What will happen to the job market for hospitalists?

[AORiverContra]

I am planning on becoming a hospitalist when I graduate in 3 years. I was talking to a fellow the other day and he was very negative about the job market prospects long term, saying that the doctors are going to be replaced by NPs who will just farm out consults, one doctor will be "supervising" 8-10 NPs. And of course many states have or will have unsupervised NPs. I am planning on practicing in CA where AB 890 is being debated to give NPs unsupervised access. Do you think the job market for physician hospitalists is going to decrease due to replacement by midlevels?

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[thumbz]

Having accepted transfers and seeing midlevels practice, absolutely not.

Here's why:

Imagine for a second you run a hospital with 300 beds, and in this example all of these are medical beds staffed by midlevels. Each midlevel rounds on 15 patients, so you have 20 midlevels. The problem is they do exactly what you said - they run consult services because they have little to no clinical acumen (some superstars excluded, but the new grad NP's are awful).

So now you have 20 midlevels who each consult cardiology on half their patients (simple heart failures, resistant hypertension, new afib, old afib with new RVR - basically all the bread and butter stuff we hospitalists manage independently).

That means you need enough cardiologists to see 150 patients. Trust me, that's a lot more expensive than hiring hospitalists instead of NP's. So then as the admin you say "well fine, I'll hire 2 dozen cardiology NP's" - well now you're going to spend on your midlevel army what you would have spent on a real hospitalist group. Now wait for your outcomes to suffer and patients to stop coming because "I want to see a doctor". Because trust me, patients are starting to catch on and I get a lot of people these days who "want to see a doctor, not a nurse practitioner or PA" who end up on my service.

I understand there is a lot of doom and gloom, but the sky is not falling by any means. Yeah, my salary isn't going to go up as fast as it would have if midlevels did not exist, but I have no concerns I'm going to wake up to no job opportunities in 10 years.

 

[CCM-MD]

Who do you think is doing the consults on the subspecialty services? It’s midlevels. Midlevels are also doing cardiac cath and endoscopy in some centers - I have posted the studies on this forum before. The sickest of the sick in the ICU are being seen by midlevels.

Nothing is “safe” from encroachment except the actually operative parts of surgery.

 

[DrMetal]

Who do you think is doing the consults on the subspecialty services? It’s midlevels. Midlevels are also doing cardiac cath and endoscopy in some centers - I have posted the studies on this forum before. The sickest of the sick in the ICU are being seen by midlevels.

Nothing is “safe” from encroachment except the actually operative parts of surgery.

It's really quite true what you stated in this post, and quite sad.

We did this onto ourselves. We made it so difficult (and expensive, in terms of cost, youth time lost) to become a doctor, and so difficult to stay a doctor (BC/MOC, admin requirements) that we've created a deep physician shortage. Instead of fixing said shortage, society (the economics of it, which any game theory expert could have predicted) has found a way to circumvent us, by introducing mid-levels into the system.

 

[VA Hopeful Dr]

It's really quite true what you stated in this post, and quite sad.

We did this onto ourselves. We made it so difficult (and expensive, in terms of cost, youth time lost) to become a doctor, and so difficult to stay a doctor (BC/MOC, admin requirements) that we've created a deep physician shortage. Instead of fixing said shortage, society (the economics of it, which any game theory expert could have predicted) has found a way to circumvent us, by introducing mid-levels into the system.

None of that has anything to do with a shortage of doctors. Med schools have always filled, residency programs have always filled.

The issue is a growing population and, until recently, an unchanging number of residency positions.

 

[DrMetal]

The issue is a growing population and, until recently, an unchanging number of residency positions.

Yeah, that too. The stuff I mentioned I think has had something to do with it. If Dr. Metal were in charge: I would
- make med school 3 years instead of 4 (we all know the 4th year of school was a F-off year, I'm sure you'd rather save the $100K),
- maybe knock off a year of bachelors programs as well (that's doable now....so the combined BS+MD = 6 years, instead of 8, I think some programs like that exist),
- create more residency spots by utilizing more community hospitals (consolidate admin and academics: one office could support 5 county hospitals, etc)
- pay residents more (a pgy4 GS resident should be making $80k/year. A fellow $90K: yeah that doesn't make you rich, but at least you can live decently).
- more student loan payoff options: no one should have a debt >$200K for going into this ofthentimes thankless profession.
- get rid of MOC. BC should be a one time deal. After you obtain it, you're judged by the merits of your own practice.

