MD & DO PA/NP RESIDENCY at UNC????

[Pepe18]

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[ExplodingUlcers]

Well for what it's worth, I know of a large hospital system in my state who will not hire anymore mid-levels except for certain specialities. I have a feeling these mid-levels will bring about their own demise with so much proliferation that employers and patients will start to see them as being inferior compared to MD/DO.

I'm in an optimistic mood today.

 

[deleted480308]

My issue is less with deciding to take tons of loans out and more with the idea that "well your parents can't help you, your loans are super high, you might as well just give up on becoming an MD and pursue something different because it's 'wiser' to do so." If that's the case, then the outcome is that the majority of MDs end up being from upper-class/rich families or the majority of lower-income students have to become midlevels even if they want to become physicians. That should be seen as a problem.

I hate turning it into an SES issue but it's true. But everyone is entitled to their opinion so I'll leave it at that.

But anyways

Stuff costs what it costs.

 

[nimbus]

Well for what it's worth, I know of a large hospital system in my state who will not hire anymore mid-levels except for certain specialities. I have a feeling these mid-levels will bring about their own demise with so much proliferation that employers and patients will start to see them as being inferior compared to MD/DO.

I'm in an optimistic mood today.

FWIW, when I started working at my current hospital in 2002, we had 1 surgical PA who worked in our OR’s. Now there are so many that I don’t know an exact tally, maybe 15-20. I don’t thiink they are going anywhere. And they don’t work for the hospital. When surgeons need an assistant, their office schedules them and they bill on their own. A few are employed by the surgical groups.

 

[libertyyne]

FWIW, when I started working at my current hospital in 2002, we had 1 surgical PA who worked in our OR’s. Now there are so many that I don’t know an exact tally, maybe 15-20. I don’t thiink they are going anywhere.

IMO, I think there is a large difference between and independently practicing Pa / NP vs a surgical first assist PA/NP. One does the entire job vs the other is more of a first assist. One continually pushes for full autonomy and parity vs the other does not.

 

[Aphiah]

Get ready to cross many more off the list as midlevels are everywhere now, including surgery.

Radiology is the only specialty free of this nonsense.

 

[nimbus]

IMO, I think there is a large difference between and independently practicing Pa / NP vs a surgical first assist PA/NP. One does the entire job vs the other is more of a first assist. One continually pushes for full autonomy and parity vs the other does not.

Yeah the PA’s I see are definitely not practicing independently.

 

[libertyyne]

Radiology is the only specialty free of this nonsense.

Radiologists have their own boogeymen including decreasing reimbursement and AI, not to mention radiology physician assistant

 

[KeikoTanaka]

On one hand, if midlevels are going to be in medicine (which they will be) they should be well-trained, and therefore should be more than able to secure "residency-style" positions to better train them. However, they should not put the burden of training them on the MD/DOs/Residents.

Senior PAs should be teaching PAs and senior NPs should be teaching NPs. Because, they know the role they were assigned to, and therefore should be apt at being able to handle what they handle. There should never be any cross-over between MD/DO residencies which are mandated, and optional PA/NP residencies.

The PAs at UNC did not need to take 60k pay cut to make 60k, they could be a fresh new grad with 0 experience making 115k in that same year. So, honestly, that isn't the problem I see with this. The only problem I see is if there is in ANYWAY SHAPE OR FORM a hinderance to the education of the MD/DO residents who earned that spot and are mandated by laws to provide them the appropriate education. The moment that a PA/NP "residency" interferes with that, the ACGME should bring down the hammer.

Idc about the salary difference, because that PA is taking a pay cut so they aren't a danger to their future patients and don't have to ask dumb questions to the attendings, they "learned it in residency" - so if they actually have a question, it's about something complex.

 

[Aphiah]

Radiologists have their own boogeymen including decreasing reimbursement and AI, not to mention radiology physician assistant

Radiology PA?!

 

[boolin_1]

On one hand, if midlevels are going to be in medicine (which they will be) they should be well-trained, and therefore should be more than able to secure "residency-style" positions to better train them. However, they should not put the burden of training them on the MD/DOs/Residents.

