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

[Goro]

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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

So that's why I heard exploding heads off in the distance!



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).
It dawned upon me that the OP cited a reddit post. Just keep in mind that reddit is the cesspool of the internet.

 

[Goro]

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

Hospital or HMO CFOs?

 

[Lexdiamondz]

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.

Facts. The reality is that the ****show that is medicine today largely happened under their watch, and the short term gains in income that they get from midlevels will screw the generation behind them severalfold.

 

[Black Coffee 24/7]

Hospital or HMO CFOs?

Nope. Just uncaring ignorance from current docs right now bc they got their own paperwork, buttons to click, and collegiate workflow to worry about to gaf about the slow assault on medical education to medical students and residents.

 

[Goro]

Nope. Just uncaring ignorance from current docs right now bc they got their own paperwork, buttons to click, and collegiate workflow to worry about to gaf about the slow assault on medical education to medical students and residents.

This is like blaming the quarterbacks for the ineptitude of General Mgrs.

 

[Black Coffee 24/7]

This is like blaming the quarterbacks for the ineptitude of General Mgrs.

Except that docs are franchise qbs who being in 90% of the revenue.

 

[Aerus]

Why not just refuse and go work elsewhere?

That's what usually happens, but it is frustrating nonetheless.

 

[Aerus]

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.

The sad part is that the future generation of doctors have to fight both the midlevel encroachment AND the battle on our own turf. Many of these physicians will be out of practice by the time this becomes a large issue. Right now, they're fine selling out medicine to make the job easier.

 

[Black Coffee 24/7]

The sad part is that the future generation of doctors have to fight both the midlevel encroachment AND the battle on our own turf. Many of these physicians will be out of practice by the time this becomes a large issue. Right now, they're fine selling out medicine to make the job easier.

Read the thread in the EM forum about one doc being fine with it as long as he co-signs the PA charts and notes at home and then receives all the extra RVUs to his bottom line. It’s pretty disgusting, but he certainly is part of the majority of docs out there right now.

 

[alprazoslam]

So that's why I heard exploding heads off in the distance!



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).
It dawned upon me that the OP cited a reddit post. Just keep in mind that reddit is the cesspool of the internet.

They have the actual article on the ND PA websitr

 

[alprazoslam]

Those being pro midlevel- it’s not about lines and intubation. I could care less about those. Did plenty as a nurse (lol not Spose to but they let us intubate and put in femorals w surgeons in the room. Not fun, didn’t enjoy after a few).


It’s about as the others are saying training our replacements. NPs are out to take jobs. Why otherwise would they make all these equivalence studies? Just take a look at how PRO midlevel medscape articles are. To think it’s simply about “cool procedures” it’s like thinking the Boston tea parry was due to a dislike of tea.
It’s worse we got attendings on here being OK with it thinking it’s a bunch of whiny med students crying over who can Snapchat the coolest selfy after throwing in an art line.

I assure you we will see (if not already out or in progress) some BS study saying how much better midlevels are at XYZ line placement vs physicians

A lot of places used midlevels properly, and an assistant, writer of h and ps, and for simple patient presentations

 

[943710]

Those being pro midlevel- it’s not about lines and intubation. I could care less about those. Did plenty as a nurse (lol not Spose to but they let us incubate and put in femorals w surgeons in the room. Not fun, didn’t enjoy after a few).


It’s about as the others are saying training our replacements. NPs are out to take jobs. Why otherwise would they make all these equivalence studies? Just take a look at how PRO midlevel medscape articles are. To think it’s simply about “cool procedures” it’s like thinking the Boston tea parry was due to a dislike of tea.
It’s worse we got attendings on here being OK with it thinking it’s a bunch of whiny med students crying over who can Snapchat the coolest selfy after throwing in an art line.

I assure you we will see (if not already out or in progress) some BS study saying how much better midlevels are at XYZ line placement vs physicians

Then why is no one doing anything about it?

 

[Aerus]

Then why is no one doing anything about it?

