The future?

[Styrene]

From a May 2020 article I was just reading. Referencing GSS/NAICS.

---

Members don't see this ad.

 

[Redpancreas]

I have some notion of what occupational prestige means, but didn't know it was a thing people cared about so I googled it. Seems like a measure sociologists keep track of based off of polls/indexes. Regardless, most charts I look at still have physicians at the top. Anyhow...this means nothing.

Nurse practitioners will come under fire the moment they have to incur any form of professional liability. Some are so used to selling themselves as independent practitioners but retreating under a physician's liability when push comes to shove. The minute they get any sort of independence the legal system's going to tear their system to shreds.

 

[7331poas]

I understand what occupational prestige means, but didn't know it was a thing people put weight on so I googled it. Seems like a measure sociologists keep track of based off of polls/indexes. Regardless, most charts I look at still have physicians at the top. Anyhow...this means nothing.

Nurse practitioners will come under fire the moment they have to incur any form of professional liability. They're so used to selling themselves as independent practitioners but retreating under a physician's liability when push comes to shove. The minute they get any sort of independence the legal system's going to tear their system to shreds.

Strong disagree. The legal system is not a meritocracy. Lawyers go after the people who can pay them the most. They will always target the physician/hospital system, even if the NP was the primary provider.

Personally I see NPs and PAs as a big threat because you can just hire 1 doc and 9 NPs for the cost of 3 doctors. Even if NP salaries rise, you can still hire 5-6 for the price of 2 docs. Even if NPs lead to more litigation, it still has to be weighed against the savings in payroll. Thats why you need to think about the future of your given sub-specialty carefully.

Just my 2c. I think way too many people are complacent on the NP issue.

 

[Redpancreas]

Strong disagree. The legal system is not a meritocracy. Lawyers go after the people who can pay them the most. They will always target the physician/hospital system, even if the NP was the primary provider.

Personally I see NPs and PAs as a big threat because you can just hire 1 doc and 9 NPs for the cost of 3 doctors. Even if NP salaries rise, you can still hire 5-6 for the price of 2 docs. Even if NPs lead to more litigation, it still has to be weighed against the savings in payroll. Thats why you need to think about the future of your given sub-specialty carefully.

Just my 2c. I think way too many people are complacent on the NP issue.

OK fair enough. I'm not an expert on how these systems work but my previous post's been how I've thought about it.

 

[Matthew9Thirtyfive]

Strong disagree. The legal system is not a meritocracy. Lawyers go after the people who can pay them the most. They will always target the physician/hospital system, even if the NP was the primary provider.

Personally I see NPs and PAs as a big threat because you can just hire 1 doc and 9 NPs for the cost of 3 doctors. Even if NP salaries rise, you can still hire 5-6 for the price of 2 docs. Even if NPs lead to more litigation, it still has to be weighed against the savings in payroll. Thats why you need to think about the future of your given sub-specialty carefully.

Just my 2c. I think way too many people are complacent on the NP issue.

That's why these groups are pushing for these "providers" to have full liability and to not have physicians share any of it if they want to be independent. You can't sue a physician who isn't involved at all and doesn't share any liability. The hospitals will be forced to eat the costs, and we have to just hope they'll see how much it costs them to keep dealing with the suits, since clearly they don't actually care about the patients.

 

[Lawpy]

Should physicians be sued and fined severely if they're actively hiring and promoting midlevels, and midlevels screwed something up?

 

[Matthew9Thirtyfive]

Should physicians be sued and fined severely if they're actively hiring and promoting midlevels, and midlevels screwed something up?

Depends on the model. If it is a supervision state, then the physician should be appropriately supervising and held responsible if they aren’t.

For specialties like EM, it gets more complicated.

 

[7331poas]

That's why these groups are pushing for these "providers" to have full liability and to not have physicians share any of it if they want to be independent. You can't sue a physician who isn't involved at all and doesn't share any liability. The hospitals will be forced to eat the costs, and we have to just hope they'll see how much it costs them to keep dealing with the suits, since clearly they don't actually care about the patients.

How many patients in the hospital have to seen where there was literally no one else connected except the primary?

 

[Matthew9Thirtyfive]

How many patients in the hospital have to seen where there was literally no one else connected except the primary?

That's why it is easy for them to fly under the radar.

 

[Rekt]

Whatever this is, is probably getting direct funding from the psychopaths at the AANP.

Medicine is such a dumpster fire. Physicians are literally at the bottom of the totem pole nowadays. I'd never recommend medicine to anyone.

Unfortunately you don't get to see all this until it's too late so you're screwed.

 

[Matthew9Thirtyfive]

Whatever this is, is probably getting direct funding from the psychopaths at the AANP.

Medicine is such a dumpster fire. Physicians are literally at the bottom of the totem pole nowadays. I'd never recommend medicine to anyone.

Unfortunately you don't get to see all this until it's too late so you're screwed.

This was exactly what I was thinking. AANP dollars go far, and I completely believe they threw money at this to make this happen.

 

[Lawpy]

Whatever this is, is probably getting direct funding from the psychopaths at the AANP.

Medicine is such a dumpster fire. Physicians are literally at the bottom of the totem pole nowadays. I'd never recommend medicine to anyone.

Unfortunately you don't get to see all this until it's too late so you're screwed.

Why can't physicians lobby? Why are MS1s siding with midlevels? Why are there physicians working with midlevels and supporting/covering midlevel liabilities?

 

[Matthew9Thirtyfive]

Why can't physicians lobby? Why are MS1s siding with midlevels? Why are there physicians working with midlevels and supporting/covering midlevel liabilities?

Physicians have been beat down and brainwashed since day one of med school to put patients first and their own interests last. The AMA is who we rely on, but they are spineless.