Senior PAs should be teaching PAs and senior NPs should be teaching NPs. Because, they know the role they were assigned to, and therefore should be apt at being able to handle what they handle. There should never be any cross-over between MD/DO residencies which are mandated, and optional PA/NP residencies.

The PAs at UNC did not need to take 60k pay cut to make 60k, they could be a fresh new grad with 0 experience making 115k in that same year. So, honestly, that isn't the problem I see with this. The only problem I see is if there is in ANYWAY SHAPE OR FORM a hinderance to the education of the MD/DO residents who earned that spot and are mandated by laws to provide them the appropriate education. The moment that a PA/NP "residency" interferes with that, the ACGME should bring down the hammer.

Idc about the salary difference, because that PA is taking a pay cut so they aren't a danger to their future patients and don't have to ask dumb questions to the attendings, they "learned it in residency" - so if they actually have a question, it's about something complex.

preach it

 

[Alkaidius]

Radiology is the only specialty free of this nonsense.

Somewhere over the horizon one PA just said to another PA, “hold my beer”.

 

[Mass Effect]

All the more reason for students to make sound financial decisions. Apparently for some, the best decision is not to go to medical school. You of all people can understand personal responsibility. Not everyone gets a trophy, right?

Personal responsibility among the students is one thing, but what about personal responsibility among the school? Do you really think it's responsible to jack up tuition costs and encourage students to enter PSLF to get their loans forgiven?

Stuff costs what it costs.

Actually, it doesn't. If it did, all med schools would cost the same, in-state and out-of-state wouldn't matter, some med schools wouldn't be for-profit, on and on and on.

 

[nimbus]

Personal responsibility among the students is one thing, but what about personal responsibility among the school? Do you really think it's responsible to jack up tuition costs and encourage students to enter PSLF to get their loans forgiven?

I agree with you that it’s a scam and gullible young people should not fall for it. They’ll be dragging that debt around a long time. That’s why I posted before that medical school is not always a good choice.

 

[Aphiah]

The future of medicine is questionable. No one has ever clearly defined what the purpose of an NP is. A PA that works independently wouldn't make sense ("Physician Assistant" after all). But what is the Nurse Practioner?

I'm an M3 on IM. NP's at my hospital are able to cancel orders that IM attnedings and residents make. The attending gets frustrated and the residents (obviously) but it only ends in frustration. There was even an instance where the Cardiology NP was giving orders to the Hospitalist Attending on discharge meds. If an NP can give a physician orders, if an NP can create their own plan for a patient, if an NP can cancel a physician's orders, why go to medical school?

 

[nimbus]

The future of medicine is questionable. No one has ever clearly defined what the purpose of an NP is. A PA that works independently wouldn't make sense ("Physician Assistant" after all). But what is the Nurse Practioner?

I'm an M3 on IM. NP's at my hospital are able to cancel orders that IM attnedings and residents make. The attending gets frustrated and the residents (obviously) but it only ends in frustration. There was even an instance where the Cardiology NP was giving orders to the Hospitalist Attending on discharge meds. If an NP can give a physician orders, if an NP can create their own plan for a patient, if an NP can cancel a physician's orders, why go to medical school?

Great question! NP is a great career. A cardiology NP may have more expertise in managing cardiac meds than a hospitalist. Obviously the primary service consulted the cardiology service for a reason. But there are still things that the cardiologist can do that a cardiology NP doesn’t. Maybe they are busy doing TAVR’s and Mitraclips while the NP is fielding consults and minding the floors. That’s a pretty good reason for the cardiologist to go to med school and to hire NP’s to help them out.

 

[slowthai]

I'm an M3 on IM. NP's at my hospital are able to cancel orders that IM attnedings and residents make. The attending gets frustrated and the residents (obviously) but it only ends in frustration. There was even an instance where the Cardiology NP was giving orders to the Hospitalist Attending on discharge meds. If an NP can give a physician orders, if an NP can create their own plan for a patient, if an NP can cancel a physician's orders, why go to medical school?

This is like the beginning of my worst nightmare. Good night, what in Hippocrates' name is this garbage?

