The future?

[Lawpy]

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This thread is convincing me that there's so many things med students can do to be helpful but can't because attendings and hospitals think they're a liability and a burden who waste time and multiply their work.

 

[Lem0nz]

Do we just accept it and move to a model where physicians are mostly managers, like anesthesia in the south?

This would be my solution, yes. I believe the function of an NP or PA is to allow someone to function at the top of their license. I believe an FM or IM doc could safely manage and oversee multiple APPs with low risk and uncomplicated problems while funneling complicated patients to the MD. I believe a surgeon could use them to offload almost all non operative work and work up for new consults and allow said surgeon to do one pre-op visit and the operation for patients proceeding along pathway with normal recovery. Not everything - you still round on patients once a day. If they deviate from routine recovery you see them. But even when they deviate sometimes you don’t need to physical see them for the next step to be performed - maybe they need a CT first, and then they come see the surgeon. That is a visit and evaluation that could safely be done by my PAs currently and expedites and streamlines care.

Again - not advocating at all for a totally independent practice. I think that’s insane. But independent practice within a care team that is planned and trained and executed well - 100% for it.

 

[Steve_Zissou]

For the record, I agree with @Matthew9Thirtyfive. Reliance on midlevels seems unnecessary looking at other countries, and becoming reliant on them will only hurt physicians. In an ideal world, the AANP would not be such a big political force and actually want their NPs to be extenders for physicians, but we don’t live in an ideal world. That is why you see the AANP putting out propaganda that NPs provide similar OR BETTER outcomes than physicians. I’ll let you draw your own conclusion as to why they’re putting out that sort of propaganda. Same with the CRNAs.

 

[Steve_Zissou]

This would be my solution, yes. I believe the function of an NP or PA is to allow someone to function at the top of their license. I believe an FM or IM doc could safely manage and oversee multiple APPs with low risk and uncomplicated problems while funneling complicated patients to the MD. I believe a surgeon could use them to offload almost all non operative work and work up for new consults and allow said surgeon to do one pre-op visit and the operation for patients proceeding along pathway with normal recovery. Not everything - you still round on patients once a day. If they deviate from routine recovery you see them. But even when they deviate sometimes you don’t need to physical see them for the next step to be performed - maybe they need a CT first, and then they come see the surgeon. That is a visit and evaluation that could safely be done by my PAs currently and expedites and streamlines care.

Again - not advocating at all for a totally independent practice. I think that’s insane. But independent practice within a care team that is planned and trained and executed well - 100% for it.

I wonder how appealing being a mid level manager, with a couple patients here and there, is to most people. Sure you make more money, but there’s no way you can make sure your midlevels didn’t miss things on however many patients you’re giving them every day.

I, for one, did not choose to pursue medicine to be a manager. I was interested in anesthesia and completely said “nope” after shadowing one who works in the south during my first year of med school.

 

[Lem0nz]

This thread is convincing me that there's so many things med students can do to be helpful but can't because attendings and hospitals think they're a liability and a burden who waste time and multiply their work.

I hear your crusade and don’t disagree but the problem is a medicolegal issue. There are only certain, very small, very specific parts of your work that can be used and billed for and not have to be duplicated. It creates a problem in high volume places that are busy.

As for procedure type things, that’s a little different. As a resident I occasionally taught them but only to gunner MS4s - MS3s change their mind or don’t end up in the field way, way to often and many will never use the skill. And I only have a finite amount of time with an MS3 where afterwards you may never come to surgery for the rest of your life. And there are *so many* of you, as opposed to one or two MS4s at a time vs a resident who is there for five years. Some of these skills need lots of repetitions and finding the opportunities and times can be very challenging to make it worthwhile for both the student and teacher.

 

[Lawpy]

I hear your crusade and don’t disagree but the problem is a medicolegal issue. There are only certain, very small, very specific parts of your work that can be used and billed for and not have to be duplicated. It creates a problem in high volume places that are busy.

