Nurses doing colonoscopies on black patients

[Lawpy]

Personally i feel very uncomfortable with the idea of deciding a specialty before med school to go to a specialized school like rad school, derm school etc. What if someone is interested in cancer research that is literally applicable for any specialty but realized in clinical years they like derm because they're particularly interested in skin cancers?

I personally need that time and guidance to decide what i actually want to do and not make hasty decisions

---

Members don't see this ad.

 

[Lawpy]

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.

The thing is the quality of NP education is so unstandardized and variable that training nurses or techs or MAs how to navigate through the system would be easier and more efficient (and many techs/MAs do know how to navigate as do even many premed scribes) i think we're giving way too much credit and power to the midlevels when they aren't necessary and can be replaced

 

[Lem0nz]

The thing is the quality of NP education is so unstandardized and variable that training nurses or techs or MAs how to navigate through the system would be easier and more efficient (and many techs/MAs do know how to navigate as do even many premed scribes) i think we're giving way too much credit and power to the midlevels when they aren't necessary and can be replaced

I'm not going to comment on whether or not we should be training midlevels to do this at all. I honestly just don't care which is a side effect of me spending too much time on Reddit arguing with people.

But I will say that training randos vs. putting NPs or PAs through additional school are definitely not the same. The midlevels will do better. Your argument is that they lack structure and every year of education you tack onto them and every layer of education that pigeon holes them into one specific field instead of making them a swiss army knife that can change disciplines every year is addressing the exact problem you're saying exists. So no. These sorts of 'fellowships' are actually directly addressing the problem of variable and under standardized education by adding structure and committing a graduate to (very likely) stay in a well defined scope of practice, which is actually a fantastic addition to the midlevel curriculum whether you like them or not. It makes them safer and more defined.

 

[Lawpy]

I'm not going to comment on whether or not we should be training midlevels to do this at all. I honestly just don't care which is a side effect of me spending too much time on Reddit arguing with people.

But I will say that training randos vs. putting NPs or PAs through additional school are definitely not the same. The midlevels will do better. Your argument is that they lack structure and every year of education you tack onto them and every layer of education that pigeon holes them into one specific field instead of making them a swiss army knife that can change disciplines every year is addressing the exact problem you're saying exists. So no. These sorts of 'fellowships' are actually directly addressing the problem of variable and under standardized education by adding structure and committing a graduate to (very likely) stay in a well defined scope of practice, which is actually a fantastic addition to the midlevel curriculum whether you like them or not. It makes them safer and more defined.

Wait i'm a little less clear on that one point: why do we need midlevels to be more general and flexible to change specialties? And on a related point, why not train nurses to do it, since an NP degree is at the very least just further education for nurses that may not be needed?

Because what i'm pushing for is specialized techs or aides for only one specific specialty. That way the scope of practice is clearly defined and there isn't a need to push for independent practice while being respected as important professionals. And maybe i need to look into the practice more because the NPs and PAs i'm seeing in specialties are themselves pretty specialized who rarely switch out.

 

[Lem0nz]

We need midlevels to be general and flexible because there are not residencies or fellowships or a match for midlevels. A graduate NP or PA is the midlevel equivalent of a medical student. Imagine having medical students in a world where there is no such thing as residency (at all) or fellowship or a match Lawp. Just medical students, and attendings. The only option in that world is having some very generic, not super useful graduate who has a basic set of skills but needs years of additional on the job training.

The next step up in organizing that system? Surprise. Midlevels are making 'residencies' and 'fellowships'.

Twenty years from now I would not be surprised if they had a match.

Its the groundhog's day of medicine.

 

[efle]

The reason I think medical education/training bloat is relevant is that I see that as the source of the midlevel threat. They're able to learn the fundamentals and language of medicine, jump right to some high yield training in job basics in a "midlevel residency/fellowship", and then can offer the less complex bread and butter that make up a lot of MD practice for much less (in this example, screening scopes for a GI group).

If we weren't putting GI fellows through 4 years of medschool and 3 years of IM before training them to do their actual job, extenders lose their appeal.