 

[Aphiah]

Great question! NP is a great career. A cardiology NP may have more expertise in managing cardiac meds than a hospitalist. Obviously the primary service consulted the cardiology service for a reason. But there are still things that the cardiologist can do that a cardiology NP doesn’t. Maybe they are busy doing TAVR’s and Mitraclips while the NP is fielding consults and minding the floors. That’s a pretty good reason for the cardiologist to go to med school and to hire NP’s to help them out.

I appreciate you explaining that, but I still find it concerning. I have been told several horror stories of physicians either being sued or losing their license because they did not look over the NP's notes/plan. Attendings have told me these stories. In one case, an NP's plan lead to the death of a patient but the physician ended up in court, lost his license, and the NP still kept her job. This physician was good friends with the attending who told me this story. Imagine if that was your friend.

Why in the world would any physician want to constantly have to overlook the work of another? Most physicians don't live in fear because most times nothing terrible happens. And yes, I know that MD's and DO's make mistakes too but at least their responsible for their own actions. As a physician who has NP's or PA's you are automatically responsible for their decisions as well. That's terrifying.

A cardiology NP may have more expertise in managing cardiac meds than a hospitalist. Obviously the primary service consulted the cardiology service for a reason. But there are still things that the cardiologist can do that a cardiology NP doesn’t. Maybe they are busy doing TAVR’s and Mitraclips while the NP is fielding consults and minding the floors. That’s a pretty good reason for the cardiologist to go to med school and to hire NP’s to help them out.

If an NP is more capable for managing cardiology drugs than a hospitalist, then what is the difference between a Cardiology NP and a Cardiologist who only does clinic?

At some point, I think we enter into this zone where we blur the line between NP and MD especially when an NP is considered more knowledgable in a particular facet of medicine (ex. cardiology) than a primary care physician.

 

[risus_sardonicus]

Why in the world would any physician want to constantly have to overlook the work of another? Most physicians don't live in fear because most times nothing terrible happens. And yes, I know that MD's and DO's make mistakes too but at least their responsible for their own actions. As a physician who has NP's or PA's you are automatically responsible for their decisions as well. That's terrifying.

Simple answer: greed.

The boomers have sold out our profession to make a quick buck. The only way it will change is when litigations become so common that these boomers will think 3x before hiring an inappropriately trained person to risk patient’s lives.



Sent from my iPhone using SDN

 

[Giovanotto]

Lets take medicine back into private practice and compete with NPs/PAs that want independence practice right in that setting. Make patients decide where they want to spend their buckaroos. I want to see how HCAs and larger health care systems feel when physicians start taking their talents and expertise elsewhere. I don't see this going any other way. I'm entering residency with my sights set on private practice unless things change, it's terrible to see the direction medicine is heading in right now. Hell, I may even consider working in another country at this point, especially given my multi-nationality.

Of course there are pitfalls to my argument. If my residency training is affected by midlevels, which it may be, then I may in fact not be as superior of a product as I believe. Academia may well be the last bastion of hope.

 

[Aphiah]

Lets take medicine back into private practice and compete with NPs/PAs that want independence practice right. Make patients decide where they want to spend their buckaroos. I want to see how HCAs and larger health care systems feel when physicians start taking their talents and expertise elsewhere. I don't see this going any other way.

Sadly, I believe this is the only way to change things. Salaries may take a hit for non-procedural specialties but I think it would eventually turn around. Let the NP and PA be trained independently and then work independently. Then we will see if MD and DO education (including residency) makes a difference.

 

[Giovanotto]

This story reminded me of something that I experienced as early as an MS3. During my ob/gyn clerkship's L&D week, I had to sit by while I saw the residents run to call the PA "fellow" for a delivery, over and over again, while us, medical students, stood idly by. My entire week on that service I assisted with one delivery, while the PA "fellow" got first dibs. I was also very clear with the residents at the beginning of that week that I was interested in ob/gyn and wanted to do a few deliveries. And I was lucky, many of my colleagues didn't get a single delivery. That was a turning point for me, to see residents themselves choosing to train PA 'fellows' over medical students.

