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

[SurfingDoctor]

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Does it make me a weaker future PCP to not throw 50 central lines in?? Because if that’s what you’re saying I fundamentally disagree.

The checkbox for sterile Seldinger technique is right under the checkbox for smoking cessation and counseling. It's the ying and yang of primary care.

 

[Redpancreas]

Does it make me a weaker future PCP to not throw 50 central lines in?? Because if that’s what you’re saying I fundamentally disagree.

Not to interject to a question you're phrasing to him, but obviously not. IM residency's greatest strength and weakness (IMO) is its versatility. There are competencies but then which ones apply to you specifically when you have a focus on one area? In EM, for example, you're doing a very similar job whereas in IM there are literally 4 distinctly different career paths (fellowship, outpatient PCP, hospitalist, and academic hybrid) each requiring a fundamentally different skillset. Ultimately what makes IM residency demanding is that residency is ideally supposed to prepare you for all of them which is a very broad skillset, but in reality no one is actually standardizing the process so every resident doesn't necessarily have mastery in all the areas, but enough to get by provided they follow the four golden rules

1.) Pristine documentation
2.) Orders/Consults done and followed up on before afternoon rounds
3.) If something new arises, have a basic interpretation and present it to the attending accurately while providing timely care if needed.
4.) If something is clearly X (ex. DKA), find a validated treatment for X (ex. table 1 of DKA on Uptodate) and do it.

The rest like procedures, knowing which antibiotic to use, the ability to interpret CXRs/EKGs, etc. are not skills IM residents are tested on in a standardized way. It would be nice for them to know how to do these things but procedure teams, consultants, radiology reads, etc. are all available to allow residents to skate by.

 

[Wordead]

Does it make me a weaker future PCP to not throw 50 central lines in?? Because if that’s what you’re saying I fundamentally disagree.

Lazy people are lazy regardless of the semantics.

Oh look Im going to skip these codes and central lines to just crush this outpatient diabetes management.

Dont be delusional

 

[Lem0nz]

Does it make me a weaker future PCP to not throw 50 central lines in?? Because if that’s what you’re saying I fundamentally disagree.

No, but it makes you a great critical care resident, and you if you don't give a **** at being a good critical care resident while you're in the MICU that's part of the problem. And no, you don't need 50. That was an example for surgery. You need probably 10-20 so that you can comfortably put them in when they're easy and have a reasonable chance at putting them into someone who is hypotensive, and know when to call for help from someone with far more experience when challenging scenarios arise. Surgery needs 50 because surgery is the one you're going to call when you can't do it as IM so we need to be able to do the extremely challenging cases, or the subclavian cases, or the temporary dialysis catheters, etc.

 

[SurfingDoctor]

Not to interject to a question you're phrasing to him, but obviously not. IM residency's greatest strength and weakness (IMO) is its versatility. There are competencies but then which ones apply to you specifically when you have a focus on one area? In EM, for example, you're doing a very similar job whereas in IM there are literally 4 distinctly different career paths (fellowship, outpatient PCP, hospitalist, and academic hybrid) each requiring a fundamentally different skillset. Ultimately what makes IM residency demanding is that residency is ideally supposed to prepare you for all of them which is a very broad skillset, but in reality no one is actually standardizing the process so every resident doesn't necessarily have mastery in all the areas, but enough to get back provided they follow the four golden rules

1.) Pristine documentation
2.) Orders/Consults done and followed up on before afternoon rounds
3.) If something new arises, have a basic interpretation and present it to the attending accurately while providing timely care if needed.
4.) If something is clearly X (ex. DKA), find a validated treatment for X (ex. table 1 of DKA on Uptodate) and do it.

The rest like procedures, knowing which antibiotic to use, the ability to interpret CXRs/EKGs, etc. are not skills IM residents are tested on in a standardized way. It would be nice for them to know how to do these things but procedure teams, consultants, radiology reads, etc. are all available to allow residents to skate by.

We don’t make our residents write notes in the unit. They felt it was too burdensome. They have better things to do I guess.

Talk about de-incentivizing oneself...

 

[Redpancreas]

We don’t make our residents write notes in the unit. They felt it was too burdensome. They have better things to do I guess.

Talk about de-incentivizing oneself...

That's laudable but in most fields that's literally (actual, not ideal) core competency of the ICU intern.