I'm also surprised to hear intern year isnt enough to learn medicine basics - it's all we require for Step 3 and for going into fields like neurology or gas

 

[Lem0nz]

It probably is enough for some, but it isn't enough for all. Heme/onc is the prime example. You need a mastery of nephrology, cardiology, pulmonology, some working knowledge of GI, mastery of ID, at least working knowledge of rheum. Then you look at GI and... yea. An interventional GI doc probably would be just fine with only an intern year.

The question then becomes if we should. Just because we CAN make heme/onc six years and GI four years, should we? Idk. If you do that you radically alter the landscape of GME. And I don't think it solves any of your midlevel problems. Midlevels make sense because you can peel off the really easy **** that makes money. Screening c-scopes in this case for GI. Making GI shorter doesn't make more GI fellowships or more GI spots or more GI providers or change that a screening c-scope takes the least amount of time and reimburses much higher at scale than interventional GI.

The solution to making less midlevel scope creep has nothing to do with training in my opinion. Its reimbursement. It should be changed to HEAVILY incentivize more complex patients and cases. We keep talking about the '20%' of things that need a physician and aren't appropriate - pay them twice as much as the 80% and MDs will suddenly be a lot less upset about midlevels doing easy/safe things, probably a lot more willing to work with them collaboratively, and are protected because there are things that require a decade of learning before you're safe to take care of them.

 

[efle]

It probably is enough for some, but it isn't enough for all. Heme/onc is the prime example. You need a mastery of nephrology, cardiology, pulmonology, some working knowledge of GI, mastery of ID, at least working knowledge of rheum. Then you look at GI and... yea. An interventional GI doc probably would be just fine with only an intern year.

The question then becomes if we should. Just because we CAN make heme/onc six years and GI four years, should we? Idk. If you do that you radically alter the landscape of GME. And I don't think it solves any of your midlevel problems. Midlevels make sense because you can peel off the really easy **** that makes money. Screening c-scopes in this case for GI. Making GI shorter doesn't make more GI fellowships or more GI spots or more GI providers or change that a screening c-scope takes the least amount of time and reimburses much higher at scale than interventional GI.

The solution to making less midlevel scope creep has nothing to do with training in my opinion. Its reimbursement. It should be changed to HEAVILY incentivize more complex patients and cases. We keep talking about the '20%' of things that need a physician and aren't appropriate - pay them twice as much as the 80% and MDs will suddenly be a lot less upset about midlevels doing easy/safe things, probably a lot more willing to work with them collaboratively, and are protected because there are things that require a decade of learning before you're safe to take care of them.

Didnt a lot of fields used to be fellowships that now arent - neuro after IM, plastics after gensurg, stuff like that? Doesnt seem to have blown up the landscape.

I imagine the pay for a GI would come down dramatically if they didnt have so many years and debt dollars sunk into reaching their fellowship. Cutting out 80% of the labor and still paying the same sounds great but less likely to me...

 

[Matthew9Thirtyfive]

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.

Totally agree. It’s too expensive, and too many schools have too much clinically irrelevant material in preclerkship and poor clinical experiences. When people are basically paying 200k to teach themselves and then shadow for 2 years, no wonder they feel like they’re being overtrained.

 

[efle]

Totally agree. It’s too expensive, and too many schools have too much clinically irrelevant material in preclerkship and poor clinical experiences. When people are basically paying 200k to teach themselves and then shadow for 2 years, no wonder they feel like they’re being overtrained.

It can feel pretty excessive even with good schooling. I had classmates come in that already knew they wanted to do pathology. Crazy to think we forced them to pay $1000/week to write magnesium notes all night on L&D in the name of being "well rounded"

 

[Redpancreas]

Totally agree. It’s too expensive, and too many schools have too much clinically irrelevant material in preclerkship and poor clinical experiences. When people are basically paying 200k to teach themselves and then shadow for 2 years, no wonder they feel like they’re being overtrained.

This. The quality of medical education has been in steep decline yet medical school tuition keeps getting higher.

The problem isn’t a lack of people who are good at teaching. It’s that these outstanding educators have to fight against the culture or opt higher paid career routes instead.

