Which subspecialty is most resistant to encroachment or expansion?

[rokshana]

The greed of someone teaching an NP to scope. For 10 years after that the GI salaries are going to balloon, boomers will cash out and the field forever more will be dead.

Greed and ego pure and simple.

And this was the golden age of medicine?

Who said that? The golden age of medicine was the 1980s... before the advent of HMOs...

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[VA Hopeful Dr]

The military: where at least know going into it that you're going to be dealing with a huge beaurocracy, you might get shot at, and you might be disrespected (depending on your rank of course).

We had no idea that all of the above also applies to medicine now (and that wasn't always the case).

If you didn't, that's on you (I'm assuming we're roughly contemporaneous as far as medical educations goes). When I started med school in 2005, most of the doctors locally and where I went to med school were employed by hospitals. Medicare/Insurance were bad (admittedly somewhat worse now, but that's been a trend since the early 90s). NPs might be worse now, I'm not sure on that one but as the son of an optometrist I was well aware of non-physician providers trying for bigger pieces of the pie.

 

[Renal_Prometheus]

The paradigm has changed, but dialysis remains by far the most profitable part of nephrology care. I have worked within both systems, physician owned and with DaVita, and both systems have pros and cons. On the one hand, a practice can be more responsible for the logistics of the unit and reap more of a financial benefit, and on the other hand, a practice can relinquish that responsibility and spend its time elsewhere. Dialysis is very territorial; the companies cannot just establish their own dialysis clinic down the road and bully out the already established doctors. Number and range of dialysis clinics is tightly regulated. A need has to be established. If dialysis patients are already being served, there is not a need for a new unit. Historically, DaVita and others bought out practices who crunched the numbers and found it beneficial to let it go. I would liken it to IR taking over many procedures. Sometimes it's not worth the hassle.

However, DaVita and practices have joint ventures all the time. Practices will often own the property, and DaVita rent space to perform dialysis. These companies' business models are really focused on the dialysis component. They do not necessarily want to buy property. They do not want to hire their own doctors. They are happy to work with practices and rent space. There are also medical directorships that can be lucrative.

So it's a nice setup. Bill for the patient care. Bill for the medical directorship. Possibly collect rent on top of that.

Now, I'll be clear and say that working with a large health care entity is not all rainbows and butterflies, but my complaints are about other things and not what was just discussed.

Reimbursement is controlled by Medicare primarily, not DaVita. Coincidentally, reimbursement for nephrology is expected to go up quite a bit with changes to how dialysis compensation works, efforts to promote home modalities, etc.

It remains to be seen if the current fellowship load is still too much or enough for the specialty. The number of spots filled has not changed much over the years. There might have been slightly more over this past year. The lower end programs continue to run half full. There is a world where the field may be contracting, and good graduates will be in high demand. Anecdotally, it may take a practice a couple of years to find a good candidate. That has been the experience in my region.

That was probably more than you wanted! The above does not have much to do with midlevels. We use midlevels to help with dialysis rounding. Each patient needs to be seen four times monthly (3 quicker visits and 1 comprehensive visits) for maximum billing so docs will do the comprehensive visit and maybe a limited visit while the midlevels do the rest. That frees us docs up to be more productive in clinic (or maintain our 4-day work weeks).

I think nephrology is safe from midlevel takeover for a while. There is not more money in regular clinic visits...more complicated patients with similar billing to everyone else (unless they are transplants or GNs). They cannot handle the complexity. They cannot treat GN. We have to teach them how to manage hypertension for Pete's sake. Midlevels would have to go after dialysis and see patients independently for it to be worthwhile, but dialysis is so tightly regulated by the government/Medicare that I think it is going to be a long time before we see anything like that. I'm sure DaVita would like to make a buck, but dialysis patients are complicated, and we provide a lot of oversight. Outcomes would be poor. Midlevels don't learn any nephrology in their training so if there is not a nephrologist, DaVita would have to train them, and they have not shown much interest in doing that at this time.

Just do what you want. As long as you do private practice, you have a lot of control as far as midlevels go. You have less say if you are employed.

This guy is just full of BS every time due to his own ego. I've been in nephrology a lot longer than him and I cant tell you 80% of what a nephrologist can do can be replacement by a midlevel.

 

[rokshana]

This guy is just full of BS every time due to his own ego. I've been in nephrology a lot longer than him and I cant tell you 80% of what a nephrologist can do can be replacement by a midlevel.

Please stop with the personal attacks...that is his opinion based on his experiences...if you have experiences that say otherwise please share...but it is tiring to see you come into a thread to nephrology-bash... we get it .

and if you advocate for mid level replacement of physicians... well... you are part of the problem...

 

[whoknows2012]

I'd do it again in a heartbeat

I would too. A lot of doom and gloom in here, I love what I do for a living

 

[bronx43]

and if you advocate for mid level replacement of physicians... well... you are part of the problem...

Lol, come on now... let's not act like just because we come on SDN and anonymously bash on midlevels, we are somehow valiant soldiers in this war against the ongoing invasion of our profession.

Let's face it. Anyone who employs, supervises, or even works for a health system that is pushing midlevels encroachment is part of the problem. And unfortunately, that's the majority of us.