You guys want another anecdote? Last year I was in the OR with two surgeons, a chief surgery resident and a PA in-training. The chief surgical resident was playing second fiddle to the PA in-training given that one of the surgeons was training her for full time work. I was embarrassed and saddened to see a resident with 11 (4+5+2-research years) years in training having to stand there for a 9 hour surgery.

 

[Mass Effect]

The future of medicine is questionable. No one has ever clearly defined what the purpose of an NP is. A PA that works independently wouldn't make sense ("Physician Assistant" after all). But what is the Nurse Practioner?

I'm an M3 on IM. NP's at my hospital are able to cancel orders that IM attnedings and residents make. The attending gets frustrated and the residents (obviously) but it only ends in frustration. There was even an instance where the Cardiology NP was giving orders to the Hospitalist Attending on discharge meds. If an NP can give a physician orders, if an NP can create their own plan for a patient, if an NP can cancel a physician's orders, why go to medical school?

This is actually one of the few things that makes sense. If an NP is acting in the capacity of a cardiology NP, then yes, they get to recommend d/c meds, just like any other specialty would. As a psych resident, I often recommended psych meds on discharge to the IM hospitalist. If I admitted a patient to my psych unit, the meds are my responsibility and there were times I discontinued and/or changed a med the hospitalist had started. That doesn't raise red flags to me.

 

[UnoMas]

This is actually one of the few things that makes sense. If an NP is acting in the capacity of a cardiology NP, then yes, they get to recommend d/c meds, just like any other specialty would. As a psych resident, I often recommended psych meds on discharge to the IM hospitalist. If I admitted a patient to my psych unit, the meds are my responsibility and there were times I discontinued and/or changed a med the hospitalist had started. That doesn't raise red flags to me.

My best guess is the NP gave the Cardiologist's recommendations. The same way, me, a PGY1, made recommendations to my IM attendings when I was on Cardiology Consult service. I presented and discussed the patient with my attending Cardiologist or the fellow, agreed on a plan and ten communicated to the primary team. However, cancelling the primary team's orders without communicating with them is a big no-no.

 

[nimbus]

I appreciate you explaining that, but I still find it concerning. I have been told several horror stories of physicians either being sued or losing their license because they did not look over the NP's notes/plan. Attendings have told me these stories. In one case, an NP's plan lead to the death of a patient but the physician ended up in court, lost his license, and the NP still kept her job. This physician was good friends with the attending who told me this story. Imagine if that was your friend.

Why in the world would any physician want to constantly have to overlook the work of another? Most physicians don't live in fear because most times nothing terrible happens. And yes, I know that MD's and DO's make mistakes too but at least their responsible for their own actions. As a physician who has NP's or PA's you are automatically responsible for their decisions as well. That's terrifying.

The short answer is that the physicians need the nurse practitioners. They are not extraneous bodies there to upset medical students and house staff.

I’m in private practice in anesthesiology.

I spend many hours in the operating room with a cardiac surgeon who uses a nurse practitioner. They have been working together for at least 15years. She does endoscopic vein and artery harvest better and faster than anyone I’ve ever seen. Then she leaves to round on postops in ICU and step down, she examines everyone, collects all the data and returns to the OR to report back much like a resident does. She is superb at her job which she has been doing for a long time.

I also work with a cardiac electrophysiologist who has a nurse practitioner. The NP doesn’t do anything procedural but she does field consults and rounds while the doctor is doing 5-6 hr ablations in EP lab. Then she comes to EP lab and they go over and discuss all the patients much like a resident and attending would.

I do think it is important to build a relationship and trust when working with midlevels. I’m sure not all of them are competent.

 

[nimbus]

My best guess is the NP gave the Cardiologist's recommendations. The same way, me, a PGY1, made recommendations to my IM attendings when I was on Cardiology Consult service. I presented and discussed the patient with my attending Cardiologist or the fellow, agreed on a plan and ten communicated to the primary team. However, cancelling the primary team's orders without communicating with them is a big no-no.

That is more than likely what was going on.