We had one outstanding clinical pathologist who everyone loved who singlehandedly rewrote the lecture notes for the entire second year curriculum and made a system for students to follow. When I left, she was telling me how she hated her job, was underpaid, and wanted to leave because she did not feel supported and felt like she was being asked to do too much. Every time some issue came up with the notes, it got piled on her plate. Now, if she was being paid for the hours of work she was doing with curriculum, that’s one thing, but surely she was just paid the standard teaching stipend.

Each generation has felt more obligated to invest in themselves. Tons of teaching attendings spend more time now curating a social media presence advertising to others “how they can have it all” (the medical career,
several kids, stay in shape, cook, travel, etc.). I frankly don’t blame them either because they’re enjoying their life and it’s not like if they invested their time in actually teaching medical students they’d be rewarded for it.

If we want medical education to improve, we have to put money and resources in smart places in medical education. All you Anki-Kings...maybe if it’s effective we can figure out how to automate it and integrate it nationwide into the curriculum. Then we can do a study across schools and validate the method for learning. Then we can restructure the PhD-lecture model we currently have in place. That’s one example. Another is seriously considering providing a very generous stipend and hire smart people who are solely dedicated to the curriculum in medical education.

 

[VA Hopeful Dr]

It can feel pretty excessive even with good schooling. I had classmates come in that already knew they wanted to do pathology. Crazy to think we forced them to pay $1000/week to write magnesium notes all night on L&D in the name of being "well rounded"

Yeah back in the good old days it wasn't 1k/week even including food, rent, gas, and everything.

 

[Ho0v-man]

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.

I’ll have you know that I use my knowledge of the shape of every viral capsid every single day.

 

[Matthew9Thirtyfive]

It can feel pretty excessive even with good schooling. I had classmates come in that already knew they wanted to do pathology. Crazy to think we forced them to pay $1000/week to write magnesium notes all night on L&D in the name of being "well rounded"

Again, I don’t think that is a reason to drastically change the med school curriculum. Path is one of a few niche specialties where they honestly probably don’t need med school at all.

But I actually really wanted to do path for the first half of MS1, and now I want to do surgery or psych lol.

 

[efle]

Again, I don’t think that is a reason to drastically change the med school curriculum. Path is one of a few niche specialties where they honestly probably don’t need med school at all.

But I actually really wanted to do path for the first half of MS1, and now I want to do surgery or psych lol.

It is interesting to think about requiring the decision up front. We make people do it for dental, pod, pharma, and various other allied degrees like audiology or optometry. But med students switch around so often youd have to put in a lot more work during premed to figure yourself out.

 

[Matthew9Thirtyfive]

It is interesting to think about requiring the decision up front. We make people do it for dental, pod, pharma, and various other allied degrees like audiology or optometry. But med students switch around so often youd have to put in a lot more work during premed to figure yourself out.

Yeah I know for me I don’t think I would have been able to do that. There’s no way I would have known I would love psych until actually being in it.

 

[Wordead]

Lol radiology school. Let's make the radiologists even more useless. Great idea.

It's amazing what great revolutionary ideas people come up with. A doctor who has no idea what pregnancy involves? Sweet

 

[Ho0v-man]

I think the first 3 years are pretty good for almost every field, including rads and path. Especially since most people change their minds. You can usually get exposure to stuff you’re interested in outside of the core specialties as electives after March of third year. No matter what you’re going for, there’s going to be some fluff but this gives valuable exposure and education to easily 90%+ of med students. I can’t get mad that as a future radiologist the system didn’t go out of its way to make sure my education was tailored specifically to me when I’m pursuing a niche specialty. I need to at least have an idea of what’s going on with my future referrers.

People complain about preclinical minutiae and I agree it’s out of hand. But my big gripe is that while rotating with IM subspecialists this year that a lot of the basic science comes up but in general IM it doesn’t so much. I.e., I did well on boards but I promise peak step 1 me has nothing on the random endocrinologist I rotated with. This makes me feel like preclinical education has a lot of value that we just blow off so we can spend a year writing notes no one reads and answering pimp questions about electrolytes.