Academic physicians simp hard for midlevels because midlevels let them do less work and make the hospital more money by charging the same but being paid less (and using more tests). M1s who have no idea what they are talking about are simping for midlevels to get in good graces with the academics destroying our profession and then many are also being forced to take interprofessional classes where they are told repeatedly that midlevels are just as good or better.

And then you have the non-academic physicians who don’t give a crap about what midlevels are doing to medicine because they make money off them.

 

[7331poas]

That's why it is easy for them to fly under the radar.

What does that have to do with anything? My point is that if the NP hospitalist ****s up, the specialists are going to be the targets, even if they had nothing to do with the error.

 

[Matthew9Thirtyfive]

What does that have to do with anything? My point is that if the NP hospitalist ****s up, the specialists are going to be the targets, even if they had nothing to do with the error.

It has to do with everything. In hospitals where the physicians are required to “supervise” the midlevels are protected because the physicians will be liability sponges. In hospitals where they are acting independently, they do tons of consults and many of their mistakes are fixed before significant morbidity or mortality can occur, and even when it does the hospital is more likely to absorb the liability. So all of this makes it easier for them to avoid being outed to the public for how dangerous they are.

You’re telling me you don’t see how that’s relevant?

 

[7331poas]

It has to do with everything. In hospitals where the physicians are required to “supervise” the midlevels are protected because the physicians will be liability sponges. In hospitals where they are acting independently, they do tons of consults and many of their mistakes are fixed before significant morbidity or mortality can occur, and even when it does the hospital is more likely to absorb the liability. So all of this makes it easier for them to avoid being outed to the public for how dangerous they are.

You’re telling me you don’t see how that’s relevant?

You keep going on with this argument that NPs will be "outed" to the public. Do you really think that is going to matter at the end of the day? Hospitals are the ones who hire NPs. No one is going to demand a re-route when their ambulance is headed to UTSW because they heard that NPs are working in the NICU. Most of the time patient's dont even know they are talking to an NP.

It reminds me of the Fight Club "motor company": if the cost of litigation is less than than the cost of recall, then do not recall the vehicle.

 

[Matthew9Thirtyfive]

You keep going on with this argument that NPs will be "outed" to the public. Do you really think that is going to matter at the end of the day? Hospitals are the ones who hire NPs. No one is going to demand a re-route when their ambulance is headed to UTSW because they heard that NPs are working in the NICU. Most of the time patient's dont even know they are talking to an NP.

It reminds me of the Fight Club "motor company": if the cost of litigation is less than than the cost of recall, then do not recall the vehicle.

That is exactly my point, so I guess you agree with me.

 

[7331poas]

That is exactly my point, so I guess you agree with me.

okay, my only comments. 1) it is completely irrelevant whether they are outed or not. 2) Even if NPs are independent, it will not significantly impact the hospital's risk, thus making them a great asset compared to physicians 3) pick a specialty that is positioned well against NP encroachment because it is coming (or NPs will drive down salaries of physicians and it will be both groups who lose out).

aight im out

 

[Matthew9Thirtyfive]

okay, my only comments. 1) it is completely irrelevant whether they are outed or not. 2) Even if NPs are independent, it will not significantly impact the hospital's risk, thus making them a great asset compared to physicians 3) pick a specialty that is positioned well against NP encroachment because it is coming (or NPs will drive down salaries of physicians and it will be both groups who lose out).

aight im out

Totally agree with your 2 and 3. I think 1 is important because it will help with lobbying. The public views our efforts as being about money and the AANP’s efforts as being about patients, which is ironic since it’s mostly the reverse. If the public is on our side, we have more power.

 

[Lem0nz]

Unpopular opinion, but conversation is usually more civil here on than Reddit where I get blasted, but the entire NP/PA discussion needs to be much better framed to talk about scope creep and scope creep alone. NPs and PAs are fking fantastic for surgical disciplines. I see a lot of the academic kids ranting on Reddit about how they're stealing procedures and it isn't OK but I'm sorry, I legitimately think you chose the wrong residency. My residency was overwhelmed with central lines and a-lines and... whatever. Pick your poison. I *wish* our NPs could have done lines because it would have freed us up to be in the operating room more. My fellowship is a community place that doesn't have residents and I would absolutely die without our NPs and PAs.

I've seen **** like "Physicians shouldn't teach NPs or PAs, its unacceptable." "NPs/PAs make tons of mistakes and its unacceptable." "NPs/PAs are incapable of thinking like physicians or being experts at something." "NPs/PAs should NEVER teach physicians or medical students."

All horse ****. They're people. Good ones can be taught nearly anything. Excellent ones can perform better than many physicians in their particular niche. My residency was clamoring for more so we could offload paperwork and routine tasks/consults to make room for more complex rotations and more OR time. If you're in a place where you are fighting an APP student or APP for something, you chose a place that has crummy volume for training. (And the med students being upset they aren't doing procedures over APPs - med students were rarely allowed and were never routinely taught procedures like central lines anywhere I've ever trained. There were exceptions for highly motivated people in extremely slow down times but that's it. That's part of residency training for most places).

You say in one sentence that NPs/PAs make mistakes but are corrected before it becomes readily apparent - so does literally every intern, PGY2, PGY3, and even PGY4 or 5 residents. That's called learning. The system is working if mistakes are caught and you aren't seeing tons of headlines about NPs murdering patients. I don't care if my NP makes a mistake and I check over their work and catch it and have to correct it, if 95% of everything else he did was right and we talk about why the mistake was made and fix it. The same way I wouldn't care if an intern or a medical student did it. Why is that a qualifier, that they aren't perfect?

