Mid level Uprising

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mabinante

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So the UC I moonlight at just wrote me to tell me they're canceling all of my future 6-10 pm shifts as they only want PAs to work them. Have you guys seen this?

Honestly, I can't fault them. We charge more than double what a midlevel does and the UC gets equal reimbursement for our work. Doesn't seem like I have any recourse to take here. I guess PAs will displace more and more physicians. What am I missing?

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Yep -- the UC I worked for full time went through and let a lot of UC physicians go -- they planned on replacing them with NPs since we were more expensive -- it was a business/overhead thing -- wanted to increase the profit margins as much as possible. Remember that most of the public calls anyone in a white coat "Dr" and has no clue about the differences between MD/DO vs PA vs NP vs DP vs DC vs ND vs Ph.D vs resident vs med student vs pre-med vs "I watched every episode of Grey's Anatomy and House and took really good notes" ---

Believe me -- as Blue Dog once said,"If you're concerned about being replaced by a mid-level, you should be" or words to that effect --- I had doubts about my training/abilities --- last week I had a situation where I worked with a PA with one year of experience --- If you graduated from med school, did a full residency and are BC -- you have nothing to worry about.....
 
Who runs the urgent care? Businessmen?

I'm sure if the public was given a choice, they would choose the doctor every time, especially since it's like they're responsible for the cost. However, they don't get to make an informed decision, it's just "I have a cold, where is the closest urgent care?"
 
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Urgent Care to Install Drive Through Window
http://gomerblog.com/2015/05/urgent-care-2/

Are you trying to make me spit coffee through my nose?

We used to joke about the Parkland ER special -- as they walk in, they lie down on a gurney and get vitalized, tubes drawn for CBC/CMP/TSH, 5 of morphine IV, CXR, CT, trops, ekg, 1L NS, Echo and off to a room.
 
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So the UC I moonlight at just wrote me to tell me they're canceling all of my future 6-10 pm shifts as they only want PAs to work them. Have you guys seen this?

Honestly, I can't fault them. We charge more than double what a midlevel does and the UC gets equal reimbursement for our work. Doesn't seem like I have any recourse to take here. I guess PAs will displace more and more physicians. What am I missing?

It's business as usual.
 
That is scary. Is this a new trend amongst all urgent cares? or is this an isolate incident?

These kind of stories are a big concern to those of us considering FM.
 
That is scary. Is this a new trend amongst all urgent cares? or is this an isolate incident?

These kind of stories are a big concern to those of us considering GODFORSAKEN URGENT CARE.

FTFY...
 
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Dude, Its a spoof article. Lighten up.

I was responding to the original post about real urgent cares replacing physicians with midlevels.

and I'm a girl.
 
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Ok -- dudette, it's a spoof article. lighten up ;) -- It's becoming more common in Texas among the corporate UC companies -- Now in the burb where I live, I've got a UC or free standing ER on virtually every street corner for the major streets -- and it caters to the consumer -- designer coffee, pastry, satellite TV with videos for the kiddos, lounge chairs/couches for family members to sit on, call ahead with no wait, etc. -- I'm surprised no one has put a massage therapist doing chair massages or nail salons in there.... boutique medicine at it's finest.

There'll always be a need for FM no matter what -- radiology is already being outsourced to Israel/India as is CT/Ortho surgery -- heck, in India they've got surgery vacations -- while a family member is being cut on for 1/3 of the price by a US trained surgeon, the rest of the family goes on vacation while they're recuperating for a week....

In FM, I'm hands on for the most common complaints, deal with a lot of the stuff in my office, treat the most common complaints and complete the workup before I refer....
 
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I guess PAs will displace more and more physicians. What am I missing?

That this is happening at an urgent care. It is not surprising that every field of medicine where work is mostly protocol driven and over-reimbursed is seeing move towards cheaper labor. It surprises me that providers are shocked as positions (where one is over paid to exercise minimal intellectual skill) gradually dissapear. As long as pay for skilled primary care remains on the bottom rung of healthcare spending and we are expected to deal with all the problems the dysfunctional U.S. healthcare system creates, we will all continue to have more job offerings than we can delete from our inboxes.
Hopefully FM learns from other specialties (and really labor disputes in general) as we fight for better reimbursement and decreased work burden. At some point, if your job becomes too comfortable and too well paid, economic forces will encourage finding a solution that no longer involves paying you to do said job.
 