Fourth year is an absolute waste of time and only exists to rob us of tuition dollars. Most, if not all medical schools don’t pay anything beyond liability insurance for their students in fourth year. So of course it’s “chill” and you go home early. Education isn’t incentivized at all and only serves to make us less prepared for intern year.

 

[Redpancreas]

I think the first 3 years are pretty good for almost every field, including rads and path. Especially since most people change their minds. You can usually get exposure to stuff you’re interested in outside of the core specialties as electives after March of third year. No matter what you’re going for, there’s going to be some fluff but this gives valuable exposure and education to easily 90%+ of med students. I can’t get mad that as a future radiologist the system didn’t go out of its way to make sure my education was tailored specifically to me when I’m pursuing a niche specialty. I need to at least have an idea of what’s going on with my future referrers.

People complain about preclinical minutiae and I agree it’s out of hand. But my big gripe is that while rotating with IM subspecialists this year that a lot of the basic science comes up but in general IM it doesn’t so much. I.e., I did well on boards but I promise peak step 1 me has nothing on the random endocrinologist I rotated with. This makes me feel like preclinical education has a lot of value that we just blow off so we can spend a year writing notes no one reads and answering pimp questions about electrolytes.

Fourth year is an absolute waste of time and only exists to rob us of tuition dollars. Most, if not all medical schools don’t pay anything beyond liability insurance for their students in fourth year. So of course it’s “chill” and you go home early. Education isn’t incentivized at all and only serves to make us less prepared for intern year.

I think this is a good point. For managing COPD/CHF exacerbations, you don't need any basic science, but that is the stuff we learn prior to being allowed on the wards. I think the preclinical mechanisms like Wolf-Chaikoff can be revisited via didactics in M2+ when students are on wards learning about amiodarone induced hyperthyroidism. The first time, in M1, Wolf-Chaikoff can be just taught at face value for students to know for the boards.

 

[efle]

Lol radiology school. Let's make the radiologists even more useless. Great idea.

It's amazing what great revolutionary ideas people come up with. A doctor who has no idea what pregnancy involves? Sweet

I'm guessing you also would've wanted rads to stay a fellowship after IM? Wouldnt let your ankle be operated on by someone who went to pod school and didnt rotate on L&D? Those takes seem crazier to me. Cuts and revisions to training pathways have already been made many times. Alternative degrees to MD for specialized areas (who are still called doctors) have already existed for a long time.

 

[curbsideconsult]

It'll be interesting to see how the opinions of med students in this thread will change with intern year. With a year of physician-ing under my belt, my belief that physicians need to take back control are even stronger. But I could easily see how others would go in the opposite direction.

Personally, what I've found is that while many experienced midlevels can do certain parts of their respective specialty very well, they're generally still not doing the high level of thinking that upper level residents and attendings do. Some of them don't know what they don't know and that leads to hubris which compromises patient care. The best analogy I can think of at the moment is driving: I've had my driver's license and have been driving for longer than most SDNers have been alive, but that doesn't make me anywhere near qualified to start driving an 18-wheeler. Could I practice without the proper education/training and get to the point where I don't take out the corners of buildings and run over little cars? Sure. But should I? No.

There are many midlevels at my hospital I adore and work with very well. They're the ones who know their limits and are quick to say "let me talk to my attending and get back to you." Luckily there are more of those at my hospital than the ones I dislike with a fiery passion who are quick to dismiss PGY-1s because we're "just" interns.

As for med school and residency bloat: yes and no. As mentioned above, the minutiae taught in med school is a bit much and there are many useless hours spent on "professionalism" and "being a team player" (which are basically euphemisms for teaching med students to become self-flagellating physicians any time we even think about being the leader of a team of nurses and midlevels). Med school can definitely be shortened to 3-3.5 years if we got rid of all of those bullshyte classes or condensed them to one week of caning each other into administrative professionalistic submission. However, the scientific minutiae do come up more often than I was led to believe. Just this week I had a PTSD-inducing didactic session that brought us back to the tiny little molecules of biochemistry and Step 1. I think I blacked out for a few minutes. Regarding residency, it really burns me up that midlevels can be trained to do procedures, but IM residents who want to do GI are barely allowed to even look at a scope before fellowship. I know this is not the case with just my institution or even my state. I've heard this about other IM programs as well. If attendings are going to allow midlevels to do what they do, they should also be teaching residents to do the same.

