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

[ohmanwaddup]

The issue is med education is set up to create generalists in mind, not surgical subs

I mean, as it should be I think. would not be surprised if we see some form of specialist school within an already established medical school in the next decade though. Could see big name places trying to pull this off, charge way more tution under the guise of "practicing surgical skills or something"

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[PTPuser]

I'm on the pod path and I'm sure many of you don't believe we are physicians etc (I've seen the way people talk down about pod lol) I will preface this with the fact that I am happy with my choice and have no desire to do anything above the tibial tuberosity, or infiltrate anything further from Orthopaedic surgeons.

But as someone who's taken upper level courses in biomechanics, ortho related courses, I can assure you no NPP will be doing knees safely by themselves anytime soon. Balancing a knee is very difficult and some might even argue that it's even tough for beginning ortho residents. We do not do knees (nor do I want to) but during our residency we rotate with ortho in all aspects except for spines but that's mostly trauma etc.

 

[efle]

I'm on the pod path and I'm sure many of you don't believe we are physicians etc (I've seen the way people talk down about pod lol) I will preface this with the fact that I am happy with my choice and have no desire to do anything above the tibial tuberosity, or infiltrate anything further from Orthopaedic surgeons.

But as someone who's taken upper level courses in biomechanics, ortho related courses, I can assure you no NPP will be doing knees safely by themselves anytime soon. Balancing a knee is very difficult and some might even argue that it's even tough for beginning ortho residents. We do not do knees (nor do I want to) but during our residency we rotate with ortho in all aspects except for spines but that's mostly trauma etc.

I hope the irony is not wasted of saying in one breath that people look down on pod training and then categorically dismissing that APPs could learn the same kind of craft in the next. Everyone seems to think we're much more special than we are. There are many RNs, let alone NPs, that go into MD or dental or pharma or pod or other medical training every year. We're not a magic substrate uniquely capable of receiving training on balancing a joint or any other aspect of residency, or harder working, or smarter, or anything else just by virtue of going straight into med school from a bachelors.

 

[FutureSurgical]

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

So the argument is “MD students shadow on rotations, just like NP students for most, if not all of their hours of shadowing. Thus, NPs can go through an ortho residency just as well as an MD”?

I’m sorry but you're using a ****ty microscope to look at one tiny aspect of an MS4 vs. a (newly-graduated) NP in a sea of differences. I can guarantee you the education and experiences in an up-and-coming orthopedic surgery resident vastly differ from an NP.

NP students have almost zero standards with "clinical hours" that must be met to graduate. Let's take Johns Hopkins DNP program for example. Their clinically-based "education" is that they just shadow a specialty for a couple of days. That's it. Where do you learn continuity of care? How can you honestly learn how to care for patients within a specialty given such a shortened timeframe. I'm failing to understand the logic in equivalence right here already.

The solution isn't to find the least-trained individual and stick them in a program they specifically avoided when they got their NP degree. I don't remember if I made this point in this thread or one of the plethora of others here talking about midlevels - ask any PA or NP why they didn't want to do MD/DO. I would bet money at least 95% of them would bring up length of training, rigor, difficulty, etc. up as a deterrent for physician training.

Lastly, the whole "well, MD's don't know EVERYTHING/make mistakes/can't do X; thus, NP's should be able to do the same programs/work as MD's/DO's do!" argument is fallacious. If a majority of NP's can't even pass a watered-down Step III, what makes them qualified to go through a residency? Where's the logic in allocating money towards midlevels with crappy, non-existent standards in education (clinically and in basic science (even at the best institutions like Vandy or Duke,)) when there are thousands of unmatched physicians who'd gladly become orthopedic surgeons? You argue "medical students do almost all shadowing in a clinical rotation. Thus, because NP students shadow, they should be allowed to do residency as well" really misses the mark. I agree things need to change with rotations like that for medical students. Even with high standards already in place, there needs to be improvement. But... allow midlevels to take GME funding? To replace physicians like that? Argue for better medical student clinical education, not "well NP's 'shadow,' which is what medical students do too." Your mindset allows:

• NP's to do colonoscopies on POC and lower SES patients at Johns Hopkins.
• Midlevels to replace physicians in multiple specialties because "they're cheaper."
• Primary care physicians to be pushed into mostly (purely) supervisor roles for mid levels to see patients.
• Primary care physicians to be given zero allowance to do certain procedures specialists don't want them doing, despite allowing their midlevels to do them (colonoscopies is an example; GI docs took it away from PCP's only to start letting midlevels to do them. How does this make sense?)
• Midlevels to dismiss a radiologist's reading to implement their own treatment plan, unrelated to anything in the said report.

Overall, it's a slippery slope my friend. It happened/is happening in EM, where midlevels were allowed to take on EM physician roles because "well, EM attendings were training them here and there. Resident physicians are trained by EM attendings, so they're the same thing, right?" Now we have too many EM physicians due to, in part, midlevel encroachment.

 

[Lawpy]

So the argument is “MD students shadow on rotations, just like NP students for most, if not all of their hours of shadowing. Thus, NPs can go through an ortho residency just as well as an MD”?

I’m sorry but you're using a ****ty microscope to look at one tiny aspect of an MS4 vs. a (newly-graduated) NP in a sea of differences. I can guarantee you the education and experiences in an up-and-coming orthopedic surgery resident vastly differ from an NP.

NP students have almost zero standards with "clinical hours" that must be met to graduate. Let's take Johns Hopkins DNP program for example. Their clinically-based "education" is that they just shadow a specialty for a couple of days. That's it. Where do you learn continuity of care? How can you honestly learn how to care for patients within a specialty given such a shortened timeframe. I'm failing to understand the logic in equivalence right here already.

