How on earth are people supposed to get good at stuff if they can't flounder a little while being supervised? That has always been the trade-off. Of course I'd rather have the super-specialist doing anything to me personally but the reality of medicine is you have to keep training people and the quality of care is on average decreased. But that's necessary.
Disagree. Clinical skills aren't what separates physicians from midlevels, an in-depth knowledge and understanding of the foundations of medicine is. Most programs would not be successful in implementing a 1+3 model, it's really something you need to have exceptional teachers for. Hell, in most countries they get an additional year over what we get on both ends (3+3) because there's that much foundational stuff to be covered.
Hmm this is not fun because at this point it's largely due to differences in years of experience. A midlevel doing this for 20+ years gets to take priority over a resident doing it for 0-3 years.
It comes down to what "super specialist" means to you. To me, it's someone with the experience. To others, it seems there's something during the MD degree I missed that is more important.
I'd be more for a 3+3 if I didn't have to undergrad.
You can blame all you want and rage against the way things should be or we can have an honest conversation about the way things are and what we can make with the cards we’ve been dealt. Steve doesn’t ever want to work with a midlevel. Great. I want every surgery to be open multivisceral resections because they’re more fun. And I want to get paid like it’s 1980. You want doctors to have robust broad medical training like it’s 1995. Unfortunately, those wants are not congruent with the reality of medicine as it currently stands in most places. Our medicine is more complex, our teams are bigger, our censuses are larger, our reimbursement is lower, our liability risk is higher, our outcomes are under a microscope, our documentation is for accreditation and reimbursement and not to convey actual information between clinicians.
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.
Yes a super-specialist in this context I would consider anyone with ample experience doing whatever task I need done. I want the best care possible for myself, don't care who performs it. But that's what I want. What is necessary is the fact that future physicians need to be trained and someone somewhere has to take a hit in the quality of care they receive.
In PM&R we are a small field that still retains reasonable autonomy without being flooded by mid levels however and given thy there are not a ton of us out there we are relatively ok now. The issue is that I think a lot of mid levels are not truly knowledgeable - some have appearance of knowledge because they deal w simple cases. Nurses have same issue. Recently I had a nurse who didn’t know what a ketorolac IM injection was.I cried a little internally and kindly explained.
Bro, how can you go off insulting me when you don’t even know my position on midlevels? I’ve stated before multiple times that I’m fine with midlevels existing and working under physicians, I disagree with independent practice and the way some physicians use midlevels to do all their work so they can be a lazy POS. Also, if you’re going to talk **** about me/call me out, have the balls to @ me so I don’t miss it. I’ll likely ignore it, because I somehow seem to have triggered you hard enough to develop a pretty robust dislike of me over the course of maybe 10-20 posts, but it would still be kinda funny to read.
I think we should reject the status quo and push for large scale changes in US healthcare with better physician lobbying at federal, state and local levels and end the practice of defensive medicine. I think we need to appreciate and utilize preventive care a lot more and society needs to accept that. I also think we need to resolve the problem of dysfunctional capitalism for turning medicine into a profit-driven business that endangers patients by giving them the cheapest and lowest quality care. This requires massive policy changes that are likely more far reaching than ACA. I don't think this is idealistic or out of reach in the coming years and decades.
Here’s the rub though - you do get priority. You just don’t get it nearly as early as a decade ago.
I'm probably gonna get a lot of flak for this, but I think MD/DO should have first priority if they want it. I'm doing a PGY-1 year before DR. I have zero interest at all in becoming expert at codes during any of my ED, ICU or floor rotations. Someone getting mad on my behalf that an experienced NP ran my patient's code instead of me is odd. I'm perfectly fine with it.
You didn’t @Me here, and your dripping sarcasm speaks otherwise.
I was responding to you directly?
I find it annoying that you take shots at me with sarcastic passive aggressive posts about surgeons overseeing an army of midlevels which grossly mischaracterizes me but I didn’t cry. Toughen up buttercup. Gonna be a long road in residency.
There’s a place for midlevels in underserved areas where physicians need extenders. Otherwise, I don’t see why we need them.
Kinda sounds like you took it personally tbh. That being said, this is quickly going to devolve even further if I snap back at you so I’ll just leave it be.
The distribution issue of physicians needs to be resolved effectively as well.
What is the PPPs plan to solve this?
The pt of training a resident is so that they become even more competent than the NP. How do we train them if we let mid levels take over? Do you want an NP whose done 1000 lap choles or PGY 3 gen surg resident whose done a 1000?
