SDN blowing mid-level encroachment out of proportion or is it real?

[Neopolymath]

I agree. With the caveat that I think the vast majority of NPPs just don’t have the work ethic to survive any residency program, let alone a surgical residency.

Working weekends or past 4pm? SHOCK HORROR

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[Iamnew2]

Working weekends or past 4pm? SHOCK HORROR

*passes out*

 

[YCAGA]

Working weekends or past 4pm? SHOCK HORROR

Midlevels have no problem doing that...



for double pay after 4pm.

But really this just highlights the sad state of affairs for physicians in the US. Plenty of countries with similar GDP's to the US pay their residents and attendings overtime. Fair pay and working conditions are part of their culture, inside and outside of medicine. I have talked trash about midlevels in the past when they want to leave on time and/or for extra pay for weekends/overtime, but the more I think about it, we shouldn't be using that as an argument for physicians being the best for patients.

"We might be more educated and have better outcomes, but what you really will like about us, Mr. MBA CEO, is that we are trained to work insane hours for no increase in pay from day one and any questioning of that is a sign of weakness!"

And to be clear: of course physicians (and nurses, midlevels, environmental services, etc) have to stay past 4pm because sick people don't get sick 9-5pm. But we don't have to accept no overtime or post-call days if you get called in overnight (a requirement for attendings in some countries...just like pilots have to take time off if they get called in for a red-eye but were supposed to also work the next day).

 

[paki20]

It's real. I'm at a top hospital institution that is loaded with midlevels. Hospital administration loves hiring midlevels at a fraction of the cost of hiring a physician. They function as residents in terms of covering patients without the knowledge (they function at the level of a 2nd year medical student knowledge wise), they get on the job training and see the same type of pathology so they learn to function at the level of a resident. They are able to do procedures including the simpler IR procedures. They can put in central lines and alines without supervision. They can do paracentesis and thoracentesis without supervision. They're in every department including ED, critical care units including MICU, CCU, CTICU, SICU, medicine and its subspecialties, surgery, anesthesiology, neurology, OB/GYN, derm, pysch, IR, orthopedics and neurosurgery. As outpatients they can see their own patients independently without physician supervision. You'll see that nurses have the most power in the hospital including many top leadership positions. Youll see that most physicians are too scared to speak up when it comes to nurses and go along with the narrative that all nurses are amazing and the true caregivers of patients. Many physicians will talk crap about other physicians to nurses but are too scared to talk badly about nurses. I suspect it's only going to get worse for physicians.

 

[deleted1100659]

psychiatry is so high in demand, even with midlevels there is still a massive shortage.

 

[Matthew9Thirtyfive]

I mean I have an MD and the ortho NPs knows a ton more about replacing a knee or ORIFs than I do. If we both started an ortho residency tomorrow they'd be miles ahead and the product at the end of training would be the same.

Bro. Please stop these ridiculous arguments before you end up simping on Twitter and throwing other MDs under the bus in favor of midlevel clout.

 

[efle]

Bro. Please stop these ridiculous arguments before you end up simping on Twitter and throwing other MDs under the bus in favor of midlevel clout.

Remember that time you didn't believe midlevels are out there functioning as indie PCP clinics? Same thing here, you just haven't experienced the wonders of community subspecialist consults yet. It's sad - I in no way endorse how these guys are practicing - but true, that they are only providing the procedure and passing off all other medical care. You simply do not need 4 years of general medical education to provide what they provide.

 

[YCAGA]

I mean I have an MD and the ortho NPs knows a ton more about replacing a knee or ORIFs than I do. If we both started an ortho residency tomorrow they'd be miles ahead and the product at the end of training would be the same.

So you’re basically saying medical school is a waste of time?

Also as others have said, ortho is a complete outlier in this debate because ortho attendings have convinced everyone that they can’t do anything but MSK. That fits nicely into your argument that a residency is basically just on-the-job technical training and you don’t need medical school as foundation, and that more hours of on-the-job training = better end product, regardless of intelligence, work ethic, or background/foundational knowledge.

