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

[MedicineZ0Z]

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? 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.

Why should a midlevel even be doing them?? It should be the attending who does it, plain and simple. Instead they let their procedural skills atrophy...
Also, plenty of hospitalist jobs require those skills so no it is not a waste in any way and it is extremely important actually. Residencies with poor procedural volume (and there are a ton) shut off their grads from many hospitalist jobs, especially the better paying/less boring ones.

---

Members don't see this ad.

 

[fldoctorgirl]

I learned this when I shadowed an MD and his PA had to grab him anytime anything more than a basic bread and butter case popped up. At least she was smart enough to get help and not put patients in danger, but I'm talking about needing the MD for every other case.....that shows a huge gap in knowledge.

 

[nimbus]

Why should a midlevel even be doing them?? It should be the attending who does it, plain and simple. Instead they let their procedural skills atrophy...
Also, plenty of hospitalist jobs require those skills so no it is not a waste in any way and it is extremely important actually.

Ive been practicing anesthesia for over 20 years. In my community, hospitalists never insert central lines nor do they want to.

Midlevels do them if they’re on a trauma or icu service to offload the workload of the attending. It’s their actual job.

 

[MedicineZ0Z]

I learned this when I shadowed an MD and his PA had to grab him anytime anything more than a basic bread and butter case popped up. At least she was smart enough to get help and not put patients in danger, but I'm talking about needing the MD for every other case.....that shows a huge gap in knowledge.

This is the norm nationwide. Only people with anecdotes of top tier very exceptional and rare PAs/NPs will post on here and talk about them positively. The vast majority are like what you describe.

On more than one occasion as an ms3 I taught a practicing midlevel how to read an ekg.

Ive been practicing anesthesia for over 20 years. In my community, hospitalists never insert central lines nor do they want to.

Midlevels do them if they’re on a trauma or icu service to offload the workload of the attending.

Again, that's your community. It's a big country and there are many hospitalist jobs which require broad skillsets. Not everyone will go urban. Many will go underserved. And plenty of people practice in the midwest/south. Covering the icu, intubating, lines, running the vent etc are all things various hospitalist jobs can expect.

 

[Stagg737]

Ive been practicing anesthesia for over 20 years. In my community, hospitalists never insert central lines nor do they want to.

Midlevels do them if they’re on a trauma or icu service to offload the workload of the attending. It’s their actual job.

In my state I believe this is illegal without a physician present to supervise. I know attendings and residents are the only ones who do it at the hospitals in my residency program.

 

[nimbus]

This is the norm nationwide. Only people with anecdotes of top tier very exceptional and rare PAs/NPs will post on here and talk about them positively. The vast majority are like what you describe.

On more than one occasion as an ms3 I taught a practicing midlevel how to read an ekg.

Again, that's your community. It's a big country and there are many hospitalist jobs which require broad skillsets. Not everyone will go urban. Many will go underserved. And plenty of people practice in the midwest/south. Covering the icu, intubating, lines, running the vent etc are all things various hospitalist jobs can expect.

I am not against learning a skill if you plan to actually use them. I am against doing a handful of procedures for the sake of saying you’ve done them. At that point you’re not remotely competent and the only way to develop competence is by doing them as a regular part of your practice. To do 50 central lines in training and then do them sporadically in practice does not make one an expert. It just makes you dangerous.

 

[Goro]

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

Yeah, I know it's dish, and I love dish myself, but I have a feeling I'm be telling more details of the story to my students, and so am afraid of outing myself. I know of at least five of my students who are SDNers.

So to quote the early 1900s labor organizer Joe Hill, who was framed for murder and then executed, "Don't mourn, organize!"

 

[VA Hopeful Dr]

This is the norm nationwide. Only people with anecdotes of top tier very exceptional and rare PAs/NPs will post on here and talk about them positively. The vast majority are like what you describe.

On more than one occasion as an ms3 I taught a practicing midlevel how to read an ekg.

Again, that's your community. It's a big country and there are many hospitalist jobs which require broad skillsets. Not everyone will go urban. Many will go underserved. And plenty of people practice in the midwest/south. Covering the icu, intubating, lines, running the vent etc are all things various hospitalist jobs can expect.

My wife was a hospitalist at a 90 bed hospital in the South. She was quite good at central lines when she started that job but quickly realized that in the time it took from start to finish to do a line she could usually round on 2-3 patients.

Within the first 3 months she'd given up doing them without regret.

When I was in residency I really enjoy Gyn procedures. I busted my ass to become competent in colposcopy, IUD insertion, and EMB.

You know what family doctors don't do anymore? Any of that. I'd have been much better served using the time to see more MSK/psych patients.

 

[VA Hopeful Dr]

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.

That has not been my experience.

In 2 jobs in 2 different cities I get a fair number of new patients who see me specifically because they don't want to see a mid-level.