The solution isn't to find the least-trained individual and stick them in a program they specifically avoided when they got their NP degree. I don't remember if I made this point in this thread or one of the plethora of others here talking about midlevels - ask any PA or NP why they didn't want to do MD/DO. I would bet money at least 95% of them would bring up length of training, rigor, difficulty, etc. up as a deterrent for physician training.

Lastly, the whole "well, MD's don't know EVERYTHING/make mistakes/can't do X; thus, NP's should be able to do the same programs/work as MD's/DO's do!" argument is fallacious. If a majority of NP's can't even pass a watered-down Step III, what makes them qualified to go through a residency? Where's the logic in allocating money towards midlevels with crappy, non-existent standards in education (clinically and in basic science (even at the best institutions like Vandy or Duke,)) when there are thousands of unmatched physicians who'd gladly become orthopedic surgeons? You argue "medical students do almost all shadowing in a clinical rotation. Thus, because NP students shadow, they should be allowed to do residency as well" really misses the mark. I agree things need to change with rotations like that for medical students. Even with high standards already in place, there needs to be improvement. But... allow midlevels to take GME funding? To replace physicians like that? Argue for better medical student clinical education, not "well NP's 'shadow,' which is what medical students do too." Your mindset allows:

• NP's to do colonoscopies on POC and lower SES patients at Johns Hopkins.
• Midlevels to replace physicians in multiple specialties because "they're cheaper."
• Primary care physicians to be pushed into mostly (purely) supervisor roles for mid levels to see patients.
• Primary care physicians to be given zero allowance to do certain procedures specialists don't want them doing, despite allowing their midlevels to do them (colonoscopies is an example; GI docs took it away from PCP's only to start letting midlevels to do them. How does this make sense?)
• Midlevels to dismiss a radiologist's reading to implement their own treatment plan, unrelated to anything in the said report.

Overall, it's a slippery slope my friend. It happened/is happening in EM, where midlevels were allowed to take on EM physician roles because "well, EM attendings were training them here and there. Resident physicians are trained by EM attendings, so they're the same thing, right?" Now we have too many EM physicians due to, in part, midlevel encroachment.

Why are you comparing with a newly graduated NP? The NPs discussed here are ortho NPs with some good experience in their jobs

 

[efle]

So the argument is “MD students shadow on rotations, just like NP students for most, if not all of their hours of shadowing. Thus, NPs can go through an ortho residency just as well as an MD”?

I’m sorry but you're using a ****ty microscope to look at one tiny aspect of an MS4 vs. a (newly-graduated) NP in a sea of differences. I can guarantee you the education and experiences in an up-and-coming orthopedic surgery resident vastly differ from an NP.

NP students have almost zero standards with "clinical hours" that must be met to graduate. Let's take Johns Hopkins DNP program for example. Their clinically-based "education" is that they just shadow a specialty for a couple of days. That's it. Where do you learn continuity of care? How can you honestly learn how to care for patients within a specialty given such a shortened timeframe. I'm failing to understand the logic in equivalence right here already.

The solution isn't to find the least-trained individual and stick them in a program they specifically avoided when they got their NP degree. I don't remember if I made this point in this thread or one of the plethora of others here talking about midlevels - ask any PA or NP why they didn't want to do MD/DO. I would bet money at least 95% of them would bring up length of training, rigor, difficulty, etc. up as a deterrent for physician training.

Lastly, the whole "well, MD's don't know EVERYTHING/make mistakes/can't do X; thus, NP's should be able to do the same programs/work as MD's/DO's do!" argument is fallacious. If a majority of NP's can't even pass a watered-down Step III, what makes them qualified to go through a residency? Where's the logic in allocating money towards midlevels with crappy, non-existent standards in education (clinically and in basic science (even at the best institutions like Vandy or Duke,)) when there are thousands of unmatched physicians who'd gladly become orthopedic surgeons? You argue "medical students do almost all shadowing in a clinical rotation. Thus, because NP students shadow, they should be allowed to do residency as well" really misses the mark. I agree things need to change with rotations like that for medical students. Even with high standards already in place, there needs to be improvement. But... allow midlevels to take GME funding? To replace physicians like that? Argue for better medical student clinical education, not "well NP's 'shadow,' which is what medical students do too." Your mindset allows:

• NP's to do colonoscopies on POC and lower SES patients at Johns Hopkins.
• Midlevels to replace physicians in multiple specialties because "they're cheaper."
• Primary care physicians to be pushed into mostly (purely) supervisor roles for mid levels to see patients.
• Primary care physicians to be given zero allowance to do certain procedures specialists don't want them doing, despite allowing their midlevels to do them (colonoscopies is an example; GI docs took it away from PCP's only to start letting midlevels to do them. How does this make sense?)
• Midlevels to dismiss a radiologist's reading to implement their own treatment plan, unrelated to anything in the said report.

Overall, it's a slippery slope my friend. It happened/is happening in EM, where midlevels were allowed to take on EM physician roles because "well, EM attendings were training them here and there. Resident physicians are trained by EM attendings, so they're the same thing, right?" Now we have too many EM physicians due to, in part, midlevel encroachment.

Honest question, do you actually think the local dinosaur community joints guys would pass modern medschool boards if they sat for them tomorrow, either? At some point we have to admit the content of an MD and the content of some subspecialist jobs is nearing zero overlap. It's residency training that taught them what they use in their daily work. There must be a better argument than that NPs are categorically too lazy or stupid to handle that training.

 

[Lawpy]

Also there are MANY RNs and NPs who flat out destroy the MCAT with 520+ scores who land up at top tier med schools

 

[Captain_Falcon]

Also there are MANY RNs and NPs who flat out destroy the MCAT with 520+ scores who land up at top tier med schools

I've never met an NP that has gone to med school. A few students in my class of nearly 200 students were RNs before, but that's it. I highly doubt that "many" RNs / NPs "destroy the MCAT" with a 520 score because <1% of test takers that take it score that. Gross exaggeration of something that I am sure has happened, but is nowhere near the norm.

