Physician assistants are surgical residents. Shameful.

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MIMIS is a center of excellence to instruct surgeons, surgical residents (physician and PAs) in established laparoscopic techniques and to develop new techniques and instrumentation. For the PA and physician residents there are dry lab sessions available throughout their tenure where computer based exercises sharpen skills and record progress over time as well as mechanical trainers to practice intracorporeal suturing techniques in a three dimensional trainer viewed on a two-dimensional video screen (just as in the OR). The last three weeks of the didactic session are spent on the surgical service the PA resident will be assigned for his or her first month of the clinical session.

Clinical Program​

The clinical session is composed of eleven one-month rotations through three major urban hospitals. At the Jacobi Medical Center, a member of the New York City Health and Hospitals Corporation, PA residents serve in the area's largest and best-known Level One trauma center. They participate as surgical interns on the in-patient service learning to manage patients with both penetrating and blunt trauma.

In conjunction with their trauma experience the PAs spend an additional month at Jacobi as the surgical intern in the SICU. This combination of trauma and the SICU at a Level One urban Trauma Center truly sharpens skills needed to assess, diagnose and treat critically injured and fragile patients.

From Jacobi, the PA residents usually travel to the Weiler Division of the Montefiore Medical Center, a close geographic neighbor to Jacobi. At Weiler, the PA residents serve on the specialty care surgical service This service has varied in-patient population from pediatric (neonatal) to geriatric. Emphasis, as in all the surgical rotations, is on the preoperative care, inrtaoperative first assisting and postoperative management with appropriate in-patient care on the general floors or intensive care units. Participation at surgical clinics and follow-up office visits are also required.

Crossing the Bronx, the PA residents receive the majority of their surgical experience at the Moses Division of the Montefiore Medical Center. Here the PA residents serve for one month each on the Vascular Surgery Service, Pediatric Surgery, the Acute Care Service (covering patients admitted through the Emergency Department who need surgical care), the Adult Specialty Care Service (general surgery, endocrine surgery, bariatric surgery, liver/pancreatic surgery, oncologic surgery), Cardiothoracic Surgery and as the surgical PA intern in the Emergency Medicine Department. They also spend one month in the Surgical Intensive Care Unit (SICU).

Montefiore's Postgraduate Residency in Surgery is not only the first postgraduate training program but has stayed the test of time, continually graduating surgical physician assistants who rise to the challenges of surgical practice and remain involved on the national, state and local scene directing the role of the surgical PA. Taking the lead again, there has been a substantial increase in base salary ($50K per year over 14.5 months is approx $60K) as well as the institution of a "Graduation Bonus ($5K)" to be given to each member of the class upon completion of the full residency.

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No, they’re PA residents. These programs give PAs more experience so they hit the ground running and can function as an experienced PA right out the gate. These PAs are treated like surgical interns, which anyone who’s trained at an academic hospital can tell you, is not great.

There’s a lot of reasons to be unhappy with the state of medicine. This isn’t one of them. These one year “residencies” have been around and are not about to become 5 year residencies graduating surgeons...
 
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No, they’re PA residents. These programs give PAs more experience so they hit the ground running and can function as an experienced PA right out the gate. These PAs are treated like surgical interns, which anyone who’s trained at an academic hospital can tell you, is not great.

There’s a lot of reasons to be unhappy with the state of medicine. This isn’t one of them. These one year “residencies” have been around and are not about to become 5 year residencies graduating surgeons...
Not saying I agree with the doom and gloom of the OP in this particular case, but a friend at a VA says mid levels are doing carpal tunnel releases.

We should all be mindful of scope creep. I’m sure the anesthesiologists thought it wouldn’t happen to them.
 
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Not saying I agree with the doom and gloom of the OP in this particular case, but a friend at a VA says mid levels are doing carpal tunnel releases.

We should all be mindful of scope creep. I’m sure the anesthesiologists thought it wouldn’t happen to them.
Absolutely. I’m not sure a residency like this is the problem vs surgeons training PAs to off load them.
 
Absolutely. I’m not sure a residency like this is the problem vs surgeons training PAs to off load them.
Agreed. But calling something a residency and treating someone with less training than an intern as an intern and telling them they are equal to interns blurs the lines and allows for propaganda and marketing for “advanced training alongside doctors.” Doom and gloom for what the program is at present - no. But being mindful of what it could lead to - yes.
 
