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

[PikminOC]

Op, I didn't know about this mid-level threat in late 2005 or so when I graduated residency. This explosion of mid-levels is a real threat and is only increasing. I am not sure what you should do.
I think we will see more of this

M.D. is no prescription for job security at hospital chains

Physicians who become employees are just as susceptible as other workers when hospitals are under pressure to cut costs. Just ask staffers at Edward-Elmhurst.

www.chicagobusiness.com

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Members don't see this ad.

 

[Wobbler]

This is not what I wanted to hear, so the sky really is falling. Is it worth seriously considering a change before I have 400k in debt and no job opportunity to pay it off or one that doesn’t pay enough to actually overcome the debt?

 

[PikminOC]

The sky is falling but the new generations of physicians can fight back.
Start with making your way into the upper levels of the AMA so that it can start working for our actual profession instead of doing random BS.
Join and Donate to smaller activist groups like the Physicians for Patient Protection.
We need to claw back the ground that greedy boomer docs gave up to MBAs and the nursing lobby.
Refuse to train your replacements...teach residents only, not some airhead who couldn't even get into dental school let alone pass the MCAT.

Not that easy to do. With large debt doctors work at hospitals. And then they force you to supervise mid-level

Mid-level lobby is much stronger than ama. They have many more members and are not fractured
Even psychologist lobby is strong and they have prescription rights in a few states.
It all comes down to lobbying money

 

[Instatewaiter]

Right. This is the kind of stuff that’s out there.

https://jdc.jefferson.edu/cgi/viewcontent.cgi?article=1084&context=nursfp

Tl;dr is that the NP staffed MICU and the resident staffed MICU had equal outcomes. But the NPs had zero additional duties, had like a 5th of the patients, and had access to a critical care fellow and an ICU attending. So really it doesn’t tell us anything.

And then there’s this gem: Error - Cookies Turned Off

where again outcomes were equal. Except that after randomization, 47% of the patients randomized to the NPs were transferred to physicians.

There’s also this: Google Scholar

Where again outcomes are equal. In this one they flat out say that residents worked more hours, consulted less, and had sicker and more patients. So NPs and PAs had equal outcomes, but their patients were lower acuity and they had fewer of them and worked less.

no **** an NP is going to have similar outcomes as the resident. They are all overseen by fellows and attendings. There are guard rails preventing disaster. If you studied it, probably could set up the same outcome if you used nursing students... Not sure why this is getting anyone riled up tbh.

I could prove that blind amputees would have the same outcomes as a mechanic's apprentice if they were both overseen by a mechanic.

 

[biomom]

no **** an NP is going to have similar outcomes as the resident. They are all overseen by fellows and attendings. There are guard rails preventing disaster. If you studied it, probably could set up the same outcome if you used nursing students... Not sure why this is getting anyone riled up tbh.

I could prove that blind amputees would have the same outcomes as a mechanic's apprentice if they were both overseen by a mechanic.

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

 

[Instatewaiter]

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

Good story.... Either you quoted me accidentally or I think my point may have sailed over your head.

 

[biomom]

Good story.... I think my point may have sailed over your head.

Lol. I think I replied to the wrong person.

 

[Matthew9Thirtyfive]

no **** an NP is going to have similar outcomes as the resident. They are all overseen by fellows and attendings. There are guard rails preventing disaster. If you studied it, probably could set up the same outcome if you used nursing students... Not sure why this is getting anyone riled up tbh.

I could prove that blind amputees would have the same outcomes as a mechanic's apprentice if they were both overseen by a mechanic.

I think you might have missed my point. And let’s try to keep it professional, shall we?

 

[RangerBob]

Not that easy to do. With large debt doctors work at hospitals. And then they force you to supervise mid-level

Mid-level lobby is much stronger than ama. They have many more members and are not fractured
Even psychologist lobby is strong and they have prescription rights in a few states.
It all comes down to lobbying money

The AMA has one of the largest lobbying budgets of any organization in the US. Blue Cross/Blue Shield and the American Hospital Association spend more, but not that much more.

It makes one wonder what all that money the AMA is spending is actually doing. Because I agree our lobbying doesn't seem as effective as midlevels.

I agree part of the problem is physicians working for hospitals/others, and not having the autonomy we used to have in the past. Unfortunately these seems to be the trend, with fewer solo docs/physician-owned practices.