 

[Ho0v-man]

I've never met an NP that has gone to med school. A few students in my class of nearly 200 students were RNs before, but that's it. I highly doubt that "many" RNs / NPs "destroy the MCAT" with a 520 score because <1% of test takers that take it score that. Gross exaggeration of something that I am sure has happened, but is nowhere near the norm.

Too lazy to look up the stats. But iirc, people from a healthcare background typically perform worse than most on the mcat. I remember this bc I was one of them lol

 

[voxveritatisetlucis]

MCAT literally has nothing to do with actual healthcare. It’s all just basic sciences.

 

[Aheadbyacentury]

MCAT literally has nothing to do with actual healthcare. It

xcept it forms the basis for everything we do

 

[FutureSurgical]

Honest question, do you actually think the local dinosaur community joints guys would pass modern medschool boards if they sat for them tomorrow, either? At some point we have to admit the content of an MD and the content of some subspecialist jobs is nearing zero overlap. It's residency training that taught them what they use in their daily work. There must be a better argument than that NPs are categorically too lazy or stupid to handle that training.

Do you think seasoned NPs would pass medical school boards? They already studied this and the answer is a resounding “no.”

My point is: if you want to be a physician, in any specialty you want to pick, go to medical school. That’s it. We can certainly discuss how that should/can change. Years of school, clinical rotations, testing, etc.

I’m not sure where you got the idea that I think mid levels are dumber. I never claimed that. But if I needed to be represented in a court of law, I’m taking a new lawyer over a paralegal in his or her career for decades to represent me. I don’t care how much they’ve worked with lawyers and read books. I want the person who went to school and had specific training to be a lawyer. Same thing with NPs. They provide a fantastic service when they’re in their specific role they’re trained in. But arguing they should be put in residencies and get similar outcomes (when the evidence shows that’s the opposite) is completely off. To be honest, I’d much rather put a pre med with a biology degree into residency before an NP. That’s just me.

I’ll repeat my main argument: you’re trying to move the needle in the wrong direction. Make education for med students better. Allow unmatched physicians to work for a year while they reapply for residency. Hell, open more residency spots. The solution is not looking for the cheapest labor with substandard education.

 

[efle]

Do you think seasoned NPs would pass medical school boards? They already studied this and the answer is a resounding “no.”

My point is: if you want to be a physician, in any specialty you want to pick, go to medical school. That’s it. We can certainly discuss how that should/can change. Years of school, clinical rotations, testing, etc.

I’m not sure where you got the idea that I think mid levels are dumber. I never claimed that. But if I needed to be represented in a court of law, I’m taking a new lawyer over a paralegal in his or her career for decades to represent me. I don’t care how much they’ve worked with lawyers and read books. I want the person who went to school and had specific training to be a lawyer. Same thing with NPs. They provide a fantastic service when they’re in their specific role they’re trained in. But arguing they should be put in residencies and get similar outcomes (when the evidence shows that’s the opposite) is completely off. To be honest, I’d much rather put a pre med with a biology degree into residency before an NP. That’s just me.

I’ll repeat my main argument: you’re trying to move the needle in the wrong direction. Make education for med students better. Allow unmatched physicians to work for a year while they reapply for residency. Hell, open more residency spots. The solution is not looking for the cheapest labor with substandard education.

My point is that the person doing a procedure doesnt need to be boarded if they arent doing any significant preop or postop medical care.

It was others who suggested NPs are incapable of pursuing procedural training due to work ethic/ability to learn the content

How do you feel about the existing proceduralists who dont get a general med ed? Shouldnt you object to oral surgery or ankle work from someone who never spent months in OBGYN, peds, etc? It seems to me if most or all of medschool is irrelevant like this, the answer is to shore up residency with whatever background from MD is actually useful to that field and go straight to that.

 

[efle]

I have an MD from a good med school. I'm working as a medicine intern in a good private hospital. I'm aware that OMFS is dual pathway and that DPMs and DDS are doctorates with schooling (though not generalist like MD schooling). I'm just pointing out the argument that you need GENERAL med ed full of irrelevant rotations is already disproved by these more subject-oriented training paths. It makes no sense to me why a knee replacement requires you take broad scope USMLEs and rotate for many months in stuff like OBGYN when an ankle or jaw doesnt.

Can you clarify why its OK for their training to differ from MD curriculum but would be absurd for a screening colonoscopy or elective joints gig? We can strike the NP thing if that's triggering you, and just say "students" could enter a specific path of brief, more subject oriented studies followed directly by subject specific clinical training to learn the job itself ("residency").

 

[PikminOC]

What better alternative is there? Do you want to increase the number of physicians?
Pretty much the only leverage physicians have in this market is we are scarce and employers have to pay us well to have the expert in their hospital.
I think it's a better fight to ask for better collaborative agreements so both physicians and mid-levels are happy than flooding the market with physicians and making the job market go to crap.
I used to be against mid-levels like many in this forum but if you think about in the 10 last years even with the increase in mid-levels, physician salaries have been going up or at least remained constant. Most people will agree that they will go down if the shortage was addressed with more supply of the physicians than mid-levels.
Law job market is a nice example of what happens when you have more supply than demand.

Better collaboration? They are working with no collaboration in many states...

 

[PikminOC]

My husband is an infectious disease specialist. He says that 99% of NP consults are inappropriate.

But hospital loves this as it's more revenue..

 

[PikminOC]

Wow this crap has been going on way back in 2014

Even before that..