As for procedure type things, that’s a little different. As a resident I occasionally taught them but only to gunner MS4s - MS3s change their mind or don’t end up in the field way, way to often and many will never use the skill. And I only have a finite amount of time with an MS3 where afterwards you may never come to surgery for the rest of your life. And there are *so many* of you, as opposed to one or two MS4s at a time vs a resident who is there for five years. Some of these skills need lots of repetitions and finding the opportunities and times can be very challenging to make it worthwhile for both the student and teacher.

Iirc there's a recent revision to make med student notes billable:

MD & DO - Medical Student Notes Now Billable

Title is pretty self-explanatory, but here's a link for those interested: https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2018Downloads/R3971CP.pdf Thoughts? Critiques? Overly-dramatic opinions about the end of medicine as we know it?

forums.studentdoctor.net

I was thinking to delegate the procedures to MS4s/sub Is to keep them busy (even if it's like a dozen) and let MS3s to do the orders and wound checkups, even if they aren't interested in surgery?

This probably depends on the curriculum. In a 1 yr preclinical model, the interest in surgery can be solidified by 3rd year. So there'll be more interested MS3s and MS4s to help out

 

[Lem0nz]

I wonder how appealing being a mid level manager, with a couple patients here and there, is to most people. Sure you make more money, but there’s no way you can make sure your midlevels didn’t miss things on however many patients you’re giving them every day.

I, for one, did not choose to pursue medicine to be a manager. I was interested in anesthesia and completely said “nope” after shadowing one who works in the south during my first year of med school.

That’s totally fair and I can’t argue with that, but in the same vein I think you’d have trouble arguing that with how robust evidence based medicine is becoming that a lot of it isn’t formulaic. New patient comes in with hypertension can be boiled down to a protocol and unless x deviations exist gets x work up and started on x drug; if x deviation, notify MD. A protocol like that should be made by an MD in my opinion but can safely and cheaply be carried out by an APP. Do you disagree with that?

Maybe you lose the enjoyment of seeing more patients in that world but for better or worse we live in a capitalist society and that’s just us becoming more efficient. It may suck for a lot of people but it doesn’t make it wrong or dangerous, unfortunately.

 

[Lem0nz]

Iirc there's a recent revision to make med student notes billable:

MD & DO - Medical Student Notes Now Billable

Title is pretty self-explanatory, but here's a link for those interested: https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2018Downloads/R3971CP.pdf Thoughts? Critiques? Overly-dramatic opinions about the end of medicine as we know it?

forums.studentdoctor.net

I was thinking to delegate the procedures to MS4s/sub Is to keep them busy (even if it's like a dozen) and let MS3s to do the orders and wound checkups, even if they aren't interested in surgery?

This probably depends on the curriculum. In a 1 yr preclinical model, the interest in surgery can be solidified by 3rd year. So there'll be more interested MS3s and MS4s to help out

We can’t delegate procedures to Med students unsupervised, ever. That’s the key difference and it’s wildly important. Once an intern learns how to do a line they can do a line independently. A Med student can never, ever do that. Doesn’t matter how competent you are - if you screw up or there’s a complication (even if it’s not your fault) that is a set up to get sued and lose a medical license real quick.

 

[Steve_Zissou]

That’s totally fair and I can’t argue with that, but in the same vein I think you’d have trouble arguing that with how robust evidence based medicine is becoming that a lot of it isn’t formulaic. New patient comes in with hypertension can be boiled down to a protocol and unless x deviations exist gets x work up and started on x drug; if x deviation, notify MD. A protocol like that should be made by an MD in my opinion but can safely and cheaply be carried out by an APP. Do you disagree with that?

Maybe you lose the enjoyment of seeing more patients in that world but for better or worse we live in a capitalist society and that’s just us becoming more efficient. It may suck for a lot of people but it doesn’t make it wrong or dangerous, unfortunately.

It’s formulaic until it isn’t. If that were the case, why would we need mid levels? Why not just have your CNA take their vitals and have them fill out some boxes on a digital spreadsheet?

 

[Lem0nz]

It’s formulaic until it isn’t. If that were the case, why would we need mid levels? Why not just have your CNA take their vitals and have them fill out some boxes on a digital spreadsheet?

