PA vs Residents

[Matthew9Thirtyfive]

---

Members don't see this ad.

People rise to their level of training and experience.

The phrase I’ve always heard in the military is “people don’t rise to the level of their expectations, they fall to the level of their training.” I think it’s very apropos here. You can’t expect an NP with 3% of the training of a physician to perform as well as a physician.

 

[CherryRedDracul]

Eh I think that by January/February I was at that level

Same. I essentially was able to manage my patients on my own by that point.

The attending was there to sign my notes.

 

[MedicineZ0Z]

People rise to their level of training and experience.

It is an absolute rarity to find a 6 month pgy 1 who can come up with a reasonable complete assessment and plan on a moderately complicated hospitalized patient...I also don’t consider medical students qualified to render educated opinions on appropriate medical care or education.

You're working amongst grossly incompetent individuals it sounds. And render opinions on education? wha? Who are you exactly? Your comment makes you unqualified to comment on any form of education.

And your beloved PA missed a wellens on an ekg that I caught last week in the ER. So I beg to difer.

 

[MedicineZ0Z]

Lol... Even FM docs with 1-yr fellowship... Like there is something so special about EM

They'd gladly hand over the whole ED to an NP (who has less knowledge than a july 1st intern) but lose their minds over the thought of FM being in any ER.

 

[Lexdiamondz]

They'd gladly hand over the whole ED to an NP (who has less knowledge than a july 1st intern) but lose their minds over the thought of FM being in any ER.

Who the fxck is they?

 

[Lexdiamondz]

First, you have to define what is moderately complicated? I don't know any of my PGY1 colleagues at this stage who can't come up with a reasonably complete assessment and plan of a patient with pneumonia, CHF/COPD exacerbation, DKA, HHNS, Hypertensive urgency/emergency, a-fib etc... that have other comorbidities...

None of those things are remotely complicated. You can diurese a chf-er in your living room dude.

 

[MedicineZ0Z]

Who the fxck is they?

They = ED docs.

 

[Instatewaiter]

and we now have PA-EM residencies (lol) and NP ICU residencies (lolol) so that they can be independent in those settings.

We need to be either all in (in favor of) or all out (opposing) midlevels. There's no winning otherwise.


Saying interns are inferior to midlevels only happens in two scenarios:

1. very low quality intern

or

2. uninterested off service intern

You're just wrong about this. My NPs are better than the majority of attending PCPs with regard to management and knowledge within my specialty. It is because it is what they do all day long for many years .

Are there bad midlevels- definitely.
Are the vast majority of attending vastly Superior to NPs within specialties- yup
That doesn't mean every MD knows more than every NP about everything.

 

[Lexdiamondz]

They = ED docs.

Do you....actually know anything about EM, MS3?

 

[Matthew9Thirtyfive]

You're just wrong about this. My NPs are better than the majority of attending PCPs with regard to management and knowledge within my specialty. It is because it is what they do all day long for many years .

Are there bad midlevels- definitely.
Are the vast majority of attending vastly Superior to NPs within specialties- yup
That doesn't mean every MD knows more than every NP about everything.

Right, and sometimes a cough is sarcoidosis. That doesn't mean you should put it at the top of your differential for every patient who presents with cough and dyspnea.

 

[NITRAS]

First, you have to define what is moderately complicated? I don't know any of my PGY1 colleagues at this stage who can't come up with a reasonably complete assessment and plan of a patient with pneumonia, CHF/COPD exacerbation, DKA, HHNS, Hypertensive urgency/emergency, a-fib etc... that have other comorbidities...

The patient you can figure out from your computer from your team room isn't complicated.

Look, come back to me in a year and tell me how your interns are doing. I wasn't trying to insult you, but the next 12 months are when you will learn the most of how to actually practice medicine. I might be relying on my own personal experience too much, but most residents over-estimate their capability.

 

[W19]

The patient you can figure out from your computer from your team room isn't complicated.

Look, come back to me in a year and tell me how your interns are doing. I wasn't trying to insult you, but the next 12 months are when you will learn the most of how to actually practice medicine. I might be relying on my own personal experience too much, but most residents over-estimate their capability.

No offense taken... You might want to provide a few examples of complicated patients so we can start somewhere in this conversation... The examples I just agve are arguably 70% of inpatient IM admission and I am at biggest trauma center in my state.

 

[GoSpursGo]

Right, and sometimes a cough is sarcoidosis. That doesn't mean you should put it at the top of your differential for every patient who presents with cough and dyspnea.

What are you even trying to say here?

It's no dig when those of us in sub-specialties say that our APPs who practice our subspecialty day-in-day-out for years are better trained than residents. It's just true, and even as a fellow I learn a lot from our APPs. I think it makes a great deal of sense for APPs to be heavily utilized in specialty clinics and ICUs where they have immediate attending backup, as they can handle 90% of common problems and ask for help on the other 10%.

What probably ISN'T great is the army of APPs in primary care clinics who keep referring patients to my heme clinic because of a kid with a virus has a platelet count of 500k...

 

[Lexdiamondz]

No offense taken... You might want to provide a few examples of complicated patients so we can start somewhere in this conversation... The examples I just agve are arguably 70% of inpatient IM admission and I am at biggest trauma center in my state.

