Midlevels stealing procedures from residents, how did it come to this?

[MedicineZ0Z]

Add this to the growing number of residents who are supervised by midlevels.

But... we need to be collaborative and work together? Right?

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[sinombre]

Where I am only the interns in the ICU or on trauma are supervised by mid levels (I’m a surgery resident). We definitely get priority for procedures, and there is no shortage of them. I am not supervised by a mid level nor have I ever had a procedure stolen.

 

[Gastrapathy]

Where I am only the interns in the ICU or on trauma are supervised by mid levels (I’m a surgery resident). We definitely get priority for procedures, and there is no shortage of them. I am not supervised by a mid level nor have I ever had a procedure stolen.

Only the interns? It makes me sad that we think that’s ok

 

[MedicineZ0Z]

Where I am only the interns in the ICU or on trauma are supervised by mid levels (I’m a surgery resident). We definitely get priority for procedures, and there is no shortage of them. I am not supervised by a mid level nor have I ever had a procedure stolen.

uh...

Only the interns? It makes me sad that we think that’s ok

lol. Culture of acceptance apparently.

 

[operaman]

Yeah definitely not my experience either and I’m at an institution with a very strong and capable mid level presence on multiple services. Maybe ours are just really good but none of them seem to give a crap about taking procedures from a resident, much the same way I’m more than happy to “let” the intern or pgy2 do them whenever I can.

Some thoughts:

1) maybe the resident sucks and struggles with procedures they’d rather just let the PA do it. This is doubly likely if the sucky resident isn’t even on their service.

2) mislevels need training too and the faster they learn, the better everyone’s life gets. These scenarios may have been new PAs learning the ropes.

3) you gotta hustle and demonstrate competence to get procedures, especially if the person supervising has no personal benefit from teaching you

4) my priority for teaching procedures is to funnel everything I can to my junior residents. The faster they get good, the easier my life is. Sorry med students but you’re getting a shot only if there’s no junior around to teach. If we have a new mid level who needs to learn, then they get priority too.

Operaman’s patented method for getting procedures:

1) be prepared and know how to set up the procedure
2) help set up and gather supplies
3) ask if you can do whatever the first part of the procedure is. Central line? Ask to hold the ultrasound probe and find vessels before they do the stick. Intubation? Ask if you can bag mask befor they DL. Most of the time, if you’re already standing there in position to do the procedure, they’ll just walk you through it. I used this like nobody’s business as a student and intern. Works like a charm.
4) don’t suck
5) send Operaman a beer for revealing the secret of getting procedures.

 

[Stagg737]

Yeah definitely not my experience either and I’m at an institution with a very strong and capable mid level presence on multiple services. Maybe ours are just really good but none of them seem to give a crap about taking procedures from a resident, much the same way I’m more than happy to “let” the intern or pgy2 do them whenever I can.

Some thoughts:

1) maybe the resident sucks and struggles with procedures they’d rather just let the PA do it. This is doubly likely if the sucky resident isn’t even on their service.

2) mislevels need training too and the faster they learn, the better everyone’s life gets. These scenarios may have been new PAs learning the ropes.

3) you gotta hustle and demonstrate competence to get procedures, especially if the person supervising has no personal benefit from teaching you

4) my priority for teaching procedures is to funnel everything I can to my junior residents. The faster they get good, the easier my life is. Sorry med students but you’re getting a shot only if there’s no junior around to teach. If we have a new mid level who needs to learn, then they get priority too.

Operaman’s patented method for getting procedures:

1) be prepared and know how to set up the procedure
2) help set up and gather supplies
3) ask if you can do whatever the first part of the procedure is. Central line? Ask to hold the ultrasound probe and find vessels before they do the stick. Intubation? Ask if you can bag mask befor they DL. Most of the time, if you’re already standing there in position to do the procedure, they’ll just walk you through it. I used this like nobody’s business as a student and intern. Works like a charm.
4) don’t suck
5) send Operaman a beer for revealing the secret of getting procedures.

Sorry, but I disagree. The point of residency is to become competent at your job. If you're giving away the opportunities for residents to do that then you're just screwing the profession even more. Also, how can you expect your young residents to be competent and "not suck" if they never got the chance to learn the basics as med students because the senior residents and mid-level "attendings" let all the mid-levels do them first? You really expect the residents who suck to stop sucking without showing them how to do the basics? I understand when on-service mid-levels get teaching preference over off-service residents (as a psych resident I wouldn't have been insulted if the ICU PA got to learn how to place a central line over me when I did my IM rotation), but if they're on-service training the physicians should take priority as that's literally the entire reason they're there.