Edit: I mean even our own previously very pro-mid-level @Goro has seen the difference

 

[operaman]

I am not against learning a skill if you plan to actually use them. I am against doing a handful of procedures for the sake of saying you’ve done them. At that point you’re not remotely competent and the only way to develop competence is by doing them as a regular part of your practice. To do 50 central lines in training and then do them sporadically in practice does not make one an expert. It just makes you dangerous.

Ding ding ding! This is the correct answer.

If I had to do one now I would probably call whichever NP friend was in house to come spot me. It’s one thing to bang one out with an old attending nearby who can fix anything you screw up and quite another to forge ahead alone unaware and perhaps unable to manage the complications.

I also no longer understand the appeal of these little procedures. When I see attendings doing them they all have that FML look in their eyes. Once the newness wears off I think most are more than happy to outsource that job to anyone else just like they’re thrilled to have someone else doing their paperwork.

 

[VA Hopeful Dr]

Ding ding ding! This is the correct answer.

If I had to do one now I would probably call whichever NP friend was in house to come spot me. It’s one thing to bang one out with an old attending nearby who can fix anything you screw up and quite another to forge ahead alone unaware and perhaps unable to manage the complications.

I also no longer understand the appeal of these little procedures. When I see attendings doing them they all have that FML look in their eyes. Once the newness wears off I think most are more than happy to outsource that job to anyone else just like they’re thrilled to have someone else doing their paperwork.

Exactly.

From a financial standpoint, most procedures aren't worth it for me to do them (the main exception in primary care being joint injections). I can easily see 2 patients in the time it takes me to do 1 derm procedure (outside cryo), and those 2 office visits will almost certainly pay me more than that 1 biopsy of whatever flavor.

 

[bananafish94]

Everybody wants to be a doctor, but don't nobody wanna lift no heavy-ass medical school.

 

[235009]

Oh look, another SDN thread where premeds + med students are being very vocal and getting triggered while actual doctors with actual experience in the real world are disagreeing.

Your worth as a physician isn't in doing time consuming procedures. If an NP is skilled, competent and has done dozens (or even hundreds) of the procedure on an almost daily basis then they 1) should absolutely be doing them unsupervised to free up the attending 2) should teach and supervise trainees who have less experience.

3rd and 4th year of med school isn't the time to try and do procedures. It's completely worthless for you to do one or two central lines then either never do it again or not do one for another 1-2 years. You haven't learned anything at that point and just slowed everything down.

 

[operaman]

What’s also funny to me is how students want to “do” the procedure but don’t even know how to set up for it. Now THAT is a useful skill to learn: how to set up for a bedside central line or how to set up for a direct laryngoscopy and endotracheal intubation, how to bag mask well while someone sets up airway equipment.

What students and some interns usually mean by “doing” the procedure is for the senior physician to set everything up and then hand them the key instrument at the last minute so they can do whatever that move is. It’s not like the students are setting everything up beautifully and then someone else snags the procedure.

For most of these things, the setup and equipment selection is actually the most important part. It’s the primary reason I’d ask for help if I had to do one i hadn’t done in awhile so I don’t forget something stupid.

I’ve said it before- students, if you want to do procedures, ask to set up for them, to fetch the right equipment and have everything ready to go. Nobody likes setting these things up and if you do a good job, your chances of getting to do it go up significantly.

 

[jw3600]

Some of the lines are getting blurred here and I want to try and refocus.

The initial point of this thread:

Midlevels are taking procedures away from residents who WANT them and NEED them for competence in areas where they will do/supervise them as attendings e.g central lines, chest tubes, intubations, art lines.

-EM resident.


I don't really know about the prevalence of hospitalists doing invasive lines and will defer to those who are around that more. And for the comments about it not being worth the time payment/RVU wise, again irrelevant. We are talking about NECESSARY and potentially life saving procedures that residents are being passed up for for midlevels. This is like a surgical PA getting the chance to perform the CEA over the surgical resident going into vasuclar. It. Is. Nonsense.

 

[VA Hopeful Dr]

Some of the lines are getting blurred here and I want to try and refocus.

The initial point of this thread:

Midlevels are taking procedures away from residents who WANT them and NEED them for competence in areas where they will do/supervise them as attendings e.g central lines, chest tubes, intubations, art lines.

-EM resident.


I don't really know about the prevalence of hospitalists doing invasive lines and will defer to those who are around that more. And for the comments about it not being worth the time payment/RVU wise, again irrelevant. We are talking about NECESSARY and potentially life saving procedures that residents are being passed up for for midlevels. This is like a surgical PA getting the chance to perform the CEA over the surgical resident going into vasuclar. It. Is. Nonsense.

But we don't know the details. Those, as always, are key.

Was this EM resident on the trauma service and passed over in favor of the PA? If yes, that's troubling. If the resident was just working in the ED and was mad the surgeons didn't offer the procedure to him? Meh, that's not a big deal.

 

[jw3600]

But we don't know the details. Those, as always, are key.

