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

[Lem0nz]

This discussion reminds me of an irritating Emergency medicine PA on the PA forums. He often staffed rural ERs by himself and residents rotated under him. He complained that residents had made so many mistakes during codes due to not knowing what they were doing. So, he would often brag about how he had to utilize his knowledge and skills from being a very seasoned paramedic (over ten years, I think) in order to be able to run codes and teach his residents.

it was almost like he doesn't understand that there is so much more to learn than being on an ambulance and going to PA school. That PA training is not condensed medical school.

Anyway, he is irritating.

Then why participate in it? The internet is vast friend. Cat memes abound.

---

Members don't see this ad.

 

[fluorescent colors]

Then why participate in it? The internet is vast friend. Cat memes abound.

Why not? Weird response.

 

[Idahomie]

Yo I wonder when this thread is going to get locked? Anyone wanna place bets?

 

[Lawpy]

How is the government going to track if I use my $25,000 for rent, or food, or going to the movies, or tuition, or contributing to my roth for the year, or buying gamestop stonks? Should they? That seems incredibly invasive to me.

Why on Earth would med schools offer more full ride scholarships without some crazy benefactor that gave them a MASSIVE endowment to pay for it? How are they going to pay their staff and run the school if they start making it free?

I don't *know* if we'll saturate the FM market. We did it to rad-onc and EM and it sounds like we got close with path. Peds already has laughably low salaries - what will happen to them if we increase their residency spots? Are more surgeons really going to solve the rural critical access issue? Surgery residency doesn't teach ortho procedures, or c-sections, and their training on endoscopy is just so-so depending on where you are and can be 50 scopes in a month somewhere around PGY2 and have zero interventional experience. After my scope experience (which was... idk. 40 upper and maybe 75 lower?) I could tell you there's a polyp, and I could probably do a simple snare consistently and reliably, and get a biopsy, but 75 scopes with 2/3 of them being normal is not enough for me to recognize a great deal of pathology. Definitely not enough for upper to deal with anything real like an acute bleed. Honestly all my uppers were PEG tubes. And none of that addresses that >80% of residents go on to do a fellowship and fellowship trained surgeons is rarely what critical access hospitals need.

In regards to your other ideas:
We already have huge physician lobbying and they're clearly failing us. Why would we send more money their direction? Most people already think the AMA and our individual governing bodies are just out for money and greed through MOC and continuing education requirements that are not pertinent to actual practice most of the time. How do you plan to end the practice of defensive medicine without major tort reform? Who's going to push that? How're we going to be successful in doing that? What happens when we start missing things because we didn't order every test under the sun and get sued? How're we going to motivate patients to go see their primarys for preventative visits when they're already free? And when your yearly c-scope after 50 is completely covered by insurance? When your lung screening CT is already paid for? There's this recurring theme that all of medicine is dysfunctional capitalism, but huge huge swaths of medicine is just trying to stay neutral and net positive for the year without firing anyone. And if you want to socialize the healthcare system and stretch beyond the ACA - do you (or any of us?) really understand the ramifications of that? What that's going to do to physician salaries? Med school debt? People with existing debt that already paid it but lost 10-20 years of earning potential and now suddenly make half of what other doctors did a couple years prior to major legislation overhaul? Do you think socialized medicine will suddenly change the over utilization of healthcare... at all? Or liability?

I'm not asking all of these questions just to be a jerk. My point in doing this is that organizations at the national, state, and local level have already been working on this for decades and still are, actively, every single day. It may not seem like it as a medical student but you have to understand that those groups have to do that in the constraint of the existing system and still have to get paid. And let's be real, after going into debt for 300-500k for medical school and then working 80+ hours a week for 3-7 years making less than the janitor staff on an hourly rate, you DO deserve to be paid half a million dollars a year when you're one of the only people out of a hundred thousand people who can do what you do, and I'm not upset at the physicians who are looking at the system and trying to figure out how they can finally start making a ton of money to do whatever the hell they want that makes them happy after all of that hard work, be it saving for retirement finally, or traveling the earth, or buying a huge house and a tesla, or having six kids and sending them all to college and medical school debt free. They deserve that life after all that hard work if they're going to continue to work hard and find innovative ways to make money. Why are we demonizing that?

I guess Lawpy, I'm trying to say, its complicated man. That pie in the sky stuff sounded great to me too ten years ago and it seemed so simple. Now as I'm getting ready to set foot into the real world for the first time in a couple months, I realize that there is a lot more going on here than I could have ever imagined.

The federal loans should make it clear that investments aren't daily spending and keep track of that. I'm not sure on the exact details on how that work, and honestly, i thought it was currently illegal to use federal loans to invest because the government can track investments.