Because we are fighting on two fronts: against them and against a lot of doctors (as seen in this thread). Many current doctors do not think it's an actual problem. It doesn't help that the current media and culture is super pro-midlevel. NPs basically control how healthcare is perceived to the general public.

 

[Ho0v-man]

Then why is no one doing anything about it?

Bc med students are still years away from being allowed to question the powers that be without tanking their careers.

 

[MedicineZ0Z]

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.

Ok... but you quickly stop doing it and never do it again. You should absolutely learn and I've done so myself and practiced. But poking veins doesn't train you to intubate a crashing patient at 3am. Nor does it train you to intubate a difficult airway without calling anesthesia. Who do you want intubating people out in the rural areas with no anesthesia within 75 miles? Someone who has done it since ms3 and has improved their technique slowly and mastered it over residency? Or someone who wasn't even doing it properly until pgy2?

 

[MedicineZ0Z]

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.

This whole "attendings know best" is pure nonsense. I've talked to at least 40-50 attendings about this issue, if not more (seriously). I can count on one hand the number who even had a good grasp of the midlevel issue. Most viewed it as bad, many viewed the midlevels as a positive but neither had any real reason why.
Truth is - no one is thinking about the profession and the severe damage midlevels are causing it.

 

[alprazoslam]

Then why is no one doing anything about it?

I don’t have the answer to that but I guess bc nobody’s wallet has gotten skinny yet

 

[deleted87051]

Ok... but you quickly stop doing it and never do it again. You should absolutely learn and I've done so myself and practiced. But poking veins doesn't train you to intubate a crashing patient at 3am. Nor does it train you to intubate a difficult airway without calling anesthesia. Who do you want intubating people out in the rural areas with no anesthesia within 75 miles? Someone who has done it since ms3 and has improved their technique slowly and mastered it over residency? Or someone who wasn't even doing it properly until pgy2?

What if your crashing patient at 3am has no IV access? What if they have an airway but they’re bleeding to death? There’s no reason to stop doing them and lose proficiency.

If I had a crashing patient who needed an airway and I was inexperienced at intubation, I’d slip in an LMA which is one of the easiest procedures in all of medicine. It’s damned near idiot proof. Every anesthesiologist has stories about how the LMA saved their ass. Remember ventilation is the goal, not intubation.

And if you’re going into anesthesia, it won’t matter whether you did zero or 50 intubations as a medical student. All CA-1s are expected to suck bigly and do. We learn to be less sucky during residency.

 

[Black Coffee 24/7]

What if your crashing patient at 3am has no IV access? What if they have an airway but they’re bleeding to death? There’s no reason to stop doing them and lose proficiency.

If I had a crashing patient who needed an airway and I was inexperienced at intubation, I’d slip in an LMA which is one of the easiest procedures in all of medicine. It’s damned near idiot proof. Every anesthesiologist has stories about how the LMA saved their ass. Remember ventilation is the goal, not intubation.

And if you’re going into anesthesia, it won’t matter whether you did zero or 50 intubations as a medical student. All CA-1s are expected to suck bigly and do. We learn to be less sucky during residency.

And yet we keep having threads in the Gas forum posted by current attending physicians about how the incoming residents suck at everything.

Which is it, doc?

 

[deleted87051]

And yet we keep having threads in the Gas forum posted by current attending physicians about how the incoming residents suck at everything.

Which is it, doc?

We do?? That’s news to me.

No one expects any procedural skills from a beginning CA-1. Everyone on the anesthesia forum emphasizes that med students and interns focus on learning medicine, not procedures. You will be drowning in procedures during residency.

 

[943710]

Are mid-levels much of a threat to IM subspecialties?

 

[MedicineZ0Z]

What if your crashing patient at 3am has no IV access? What if they have an airway but they’re bleeding to death? There’s no reason to stop doing them and lose proficiency.

If I had a crashing patient who needed an airway and I was inexperienced at intubation, I’d slip in an LMA which is one of the easiest procedures in all of medicine. It’s damned near idiot proof. Every anesthesiologist has stories about how the LMA saved their ass. Remember ventilation is the goal, not intubation.

