Which subspecialty is most resistant to encroachment or expansion?

[rokshana]

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.

I think i saw a rheumatologist inpt a total of 2 time while I was a resident and have never seen one since I finished residency.

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[bronx43]

I think i saw a rheumatologist inpt a total of 2 time while I was a resident and have never seen one since I finished residency.

Ok. Not sure what your point is other than you not working at a major academic institution. Our consult list here runs 8-10. Not a ton but we go in daily.

 

[Nespresso]

This is my subjective assessment and how I rank subspecialties purely based on job availability, salary and lifestyle

1. GI - more jobs due to more demand than supply, better lifestyle, one of the top paying speciality (~500k median) very competitive

2. Cardiology - good salary (500-550k), lifestyle is not as good as GI unless you are doing EP, imaging, heart failure fellowship. STEMI calls for interventional cards and ED calls for gen cards make it less lifestyle friendly compared to GI. I have also seen few people concerned about midlevels tightening jobs for gen cards but ability to read echos,ekgs,stress tests are valuable (which midlevels can't do). Job market can be tight in desirable cities. Job market is very tight for EP because it's a very small field.

3. Hem/Onc good pay for non-procedural speciality, outpatient lifestyle, job satisfaction. Concerns could be more midlevel encroachment pushing new grads to less desirable places and ?AI

4. Pulm/crit - more popular now due to shift based work, tele-icu for higher pay per hour. Still there is high % of burnout and has potential to follow path of ER with contract management groups buying practices/tele-ICU. Have midlevels run the ICU with doc in tele-ICU supervising 2-3 community hospitals.

5. Rheumatology - good private practice potential, decent pay

6. Hospitalist - pay around 250k, shift based. More risk for midlevel encroachment but being already paid low sometimes midlevels don't save a lot of money unless they see as much patients we docs for less pay (which they don't)

7. Endo/ID/Palliative - same or less pay compared to 3 yr residency but you lose 2 yr salary potential. If you like the field it's worth it in the long run. Hospital medicine has poor job satisfaction, less respect and more burnout

8. Nephro - see the dedicated Neph thread you will learn about the issues with that field

Thread should end with this first reply.

The new general recommendations for colonoscopy screen at 45 now pushes GI even higher. My hunch is it will even go to 40yo in the next decade and GI will become even more competitive than it already is today.

 

[sloh]

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.

PGY-1 and 2: Wow they really appreciated the consult!

PGY 4: This is just part of their standard template.

Attending: Offended. But who cares, less work for me!

 

[chessknt]

Thread should end with this first reply.

The new general recommendations for colonoscopy screen at 45 now pushes GI even higher. My hunch is it will even go to 40yo in the next decade and GI will become even more competitive than it already is today.

Until CMS decides to cut colo reimbursement significantly, then they are in the same boat the rest of the plebs are.

 

[Chemist0157]

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?

Not really an issue here as we control all our appointments. People just don’t feel really motivated to come to a routine visit with a midlevel. They’ll come if they need something.

 

[rokshana]

Ok. Not sure what your point is other than you not working at a major academic institution. Our consult list here runs 8-10. Not a ton but we go in daily.

That generally rheum is seen as out Pt...my friends that are rheum don’t do any inpt .
And I trained at a tertiary care center... it had a rheum fellowship...and they were vastly outpt in focus.

lighten up dude... you used to do post really valuable information... not you are running a close second to renal promethus...

 

[rokshana]

Not really an issue here as we control all our appointments. People just don’t feel really motivated to come to a routine visit with a midlevel. They’ll come if they need something.

Find that the pts that see the np for their diabetes follow ups are pretty happy with them... but they want the endocrinologist to see them on a periodic basis...generally if they are well controlled, will see them once a year... if not we’ll controlled, then the visits are alternating...this of course requires that everyone is on the same page ... the best utilization of mid levels is this... more frequent follow up visits for algorithmic things,.. they can spend more time with the pt and keep up with monitoring sugars.

 

[bronx43]

That generally rheum is seen as out Pt...my friends that are rheum don’t do any inpt .
And I trained at a tertiary care center... it had a rheum fellowship...and they were vastly outpt in focus.

lighten up dude... you used to do post really valuable information... not you are running a close second to renal promethus...