 

[blue.jay]

For now, I believe most hospitalists groups have no midlevels. The few that use them have them as admitters or for pager cross cover. Certainly the situation is not as bad as CRNA encroachment.
Overall, in the broad scheme of things I don't see having midlevels very beneficial in hospital medicine. For eg, I get 220k to see a day time pt census of 12-14 with 1-2 admissions. During nights I cross cover, attend rapid response and codes and admit 5-6 pts plus supervise midlevels. Our midlevels during the day carry 4-6 pts and at nights admit 3-4 pts, sleep for 4 hours and cross cover for 3 hours.
They are useful if they do physician level work for half the pay but they work proportionately less (at least in my place).

I also assume the admins might try to squeeze salary from higher paying specialities like GI, cards, anesthesia by using more midlevels. I don't see the value of trying to save 50-80k in salary by having midlevels who cant see as many complicated patients as physicians.

Im sure if the midlevels are given my responsibility of busier census, rapids and codes plus the liability they will ask for our pay.

If the market gets saturated (which will probably happen) people won't be upset with a salary drop from 220k to 180k compared to let's say 350k to 250k. Heck, I always tell that our midlevels have a chill 8-4 job for half the year for seeing 5 pts and getting 80-100k. If I'm the admin I'll fire them and give their pay as a bonus to the other 4 physicians if they can split up the N census of 6 pts (our rounds will be 30 min longer). Sadly, this world famous academic place I work for is a midlevel factory who thinks midlevels with more than 5 year experience are as good as hospitalist (of course after free residency training under your license)

Admins are hiring midlevels partly to put us in place, to remind us that we all are replaceable. My worry is not job security but the same concerns every speciality has, being forced to work with these rogue midlevels who do **** under our liability and not really collaborate with us.

 

[wjs010]

But they can’t do anything without a doc co-signing.

Who do you think is doing the consults on the subspecialty services? It’s midlevels. Midlevels are also doing cardiac cath and endoscopy in some centers - I have posted the studies on this forum before. The sickest of the sick in the ICU are being seen by midlevels.

Nothing is “safe” from encroachment except the actually operative parts of surgery.

 

[CCM-MD]

But they can’t do anything without a doc co-signing.

That depends on the institution. What's your point?

 

[TAVR4life]

Hospitals already use NPs in a way similar to the way they use residents. One attending overseeing a bunch of NPs who serve as the first line for patients. This is already happening. I’ve noticed that even the most seasoned NP is at BEST at the level of an new intern in terms of medical knowledge—most are very mediocre and get on the job training while getting paid and full salary which is more than a residents salary. Their scope of knowledge is very very limited. However that does not stop administration and nursing lobby to continue to push them forward given their a cost saving measure for the hospital (cheaper salary than paying a MD).

 

[DrMetal]

Their scope of knowledge is very very limited.

So the sad truth is, nobody really cares that we doctors have so much more 'knowledge'. And do we really? What are we, PhD chemists/microbiologists? And you really don't need the extra knowledge to treat patients correctly, in our now 21st-century algorithmic (look-it-up-on-Up-to-Date) world. Sure, we know the mechanisms of Sarcoidosis and tissue granulation (or do we really? how many doctors can recite this off the cuff?), but you don't necessarily need that knowledge. You just have to remember that first line treatment is steroids, and execute said treatments.

So arguing that we know more isn't going to get us anywhere. Sure it's true, but is that important? The mechanic who's been working on Ferrarris for 40 years can't diagram out the internal combustion engine, but he's good at fixing cars.

I think the only way we can stop the mid-level crazy train is if we
a) refuse to supervise them (that's a tough one, especially if your institution pays you to do that)
and b) encourage our patients to ask for a real doctor when they're seeking treatment (also tough: is a patient really going to argue, if they can get the same result---their albuterol, or their xay--- from a PA). But this is key, as patients are the customers driving the demand. If patients don't mind being seen by mid-levels, then we're F-ed.

 

[VA Hopeful Dr]

Yeah, that too. The stuff I mentioned I think has had something to do with it. If Dr. Metal were in charge: I would
- make med school 3 years instead of 4 (we all know the 4th year of school was a F-off year, I'm sure you'd rather save the $100K),
- maybe knock off a year of bachelors programs as well (that's doable now....so the combined BS+MD = 6 years, instead of 8, I think some programs like that exist),
- create more residency spots by utilizing more community hospitals (consolidate admin and academics: one office could support 5 county hospitals, etc)
- pay residents more (a pgy4 GS resident should be making $80k/year. A fellow $90K: yeah that doesn't make you rich, but at least you can live decently).
- more student loan payoff options: no one should have a debt >$200K for going into this ofthentimes thankless profession.
- get rid of MOC. BC should be a one time deal. After you obtain it, you're judged by the merits of your own practice.

No, the stuff you mentioned doesn't have any significant impact. Residency programs fill 100% every year. Very few doctors retire or leave the profession super early. The problem is and always has been the number of residency spots. This is being slowly corrected, but not every specialty can expand much. FM can open up at smaller places but you internists need a hospital of a certain size. There is a very finite amount of those. Then you have EM where people are getting angry about the new programs both from a quality standpoint and from a decreasing pay due to increasing supply standpoint.