The last part of that sentence doesn't have any bearing on the first part...


#intern

 

[W19]

The last part of that sentence doesn't have any bearing on the first part...


#intern

I am angry that you are calling me intern 🙄...

I am still waiting for few example of a complicated cases

 

[Lexdiamondz]

I am angry that you are calling me intern 🙄...

I am still waiting for few example of a complicated cases

You are an intern dude. What else would I call you?

 

[W19]

You are an intern dude. What else would I call you?

I want you to call me Dr. D' Alessandro 😉... like everyone else call me. Still waiting for a few complicated cases in which consultants will not be involved

 

[W19]

Still waiting big docs and residents...

 

[Matthew9Thirtyfive]

What are you even trying to say here?

It's no dig when those of us in sub-specialties say that our APPs who practice our subspecialty day-in-day-out for years are better trained than residents. It's just true, and even as a fellow I learn a lot from our APPs. I think it makes a great deal of sense for APPs to be heavily utilized in specialty clinics and ICUs where they have immediate attending backup, as they can handle 90% of common problems and ask for help on the other 10%.

What probably ISN'T great is the army of APPs in primary care clinics who keep referring patients to my heme clinic because of a kid with a virus has a platelet count of 500k...

I guess it was more cryptic than I meant it to be. I wasn’t saying those APPs don’t exist or that it’s an insult to say they do. My wife is a peds heme/onc RN, so I’ve met some of the fellows she works with who gladly admit the NPs working on the service were way better than them when they were residents and when they started fellowship.

Unless I misread the post I quoted (totally possible), it seemed like they were trying to argue against another poster who said midlevels are never better than an intern unless the intern doesn’t care or is exceptionally bad. Yes it’s true that there are great midlevels, but that doesn’t change that many of them are woefully under prepared to practice, which was the whole point. But maybe I just got my threads mixed up. There are a lot of them on midlevels here lol.

 

[Lawpy]

You're just wrong about this. My NPs are better than the majority of attending PCPs with regard to management and knowledge within my specialty. It is because it is what they do all day long for many years .

Are there bad midlevels- definitely.
Are the vast majority of attending vastly Superior to NPs within specialties- yup
That doesn't mean every MD knows more than every NP about everything.

What are you even trying to say here?

It's no dig when those of us in sub-specialties say that our APPs who practice our subspecialty day-in-day-out for years are better trained than residents. It's just true, and even as a fellow I learn a lot from our APPs. I think it makes a great deal of sense for APPs to be heavily utilized in specialty clinics and ICUs where they have immediate attending backup, as they can handle 90% of common problems and ask for help on the other 10%.

What probably ISN'T great is the army of APPs in primary care clinics who keep referring patients to my heme clinic because of a kid with a virus has a platelet count of 500k...

Just to clarify, there's a huge difference between midlevels who have been working for many years and are experienced in what they do, and new midlevels with poor education backgrounds who are fresh into the job. The former are reliable colleagues and I don't see them protesting for independent practice rights. It's the latter group that's extremely annoying to deal with and it's also this group that poses a major threat to patient health outcomes.

 

[mimelim]

You're working amongst grossly incompetent individuals it sounds. And render opinions on education? wha? Who are you exactly? Your comment makes you unqualified to comment on any form of education.

And your beloved PA missed a wellens on an ekg that I caught last week in the ER. So I beg to difer.

No they aren't. It is rare to have interns at this point in the year who are able to come up with definitive assessments and plans. ****, we have a relatively strong resident compliment in a fairly competitive specialty and it generally takes getting to your PGY3 level before you can really start to fly on your own in terms of running the services. I say this as someone who has spent the last decade in higher education and medical education from a teaching side since you seem to be hung up on this 'qualifications to comment' thing.

I have said it numerous times, but physician hubris is a far bigger threat to patient's and their safety than any of this psychobabble about midlevels. I see it day in, day out in clinical practice.

 

[MedicineZ0Z]

No they aren't. It is rare to have interns at this point in the year who are able to come up with definitive assessments and plans. ****, we have a relatively strong resident compliment in a fairly competitive specialty and it generally takes getting to your PGY3 level before you can really start to fly on your own in terms of running the services. I say this as someone who has spent the last decade in higher education and medical education from a teaching side since you seem to be hung up on this 'qualifications to comment' thing.

I have said it numerous times, but physician hubris is a far bigger threat to patient's and their safety than any of this psychobabble about midlevels. I see it day in, day out in clinical practice.

Oh hi. I've seen all your super pro-midlevel comments. Why not stop killing your own profession and say something helpful for once? Also, not every field is a surgical subspecialty. I've seen more than a fair share of IM interns or pgy2s who blow away the experienced midlevels as far as knowledge goes.

Do you....actually know anything about EM, MS3?

I'm an MS4. Do you enjoy degrading your profession? I feel like it's a form of projection. There are other outlets for self degradation that are more constructive.

 

[alprazoslam]

No they aren't. It is rare to have interns at this point in the year who are able to come up with definitive assessments and plans. ****, we have a relatively strong resident compliment in a fairly competitive specialty and it generally takes getting to your PGY3 level before you can really start to fly on your own in terms of running the services. I say this as someone who has spent the last decade in higher education and medical education from a teaching side since you seem to be hung up on this 'qualifications to comment' thing.

