Which specialties will survive the rush of mid-levels?

[working_hard1]

Mid-levels (PAs and NPs) are increasingly becoming the sole "providers" in many medical care settings and specialities, including IM and ED where there are only a few docs overseeing many mid-levels who act as the sole care provider for patients. It's concerning that doctors are becoming less "prized" in many specialties. What are some specialities that will survive the influx of mid-levels into positions that traditionally were only MD/DO? I'm guessing surgery and ob-gyn will still be doctor-focused, what are the other specialties?

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[deleted1139416]

I truly believe that in the long run this will actually make doctor's more in demand. After being an MS-3 for just a few months, I'm realizing just how complicated medicine is and that even doctors struggle with the complexity. Having midlevels is a recipe to make things worse. Just as an example, on my family medicine rotation a PA prescribed viagra to a patient with history of hypotension and that patient ended up in the Emergency Department one week later.

 

[hamstergang]

SDN shows me people asking this question at least a full decade back (though I'm sure older such threads could be found). Have mid-levels yet taken over any specialty? Have they led to a drop in physician pay?

 

[Future_Bone_Docta]

Mid-levels (PAs and NPs) are increasingly becoming the sole "providers" in many medical care settings and specialities, including IM and ED where there are only a few docs overseeing many mid-levels who act as the sole care provider for patients. It's concerning that doctors are becoming less "prized" in many specialties. What are some specialities that will survive the influx of mid-levels into positions that traditionally were only MD/DO? I'm guessing surgery and ob-gyn will still be doctor-focused, what are the other specialties?

There is speculation that mid-levels will not so much "replace" doctors, but more so that the healthcare system will become increasingly stratified.

The rich will be able to afford and see doctors, while the poor will be seen by mid-levels. Thanks private equity and the profit driven model...

But no one knows, only time will tell.

The more it becomes stratified, the less mid-levels will be adequately trained by expert physicians within the field as well. You see this with profit driven urgent cares. They are fully staffed by mid-levels (some it being there first job and they are brand new), and there training comes from other middles within the field... It is the blind leading the blind.

Just the other day one of my friends went to an urgent care because he got something in his eye and told the PA that. PA said it was just a corneal abrasion and he shouldn't worry after performing an exam. Fast forward 4 hours and he found a piece of metal had punctured his cornea.

 

[operaman]

I think the surgical fields are probably safest. Patients may not care who gives them a zpack for their cold, but they do tend to care more about credentials when it comes to surgery.

That said, I wouldn’t be surprised to see some creep. Anything you can teach a PGY1/2 to do well is something that could probably be learned by a midlevel and done safely with MD supervision and backup. But it will probably take a lot longer to get there than other fields.

 

[deleted1139416]

I think the surgical fields are probably safest. Patients may not care who gives them a zpack for their cold, but they do tend to care more about credentials when it comes to surgery.

That said, I wouldn’t be surprised to see some creep. Anything you can teach a PGY1/2 to do well is something that could probably be learned by a midlevel and done safely with MD supervision and backup. But it will probably take a lot longer to get there than other fields.

I think you may think that way because you’re a seasoned physician. But I think if you remember how difficult PGY 1 and 2 were academically, do you think a midlevel could handle that?

 

[Lawpy]

All specialties will survive. Feel free to quote me on this a decade from now

 

[Lawpy]

I truly believe that in the long run this will actually make doctor's more in demand. After being an MS-3 for just a few months, I'm realizing just how complicated medicine is and that even doctors struggle with the complexity. Having midlevels is a recipe to make things worse. Just as an example, on my family medicine rotation a PA prescribed viagra to a patient with history of hypotension and that patient ended up in the Emergency Department one week later.

Yep. Primary care, EM and anesthesia, which appear most susceptible to midlevel encroachment, can deal with complex and challenging cases that physicians can be confident they’ll be safe even decades from now. Trusting midlevels on these cases is a recipe for disaster. Even cases that at first glance appear to be standard bread and butter can have complex nuances that physicians are far more prepared in addressing them

 

[Future_Bone_Docta]

Yep. Primary care, EM and anesthesia, which appear most susceptible to midlevel encroachment, can deal with complex and challenging cases that physicians can be confident they’ll be safe even decades from now. Trusting midlevels on these cases is a recipe for disaster. Even cases that at first glance appear to be standard bread and butter can have complex nuances that physicians are far more prepared in addressing them

Once they are held to physician standards, and the malpractice cases start rolling in, admins will notice it isn't financially beneficial.