 

[MedicineZ0Z]

Yeah definitely not my experience either and I’m at an institution with a very strong and capable mid level presence on multiple services. Maybe ours are just really good but none of them seem to give a crap about taking procedures from a resident, much the same way I’m more than happy to “let” the intern or pgy2 do them whenever I can.

Some thoughts:

1) maybe the resident sucks and struggles with procedures they’d rather just let the PA do it. This is doubly likely if the sucky resident isn’t even on their service.

2) mislevels need training too and the faster they learn, the better everyone’s life gets. These scenarios may have been new PAs learning the ropes.

3) you gotta hustle and demonstrate competence to get procedures, especially if the person supervising has no personal benefit from teaching you

4) my priority for teaching procedures is to funnel everything I can to my junior residents. The faster they get good, the easier my life is. Sorry med students but you’re getting a shot only if there’s no junior around to teach. If we have a new mid level who needs to learn, then they get priority too.

Operaman’s patented method for getting procedures:

1) be prepared and know how to set up the procedure
2) help set up and gather supplies
3) ask if you can do whatever the first part of the procedure is. Central line? Ask to hold the ultrasound probe and find vessels before they do the stick. Intubation? Ask if you can bag mask befor they DL. Most of the time, if you’re already standing there in position to do the procedure, they’ll just walk you through it. I used this like nobody’s business as a student and intern. Works like a charm.
4) don’t suck
5) send Operaman a beer for revealing the secret of getting procedures.

Yeah.. no.. no midlevel should ever get priority over anything when it comes to medical education. Plain and simple. They are there to supplement and fill in gaps. I understand your position is helping to facilitate them taking over the practice of medicine, whether you realize it or not.

And it's reasonable to expect a little effort from students for getting procedures but even then they should be offered it once interns are signed off. Residents should be directly offered every time. Midlevels can have what remains when there's no one left to teach.

Sorry, but I disagree. The point of residency is to become competent at your job. If you're giving away the opportunities for residents to do that then you're just screwing the profession even more. Also, how can you expect your young residents to be competent and "not suck" if they never got the chance to learn the basics as med students because the senior residents and mid-level "attendings" let all the mid-levels do them first? You really expect the residents who suck to stop sucking without showing them how to do the basics? I understand when on-service mid-levels get teaching preference over off-service residents (as a psych resident I wouldn't have been insulted if the ICU PA got to learn how to place a central line over me when I did my IM rotation), but if they're on-service training the physicians should take priority as that's literally the entire reason they're there.

Even when off service, residents who may be interested/have a different future scope of practice should always get dibs. This should be asked at the start of the rotation.

 

[sinombre]

Only the interns? It makes me sad that we think that’s ok

You think second or third year residents need to be supervised to place a central line? I mean I probably did 30+ lines intern year alone. We routinely do central lines, a lines, chest tubes unsupervised.

 

[Gastrapathy]

You said midlevels supervise interns. That’s lame.

 

[sinombre]

Only the interns? It makes me sad that we think that’s ok

Or maybe I'm misinterpreting what you're saying (i.e. not that second or third year residents should be supervised for basic procedures, but that interns shouldn't be supervised by midlevels). I think anyone with experience doing those procedures could supervise an intern. You could train anyone with a very basic knowledge of anatomy to place a central line or chest tube.

 

[sinombre]

You said midlevels supervise interns. That’s lame.

Only for procedures if there is no attending or resident to supervise, not for anything else.

 

[username456789]

Only for procedures if there is no attending or resident to supervise, not for anything else.

Oh ok, so only for the dangerous stuff. Thank goodness.

 

[VA Hopeful Dr]

Oh ok, so only for the dangerous stuff. Thank goodness.

Don't be queen of drama. If a midlevel is doing a procedure, everywhere I've been that procedure ends up being one of their main jobs. Odds are good they're pretty skilled at it so having them supervise someone else isn't the end of the world.

Where I trained, RT did something like 99% of intubations that weren't in the OR. Residents that wanted to learn to intubate followed them around for a few weeks in the various ICUs.

 

[sovereign0]

I saw this on Reddit and was a bit confused because the context wasn't really fleshed out. It seems like this was a trauma, and there was no resident on trauma at the time so they gave the procedure to the trauma mid-level. The OP was an EM resident on EM... I don't really see a problem here if that's the case. The trauma folks don't have any obligation to pull people from other services to do a procedure, and the EM residents should have their own trauma rotations. The mid-level was actually on that service.

Now, if the poster was an EM resident rotating on the trauma service and got bumped for a trauma mid-level, then that's a big problem.