 

[Lem0nz]

We don’t make our residents write notes in the unit. They felt it was too burdensome. They have better things to do I guess.

Talk about de-incentivizing oneself...

...wut. Yea, I'd replace those residents with a midlevel too. :\

 

[sunshinefl]

No, but it makes you a great critical care resident, and you if you don't give a **** at being a good critical care resident while you're in the MICU that's part of the problem. And no, you don't need 50. That was an example for surgery. You need probably 10-20 so that you can comfortably put them in when they're easy and have a reasonable chance at putting them into someone who is hypotensive, and know when to call for help from someone with far more experience when challenging scenarios arise. Surgery needs 50 because surgery is the one you're going to call when you can't do it as IM so we need to be able to do the extremely challenging cases, or the subclavian cases, or the temporary dialysis catheters, etc.

I always give a **** about being great in whatever I’m doing. But I don’t think running and jumping to the front of the crowd to do every line no matter what service I’m on is realistic or a good use of time and energy.

 

[Lem0nz]

I always give a **** about being great in whatever I’m doing. But I don’t think running and jumping to the front of the crowd to do every line no matter what service I’m on is realistic or a good use of time and energy.

You are going to have to tell me where I wrote that at all. Also call 9-1-1, I think I'm having a stroke because I can't remember saying any of that crap.

 

[sunshinefl]

Lazy people are lazy regardless of the semantics.

Oh look Im going to skip these codes and central lines to just crush this outpatient diabetes management.

Dont be delusional

Bro you could just say that as an excuse to dump more and more on residents/doctors/humans. We can’t be everywhere all the time being all things to all people.

 

[VA Hopeful Dr]

Lazy people are lazy regardless of the semantics.

Oh look Im going to skip these codes and central lines to just crush this outpatient diabetes management.

Dont be delusional

That's some truth in this. Mainly because there's a difference between doing your job (lines on your own patients, codes) and going above and beyond to get more experience (seeking out procedures).

 

[sunshinefl]

You are going to have to tell me where I wrote that at all. Also call 9-1-1, I think I'm having a stroke because I can't remember saying any of that crap.

That was what the whole conversation was about. That a hospital would have mid levels on code / rapid teams because the IM residents were just too lazy to run around the hospital cowboying everything. Like they don’t have other things they’re doing and like all of medicine hasn’t moved towards specialized teams and roles.

 

[sunshinefl]

That's some truth in this. Mainly because there's a difference between doing your job (lines on your own patients, codes) and going above and beyond to get more experience (seeking out procedures).

Yes but every minute of time and energy to one thing means taking it from something else.

 

[managedcarefin]

Bro you could just say that as an excuse to dump more and more on residents/doctors/humans. We can’t be everywhere all the time being all things to all people.

I can only speak to doctors but part of it is just doing your job... if you are unwilling to do that while you are being paid you'll get replaced with someone who will.

 

[SurfingDoctor]

That's laudable but in most fields that's literally the core competency of the ICU intern.

I'm not sure laudable is the term I would use...

 

[sunshinefl]

I can only speak to doctors but part of it is just doing your job... if you are unwilling to do that while you are being paid you'll get replaced with someone who will.

Yes but you can’t just magically start assigning a bunch of things that aren’t your job and then say a ha! Gotcha!

 

[managedcarefin]

Yes but you can’t just magically start assigning a bunch of things that aren’t your job and then say a ha! Gotcha!

But you can assign people additional responsibilities and expect that they should be able to meet those targets.

 

[Lem0nz]

That was what the whole conversation was about. That a hospital would have mid levels on code / rapid teams because the IM residents were just too lazy to run around the hospital cowboying everything. Like they don’t have other things they’re doing and like all of medicine hasn’t moved towards specialized teams and roles.

I mean, did you bother to read the context of the original article and posts? Its talking about GMB/BK/NF. General med team, backup, night float. I promise you that at night and on weekends, the collection of that three teams *IS* responsible for all of those patients who are going to code and that all of those patients belong to that team. RWJ has attendings in house during the day who are going to their codes. It is common practice at night that a resident team is in fact responsible for 100+ patients. That's how it works. I will say that knowing literally nothing about RWJ's IM program because that's how every hospital night float team works... everywhere. It isn't cowboying. Their job is to put out fires and deal with emergencies overnight. That's probably their ENTIRE job because I suspect they have a separate consult team, which most places do.