 

[Mad Jack]

Past take far fewer resources to train due to the nonexistent requirements inherent in unaccredited training programs. They can also bill for full services from day one depending on the state and can see patients independently. Residents should make more than they do, but it's really an apples to oranges comparison

 

[nimbus]

I appreciate you explaining that, but I still find it concerning. I have been told several horror stories of physicians either being sued or losing their license because they did not look over the NP's notes/plan. Attendings have told me these stories. In one case, an NP's plan lead to the death of a patient but the physician ended up in court, lost his license, and the NP still kept her job. This physician was good friends with the attending who told me this story. Imagine if that was your friend.

Why in the world would any physician want to constantly have to overlook the work of another? Most physicians don't live in fear because most times nothing terrible happens. And yes, I know that MD's and DO's make mistakes too but at least their responsible for their own actions. As a physician who has NP's or PA's you are automatically responsible for their decisions as well. That's terrifying.



If an NP is more capable for managing cardiology drugs than a hospitalist, then what is the difference between a Cardiology NP and a Cardiologist who only does clinic?

At some point, I think we enter into this zone where we blur the line between NP and MD especially when an NP is considered more knowledgable in a particular facet of medicine (ex. cardiology) than a primary care physician.

People develop their own areas of expertise over the years. Medical school does not make you the king of all medicine. Just because I attended medical school doesn’t mean I know more about skin diseases than a derm PA.

 

[UnoMas]

as we can see from presumably the eldest physician in this thread the problem is.... them... baby boomers and early gen X had the golden goose and they screwed over everyone who followed and as you can see they continue to defend said screwing over

@nimbus will make it right and pay it forward by hooking me up with the most lucrative private practice Anesthesia gig ever known to man in SoCal in 2 more years

 

[Mass Effect]

My best guess is the NP gave the Cardiologist's recommendations. The same way, me, a PGY1, made recommendations to my IM attendings when I was on Cardiology Consult service. I presented and discussed the patient with my attending Cardiologist or the fellow, agreed on a plan and ten communicated to the primary team. However, cancelling the primary team's orders without communicating with them is a big no-no.

They didn't say it was the primary team versus not primary team. The poster said "NP's at my hospital are able to cancel orders that IM attendings and residents make." So if the NP is also primary team and comes on overnight, why shouldn't the NP be able to change the med the IM attending ordered at 9 am when the patient's circumstances were different? That's the point of the NP being there overnight, to treat the patient's status overnight, which may differ from the treatment plan that was ordered during the day shift. Likewise, if the NP is a neurology NP and the IM attending ordered a med, the NP gets to change whatever med he/she wants when admitting to his/her service. Both of these are totally ok in my book.

 

[Mass Effect]

as we can see from presumably the eldest physician in this thread the problem is.... them... baby boomers and early gen X had the golden goose and they screwed over everyone who followed and as you can see they continue to defend said screwing over

As someone from YOUR generation, let me assure you this isn't a good look. Every generation in medicine thinks the ones above them "ruined" it. Don't believe me? Check out some of the writings around the duty hour change. Whining that daddy ruined things for you is a sure-fire way to make sure no one takes you seriously. I suggest we retire all the boomer crap.

 

[nimbus]

as we can see from presumably the eldest physician in this thread the problem is.... them... baby boomers and early gen X had the golden goose and they screwed over everyone who followed and as you can see they continue to defend said screwing over

I’m just sharing my experience and perspective because I’ve been out for awhile. Otherwise SDN becomes an echo chamber. Hopefully some readers find it useful.

 

[Epilepsy365]

Radiology is the only specialty free of this nonsense.

Wrong. There are def Radiology PAs. I met the first hired one at my hospital tumor board 6 months ago.

If you want independence, you better work on a side gig in order to give the middle finger to the system when the time does come.

 

[UnoMas]

Last I heard, Radiologists are actively training midlevels to read CXRs because CXRs are not profitable at all. While I see where they are coming from, it's a slippery slope that they don't want to head down.

 

[libertyyne]

@nimbus will make it right and pay it forward by hooking me up with the most lucrative private practice Anesthesia gig ever known to man in SoCal in 2 more years

too late the CRNA's are going to be doing that.