Can’t tell if that is just a really bad hot take or a quasi-troll post.

 

[YCAGA]

@efle We might as well start ortho residency in early high school if we just need to get people some on the job training. Once you can read/write, do basic arithmetic, and know mitochondria is the powerhouse of the cell, I guess you are a few years away from being the same end product as a PGY-5 ortho resident.

 

[Lawpy]

I mean you could say this for literally any part of school ever since kindergarten. Just because you don't consciously use it doesnt mean its useless.

Well K12 is in fact mostly useless... and they also teach wrong and outdated information too

Med school education is based on a model set up by a racist educator over a century ago. It needs a very heavy overhaul

 

[paki20]

Second year med student is beyond generous. Their medical knowledge is below a MS1. The questions I get asked are truly shocking… if algorithms suddenly didn’t exist they would quite literally have no idea what to do

Yes 100%. Should have clarified their CLINICAL knowledge is like that of a 2nd year meaning it's not much. They don't know any basic science that's for sure.

 

[jambro]

We need to stop hyping up rads so much on SDN, otherwise it will for sure end up like EM/radonc in very near future

It won't end up like EM/radonc unless you have a massive expansion of residency spots, which obviously SDN hype wouldn't affect. You could make it more competitive, but too few people are on the internet reading about this stuff for it to make a difference. I'm amazed by how easily my classmates write off rads but would speak about derm with such high praise lol. This is played out nationally too. I think it's silly that derm is so competitive and rads isn't

 

[Iamnew2]

It won't end up like EM/radonc unless you have a massive expansion of residency spots, which obviously SDN hype wouldn't affect. You could make it more competitive, but too few people are on the internet reading about this stuff for it to make a difference. I'm amazed by how easily my classmates write off rads but would speak about derm with such high praise lol. This is played out nationally too. I think it's silly that derm is so competitive and rads isn't

Umm around 2008-2012 or so give or take a few years, Rads was a complete and total disaster. Tons of applicants per job, no jobs, people doing 1-2 fellowships. Now rads has stabilized a bit more, however nothing to brag about. Rads is plenty competitive and there was a massive expansion of Rad spots - one of the reasons the job market was so saturated in addition to the fact that no one was retiring with the 2008 collapse.

 

[jambro]

Umm around 2008-2012 or so give or take a few years, Rads was a complete and total disaster. Tons of applicants per job, no jobs, people doing 1-2 fellowships. Now rads has stabilized a bit more, however nothing to brag about. Rads is plenty competitive and there was a massive expansion of Rad spots - one of the reasons the job market was so saturated in addition to the fact that no one was retiring with the 2008 collapse.

All i was saying is that hyping it up online wont make it turn into EM/radonc (see: "UNLESS"). Rads doesnt seem that competitive if you just want to match - one of the highest match rates for US MD seniors. Also, my understanding is job market for rads is fire right now

 

[efle]

@efle We might as well start ortho residency in early high school if we just need to get people some on the job training. Once you can read/write, do basic arithmetic, and know mitochondria is the powerhouse of the cell, I guess you are a few years away from being the same end product as a PGY-5 ortho resident.

It's not just ortho. Seen it with podiatric, vascular, neurosurg spine, just as a few examples. The maximally profitable setup is to skim over people's medical history and focus on moving meat through the OR. Have someone from med or cards do the preop clearance and consult them for anything postop that your midlevel staff cant cover alone. Like I said it's not the system I'd design, I dont want to sound like I'm a fan of surgeons that do nothing besides the procedure. But its reality, unfortunately, that someone with extremely basic background followed by a surgical residency would be interchangeable. Workflow through the hospital would be unchanged.

