Never Waste a Crisis

[alphaholic06]

Advertisement - Members don't see this ad

AAPA Won’t Rest Until PAs are Fully Empowered to Respond to COVID-19

What is AAPA doing to respond to the COVID-19 crisis? We are aggressively advocating on behalf of PAs and their patients, providing members with important resources, and raising public awareness about the profession.

www.aapa.org

Sent from my SM-T830 using SDN mobile

 

[deleted480308]

AAPA Won’t Rest Until PAs are Fully Empowered to Respond to COVID-19

What is AAPA doing to respond to the COVID-19 crisis? We are aggressively advocating on behalf of PAs and their patients, providing members with important resources, and raising public awareness about the profession.

www.aapa.org

View attachment 302452

Sent from my SM-T830 using SDN mobile

Maybe people can stop pretending they don’t want independent practice now

 

[RustedFox]

The only way out of this situation is to give them what they want and watch them drown when the public figures out via trial and error (and harm) that the Dunning-Kruger force is strong with the MLP crowd. Granted [PA] is light-years better than [NP], but it still ain't [MD/DO].

 

[erdoc00]

I think part of the problem here is that many doctors act like mid-levels so the mid-levels have convinced themselves (and the public) that practicing medicine doesnt require medical school and residency. This is further compounded by the fact that much of medical care at this point has become a song and dance routine, and many patients who receive treatment actually require nothing.

I'm in the camp that the best way to solve this is to grant them independent practice and expose their ignorance.

The mid-level sentiment seems to be the general trend of society though which is that everyone wants to reap the rewards but nobody wants to put in the time and effort required or accept the responsibility.

 

[SXMMD]

A huge proportion of care we provide is to the worried well. Optics on outcomes by midlevels probably won't be good, but they may not be as bad as we tell ourselves they would be.

 

[RustedFox]

A huge proportion of care we provide is to the worried well. Optics on outcomes by midlevels probably won't be good, but they may not be as bad as we tell ourselves they would be.

See, I thought about this as well; but I can't help but think about the long list of ER referrals from the batallions of Jenny McJennysons that are completely misdiagnosed and mismanaged. Maybe its particularly bad in my area (west Florida), but it really is about the rate of 1.5+ phone calls an hour that a Jenny makes to our shop that I have to field.

 

[BoardingDoc]

See, I thought about this as well; but I can't help but think about the long list of ER referrals from the batallions of Jenny McJennysons that are completely misdiagnosed and mismanaged. Maybe its particularly bad in my area (west Florida), but it really is about the rate of 1.5+ phone calls an hour that a Jenny makes to our shop that I have to field.

Do you anticipate that things will change if they have independent practice? My concern is that they will simply do even more of this so that they can keep seeing all the worried well BS and then when anyone actually requires a doctor (or they're too dumb to realize that they don't) they just send them to the ED.

 

[RustedFox]

Do you anticipate that things will change if they have independent practice? My concern is that they will simply do even more of this so that they can keep seeing all the worried well BS and then when anyone actually requires a doctor (or they're too dumb to realize that they don't) they just send them to the ED.

No. I actually anticipate it getting worse with respect to more nonsense referrals and mismanagement.
It will only be after the physicians see them and point out the gross mismanagement (to the patients) that the muggles will then begin to demand to see a physician. This will only happen after the muggle realizes that it was their choice to see a MLP that put his/herself in danger.
Of course, we will need to refuse to give feedback to the MLPs (positive or negative). Just give them the silent treatment.

 

[NYEMMED]

I think part of the problem here is that many doctors act like mid-levels so the mid-levels have convinced themselves (and the public) that practicing medicine doesnt require medical school and residency. This is further compounded by the fact that much of medical care at this point has become a song and dance routine, and many patients who receive treatment actually require nothing.

I'm in the camp that the best way to solve this is to grant them independent practice and expose their ignorance.

The mid-level sentiment seems to be the general trend of society though which is that everyone wants to reap the rewards but nobody wants to put in the time and effort required or accept the responsibility.

Let them have independent practice; but remove any supervising physician requirements, remove any physician from having to sign their chart, etc... You want to be independent? Then get sued independently...

The lawsuits against them would probably spike and limit their growth...

 

[docB]

I think part of the problem here is that many doctors act like mid-levels so the mid-levels have convinced themselves (and the public) that practicing medicine doesnt require medical school and residency. This is further compounded by the fact that much of medical care at this point has become a song and dance routine, and many patients who receive treatment actually require nothing.

