Question for the hospitalists out there

[chessknt]

I am curious about the health of the field of hospitalist medicine--is there a credible threat from midlevels taking these jobs away by taking lower pay? Is pay for these jobs expected to go down with the ACA? Is there a good chance of it transitioning to a supervisory model?

I am trying to assess if it is in the same place anesthesia was 10 years ago, with a rising ignored threat from midlevels that will force global pay to eventually go down regardless of inflation.

Any input from experienced hospitalists who have been out in the world and think they have a good idea of the trend would be appreciated!

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[drstar842]

I am curious about the health of the field of hospitalist medicine--is there a credible threat from midlevels taking these jobs away by taking lower pay? Is pay for these jobs expected to go down with the ACA? Is there a good chance of it transitioning to a supervisory model?

I am trying to assess if it is in the same place anesthesia was 10 years ago, with a rising ignored threat from midlevels that will force global pay to eventually go down regardless of inflation.

Any input from experienced hospitalists who have been out in the world and think they have a good idea of the trend would be appreciated!

I personally have not seen a NP hospitalist and didn't even know they existed. But, a quick google answered that question. I honestly think EVERY job/specialty held by physicians will eventually become vulnerable. I found and read the below article while googling "NP hospitalists" and it certainly seems like the AACN is prepared to do whatever is necessary to change how healthcare is delivered in this country. According to this article, they are ready to go right for the jugular by influencing policy makers and lobbyists by whatever means necessary. Physicians are in trouble because our representation seems to have brought a knife to a gun fight.

http://nurse-practitioners-and-phys.../Column/DNP-Perspectives/Policy-Politics.aspx

DNPs are a powerful force to lead chance and advance health.
By Ying Mai Kung, DNP, MPH, FNP-BC

I once saw a picture with a fish asking, "What is this 'water' that people are talking about?" The reality is that policy and politics are like water for the fish and the air that we breathe. We are immersed in it without realizing the influence it has in our daily lives.

For example, Florida APRNs practice under a supervisory protocol with a physician (or dentist); it is the only state where APRNs are not authorized to prescribe controlled substances. Similarly, RNs need orders to give over-the-counter-medications for a fever or a headache. They follow orders for basic nursing care such as taking vital signs and ambulating patients, and even need an order for a bedside commode for those who have difficulty getting to a bathroom.

Is nursing a profession or an occupation? A profession requires its members to have a high level of education, knowledge, responsibility, accountability and practice by ethical principles to deliver a vital service for society. A profession enjoys independent decision-making (self-determination, self-government), is well organized, and well represented.1 To illustrate the differences, an engineer who designs a bridge is considered as having a professional career while laborers who construct the bridge are considered as having an occupation in construction.

For generations nursing has been working to change the "handmaiden" image associated more with an occupation than a profession. We've made significant progress, but how is nursing perceived when compared with other professionals such as physicians, lawyers, scientists or engineers?

Recently, disturbing comments from responders to an article about APRNs and independent practice in Florida stated, "A doctor is the captain of the ship, if your job contains 'nurse', you will be supervised," and, "When I need healthcare I want to see a doctor who has the most medical knowledge. There are some great nurses I have had, also. assisting my doctor."2

Advocating for Change

For the sake of our patients and for our profession, "Nurses must see policy as something they can shape and develop rather than something that happens to them."3 Like the fish and water, policy and law have a profound life and death effect on our practice.

Nurses must advocate for policy changes to remove practice barriers to deliver patient-centered, timely, equitable, effective and efficient care to our patients to guarantee that the care is high quality and safe.

Our profession must be well-represented and well-organized in its approach to achieve legislative changes in government and in boardrooms. Whether in the workplace or the legislature, the first step in policy work is to be involved and to be present.

As they say, "If you are not at the table, you are on the menu." Nurses also need to be unified and speak with one voice. We need to speak with a voice that not only nurses understand, but a voice that other healthcare providers, legislators, administrators and consumers understand. Carefully crafting out messages specific for individual audience is of the essence. For example, winning a campaign is important for legislators; therefore, campaign contributions and number of votes speak volumes.