 

[blue.jay]

It's real. I'm at a top hospital institution that is loaded with midlevels. Hospital administration loves hiring midlevels at a fraction of the cost of hiring a physician. They function as residents in terms of covering patients without the knowledge (they function at the level of a 2nd year medical student knowledge wise), they get on the job training and see the same type of pathology so they learn to function at the level of a resident. They are able to do procedures including the simpler IR procedures. They can put in central lines and alines without supervision. They can do paracentesis and thoracentesis without supervision. They're in every department including ED, critical care units including MICU, CCU, CTICU, SICU, medicine and its subspecialties, surgery, anesthesiology, neurology, OB/GYN, derm, pysch, IR, orthopedics and neurosurgery. As outpatients they can see their own patients independently without physician supervision. You'll see that nurses have the most power in the hospital including many top leadership positions. Youll see that most physicians are too scared to speak up when it comes to nurses and go along with the narrative that all nurses are amazing and the true caregivers of patients. Many physicians will talk crap about other physicians to nurses but are too scared to talk badly about nurses. I suspect it's only going to get worse for physicians.

This sounds like Cleveland clinic

 

[2021Doctor]

 

[Aheadbyacentury]

This is disappointing because it means med school is a complete waste of time

Completing medical school demonstrates many things about a person not the least of which is the ability to focus hard enough to learn difficult tasks in the face of adversity and time pressure.. these are people you want doing surgery on you and making medical decisions. You dont want people who cannot and will not do those things. Medical practice will devolve into a complete **** storm where you have no confidence in the people delivering it. And thats a bad thing. The politicians do not care because they take the easy way out. They just want to be voted in. By the time they will deal with the **** storm, they will be dead. How much credibility does someone have if they cant or not willing to make the sacrifices to get a medical degree?

 

[efle]

Completing medical school demonstrates many things about a person not the least of which is the ability to focus hard enough to learn difficult tasks in the face of adversity and time pressure.. these are people you want doing surgery on you and making medical decisions. You dont want people who cannot and will not do those things. Medical practice will devolve into a complete **** storm where you have no confidence in the people delivering it. And thats a bad thing. The politicians do not care because they take the easy way out. They just want to be voted in. By the time they will deal with the **** storm, they will be dead. How much credibility does someone have if they cant or not willing to make the sacrifices to get a medical degree?

Good point we should make medical school 10 years long and only allow 50% of the starting class to graduate. Then we can really trust the guys replacing grandma's knee

 

[paki20]

Completing medical school demonstrates many things about a person not the least of which is the ability to focus hard enough to learn difficult tasks in the face of adversity and time pressure.. these are people you want doing surgery on you and making medical decisions. You dont want people who cannot and will not do those things. Medical practice will devolve into a complete **** storm where you have no confidence in the people delivering it. And thats a bad thing. The politicians do not care because they take the easy way out. They just want to be voted in. By the time they will deal with the **** storm, they will be dead. How much credibility does someone have if they cant or not willing to make the sacrifices to get a medical degree?

Society is also now all about equality of outcomes which they mistakenly equate to equality of opportunities. You can't say doctors are smarter than nurses, that's putting down nurses. Everyone wants to be equal these days.

 

[EmilKraepelin55]

Good point we should make medical school 10 years long and only allow 50% of the starting class to graduate. Then we can really trust the guys replacing grandma's knee

Are you really this cynical about the utility of our profession in comparison to lower trained providers? Are you okay with having an NP making medical decisions over an MD/DO? I mean, let’s be real, much of what you have been suggesting is astounding. 10+ years of specific training and preparation for independent practice is somehow equivalent to 4 years of nursing plus 2 years of which 90% is focused on leadership/lobbying, 5% pathophysiology, and 5% clinical rotations? Absurdity at its finest.

 

[Lawpy]

Are you really this cynical about the utility of our profession in comparison to lower trained providers? Are you okay with having an NP making medical decisions over an MD/DO? I mean, let’s be real, much of what you have been suggesting is astounding. 10+ years of specific training and preparation for independent practice is somehow equivalent to 4 years of nursing plus 2 years of which 90% is focused on leadership/lobbying, 5% pathophysiology, and 5% clinical rotations? Absurdity at its finest.