I have said it numerous times, but physician hubris is a far bigger threat to patient's and their safety than any of this psychobabble about midlevels. I see it day in, day out in clinical practice.

Just wondering what your thoughts are on nurse practitioners are PAs let’s say on hospital IM. Are they fully prepared to write up these plans on complex patients you speak of by the time they graduate and are thrown into the world without a residency?

As of yet I’ve only seen comparisons of pgy1s vs seasoned APPs which is not a proper comparison. Anyone should be decent at something they have been doing for 10 years

 

[mimelim]

Oh hi. I've seen all your super pro-midlevel comments. Why not stop killing your own profession and say something helpful for once? Also, not every field is a surgical subspecialty. I've seen more than a fair share of IM interns or pgy2s who blow away the experienced midlevels as far as knowledge goes.

I'm an MS4. Do you enjoy degrading your profession? I feel like it's a form of projection. There are other outlets for self degradation that are more constructive.

I read this akin to the political diatribes spewing from various political parties about needing to protect their own at all costs. I'm not pro-midlevel. I am not anti-physician or pro-physician. While your sole focus is clearly on protecting your own self interest and maybe those in your profession some of us take a far larger look at the world around us. Helpful? Surely you are joking? Your zealous, us vs. them rantings and ravings help no one. You are protectionist and in no way looking for solutions to providing maximal healthcare to a population. I have a hard time respecting or really even having a reasoned conversation with someone who is only motivated by self interest and beyond that lacks really any experience in this field. We get it, you are an MS4 that look up to your interns and PGY2s, those of us that have spent years training people at that level know their limitations a hell of a lot better than you. I'm sorry, I don't pull rank or cite hierarchy, but given your proclivity for outlandish claims with zero basis and seem fixated on that point, it seems necessary.

More than your lack of 'years' of experience, my real issue lies with your foundation for a lot of your claims. How many years of non-academic center experience do you have? The vast majority of healthcare in the US is not delivered in the environment that most medical schools are in and it gives a false view of the realities of delivering healthcare in the US. We have a major healthcare problem in our country. It is multifaceted and obviously extremely complex without simple solutions. That problem arrises from a multitude of sources, but one of the major sources is shortage and maldistribution of healthcare providers. Unlike you, I don't claim to have all the answers. But, I do claim that mid-levels are going to be a part of virtually every solution that will be proposed and frankly, they should be given the realities of physician education and where/how physicians practice.

 

[mimelim]

Just wondering what your thoughts are on nurse practitioners are PAs let’s say on hospital IM. Are they fully prepared to write up these plans on complex patients you speak of by the time they graduate and are thrown into the world without a residency?

As of yet I’ve only seen comparisons of pgy1s vs seasoned APPs which is not a proper comparison. Anyone should be decent at something they have been doing for 10 years

Are they ready to hit the ground running full speed when they graduate? No, of course not. Others certainly have different opinions of this, but the vast majority of APPs I see have a clinical foundation from their school/rotations/work experience +/- PA residency on top of which must be layered an understand of how to be an actual health care professional. In my experience, this process is much easier with NPs/PAs than medical students/interns. Part of it is ego/hubris, part of it is work experience, and admittedly there is huge overlap between the populations. They clearly lack the massive knowledge base that medical students come in with. At the end of the day, they are both inexperienced labor that needs apprenticeship to realize their potential.

There is a significant divergence in how that apprenticeship is focused. While in general the residency process is focused on creating a well rounded physician capable of doing anything and everything in an entire specialty, APPs are generally trained to function in a very specific role in a specific environment. These are of course generalities and there is tremendous local variability. It all depends on what prism you are looking through. For me personally, I see massive need. I also don't see physicians or really anyone, flocking to areas that need them, despite massive financial advantages to do so. Unlike others in this thread, I don't profess to know the answer to these problems, but I know that it will require both midlevels as well as physicians. As I previously stated, from where I sit, I see more harm every day from physician hubris than I do from overtly zealous APPs.

 

[Wordead]

What are you even trying to say here?

It's no dig when those of us in sub-specialties say that our APPs who practice our subspecialty day-in-day-out for years are better trained than residents. It's just true, and even as a fellow I learn a lot from our APPs. I think it makes a great deal of sense for APPs to be heavily utilized in specialty clinics and ICUs where they have immediate attending backup, as they can handle 90% of common problems and ask for help on the other 10%.

What probably ISN'T great is the army of APPs in primary care clinics who keep referring patients to my heme clinic because of a kid with a virus has a platelet count of 500k...

Fully agree. Our midlevels in ENT are great because they can learn to properly workup and manage a limited set of pathologies. But it's terrifying that they can go into a primary care or ED setting with undifferentiated patients when theyve learned like 200 pathologies in their schooling and be expected to pick up on everything else.

 

[Perrotfish]

It's no dig when those of us in sub-specialties say that our APPs who practice our subspecialty day-in-day-out for years are better trained than residents. It's just true, and even as a fellow I learn a lot from our APPs. I think it makes a great deal of sense for APPs to be heavily utilized in specialty clinics and ICUs where they have immediate attending backup, as they can handle 90% of common problems and ask for help on the other 10%.
...