 

[Lem0nz]

I think you may think that way because you’re a seasoned physician. But I think if you remember how difficult PGY 1 and 2 were academically, do you think a midlevel could handle that?

I do. And I agree with him. They don’t have the same timeline as residents and they don’t rotate, they only do one thing usually and it’s generally pretty consistent. Vastly different experiential training paradigm. Very hard to compare.

 

[voxveritatisetlucis]

Radiology, pathology, surgery (all types). That’s about it. Unless physicians refuse to work anywhere that employs midlevels which won’t happen of course

Maybe dermatology but at least in the northeast there are already tons of derm midlevels opening practices and working at academic hospitals

In some states there’s lobbying for med levels to do scopes. That would pretty much be the end of GI docs working 3 days a week making 600k

 

[Gilakend]

With increasing private equity in medicine, the shrinking of physician owned and led practices, and the increasing focus on the bottom line by hospital/corporation execs, all medical fields will have encroachment. However, I agree with @Lawpy that this will end no specialty. No matter what people say, midlevels simply cannot do what physicians can. This will hopefully be foresight, but if not will quickly become very apparent.

I think @operaman is exactly right that anything a PGY 1-2 could do in a medical or surgical specialty someone could argue that a midlevel could do with training. The only field I would say there is absolutely 0% chance that you could say this for is radiology (and maybe path, but I don't know enough about path).

 

[Ho0v-man]

Patients sure as hell won’t.

 

[voxveritatisetlucis]

Patients sure as hell won’t.

They would if they knew they were paying the same to see an NP as they are to see somebody with 4 years of med school plus 3-10 years of GME

 

[Billiam95]

In preclinical, I thought encroachment would be a big issue. Then, in just a few months of MS3, I saw all the ridiculous mismanagement of patients coming from NPs - overall poor care, gargantuan med lists, terrible referrals (indirect inguinal hernia referred to urology - why?).
In the long run, I do not think that holding NPs to a different standard than MDs is sustainable, and I think once that happens, the economics (and patient choice) will work itself out.

 

[voxveritatisetlucis]

In preclinical, I thought encroachment would be a big issue. Then, in just a few months of MS3, I saw all the ridiculous mismanagement of patients coming from NPs - overall poor care, gargantuan med lists, terrible referrals (indirect inguinal hernia referred to urology - why?).
In the long run, I do not think that holding NPs to a different standard than MDs is sustainable, and I think once that happens, the economics (and patient choice) will work itself out.

Yes but do most patients really know or care?

 

[Billiam95]

Based on the number of times I hear 'finally, a doctor' - yeah, I think they're catching on.
n=1

 

[Putkernerinthehall]

Patients sure as hell won’t.

"Patients sure as hell won't" what ? What question / post are you answering ?

 

[Ho0v-man]

"Patients sure as hell won't" what ? What question / post are you answering ?

Patients won’t survive the midlevel onslaught. They already aren’t.

 

[deleted1139416]

Patients won’t survive the midlevel onslaught. They already aren’t.

It’ll happen, but it’s gonna take time. State governments are also giving midlevels accountability for autonomy (I.e. you can practice independently but you will be liable for your mistakes). Hospitals will have to get malpractice coverage to cover the mistakes their nurses make and many malpractice insurance companies won’t be too happy about that. Not to mention the onslaught in the legal system.

The whole midlevel creep thing will make a U turn eventually. It’s just a matter of whether 1 thousand patients need to be harmed or 1 million patients need to be harmed.

 

[operaman]

I think you may think that way because you’re a seasoned physician. But I think if you remember how difficult PGY 1 and 2 were academically, do you think a midlevel could handle that?

I do. Midlevels don’t have the same learning requirements so you’re really just training them to perform a very basic task. Also, when I say PGY1/2, I mean cases they can actually do solo, not the ones where the attending let’s them fly more but still actively helps.