 

[MedicineZ0Z]

I saw this on Reddit and was a bit confused because the context wasn't really fleshed out. It seems like this was a trauma, and there was no resident on trauma at the time so they gave the procedure to the trauma mid-level. The OP was an EM resident on EM... I don't really see a problem here if that's the case. The trauma folks don't have any obligation to pull people from other services to do a procedure, and the EM residents should have their own trauma rotations. The mid-level was actually on that service.

Now, if the poster was an EM resident rotating on the trauma service and got bumped for a trauma mid-level, then that's a big problem.

Uhm, no. My understanding is they are rotating on that service and are passed up for a midlevel. In addition, other examples cited:

1. resident rotating on X service and the PA on X service gets the chest tube

2. neonatal resus. going to NPs instead of the residents rotating on their service

So in every case, it's the same service the resident is rotating on and the midlevel is stealing the procedures.

 

[ortnakas]

Don't be queen of drama. If a midlevel is doing a procedure, everywhere I've been that procedure ends up being one of their main jobs. Odds are good they're pretty skilled at it so having them supervise someone else isn't the end of the world.

Where I trained, RT did something like 99% of intubations that weren't in the OR. Residents that wanted to learn to intubate followed them around for a few weeks in the various ICUs.

This is reasonable. Midlevels/RTs shouldn’t be teaching us how to think like a doctor, but the experienced ones often have more procedural experience than senior residents or even attendings. As an example, I don’t see a problem with a RT who has done seven art lines already this morning be the person to walk me (a medicine intern) through it.

 

[Cryc_to_the_point]

Even if you're off service rotating, why should a resident be passed up? What's the point if you're not getting a full spectrum experience?

 

[MedicineZ0Z]

Even if you're off service rotating, why should a resident be passed up? What's the point if you're not getting a full spectrum experience?

Agree. Being on their service though makes it mind blowing.

 

[MedicineZ0Z]

This is reasonable. Midlevels/RTs shouldn’t be teaching us how to think like a doctor, but the experienced ones often have more procedural experience than senior residents or even attendings. As an example, I don’t see a problem with a RT who has done seven art lines already this morning be the person to walk me (a medicine intern) through it.

Experienced non-physicians will be a thing of the past. As medical training has become very weak clinically/procedurally, non-medical folks like PAs/NPs and even more so RTs will be even more poorly trained.

 

[jw3600]

Just another symptom of current attendings selling out future physicians in training.

 

[jw3600]

Also no way should any midlevel be getting trauma procedures over EM residents in the ED. If it’s a line or tube in the SICU that’s a little different. If it’s a level 1 or 2 in the ED and the surgery residents aren’t doing it, EM should 100% be next.

 

[operaman]

Sorry, but I disagree. The point of residency is to become competent at your job. If you're giving away the opportunities for residents to do that then you're just screwing the profession even more. Also, how can you expect your young residents to be competent and "not suck" if they never got the chance to learn the basics as med students because the senior residents and mid-level "attendings" let all the mid-levels do them first? You really expect the residents who suck to stop sucking without showing them how to do the basics? I understand when on-service mid-levels get teaching preference over off-service residents (as a psych resident I wouldn't have been insulted if the ICU PA got to learn how to place a central line over me when I did my IM rotation), but if they're on-service training the physicians should take priority as that's literally the entire reason they're there.

Maybe my post wasn’t clear. Obviously my priority is teaching my own residents. Full stop.

Med students are another story. Many of them are pretty bad and show zero interest at all so there’s no way I’m wasting effort on them. That said, I’ve taken truly interested students through a number of procedures and even come in on days off to teach them how to drill in the tbone lab or do procedures in the fresh tissue cadaver lab. These students are rare though.

What people don’t seem to realize is that most midlevels don’t give a flip about actually doing these procedures. Many of them took me through things as an intern and Had no problem with me doing it. They get paid either way!

That said, I stand by my preference to teach our midlevels procedural skills over rotating students because the midlevels actually need to learn it ASAP while the students will rotate off. Once the midlevels are comfortable then they can take students through things whenever they want.

In truth there are far more important things for students to learn. Any idiot can intubate a patient; not everyone can think through the intricacies of advanced airway management. Any nitwit can do an endoscopy; not many people can interpret accurately what they’re seeing and know how to manage it. Sticking a line in someone is easy. Knowing when to put a line in and how to manage the meds you’re using it for is far more valuable for students. To get competent technically you really need repetition and that often isn’t possible students who have relatively short rotations and may be on other services for many months afterward.

 

[jw3600]

Maybe my post wasn’t clear. Obviously my priority is teaching my own residents. Full stop.

