Midlevel autonomy

Discussion in 'Internal Medicine and IM Subspecialties' started by RyanR634, Apr 23, 2012.

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  1. RyanR634


    Apr 23, 2012
    Okay, I'm not trying to be bitter but this year has been my first real interaction with PAs and NPs since where I trained for residency didn't have many (none that I worked with) and I would really like some clarification on a few points. Also, before you continue, I encourage you to glance over this article if you have not already read it:

    http://www.nytimes.com/2011/10/02/health/policy/02docs.html?scp=4&sq=nurse practitioners&st=cse

    Okay, so I really REALLY think that this whole concept of midlevel providers is progressing to an unhealthy extent for several reasons. I am open to the notion that I do not know all of the facts, and that is what I would like clarification on, because what I know now really bothers me.

    First of all, I have been having more and more frequent encounters with midlevels that only introduce themselves as titles such as "hospitalist" and "orthopedist" without portraying their true titles, either to other providers or the patients. I think this is a gross misrepresentation of their training and knowledge base (yes I understand that some midlevels have more experience, etc than some physicians) but it doesn't justify them arguably misleading others to think they have a degree of which was not earned. In my new hospital/area I have also encountered midlevels who have PRIVATE practices and do not have to practice under the license of a physician. Are you kidding me?!?!?! Why then are we going to medical school for 4 years and THEN doing a full length residency. Many will say we still receive a higher salary. It seems that is even changing, as I have met PAs and NPs who easily make over 100K doing primary care. On top of this, midlevels have MUCH more flexibility in their careers and lifestyles than physicians (again, as it appears to me so far). Not only are their hours much better but they are able to switch between specialties on almost a whim. I have seen several switch between vastly different fields such as pediatrics and orthopedic surgery almost seamlessly. It would be a much more difficult transition for any true physician, causing major disruptions in lifestyle and salaries while they go back and repeat a residency. It seems they have all of the benefits of a physician but lack many of the taxing limitations/burdens. And they are constantly fighting for MORE responsibility and equality with physicians.

    It's the little things that happen around my hospital that really irk me throughout the day. As an example, where I trained and also where I am currently a fellow, the 1st year residents (interns) are not allowed to write prescriptions and must get all outpatient scripts cosigned. One of the people who can cosign these is a MIDLEVEL. In fact, we will have PAs and NPs graduating in December who are able to cosign scripts for interns who have already been doctors for 6 months! How effed up is that? These interns went to undergrad for 4 years, med school 4 years and are already halfway through their internship and someone who has 2 years of formal medical training is essentially supervising them???? It's essentially like a 3rd year med student cosigning their scripts. That just makes no sense whatsoever. A recent medical school grad cannot even practice until they do at least 1 year of post grad training and in some states two, yet someone with 2 years can start working immediately.

    And these studies which the nursing association cite showing that midlevels care is equivalent to physician care. Keep in mind that the diagnoses and treatments they are administering are possibly more straightforward cases AND the studies have been done by the nursing association....which is an inherently biased study. That is equivalent to a drug company showing their drug is superior to other drugs. Why have more formal studies not been done on this???

    And the article that I posted earlier, how utterly ridiculous is that???? This additional year of training to make them "doctorates" is not even clinical training. Within a few years they will fight to be formally called "Dr so and so" and they will most likely win that battle. Sadly, nurses have the numbers in terms of population size, and it appears they will keep fighting for autonomy and get what they demand. It seems absurd that they could refer to themselves as doctors. I have seen medical students with PhDs, but there are rules preventing them from introducing themselves in the hospital as "Dr. so and so", and appropriately so. If they truly want to be called "doctors" and practice independantly , they should at least be required to complete a formal residency.

    So the counter argument is that "midlevels are needed to fill the gaps in healthcare". Is that REALLY the answer? I don't know of any other country that requires such a significant amount of midlevels (if any) and they seem to do just fine. Should one of the answers be to decrease midlevel positions and decrease the length of residency? It seems unheard of to allow recent med school grads to start practicing immediately or even after a year, but maybe that is what we need. We are having less qualified individuals do exactly this. There are an abundance of FMGs dying to practice in the US, and instead of making this an easier transition for them, we are allowing individuals with a master's degree equivalent practice medicine.