Nurses consist of the largest segment of the healthcare workforce. We have significant power and influence that we have not tapped into. Understanding how policy is developed and laws are passed is an important component of effective legislative advocacy.

Strong representation through professional organizations is critical. Professional organizations can harness the energy and the flow of ideas of their members to articulate nursing values to proactively advocate for the needs of society while maintaining the integrity of the profession and its practice. In other words, our voice is louder and clearer when it is spoken through professional organizations.

Policy and the DNP

How do DNPs fit in? DNPs are highly educated, practice oriented professionals. DNP curricula must include leadership and systems thinking, analytical methods for evidence-based practice, healthcare policy and advocacy, and interprofessional collaboration.4 DNPs can choose to specialize in clinical advance practice as well as health system leadership, policy or education. Regardless of the track students choose, their charge is to improve the health of our nation through innovations in healthcare systems and to improve the quality of care and access while reducing costs.

I have to confess: I did not appreciate the value of policy work until I was faced with barriers practicing as a family nurse practitioner. I realized that no amount of education or expertise I gained would help my patients unless I had the statutory authority to practice (scope of practice stipulated per the Florida Nurse Practice Act). Yes, we have developed work-arounds to care for our patients, but at whose expense?

Furthermore, are we enabling a broken system? Completing my DNP gave me an improved understanding of my advocacy role for patients and for the nursing profession. The curriculum also offered me and my classmates an improved understanding of our leadership role to make a difference in the workplace and legislature.

DNPs are educated to be leaders and innovators not only for nurses, but for our society. DNPs as well as all nurses need to realize that we do not work in silos. We must collaborate with a wide array of professionals from various backgrounds and disciplines. DNPs must be organized and be a strong unifying force to bring all nurses together. DNPs need to support professional organization(s) and ensure the voice of nursing is heard.

Above all, DNPs must engage in advocacy and actively shape policy for professional autonomy and the right to self-determination. Through embracing policy and politics, DNPs can revolutionize not only our profession, but as the IOM's Future of Nursing Report states to "Lead Change, Advance Health."3

 

[chessknt]

I agree and understand that midlevels are going after ever field of medicine (I have seen NPs covering surgery patients as well as acting as interns on medicine services with attending oversight). My question is--how prevalent is this? Are NPs infiltrating the majority of the private market and operating independently from physicians--admitting their own patients and billing like an IM doc would? Or are they a curiosity seen mainly in academic centers?

 

[drstar842]

"How prevalent is it?"
According to the first link and info below, it sounds like 17 states will allow mid-levels to practice as hospitalists, independently.

"Currently, only 17 states and the District of Columbia provide for NPs to work at the peak of their training and licensure without the supervision of physicians, in keeping with the IOM and NGA recommendations. Effectively, these states allow NPs to evaluate patients; diagnose, order and interpret diagnostic tests; initiate and manage treatments; and prescribe medication under the exclusive authority of the state board of nursing, rather than under the authority of a physician. In these 17 states, NPs are able to set up their own primary care practices and see patients autonomously, significantly increasing the supply of primary care services”
http://www.elderbranch.com/blog/nurse-practitioners/


Now, according to the info below from a different source, it sounds like hospitals are saying "screw it" even if they only get 85% reimbursement from Medicare or other insurance companies (as others have gone on to model Medicare's reimbursement of mid-levels), because they will come out on top in the end because of how much cheaper it is to pay a mid-level hospitalist.