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Just a question, but I'm a 4th year med student looking to go into Family medicine. I've been wondering though, are there any specific examples of how physicians practice differently than NPs and PAs? As a physician we will have more training, but what about specific practice experience? I just want to know why some think that mid level providers are equivalent to a full physician.
Thanks!
Ryan
 
So the UC I moonlight at just wrote me to tell me they're canceling all of my future 6-10 pm shifts as they only want PAs to work them. Have you guys seen this?

Honestly, I can't fault them. We charge more than double what a midlevel does and the UC gets equal reimbursement for our work. Doesn't seem like I have any recourse to take here. I guess PAs will displace more and more physicians. What am I missing?
trick is to start your own urgent care and steal the other urgent care's PAs ;)
 
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trick is to start your own urgent care and steal the other urgent care's PAs ;)

Now that medicine is corporitized and employed the only ones opening up urgent cares and other facilities will be massive corporate entities. Good luck trying to compete with those orgs as a newly minted physician with 300k in debt and 150k income stream from moonlighting to finance your venture.
 
I just want to know why some think that mid level providers are equivalent to a full physician.
Part of the reason is not knowing what they don't know.
The other reason is how protocolized things are. The whole intellectual and reasoning aspect is taken away entirely, and things often become a list to do. E.x. "oh you didn't know for the first two hours I have to check the vitals on this patient every 30 mins for this specific disease?", says Nurse X.
No, I didn't know that. But that's just some dumb rule. And these rules change all the time.
 
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Just a question, but I'm a 4th year med student looking to go into Family medicine. I've been wondering though, are there any specific examples of how physicians practice differently than NPs and PAs? As a physician we will have more training, but what about specific practice experience? I just want to know why some think that mid level providers are equivalent to a full physician.

The other reason is that it's medically unethical to conduct a study in which you are knowingly exposing patients to harm. Midlevels need oversight both legally and because of their knowledge gaps. If left alone, there would very likely be harm to the patients when presented with a tough medical situation. It's the same reason there's never been a study on the effectiveness of parachutes. Would you expose your control group to 14,000 feet without a parachute?

It's been said before, but the real problem is the distribution of physicians in the U.S. We have enough physicians to cover the demographic, but they are concentrated in the cities (not necessarily in the specialties). Part of the history of NP practice rights was the argument that someone would be able to prescribe medications more often for those out in the country who desperately needed them but had to take a day trip to see a doc.
 
Midlevels need oversight both legally and because of their knowledge gaps.

Just something to add onto this. I feel like there must be knowledge gaps because of the amount of training that we get compared to NPs and PAs, but I really wonder what specific knowledge gaps there are. Is it pathophysiology of diseases? Do we learn more about medications, MOAs, side effects? Do we learn about more diseases in general? Is it all of these things? If so, next time someone says that I'm in danger of having job security just because I want to do family medicine, I just want to yell BS! Haha. I mean to me NPs and PAs are a huge benefit, but I have never considered myself worried about losing a job to either profession. Family medicine has always been something I've been set on, and I don't like people telling me, "oh you shouldn't do this because it doesn't have a good career outlook... etc etc."
 
Now that medicine is corporitized and employed the only ones opening up urgent cares and other facilities will be massive corporate entities. Good luck trying to compete with those orgs as a newly minted physician with 300k in debt and 150k income stream from moonlighting to finance your venture.
There's plenty of successful UC owners in the EM forums. It's very doable if you have some business sense, as is opening your own practice (albeit not immediately after graduation). It also largely depends on what state you're in- every UC owner I personally have talked with us in Texas, where it's cheap and easy to set one up and the reimbursement is great.
 
The other reason is that it's medically unethical to conduct a study in which you are knowingly exposing patients to harm. Midlevels need oversight both legally and because of their knowledge gaps. If left alone, there would very likely be harm to the patients when presented with a tough medical situation. It's the same reason there's never been a study on the effectiveness of parachutes. Would you expose your control group to 14,000 feet without a parachute?