Med students are another story. Many of them are pretty bad and show zero interest at all so there’s no way I’m wasting effort on them. That said, I’ve taken truly interested students through a number of procedures and even come in on days off to teach them how to drill in the tbone lab or do procedures in the fresh tissue cadaver lab. These students are rare though.

What people don’t seem to realize is that most midlevels don’t give a flip about actually doing these procedures. Many of them took me through things as an intern and Had no problem with me doing it. They get paid either way!

That said, I stand by my preference to teach our midlevels procedural skills over rotating students because the midlevels actually need to learn it ASAP while the students will rotate off. Once the midlevels are comfortable then they can take students through things whenever they want.

In truth there are far more important things for students to learn. Any idiot can intubate a patient; not everyone can think through the intricacies of advanced airway management. Any nitwit can do an endoscopy; not many people can interpret accurately what they’re seeing and know how to manage it. Sticking a line in someone is easy. Knowing when to put a line in and how to manage the meds you’re using it for is far more valuable for students. To get competent technically you really need repetition and that often isn’t possible students who have relatively short rotations and may be on other services for many months afterward.

I don’t think anyone really has a problem with midlevels > students for procedures. I didn’t think that was the main issue here.
Also you just gave a great reason why residents should be FIRST priority for everything. We need repetition to become competent.

 

[MedicineZ0Z]

Maybe my post wasn’t clear. Obviously my priority is teaching my own residents. Full stop.

Med students are another story. Many of them are pretty bad and show zero interest at all so there’s no way I’m wasting effort on them. That said, I’ve taken truly interested students through a number of procedures and even come in on days off to teach them how to drill in the tbone lab or do procedures in the fresh tissue cadaver lab. These students are rare though.

What people don’t seem to realize is that most midlevels don’t give a flip about actually doing these procedures. Many of them took me through things as an intern and Had no problem with me doing it. They get paid either way!

That said, I stand by my preference to teach our midlevels procedural skills over rotating students because the midlevels actually need to learn it ASAP while the students will rotate off. Once the midlevels are comfortable then they can take students through things whenever they want.

In truth there are far more important things for students to learn. Any idiot can intubate a patient; not everyone can think through the intricacies of advanced airway management. Any nitwit can do an endoscopy; not many people can interpret accurately what they’re seeing and know how to manage it. Sticking a line in someone is easy. Knowing when to put a line in and how to manage the meds you’re using it for is far more valuable for students. To get competent technically you really need repetition and that often isn’t possible students who have relatively short rotations and may be on other services for many months afterward.

Students shouldn't have to go out of their way to show interest. When you're the bottom man on the totem pole, it's tough to show any interest to begin with. Maybe you can assess their interest by.. asking them? If a procedure is in any way related to their future career, they should have dibs. You have months and days where you have no students and sometimes no residents who need or want the procedure. Those are the days for training midlevels.


Also I very strongly disagree with your last paragraph. Skills require numbers. And getting numbers/reps in during 2018 is very difficult. This thread is a literal example! Procedure training is so diluted and even when you hit required numbers you don't have the confidence to do it with 0 backup nowadays. I had to brutally fight to get a few lines in during my icu rotation (and yes I know I'm a student).
Knowing when to put them in and how to manage them comes with experience/time over residency and also it's stuff you can read & learn. You can't simply get 40 tubes in quickly whereas I can learn more about knocking someone out for them via googling.

So no, procedural skills are far more difficult to learn for any learner. The rest comes via osmosis... just be present. literally.

 

[MedicineZ0Z]

I don’t think anyone really has a problem with midlevels > students for procedures. I didn’t think that was the main issue here.
Also you just gave a great reason why residents should be FIRST priority for everything. We need repetition to become competent.

I don't see why midlevels even need to be doing these procedures. Attendings should be doing it themselves in places without residents. Where you have residents, attendings teach them and do it when they arent' there. That's the model used in every other country in the world....

Med students should have reps in for procedures on day 1 of residency. Starting at ground zero and trying to accelerate to full independent competency as an intern is very difficult and doesn't even work usually.

 

[libertyyne]

 

[alprazoslam]

Mid levels shouldn’t be given any procedures like this! Why?


Because in the future we will see faulty nursing propaganda studies showing “nurse practitioner placement of xyz catheters shown to have lower diastolic blood pressure lower cholesterol and, and higher patient satisfaction than physician placed lines”

 

[Lnsean]

I don't see why midlevels even need to be doing these procedures. Attendings should be doing it themselves in places without residents. Where you have residents, attendings teach them and do it when they arent' there. That's the model used in every other country in the world....

Med students should have reps in for procedures on day 1 of residency. Starting at ground zero and trying to accelerate to full independent competency as an intern is very difficult and doesn't even work usually.

it's kind a scary that we're just giving up our turf like this...without even a slight resistance.

