Voting on midlevel credentialling in ICU

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sylvanthus

sylvanthus

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Apparently we got an email asking us to vote to approve midlevel credentialling in the ICU. We dont currently have midlevels. Were all intensivist coverage.

“This is being done to keep things consistent between hospitals in the system.”.

Alarm bells are going off. It could be what they are saying. However being EM trained ive seen the EDs across the country implode and seen emergency medicine become a joke of a specialty. My concern is the inevitable “foot in the door” and then “cost savings” with replacing intensivists with midlevels.

Am I too paranoid? Time to update my CV?
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sylvanthus said:
Apparently we got an email asking us to vote to approve midlevel credentialling in the ICU. We dont currently have midlevels. Were all intensivist coverage.

“This is being done to keep things consistent between hospitals in the system.”.

Alarm bells are going off. It could be what they are saying. However being EM trained ive seen the EDs across the country implode and seen emergency medicine become a joke of a specialty. My concern is the inevitable “foot in the door” and then “cost savings” with replacing intensivists with midlevels.

Am I too paranoid? Time to update my CV?
Click to expand...

Update that CV bud…cause the next few years gonna be fun
 
sylvanthus said:
Apparently we got an email asking us to vote to approve midlevel credentialling in the ICU. We dont currently have midlevels. Were all intensivist coverage.

“This is being done to keep things consistent between hospitals in the system.”.

Alarm bells are going off. It could be what they are saying. However being EM trained ive seen the EDs across the country implode and seen emergency medicine become a joke of a specialty. My concern is the inevitable “foot in the door” and then “cost savings” with replacing intensivists with midlevels.

Am I too paranoid? Time to update my CV?
Click to expand...
You're going to train your replacements, then they'll replace you. It's Turkey Day, and you're the turkey; they've been feeding you until now for a reason, not out of love.

This has nothing to do with consistency. The writing is on the wall. Find a better job.
 
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This profession (that of a physician, no matter the specialty) is doomed.

All of medicine (diagnosis, treatment, procedures) has become algorithmic, formulaic, and now subject to economic and capitalistic pressures (and this happens in every industry). That's why we see the rise of the mid-level: they're cheaper, their education/training is not as long (and so they can enter the work force sooner), and they can provide nearly the same service (or close enough).

The only thing that keeps doctors employed, is the demand by the patient/family to "talk to the doctor", the demand by the insurance company for the doctor's signature on the CPAP order, the demand by the hospital administration that a doctor cosigns the note, etc. That's why I get paid $2K/shift, to do a job a computer and or well-trained monkey could do.

As soon as these demands go away (when the family becomes Ok with talking to an NP, the insurance company accepts an NPs signature instead, they're allowed to practice independently without cosig), then we as physicians are done. The profession will be over, and we'll laugh at the notion of a physician doing medicine, the same way we regard apothecaries now.
 
DrMetal said:
That's interesting. Why? something bad happen with the midlevels? They actually shoveled out the cash to hire more doctors? That's great.
Click to expand...

Probably had a bad outcome or several. I doubt it was being proactive
 
DrMetal said:
That's interesting. Why? something bad happen with the midlevels? They actually shoveled out the cash to hire more doctors? That's great.
Click to expand...

Combination of bad outcomes, ****ty care and complaining patients + surgeons. I saw a similar change happen at a hospital I did not work at in a different region in the past.

Though this is nice to see, I agree with the sentiment that things are probably headed towards more ICU mid levels in the next 5-10 years - there’s no reason to think the CCM is going to be any different from EM/anesthesia/hospitalist.
 