Sub-specialty midlevels are one of the worst things to happen to my job. Most pediatric subspecialists in my area are a workhorse midlevel 'supervised' by a doctor who doesn't really work, and the practical upshot is that there is no such thing as a consult anymore. In most cases, no matter what I send them or what I tried/tested before sending the patient over I get back the most common diagnosis in their field accompanied by the first line treatment for their diagnoses. It drives me nuts. If I have personally tagged these patients as too complicated for me to figure out I guarantee a midlevel is not going to help.

My personal favorite was the kid I sent to derm with a complicated and confusing skin condition. He came back with a note, still signed by the NP, that said 'recommend referral to dermatology' and gave me the address for the local academic hospital. Apparently the 'supervising' physician couldn't bother to see the kid even when the midlevel was admitting he had no idea what he was looking at.

 

[Instatewaiter]

As I previously stated, from where I sit, I see more harm every day from physician hubris than I do from overtly zealous APPs.

While I agree with most of your points, to play devil's advocate, the reason why overzealous APPs don't cause more harm is because there are major, major restraints preventing them from doing too much. Take those restraints away and you will likely have major problems.

 

[Instatewaiter]

Sub-specialty midlevels are one of the worst things to happen to my job. Most pediatric subspecialists in my area are a workhorse midlevel 'supervised' by a doctor who doesn't really work, and the practical upshot is that there is no such thing as a consult anymore. In most cases, no matter what I send them or what I tried/tested before sending the patient over I get back the most common diagnosis in their field accompanied by the first line treatment for their diagnoses. It drives me nuts. If I have personally tagged these patients as too complicated for me to figure out I guarantee a midlevel is not going to help.

My personal favorite was the kid I sent to derm with a complicated and confusing skin condition. He came back with a note, still signed by the NP, that said 'recommend referral to dermatology' and gave me the address for the local academic hospital. Apparently the 'supervising' physician couldn't bother to see the kid even when the midlevel was admitting he had no idea what he was looking at.

I agree with this. Honestly, NPs are good for followup for basic cases. First consults should be seen by the MD. That doesn't always happen though...

 

[VA Hopeful Dr]

I agree with this. Honestly, NPs are good for followup for basic cases. First consults should be seen by the MD. That doesn't always happen though...

Yeah I don't mind midlevels seeing the patients I refer to y'all in follow up but the initial visit damned well better be with the MD.

 

[Perrotfish]

Helpful? Surely you are joking? Your zealous, us vs. them rantings and ravings help no one. You are protectionist and in no way looking for solutions to providing maximal healthcare to a population. I have a hard time respecting or really even having a reasoned conversation with someone who is only motivated by self interest and beyond that lacks really any experience in this field. We get it, you are an MS4 that look up to your interns and PGY2s, those of us that have spent years training people at that level know their limitations a hell of a lot better than you. I'm sorry, I don't pull rank or cite hierarchy, but given your proclivity for outlandish claims with zero basis and seem fixated on that point, it seems necessary.

Do you think that the FDA's drug approval process is also protectionist? I know a lot of wanabee drug manufacturers who think so. After all, the FDA is only obstructing the approval of new drugs while the noble manufacturers are 'looking for solutions' to provide cures to a desperate population.

One of the greatest triumphs in healthcare is that we agreed to stop experimenting on unconsenting people. If you want to try something new in healthcare the people you are trying it out on need to know that they're in a trial, a large group needs to have reviewed the trial to determine that its ethical, and the burden of proof lies with the person trying the new thing. For some reason we forgot to apply those ethics to new training models, and physicians started supporting a training model that not only has no evidence behind it, but that can't even manage to stay consistent from one year to the next.

 

[mvenus929]

Someone offered me 11x guaranteed for 4 years excluding bonuses and whatnot. Oh and a signing bonus worth just under double my annual PGY7 salary. Granted, I didn't take the job for mainly geographic reasons. There aren't that many people with the opportunities to make 200k+ right? I mean I get that people may pick to not go to particular locations and will take paycuts for a variety of reasons, but that isn't to say that there aren't opportunities upon graduating for just about everyone graduating.

I'm not saying it's not possible to make a boatload of money. I'm questioning the 'minimum' (i.e. guaranteed) 4x increase in salary. That's not really realistic for many of the people graduating from a peds residency, like me, and even less likely for those, like me, who go into the 'cerebral' pediatric subspecialties that at baseline make less than a general pediatrician (in part because there aren't as many opportunities in private practice). Before I went back to fellowship, my friend was making ~2x a resident's income as a base salary. I was offered a job for ~3x a resident's income, and two of my friends worked that job when I turned them down. So it's not like it's an uncommon thing to make less than 4x a resident's salary out of residency.

I don't regret my choice, but I will never have the income potential you will.

 

[MedicineZ0Z]

I read this akin to the political diatribes spewing from various political parties about needing to protect their own at all costs. I'm not pro-midlevel. I am not anti-physician or pro-physician. While your sole focus is clearly on protecting your own self interest and maybe those in your profession some of us take a far larger look at the world around us. Helpful? Surely you are joking? Your zealous, us vs. them rantings and ravings help no one. You are protectionist and in no way looking for solutions to providing maximal healthcare to a population. I have a hard time respecting or really even having a reasoned conversation with someone who is only motivated by self interest and beyond that lacks really any experience in this field. We get it, you are an MS4 that look up to your interns and PGY2s, those of us that have spent years training people at that level know their limitations a hell of a lot better than you. I'm sorry, I don't pull rank or cite hierarchy, but given your proclivity for outlandish claims with zero basis and seem fixated on that point, it seems necessary.