 

[Aerus]

Doctors who give midlevels procedural practice are just training their future replacements or the replacements of future generations of doctors. This is honestly such a disappointing direction when we have current doctors who are giving future midlevel providers more reasons to convince hospital administration to replace doctors ("we can do the same thing as doctors for less money with better bedside manners and higher patient satisfaction").

 

[puahate]

So this is the future?

Scary times out here.

 

[MedicineZ0Z]

it's kind a scary that we're just giving up our turf like this...without even a slight resistance.

Doctors who give midlevels procedural practice are just training their future replacements or the replacements of future generations of doctors. This is honestly such a disappointing direction when we have current doctors who are giving future midlevel providers more reasons to convince hospital administration to replace doctors ("we can do the same thing as doctors for less money with better bedside manners and higher patient satisfaction").

Lol not just training replacements but training them in favor of actual doctors. It's like a double insult to injury.

No idea what goes through these attendings' minds. I've seen many who are strongly opposed to midlevels, which is great. But then many carry this super pro-midlevel stance which is terrifying. At least if there's one thing the younger generation has agreed on is this opposition but it's too little too late.

 

[Lnsean]

Lol not just training replacements but training them in favor of actual doctors. It's like a double insult to injury.

No idea what goes through these attendings' minds. I've seen many who are strongly opposed to midlevels, which is great. But then many carry this super pro-midlevel stance which is terrifying. At least if there's one thing the younger generation has agreed on is this opposition but it's too little too late.

First it was just family medicine and alleviating the so called "doctor shortage," now you see mid-level penetration everywhere...in gas then in IM...and then I come onto SDN to see that now they're taking on procedures too? wtf...lol. Next we'll have PA surgeons and NP trained in IR.

 

[Aerus]

First it was just family medicine and alleviating the so called "doctor shortage," now you see mid-level penetration everywhere...in gas then in IM...and then I come onto SDN to see that now they're taking on procedures too? wtf...lol. Next we'll have PA surgeons and NP trained in IR.

What many current doctors don't realize is that EVERYONE is against us in support of midlevel providers. The media, the general public, pop culture, healthcare admins, and even many doctors. The midlevel movement for more practice rights and more autonomy is very, very strong and a lot of doctors either do not know this is happening or do not care because they will retire by the time this becomes a huge problem.

 

[MedicineZ0Z]

First it was just family medicine and alleviating the so called "doctor shortage," now you see mid-level penetration everywhere...in gas then in IM...and then I come onto SDN to see that now they're taking on procedures too? wtf...lol. Next we'll have PA surgeons and NP trained in IR.

Not only do they not alleviate the doctor shortage, they actually worsen the job market for physicians in somewhat saturated areas.

What many current doctors don't realize is that EVERYONE is against us in support of midlevel providers. The media, the general public, pop culture, healthcare admins, and even many doctors. The midlevel movement for more practice rights and more autonomy is very, very strong and a lot of doctors either do not know this is happening or do not care because they will retire by the time this becomes a huge problem.

True, but if doctors stopped training midlevels we wouldn't have this problem anymore. It's one thing to ignore it, but another to actively contribute towards it.
I understand hiring one and profiting. But training one? cmon.. And training one over a resident? That's insanity.

Lots of doctors have actually ceased training midlevels. So some DO listen in fact. It's just not enough.

 

[Lawpy]

I’m just sad that there are physicians who are willing to throw their colleagues and trainees under the bus by training cheap midlevels (who are functioning as their cheap replacements) just to cut costs. They are willing to sacrifice long-term economic and healthcare successes for short-term financial gains. What a shame.

 

[MedicineZ0Z]

I’m just sad that there are physicians who are willing to throw their colleagues and trainees under the bus by training cheap midlevels (who are functioning as their cheap replacements) just to cut costs. They are willing to sacrifice long-term economic and healthcare successes for short-term financial gains. What a shame.

There has to be a way to beat this.

The ACGME can ban midlevel supervision of residents and mandate attending supervision.
There must also be a way to prevent midlevels from stealing these from residents.

 

[Lawpy]

There has to be a way to beat this.

The ACGME can ban midlevel supervision of residents and mandate attending supervision.
There must also be a way to prevent midlevels from stealing these from residents.

I think physician lobbying should be a lot stronger. Right now, it honestly doesn’t seem they care, which leads to physicians leading the regulatory bodies not to care either. Their focus seems to be on short-term gains. This results in residents and students getting screwed over.