 

[Epilepsy365]

Last I heard, Radiologists are actively training midlevels to read CXRs because CXRs are not profitable at all. While I see where they are coming from, it's a slippery slope that they don't want to head down.

AI can read CXR better than radiologists.

It is time to put out new guidelines to relieve the radiology work burden.

 

[UnoMas]

too late the CRNA's are going to be doing that.

To be honest, I feel like the CRNA issues are more well-controlled than the midlevel issues in other specialties, especially EM.

They have been kicking and screaming for years, same bills get introduced years after years only to get shot down, all midlevels are granted independent practice at the VA except CRNA-the most vocal and militant group.

Now with the rapid encroachment into other specialties, there's only going to be more awareness on the issue. Other specialties have been sitting out and watching the rabid CRNAs biting the Anesthesiologists, now they are jumping in because it finally has gotten to them. if anything, the CRNA momentum will be lessened.

 

[deleted407021]

I’m going into medicine so I can be an expert in my area of study. Financially, I’m looking to be comfortable with extra left over to do some life fulfilling things. These docs taking on middle levels to bolster their income, well...

Market logic creating more problems than it solves.

 

[libertyyne]

To be honest, I feel like the CRNA issues are more well-controlled than the midlevel issues in other specialties, especially EM.

They have been kicking and screaming for years, same bills get introduced years after years only to get shot down, all midlevels are granted independent practice at the VA except CRNA-the most vocal and militant group.

Now with the rapid encroachment into other specialties, there's only going to be more awareness on the issue. Other specialties have been sitting out and watching the rabid CRNAs biting the Anesthesiologists, now they are jumping in because it finally has gotten to them. if anything, the CRNA momentum will be lessened.

I was being facetious with that comment. That being said there is a difference between a midlevels in surgical and procedural subspecialties vs midlevel encroachment in terms of replacement of entire function. You dont hear the cardiology or ENT or surgical midlevels say they can replace the physicians they work with. You do hear that in primary care, and anasthesia.

I think a more interesting question amongst all of this is: If we think its legally , ethically, appropriate to let an NP do the work of a primary care physician , em, and dermatologist without oversight. Then we are clearly doing a disservice to our own by implementing all of these additional training requirements and years of education.

If this is really the case then we need to burn down the entire medical training establishment and do something else. because clearly people think its ok that their family members be treated by people with half the training and less.

 

[Aphiah]

This is actually one of the few things that makes sense. If an NP is acting in the capacity of a cardiology NP, then yes, they get to recommend d/c meds, just like any other specialty would. As a psych resident, I often recommended psych meds on discharge to the IM hospitalist. If I admitted a patient to my psych unit, the meds are my responsibility and there were times I discontinued and/or changed a med the hospitalist had started. That doesn't raise red flags to me.

I get you. Just have been confused as to who actually is developing the plan.

The short answer is that the physicians need the nurse practitioners. They are not extraneous bodies there to upset medical students and house staff.

I’m in private practice in anesthesiology.

I spend many hours in the operating room with a cardiac surgeon who uses a nurse practitioner. They have been working together for at least 15years. She does endoscopic vein and artery harvest better and faster than anyone I’ve ever seen. Then she leaves to round on postops in ICU and step down, she examines everyone, collects all the data and returns to the OR to report back much like a resident does. She is superb at her job which she has been doing for a long time.

I also work with a cardiac electrophysiologist who has a nurse practitioner. The NP doesn’t do anything procedural but she does field consults and rounds while the doctor is doing 5-6 hr ablations in EP lab. Then she comes to EP lab and they go over and discuss all the patients much like a resident and attending would.

I do think it is important to build a relationship and trust when working with midlevels. I’m sure not all of them are competent.

I won't deny your experience. It actually sounds nice that you work on a cohesive and productive team.

My issue is with NP's in non-surgical specialties. I keep asking the question: if an NP can give orders (without consulting a physician) what is the purpose of the physician? And if they can do it sometimes, why not more times? And if more times, why not all the time?