More than your lack of 'years' of experience, my real issue lies with your foundation for a lot of your claims. How many years of non-academic center experience do you have? The vast majority of healthcare in the US is not delivered in the environment that most medical schools are in and it gives a false view of the realities of delivering healthcare in the US. We have a major healthcare problem in our country. It is multifaceted and obviously extremely complex without simple solutions. That problem arrises from a multitude of sources, but one of the major sources is shortage and maldistribution of healthcare providers. Unlike you, I don't claim to have all the answers. But, I do claim that mid-levels are going to be a part of virtually every solution that will be proposed and frankly, they should be given the realities of physician education and where/how physicians practice.

All I'm doing is calling out the hypocrisy. There's extreme bias against generalist physicians doing anything in specialist turf. Yet midlevels doing it? It's totally okay. Not sure why you can't see those double standards. There's a world outside of your town/state/specialty.
And also, you're not pro-physician? That sums up your whole post.

And when it comes down to it, most of us would freak out over the idea of a midlevel making medical decisions over our family members. From a patient care perspective, that's all that matters. Y

Are they ready to hit the ground running full speed when they graduate? No, of course not. Others certainly have different opinions of this, but the vast majority of APPs I see have a clinical foundation from their school/rotations/work experience +/- PA residency on top of which must be layered an understand of how to be an actual health care professional. In my experience, this process is much easier with NPs/PAs than medical students/interns. Part of it is ego/hubris, part of it is work experience, and admittedly there is huge overlap between the populations. They clearly lack the massive knowledge base that medical students come in with. At the end of the day, they are both inexperienced labor that needs apprenticeship to realize their potential.

There is a significant divergence in how that apprenticeship is focused. While in general the residency process is focused on creating a well rounded physician capable of doing anything and everything in an entire specialty, APPs are generally trained to function in a very specific role in a specific environment. These are of course generalities and there is tremendous local variability. It all depends on what prism you are looking through. For me personally, I see massive need. I also don't see physicians or really anyone, flocking to areas that need them, despite massive financial advantages to do so. Unlike others in this thread, I don't profess to know the answer to these problems, but I know that it will require both midlevels as well as physicians. As I previously stated, from where I sit, I see more harm every day from physician hubris than I do from overtly zealous APPs.

Yeah dude midlevels are not going into areas of need. They're flocking in large numbers to well desired areas and driving down physician pay and taking out physician jobs. There's endless evidence for this and if you don't know this as of now (this news is years old btw, worsening monthly) then there's no point in even discussing it.

And a good point came up in this thread. Since when did patients consent to being seen by people with minimal training??

 

[MedicineZ0Z]

Fully agree. Our midlevels in ENT are great because they can learn to properly workup and manage a limited set of pathologies. But it's terrifying that they can go into a primary care or ED setting with undifferentiated patients when theyve learned like 200 pathologies in their schooling and be expected to pick up on everything else.

Learned in this context means one slide in a powerpoint. For a doctor it means a dozen lectures, seeing it 100 more times during board prep, then seeing it in person a few dozen times.

 

[Wordead]

I agree with this. Honestly, NPs are good for followup for basic cases. First consults should be seen by the MD. That doesn't always happen though...

Yeah I don't mind midlevels seeing the patients I refer to y'all in follow up but the initial visit damned well better be with the MD.

The point of the midlevel is to filter out the BS in subspecialty clinics. They can get a detailed history and start the workup. And yes maybe you guys are good and have consults fully teed up but trust me the majority of the people these days referring to us have not and it's a gigantic waste of time for surgical specialties to finish a workup or see someone and start them on first line therapies that the referring physician should have done already anyway.

 

[mimelim]

While I agree with most of your points, to play devil's advocate, the reason why overzealous APPs don't cause more harm is because there are major, major restraints preventing them from doing too much. Take those restraints away and you will likely have major problems.

In the same way that physicians don't cause more harm is because there are also major restraints. I have never advocated for specific 'rights' are practices for APP because frankly I am no expert in the matter and have no idea where the line should be. I don't think that anyone should interpret me as being rosy eyed about APPs. I just don't think that they are any worse than anyone else. Maybe I became too cynical over the last decade, but it is rare to find a physician not primarily motivated by self interest. Which should hardly be surprising because it is rare to find a person not primarily motivated by self interest. Take the medical student in this thread adopting an overt false dilemma fallacy. The advocacy isn't about 'better patient outcomes', 'quality' or really anything about patient care. It is purely a who gets to do what and ultimately who gets to make money off of what. What drives me nuts is the ridiculous amount of, "but we are smarter and are in school longer, so we should get the piece of the pie."

I agree with this. Honestly, NPs are good for followup for basic cases. First consults should be seen by the MD. That doesn't always happen though...

Yeah I don't mind midlevels seeing the patients I refer to y'all in follow up but the initial visit damned well better be with the MD.