 

[Chemist0157]

I would too. A lot of doom and gloom in here, I love what I do for a living

SDN has always been a weird mix of unicorn jobs and the sky falling. I’m not sure SDN has been a good representation of the general student/resident/fellow/attending populations (everyone seemed like a genius freak here when I was applying to medical school for instance) , but it is good to get exposure to a large swath of experiences and opinions.

I enjoy what I do and would do it again as well.

 

[rokshana]

Lol, come on now... let's not act like just because we come on SDN and anonymously bash on midlevels, we are somehow valiant soldiers in this war against the ongoing invasion of our profession.

Let's face it. Anyone who employs, supervises, or even works for a health system that is pushing midlevels encroachment is part of the problem. And unfortunately, that's the majority of us.

That is the beauty of working locums ... it is a deal breaker for me if they want someone to supervise midlevels.

will I work in an office with midlevels? yes because I don’t have control over who they do or don’t hire...and I’ll even help answer questions if they come ask me since they might as well get a better idea of how to manage pts...and bless their hearts, the new ones are so deer in headlights...the last place I was hired a noob NP in Jan and I hear she had already has handed in her resignation...

don’t get me wrong, there is a place for mid levels...it’s just not as a physician replacement.

 

[blue.jay]

That is the beauty of working locums ... it is a deal breaker for me if they want someone to supervise midlevels.

will I work in an office with midlevels? yes because I don’t have control over who they do or don’t hire...and I’ll even help answer questions if they come ask me since they might as well get a better idea of how to manage pts...and bless their hearts, the new ones are so deer in headlights...the last place I was hired a noob NP in Jan and I hear she had already has handed in her resignation...

don’t get me wrong, there is a place for mid levels...it’s just not as a physician replacement.

I don’t understand...it’s a dealbreaker to supervise midlevels as hospitalist but okay in outpatient setting ?

 

[rokshana]

I don’t understand...it’s a dealbreaker to supervise midlevels as hospitalist but okay in outpatient setting ?

No... I don’t supervise midlevels...period.
I’ll work in a hospital or clinic that has midlevels, but I won’t put up my license to supervise them... my name does not go into their records nor will I co sign their notes.

 

[Osteoth]

The craziest thing is that mid levels don’t even really save the hospital that much $.

They see half the patients at best, less efficiently and make about half…

Why is this myth that they’re a viable replacement a thing?

 

[DrMetal]

If you didn't, that's on you (I'm assuming we're roughly contemporaneous as far as medical educations goes). When I started med school in 2005, most of the doctors locally and where I went to med school were employed by hospitals. Medicare/Insurance were bad (admittedly somewhat worse now, but that's been a trend since the early 90s). NPs might be worse now, I'm not sure on that one but as the son of an optometrist I was well aware of non-physician providers trying for bigger pieces of the pie.

Yeah, it is on me. I didn't come from a healthcare related family. My parents were immigrants who made a combined salary of $40k/year (I've been working since I was 13). We never went to the doctor (had no insurance, I didn't even understand the concept until my early 20s).

Here's what I didn't know about medicine (that had I known, maybe would've ventured elsewhere).

1. the plethora of bullsht medicine we do, CYA medicine, BS exams for CMS, the BS f/u, the BS well check on completely asymptomatic people. 90% of our job is a façade. COVID brought this to light nicely, as all of these things were canceled.

2. how non compliant people can be. I never went to the doctor, but when I did, I hung on his every word. Nowadays, everybody thinks they're that much smarter.

3. that we're never left alone to practice. from BC to MOC to CME to other administrative headaches . . .it's not enough to just be a good clinician, to get your patient from point A to point B, to do good work . . . we're always in some other kinda rat race.

4. in this country, the # of unnecessary first world problems (psuedoseizures, psuedo this and that, 'chronic fatigue syndrome') that we have to pretend to care about.

5. the marginalization of the physician (the reduction of salaries, the hiring of NPs/PAs over MDs, etc etc).

6. the plethora of psychosocial circumstances that if you can't fix---and you can't, you don't live with your patients----no amount of medicine will do them any good. People really are on their own trajectories, for better or worse.

 

[wamcp]

Yeah, it is on me. I didn't come from a healthcare related family. My parents were immigrants who made a combined salary of $40k/year (I've been working since I was 13). We never went to the doctor (had no insurance, I didn't even understand the concept until my early 20s).

Here's what I didn't know about medicine (that had I known, maybe would've ventured elsewhere).

1. the plethora of bullsht medicine we do, CYA medicine, BS exams for CMS, the BS f/u, the BS well check on completely asymptomatic people. 90% of our job is a façade. COVID brought this to light nicely, as all of these things were canceled.

2. how non compliant people can be. I never went to the doctor, but when I did, I hung on his every word. Nowadays, everybody thinks they're that much smarter.

3. that we're never left alone to practice. from BC to MOC to CME to other administrative headaches . . .it's not enough to just be a good clinician, to get your patient from point A to point B, to do good work . . . we're always in some other kinda rat race.