It's full ride with conditions and specific selection criteria that a fraction of students will actually work in primary care for few years. I think all MD schools have large enough endowments to make this possible.

I agree drastic residency expansion will cause salaries to drop on average, but if physicians are serving essential needs by working in rural and underserved areas, they'll easily make well above specialty average. I don't have answers for the surgery issues other than relying on referrals with major academic centers even if it's hours away.

I think PPP is the only credible physician lobbying group tbh. Major tort reform is inevitable.

I appreciate your detailed and thorough responses as always. I realize it's complex and i'm mostly airing out my ignorance since i'm not even in residency yet but the issues you raise are major with no easy answers.

Well now we're getting into the weeds. And this is good!

At my hospital, the MICU was staffed by a PGY2 IM or PGY3 IM overnight and then an intern (or two). The interns could be from radiology, or family medicine. As others pointed out, what's the utility of an FM running that code? Or the rads guy? What about any number of other residencies that require a prelim or TY that may be rotating through this MICU and are only there for one month ever? The essence of the rotation is exposure - not for them to actually learn to do the job. But that's who's staffing the team for that month. Do we then make policy around how best to teach the IM residents? Do we make carveouts and special rules for when there are IM residents on service vs. IM residents not on service? Is this providing a different quality of care from month to month? What about when we get the scenario of an IM senior going into ID who doesn't want anything to do with running a code and an IM intern who's fresh out of school in July?

Can you start to see why midlevels who aren't revolving doors might be pushed into some of these roles at least? Is it really the wrong move to do what is best for the patient even if it sacrifices some aspects of training, assuming we'll make up those deficiencies in training in fellowship where we'll specifically be teaching to the person we KNOW is going to use the relevant material?

To be clear - I am NOT for IM residents not knowing how to do their own codes and procedures for a MICU. I *absolutely* think they should be required to know how to do central lines and a-lines and run codes. But I definitely can start to see why this has eroded and may continue to erode further, and I can also concede that I might just be wrong on this issue.

Yeah i realized earlier that the longevity in midlevel experience in the hospital system gives them the edge over residents who mostly come and go.

I guess one last thing I would add is that you keep referencing primary care, which is fine, but what about the other fields? We have independent CRNAs, psych midlevels, IM midlevels... the sky is the limit. What's the PPPs plan (or yours) there? What about midlevels employed by physicians? I know there's a lot of shade towards physicians being expected to oversee midlevels, but what about the ones that want to? What if they want to precept and train midlevels and use them in their organization? Should we tell them how to practice medicine and what they can and can't do? Serious questions.

I think the similar position applies for those fields except maybe anesthesia (i'm still trying to understand the CRNA problem in the recent gas thread on how to avoid being like EM). I don't think FM, IM or psych will be saturated even with aggressive residency expansion. But. I didn't anticipate EM being oversaturated either, so i don't have a good sense of understanding the job markets.

But i'll say physicians who are willing to supervise and train midlevels especially over residents and students should be condemned. Yes it sounds like preaching them on how to do their jobs but i think it's necessary to push for PPP messages to them.

 

[Lawpy]

Yo I wonder when this thread is going to get locked? Anyone wanna place bets?

Why? I personally learned a lot from this thread even though i have some disagreements

 

[Ho0v-man]

 

[Lawpy]

View attachment 334997

How do @medgator @elementaryschooleconomics respond?

 

[medgator]

How do @medgator @elementaryschooleconomics respond?

A thread on this already, kinda. I don't see people going to a nurse to get a prescription for radiation, not even sure a nurse would be able to give the right dose and evaluate and approve a plan. There are definitely issues though with supervision, namely that it can be done via telehealth now, which is not what a new rad Onc residency grad wants to hear.

Supervision by mid levels

I believe this may have been discussed, but is there a likely probability of supervision even in freestanding centers to be provided by mid-levels permanently? This is from the Astro website section VI.. seems like it may eventually be a permanent change...

forums.studentdoctor.net

 

[Mad Jack]

Med schools do a bad job covering in depth foundations when compared to resources like UFAPS/B&B/Anki. 2 years is unnecessarily excessive especially with Step 1 being P/F. I think clinical skills with UFAPS-powered knowledge is going to be the key distinction.