 

[PikminOC]

I know you are a nurse practitioner student. Why do you even come on here? Just write a letter to Obama and Biden and he will grant you independent practice rights. You will be allowed to do anything your little heart desires from clipping toe nails----> intracranial aneyrysm resection because after all you want to practice at the top of your license.

And to correct you, many of the Oral Surgeons have dual MD/DDS degrees. And even if they dont they spend considerable time in a surgical residency after Dental School which pretty much has the same requirements for entrance as medical school.

As for the Podiatrists, their schooling is four years like medical school, and they spent 3-4 post-graduate years in residency.

GO back to simpin' at allnurses.

Head of all nurses did murder suicide of family

 

[YCAGA]

The logic being used in this thread is so sad when you put it simply:

"The medical school curriculum is not perfect, therefore MD = NP."

 

[GoSpursGo]

In the interest of transparency, we've banned "Aheadbyacentury" and removed many of their recent posts for repeatedly being rude towards other members despite warnings.

These discussions frequently become heated, but please treat each other with respect.

 

[YCAGA]

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.

If it is not jealousy, then what is causing the delusion in this thread? A lack of knowledge of orthopedic surgery as a field? Pathologic cynicism? I just don't understand.

Also, let's be real for a second, the claim that "if NP's did an ortho residency they would be the same product as an MD/DO who did an ortho residency" is based on the premise that NP's could handle an ortho residency and pass ortho boards. Quite the claim to make.

I am pretty sure the ortho boards pass rate is like 90% in a field where half of residents were AOA and the average step 1 score is almost 250. The high scores come from competitiveness, but they show that even a cohort of top medical students (where the average medical student is already far ahead of the average NP) do not just waltz through ortho residency. And this can be extrapolated to all of medicine where much higher performing students than an above average NP do not pass their speciality boards on the first attempt, or ever.

 

[efle]

If it is not jealousy, then what is causing the delusion in this thread? A lack of knowledge of orthopedic surgery as a field? Pathologic cynicism? I just don't understand.

Also, let's be real for a second, the claim that "if NP's did an ortho residency they would be the same product as an MD/DO who did an ortho residency" is based on the premise that NP's could handle an ortho residency and pass ortho boards. Quite the claim to make.

I am pretty sure the ortho boards pass rate is like 90% in a field where half of residents were AOA and the average step 1 score is almost 250. The high scores come from competitiveness, but they show that even a cohort of top medical students (where the average medical student is already far ahead of the average NP) do not just waltz through ortho residency. And this can be extrapolated to all of medicine where much higher performing students than an above average NP do not pass their speciality boards on the first attempt, or ever.

How would you feel if I implied most DO or DDS or Pod students are probably too stupid to handle ortho training and licensure? Come on now podiatry school doesnt exactly require straight As and high test scores to enter but we dont pretend they're not capable of learning to operate on a joint

 

[AnonymousDoctorGuyPerson]

I've never met an NP that has gone to med school. A few students in my class of nearly 200 students were RNs before, but that's it. I highly doubt that "many" RNs / NPs "destroy the MCAT" with a 520 score because <1% of test takers that take it score that. Gross exaggeration of something that I am sure has happened, but is nowhere near the norm.

Just to put in a n=1

There's a NP in my program, who after speaking with me about MCAT tutoring has implied they have an MCAT score around mine. So they do exist, but in the same note ofc you're not gonna find many NPs in med school, there's a reason why nontraditional are called nontraditional. Most people who are med students didn't have a career before med school, and most who did didn't have well-paying careers that required lots of prior schooling (such as NP) so I doubt there's any significant data on this matter and like my own is purely anecdotal.

 

[Captain_Falcon]

Just to put in a n=1

There's a NP in my program, who after speaking with me about MCAT tutoring has implied they have an MCAT score around mine. So they do exist, but in the same note ofc you're not gonna find many NPs in med school, there's a reason why nontraditional are called nontraditional. Most people who are med students didn't have a career before med school, and most who did didn't have well-paying careers that required lots of prior schooling (such as NP) so I doubt there's any significant data on this matter and like my own is purely anecdotal.

Which is why saying many RNs/NPs have "totally destroyed the mcat with 520+!!!" is weird because it's not true. Yes there may be a few in the country that do this yearly but it is a far minority

 

[Lawpy]

I've never met an NP that has gone to med school. A few students in my class of nearly 200 students were RNs before, but that's it. I highly doubt that "many" RNs / NPs "destroy the MCAT" with a 520 score because <1% of test takers that take it score that. Gross exaggeration of something that I am sure has happened, but is nowhere near the norm.

Must be selection bias since i'm seeing a lot of former RNs and NPs really excelling. My point with the MCAT example is to refute the notion they're ignorant which i'm repeatedly seeing in this thread and other midlevel discussions

Too lazy to look up the stats. But iirc, people from a healthcare background typically perform worse than most on the mcat. I remember this bc I was one of them lol

I've seen this true for bio majors

MCAT literally has nothing to do with actual healthcare. It’s all just basic sciences.

MCAT is based very heavily on critical thinking/test taking skills which are crucially important for boards/shelfs

 

[NicMouse64]

Must be selection bias since i'm seeing a lot of former RNs and NPs really excelling. My point with the MCAT example is to refute the notion they're ignorant which i'm repeatedly seeing in this thread and other midlevel discussions


I've seen this true for bio majors


MCAT is based very heavily on critical thinking/test taking skills which are crucially important for boards/shelfs

MCAT and boards/shelfs two very different beasts. I would argue those who do well on the MCAT are likely better clinically with some degree of competency on boards/shelfs. The problem is boards/shelfs are mainly memorization and MCAT is mainly critical thinking. A good doctor will have both, not just one or the other. I'm one of those high MCAT, average board/shelf people who have been told I excel in clinical thinking. That's my N=1 at least.......