 

[Aphiah]

They didn't say it was the primary team versus not primary team. The poster said "NP's at my hospital are able to cancel orders that IM attendings and residents make." So if the NP is also primary team and comes on overnight, why shouldn't the NP be able to change the med the IM attending ordered at 9 am when the patient's circumstances were different? That's the point of the NP being there overnight, to treat the patient's status overnight, which may differ from the treatment plan that was ordered during the day shift. Likewise, if the NP is a neurology NP and the IM attending ordered a med, the NP gets to change whatever med he/she wants when admitting to his/her service. Both of these are totally ok in my book.

Thanks for this response too. You're right. It was actually a Neurology NP and the neurologist was out of town. NP seemed to be working independently and canceled orders without even talking to the physicians who made the orders.

So this gets back to my original question: If the NP has such rights (without consulting an MD), what then is the difference between NP and MD? This is my only question. Put procedures aside. I already know most NP's can't do surgery.

(by the way, all the best during residency!)

 

[ciestar]

People develop their own areas of expertise over the years. Medical school does not make you the king of all medicine. Just because I attended medical school doesn’t mean I know more about skin diseases than a derm PA.

This. I work with a GI PA who knows more about GI than i think i ever could. When you’ve been doing that job as a PA in a specific field for a decade.. going to medical school doesnt automatically make you more knowledgable. (I say this as an M4 who is definition low man lol)

 

[hallowmann]

That’s what’s so strange to me. People complain that my state is a sh*thole with fires, homeless and high taxes and would never live here. But I do live here and I think it is fantastic.

Honestly, I'm planning to live there too. Its where my wife, who managed to go to a great university (yay to the handful of states with excellent public universities that actually favor IS) with no debt (scholarships), grew up. The truth is that there's not a lot of states like that, and even there, competition for even undergrad, let alone med school is steep. TX has some cheap med schools, some midwest and mountain states have some that are easier to get into, a lot of states don't though. I went to the cheapest med school in my state - also the cheapest in surrounding states given my state residence - and its a private school that charges slightly more than your state school.

The short answer is that the physicians need the nurse practitioners. They are not extraneous bodies there to upset medical students and house staff.

I’m in private practice in anesthesiology.

I spend many hours in the operating room with a cardiac surgeon who uses a nurse practitioner. They have been working together for at least 15years. She does endoscopic vein and artery harvest better and faster than anyone I’ve ever seen. Then she leaves to round on postops in ICU and step down, she examines everyone, collects all the data and returns to the OR to report back much like a resident does. She is superb at her job which she has been doing for a long time.

I also work with a cardiac electrophysiologist who has a nurse practitioner. The NP doesn’t do anything procedural but she does field consults and rounds while the doctor is doing 5-6 hr ablations in EP lab. Then she comes to EP lab and they go over and discuss all the patients much like a resident and attending would.

I do think it is important to build a relationship and trust when working with midlevels. I’m sure not all of them are competent.

I think there are a lot of situations where midlevels make sense. Their existence is unfortunately a result of fear of flooding the market with specialists (that was our fault), excessive procedural reimbursement (kind of our fault too), and hospitals wanting to avoid paying two cardiologists to do the work of two cardiologists. The solution was PAs and NPs. Now that they're here, we can't exactly put the genie back in the bottle.

I think the issue really comes in when they weaken training for residents and when they try to practice independently, which is unfortunately the way things are moving in a lot of states. I don't care if they get paid more as long as it doesn't mean we get paid less or have poorer training.

My brother is a Gen-Xer who used to always extol how great midlevels were (he had one in clinic improving his productivity and number of procedure$). His debt was 2.5-3x yours coming out of med school (debt free now though). He has since changed his attitude when his first PA left, and he got another one that was "top" of her class. He struggles to explain basic concepts to her and she relies purely on pattern recognition. Now he questions the quality control quite a bit, not quite enough to stop hiring them, but he is tempted at times. He actually does review her documentation and has PAs staff their patients like a resident.

 

[nimbus]

too late the CRNA's are going to be doing that.