If/when I go to hire my own PA what I’m going to be looking for is someone who can recognize when something deviates from protocol. They don’t need to necessarily know what to do next (over time they might), that’s the MDs role, but learning that sort of pattern recognition is the value of PA school to me and what they should be taught pre-graduate, and that can be done without going to medical school. Medical school teaches people to deal with every eventuality and the consequences of doing something. That’s what I believe the difference to be.

I’m sure many on these forums have heard the phrase “I can teach a monkey to do surgery. Surgeons exist to deal with the complications.” Or some variation of it. There is some truth to this.

 

[Lawpy]

We can’t delegate procedures to Med students unsupervised, ever. That’s the key difference and it’s wildly important. Once an intern learns how to do a line they can do a line independently. A Med student can never, ever do that. Doesn’t matter how competent you are - if you screw up or there’s a complication (even if it’s not your fault) that is a set up to get sued and lose a medical license real quick.

I'm confused why midlevels are trusted to do these procedures unsupervised? Because if midlevels screw up, won't the supervising physicians be in trouble?

 

[Steve_Zissou]

If/when I go to hire my own PA what I’m going to be looking for is someone who can recognize when something deviates from protocol. They don’t need to necessarily know what to do next (over time they might), that’s the MDs role, but learning that sort of pattern recognition is the value of PA school to me and what they should be taught pre-graduate, and that can be done without going to medical school. Medical school teaches people to deal with every eventuality and the consequences of doing something. That’s what I believe the difference to be.

I’m sure many on these forums have heard the phrase “I can teach a monkey to do surgery. Surgeons exist to deal with the complications.” Or some variation of it. There is some truth to this.

What I’m saying is, why do you even need a PA or NP if all you need is a protocol and a warning when someone’s situation deviates from it? Taking your formulaic idea further, why not just get rid of half of internists, have some CNAs memorize a sheet of questions, and treat patients that way?

Mid levels can have a place in medicine, but when you’re giving up the vast majority of your scope to them, don’t be surprised when they think they are equivalent to you and come for your job.

 

[Lem0nz]

I'm confused why midlevels are trusted to do these procedures unsupervised? Because if midlevels screw up, won't the supervising physicians be in trouble?

They are licensed and credentialed. Medical students are not. Yes, the supervising physician is responsible, and a certain level of complications is expected no matter who’s hands a procedure is in. But that’s different from an unlicensed and uncredentialed trainee. I don’t know how else to explain it than that. It’s malpractice to let someone with no license do things unsupervised. APPs have licenses and credentials.

 

[Lem0nz]

I'm confused why midlevels are trusted to do these procedures unsupervised? Because if midlevels screw up, won't the supervising physicians be in trouble?

You’re comparing a medical student to a mid level. That’s not equivalent. Comparing a Med student to an NP or PA student would be more appropriate, from a licensing and liability perspective.

 

[Lawpy]

They are licensed and credentialed. Medical students are not. Yes, the supervising physician is responsible, and a certain level of complications is expected no matter who’s hands a procedure is in. But that’s different from an unlicensed and uncredentialed trainee. I don’t know how else to explain it than that. It’s malpractice to let someone with no license do things unsupervised. APPs have licenses and credentials.

In that case, midlevels should face the brunt of liability lawsuits, not the supervising physician.

 

[Lem0nz]

In that case, midlevels should face the brunt of liability lawsuits, not the supervising physician.

...no. That’s like saying if a resident ****s up the resident should be liable and not the attending. Incorrect. Attending is responsible. If you feel that an APP or resident isn’t qualified to do something safely then you don’t allow them to do it. Otherwise you be prepared to deal with the consequences if/when something goes wrong.

 

[Dr.SPAC3MAN]

They are licensed and credentialed. Medical students are not. Yes, the supervising physician is responsible, and a certain level of complications is expected no matter who’s hands a procedure is in. But that’s different from an unlicensed and uncredentialed trainee. I don’t know how else to explain it than that. It’s malpractice to let someone with no license do things unsupervised. APPs have licenses and credentials.