This isn't medicine being called to surgery patient codes, or called to the cardiac ICU. Those teams will deal with their own patients. This was an IM chief complaining he's being told he's second fiddle to a MICU APN, and we've dissected why this probably happened.

 

[sunshinefl]

But you can assign people additional responsibilities and expect that they should be able to meet those targets.

Not endlessly no.

 

[Redpancreas]

That was what the whole conversation was about. That a hospital would have mid levels on code / rapid teams because the IM residents were just too lazy to run around the hospital cowboying everything. Like they don’t have other things they’re doing and like all of medicine hasn’t moved towards specialized teams and roles.

No one said too lazy. Tired of @'ing people but Lem0nz never said laziness, but rather that it wasn't something IM residents did. Lawpy mischaracterized it as laziness and said whoops later. I think we've said for a variety of factors it is not a core competency in practice that IM residents all learn.

 

[sunshinefl]

I mean, did you bother to read the context of the original article and posts? Its talking about GMB/BK/NF. General med team, backup, night float. I promise you that at night and on weekends, the collection of that three teams *IS* responsible for all of those patients who are going to code and that all of those patients belong to that team. RWJ has attendings in house during the day who are going to their codes. It is common practice at night that a resident team is in fact responsible for 100+ patients. That's how it works. I will say that knowing literally nothing about RWJ's IM program because that's how every hospital night float team works... everywhere. It isn't cowboying. Their job is to put out fires and deal with emergencies overnight. That's probably their ENTIRE job because I suspect they have a separate consult team, which most places do.

This isn't medicine being called to surgery patient codes, or called to the cardiac ICU. Those teams will deal with their own patients. This was an IM chief complaining he's being told he's second fiddle to a MICU APN, and we've dissected why this probably happened.

Well between my home hospital, aways, places I interviewed, and my upcoming residency, every place was different in who/what/when/where/why/how IM residents were involved in codes.

 

[managedcarefin]

Not endlessly no.

We'll your a student now, soon you'll be a reason and in the future you'll be an attending. I'm interested to see how your feelings evolve overtime. I agree things can't endlessly be added to one's plate.

 

[sunshinefl]

We'll your a student now, soon you'll be a reason and in the future you'll be an attending. I'm interested to see how your feelings evolve overtime. I agree things can't endlessly be added to one's plate.

Yes I’m also 35 and worked as a correctional officer, CNA, and RN before. So this won’t be my first professional job. At least we can agree that you can’t just add things endlessly. And my feelings will never change about that.

 

[managedcarefin]

Yes I’m also 35 and worked as a correctional officer, CNA, and RN before. So this won’t be my first professional job. At least we can agree that you can’t just add things endlessly. And my feelings will never change about that.

Less about your experience generally more about your experience in the business of medicine. 60% of all hospital costs is typically labor, because of labor will perpetually be squeezed to drive down cost. Everyone has a point where they say enough is enough, and they do something else. But know there will always be someone or something to fill in as a replacement or the system would break down.

 

[inthezone2]

Does it make me a weaker future PCP to not throw 50 central lines in?? Because if that’s what you’re saying I fundamentally disagree.

I'm emphasizing the slope here not only for procedures. When we back away from doing things, obviously someone has to do them. That's how our privileges get eroded away. This statement applies to more than just procedures: "Oh, 1/2 of the IM residents wanting to do fellowship don't seem invested in clinic and are doing the bare minimum. We should have the dedicated NP's supervise them." Boom, another piece of medicine gets chipped away and we become less competent. I'm not the biggest fan of primary care clinic, but I would fight tooth and nail to keep it within our scope if something like this happened

 

[Redpancreas]

I'm emphasizing the slope here not only for procedures. When we back away from doing things, obviously someone has to do them. That's how our privileges get eroded away. This statement applies to more than just procedures: "Oh, 1/2 of the IM residents wanting to do fellowship don't seem invested in clinic and are doing the bare minimum. We should have the dedicated NP's supervise them." Boom, another piece of medicine gets chipped away and we become less competent. I'm not the biggest fan of primary care clinic, but I would fight tooth and nail to keep it within our scope if something like this happened

Maybe you're just mentioning the bolded to make the point about the underlined, but residents/laziness/etc. aren't the primary cause for what I'm just going to call training erosion. It's multifactorial and deals with the systems the hospital has in place, the incentives attendings have to teach, the institutional culture, and THEN resident engagement.