It’s almost like people don’t like it when you deliberately make fun of them or use sideways remarks you know will piss them off. I could have sworn I saw someone do this in this very thread a few hours earlier but I just can’t recall where... alas.
This is what i found:
www.inquirer.com
This assumes you should compare an NP or PA with any level of training or experience with a resident which is incorrect. A midlevel who has been doing lap choles (weird choice for our example, but whatever) for ten years with exceptional outcomes after being trained and working with a general surgeon for ten years, or a resident who probably isn’t even measuring their outcomes yet because it’s under their attending who did 100 while rotating to a different service every month are not equal things.
How does that fairly address physician distribution at all? What part of that makes rural and underserved areas more appealing to new grads?This is what i found:
Nurse practitioners are not the solution to primary care problems in N.J. or elsewhere | Opinion
We support the rejection of New Jersey legislation to let nurse practitioners replace the role of doctors.
"Legislators should focus instead on increasing the supply of physicians — starting with preventing the closure of residency training programs like the one at Hahnemann University Hospital in Philadelphia, which disrupted the training of nearly 600 Pennsylvania physicians. They can do so by backing legislation to expand graduate medical education with more residency program slots. The growth of medical schools in the U.S. has far outpaced that of the residency training programs necessary for medical school graduates to practice."
That logic holds if you're training a resident for something they'll actually use. Of course I want surgical residents to still get the proper number of cases during their residency.
I agree that a ton of what we do in medicine is unnecessary and at some point it is dumb to make a future endocrinologist do a bunch of intubations or something. But it erodes medical training if those before us don't care about certain experiences, changed policy so they didn't have to do it, and force future trainees that do want to do whatever procedure/task to play nice with the midlevels or whoever the procedure was passed on to.
Personally i think there should be full ride offers and debt relief for all med students who are willing to work in underserved and rural settings after training.
Generally, I think cutting out requirements or making them optional forces trainees to cede certain early training that would help them in the future, even if they aren't going into a subspecialty that uses them regularly. There's a line to be drawn though, as with endocrinologists doing a ton of intubations or something.
I mean, it’s great to say that but who’s going to pay for that? The hospital? The federal government? Local governments? Some of those can barely afford to keep their critical access hospitals open as is. County hospitals routinely run in the red. Those doctors already can get PSLF after ten years and get nearly half of the cost of medical school (or more) forgiven if they are careful and pay the minimum. And they already get paid quite a bit more than their counterparts in the city. And some city dwelling docs can still get their loans forgiven, so is that really enough, or the correct incentive? And what national organization is arguing for this? How do we implement this, and who?
Full rides come from med schools themselves. I think primary care residencies and hospitals should have some sort of generous debt repayment programs. Interest rates for federal loans should drop to zero.
Why?
If your interest rate is zero why would you ever pay back a student loan, not just take out the maximum, and then invest it all in the stock market and make a ton of money?
I don't think federal loans should be given without conditions on how they should be used (and so preventing using the loans to invest in the stock markets)
Because I'm never going to run codes as a radiologist
but but IR!!!!
The idea of having DR residents do a intern year, as I understand it, is so they get a better understanding of the tie between clinical medicine and radiology (on top of building general clinical knowledge). Every rotation I’ve been on, a large part of my focus has been “how can I, in the future, as a radiologist better work with this specialty.” I have to imagine that intern year only serves to reinforce that.
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.
Right, I forgot not every resident uses all their skills as an attending. I always thought it was wierd that rads residents have to do IM for a year, and learn all these skills they'll never use. But I also can't imagine a doc who can't run a code. Anyway, you're right if its residents who don't want to learn.
Well now we're getting into the weeds. And this is good!
Is IR a fellowship of DR? Do you plan on doing that?
Not the worst idea, very similar to the UK model.
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.This is what i found:
Nurse practitioners are not the solution to primary care problems in N.J. or elsewhere | Opinion
We support the rejection of New Jersey legislation to let nurse practitioners replace the role of doctors.
"Legislators should focus instead on increasing the supply of physicians — starting with preventing the closure of residency training programs like the one at Hahnemann University Hospital in Philadelphia, which disrupted the training of nearly 600 Pennsylvania physicians. They can do so by backing legislation to expand graduate medical education with more residency program slots. The growth of medical schools in the U.S. has far outpaced that of the residency training programs necessary for medical school graduates to practice."
Then why participate in it? The internet is vast friend. Cat memes abound.