CCM-MD said:
Midlevel encroachment is inevitable. But FWIW, I recently joined another hospital employed position in a bigger city in the West where they just transitioned from night time coverage with midlevels to 24/7 physicians.
Click to expand...
When bodies start piling up the administrators start doing math and come to what resembles their senses but is actually just cold calculation
E_dI-G7XMAYPPH7.jpeg.jpg
 
While it doesn't surprise me, it's still disheartening to the idealistic portion of me that's left, to see much of medicine becoming nothing more than another example of corporate greed with no concern for patient outcomes unless it impacts $$$. Also, for anyone who missed it, this was a very interesting paper (not in terms of outcome, more in terms of being published) from the EM forum that I'm sure all the admin types will do their very best to ignore:

www.nber.org

The Productivity of Professions: Evidence from the Emergency Department

Founded in 1920, the NBER is a private, non-profit, non-partisan organization dedicated to conducting economic research and to disseminating research findings among academics, public policy makers, and business professionals.
www.nber.org www.nber.org

Summary: "Using data from the Veterans Health Administration and quasi-experimental variation in the patient probability of being treated by physicians versus NPs in the emergency department, we find that, compared to physicians, NPs significantly increase resource utilization but achieve worse patient outcomes. We find evidence suggesting mechanisms relating to lower human capital among NPs relative to physicians and worker-task assignment responding to the lower skill of NPs. Counterfactual analysis suggests a net increase in medical costs with NPs, even when accounting for NPs’ wages that are half as much as physicians’."
 
grt398 said:
While it doesn't surprise me, it's still disheartening to the idealistic portion of me that's left, to see much of medicine becoming nothing more than another example of corporate greed with no concern for patient outcomes unless it impacts $$$. Also, for anyone who missed it, this was a very interesting paper (not in terms of outcome, more in terms of being published) from the EM forum that I'm sure all the admin types will do their very best to ignore:

www.nber.org

The Productivity of Professions: Evidence from the Emergency Department

Founded in 1920, the NBER is a private, non-profit, non-partisan organization dedicated to conducting economic research and to disseminating research findings among academics, public policy makers, and business professionals.
www.nber.org www.nber.org

Summary: "Using data from the Veterans Health Administration and quasi-experimental variation in the patient probability of being treated by physicians versus NPs in the emergency department, we find that, compared to physicians, NPs significantly increase resource utilization but achieve worse patient outcomes. We find evidence suggesting mechanisms relating to lower human capital among NPs relative to physicians and worker-task assignment responding to the lower skill of NPs. Counterfactual analysis suggests a net increase in medical costs with NPs, even when accounting for NPs’ wages that are half as much as physicians’."
Click to expand...
Savage
 
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sylvanthus said:
Apparently we got an email asking us to vote to approve midlevel credentialling in the ICU. We dont currently have midlevels. Were all intensivist coverage.

“This is being done to keep things consistent between hospitals in the system.”.

Alarm bells are going off. It could be what they are saying. However being EM trained ive seen the EDs across the country implode and seen emergency medicine become a joke of a specialty. My concern is the inevitable “foot in the door” and then “cost savings” with replacing intensivists with midlevels.

Am I too paranoid? Time to update my CV?
Click to expand...
Vote against it. And update your CV. Medicine in the USA is going to the dogs.

Edit: I see the update. I say stand your ground or tell them you are gonna have a mass exodus and mean it. Glad a majority of y'all voted against it.
 
Last edited:
DrMetal said:
This profession (that of a physician, no matter the specialty) is doomed.

All of medicine (diagnosis, treatment, procedures) has become algorithmic, formulaic, and now subject to economic and capitalistic pressures (and this happens in every industry). That's why we see the rise of the mid-level: they're cheaper, their education/training is not as long (and so they can enter the work force sooner), and they can provide nearly the same service (or close enough).

The only thing that keeps doctors employed, is the demand by the patient/family to "talk to the doctor", the demand by the insurance company for the doctor's signature on the CPAP order, the demand by the hospital administration that a doctor cosigns the note, etc. That's why I get paid $2K/shift, to do a job a computer and or well-trained monkey could do.

As soon as these demands go away (when the family becomes Ok with talking to an NP, the insurance company accepts an NPs signature instead, they're allowed to practice independently without cosig), then we as physicians are done. The profession will be over, and we'll laugh at the notion of a physician doing medicine, the same way we regard apothecaries now.
Click to expand...
Respectfully, this is an American problem.
 