4. in this country, the # of unnecessary first world problems (psuedoseizures, psuedo this and that, 'chronic fatigue syndrome') that we have to pretend to care about.

5. the marginalization of the physician (the reduction of salaries, the hiring of NPs/PAs over MDs, etc etc).

6. the plethora of psychosocial circumstances that if you can't fix---and you can't, you don't live with your patients----no amount of medicine will do them any good. People really are on their own trajectories, for better or worse.

100%.

I would have gone into computer science...or finance...had I known the above.

The CYA medicine really is the biggest factor to my dissatisfaction. Because even if YOU don't do CYA, everyone ELSE does. That means other consultants will run a train of unnecessary tests on your patient that you have no control over....and trying to tell the patient they don't need to listen to these other docs only erodes the trust and rapport of everyone involved.

I'm also sick and tired of getting transfer patients to our hospital for BS like "patient has abdominal pain and vomiting. CT scan shows SMA atherosclerosis. Yes, the pain is gone now. Lactate was normal. Sure, it could be gastroenteriitis. But....WE DON'T HAVE VASCULAR SURGERY THEY MUST GO TO YOUR INSTITUTION!!"

"This patient has COPD exacerbation at our critical access hospital. THey're on room air and blood gas is fine, yes the nurse did chart resp rate of 18. No I don't want to send them home. WE DON'T HAVE A PULMONOLOGIST SO WE DON"t KNOW whAT TO DO!!. They must transfer, goodbye!"

"I have a patient that came in for a fall. CT brain was done and the radiologist thinks it's a calcifcation but it COULD BE A SMALL BLEED! We must transfer to you, we don't have neurosurgery"

And so on and so on.

 

[blue.jay]

No... I don’t supervise midlevels...period.
I’ll work in a hospital or clinic that has midlevels, but I won’t put up my license to supervise them... my name does not go into their records nor will I co sign their notes.

It doesn't seem like an option these days. Most employers while hiring have a expectation that we cosign midlevel notes. It is more like a requirement these days.
I am a relatively fresh out of residency attending and I don't know if I am risking my license by blindly cosigning NP/PA notes.

 

[VA Hopeful Dr]

Yeah, it is on me. I didn't come from a healthcare related family. My parents were immigrants who made a combined salary of $40k/year (I've been working since I was 13). We never went to the doctor (had no insurance, I didn't even understand the concept until my early 20s).

Here's what I didn't know about medicine (that had I known, maybe would've ventured elsewhere).

1. the plethora of bullsht medicine we do, CYA medicine, BS exams for CMS, the BS f/u, the BS well check on completely asymptomatic people. 90% of our job is a façade. COVID brought this to light nicely, as all of these things were canceled.

2. how non compliant people can be. I never went to the doctor, but when I did, I hung on his every word. Nowadays, everybody thinks they're that much smarter.

3. that we're never left alone to practice. from BC to MOC to CME to other administrative headaches . . .it's not enough to just be a good clinician, to get your patient from point A to point B, to do good work . . . we're always in some other kinda rat race.

4. in this country, the # of unnecessary first world problems (psuedoseizures, psuedo this and that, 'chronic fatigue syndrome') that we have to pretend to care about.

5. the marginalization of the physician (the reduction of salaries, the hiring of NPs/PAs over MDs, etc etc).

6. the plethora of psychosocial circumstances that if you can't fix---and you can't, you don't live with your patients----no amount of medicine will do them any good. People really are on their own trajectories, for better or worse.

1. $$$$$ I wouldn't say 90% of what we do isn't meaningful, but I'm also not a hospitalist.

2. Who cares? If they don't listen, they get worse. That's on them. Don't let it bother you.

3. Seriously? MOC takes me about 6 hours every 3 years. CME is 15 minutes once a month (AAFP CME quizzes) and 1 conference every 3 years (last one was in Hawaii so totally worth it). Maybe I have the best job ever, but admin leaves me alone.

4. Pretend to care, give them a mostly harmless med, profit

5. Salaries for FM have been going up every year in my state since I finished residency in 2013. No clue about other specialties.

6. Help with what you can, ignore the rest.

But even if we ignore all of that, like any job medicine has its frustrations. But there's no other job that once you get into school you're pretty much guaranteed a top 1% (or close to it) income. I'm in the 2nd lowest paid specialty and I still do quite well.

I feel like @efle 's input could be valuable here.

 

[Redpancreas]

Yeah, it is on me. I didn't come from a healthcare related family. My parents were immigrants who made a combined salary of $40k/year (I've been working since I was 13). We never went to the doctor (had no insurance, I didn't even understand the concept until my early 20s).

Here's what I didn't know about medicine (that had I known, maybe would've ventured elsewhere).

1. the plethora of bullsht medicine we do, CYA medicine, BS exams for CMS, the BS f/u, the BS well check on completely asymptomatic people. 90% of our job is a façade. COVID brought this to light nicely, as all of these things were canceled.

2. how non compliant people can be. I never went to the doctor, but when I did, I hung on his every word. Nowadays, everybody thinks they're that much smarter.

3. that we're never left alone to practice. from BC to MOC to CME to other administrative headaches . . .it's not enough to just be a good clinician, to get your patient from point A to point B, to do good work . . . we're always in some other kinda rat race.