I'm in the camp that the best way to solve this is to grant them independent practice and expose their ignorance.

The mid-level sentiment seems to be the general trend of society though which is that everyone wants to reap the rewards but nobody wants to put in the time and effort required or accept the responsibility.

You make some really good points, particularly that too many doctors function like MLPs. I think that this is because we have allowed ourselves to be forced to see so many patients (in the EDs and primary care) that no one can stop and think about anything. Everything has to be done as react, order, turf. This has happened because almost every specialty has increased volume as the way to keep income stable despite decreased payments and increased unpaid metrics. This is actually the phenomena that has led to the steadily increasing roles of MLPs in general.

I don't think that their ignorance will be exposed if they are made independent. The system is too opaque and the public is too ignorant of what appropriate medicine is to judge. That's why we're in a situation where a crappy doctor with a used car salesman bedside manner is held in higher esteem by the system than a great clinician who doesn't inspire 5s.

 

[alphaholic06]

Agreed. If they are going to be independent, they don't need a physician to sign their charts and provide legal cover against malpractice suits. Be truly independent.

Let them have independent practice; but remove any supervising physician requirements, remove any physician from having to sign their chart, etc... You want to be independent? Then get sued independently...

The lawsuits against them would probably spike and limit their growth...

"Adversity introduces a man to himself."

 

[docB]

No. I actually anticipate it getting worse with respect to more nonsense referrals and mismanagement.
It will only be after the physicians see them and point out the gross mismanagement (to the patients) that the muggles will then begin to demand to see a physician. This will only happen after the muggle realizes that it was their choice to see a MLP that put his/herself in danger.
Of course, we will need to refuse to give feedback to the MLPs (positive or negative). Just give them the silent treatment.

I get your point but sadly I don't think any of it will ever make any difference. Americans will rattle off a lot of wants in their health care system but those all go right out the window if they're forced to pull out their wallets. If demanding to see the physician means an extra $50 on your copay those demands will disappear. There won't even be an option for the no co pay folks i.e. Medicaid.

Even if there were a demand for doctors at a higher price the patients are not good at self triage so we'd likely wind up seeing anxious silliness rather than the serious cases. Think of the patients you saw last shift, the 20yo with normal everything who knows they're going to die immediately from their mild gastritis right next to the 85yo chemo patient with no blood cells of any kind and a temp of 93 who says he feels ok and wants to go home if maybe he could just get a Tylenol.

 

[Rekt]

I'm confused on how they're going to magically increase their medical knowledge. What do they expect? They're going to take an ED admit that's intubated, presumed Covid +, history of ESRD, CAD, HTN, DM, etc.? ED doc says "Thanks, someone else is crashing, gotta go!".

There's a good amount of things that mid-levels are great at Googling/UpTodate-ing, but ventilator managet, complex medical patients, and multi-system failure isn't one of them. They'll run back crying to the intensivist immediately as soon as they even see the "breathing box".

 

[docB]

I'm confused on how they're going to magically increase their medical knowledge. What do they expect? They're going to take an ED admit that's intubated, presumed Covid +, history of ESRD, CAD, HTN, DM, etc.? ED doc says "Thanks, someone else is crashing, gotta go!".

There's a good amount of things that mid-levels are great at Googling/UpTodate-ing, but ventilator managet, complex medical patients, and multi-system failure isn't one of them. They'll run back crying to the intensivist immediately as soon as they even see the "breathing box".

One problem with what we do is that it looks easy most of the time. That's why so many experienced nurses have a lot of difficulty when they become NPs and have to start making decisions rather than just observing others make decisions and criticize them. Take for example when a nurse asks you to explain a clinical choice. I often find that walking them through the multi organ system risk benefit process of choosing a particular course of action results in "Oh wow! I never thought of all those things in regard to this." but we all do that whole process in our heads every time without them being aware of it.

A different but similar example is the continual and agonizing fight about treating numbers. We've all tried to explain why we shouldn't "treat" asymptomatic htn or marginal hypokalemia but they just stare at you and quote some non existent policy. Or they invoke the always popular "I can't send them home or to the floor like this." They are very concrete. If the number is this it gets treated. If the complaint is this they get this. How often have you seen an appropriate clinical decision get criticized because it wasn't what the nurse was expecting?