 

[NITRAS]

Yeah, that too. The stuff I mentioned I think has had something to do with it. If Dr. Metal were in charge: I would
- make med school 3 years instead of 4 (we all know the 4th year of school was a F-off year, I'm sure you'd rather save the $100K),
- maybe knock off a year of bachelors programs as well (that's doable now....so the combined BS+MD = 6 years, instead of 8, I think some programs like that exist),
- create more residency spots by utilizing more community hospitals (consolidate admin and academics: one office could support 5 county hospitals, etc)
- pay residents more (a pgy4 GS resident should be making $80k/year. A fellow $90K: yeah that doesn't make you rich, but at least you can live decently).
- more student loan payoff options: no one should have a debt >$200K for going into this ofthentimes thankless profession.
- get rid of MOC. BC should be a one time deal. After you obtain it, you're judged by the merits of your own practice.

I’m with VA on this. We shouldn’t compete with mid levels by out producing them. It’s even more difficult to create residency spots for our surgical colleagues due to amount of cases needed.

Maybe we shouldn’t waste 4th year Of medical school? Do we lose residents due to lack of pay? Do we need more government intervention for loans?

 

[grt398]

But this is key, as patients are the customers driving the demand. If patients don't mind being seen by mid-levels, then we're F-ed.

Problem is most patients don't know the difference, and at least when I was doing primary care clinic in residency, frequently were seeing specialist mid-levels or came from a previous primary care mid-level, thought they had been seeing a doctor, and of course weren't told otherwise. And patients obviously don't have the knowledge base to know when they aren't receiving appropriate care. Like CCM-MD posted above, nothing is safe except operative surgery (for now) and even that may change...NHS over in England is starting to teach basic surgical skills to mid-levels. Here's a summary to keep in mind from ACP:

"Dr. Choi, who was an NP before she became a physician, said that the best working relationships between physicians and APPs are those that are founded on collegiality and collaboration. “The organization has to respect the APPs like team members and not look at them as subservient or subordinate. That's why we don't use the word ‘midlevel.’ No one goes to school and spends that much time and effort on training, saying they want to be a ‘midlevel.’”

Source: Getting the most from advanced practice providers

A lot of posters have mentioned it before...but the national society "leaders" are not on your side. Do what you can to become financially independent as early as possible, and then you'll have a lot more freedom to choose when/where/how you want to work when things change, because they will.

 

[aafisahar]

Who do you think is doing the consults on the subspecialty services? It’s midlevels. Midlevels are also doing cardiac cath and endoscopy in some centers - I have posted the studies on this forum before. The sickest of the sick in the ICU are being seen by midlevels.

Nothing is “safe” from encroachment except the actually operative parts of surgery.

Midlevels are good for scut. As the fellow on cards, we have a hybrid model where I staff all the midlevels consults then speed table round with attending. The midlevels serve to insulate us from scutwork and pages. Patient "needs" a life vest? Scut it out to the NP. Discharge this post procedure patient? Scut it out to the NP. New afib? Have the NP arrange cardioversion +/- TEE. Have the NP do the preauth paperwork for eliquis or repatha or whatever.

NPs aren't taking your jobs anymore than cleaning up after yourself is taking away jobs from the janitor. They free up time so you aren't responding to pages of K is 3.9, replete?

If an NP is making decisions independently, then it's a different story. My experience has been that NPs/PAs are scared to make any real medical decisions other than stuff a fresh 3rd year can do. Even simple stuff like "discharge on keflex?" for a UTI gets asked one way or another. I've not seen an NP/PA actually make real medical decisions or do a workup without asking the attending first.

 

[DrMetal]

Problem is most patients don't know the difference, and at least when I was doing primary care clinic in residency,

Yeah, that's the problem. It's a basic economics dilemma: you have a high quality product that may be too expensive or too scarce, vs. a less quality one that can get the job done nearly the same and is more available. Which does society pick? (especially if the former is really hard to make and acquire).

"Dr. Choi, who was an NP before she became a physician, said that the best working relationships between physicians and APPs are those that are founded on collegiality and collaboration. “The organization has to respect the APPs like team members and not look at them as subservient or subordinate. That's why we don't use the word ‘midlevel.’ No one goes to school and spends that much time and effort on training, saying they want to be a ‘midlevel.’”

We all work well with them. No one's yelling and cussing them out (shouldn't be at least). The problem for us isn't the work environment once we're in it; the problem will soon be getting into the work environment at the start.

How would you feel is you're trying to get a job in a particular market (because you're from there, and that's where you want to live) but can't find the job b/c its saturated with mid-levels? (a la the current hospitalist market in southern California---also flooded by other doctors too, but the high # of midlevels running around floors don't help). Bottom line is, you don't get the job you want, and you have to settle for something else.