If a mistake/complication occurred while a medical student (unlicensed) was working, it costs them their future. If a mistake/complication occurred while a NP/PA (licensed) was working, it falls on the hands of the supervising physician. Seems like there should be more consequences for NPs/PAs. And I understand why it is problematic for unlicensed personnel to practice (legal nightmare), but shouldn't there be more severe consequences for NPs/PAs ? seems like they want their cake and eat it too. Just my thoughts.

 

[Lawpy]

...no. That’s like saying if a resident ****s up the resident should be liable and not the attending. Incorrect. Attending is responsible. If you feel that an APP or resident isn’t qualified to do something safely then you don’t allow them to do it. Otherwise you be prepared to deal with the consequences if/when something goes wrong.

A resident is in training though. So the supervision is necessary. Midlevels are practically healthcare professionals in their own right. Even the midlevel organizations strongly believe they're independent professionals. So treat them that way by prosecuting them directly when they mess up, commit illegal/unethical practices etc.

 

[Steve_Zissou]

If a mistake/complication occurred while a medical student (unlicensed) was working, it costs them their future. If a mistake/complication occurred while a NP/PA (licensed) was working, it falls on the hands of the supervising physician. Seems like there should be more consequences for NPs/PAs. And I understand why it is problematic for unlicensed personnel to practice (legal nightmare), but shouldn't there be more severe consequences for NPs/PAs ? seems like they want their cake and eat it too. Just my thoughts.

Seems like the physicians hiring them and not giving them proper oversight want to have their cake and eat it too. If we’re working within the framework that they are not well enough trained to be independent, then the physician should get sued to all hell if their NP or PA ****s up and they don’t catch it. If we cede that they should be able to practice independently, then med levels should bear the brunt of their mistakes.

I’m find with physicians getting run into the ground if their mid levels **** up and they don’t catch it. The issue is when hospitals force physicians to oversee midlevels. Then it should be the hospital getting run into the ground, not the physician.

 

[Lem0nz]

Seems like the physicians hiring them and not giving them proper oversight want to have their cake and eat it too. If we’re working within the framework that they are not well enough trained to be independent, then the physician should get sued to all hell if their NP or PA ****s up and they don’t catch it. If we cede that they should be able to practice independently, then med levels should bear the brunt of their mistakes.

I’m find with physicians getting run into the ground if their mid levels **** up and they don’t catch it. The issue is when hospitals force physicians to oversee midlevels. Then it should be the hospital getting run into the ground, not the physician.

I agree with everything here.

As for Spaceman’s comment, if the NP or PA is going to BILL for the procedure the same as a physician would then they should be liable completely. If they’re going to function like residents and do procedures to offload work while the hospital does whatever billing it does for supervised procedures (if any) and the APP doesn’t bill, then they stay under the umbrella of the supervising doc for liability.

 

[Lem0nz]

A resident is in training though. So the supervision is necessary. Midlevels are practically healthcare professionals in their own right. Even the midlevel organizations strongly believe they're independent professionals. So treat them that way by prosecuting them directly when they mess up, commit illegal/unethical practices etc.

I guess I’m still not doing a good enough job explaining this but residents and APPs do not always need supervision but are still under the liability umbrella of the attending. The way this worked in my residency was that there was a set criteria and training for central line placement. Once you did five supervised lines with no input from the supervising person successfully you were deemed safe to do them without supervision and that at that point you should have an acceptable complication rate compared to everyone else in the facility doing that procedure. If something goes wrong while you’re doing it unsupervised then the attending needs to be able to safely handle the complication.

You have to be licensed and credentialed to get that training. An APP license or medical training license is sufficient. A nursing license isn’t. A medical student with no license isn’t. That was how my hospital decided to make sure people doing the procedure were safe enough, and that whatever harm they may cause can be dealt with by their attending.

 

[Lawpy]

I guess I’m still not doing a good enough job explaining this but residents and APPs do not always need supervision but are still under the liability umbrella of the attending. The way this worked in my residency was that there was a set criteria and training for central line placement. Once you did five supervised lines with no input from the supervising person successfully you were deemed safe to do them without supervision and that at that point you should have an acceptable complication rate compared to everyone else in the facility doing that procedure. If something goes wrong while you’re doing it unsupervised then the attending needs to be able to safely handle the complication.