CCM-MD said:
Midlevel encroachment is inevitable. But FWIW, I recently joined another hospital employed position in a bigger city in the West where they just transitioned from night time coverage with midlevels to 24/7 physicians.
Click to expand...
Please tell us a tale as to why. I thought they were just as good as us.

Edit: I see someone already asked and read the answer. Just what I thought.
 
DrMetal said:
This profession (that of a physician, no matter the specialty) is doomed.

All of medicine (diagnosis, treatment, procedures) has become algorithmic, formulaic, and now subject to economic and capitalistic pressures (and this happens in every industry). That's why we see the rise of the mid-level: they're cheaper, their education/training is not as long (and so they can enter the work force sooner), and they can provide nearly the same service (or close enough).

The only thing that keeps doctors employed, is the demand by the patient/family to "talk to the doctor", the demand by the insurance company for the doctor's signature on the CPAP order, the demand by the hospital administration that a doctor cosigns the note, etc. That's why I get paid $2K/shift, to do a job a computer and or well-trained monkey could do.

As soon as these demands go away (when the family becomes Ok with talking to an NP, the insurance company accepts an NPs signature instead, they're allowed to practice independently without cosig), then we as physicians are done. The profession will be over, and we'll laugh at the notion of a physician doing medicine, the same way we regard apothecaries now.
Click to expand...
There will never be a day where patients prefer an NP over a physician. Patients are very selfish and want "the best" care for themselves and their families. I'm not worried. Freaking still super busy.
 
sss2g2 said:
There will never be a day where patients prefer an NP over a physician.
Click to expand...

Famous last words . . .c'est la vie

Most patients are too stupid to know the difference. And most doctors are too stupid to know how stupid their patients are.
 
DrMetal said:
Famous last words . . .c'est la vie

Most patients are too stupid to know the difference. And most doctors are too stupid to know how stupid their patients are.
Click to expand...
A lot of mids have post-doc degrees now and don’t shrink from introducing themselves as “doctor” at pt encounters. I did two back-to-backs with a single patient who required round the clock supervision in the neuro PCU. The overnight APRN busted in calling herself “Dr. X.” The pt wife rooming in explicitly asked 3 times if the APRN was a physician, and the APRN finally admitted to being a post-doc NP. The, “Oh, you’re a nurse…I asked to see a physician,” did not go over well. Next morning the Neuro APRN did the same. Claimed to be a neurologist and required what felt like 38 questions for the APRN finally to introduce herself (give her name and reveal she was an NP). Needless to say, two years later special education for pt encounters with mid-levels is still ongoing. Apparently up to that point two years ago the admins encouraged artful expression to avoid having to pay physicians to see pts. Interesting thing from billing scuttlebut: on record review, physician attestations of in person evals that never happened so they could still bill the pts directly. DHHS is scrutinizing the matter and I’m guessing this will eventually push the board to sell out to keep the stain of legal meshuggas off their radar.
 
nikolaite said:
A lot of mids have post-doc degrees now and don’t shrink from introducing themselves as “doctor” at pt encounters. I did two back-to-backs with a single patient who required round the clock supervision in the neuro PCU. The overnight APRN busted in calling herself “Dr. X.” The pt wife rooming in explicitly asked 3 times if the APRN was a physician, and the APRN finally admitted to being a post-doc NP. The, “Oh, you’re a nurse…I asked to see a physician,” did not go over well. Next morning the Neuro APRN did the same. Claimed to be a neurologist and required what felt like 38 questions for the APRN finally to introduce herself (give her name and reveal she was an NP). Needless to say, two years later special education for pt encounters with mid-levels is still ongoing. Apparently up to that point two years ago the admins encouraged artful expression to avoid having to pay physicians to see pts. Interesting thing from billing scuttlebut: on record review, physician attestations of in person evals that never happened so they could still bill the pts directly. DHHS is scrutinizing the matter and I’m guessing this will eventually push the board to sell out to keep the stain of legal meshuggas off their radar.
Click to expand...