Was this EM resident on the trauma service and passed over in favor of the PA? If yes, that's troubling. If the resident was just working in the ED and was mad the surgeons didn't offer the procedure to him? Meh, that's not a big deal.

Agreed. But it seems like some were saying it wouldn’t be a big deal if it was the former. I vehemently disagree and see it as further selling out of younger physicians.

 

[surfsuncali]

Everybody wants to be a doctor, but don't nobody wanna lift no heavy-ass medical school.

I do it though! Yeahhhhh buddy!

 

[863168]

In all seriousness, we are indoctrinated to believe that doctors are incompetent and their patient load makes them unreliable in the care of patients. We are told that we are some mythical last line of defense from doctors harming our patients. The most passionate advocate for this point of view was a retired nurse practitioner who couldn't teach a 15 minute lecture on the pathophysiology of diabetes in our pediatrics class. Our classes are riddled with agenda that can't be backed by competence. There is now a movement that we no longer have to "pay our dues" and should jump straight into mid-level opportunities the moment they open up if we feel confident in our own abilities. There is no accountability for the quality of education and it shows in the high variation among the teachers and the students.

 

[863168]

I'm sorry. Another case that has stuck out to me was when we were asked to identify an unknown pathogen that was affecting a patient after rule out antibiotics had been administered. I had suggested that a biopsy be performed and then a gram stain be performed on the tissue to narrow down the bacteria. I was told that this was an awful recommendation and that there was no specialist who would be able to perform this. I asked what type of specialist would be needed and was informed that it would take several days to send a sample to the CDC for testing. For a gram stain procedure. A gram stain. Procedure.

 

[Psai]

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.

Most of the midlevel hate you see on SDN is not motivated by the fear of loss of earnings, nor of patient safety, but of the mindset of "how dare those peasants move beyond their station!"

People who think that they're God's anointed have trouble dealing with threats to their egos.

My 16 year son has that same black/white thinking that you do.

I'm necessarily not pro-mid-level, although the NP who was my PCP for awhile did a fine job for both my wife and me. On the other hand, my kid's pediatrician (on look, I'm using a word meant for the anointed!) is an NP and she gets in over her head when things her more complicated than the run of the mill kid's stuff.

I just think that all the hate, bile, and vitriol you spew out at them is pathological. I'm anti-ego. Side note: You're not God's gift to medicine.

pft lmao

 

[Aerus]

That has not been my experience.

In 2 jobs in 2 different cities I get a fair number of new patients who see me specifically because they don't want to see a mid-level.

Edit: I mean even our own previously very pro-mid-level @Goro has seen the difference

With all due respect (and I mean that seriously because I know you're a very knowledgeable FM Physician and have read many of your locums posts), not all physicians have the same experience. I know a few physicians myself who were asked specifically by their hospital to train NPs since the hospital is choosing to replace them with those NPs (unbelievable I know). Luckily, tons of patients and hospitals still have sense in them and do not think midlevel providers can do everything a physician can, but the culture of healthcare is shifting towards that right now.

 

[Aerus]

Oh look, another SDN thread where premeds + med students are being very vocal and getting triggered while actual doctors with actual experience in the real world are disagreeing.

Your worth as a physician isn't in doing time consuming procedures. If an NP is skilled, competent and has done dozens (or even hundreds) of the procedure on an almost daily basis then they 1) should absolutely be doing them unsupervised to free up the attending 2) should teach and supervise trainees who have less experience.

3rd and 4th year of med school isn't the time to try and do procedures. It's completely worthless for you to do one or two central lines then either never do it again or not do one for another 1-2 years. You haven't learned anything at that point and just slowed everything down.

Oh look, a doctor who thinks that because they are a doctor talking to those who aren't yet doctors that their opinion is the only truth. Sorry to say, but many doctors will also disagree with you.

I am not advocating for the absolute teaching of medical students in procedures (although that SHOULD be the case but that is a different topic altogether), but rather the attitude of letting midlevel providers be trained in procedures and letting them perform them unsupervised just because it makes things "easier", especially over those training to be doctors (medical students and interns). In the future, this will just be used against physicians as a whole when NP propaganda uses this against us when rallying for complete independent autonomy. If you follow the AANP and their movements on social media, it's pretty obvious that it is already happening, but many doctors just choose to ignore this.

Sure does doing this help flow short-term? Yes. But when midlevel providers are granted independent autonomy in all 50 states and when they are allowed to do everything a physician can, that will ultimately be to the harm of patients.

 

[VA Hopeful Dr]

With all due respect (and I mean that seriously because I know you're a very knowledgeable FM Physician and have read many of your locums posts), not all physicians have the same experience. I know a few physicians myself who were asked specifically by their hospital to train NPs since the hospital is choosing to replace them with those NPs (unbelievable I know). Luckily, tons of patients and hospitals still have sense in them and do not think midlevel providers can do everything a physician can, but the culture of healthcare is shifting towards that right now.