"Payment issues pose other problems. Per Medicare rules, NPs and PAs can bill out at only 85% of the physician rate if they bill under their own provider number. That's led some hospitalist programs to assume they'll make less revenue if they hire midlevels, which isn't usually the case, says Michael Powe, director of health systems and reimbursement for the American Academy of Physician Assistants. With a 2006 mean of $84,396, PA salaries amount to a little more than half of a typical hospitalist's. Groups that achieve significant efficiencies can increase their census or reduce their hospitalist staffing-and see a bottom-line improvement."
http://www.todayshospitalist.com/index.php/index.php?b=articles_read&cnt=35#sthash.ANrK78K4.dpuf


Overall, to answer your question, it seems that NPs are competing with physicians in primary care and at hospitals in 17 states. The other states that require physician oversight have legislation pending or are in the process of implementing full independence for NPs, according to what I read from multiple AACN blogs and reports.
Now, in the states where physician oversight is required, from what I could gather, it is becoming the norm for hospitalist groups to have a team of mid-levels helping to manage the practice. Unfortunately, what these docs in those states don't get is that as soon as the whistle blows for mid-level independence, you better believe that the NPs, who they spent years helping to train, won't even hesitate to walk away from the group. Then, they will most likely get hired from the hospital for a much better salary than they got from the hospitalist group (basic economics) and have an immediate impact on the hospitalist group's census and thus the group's profitability.

 

[The kitchen sink]

"How prevalent is it?"
According to the first link and info below, it sounds like 17 states will allow mid-levels to practice as hospitalists, independently.

"Currently, only 17 states and the District of Columbia provide for NPs to work at the peak of their training and licensure without the supervision of physicians, in keeping with the IOM and NGA recommendations. Effectively, these states allow NPs to evaluate patients; diagnose, order and interpret diagnostic tests; initiate and manage treatments; and prescribe medication under the exclusive authority of the state board of nursing, rather than under the authority of a physician. In these 17 states, NPs are able to set up their own primary care practices and see patients autonomously, significantly increasing the supply of primary care services”
http://www.elderbranch.com/blog/nurse-practitioners/


Now, according to the info below from a different source, it sounds like hospitals are saying "screw it" even if they only get 85% reimbursement from Medicare or other insurance companies (as others have gone on to model Medicare's reimbursement of mid-levels), because they will come out on top in the end because of how much cheaper it is to pay a mid-level hospitalist.

"Payment issues pose other problems. Per Medicare rules, NPs and PAs can bill out at only 85% of the physician rate if they bill under their own provider number. That's led some hospitalist programs to assume they'll make less revenue if they hire midlevels, which isn't usually the case, says Michael Powe, director of health systems and reimbursement for the American Academy of Physician Assistants. With a 2006 mean of $84,396, PA salaries amount to a little more than half of a typical hospitalist's. Groups that achieve significant efficiencies can increase their census or reduce their hospitalist staffing-and see a bottom-line improvement."
http://www.todayshospitalist.com/index.php/index.php?b=articles_read&cnt=35#sthash.ANrK78K4.dpuf


Overall, to answer your question, it seems that NPs are competing with physicians in primary care and at hospitals in 17 states. The other states that require physician oversight have legislation pending or are in the process of implementing full independence for NPs, according to what I read from multiple AACN blogs and reports.
Now, in the states where physician oversight is required, from what I could gather, it is becoming the norm for hospitalist groups to have a team of mid-levels helping to manage the practice. Unfortunately, what these docs in those states don't get is that as soon as the whistle blows for mid-level independence, you better believe that the NPs, who they spent years helping to train, won't even hesitate to walk away from the group. Then, they will most likely get hired from the hospital for a much better salary than they got from the hospitalist group (basic economics) and have an immediate impact on the hospitalist group's census and thus the group's profitability.

Thank you. Very informative post. I am looking to do IM and then CC and practice as an intensivist, so I am hoping that this market is relatively untouched by NPs/Midlevels.

 

[sacrament]

An unsupervised hospitalist NP is a scary notion. NPs doing outpatient medicine is slightly less scary if only because the majority of outpatient visits will not result in severe morbidity or mortality if incorrectly managed. But hospitalized patients are, almost by definition, actually sick. I can only imagine that most unsupervised hospitalist NPs would function essentially as a consulting machine.

