sallyhasanidea

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Is there any threat of midlevel encroachment in heme/onc?

I see in general IM, outpatient primary care + hospitalist, PA's/NP's are increasingly being hired; is there any possibility of midlevels encroaching in heme onc and saturating the job market?
 

whoknows2012

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Is there any threat of midlevel encroachment in heme/onc?

I see in general IM, outpatient primary care + hospitalist, PA's/NP's are increasingly being hired; is there any possibility of midlevels encroaching in heme onc and saturating the job market?

No
 
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whoknows2012

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Could you please elaborate

For several reasons I don’t see this as an issue. (For mal heme and solid tumor Onc at least, benign/non-malignant heme aside)

1) research driven nature of field (in academics at least)
2) importance of experience in the “art” or oncology which is more so than most fields
3) increasing age of population and cancers as a result
4) nothing on the ground supporting encroachment at the moment

As an aside there is definitely a huge push to hire NPs and PAs to help in workflow, prior auths, infusion center visits, etc. this costs money and COULD result in a center deciding to hire more mid levels and less oncologists but I don’t view this as encroachment as Much as I see it as a necessary aspect of the current oncology care model in 2020

I have a small amount of knowledge on the pp/hybrid side and so mine is more academic tilted but @gutonc can share more from his perspective
 

sallyhasanidea

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For several reasons I don’t see this as an issue. (For mal heme and solid tumor Onc at least, benign/non-malignant heme aside)

1) research driven nature of field (in academics at least)
2) importance of experience in the “art” or oncology which is more so than most fields
3) increasing age of population and cancers as a result
4) nothing on the ground supporting encroachment at the moment

As an aside there is definitely a huge push to hire NPs and PAs to help in workflow, prior auths, infusion center visits, etc. this costs money and COULD result in a center deciding to hire more mid levels and less oncologists but I don’t view this as encroachment as Much as I see it as a necessary aspect of the current oncology care model in 2020

I have a small amount of knowledge on the pp/hybrid side and so mine is more academic tilted but @gutonc can share more from his perspective

2) importance of experience in the “art” or oncology which is more so than most fields --- could you please expand on examples of what you mean by this?
 

whoknows2012

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2) importance of experience in the “art” or oncology which is more so than most fields --- could you please expand on examples of what you mean by this?

Here I was hoping just responding “no” would suffice. Really making my job tough on this Sunday morning!

With nccn guidelines oncology can feel very cookie cutter and guideline based, advanced colon ca, FOLFOX, AML 7+3, metastatic pancreatic ca FOLFIRINOX etc. the truth is though the best oncologists know when to deviate from these guidelines and beyond that know how to deal with extremely complex cases. This is what I refer to as the “art” of oncology. Knowing when to treat vs wait for certain results to come back. Knowing when to refer for a trial. Knowing when to recommend hospice. Knowing if a patient can tolerate an intense regimen. I can go on an on. When you’ve seen some of the better oncologists this idea is as clear as day and would be difficult (impossible?) to achieve as a mid level
 
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CatFactorial

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Nope. Breadth and depth of material is too extensive for encroachment.
 
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bobsmith

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There's such a wide range of patients that heme/onc physicians see - I think with appropriate backup, mid-levels could (and many already do) handle some stable non-malignant hematology patients (pts receiving IV iron, epo, etc), some patients that are on stable chemotherapy regimens, follow-up surveillance scans, and patients stable on some oral chemotherapy regimens.

But really hard to imagine mid-levels rising to being able to see a new pt and determining a treatment strategy, or any patient that requires a change in chemo regimen.

This is in stark contrast to primary care where mid-levels can get trained in a good amount of bread and butter problems or go through a preventive care checklist relatively easily.

Because of this, survivorship is probably the best and most natural place for them to expand.
 
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sallyhasanidea

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There's such a wide range of patients that heme/onc physicians see - I think with appropriate backup, mid-levels could (and many already do) handle some stable non-malignant hematology patients (pts receiving IV iron, epo, etc), some patients that are on stable chemotherapy regimens, follow-up surveillance scans, and patients stable on some oral chemotherapy regimens.

But really hard to imagine mid-levels rising to being able to see a new pt and determining a treatment strategy, or any patient that requires a change in chemo regimen.