I'm pretty sure he recognizes the usefulness of residency. It's that med school is a complete waste of time

 

[Lawpy]

Completing medical school demonstrates many things about a person not the least of which is the ability to focus hard enough to learn difficult tasks in the face of adversity and time pressure.. these are people you want doing surgery on you and making medical decisions. You dont want people who cannot and will not do those things. Medical practice will devolve into a complete **** storm where you have no confidence in the people delivering it. And thats a bad thing. The politicians do not care because they take the easy way out. They just want to be voted in. By the time they will deal with the **** storm, they will be dead. How much credibility does someone have if they cant or not willing to make the sacrifices to get a medical degree?

Residency teaches and trains all of that much better than med school. When half of med school depends on regurgitating crap that's better taught by boards resources and 3rd year in many places is nothing more than glorified shadowing and playing the game of finding the 5 givers, we need to step back and reassess the point of med school and realize the massive changes that need to be done

 

[efle]

Are you really this cynical about the utility of our profession in comparison to lower trained providers? Are you okay with having an NP making medical decisions over an MD/DO? I mean, let’s be real, much of what you have been suggesting is astounding. 10+ years of specific training and preparation for independent practice is somehow equivalent to 4 years of nursing plus 2 years of which 90% is focused on leadership/lobbying, 5% pathophysiology, and 5% clinical rotations? Absurdity at its finest.

Putting some words in my mouth there. I have never said an NP should be running a medicine floor or even being a PCP let alone make decisions over MDs. I said some specialized services like the surgical ones I listed above have so completely eschewed medicine that they may as well not be MDs because they're not using any of their general med ed anymore. They bang out joints or stents or whatever and punt the rest.

As a real life example I had a surgeon consult for HTN in a young patient postop. Brief chart review and 30 seconds talking with the patient revealed the pressures correlated to pain med timings and he had known hx of HTN already. You cannot tell me that guy is making good use of his MD. He's there to operate. Anything as much as reading his patients PCP notes gets a punt to medicine. I dont see how an NP with the same procedural training would be any different for that patients care.

 

[YCAGA]

Putting some words in my mouth there. I have never said an NP should be running a medicine floor or even being a PCP let alone make decisions over MDs. I said some specialized services like the surgical ones I listed above have so completely eschewed medicine that they may as well not be MDs because they're not using any of their general med ed anymore. They bang out joints or stents or whatever and punt the rest.

As a real life example I had a surgeon consult for HTN in a young patient postop. Brief chart review and 30 seconds talking with the patient revealed the pressures correlated to pain med timings and he had known hx of HTN already. You cannot tell me that guy is making good use of his MD. He's there to operate. Anything as much as reading his patients PCP notes gets a punt to medicine. I dont see how an NP with the same procedural training would be any different for that patients care.

I see the point you are making but I think the fallacy in your logic is that surgery and procedures in the real world is just mindless technical skill. I’m not a surgeon, and it sounds like you aren’t either, but from what I have been told, one of the most important skills in surgery is what operation to do and when to do it. Not just HOW to do it.

It’s been said time and time again by actual surgeons that you could teach a monkey to operate.

If you said that an NP after 5 years of ortho residency could do an ACL repair from the initial incision to closing skin as well as an MD after 5 years of ortho residency then that is a less insane argument. I still don’t agree because of the numerous small decisions made during every surgery, but your point would have been more clear. But to say that an MD and an NP are “the same product” after a hypothetical combined ortho residency is insanity.

 

[Lawpy]

I see the point you are making but I think the fallacy in your logic is that surgery and procedures in the real world is just mindless technical skill. I’m not a surgeon, and it sounds like you aren’t either, but from what I have been told, one of the most important skills in surgery is what operation to do and when to do it. Not just HOW to do it.

It’s been said time and time again by actual surgeons that you could teach a monkey to operate.

If you said that an NP after 5 years of ortho residency could do an ACL repair from the initial incision to closing skin as well as an MD after 5 years of ortho residency then that is a less insane argument. I still don’t agree because of the numerous small decisions made during every surgery, but your point would have been more clear. But to say that an MD and an NP are “the same product” after a hypothetical combined ortho residency is insanity.