    Yes, I may sound petty in this post, but it is a rant, so take it for that. Also, I admittedly do not know how the system works in its entirety and may be missing some crucial points. I want to understand these missing points so I can appreciate the growth of midlevels in population and responsibility.

    As a final point, should we as physicians finally become unionized? I mean, both nurses and PAs are unionized and have been extremely successful in fighting the medical system with seemingly absurd demands. Okay, rant completed.
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  3. dd128

    dd128 7+ Year Member

    May 30, 2007
    We had a few lectures on this during our transition to residency month a month back. Long story short physicians are becoming much more organized on these policies, and not as laid back as we use to be. I whole heartedly agree with your 'rant' and think we can only combat this if we are just as organized as those groups.

    Though I wasn't aware that midlevels could have any independent practices. Is this state dependent? How can you practice without a license? I've heard of midlevels working on their own, though it's still under the relative "supervision" of a physician in the practice. Anyway, if these people want to practice on their own let's see what happens when they royally eff up and get sued.
  4. surge55

    surge55 2+ Year Member

    Mar 30, 2012
    I hear you. It does get frustrating because they are the equivalent in training of a 4th year medical student out in the real world and when I was a 4th year medical student I still felt like I didn't know anything. I wouldn't feel entitled to do anything like many nurses and PAs do.

    granted, they are a huge asset as they are excellent h+p folks and usually have more time to explain things to patients...that said they shouldn't be so autonomous that they can call themselves whatever they want to the patient and get away with it.

    Also a word of advice - if they are able to do what you say, I would get the heck out of that hospital. a hospital that allows PAs and NPs to essentially be physicians (other than cookie cutter hospitalist admissions) and allows them to sign off on resident notes...well that's just ridiculous (now, getting advice and training from said PA and NP is one thing...but getting sign off from them as opposed to an attending MD/DO? that's absurd).
  5. suryapet

    suryapet 7+ Year Member

    Sep 12, 2008
    I agree and share the rant of the author completely. I have been bothered by these same things for a long time.

    However, i would want the nurses to be allowed to practice independently without physician supervision. Guess what will happen? With all the extensive training that physicians get, if the malpractice and medical errors are so high, what would happen if nurse practitioners practice independently? Whoever is calling for equal rights for nurses on par with physicians deserve to know where they stand and what's their true value in the medical care. Don't get me wrong. I am in no way trying to downplay the role of nurses or midlevels. Everybody in the healthcare chain are important and has their own role defined very clearly. My only question is : You went to nursing college to become a nurse. Then, why try to be a physician ? If you really want to be a physician, why not go to a medical school now? who is stopping you.

    And the talk of having not many primary care physicians is utter nonsense. If my fridge is not working, i will go to electrician but not plumber, even if it means that i have to wait 3 months or have to travel 100 miles.
  6. chessknt87

    chessknt87 10+ Year Member

    Oct 10, 2007
    It is not just the patient safety factor that should be a concern. Economic efficiency of allowing midlevels to act as primaries needs to be addressed as well since it is the heart of the issue. A solo NP that refers every other patient to an MD specialist for a slew of issues he/she is not prepared to address is just as bad for our healthcare system as the NP that misses the diagnosis without referral. Until neutral studies can demonstrate that midlevels can both diagnose and refer at the same level as MDs then it is an unconscionable decision to give them autonomy, both for the patient's sake and for the future of our healthcare system.
  7. Notanerd

    Notanerd 5+ Year Member

    Apr 2, 2012
    To the OP that stated "is it time to unionize?"... This is way long past due. In my opinion physicians have been taken advantage of for an extremely long time in regards to the services they provide and the rate of reimbursement decline. Its crazy that we get paid less and less every year yet these hospitals are building gorgeous structures that are 2/2 none, drug companies are making record profits, insurance companies are making record profits and again we are getting nickeled and dimed year after year and it is starting to add up. The fact of the matter is no one can really do what we do , no PA no CRNA no NP... yet physicians bc of the oaths we have taken and our moral responsibilities to patients keep on getting screwed bc the people that pay us have no moral responsibility just the responsibility to earn high profit margins which is a % of our paychecks.