 

[LoudBark]

An unsupervised hospitalist NP is a scary notion. NPs doing outpatient medicine is slightly less scary if only because the majority of outpatient visits will not result in severe morbidity or mortality if incorrectly managed. But hospitalized patients are, almost by definition, actually sick. I can only imagine that most unsupervised hospitalist NPs would function essentially as a consulting machine.

Be very careful what you wish for!!!!!

As a hospitalist it is much, much better for the NP to be in a state where they can independently do whatever the heck they want without ever making eye contact with a supervising physician.

Why? Imagine the scenario in a state that requires physician supervision. They must be supervised. They give a brief sign out to a doctor on all patients they see. They do some stupid crap. There is an adverse outcome. Pt either dies or is permanently disabled. At the bottom of their progress note they inevitably write: "discussed the above plan and patient with Dr. Smith and he agrees with the above"

Now all of a sudden you are liable. You were their supervising physician and approved of what they did. They may not have even told you half of the stupid crap they want to do, but they have your name there and you are in a state where you have to supervise them. If there is a law suit, you better believe you are also pulled into it.

Now look at it the other way. In states where they can work independently, if they do some stupid stuff that kills a patient or permanently maims them....it is on the DNP / NP and not on the doctor from a liability standpoint. After all, the state says they can make all decisions independent of a doctor.

From a liability stand point, it is much, much better for a hospitalist to work in a state that allows the DNP/ NP to work completely independently.

 

[Otto of the Silver-Hand]

Thank you. Very informative post. I am looking to do IM and then CC and practice as an intensivist, so I am hoping that this market is relatively untouched by NPs/Midlevels.

Don't be too sure. Most NPs I know were ICU nurses.

 

[wjs010]

Be very careful what you wish for!!!!!

As a hospitalist it is much, much better for the NP to be in a state where they can independently do whatever the heck they want without ever making eye contact with a supervising physician.

Why? Imagine the scenario in a state that requires physician supervision. They must be supervised. They give a brief sign out to a doctor on all patients they see. They do some stupid crap. There is an adverse outcome. Pt either dies or is permanently disabled. At the bottom of their progress note they inevitably write: "discussed the above plan and patient with Dr. Smith and he agrees with the above"

Now all of a sudden you are liable. You were their supervising physician and approved of what they did. They may not have even told you half of the stupid crap they want to do, but they have your name there and you are in a state where you have to supervise them. If there is a law suit, you better believe you are also pulled into it.

Now look at it the other way. In states where they can work independently, if they do some stupid stuff that kills a patient or permanently maims them....it is on the DNP / NP and not on the doctor from a liability standpoint. After all, the state says they can make all decisions independent of a doctor.

From a liability stand point, it is much, much better for a hospitalist to work in a state that allows the DNP/ NP to work completely independently.

But in states that won't let them practice ind, can't the nurse just get sued? I mean there's gotta be a way to show the nurse didn't discuss the proper treatment plans with the physician .

 

[drstar842]

This is an example of mid-level care gone wrong. It is not a secret that doctors have been dealing with malpractice lawsuits for decades. But, as LoudBark stated above, it would be a lot better for a hospitalist to not be listed as the supervising physician due to the increase in malpractice lawsuits against mid level providers. We all hear the horror stories during 'M&Ms' and, thus, always strive to learn from our mistakes to hopefully provide error-free care.
This lawsuit a BIG miss for the NP and the settlement shows it.
The case below describes an outpatient case, but the NP was providing care at the patient's home, essentially acting like a hospitalist for one patient. They were responsible for assessing and managing the patient's home care and recovery post surgery with the full autonomy to make executive decisions if medically necessary. I believe this case illustrates the breakdown of this provider's critical thinking and medical decision making for an acute emergency situation. The patient's acute (<24 h) history of falls, weakness, tingling in hands in addition to a physical exam that included a concerning drop in BP, tachycardia, significantly low body temperature and thrush should have prompted a DDx that included septic shock at the top of the list (considering the patient already had a diagnosis of SIRS based off of HR and temp). It seems as if the NP in this case either felt as if the patient would be OK despite the findings or was just completely oblivious and that since the surgeon was going to see them the following day, there was no need to worry. Unfortunately, for this patient, the nurse was dead wrong.