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This is how it starts. Take a look across the pond.

Across the pond is facing an entirely different set of problems that is not remotely applicable to US healthcare. UK docs on Reddit commented on this at length and are quite appreciative of it - they're offloading simple things like cyst removals and skin excisions because they have a severe shortage. This is not nurses doing gallbladders and colon resections.

I strongly agree with ACSurgeon. This got posted in Noctor on Reddit like it was some sort of cooptation of surgery, and it isn't. This is literally exactly what we should want out of PA training - additional training that 1) defines their scope 2) adds structure to an otherwise unstructured, on the job training 3) Exposes them to a more intense and rigorous management of perioperative surgical patients on the floor so that they can recognize problems and act on them appropriately.

The biggest complaints the "omg I hate NP/PA" crowd makes are that they aren't trained enough and/or safe, there isn't structure, their scope is out of control, and they over utilize services because they lack additional education. This program addresses literally every single point of that and if you read the description the intra-operative experience is literally designed to teach them to be a first-assist to a surgeon for like ~7 months or something. That's wonderful and extremely useful. Particularly at an MIS heavy program where they can learn the ins and outs of the instruments, hopefully get some bedside robotic experience, etc. which is what they are used for in the real world.

We shouldn't be discouraging these programs, we should be proliferating them and pigeon holing graduates into them or straight up forcing them to do programs like this in whatever discipline they decide they finally want to practice in, for precisely the reason that then they can't simply "job hop" to a new completely unrelated field of medicine at a whim. PAs aren't going away. NPs aren't going away. This is the best next logical step to ensure they are utilized correctly, efficiently, and safely.

They aren't there to be called surgeon or surgical intern, but the curriculum of a surgical intern and the curriculum of a fresh grad PA who's going to be hired by a surgeon happen to be exactly identical. 'Equating' them for the sake of getting them to the next step in their training - PGY2 year for the surgeon and a job running the floor and being an FA to a surgeon for the PA, just makes sense.
 
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My intern year we had two PAs do a one year “residency.” One had been out of the workforce for 20 years and wanted to rejoin now that her kids were grown. One wanted skills to get a surgical assist job.

We need our leadership to do a better job setting limits and regaining some of that actual leadership of American medicine. I can understand people being concerned that this is a step that will get out of control and devolve into multiple-year training programs that make PAs independent “surgeons”. True leadership in place should prevent that from happening. Such leadership is missing so the concern isn’t entirely crazy.

After my intern year that PA residency program shut down because of lack of interest. It’s harder than you think to recruit PAs to work 80 hours a week in abusive conditions for a 1/2 the pay of a normal PA job... my experience is that most PAs go down that route to quickly get a “high” paying job that allows for a great work life balance. Spending one or more years working 80h per week is hardly inline with that mindset.
 
I can understand people being concerned that this is a step that will get out of control and devolve into multiple-year training programs that make PAs independent “surgeons”. True leadership in place should prevent that from happening. Such leadership is missing so the concern isn’t entirely crazy.

I know it sounds cliche, but I do think surgery is somewhat different and "it's unlikely to happen here" is generally true.

There is already a precedent for why falling into the trap of anesthesia/CRNAs where one surgeon supervises multiple rooms is a longshot. The recent brouhaha over concurrent/simultaneous surgeries suggests that the general public has no appetite for that model.
 
I know it sounds cliche, but I do think surgery is somewhat different and "it's unlikely to happen here" is generally true.

There is already a precedent for why falling into the trap of anesthesia/CRNAs where one surgeon supervises multiple rooms is a longshot. The recent brouhaha over concurrent/simultaneous surgeries suggests that the general public has no appetite for that model.
Maybe its still 'old school' in some places but every single experience I have had in residency and fellowship an attending has been more or less in the room the entire time. Maybe not scrubbed, but I have yet to see the simultaneous room thing... ever.
 