A lot of posters have mentioned it before...but the national society "leaders" are not on your side. Do what you can to become financially independent as early as possible, and then you'll have a lot more freedom to choose when/where/how you want to work when things change, because they will.

Yep, pretty much. We've essentially accepted this change. It's happening.

 

[DrMetal]

Midlevels are good for scut.

And this is our arrogance. We've deemed much of our business to be 'scut' work, farmed it out. But at the end of the day, we realized that 90% of our jobs is scut work, and if we've farmed out successfully, then we become the ones who are farmed out! I'd rather keep the scut work and have a good job, when/where I want it. I'll gladly replete that K of 3.9.

 

[VA Hopeful Dr]

I’m with VA on this. We shouldn’t compete with mid levels by out producing them. It’s even more difficult to create residency spots for our surgical colleagues due to amount of cases needed.

Maybe we shouldn’t waste 4th year Of medical school? Do we lose residents due to lack of pay? Do we need more government intervention for loans?

FM residencies are expanding, have had 2 new programs in my state in the last 6 years. That'll help, it just takes time.

Cutting out a year of residency won't help with numbers, its still all about residency spots.

Loans, shortening school, not needing a bachelor's are all ideas worth considering but none of them have anything to do with physician numbers.

 

[rokshana]

Midlevels are good for scut. As the fellow on cards, we have a hybrid model where I staff all the midlevels consults then speed table round with attending. The midlevels serve to insulate us from scutwork and pages. Patient "needs" a life vest? Scut it out to the NP. Discharge this post procedure patient? Scut it out to the NP. New afib? Have the NP arrange cardioversion +/- TEE. Have the NP do the preauth paperwork for eliquis or repatha or whatever.

NPs aren't taking your jobs anymore than cleaning up after yourself is taking away jobs from the janitor. They free up time so you aren't responding to pages of K is 3.9, replete?

If an NP is making decisions independently, then it's a different story. My experience has been that NPs/PAs are scared to make any real medical decisions other than stuff a fresh 3rd year can do. Even simple stuff like "discharge on keflex?" for a UTI gets asked one way or another. I've not seen an NP/PA actually make real medical decisions or do a workup without asking the attending first.

Just wait...

It’s not an issue of are they capable, but do they think they are capable...and their unions, associations, and lobbies are telling them yes, they are! And they need to demand to be treated equally.

 

[grt398]

Yeah, that's the problem. It's a basic economics dilemma: you have a high quality product that may be too expensive or too scarce, vs. a less quality one that can get the job done nearly the same and is more available. Which does society pick? (especially if the former is really hard to make and acquire).

We all work well with them. No one's yelling and cussing them out (shouldn't be at least). The problem for us isn't the work environment once we're in it; the problem will soon be getting into the work environment at the start.

How would you feel is you're trying to get a job in a particular market (because you're from there, and that's where you want to live) but can't find the job b/c its saturated with mid-levels? (a la the current hospitalist market in southern California---also flooded by other doctors too, but the high # of midlevels running around floors don't help). Bottom line is, you don't get the job you want, and you have to settle for something else.

Yep, pretty much. We've essentially accepted this change. It's happening.

I agree with much of what you've said and I also agree that's it's completely the fault of physicians themselves for a whole variety of reasons. I may be taking a bit too much liberty with this assumption, but at least some of us still in training have "accepted" it because it's been made very clear to us by the academic attendings who control whether we graduate residency/fellowship, and many are very pro mid-level independence, that differing opinions are not welcome and may lead to professional repercussions. Quite frankly, that's a very dangerous thing to those of us graduating with >300k in loans and no other practical way to pay them back. Thirty years ago when some attendings I know were able to pay for state medical school with a summer job, the financial ruin aspect wasn't there. To paraphrase a 1980s movie, sometimes the only winning move is not to play. Hence the increasing number of physicians looking to financial independence ASAP.

And FWIW, at this point I think the only people who should consider medical school are those who can graduate debt free via whatever mechanism, or go somewhere like TX where there's still cheap options. And they should be ok with a significant paycut from current salaries (I may be more negative than most, but wouldn't be surprised to see my future salary drop 30-40% from where it is now).

 

[CCM-MD]

Midlevels are good for scut. As the fellow on cards, we have a hybrid model where I staff all the midlevels consults then speed table round with attending. The midlevels serve to insulate us from scutwork and pages. Patient "needs" a life vest? Scut it out to the NP. Discharge this post procedure patient? Scut it out to the NP. New afib? Have the NP arrange cardioversion +/- TEE. Have the NP do the preauth paperwork for eliquis or repatha or whatever.