 

[zero0]

Not that easy to do. With large debt doctors work at hospitals. And then they force you to supervise mid-level

Mid-level lobby is much stronger than ama. They have many more members and are not fractured
Even psychologist lobby is strong and they have prescription rights in a few states.
It all comes down to lobbying money

This is exactly how the MBAs how found they can control us. "Put em 400k in debt and they won't dare say no." Which inevitably brings us back to big academia and the outrageous cost of education nowadays, along with unreasonably long training times for residents, etc. the list goes on and on. Tell me again how a midlevel can do a physician's job after 2 years of graduate school but 4 years for med school and 1 year of residency isn't enough for primary care? Then of course you have the old guard dinosaur boomer sellouts crying "I had to do it and they should too." It's mind boggling how many forces are working against us at this point in history. Our generation is just being royally ****ed from every angle.

 

[PikminOC]

The AMA has one of the largest lobbying budgets of any organization in the US. Blue Cross/Blue Shield and the American Hospital Association spend more, but not that much more.

It makes one wonder what all that money the AMA is spending is actually doing. Because I agree our lobbying doesn't seem as effective as midlevels.

I agree part of the problem is physicians working for hospitals/others, and not having the autonomy we used to have in the past. Unfortunately these seems to be the trend, with fewer solo docs/physician-owned practices.

AMA is busy kowtowing to sell out physicians. They lobby against us. No tort reform, help with insurance companies, etc. They talk about universal healthcare and turning us into employees.

 

[Sleepingdoc]

Sorry if i offend any NP's or family member of NP's.... but NP's are not the same as MD's or DO's.., period- the education, the intensity of residency, the board exams- and just the overall training... If you wanna act like a doctor, go to a medical school...

 

[Giovanotto]

Which strikes me as odd since a quick search reveals I've made almost that exact post 5 times in the last 2 years, but whatever works for you.

Are you suggesting that I follow you so I don't miss the < 25% of your posts that I agree with?

 

[frenchyn]

Idk how many times my NP friend told me oh wait until you become a resident, you will learn...n it can just be simple technical thing like some subspecialty surgery has Or nurse tend to do that specialty case...like I don’t even need a degree to even know that...lmao...

 

[VA Hopeful Dr]

Are you suggesting that I follow you so I don't miss the < 25% of your posts that I agree with?

Given how of the two most recent ones before this, one was a response to a post of yours and the other you liked...

 

[Flodaddy]

I have been making this exact argument for some time time now, but it seems our clinical colleagues have learned helplessness, because all I get are excuses as to why it can't be done, even in Retrospective studies.

There was a recent JAMA study aiming to show that surgical outcomes at top cancer centers are superior to outcomes at these cancer centers' affiliate sites. There have been a few articles on this topic in the past year. Academics love doing redundant studies that show they are better than other physicians. Plus, comparing independent NP outcomes to physicians is a gold mine of low-hanging fruit studies. Academics eat up low-hanging fruit to grow their CV. That these studies aren't being done makes me think it's out of fear of retribution for not being a team player or they are sleeping on the topic until there is more data

 

[Cornfed101]

Here's my theory: COVID was created by NPs to increase the value of their online school because med schools will now be online...








/s (actually not sarcasm... I'm being serious)

 

[PikminOC]

Sorry if i offend any NP's or family member of NP's.... but NP's are not the same as MD's or DO's.., period- the education, the intensity of residency, the board exams- and just the overall training... If you wanna act like a doctor, go to a medical school...

No, the say they are better. Heart of a nurse, brains of a doctor...

 

[Matthew9Thirtyfive]

No, the say they are better. Heart of a nurse, brains of a doctor...

Which is hilarious because that is just insulting to everyone.

 

[PikminOC]

Here's my theory: COVID was created by NPs to increase the value of their online school because med schools will now be online...








/s (actually not sarcasm... I'm being serious)

Online or not, the base knowledge and people you are competing against in med school is very high

 

[Giovanotto]

Given how of the two most recent ones before this, one was a response to a post of yours and the other you liked...

I'm not denying that at times you've lent a helping hand. I'm simply highlighting our differing opinions on various medicine or life topics. Which is perfectly fine, this is an open forum after all.

 

[MedicineZ0Z]

Midlevels encroachment is as bad as it seems and continues to get worse. 100% reality.

 

[mariajane]

I’m an NP. Here’s my experience followed by my unsolicited opinion.