 

[Lawpy]

MCAT and boards/shelfs two very different beasts. I would argue those who do well on the MCAT are likely better clinically with some degree of competency on boards/shelfs. The problem is boards/shelfs are mainly memorization and MCAT is mainly critical thinking. A good doctor will have both, not just one or the other. I'm one of those high MCAT, average board/shelf people who have been told I excel in clinical thinking. That's my N=1 at least.......

Hmm i'm not sure about that. Memorization is def important but the questions can get convoluted and difficult enough that test taking skills become necessary to do well. There's also a lot of people who relied heavily/exclusively on memorozation and ended up with barely passing or worse... failing.

 

[Captain_Falcon]

Must be selection bias since i'm seeing a lot of former RNs and NPs really excelling. My point with the MCAT example is to refute the notion they're ignorant which i'm repeatedly seeing in this thread and other midlevel discussions

Self-selection bias. If 100 former RNs/NPs take the MCAT, <2% will score 520+. The majority of them, statistically, will be far under the average MCT for admissions (which is ~512). 50% will be <500. I would say the majority of people cannot make it through the MCAT + Med School + Residency. That includes people from all walks of life, and some of those people would revert to other healthcare fields that are easier (insert MA, X-ray techs, RNs, NPs, and PAs). Just because some of those people could make it through, doesn't mean "So many of them absolutely double murder the MCAT and are some of duh best students at top schools!"

 

[efle]

Self-selection bias. If 100 former RNs/NPs take the MCAT, <2% will score 520+. The majority of them, statistically, will be far under the average MCT for admissions (which is ~512). 50% will be <500. I would say the majority of people cannot make it through the MCAT + Med School + Residency. That includes people from all walks of life, and some of those people would revert to other healthcare fields that are easier (insert MA, X-ray techs, RNs, NPs, and PAs). Just because some of those people could make it through, doesn't mean "So many of them absolutely double murder the MCAT and are some of duh best students at top schools!"

Yet the AAMC itself suggests a 500 is good to go for handling medschool and residency dropouts and board failures are a small minority pretty much across the board. Not to mention many currently practicing older docs went to school in a time when admissions standards and required board performance were far, far far less than now. But nobody seems terrified of letting an old vascular surgeon do their stent placement

 

[YCAGA]

How would you feel if I implied most DO or DDS or Pod students are probably too stupid to handle ortho training and licensure? Come on now podiatry school doesnt exactly require straight As and high test scores to enter but we dont pretend they're not capable of learning to operate on a joint

Breaking this down by profession:

DO students can handle ortho residency because they literally do it every year. Also most DO students these days have an MCAT above a 500 which is the line where the MCAT starts to correlate with failing out of medical school.

DDS students are in a different field of healthcare, so it seems weird to bring them into this. They also have a 4 year doctorate which is actually very similar to what you are advocating for orthopedics, unlike NP's. They train for 4 years in basically one part of the body, but even then, DDS who want to do extra stuff other than "basic" dentistry have to do residency. This is on top of dental school where they already do a ton of technical and practical training, again, unlike NP's. So a less crazy proposition would to have a 4 year doctorate in MSK primary care (like dentists have for teeth) and then a 5 year residency in orthopedic surgery. But RN to NP to ortho surgery residency is just...

Many people would argue that podiatrists should not be doing surgery and their expertise should be limited to outpatient and office procedures (wound care, toenails, orthotics, etc). The average matriculant MCAT for the past 5 years for podiatry school has been 492-495. The average science GPA was 3.1-3.2. Not even comparable to DO (3.4 science GPA and 503 MCAT) or DDS students. Add to that that they basically self regulate their licensing and accreditation like NP's and there is simply no way their doctorate is of the same consistency and quality as an LCME accredited MD degree. And we all know that going to an LCME medical school doesn't guarantee that it is not a lemon, so imagine how bad it is without LCME.

DO's aren't DDS's who aren't DPM's who aren't NP's who aren't MD's. They have different training and scope for a reason.

I am going to tap out of this thread since we have gotten to the point where someone is unironically arguing that dentists could excel in ortho residency.

 

[Lem0nz]

I'm simultaneously surprised this thread hasn't died and not surprised this thread hasn't died.

I have some unsolicited thoughts I'll throw down as someone ~6 weeks into practice now who hired a nurse in NP school that has six months left before she graduates. Her background is RNFA for ~15 years prior, 10 of that with general surgery/trauma/HPB and 5 with breast.

As Efle has said, the technical skills can 1000% be taught to anyone. To be fair, this girl is a gem - I would put her at like 97%ile at least of NPs I've ever worked with in ability to learn, retain, etc. But just knowing what I know now in this limited time I could teach an average NP to do what she is doing, it would just take years instead of a couple weeks. We did a whipple together - her first - and her prior experience in surgery in general allowed her to see tissue planes without me having to point them out. She didn't know what the tissue planes were called, didn't know what was necessarily behind them, didn't know what the next steps were or why we go fast in some spots and slow in others, but the ability to recognize that and present the tissue for dissection and be able to bovie/ligasure confidently which personally took me until like PGY-4ish to get to where she's at around major scary structures... pretty neat. And reinforces that the technical skills are very, very reproducible. Surgeons before were not specifically teaching her this - she picked it up on her own over a decade of experience. I know this because I talked to her previous surgeons before hiring her.

That said, the ability to problem solve complex clinical issues in and out of the operating room is not there... yet. She's completely reliant on me at present. I do see her potential to take care of almost all perioperative issues including work-up and management (on this front I do think it will take a couple years at least to get her there) but it would be based on everything I taught her and I think she would struggle if a scenario arose where she hadn't seen it before. The unquantifiable difference, but the most important difference between us, is that I can use all of the surgical principles in the operating room that she more or less also has and on the fly in seconds 'make up' surgery to solve a problem and do something I've never read about, never done, but just makes sense as the only logical step. Extrapolating that to perioperative care is even more challenging. There are TONS of pathologies I've maybe read about once and never seen, and even some I've never even read about, that I'm asked to give an opinion on like... once a week so far. With time and experience this will lesson but even without that experience I'm capable of rendering a sound clinical judgement in extremely short order to at minimum triage, if not out right solve, pretty much any issue.