Also, there are systems in place in the outpatient side at big hospitals where outpatient pharmacists call residents if anything we prescribe anything they have a question/concern about.

 

[mwsapphire]

Was it not the AMA that lobbied for a cap on residency positions in the 90s because they feared oversaturation?

I mean, being overstaturated like Law is would still be a bad thing , because then we would still have graduates with debt and no jobs. But with how hard it is to open a good med school with quality rotation sites and the fact that we clearly have more demand than supply for residency spots ( barely more than the amount of US MD/DO grads in a year, not nearly enough places for IMGs and FMGs) , it's a no brainer to increase spots. There was a bill being put for vote that increases residency spots by 2,000 ever year until 2027. If it passes we can at least help mitigate unmatched US DO's and MDs.

Every physician should at least have 1st level necromancy spells in their arsenal

🤣

 

[Steve_Zissou]

Last night, in my dreams, I had a vision of a glorious future comrades.

In this dream every specialty was 1 to 4. All physicians were supervisors, there to support the superior, hands on NPs and PAs. The NPs were the most fantastic surgeons, and the physician stood by simply to help if an extra pair of hands and just a little more knowledge was needed. Oh, and of course the physicians took all the call, because it would be uncouth of someone with the status of an NP to take call. The surgeons also saw patients in clinic to decide whether they needed surgery or not, and which surgery but there was no need for them to actually perform the surgeries since you can “teach a monkey” to do surgery itself. Our glorious MBA and NP overlords realized that you can teach NPs, surprisingly just as well as monkeys, to do the hands-on portion of surgery, and save the hospital/pocket lots and lots of cash in the process. In this dream, the surgeons were all too happy to give their tedious work to the NPs; to train them day in and day out instead of residents because residents were transient and slowed them down while the NPs were permanent and could make them money. Only the young medical students and residents complained, but then again, what did their opinion matter? They’re still just in training and did not understand the true way of the world.

It was a beautiful dream comrades, now let us work together to make this the future.

 

[efle]

Last night, in my dreams, I had a vision of a glorious future comrades.

In this dream every specialty was 1 to 4. All physicians were supervisors, there to support the superior, hands on NPs and PAs. The NPs were the most fantastic surgeons, and the physician stood by simply to help if an extra pair of hands and just a little more knowledge was needed. Oh, and of course the physicians took all the call, because it would be uncouth of someone with the status of an NP to take call. The surgeons also saw patients in clinic to decide whether they needed surgery or not, and which surgery but there was no need for them to actually perform the surgeries since you can “teach a monkey” to do surgery itself. Our glorious MBA and NP overlords realized that you can teach NPs, surprisingly just as well as monkeys, to do the hands-on portion of surgery, and save the hospital/pocket lots and lots of cash in the process. In this dream, the surgeons were all too happy to give their tedious work to the NPs; to train them day in and day out instead of residents because residents were transient and slowed them down while the NPs were permanent and could make them money. Only the young medical students and residents complained, but then again, what did their opinion matter? They’re still just in training and did not understand the true way of the world.

It was a beautiful dream comrades, now let us work together to make this the future.

Again I'd rather have an NP doing their 1000th lap chole than a junior resident doing their first handful. Whether we should lock certain training away behind the MD degree is a separate debate but this is an odd example to pick because you can indeed train anyone to take out a gallbladder

 

[Redpancreas]

Last night, in my dreams, I had a vision of a glorious future comrades.

In this dream every specialty was 1 to 4. All physicians were supervisors, there to support the superior, hands on NPs and PAs. The NPs were the most fantastic surgeons, and the physician stood by simply to help if an extra pair of hands and just a little more knowledge was needed. Oh, and of course the physicians took all the call, because it would be uncouth of someone with the status of an NP to take call. The surgeons also saw patients in clinic to decide whether they needed surgery or not, and which surgery but there was no need for them to actually perform the surgeries since you can “teach a monkey” to do surgery itself. Our glorious MBA and NP overlords realized that you can teach NPs, surprisingly just as well as monkeys, to do the hands-on portion of surgery, and save the hospital/pocket lots and lots of cash in the process. In this dream, the surgeons were all too happy to give their tedious work to the NPs; to train them day in and day out instead of residents because residents were transient and slowed them down while the NPs were permanent and could make them money. Only the young medical students and residents complained, but then again, what did their opinion matter? They’re still just in training and did not understand the true way of the world.