Still not sure what your point is. Like seriously. What does rheum being mostly outpatient have anything to do with endo consults by NPs?
Idk who renal Prometheus even is but ok... weird diss

 

[Chemist0157]

Find that the pts that see the np for their diabetes follow ups are pretty happy with them... but they want the endocrinologist to see them on a periodic basis...generally if they are well controlled, will see them once a year... if not we’ll controlled, then the visits are alternating...this of course requires that everyone is on the same page ... the best utilization of mid levels is this... more frequent follow up visits for algorithmic things,.. they can spend more time with the pt and keep up with monitoring sugars.

I have a sneaking suspicion they get a lot of hospital follow ups that may have never had any intention coming anyway, but we do have quite a few patients who just don't ever want to see an NP/PA. I guess the threat of dialysis is enough to get them to come see the doctor but not enough to see an NP in between I can generally make it work if I have them come back for just a quicker lab/BP check after a medication change.

 

[TaroBubbleTea]

Still not sure what your point is. Like seriously. What does rheum being mostly outpatient have anything to do with endo consults by NPs?
Idk who renal Prometheus even is but ok... weird diss

Renal Prometheus is a poster who has been warning about the end of nephrology as a specialty since time immemorial. I think their posts are quite entertaining and a bit educational with a dash of hyperbole.

 

[rokshana]

Still not sure what your point is. Like seriously. What does rheum being mostly outpatient have anything to do with endo consults by NPs?
Idk who renal Prometheus even is but ok... weird diss

Well it’s as relevant as you, a rheumatologist, making statements about endocrinology...smh

 

[Drrrrrr. Celty]

Thread should end with this first reply.

The new general recommendations for colonoscopy screen at 45 now pushes GI even higher. My hunch is it will even go to 40yo in the next decade and GI will become even more competitive than it already is today.

Or Gen Surgery will progressively fill the niche.

 

[CCM-MD]

Or Gen Surgery will progressively fill the niche.

Or NPs.

 

[Renal_Prometheus]

That generally rheum is seen as out Pt...my friends that are rheum don’t do any inpt .
And I trained at a tertiary care center... it had a rheum fellowship...and they were vastly outpt in focus.

lighten up dude... you used to do post really valuable information... not you are running a close second to renal promethus...

not sure what prompted this diss. I know you don’t like me rokshana. But I want to point out I get plenty of praise on “nephrology is dead” thread.

 

[rokshana]

not sure what prompted this diss. I know you don’t like me rokshana. But I want to point out I get plenty of praise on “nephrology is dead” thread.

I dont know you personally to like or not like you....you however have shown, in your posts, that you are disillusioned with nephrology and bear the specialty ill will...this is not unknown or new to that this is how I see your posts.

you certainly have had posts that are informative, but they get drowned out by all the fighting you do with other nephrology posters and your persistent posts on the nephrology fellowship thread on trying to shoo away applicants...again this should not be new or unknown to you.

 

[CCM-MD]

I dont know you personally to like or not like you....you however have shown, in your posts, that you are disillusioned with nephrology and bear the specialty ill will...this is not unknown or new to that this is how I see your posts.

you certainly have had posts that are informative, but they get drowned out by all the fighting you do with other nephrology posters and your persistent posts on the nephrology fellowship thread on trying to shoo away applicants...again this should not be new or unknown to you.

I haven’t read all of his posts but a few less applicants to nephrology might be the best thing for the specialty, the applicants and practicing nephrologists. Might actually give things a chance to get better.

 

[rokshana]

I haven’t read all of his posts but a few less applicants to nephrology might be the best thing for the specialty, the applicants and practicing nephrologists. Might actually give things a chance to get better.

Nephrologist not working til they are 90 would help...and decreasing the number of spots would help as well...but assuming that someone who had made the decision to go into fellowship, regardless of specialty, has not done their due diligence is a bit presumptuous.

we all know the desirability of specialties can be ebb and flow and are somewhat cyclical... 10 years ago rad onc was impossible to get, radiology was Uber competitive and critical care fellowship was not that competitive...now? 10 years from now? Who knows? Basically, one should do what they like and/or are good at... one can always make decent money... sometimes it will take more work, sometimes less.

 

[CCM-MD]

Nephrologist not working til they are 90 would help...and decreasing the number of spots would help as well...but assuming that someone who had made the decision to go into fellowship, regardless of specialty, has not done their due diligence is a bit presumptuous.

I know plenty of medical students and residents that have made decisions to go into their chosen specialties based on interest in the subject matter and various other factors, and without knowing financial aspects and job market realities. I haven’t read all of his posts so I am not trying to defend everything he has posted but I do think that some of his posts have helped prospective applicants who don’t know about the various challenges in nephrology.