4. in this country, the # of unnecessary first world problems (psuedoseizures, psuedo this and that, 'chronic fatigue syndrome') that we have to pretend to care about.

5. the marginalization of the physician (the reduction of salaries, the hiring of NPs/PAs over MDs, etc etc).

6. the plethora of psychosocial circumstances that if you can't fix---and you can't, you don't live with your patients----no amount of medicine will do them any good. People really are on their own trajectories, for better or worse.

I generally don't like cynicism but the bolded especially is so eloquently phrased. I also came from a family of immigrants and had a completely different understanding of what a physician was.

That said, you mention 90% of the work is a facade. That may be true...for the patient it is, but someone needs that signature to advance what they do. And if we train ourselves to be efficient, maybe we can avoid some of that BS.

With me, I would have still done this because I dont know what else I'd do. Hoping I find some higher purpose some day in medical education or bettering the field.

 

[DrMetal]

1. $$$$$ I wouldn't say 90% of what we do isn't meaningful, but I'm also not a hospitalist.

2. Who cares? If they don't listen, they get worse. That's on them. Don't let it bother you.

3. Seriously? MOC takes me about 6 hours every 3 years. CME is 15 minutes once a month (AAFP CME quizzes) and 1 conference every 3 years (last one was in Hawaii so totally worth it). Maybe I have the best job ever, but admin leaves me alone.

4. Pretend to care, give them a mostly harmless med, profit

5. Salaries for FM have been going up every year in my state since I finished residency in 2013. No clue about other specialties.

6. Help with what you can, ignore the rest.

But even if we ignore all of that, like any job medicine has its frustrations. But there's no other job that once you get into school you're pretty much guaranteed a top 1% (or close to it) income. I'm in the 2nd lowest paid specialty and I still do quite well.

I feel like @efle 's input could be valuable here.

I'm actually ok with all of the above. I just do my thing, drink, play guitar and golf. But it's enough for me to NOT recommend this profession to any one else, especially my kids. I've got about 20 years of work left in me (15 if I can get my portfolio right), so I'm good. Being in the military has provided a nice cushion as well.

I generally don't like cynicism

You should, it makes for more comedy (maybe tragic comedy, but still).

 

[VA Hopeful Dr]

I'm actually ok with all of the above. I just do my thing, drink, play guitar and golf. But it's enough for me to NOT recommend this profession to any one else, especially my kids. I've got about 20 years of work left in me (15 if I can get my portfolio right), so I'm good. Being in the military has provided a nice cushion as well.



You should, it makes for more comedy (maybe tragic comedy, but still).

To each his own I guess. I'd be thrilled if my kids end up as physicians.

 

[blue.jay]

To each his own I guess. I'd be thrilled if my kids end up as physicians.

Why not physician associates or MCP (medical care practitioners) ? They can do anything from pediatrics, psychiatry to cardiothoracic/neurosurgery with only 2 yrs of schooling.

 

[VA Hopeful Dr]

Why not physician associates or MCP (medical care practitioners) ? They can do anything from pediatrics, psychiatry to cardiothoracic/neurosurgery with only 2 yrs of schooling.

What about it? I didn't say I'd be unhappy if they ended up doing that.

 

[rokshana]

It doesn't seem like an option these days. Most employers while hiring have a expectation that we cosign midlevel notes. It is more like a requirement these days.
I am a relatively fresh out of residency attending and I don't know if I am risking my license by blindly cosigning NP/PA notes.

It is... the fact that there is demand for endocrinologists allows me to be able to define what I will or won’t do... been doing locums for a few years now and other than last year, have had no issues with finding an assignment... and even then, I had work locally with the local endocrinologist doing inpt consults for him ( which I have been doing since 2018, just ended up doing it pretty much March to October) as well as some covid surge work as a hospitalist... have not supervise a mid level ever.

 

[sallyhasanidea]

Can we bring this topic back on track, with residencies expanding, we can kick the can down the road and assume that fellowship will be the next gate keeper for saturation. So should IM residents go into GI or should they go into cardiology?

 

[blue.jay]

Can we bring this topic back on track, with residencies expanding, we can kick the can down the road and assume that fellowship will be the next gate keeper for saturation. So should IM residents go into GI or should they go into cardiology?

There are more than 8000 IM residents per year and there are about 1000 cardiology positions and 600 GI spots every year. So majority can't become cardiologist or GI. Majority will be in primary care, hospitalist and other non-procedural specialities which are being encroached by midlevels. If you have stellar CV then you should apply for GI or cardiology and hopefully don't have to compete with physician 'associates' for jobs.

 

[rokshana]

Can we bring this topic back on track, with residencies expanding, we can kick the can down the road and assume that fellowship will be the next gate keeper for saturation. So should IM residents go into GI or should they go into cardiology?

Sooo....the “topic” would be which specialty has the least encroachment... GI and cards are not them...so neither would be the aim for the IM resident right now...now if the topic was which o e makes the most money and likely to still make money? Either... though you will probably need to do a sub specialty fellowship such as EP or interventional cards to make money and avoid midlevel creep.