The other piece is the confidence and responsibility. It just isn't there. There is a fundamental difference in our training models that is directly derived by the rigor of the training. If forced into a corner, sure - she would probably render an opinion rather than sit down and start to cry. But it would be riddled with doubt and she would perseverate over the outcome both in the moment and after, and it would make her more error prone if forced to do so. I know this because I've asked her to do stuff like that and that's exactly what happened. In a similar situation I've been specifically trained to make a decision, enact that decision, accept the consequences and move on because I am such a finite resource as 'the guy' making the decisions that there is no other option. This comes with an entire host of weirdness that we could talk about for days (wellness, burnout, depression, money/compensation, job satisfaction) that is very very different between me and her but the reason all of those things are different for us is the way we think. The way we solve problems and respond to them developed very, very differently and that critical thinking and reasoning did in fact start in medical school. Maybe even in undergrad, but was built upon in many iterative phases over the last ~15 years I've been in school if you count GME.

At the end of the day our work ethic is incredibly similar - we both go home perseverating over our new service line. She's constantly checking epic from him and her emails, as am I. I'm never not on call at this job at present. And we both like it like this - the ownership, the responsibility, and the privilege of taking care of really sick humans. The last difference I want to point out though is that I had at least seven years of very intense mentorship by a very small finite amount of people who have ingrained a lot of lessons about thinking about a lot of other things than what we need to do on Monday morning when we get back to work. Right now she is planning in her head all of the stuff we need to cram into our calendar where as I sent her a text reminding her that we need to be doing this for the next ten years (at least) and she needs to spend today hanging out with her daughters not thinking about work. We think very differently. And it is absolutely the way we were trained and our jobs over the last ~15-20 years. Her job is to make sure I don't struggle and that our patients get taken care of. My job is that + make sure that WE'RE both taken care of.

TLDR~ NPs are fantastic when used correctly and can be trained to do anything. I'm sure this girl could do a whipple by herself in about 2-3 years from now. But she still shouldn't because when something goes wrong her ability to rescue is nothing comparable to mine and it is not because she can't sew vascular if there's bleeding or dissect bad pancreatitis - that can still be taught too. Its because she has twenty years of algorithmic thinking which is incredibly useful and complimentary to my fifteen years of abstract critical thinking and problem solving. I do not think that this phenomenon should be limited to complex procedures or rare pathologies - for most of surgery I think this holds true. As Elfie, I, and others have pointed out more than once though there is a lot of 'bread and better' medicine (and smaller procedures, including some surgical) that have extremely little variance and could be safely boiled down into an algorithm. It is probably inevitable that these things will be identified and risk stratified into allowing non-physicians to deal with them with physician oversight to safely deal with small variances that arise. From a system and resource level this probably makes the most sense. I know and understand why physicians wouldn't want to do this - it makes our job dealing with only the complicated hard **** which burns a lot of people out and changes our job into a management type position for a lot of us but I think that's probably the reality of medicine in 2021 already. If it isn't, it seems extremely likely it will be for all of us in the next 10, 20, or 30 years.

Somewhat unrelated, this last month has been a huge eye opener. I really wish more medical students and residents had exposure to seasoned NPs working under physicians who are NOT independently practicing to see what their value and utility is in community health systems. I'm interested to see what's going to happen when we get residents next year because all I've really gotten to see is the SDN/Reddit echo chamber which is super negative at baseline.

 

[Lem0nz]

Also its ****ing annoying but I think all of the old fogies, including here on SDN, who told me "there's a reason training should be so long and is so difficult and you shouldn't be able to do X without X amount of life experience" may have been right. I have zero data for this, only feels. But as I have stepped into a role of being on call 24/7 indefinitely unless I specifically take vacation, knowing my physical and mental limits that I learned in general surgery residency doing those asinine 28-30 hour shifts became suddenly extremely EXTREMELY relevant. I'm quickly souring on the opinion that medical education should be shortened or made easier in really any significant fashion. I do think it should be paid for up front though and not have a loan component similar to Germany or Australia and such.

 

[efle]

Breaking this down by profession:

DO students can handle ortho residency because they literally do it every year. Also most DO students these days have an MCAT above a 500 which is the line where the MCAT starts to correlate with failing out of medical school.

DDS students are in a different field of healthcare, so it seems weird to bring them into this. They also have a 4 year doctorate which is actually very similar to what you are advocating for orthopedics, unlike NP's. They train for 4 years in basically one part of the body, but even then, DDS who want to do extra stuff other than "basic" dentistry have to do residency. This is on top of dental school where they already do a ton of technical and practical training, again, unlike NP's. So a less crazy proposition would to have a 4 year doctorate in MSK primary care (like dentists have for teeth) and then a 5 year residency in orthopedic surgery. But RN to NP to ortho surgery residency is just...

Many people would argue that podiatrists should not be doing surgery and their expertise should be limited to outpatient and office procedures (wound care, toenails, orthotics, etc). The average matriculant MCAT for the past 5 years for podiatry school has been 492-495. The average science GPA was 3.1-3.2. Not even comparable to DO (3.4 science GPA and 503 MCAT) or DDS students. Add to that that they basically self regulate their licensing and accreditation like NP's and there is simply no way their doctorate is of the same consistency and quality as an LCME accredited MD degree. And we all know that going to an LCME medical school doesn't guarantee that it is not a lemon, so imagine how bad it is without LCME.