 

[efle]

It'll be interesting to see how the opinions of med students in this thread will change with intern year. With a year of physician-ing under my belt, my belief that physicians need to take back control are even stronger. But I could easily see how others would go in the opposite direction.

Personally, what I've found is that while many experienced midlevels can do certain parts of their respective specialty very well, they're generally still not doing the high level of thinking that upper level residents and attendings do. Some of them don't know what they don't know and that leads to hubris which compromises patient care. The best analogy I can think of at the moment is driving: I've had my driver's license and have been driving for longer than most SDNers have been alive, but that doesn't make me anywhere near qualified to start driving an 18-wheeler. Could I practice without the proper education/training and get to the point where I don't take out the corners of buildings and run over little cars? Sure. But should I? No.

There are many midlevels at my hospital I adore and work with very well. They're the ones who know their limits and are quick to say "let me talk to my attending and get back to you." Luckily there are more of those at my hospital than the ones I dislike with a fiery passion who are quick to dismiss PGY-1s because we're "just" interns.

As for med school and residency bloat: yes and no. As mentioned above, the minutiae taught in med school is a bit much and there are many useless hours spent on "professionalism" and "being a team player" (which are basically euphemisms for teaching med students to become self-flagellating physicians any time we even think about being the leader of a team of nurses and midlevels). Med school can definitely be shortened to 3-3.5 years if we got rid of all of those bullshyte classes or condensed them to one week of caning each other into administrative professionalistic submission. However, the scientific minutiae do come up more often than I was led to believe. Just this week I had a PTSD-inducing didactic session that brought us back to the tiny little molecules of biochemistry and Step 1. I think I blacked out for a few minutes. Regarding residency, it really burns me up that midlevels can be trained to do procedures, but IM residents who want to do GI are barely allowed to even look at a scope before fellowship. I know this is not the case with just my institution or even my state. I've heard this about other IM programs as well. If attendings are going to allow midlevels to do what they do, they should also be teaching residents to do the same.

What specifically bothers you about NPs being taught procedures - that they lack something learned during physician residency they need to know to do it correctly? That they're getting to snatch up the high reimbursement? Something else?

 

[curbsideconsult]

What specifically bothers you about NPs being taught procedures - that they lack something learned during physician residency they need to know to do it correctly? That they're getting to snatch up the high reimbursement? Something else?

Exactly what I said. It's not so much that midlevels are being taught these procedures. It's that physician residents are not.

 

[efle]

Exactly what I said. It's not so much that midlevels are being taught these procedures. It's that physician residents are not.

I feel like that's a hard sell to legislatures though haha

 

[Jack Donaghy]

Honestly, a see a lot of but "I would rather have GPs than NPs to do colonoscopies" talk, but in reality are they? What component of training are they better at inherently based off their training? An NP can basically do a lot because they're going to get good at doing that one thing, whereas as FM doctor unless they're really practicing out in the boonies will not get the same volume. It's not doctor v. NP/PA. It's for the patient at the end of the day. There will still be GI doctors ultimately leading these facilities, coordinating with Pathology, etc.

I'm saying this as a GI aspirant who's likely going to start practicing when this comes into play.

1) "GP" isn't a thing in this country. FM docs are residency trained specialists.

2) my FM program has been and currently still trains FM residents to do colonoscopies, to the point that many graduates leave with hospital privileges. This is at a medium sized academic center with a dozen residency programs, including surgery.

 

[Redpancreas]

1) "GP" isn't a thing in this country. FM docs are residency trained specialists.

2) my FM program has been and currently still trains FM residents to do colonoscopies, to the point that many graduates leave with hospital privileges. This is at a medium sized academic center with a dozen residency programs, including surgery.