It was a beautiful dream comrades, now let us work together to make this the future.

@Steve_Zissou I think this is the ideal way all medicine should be practiced. It's a shame medical students on here think differently. Personally I have spoken to the mods about having those trouble-makers banned, but unfortunately was not successful. This is the way everything is going and is the only way to maintain our income stream and leadership in medicine.

 

[Steve_Zissou]

Again I'd rather have an NP doing their 1000th lap chole than a junior resident doing their first handful. Whether we should lock certain training away behind the MD degree is a separate debate but this is an odd example to pick because you can indeed train anyone to take out a gallbladder

It seems that we agree comrade, surgery should belong to the NPs and the monkeys, it is not for the residents at all. Perhaps we will live to see the day that one physician oversees a fleet of NPs who oversee a even larger fleet of CNAs who perform all surgeries. To one day be a NP battalion commander is but a distant dream. Ah well, perhaps we can pave the road for future generations.

 

[efle]

It seems that we agree comrade, surgery should belong to the NPs and the monkeys, it is not for the residents at all. Perhaps we will live to see the day that one physician oversees a fleet of NPs who oversee a even larger fleet of CNAs who perform all surgeries. To one day be a NP battalion commander is but a distant dream. Ah well, perhaps we can pave the road for future generations.

You're trying to joke but there are a lot of booming practices out there of a group of NPs seeing patients while the MD sits in the back weighing in and signing stuff when needed. I think you picked surgery because it's supposed to be this sacred physician-only training but like I said, if it's my life on the line, I care about what experience they have not their Step scores or the letters after their name

 

[Lem0nz]

I hope you go into private practice and live a long, happy, and fulfilling life Steve. You will not be happy employed under someone else I think. Also maybe go into DR or path so you, you know, don't have to work with other people very often. Maybe forensic pathology. I feel like you would get along with things that can't speak back to you.

 

[Steve_Zissou]

You're trying to joke but there are a lot of booming practices out there of a group of NPs seeing patients while the MD sits in the back weighing in and signing stuff when needed. I think you picked surgery because it's supposed to be this sacred physician-only training but like I said, if it's my life on the line, I care about what experience they have not their Step scores or the letters after their name

I agree, this is the way.

 

[Steve_Zissou]

I hope you go into private practice and live a long, happy, and fulfilling life Steve. You will not be happy employed under someone else I think. Also maybe go into DR or path so you, you know, don't have to work with other people very often. Maybe forensic pathology. I feel like you would get along with things that can't speak back to you.

Sometimes I shout at the wind. Sometimes it shouts back.

 

[blue.jay]

Future IM applicants, this comment is gold. On the interview trail, there were indeed highly ranked programs that you'd probably salivate at getting into, particularly a number of the "clinics", but you may not get the same autonomy to become a truly independent physician. I remember interviewing at one of these "clinics" and a resident admitted to me that 80% of the patients come in with an established specialist on board or with workup done from an affiliate hospital and your job as the medicine intern is to put in whatever orders said specialist wanted you to put in. You get very little ownership of your patients. Sure the fellowship results look beautiful, but you really have to evaluate what you truly want. Do you want to be a better doctor or ivory tower socialite? No wrong answer here, but ya'll can probably see my preference.

This gotta be ****land Clinic aka Midlevel-land Clinic Foundation

 

[Lawpy]

You're trying to joke but there are a lot of booming practices out there of a group of NPs seeing patients while the MD sits in the back weighing in and signing stuff when needed. I think you picked surgery because it's supposed to be this sacred physician-only training but like I said, if it's my life on the line, I care about what experience they have not their Step scores or the letters after their name

Pretty striking of you to favor experienced midlevels over a junior resident. Smh dude

 

[Wordead]

Bro you could just say that as an excuse to dump more and more on residents/doctors/humans. We can’t be everywhere all the time being all things to all people.