    I do not know where medicine is heading but the changes that older physicians complain about will happen to our generation and it will not be fun
  8. dragonfly99

    dragonfly99 5+ Year Member

    May 15, 2008
    Traditionally, physicians were not allowed to unionize because of some obscure federal antitrust legislation. This was when most physicians were in private practice. If you are employed, like a hospitalist or resident, there is no federal law preventing a union. I used to be against unions but after I saw how powerful the nurses' unions are, I changed my tune. I think it would help residents, at least a little, at least in theory, if more were unionized. In California the nurses' union is backing a bill in the state legislature that will keep hospitals or clinics from being able to require flu shots for nurses...this is based on the fact it "tramples workers' rights". This is despite the fact that one of the most common causes of hospital acquired flu infections is transmission from hospital workers. I think at some point their unions will go too far in regards to issues like these.
    As far as PA's or NP's passing themselves off as doctors or specialist doctors, I think that is very unethical. Smarter patients will figure this out, but some will not. You can't personally stop another person from doing something unethical, unless they are really blatant about it or unless your hospital passes a rule against it. I suspect this person is in some state like Massachusetts, perhaps. If this bothers you a lot and you are mobile, I guess you could look into another state or maybe another hospital system where this doesn't go on so much.
  9. dazed1980

    dazed1980 10+ Year Member

    Dec 3, 2006
    To the OP:
    Just a brief note from a midlevel perspective; i think your hospital is probably an outlier. Myself and most PA's i know do not misrepresent ourselves. My training program made sure to emphasize to us that our program was not training us to become physicians, and if we thought that then we needed to get out now and apply to med school.

    As far as practising on our own, we never really do even if we have "our own practises". There is always a supervising physician attached to us.

    I guess what i'm getting at is that you are getting a skewed view of midlevels; PAs anyway.
  10. surge55

    surge55 2+ Year Member

    Mar 30, 2012
    indeed; at least in hospitals I've been in, they are more like your situation.

    Like I told the OP, he might want to get out of that hospital if he can; that doesn't sound like a kosher situation.
  11. maurapnp


    Jul 12, 2012
    A preface. I am an NP (pediatric, acute care and primary care certified, an RN, and finishing my RNFA). I have worked at an acedemic insitution in Pediatric Neurosurgery for over 5 years. I have a total of 8 years of schooling (if I had my DNP it would be 2 more years). I work with 5 neurosurgeons, typically 2 fellows, and q 3 month rotating residents.

    I have a ton of autonomy. I am NOT an MD nor do I ever advertise myself as that. In fact, I created a handout for patients explaining the midlevel role and what training/privileges we have.

    My duties: ER consults, ICU consults, daily rounding, progress notes, discharges, admissions, procedures (including placing EVDs, ICP monitors, and assisting in surgery). I even take night call, alone, in house with no MD present. I am an education officer for the hospital, I lecture, I present, I do research. The list goes on. I basically function similar to a resident. Our surgeons train and trust us to make decisions as well as to recognize when something is out of our realm. A good midlevel knows their resources.

    "A solo NP that refers every other patient to an MD specialist for a slew of issues he/she is not prepared to address is just as bad for our healthcare system as the NP that misses the diagnosis without referral."
    - I have to say i receive more lame calls than I care for from the ER MD/residents because they don't know how to work up a patient appropriately. Anyone can make bad referrals, including MDs. please don't offload onto all midlevels.

    Regarding H/Ps. I am more than a history taker. I have a brain and critical thinking skills. I can independtly workup a trauma kid who needs a stat crani for evacuation of a bleed all the way to a shunt and exactly why and where it is broken.

    Regarding independent practice. Almost always there is a collaborating physician though in some states, they do not need to be on site. Also, I do believe some states allow independent practice. We all carry our own malpractice insurance as well.

    If I ever got my DNP (which honestly im not a fan of this) I would not call myself doctor. However, PT/OT, etc all get doctorates. It's more schooling, not a single defining term.