I would argue that with Step 1 being P/F preclinical being more in-depth and focused on minutiae than the boards is more appropriate, since minutiae are no longer taking away from board study time and may contribute to saving a life or two someday. The stuff that is the difference between a decent doctor than a good doctor is all foundational, much of it you will only see once or twice in practice and no amount of experience outside of the books will make you ready for the zebras. Just my two cents though, I find an esoteric case or two every year that I only manage to snag because of preclinical

 

[Lawpy]

I would argue that with Step 1 being P/F preclinical being more in-depth and focused on minutiae than the boards is more appropriate, since minutiae are no longer taking away from board study time and may contribute to saving a life or two someday. The stuff that is the difference between a decent doctor than a good doctor is all foundational, much of it you will only see once or twice in practice and no amount of experience outside of the books will make you ready for the zebras. Just my two cents though, I find an esoteric case or two every year that I only manage to snag because of preclinical

*shrug*

I don't think schools do a good job covering the foundation and anything esoteric can be found online through a quick literature search or looking up on UpToDate

 

[Mad Jack]

*shrug*

I don't think schools do a good job covering the foundation and anything esoteric can be found online through a quick literature search or looking up on UpToDate

You don't know what to look for if you never learned it. If you could just UpToDate everything, there would be no need for physicians, just people incredibly good at boolean searching.

The weird cases are things that don't fit neatly into searches or normal boxes. They're things you will only know if you know them, because, as the saying goes, you don't know what you don't know. That knowledge is what separates a physician from a midlevel, and almost all of it is picked up in preclinical, unless you also happen to do a lot of reading of bizarre case studies like myself

 

[Lem0nz]

You don't know what to look for if you never learned it. If you could just UpToDate everything, there would be no need for physicians, just people incredibly good at boolean searching.

The weird cases are things that don't fit neatly into searches or normal boxes. They're things you will only know if you know them, because, as the saying goes, you don't know what you don't know. That knowledge is what separates a physician from a midlevel, and almost all of it is picked up in preclinical, unless you also happen to do a lot of reading of bizarre case studies like myself

I feel differently from both of you. I think the difference between a good physician and a mediocre one is the critical thinking and deductive process. Maybe it’s a cancer thing, but none of my patients follow the textbook anymore it seems like. At all. Half of treatment has become a multi-D discussion where we make **** up based on the best evidence we have which doesn’t quite describe the patient well. It’s actually quite refreshing and it makes me really enjoy my job.

That said, the ability to deal with all of these cases is from a decades worth of training in surgery and cancer and learning how to think about it. Having foundational surgical principles, oncologic principles, and being able to adapt them to things we haven’t seen or heard of or are emerging therapies. You can’t read what we’re doing half the time because we’re extrapolating it for all the scenarios that simply can’t be taught.

I’m not sure where in the process I learned how to think like that and innovate in medicine, but it’s awesome. I suspect it was a gradual development over all 10+ years that I have been iteratively refining.

 

[elementaryschooleconomics]

How do @medgator @elementaryschooleconomics respond?

I believe, though I have not 100% dug into this myself to verify, that this bill is for fluoro procedures, not for therapeutic ionizing radiation.

That being said, I'm sort of torn on this topic. On the one hand, I have significant personal experience with APPs/mid-levels/whatever the preferred term is now in both the academic and private setting in Radiation Oncology. In the setups I've seen in real life, it actually functions how I always envisioned a "mid-level" was supposed to function (similar to Neurosurgery, where the MDs/DOs are doing the operating and the APPs are running routine floor patients). Our APPs handle routine/long-term follow-ups or triage palliative inpatient consults/phone calls. They have nothing to do with the prescribing and delivering of radiation, nor have I ever heard of one remotely interested in that part of the job (I'm sure they exist, however).

In the end though, I always think about a term for them that I think is no longer PC, but still apt: physician-extender. In Radiation Oncology, where our main concern currently is oversupply, and there's more docs than jobs, do you really need to utilize "physician-extenders"? If there's too much work for your current cadre of RadOnc physicians to handle, you should be hiring more physicians, because we're sure making a lot of them.

However, I'm aware that's not how the free market works.

 

[Señor S]

There was actually a lot of good discussion in this thread, although as usual a few posters have managed to largely derail it.

BacktotheBasics and Lem0nz have addressed a lot of the key issues. There is indeed quite a bit of clock punching, laziness and generally bad attitudes in Internal Medicine, at all levels. Some of this is unfortunately brought into the specialty by the type of people it attracts, but I think a lot of it is a "learned helplessness" that one encounters during training and beyond. There is in general very little autonomy; the attendings have made up their minds what they want to do before they even heard your presentation, or they just want to consult everybody for everything. Procedures can be hard to come by; the fellows want to do everything themselves (because it's faster) and the attendings just want to send it to IR (because it's easier). In that sort of environment it's very easy for even an enthusiastic person to adopt a defeatist attitude. The problem is that for relatively "interesting" or "glamorous" things like CVLs and codes there's always an army of NPs and PAs who are all too happy to demand these responsibilities be given to them, and then come on SDN and brag about how they're better than the residents (or whatever). And since there's no ABIM/ACGME requirement that residents actually do these things (because both the ACGME and the ABIM are a joke), nobody objects too strongly.