Maybe its still 'old school' in some places but every single experience I have had in residency and fellowship an attending has been more or less in the room the entire time. Maybe not scrubbed, but I have yet to see the simultaneous room thing... ever.

my experience with simultaneous surgery was where the fancy surgeon would have 3 cases with some overlap and do the difficult parts of all the cases with other attending surgeons of the same specialty helping with some of the less critical parts of the surgery. So, never was the patient operated on without an attending scrubbed but maybe not the “main surgeon” they thought was doing the entire case.
 
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This is how it starts. Take a look across the pond.


A cyst here a biopsy over there. Its just the beginning. They'll have derms supervising mohs and orthopods supervising TKAs.

This wont help them learn their bounds it'll encourage them to push further and further into the scope of MDs with the rationale of "I did a residency too!" NP/PA lobby will love this.
 
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A cyst here a biopsy over there. Its just the beginning. They'll have derms supervising mohs and orthopods supervising TKAs.

This wont help them learn their bounds it'll encourage them to push further and further into the scope of MDs with the rationale of "I did a residency too!" NP/PA lobby will love this.
You know what man, you're totally right.

Let's be proper Americans then and go do what we do best - tell other people that their lives and problems don't matter, only ours do, because we're America. UK better knock that **** out because its going to affect OUR job market. Those tea loving sons of bitches. :p
 
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You know what man, you're totally right.

Let's be proper Americans then and go do what we do best - tell other people that their lives and problems don't matter, only ours do, because we're America. UK better knock that **** out because its going to affect OUR job market. Those tea loving sons of bitches. :p

Their lives don't matter which is why we utilize midlevel's in the first place. Like the UK docs had any say in the matter to use midlevels LOL.
 
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There is absolutely no reason to let midlevels perform intercorporeal suturing. For any procedure that requires it, that is a "critical portion" and you just took the learning opportunity away from the resident.
 
There is absolutely no reason to let midlevels perform intercorporeal suturing. For any procedure that requires it, that is a "critical portion" and you just took the learning opportunity away from the resident.
...on a mechanical trainer. I can see a lot of good reasons to let them practice this in a box, starting with they will probably be the one passing the needles back and forth. Getting a good idea of the difficulty, how the needles need to be loaded, how they can get stuck in a trocar or have to be bent sometimes, knowing the proper length to cut them to for laparoscopy or robotic surgery.

You really can’t see why that would be useful?
 
...on a mechanical trainer. I can see a lot of good reasons to let them practice this in a box, starting with they will probably be the one passing the needles back and forth. Getting a good idea of the difficulty, how the needles need to be loaded, how they can get stuck in a trocar or have to be bent sometimes, knowing the proper length to cut them to for laparoscopy or robotic surgery.

You really can’t see why that would be useful?
All that stuff falls under laparoscopic fundamentals to me. I was more focused on actually throwing stiches and tying. If its just in the trainer box go nuts, but I doubt it will stop there.
 
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All that stuff falls under laparoscopic fundamentals to me. I was more focused on actually throwing stiches and tying. If its just in the trainer box go nuts, but I doubt it will stop there.
Welp, their description literally says in a mechanical trainer and that in the OR they are trained as a first assist so... I bet it stops there. 🤣
 
Not sure what would motivate a surgeon to have a NP/PA throw AND tie intracorporeal sutures. Seems like all downside and risk for no good reason.
 
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Honestly, in Canada, this already exists. There are RN first assists who harvest open vein for CABGs. At the end of the day, it is an issue, but this has been going on for years, it isn't new.
 
For now. NPs weren’t being taught to do colonoscopies before either. They are now.
By one place, by one attending. I will reiterate what I have said ad nauseum here and elsewhere. Midlevels fill a need. Whether we like it or not there is some void that led to someone teaching that. If a midlevel starts doing intracorporal suturing or *insert anything in surgery here* its probably because the attending couldn't get consistent help. Maybe there are no residents. Maybe the RNFAs rotate every day and it is a complex skill. Maybe it was not economically viable to have a second surgeon assisting. Maybe they've been hiring for another surgeon for years and haven't found someone willing to take the call or move to the place and they literally can't afford to pay an extra 100k to make it viable. I doubt it was for ****s and giggles because they thought it would be fun to teach their own replacement. I also doubt an attending is teaching a midlevel to do this outside a mechanical trainer, and I suspect they're ONLY learning it in a mechanical trainer because it happened to be part of the existing surgical intern curriculum with the residency and it was far easier to piggyback than make something new and separate.