The point of the midlevel is to filter out the BS in subspecialty clinics. They can get a detailed history and start the workup. And yes maybe you guys are good and have consults fully teed up but trust me the majority of the people these days referring to us have not and it's a gigantic waste of time for surgical specialties to finish a workup or see someone and start them on first line therapies that the referring physician should have done already anyway.

Every new outpatient consult gets seen by an MD on first visit for us, but I don't think that this is strictly necessary. I think in some models, where there are fairly well established initial workup protocols and you have experienced APPs, you can have APPs see patient's first to make things more efficient. A mandatory requirement of this is good supervision and prompt availability of the MD for support, but we all know that most MDs (people) are not going to do that. @Wordead , I get as much of that bull**** as anyone. Complete misses (acute sockemia) or just run of the mill, "Patient has PE, consult vascular surgery." okay... But, they are the easiest 99255 consults ever for me, thank you for the 4 wRVUs and move on. Is it annoying? Yes, and that is why I am very okay with having a good inpatient APP seeing people before me. The real diagnostic skill I need them to have is, "Sick or not sick". Which my PD was famous for drilling into our PGY1s and 2s. They allow me to see more patients faster and provide more healthcare to an area that needs it. If your APP can't effectively triage that in my line of work, then they aren't being effectively deployed.

Do you think that the FDA's drug approval process is also protectionist? I know a lot of wanabee drug manufacturers who think so. After all, the FDA is only obstructing the approval of new drugs while the noble manufacturers are 'looking for solutions' to provide cures to a desperate population.

One of the greatest triumphs in healthcare is that we agreed to stop experimenting on unconsenting people. If you want to try something new in healthcare the people you are trying it out on need to know that they're in a trial, a large group needs to have reviewed the trial to determine that its ethical, and the burden of proof lies with the person trying the new thing. For some reason we forgot to apply those ethics to new training models, and physicians started supporting a training model that not only has no evidence behind it, but that can't even manage to stay consistent from one year to the next.

I don't have much of an opinion of the FDA because I don't know much about it. Don't get me wrong, I'm not blind and I'm not exactly ignoring the glaring issues, but I don't presume to have enough context or knowledge to propose an alternative practice. We get our devices (FDA regulated) a full 5 years after Europe does and I don't really see rampant drop off in quality control over there. Clearly the FDA has major inefficiencies and can be ineffective in some arenas. On the other hand, as you rightly point out there can't be zero regulation either. What I don't like is this concept that our current training model is somehow ideal or 'proven'. There is no evidence (certainly not strong, well designed evidence) to really support how we currently deliver healthcare. It is just how we done it and over time it has slowly evolved. The reality is that nobody really knows what training model is the best or how to structure things best. Everyone has anecdotes about different failure points, but as far as I can tell, the rest is just hand waving, which is why APP lobbies can push as hard as they can. Their studies may be bull**** from a science standpoint, but it isn't like there is evidence pointing against it either.

I'm not saying it's not possible to make a boatload of money. I'm questioning the 'minimum' (i.e. guaranteed) 4x increase in salary. That's not really realistic for many of the people graduating from a peds residency, like me, and even less likely for those, like me, who go into the 'cerebral' pediatric subspecialties that at baseline make less than a general pediatrician (in part because there aren't as many opportunities in private practice). Before I went back to fellowship, my friend was making ~2x a resident's income as a base salary. I was offered a job for ~3x a resident's income, and two of my friends worked that job when I turned them down. So it's not like it's an uncommon thing to make less than 4x a resident's salary out of residency.

I don't regret my choice, but I will never have the income potential you will.

I'm not sure what we are discussing (what points we disagree on) secondary to the fireworks in the rest of the thread. I think my main point is that while not every job or specific dream job may be 200k+, every specialty does have those jobs available. You chose to do a pediatric fellowship, presumably because you thought (think) that you will be happier doing that then general pediatrics. The fact that you will turn down the general pediatric jobs that pay more doesn't mean that the opportunity to make 200k+ doesn't exist, it just means that you value something else more than the incremental salary increase. I certainly do not know the pediatrics job market very well, but I would assume that there is also tremendous regional/locale bias as well?

 

[VA Hopeful Dr]

The point of the midlevel is to filter out the BS in subspecialty clinics. They can get a detailed history and start the workup. And yes maybe you guys are good and have consults fully teed up but trust me the majority of the people these days referring to us have not and it's a gigantic waste of time for surgical specialties to finish a workup or see someone and start them on first line therapies that the referring physician should have done already anyway.

I'd have no objection if y'all looked over the note we send and make the determination as to who sees the patient first based on that.

If memory serves, you're ENT. Feel free to have the PA see the cerumen impaction or persistent serous otitis. Both of those are usually people I'm just tired of dealing with anyway.

But if the NP sees the thyroid nodule I send you or the concerning lymph node that's been there for 2 months and is rock hard on exam on the first visit, there will not be another.