Bottom line: it shouldn't really be up to trainees to decide what is and isn't a good use of their time. Many residents would be perfectly happy to "give up" their primary care clinics, too, if only they were allowed to...but they aren't allowed to, so they soldier on and do their jobs (for the most part), even if their only ambition in life is to do scopes all day and never titrate Metformin again. It should be that way for other things too, regardless of the manipulative demands of a bunch of NPs who want to feel important.

 

[Styrene]

Absolutely not psych. At least outpatient stuff. NPs are everywhere.

The incompetence of various psych NPs is alarming when I review records. But I think the stakes are lower in the eyes of many due to negative consequences being more long-term. I think at least half my patients see only a psych NP outpatient.

 

[Matthew9Thirtyfive]

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

I think your med school might be brainwashing you. Blink twice if you’re just saying this so you don’t get expelled.

 

[Redpancreas]

There was actually a lot of good discussion in this thread, although as usual a few posters have managed to largely derail it.

BacktotheBasics and Lem0nz have addressed a lot of the key issues. There is indeed quite a bit of clock punching, laziness and generally bad attitudes in Internal Medicine, at all levels. Some of this is unfortunately brought into the specialty by the type of people it attracts, but I think a lot of it is a "learned helplessness" that one encounters during training and beyond. There is in general very little autonomy; the attendings have made up their minds what they want to do before they even heard your presentation, or they just want to consult everybody for everything. Procedures can be hard to come by; the fellows want to do everything themselves (because it's faster) and the attendings just want to send it to IR (because it's easier). In that sort of environment it's very easy for even an enthusiastic person to adopt a defeatist attitude. The problem is that for relatively "interesting" or "glamorous" things like CVLs and codes there's always an army of NPs and PAs who are all too happy to demand these responsibilities be given to them, and then come on SDN and brag about how they're better than the residents (or whatever). And since there's no ABIM/ACGME requirement that residents actually do these things (because both the ACGME and the ABIM are a joke), nobody objects too strongly.

Bottom line: it shouldn't really be up to trainees to decide what is and isn't a good use of their time. Many residents would be perfectly happy to "give up" their primary care clinics, too, if only they were allowed to...but they aren't allowed to, so they soldier on and do their jobs (for the most part), even if their only ambition in life is to do scopes all day and never titrate Metformin again. It should be that way for other things too, regardless of the manipulative demands of a bunch of NPs who want to feel important.

This is the reality at a large number of residencies. We can rant about this, but if you voice the sentiment 99% of us are expressing on this thread it'll come off as rude. I once was given the eye by an attending for calling an NP a PA by mistake. IM attendings love midlevels and frankly trust them more than the residents. Who's to blame them? The attending's been around for 5-or-so years in their post and have gotten comfortable with all the midlevels around them ...meanwhile there's residents who come in and out. The majority of the hospitalists already have a good idea of what they want to do for their patients and don't really need miniature versions of themselves to mentor or convince, but rather someone who simply gets the work done. There is that older generation of faculty that actually still have that passion for "teaching young minds" and maybe a few energetic young attendings who are trying to do it on their own, but the majority of the Gen X and early millenial attendings have become accustomed to midlevels being their main go-tos and couldn't care less about investing significant time mentoring residents and on the other side many residents don't mind and would rather take their credit and move on to Heme/Onc or whatever (GI/cards aren't the only culprits).

I think your med school might be brainwashing you. Blink twice if you’re just saying this so you don’t get expelled.

Meh, I think he/she is speaking honestly as a post-matched M4 who probably realizes after their 4 years that med school didn’t prepare them to save lives as much as they thought it did coming in.

 

[Lawpy]

This is the reality at a large number of residencies. We can rant about this, but if you voice the sentiment 99% of us are expressing on this thread it'll come off as rude. I once was given the eye by an attending for calling an NP a PA by mistake. IM attendings love midlevels and frankly trust them more than the residents. Who's to blame them? The attending's been around for 5-or-so years in their post and have gotten comfortable with all the midlevels around them ...meanwhile there's residents who come in and out. The majority of the hospitalists already have a good idea of what they want to do for their patients and don't really need miniature versions of themselves to mentor or convince, but rather someone who simply gets the work done. There is that older generation of faculty that actually still have that passion for "teaching young minds" and maybe a few energetic young attendings who are trying to do it on their own, but the majority of the Gen X and early millenial attendings have become accustomed to midlevels being their main go-tos and couldn't care less about investing significant time mentoring residents and on the other side many residents don't mind and would rather take their credit and move on to Heme/Onc or whatever (GI/cards aren't the only culprits).

