestly not worried about it. There is such a shortage currently(and projected to remain so for decades) that in my career I don't foresee an EP hurting to find work in the majority of places. I would be worried if I was another speciality doing EM(except for the rural areas) without an EM residency.

 

[qwerty89]

Honestly not worried about it. There is such a shortage currently(and projected to remain so for decades) that in my career I don't foresee an EP hurting to find work in the majority of places. I would be worried if I was another speciality doing EM(except for the rural areas) without an EM residency.

True. But I would be curious to see the actual methodology for the shortages. There was supposed to be (and allegedly still is) a pharmacy shortage. But we all know thats BS. Those estimates forgot to take into account the massive increase in schools (i.e. they predicted <5 new schools per decade lolwut).

Shortage is a funny term. There is still a shortage of radiologists. Its not like every job in bumblef*** nowhere is taken. But it is saturated in major metropolitan areas. The job market should be measured by how easy/hard it is to get a job in and around major cities, because thats where people want to live. While there will likely be a shortage of EM providers in the future, that does not necessarily mean that it will be easy to get good jobs in the future in desirable locations. The shortage just means that some people in bumblef*** nowhere have a hart time recruiting.

Specialties change over time. EM is clearly in a bull market. Good job market presently. Free-standing Emergency Departments (FSED) are a cash cow for entrepreneurial EM docs. But that won't last. CMS will crack down on that eventually.

One thing that EM has for it with regards to the job market is that the people going into it these days are very much concerned about lifestyle. This means that they are more likely to work fewer hours or part-time as an attending. Unlike Radiology, EM has many women which bodes well for the job market. Men are far more likely to work full time than women. 2 female 0.5 FTE = 1 male 1.0 FTE

 

[Makati2008]

True. But I would be curious to see the actual methodology for the shortages. There was supposed to be (and allegedly still is) a pharmacy shortage. But we all know thats BS. Those estimates forgot to take into account the massive increase in schools (i.e. they predicted <5 new schools per decade lolwut).

Shortage is a funny term. There is still a shortage of radiologists. Its not like every job in bumblef*** nowhere is taken. But it is saturated in major metropolitan areas. The job market should be measured by how easy/hard it is to get a job in and around major cities, because thats where people want to live. While there will likely be a shortage of EM providers in the future, that does not necessarily mean that it will be easy to get good jobs in the future in desirable locations. The shortage just means that some people in bumblef*** nowhere have a hart time recruiting.

Specialties change over time. EM is clearly in a bull market. Good job market presently. Free-standing Emergency Departments (FSED) are a cash cow for entrepreneurial EM docs. But that won't last. CMS will crack down on that eventually.

One thing that EM has for it with regards to the job market is that the people going into it these days are very much concerned about lifestyle. This means that they are more likely to work fewer hours or part-time as an attending. Unlike Radiology, EM has many women which bodes well for the job market. Men are far more likely to work full time than women. 2 female 0.5 FTE = 1 male 1.0 FTE

Good post. I agree the FSED model will change drastically and I predict it occurs within the next 5-10yrs if not sooner.

 

[IlDestriero]

10 years ago you could've said that there probably aren't that many CRNAs practicing independently, and that if you're worried about encroachment you could always stick to cardiac.

I would still say that now. I don't believe this is widespread at all, and most rural places and gi centers, etc where they tend to practice independently don't do any real cardiac.

 

[calvnandhobbs68]

And, this might be a little extreme but....if health-care was totally a free market how cool would it be for doctors. Patients could buy there surgeries based on reviews and what-not; and the best doctors (best reviews, best results etc.) would be able to charge the most and make the most.

Right now it seems like one doctor MD may be a wayyyyyyy better surgeon and get miraculous results whereas another doctor at the same hospital doesn't get the best results and reviews for patient care, yet both doctors make essentially the same or have comparable positions in terms of lucrativeness--this must frustrate the great surgeons who have better ideas. This is kind of indirectly harming the quality of health-care b/c it takes away some of the incentive for doctors to keep getting better at what they do. Idk now i'm rambling but think about it

I have the feeling you've had very little contact with the healthcare system.