I graduated from high school with 4.0. Wanted to go to medical school since forever but also wanted a normal lifestyle, to be a mostly-stay-at-home mom, etc. So I went to nursing school...again 4.0. Then straight (no bedside nursing required) to NP school (considered a prestigious university) for NP...4.0...I was shocked to discover that I had to study more for an undergrad degree than for the master’s. Worked in beside nursing for 3 yrs after graduation to get hospital experience.Then hired by hospitalist group at same hospital (large teaching hospital). As a perfectionist I knew I was unprepared for the job at hand....I was wholly unprepared. I worked alongside numerous midlevels not understanding how they could have job satisfaction knowing they, too, didn’t have/know 25-50% of what it takes to do the complex work of hospitalist medicine effectively and independently. The MDs knew it, I knew it, yet they didn’t shut down the program. My realization was that 1) I regretted getting this education. 2). I need to utilize it better. I have since moved to an outpatient subspecialty... pain mgmt. Truthfully, I am a smart person and was just as intelligent as previous acquaintances who went on to pursue medicine as MDs. Because of this, I am keenly aware of what I do and do not know. I honestly do really strong work in my current setting, seeing follow ups and new consults. I study continually and take great pleasure in the diagnostic aspect of my job.... understanding that a solid diagnosis allows the pain interventionist I work with to then treat the patient (which, yes translates into profit $$$) and the patient to go from point A to point B. I don’t get excited about doing injections and things because I feel I’m trying to play doctor when I’m not one...I do trigger point inj a fair amount to spare the docs that are bored by them though.

My opinion: NP school sucks. (PA school definitely superior.). There should be a level of rigor in it to weed out dummies in the first year. It should also be three years in total and include at least triple the clinical hours.

I definitely believe there is a role for midlevels, supervised only. A great doctor can train his/her own midlevel in such a way to greatly benefit his practice, lifestyle, and profit margins. I do not believe, as things currently stand, NP’s are equipped to manage primary care; and I personally see only an MD (unless I already know what’s wrong).

 

[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.

There's no real collaboration. That's my point

 

[inthezone2]

I didn't think much of this issue at first, but at least on reddit they openly **** on physicians in their circles. This is a thread they made in response to what happened in Wisconsin.

 

[Lost in Translation]

I didn't think much of this issue at first, but at least on reddit they openly **** on physicians in their circles. This is a thread they made in response to what happened in Wisconsin.

Reddit as a whole loves to **** on anyone with any sort of white collar ambition, doubly so if that profession has any “power” over others (i.e. doctors who have “power” over their patients). They take class warfare to a new level.

 

[efle]

And what happens if we did those studies and it turns out we're wrong?

This is what I fear will be gas on the fire and I never see it discussed in these kinds of threads. Do we really want to have good comparison studies? Could it be that we overtrain people for the bread and butter of primary care? Studies aren't going to show PCPs catching zebras while midlevels miss them. They're going to look at long term outcomes for the major determinants of chronic health - DM2, HTN, HLD, smoking rates, etc. I have to wonder if 7 years of education and training is overkill for the common chronic conditions. I can see someone with a lot less training coming out non-inferior depending on what's measured.

 

[VA Hopeful Dr]

This is what I fear will be gas on the fire and I never see it discussed in these kinds of threads. Do we really want to have good comparison studies? Could it be that we overtrain people for the bread and butter of primary care? Studies aren't going to show PCPs catching zebras while midlevels miss them. They're going to look at long term outcomes for the major determinants of chronic health - DM2, HTN, HLD, smoking rates, etc. I have to wonder if 7 years of education and training is overkill for the common chronic conditions. I can see someone with a lot less training coming out non-inferior depending on what's measured.

Its the difference between "good enough" and "best practices". Based on the current evidence, my diabetic patients' medication regimens are far superior to the NPs in the office. But given the NNT and everything, how much of a real world difference does that actually make? I don't know.

 

[Redpancreas]

Basically I’ve gone down a rabbit hole searching the internet about mid-levels. I’ve come to the point where I need a realistic answer to the threat they impose. After all my reading I’m terrified of taking on half a million in debt because the way I see it is mid-levels will be doing everything in 10 years and there will just be a hand full of Docs supervising. I feel like it will be marketed to the general public as a solution to high healthcare costs. What are your guy’s thoughts?

Certain Reddit threads and SDN posters look for extreme NP/PA views to a physician group. Of course it's going to trigger us. Then there are necessary people on Reddit/SDN that post stories about terrible things midlevels do that we need to be aware of. In my experience, as a physician you will always earn the top $ and have the most authority but there may be times where midlevels get to do more than you're comfortable with. There will always be a pendulum swinging between high cost and high quality care. Additionally the doctor's salary is far less of a target than so many other things and if we saturate the field with midlevels doing the same thing as doctors, things will be even more chaotic. It's up to you to do what you can to reign that in when it comes to patient safety.

