Nurses doing colonoscopies on black patients

[Matthew9Thirtyfive]

Cite plz dont have it

https://doi.org/10.7326/0003-4819-80-2-137

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[efle]

https://doi.org/10.7326/0003-4819-80-2-137

Setting aside that this was a study of two nurses trained in the 1940s-50s, I cant for the life of me find anything about the docs needing to change their care plan in half the cases

Closest I'm finding is this

"In 392 episodes of care for the 10 indicator conditions, the management was rated as adequate for 66 per cent of episodes in the conventional [physician] and for 69 per cent in the nurse-practitioner group. In 510 prescriptions similarly analyzed, an adequate rating was given to 75 per cent in the conventional group, and to 71 per cent in the nurse-practitioner group."

 

[Matthew9Thirtyfive]

Setting aside that this was a study of two nurses trained in the 1940s-50s, I cant for the life of me find anything about the docs needing to change their care plan in half the cases

Closest I'm finding is this

"In 392 episodes of care for the 10 indicator conditions, the management was rated as adequate for 66 per cent of episodes in the conventional [physician] and for 69 per cent in the nurse-practitioner group. In 510 prescriptions similarly analyzed, an adequate rating was given to 75 per cent in the conventional group, and to 71 per cent in the nurse-practitioner group."

So for one, that's part of the point. There aren't any studies that are comparing unsupervised midlevels to physicians. This kind of stuff is pretty much the closest we have. There are some larger, actual studies comparing them, but they are always supervised.

I don't have access to that specific paper anymore, but somewhere in there, it says that they needed assistance 33% of the time and were as safe and effective as physicians like 55-65% of the time. I might be slightly off since I'm going off memory, but those numbers are pretty close. It's not stellar data, but what it says is that even in NPs who are excellently trained and adequately supervised, there are still a huge number of cases where they need a physician to intervene.

 

[Lawpy]

All of surgical oncology is rooted in general surgery. The bowel work requires basic and complex bowel knowledge of how the tissue responds when normal, inflamed, perforated. There's vascular work that you need the vascular background for (portal vein resections, vena cava resections for sarcoma, extremity sarcoma resections, vascular tumors, occasional arterial bypasses for more exotic things). To understand the complex biliary anatomy you absolutely need to know the simple biliary anatomy. You need to have a very strong foundation and working knowledge of the chest if you're going to do esophagus work or need to do partial diaphragm resections. You need to know enough about plastics and herniology to understand when you can do simple closures or when you need to do complex closures and if/when to call a specialist. A lot of general surgery covers the straightforward cancers too: colon, skin, breast, thyroid/parathyroid. Etc. Finally, MANY surgical oncology jobs will have some component of general surgery call, and sometimes trauma call. This is getting less, but is still probably at least 25 if not 50% of jobs (the component may be small, like 2 calls/month or as high as 10 calls/month, but its not zero).

Surgical oncology should never be decoupled from general surgery. You absolutely need all, literally all, of the fundamentals provided by a general surgery residency from the ICU to the floor to the OR.

A 4+2 or 3+3 model could be entertained.

I think i got suddenly more interested in gen surg after reading this

 

[medgator]

Wait that's a very good point. Cards, GI and heme/onc should all be like rads, derm in having a 1 yr IM + 3 years of that fellowship training

@elementaryschooleconomics @medgator is radonc residency 1 yr IM + 4 years of radonc residency?

@Lem0nz why can't we make surgical oncology a surgical subspecialty with 1 yr gen surg + 5 yrs surg onc?

Sorry for the tags i'm just thinking out loud here

Radonc is a year of anything im, surgery or transitional and a 4 year RO residency. Fellowships are proliferating but none are ACGME accredited and it's totally in response to the worsening job market in larger cities

 

[efle]

So for one, that's part of the point. There aren't any studies that are comparing unsupervised midlevels to physicians. This kind of stuff is pretty much the closest we have. There are some larger, actual studies comparing them, but they are always supervised.