So in my field that means things like basic ear tubes, tonsils, scopes, debridements, etc. Midlevels are already used heavily in many clinics for these sorts of procedures; I don’t see why the same PA who can place an ear tube in the office awake couldn’t just as easily place one asleep. I don’t personally want to practice this way, but I think it could be done safely.

Just like a resident, you’d want to have attending backup available and obviously things can and do go awry sometimes. But if an intern or 2 can learn to do it truly solo in a few weeks, surely a good PA can be taught to do it given enough time and reps.

 

[deleted1139416]

I do. Midlevels don’t have the same learning requirements so you’re really just training them to perform a very basic task. Also, when I say PGY1/2, I mean cases they can actually do solo, not the ones where the attending let’s them fly more but still actively helps.

So in my field that means things like basic ear tubes, tonsils, scopes, debridements, etc. Midlevels are already used heavily in many clinics for these sorts of procedures; I don’t see why the same PA who can place an ear tube in the office awake couldn’t just as easily place one asleep. I don’t personally want to practice this way, but I think it could be done safely.

Just like a resident, you’d want to have attending backup available and obviously things can and do go awry sometimes. But if an intern or 2 can learn to do it truly solo in a few weeks, surely a good PA can be taught to do it given enough time and reps.

But another important factor in provider care is recognizing when things start to go wrong or predicting if things may go wrong soon. For example, a simple infection turning into sepsis and septic shock.

 

[deleted1065184]

The rich will be able to afford and see doctors, while the poor will be seen by mid-levels. Thanks private equity and the profit driven model...

This is already the case in many areas...esp. in the rural South. Growing up, I never saw a physician, only an NP. My family's PCP is still the same NP. And even though I like him as a person, as a med students I've already started to see significant flaws in his practice. It is absolutely subpar care.

 

[operaman]

But another important factor in provider care is recognizing when things start to go wrong or predicting if things may go wrong soon. For example, a simple infection turning into sepsis and septic shock.

Agreed 100 %. I think a key distinction with these more simple procedures is that they are short, predictable, with minimal opportunity to go awry. Managing a potentially septic patient is much more challenging and definitely requires high level skills and decision making. With a tonsil, the biggest decision intraop is whether to start with the left one or the right one.

With a few months of dedicated training you could get a PA to a higher case volume for any one simple procedure than any resident gets since they tend to move onward and upward to more complex things. With an MD in house as backup, I think they could fly solo just fine.

I like to recall that it’s relatively recent that surgeons were also physicians. Much of my intra operative decision making has little or nothing to do with medical knowledge. It’s much more of a craft. Most of the high level decisions are made in the office, though much of that can be fairly algorithmic.

While US patients would probably balk, I could see other countries with limited docs start having midlevels train to do high volume simple cases under a supervised model.

 

[Drrrrrr. Celty]

I do. Midlevels don’t have the same learning requirements so you’re really just training them to perform a very basic task. Also, when I say PGY1/2, I mean cases they can actually do solo, not the ones where the attending let’s them fly more but still actively helps.

So in my field that means things like basic ear tubes, tonsils, scopes, debridements, etc. Midlevels are already used heavily in many clinics for these sorts of procedures; I don’t see why the same PA who can place an ear tube in the office awake couldn’t just as easily place one asleep. I don’t personally want to practice this way, but I think it could be done safely.

Just like a resident, you’d want to have attending backup available and obviously things can and do go awry sometimes. But if an intern or 2 can learn to do it truly solo in a few weeks, surely a good PA can be taught to do it given enough time and reps.

That's the thing though. You're training someone to do a job at that point. And a job with specific limitations and oversight.
Which I think that ends up representing a significant issue within medicine. It's becoming convoluted, expensive, and bureaucratic. We've gone from a physician doing most everything to needing 4 administrators to make sure there's an adequate amount of xyz specialists, nps, and hospitalists, and pcps to manage the most simple of conditions for the sake of overbilling and medicolegal protection.

The reality is that RVUs, billing, etc should be based on complexity, quality, and time spent as opposed to the industrial kiln that it is today that births the need for mid level subspecialists.

