- Dec 28, 2010
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SDN blowing mid-level encroachment out of proportion or is it real?
- Thread starter Wobbler
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- Dec 28, 2010
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To answer the thread’s header, is SDN overblowing midlevel encroachment? Having a bit of experience with the system now, I can pretty confidently say no. It’s pretty on point with what’s out there in the real world. Some on this thread may be more insulated (to no fault of their own) than others depending on where they’re training but in private practice that employs NPPs to maximize profits outside of academia the situations look quite ugly. One example off the top of my head was an NP diagnosing a patient with AF and starting anticoagulants and then the physician co-signing the note 10 days later (to bill). There was only PACs and I called the physician and he confirmed the patient should be off anticoagulants at an outpatient follow up.
Unfortunately the way the medical system works allows PAs/NPs to hide from their incompetence. Big medical errors aren’t usually caught on the day they happen to allow all parties involved to realize what happened. The only major immediate incidents are allergies and we have fail safes for that built into the EMR to avoid that. When we bring patients in, put them in little heuristic boxes, and employ mindless algorithms to them, and write ****** documentation so no one can actually realize what happened, it’s really hard to spot medical errors right away. If you really care about the situation though and stop viewing patients as drug-seekers, gomers, etc. and reference things like the MAR and vitals instead of the notes, you start picking up terrifying things and realize how badly some in medicine (especially PAs/NPs) are harming patients. They basically epitomize the robotic, thoughtless, and frankly near-sociopathic practice of medicine where they cut every corner, provide bad care, and know they can get away with it because hospital administrators accept their lie-ridden documentation so long as it pays the bills. The worst part and why I call it near sociopathic is because they know the care they provide is terrible, but know they can get away with it because they’re caring for the most vulnerable patients who wouldn’t even know where to start with figuring out which provider messed them up…Most hospitalized patients are already circling the drain to begin with, what’s throwing on an unnecessary anticoagulant going to do for that? No one’s going to realize the mistake because hardly anyone is going to track the MAR, look for the tele strip, and the best part is even if their error is discovered, it’s the Cardiologist who co-signed their note 10 days later to bill who’s getting the liability…
Unfortunately the way the medical system works allows PAs/NPs to hide from their incompetence. Big medical errors aren’t usually caught on the day they happen to allow all parties involved to realize what happened. The only major immediate incidents are allergies and we have fail safes for that built into the EMR to avoid that. When we bring patients in, put them in little heuristic boxes, and employ mindless algorithms to them, and write ****** documentation so no one can actually realize what happened, it’s really hard to spot medical errors right away. If you really care about the situation though and stop viewing patients as drug-seekers, gomers, etc. and reference things like the MAR and vitals instead of the notes, you start picking up terrifying things and realize how badly some in medicine (especially PAs/NPs) are harming patients. They basically epitomize the robotic, thoughtless, and frankly near-sociopathic practice of medicine where they cut every corner, provide bad care, and know they can get away with it because hospital administrators accept their lie-ridden documentation so long as it pays the bills. The worst part and why I call it near sociopathic is because they know the care they provide is terrible, but know they can get away with it because they’re caring for the most vulnerable patients who wouldn’t even know where to start with figuring out which provider messed them up…Most hospitalized patients are already circling the drain to begin with, what’s throwing on an unnecessary anticoagulant going to do for that? No one’s going to realize the mistake because hardly anyone is going to track the MAR, look for the tele strip, and the best part is even if their error is discovered, it’s the Cardiologist who co-signed their note 10 days later to bill who’s getting the liability…
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IT costs money to find out what the **** happened. Real money, like 500 dollars an hour to an attorney. They are not gonna do that until as you said something really fu cked up happened
What you are saying is NOT true. You are a completely misguided. I dont know if you are in high school or what? THat's akin to saying a lawyer while writing his 100 page argument, does not rely on anything before lawschool so everything he/she learned in college and high school is irrelevant.
Do you think a surgeon has to know Anatomy? If yes, when did you think he learned it? Do you think a surgeon has to know pharmacology? Where do you think he learned it? If you are a nurse, just take the pre reqs and go to medical school. IF you dont want to, then go to allnurses.com and tell THEM how useless medical school is?
- Jan 11, 2016
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Yeah I get the sentiment, but it’s ridiculous. And he literally said there are NPs doing surgery while the attendings are seeing patients. I doubt that’s true though, since I’m pretty sure that’s illegal.