Oh yeah 20-50 procedures over 3 years my goodness the strain on your time who will play you in the lifetime movie

I have no dog in this race I don't really care if IM becomes a slightly worse trained NP/PA. More referrals for me I guess.

 

[Lawpy]

I suppose adcoms and PDs are idiots who don't know what they're doing if the education and training they're promoting is so substandard and intellectually dull that even experienced midlevels are preferred over a resident with several years of rigorous education and training. Give me a break

 

[Lawpy]

The midlevel favoritism and sympathy displayed in this thread is the reason why medicine is self destructing. We should be defending our profession against the unified, corporate-supported midlevel lobbying, and here we have MS4s, residents and fellows openly admitting the superiority of midlevels over residents and med students.

 

[efle]

Pretty striking of you to favor experienced midlevels over a junior resident. Smh dude

You'll understand when you've finished the MD and still feel clueless due to lack of experience. If someone codes on me in a couple months and there's a veteran ICU midlevel there who knows how to run a code, it will be BETTER for the patient than me running it.

 

[Lawpy]

You'll understand when you've finished the MD and still feel clueless due to lack of experience. If someone codes on me in a couple months and there's a veteran ICU midlevel there who knows how to run a code, it will be BETTER for the patient than me running it.

An intern can learn fast during PGY1 though. And they're being supervised by senior residents and attendings. This is looking like it's a systemic problem with incompetent residents not knowing basic skills running loose. If that's the case, the residency program should be in probation and have their accreditation withdrawn

 

[Lawpy]

Btw this is exactly why i support a 1 yr preclinical/3 yr clinical model everywhere

 

[managedcarefin]

The midlevel favoritism and sympathy displayed in this thread is the reason why medicine is self destructing. We should be defending our profession against the unified, corporate-supported midlevel lobbying, and here we have MS4s, residents and fellows openly admitting the superiority of midlevels over residents and med students.

And people wonder how certain specialties got to where they are now...lol

 

[Lawpy]

And people wonder how certain specialties got to where they are now...lol

I blame medicolegal liability issues.

 

[Mad Jack]

An intern can learn fast during PGY1 though. And they're being supervised by senior residents and attendings. This is looking like it's a systemic problem with incompetent residents not knowing basic skills running loose. If that's the case, the residency program should be in probation and have their accreditation withdrawn

Running a code is the same as anything else, practice makes perfect. In many programs, there just aren't enough codes to get that practice because people have the audacity to not die with enough regularity to provide residents with the needed practice

 

[Lawpy]

Running a code is the same as anything else, practice makes perfect. In many programs, there just aren't enough codes to get that practice because people have the audacity to not die with enough regularity to provide residents with the needed practice

But those programs are unlikely to have midlevels running the codes right?

 

[Redpancreas]

Btw this is exactly why i support a 1 yr preclinical/3 yr clinical model everywhere

One thing that's clear is we need earlier clinical exposure. LCME has been telling medical schools this for years but the schools are rooted in their ways with dinosaur Ph.Ds and fat cat administrators who don't really want to make the changes to benefit students or god forbid do something that to address issues on the horizon. When LCME dings a school on lack of early clinical exposure, the school shoves a few lectures somewhere else and then puts in a week of lectures branded as early clinical exposure when the real solution's to work to truly integrate the basic science with clinical reasoning with continuous exposure to wards in M1/2.

 

[Lawpy]

One thing that's clear is we need earlier clinical exposure. LCME has been telling medical schools this for years but the schools are rooted in their ways with dinosaur Ph.Ds and fat cat administrators who don't really want to make the changes to benefit students or god forbid do something that to address issues on the horizon. When LCME dings a school on lack of early clinical exposure, the school shoves a few lectures somewhere else and then puts in a week of lectures branded as early clinical exposure when the real solution's to work to truly integrate the basic science with clinical reasoning with continuous exposure to wards in M1/2.

I think a lot of MD schools already have this though. I just think M2s should be hitting the wards immediately with M3 and M4 years serving to learn a lot more clinical skills

 

[Mad Jack]

But those programs are unlikely to have midlevels running the codes right?

It's going to vary widely. You're more likely to have midlevel involvement at smaller hospitals though due to the simple economics of things. Whether senior residents or midlevels are running the show is going to depend on the place and the service.