And if you’re going into anesthesia, it won’t matter whether you did zero or 50 intubations as a medical student. All CA-1s are expected to suck bigly and do. We learn to be less sucky during residency.

Well one of those things a nearby nurse can do whereas the other stuff they cannot. Also, not sure why in 2018 it's a stretch to expect graduating doctors to have airway skills? What if a graduate ends up as a rural FM covering the ED?

We do?? That’s news to me.

No one expects any procedural skills from a beginning CA-1. Everyone on the anesthesia forum emphasizes that med students and interns focus on learning medicine, not procedures. You will be drowning in procedures during residency.

Actually doing the procedure helps you learn the medicine associated with it... when you do the intubation itself and see the drugs used and why; it'll actually sink in more.
Also, what's the issue with having incoming residents have fundamental procedural skills? You know the basics, and build on it. It's also far less intimidating when you have a couple out of the way.

 

[AlbinoHawk DO]

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.

Then your program is a **** hole. A physician should never have to be supervised by a mid level or get to do any procedure unless all physicians don't want it

 

[deleted87051]

Well one of those things a nearby nurse can do whereas the other stuff they cannot. Also, not sure why in 2018 it's a stretch to expect graduating doctors to have airway skills? What if a graduate ends up as a rural FM covering the ED?

Actually doing the procedure helps you learn the medicine associated with it... when you do the intubation itself and see the drugs used and why; it'll actually sink in more.
Also, what's the issue with having incoming residents have fundamental procedural skills? You know the basics, and build on it. It's also far less intimidating when you have a couple out of the way.

I don’t want to keep going back and forth but I have the benefit of hindsight and know how unimportant it is to do a handful of intubations as a medical student. If you get some, great! If not or you miss your first 5intubations, don’t worry about it. It may seem important to you now but it will in no way affect your development as a physician. I think you’ll realize that too as you get farther into your training. Peace.

 

[Stagg737]

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.

To the bolded: HELL NO. That's a bs attitude and frankly you should know better. If you don't, then you haven't worked with enough midlevels. Improper care can be worse than no treatment at all and we shouldn't be allowing individuals who don't even know that Nystatin isn't for high cholesterol (I can't tell you how many NPs I've talked to who don't know this) to be seeing patient unsupervised.

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).

I understand what you're saying, but I feel like you're also forgetting that a large part of med school and experiencing as much "cool stuff" as possible is so medical students can figure out what field they want to enter. As others have said, no one is going to get competent at performing procedures by learning them in medical school. But if they never have the opportunity to get those experiences how will they know if they want to enter those fields? Coming into med school I was 99% certain I wanted to do surgery. After my surgery rotation where I got to first assist quite a bit, I realized it wasn't for me. I wouldn't have known that if I didn't get the chance to get my hands dirty. I also was almost 100% sure I wouldn't even consider psych, and after doing my rotations in with an attending who basically treated me like a resident, I realized I loved it. No way that would have happened if I'd just been watching an attending or the residents do all the H+P's while I did grunt work.

Maybe you knew you were going into FM from before clinical rotations. If so, then yes, it would have been more beneficial for you to see more consults. However, most people don't know what they actually want to do going into 3rd year and many who do end up changing their minds (like me). So getting a plethora of experiences is important.

Then why is no one doing anything about it?

Some of us are. I'm in a group of ~10,000 physicians and residents who are fighting inappropriate mid-level expansion through legislation and we've had some successes. Problem is that the nursing lobby and organizations are far more powerful and united. Imo physicians aren't going to know what hit them until it's too late. You just have to hope your field is protected enough to have minimal impact on your practice.

Are mid-levels much of a threat to IM subspecialties?

Depends on the field. For example there are now cardiac NPs seeing and treating patients independently and calling themselves cardiologists. They're not doing procedures like caths in the US yet, but they are seeing patients in clinic and managing their meds.