99.9% of surgeons do not do things because they have free time and for funsies in the OR.
 
By one place, by one attending. I will reiterate what I have said ad nauseum here and elsewhere. Midlevels fill a need. Whether we like it or not there is some void that led to someone teaching that. If a midlevel starts doing intracorporal suturing or *insert anything in surgery here* its probably because the attending couldn't get consistent help. Maybe there are no residents. Maybe the RNFAs rotate every day and it is a complex skill. Maybe it was not economically viable to have a second surgeon assisting. Maybe they've been hiring for another surgeon for years and haven't found someone willing to take the call or move to the place and they literally can't afford to pay an extra 100k to make it viable. I doubt it was for ****s and giggles because they thought it would be fun to teach their own replacement. I also doubt an attending is teaching a midlevel to do this outside a mechanical trainer, and I suspect they're ONLY learning it in a mechanical trainer because it happened to be part of the existing surgical intern curriculum with the residency and it was far easier to piggyback than make something new and separate.

99.9% of surgeons do not do things because they have free time and for funsies in the OR.

Whatever you have to tell yourself.
 
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Illuminating. Thanks.

It’s not worth arguing with someone who just continually moves the goal posts. Every example of continued midlevel encroachment is justified by you in the name of “filling a need.” Then I could point out how they don’t actually fill those needs because they demonstrably do not practice where there are shortages. And that will get justified some other way. You’ve posted before on how you think it’s great that docs are using armies of midlevels to make bank at the expense of the medical profession and those of us still in training. That view is obvious in your constant defense of undertrained practitioners doing more and more to encroach upon the field.
 
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It’s not worth arguing with someone who just continually moves the goal posts. Every example of continued midlevel encroachment is justified by you in the name of “filling a need.” Then I could point out how they don’t actually fill those needs because they demonstrably do not practice where there are shortages. And that will get justified some other way. You’ve posted before on how you think it’s great that docs are using armies of midlevels to make bank at the expense of the medical profession and those of us still in training. That view is obvious in your constant defense of undertrained practitioners doing more and more to encroach upon the field.
Excuse me? Please dig that up. I've posted how midlevels can be used by those of us still in training to great effect to give you more time for educational opportunities and less time to do scut and service. I've posted how I do think its great that systems that have no residents use midlevels functionally and appropriately. Do not put words in my mouth and gtfo with your hyperbole.

The hypocrisy of being upset at "undertrained practitioners" in medicine seeking out more training to do their job well before going out into the world so they can be safer and more effective is real. From the description of the program: "Emphasis, as in all the surgical rotations, is on the preoperative care, inrtaoperative first assisting and postoperative management with appropriate in-patient care on the general floors or intensive care units. Participation at surgical clinics and follow-up office visits are also required."

wE'rE tRaInInG tHeM tO sTeAl OuR sUrGeRy!
 
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Excuse me? Please dig that up. I've posted how midlevels can be used by those of us still in training to great effect to give you more time for educational opportunities and less time to do scut and service. I've posted how I do think its great that systems that have no residents use midlevels functionally and appropriately. Do not put words in my mouth and gtfo with your hyperbole.

The hypocrisy of being upset at "undertrained practitioners" in medicine seeking out more training to do their job well before going out into the world so they can be safer and more effective is real. From the description of the program: "Emphasis, as in all the surgical rotations, is on the preoperative care, inrtaoperative first assisting and postoperative management with appropriate in-patient care on the general floors or intensive care units. Participation at surgical clinics and follow-up office visits are also required."

wE'rE tRaInInG tHeM tO sTeAl OuR sUrGeRy!

Guess you forgot about this:


Bravo to the community docs who built huge practices and manage their midlevels to generate revenue. If they do it safely, more power to them. If they don't do it safely, you're right, they'll get sued, and they'll be out of a job. It will sort itself out.
 
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What part of that is at yours, or medicine's, expense? Pretty sure I carved out the emphasis on doing it safely there. Unless I'm just blind.
 