 

[alprazoslam]

Def never will train or hire an NP. I know PAs (some) are on the independent bus too but I do not really see that happening due to who holds their licensure (medical board)

Hire pa and aa’s not NP or CRNA. Some are nice and great people but the group as a whole is out to “took er jerbs” even though they do not admit it. It may never happen but I’m not one to chance it

Nursing is for nursing not medicine


The sad part is a lot of nps are just working for the job wanting to do what’s best for their patients. But their parent organizations keep pushing for more and more making them all look shady

 

[jw3600]

I personally don’t have a problem with teaching midlevels procedures. Just not at the expense of residents. *shrug*

 

[operaman]

Students shouldn't have to go out of their way to show interest. When you're the bottom man on the totem pole, it's tough to show any interest to begin with. Maybe you can assess their interest by.. asking them? If a procedure is in any way related to their future career, they should have dibs. You have months and days where you have no students and sometimes no residents who need or want the procedure. Those are the days for training midlevels.


Also I very strongly disagree with your last paragraph. Skills require numbers. And getting numbers/reps in during 2018 is very difficult. This thread is a literal example! Procedure training is so diluted and even when you hit required numbers you don't have the confidence to do it with 0 backup nowadays. I had to brutally fight to get a few lines in during my icu rotation (and yes I know I'm a student).
Knowing when to put them in and how to manage them comes with experience/time over residency and also it's stuff you can read & learn. You can't simply get 40 tubes in quickly whereas I can learn more about knocking someone out for them via googling.

So no, procedural skills are far more difficult to learn for any learner. The rest comes via osmosis... just be present. literally.

I think we may just have drastically different points of view on this. I know my perception of procedures has changed as I’ve progressed through training. Things I was once fighting for are now things I’ve literally logged thousands of and the procedural aspect is less exciting than the thinking that goes into it. I really think the procedural training you get in good residency programs is much more intense than the handful you get as a student. I probably did a handful of central lines as a student; I did 40-50 in one rotation as an intern. I probably did 10-15 intubations as a student; I did >100 in a month as an intern. I’ve seen ED residents rotate with us and do 40-50 intubations in a couple of days. There are plenty of numbers to go around!

If you’re getting procedures as a student - even if you’re having to fight for them - you’re actually going to be much further along than you think. I had to do the same thing and was pretty comfortable with most bedside procedures before starting intern year. Be sure to get practice with less glamorous procedures. Every student wants to drop central lines and do intubations and bronchs but then dont even practice basic venipuncture or bag mask ventilation.

The midlevel debate is going to be an ongoing one. We have added inpatient and outpatient midlevels on nearly all our service lines and they have been universally positive. They do daily notes and discharges and all the social handholding that pulls junior residents out of the OR. They absorb a lot of the less interesting clinic volume and let attendings and residents focus on more interesting operative cases. They mitigate the issue of cyclical ignorance inherent in teaching hospitals; interns come and go but they remain and can keep the service running smoothly. Patients get discharged faster with fewer bounce backs. They can do the less interesting bedside procedures that residents quickly lose interest in doing. They serve as incredible teachers too - 80% of what I know about caring for pediatric tracheostomies I learned from our badass NP. All in all they become a great resource and offload much of the scut work from residents.

I hear the job competition arguments and I think they are valid in certain fields. Selfishly I don’t perceive much threat from them as there are enough aspects of what I do that are beyond their ability and comfort level and for which the public simply won’t accept a non physician provider.

 

[Goro]

Just a couple of ideas to chew on:
1) Organize. If the AMA doesn't have your back at the national level, try your state medical assn's. Or your specialty organizations. The American College of X has to be worth something politically.
2) Lobby those who make the rules
3) Study what the NPs have done to gain such success. Copy that. It worked for the Dems this year by copying the Tea Party successes of the 2010 and 2014 elections (and please don't hijack the thread into the SPF)
4) Here's probably the most important one: find a way to make economic sense that it's cheaper for a doctor to do something than a midlevel. It's not doctors driving what your complaints are centered on, but hospital mgt.
5) A corollary to #4 is that it will be more expensive in the long run to let mid levels do doctor things. There has to be a way to do retrospective studies to show that patient outcomes are worse if midlevels are doing doctor things.
6) Please, I understand where you're coming form, but lose the sky is falling mentality. It doesn't do you any good. Frame the argument in the light of patient safety.

What's that you say? What's Goro doing making anti-midlevel arguments???!! Let's just say from recent personal experience, I've turned away from the Dark Side of the Force.