I don't have access to that specific paper anymore, but somewhere in there, it says that they needed assistance 33% of the time and were as safe and effective as physicians like 55-65% of the time. I might be slightly off since I'm going off memory, but those numbers are pretty close. It's not stellar data, but what it says is that even in NPs who are excellently trained and adequately supervised, there are still a huge number of cases where they need a physician to intervene.

Youd think with the massive volume of CRNA run cases and primary care NPs in states allowing it, we should have a wealth of stuff to study. Will be keeping an eye out for it, let me know if you come across anything

 

[Matthew9Thirtyfive]

Youd think with the massive volume of CRNA run cases and primary care NPs in states allowing it, we should have a wealth of stuff to study. Will be keeping an eye out for it, let me know if you come across anything

Anecdotes are anecdotes. An IRB isn’t going to approve any sort of study on this. And the vaaaaast majority of NPs working in FPA states are still working in places where they have at least indirect supervision and they have consults available that they use.

 

[efle]

Anecdotes are anecdotes. An IRB isn’t going to approve any sort of study on this. And the vaaaaast majority of NPs working in FPA states are still working in places where they have at least indirect supervision and they have consults available that they use.

We better hope IRBs approve some studies if we dont want full practice trends to continue - assuming there will be glaring differences in outcomes, that is.

 

[Matthew9Thirtyfive]

We better hope IRBs approve some studies if we dont want full practice trends to continue - assuming there will be glaring differences in outcomes, that is.

Yeah, I mean if we can find some setting where there are no physicians available maybe a retrospective analysis could be done, but I seriously doubt an IRB will approve a head to head study to compare a lesser trained provider to a physician.

 

[efle]

Yeah, I mean if we can find some setting where there are no physicians available maybe a retrospective analysis could be done, but I seriously doubt an IRB will approve a head to head study to compare a lesser trained provider to a physician.

A survey in 2012 found that 10% of NPs were practicing entirely without a physician so I think there's already likely hundreds and hundreds of clinics to gather data from

 

[Matthew9Thirtyfive]

A survey in 2012 found that 10% of NPs were practicing entirely without a physician so I think there's already likely hundreds and hundreds of clinics to gather data from

What setting? Hundreds of medspas aren’t really going to tell us anything and there aren’t really any physicians working at minuteclinics to compare to.

 

[efle]

What setting? Hundreds of medspas aren’t really going to tell us anything and there aren’t really any physicians working at minuteclinics to compare to.

Their wording was "percent of NPs worked in a primary care practice without a physician and billed for all their services under their own National Provider Identifier (NPI)"

I dunno what grounds an IRB would have to deny data collection on independent practice in FPA states. Would be pretty funny, they'd have to insist their own state's regulations were unethical to exist.

 

[Matthew9Thirtyfive]

Their wording was "percent of NPs worked in a primary care practice without a physician and billed for all their services under their own National Provider Identifier (NPI)"

I dunno what grounds an IRB would have to deny data collection on independent practice in FPA states. Would be pretty funny, they'd have to insist their own state's regulations were unethical to exist.

I mean the IRB doesn’t have anything to do with the regulations. I think any state with laws allowing independent midlevel practice is unethical. I mean they are literally letting people with 3% of the training of physicians and zero specialty training to practice in any setting they want with no oversight. How does anyone think this is a good idea?

 

[efle]

I mean the IRB doesn’t have anything to do with the regulations. I think any state with laws allowing independent midlevel practice is unethical. I mean they are literally letting people with 3% of the training of physicians and zero specialty training to practice in any setting they want with no oversight. How does anyone think this is a good idea?

You'll just have to get some horrifically unethical institution like Hopkins to approve it, I suppose. Pretty sure MD is one of the full practice states, there's probably some local candidates...

 

[Matthew9Thirtyfive]

You'll just have to get some horrifically unethical institution like Hopkins to approve it, I suppose. Pretty sure MD is one of the full practice states, there's probably some local candidates...