 

[Choсolate]

If I am planning toward becoming a PA, how concerned should I be concerned about any clinical misdiagnosis I am prone to with my fewer years of training? Should I consider going the MD/DO route instead or is this thread just blowing smoke into the eyes?

 

[Goro]

All of them

 

[AnonymousDoctorGuyPerson]

I can't imagine a mid-level running the floor let alone something like the ICU.

 

[voxveritatisetlucis]

If I am planning toward becoming a PA, how concerned should I be concerned about any clinical misdiagnosis I am prone to with my fewer years of training? Should I consider going the MD/DO route instead or is this thread just blowing smoke into the eyes?

Well of course you’re going to get biased answers here but it’s pretty basic logic that somebody with 2 years and 400 hours of training is going to misdiagnose more than somebody with 8 years and 10000 hours

 

[Ho0v-man]

Well of course you’re going to get biased answers here but it’s pretty basic logic that somebody with 2 years and 400 hours of training is going to misdiagnose more than somebody with 8 years and 10000 hours

While your statement is generally correct, PAs do a full clinical year, about 2,000 hrs.

Most docs break 10,000 hours easily by the end of of a three year residency if we’re including med school. Our standards to which we’re held are typically higher during those hours.

 

[deleted1095841]

My admittedly optimistic take on this is that there is no danger of doctors running out of work. There will be more work for doctors than ever. It's just that, to borrow the words of Earl C. Kelly, that they will work at a higher level and on more important things.

 

[Shunsui]

so what I'm hearing is more specialized = safer

 

[voxveritatisetlucis]

While your statement is generally correct, PAs do a full clinical year, about 2,000 hrs.

Most docs break 10,000 hours easily by the end of of a three year residency if we’re including med school. Our standards to which we’re held are typically higher during those hours.

I didn’t know they did 40-50 hour weeks though. I mean even in med school, some rotations don’t even seem to be 50+

Thought it was more like a part time thing

 

[Future_Bone_Docta]

While your statement is generally correct, PAs do a full clinical year, about 2,000 hrs.

Most docs break 10,000 hours easily by the end of of a three year residency if we’re including med school. Our standards to which we’re held are typically higher during those hours.

I think it may be school dependent, I know PA's who definitely did not do full time work during their clinical year so 2k hours is a little steep in some instances (It was an in at 8 and leave by 12-2 gig).

 

[deleted1139416]

I think it may be school dependent, I know PA's who definitely did not do full time work during their clinical year so 2k hours is a little steep in some instances (It was an in at 8 and leave by 12-2 gig).

It’s essentially 3rd year med school level stuff. And then they start practicing…. not to mention that they never get a detailed education on Step 1 or Step 2 level material

 

[Future_Bone_Docta]

It’s essentially 3rd year med school level stuff. And then they start practicing…. not to mention that they never get a detailed education on Step 1 or Step 2 level material

Yeah I took a practice PANCE for fun, it definitely is not even comparable.

 

[GadRads]

I think radiology and pathology are the safest, since direct medical knowledge is needed to do the job. Radiology does use sonographers who are generally knowledgeable but not they do not know enough to integrate the whole clinical picture and try to take over radiology.

 

[Ho0v-man]

I didn’t know they did 40-50 hour weeks though. I mean even in med school, some rotations don’t even seem to be 50+

Thought it was more like a part time thing

That’s NPs. PAs actually do have training, just not as much as us.

 

[Ho0v-man]

I think it may be school dependent, I know PA's who definitely did not do full time work during their clinical year so 2k hours is a little steep in some instances (It was an in at 8 and leave by 12-2 gig).

Yeah I noticed that too in retrospect on a couple rotations I had with PAs. But on others I saw them staying almost as long as the med students. Was trying to give them the benefit of the doubt. But you’re probably right.

Yeah I took a practice PANCE for fun, it definitely is not even comparable.

Same. I thought it was at least a reasonable exam that had some realistic expectations and didn’t care about memorizing genes and cell receptors. Then a PA I was talking to said that practice test I just breezed through was much harder than the real deal.