 

[VA Hopeful Dr]

One problem with what we do is that it looks easy most of the time. That's why so many experienced nurses have a lot of difficulty when they become NPs and have to start making decisions rather than just observing others make decisions and criticize them. Take for example when a nurse asks you to explain a clinical choice. I often find that walking them through the multi organ system risk benefit process of choosing a particular course of action results in "Oh wow! I never thought of all those things in regard to this." but we all do that whole process in our heads every time without them being aware of it.

A different but similar example is the continual and agonizing fight about treating numbers. We've all tried to explain why we shouldn't "treat" asymptomatic htn or marginal hypokalemia but they just stare at you and quote some non existent policy. Or they invoke the always popular "I can't send them home or to the floor like this." They are very concrete. If the number is this it gets treated. If the complaint is this they get this. How often have you seen an appropriate clinical decision get criticized because it wasn't what the nurse was expecting?

And part of the issue is that we often do this without actually consciously thinking through every step of it.

 

[Piebaldi]

Maybe people can stop pretending they don’t want independent practice now

I just dont get this - then why do we have med schools? The whole concept is idiotic.

 

[Piebaldi]

Let them have independent practice; but remove any supervising physician requirements, remove any physician from having to sign their chart, etc... You want to be independent? Then get sued independently...

The lawsuits against them would probably spike and limit their growth...

i kind of agree with this - and be a willing partner to lawyers to testify against midlevels- imagine commercial: have you been harmed by a midlevle practitioner without supervision? call douche and douche! we are here for you! get the compensation you deserve!

 

[RustedFox]

I get your point but sadly I don't think any of it will ever make any difference. Americans will rattle off a lot of wants in their health care system but those all go right out the window if they're forced to pull out their wallets. If demanding to see the physician means an extra $50 on your copay those demands will disappear. There won't even be an option for the no co pay folks i.e. Medicaid.

Even if there were a demand for doctors at a higher price the patients are not good at self triage so we'd likely wind up seeing anxious silliness rather than the serious cases. Think of the patients you saw last shift, the 20yo with normal everything who knows they're going to die immediately from their mild gastritis right next to the 85yo chemo patient with no blood cells of any kind and a temp of 93 who says he feels ok and wants to go home if maybe he could just get a Tylenol.

Great points.
This is not a rebuttal; just some more thoughts.
I'm just kneading the dough; not throwing it.

1. The "extra $50 copay" item is one that I never thought about. I imagine that a sizable amount of people will pay that extra $50 based (only) on my personal experience of the increasing number of people who say something akin to: "Jenny keeps doing this and this and it isn't working, so I need to see a REAL doctor now." No joke; I'm seeing a good number of these patients at my shops.

2. I don't see the 20 year-old vs. the 85 year-old being a problem with regard to self-triage. They have to make that choice themselves under this hypothetical system of "Do I need to see a physician or just a Jenny?" If that 85 year-old is seen by a Jenny; then Jenny can either reap what they sow, or they can escalate care. Eventually, Jenny's "body count" will climb high enough that people won't go to Jenny anymore... if they're smart. If they're not that smart... well; you can't fix stupid.

 

[RustedFox]

I'm confused on how they're going to magically increase their medical knowledge. What do they expect? They're going to take an ED admit that's intubated, presumed Covid +, history of ESRD, CAD, HTN, DM, etc.? ED doc says "Thanks, someone else is crashing, gotta go!".

There's a good amount of things that mid-levels are great at Googling/UpTodate-ing, but ventilator managet, complex medical patients, and multi-system failure isn't one of them. They'll run back crying to the intensivist immediately as soon as they even see the "breathing box".

See, you're right-on... and this will limit their growth and scope until they're back where they belong.

 

[Piebaldi]

Great points.
This is not a rebuttal; just some more thoughts.
I'm just kneading the dough; not throwing it.

1. The "extra $50 copay" item is one that I never thought about. I imagine that a sizable amount of people will pay that extra $50 based (only) on my personal experience of the increasing number of people who say something akin to: "Jenny keeps doing this and this and it isn't working, so I need to see a REAL doctor now." No joke; I'm seeing a good number of these patients at my shops.

2. I don't see the 20 year-old vs. the 85 year-old being a problem with regard to self-triage. They have to make that choice themselves under this hypothetical system of "Do I need to see a physician or just a Jenny?" If that 85 year-old is seen by a Jenny; then Jenny can either reap what they sow, or they can escalate care. Eventually, Jenny's "body count" will climb high enough that people won't go to Jenny anymore... if they're smart. If they're not that smart... well; you can't fix stupid.

more and more patients are not wanting to see midlevels. my mom recently told me - i went ot the dermatologist and thought i would see the doctor. i saw a PA - she was terrible. she didn't know anything. never again.

i was like mom! you need to see the doctor always.