 

[Redpancreas]

This is what I fear will be gas on the fire and I never see it discussed in these kinds of threads. Do we really want to have good comparison studies? Could it be that we overtrain people for the bread and butter of primary care? Studies aren't going to show PCPs catching zebras while midlevels miss them. They're going to look at long term outcomes for the major determinants of chronic health - DM2, HTN, HLD, smoking rates, etc. I have to wonder if 7 years of education and training is overkill for the common chronic conditions. I can see someone with a lot less training coming out non-inferior depending on what's measured.

Truth bomb...maybe not. But I would like to see the actual differences myself. Too many of us assume the best but we don't actually know for sure.

 

[Lawpy]

Basically I’ve gone down a rabbit hole searching the internet about mid-levels. I’ve come to the point where I need a realistic answer to the threat they impose. After all my reading I’m terrified of taking on half a million in debt because the way I see it is mid-levels will be doing everything in 10 years and there will just be a hand full of Docs supervising. I feel like it will be marketed to the general public as a solution to high healthcare costs. What are your guy’s thoughts?

The answer lies in market forces arising from American capitalism.

I'm also curious about long term physician vs midlevel comparison studies for bread and butter cases. If the studies show no difference, the entire medical education system is going to be dramatically overhauled

 

[CargoPants]

I'm also curious about long term physician vs midlevel comparison studies for bread and butter cases. If the studies show no difference, the entire medical education system is going to be dramatically overhauled

With a lot of chronic conditions (diabetes/HTN/HLD), if you can get them to take their medications reliably and make some lifestyle changes, you can usually manage their numbers pretty well.

If you were to make an argument that NP/PAs had more time to talk and listen to patient, and they were better in getting the patients to buy into their own care, I could see that being true.

 

[efle]

With a lot of chronic conditions (diabetes/HTN/HLD), if you can get them to take their medications reliably and make some lifestyle changes, you can usually manage their numbers pretty well.

If you were to make an argument that NP/PAs had more time to talk and listen to patient, and they were better in getting the patients to buy into their own care, I could see that being true.

Yeah this is why I think studies might hurt more than help. Teach someone the first line, second line, etc. Then it becomes more about adherence and consistently returning for followups. I don't think the extra schooling is going to keep the A1c's any lower in the physician-managed arm of the study.

 

[Lawpy]

Yeah this is why I think studies might hurt more than help. Teach someone the first line, second line, etc. Then it becomes more about adherence and consistently returning for followups. I don't think the extra schooling is going to keep the A1c's any lower in the physician-managed arm of the study.

Then we need to rethink the 4 years med school and a major residency overhaul for at least some specialties. I already railed against the uselessness of 2 years preclinical

 

[biomom]

My mom is an FNP. She was a nurse for 30 years before going to graduate school. She points to studies of equal outcomes all the time and equates her years as a nurse with residency. She is smart, but she doesn’t know what she doesn’t know. She often calls my husband in regards to patient problems that are over her head. He is floored by her lack of knowledge about pharmacology and general medicine. She is super nice though and I know she gets good patient evaluations. My mom often refers out for problems a FP could handle.

 

[efle]

She is super nice though and I know she gets good patient evaluations.

There's the even scarier possibility - not only will midlevels be non-inferior, they might have better results if their patients like them better and adhere to their prescriptions and followups more. They might like them more for the wrong reasons (e.g. patients are happier when they get unnecessary antibiotics for a URI, or visits being cheaper, or buying the "heart of a nurse" stuff...) but at the end of the day if their A1c comes back lower, huge win for independent practice lobbies.

 

[Lawpy]

There's the even scarier possibility - not only will midlevels be non-inferior, they might have better results if their patients like them better and adhere to their prescriptions and followups more. They might like them more for the wrong reasons (e.g. patients are happier when they get unnecessary antibiotics for a URI, or visits being cheaper, or buying the "heart of a nurse" stuff...) but at the end of the day if their A1c comes back lower, huge win for independent practice lobbies.

That's already known. Midlevels already won the war in persuading the public and legislators that they're more friendly and nicer than physicians --> huge win in patient adherence

 

[ohmanwaddup]

To me it seems real. I have not seen a single gas doc all year during 3rd year clinicals. None of my surgeries were with them either.