 

[Renal_Prometheus]

I know plenty of medical students and residents that have made decisions to go into their chosen specialties based on interest in the subject matter and various other factors, and without knowing financial aspects and job market realities. I haven’t read all of his posts so I am not trying to defend everything he has posted but I do think that some of his posts have helped prospective applicants who don’t know about the various challenges in nephrology.

thank you for defending me. I know some people appreciate what I'm trying to do. Ultimately, I believe the applicant stands to benefit from all of my criticism of the specialty, as it will allow for a more informed decision. Some people are on the fence, and would really benefit from what I have to say. And for those who are dead set on doing nephrology, what I say won't make a difference. And I disagree with Roksana's statement that people who go into a fellowship have done their research. They have done some research, they just don't know the whole story. I say this because majority of my nephrology friends, years out of fellowship, are no longer practicing nephrology anymore. They believed what the academics were selling them, that was the problem. I serve a purpose because I am here to tell them the other side of the story so that they have the option of not wasting years of their lives to find out.

 

[Nespresso]

Or Gen Surgery will progressively fill the niche.

If Gen Surg is willing to do them instead of being in the OR. They would then need to start prioritizing them in their training.

 

[Drrrrrr. Celty]

If Gen Surg is willing to do them instead of being in the OR. They would then need to start prioritizing them in their training.

At my program Gen Surgery does a lot of them outpatient. I don't know if they necessarily enjoy doing it. But they bring up a legitimate point. If there's something they're going to be the ones surgerizing the patients anyway.

 

[sunshinefl]

At my program Gen Surgery does a lot of them outpatient. I don't know if they necessarily enjoy doing it. But they bring up a legitimate point. If there's something they're going to be the ones surgerizing the patients anyway.

The residents on my general surgery clerkships did colonoscopies as well, both inpatient and especially at an ambulatory surgery center.

 

[chessknt]

The residents on my general surgery clerkships did colonoscopies as well, both inpatient and especially at an ambulatory surgery center.

In the community gen surg will not uncommonly do upper/lower endoscopy since they are more present than GI.

 

[sloh]

thank you for defending me. I know some people appreciate what I'm trying to do. Ultimately, I believe the applicant stands to benefit from all of my criticism of the specialty, as it will allow for a more informed decision. Some people are on the fence, and would really benefit from what I have to say. And for those who are dead set on doing nephrology, what I say won't make a difference. And I disagree with Roksana's statement that people who go into a fellowship have done their research. They have done some research, they just don't know the whole story. I say this because majority of my nephrology friends, years out of fellowship, are no longer practicing nephrology anymore. They believed what the academics were selling them, that was the problem. I serve a purpose because I am here to tell them the other side of the story so that they have the option of not wasting years of their lives to find out.

The other thing is I think it’s always worth listening to attending physicians who talk about the negatives of their own specialties. There are many reasons for physicians to talk glowingly about their specialties including sunk costs and wanting to feel like all the time, energy, money they dedicated was worth it. There isn’t much to be gained talking about the downsides.

 

[sallyhasanidea]

In the community gen surg will not uncommonly do upper/lower endoscopy since they are more present than GI.

I was under the impression that for the most part GI owned the referral patterns because most people go through IM(primary care)/FM --> GI for colonoscopy, with IM leaning towards GI as they are also IM trained

 

[chessknt]

I was under the impression that for the most part GI owned the referral patterns because most people go through IM(primary care)/FM --> GI for colonoscopy, with IM leaning towards GI as they are also IM trained

Yea there is no GI at 2 of the hospitals I have worked at so gen surg stepped up and does endo both inpatient and outpatient. Screening colo and even banding. No choice but even if I did I would give a referral to someone who is willing to come in at night and responds asap to help me out any day before I gave it to a GI who doesnt do that.

 

[rokshana]

I was under the impression that for the most part GI owned the referral patterns because most people go through IM(primary care)/FM --> GI for colonoscopy, with IM leaning towards GI as they are also IM trained

depends on where you are and the experiences you have had with the specialist one refers to...most people will refer to the people they have had good experiences with...so if the surgeon who is better to work with and has good results will get the referral over a GI that isn't...just depends

 

[hopefulhealth]

Anyone who thinks their specialty is immune to mid-level encroachment is smoking the crackpipe. I'd encourage you to read the Anes forums, circa 2005/2006, where some thought the CRNA thing was just a 'fad' and would go away.