You have to be licensed and credentialed to get that training. An APP license or medical training license is sufficient. A nursing license isn’t. A medical student with no license isn’t. That was how my hospital decided to make sure people doing the procedure were safe enough, and that whatever harm they may cause can be dealt with by their attending.

I'm wondering why midlevels even require being under the liability umbrella of an attending in the first place. Residents have the ultimate goal of being a physician where all liability falls on them. For that, they need to learn from the attendings themselves. What's the end goal for midlevels? To stay forever under the liability umbrella while being practically independent professionals?

The midlevel organizations are right to push for independent practice for that reason because it makes no sense for them to always depend on a supervising physician and not be independent on their own right. Yes SDN strongly opposes independent practice rights but forcing midlevels to face the complete brunt of liability and malpractice lawsuits will end any and all encroachment for good.

 

[Lem0nz]

Well I’ve made my unpopular opinion known and I can’t explain myself any further. Feel free to blast it apart. More than anything I support my fellow physicians to disagree with me and have other opinions and I encourage it. This topic is complicated.

 

[Neopolymath]

I'm going to make one post in this thread and then unwatch it because it fatigues me to see this discussed ad nauseum BUT I have noticed a trend in the OR for many, many years as well as during medical school afterwards.

Surgeons have some compelling reasons to use midlevels as attendings and in training programs. I can't argue that having a PA do all the BS so you can perfect your tradecraft doesn't sound appealing. It really does sound awesome. It's basically how ortho uses the hospitalist service (lol no shade, seriously) so that they can concentrate on what they enjoy. Smart.

What I have a problem with is the bigger picture. Surgery is not the majority of medicine. Surgery also doesn't give a **** about anyone else's fields even if they pretend they do online on sdn and reddit. Because it helps surgery and they are insulated (for now) from these issues they don't give a **** about other fields very real problems with midlevels. I'm not going to say they are *actively* selling us all down the river but they definitely are passively doing so. To the public, surgery is scary and hard so if they condone midlevels being used then sure they can take over all the less scary and easier fields. The prestigious minority of medicine is sending a message that affects everyone else. To them, the ability for their day to day to be better is more important than anything else. Think I'm wrong? Go spend some time speaking with anesthesiologists who have to compromise their art or lose their contract. Go talk to people who get told no regional for this patient because it might add 10 minutes to the schedule for a slow as piss surgeon.

You want midlevels to stay in their lane? You need surgery on board. You just aren't going to get that as past behavior predicts future behavior quite well.

Note: This post is not directed at Lemon but in general. I don't know this guy.

 

[Lawpy]

Well I’ve made my unpopular opinion known and I can’t explain myself any further. Feel free to blast it apart. More than anything I support my fellow physicians to disagree with me and have other opinions and I encourage it. This topic is complicated.

I don't have much issue other than confusion over the midlevel liability part. I get why students aren't allowed to do central lines because they're unlicensed vs midlevels being licensed. I just don't know why midlevels are covered by liability umbrella of attendings vs being independent.

 

[Lawpy]

I know i'm the rebel here for pushing midlevel independence but i argue that's better than midlevels being covered by attendings. It doesn't make midlevels viewed as trainees forever and rather as independent professionals who can be prosecuted to the fullest extent of liability and malpractice laws

 

[Captain_Falcon]

I'm still waiting for my Midlevel lawyer idea to take off to handle all the easy court stuff. Dont tell the JDs in my family about it though!

 

[7331poas]

What is odd to me is how surgery perceives its role in anything outside of the OR. How can you just "send down the PA" and claim that is sufficient?

The one thing I have taken away from clinical year is how absurd the interaction is when an EM doc calls a specialty service. Call nsg to evaluate a patient with a brain bleed... and they send down the PA. What does that solve? What is the neurosurg PA going to offer here other than an excuse for the neurosurgeon to avoid evaluating a patient?