General Practitioners exist, they just are effectively being driven by politics of necessity of board certification for primary care fields ex. FM/IM). I think it's good that FM can train residents to do colonoscopies to meet screening colonoscopy needs to rural areas. I personally would rather have a tech, GI physician, or GI midlevel doing it simply for the expertise, not someone who is a "jack of all trades" and has to know about OB/GYN and fetal tracings. We all have pride in our fields, but endoscopy is not something I would go to a FM trained physician for given the choice.

 

[Matthew9Thirtyfive]

General Practitioners exist, they just are effectively being driven by politics of necessity of board certification for primary care fields ex. FM/IM). I think it's good that FM can train residents to do colonoscopies to meet screening colonoscopy needs to rural areas. I personally would rather have a tech, GI physician, or GI midlevel doing it simply for the expertise, not someone who is a "jack of all trades" and has to know about OB/GYN and fetal tracings. We all have pride in our fields, but endoscopy is not something I would go to a FM trained physician for given the choice.

You would rather have a tech who hasn’t done medical school or residency do your scope than a residency trained FP who did enough scopes in residency to be able to get privileges? That is absolutely bonkers.

 

[Redpancreas]

You would rather have a tech who hasn’t done medical school or residency do your scope than a residency trained FP who did enough scopes in residency to be able to get privileges? That is absolutely bonkers.

Yes. A tech would presumably have done hundred of these procedures and there would be a robust academic system in place to escalate care. The same thing could be said about an NP. They would have high volume and know what their doing whereas a FM physician, regardless of having a lecture on the histopathology of a colon, wouldn't generate a volume I would be comfortable with given they are also managing knee pain, workers comp, OB/GYN, sick kids, etc. I remember GI physicians do about 3000 scopes but the number to be certified is 10x less if I'm not mistaken. I think I'd rather have people who have the experience doing 1000s over someone who is just certified to do them. Not to delve into SPF territory, but I imagine you're familiar with Adam Smith's The Wealth of Nations and one of the predominant themes include division of labor. I think it is most efficient to have someone who has done something 1000x do it and then arrange the structure so that they are supervised by the appropriate personel (GI physicians) as opposed to giving the work to someone who simply "deserves it more" because they went to medical school.

Now, I think a solution for this to benefit physicians is earlier integration of clinical skills into medical school. I think that would allow medical students to acquire the pertinent book knowledge (gut pathophysiology > what is a western blot), but then rapidly transition to the hands-on skills needed. M2 could be about clinical medicine skills and M3/4 can start teaching students practical stuff (ex. procedural elements). This would put medical trainees in a stronger position when competing against midlevels for experience in the setting of medical training.

 

[Lawpy]

You would rather have a tech who hasn’t done medical school or residency do your scope than a residency trained FP who did enough scopes in residency to be able to get privileges? That is absolutely bonkers.

Why does a residency trained FP even exist

 

[VA Hopeful Dr]

Yes. A tech would presumably have done hundred of these procedures and there would be a robust academic system in place to escalate care. The same thing could be said about an NP. They would have high volume and know what their doing whereas a FM physician regardless of having a lecture on the histopathology of a colon wouldn't generate a volume I would be comfortable with given they are also managing knee pain, workers comp, OB/GYN, sick kids, etc. Not to delve into SPF territory, but I imagine you're familiar with Adam Smith's The Wealth of Nations and one of the predominant themes include division of labor. I think it is most efficient to have someone who has done something 1000x do it and then arrange the structure so that they are supervised by the appropriate personel (GI physicians) as opposed to giving the work to someone who simply "deserves it more" because they went to medical school.

Now, I think a solution for this is earlier integration of clinical skills into medical school. I think that would allow medical students to acquire the pertinent book knowledge (gut pathophysiology > what is a western blot), but then rapidly transition to the hands-on skills needed. M2 could be about clinical medicine skills and M3/4 can start teaching students practical stuff (ex. procedural elements). This would put medical trainees in a stronger position when competing against midlevels for experience in the setting of medical training.

You have to have a large number of scopes in training to get privileges to do them. I know when I left residency it was 200.

There aren't FPs out there who did 10 scopes in residency doing them in practice.