 

[sallyhasanidea]

Sooo....the “topic” would be which specialty has the least encroachment... GI and cards are not them...so neither would be the aim for the IM resident right now...now if the topic was which o e makes the most money and likely to still make money? Either... though you will probably need to do a sub specialty fellowship such as EP or interventional cards to make money and avoid midlevel creep.

What makes you say that GI and cards are not the specialties with the least encroachment? Yes there are NPs, but they are used to see patients so physicians can focus on procedures, in that sense not true encroachment?

Would you rather do GI or cards?

 

[InternistDO]

What makes you say that GI and cards are not the specialties with the least encroachment? Yes there are NPs, but they are used to see patients so physicians can focus on procedures, in that sense not true encroachment?

Would you rather do GI or cards?

Because if it takes two physicians to see the patients and do the procedures, but only one to do the procedures + 2 NPs to see the patients, thats still one specialist without a job.

That being said a specialty focused on making money off a few specific procedures is probably more at risk from reimbursement change or change in indication for the procedure as opposed to midlevel encroachment.

 

[Osteoth]

Because if it takes two physicians to see the patients and do the procedures, but only one to do the procedures + 2 NPs to see the patients, thats still one specialist without a job.

That being said a specialty focused on making money off a few specific procedures is probably more at risk from reimbursement change or change in indication for the procedure as opposed to midlevel encroachment.

This.

Cardiology is like the IM of Subspecialties. A lot of variability. Inpatient, clinic, EP, cath, nucs, echos. A lot you can.

GI is dependent on screening colons to pay the bills. The government chops those then the bread loses a couple of slices. The super specialties in GI don’t make you more money either so they don’t help.

If you want to most flexible career, general cards is decent cheese and unlikely to be taken over. Midlevels reading echos? Unlikely

 

[rokshana]

What makes you say that GI and cards are not the specialties with the least encroachment? Yes there are NPs, but they are used to see patients so physicians can focus on procedures, in that sense not true encroachment?

Would you rather do GI or cards?

Right...you didn’t see what they are doing at JH...

and neither...the idea of having to do procedures everyday would be my 7 th circle of hell...I don’t even really want to do the fna of thyroids that is on my specialty.

 

[rokshana]

This.

Cardiology is like the IM of Subspecialties. A lot of variability. Inpatient, clinic, EP, cath, nucs, echos. A lot you can.

GI is dependent on screening colons to pay the bills. The government chops those then the bread loses a couple of slices. The super specialties in GI don’t make you more money either so they don’t help.

If you want to most flexible career, general cards is decent cheese and unlikely to be taken over. Midlevels reading echos? Unlikely

Midlevels read radiology images... not sure why an echo wouldn’t be possible.

 

[blue.jay]

This.

Cardiology is like the IM of Subspecialties. A lot of variability. Inpatient, clinic, EP, cath, nucs, echos. A lot you can.

GI is dependent on screening colons to pay the bills. The government chops those then the bread loses a couple of slices. The super specialties in GI don’t make you more money either so they don’t help.

If you want to most flexible career, general cards is decent cheese and unlikely to be taken over. Midlevels reading echos? Unlikely

I don’t think midlevels will be reading echos in the near future but echo reads are not that hard expect on few occasions for prosthetic valve disease. Majority of cases, prelim echo reads with EF, diastolic function, measurements are already done by the echo tech. Cardiologist don’t perform the scan which is the hardest part esp in patients with poor body habitus.

That being said it takes few minutes to read stress test and echos and hence $$$

 

[cards67]

I'm not terribly worried about independent midlevels in cardiology. For one, patients want to be seen by a doctor. I see it all the time, patients leave midlevel heavy practices or hospitals, or PCPs don't refer to those places. Especially for something cardiac, it freaks patients and other doctors out, if just from the liability standpoint. Cardiology also can be a very powerful group within the hospital. And they're also pretty good about protecting their turf...and sometimes encroaching on others, lol. But midlevels can certainly have a role. I've been at places where echo techs help with reads, or NPs are used as pseudo-residents or in HF clinic, etc. IMO, a very good cardiologist that is able to see/help more patients by using an NP isn't necessarily a bad thing.

 

[rokshana]

I have yet to see a midlevel in ID, nephro, endo, in the inpt setting...see tons of them in gi, cards, cc... I’m sure at some point, if not already, they think they can do it without a supervisor...simply put...the more lucrative the specialty, the more midlevels will look to enter the field

 

[blue.jay]

I have yet to see a midlevel in ID, nephro, endo, in the inpt setting...see tons of them in gi, cards, cc... I’m sure at some point, if not already, they think they can do it without a supervisor...simply put...the more lucrative the specialty, the more midlevels will look to enter the field

I haven't seen them in hospital setting as well but they are abundant in outpatient clinics. Midlevels either like hospital shift based jobs (choose EM, hospitalist, ICU, GI, CCM) or prefer outpatient lifestyle 9-5 gigs (Endo,ID,Nephro).
It is not profitable to use them to see few consults like say in rhem or Endo and I'm sure midlevels don't be cool driving to various hospitals to do Nephro consults.