 

[sinombre]

Then your program is a **** hole. A physician should never have to be supervised by a mid level or get to do any procedure unless all physicians don't want it

🙄

A new intern placing a central line should absolutely be supervised by someone who has done a lot of them, and a mid level on a trauma service who has been doing them for years is perfectly fine. As is a more senior resident. Or attending.

You could train anyone to do ICU procedures. You just have to understand the anatomy, possible complications, and how to deal with them when they arise.

Not sure why that is controversial. New NPs or PAs are not the ones supervising new interns.

 

[943710]

To the bolded: HELL NO. That's a bs attitude and frankly you should know better. If you don't, then you haven't worked with enough midlevels. Improper care can be worse than no treatment at all and we shouldn't be allowing individuals who don't even know that Nystatin isn't for high cholesterol (I can't tell you how many NPs I've talked to who don't know this) to be seeing patient unsupervised.



I understand what you're saying, but I feel like you're also forgetting that a large part of med school and experiencing as much "cool stuff" as possible is so medical students can figure out what field they want to enter. As others have said, no one is going to get competent at performing procedures by learning them in medical school. But if they never have the opportunity to get those experiences how will they know if they want to enter those fields? Coming into med school I was 99% certain I wanted to do surgery. After my surgery rotation where I got to first assist quite a bit, I realized it wasn't for me. I wouldn't have known that if I didn't get the chance to get my hands dirty. I also was almost 100% sure I wouldn't even consider psych, and after doing my rotations in with an attending who basically treated me like a resident, I realized I loved it. No way that would have happened if I'd just been watching an attending or the residents do all the H+P's while I did grunt work.

Maybe you knew you were going into FM from before clinical rotations. If so, then yes, it would have been more beneficial for you to see more consults. However, most people don't know what they actually want to do going into 3rd year and many who do end up changing their minds (like me). So getting a plethora of experiences is important.



Some of us are. I'm in a group of ~10,000 physicians and residents who are fighting inappropriate mid-level expansion through legislation and we've had some successes. Problem is that the nursing lobby and organizations are far more powerful and united. Imo physicians aren't going to know what hit them until it's too late. You just have to hope your field is protected enough to have minimal impact on your practice.



Depends on the field. For example there are now cardiac NPs seeing and treating patients independently and calling themselves cardiologists. They're not doing procedures like caths in the US yet, but they are seeing patients in clinic and managing their meds.

Interesting. Is your group growing quite a bit?

 

[AlbinoHawk DO]

🙄

A new intern placing a central line should absolutely be supervised by someone who has done a lot of them, and a mid level on a trauma service who has been doing them for years is perfectly fine. As is a more senior resident. Or attending.

You could train anyone to do ICU procedures. You just have to understand the anatomy, possible complications, and how to deal with them when they arise.

Not sure why that is controversial. New NPs or PAs are not the ones supervising new interns.

You should be supervised, but you shouldn't be supervised by a PA or an NP. Yes, they are probably capable, but no, it's not okay to muddy the hierarchy.

 

[alprazoslam]

To the bolded: HELL NO. That's a bs attitude and frankly you should know better. If you don't, then you haven't worked with enough midlevels. Improper care can be worse than no treatment at all and we shouldn't be allowing individuals who don't even know that Nystatin isn't for high cholesterol (I can't tell you how many NPs I've talked to who don't know this) to be seeing patient unsupervised.



I understand what you're saying, but I feel like you're also forgetting that a large part of med school and experiencing as much "cool stuff" as possible is so medical students can figure out what field they want to enter. As others have said, no one is going to get competent at performing procedures by learning them in medical school. But if they never have the opportunity to get those experiences how will they know if they want to enter those fields? Coming into med school I was 99% certain I wanted to do surgery. After my surgery rotation where I got to first assist quite a bit, I realized it wasn't for me. I wouldn't have known that if I didn't get the chance to get my hands dirty. I also was almost 100% sure I wouldn't even consider psych, and after doing my rotations in with an attending who basically treated me like a resident, I realized I loved it. No way that would have happened if I'd just been watching an attending or the residents do all the H+P's while I did grunt work.