 

[VA Hopeful Dr]

Why does a residency trained FP even exist

You never cease to disappoint

 

[efle]

You would rather have a tech who hasn’t done medical school or residency do your scope than a residency trained FP who did enough scopes in residency to be able to get privileges? That is absolutely bonkers.

I'm with him, I'd much rather have an experienced scoper who screens all day every day with no mental UWorld database instead of an FM resident who met minimum reps. Polyp or no polyp + sample the polyp, isnt brainy, the brainy part is path's job or an MD that will treat me if its warranted on the results.

 

[Redpancreas]

You have to have a large number of scopes in training to get privileges to do them. I know when I left residency it was 200.

There aren't FPs out there who did 10 scopes in residency doing them in practice.

Sorry, I edit my posts too much. Anyhow, I think if I'm not mistaken the number to do them is like 300 to be certified for general surgery but then GI does like 3000s. Techs/GI midlevels/GI physicians would be in the 1000s. FPs would be in the 100s.

 

[Lawpy]

You never cease to disappoint

I mean i'm trying to make residency a physician-exclusive term and just have specialized 1-2 yr training for anyone else for a specialized area at hand. The idea of a midlevel residency is controversial because that would lead to weird competition or even preference of midlevels over residents on a lot of things.

 

[Redpancreas]

Why does a residency trained FP even exist

Because they offer a very broad skillset which in many instances is extremely valuable. They essentially gatekeep medicine and form relationships with families for education and prevent unnecessary specialist referrals. They can deal with simple issues IM can deal with (chronic medical comorbidities) but also manage common pediatric ailments as well as OB/GYN issues. No other field has this level of versatility with the opportunity to follow patients longitudinally. Med/Peds tries to replicate it but they can't because FM is not just Medicine and Peds.

That said, I think FM should be involved in colonoscopies especially in underserved areas, but I don't think it's as good of a solution as having people who've done thousands who are under constant supervision specialists.

 

[VA Hopeful Dr]

Sorry, I edit my posts too much. Anyhow, I think if I'm not mistaken the number to do them is like 300 to be certified for general surgery but then GI does like 3000s. Techs/GI midlevels/GI physicians would be in the 1000s. FPs would be in the 100s.

Not certified, hospital privileges. Totally different things.

 

[Redpancreas]

Not certified, hospital privileges. Totally different things.

Will look into that nuance. Thanks!

 

[Lawpy]

Because they offer a very broad skillset which in many instances is extremely valuable. They essentially gatekeep medicine and form relationships with families for education and prevent unnecessary specialist referrals. They can deal with simple issues IM can deal with (chronic medical comorbidities) but also manage common pediatric ailments as well as OB/GYN issues. No other field has this level of versatility. Med/Peds tries to replicate it but they can't because FM is not just Medicine and Peds.

I think what kinda unsettles me is this division of simple issues for midlevels and complex issues for physicians. And i'm not sure midlevels prevent unnecessary referrals since at least anecdotally suggests the opposite

 

[Matthew9Thirtyfive]

Yes. A tech would presumably have done hundred of these procedures and there would be a robust academic system in place to escalate care. The same thing could be said about an NP. They would have high volume and know what their doing whereas a FM physician, regardless of having a lecture on the histopathology of a colon, wouldn't generate a volume I would be comfortable with given they are also managing knee pain, workers comp, OB/GYN, sick kids, etc. I remember GI physicians do about 3000 scopes but the number to be certified is 10x less if I'm not mistaken. I think I'd rather have people who have the experience doing 1000s over someone who is just certified to do them. Not to delve into SPF territory, but I imagine you're familiar with Adam Smith's The Wealth of Nations and one of the predominant themes include division of labor. I think it is most efficient to have someone who has done something 1000x do it and then arrange the structure so that they are supervised by the appropriate personel (GI physicians) as opposed to giving the work to someone who simply "deserves it more" because they went to medical school.

Now, I think a solution for this to benefit physicians is earlier integration of clinical skills into medical school. I think that would allow medical students to acquire the pertinent book knowledge (gut pathophysiology > what is a western blot), but then rapidly transition to the hands-on skills needed. M2 could be about clinical medicine skills and M3/4 can start teaching students practical stuff (ex. procedural elements). This would put medical trainees in a stronger position when competing against midlevels for experience in the setting of medical training.