DO's aren't DDS's who aren't DPM's who aren't NP's who aren't MD's. They have different training and scope for a reason.

I am going to tap out of this thread since we have gotten to the point where someone is unironically arguing that dentists could excel in ortho residency.

Yea if you're ready to argue foot and ankle surgeons shouldnt be allowed to do foot and ankle surgery I guess I'm ready to tap out too

Also you must realize you only view dental as a separate entity because it already is. If OMFS was currently only accessible under the MD umbrella, no doubt you'd be insisting dentists have no business coming anywhere near OMFS postgrad training either.

 

[efle]

Also its ****ing annoying but I think all of the old fogies, including here on SDN, who told me "there's a reason training should be so long and is so difficult and you shouldn't be able to do X without X amount of life experience" may have been right. I have zero data for this, only feels. But as I have stepped into a role of being on call 24/7 indefinitely unless I specifically take vacation, knowing my physical and mental limits that I learned in general surgery residency doing those asinine 28-30 hour shifts became suddenly extremely EXTREMELY relevant. I'm quickly souring on the opinion that medical education should be shortened or made easier in really any significant fashion. I do think it should be paid for up front though and not have a loan component similar to Germany or Australia and such.

Does this mean you consider surgeons in countries with faster and less brutal training pathways to be worse at the job from it? E.g. european countries where medical training starts as a teenager and residency is never anything close to 80-100hr weeks with 30hr calls

 

[Lem0nz]

Does this mean you consider surgeons in countries with faster and less brutal training pathways to be worse at the job from it? E.g. european countries where medical training starts as a teenager and residency is never anything close to 80-100hr weeks with 30hr calls

If we were to transplant them to practice surgery in America, yes. 100%. Now that I get to use those fancy retrospection goggles we do a very, very good job at training our surgeons to our weird geographic needs, requirements for independence, and smattering of completely incoherent and variable rules/laws that faces a doctor in America. We may not always be technically better surgeons (we're equivalent which speaks to your argument that the technical skills are not the hardest part) but we are probably far more adaptable because our system requires it. On the same token, there's a good chance I would not do well in those systems with faster and less brutal training with their 40 hour work weeks. My expectations and resources that I use and require to do my job the way I've been taught to do it well would probably leave me frustrated and make me quit, the same way I imagine many of them would if they were subjected to our weird lifestyle.

For the record though most other countries are not shorter training pathways for surgery. They often have extra registrar years or weird years built in where they're sort of surgeons but not really that they have to do for multiple years before progressing to the next step and it comes out quite similar across the board. Definitely for UK, most of Europe, and Australia. Very similar for Latin America as well. I don't know how Asia, Africa, or the Middle East does it but I have heard Asia has an extremely hierarchal structure where it might matter less because you're assisting for decades as a juniorish surgeon to the senior guy until he dies at which point you take over.

Comparing healthcare systems is incredibly useful but it has major limitations. Socialized healthcare and 'humane' socialized training models are adapted to a different type of people than Americans are.

 

[VA Hopeful Dr]

Does this mean you consider surgeons in countries with faster and less brutal training pathways to be worse at the job from it? E.g. european countries where medical training starts as a teenager and residency is never anything close to 80-100hr weeks with 30hr calls

In many countries you work fewer hours but the training is longer. Anesthesia in Germany, for example, is a 5 year program. So is internal medicine. In fact it looks like the shortest clinical residency there is 5 years.

 

[Lem0nz]

Also I have no freaking idea if its relevant to this thread but I feel like it is: I now equate midlevel students who say "I can't wait to practice independently" with US MS1s in the bottom quartile of their class who are saying "ortho only bro". I really really wish our collective exposure to actual midlevels outside of these academic echo chambers was better. I feel it would dramatically alter the conversation here.

 

[efle]

Also I have no freaking idea if its relevant to this thread but I feel like it is: I now equate midlevel students who say "I can't wait to practice independently" with US MS1s in the bottom quartile of their class who are saying "ortho only bro". I really really wish our collective exposure to actual midlevels outside of these academic echo chambers was better. I feel it would dramatically alter the conversation here.

Yeah the independently practicing NP PCP clinics I find pretty disturbing. Way more inappropriate than, say, an NP learning to do screening colonoscopies or review camera capsule images as part of a GI practice/hospital where MDs are readily available for making a plan about the findings. But like you mention I've found reddit and SDN to be rabid echo chambers against any and all APP role overlap with what was traditionally docs. If you suggest there's a more efficient version of the system where rote procedural work is offloaded to specifically trained midlevels, you're either an idiot or a traitor.

 

[Lawpy]

Yeah the independently practicing NP PCP clinics I find pretty disturbing. Way more inappropriate than, say, an NP learning to do screening colonoscopies or review camera capsule images as part of a GI practice/hospital where MDs are readily available for making a plan about the findings. But like you mention I've found reddit and SDN to be rabid echo chambers against any and all APP role overlap with what was traditionally docs. If you suggest there's a more efficient version of the system where rote procedural work is offloaded to specifically trained midlevels, you're either an idiot or a traitor.

Wait wait i thought SDN was supportive of delegating specific tasks to midlevels and support midlevel supervision?? I'm lost here

 

[efle]

Wait wait i thought SDN was supportive of delegating specific tasks to midlevels and support midlevel supervision?? I'm lost here

SDN and reddit like the idea of extenders that make you more money and reduce hassle by dealing with charting and providing most of the interface with patients. Sort of like how some private hospitals have a fleet of PGY1 prelims that run most of the grunt work while a few attendings supervise. Suggesting a cash cow like screening colonoscopies could be learned by midlevels is anathema though, for rea$on$.