Maybe you knew you were going into FM from before clinical rotations. If so, then yes, it would have been more beneficial for you to see more consults. However, most people don't know what they actually want to do going into 3rd year and many who do end up changing their minds (like me). So getting a plethora of experiences is important.



Some of us are. I'm in a group of ~10,000 physicians and residents who are fighting inappropriate mid-level expansion through legislation and we've had some successes. Problem is that the nursing lobby and organizations are far more powerful and united. Imo physicians aren't going to know what hit them until it's too late. You just have to hope your field is protected enough to have minimal impact on your practice.



Depends on the field. For example there are now cardiac NPs seeing and treating patients independently and calling themselves cardiologists. They're not doing procedures like caths in the US yet, but they are seeing patients in clinic and managing their meds.

They use holistic nystatin - treats fungus and cholesterol. Great things happen when tou actually care about patients like they do

 

[VA Hopeful Dr]

I understand what you're saying, but I feel like you're also forgetting that a large part of med school and experiencing as much "cool stuff" as possible is so medical students can figure out what field they want to enter. As others have said, no one is going to get competent at performing procedures by learning them in medical school. But if they never have the opportunity to get those experiences how will they know if they want to enter those fields? Coming into med school I was 99% certain I wanted to do surgery. After my surgery rotation where I got to first assist quite a bit, I realized it wasn't for me. I wouldn't have known that if I didn't get the chance to get my hands dirty. I also was almost 100% sure I wouldn't even consider psych, and after doing my rotations in with an attending who basically treated me like a resident, I realized I loved it. No way that would have happened if I'd just been watching an attending or the residents do all the H+P's while I did grunt work.

Maybe you knew you were going into FM from before clinical rotations. If so, then yes, it would have been more beneficial for you to see more consults. However, most people don't know what they actually want to do going into 3rd year and many who do end up changing their minds (like me). So getting a plethora of experiences is important.

I've long been a proponent of students having as much independent on rotations as is safe. When I have students with me, they see the patient alone, come up with a plan, present to me and then we go in together to see them. That's how it should be. That'll tell you whether you like FM, IM, Peds, or psych (4 of the 8 core rotations). On OB you should catch at least 1 baby. Surgery you should scrub in a handful of cases, even if you just hold the retractor. Most people from what I remember know pretty quickly whether or not they enjoy the OR. Maybe my class was weird, but people knew pretty quickly on each rotation whether or not it was for them.

Beyond that, what is of significant value is learning the bread and butter cases of each field and how they deal with them. It'll help in future interactions with other fields which is much more important that it seems.

 

[Matthew9Thirtyfive]

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 knew there was still good in you.

 

[VincentAdultman]

Two things:

1. I don't see anything wrong with midlevels teaching interns technical things.

2. My favorite thing in the world about SDN is reading med students lecturing residents (and above) about the way it should be.

 

[Goro]

Two things:

1. I don't see anything wrong with midlevels teaching interns technical things.

2. My favorite thing in the world about SDN is reading med students lecturing residents (and above) about the way it should be.

And premeds lecturing med students (and above) about the way it should be!

 

[VincentAdultman]

And premeds lecturing med students (and above) about the way it should be!

Yeah I don’t go there much. The angst is palpable.

 

[Goro]

Yeah I don’t go there much. The angst is palpable.

🤣🤣🤣🤣🤣🤣🤣🤣🤣🤣🤣🤣🤣
😆😆😆😆😆😆😆😆😆😆😆😆😆😆😆😆😆😆😆😆😆

 

[MedicineZ0Z]

Two things:

1. I don't see anything wrong with midlevels teaching interns technical things.

2. My favorite thing in the world about SDN is reading med students lecturing residents (and above) about the way it should be.

Cause people higher on the hierarchy doesn't mean you understand education. And this so called hierarchy is screwed over by nurses and assistants teaching doctors.

 

[235009]

You should be supervised, but you shouldn't be supervised by a PA or an NP. Yes, they are probably capable, but no, it's not okay to muddy the hierarchy.