Meh, I think he/she is speaking honestly as a post-matched M4.

Finally, we can stop hating the boomers and start bashing Gen Xers and millennials /s

No but really, the revolving door of residents is contributing to this problem which the stability of midlevels resolves

 

[Redpancreas]

Yeah, like back In the good ol’ days residents were the ones running the hospital. The interesting, but uncomfortable truth no ones mentioned because it sounds terrible is that they probably made more mistakes back then and they learnt from them. Nowadays, we practice shotgun/defensive/very proactive medicine. An infiltrate with mild symptoms may very well get antibiotics, lasix, steroids, duonebs (lol), and god knows what else. Diseases are no longer what we see in textbooks or even the most realistic vignettes anymore because we intervene on them things before they get to the stage where vitals become abnormal.

Back in those days, the residents came out as battle tested veterans with proprietary experience whereas nowadays, both a mid level or a resident can throw the kitchen sink at a symptomatic chest infiltrate and the patient will improve one way or the other.

 

[efle]

I think your med school might be brainwashing you. Blink twice if you’re just saying this so you don’t get expelled.

Yea maybe, whatever they put in the water to make me dislike Step 1 mania must have also convinced me med school is low yield for how specialized modern practice has gotten. Soon you'll probably see me talking about how unnescessary a medicine intern year requirement is for a radiologist, too. Thinking you could train an NP to remove gallbladders is like the least hot of my takes.

 

[Lawpy]

Yea maybe, whatever they put in the water to make me dislike Step 1 mania must have also convinced me med school is low yield for how specialized modern practice has gotten. Soon you'll probably see me talking about how unnescessary a medicine intern year requirement is for a radiologist, too. Thinking you could train an NP to remove gallbladders is like the least hot of my takes.

I'm still confused about the medicine PGY1 for rads and i'm not even a resident!

 

[Redpancreas]

Finally, we can stop hating the boomers and start bashing Gen Xers and millennials /s

No but really, the revolving door of residents is contributing to this problem which the stability of midlevels resolves

Plenty of blame to go around but these generations have really shifted how attending physicians practice. As residents, there is still an opportunity to make a difference and learn medicine well but it takes an loud, firm personality and whatever you do don’t come in clueless because people hardly get over their first impressions.

I'm still confused about the medicine PGY1 for rads and i'm not even a resident!

It’s supposed to put Radiologists, PM&R people, Psychiatrists, Neurologist, etc. in medicine’s shoes to understand the basic work ups so when they’re consulted or asked to correlate radiographically, they understand where the medicine guy is coming from having been there little while ago.

What Efle is saying is that in practice he/she is not very interested in certain elements that people with more experience have especially since he/she isn’t going to be involved in doing them in the future.

A proposed solution is hospitalist tracks and primary care tracks that take a small group of residents who have committed to the generalist nature of medicine but even then there’s still people changing their minds/doing fellowships after and the tracks aren’t large enough to counterbalance the term someone else used as “army of NPs”.

 

[Lem0nz]

Yea maybe, whatever they put in the water to make me dislike Step 1 mania must have also convinced me med school is low yield for how specialized modern practice has gotten. Soon you'll probably see me talking about how unnescessary a medicine intern year requirement is for a radiologist, too. Thinking you could train an NP to remove gallbladders is like the least hot of my takes.

Lay out your hottest takes please, in order of lukewarm to kill it with fire. I'm ready.

 

[efle]

Lay out your hottest takes please, in order of lukewarm to kill it with fire. I'm ready.

Here's a few, no particular order -

I think the current system was designed 100 years ago to set people up to become well rounded GPs, and is barely applicable these days outside primary care folks. Tons of specialties should be spun off into their own training programs - think radiologist school or pathologist school like we have dental and podiatry. At the minimum preclinical should drop to 1 year of Pass/Fail and people should spend most of M2-M3 rotating through electives to explore their interests or doing a bunch of auditions, instead of doing mostly required subjects theyll never touch again until only a few months before ERAS.

Extensive research experience should not be a de facto requirement to go into small surgical fields. I have friends doing full time research years that plan never to touch research again. It's mostly a ratrace to rack up small impact projects that nobody will read instead of meaningful work on long term projects. Dumb.

Residency application caps need to happen ASAP.

Step 2 should also be pass fail like the bar/other licensing exams, step 1 will be and CS was.

Plus some spicy speculations - like that NPs will probably come out noninferior for bread and butter primary care patients if we do the studies, or that theres nothing in an MD that makes someone better at learning procedures. At least, nothing in my MD I can appreciate.

Oh one more good one - people who choose medicine for the "wrong reasons" like a stable, high income, interesting job are more likely to have their expectations met than the altruists are.