Settlement: $706,250

"The deceased plaintiff was a 59-year-old woman who had undergone an inpatient bilateral salpingo-oophorectomy three days before being discharged to home care. Discharge orders included a home care referral for wound care and assessment of perceived changes in the patient’s mental status.

The defendant nurse practitioner was a contracted staff member of the home care agency that was providing the patient’s home care. The defendant nurse practitioner was assigned to assess and manage the plaintiff’s home care and to supervise the daily nursing and wound care provided by the agency’s licensed nurses.

The patient’s subsequent wound infection was managed by the surgeon who ordered wound care that he identified as “an old-fashioned wound remedy” which involved placing honey into the wound. This was not a treatment known to the defendant nurse practitioner.

Resolution

Documentation regarding evidence of infection, wound appearance, wound size, drainage amount and appearance is inconsistent among the nurses caring for the patient. Temperatures were taken regularly, but the patient’s blood pressure was not recorded until day 14 of home care when vital signs were 124/58, 80, 16 and 97.8. The next day vital signs were 112/64, 88, 16 and 98.3.

On day 16, the defendant nurse practitioner saw the patient and was informed that she had fallen twice during the night. The patient complained of increased weakness, fatigue, and tingling pain in her hands. Her tongue was noted to be covered with white plaque. Vital signs were 102/54, 100, 18 and 95. The patient was scheduled to see her surgeon the following day.

Despite multiple falls, vital sign changes and evidence of dehydration, the defendant nurse practitioner did not recommend or initiate emergency care and did not notify the surgeon of the falls or the other changes in the patient’s condition.

On day 17, the patient’s family notified the home care agency that the patient had fallen in the shower and was unable to get up, 911 was called and despite emergency intubation and cardiopulmonary resuscitation efforts, the patient died.

Risk Management
The nurse practitioner did not ensure that essential monitoring of vital signs, fluid intake and urine output were properly performed and/or recorded. The patient’s deterioration and increased severity of symptoms were neither treated as medically urgent nor were they communicated to the surgeon. The originally ordered assessment of changes in the patient’s mental status was neither performed nor was a consultation ordered by the nurse practitioner. The patient’s increasing complaints of weakness, fatigue and anxiety were ignored or not deemed to warrant additional investigation or discussion with the surgeon.

 

[shiftingmirage]

How do DNPs fit in? DNPs are highly educated, practice oriented professionals. DNP curricula must include leadership and systems thinking, analytical methods for evidence-based practice, healthcare policy and advocacy, and interprofessional collaboration.4 DNPs can choose to specialize in clinical advance practice as well as health system leadership, policy or education.

It's interesting that the DNP curricula listed doesn't include things like physiology, pathology, pharmacology, microbiology, etc, things that are vital to diagnosing and treating patients.

 

[Otto of the Silver-Hand]

It's interesting that the DNP curricula listed doesn't include things like physiology, pathology, pharmacology, microbiology, etc, things that are vital to diagnosing and treating patients.

That explains why the competent ones function like interns and the better ones are like PGY2's. One of my med school professors told me, " Nurses will know what to give, but you'll know why it's given."

 

[Smokemont]

It's interesting that the DNP curricula listed doesn't include things like physiology, pathology, pharmacology, microbiology, etc, things that are vital to diagnosing and treating patients.

It's because those things are part of doctoring philosophy as opposed to nursing philosophy that nurses use....heard this straight from a NP.

 

[bronx43]

That explains why the competent ones function like interns and the better ones are like PGY2's. One of my med school professors told me, " Nurses will know what to give, but you'll know why it's given."

If you're a PGY2 IM resident, and you're functioning like a NP, then you should probably switch fields.

 

[bronx43]

Be very careful what you wish for!!!!!