You should be supervised by whoever has more experience doing the procedure. Putting the hierarchy ahead of patient care is ridiculous. As a PCCM fellow I've had NPs, PAs, PGY2 surgical and anesthesia residents supervise some of my procedures. Check your ego at the door and do what's best for the patient.

This whole "attendings know best" is pure nonsense. I've talked to at least 40-50 attendings about this issue, if not more (seriously). I can count on one hand the number who even had a good grasp of the midlevel issue. Most viewed it as bad, many viewed the midlevels as a positive but neither had any real reason why.
Truth is - no one is thinking about the profession and the severe damage midlevels are causing it.

We no longer make the rules....

The hospital administrators have made it so that now physicians have to see more patients, write more notes, bill more accurately etc while medical care has gotten infinitely more complicated so now you have to look up more stuff, pore over years of medical records, manage multiple comorbidities, talk to more consultants just to take care of the same number of patients. Hospital administration have created all kinds of rules and reimbursement structures that we have to abide by. If you're getting paid based on notes and billing which is done after you round on patients there is no way you're going to spend 30-60 minutes doing a single procedure instead of rounding on 3-4 patients. In fact you can have the PA/NP call you into the room when they're ready to do the main part of the procedure (after all the setup) and still bill for supervising. The current system (as you see above) wasn't created by the current generation of attendings. It dates back to the 80s and 90s and is directly linked to healthcare as a business in the US and the death of health care reform in the 90s. Unless we somehow are able to pass single payer healthcare this is just going to keep getting worse and there's nothing we can do about it. It's too late.

Two things:

1. I don't see anything wrong with midlevels teaching interns technical things.

2. My favorite thing in the world about SDN is reading med students lecturing residents (and above) about the way it should be.

Amen to #2. And of course they approach everything with the view that the med student should be the center of the universe.

 

[VincentAdultman]

Cause people higher on the hierarchy doesn't mean you understand education. And this so called hierarchy is screwed over by nurses and assistants teaching doctors.

Cool.

If you're getting paid based on notes and billing which is done after you round on patients there is no way you're going to spend 30-60 minutes doing a single procedure instead of rounding on 3-4 patients.

Yeppppppppp

 

[Lawpy]

You should be supervised by whoever has more experience doing the procedure. Putting the hierarchy ahead of patient care is ridiculous. As a PCCM fellow I've had NPs, PAs, PGY2 surgical and anesthesia residents supervise some of my procedures. Check your ego at the door and do what's best for the patient.

Well you're likely working in a good hospital that knows what they're doing if midlevels carrying out procedures and supervising medical trainees didn't endanger patient outcomes.

 

[AlbinoHawk DO]

You should be supervised by whoever has more experience doing the procedure. Putting the hierarchy ahead of patient care is ridiculous. As a PCCM fellow I've had NPs, PAs, PGY2 surgical and anesthesia residents supervise some of my procedures. Check your ego at the door and do what's best for the patient.

I think it's ridiculous that you believe that. Patient care is obviously essential, but by your logic, only experienced people should ever do it; it's the only way so ensure patients get the best. The point of the hierarchy is not to belittle anyone or agrandice oneself. It's there to ensure order. It's there so PA and NPs don't second guess doctors. It's there so these PAs and NPs don't go to the state and say "look, I am even better that doctors because I train them. Now give me more independent rights." The moment you allow this erosion, it's on you that the profession has its midlevel encroachment. There's a reason why the military doesn't allow their newly minted second lieutenant be supervised by their highest sargeant.

 

[lemurcatta]

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.

You seem to have a very narrow view of how things tend to work. I am at what might be the largest academic center in the midwest, and here is a just one tiny little insight for you: I spent some time on heme onc, and saw that most of the bone marrow biopsies are done by PAs and fellows. The PAs do so many of them they are often showing the new heme/onc fellows how to do them. PAs are not teaching fellows or residents how to think like doctors. The fellows and the PAs get along splendidly, as do the attendings and PAs. It's all pretty cool actually. The PAs and the docs all know that PAs are not going to replace oncologists. They do a good job of keeping the service running smoothly, especially when new people oct eon service, and they know their roles well.