To be clear - this has ABSOLUTELY NOTHING to do with APPs independently practicing. But the overwhelming zealotry and persecution of all APPs at every level: how they learn, how they function in day to day work, how they teach, how they are train, how they are taught, how they make mistakes like literally every other human being in medicine, is bull****. People using those things and drawing lines in the sand so they have more perceived reasons to fight scope creep is just wrong. Its wrong. And the attitude towards these people who are also caregivers is wrong. Demonizing all of them is really really ****ty. If you're getting shoved out of the way at a big name academic institution, welcome to medicine. Don't choose to go to a big name academic institution because that doesn't stop for the rest of your life in those places.

In one breath you say physicians are brainwashed to put patients first and themselves last, and in the next complain about how community physicians are using the system correctly to make themselves more money. You can't have it both ways. Bravo to the community docs who built huge practices and manage their midlevels to generate revenue. If they do it safely, more power to them. If they don't do it safely, you're right, they'll get sued, and they'll be out of a job. It will sort itself out.

End of unpopular opinion.

 

[Steve_Zissou]

 

[Lem0nz]

Got a real hard time believing GW hospital doesn't have a resident lounge somewhere. #academicproblems

 

[Matthew9Thirtyfive]

Got a real hard time believing GW hospital doesn't have a resident lounge somewhere. #academicproblems

You missed the point. They are literally equating physicians and NPs.

As for your other post, I somewhat agree with you. But you said a couple things that just don’t track. Midlevels making mistakes is not the same as residents making mistakes. Residents are supposed to make mistakes in training. They’re in training. Midlevels are not in training. When they make a mistake with a patient where there are layers of protection, they hurt people.

And even when they are overseen by physicians, they are still hurting people. When they send people home without consulting the supervising physician and the patient has an adverse event, they are hurting people. When they order unnecessary tests and inappropriate consults, they are hurting people. When they don’t tell the whole story on the phone when calling a consult because they don’t understand it, they’re hurting people.

These aren’t hypotheticals. This literally happens every day. The reason this is important is these people are trying to practice medicine without a medical license. They are pushing for independent practice in every state when they don’t even have the same knowledge base as an MS3.

Surgery PAs and NPs can be a huge help to surgery. That’s great. When they start doing lumps and bumps and minor cases, do you think they will stop there? Absolutely not, and that’s why you’re now starting to see surgeons finally complaining about scope creep. They will not stop anywhere, because for their lobby groups it is about ego and money. They don’t care about the patients. If they did, they wouldn’t fabricate bull**** studies and misrepresent data.

You’re a super specialized surgeon. It makes sense that you don’t see it in your field. But don’t fall into the trap of solipsism. Midlevel creep is literally killing patients.

And yes you can have it both ways. We don’t protest and strike because ultimately patients will get hurt. So we keep seeing patients and hoping that the spineless AMA will lobby for us. Except the people who did this to us are the boomer docs who grew up in medicine without this problem and then created it by training midlevels to replace docs in order to make as much money as possible while publishing ridiculous studies like the one out of Yale or UPenn, selling the younger generation down the river. It is absolutely happening both ways.

 

[Lem0nz]

You missed the point. They are literally equating physicians and NPs.

I did not miss the point, I am not that dense. Nor do I think you missed mine. Residents have probably had their own space in that hospital for 50-100 years. NPs/PAs are not nurses and shouldn't have to share their lounge, and are not residents and shouldn't invade their space either. Also, people like to pretend every single NP/PA is 1-3 years out of graduating. The vast majority have been doing something for 5 years+ and have more experience at that one thing than a resident. That doesn't make them better at medicine. It doesn't make them worse. It makes it different. By your logic you're equating chief residents with attendings, and fellows with attendings. They are not. They are above residents and below attendings. But they can share a lounge and deserve to be in a place that isn't a nurse lounge (the same as chiefs and fellows) but should not be allowed to invade the space of residents which can and should be separate and protected from all of those people. Attendings aren't allowed in resident lounges anywhere I've ever gone (unless its by invitation by the residents). They certainly don't go there to shoot the **** and steal their space. Its safe from all other providers. If you want to advocate for an APP only lounge, please. One hospital I interviewed at had that, and it was about equivalent to a resident lounge, and that was fantastic. But many hospitals struggle to find that sort of space. My residency could not have accommodated that.

As for your other post, I somewhat agree with you. But you said a couple things that just don’t track. Midlevels making mistakes is not the same as residents making mistakes. Residents are supposed to make mistakes in training. They’re in training. Midlevels are not in training. When they make a mistake with a patient where there are layers of protection, they hurt people.

I simply disagree with you - you are wrong. Residents are now doctors, they are out of medical school. NPs and PAs are now practitioners, they are also out of school. That does not mean they don't need to continue learning and being taught and that they won't make mistakes, the same as residents. When they make a mistake where there are layers of protection they do not hurt people, that's the entire point of layers of protection. That's... why its called... protection...

And even when they are overseen by physicians, they are still hurting people. When they send people home without consulting the supervising physician and the patient has an adverse event, they are hurting people. When they order unnecessary tests and inappropriate consults, they are hurting people. When they don’t tell the whole story on the phone when calling a consult because they don’t understand it, they’re hurting people.

If you have not seen a resident do each and every one of these things yet without consulting their attending, do not fret friend. You will. And they hurt people at no more or no less the rate than NPs/PAs making the exact same mistakes. I have seen residents send patients home because they assumed the attending would want that (the same as an NP or PA would) and get burned. I have seen residents order unnecessary tests by the truck loads, and they get yelled at for doing it, the same as an NP or PA would in my institution. Medicine inappropriately consults surgery as a fact of life, and those consults come from residents. Welcome to my entire world. Its fine, it happens. The consequences, again, are the same as for an NP or PA. And seriously, who do you think calls in consults in the middle of the night at the ER? You think the chief resident who knows everything about the patient is doing it, or even the mid level? No sir. That's the intern, who was told to do it and probably had the bare minimum context. It is, absolutely, no different. Its a mistake when they do it, its a mistake when a NP or PA does it, its just a mistake. And this is my point. Do attendings do this? Not nearly as often. Do NPs or PAs who have been working someplace for five years do this? Not nearly as often. Do NPs or PAs 1-3 years into their job or PGY1-3s do this? Sure do.