 

[LutGholein]

Don’t mind me folks, I’m just here to give a quick plug to PPP.

 

[Captain_Falcon]

Don’t mind me folks, I’m just here to give a quick plug to PPP.

https://www.google.com/url?sa=t&sou...4QFnoECAMQAQ&usg=AOvVaw3G9-fK5e7apOIcUJCMHjdh

[/URL]

Link ^^^

 

[Lawpy]

Don’t mind me folks, I’m just here to give a quick plug to PPP.

I know for a fact that many surgery attendings support this

 

[Lawpy]

What is odd to me is how surgery perceives its role in anything outside of the OR. How can you just "send down the PA" and claim that is sufficient?

The one thing I have taken away from clinical year is how absurd the interaction is when an EM doc calls a specialty service. Call nsg to evaluate a patient with a brain bleed... and they send down the PA. What does that solve? What is the neurosurg PA going to offer here other than an excuse for the neurosurgeon to avoid evaluating a patient?

I'm more upset that EM gets viewed as "dumb" or "annoying folks" in these consult calls, but i just hate specialty bashing of any kind

 

[Maimonides1]

Remember that some/majority of all Mid-Levels are the dreamers “physicians-want-to-be” who failed the highly selective process and did not matriculate in ANY medical school and ultimately took their short paths.., are highly represented in AANP!

Every physician specialty that utilized them -despite the obvious short term advantages in efficiency- ended up paying the heavy price down the road in eroding their practice scope, academic standing and reimbursements!!

 

[Steve_Zissou]

There are med students on reddit advocating for PAs to take all their science courses with MDs. We will be our own downfall, if ever we do fall.

 

[Lawpy]

There are med students on reddit advocating for PAs to take all their science courses with MDs. We will be our own downfall, if ever we do fall.

Why are med students sabotaging each other while aggressively obsessing over prestige and top tiers

@efle @Matthew9Thirtyfive something went horribly wrong help pls

 

[Matthew9Thirtyfive]

Why are med students sabotaging each other while aggressively obsessing over prestige and top tiers

@efle @Matthew9Thirtyfive something went horribly wrong help pls

They are seeing it modeled by academic attendings who just simp nonstop for midlevels. Not that I have to worry about this, but if I ever did the civilian match, I would not rank a single program that equated midlevels and physicians. There are programs who on Twitter are saying NPs know as much medicine as they do. If you’re an attending physician and an NP knows as much medicine as you do, something has gone horribly wrong in your education.

 

[DrNotaDr]

Remember that some/majority of all Mid-Levels are the dreamers “physicians-want-to-be” who failed the highly selective process and did not matriculate in ANY medical school and ultimately took their short paths.., are highly represented in AANP!

Every physician specialty that utilized them -despite the obvious short term advantages in efficiency- ended up paying the heavy price down the road in eroding their practice scope, academic standing and reimbursements!!

The majority of all mid levels applied to medical school and failed to gain entry. Can you prove that statement?

 

[Matthew9Thirtyfive]

The majority of all mid levels applied to medical school and failed to gain entry. Can you prove that statement?

Well that’s not what he said, so probably not.

 

[DrNotaDr]

Well that’s not what he said, so probably not.

Fine, as a faculty physician his words carry weight, as they should, and it should be easy to prove most mid levels in the AANP tried and failed to gain entry to medical school.

 

[Matthew9Thirtyfive]

Fine, as a faculty physician his words carry weight, as they should, and it should be easy to prove most mid levels in the AANP tried and failed to gain entry to medical school.

But again, that’s not what he said.

 

[Lem0nz]

I'm going to make one post in this thread and then unwatch it because it fatigues me to see this discussed ad nauseum BUT I have noticed a trend in the OR for many, many years as well as during medical school afterwards.

Surgeons have some compelling reasons to use midlevels as attendings and in training programs. I can't argue that having a PA do all the BS so you can perfect your tradecraft doesn't sound appealing. It really does sound awesome. It's basically how ortho uses the hospitalist service (lol no shade, seriously) so that they can concentrate on what they enjoy. Smart.