It's been said before, but the real problem is the distribution of physicians in the U.S. We have enough physicians to cover the demographic, but they are concentrated in the cities (not necessarily in the specialties). Part of the history of NP practice rights was the argument that someone would be able to prescribe medications more often for those out in the country who desperately needed them but had to take a day trip to see a doc.
There are plenty of states where they operate completely independently and own their own practices with no physicians present. We're not saying they can't refer patients in such a study, merely that these independent NPs that have zero physician oversight be compared directly to physicians and all the outcomes measured directly rather than being cherry picked as the current studies do.
 
I know that starting a whole practice under a traditional model is an expensive proposition, both financially and in terms of your time and other resources, but most of the services a UC offers can be provided with little more than a stethoscope, a lap top, and a private room... and on a time limited basis.

If you are only working 6-10p at the UC anyway, why not see if a local gym or fitness center will rent you a room to use for a wellness clinic for a couple hundred a month (or, heck, even pay you that for being a unique additional service that they can offer!) Arrange at least one or two regular times per week when you would be available to see patients for minor issues. You can get most of the equipment you need for a few hundred dollars, if you don't already own it. Labs and imaging, write scripts and send them out to get those done. Use a messaging service ($20/month) to manage your calls, if you don't want to just give patients your cell phone number. Accept cash only, with a discount to gym members. Patients can do walk-in appointments, or self-schedule via web or phone app (that can be free or very cheap to set up.)

You can advertise separately from whatever the gym does to promote your clinic if you need to, but it is likely that you can build a reasonable panel just from existing gym members who want support meeting weight loss goals or who have minor injuries, etc. This benefits everyone, since patients who establish with you in this way may be more likely to keep coming to the gym, and new gym members may be drawn to join because they can see their doctor there. And you can directly observe your patients during a workout, and be able to give immediate feedback and recommendations.

No staff, low overhead, low hassle. You could be providing a service that is convenient for mostly healthy, highly motivated patients to be seen for routine care, where you can charge less for an appointment and end up taking home a lot more than when you were working for hire.

This is something that a midlevel can't displace you from. It is scalable, so that if you want it to, it can serve as a springboard to a larger practice, or stay a side-line while you pursue other opportunities. It is a sketch of one of my possible future business plans, feel free to steal it if you like it. Since I want to spend a good portion of time serving people who can't really afford to pay me much of anything, I have these schemes for ways to maximize my income where I can. .
 
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There's plenty of successful UC owners in the EM forums. It's very doable if you have some business sense, as is opening your own practice (albeit not immediately after graduation). It also largely depends on what state you're in- every UC owner I personally have talked with us in Texas, where it's cheap and easy to set one up and the reimbursement is great.

Sure, that's why I used the future tense. It may be my inherently pessimistic and neurotic nature, but I feel that the negative trends we are witnessing are just getting started. Medicine is already corporitized to a large extent, and I see that trend as only accelerating in the future.
 
Sure, that's why I used the future tense. It may be my inherently pessimistic and neurotic nature, but I feel that the negative trends we are witnessing are just getting started. Medicine is already corporitized to a large extent, and I see that trend as only accelerating in the future.
Personally I doubt it'll ever be impossible. It'll just be higher risk, and physicians tend to be risk averse, so far less will take the chance. But, just as today, those who do it right can still make it big.
 
Just something to add onto this. I feel like there must be knowledge gaps because of the amount of training that we get compared to NPs and PAs, but I really wonder what specific knowledge gaps there are. Is it pathophysiology of diseases? Do we learn more about medications, MOAs, side effects? Do we learn about more diseases in general? Is it all of these things? If so, next time someone says that I'm in danger of having job security just because I want to do family medicine, I just want to yell BS! Haha. I mean to me NPs and PAs are a huge benefit, but I have never considered myself worried about losing a job to either profession. Family medicine has always been something I've been set on, and I don't like people telling me, "oh you shouldn't do this because it doesn't have a good career outlook... etc etc."

Having worked with a number of PAs and NPs, it is all of those things.

The problem with midlevels is that their training is very inconsistent. Some are EXCELLENT, but it is clear that someone took the time to review their patients with them in depth, and to teach. There are many who were largely self-taught, and that can be a disaster, especially if they don't know just how patchy their knowledge is.

Med school and residency tend to provide a more uniform training basis.
 
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