 

[MedicineZ0Z]

I think we may just have drastically different points of view on this. I know my perception of procedures has changed as I’ve progressed through training. Things I was once fighting for are now things I’ve literally logged thousands of and the procedural aspect is less exciting than the thinking that goes into it. I really think the procedural training you get in good residency programs is much more intense than the handful you get as a student. I probably did a handful of central lines as a student; I did 40-50 in one rotation as an intern. I probably did 10-15 intubations as a student; I did >100 in a month as an intern. I’ve seen ED residents rotate with us and do 40-50 intubations in a couple of days. There are plenty of numbers to go around!

If you’re getting procedures as a student - even if you’re having to fight for them - you’re actually going to be much further along than you think. I had to do the same thing and was pretty comfortable with most bedside procedures before starting intern year. Be sure to get practice with less glamorous procedures. Every student wants to drop central lines and do intubations and bronchs but then dont even practice basic venipuncture or bag mask ventilation.

The midlevel debate is going to be an ongoing one. We have added inpatient and outpatient midlevels on nearly all our service lines and they have been universally positive. They do daily notes and discharges and all the social handholding that pulls junior residents out of the OR. They absorb a lot of the less interesting clinic volume and let attendings and residents focus on more interesting operative cases. They mitigate the issue of cyclical ignorance inherent in teaching hospitals; interns come and go but they remain and can keep the service running smoothly. Patients get discharged faster with fewer bounce backs. They can do the less interesting bedside procedures that residents quickly lose interest in doing. They serve as incredible teachers too - 80% of what I know about caring for pediatric tracheostomies I learned from our badass NP. All in all they become a great resource and offload much of the scut work from residents.

I hear the job competition arguments and I think they are valid in certain fields. Selfishly I don’t perceive much threat from them as there are enough aspects of what I do that are beyond their ability and comfort level and for which the public simply won’t accept a non physician provider.

I think you're overly fixating on how your one location does things. There are truckloads of acgme residencies where senior IM residents don't even have 5 central lines. Most residencies don't offer that sort of volume to any resident. Many also intake a lot of residents that don't exactly install confidence and hence attendings are way more hands-on. Not to mention a lot of places with hands on fellows.
So sure, in some places you do get killer volume. And in many you get minimal and even as a pgy3 you can lack the volume to be competent.

My approach of having some marginal competency at fundamental procedures as a ms4 matters because you can then build on it over residency.

As for midlevels, a lot of what you describe is done by med students outside of USA. They do the physician-relevant scutwork rather than sit around and do nothing or just shadow a resident while day dreaming.

 

[MedicineZ0Z]

Just a couple of ideas to chew on:
1) Organize. If the AMA doesn't have your back at the national level, try your state medical assn's. Or your specialty organizations. The American College of X has to be worth something politically.
2) Lobby those who make the rules
3) Study what the NPs have done to gain such success. Copy that. It worked for the Dems this year by copying the Tea Party successes of the 2010 and 2014 elections (and please don't hijack the thread into the SPF)
4) Here's probably the most important one: find a way to make economic sense that it's cheaper for a doctor to do something than a midlevel. It's not doctors driving what your complaints are centered on, but hospital mgt.
5) A corollary to #4 is that it will be more expensive in the long run to let mid levels do doctor things. There has to be a way to do retrospective studies to show that patient outcomes are worse if midlevels are doing doctor things.
6) Please, I understand where you're coming form, but lose the sky is falling mentality. It doesn't do you any good. Frame the argument in the light of patient safety.

What's that you say? What's Goro doing making anti-midlevel arguments???!! Let's just say from recent personal experience, I've turned away from the Dark Side of the Force.

Personal experience?? Please share!

 

[operaman]

Just a couple of ideas to chew on:
1) Organize. If the AMA doesn't have your back at the national level, try your state medical assn's. Or your specialty organizations. The American College of X has to be worth something politically.
2) Lobby those who make the rules
3) Study what the NPs have done to gain such success. Copy that. It worked for the Dems this year by copying the Tea Party successes of the 2010 and 2014 elections (and please don't hijack the thread into the SPF)
4) Here's probably the most important one: find a way to make economic sense that it's cheaper for a doctor to do something than a midlevel. It's not doctors driving what your complaints are centered on, but hospital mgt.
5) A corollary to #4 is that it will be more expensive in the long run to let mid levels do doctor things. There has to be a way to do retrospective studies to show that patient outcomes are worse if midlevels are doing doctor things.
6) Please, I understand where you're coming form, but lose the sky is falling mentality. It doesn't do you any good. Frame the argument in the light of patient safety.

What's that you say? What's Goro doing making anti-midlevel arguments???!! Let's just say from recent personal experience, I've turned away from the Dark Side of the Force.

Even before that I think we as physicians need to find a way to articulate what it is we do that nobody else can do. The value and safety arguments may have validity but I think we have to first find answers to the fundamental question of what all our education and training is worth.