This is in stark contrast to primary care where mid-levels can get trained in a good amount of bread and butter problems or go through a preventive care checklist relatively easily.

Because of this, survivorship is probably the best and most natural place for them to expand.

Do you think this will cause a saturation in heme onc job market at some point, if mid levels run all the survivorship clinics?
 

gutonc

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Do you think this will cause a saturation in heme onc job market at some point, if mid levels run all the survivorship clinics?
No.

I use NPs a lot. I still have more patients on my schedule than I know what to do with. They are more than welcome to the "survivorship" visits (however you want to define that). Seeing a stable Stage I old lady breast cancer on year 4 of 5 of an AI doesn't make me any money. Seeing 4 new patients and getting them started on chemo makes me a lot of money.

I also use NPs like residents/fellows for my new patients. They write the note except for the assessment and plan. I write the chemo orders and bill. I can easily 7 or 8 new patients in a day with an NP where 3 or 4 is pushing it (assuming all are new cancers needing chemo) by myself.
 
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gutonc

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Just to add to this. My current next open new patient appointment is October 8th. I have 9 new patient referrals sitting my queue waiting for me to figure out how to schedule them sooner than that.
 
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whoknows2012

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Do you think this will cause a saturation in heme onc job market at some point, if mid levels run all the survivorship clinics?

Is this concern of yours about mid level encroachment related to wanting to pursue hem/Onc and unsure of prospects? Some other reason?
 
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Another angle to think about this is down the line what things might look like if we end up in a single payer system. I imagine mid-levels will become widespread as a cheaper alternative to prop up an inefficient system (see: recent push to completed replace Anesthesiologists with CRNAs at VAs). When I try to think of "non-surgical fields in which patients might get pissed at their politicians trying to replace us with mid-levels" I think Oncology has to be pretty high on that list but perhaps I am biased.

FWIW I also enjoy the mid-levels that I've worked with in clinic, they are pretty awesome people although I have only been a fellow for a few months.
 

whoknows2012

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Another angle to think about this is down the line what things might look like if we end up in a single payer system. I imagine mid-levels will become widespread as a cheaper alternative to prop up an inefficient system (see: recent push to completed replace Anesthesiologists with CRNAs at VAs). When I try to think of "non-surgical fields in which patients might get pissed at their politicians trying to replace us with mid-levels" I think Oncology has to be pretty high on that list but perhaps I am biased.

FWIW I also enjoy the mid-levels that I've worked with in clinic, they are pretty awesome people although I have only been a fellow for a few months.

No

(take 2)
 

whoknows2012

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Could you please elaborate

(take 2)

don’t need to repeat myself. Read the totality of what @gutonc and I have posted above. I don’t think that matters if we’re single payer, MFA or with the current system (or some hybrid). Might reimbursements to down? Surely a possibility-but that doesn’t mean more mid levels will be hired to replace MDs. There zero evidence of this and I can promise you no one is worried about this (outside of SDN apparently?)
 
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bronx43

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Frankly, I don't see how "I use NPs all the time" and "there is/will be no midlevel encroachment" can be anything other than contradictory. And this isn't a heme onc issue, but one regarding medicine as a whole.

The question isn't "will mid-levels replace [specialty X]?" The question is "will there be encroachment," whereby the logical definition of "encroachment" is "does the midlevel take on any of the duties which was or currently is ascribed to a physician?" Just in the last decade, I have seen more midlevels at every level of the healthcare delivery enterprise and in every segment of the industry - academic, private hospital, physician owned. Therefore, encroachment has already and is currently happening - perhaps at breakneck speed. With midlevels, employers can hire fewer docs to perform the same or more work.

The actual question which I think OP is asking is inherently different, which is "will this cause saturation in the job market." Based on the answers here, it seems like the answer is "not right now."

What will happen in the next 10 years as the boomers fade, and the smaller gen Xers come in to replace them, while fellowships/residencies continue to expand and hospital systems are looking to cut cost? Who knows... but on a macro level, it's not looking great for us physicians.

And in the end, what's safer? Heme onc or GIM? Most likely heme onc.
 
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whoknows2012

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Frankly, I don't see how "I use NPs all the time" and "there is/will be no midlevel encroachment" can be anything other than contradictory. And this isn't a heme onc issue, but one regarding medicine as a whole.