Yeah sorry, as someone who was an endo tech and did hundreds of them (like actually pushed scope with a doc right over my shoulder), I absolutely would not want my c scope done by a tech. And you completely changed my question. I didn’t say a tech vs an FP who has not had the volume to become competent. I said a tech vs an FP who has done a significant amount of scopes in residency and has gotten privileges to do them.

 

[Matthew9Thirtyfive]

I'm with him, I'd much rather have an experienced scoper who screens all day every day with no mental UWorld database instead of an FM resident who met minimum reps. Polyp or no polyp + sample the polyp, isnt brainy, the brainy part is path's job or an MD that will treat me if its warranted on the results.

I was an endo tech and did hundreds of scopes. Your opinion is not based in reality. It doesn’t matter if you get hundreds of reps if you don’t have the education to know what your looking for and why.

 

[Lawpy]

Yeah sorry, as someone who was an endo tech and did hundreds of them (like actually pushed scope with a doc right over my shoulder), I absolutely would not want my c scope done by a tech. And you completely changed my question. I didn’t say a tech vs an FP who has not had the volume to become competent. I said a tech vs an FP who has done a significant amount of scopes in residency and has gotten privileges to do them.

On a related point, what about a residency trained tech with hospital privileges to do them? They'd be indistinguishable from the FP?

 

[efle]

I was an endo tech and did hundreds of scopes. Your opinion is not based in reality. It doesn’t matter if you get hundreds of reps if you don’t have the education to know what your looking for and why.

Theyd get the education, is the idea. Just specifically an education in screening. I also worked a year in academic GI suites and fresh trainees with an MD were also blank slates.

 

[Lawpy]

Also i think phasing out the NPs completely and expanding the roles of PAs answer the question based on their roles.

 

[Matthew9Thirtyfive]

On a related point, what about a residency trained tech with hospital privileges to do them? They'd be indistinguishable from the FP?

If you put a tech through like a year of doing nothing but screening scopes and didactics, he’d probably have equal detection rates to the FP, or maybe even better. But that’s literally all he could do lol. I guess that’s useful, and honestly would eliminate a lot of the headaches with NPs.

 

[efle]

If you put a tech through like a year of doing nothing but screening scopes and didactics, he’d probably have equal detection rates to the FP, or maybe even better. But that’s literally all he could do lol. I guess that’s useful, and honestly would eliminate a lot of the headaches with NPs.

Hes starting to get it

 

[Matthew9Thirtyfive]

Also i think phasing out the NPs completely and expanding the roles of PAs answer the question based on their roles.

I wonder if the AAPA would continue pushing for independent practice if NPs suddenly disappeared.

 

[Lawpy]

If you put a tech through like a year of doing nothing but screening scopes and didactics, he’d probably have equal detection rates to the FP, or maybe even better. But that’s literally all he could do lol. I guess that’s useful, and honestly would eliminate a lot of the headaches with NPs.

Ok nvm i was getting hung up on semantics.

 

[Matthew9Thirtyfive]

Hes starting to get it

Condescension aside, I’m not necessarily against that kind of a model in certain situations. I am against midlevels doing these things because they aren’t trying to just do these things. They are doing the procedures and then trying to manage the patient completely, which they just don’t have the knowledge base to do.

 

[Lem0nz]

Sorry, I edit my posts too much. Anyhow, I think if I'm not mistaken the number to do them is like 300 to be certified for general surgery but then GI does like 3000s. Techs/GI midlevels/GI physicians would be in the 1000s. FPs would be in the 100s.

Hahaha. The number for general surgery is 50.

Enjoy that nugget of information.

 

[Lawpy]

I wonder if the AAPA would continue pushing for independent practice if NPs suddenly disappeared.

Maybe, i think the problem arose due to the antagonistic nature of healthcare that was pushed forward by NPs. That's why i'm asking and presenting these hypotheticals to clearly define the various roles and how they all have a major role in patient care