Theres probably more I'm forgetting

 

[Lem0nz]

Here's a few, no particular order -

I think the current system was designed 100 years ago to set people up to become well rounded GPs, and is barely applicable these days outside primary care folks. Tons of specialties should be spun off into their own training programs - think radiologist school or pathologist school like we have dental and podiatry. At the minimum preclinical should drop to 1 year of Pass/Fail and people should spend most of M2-M3 rotating through electives to explore their interests or doing a bunch of auditions, instead of doing mostly required subjects theyll never touch again until only a few months before ERAS.

Extensive research experience should not be a de facto requirement to go into small surgical fields. I have friends doing full time research years that plan never to touch research again. It's mostly a ratrace to rack up small impact projects that nobody will read instead of meaningful work on long term projects. Dumb.

Residency application caps need to happen ASAP.

Step 2 should also be pass fail like the bar/other licensing exams, step 1 will be and CS was.

Plus some spicy speculations - like that NPs will probably come out noninferior for bread and butter primary care patients if we do the studies, or that theres nothing in an MD that makes someone better at learning procedures. At least, nothing in my MD I can appreciate.

Oh one more good one - people who choose medicine for the "wrong reasons" like a stable, high income, interesting job are more likely to have their expectations met than the altruists are.

Theres probably more I'm forgetting

Won't step 2 P/F just take the research rat race and crank it up to 1000? Agree research is the stupidest measuring stick we have.

 

[efle]

Won't step 2 P/F just take the research rat race and crank it up to 1000? Agree research is the stupidest measuring stick we have.

Probably. I'd prefer we go off auditions, recommendations (maybe in SLOE format?) and interviews but until applications are capped I don't see that happening.

 

[Matthew9Thirtyfive]

Meh, I think he/she is speaking honestly as a post-matched M4 who probably realizes after their 4 years that med school didn’t prepare them to save lives as much as they thought it did coming in.

What does this have to do with letting an NP perform your lap chole over an R2?

 

[Matthew9Thirtyfive]

Yea maybe, whatever they put in the water to make me dislike Step 1 mania must have also convinced me med school is low yield for how specialized modern practice has gotten. Soon you'll probably see me talking about how unnescessary a medicine intern year requirement is for a radiologist, too. Thinking you could train an NP to remove gallbladders is like the least hot of my takes.

I mean you can train most people to do the basic steps of a procedure. That doesn’t mean you should. Have you scrubbed any gallbladders that were complicated? God forbid your gallbladder isn’t straightforward. I’ll take the R2 over any NP every day of the week and twice on Sunday.

 

[VA Hopeful Dr]

Here's a few, no particular order -

I think the current system was designed 100 years ago to set people up to become well rounded GPs, and is barely applicable these days outside primary care folks. Tons of specialties should be spun off into their own training programs - think radiologist school or pathologist school like we have dental and podiatry. At the minimum preclinical should drop to 1 year of Pass/Fail and people should spend most of M2-M3 rotating through electives to explore their interests or doing a bunch of auditions, instead of doing mostly required subjects theyll never touch again until only a few months before ERAS.

Extensive research experience should not be a de facto requirement to go into small surgical fields. I have friends doing full time research years that plan never to touch research again. It's mostly a ratrace to rack up small impact projects that nobody will read instead of meaningful work on long term projects. Dumb.

Residency application caps need to happen ASAP.

Step 2 should also be pass fail like the bar/other licensing exams, step 1 will be and CS was.

Plus some spicy speculations - like that NPs will probably come out noninferior for bread and butter primary care patients if we do the studies, or that theres nothing in an MD that makes someone better at learning procedures. At least, nothing in my MD I can appreciate.

Oh one more good one - people who choose medicine for the "wrong reasons" like a stable, high income, interesting job are more likely to have their expectations met than the altruists are.

Theres probably more I'm forgetting

 

[Matthew9Thirtyfive]

Plus some spicy speculations - like that NPs will probably come out noninferior for bread and butter primary care patients if we do the studies, or that theres nothing in an MD that makes someone better at learning procedures. At least, nothing in my MD I can appreciate.

I agree with everything but these. I have yet to meet an NP who has an actual grasp of pharmacology or pathophys.

 

[curbsideconsult]

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

Couldn't this be said of any medical specialty? Out of curiosity, how do you feel about those rads studies stating midlevels are as good or better at reading certain images than residents? And should they be trained to do so?

Hot take - if I was the patient I'd rather have my code run by an experienced NP than a brand new resident. Knowing what receptor subtype the epinephrine binds to isnt what will save my life.