These aren’t hypotheticals. This literally happens every day. The reason this is important is these people are trying to practice medicine without a medical license. They are pushing for independent practice in every state when they don’t even have the same knowledge base as an MS3.

You're right. This does happen every day. By residents, NPs, and PAs who are inexperienced. You as a PGY1-3 will be trying to practice medicine with a medical training license. Your NP/PA will be practicing with their own licensure and credentialing which, 1-3 years out of practice, almost always is under very strict supervision by someone more senior. And now you're tying a very normal occurrence back to independent medical practice with no supervision for someone straight out of NP/PA school which is NOT THE SAME THING. Of course I think APPs immediately out of school practicing independently is bat**** insane. I would never want that for a patient. But that is not the vast majority of NPs or PAs in the real world.

Surgery PAs and NPs can be a huge help to surgery. That’s great. When they start doing lumps and bumps and minor cases, do you think they will stop there? Absolutely not, and that’s why you’re now starting to see surgeons finally complaining about scope creep. They will not stop anywhere, because for their lobby groups it is about ego and money. They don’t care about the patients. If they did, they wouldn’t fabricate bull**** studies and misrepresent data.

I don't care if they don't stop. I've seen many general surgeons stop doing big cases because they're afraid of the risk and liability. If NPs and PAs want to try their hand at that level of risk, they will quickly realize why surgeons do surgery and subspecialist surgeons do harder surgery and they will either succeed and be excellent surgeons (I doubt it) or they will crash and burn. It will sort itself out.

You’re a super specialized surgeon. It makes sense that you don’t see it in your field. But don’t fall into the trap of solipsism. Midlevel creep is literally killing patients.

You are a medical student. Don't fall into the trap of solipsism that what you have seen in academic practice and all of the rants and raves on reddit are anymore than what they are - a sampling of academic teaching institutions which is an echo chamber often magnified by other trainees who do not have nearly a decade or more of medicine under their belts yet. There are far less community practice, attending type people posting on SDN and Reddit because what they have is extremely functional and makes sense. Midlevel creep may literally be killing patients, but midlevels who are in their first few years out of a job are not. Midlevels who are practicing under physicians (even at 1:9 ratios)... they probably aren't man. Midlevels who are doing their job, even if it includes procedures and complex surgery (we have an NP who does the contralateral breast simultaneously with a plastic surgeon - their results are fantastic), they aren't hurting or killing people. Their outcomes are fine, and reproducible, just like a surgeon's can be if they are trained appropriately.

And yes you can have it both ways. We don’t protest and strike because ultimately patients will get hurt. So we keep seeing patients and hoping that the spineless AMA will lobby for us. Except the people who did this to us are the boomer docs who grew up in medicine without this problem and then created it by training midlevels to replace docs in order to make as much money as possible while publishing ridiculous studies like the one out of Yale or UPenn, selling the younger generation down the river. It is absolutely happening both ways.

I'm going to be honest and while the rest of my post may have been a bit of a snarky come back, I'm taking a step back here and I really do not mean this to be rude. In my experience in a handful of academic institutions, I have never been treated like an equal coming from a community non-university place. I've been treated kindly, and not been abused at all, but there were very few who treated my opinion like it was equal to theirs. That's fine. I'm not upset by that. But when you say things like community docs don't give a **** because they're making money - I reiterate, bravo to them for doing what's important to them and what they want to. Why should these docs rally for the plight of academia who has never really looked highly on them?

But even if they did, I'll set that aside for a second and say what I said to Reddit. In the real world community setting, attendings are often covering multiple hospitals and multiple clinics. Even if you have residents, they're likely to only be at the flagship hub for 24/7 coverage and not at the smaller spokes. APPs are vital to making sure their time is maximized, even for residents and medical students, so that if there's a central line way out in BFE that your attending is not driving half an hour to do a 30 minute minor procedure and driving back half an hour + 30 minutes for paperwork and BS which is two hours he could have been in the operating room teaching you something. This does not just apply to surgery - its the same for routine consults for FM or IM or whatever. Pick your specialty. You don't want your attending wasting two hours when it can be done better, faster, and more efficiently in an umbrella type set-up. That will often mean that said APP will have to be trained at the hub institution as well because that's probably where the volume is concentrated to allow for actual training to occur. This is life. Many of those attendings are salaried to boot! So when I say avoid solipsism which I definitely did dripping with sarcasm, there is some truth to it. Your view on this will 100% change when you're the attending trying to balance all of the BS paperwork, the minor procedures no one wants to do, the routine consults that do not need to be seen by you right away to get the ball rolling and tests moving so that when you come to see them results are already available and you can start treatment, the teaching obligations for multiple tiers of trainees in various points of experience, whatever.

The vast majority of APPs are not hurting and killing people. That's some gaslighting scare tactic **** to fit your narrative. APPs independently practicing without any experience are scary, and they are real, and they should be crushed. APPs independently practicing with 5-10 years or more of experience are an entirely different beast and may be appropriate in a whole variety of settings and should be their own discussion as well. The blind APP rage and hate on Reddit and permeating here as well is stupid and I hate it and I will continue to speak out against it.