NPs aren't taking your jobs anymore than cleaning up after yourself is taking away jobs from the janitor. They free up time so you aren't responding to pages of K is 3.9, replete?

If an NP is making decisions independently, then it's a different story. My experience has been that NPs/PAs are scared to make any real medical decisions other than stuff a fresh 3rd year can do. Even simple stuff like "discharge on keflex?" for a UTI gets asked one way or another. I've not seen an NP/PA actually make real medical decisions or do a workup without asking the attending first.

They absolutely do scut right now. You don't think I love it when my NP does writes my notes, does my transfer orders, calls consults, repletes electrolytes? I absolutely love it. But this is how it starts, not how it ends. Just look at our colleagues in anesthesiology and emergency medicine. Pretending things are going to be "ok" in any particular specialty is the wrong strategy here. We need to recognize there is a problem so we can do something about it.

You don't think they are working outpatient independently? Guess what, they are.
You don't think they will perform cath? endoscopy? Guess what, they are.
You don't think they will man an ICU independently? Guess what, they are.

Midlevels have a role, I like working with them. They make my life easy. But they are not physicians and the lines get more and more blurry with each passing day.

 

[Syndicate]

Mid-level encroachment is one of the major factors drawing me towards applying for fellowship rather than becoming a Hospitalist. Make yourself irreplaceable, as much as you can.
Yes, some cardiology NPs may do caths, but does a patient want a NP who completed an online program to put in their stent?
Does a patient want a GI NP doing their colonoscopy?
Does a patient want a oncology NP advising him/her on the most recent treatments for their stage 4 cancer?

I hope not..

 

[blue.jay]

Mid-level encroachment is one of the major factors drawing me towards applying for fellowship rather than becoming a Hospitalist. Make yourself irreplaceable, as much as you can.
Yes, some cardiology NPs may do caths, but does a patient want a NP who completed an online program to put in their stent?
Does a patient want a GI NP doing their colonoscopy?
Does a patient want a oncology NP advising him/her on the most recent treatments for their stage 4 cancer?

I hope not..

So go to medschool/residency/fellowship to be a cardiologist (who doesn't do this speciality scut other than TEE, Cath) GI (sits in OR scoping) or surgical speciality (giving clinics to midlevels and staying in OR) ?
Why do they even have other menial residencies like FM, peds, psych, anesthesia, PMR, EM which are run by midlevels?
If they can encroach all these specialities which requires a broad level of knowledge don't you think they can be trained to do endoscopies rather than wait for some one with 4+3+3 yr training to do it?
Don't you think midlevels cant follow NCCN guidelines for straight forward cancers?

Jobs which had 4-5 cardiologists now have 2-3 with plenty midlevels because you guys don't want to do scutwork. Midlevels are also affecting your job market and needs, the pressure to super-specialize and spend more years training.

No midlevels are not good as hospitalists. They can consult everyone, have higher length of stay and order more tests. I'm not sure if that's worth the cost of internists already low salary. The good ones are good because they have been getting stress-free fully paid residency training. The solution for this is to stop hiring or training midlevels in primary care IM/peds/FM/EM positions. May be the highly paid cardiologist, GI, surgeons can use them for scutwork.

 

[CCM-MD]

Mid-level encroachment is one of the major factors drawing me towards applying for fellowship rather than becoming a Hospitalist. Make yourself irreplaceable, as much as you can.
Yes, some cardiology NPs may do caths, but does a patient want a NP who completed an online program to put in their stent?
Does a patient want a GI NP doing their colonoscopy?
Does a patient want a oncology NP advising him/her on the most recent treatments for their stage 4 cancer?

I hope not..

The slippery slope is real, my friend. I am sure in 2005 many spoke similarly about independent CRNAs providing anesthesia, managing and performing procedures in the ER/on the critically ill. What was unthinkable in 2005, is the reality in 2020.

 

[grt398]

Mid-level encroachment is one of the major factors drawing me towards applying for fellowship rather than becoming a Hospitalist. Make yourself irreplaceable, as much as you can.
Yes, some cardiology NPs may do caths, but does a patient want a NP who completed an online program to put in their stent?
Does a patient want a GI NP doing their colonoscopy?
Does a patient want a oncology NP advising him/her on the most recent treatments for their stage 4 cancer?

I hope not..

Patients don't know the difference; either they assume the person with the white coat introducing themselves is a physician and call them "doctor" which the DNP/PA doesn't correct, or that GI NP will introduce themselves as "Dr So & So" because they feel their DNP is equivalent. It happens all the time. I think the only time I've ever seen a PA correct a patient was on the CT surgery service at one institution I trained at where the PA's were very clear to the patient about who the surgeon was and who they were. If I had to guess, I suspect at least one of the CT surgeons had a discussion with them at some point about it and hence the clarification of roles. It's also why I tell all friends/family to ask very specifically about who they are seeing when they get medical care these days. And just to be clear, there are some outstanding PA's/NPs out there who are truly dedicated to their field but it's just so inconsistent that until you've worked with them for months to years, there's no way to tell.