 

[Piebaldi]

See, you're right-on... and this will limit their growth and scope until they're back where they belong.

not to mention, the whole midlevle thing is about economics - not quality. if midlevels cost the same as physicians, it really is a no brainer.
i think however if we are smart as we are supposed to be as physicians, speaking of change, we should use the complete immunity when it comes to covid patients to push for immunity in terms of legal/malpractice going forward.

i was recently talking to an attending whose from russia - this attending was telling me how no one ever sues doctors in europe - so there is no malpracitce or anything like that. this idea that somehow doctors need to be punished for BS needs to stop.
we need to establish Tx or IN type legal environments across the nation.

 

[RustedFox]

more and more patients are not wanting to see midlevels. my mom recently told me - i went ot the dermatologist and thought i would see the doctor. i saw a PA - she was terrible. she didn't know anything. never again.

i was like mom! you need to see the doctor always.

I posted on here awhile ago about my own experience seeing the Jenny at my GI appointment.
She actually tried to lie to me; that is - she stated a demonstrable scientific untruth and told me that I was wrong.
She didn't know I was a physician at the time.
Wow, was she embarrassed.
She doesn't work there anymore.

 

[Piebaldi]

I posted on here awhile ago about my own experience seeing the Jenny at my GI appointment.
She actually tried to lie to me; that is - she stated a demonstrable scientific untruth and told me that I was wrong.
She didn't know I was a physician at the time.
Wow, was she embarrassed.
She doesn't work there anymore.

did you "tell" on her or did she self leave? why would nurses get the pay - really what they are looking for - of physicians if they are nurses? i mean then go to med school. whatwould be the point of paying a nurse physician pay with nurse level education?

 

[VA Hopeful Dr]

Great points.
This is not a rebuttal; just some more thoughts.
I'm just kneading the dough; not throwing it.

1. The "extra $50 copay" item is one that I never thought about. I imagine that a sizable amount of people will pay that extra $50 based (only) on my personal experience of the increasing number of people who say something akin to: "Jenny keeps doing this and this and it isn't working, so I need to see a REAL doctor now." No joke; I'm seeing a good number of these patients at my shops.

I feel like I tell this story about once/quarter somewhere on this site...

A few years ago I started a cash-only PCP office. Once I got going, easily 1-2 new patients/week came to me because they were tired of seeing the midlevels at their old PCP's office.

Patients were choosing to not use their insurance, and pay cash to me, to make sure they saw a doctor every time they wanted an appointment.

 

[Piebaldi]

I feel like I tell this story about once/quarter somewhere on this site...

A few years ago I started a cash-only PCP office. Once I got going, easily 1-2 new patients/week came to me because they were tired of seeing the midlevels at their old PCP's office.

Patients were choosing to not use their insurance, and pay cash to me, to make sure they saw a doctor every time they wanted an appointment.

I think that this is going to be more and more the model - people who are middle class and up who can see a doctor will pay, those who cant will see midelvels "supervised" by doctors. once enough people die/get harmed, eventually things will revert

 

[RustedFox]

did you "tell" on her or did she self leave? why would nurses get the pay - really what they are looking for - of physicians if they are nurses? i mean then go to med school. whatwould be the point of paying a nurse physician pay with nurse level education?

After I explained the law of conservation of mass and energy, I explained to her just why she was wrong, and that I was a physician.
She looked pretty sheepish, and went and got the physician.

 

[Piebaldi]

After I explained the law of conservation of mass and energy, I explained to her just why she was wrong, and that I was a physician.
She looked pretty sheepish, and went and got the physician.

Lol. Good job RF. I have noticed that nurses/midlevels have the need to argue with physicians frequently - i had an aesthetic nurse argue with me - i endedup emailing their medical director and ripping him a new one over his inappropriate clueless nurse.

 

[NYEMMED]

After I explained the law of conservation of mass and energy, I explained to her just why she was wrong, and that I was a physician.
She looked pretty sheepish, and went and got the physician.

I think we have all had these experiences.
I was with my grandmother in another ED I do not work in. She presented as a classic bowel obstruction. Jenny McJennerson (stolen) came in and after just doing blood work said "its just a virus". I said: did you feel her abdomen? Its an acute abdomen, its rigid, its exquisitely tender, she's in her 70s, you really think this is a virus?
"She was like well I've been doing this for a very long time (joke), and medically trained people know what they are looking for."