Wait wait wait

You think an MS4 and an NP both going to the same ortho residency won't be equivalent after finishing residency?

Surgery in MS3 and MS4 is not great in many many places and rotation sites

 

[ohmanwaddup]

Well K12 is in fact mostly useless... and they also teach wrong and outdated information too

Med school education is based on a model set up by a racist educator over a century ago. It needs a very heavy overhaul

Does wrong or outdated matter at the very basic levels. I was taught there were 3 forms of matter, that’s not true but it’s true enough for 4th grade

 

[Lawpy]

Does wrong or outdated matter at the very basic levels. I was taught there were 3 forms of matter, that’s not true but it’s true enough for 4th grade

Yeah it matters and even a lot of basic stuff is taught completely wrong and given false information (like in a lot of science and history classes).

Math was so badly inefficient that i completely relate to everyone who hated it

 

[Redpancreas]

I think there's a lot of good points here. I think anyone who's been on IM Consults for a day can relate to what Efle is saying which is that sometimes surgical teams punt any modicum of non-surgical management (even if, like Efle says, it requires just looking at the last PCP note and recognizing the patient carries a dx and starting a home med). Having friends on the surgical side, they're kind of stuck too. They have a checklist which includes making sure the patient is T+S'ed, has an OR spot, that they've read up about the logistics of the case and prepped for it, etc. The lowest priority of that checklist includes recognizing the patient's comorbidities and medically managing them. The much more efficient thing (and something their attendings want and encourage) is for them to make sure IM is consulted if the patient has a medical diagnosis. Residents will literally get yelled at and judged and told they're too slow and inefficient if they waste even a minute digging through the history and trying to learn about the patients.

No one here is saying a PA can do the same job an MD can do.

 

[efle]

I see the point you are making but I think the fallacy in your logic is that surgery and procedures in the real world is just mindless technical skill. I’m not a surgeon, and it sounds like you aren’t either, but from what I have been told, one of the most important skills in surgery is what operation to do and when to do it. Not just HOW to do it.

It’s been said time and time again by actual surgeons that you could teach a monkey to operate.

If you said that an NP after 5 years of ortho residency could do an ACL repair from the initial incision to closing skin as well as an MD after 5 years of ortho residency then that is a less insane argument. I still don’t agree because of the numerous small decisions made during every surgery, but your point would have been more clear. But to say that an MD and an NP are “the same product” after a hypothetical combined ortho residency is insanity.

My argument is that statement plus "many community surgeons are elective op based and also use other docs to tell them when its OK to operate (preop clearance)"

Trauma surg at a big center? They need an MD. But would I freak out if there was a hospital with MDs doing preop clearance and abnormal postop management, with an NP+residency doing the cutting in between, for something like elective knee replacement or vascular stent? Nope, because that's already how it is, at least at the private community hospital I'm at now.

 

[NY_Med]

My argument is that statement plus "many community surgeons are elective op based and also use other docs to tell them when its OK to operate (preop clearance)"

Trauma surg at a big center? They need an MD. But would I freak out if there was a hospital with MDs doing preop clearance and abnormal postop management, with an NP+residency doing the cutting in between, for something like elective knee replacement or vascular stent? Nope, because that's already how it is, at least at the private community hospital I'm at now.

Wait, can you go in more depth here, NPs are doing knee replacements? Why the F*ck am I going to medical school and trying to match into the hardest residency when I could do a one year online NP program and do it...

 

[Lawpy]

Wait, can you go in more depth here, NPs are doing knee replacements? Why the F*ck am I going to medical school and trying to match into the hardest residency when I could do a one year online NP program and do it...

NP + residency is the key here

 

[Matthew9Thirtyfive]

My argument is that statement plus "many community surgeons are elective op based and also use other docs to tell them when its OK to operate (preop clearance)"

Trauma surg at a big center? They need an MD. But would I freak out if there was a hospital with MDs doing preop clearance and abnormal postop management, with an NP+residency doing the cutting in between, for something like elective knee replacement or vascular stent? Nope, because that's already how it is, at least at the private community hospital I'm at now.