The profession is here to stay, its the push for independence that bothers me a lot. I've tried to educate friends and family, but I've been hit with some severe backlash which surprised me, and all I was doing was showing differenced in education years/hours.

I don't plan on supervising or training once I graduate if i can avoid it. I've joined PPP

 

[Matthew9Thirtyfive]

Yeah, given what I’ve seen as far as midlevels managing patients, I don’t think we’d have to worry about studies showing equivalence or them being better lol. Also there are a number of studies with midlevels being supervised and still either not being equivalent or having equal outcomes when appropriately supervised by a physician. In these studies, the midlevels always use more tests and consults. If there was truly an independent practice study where they couldn’t just ask a physician every time they didn’t know something, the difference in outcomes would be obvious.

 

[Lawpy]

To me it seems real. I have not seen a single gas doc all year during 3rd year clinicals. None of my surgeries were with them either.

The profession is here to stay, its the push for independence that bothers me a lot. I've tried to educate friends and family, but I've been hit with some severe backlash which surprised me, and all I was doing was showing differenced in education years/hours.

I don't plan on supervising or training once I graduate if i can avoid it. I've joined PPP

I think American capitalism will favor increased role of private equity in medicine to the extent that physicians will have no choice but to supervise and train midlevels

 

[theendisnigh]

In the ED I used to work at we called the PAs/NPs midlevels. When I transitioned to working in a private practice, I was in a conversation with a NP referencing midlevels and she corrected me that it was a derogatory word, then sent me this via a text:

Stop calling nurse practitioners mid-level providers

The term "mid-level provider” is primarily aimed at nurse practitioners (NPs). It is insulting to health professionals as well as to the patients they serve.

www.kevinmd.com

 

[Matthew9Thirtyfive]

In the ED I used to work at we called the PAs/NPs midlevels. When I transitioned to working in a private practice, I was in a conversation with a NP referencing midlevels and she corrected me that it was a derogatory word, then sent me this via a text:

Stop calling nurse practitioners mid-level providers

The term "mid-level provider” is primarily aimed at nurse practitioners (NPs). It is insulting to health professionals as well as to the patients they serve.

www.kevinmd.com

Ffs, could that guy blow any more smoke? He must be gunning for an academic chair.

 

[Lawpy]

In the ED I used to work at we called the PAs/NPs midlevels. When I transitioned to working in a private practice, I was in a conversation with a NP referencing midlevels and she corrected me that it was a derogatory word, then sent me this via a text:

Stop calling nurse practitioners mid-level providers

The term "mid-level provider” is primarily aimed at nurse practitioners (NPs). It is insulting to health professionals as well as to the patients they serve.

www.kevinmd.com

Wow this crap has been going on way back in 2014

 

[Sleepingdoc]

Forget Medical school, everyone go to Nursing school...

 

[managedcarefin]

So I'm one of those people that works with hospitals to advise them to shift primary care from physician to APP/APC. The threat is very very very real, health systems and constantly reaching out to the leaders of my firm to help organize care models that will allow them to maximize revenue in an ever changing reimbursement market. I wouldn't be shocked if in ~20 years primary care physicians largely only provide advisory roles for new doctors.

 

[Mad Jack]

Depends on the field. In anesthesia and EM it is absolutely an issue

 

[Mad Jack]

In the ED I used to work at we called the PAs/NPs midlevels. When I transitioned to working in a private practice, I was in a conversation with a NP referencing midlevels and she corrected me that it was a derogatory word, then sent me this via a text:

Stop calling nurse practitioners mid-level providers

The term "mid-level provider” is primarily aimed at nurse practitioners (NPs). It is insulting to health professionals as well as to the patients they serve.

www.kevinmd.com

Let's just call them what they are: non-physician providers

 

[Mad Jack]

Also I've got to say it's kind of sad that the United States is the only developed nation where we do not believe our citizens deserve regular physician-level care

 

[ohmanwaddup]

So I'm one of those people that works with hospitals to advise them to shift primary care from physician to APP/APC. The threat is very very very real, health systems and constantly reaching out to the leaders of my firm to help organize care models that will allow them to maximize revenue in an ever changing reimbursement market. I wouldn't be shocked if in ~20 years primary care physicians largely only provide advisory roles for new doctors.

I'd be absolutely disgusted if this becomes the case.

Also why the hell are you helping this happen?

 

[Steve_Zissou]

I'd be absolutely disgusted if this becomes the case.

Also why the hell are you helping this happen?

$$$$$$$$$$$$$$$$$$$$$$$$$$$