Then I lost it on her and responded with I am an EM Physician, blasted her, told her that her medical director is my friend from residency and I just texted him...

Attending comes in: CT ordered, Surgeon at bedside before rads report...
CT Says: Large grade bowel obstruction with microperforation. She would have died because of Jenny McJennerson, if I wasn't there...

 

[Piebaldi]

I think we have all had these experiences.
I was with my grandmother in another ED I do not work in. She presented as a classic bowel obstruction. Jenny McJennerson (stolen) came in and after just doing blood work said "its just a virus". I said: did you feel her abdomen? Its an acute abdomen, its rigid, its exquisitely tender, she's in her 70s, you really think this is a virus?
"She was like well I've been doing this for a very long time (joke), and medically trained people know what they are looking for."

Then I lost it on her and responded with I am an EM Physician, blasted her, told her that her medical director is my friend from residency and I just texted him...

Attending comes in: CT ordered, Surgeon at bedside before rads report...
CT Says: Large grade bowel obstruction with microperforation. She would have died because of Jenny McJennerson, if I wasn't there...

yeah, the problem is that at times it *seems* that midlevels know what they are doing beause they do simple stuff - for example, they do the knee injections where i'm at, or simply refill meds, or do trigger point injections. an undergrad can likely do that.
but when things get difficult, then they have no clue and look at you- hey doc could you check this patient out type of thing. it is scary how little some of them know.
sometimes the best course of action is to let crap hit the fan. ie - let them practice independently and see how they do. i'll be right there as a witness charging the $800 an hour to testify that standard of care was not followed, and that there was no physician supervising and that this person acted independently. might seem harsh, but what midlevles are trying to do is criminal. how something like this is even attempted is beyond me. and sadly they are not cost effective - sometimes i look at the work ups that some of our midlevels do - and they undergo training - and i facepalm and think-how could they not know this is x, y, z?
at the end of the day, sometimes you just gotta let people do what they want to do - they won't learn their lesson until they do.

 

[SXMMD]

I would not be surprised if we saw the phenomenon RF described with the Jenny's turfing tough or mismanaged patient intensifying.

E.g. patient in ed crashing? Midlevel will turf referral to ed doc. Ed doc will refuse, patient will die, headline will read "patient died because doctor refused to help", laws will get passed forcing physicians in generalist roles to take on additional role as consultants to midlevels, not unlike specialists, forcing us to have skin in the game. Essentially nothing changes from today's practice of attendings signing midlevel charts, soaking up liability and responsibility. Except now you don't get paid for managing midlevels (who knows maybe they'll pay you consultant rates for consults by midlevels...)

I know that it sounds independent practice will put midlevels at a disadvantage, but there are too many ways to game the system and put the onus back on physicians (without commensurate pay or malpractice protection) for things to work out as simply as we envision

I do not think the "let them have independence and fall flat on their face" strategy will work as hoped...

 

[NurWollen]

I dig the scare quotes around "supervising."

Sent from my SM-G930V using SDN mobile

 

[Piebaldi]

I would not be surprised if we saw the phenomenon RF described with the Jenny's turfing tough or mismanaged patient intensifying.

E.g. patient in ed crashing? Midlevel will turf referral to ed doc. Ed doc will refuse, patient will die, headline will read "patient died because doctor refused to help", laws will get passed forcing physicians in generalist roles to take on additional role as consultants to midlevels, not unlike specialists, forcing us to have skin in the game. Essentially nothing changes from today's practice of attendings signing midlevel charts, soaking up liability and responsibility. Except now you don't get paid for managing midlevels (who knows maybe they'll pay you consultant rates for consults by midlevels...)

I know that it sounds independent practice will put midlevels at a disadvantage, but there are too many ways to game the system and put the onus back on physicians (without commensurate pay or malpractice protection) for things to work out as simply as we envision

I do not think the "let them have independence and fall flat on their face" strategy will work as hoped...