95%+ MD only in SoCal despite being an op out state (full independent practice rights) since Schwarzenegger was governor. CRNAs mostly only at Kaiser, academics, and VA.

 

[Alkaidius]

This. I work with a GI PA who knows more about GI than i think i ever could. When you’ve been doing that job as a PA in a specific field for a decade.. going to medical school doesnt automatically make you more knowledgable. (I say this as an M4 who is definition low man lol)

I doubt that anyone is really talking about the PAs that have worked a single specialty for the better part of 1-2 decades. But on average, I would put money on a physician with 10 years of training in a specialty being more likely to know more than a PA with the same amount. I feel like medical school does a great job of pushing medical students, and thus physicians, to always learn and strive toward perfection. Because for most students, med school pushes you beyond where you were. Like building a muscle. Not saying PA schools don’t do this, but we do learn more, and with Step/Comlex we are pushed harder. I would think we would come out the other end a much more absorbent sponge for information than our mid-level colleagues.

 

[slowthai]

I would think we would come out the other end a much more absorbent sponge for information than our mid-level colleagues.

Subordinates, you mean. This is how they grow wings. "Oh, I'm a colleague now? I'm basically a doctor then!"

I'm kidding...kind of lol

 

[slowthai]

Subordinates, you mean. This is how they grow wings. "Oh, I'm a colleague now? I'm basically a doctor then!"

I'm kidding...kind of lol

Then this same "colleague" would be like, "Since I too am also a doctor, let me start this derm spa right across the street and steal all this guy's patients. Our slogan'll be 'We'll see you right away!'"

Yeah, I know about non-competes, but just go with it pls

 

[UnoMas]

Subordinates, you mean. This is how they grow wings. "Oh, I'm a colleague now? I'm basically a doctor then!"

I'm kidding...kind of lol

I know you are kidding but people should take this seriously. They are not in the same league so no colleague, coworker maybe. These little people know how to use 'political terms' and 'politics spek' very well.
Collaboration not supervision. Collaboration implies equality; Supervision implies a superior-subordinate relationship. It is not a collaboration if one's license is on the line for another's actions.
Correct these and use them meaningfully in your daily interactions.

 

[UnoMas]

I was being facetious with that comment. That being said there is a difference between a midlevels in surgical and procedural subspecialties vs midlevel encroachment in terms of replacement of entire function. You dont hear the cardiology or ENT or surgical midlevels say they can replace the physicians they work with. You do hear that in primary care, and anasthesia.

I think a more interesting question amongst all of this is: If we think its legally , ethically, appropriate to let an NP do the work of a primary care physician , em, and dermatologist without oversight. Then we are clearly doing a disservice to our own by implementing all of these additional training requirements and years of education.

If this is really the case then we need to burn down the entire medical training establishment and do something else. because clearly people think its ok that their family members be treated by people with half the training and less.

I see your point. I don't know. I am Anesthesia so I am very skeptical of midlevels, sure you don't see that in Cardiology or the surgical specialties now but I would still try to nib it in the buds. If you go a few years back on the EM forum, the argument 'Midlevels will never replace EM physicians because of the acuity and high liability,' look where we are now. It's multifactorial. As the presence of Private Equity increases in the medicine, it's harder and harder for the physicians to reign control of the situation, and it's one giant factor for EM.

All it takes is:
1) for the private equity to start buying up Surgical Practices
2) more and more surgeons become employees to the system
3) a few zealous academic Cardiologists to train/open programs to teach midlevels how to cath, Surgeons to teach 'Surgical Midlevels' to operate with onsite supervision

You are saying the the proceduralists are safe now, I am saying they need to wake up and be on the lookout. Prevention >>> Damage control

 

[deleted480308]

I know you are kidding but people should take this seriously. They are not in the same league so no colleague, coworker maybe. These little people know how to use 'political terms' and 'politics spek' very well.
Collaboration not supervision. Collaboration implies equality; Supervision implies a superior-subordinate relationship. It is not a collaboration if one's license is on the line for another's actions.
Correct these and use them meaningfully in your daily interactions.

I’ve been correcting recruiters when they use the word collaboration. They don’t love it