 

[Trogghunter]

Man, I'd love to work with the folks that you all are describing. I haven't met a single one among the ~30 I work with from various specialties that fit your descriptions and capacity to care for patients. Wherever they are, send 'em our way! Even at 10-20yrs of experience, they function at the level of an IM intern in October, at the best.

 

[Splenda88]

For now, I believe most hospitalists groups have no midlevels. The few that use them have them as admitters or for pager cross cover. Certainly the situation is not as bad as CRNA encroachment.
Overall, in the broad scheme of things I don't see having midlevels very beneficial in hospital medicine. For eg, I get 220k to see a day time pt census of 12-14 with 1-2 admissions. During nights I cross cover, attend rapid response and codes and admit 5-6 pts plus supervise midlevels. Our midlevels during the day carry 4-6 pts and at nights admit 3-4 pts, sleep for 4 hours and cross cover for 3 hours.
They are useful if they do physician level work for half the pay but they work proportionately less (at least in my place).

I also assume the admins might try to squeeze salary from higher paying specialities like GI, cards, anesthesia by using more midlevels. I don't see the value of trying to save 50-80k in salary by having midlevels who cant see as many complicated patients as physicians.

Im sure if the midlevels are given my responsibility of busier census, rapids and codes plus the liability they will ask for our pay.

If the market gets saturated (which will probably happen) people won't be upset with a salary drop from 220k to 180k compared to let's say 350k to 250k. Heck, I always tell that our midlevels have a chill 8-4 job for half the year for seeing 5 pts and getting 80-100k. If I'm the admin I'll fire them and give their pay as a bonus to the other 4 physicians if they can split up the N census of 6 pts (our rounds will be 30 min longer). Sadly, this world famous academic place I work for is a midlevel factory who thinks midlevels with more than 5 year experience are as good as hospitalist (of course after free residency training under your license)

Admins are hiring midlevels partly to put us in place, to remind us that we all are replaceable. My worry is not job security but the same concerns every speciality has, being forced to work with these rogue midlevels who do **** under our liability and not really collaborate with us.

You must work for Emory or Vandy... They are the 'midlevel factor' in the south...

 

[TAVR4life]

Man, I'd love to work with the folks that you all are describing. I haven't met a single one among the ~30 I work with from various specialties that fit your descriptions and capacity to care for patients. Wherever they are, send 'em our way! Even at 10-20yrs of experience, they function at the level of an IM intern in October, at the best.

Still doesn’t stop hospital administrators and government from giving them a more prominent role in patient care including working independently in some states.

The golden ticket for hospital administration is pushing government to allow mid levels to bill at the same reimbursement rates as physicians. This is already happening.

Already a push to lump physicians together with mid levels all as “healthcare providers” to confuse the patient.

Very systematic and deliberate campaign by hospital administration and nursing lobby—physicians so far losing this battle badly.

 

[DrNotaDr]

I work as a midlevel inpatient provider. A lot of what you guys are saying is true. When I'm erroneously called doctor, I correct the patient twice, and then I ignore it after that. If you see a patient call me that and I don't correct them it's because I already tried; a lot of patients will just continue using the title. When I go to work I try to save my attending's time so that they can be free to make the more complex medical decisions that only their education allows. There are simple cellulitis cases a NP can handle. There are social discharge and placement patients an NP can handle. We can consult the social worker and the case manager and do the scut work necessary so that when that sick patient comes in that needs the attending they aren't bombarded with the phone calls other people can take care of. The attendings have varying levels of trust, some trust the midlevels a lot, some not at all. I don't take offense at either decision, an attending has a right to feel comfortable with how their licenses are being used. The midlevel's are on SDN too, and we understand the view points of the docs, and the less militant of us aren't bothered by our limitations and know we can save the docs many hours if we are assigned the right patients.

 

[DrMetal]

I work as a midlevel inpatient provider. A lot of what you guys are saying is true. When I'm erroneously called doctor, I correct the patient twice, and then I ignore it after that. If you see a patient call me that and I don't correct them it's because I already tried; a lot of patients will just continue using the title.

I believe you. Most hospitalized patients are in some kind of mental stress and don't remember their right from left let alone the exact titles of the parade of people walking into the room.

There are simple cellulitis cases a NP can handle. There are social discharge and placement patients an NP can handle. We can consult the social worker and the case manager and do the scut work necessary

Again it's interesting what we physicians deem to be 'scut' work. What's a simple cellulitis? If it was so simple, why was the patient admitted? If the patient goes septic, what do we do? (call ID and transfer to the ICU). Can't a NP do that? I think we physicians need to be real careful what we call 'scut' work; if we deem everything to be scut and farm it out, we'll be out of jobs. Or, we'll have to take reduced wages to do the same job. It's just economics.