Problem is that we as physicians are sheep - we let insurnace take advantage of us. we let our governing bodies take advantage of us. we let thelegal system take advantage of us.
why do we have to practice with insurnace? what other industry does this?none. where are lawyers going to dig if there is no deep pockets of malpractice? nowhere. more and more physician practice with no insurance - where patients sign waiver/mediation forms. let's stop being sheep. what other industry do you "choose" whetheru want to pay for services? can u choose not to pay at the restaurant?or the grocery store?or the accountant?or landlord?ormortgage? or lawyer?nope.
why are our services up for sale? we are the mosthighly educated, indebted, hard working group of people but we get treated like crap. we need to stand together and our ground.
we are essential - but are treated as disposable. we need to starttaking charge of our futures dudes!

 

[hundreddaysoff]

How often have you seen an appropriate clinical decision get criticized because it wasn't what the nurse was expecting?

This. All they see is the ritual, and the surface-level complaint, and they close their minds and assume that's all there is to it.

And ironically from a "customer service" perspective, they often completely ignore the deeper issue of what the patient actually needs.

RLQ pain? "Are you gonna scan that guy in room 2?" No? Well, it wasn't literally a question, it was an expectation they had, and now I'm a terrible doctor in their eyes even though no TTP, no fever, and this started suddenly 15 minutes ago and feels just like his last kidney stone. Oh, and he's a healthy 21M w/o insurance who has better things to do than get his credit ruined by me for a useless CT scan.

Now try to explain all this, discussing and educating while trying very hard not to sound argumentative, and watch their eyes glaze over.

Admins do this too. Guy who just won doctor of the week at my shop prescribes antibiotics for any URI symptoms, always, even with a negative Strep test. "Because that's what patients expect. It's just the culture around here."

 

[RustedFox]

I would not be surprised if we saw the phenomenon RF described with the Jenny's turfing tough or mismanaged patient intensifying.

E.g. patient in ed crashing? Midlevel will turf referral to ed doc. Ed doc will refuse, patient will die, headline will read "patient died because doctor refused to help", laws will get passed forcing physicians in generalist roles to take on additional role as consultants to midlevels, not unlike specialists, forcing us to have skin in the game. Essentially nothing changes from today's practice of attendings signing midlevel charts, soaking up liability and responsibility. Except now you don't get paid for managing midlevels (who knows maybe they'll pay you consultant rates for consults by midlevels...)

I know that it sounds independent practice will put midlevels at a disadvantage, but there are too many ways to game the system and put the onus back on physicians (without commensurate pay or malpractice protection) for things to work out as simply as we envision

I do not think the "let them have independence and fall flat on their face" strategy will work as hoped...

Uh, as soon as I accept the patient; its my patient - and I get paid for it.

 

[Birdstrike]

The #1 thing fueling the rise of the mid levels is you. Everytime an Emergency Physician sings a mid-level chart you provide the wind beneath their wings. Let them fly solo and see what 1/2 the pay with 100% of the malpractice liability feels like. Only this will allow Emergency Physician resentment of mid levels to become a thing of the past.

 

[Piebaldi]

The #1 thing fueling the rise of the mid levels is you. Everytime an Emergency Physician sings a mid-level chart you provide the wind beneath their wings. Let them fly solo and see what 1/2 the pay with 100% of the malpractice liability feels like, on a level playing field.

Agreed.this precisely.

 

[emletters]

I still think it’s gonna be “good enough” for the general public and lawmakers. Like you guys have already said, people don’t know what good medicine is supposed to look like. They just want their antibiotics for their URI and a CT whenever they have a headache. It’s becoming a customer service game. So as long as the customer gets what they want and a mid level has the legal authority to give it, society will accept a slightly increased morbidity/mortality if that means more dollars in their pocket

 

[thegenius]

I still think it’s gonna be “good enough” for the general public and lawmakers. Like you guys have already said, people don’t know what good medicine is supposed to look like. They just want their antibiotics for their URI and a CT whenever they have a headache. It’s becoming a customer service game. So as long as the customer gets what they want and a mid level has the legal authority to give it, society will accept a slightly increased morbidity/mortality if that means more dollars in their pocket

It’s precisely the single most important thing we can do in our nation regarding delivering higher quality, low cost health care.

Shift costs to the consumer. A third payer system allows all of this nonsense waste to happen.

Consumers won’t want that useless CT if it costs them $300 bucks.

 

[HoosierdaddyO]

So after reading all of this!!! I guess my
question is... so instead of talking about all these positive changes that need to be made and essentially blowing hot air around in a circle, how do we actually go about doing it? Who should and will take charge to fight for us??

Who is going to be our Spartacus??

 

[NYEMMED]

So after reading all of this!!! I guess my
question is... so instead of talking about all these positive changes that need to be made and essentially blowing hot air around in a circle, how do we actually go about doing it? Who should and will take charge to fight for us??