You must be confusing me with someone else, as I have never done locums nor made a post about it.

But irrelevant. It's certainly possible that my state is a massive outlier as far as nurse practitioners and physician assistants goes, but every hospital system in the state is moving towards more physicians and fewer mid-levels. This includes one major academic medical center, and two smaller ones plus a number of mid-sized community hospitals. the only places where I'm seeing mid-levels on more than about a 1 to 8 ratio with physicians is either in private practice groups or in very rural locations. the former because the owning physicians are greedy and the latter because they can't find physicians. For everyone else, at least in primary care, the trend is to have one nurse practitioner or physician assistant / office whose job is to take over flow acute visits.

 

[Psai]

I just think that it's absurd that procedures are going to mid levels instead of physicians and that this is being facilitated by physicians. The more you give away, the easier you are to replace. I'm starting to see people bringing more and more midlevels into the OR and teaching them how to do the operations (midwives participating in c-sections, PAs harvesting arteries for cardiac surgeries, etc.) It's a sad state of affairs.

I also think it's a little hard on students to expect them to know how to set up for procedures before teaching them. There aren't a million opportunities and really you don't know what you need before you actually learn the proecdures. I've done a million a lines but the last one I did, I forgot to put down some 4x4s and got blood all over my scrubs. Because of a focus on getting through patient care and get through the day, education is falling by the wayside. I do understand the whole "students seeming uninterested" thing and feeling less enthusiastic about teaching them but I also remember what it's like to be a student trying to stack those Hs.

 

[nimbus]

Another point I’d like to make is that whoever sees, admits, and works up the patient should be the one “rewarded” with the procedure if the patient should need one. That’s how things worked when I was a medical student. When I was in ICU and I admitted the patient, wrote the admitting note, wrote the orders, then if the patient needed an Aline, I would get a chance to try. IMO, it is not ok for a trainee to expect a procedure if they are not truly involved in the care of a specific patient. Whether they are a mid level or resident or medical student, whoever is doing the brunt of the work should get the procedure. As an anesthesiologist, I’ve had people asking to intubate patients after I’ve induced them having never even introduced themselves to the patient. In those cases the answer is always no.

 

[nimbus]

With all due respect (and I mean that seriously because I know you're a very knowledgeable FM Physician and have read many of your locums posts), not all physicians have the same experience. I know a few physicians myself who were asked specifically by their hospital to train NPs since the hospital is choosing to replace them with those NPs (unbelievable I know). Luckily, tons of patients and hospitals still have sense in them and do not think midlevel providers can do everything a physician can, but the culture of healthcare is shifting towards that right now.

Sometimes a NP can do things that no one else can, including physicians. For example I work with a NP who does endoscopic radial artery harvest for CABG. No one else in my hospital system does them. When she is on vacation, the cardiac surgeon, or one of several assistant surgeons, harvests open leaving a foot long incision on the forearm.

 

[Lawpy]

By the way, in case you guys aren't updated:

PAs in North Dakota no longer need physician supervision

Some of the responses in that thread are interesting

 

[MedicineZ0Z]

My wife was a hospitalist at a 90 bed hospital in the South. She was quite good at central lines when she started that job but quickly realized that in the time it took from start to finish to do a line she could usually round on 2-3 patients.

Within the first 3 months she'd given up doing them without regret.

When I was in residency I really enjoy Gyn procedures. I busted my ass to become competent in colposcopy, IUD insertion, and EMB.

You know what family doctors don't do anymore? Any of that. I'd have been much better served using the time to see more MSK/psych patients.

There are still lots of positions which require competency at those procedures. Those jobs also pay more typically. Lot of IMGs actually who require visa waivers have to go for those jobs, and they're usually at community residencies with low procedure volume.

Ding ding ding! This is the correct answer.

If I had to do one now I would probably call whichever NP friend was in house to come spot me. It’s one thing to bang one out with an old attending nearby who can fix anything you screw up and quite another to forge ahead alone unaware and perhaps unable to manage the complications.

I also no longer understand the appeal of these little procedures. When I see attendings doing them they all have that FML look in their eyes. Once the newness wears off I think most are more than happy to outsource that job to anyone else just like they’re thrilled to have someone else doing their paperwork.

Okay and.. how long until appes and choles are outsourced to midlevels? Why not train a PA/NP to take those out?

Oh look, another SDN thread where premeds + med students are being very vocal and getting triggered while actual doctors with actual experience in the real world are disagreeing.

Your worth as a physician isn't in doing time consuming procedures. If an NP is skilled, competent and has done dozens (or even hundreds) of the procedure on an almost daily basis then they 1) should absolutely be doing them unsupervised to free up the attending 2) should teach and supervise trainees who have less experience.

3rd and 4th year of med school isn't the time to try and do procedures. It's completely worthless for you to do one or two central lines then either never do it again or not do one for another 1-2 years. You haven't learned anything at that point and just slowed everything down.