I mean they’re actively trying to destroy this profession, so I doubt they would approve something like that since they must know what it would show. Although maybe they’re so delusional that they actually think the outcomes would be equivalent.

 

[efle]

I mean they’re actively trying to destroy this profession, so I doubt they would approve something like that since they must know what it would show. Although maybe they’re so delusional that they actually think the outcomes would be equivalent.

I had someone correct my use of the word "midlevel" recently so they might indeed want to see the data

 

[Redpancreas]

I had someone correct my use of the word "midlevel" recently so they might indeed want to see the data

This is not uncommon. I was chastised by an attending as an intern for calling a PA an NP incidentally.

PSA for Preclerkship medical students: Attendings work with these "midlevels" more than they do with you and trust them more. Don't expect your attendings to share your anti-midlevel sentiment on rounds. This is a very SDN/Reddit thing.

 

[Matthew9Thirtyfive]

I had someone correct my use of the word "midlevel" recently so they might indeed want to see the data

What did they say and who were they?

 

[efle]

What did they say and who were they?

US MD fellow, "midlevel is considered the wrong term we use "advanced practitioners""

 

[Matthew9Thirtyfive]

US MD fellow, "midlevel is considered the wrong term we use "advanced practitioners""

So what is the fellow? A super supreme ultimate practitioner?

 

[efle]

So what is the fellow? A super supreme ultimate practitioner?

"Excessively overtrained in other areas practitioner" I guess

 

[Matthew9Thirtyfive]

"Excessively overtrained in other areas practitioner" I guess

It disturbs me that med students think they’re over trained or will be over trained.

 

[efle]

It disturbs me that med students think they’re over trained or will be over trained.

I'll say it again as a radiologist if that helps

 

[Matthew9Thirtyfive]

I'll say it again as a radiologist if that helps

I can’t imagine ever feeling over trained to do something physicians do to a real person.

 

[efle]

I can’t imagine ever feeling over trained to do something physicians do to a real person.

Really? You wouldnt let an IR touch your grandma if he hadnt taken a peds rotation? A good outpatient psychiatrist has to know which cytokines attract neutrophils? Theres so, so much bloat. This system was designed 100 years ago to train GPs. It really hurts the argument that MDs are value added when people take the absurdist stance that ALL of EVERY pathway is ALWAYS value added.

 

[Matthew9Thirtyfive]

Really? You wouldnt let an IR touch your grandma if he hadnt taken a peds rotation? A good outpatient psychiatrist has to know which cytokines attract neutrophils? Theres so, so much bloat. This system was designed 100 years ago to train GPs. It really hurts the argument that MDs are value added when people take the absurdist stance that ALL of EVERY pathway is ALWAYS value added.

Well that’s not really my argument. Like I already said, I think med school is the foundation for specialty training. I think we can all learn important things from every core rotation, or at least I have been so far. But I also don’t think every specialty will benefit from that. A niche specialty like IR probably won’t. But even surgeons can learn things from their med school psych and peds rotations.

But anyway, what I was actually arguing is that I could never imagine being a residency trained physician and thinking I was in any way overtrained. I agree there are places where things could be shortened, but I don’t think that’s the same thing. The fact that any physicians make the argument that an NP with 500 shadowing hours can do as good a job as a residency and sometimes fellowship trained physician just blows my mind and reeks of caring for nothing but self promotion and money.

 

[Lawpy]

It disturbs me that med students think they’re over trained or will be over trained.

I don't know who thinks that tbh.

 

[Matthew9Thirtyfive]

I don't know who thinks that tbh.

I was responding to one.

 

[Lawpy]

I was responding to one.