Who is going to be our Spartacus??

You would think any president of ACEP, ACOEP, AMA, AOA, etc would be that Spartacus for us. But it seems you pay dues to be told what insurance companies want you to do.

 

[deleted480308]

So after reading all of this!!! I guess my
question is... so instead of talking about all these positive changes that need to be made and essentially blowing hot air around in a circle, how do we actually go about doing it? Who should and will take charge to fight for us??

Who is going to be our Spartacus??

Aaem, join them, volunteer and donate

 

[Piebaldi]

You would think any president of ACEP, ACOEP, AMA, AOA, etc would be that Spartacus for us. But it seems you pay dues to be told what insurance companies want you to do.

I think realistically people start coming together and making demands - teacher style - what would happen if physicians started saying "no"? oh im going to supervise 3 midlevels? no. problem - we need a unified front. bc whenever the one douche says oh ok! the whole thing comes crashing down.

 

[docB]

yeah, the problem is that at times it *seems* that midlevels know what they are doing beause they do simple stuff

This is one of the most insidious issues that I encounter routinely. Our MLPs primarily work in fast track while we cover the higher acuity areas. They discharge the vast majority of their patients while we admit the majority of ours. This biases both sets and I admit that the docs probably admit softer admits than we should. But the bias toward discharge is way more dangerous. I frequently am asked to ok them sending out elderly, highly comorbid patients because they have vague complaints and more or less normal work ups.
Me: He can barley walk
MLP: His labs were the same as last time
Me: He looks like crap
MLP: The internist will fight me
Me: (sigh) Sign it over and I'll take care of it.
They get used to working up healthy, young non sick people who should go after a negative work up that they try to apply that across the board.

The #1 thing fueling the rise of the mid levels is you. Everytime an Emergency Physician sings a mid-level chart you provide the wind beneath their wings. Let them fly solo and see what 1/2 the pay with 100% of the malpractice liability feels like. Only this will allow Emergency Physician resentment of mid levels to become a thing of the past.

This is true. We have embraced, nay created, this system to prevent us from accepting the income losses from reimbursement decreases over the years. I can attest that adding MLPs was the only way to go from 2 per hour to 5 per hour without adding doc staffing.

So after reading all of this!!! I guess my
question is... so instead of talking about all these positive changes that need to be made and essentially blowing hot air around in a circle, how do we actually go about doing it? Who should and will take charge to fight for us??

Who is going to be our Spartacus??

We won't. Not willingly. There would be too much pain and inequity for anyone to agree to anything. Your reference to Spartacus is quite apt as that is likely how anyone who tries to fight the emerging system will wind up.
It's likely that the role of MLPs will drastically expand when we are fully socialized.* Just as PMDs were supposed to be the gatekeepers to expensive diagnostics and specialists the future will see MLPs as the gatekeepers to expensive physicians.

*I've been away for a while so I feel the need to say this. I am not a socialist not do I advocate socialism. In a former life I was a political analyst so sometimes I say things about policy and social issues in objective terms. This has been interpreted in the past as an agenda. Just remember that the statement "I believe US healthcare will become fully socialized." doesn't mean I want it, just that my interpretation is that it will happen.

 

[KGflyboy]

So after reading all of this!!! I guess my
question is... so instead of talking about all these positive changes that need to be made and essentially blowing hot air around in a circle, how do we actually go about doing it? Who should and will take charge to fight for us??

Who is going to be our Spartacus??

This will obviously be tough. Our best chance is if everyone joins AAEM and donates. They are the only organization that truly supports physicians on this issue. Next, we should work on some sort of union type organization. That will be easier if we first get the ball rolling with AAEM and advocacy.

Screw ACEP. I will never give them a dime unless they significantly change their positions and their leadership composition.

 

[Piebaldi]

This is one of the most insidious issues that I encounter routinely. Our MLPs primarily work in fast track while we cover the higher acuity areas. They discharge the vast majority of their patients while we admit the majority of ours. This biases both sets and I admit that the docs probably admit softer admits than we should. But the bias toward discharge is way more dangerous. I frequently am asked to ok them sending out elderly, highly comorbid patients because they have vague complaints and more or less normal work ups.
Me: He can barley walk
MLP: His labs were the same as last time
Me: He looks like crap
MLP: The internist will fight me
Me: (sigh) Sign it over and I'll take care of it.
They get used to working up healthy, young non sick people who should go after a negative work up that they try to apply that across the board.