I also took a practice test for the NP boards (forget what it’s called). Can’t believe how easy that is.

 

[ProReduction]

None of the specialties will survive the rush long-term, as contemporary medicine values expedient, low-quality, inexpensive evaluation over delayed, high-quality, more expensive evaluation. Mid-levels are already replacing Emergency Physicians, Intensivists, Anesthesiologists, Internists, Primary Care Providers, and more. There is already talk of NP/PA "Neurology Residencies" to address the Neurologist shortage. All specialties will be replaced, with surgical subspecialties last to take the hit. Radiology and Pathology will see severe reductions in demand via AI-assisted work, where 2 Radiologists and Pathologists in 2040 will be doing the work that 10 Radiologists and Pathologists were doing in 2020. The majority of my time is spent in deep learning research. The pace of achievement accelerates each year.

Attachment is the great fabricator of illusions. Too many physicians are horse-carriage operators, whether by ignorance or by arrogance, eyeing the model T saying "that thing will never replace me". It is better to evolve than to become extinct.

 

[Captain_Falcon]

None of the specialties will survive the rush long-term, as contemporary medicine values expedient, low-quality, inexpensive evaluation over delayed, high-quality, more expensive evaluation. Mid-levels are already replacing Emergency Physicians, Intensivists, Anesthesiologists, Internists, Primary Care Providers, and more. There is already talk of NP/PA "Neurology Residencies" to address the Neurologist shortage. All specialties will be replaced, with surgical subspecialties last to take the hit. Radiology and Pathology will see severe reductions in demand via AI-assisted work, where 2 Radiologists and Pathologists in 2040 will be doing the work that 10 Radiologists and Pathologists were doing in 2020. The majority of my time is spent in deep learning research. The pace of achievement accelerates each year.

Attachment is the great fabricator of illusions. Too many physicians are horse-carriage operators, whether by ignorance or by arrogance, eyeing the model T saying "that thing will never replace me". It is better to evolve than to become extinct.

First I'm hearing of this, though I find it kinda funny considering neurology as a field is essentially one that most other physicians in other fields have no idea how to deal with it, and it's a highly sub-specialized field with so much breadth to it that I find it not being attractive to MLPs unless they focus only on something like "headache" or "pain" and become a headache/pain clinic

 

[hamstergang]

I think radiology and pathology are the safest, since direct medical knowledge is needed to do the job.

What medical field doesn't require "direct medical knowledge" to do?

 

[Future_Bone_Docta]

Yeah I noticed that too in retrospect on a couple rotations I had with PAs. But on others I saw them staying almost as long as the med students. Was trying to give them the benefit of the doubt. But you’re probably right.


Same. I thought it was at least a reasonable exam that had some realistic expectations and didn’t care about memorizing genes and cell receptors. Then a PA I was talking to said that practice test I just breezed through was much harder than the real deal.

I also took a practice test for the NP boards (forget what it’s called). Can’t believe how easy that is.

Yeah the NP exam is scary easy.

 

[GadRads]

What medical field doesn't require "direct medical knowledge" to do?

Of course they all require direct knowledge, however the breadth of knowledge needed for radiology makes it near impossible to "wing it" as some midlevels can in other fields, even though their clinical knowledge and care is generally subpar. In radiology and pathology, incompetence quickly stands out. Images and reports don't change and can always be reviewed in the future.

 

[ProReduction]

First I'm hearing of this, though I find it kinda funny considering neurology as a field is essentially one that most other physicians in other fields have no idea how to deal with it, and it's a highly sub-specialized field with so much breadth to it that I find it not being attractive to MLPs unless they focus only on something like "headache" or "pain" and become a headache/pain clinic

They already exist, and other major academic centers are organizing to create more programs:

Advanced Practice Providers Fellowship Program | Duke Department of Neurology

Graduates of an accredited NP or PA program are eligible. Fellows will be educated in general neurological principals and be capable of working in a general or subspecialty neurology practice upon completion. There will be experience in both outpatient and inpatient settings. Our graduates are...

neurology.duke.edu

Every graduate of these programs fills a 175k job in the midwest or south that would otherwise have to pay a Neurologist 400K+ to work in that same setting.