Oh i thought @efle was playing advocate's devil's advocate

I think if anything, we're badly undertrained. The Flexner system needs to be replaced

 

[Matthew9Thirtyfive]

Oh i thought @efle was playing advocate's devil's advocate

I think if anything, we're badly undertrained. The Flexner system needs to be replaced

I wouldn’t say we are undertrained at all. I think many med schools could stand changes in their curricula. I really loved my school’s, and continue to now that I’m on rotations. There are still some things I think maybe we didn’t need to learn/do, but at least at my school, we didn’t waste time learning individual steps of enzymatic reactions or specific CYP types.

 

[Lawpy]

I wouldn’t say we are undertrained at all. I think many med schools could stand changes in their curricula. I really loved my school’s, and continue to now that I’m on rotations. There are still some things I think maybe we didn’t need to learn/do, but at least at my school, we didn’t waste time learning individual steps of enzymatic reactions or specific CYP types.

There's a very huge variability in rotation quality though. A lot of schools have garbage rotations that involve mostly shadowing. Others have the weird hierarchy where midlevel students are favored over MS3s. Still many places don't allow med students to be clinically proficient at intern level because hospital liability

 

[Matthew9Thirtyfive]

There's a very huge variability in rotation quality though. A lot of schools have garbage rotations that involve mostly shadowing. Others have the weird hierarchy where midlevel students are favored over MS3s. Still many places don't allow med students to be clinically proficient at intern level because hospital liability

Yeah I agree that many schools require an overhaul in their clinical rotations. That means those programs are undertraining their students, but if they improved the rotations they wouldn’t be.

 

[efle]

Its not that people get overtrained for the specialty they practice. It's that YEARS along the way are spent on exposure and memorization of things you'll never need again. You cant possibly believe an ophthalmologist needs to carry around knowledge of fetal tracing categories to be great at their job. I must be on crazy pills if that's a hot take. What would you call that if not extra schooling they never utilize?

 

[Lawpy]

Its not that people get overtrained for the specialty they practice. It's that YEARS along the way are spent on exposure and memorization of things you'll never need again. You cant possibly believe an ophthalmologist needs to carry around knowledge of fetal tracing categories to be great at their job. I must be on crazy pills if that's a hot take. What would you call that if not extra schooling they never utilize?

2 years of preclinical are a waste when 1 is plenty

The core rotations are designed with the assumption that everyone will graduate at minimum a PCP

Like i said, the Flexner report is outdated crap that needs to be replaced.

 

[Matthew9Thirtyfive]

Its not that people get overtrained for the specialty they practice. It's that YEARS along the way are spent on exposure and memorization of things you'll never need again. You cant possibly believe an ophthalmologist needs to carry around knowledge of fetal tracing categories to be great at their job. I must be on crazy pills if that's a hot take. What would you call that if not extra schooling they never utilize?

Like I said, I think there are some specialties that probably don’t need a lot of what we learn in med school. But unless you’re saying we should split those specialties into their own schools, I don’t think it makes sense to throw out all that stuff for a minority of specialties.

 

[Matthew9Thirtyfive]

2 years of preclinical are a waste when 1 is plenty

The core rotations are designed with the assumption that everyone will graduate at minimum a PCP

Like i said, the Flexner report is outdated crap that needs to be replaced.

I mean yes, but actually no. Believe it or not, surgeons deal with patients who have psych conditions. They deal with patients with medical conditions. Etc. Internists deal with patients who need surgery or have psych conditions. There are important things to learn in every rotation no matter what kind of doctor you’re going to be except for a small number of super focused specialties.

 

[efle]

Like I said, I think there are some specialties that probably don’t need a lot of what we learn in med school. But unless you’re saying we should split those specialties into their own schools, I don’t think it makes sense to throw out all that stuff for a minority of specialties.

That's exactly what I'd do actually! Radiology school. Derm school. Psychiatry school. Doesnt seem that crazy when we have stuff like dental and podiatry. Would certainly make it easier to prevent competition from people who skip low yield years and go right to the relevant residency-style training.