What I have a problem with is the bigger picture. Surgery is not the majority of medicine. Surgery also doesn't give a **** about anyone else's fields even if they pretend they do online on sdn and reddit. Because it helps surgery and they are insulated (for now) from these issues they don't give a **** about other fields very real problems with midlevels. I'm not going to say they are *actively* selling us all down the river but they definitely are passively doing so. To the public, surgery is scary and hard so if they condone midlevels being used then sure they can take over all the less scary and easier fields. The prestigious minority of medicine is sending a message that affects everyone else. To them, the ability for their day to day to be better is more important than anything else. Think I'm wrong? Go spend some time speaking with anesthesiologists who have to compromise their art or lose their contract. Go talk to people who get told no regional for this patient because it might add 10 minutes to the schedule for a slow as piss surgeon.

You want midlevels to stay in their lane? You need surgery on board. You just aren't going to get that as past behavior predicts future behavior quite well.

Note: This post is not directed at Lemon but in general. I don't know this guy.

@Neopolymath

This is a good post and largely accurate. Its probably worth having a conversation about why this is more than anything. What do you think you could say to convince me to get on board? You're completely right - I am not. Midlevels make my life much better (both now and in residency) and after a really tough residency that is longer and (for the most part) more challenging than other fields, I'm not inclined to go to war for FM or IM or psych when doing so is going to hurt me and give me more hours to work doing mundane tasks I hate that don't reimburse well. As is in fellowship we get pushback for what hospitalists feel are unnecessary medical consults leaving us to manage our own medicine. Totally fine but I offload it onto my PA if the hospitalists want no part in it. There are just more valuable uses of my time. You say that for us the ability for our day to day to be better is more important than anything else and that's 100% correct. Quality of life for myself when I usually show up earlier and leave later than my medical counterparts, quality of care I provide to my patients, and quantity of care I can provide to my patients matter more to me than anything else.

I don't think its correct to say we do it all out of greed or just quality of life for ourselves. Like your regional block comment - I would advocate strongly for that in my patients and wish anesthesia would do it so we could stop using epidurals, but that trifecta - quality of life, care I provide, and quantity of care I provide is absolutely how I feel.

So as a surgical subspecialist - I'm legitimately asking, how do you get me on board? Everyone is always pushing all of us to do more with less and I have very little less to give at this point in my life - APPs are a very good way to mitigate that. Particularly in places with no residents, but even in places with residents.

 

[Maimonides1]

As a super surgical sub specialist I have lots of respect and admiration for the great detailed and diverse work my physician colleagues do in Internal medicine Pediatrics and other primary cares.., and I don’t understand the lack of respect from health administrators, insurance bean counters and Gov bureaucrats who are enabling Mid levels through legislation rather than education..!?
A well trained seasoned primary care physician should shine everyday in this unfair system and prove to all the value of his delicate care and lifelong education and keep the midlevels do their safe at their base.

 

[Jack Donaghy]

@Neopolymath

This is a good post and largely accurate. Its probably worth having a conversation about why this is more than anything. What do you think you could say to convince me to get on board? You're completely right - I am not. Midlevels make my life much better (both now and in residency) and after a really tough residency that is longer and (for the most part) more challenging than other fields, I'm not inclined to go to war for FM or IM or psych when doing so is going to hurt me and give me more hours to work doing mundane tasks I hate that don't reimburse well. As is in fellowship we get pushback for what hospitalists feel are unnecessary medical consults leaving us to manage our own medicine. Totally fine but I offload it onto my PA if the hospitalists want no part in it. There are just more valuable uses of my time. You say that for us the ability for our day to day to be better is more important than anything else and that's 100% correct. Quality of life for myself when I usually show up earlier and leave later than my medical counterparts, quality of care I provide to my patients, and quantity of care I can provide to my patients matter more to me than anything else.

I don't think its correct to say we do it all out of greed or just quality of life for ourselves. Like your regional block comment - I would advocate strongly for that in my patients and wish anesthesia would do it so we could stop using epidurals, but that trifecta - quality of life, care I provide, and quantity of care I provide is absolutely how I feel.