For me, it’s the ability to integrate a vast amount of complex data from the patient, family, records, exam, imaging, labs, etc., and including unspoken implied info from these same sources, and synthesize that along with the vast amount of fundamental knowledge gleaned from med school and residency, and form that into both a diagnosis and treatment plan and then interpret that back into laymen’s terms and teach the patient what’s happening, continuing to refine and synthesize more info, until they are able to come to decision about what they want to do. If this means surgery, it means carrying that same thinking into the OR and safely performing the procedure and managing whatever unexpected issues arise during or after the case.

Broadly speaking that’s what I think we do that others can’t. I think that needs to be clarified and refined or else any lobbying or studies will fall on deaf ears.

 

[Stagg737]

First it was just family medicine and alleviating the so called "doctor shortage," now you see mid-level penetration everywhere...in gas then in IM...and then I come onto SDN to see that now they're taking on procedures too? wtf...lol. Next we'll have PA surgeons and NP trained in IR.

I think this is the first thing we've actually agreed on, ever. It's a dam important thing though imo, especially with growing rates of mid-level autonomy. They started taking over procedures a while ago. In the UK NPs have already performed cardiac caths without a physician. Hasn't happened in the US yet, but given the direction we're heading I'd expect to see it down the road.

What's that you say? What's Goro doing making anti-midlevel arguments???!! Let's just say from recent personal experience, I've turned away from the Dark Side of the Force.

I hope this doesn't involve the family member I think it does and I hope it wasn't serious. Part of the problem though is that patients are like the NPs. They don't know what they don't know and think that they're getting good care until something really bad happens, and when it does someone tries to justify it. I've heard stuff like "well doctors miss it all the time too!" or "There's no way we could have predicted this." when those arguments are just wrong. It's infuriating being on this side where I can now see how horrible some of these diagnoses and treatment plans are and knowing that mid-level expansion is just growing. It's even worse now that I'm in a physician group that documents cases of mismanagement. Some of the things shared are legitimately terrifying and would result in a physician losing their license.

 

[MedicineZ0Z]

I think this is the first thing we've actually agreed on, ever. It's a dam important thing though imo, especially with growing rates of mid-level autonomy. They started taking over procedures a while ago. In the UK NPs have already performed cardiac caths without a physician. Hasn't happened in the US yet, but given the direction we're heading I'd expect to see it down the road.



I hope this doesn't involve the family member I think it does and I hope it wasn't serious. Part of the problem though is that patients are like the NPs. They don't know what they don't know and think that they're getting good care until something really bad happens, and when it does someone tries to justify it. I've heard stuff like "well doctors miss it all the time too!" or "There's no way we could have predicted this." when those arguments are just wrong. It's infuriating being on this side where I can now see how horrible some of these diagnoses and treatment plans are and knowing that mid-level expansion is just growing. It's even worse now that I'm in a physician group that documents cases of mismanagement. Some of the things shared are legitimately terrifying and would result in a physician losing their license.

what the ****....

 

[Stagg737]

what the ****....

Yep, read an article on it in a physician group. Tried to find it but had a hard time. If I do I'll post it.

 

[Goro]

Personal experience?? Please share!

Let's just say I learned that they're good for shots and sniffles, but if anything more complicated pops up they're out of their element. Way out of their element, and don't even know when to ask for a consult.

 

[nimbus]

I think you're overly fixating on how your one location does things. There are truckloads of acgme residencies where senior IM residents don't even have 5 central lines. Most residencies don't offer that sort of volume to any resident. Many also intake a lot of residents that don't exactly install confidence and hence attendings are way more hands-on. Not to mention a lot of places with hands on fellows.
So sure, in some places you do get killer volume. And in many you get minimal and even as a pgy3 you can lack the volume to be competent.

My approach of having some marginal competency at fundamental procedures as a ms4 matters because you can then build on it over residenc.

I would argue that it’s a waste of time for most IM residents to learn central lines just like it was a waste of time for me to do pelvic exams as a medical student. I’ve done exactly zero pelvic exams after my OB rotation and I’m glad. How many internists will do central lines in practice? If they’re not going to work in an icu, Cath lab, or ER, there’s no reason to learn to insert a central line. They will never do it again. Better for the mid level who’s job will be to insert central lines to learn them. Even most practicing surgeons don’t insert central lines unless they’re an intensivist or a trauma surgeon.

 

[MedicineZ0Z]

Let's just say I learned that they're good for shots and sniffles, but if anything more complicated pops up they're out of their element. Way out of their element, and don't even know when to ask for a consult.

Any chance you could provide a miniscule amount of detail/context for their screw up? Just curious in what field it was in.