As a hospitalist it is much, much better for the NP to be in a state where they can independently do whatever the heck they want without ever making eye contact with a supervising physician.

Why? Imagine the scenario in a state that requires physician supervision. They must be supervised. They give a brief sign out to a doctor on all patients they see. They do some stupid crap. There is an adverse outcome. Pt either dies or is permanently disabled. At the bottom of their progress note they inevitably write: "discussed the above plan and patient with Dr. Smith and he agrees with the above"

Now all of a sudden you are liable. You were their supervising physician and approved of what they did. They may not have even told you half of the stupid crap they want to do, but they have your name there and you are in a state where you have to supervise them. If there is a law suit, you better believe you are also pulled into it.

Now look at it the other way. In states where they can work independently, if they do some stupid stuff that kills a patient or permanently maims them....it is on the DNP / NP and not on the doctor from a liability standpoint. After all, the state says they can make all decisions independent of a doctor.

From a liability stand point, it is much, much better for a hospitalist to work in a state that allows the DNP/ NP to work completely independently.

This is exactly right. When they f*** up, and they certainly will, let the hammer drop on their head. I'm sure the malpractice lawyers are salivating at the thought of independent practice by midlevels. Honestly, if they were smart, they would keep the status quo and milk out as much of the gravy train as possible. Independent practice won't increase their income, but it will expose them to legal liability. My guess is that if this were to happen, hospital systems would quickly realize that they aren't saving any money with mid-levels when they have to pay their malpractice.

 

[Otto of the Silver-Hand]

If you're a PGY2 IM resident, and you're functioning like a NP, then you should probably switch fields.

Unfortunately they don't switch fields

 

[EMDO2018]

I read in a paper somewhere that hospitals didn't hire NP hospitalist because they called consults 24/7. I think you actually have to be very knowledgeable in medicine to be a good hospitalist and deal with very ill patients. It isn't like Anesthesia where the nurses don't have to know a lot about medicine to give the drugs.

 

[Raryn]

If you're a PGY2 IM resident, and you're functioning like a NP, then you should probably switch fields.

We have NPs to help out in the unit.

The really good one who used to be an ICU nurse functions about as well as an intern 3/4 of the way through the year, frequently carrying 5 patients or doing admissions primarily and just staffing them later that day with the resident.

The other(s)? Maybe an intern. In july.

 

[Bostonredsox]

Lol old time outpatient internists deciding to practice as hospitalists scares me enough....the idea of an np providing unsupervised hospitalist scare is insane. Let it go on for 10 years...the rise in mortality will force them out.

 

[DiagnasaurusRex]

Midleveles providing care is a credible threat but hospitalists will likely hang on for a few reasons

1) patients admitted to the hospital don't fancy talking just to PA or NP, everybody wants to see the doctor.
2) as stated above, malpractice is becoming an issue especially with minimally or unsupervised NPs
3) NPs/PAs can only bill like 80 cents on the dollar according to Medicare (and Medicaid I believe) and frequently miss diagnoses and underbill - lowering RVUs and case mix index. Hospitalists can bill for critical care (more credibly in a way that will yield in payment) and prolonged service, ekg reading etc..
4) States limit how many PAs you can supercise. In Colorado, you can only have 4 PAs under supervision per physician license and usually that goes to the hospitalist leadership - not rank and file doctor. You can always refuse; a hospital cannot make you attach a PA to your medical license.

I think for surgical subspecialties it makes more sense because PAs can do routine post op care, get consent, check wounds, discharge patients etc... which maximizes how much the surgeon is able to spend time operating.

 

[KnuxNole]

We have NPs and PAs that work as hospitalists. Usually they carry between 10-12 and do an average of 2 admits per shifts. So, they take roughly the same load as the MDs in the groups. They usually see them independently, manage, get consults, and the MD that is assigned to them usually stops by the room to say hello and co-signs. It does help with a large census in terms of rounding and helping out with admissions. Even though a doc has to stop by and check out the patients, the ones that we have are fairly component in their role. And, know when to ask for help/advice, which helps the team-like approach. Because it is also my license on my line, if I do have to staff a NP patient, I usually go over the labs, notes, check the patient out, and give my suggestions to the NP, as opposed to just signing their note, standing by the door and waving hi....which does happen, which means some patients say the only person they actually talk to and see is a NP.