 

[blue.jay]

Midlevels have encroached every speciality except may be radiology or pathology.
In certain specialities (surgical,GI,card) they function truly as perpetual residents.

In anesthesia, IM, FM, Peds, EM they are being told by their bosses that they are as good as their collaborating docs and can do whatever the **** they want.

 

[Trousseau]

I have yet to see a midlevel in ID, nephro, endo, in the inpt setting...see tons of them in gi, cards, cc... I’m sure at some point, if not already, they think they can do it without a supervisor...simply put...the more lucrative the specialty, the more midlevels will look to enter the field

I see a fair amount of them in ID/Nephro/Endo. But there's a ceiling on how many you can have. When patients go to a specialist, many of them (justifiably) want to see a physician. On my Endo rotations, multiple patients started raging when they were assigned to see an NP/PA even if their case was relatively simple.

Also the pay in the "cognitive" IM subspecialties isn't that great, so you don't save much from the midlevel route.

 

[bronx43]

I have yet to see a midlevel in ID, nephro, endo, in the inpt setting...see tons of them in gi, cards, cc... I’m sure at some point, if not already, they think they can do it without a supervisor...simply put...the more lucrative the specialty, the more midlevels will look to enter the field

Endo? There are tons of midlevels doing inpatient DM. I'm at an academic institution and they have midlevels galore both in and outpatient.

 

[Redpancreas]

Endo? There are tons of midlevels doing inpatient DM. I'm at an academic institution and they have midlevels galore both in and outpatient.

I concur. DM is mainly handled by PAs/NPs with attending supervision of the numbers.

 

[CCM-MD]

Endo? There are tons of midlevels doing inpatient DM. I'm at an academic institution and they have midlevels galore both in and outpatient.

99% of inpatient diabetes management doesn’t need an endocrinologist to begin with.

 

[Chemist0157]

I haven't seen them in hospital setting as well but they are abundant in outpatient clinics. Midlevels either like hospital shift based jobs (choose EM, hospitalist, ICU, GI, CCM) or prefer outpatient lifestyle 9-5 gigs (Endo,ID,Nephro).
It is not profitable to use them to see few consults like say in rhem or Endo and I'm sure midlevels don't be cool driving to various hospitals to do Nephro consults.

I just don't know why a midlevel would ever really go looking to do a gig like outpatient renal or endocrinology. More complexity and not much more money. CKD clinic makes up about 1/6 of our revenue. If they want to see patients until they are closer to needing dialysis/transplant, okay thanks! That is what the local VA does anyway.

I'll echo a point above that patients do want to see a physician for a subspecialty issue. Our show rate for our NPs in clinic is relatively low, despite our best efforts to try to impress upon them their CKD management is a TEAM effort.

We have one NP that helps us see ESRD patients in the hospital, but she has been in nephrology for about 50 years. She is quite a different bird compared to what is cranking out of these half online NP programs.

 

[rokshana]

Endo? There are tons of midlevels doing inpatient DM. I'm at an academic institution and they have midlevels galore both in and outpatient.

Gluc services are different animal...and frankly the best place for them.

actual endocrine issues ( rather that just sugar control) are fairly complicated and midlevels just don’t ability to figure them out ( some make my head spin)!

 

[rokshana]

I concur. DM is mainly handled by PAs/NPs with attending supervision of the numbers.

Again, gluco services are a different thing...the algorithmic pattern of inpt glucose control is actually a perfect use of midlevels).

 

[rokshana]

99% of inpatient diabetes management doesn’t need an endocrinologist to begin with.

Lol...I agree... a board certified hospitalist should be able to manage that and a gluco service should be able to handle the sugars for the surgical services.

 

[bronx43]

Gluc services are different animal...and frankly the best place for them.

actual endocrine issues ( rather that just sugar control) are fairly complicated and midlevels just don’t ability to figure them out ( some make my head spin)!

... we were responding to your claim that you have never seen NPs on inpatient endo consults. Are you claiming that DM is not part of endo consults (even though the majority of inpatient consults are for gluc)? If so, then it's like the cardiologist who claims there are no NPs on cards consults either, because chest pain rule out aren't considered cardiology. In fact, we're all saved, because there are actually NO midlevels in medicine at all! Well, not REAL medicine anyways.

This is the "no true scotsman" fallacy.

 

[Redpancreas]

I just don't know why a midlevel would ever really go looking to do a gig like outpatient renal or endocrinology. More complexity and not much more money. CKD clinic makes up about 1/6 of our revenue. If they want to see patients until they are closer to needing dialysis/transplant, okay thanks! That is what the local VA does anyway.

I'll echo a point above that patients do want to see a physician for a subspecialty issue. Our show rate for our NPs in clinic is relatively low, despite our best efforts to try to impress upon them their CKD management is a TEAM effort.

We have one NP that helps us see ESRD patients in the hospital, but she has been in nephrology for about 50 years. She is quite a different bird compared to what is cranking out of these half online NP programs.

I think our Nephro program had the same issue. They handled it by coming to resident lectures and telling us to not schedule the nephro follow ups and that they'd handle it. Apparently we were scheduling it aggressively. Have ya'll tried that?