Oh look another doctor who thinks practicing medicine has the slightest relevance to being an educator.

Also, this whole system is flawed. The NP should be doing the doctor's paperwork while the Dr puts the line in (if no resident available). Not sure where we got this idea of an NP even putting one in to begin with. Physicians are paid well given the difficulty of the work involved.

Also your argument about med student procedures being useless is insane. Until my anesthesia elective, my intubations were very spaced out (surgery to im to icu) and yet I was retaining what I learned and improving each time. Also, the comfort level drastically rises and the nerves calm down big time after the first few ones. This is why I'm saying practicing medicine in no way = / = good educator.

 

[MedicineZ0Z]

What’s also funny to me is how students want to “do” the procedure but don’t even know how to set up for it. Now THAT is a useful skill to learn: how to set up for a bedside central line or how to set up for a direct laryngoscopy and endotracheal intubation, how to bag mask well while someone sets up airway equipment.

What students and some interns usually mean by “doing” the procedure is for the senior physician to set everything up and then hand them the key instrument at the last minute so they can do whatever that move is. It’s not like the students are setting everything up beautifully and then someone else snags the procedure.

For most of these things, the setup and equipment selection is actually the most important part. It’s the primary reason I’d ask for help if I had to do one i hadn’t done in awhile so I don’t forget something stupid.

I’ve said it before- students, if you want to do procedures, ask to set up for them, to fetch the right equipment and have everything ready to go. Nobody likes setting these things up and if you do a good job, your chances of getting to do it go up significantly.

Oh sure, the ms3/ms4 is the only student on the service... low man on the totem pole, doesn't know where anything is cause no one showed him/her - yet I'm sure they'll jump on youtube, watch 15 videos (cause all are different) on how to do xyz, then magically find the exact equipment and unexpectedly set it all up not even knowing when the procedure will be done. Sounds dandy.

How about you take some time to show them where everything is? What's needed for xyz? Then walk them through it step by step... and then expect them to do it next time. Cause as an ms4, I've done that for ms3s cause residents wouldn't despite having free time. And attendings? forget it.

But we don't know the details. Those, as always, are key.

Was this EM resident on the trauma service and passed over in favor of the PA? If yes, that's troubling. If the resident was just working in the ED and was mad the surgeons didn't offer the procedure to him? Meh, that's not a big deal.

Yes it's the resident on that service having procedures stolen.

With all due respect (and I mean that seriously because I know you're a very knowledgeable FM Physician and have read many of your locums posts), not all physicians have the same experience. I know a few physicians myself who were asked specifically by their hospital to train NPs since the hospital is choosing to replace them with those NPs (unbelievable I know). Luckily, tons of patients and hospitals still have sense in them and do not think midlevel providers can do everything a physician can, but the culture of healthcare is shifting towards that right now.

Why not just refuse and go work elsewhere?

I just think that it's absurd that procedures are going to mid levels instead of physicians and that this is being facilitated by physicians. The more you give away, the easier you are to replace. I'm starting to see people bringing more and more midlevels into the OR and teaching them how to do the operations (midwives participating in c-sections, PAs harvesting arteries for cardiac surgeries, etc.) It's a sad state of affairs.

I also think it's a little hard on students to expect them to know how to set up for procedures before teaching them. There aren't a million opportunities and really you don't know what you need before you actually learn the proecdures. I've done a million a lines but the last one I did, I forgot to put down some 4x4s and got blood all over my scrubs. Because of a focus on getting through patient care and get through the day, education is falling by the wayside. I do understand the whole "students seeming uninterested" thing and feeling less enthusiastic about teaching them but I also remember what it's like to be a student trying to stack those Hs.

It's amazing that doctors are self destructing the profession due to laziness and an extra buck. These docs had it easy enough with their cheap tuition and 100 page first aid books and now want to ruin the whole show for everyone.

 

[Stagg737]

I just think that it's absurd that procedures are going to mid levels instead of physicians and that this is being facilitated by physicians. The more you give away, the easier you are to replace. I'm starting to see people bringing more and more midlevels into the OR and teaching them how to do the operations (midwives participating in c-sections, PAs harvesting arteries for cardiac surgeries, etc.) It's a sad state of affairs.

This is another problem with letting mid-levels do more "easy" procedures, they start thinking they can do harder ones which they don't even understand the anatomic/physiologic basis for. So do we just allow individuals whose extent of anatomy was taking a semester of UG level (often lower) start doing surgical procedures? Because that's what you're getting with some NPs, maybe many. I'm sure someone will argue that this is a slippery slope fallacy, but it's already happening. Independent practice of mid-levels is rapidly expanding and they're doing things they were never trained to do beyond a couple weeks (or even days) crash course. Teaching mid-levels how to do more without the foundational education is just asking for poor outcomes and imo more reason why we should be training residents and not mid-levels.