 

[Matthew9Thirtyfive]

I did not miss the point, I am not that dense. Nor do I think you missed mine. Residents have probably had their own space in that hospital for 50-100 years. NPs/PAs are not nurses and shouldn't have to share their lounge, and are not residents and shouldn't invade their space either. Also, people like to pretend every single NP/PA is 1-3 years out of graduating. The vast majority have been doing something for 5 years+ and have more experience at that one thing than a resident. That doesn't make them better at medicine. It doesn't make them worse. It makes it different. By your logic you're equating chief residents with attendings, and fellows with attendings. They are not. They are above residents and below attendings. But they can share a lounge and deserve to be in a place that isn't a nurse lounge (the same as chiefs and fellows) but should not be allowed to invade the space of residents which can and should be separate and protected from all of those people. Attendings aren't allowed in resident lounges anywhere I've ever gone (unless its by invitation by the residents). They certainly don't go there to shoot the **** and steal their space. Its safe from all other providers. If you want to advocate for an APP only lounge, please. One hospital I interviewed at had that, and it was about equivalent to a resident lounge, and that was fantastic. But many hospitals struggle to find that sort of space. My residency could not have accommodated that.

I simply disagree with you - you are wrong. Residents are now doctors, they are out of medical school. NPs and PAs are now practitioners, they are also out of school. That does not mean they don't need to continue learning and being taught and that they won't make mistakes, the same as residents. When they make a mistake where there are layers of protection they do not hurt people, that's the entire point of layers of protection. That's... why its called... protection...

If you have not seen a resident do each and every one of these things yet without consulting their attending, do not fret friend. You will. And they hurt people at no more or no less the rate than NPs/PAs making the exact same mistakes. I have seen residents send patients home because they assumed the attending would want that (the same as an NP or PA would) and get burned. I have seen residents order unnecessary tests by the truck loads, and they get yelled at for doing it, the same as an NP or PA would in my institution. Medicine inappropriately consults surgery as a fact of life, and those consults come from residents. Welcome to my entire world. Its fine, it happens. The consequences, again, are the same as for an NP or PA. And seriously, who do you think calls in consults in the middle of the night at the ER? You think the chief resident who knows everything about the patient is doing it, or even the mid level? No sir. That's the intern, who was told to do it and probably had the bare minimum context. It is, absolutely, no different. Its a mistake when they do it, its a mistake when a NP or PA does it, its just a mistake. And this is my point. Do attendings do this? Not nearly as often. Do NPs or PAs who have been working someplace for five years do this? Not nearly as often. Do NPs or PAs 1-3 years into their job or PGY1-3s do this? Sure do.

You're right. This does happen every day. By residents, NPs, and PAs who are inexperienced. You as a PGY1-3 will be trying to practice medicine with a medical training license. Your NP/PA will be practicing with their own licensure and credentialing which, 1-3 years out of practice, almost always is under very strict supervision by someone more senior. And now you're tying a very normal occurrence back to independent medical practice with no supervision for someone straight out of NP/PA school which is NOT THE SAME THING. Of course I think APPs immediately out of school practicing independently is bat**** insane. I would never want that for a patient. But that is not the vast majority of NPs or PAs in the real world.

I don't care if they don't stop. I've seen many general surgeons stop doing big cases because they're afraid of the risk and liability. If NPs and PAs want to try their hand at that level of risk, they will quickly realize why surgeons do surgery and subspecialist surgeons do harder surgery and they will either succeed and be excellent surgeons (I doubt it) or they will crash and burn. It will sort itself out.

You are a medical student. Don't fall into the trap of solipsism that what you have seen in academic practice and all of the rants and raves on reddit are anymore than what they are - a sampling of academic teaching institutions which is an echo chamber often magnified by other trainees who do not have nearly a decade or more of medicine under their belts yet. There are far less community practice, attending type people posting on SDN and Reddit because what they have is extremely functional and makes sense. Midlevel creep may literally be killing patients, but midlevels who are in their first few years out of a job are not. Midlevels who are practicing under physicians (even at 1:9 ratios)... they probably aren't man. Midlevels who are doing their job, even if it includes procedures and complex surgery (we have an NP who does the contralateral breast simultaneously with a plastic surgeon - their results are fantastic), they aren't hurting or killing people. Their outcomes are fine, and reproducible, just like a surgeon's can be if they are trained appropriately.

I'm going to be honest and while the rest of my post may have been a bit of a snarky come back, I'm taking a step back here and I really do not mean this to be rude. In my experience in a handful of academic institutions, I have never been treated like an equal coming from a community non-university place. I've been treated kindly, and not been abused at all, but there were very few who treated my opinion like it was equal to theirs. That's fine. I'm not upset by that. But when you say things like community docs don't give a **** because they're making money - I reiterate, bravo to them for doing what's important to them and what they want to. Why should these docs rally for the plight of academia who has never really looked highly on them?

But even if they did, I'll set that aside for a second and say what I said to Reddit. In the real world community setting, attendings are often covering multiple hospitals and multiple clinics. Even if you have residents, they're likely to only be at the flagship hub for 24/7 coverage and not at the smaller spokes. APPs are vital to making sure their time is maximized, even for residents and medical students, so that if there's a central line way out in BFE that your attending is not driving half an hour to do a 30 minute minor procedure and driving back half an hour + 30 minutes for paperwork and BS which is two hours he could have been in the operating room teaching you something. This does not just apply to surgery - its the same for routine consults for FM or IM or whatever. Pick your specialty. You don't want your attending wasting two hours when it can be done better, faster, and more efficiently in an umbrella type set-up. That will often mean that said APP will have to be trained at the hub institution as well because that's probably where the volume is concentrated to allow for actual training to occur. This is life. Many of those attendings are salaried to boot! So when I say avoid solipsism which I definitely did dripping with sarcasm, there is some truth to it. Your view on this will 100% change when you're the attending trying to balance all of the BS paperwork, the minor procedures no one wants to do, the routine consults that do not need to be seen by you right away to get the ball rolling and tests moving so that when you come to see them results are already available and you can start treatment, the teaching obligations for multiple tiers of trainees in various points of experience, whatever.