 

[Lem0nz]

SDN and reddit like the idea of extenders that make you more money and reduce hassle by dealing with charting and providing most of the interface with patients. Sort of like how some private hospitals have a fleet of PGY1 prelims that run most of the grunt work while a few attendings supervise. Suggesting a cash cow like screening colonoscopies could be learned by midlevels is anathema though, for rea$on$.

I think Efle's example is too extreme. Its more of the mentality that a midlevel can't do anything except charting and putting in orders. That particular mentality is... well, wrong. And also extremely unconstructive. I've had lots of people tell me I'm a ****ty surgeon and should quit medicine because I think midlevels are able to round on post-operative patients in the morning or that they can see patients in post-op clinics, do pre-operative evaluations and referrals, assist in surgery, whatever. Pick your poison.

 

[deleted393595]

Fellow married to a nurse gave away my central line to a NP.

If you're wondering where the mid-level encroachment started, look no further than our own profession.

I've had lots of people tell me I'm a ****ty surgeon and should quit medicine because I think midlevels are able to round on post-operative patients in the morning or that they can see patients in post-op clinics, do pre-operative evaluations and referrals, assist in surgery, whatever.

Are you still seeing the patient after the mid-level has seen them? If no, then that's a clear violation of the standard of care. I wouldn't let you operate on me - let alone have anyone be sent to you.

 

[Lawpy]

Fellow married to a nurse gave away my central line to a NP.

If you're wondering where the mid-level encroachment started, look no further than our own profession.

That's pretty clear. Self serving physicians are medicine's own worst enemy. The same goes for those old docs happily selling practices to private equity and aggressively supporting corporatization of medicine. Combine this with self-flagellation that's thoroughly indoctrinated in medical education and we get this mess

 

[Lem0nz]

Fellow married to a nurse gave away my central line to a NP.

If you're wondering where the mid-level encroachment started, look no further than our own profession.



Are you still seeing the patient after the mid-level has seen them? If no, then that's a clear violation of the standard of care. I wouldn't let you operate on me - let alone have anyone be sent to you.

Clearly you've already made up your mind about me before I can even answer your question so what does it matter? Thank you for illustrating my point though. Instead of letting outcomes be your metric you just want to trash another doc who's view isn't congruent with your own.

 

[deleted393595]

Clearly you've already made up your mind about me before I can even answer your question so what does it matter? Thank you for illustrating my point though. Instead of letting outcomes be your metric you just want to trash another doc.

I've already seen enough botched surgical NP rounding and management in my (absurdly) young career. We nearly lost a patient a few weeks ago because a NP didn't bother to read a critical CT result. And these were fairly seasoned NPs to begin with. There is no way I would ever let myself be subject to NP care given what I know about the system. To think that a GS attending - who arguably has vastly more experience and medicine knowledge - would think that a NP can provide an adequate level of care seems wild. There's a reason why many ortho groups for instance have kicked out their NPs and brought on IM physicians instead to take care of their patients (there's your metric).

Your utter callousness about patient care is a huge red flag. I have no idea how you made it so far through the medical system. But hopefully you someday develop a set of ethics and a conscience. Because I'd hate for the only way you can stop harming patients to be a license revocation through a serious lawsuit. Having a NP assist in the OR is one thing. Having an NP manage medical care is a completely different thing.

 

[Lem0nz]

I've already seen enough botched surgical NP rounding and management in my (absurdly) young career. We nearly lost a patient a few weeks ago because a NP didn't bother to read a critical CT result. And these were fairly seasoned NPs to begin with. There is no way I would ever let myself be subject to NP care given what I know about the system. To think that a GS attending - who arguably has vastly more experience and medicine knowledge - would think that a NP can provide an adequate level of care seems wild. There's a reason why many ortho groups for instance have kicked out their NPs and brought on IM physicians instead to take care of their patients (there's your metric).

Your utter callousness about patient care is a huge red flag. I have no idea how you made it so far through the medical system. But hopefully you someday develop a set of ethics and a conscience. Because I'd hate for the only way you can stop harming patients to be a license revocation through a serious lawsuit. Having a NP assist in the OR is one thing. Having an NP manage medical care is a completely different thing.

Cool story. Thank you for sharing your experience and continuing to make a lot of assumptions. You will go far.




/s

 

[xDNA]

Also there are MANY RNs and NPs who flat out destroy the MCAT with 520+ scores who land up at top tier med schools

I'm a RN, and I can say with full confidence I absolutely DID NOT crush the MCAT, and probably WONT be attending a top tier med school. In fact, the MCAT abused me for about 18months straight . ofc n=1.

But like someone else mentioned, I actually read or heard healthcare professionals generally score lower on mcat AND RNs (BSN) in particular have one of the lowest matriculation rates into medical school of all college majors

 

[Dave1980]

Your utter callousness about patient care is a huge red flag. I have no idea how you made it so far through the medical system. But hopefully you someday develop a set of ethics and a conscience. Because I'd hate for the only way you can stop harming patients to be a license revocation through a serious lawsuit. Having a NP assist in the OR is one thing. Having an NP manage medical care is a completely different thing.

SDN turns to the "I feel sorry for your patients" and "you shouldn't be doctor" so quick. It's usually pre-meds but today apparently it was a resident

 

[deleted393595]

Cool story. Thank you for sharing your experience and continuing to make a lot of assumptions. You will go far.




/s

That you can't give a straightforward response shows that you're an unserious individual. Pretty sure I'll go further than the dude who couldn't figure out tissue planes until PGY4 year. I figured it out as M4 on my sub-i's. Not that hard.

SDN turns to the "I feel sorry for your patients" and "you shouldn't be doctor" so quick. It's usually pre-meds but today apparently it was a resident

Hehehe

 

[ohmanwaddup]

"grabs 10th bucket of popcorn"......