 

[DrNotaDr]

I believe you. Most hospitalized patients are in some kind of mental stress and don't remember their right from left let alone the exact titles of the parade of people walking into the room.



Again it's interesting what we physicians deem to be 'scut' work. What's a simple cellulitis? If it was so simple, why was the patient admitted? If the patient goes septic, what do we do? (call ID and transfer to the ICU). Can't a NP do that? I think we physicians need to be real careful what we call 'scut' work; if we deem everything to be scut and farm it out, we'll be out of jobs. Or, we'll have to take reduced wages to do the same job. It's just economics.

I’ve found, in my system, likely 1/3 of our admissions could likely be discharged (if the patient is compliant) but are often only admitted due to defensive medicine. Mid levels can be utilized to help this population safely, but only if our role is not viewed antagonistically. Even so, I do my best to understand why some of the docs feel the way they do and work hard to save them time too so that they will value my work. In some cases it won’t matter what I do, I still try though.

 

[Splenda88]

I believe you. Most hospitalized patients are in some kind of mental stress and don't remember their right from left let alone the exact titles of the parade of people walking into the room.



Again it's interesting what we physicians deem to be 'scut' work. What's a simple cellulitis? If it was so simple, why was the patient admitted? If the patient goes septic, what do we do? (call ID and transfer to the ICU). Can't a NP do that? I think we physicians need to be real careful what we call 'scut' work; if we deem everything to be scut and farm it out, we'll be out of jobs. Or, we'll have to take reduced wages to do the same job. It's just economics.

I think scut work is getting bombarded with social admit or discharge...

 

[Splenda88]

I’ve found, in my system, likely 1/3 of our admissions could likely be discharged (if the patient is compliant) but are often only admitted due to defensive medicine. Mid levels can be utilized to help this population safely, but only if our role is not viewed antagonistically. Even so, I do my best to understand why some of the docs feel the way they do and work hard to save them time too so that they will value my work. In some cases it won’t matter what I do, I still try though.

Physicians did not see midlevels role as antagonistic; it's you guys that are trying to encroach into physicians' territory. Pushing for equal 'treatment' and pay...

 

[DrNotaDr]

Physicians did not see midlevels role as antagonistic; it's you guys that are trying to encroach into physicians' territory. Pushing for equal 'treatment' and pay...

Nope. Many physicians feel the very existence of mid levels in any role at all is a threat to their profession, I know a few of them.

 

[tantacles]

I'll be honest: If the ICU at my hospital didn't have an NP, I would not be able to do my job. Those patients could keep me busy literally all night, and I'm often expected to admit 6-8 in a night, which would be totally unreasonable.

 

[CCM-MD]

I'll be honest: If the ICU at my hospital didn't have an NP, I would not be able to do my job. Those patients could keep me busy literally all night, and I'm often expected to admit 6-8 in a night, which would be totally unreasonable.

One could argue it’s totally unreasonable that an NP is managing the sickest of the sick that would keep a fully trained physician busy all night.

 

[DrMetal]

One could argue it’s totally unreasonable that an NP is managing the sickest of the sick that would keep a fully trained physician busy all night.

Exactly. What the hell then is the role of the physician?

 

[CCM-MD]

Exactly. What the hell then is the role of the physician?

Looks like in that kind of job, the physicians role is to provide liability insurance to the non physician provider. Midlevels love to be doctor until the lawyers show up. At which point they will happily say they were just acting under the supervision of a physician. But as it goes in the insurance business: most of the time nothing goes wrong, but when it does it’s bad. Simultaneously, the patients get ****ty care - but in today’s world, who cares about that?

 

[DrMetal]

Looks like in that kind of job, the physicians role is to provide liability insurance to the non physician provider. Midlevels love to be doctor until the lawyers show up. At which point they will happily say they were just acting under the supervision of a physician. But as it goes in the insurance business: most of the time nothing goes wrong, but when it does it’s bad. Simultaneously, the patients get ****ty care - but in today’s world, who cares about that?

If I can't find a job in the locale that I'm looking at, can I ask for the NP's role, which used to be the physician's role before we farmed it out? LOL.

 

[CCM-MD]

If I can't find a job in the locale that I'm looking at, can I ask for the NP's role, which used to be the physician's role before we farmed it out? LOL.

No. My recommendation is that you should ask to practice at the “top of your license” and request privileges to perform hemicraniectomies, TAVR, and colonoscopies.

Think big, my friend. Think big.

 

[Splenda88]

No. My recommendation is that you should ask to practice at the “top of your license” and request privileges to perform hemicraniectomies, TAVR, and colonoscopies.