The question isn't "will mid-levels replace [specialty X]?" The question is "will there be encroachment," whereby the logical definition of "encroachment" is "does the midlevel take on any of the duties which was or currently is ascribed to a physician?" Just in the last decade, I have seen more midlevels at every level of the healthcare delivery enterprise and in every segment of the industry - academic, private hospital, physician owned. Therefore, encroachment has already and is currently happening - perhaps at breakneck speed. With midlevels, employers can hire fewer docs to perform the same or more work.

The actual question which I think OP is asking is inherently different, which is "will this cause saturation in the job market." Based on the answers here, it seems like the answer is "not right now."

What will happen in the next 10 years as the boomers fade, and the smaller gen Xers come in to replace them, while fellowships/residencies continue to expand and hospital systems are looking to cut cost? Who knows... but on a macro level, it's not looking great for us physicians.

And in the end, what's safer? Heme onc or GIM? Most likely heme onc.

Fair points all around. I think the necessary question is a relative one as you mentioned at the end. May be useful to know which specialties if any are more prone to issues stemming from this, which for the sake of this discussion id place hem/onc on the lower end
 
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Fair points all around. I think the necessary question is a relative one as you mentioned at the end. May be useful to know which specialties if any are more prone to issues stemming from this, which for the sake of this discussion id place hem/onc on the lower end

I may not have worded my post very well but this is exactly what I was trying to say. For many reasons, I think Oncology would be one of the safer non-procedural specialties if OP is concerned about encroachment.
 

CatFactorial

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Frankly, I don't see how "I use NPs all the time" and "there is/will be no midlevel encroachment" can be anything other than contradictory. And this isn't a heme onc issue, but one regarding medicine as a whole.

The question isn't "will mid-levels replace [specialty X]?" The question is "will there be encroachment," whereby the logical definition of "encroachment" is "does the midlevel take on any of the duties which was or currently is ascribed to a physician?" Just in the last decade, I have seen more midlevels at every level of the healthcare delivery enterprise and in every segment of the industry - academic, private hospital, physician owned. Therefore, encroachment has already and is currently happening - perhaps at breakneck speed. With midlevels, employers can hire fewer docs to perform the same or more work.

The actual question which I think OP is asking is inherently different, which is "will this cause saturation in the job market." Based on the answers here, it seems like the answer is "not right now."

What will happen in the next 10 years as the boomers fade, and the smaller gen Xers come in to replace them, while fellowships/residencies continue to expand and hospital systems are looking to cut cost? Who knows... but on a macro level, it's not looking great for us physicians.

And in the end, what's safer? Heme onc or GIM? Most likely heme onc.
I respectfully don't see the contradiction. I am taking "encroachment" to mean that an APRN would compete with me for a clinical position. I just don't see that happening. Even if midlevels are increasingly being used in survivorship or in resident/fellow capacities requiring attending physician oversight, i don't think that kind of participation counts as saturating the market for an attending.

In heme/onc, the training for an APRN works well under physician direction. Independence? Nah.
 
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I am taking "encroachment" to mean that an APRN would compete with me for a clinical position. I just don't see that happening.

I think the better question is whether or not 3-4 APRNs could compete with you because that’s how much you cost to hire. Again, I think our field is a relatively better protected one for many reasons but it is clearly happening in other fields (Anesthesia, Peds, Psych, EM).
 

CatFactorial

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I think the better question is whether or not 3-4 APRNs could compete with you because that’s how much you cost to hire. Again, I think our field is a relatively better protected one for many reasons but it is clearly happening in other fields (Anesthesia, Peds, Psych, EM).
My answer to whether 3-4 APRNs could successfully compete would be the same. Those APRNs would still need to report to an attending oncologist.

Oncology is not just better protected than the fields you mentioned. The treatments in oncology are in general much more severe than in other fields. The liability that comes with cancer patients and their treatments is too much to leave to independent APRNs.
 
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RadsWFA1900

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My answer to whether 3-4 APRNs could successfully compete would be the same. Those APRNs would still need to report to an attending oncologist.

Oncology is not just better protected than the fields you mentioned. The treatments in oncology are in general much more severe than in other fields. The liability that comes with cancer patients and their treatments is too much to leave to independent APRNs.

After reading through these posts, I am not convinced that there is some sort of special halo over heme-onc that makes it more immune.
 

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