 

[rokshana]

... we were responding to your claim that you have never seen NPs on inpatient endo consults. Are you claiming that DM is not part of endo consults (even though the majority of inpatient consults are for gluc)? If so, then it's like the cardiologist who claims there are no NPs on cards consults either, because chest pain rule out aren't considered cardiology. In fact, we're all saved, because there are actually NO midlevels in medicine at all! Well, not REAL medicine anyways.

This is the "no true scotsman" fallacy.

there are some places, mostly big academic centers, that have gluco services manned by an army of midlevels(usually NPs), but the average community hospital doesn't do this...not really worth the time for an endocrinologist, since one can barely code for a level 1...used to have an attending in fellowship that wasn't worried about billing for inpt since he could make more in RVUs with clinic pts than the time he would spend with having to see hospital pts.

in many community hospitals, the hospitalists will manage the dm on their pts unless it becomes difficult to control or if the pt is on an insulin pump. I do inpt consults for a local endocrinologist (who is the only local endo to even do inpt consults....many endocrinologist don't even do inpt consults at the community level) and rarely get consulted for routine DM management. As locums, many of the places are not even doing inpt consults...if they are not doing it because the money is not there, unlikely for a midlevel to be doing the job...they would get even less money (and if not in an LIP state, would need a supervising physician).

point being, that the non procedural (ie less money), more "cognitive" specialties are not as inundated with midlevels...are they there? sure? are the a problem? if they think they can do it without physician supervision, big problem...but we (at least endo, and wold imagine for ID and nephrology as well) don't have that big a carrot of money that makes them want to enter the field...those that do, like the physicians that decide to become endocrinologist, have an interest in the field.

but thank you for mansplaining to me what the majority of inpt consults for endocrinology are for ... aren't you a rheumatologist....have you even entered a hospital since fellowship? did you even do it then?

 

[Redpancreas]

there are some places, mostly big academic centers, that have gluco services manned by an army of midlevels(usually NPs), but the average community hospital doesn't do this...not really worth the time for an endocrinologist, since one can barely code for a level 1...used to have an attending in fellowship that wasn't worried about billing for inpt since he could make more in RVUs with clinic pts than the time he would spend with having to see hospital pts.

in many community hospitals, the hospitalists will manage the dm on their pts unless it becomes difficult to control or if the pt is on an insulin pump. I do inpt consults for a local endocrinologist (who is the only local endo to even do inpt consults....many endocrinologist don't even do inpt consults at the community level) and rarely get consulted for routine DM management. As locums, many of the places are not even doing inpt consults...if they are not doing it because the money is not there, unlikely for a midlevel to be doing the job...they would get even less money (and if not in an LIP state, would need a supervising physician).

point being, that the non procedural (ie less money), more "cognitive" specialties are not as inundated with midlevels...are they there? sure? are the a problem? if they think they can do it without physician supervision, big problem...but we (at least endo, and wold imagine for ID and nephrology as well) don't have that big a carrot of money that makes them want to enter the field...those that do, like the physicians that decide to become endocrinologist, have an interest in the field.

but thank you for mansplaining to me what the majority of inpt consults for endocrinology are for ... aren't you a rheumatologist....have you even entered a hospital since fellowship? did you even do it then?

This is an incredibly insightful post on this. I have some questions.

1.) You mentioned it in parenthesis, but you say usually NPs. Why not PAs. Is there a difference or they effectively the same?

2.) To what extent do you agree with this statement: "Outside of insulin pumps, many hospitalists/academic teams consult endocrinology solely to transfer the liability/workload of controlling sugars to the endocrinologist"? At an institution I was at, you could not simply reject these consults as an endo fellow with the pager because if your attending found out it would be some drama which I surmised meant that the people at the top wanted endo consulted on everything...why is that the case at my academic, non-profit, well-known hospital?

3.) Obviously we all prioritize patient care. That said, in your experience, what's generally the highest compensated thing you do. I am asking so I know who I am pissing off or incentivizing when I do things.

 

[bronx43]

there are some places, mostly big academic centers, that have gluco services manned by an army of midlevels(usually NPs), but the average community hospital doesn't do this...not really worth the time for an endocrinologist, since one can barely code for a level 1...used to have an attending in fellowship that wasn't worried about billing for inpt since he could make more in RVUs with clinic pts than the time he would spend with having to see hospital pts.

in many community hospitals, the hospitalists will manage the dm on their pts unless it becomes difficult to control or if the pt is on an insulin pump. I do inpt consults for a local endocrinologist (who is the only local endo to even do inpt consults....many endocrinologist don't even do inpt consults at the community level) and rarely get consulted for routine DM management. As locums, many of the places are not even doing inpt consults...if they are not doing it because the money is not there, unlikely for a midlevel to be doing the job...they would get even less money (and if not in an LIP state, would need a supervising physician).

point being, that the non procedural (ie less money), more "cognitive" specialties are not as inundated with midlevels...are they there? sure? are the a problem? if they think they can do it without physician supervision, big problem...but we (at least endo, and wold imagine for ID and nephrology as well) don't have that big a carrot of money that makes them want to enter the field...those that do, like the physicians that decide to become endocrinologist, have an interest in the field.

but thank you for mansplaining to me what the majority of inpt consults for endocrinology are for ... aren't you a rheumatologist....have you even entered a hospital since fellowship? did you even do it then?