 

[VA Hopeful Dr]

I'm not saying it's not possible to make a boatload of money. I'm questioning the 'minimum' (i.e. guaranteed) 4x increase in salary. That's not really realistic for many of the people graduating from a peds residency, like me, and even less likely for those, like me, who go into the 'cerebral' pediatric subspecialties that at baseline make less than a general pediatrician (in part because there aren't as many opportunities in private practice). Before I went back to fellowship, my friend was making ~2x a resident's income as a base salary. I was offered a job for ~3x a resident's income, and two of my friends worked that job when I turned them down. So it's not like it's an uncommon thing to make less than 4x a resident's salary out of residency.

I don't regret my choice, but I will never have the income potential you will.

General pediatricians everywhere I've been start at right around 200k (lowest is 170k). Most make more than that within a few years.

3rd year peds residents at the closest program make 56k their last year. So worst case its 3X resident salary, average is 3.5k.

Forgive me for being so imprecise.

As for peds subspecialists, y'all only make up a little over 2% of physicians. So should I change my original post to say this:

98% of physicians will make 3.5X more than they do as residents.

Would that make you happy?

But wait, I left out all the part time doctors too. The nerve!

 

[GoSpursGo]

I guess it was more cryptic than I meant it to be. I wasn’t saying those APPs don’t exist or that it’s an insult to say they do. My wife is a peds heme/onc RN, so I’ve met some of the fellows she works with who gladly admit the NPs working on the service were way better than them when they were residents and when they started fellowship.

Unless I misread the post I quoted (totally possible), it seemed like they were trying to argue against another poster who said midlevels are never better than an intern unless the intern doesn’t care or is exceptionally bad. Yes it’s true that there are great midlevels, but that doesn’t change that many of them are woefully under prepared to practice, which was the whole point. But maybe I just got my threads mixed up. There are a lot of them on midlevels here lol.

That's fair.

I think context really matters. The NPs who get their degree via some online-only program right after they get their RN, those lead to either dangerously poor management decisions or unnecessary specialist/ED referrals. Totally different from ones with legit experience.

Sub-specialty midlevels are one of the worst things to happen to my job. Most pediatric subspecialists in my area are a workhorse midlevel 'supervised' by a doctor who doesn't really work, and the practical upshot is that there is no such thing as a consult anymore. In most cases, no matter what I send them or what I tried/tested before sending the patient over I get back the most common diagnosis in their field accompanied by the first line treatment for their diagnoses. It drives me nuts. If I have personally tagged these patients as too complicated for me to figure out I guarantee a midlevel is not going to help.

My personal favorite was the kid I sent to derm with a complicated and confusing skin condition. He came back with a note, still signed by the NP, that said 'recommend referral to dermatology' and gave me the address for the local academic hospital. Apparently the 'supervising' physician couldn't bother to see the kid even when the midlevel was admitting he had no idea what he was looking at.

That's absolute garbage--completely agree with the other user who said that it is inappropriate for a new consult to be seen up front by an APP. I didn't know that was even a thing.

 

[alprazoslam]

A lot of the fear may be overblown coming from med students here but after investing that much in their education some of the APP/midlevel rhetoric is worrisome. Check out some of the pro midlevel articles on medscape and also see what some of the NP/CRNAs think of physicians on the allnurses forum. I think we can all agree there is a lot of ego in medicine but having been in nursing I can tell you it is just as prevalent there. Compounded with a much greater overall lack of knowledge. Physicians just outwardly express ego more often due to less fear of backlash

The truth likely lies somewhere in the middle and midlevels are required for certain things in medicine. But to think that the organizations that license and lobby for midlevel practice are not out for physician jobs is naive, even if many individual midlevels have no such interest such as that in their agenda.

 

[operaman]

I'd have no objection if y'all looked over the note we send and make the determination as to who sees the patient first based on that.

If memory serves, you're ENT. Feel free to have the PA see the cerumen impaction or persistent serous otitis. Both of those are usually people I'm just tired of dealing with anyway.

But if the NP sees the thyroid nodule I send you or the concerning lymph node that's been there for 2 months and is rock hard on exam on the first visit, there will not be another.

You touch on a critical point here that I think will ultimately solve much of this mid level issue: basic free market economics. If they deliver a terrible service, referring docs will find someone better as soon as they can. If the docs who supervise them start phoning it in and letting the NP see all the new consults, well, there are bound to be other practices willing to see those patients.

Our dept is rather young yet has grown incredibly fast largely because the docs who started it made a point not just to build the academic side, but to build meaningful relationships with referring docs and to this day we have a long list of regulars that send us great cases. Not only are all news seen by MDs, but the referring docs get personal letters and sometimes even phone calls in addition to the EMR auto generated babble. If we stopped taking good care of their patients, they’d send them to any of the other 5 academic medical centers the patient drove past on their way here.

I think the free market will also solve the bad mid level issue. The reality is that the proliferation of midlevels has not driven down physician salary so much as it has driven down mid level salary. Eventually the ones with real training and experience are going to want to find ways to distinguish themselves and I think this will ultimately lead to some sort of certification and oversight from within their own field. When we are already getting hundreds of applications for posted mid level jobs and we aren’t even a big coastal area, you know things are going to have to evolve.

 

[VA Hopeful Dr]

You touch on a critical point here that I think will ultimately solve much of this mid level issue: basic free market economics. If they deliver a terrible service, referring docs will find someone better as soon as they can. If the docs who supervise them start phoning it in and letting the NP see all the new consults, well, there are bound to be other practices willing to see those patients.