If my hospital has NPs that usually run the codes because most people feel like me, that also seems fine. But on reddit and SDN you'll see a big outcry framed as "shame on Rutgers! How dare they let midlevels run their codes!"

I'm not so sure that the resentment was towards midlevels running codes so much as midlevels supervising residents who were running the codes. I would prefer that a physician run codes, but you're right that a midlevel who has been intricately involved in dozens of codes is going to be better than a brand new intern who has only watched a couple. But to be honest, I'm going to be real salty if I have to be critiqued and evaluated by a midlevel after I've run a code.

 

[Steve_Zissou]

Probably. I'd prefer we go off auditions, recommendations (maybe in SLOE format?) and interviews but until applications are capped I don't see that happening.

The issue with not having any standardized way of measuring students is that those who will benefit most will be those who go to more prestigious schools/have more connections already. Me, going to a small DO school, would get screwed by those sorts of changes. At least with standardized exams, I can work my ass off and outperform some of those students going to more prestigious schools. If the choice is nepotism vs a meritocracy, I’ll choose a meritocracy every time.

 

[FutureInternist]

Wisconsin hospital replaces anesthesiologists with CRNAs

Watertown (Wis. ) Regional Medical Center has replaced its anesthesiologists with certified registered nurse anesthetists, and some physicians aren't happy about the change, according to Medscape Medical News.

www.beckershospitalreview.com

 

[FutureInternist]

I agree with everything but these. I have yet to meet an NP who has an actual grasp of pharmacology or pathophys.

Its cooks vs chefs

 

[efle]

The issue with not having any standardized way of measuring students is that those who will benefit most will be those who go to more prestigious schools/have more connections already. Me, going to a small DO school, would get screwed by those sorts of changes. At least with standardized exams, I can work my ass off and outperform some of those students going to more prestigious schools. If the choice is nepotism vs a meritocracy, I’ll choose a meritocracy every time.

Hijacking the medical education system for everyone so that late blooming outliers can punch up doesnt make a ton of sense to me. If step is a bad metric it shouldnt be used, regardless of whether that bad metric was more accessible than the better alternatives. As dr carmody puts it, it would be very egalitarian to assign residencies based on who can memorize the most digits of pi. But we all agree that would be a terrible approach.

 

[Matthew9Thirtyfive]

Its cooks vs chefs

I like that. Gonna steal.

 

[order66.exe]

Hijacking the medical education system for everyone so that late blooming outliers can punch up doesnt make a ton of sense to me. If step is a bad metric it shouldnt be used, regardless of whether that bad metric was more accessible than the better alternatives. As dr carmody puts it, it would be very egalitarian to assign residencies based on who can memorize the most digits of pi. But we all agree that would be a terrible approach.

Sorry, but at least step has some relation to medical knowledge and is standardized. We’re getting rid of it not because it’s a bad metric but because elite institutions are trying to further their students stranglehold on certain opportunities.

Clinical grades, letter of recommendation, the interview are biased, non-standardized and just as terrible in terms of predicting future performance.

 

[efle]

We’re getting rid of it not because it’s a bad metric but because elite institutions are trying to further their students stranglehold on certain opportunities.

You dont actually believe this, do you? INCUS was for the elite med school deep state or...?

 

[Matthew9Thirtyfive]

You dont actually believe this, do you? INCUS was for the elite med school deep state or...?

I mean, do you really believe that top med schools and students aren’t in favor of it because it benefits those students while putting the rest at a disadvantage?

 

[efle]

I mean, do you really believe that top med schools and students aren’t in favor of it because it benefits those students while putting the rest at a disadvantage?

Look at the charting outcomes "top 40 NIH" proportions for competitive specialties now and 10+ years ago. Theyve been stable and similar to the overall proportion of the applicant pool. I have no idea where this myth came from that school prestige will be the new step score

 

[Steve_Zissou]

Hijacking the medical education system for everyone so that late blooming outliers can punch up doesnt make a ton of sense to me. If step is a bad metric it shouldnt be used, regardless of whether that bad metric was more accessible than the better alternatives. As dr carmody puts it, it would be very egalitarian to assign residencies based on who can memorize the most digits of pi. But we all agree that would be a terrible approach.

Are interviewing capabilities a better metric? What about the LoRs that pretty ubiquitously state that students are fantastic?

 

[Steve_Zissou]

Step 1 and step 2 are the worst metrics to measure students by, except for all the other ones.

 

[efle]

Are interviewing capabilities a better metric? What about the LoRs that pretty ubiquitously state that students are fantastic?

I'd much rather pick coworkers based on an interview than their step score yes. EM seems to be making LoRs useful for comparison if you dont think regular LoRs are enough

 

[Steve_Zissou]

I'd much rather pick coworkers based on an interview than their step score yes. EM seems to be making LoRs useful for comparison if you dont think regular LoRs are enough

Do you have any data that supports the idea that SLOEs are better metrics for success than step 1 scores?