My dude I'm a resident, have you graduated med school? Do you think your typical floor intern could tell you jack about an ankle operation, relevant anatomy included? Yes, surgeons learn things like relevant anatomy throughout residency, they dont take MS1 and walk away with the knowledge theyll practice on 10 years later.
Pretty sure what I said was that I would not object to a theoretical hospital in which an NP that had done a residency did the procedure while MDs cleared preop and wrote the plan for anything that came up postop. Maybe I'm hallucinating
What I'm so surprised about is that dermatology is has barely been touched by the mid-level takeover yet. It seems to a prime type of field for mid-level takeover, yet there's very little encroachment there.
I'm thankful, as I want to be a dermatologist, but a little surprised.
I'm thankful, as I want to be a dermatologist, but a little surprised.
Source: Wisconsin Hospital Replaces All Anesthesiologists With CRNAs
Cue "The Times They Are a-Changin" by Bob Dylan.
Many dermatologists are in pvt practice. Why would you teach a np anything?
Plus, the possibility of mis diagnosing is high in derm.
Let me get this straight. You actually believe that you should be able to start orthopedic residency right after college? Are you saying they shouldnt go to medical school at all? Are you saying NPs should be allowed to become orthopedic surgeons? I understand these woke people and even disruptive technology but that kind of wokeness is too wokey for me.
I'm telling you there are already surgeons that do not use their general MD ed to manage even the most basic issues (HTN example), they literally just do the joint and punt everything else. I'm saying an NP that did an ortho residency could provide the same level service to the hospital. This is not something I'm a fan of - though I also understand why a surgeon wants to do high volume joints or stents or whatever and not the surrounding care - but it is a reality.
- Jan 11, 2016
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What you actually said was:
So what you’re saying now is that’s not actually happening?
You think an ortho residency depends on the foundation from med school? That's the key issue here
- Jan 11, 2016
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Replace NP with anyone with a basic understanding of biology (including premeds) and the point that an ortho residency teaches everything needed to know and not dependent on med school still stands
Not yet but i don't see how that's relevant when people who are in residency now are saying the same thing
@Lawpy and @Matthew9Thirtyfive - in case it's a nick measuring contest Matthew9Thirtyfive has a longer nick... 
Really just replace NP with anyone with basic understanding of biology and the point stands.
- Jan 11, 2016
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First, that presumes that an NP has a basic understanding of biology, and I have met many who do not. But that’s beside the point. If you took someone and made sure they had a basic understanding of bio, anatomy, path, etc and put them in an ortho residency, I’m sure they’d do fine. Because that’s what med school is.
Could you take an NP and do it? I’m sure you could, but they would need a lot of extra help in the beginning I think.
- Jan 11, 2016
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Yes, and the ones who come from crappier experiences tell me they feel like they know nothing and have a huge learning curve. Now imagine coming from no med school at all.
It’s happening. There aren’t that many derms out there for the NPs/PAs to learn from.
What’s happening is the older derms are selling to private equity then taking all the midlevels because they are usually required to work for 2 years after selling.
Those midlevels will probably open private clinics after they work for a while.
It’s interesting because derm has the highest % of docs worth >5 mil as a result.
When I think of this - any number of images of Billy from the Silence of the Lambs comes to my mind...
If an ortho residency teaches everything needed to know from PGY1 onwards, does the rotation experience in med school days even matter? And by basic understanding of biology, i'm talking like college courses
Lets just tag @OrthoTraumaMD @VincentAdultman @Chillbo Baggins to resolve this debate once and for all
I feel like I am in the Twilight Zone. You are arguing, as a physician, that medical school is not superior to NP school? There is being a realist, then being a cynic, then being a cynic among cynics (SDN baseline), then like 10 levels of delusion, before you end up at a place where you are arguing that orthopods are so far removed from medicine that they could bypass medical school entirely and are the equivalent of NP's plus a residency.
I can't believe I am defending ortho like this but you and others in this thread seem to know very little about the field. If I put on my armchair physiologist hat, some people in this thread seem to be salty/jealous that ortho is making $600k+ for "dumb" work while the "real" MD's in internal medicine are only making $200k with their big brains.