Think big, my friend. Think big.

Mid level providers like that catchy phrase...

 

[tantacles]

One could argue it’s totally unreasonable that an NP is managing the sickest of the sick that would keep a fully trained physician busy all night.

One could. The NP calls me frequently to discuss the patients even for routine things if they have concerns. And ultimately, there's an intensivist on call overnight as well. I'm just not doing the grunt work of "Hey, this patient needs a renewal of restraint orders" at midnight. I've been very involved in the care of these patients; I just can't possibly fully manage their care overnight.

 

[CCM-MD]

One could. The NP calls me frequently to discuss the patients even for routine things if they have concerns. And ultimately, there's an intensivist on call overnight as well. I'm just not doing the grunt work of "Hey, this patient needs a renewal of restraint orders" at midnight. I've been very involved in the care of these patients; I just can't possibly fully manage their care overnight.

“I just can’t fully manage their care overnight” translates to the hospital doesn’t want to pay for adequate physician coverage for the ICU. Should worry about what midlevels aren’t calling about, not what they are calling about. Thats what leads to trouble.

 

[DrMetal]

“I just can’t fully manage their care overnight” translates to the hospital doesn’t want to pay for adequate physician coverage for the ICU. Should worry about what midlevels aren’t calling about, not what they are calling about. Thats what leads to trouble.

We're really losing this battle. An undergrad economics major can see this. I have about 20 years of work left in me, I hope I'll be ok. But I'm sure as hell not recommending this profession for my kids. Hopefully they'll go to PA/NP school, a father could only dream!

 

[tantacles]

“I just can’t fully manage their care overnight” translates to the hospital doesn’t want to pay for adequate physician coverage for the ICU. Should worry about what midlevels aren’t calling about, not what they are calling about. Thats what leads to trouble.

I mean, duh? Of course the hospital doesn't want to pay for physician coverage overnight. And I'm also worried about what they're not calling about. That being said, I've gotten to know the NP's pretty well, and they tend to check in pretty frequently. The setup, at least in our community hospital 10 bed ICU, works.

Of course there are issues with this setup. But it's far better than having one physician covering the ICU and admitting and doing floor cross cover.

 

[Osteoth]

I mean, duh? Of course the hospital doesn't want to pay for physician coverage overnight. And I'm also worried about what they're not calling about. That being said, I've gotten to know the NP's pretty well, and they tend to check in pretty frequently. The setup, at least in our community hospital 10 bed ICU, works.

Of course there are issues with this setup. But it's far better than having one physician covering the ICU and admitting and doing floor cross cover.

Are you compensated extra for covering the ICU?

 

[ReviewOfSystems]

Are you compensated extra for covering the ICU?

LOL.

 

[Osteoth]

LOL.

Lol yeah I’m just a dumb intern but I don’t get how hospitals get away with paying a hospitalist in an open icu hospital the same as one in a closed icu. Same with hospitalists who cover codes, do procedures etc.

Why aren’t they compensated for the extra work?

 

[tantacles]

Lol yeah I’m just a dumb intern but I don’t get how hospitals get away with paying a hospitalist in an open icu hospital the same as one in a closed icu. Same with hospitalists who cover codes, do procedures etc.

Why aren’t they compensated for the extra work?

hospitals generally don’t “pay you extrra for covering the icu..” either it is or isn’t part of your job, and you look to your total compensation to help weigh your options.

in this case, what I’m being paid is worth it when compared to the amount of work I do each night.

 

[bronx43]

Midlevels are good for scut. As the fellow on cards, we have a hybrid model where I staff all the midlevels consults then speed table round with attending. The midlevels serve to insulate us from scutwork and pages. Patient "needs" a life vest? Scut it out to the NP. Discharge this post procedure patient? Scut it out to the NP. New afib? Have the NP arrange cardioversion +/- TEE. Have the NP do the preauth paperwork for eliquis or repatha or whatever.

NPs aren't taking your jobs anymore than cleaning up after yourself is taking away jobs from the janitor. They free up time so you aren't responding to pages of K is 3.9, replete?

If an NP is making decisions independently, then it's a different story. My experience has been that NPs/PAs are scared to make any real medical decisions other than stuff a fresh 3rd year can do. Even simple stuff like "discharge on keflex?" for a UTI gets asked one way or another. I've not seen an NP/PA actually make real medical decisions or do a workup without asking the attending first.

Wait, what? Cleaning up after yourself IS taking jobs away from the janitor. The point isn't that there will be NO janitor, because there will always have to be one to take care of the big messes. The point is the bean counters will only need to hire one instead of two or three. This, in effect, will drive down the pay of the one janitor due to the fact that there are three people willing to take his job should he fail to accept the salary cut that is always around the corner.