 

[Captain_Falcon]

They already exist, and other major academic centers are organizing to create more programs:

Advanced Practice Providers Fellowship Program | Duke Department of Neurology

Graduates of an accredited NP or PA program are eligible. Fellows will be educated in general neurological principals and be capable of working in a general or subspecialty neurology practice upon completion. There will be experience in both outpatient and inpatient settings. Our graduates are...

neurology.duke.edu

Every graduate of these programs fills a 175k job in the midwest or south that would otherwise have to pay a Neurologist 400K+ to work in that same setting.

Ahh yes I’ve read about this Duke one before. Are there others out there?

 

[mrbreakfast]

Every graduate of these programs fills a 175k job in the midwest or south that would otherwise have to pay a Neurologist 400K+ to work in that same setting.

Ehh, I work in one of the regions you name in a practice with many APPs, and I would say the statement that a neurology APP is filling a general neurology position is equivalent to saying a PA that manages uncomplicated hypertension all day is filling a fellowship-trained cardiology position.

APPs are excellent at dealing with uncomplicated migraine, uncomplicated neuropathy, uncomplicated memory loss ("worried well" or pseudodementia). You could argue that a neurologist could see all of those and bill for them, but could also argue that a PCP could (and should) be able to manage basic headache, diabetic neuropathy, etc.

I enjoy working with APPs and they do see a lot of patients, and at least where I work do a good job of it. But there's zero competition between us. They couldn't do my job, and any place that's using an APP instead of paying a neurologist is probably having a ton of trouble attracting a neurologist in the first place. I'm sure you've seen the job postings these days.

 

[collegestud2013]

Mid-levels (PAs and NPs) are increasingly becoming the sole "providers" in many medical care settings and specialities, including IM and ED where there are only a few docs overseeing many mid-levels who act as the sole care provider for patients. It's concerning that doctors are becoming less "prized" in many specialties. What are some specialities that will survive the influx of mid-levels into positions that traditionally were only MD/DO? I'm guessing surgery and ob-gyn will still be doctor-focused, what are the other specialties?

Outpatient specialties may be more shielded (but not completely) since patients choose their provider in the outpatient setting, and those with the financial means will still choose the MD/DO over PA/NP in a non-emergent setting. Poorer patients with Medicaid or no insurance will have less choices and may have to settle for a PA/NP. In contrast inpatient shift-based specialties like hospitalist, EM, or even critical care are more prone since patients don't usually get to choose their provider in an acute setting.

Specialties with more "scut" work on a day-to-day basis (ie clerical or logistical work that doesn't really require high-level medical knowledge or decision making) will be more prone to midlevel use since NPs and PAs are probably no worse at doing such work than physicians. For example, hospitalist and inpatient surgery work may be more prone to using midlevels since a good amount of the work involves care coordination, and midlevels can be used to help gather information and and coordinate care (eg calling consults or talking to families or writing notes, doing discharge planning) in a relatively predictable way.

Surgical specialties are a mixed bag. The complex surgical work itself can almost never be done by a PA or NP independently, but the floor work that goes along with the surgeries (eg postop management, seeing and writing consult notes, seeing follow-ups in clinic) is often staffed heavily by PAs and NPs in non-academic settings. This may lead to a practice hiring less surgeons (to keep the surgeons that that they do hire more time in the OR).

Diagnostic Radiology and pathology are probably most shielded by midlevels since there is minimal scut that they can be helpful with. But of course in those specialties there's the concern of AI taking over.

 

[PikminOC]

Once they are held to physician standards, and the malpractice cases start rolling in, admins will notice it isn't financially beneficial.

Midlevels aren't held to physician standards and never will be.. hospitals love them as they order more tests and any errors end up with the patient right back in their hospital. $$$

 

[Neopolymath]

I think radiology and pathology are the safest, since direct medical knowledge is needed to do the job. Radiology does use sonographers who are generally knowledgeable but not they do not know enough to integrate the whole clinical picture and try to take over radiology.

This is reinforced every time a sonographer calls me about a patient they just scanned and they didn't get cines and don't know that we need more images of xyz or else it's a useless examine.