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By one place, by one attending. I will reiterate what I have said ad nauseum here and elsewhere. Midlevels fill a need. Whether we like it or not there is some void that led to someone teaching that. If a midlevel starts doing intracorporal suturing or *insert anything in surgery here* its probably because the attending couldn't get consistent help. Maybe there are no residents. Maybe the RNFAs rotate every day and it is a complex skill. Maybe it was not economically viable to have a second surgeon assisting. Maybe they've been hiring for another surgeon for years and haven't found someone willing to take the call or move to the place and they literally can't afford to pay an extra 100k to make it viable. I doubt it was for ****s and giggles because they thought it would be fun to teach their own replacement. I also doubt an attending is teaching a midlevel to do this outside a mechanical trainer, and I suspect they're ONLY learning it in a mechanical trainer because it happened to be part of the existing surgical intern curriculum with the residency and it was far easier to piggyback than make something new and separate.

99.9% of surgeons do not do things because they have free time and for funsies in the OR.

Mid-level fill a need for bean counters to reduce employment cost. In all those examples, the solution is to pay more money. And there is always money available, it just depends on how tight fisted the powers that be are.

That is it.

There is no void. It is greed from either administration or another physician when they choose to promote mid level use.

CRNAs started off at just one location. Now look at the mess that situation has become.

Once you open Pandoras box, you can't turn back.
 
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Also just to note, i'm a doctor from the UK and most of us are absolutely not happy with the midlevel encroachment that we've started to import from the US. Surgical nurses were not created due to a severe shortage of surgeons, they were created because the government essentially refused to change some new pension laws that made it uneconomical for surgeons to continue doing vast amounts of elective surgeries. Instead of the government to fix this, they made nurse surgeons. We may not have a capitalist system like the states but it always comes back to admins and in our case the government trying to save money. Midlevels absolutely do take training opportunities and a lot of us in training are as happy as you guys that they exist. Trust me midlevel surgeons will absolutely become a thing in the states as they are becoming in the UK. As long as there is money to be made, there will always be a simp to train them in the misguided belief that their job is too complex for anyone else to do. Spoiler alert, admins don't care they'll use them anyway!
 
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Also just to note, i'm a doctor from the UK and most of us are absolutely not happy with the midlevel encroachment that we've started to import from the US. Surgical nurses were not created due to a severe shortage of surgeons, they were created because the government essentially refused to change some new pension laws that made it uneconomical for surgeons to continue doing vast amounts of elective surgeries. Instead of the government to fix this, they made nurse surgeons. We may not have a capitalist system like the states but it always comes back to admins and in our case the government trying to save money. Midlevels absolutely do take training opportunities and a lot of us in training are as happy as you guys that they exist. Trust me midlevel surgeons will absolutely become a thing in the states as they are becoming in the UK. As long as there is money to be made, there will always be a simp to train them in the misguided belief that their job is too complex for anyone else to do. Spoiler alert, admins don't care they'll use them anyway!
Our midlevels don’t like to be called midlevels, they prefer advanced practice surgeon.
 
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Lol, ours are called surgical care practitioners....unironically unfortunately
 
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That is truly unfortunate. I was being sarcastic and making a play on words as many here do find the term midlevel offensive and like to be called advanced practice providers.
If the term provider means clinical diagnosis and treatment, that would include seem to include Physicans PA's and NP. What is it that is so advanced about PA's and NP's. If someone tells me they dont like midlevel ill switch to non-physician provider.
 
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What part of that is at yours, or medicine's, expense? Pretty sure I carved out the emphasis on doing it safely there. Unless I'm just blind.
Sellout
 
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A cyst here a biopsy over there. Its just the beginning. They'll have derms supervising mohs and orthopods supervising TKAs.

This wont help them learn their bounds it'll encourage them to push further and further into the scope of MDs with the rationale of "I did a residency too!" NP/PA lobby will love this.
I heard of an ortho that taught his PAs the most common joint procedures (TKA, THA, shoulder arthro) and now runs multiples room where the PAs do the procedures while he pops his head in and out every once in a while
 
I heard of an ortho that taught his PAs the most common joint procedures (TKA, THA, shoulder arthro) and now runs multiples room where the PAs do the procedures while he pops his head in and out every once in a while
That has to be illegal..
 