 

[VincentAdultman]

I think it's ridiculous that you believe that. Patient care is obviously essential, but by your logic, only experienced people should ever do it; it's the only way so ensure patients get the best. The point of the hierarchy is not to belittle anyone or agrandice oneself. It's there to ensure order. It's there so PA and NPs don't second guess doctors. It's there so these PAs and NPs don't go to the state and say "look, I am even better that doctors because I train them. Now give me more independent rights." The moment you allow this erosion, it's on you that the profession has its midlevel encroachment. There's a reason why the military doesn't allow their newly minted second lieutenant be supervised by their highest sargeant.

I read this post a couple times and I’m not sure at all how it’s relevant to what meatornado was saying.

 

[235009]

I think it's ridiculous that you believe that. Patient care is obviously essential, but by your logic, only experienced people should ever do it; it's the only way so ensure patients get the best. The point of the hierarchy is not to belittle anyone or agrandice oneself. It's there to ensure order. It's there so PA and NPs don't second guess doctors. It's there so these PAs and NPs don't go to the state and say "look, I am even better that doctors because I train them. Now give me more independent rights." The moment you allow this erosion, it's on you that the profession has its midlevel encroachment. There's a reason why the military doesn't allow their newly minted second lieutenant be supervised by their highest sargeant.

1. I'm saying that an experienced person should supervise the procedure. Of course if you go to a teaching hospital you should expect that a trainee is going to participate in your care as long as they are appropriately supervised and that ensures good patient care.

2. No one is talking about medical decision making. We're talking about bedside procedures. Not sure where "second guessing" fits in here. That being said if an experienced NP or PA who has been working in the same role for 5/10/20 years thinks something isn't being done correctly they should absolutely speak up in a respectful and collegial manner. Same goes for nurses, dietitians, x-ray techs, and janitors. Your view that the physician is the dictator and should never be questioned is antiquated and dangerous. Catch up.

3. This isn't how the world works. Independence comes with liability. If they're willing to take on the liability (which they aren't) and still take the lower pay then they'll immediately be granted independence because healthcare in the US is a business and they want the cheapest labor. Of course the reality is that they aren't willing to take on the same liability as the physicians for less pay.

 

[Stagg737]

Interesting. Is your group growing quite a bit?

Yep. I joined about 4 months ago and there were about 7,000 people then I think.

I've long been a proponent of students having as much independent on rotations as is safe. When I have students with me, they see the patient alone, come up with a plan, present to me and then we go in together to see them. That's how it should be. That'll tell you whether you like FM, IM, Peds, or psych (4 of the 8 core rotations). On OB you should catch at least 1 baby. Surgery you should scrub in a handful of cases, even if you just hold the retractor. Most people from what I remember know pretty quickly whether or not they enjoy the OR. Maybe my class was weird, but people knew pretty quickly on each rotation whether or not it was for them.

Beyond that, what is of significant value is learning the bread and butter cases of each field and how they deal with them. It'll help in future interactions with other fields which is much more important that it seems.

I agree with you, but we also both know that not all medical students get those experiences and sometimes the mid-levels are given preference over the med students with those experiences. Sorry if you disagree, but I didn't pay 40k/yr in tuition to watch mid-levels be trained to do something that I am paying to learn to do.

3. This isn't how the world works. Independence comes with liability. If they're willing to take on the liability (which they aren't) and still take the lower pay then they'll immediately be granted independence because healthcare in the US is a business and they want the cheapest labor. Of course the reality is that they aren't willing to take on the same liability as the physicians for less pay.

Except irl this isn't what's happening. In states with independent practice NPs are not held to the same levels of liability as their physician counterparts and are sometimes paid just as much. They don't have to be willing to take on her liability because no one is holding them liable. So no, the independence does not come with the liability. If you think it does then you need to look into what is happening both legally and in terms of the licensing bodies holding their respective practitioners accountable (BON almost never takes action against NPs). So yes, that is how the world (of medicine) works.