The vast majority of APPs are not hurting and killing people. That's some gaslighting scare tactic **** to fit your narrative. APPs independently practicing without any experience are scary, and they are real, and they should be crushed. APPs independently practicing with 5-10 years or more of experience are an entirely different beast and may be appropriate in a whole variety of settings and should be their own discussion as well. The blind APP rage and hate on Reddit and permeating here as well is stupid and I hate it and I will continue to speak out against it.

Bro, you are part of the problem. SMH.

 

[Lem0nz]

Shake away. Your opinion will evolve. So will mine. But independent practice of APPs with no experience does not mean its OK to vilify most APPs like your posts do. They developed for a reason. Yay capitalism.

 

[Matthew9Thirtyfive]

Shake away. Your opinion will evolve. So will mine. But independent practice of APPs with no experience does not mean its OK to vilify most APPs like your posts do. They developed for a reason. Yay capitalism.

Sad to see physicians saying stuff like this. Your viewpoint will destroy our profession and hurt people. But as long as you can sleep at night I guess.

 

[Lem0nz]

I sleep just fine, thank you. What will destroy our profession is our inability to adapt, not my viewpoint. Physicians are drawing lines in the sand and crying at the unfairness instead of thinking and evolving to expand their own scope or market share. Market forces are going to mow them down.

 

[7331poas]

I sleep just fine, thank you. What will destroy our profession is our inability to adapt, not my viewpoint. Physicians are drawing lines in the sand and crying at the unfairness instead of thinking and evolving to expand their own scope or market share. Market forces are going to mow them down.

Adding APPs does not increase the physician scope or market share, it subtracts from it. Thats why it is vital in my opinion to enter specialties where NPs are not a significant threat.

 

[Lem0nz]

I consider throughput to be a key part of market share. If you don't think adding APPs to your own service would increase your efficiency and allow you to take care of more people you're using them wrong.

 

[7331poas]

I consider throughput to be a key part of market share. If you don't think adding APPs to your own service would increase your efficiency and allow you to take care of more people you're using them wrong.

Except an independently practicing NP does not do what you are claiming, they replace physicians. When an NP opens their own clinic, they are not "increasing the efficiency" of the doctor down the road.

 

[Lem0nz]

I... jesus. Did you read anything I wrote? I literally wrote I do not support independently practicing NPs.

 

[Lem0nz]

This is why we can't have nice things. Give a medical student a 2 page paper and they read one line and take it out of context and are upset the upper year didn't teach them anything when they got the question wrong.

 

[7331poas]

This is why we can't have nice things. Give a medical student a 2 page paper and they read one line and take it out of context and are upset the upper year didn't teach them anything when they got the question wrong.

Dont worry, I have never complained about not being taught, only not being dismissed.

 

[Lem0nz]

I believe you. M935 thinks my viewpoint is the problem.

 

[Dr.SPAC3MAN]

Unpopular opinion, but conversation is usually more civil here on than Reddit where I get blasted, but the entire NP/PA discussion needs to be much better framed to talk about scope creep and scope creep alone. NPs and PAs are fking fantastic for surgical disciplines. I see a lot of the academic kids ranting on Reddit about how they're stealing procedures and it isn't OK but I'm sorry, I legitimately think you chose the wrong residency. My residency was overwhelmed with central lines and a-lines and... whatever. Pick your poison. I *wish* our NPs could have done lines because it would have freed us up to be in the operating room more. My fellowship is a community place that doesn't have residents and I would absolutely die without our NPs and PAs.

I've seen **** like "Physicians shouldn't teach NPs or PAs, its unacceptable." "NPs/PAs make tons of mistakes and its unacceptable." "NPs/PAs are incapable of thinking like physicians or being experts at something." "NPs/PAs should NEVER teach physicians or medical students."

All horse ****. They're people. Good ones can be taught nearly anything. Excellent ones can perform better than many physicians in their particular niche. My residency was clamoring for more so we could offload paperwork and routine tasks/consults to make room for more complex rotations and more OR time. If you're in a place where you are fighting an APP student or APP for something, you chose a place that has crummy volume for training. (And the med students being upset they aren't doing procedures over APPs - med students were rarely allowed and were never routinely taught procedures like central lines anywhere I've ever trained. There were exceptions for highly motivated people in extremely slow down times but that's it. That's part of residency training for most places).

You say in one sentence that NPs/PAs make mistakes but are corrected before it becomes readily apparent - so does literally every intern, PGY2, PGY3, and even PGY4 or 5 residents. That's called learning. The system is working if mistakes are caught and you aren't seeing tons of headlines about NPs murdering patients. I don't care if my NP makes a mistake and I check over their work and catch it and have to correct it, if 95% of everything else he did was right and we talk about why the mistake was made and fix it. The same way I wouldn't care if an intern or a medical student did it. Why is that a qualifier, that they aren't perfect?

To be clear - this has ABSOLUTELY NOTHING to do with APPs independently practicing. But the overwhelming zealotry and persecution of all APPs at every level: how they learn, how they function in day to day work, how they teach, how they are train, how they are taught, how they make mistakes like literally every other human being in medicine, is bull****. People using those things and drawing lines in the sand so they have more perceived reasons to fight scope creep is just wrong. Its wrong. And the attitude towards these people who are also caregivers is wrong. Demonizing all of them is really really ****ty. If you're getting shoved out of the way at a big name academic institution, welcome to medicine. Don't choose to go to a big name academic institution because that doesn't stop for the rest of your life in those places.