This is true. We have embraced, nay created, this system to prevent us from accepting the income losses from reimbursement decreases over the years. I can attest that adding MLPs was the only way to go from 2 per hour to 5 per hour without adding doc staffing.

We won't. Not willingly. There would be too much pain and inequity for anyone to agree to anything. Your reference to Spartacus is quite apt as that is likely how anyone who tries to fight the emerging system will wind up.
It's likely that the role of MLPs will drastically expand when we are fully socialized.* Just as PMDs were supposed to be the gatekeepers to expensive diagnostics and specialists the future will see MLPs as the gatekeepers to expensive physicians.

*I've been away for a while so I feel the need to say this. I am not a socialist not do I advocate socialism. In a former life I was a political analyst so sometimes I say things about policy and social issues in objective terms. This has been interpreted in the past as an agenda. Just remember that the statement "I believe US healthcare will become fully socialized." doesn't mean I want it, just that my interpretation is that it will happen.

I don't think so - in terms of socialization of healthcare. no one will go into medicine if that's the case. already other industries including finance, tech, are farrrrr easier ot get into/through and pay good salaries with none of the nonsense. why would anyone go through all these years of work for nothing?
not to mention the lawyers will fight it tooth and nail - you think anyone will pay million dollar practice suits when they are being seeing by a bunch of nurses if that's the norm?
i dont think we have much to worry about overall - i would say though that this is the dermification result - i look at my private practice in pm&r - we cover a crap ton of facilities. there are like 6 or 7 doctors and like over 12 midlevels. each of us dotors sees a significant number of patients. there just arent's enoguh of us to go around.
they have tried ot hire an additional person - doctor that is - for like 2 years to no avail - the group has expanded significantly. midlevels are the result to insufficient level of doctors.
the problem is that we are being screwed on all fronts - if we have a ton of rsponsibility we should expect a ton of pay

And the problem also in your example is our excessive niceness - this whole stupid idea of "we are a team." nurses i consider support staff - we are not a team. same with midlevels. i have had to firmly speak to a couple of our midlevels over just brainless stuff that they have done. it seems many physicians are unwilling to be the "bad" guy. luckily i work in the midwest generally speaking so there is sitll more respect. i dont have qualms over putting staff in their place when needed.

 

[docB]

I don't think so - in terms of socialization of healthcare. no one will go into medicine if that's the case. already other industries including finance, tech, are farrrrr easier ot get into/through and pay good salaries with none of the nonsense. why would anyone go through all these years of work for nothing?

I hear what you're saying but please be very careful about invoking the "no one will go into medicine" argument. Remember that there are plenty of people who want to go to med school but don't get in or don't apply because they know their app wouldn't cut it. If it will cut costs and keep the system going the powers structure will be more than happy to cut the requirements. If there were an interruption in the flow of suckers... er... candidates into medical school that would be just the argument the MLPs would need to sanctify their ascendence. I can already hear the tag lines about how in a time of crisis they stepped up, blah, blah, blah.

Short story - There will always be someone they can hang a white coat on and point to the public "There's your provider."

 

[Birdstrike]

I don't care if you're a PA, MD, lawyer or politician. If you're not seizing on crises to further your agenda, you're simply ineffective. Policies, habits, traditions and paradigms remain seemingly immovably cemented in gridlock until a crisis pops up, then everything gets scrambled, rearranged with new rules and norms formed and cemented in place. This is when 99% of social, political and economic change happens. If you're not ready to act aggressively before these crises occur, you'll lose to your opponents badly, and every time.

Could you imagine if last year either Republicans or Democrats proposed spending an extra $2 trillion dollars for small business loans, tax breaks, industry bailouts and checks to tax payers? Hell no. Gridlock would have ruled and everyone would be saying, "It's impossible. It'll take 100 years to get everyone to agree." Then a "crisis" comes along, '2.2 million Americans are going to die! Our hospital systems will collapse like Italy!" and in 48 hours, thousands of pages of law are written, hundreds in Congress of both bitterly divided parties agree, the President signs, and it's law.

It doesn't even matter that the 2.2 million dead never happened and your hospital system never "collapsed like Italy." But those who were ready for a 'crisis' seized on it, shaped it into a useful form with the help of the media, and moved the ball from their own goal line to the end-zone in record time. $2 bucks later, mission accomplished. Crisis put to maximal use.