The only art they want people practicing is the art of deception.
 
nikolaite said:
A lot of mids have post-doc degrees now and don’t shrink from introducing themselves as “doctor” at pt encounters. I did two back-to-backs with a single patient who required round the clock supervision in the neuro PCU. The overnight APRN busted in calling herself “Dr. X.” The pt wife rooming in explicitly asked 3 times if the APRN was a physician, and the APRN finally admitted to being a post-doc NP. The, “Oh, you’re a nurse…I asked to see a physician,” did not go over well. Next morning the Neuro APRN did the same. Claimed to be a neurologist and required what felt like 38 questions for the APRN finally to introduce herself (give her name and reveal she was an NP). Needless to say, two years later special education for pt encounters with mid-levels is still ongoing. Apparently up to that point two years ago the admins encouraged artful expression to avoid having to pay physicians to see pts. Interesting thing from billing scuttlebut: on record review, physician attestations of in person evals that never happened so they could still bill the pts directly. DHHS is scrutinizing the matter and I’m guessing this will eventually push the board to sell out to keep the stain of legal meshuggas off their radar.
Click to expand...

It's our own fault. We physicians are so wrapped up in our own world, doing the umpteenth fellowship, worried about BC/MOC . . . we didn't see the train of the medical-industrial complex coming our way. It rolled over us and moves on. And we're not organized/unified enough to fight against it.

Their argument is, it doesn't take 15 years of higher education and training to titrate someone's Norvasc from 2.5 to 5 mg, or to fill out FMLA paperwork, or even to do procedures. So why not let a mid-level (who costs half as much) do it? Oh b/c the physician is special, he has so much more knowledge! Who cares. The 'excess' knowledge isn't important nor worth the extra money, I guess.
 
DrMetal said:
It's our own fault. We physicians are so wrapped up in our own world, doing the umpteenth fellowship, worried about BC/MOC . . . we didn't see the train of the medical-industrial complex coming our way. It rolled over us and moves on. And we're not organized/unified enough to fight against it.

Their argument is, it doesn't take 15 years of higher education and training to titrate someone's Norvasc from 2.5 to 5 mg, or to fill out FMLA paperwork, or even to do procedures. So why not let a mid-level (who costs half as much) do it? Oh b/c the physician is special, he has so much more knowledge! Who cares. The 'excess' knowledge isn't important nor worth the extra money, I guess.
Click to expand...
They still miss important info, both gathering and reporting. Mids lack the discretion and clinical decision making ability of a physician. No one doubts mids can do procedures, titrate meds, or fill out paperwork. They’re technicians.

Doesn’t serve pts in the short term, though…and doesn’t serve the corporations in the long run…

I’ve seen enough pts hurt and harmed to abhor scope creep.
 
martvubo said:
Do you guys feel like the pendulum has started swinging the other way at all? I have had a few patients lately start off our encounter being really firm pinning me down to explicitly say I'm a physician or MD.
Click to expand...

I tell all my friends & neighbours to make sure they go to a doc…
 
To me, none of this is really surprising. Procedures can be taught to anyone, and when most of medicine is protocol based anyway... well, there it is.

I had an senior attending tell me when I was a first year fellow almost 15 years ago, "SurfingDoc... I could teach a monkey to do your job. What are you going to do that makes you more valuable than a monkey?". Well, I'm not convinced a lot of physicians got the same advice.
 
SurfingDoctor said:
To me, none of this is really surprising. Procedures can be taught to anyone, and when most of medicine is protocol based anyway... well, there it is.

I had an senior attending tell me when I was a first year fellow almost 15 years ago, "SurfingDoc... I could teach a monkey to do your job. What are you going to do that makes you more valuable than a monkey?". Well, I'm not convinced a lot of physicians got the same advice.
Click to expand...

I like to think doctors don't get paid for doing the routine stuff, they get paid for when something goes wrong. Anyone can follow a protocol/procedure, but what happens when something happens that you are not used to or when the train goes off the rails? Thats when the years of experience that our medical education provided comes into play.
 
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