    I do not mean to rant back. I agree midlevels are not doctors and there are differences. however, they should not be shortchanged because they actually do, in many cases, hold a lot of responsibility and hold it well. In my case my role allows for residents and fellows in nsgy to get the time they need in the OR. Procedures are open to the midlevels with res/fellows getting first dibs - 90% of the time they want us to do it.

    I have shown residents how to do certain procedures - and while this may bother some doctors - its not a matter of anyone knowing more. But, I can say, i probably know more neurosurgery than some ER residents and more pediatrics than some adult nsgy residents. We are all here to help each other and out patients. instead of letting insecurities and differences get in the way - work together. Of course within the legal realm of practice for whatever your title. Anyone can be a bad provider, even an MD.
  12. KRichards62

    KRichards62 2+ Year Member

    Feb 4, 2010
    Midlevel providers have essentially committed to a lifetime of being an intern. They obviously have more clinical experience than most interns, but the responsibility burden is about the same. Eventually, after many years of being an intern equivalent, it seems some midlevel providers get a chip on their shoulder because they've realized the career in which they've chosen can't advance. Don't get me wrong, it's a fine career, but I think the bad-apple NPs are the ones who become frustrated once they hit their ceiling and realize they are in eternal internship. It's hard to blame them, I probably would too.
  13. Medstudentquest

    Medstudentquest Banned Banned 5+ Year Member

    Apr 12, 2007
    I think it makes a lot more sense to have foreign docs practice here vs. midlevels. Mid levels should never practice independently, and i owuld rather see a foreign full fledged doc over a midlevel who thinks she's a doctor. They are combative and intolerable.
  14. bigkahunaburger


    Jun 30, 2012
    Nurse practitioner's can get their degree online? wtf? brain surgery with online degree wtf?
  15. bigkahunaburger


    Jun 30, 2012
  16. bigkahunaburger


    Jun 30, 2012
    *my (my bad)
  17. DCGuava

    DCGuava 2+ Year Member

    May 16, 2012
    District of Confusion
  18. chessknt87

    chessknt87 10+ Year Member

    Oct 10, 2007
    N=1. Nurses (and their unions) have funded studies in an attempt to demonstrate equivalent outcomes to MDs to support their push for equality. They have been poorly conducted but since they are the only ones available they are accepted at the political level. We need real studies funded by a neutral party (the government, for example) that tease out whether there are outcome differences or economic benefits in giving midlevels the same responsibilities as MDs.

    And don't use the ER as an example. They have a slew of factors (that aren't immediately visible to most people) that they deal with that force them to often not work up a patient "properly."
  19. Deferoxamine

    Deferoxamine Non-smoking 5+ Year Member

    May 7, 2009

    Now following.
    This should get interesting.
  20. diphenyl

    diphenyl Dancing doctor 7+ Year Member

    Jul 31, 2008
    Oh lord here it comes. :D

    How's that NP degree from University of PHX working out? The majority of which you could do online. I get very nervous people getting the same responsibility level of physicians with 1/8 of the formal training.

    My medical degree oh yes I got that from a real university. How long did it take with residency? ah yes 8 years. No online component for me. Just 20 hour days during my basic science years followed by 150 work weeks in residency.
  21. diphenyl

    diphenyl Dancing doctor 7+ Year Member

    Jul 31, 2008
    This NP movement really needs to be put in check. You want to be a nurse? Go to nursing school.

    You want to be a doctor? Suck it up, quit trying to take shortcuts. Get your premed courses and go to med school like the rest of us real doctors!!!!!!!
  22. hawkeye pierce

    hawkeye pierce 2+ Year Member

    Aug 18, 2010
    This is coming from a former pharmacist who practiced at a major academic medical for several years prior to medical school. MD/DO>PA>ARNPs. For some reason Nurse practitioners tended to make more medication mistakes in their orders by a large margin than even he PAs who still made way more than physicians. Obviously this is anecdotal, The scary part is that nurse practitioners are the ones that some states don't require to even have physician supervision. Scary very scary.
  23. Merely

    Merely 5+ Year Member

    Jul 12, 2012
    Somewhere Sunny
    hSDN Member
    These nurses need to be put in check pronto

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