 

[MedicineZ0Z]

This is another problem with letting mid-levels do more "easy" procedures, they start thinking they can do harder ones which they don't even understand the anatomic/physiologic basis for. So do we just allow individuals whose extent of anatomy was taking a semester of UG level (often lower) start doing surgical procedures? Because that's what you're getting with some NPs, maybe many. I'm sure someone will argue that this is a slippery slope fallacy, but it's already happening. Independent practice of mid-levels is rapidly expanding and they're doing things they were never trained to do beyond a couple weeks (or even days) crash course. Teaching mid-levels how to do more without the foundational education is just asking for poor outcomes and imo more reason why we should be training residents and not mid-levels.

Nearly everyone doesn't understand how poor midlevel training actually is to begin with. They all know what they know from the training they get after being hired. And the background knowledge (ex. undergrad anatomy lol) is so low that it's the same as taking anyone else in the hospital and training them to do xyz. Like any nurse can memorize algorithms and repeat them too.

 

[Lawpy]

I have to say, I'm a bit surprised to see some physicians supporting the rights of midlevels to carry out some procedures, including placing some lines. Maybe I came across crappy hospital systems, but my experiences show that midlevels and nurses are pretty terrible in placing lines and usually cause a lot of pain and discomfort for patients. I would easily trust and prefer physicians or trainees to place lines rather than midlevels.

 

[Black Coffee 24/7]

Another point I’d like to make is that whoever sees, admits, and works up the patient should be the one “rewarded” with the procedure if the patient should need one. That’s how things worked when I was a medical student. When I was in ICU and I admitted the patient, wrote the admitting note, wrote the orders, then if the patient needed an Aline, I would get a chance to try. IMO, it is not ok for a trainee to expect a procedure if they are not truly involved in the care of a specific patient. Whether they are a mid level or resident or medical student, whoever is doing the brunt of the work should get the procedure. As an anesthesiologist, I’ve had people asking to intubate patients after I’ve induced them having never even introduced themselves to the patient. In those cases the answer is always no.

How do you feel about EMT students being given preference over medical students in doing intubation in the OR?

During my time in the OR, CRNAs will never let medical students intubate any patients. Yet, they're all fine with EMT students doing the intubation. That's straight up disrespectful, especially when the medical student was involved with the CRNAs in term of preop intro, workup, and pt ed. Yet, the EMT student from nowhere jumped in and stole all the intubations. I stopped hanging out with CRNAs after that event.

It's a travesty that attending physicians here think that it's ok for mid-levels to be given preference for procedure training over medical students. Shame on all those attending physicians here. The war is already on out in the frontier with medical students feeling most of the heat right now. There will be a time when they start to assault on the so called procedure heavy specialties by pointing to better pt satisfaction and cheaper cost, as a way to replace current attending physicians.

 

[nimbus]

How do you feel about EMT students being given preference over medical students in doing intubation in the OR?

During my time in the OR, CRNA will never let medical students intubate any patients. Yet, they're all fine with EMT students doing the intubation. That's straight up disrespectful.

It's a travesty that attending physicians here think that it's ok for mid-levels to be given preference for procedure training over medical students. Shame on all those attending physicians here.

Most medical students will never intubate once they’re in practice. Those who need to intubate as part of their job will have ample opportunity to master it in residency. There’s zero reason a medical student needs to learn to intubate in medical school. EMT’s need to know how to intubate. Peoples’ lives depend on it. Nobody dies because a medical student didn’t learn to intubate in medical school. So I agree with the CRNA. It has nothing to do with respect.

 

[MedicineZ0Z]

How do you feel about EMT students being given preference over medical students in doing intubation in the OR?

During my time in the OR, CRNA will never let medical students intubate any patients. Yet, they're all fine with EMT students doing the intubation. That's straight up disrespectful.

It's a travesty that attending physicians here think that it's ok for mid-levels to be given preference for procedure training over medical students. Shame on all those attending physicians here.

Why are the CRNAs making those decisions to begin with anyway? And who thought letting these pseudoprofessions was a good idea anyway?

 

[MedicineZ0Z]

Most medical students will never intubate once they’re in practice. Those who need to intubate as part of their job will have ample opportunity to master it in residency. There’s zero reason a medical student needs to learn to intubate in medical school. EMT’s need to know how to intubate. Peoples lives depend on it. So I agree with the CRNA.

He said *never* let them intubate. That is incredibly ridiculous.
And most med students will never use biochem once in practice. Or do histology. Or need to know most of what's taught in med school. Your argument shows why you'd make a very poor educator.
But ya sure, lets further dilute true hands-on training in favor of training nurses to replace doctors.

 

[Black Coffee 24/7]

Most medical students will never intubate once they’re in practice. Those who need to intubate as part of their job will have ample opportunity to master it in residency. There’s zero reason a medical student needs to learn to intubate in medical school. EMT’s need to know how to intubate. Peoples lives depend on it. So I agree with the CRNA.