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*Simp, you got my title wrong. Let me file this carefully constructed opinion into the 'intellectually stunted toddler' bin.
No need to get offended, if the physicians keep teaching midlevels as they are currently doing in the US regardless of how "safe" it is they are only training their replacements all admins want is someone "good enough" to "replace those expensive physicians" and it's all downhill from there it is only a matter of time before we see TKA specialized PA, Bladder cancer resection NP...etc
 
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heard of an ortho that taught his PAs the most common joint procedures (TKA, THA, shoulder arthro) and now runs multiples room where the PAs do the procedures while he pops his head in and out every once in a while

Well, if you "heard of a guy" it must be true.

The likely story is that these are "overlapping" cases, not simultaneous. In other words, the PA is closing in one room while he operates in another room.

If someone actually did what you suggest, they'd be opening themselves ups to a host of issues as it relates to hospital privileging, Medicare participation and legal liability.
 
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Well, if you "heard of a guy" it must be true.

The likely story is that these are "overlapping" cases, not simultaneous. In other words, the PA is closing in one room while he operates in another room.

If someone actually did what you suggest, they'd be opening themselves ups to a host of issues as it relates to hospital privileging, Medicare participation and legal liability.
I just reported what i heard whether you want to believe it or not is up to you
 
I just reported what i heard whether you want to believe it or not is up to you
1) If this is the level of analytical thought prevalent in medicine, I find that more concerning than PA/NP scope creep.

2) If we want to be taken seriously about this topic it's going to require more than "I just reported what I heard".
 
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1) If this is the level of analytical thought prevalent in medicine, I find that more concerning than PA/NP scope creep.

2) If we want to be taken seriously about this topic it's going to require more than "I just reported what I heard".
I mean, this is basically how all internet misinformation, anti-vax, QAnon nonsense proliferates. “I heard” “they say” etc. and then seemingly the speaker feels zero impetus to back it up with, you know, proof. Or even if they do offer proof, little need to verify/ensure said proof is in fact accurate.

Welcome to the new age of information. Only sheep ask for verifiable facts.
 
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1) If this is the level of analytical thought prevalent in medicine, I find that more concerning than PA/NP scope creep.

2) If we want to be taken seriously about this topic it's going to require more than "I just reported what I heard".
1) Analytical thought? should i have asked him to take me there and show me? Do you actually think it is improbable especially with everything going on?

2) I will provide you with RCTs comparing TKAs done by physicians to those done by midlevels when they come out in the future
 
1) Analytical thought? should i have asked him to take me there and show me? Do you actually think it is improbable especially with everything going on?

2) I will provide you with RCTs comparing TKAs done by physicians to those done by midlevels when they come out in the future

Analytical though is considering what someone is saying and deciding whether it makes sense before parroting it as a talking point to others. Like I said, there's a host of reasons why that situation makes me think it's not accurate. But you were ready to take the statement at face value because it fits nicely within your preferred narrative.
 
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Mid-level fill a need for bean counters to reduce employment cost. In all those examples, the solution is to pay more money. And there is always money available, it just depends on how tight fisted the powers that be are.

That is it.

There is no void. It is greed from either administration or another physician when they choose to promote mid level use.

CRNAs started off at just one location. Now look at the mess that situation has become.

Once you open Pandoras box, you can't turn back.
It is also a matter of efficiency. I need an assistant when I’m doing a robotic case. My partners and I often assist for each other. This is fun, but a huge loss of productivity. My partner may bill 4 RVUs for a 3-4 hour case when instead they could have seen 15 patients in clinic. If I had a well trained PA for that purpose I would happily use him or her and a program that trains PAs to be good first assistants is fine by me.
 
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Analytical though is considering what someone is saying and deciding whether it makes sense before parroting it as a talking point to others. Like I said, there's a host of reasons why that situation makes me think it's not accurate. But you were ready to take the statement at face value because it fits nicely within your preferred narrative.
I was ready to take it on face value based on what i have seen, i don't have a preferred narrative, as a matter of fact i am interested in surgery but the thought of a physician training PAs to do TKAs and THAs and tripling his RVUs does not seem so far fetched, especially when the only ones to (potentially) lose are the patients, it just follows the pattern we have seen over and over again, the only difference is that it is ortho this time.
 
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