 

[Lawpy]

I mean yes, but actually no. Believe it or not, surgeons deal with patients who have psych conditions. They deal with patients with medical conditions. Etc. Internists deal with patients who need surgery or have psych conditions. There are important things to learn in every rotation no matter what kind of doctor you’re going to be except for a small number of super focused specialties.

But in all seriousness, those are good points

 

[Lawpy]

That's exactly what I'd do actually! Radiology school. Derm school. Psychiatry school. Doesnt seem that crazy when we have stuff like dental and podiatry. Would certainly make it easier to prevent competition from people who skip low yield years and go right to the relevant residency-style training.

How is a psychiatry school different from psychology grad school?

Derm and rad schools... are meh.

 

[sylvanthus]

US MD fellow, "midlevel is considered the wrong term we use "advanced practitioners""

When they call you provider, correct them in the same manner.

 

[Osminog]

2 years of preclinical are a waste when 1 is plenty

The core rotations are designed with the assumption that everyone will graduate at minimum a PCP

Like i said, the Flexner report is outdated crap that needs to be replaced.

Medicine should become an undergraduate course of study. Curriculum: One year for what we now consider “pre-med coursework” (minus organic chemistry and physics 2); one year for systems-based biomedical sciences; and finally 3-4 years of clinical education/rotations.

This would more closely resemble the medical school curricula in most other countries, including those with better quality of care and patient outcomes than our own.

 

[VA Hopeful Dr]

Medicine should become an undergraduate course of study. Curriculum: One year for what we now consider “pre-med coursework” (minus organic chemistry and physics 2); one year for systems-based biomedical sciences; and finally 3-4 years of clinical education/rotations.

This would more closely resemble the medical school curricula in most other countries, including those with better quality of care and patient outcomes than our own.

If you actually look, our outcomes data is not that much worse than anybody else's. When I get to a computer and I'm not on my phone I'll dig up the eleventy billion other times I've had to go through this exact same argument.

 

[Redpancreas]

Like I said, I think there are some specialties that probably don’t need a lot of what we learn in med school. But unless you’re saying we should split those specialties into their own schools, I don’t think it makes sense to throw out all that stuff for a minority of specialties.

Agree. We still need to cover the essentials of all fields (ie-fetal tracings) because at some point it’s a medical school and not a technical school and many people are not 100% sure what they want to do. I think this is why the M2-didactic/clerkship hybrid I’ve posted elsewhere is valuable so people can make their career decisions on more robust experiences by the time they’re done with M3.

That's exactly what I'd do actually! Radiology school. Derm school. Psychiatry school. Doesnt seem that crazy when we have stuff like dental and podiatry. Would certainly make it easier to prevent competition from people who skip low yield years and go right to the relevant residency-style training.

I think maybe there can be different tracks in medicine. I think the way to do it is to introduce the clinical information earlier. By the end of M2, students should be done with what is basically now medical school now and be allowed to spend the next two doing electives which can be tailored to their field and then start the training in their expected fields.

There are some benefits of having a broad based education especially as a general practitioner (EM/IM/FM/-makes up 50% of match lists) namely the perk that a graduate of medical school has the ability to be licensed and practice general medicine in areas of need with competence. Effectively that is not the case now.

 

[Redpancreas]

How is a psychiatry school different from psychology grad school?

Derm and rad schools... are meh.

Psychology PhD is a hybrid between a thesis/research-based component and non-pharmaceutical clinical practice. Psychiatry is a medical practice where you diagnose and treat psychiatric disorders and their medical complications. Some Psychiatrists do research, I imagine a majority do not touch it after they match in residency. The two paths are fundamentally different.

 

[Redpancreas]

Medicine should become an undergraduate course of study. Curriculum: One year for what we now consider “pre-med coursework” (minus organic chemistry and physics 2); one year for systems-based biomedical sciences; and finally 3-4 years of clinical education/rotations.

This would more closely resemble the medical school curricula in most other countries, including those with better quality of care and patient outcomes than our own.