Our dept is rather young yet has grown incredibly fast largely because the docs who started it made a point not just to build the academic side, but to build meaningful relationships with referring docs and to this day we have a long list of regulars that send us great cases. Not only are all news seen by MDs, but the referring docs get personal letters and sometimes even phone calls in addition to the EMR auto generated babble. If we stopped taking good care of their patients, they’d send them to any of the other 5 academic medical centers the patient drove past on their way here.

I think the free market will also solve the bad mid level issue. The reality is that the proliferation of midlevels has not driven down physician salary so much as it has driven down mid level salary. Eventually the ones with real training and experience are going to want to find ways to distinguish themselves and I think this will ultimately lead to some sort of certification and oversight from within their own field. When we are already getting hundreds of applications for posted mid level jobs and we aren’t even a big coastal area, you know things are going to have to evolve.

That's a fair point, especially the bold. Midlevels in my area are having trouble finding jobs while we still have lots of physician job postings

 

[Goro]

A lot of the fear may be overblown coming from med students here but after investing that much in their education some of the APP/midlevel rhetoric is worrisome. Check out some of the pro midlevel articles on medscape and also see what some of the NP/CRNAs think of physicians on the allnurses forum. I think we can all agree there is a lot of ego in medicine but having been in nursing I can tell you it is just as prevalent there. Compounded with a much greater overall lack of knowledge. Physicians just outwardly express ego more often due to less fear of backlash

The truth likely lies somewhere in the middle and mid levels are required for certain things in medicine. But to think that the organizations that license and lobby for mid level practice are not out for physician jobs is naive, even if many individual mid levels have no such interest such as that in their agenda.

Make no mistake, a good deal of the complaints (especially the more hysterical ones) about mid level encroachment come not from the valid points made in this thread, but from "I went to school for 17 years and they didn't!!!" For some people, it seems like their claim to superiority is that they had a pre-clinical education. I've taught PA students...their material is about 75% that of our OMSIs and IIs, and their clinical savvy was great than the med students.

NPs? Good for shots and sniffles.

But getting back to the OP, as has been mentioned previous, and is worth mentioning yet again. yonce you're out of residency, one will be making a avg of what, $250K? Keep your eyes on that prize.

 

[nimbus]

But getting back to the OP, as has been mentioned previous, and is worth mentioning yet again. yonce you're out of residency, one will be making a avg of what, $250K? Keep your eyes on that prize.

That’s a very low estimate for all comers.

 

[Matthew9Thirtyfive]

That's fair.

I think context really matters. The NPs who get their degree via some online-only program right after they get their RN, those lead to either dangerously poor management decisions or unnecessary specialist/ED referrals. Totally different from ones with legit experience.

I agree with you to a point. I think the subspecialty NPs with lots of experience can be great (and often are). But for example, I am friends with more than one former NP who were RNs for years before going back to NP school. They went to supposedly excellent NP schools, but when they graduated and went to practice, they decided to go back to being an RN because they felt unprepared to do primary care with little to no supervision. Small n, I know. But I think they are just the ones who are honest with themselves.

 

[Matthew9Thirtyfive]

You touch on a critical point here that I think will ultimately solve much of this mid level issue: basic free market economics. If they deliver a terrible service, referring docs will find someone better as soon as they can. If the docs who supervise them start phoning it in and letting the NP see all the new consults, well, there are bound to be other practices willing to see those patients.

Our dept is rather young yet has grown incredibly fast largely because the docs who started it made a point not just to build the academic side, but to build meaningful relationships with referring docs and to this day we have a long list of regulars that send us great cases. Not only are all news seen by MDs, but the referring docs get personal letters and sometimes even phone calls in addition to the EMR auto generated babble. If we stopped taking good care of their patients, they’d send them to any of the other 5 academic medical centers the patient drove past on their way here.

I think the free market will also solve the bad mid level issue. The reality is that the proliferation of midlevels has not driven down physician salary so much as it has driven down mid level salary. Eventually the ones with real training and experience are going to want to find ways to distinguish themselves and I think this will ultimately lead to some sort of certification and oversight from within their own field. When we are already getting hundreds of applications for posted mid level jobs and we aren’t even a big coastal area, you know things are going to have to evolve.

Interesting point. What about in EM and gas where patients don’t have a choice and it’s seems like administrators only concern themselves with the bottom line?

 

[VA Hopeful Dr]

Interesting point. What about in EM and gas where patients don’t have a choice and it’s seems like administrators only concern themselves with the bottom line?

Surgeons in the latter.

For EM, patients do get mad if they go to the emergency department and see mid-levels if they're truly sick.

 

[Matthew9Thirtyfive]

Surgeons in the latter.

For EM, patients do get mad if they go to the emergency department and see mid-levels if they're truly sick.

But how does that affect the free market? They get mad, but they can't choose which provider to see.

 

[SurfingDoctor]

Simple answer to PA v Residents: PAs are employed at will, residents are not.

Different market forces with different expectations.

 

[VA Hopeful Dr]

But how does that affect the free market? They get mad, but they can't choose which provider to see.

Lots of places have multiple EDs. My town of 35,000 has 2 with a third 10 miles outside of town.