 

[MedicineZ0Z]

You seem to have a very narrow view of how things tend to work. I am at what might be the largest academic center in the midwest, and here is a just one tiny little insight for you: I spent some time on heme onc, and saw that most of the bone marrow biopsies are done by PAs and fellows. The PAs do so many of them they are often showing the new heme/onc fellows how to do them. PAs are not teaching fellows or residents how to think like doctors. The fellows and the PAs get along splendidly, as do the attendings and PAs. It's all pretty cool actually. The PAs and the docs all know that PAs are not going to replace oncologists. They do a good job of keeping the service running smoothly, especially when new people oct eon service, and they know their roles well.

Hahahahah. Can't even believe you genuinely think is true. They're turning doctors into medical managers. The end goal is have 1 doctor oversee a dozen midlevels and shave the market demand for physicians in half.

Compare 2018 to 2018 or 1998. How many midlevels picked up the phone to answer consults? How many did the biopsies back then? How many CRNAs were supervised back then vs now?
I know how it works in real life dude. It's actually a lot worse than we make it out to be in this thread. You have a very 1 dimensional view and can't see the nationwide trend. Especially with there being exponentially more PA NP schools every year.

 

[MedicineZ0Z]

Yep. I joined about 4 months ago and there were about 7,000 people then I think.



I agree with you, but we also both know that not all medical students get those experiences and sometimes the mid-levels are given preference over the med students with those experiences. Sorry if you disagree, but I didn't pay 40k/yr in tuition to watch mid-levels be trained to do something that I am paying to learn to do.



Except irl this isn't what's happening. In states with independent practice NPs are not held to the same levels of liability as their physician counterparts and are sometimes paid just as much. They don't have to be willing to take on her liability because no one is holding them liable. So no, the independence does not come with the liability. If you think it does then you need to look into what is happening both legally and in terms of the licensing bodies holding their respective practitioners accountable (BON almost never takes action against NPs). So yes, that is how the world (of medicine) works.

All the pro-midlevel doctors in here are literally delusional. It's easy to think one way when your experience is limited to one hospital and/or one state. Every post starts with..."well in my hospital.."

 

[VincentAdultman]

Hahahahah. Can't even believe you genuinely think is true. They're turning doctors into medical managers. The end goal is have 1 doctor oversee a dozen midlevels and shave the market demand for physicians in half.

Compare 2018 to 2018 or 1998. How many midlevels picked up the phone to answer consults? How many did the biopsies back then? How many CRNAs were supervised back then vs now?
I know how it works in real life dude. It's actually a lot worse than we make it out to be in this thread. You have a very 1 dimensional view and can't see the nationwide trend. Especially with there being exponentially more PA NP schools every year.

“Let me, a person you don’t know, tell you how your personal experience is totally wrong.”

 

[Goro]

Cause people higher on the hierarchy doesn't mean you understand education. And this so called hierarchy is screwed over by nurses and assistants teaching doctors.

You lost me on this one, Z. Why does the idea or a PA teaching you a skill set offend you? The mindset of "how dare those peasants teach me, God's anointed, anything" isn't going to win many converts to your original complaint.

And a note to hawkie, I've heard from numerous ex-Army friends that in a combat situation, there is nothing more dangerous to a platoon that a newly minted lieutenant.

 

[VA Hopeful Dr]

“Let me, a person you don’t know, tell you how your personal experience is totally wrong.”

"And how my personal experience is right"

 

[RNthenDoc]

There are RNs teaching skills at my allopathic medical school. RNs! THE AUDACITY!

I’m not saying I’m siding with the “pro mid level encroachment” crowd, I’m just saying that I want to be trained on XYZ procedure by whoever can make me the best at it, regardless of initials.

That’s entirely different than clinical site liaisons/rotations/actual meat and potatoes med-ed. But if we are talking about a nurse/PA level task it isn’t shocking that they will be the best at it/the ones in the room most competent to teach it.


The midlevel encroachment argument is *valid,* but I think this specific issue is a bit tangential to it.