I think looking at outcomes of health on the national level is too abstract to tie directly to how we ultimately decide to restructure medical school.

I think medicine needs to come together and decide what is common core knowledge every MD/DO needs to know and how do we deliver it the most efficiently to students. The medical student outcomes would then be performance on those examinations and the time saved in medical training. Then, residency training can focus more on thing like providing high quality care and educating residents in ways that effects these broader outcomes.

 

[VA Hopeful Dr]

Agree. We still need to cover the essentials of all fields (ie-fetal tracings) because at some point it’s a medical school and not a technical school and many people are not 100% sure what they want to do. I think this is why the M2-didactic/clerkship hybrid I’ve posted elsewhere is valuable so people can make their career decisions on more robust experiences by the time they’re done with M3.

I think maybe there can be different tracks in medicine. I think the way to do it is to introduce the clinical information earlier. By the end of M2, students should be done with what is basically now medical school now and be allowed to spend the next two doing electives which can be tailored to their field and then start the training in their expected fields.

There are some benefits of having a broad based education especially as a general practitioner (EM/IM/FM/-makes up 50% of match lists) namely the perk that a graduate of medical school has the ability to be licensed and practice general medicine in areas of need with competence. Effectively that is not the case now.

Love the bolded.

We may go too far into minutiae during pre-clinical years (I'm not entirely sure of my feelings on the subject), but if we decided to cut back some of that it would need to be very carefully and thoughtfully. Basic clinical rotations, at least the concept, still seems fine to me. Something needs to be done to make sure the quality is uniformly good however.

 

[Matthew9Thirtyfive]

That's exactly what I'd do actually! Radiology school. Derm school. Psychiatry school. Doesnt seem that crazy when we have stuff like dental and podiatry. Would certainly make it easier to prevent competition from people who skip low yield years and go right to the relevant residency-style training.

I actually think there’s something there. Though I think maybe just having a separate track might work too. Not sure I agree psychiatrists don’t need medical school. But like ophtho probably could be like a podiatry school.

 

[Matthew9Thirtyfive]

Something needs to be done to make sure the quality is uniformly good however.

I actually think this is the main reason so many people think med school is too bloated.

 

[VA Hopeful Dr]

I actually think this is the main reason so many people think med school is too bloated.

That's been my conclusion over the last several years hearing what people here have to say. That and rising tuition. If school still cost what it did in my day (state school for everything including COL: 40k/year) and the lectures/rotations were of reasonable quality, I think we'd have far less complaints. There will always be some of course, but coming out of school with less than 200k in debt and actually learning stuff on every rotation would make a world of difference.

 

[Lem0nz]

Have a huge gap between cases this morning so I read this thread starting on page 2. Whew. You guys got out into the sticks a bit. Turned NPs doing c-scopes into anyone can do c-scopes as long as there's a doctor overseeing them to med school needs to be short again to maybe residency should be short too or split off. Kind of all over the map.

My random thoughts:
From someone who is licensed and qualified to do endoscopy (both upper and lower) as part of my residency training, having gone over the minimums - the first time I did an EGD out in the wild on a locums job in way out in BFE for GIB I found something I'd literally never seen before and thought 'maybe esophagitis', was utterly terrified that I'd actually find actual bleeding and have no practical experience in dealing with it because I've never done interventional endoscopy, and would have at best probably injected some epinephrine (and would have had to look up the dose like a derp), and I definitely couldn't band anything in the esophagus, and god forbid I had to do something silly like put in a Blakemore tube. If they even had one in stock. In actuality my decision making was has he stopped bleeding or can I very easily get him to stop bleeding, can I get some pictures for a smarter doctor to tell what's wrong and compare on a possible follow up scope, or do I have to transfer.