What are you talking about? Where is an NP doing knee replacements? Please tell me so I can never go there and tell everyone I know to stay away.

 

[NY_Med]

NP + residency is the key here

The reality is I have no doubt in my mind I could be top 5% of an NP program to land the residency. I have met some pretty incapable NP's... Medical school is a different ball game...

But I get your point.

 

[Lawpy]

The reality is I have no doubt in my mind I could be top 5% of an NP program to land the residency. I have met some pretty incapable NP's... Medical school is a different ball game...

But I get your point.

Tbh i'd trust a PA far far more than NPs simply because their education and training are a bit more standardized and rigorous. A surgery PA gets all my respect. A surgery NP...

 

[VA Hopeful Dr]

What are you talking about? Where is an NP doing knee replacements? Please tell me so I can never go there and tell everyone I know to stay away.

I believe they're saying that some orthopedic surgeons have the same medical acumen at this point as NPs, not that NPs are doing solo knee replacements.

 

[deleted966164]

Society is also now all about equality of outcomes which they mistakenly equate to equality of opportunities. You can't say doctors are smarter than nurses, that's putting down nurses. Everyone wants to be equal these days.

Lenin, Marks, and Engels would be soooo happy now

 

[Matthew9Thirtyfive]

I believe they're saying that some orthopedic surgeons have the same medical acumen at this point as NPs, not that NPs are doing solo knee replacements.

Yeah which I think is just as disingenuous.

 

[VA Hopeful Dr]

Yeah which I think is just as disingenuous.

Maybe. I can't help but remember an ortho consult when I was in residency. Patient had HTN, literally no other medical issues aside from a septic joint that needed cleaning out. BP on admission was fine on home meds, BP POD #1 was fine on home meds. We got consulted to manage the patient's completely normal BP.

Now I don't actually think that orthopedic surgeons have forgotten how to be real doctors, but when stuff like that happens I can see why some people think making them go through general medical education isn't really needed.

I don't subscribe to that school of thought, but I understand it.

 

[Aheadbyacentury]

You think an MS4 and an NP both going to the same ortho residency won't be equivalent after finishing residency?

NP wont even make it past 3 months.. They would be out of their element..
You totally underestimate the foundation that medical doctors have that studying medicine provides. If orthopedics is a medical discipline, you would need a medical education to practice said that medical discipline.
NPs dont even require a advanced Biology course, or advanced chemistry. How on earth do you think they are qualified to start let alone finish an orthopedics residency.

 

[Aheadbyacentury]

Lenin, Marks, and Engels would be soooo happy now

You mean Marx!

 

[deleted966164]

You mean Marx!

Yeah.

 

[Matthew9Thirtyfive]

Maybe. I can't help but remember an ortho consult when I was in residency. Patient had HTN, literally no other medical issues aside from a septic joint that needed cleaning out. BP on admission was fine on home meds, BP POD #1 was fine on home meds. We got consulted to manage the patient's completely normal BP.

Now I don't actually think that orthopedic surgeons have forgotten how to be real doctors, but when stuff like that happens I can see why some people think making them go through general medical education isn't really needed.

I don't subscribe to that school of thought, but I understand it.

There’s a difference between saying orthopods don’t manage a lot of medical issues for their patients and saying they’re no different than NPs.

 

[Dave1980]

I was shocked how well other specialties adapted to telemed as well. If we start to see US hospitals hiring non-US radiologists I think they'd be hiring non-US of almost all clinicians at the same time. Only procedures would really need a US doc at that point

Insurance companies will not pay for a non US trained radiologist to read their imaging.

That is not going to change

 

[Matthew9Thirtyfive]

Wait wait wait

You think an MS4 and an NP both going to the same ortho residency won't be equivalent after finishing residency?

Surgery in MS3 and MS4 is not great in many many places and rotation sites

This thread is like a crystal ball for future Twitter academics simping for midlevel clout. Very depressing seeing supposed medical students saying their education has them coming from the same place as an NP.