This is not just with CRNAs giving intubation dibs to EMT students over medical students. I'm talking about the same CRNAs not giving intubation dibs to medical students on an empty day without EMT students by making bogus excuse about the body habitus of the pt despite the pt being a healthy 25 y/o healthy slim female.

 

[Black Coffee 24/7]

Why are the CRNAs making those decisions to begin with anyway? And who thought letting these pseudoprofessions was a good idea anyway?

It's really garbage, dude. Yet, we here see attending physicians killing their own by pointing to perceived students' lack of interest on these stuff.

I bet that 9/10 medical students out there would be heavily interested in learning how to set up procedures and go through the step by step process of doing them.

 

[MedicineZ0Z]

This is not just with CRNAs giving intubation dibs to EMT students over medical students. I'm talking about the same CRNAs not giving intubation dibs to medical students on an empty day without EMT students by making bogus excuse about the body habitus of the pt despite the pt being a healthy 25 y/o healthy slim female.

I always lol @ excuses to not intubate for students. I've gotten to (successfully on attempt 1) perform more than 1 difficult airway intubation, both in the ED and icu. If you're supervised and have the technique down beforehand, there's no reason to not be attempting regardless of the perceived difficulty.
BTW, those are all fake excuses anyway. I still don't get how nurses are making the call on med students...

It's really garbage, dude. Yet, we here see attending physicians killing their own by pointing to perceived students' lack of interest on these stuff.

I bet that 9/10 medical students out there would be heavily interested in learning how to set up procedures and go through the step by step process of doing them.

Easily 9/10 students if not even more.

A med student is simply not in the position of power to engage "interest" and take initiative. I've seen med students go around asking everyone to do stuff and it's incredibly embarrassing. Honestly, seeing a guy go girl to girl in the bar getting rejected looks a lot better.

Also I don't get this whole "show interest" thing. We don't go to random university lectures to learn. We don't make our own experiments in labs. Things in school are instructed to you. Then when the time comes to learn the most critical stuff, you need to jump through a dozen hoops for an attempt.

 

[W19]

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.

Well, they are now in North Dakota...
Big News for OTP in North Dakota

 

[nimbus]

Well, they are now in North Dakota...
Big News for OTP in North Dakota

This probably has to do with the fact that an extreme minority of doctors are willing to live in North Dakota. Any warm body will do.

ND has 758,000 population, 1/3 of whom are kids, and the entire state has 75 anesthesiologists. My group is almost 4x that size serving a much smaller area and there are multiple other anesthesia groups in the community. I’m sure there are areas in ND with no doctors for 50-100 miles. In those areas an experienced PA is better than nobody.

https://www.aamc.org/download/484576/data/northdakotaprofile.pdf

 

[nimbus]

How long did it take you to feel comfortable at drawing blood/inserting an IV?

Interesting thread. I wasn’t aware that doctors are no longer trained to insert IV’s and draw blood. Med students should start with those 2 basic skills before going for “glamour” procedures like intubation and central lines. 99% of the time, step 1 of an intubation is establishing an IV. (Tip-when you’re in a surgery or anesthesia rotation, introduce yourself to the preop nurse who puts in 30 IV’s a day and ask her to show you how).

Also as someone else mentioned before, effective mask ventilation is at least as important to know as intubation. If you can mask ventilate effectively, there is no urgent need to intubate. And supraglottic airway devices....why aren’t med students obsessed with LMA insertion? Why do they count intubations but not LMA insertions? They are lifesaving and widely utilized in real life. A fixation with intubation reveals a lack of insight about airway management.

 

[VA Hopeful Dr]

How long did it take you to feel comfortable at drawing blood/inserting an IV?

Interesting thread. I wasn’t aware that doctors are no longer trained to insert IV’s and draw blood. Med students should start with those 2 basic skills before going for “glamour” procedures like intubation and central lines. 99% of the time, step 1 of an intubation is establishing an IV. And as someone else mentioned before, effective mask ventilation is at least as important to know as intubation. And supraglottic airway devices....why aren’t med students obsessed with LMA insertion? Why do they count intubations but not LMA insertions? They are lifesaving and widely utilized in real life. A fixation with intubation reveals a lack of insight about airway management.

Technically it's still taught, but it's not something done often enough for true competence.

And I get why. Since I left residency, I can count on one hand the number of patients I have even ordered an IV on and all of them did fine with the nurses doing it.

 

[VA Hopeful Dr]

There are still lots of positions which require competency at those procedures. Those jobs also pay more typically. Lot of IMGs actually who require visa waivers have to go for those jobs, and they're usually at community residencies with low procedure volume.

Hence why IM residency still teaches lines.

Good talk.