There's a ton to unpack here but I wanted to share that for some perspective. In favor of many of the things M935 has said in this thread, I have the ability to navigate that, recognize my limitations, keep the guy alive if he was actively dying, and get him in the hands of not just someone better, but someone with the correct skillset to solve the problem. There is also so much more that goes into training and so much nuance in what we do and how/why we do it. I know how to do surgical endoscopy. It is wildly different from interventional GI endoscopy. Which is wildly different from screening endoscopy. (Those statements apply to the sigmoidoscope and colonoscope as well). An NP or PA shouldn't be doing undifferentiated endoscopies. I learned from that experience that, quite frankly, neither should I, but in that capacity I'm really only there to decide if he needs to be transferred and if its an emergency or it isn't, and if he isn't stable enough for transfer than I have maximally invasive solutions to stop bleeding.

That said, on the other end - screening/surveillance endoscopies are different (lesser) beasts. You aren't there to treat something. Biopsies are not hard. It is extremely rare to get into horrible bleeding or make a perforation. I was comfortable doing that after about 10-15 upper or lower scopes. Someone who did a fellowship for a year for that with that very specific tailored need and scope of practice would absolutely be just fine at it. They would also obtain tissue and pathology just fine, and pictures just fine, and could put tattoos in just fine, and you do *not* need higher level decision making beyond that. The pathology is either normal or it isn't, you have set guidelines for when to repeat the scope, you refer. They don't need to be doctors at all to do those things. But they do need to know how to navigate the system. You can train an MA or a regular nurse to do all of that, but it requires training both of those things. How to navigate the system (consults, talk to 'providers', work with tumor boards, whatever) and then how to do the colonoscopies. So I while I agree that you could train an MA or a tech to do that stuff, the knowledge of how to plug that information into a broader system is actually why the NP or PA degree is useful and why *if* its going to be done outside of doctors, midlevels at least sort of make sense.

Other random thoughts in no particular order -

• Intern year is not about learning medicine, it is about learning process, how to put in orders, how to get things done, how to communicate, blah blah blah. You learn very little medicine in the first year (particularly the first six months). You learn how to be a functional hospital staff. So if you're going to talk about shortening or combo'ing medical school and residency I would require intern year no matter what across the board and the years after that are the ones you are talking about cutting out as unnecessary.
• For medical fellowships I do think two years of medicine (again presuming the first year is mostly a wash because intern) background is reasonable and required foundational knowledge prior to going into cards, DEFINITELY before heme/onc (everything you do screws up some organ system), and for most of the others. GI is probably the outlier. But the other systems/fellowships are all interconnected enough that I think the foundational knowledge is necessary.
• For almost all of the surgical subdisciplines you need 2-3 years of foundational knowledge. In I6 programs and Ortho or NSG that foundational knowledge just happens to be built into the curriculum and you make a decision earlier so you get to shave off a single year. You could probably bring every single surgical subdiscipline down one year to being either 5 years (CRS, MIS/bari, endocrine, etc.) or 6 years (surg/onc, peds, CV, vascular) but this would force all students to choose earlier, apply earlier, be competitive earlier, etc. That is a lot of change, pressure, and grief for a system that may not be totally optimal but is entirely functional. Is it really worth breaking to eek out 10-15% optimization which will bring 10-15% new headaches?
• There is a huge, massive, monster, Marianas trench wide difference between an NP/CRNA/PA fresh out of school (and 'fellowship') and one who has been doing the same job for 5-10 years. I think that's always worth considering. The second population of humans can be hard to distinguish from doctors in their similar fields. Anyone who does something for a decade is probably going to be proficient and safe at it.
• Comments about true 'independent' practice without other 'providers' to consult and refer to are dumb. Doctors don't work in a vacuum either. We'll never get 'independent practice' studies where midlevels are working on an island and have to make final decisions without being able to consult for additional assistance because that isn't a thing that exists in medicine for doctors either. At best we can ask for studies evaluating the use of resources and consults in particular and compare what the consults and level of decision making were for, but that's wildly subjective so... probably won't ever get any useful data at all.