 

[efle]

Do you have any data that supports the idea that SLOEs are better metrics for success than step 1 scores?

Ad ignorantiam, there was never evidence step 1 was useful either to place it in its current position. "Ability to predict board passage" applies only to the low end of the distribution near failing; 230 vs 250 does not have a significant effect. It was not even considered useful at first - in the late 1990s when ophtho was one of the most competative specialties, their matched board average was only a couple points above the national. It was due to over application and the need for a convenient sorting/filtering tool that Step became king.

 

[Steve_Zissou]

Ad ignorantiam, there was never evidence step 1 was useful either to place it in its current position. "Ability to predict board passage" applies only to the low end of the distribution near failing; 230 vs 250 does not have a significant effect. It was not even considered useful at first - in the late 1990s when ophtho was one of the most competative specialties, their matched board average was only a couple points above the national. It was due to over application and the need for a convenient sorting/filtering tool that Step became king.

Convenient, efficient, same thing. Once again, I’ll take a standardized meritocracy over a system based on nepotism and prestige (at least, more so than the current system is).

 

[doyinDO]

Here's a few, no particular order -

I think the current system was designed 100 years ago to set people up to become well rounded GPs, and is barely applicable these days outside primary care folks. Tons of specialties should be spun off into their own training programs - think radiologist school or pathologist school like we have dental and podiatry. At the minimum preclinical should drop to 1 year of Pass/Fail and people should spend most of M2-M3 rotating through electives to explore their interests or doing a bunch of auditions, instead of doing mostly required subjects theyll never touch again until only a few months before ERAS.

Extensive research experience should not be a de facto requirement to go into small surgical fields. I have friends doing full time research years that plan never to touch research again. It's mostly a ratrace to rack up small impact projects that nobody will read instead of meaningful work on long term projects. Dumb.

Residency application caps need to happen ASAP.

Step 2 should also be pass fail like the bar/other licensing exams, step 1 will be and CS was.

Plus some spicy speculations - like that NPs will probably come out noninferior for bread and butter primary care patients if we do the studies, or that theres nothing in an MD that makes someone better at learning procedures. At least, nothing in my MD I can appreciate.

Oh one more good one - people who choose medicine for the "wrong reasons" like a stable, high income, interesting job are more likely to have their expectations met than the altruists are.

Theres probably more I'm forgetting

I've felt similar for a long time. I think current medical training needs reform. Specifically, it needs to be shorter and streamlined considering what's going on with midlevels. Something has to give. An example is in the hospital in Wisconsin that replaced anesthesiologists with CRNAs. If CRNAs really end up working well and getting similar results as the previous anesthesiologists, then the medical system has failed those physicians and really needs reform. If results are worse, then the hospital will get tired of bad results and probably hire the physicians again.

 

[Lawpy]

Here's a few, no particular order -

I think the current system was designed 100 years ago to set people up to become well rounded GPs, and is barely applicable these days outside primary care folks. Tons of specialties should be spun off into their own training programs - think radiologist school or pathologist school like we have dental and podiatry. At the minimum preclinical should drop to 1 year of Pass/Fail and people should spend most of M2-M3 rotating through electives to explore their interests or doing a bunch of auditions, instead of doing mostly required subjects theyll never touch again until only a few months before ERAS.

Extensive research experience should not be a de facto requirement to go into small surgical fields. I have friends doing full time research years that plan never to touch research again. It's mostly a ratrace to rack up small impact projects that nobody will read instead of meaningful work on long term projects. Dumb.

Residency application caps need to happen ASAP.

Step 2 should also be pass fail like the bar/other licensing exams, step 1 will be and CS was.

Plus some spicy speculations - like that NPs will probably come out noninferior for bread and butter primary care patients if we do the studies, or that theres nothing in an MD that makes someone better at learning procedures. At least, nothing in my MD I can appreciate.

Oh one more good one - people who choose medicine for the "wrong reasons" like a stable, high income, interesting job are more likely to have their expectations met than the altruists are.

Theres probably more I'm forgetting

We agree with everything except the midlevel part

 

[Lawpy]

I agree with everything but these. I have yet to meet an NP who has an actual grasp of pharmacology or pathophys.

What if the midlevels learn only through B&B, Pathoma and UWorld?

 

[Lawpy]

Step 1 and step 2 are the worst metrics to measure students by, except for all the other ones.

Step exams are misused and have disgustingly huge confidence intervals. Want a standardized exam? Make the med school version of the MCAT. A norm-referenced test with very small standard errors