In one breath you say physicians are brainwashed to put patients first and themselves last, and in the next complain about how community physicians are using the system correctly to make themselves more money. You can't have it both ways. Bravo to the community docs who built huge practices and manage their midlevels to generate revenue. If they do it safely, more power to them. If they don't do it safely, you're right, they'll get sued, and they'll be out of a job. It will sort itself out.

End of unpopular opinion.

I think most people would agree to some extent with you. I don't think anyone here is arguing that NPs/PAs are useless, simply that practicing out of their scope could potentially endanger patients. Sure there are a lot of intelligent and talented NPs/PAs out there, but there is a reason for the extensive training of physicians. Now if there is data that shows that physician training is irrelevant compared to NP/PA training, that is a different discussion.

 

[Lem0nz]

I think most people would agree to some extent with you. I don't think anyone here is arguing that NPs/PAs are useless, simply that practicing out of their scope could potentially endanger patients. Sure there are a lot of intelligent and talented NPs/PAs out there, but there is a reason for the extensive training of physicians. Now if there is data that shows that physician training is irrelevant compared to NP/PA training, that is a different discussion.

Yes. I agree. My opinion when you boil it down is fairly no controversial.

What I have seen a lot though is that people who are fighting the front on NP or PA scope then generalize, like M935 did, to extend this to many other aspects of their general day to day duties. Like seeing consults in a hospital, or putting in routine orders independently or ordering tests without talking to their attending. If that is within their scope of practice that’s *normal*. If your the NP on med onc and get a consult for a new mass and you see it, write up the consult, call a consult to IR for a biopsy opinion and get a new CT with contrast and order tumor markers before talking to the attending, so that the patient’s care is being moved along while the attending is in clinic all day so results will be ready in the afternoon, that’s all normal. That is their scope of practice. I would expect the same of a resident. Attending may be notified of the consult immediately, or maybe 4-5 hours later once the rest of the work is sorted out and it’s time for round. That isn’t dangerous or killing people, it’s normal. NPs or PAs in my discipline run their own post op clinics on every service line and only notify the attending when patients deviate from normal post op course. That’s independent practice, no? I haven’t felt it to be dangerous at all and it lets the surgeons see more new consults and operate more.

Also see a lot of comments that mid levels should not be trained by physicians, or should not take precedence over training physicians. It’s not either/or, both have to occur. Some programs are clearly struggling with having enough volume to teach everyone they need to teach judging by the up in arms comments but that doesn’t mean mid levels become second class citizens. It means the system needs to do a better job to teach both. I see things like medical students saying a mid level should never teach them because they aren’t doctors... man, if a mid level been doing their specialty for 10+ years and they’re good at it, they probably have way more time than the attending to give you attention and teach and they’ll probably do a good job. They aren’t sitting on Twitter all day and they aren’t mindless apes. 🙄

 

[Lem0nz]

Like, three posts up is a rant that mid levels are not in training the second they graduate. Let’s exclude the 5% of APPs (I think it’s probably far less) who are coming out of school and trying to go into *completely, zero physician oversight* medicine on their own because I agree that’s insane. The other 95% of APPs undergo on average six months to a year, sometimes multiple years, of teaching by their bosses who range from other APPs and physicians. That’s training. They aren’t just cut loose into a hospital to roam. And the insinuation that they make more mistakes and hurt people even when they’re being overseen by physicians and other APPs during that time who are teaching them their new role inside this new scope is dumb and not true. But these are recurring themes, devoid from reality, used to try to justify the argument that APPs should not have independent practice and are dangerous.

They’re just completely separate issues and one of them is gaslighting and not true.

 

[Lawpy]

Unpopular opinion, but conversation is usually more civil here on than Reddit where I get blasted, but the entire NP/PA discussion needs to be much better framed to talk about scope creep and scope creep alone. NPs and PAs are fking fantastic for surgical disciplines. I see a lot of the academic kids ranting on Reddit about how they're stealing procedures and it isn't OK but I'm sorry, I legitimately think you chose the wrong residency. My residency was overwhelmed with central lines and a-lines and... whatever. Pick your poison. I *wish* our NPs could have done lines because it would have freed us up to be in the operating room more. My fellowship is a community place that doesn't have residents and I would absolutely die without our NPs and PAs.

I've seen **** like "Physicians shouldn't teach NPs or PAs, its unacceptable." "NPs/PAs make tons of mistakes and its unacceptable." "NPs/PAs are incapable of thinking like physicians or being experts at something." "NPs/PAs should NEVER teach physicians or medical students."

All horse ****. They're people. Good ones can be taught nearly anything. Excellent ones can perform better than many physicians in their particular niche. My residency was clamoring for more so we could offload paperwork and routine tasks/consults to make room for more complex rotations and more OR time. If you're in a place where you are fighting an APP student or APP for something, you chose a place that has crummy volume for training. (And the med students being upset they aren't doing procedures over APPs - med students were rarely allowed and were never routinely taught procedures like central lines anywhere I've ever trained. There were exceptions for highly motivated people in extremely slow down times but that's it. That's part of residency training for most places).

You say in one sentence that NPs/PAs make mistakes but are corrected before it becomes readily apparent - so does literally every intern, PGY2, PGY3, and even PGY4 or 5 residents. That's called learning. The system is working if mistakes are caught and you aren't seeing tons of headlines about NPs murdering patients. I don't care if my NP makes a mistake and I check over their work and catch it and have to correct it, if 95% of everything else he did was right and we talk about why the mistake was made and fix it. The same way I wouldn't care if an intern or a medical student did it. Why is that a qualifier, that they aren't perfect?