Let's look at the facts. M4's applying to ortho do a minimum of 2 sub-I's during which they are working 80-100 hrs/week for 4 weeks each. 3-4 sub-I's is more common than 2. This is on top of honoring M3 core surgery, which is the bare minimum to get your application looked at. Add to that the expectation that you need to have a few publications or research. Now, does doing a ton of research as an attending make you a great surgeon? Probably not, but that stuff is expected for medical students so that they can stay up to date on advancements in the field and know how to read papers, evaluate the studies quality, etc. That will make them better surgeons. So just with 3 sub-I's and honoring an 8 week core surgery rotation we are looking at 20 weeks of surgery training at 80 hours/week. That is 1,600 hours of relevant experience. The most rigorous NP programs require 1500 clinical hours TOTAL. And I can assure you that the expectations for a student NP are MUCH lower than an M4 on an away ortho rotation. I have worked with M4's applying to ortho and they are expected to at the very least know MSK anatomy at a level where they could teach it from memory to NP's students.
So in summary:
M4 applying to ortho:
- 640 hours of general surgery/sub-speciality surgery as an M3
- 960 hours of ortho as an M4
- research experience
- >3,000 hours clinical exposure in other fields
NP:
- 500-1500 clinical hours in NP school
- variable experience as an RN
The thing I would like to highlight the most is that the expectations for medical students and NP students and licensed NP's are wildly different. Or in other words, the quality of those hours is much higher for medical students, especially the M4 hours. Now, you could argue that you can just require NP's to get ortho work experience and some research before applying to their "residency." But at that point you are just recreating medical school with a different name.
Finally, another example of people not being aware of the depth of other specialities, especially when they seem to want to dismiss them as "dumb" specialities for unknown reasons, there actually can be a decent amount of basic science in ortho. Much of the foundational and latest research (for example what type of grafts work best for ACL repair) requires you to understand the basics of MSK physiology, pathology, pharmacology, etc. None of that is taught in enough detail in NP school. An M4 applying to ortho can hit the ground running. An NP would need months of book learning alone to catch up.
Finally finally for the record, I am not applying to ortho. I personally think it is way too MSK focused with not enough "medicine" like general surgery. But I am also not so arrogant to think I am better than orthopods just because I don't know that much about their field.
Ok but i don't think anyone disagrees with the ortho's expertise on MSK issues and the research/surgery honoring/aways are largely due to the hypercompetitiveness of the field and not necessarily that the field requires a foundation of all those. Remember, ortho PDs like seeing straight honors in clinicals too and it's bizarre to think psych, OB and neuro rotations have any relevance in ortho training
The issue is ortho is apparently so far removed from med school that they're consulting IM/FM for really basic medical issues that they themselves should easily know how to address and manage. That's the thing. The point of med school is to have a solid foundation to be a generalist first and specialist second, and yet this is not the case with the repeated ortho consults on very basic medical management issues.
So the question therefore lies, is med school even worth it for ortho? Especially if the only year of relevance is MS4 (for aways/ortho sub Is) and the surgery part of MS3 (and maybe anatomy/path --> so like 1.5 yr tops)
I will say again that if me and the ortho NPs started an ortho residency tomorrow theyd start out ahead of me and we'd end up equivalent for providing this service of OR-only medicine. We can toot our own horn all we want about clinical hours etc but when zero of it is useful for their job (again, they wont even manage HTN) I dont see the need for them to get MDs
This is not to suggest they are not masters of a valuable and difficult craft. It's just I think it's all teachable in residency with an MD as low value added
They’ll treat the normal acne, psoriasis and send cancer and things that don’t get better with steroids to the professionals…
While I do agree with efle that certain specialties punt basic stuff they should know, there’s no way I’d allow a NPP, residency or not, to ever operate in me. These are degrees based on being “good enough” and cutting corners. At the end of the day, lazy people get these degrees. Despite the constant ortho bashing, physicians have a commitment to excellence above the general population. This is more apparent the more I work with NPPs. Sometimes I feel like they’re just playing make-believe at recess and the docs are all there to make sure they don’t maim anyone accidentally.
And the midlevels don’t care.
And the midlevels don’t care.
Careful man, the orthos might do this to it rads-inclined folk.
Christmas 2011: Surgery: Orthopaedic surgeons: as strong as an ox and almost twice as clever? Multicentre prospective comparative study
Objective To compare the intelligence and grip strength of orthopaedic surgeons and anaesthetists.Design Multicentre prospective comparative study.Setting Three UK district general hospitals in 2011.Participants 36 male orthopaedic surgeons and 40 male ...
- May 24, 2013
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What exactly is the question here?? I'm just a dumb bone doctor so reading is difficult.