I worked as a hospitalist for a year, and liked working with the NPs/PAs. Maybe where I work is different, but the MDs and NPs consult about the same frequency. Some MDs consult for EVERYTHING and some consult for nothing, while most are a healthy medium. I know most say that NPs would consult 24/7, but maybe that's a general hospitalist thing? Only reason why I say that is because the MDs also consult 24/7. I know in the real world, consults = $$ and CYA, so both parties are happy about it.

 

[Domerr]

I don't think midlevels will be a threat. We have ~20 MDs, and only 2 PAs. We recently hired several MDs to expand the group, but we're not even considering PAs at this time. I find them really helpful, especailly when the census gets high.

 

[CCM-MD]

Anesthesia has obviously had the worst midlevel impact but midlevel threat is everywhere. I have noticed more mid level driven subspecialties than hospital medicine or primary care. Surgical fields (ortho, CTS, vascular in particular) have been the utilizing midlevels quite a bit. The more procedural medicine specialties like GI, cards, CCM use them more than things like ID, nephrology, rheum, endocrine, or even onc. Haven't seen them much in pulmonary now that I think about it but I am sure there's pulmonary midlevels somewhere in the country. They seem to be quite involved in palliative/hospice work too. ER is getting tons of midlevels also, I am sure they will start feeling the impact soon enough. I have seen hospitalist and outpatient midlevels but much less frequently.

 

[rokshana]

Anesthesia has obviously had the worst midlevel impact but midlevel threat is everywhere. I have noticed more mid level driven subspecialties than hospital medicine or primary care. Surgical fields (ortho, CTS, vascular in particular) have been the utilizing midlevels quite a bit. The more procedural medicine specialties like GI, cards, CCM use them more than things like ID, nephrology, rheum, endocrine, or even onc. Haven't seen them much in pulmonary now that I think about it but I am sure there's pulmonary midlevels somewhere in the country. They seem to be quite involved in palliative/hospice work too. ER is getting tons of midlevels also, I am sure they will start feeling the impact soon enough. I have seen hospitalist and outpatient midlevels but much less frequently.

no, endocrine utilizes NPs and frankly, probably in the right way...many inpatient glucose services are maintained by NPs and diabetes that needs more frequent f/u than just 3 months are well managed with NPs. I'm currently working in a place that is having a hard time attracting and retaining Endocrinologist and since they see the majority of the DM pts, I get to see primarily Endocrine pts (my panel is maybe 10-15% DM).

 

[CCM-MD]

no, endocrine utilizes NPs and frankly, probably in the right way...many inpatient glucose services are maintained by NPs and diabetes that needs more frequent f/u than just 3 months are well managed with NPs. I'm currently working in a place that is having a hard time attracting and retaining Endocrinologist and since they see the majority of the DM pts, I get to see primarily Endocrine pts (my panel is maybe 10-15% DM).

Thats interesting.

 

[Psai]

Surgeons use midlevels to execute their plans and write notes. They are doing it right. They should be taking the scut that frees us up to do our work, not allowing them to do our work and try to replace us.

 

[CCM-MD]

Surgeons use midlevels to execute their plans and write notes. They are doing it right. They should be taking the scut that frees us up to do our work, not allowing them to do our work and try to replace us.

Intern/scut monkey is how I like to think they function in the ICU. But I think any level of involvement opens the door to potentially worse things down the road...

 

[Trogghunter]

They don't seem to have the educational foundation to independently practice inpatient medicine beyond a straightforward admission in an otherwise healthy patient. Even the ones who have been in practice for over a decade are as well versed as an IM intern in November.