 

[Redpancreas]

Tbh i'd trust a PA far far more than NPs simply because their education and training are a bit more standardized and rigorous. A surgery PA gets all my respect. A surgery NP...

Eh, they’re both more or less eternal residents who are endlessly lobbying for more autonomy. I used to think more highly of PAs but there’s really no difference. On a cardiology rotation, once a licensed PA was crying to her partner about having 15 patients not having time to learn them all throughout the day and how it’s unfair. I laughed. The whole point of the medical education process is to graduate physicians who can be both accurate and timely, or in other words efficient.

Honestly, I think what should be done is we as physicians ought to start a new career path called a physician assistant (you know…because PAs gave up that title) and basically require a GED equivalent and pay them $40K basically. They can serve as our scribes, round with us, interview patients in standardized manners, but they’re not ordering/interpreting/performing diagnostic tests because we can do that pretty efficiently. The key to ensure quality is to create paths for them to pursue medical school so they’re doing this with thoughts of career advancement and putting their best foot forward. Then, when we have enough of them, we refuse to supervise PAs and undercut their market. PAs think they can replace us when in reality it’s much easier to replace them.

 

[VA Hopeful Dr]

There’s a difference between saying orthopods don’t manage a lot of medical issues for their patients and saying they’re no different than NPs.

But I don't think that's what anyone is saying. What I think @efle is saying is that if orthopedic surgeons aren't going to use the general medical education they received in medical school, why not take NPs and put them through an orthopedic surgery residency? There's a sentiment (right or wrong) that certain fields are basically just technicians that don't need a full general medical education so why not skip the very expensive general medical education part?

I think its unwise for multiple reasons, but given how some specialties practice I can certainly sympathize.

 

[Redpancreas]

My argument is that statement plus "many community surgeons are elective op based and also use other docs to tell them when its OK to operate (preop clearance)"

Trauma surg at a big center? They need an MD. But would I freak out if there was a hospital with MDs doing preop clearance and abnormal postop management, with an NP+residency doing the cutting in between, for something like elective knee replacement or vascular stent? Nope, because that's already how it is, at least at the private community hospital I'm at now.

The pre-operative clearance is not asking other doctors when to operate. Surgical subspecialties make their own clinical judgments using their residency training and all of that to decide if laminectomy, for example, is indicated. The purpose of the preoperative clearance is for Medicine teams to evaluate the patient’s medical conditions and ensure they are optimized peri-operatively. The only time we really put a wedge plans is through the pre-cardiac evaluation of non-cardiac surgery algorithm.

Now regarding surgery, I’m not training to be one but from an medical outsider’s perspective, there’s actually a lot of three-dimensional reasoning involved that becomes its own world that non-surgeons don’t get involved in. I had a patient come in with a GI issue, consulted the GI team and then consulted surgery for later. You read the surgical operative note and the procedure was actually quite technically complex and they describe quite a lot of very interesting stuff. There are a lot of principles involved. Granted, none of these are actually learnt in medical school which I guess brings us back to the point of what medical school as it stands is providing surgeons…

 

[efle]

I cant help but feel like people's antagonism towards midlevels is interfering with getting my point across, I'll just have to admit defeat on trying to have the discussion. Let the record show all I ever said was that some surgeons' practice is 100% based in their residency training and they dont touch any other medical management with a 10 foot pole despite their MD. It's the residency alone that let's them provide their role. Not that current NPs are performing operations or should make decisions over MDs or any other insane takes

 

[Redpancreas]

I cant help but feel like people's antagonism towards midlevels is interfering with getting my point across, I'll just have to admit defeat on trying to have the discussion. Let the record show all I ever said was that some surgeons' practice is 100% based in their residency training and they dont touch any other medical management with a 10 foot pole despite their MD. It's the residency alone that let's them provide their role. Not that current MDs are performing operations or should make decisions over MDs or any other insane takes

Your point was actually well received. I think