To be clear - this has ABSOLUTELY NOTHING to do with APPs independently practicing. But the overwhelming zealotry and persecution of all APPs at every level: how they learn, how they function in day to day work, how they teach, how they are train, how they are taught, how they make mistakes like literally every other human being in medicine, is bull****. People using those things and drawing lines in the sand so they have more perceived reasons to fight scope creep is just wrong. Its wrong. And the attitude towards these people who are also caregivers is wrong. Demonizing all of them is really really ****ty. If you're getting shoved out of the way at a big name academic institution, welcome to medicine. Don't choose to go to a big name academic institution because that doesn't stop for the rest of your life in those places.

In one breath you say physicians are brainwashed to put patients first and themselves last, and in the next complain about how community physicians are using the system correctly to make themselves more money. You can't have it both ways. Bravo to the community docs who built huge practices and manage their midlevels to generate revenue. If they do it safely, more power to them. If they don't do it safely, you're right, they'll get sued, and they'll be out of a job. It will sort itself out.

End of unpopular opinion.

There are schools with strong surgery programs that allow students to do those types of procedures. At some point, med education needs to stop treating med students as a liability and teach them skills and procedures like that had been done a few decades ago.

 

[Lawpy]

This is why i keep aggressively pushing for a 1 yr preclinical so that 3 yrs of clinical can be extremely useful to learn clinical skills and start acting more like an intern with advanced skills by 3rd year. Stop treating med students like a burden and prepare them to be strong residents by PGY1. Learning central lines as an intern can be also learned as a sub I in 4th year.

 

[Jack Donaghy]

Wow. I mean, the fact that Lem0nz saw the GW poster, didn't take any issue with it, and went on to continue his (her) crusade for midlevels tells you all you need to know. This level of simp is precisely why our profession is dead. We can't even band together and agree that people with markedly less training and oversight is a BAD thing for patient care.

 

[Lawpy]

Wow. I mean, the fact that Lem0nz saw the GW poster, didn't take any issue with it, and went on to continue his (her) crusade for midlevels tells you all you need to know. This level of simp is precisely why our profession is dead. We can't even band together and agree that people with markedly less training and oversight is a BAD thing for patient care.

He has valid reasons and i can agree midlevels have some value. I just very strongly disagree with treating med students as a liability and not teaching them procedures like central lines.

 

[VA Hopeful Dr]

Sad to see physicians saying stuff like this. Your viewpoint will destroy our profession and hurt people. But as long as you can sleep at night I guess.

Holy hyperbole Batman

 

[Lawpy]

Midlevels = lack standardized training and can practice with few hundred hours from online diploma mills = can practice doing hundreds of central lines with no issues or concerns about liability

Med students = aggressively screened and selected for by adcoms and are highly intelligent = don't teach them central lines because liability

???

 

[Dr.SPAC3MAN]

man, if a mid level been doing their specialty for 10+ years and they’re good at it, they probably have way more time than the attending to give you attention and teach and they’ll probably do a good job.

but one of the problems is the lack of standardization in the NP/PA profession that makes it almost impossible to distinguish between the 10+ years vet and the brand new online degree version NP.

 

[Lem0nz]

Wow. I mean, the fact that Lem0nz saw the GW poster, didn't take any issue with it, and went on to continue his (her) crusade for midlevels tells you all you need to know. This level of simp is precisely why our profession is dead. We can't even band together and agree that people with markedly less training and oversight is a BAD thing for patient care.

You don’t need someone with five years of residency training to see a routine consult and order some tests first so that an attending only has to see someone once later instead of twice up front. Sorry, but complete waste of resources. You don’t need someone with 5 years of training to look at a well healing wound and say you’re ok to start heavy lifting and go back to work.

Our profession isn’t dead. Stop being dramatic and gaslighting. It’s ridiculous.

 

[Lawpy]

You don’t need someone with five years of residency training to see a routine consult and order some tests first so that an attending only has to see someone once later instead of twice up front. Sorry, but complete waste of resources. You don’t need someone with 5 years of training to look at a well healing wound and say you’re ok to start heavy lifting and go back to work.

Our profession isn’t dead. Stop being dramatic and gaslighting. It’s ridiculous.

Med students can do all those though?

 

[Styrene]

Whatever this is, is probably getting direct funding from the psychopaths at the AANP.

Medicine is such a dumpster fire. Physicians are literally at the bottom of the totem pole nowadays. I'd never recommend medicine to anyone.

Unfortunately you don't get to see all this until it's too late so you're screwed.

Yea, that is a good point. AANP is interesting from what I've read.

 

[Lem0nz]

but one of the problems is the lack of standardization in the NP/PA profession that makes it almost impossible to distinguish between the 10+ years vet and the brand new online degree version NP.

Yes! Absolutely. One of many problems that I am in no way discounting and that are important. But PAs are a great example - they’re very specific to their attendings needs. How do you standardize a surgical PA, for example, who assists with liver transplant and immunosuppression vs. a CT PA who harvests veins? I don’t think you can, or should. You simply define their scope and their post graduate training and education have to then be tailored to that scope. Even an NP who did an online degree straight out of nursing school can go through a similar process. I personally would NEVER hire someone like that, but it doesn’t mean it can’t be done and if it’s a low stakes thing, maybe like running a vaccine clinic, it’s not necessarily unreasonable.

 

[Steve_Zissou]

You don’t need someone with five years of residency training to see a routine consult and order some tests first so that an attending only has to see someone once later instead of twice up front. Sorry, but complete waste of resources. You don’t need someone with 5 years of training to look at a well healing wound and say you’re ok to start heavy lifting and go back to work.

Our profession isn’t dead. Stop being dramatic and gaslighting. It’s ridiculous.

So how do you propose we combat the ever-growing scope for mid-levels that is being pushed by the AAPA and the AANP? Do physicians keep training people who want to replace them in states where NPs have total independence? Do we just accept it and move to a model where physicians are mostly managers, like anesthesia in the south?