So as a surgical subspecialist - I'm legitimately asking, how do you get me on board? Everyone is always pushing all of us to do more with less and I have very little less to give at this point in my life - APPs are a very good way to mitigate that. Particularly in places with no residents, but even in places with residents.

You exemplify what is wrong with many surgeons that I've come across: you think you're more important than other physicians and/or you think your work is more important than the work other physicians do.

Taking out a gallbladder = important.
Establishing a lifelong relationship with a patient and guiding them through the lifestyle changes necessary to prevent gallbladder disease = equally important.

You are not a god.

 

[Lem0nz]

You exemplify what is wrong with many surgeons that I've come across: you think you're more important than other physicians and/or you think your work is more important than the work other physicians do.

Taking out a gallbladder = important.
Establishing a lifelong relationship with a patient and guiding them through the lifestyle changes necessary to prevent gallbladder disease = equally important.

You are not a god.

Sorry you feel that way. I am not a god nor do I think I am. I don't think the work other physicians do is more or less important. But I do think my first duty is to my patients, my self, and my family. I need help to have my life not suck and my hours not get worse and to provide optimal care to my patients. It is provided to me by APPs where I work. If you think I have a god complex for not wanting to work more than 12 hours a day than maybe you should be evaluating yourself more than me.

Edit: PS - The way to convince someone who's actually willing to listen to the other side and wants civil dialogue is not to insult them. I hope a midlevel takes a nice healthy chunk of your business, maybe they won't know anything but at least they'll probably be kind to their patients and their peers.

 

[7331poas]

Working in the OR = making money = "worth my time and effort"

Evaluating a new patient in the ED = not making money = "not worth my time and effort"

Crazy how surgeons preach that their specialty is "more than just cutting" when they simultaneously consider everything else beneath them.

 

[VA Hopeful Dr]

Remember that some/majority of all Mid-Levels are the dreamers “physicians-want-to-be” who failed the highly selective process and did not matriculate in ANY medical school and ultimately took their short paths.., are highly represented in AANP!

Every physician specialty that utilized them -despite the obvious short term advantages in efficiency- ended up paying the heavy price down the road in eroding their practice scope, academic standing and reimbursements!!

Umm, nope.

FM income has been going up every year since I started medical school.

We have never been respected, academically speaking.

And it's ridiculous to think that midlevels are what caused our scope to narrow over the last 50 years.

 

[Mad Jack]

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.

The biggest problem that many do not understand is that nurse practitioners are not held to the same legal standards as physicians. For instance, if a FNP was being sued for negligence, you could not use a physician as an expert witness, as professions are not deemed to be able to judge the capability of other professions. This makes it just as hard to sue a FNP but you get far less return, as you need to find one of their own to sell them out and they aren't held to the same standards as physicians despite arguing that they can do the same work

 

[Mad Jack]

This thread is convincing me that there's so many things med students can do to be helpful but can't because attendings and hospitals think they're a liability and a burden who waste time and multiply their work.

Med students really do slow me down. I enjoy working with them but it's like a chef teaching their child to cook, you just can't do it as quickly or efficiently as doing it alone because you're retreading basics and checking their work. There's some small areas where they make life easier but generally teaching is something you do because the next generation needs to learn, not because they are immediately useful

 

[Maimonides1]

The biggest problem that many do not understand is that nurse practitioners are not held to the same legal standards as physicians. For instance, if a FNP was being sued for negligence, you could not use a physician as an expert witness, as professions are not deemed to be able to judge the capability of other professions. This makes it just as hard to sue a FNP but you get far less return, as you need to find one of their own to sell them out and they aren't held to the same standards as physicians despite arguing that they can do the same work

Umm, nope.

FM income has been going up every year since I started medical school.

We have never been respected, academically speaking.

And it's ridiculous to think that midlevels are what caused our scope to narrow over the last 50 years.

Shortsighted selfishness.. will ultimately lead to your perpetual professional demise..!

 

[VA Hopeful Dr]

Shortsighted selfishness.. will ultimately lead to your perpetual professional demise..!

Do what now?