I didn't claim that community hospitals are all using midlevels. People are simply responding to your claim that there are no midlevels doing inpatient endo, and that is demonstrably false in larger health systems and academia. At my institution, the DM consult list is gigantic - easily multiple times the length of the non-DM list. I rotated on it as a resident. What you're saying is basically that there isn't the demand there in smaller community hospitals for inpatient DM service. I get that, and it's fair. Your point about lower paying cognitive specialties not having as many midlevels is also well-taken. I agree on this front.

But to answer your question. Yes, I do consults now. I do inpatient consults quite frequently actually.

 

[timpview]

The main thing that puts cardiology at risk is that cardiology has become dependent on hospital employment.. this transfer of power no doubt puts the hospital in control of hiring and there will be an increasing emphasis placed on having as many clinic patients as possible be seen by midlevels. I would be a little nervous if I was straight gen cards.

from what I’ve seen GI is a little better at having independent or quasi independent groups contracted with the hospitals and their decision to have mid levels is more a financial thing that currently benefits them

I agree that patients, referring docs etc will always prefer an MD but in today’s world it’s not up to them and their preferences as long as hospitals control referral patterns, subspecialty employment and especially their regional health insurance... Perhaps docs will figure out how to gain some control Or break that system but it’s not looking good.

 

[bronx43]

The main thing that puts cardiology at risk is that cardiology has become dependent on hospital employment.. this transfer of power no doubt puts the hospital in control of hiring and there will be an increasing emphasis placed on having as many clinic patients as possible be seen by midlevels. I would be a little nervous if I was straight gen cards.

from what I’ve seen GI is a little better at having independent or quasi independent groups contracted with the hospitals and their decision to have mid levels is more a financial thing that currently benefits them

I agree that patients, referring docs etc will always prefer an MD but in today’s world it’s not up to them and their preferences as long as hospitals control referral patterns, subspecialty employment and especially their regional health insurance... Perhaps docs will figure out how to gain some control Or break that system but it’s not looking good.

There is a silver lining to all this. I'm mostly doom/gloom about the future of medicine, but I do see an opportunity for doctors IF certain conditions are met with respect to political and economic changes.

Hospitals in general are large complex systems that take up disproportionate amounts of resources - both financial and real. When compared to physician owned clinics or even smaller independent hospitals, these modern health care conglomerates are simply far too inefficient. They rely completely on their ability as pseudo-monopolies to throw their weight around extracting resources from private payers. Will this go on forever? I doubt it. I am seeing rapid saturation of health care demand in my area, and there is no further expansion to be had... the ravenous leviathan has essentially run out of food.

And this is coinciding with a tighter labor market and increasing price of supplies/raw goods. This means that their overhead has the potential of increasing dramatically, while their revenue streams are stagnant if not outright shrinking (due to decreased volumes in post-covid era). If the price of labor and goods do not revert to historic norms, then I see health systems having big problems. They may further consolidate and exert even more pressure on payers, though that is somewhat trying to squeeze more blood from a stone. Payers are not going to bend over easily and take cuts on their profit margin. If this happens, then this MAY put the power back in the hands of doctors, who may have no choice but to break off and form independent groups again.
I'm not saying this will happen, but I think it is one possibility when the dust settles. The other (maybe more likely) scenario is government just steps in and buy up failing hospitals, and then we are into universal/socialized system.

 

[rokshana]

This is an incredibly insightful post on this. I have some questions.

1.) You mentioned it in parenthesis, but you say usually NPs. Why not PAs. Is there a difference or they effectively the same?

2.) To what extent do you agree with this statement: "Outside of insulin pumps, many hospitalists/academic teams consult endocrinology solely to transfer the liability/workload of controlling sugars to the endocrinologist"? At an institution I was at, you could not simply reject these consults as an endo fellow with the pager because if your attending found out it would be some drama which I surmised meant that the people at the top wanted endo consulted on everything...why is that the case at my academic, non-profit, well-known hospital?

3.) Obviously we all prioritize patient care. That said, in your experience, what's generally the highest compensated thing you do. I am asking so I know who I am pissing off or incentivizing when I do things.

NPs, particularly in states with LIPs can have the NP stand alone, PAs by definition cannot.

no, it’s not just about transferring responsibility... many places the hospitalist is overworked...having a census of 20-25 is crazy but not uncommon and if a good number of them have dm, then it’s a lot of work on top of whatever brought the pt into the hospital... some places the culture is to just pan consult. And then there are the non medical sub specialties that just have no clue as to what to do with any chronic illness, and they are scared to death by insulin.

and yes, as a fellow, and to some extent as an attending, you cannot refuse a consult...however if you see the phrase, “ thank you for this interesting consult”... it’s the passive/aggressive way to indicate that this is a WTF, why are you calling me? Consult.

the highest compensated thing is anything I can bill at a level 5 as outpt. since I generally bill by time, anything that takes me 70 minutes inpt as a level 3 will give me the most compensation.