 

[alprazoslam]

All the pro midlevel docs here never experienced how berating toward physicians nursing school is. Even back like 8 years ago when I was in rn school it was probably half learning somewhat useful nursing stuff and half “why we are just good as physicians”

No, it doesn’t show at the work place but they are after our jobs. Why otherwise would nursing organizations push so many pro midlevel studies on why they are just as good as docs. We give them inches and they want yards

lot of my friends who did masters/doctorate in nursing said it was more of the same

Otherwise who cares who teaches who. Whoever is best should, but midlevels push against the physician establishment daily. We have to be careful

 

[VA Hopeful Dr]

I get why y'all are angry. Looking back to when I was a med student, I remember what a big deal procedures were and how great it was when I got to actually do something. I suspect I'd have been just as angry had I been passed over for training midlevel students.

But looking back from where I am now, I think differently. Yes it was cool driving the camera on the lap colectomy. But my education (since I'm not a surgeon) would've been better served learning how to work up that colon cancer. I did really like doing from start to finish that central line the surgery residents let me do, but looking back I'd have rather spent that hour seeing another consult or 2. Procedures are actually the easiest part of our jobs (generally speaking and especially for non-surgeons). But you only get to see so many patients as a trainee. When I was a med student, on our surgery rotation we spent 4 days in the OR and 1/2 day in the clinic. I'd reverse that. The OR time has made almost no difference in my practice, but seeing consults would have helped tremendously.

As for the OP, all we know is that they are an EM resident who didn't get to do a procedure in favor of a PA. They don't say if they were on the trauma service or just in the ED (as I stated before).

 

[operaman]

How long did it take you to feel comfortable at drawing blood/inserting an IV?

Interesting thread. I wasn’t aware that doctors are no longer trained to insert IV’s and draw blood. Med students should start with those 2 basic skills before going for “glamour” procedures like intubation and central lines. 99% of the time, step 1 of an intubation is establishing an IV. (Tip-when you’re in a surgery or anesthesia rotation, introduce yourself to the preop nurse who puts in 30 IV’s a day and ask her to show you how).

Also as someone else mentioned before, effective mask ventilation is at least as important to know as intubation. If you can mask ventilate effectively, there is no urgent need to intubate. And supraglottic airway devices....why aren’t med students obsessed with LMA insertion? Why do they count intubations but not LMA insertions? They are lifesaving and widely utilized in real life. A fixation with intubation reveals a lack of insight about airway management.

Preach! I always tell our students and interns that no matter how comfortable I am DLing, I don’t have a laryngoscope or induction agents or tubes in my bag at all times, but there are bags and masks in every room! Yeah some of the angry student comments here about airway management are so misguided I don’t even know where to begin.

Seconding the suggestion of learning venupuncture from a preop nurse. I found an old one at the VA who definitely didn’t mind letting me help get access and that skill continues to come in handy. Getting a second IV in the OR after induction is another great time for a learner to practice.

And kids, don’t forget that once you’re an intern, you can do almost any procedure you want on your own patients assuming you’re competent. Want some more arterial sticks? Don’t have RT or the RN draw that ABG; go do it yourself. Wanna drop an NG or practice image guided IV placement? Do those yourself. Use an unltrasound for that ABG stick and you’ve basically practiced doing an a-line. I’ve never met an overnight bedside nurse or RT who had any problem with the doc personally doing some of their procedures for them! Believe me, they will be happy to talk you through it too if you’re not quite comfortable. Of course most interns would rather camp out in the call room and whine about how they don’t get to “do” anything.

 

[Psai]

A student doesn't appreciate the airway like an anesthesiologist practicing for 2 decades does. I understand the need to learn the fundamentals but that doesn't stop the "cool things" from being cool. You don't get a good appreciation for things without experience and seeing bad outcomes.

Students don't get taught anything these days because attendings are never around and residents are too busy and then we wonder why people are less and less prepared for practice every year while being robbed by midlevels students who are completely supported by their supervisors and national interest groups.

Now I'm hearing that people are starting to get scared of doing procedures because if they don't let their midlevel do more and more things then they might leave for somewhere else. Well if everyone does the same thing, where would all these midlevels go? Their schools are pumping out more and more graduates, especially since it's increasingly easy to get a useless degree online. If you are going teach them to do everything you do, you can tell the unemployment office about how you are really good at thinking through problems.

When I want to intubate my patient or put a line in, that's what I'm going to do. I don't see why I should just stand there to "supervise" a lesser trained person to do everything while taking all the blame for things done by others without being paid for it. Thanks but no thanks.

 

[Kuratz]

Mid levels and particularly NPs are pushing hard for more and more clinical territory. In 10 years, when many of us medical students are starting to get established in practice, the problem will almost certainly be worse. So of course many of us get wound up about the issue. It may start with central lines or vessel graft harvests but then could very foreseeably go into appys, hernias etc. Physicians aren't just fighting midlevels on this issues, but also hospital administrators which is a huge deal. Just wait until some MBAs require general surgeons to teach midlevels basic surgeries as part of their contracts. It's really not a stretch. Attendings on here taking a pro-midlevel stance which is fine since they live the reality of practice everyday and should have a better view of things, but I will say the vast majority of my classmates do not see the current generation of attendings as good stewards of the profession. It's depressing.