For what it's worth, one of my ortho classmates has correctly diagnosed like 10 patients with CHF that other specialties have missed.
- Dec 28, 2010
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No one is saying/insinuating the bolded or even behaving in a way that may make a psychiatrist think this is what they're thinking. No one is calling Orthopedic Surgeons dumb. No one is doubting (as I have said) that surgery requires a lot of science. Efle's point still remains, however, that a lot of the medicine learnt in medical school curriculum is not utilized by orthopedic surgeons when they practice. Is that a problem in hospitals? Probably not because IM can take care of it.
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- Dec 28, 2010
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This is a good point, in a way the medical school performance Orthopedics requires is actually a good indicator of a successful Orthopedic surgeon. The thing though is, is it helpful for them?
They'd have to successfully complete an ortho residency. In that case, would you let them fix grandma's knee? I can't imagine anyone lazy or uncaring getting through surgical training
How likely do you think an ortho midlevel will make it through an ortho residency
I do think dealing and coping with the stressful, anxiety invoking **** show that is medical school does bring some value... even if the legitimate course material doesn't. See you later, I have to get back to studying useful stuff like muscles that make up the quadrangular space, and how the tyrosine kinase pathway is used to open up GLUTE4.
- A M1 going through emotional distress
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I see where @efle is coming from, but my main issue with the argument is that you can tell on rounds or away rotations who has good clinical accumen and where good graduates generally come from. Obviously this is widely variable within the school structure, but each institution has different expectations of their students, and accumulated over many rotations, starts to show. If medical school didn't matter whatsoever, then there wouldn't be such a wide variable between clinical accumen at the start of 4th year. I will give an example. I go to a USMD school. I went on an away at another MD school which had some DO rotators all from the same school. All the DOs were a bit behind those of us at the school and the other MD rotator as they had not had the structured rotations that we had. This isn't DO shade as the rotation was in a very specific setting, but nonetheless you could tell that the structured presentations and reporting/ H+P skills were just not quite there. There's also a decent amount from first 2 years that has ended up being important, combined with a lot of garbage. I think around 50% of the preclinical curriculum can be cut out.
It gets better.
Well, at least that’s the lie that convinced me to keep paying tuition…
About the same rate as a lot of MDs tbh. I know it's not popular on SDN or reddit to suggest MDs can be motivated by money and status and other "bad" reasons but I think we all know a few surgeons with cushy elective based lifestyle practices after their training. The idea that MDs have intrinsic work ethics and empathy categorically superior to NPs isnt something I've bought into myself
But would you be able to tell where someone had paid to shadow before their first time operating? This hypothetical would be for replacing the guys who already gloss over and omit significant patient medical history in their "H&P" and page medicine for any and all comorbidity management, not talking about the surgeons who want to own their patients outside the OR
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I did more than shadowing on most of my rotations. Definitely got to do things, call consults, have my notes be used for patient care, etc. It makes a difference when medical students are actually utilized versus when they aren't. You can tell which schools allow their students to have some responsibility versus those who don't.
That is the big big issue here. Many schools and rotation sites are straight up garbage and are nothing more than glorified shadowing experiences, which can thus justify the NP + residency is comparable to MS4 + residency claims (when most or even all of the learning is done in residency)
People are getting hung up on their hate for midlevels that they fail to see this huge problem of bad clinical rotations
Yea definitely an extremely different experience than I had rotating in subspecialty stuff like ophtho, ENT and plastics. Was 100% a shadow
They are both an issue. My point being though that medical school can be useful. I think @efle 's current argument that medical school should be abolished instead of improved is based in overall cynicism with the system. I personally believe that we need to improve the system. I received excellent clinical training, and definitely feel that it has been worth it. That doesn't mean that holds across all medical schools across the country.
I'd add that since things like ortho, vascular, pod, spine, etc aren't required by most schools there's really no grounds to expect an MD to have any kind of useful training in those areas by virtue of the degree alone. The fact I even saw those subspecialties I mentioned as a glorified shadow was by choice. The required general rotations we all spend months on and take USMLEs and shelves for? That stuff I would expect any MD to know about, hence my surprise when surgeons started punting me hypertension and basic H&P components.
Though I am on record saying I think many specialties at this point could become their own training pathway. Look at dental / OMFS or podiatry, does it really seem crazy to think fields like rads or path or niche proceduralists could have more focused training instead of general med ed?
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