The medical industrial complex---and make no mistake about it, health care is an industry, subject to all of the same economic pressures as any other industry---loves the PA/NP. They can throw them into in any context (outpatient, inpatient, adults, peds, etc), with minimal training, and they can do much of the scutwork (or what we physicians perceive to be scutwork).

They view us physicians as a total PITA: we take too long to educate and train (sometimes true: do I really need a sleep physician, PGY7+, to tell me someone's too fat to breath well at night?), we're expensive (to pay, to insure), and we're high maintenance. In any other industry, the economic mechanisms at hand will find a way to circumvent such a PITA commodity, and that's exactly what's happening in medicine.

So what do we do about it? We'll probably do nothing. We're not organized, and we don't care all that much (as individuals). Most of us have good jobs now, our immediate livelihood is not threatened. I can't say that about the generation following us.

What would I like to see happen?
-- Reduce the # of years in education/training (we've had this discussion before), so we can get physicians into the workforce sooner.
-- Stop making a fellowship/BC out of everything (again, too much formal training): more on-the-job training and certifications
-- get rid of BC, it's an unnecessary credential (test the individual all you want while they're in training, including a mandatory exit exam, but once they've graduated, they're done, and should be allowed to practice!)

People who cannot get into medical school or cannot afford medical school are also flocking into “mid level” programs instead. Every year medical school is more expensive and more competitive as the number of applicants increase. This means more PAs and more NPs coming to steal your jobs like boogeymen or make a decent living while serving their communities as healthcare professionals (depending on your take and if you’re a homeless EM doc or not) 😂.

 

[SeldingerTechneek]

Every year medical school is more expensive and more competitive as the number of applicants increase.

Is this really the case? I'm sure it's getting more expensive but more competitive? I'm not disagreeing, but there's a number of allopathic and osteopathic schools opening up and that have opened up in the last few years. It almost feels like the competition to get into any medical school is becoming diluted similar to law school. Of course, the competition to get into the traditional top 20-40 will continue and/or increase.

 

[DrMetal]

People who cannot get into medical school or cannot afford medical school are also flocking into “mid level” programs instead. Every year medical school is more expensive and more competitive as the number of applicants increase. This means more PAs and more NPs coming to steal your jobs like boogeymen or make a decent living while serving their communities as healthcare professionals (depending on your take and if you’re a homeless EM doc or not) 😂.

Is this really the case? I'm sure it's getting more expensive but more competitive? I'm not disagreeing, but there's a number of allopathic and osteopathic schools opening up and that have opened up in the last few years. It almost feels like the competition to get into any medical school is becoming diluted similar to law school. Of course, the competition to get into the traditional top 20-40 will continue and/or increase.

The number of or cost of medical school has very little to do with the current predicament, which is that the medical industry has deemed the physician to be unnecessary and has found a way to circumvent her by employing (instead) NPs/PAs.

What's changed over the past 10 years is society's (the consumer, the patients) acceptance of this. Many are now willing to accept that their medical care may not come from a physician, and they're ok with that (especially if it means getting seen at 9:30PM on a Thursday night).

Exacerbating the problem is that we physicians are trying to 'up the ante' by making more requirements for ourselves---more fellowships, more BC/MOC, excessive specialization, etc. What we don't understand is that in doing this, we will only isolate ourselves further.

Our generation of physicians is probably fine, but I sure as hell would not recommend this to anyone south of 25-yo. When you have to go to school for 4 years, then 3-7 years of residency (which is no longer enough), +3-5 more years of some fellowship . . . you'll be 40-yo before you can work in any meaningful way?

No thank you.

 

[blue.jay]

The number of or cost of medical school has very little to do with the current predicament, which is that the medical industry has deemed the physician to be unnecessary and has found a way to circumvent her by employing (instead) NPs/PAs.

What's changed over the past 10 years is society's (the consumer, the patients) acceptance of this. Many are now willing to accept that their medical care may not come from a physician, and they're ok with that (especially if it means getting seen at 9:30PM on a Thursday night).

Exacerbating the problem is that we physicians are trying to 'up the ante' by making more requirements for ourselves---more fellowships, more BC/MOC, excessive specialization, etc. What we don't understand is that in doing this, we will only isolate ourselves further.

Our generation of physicians is probably fine, but I sure as hell would not recommend this to anyone south of 25-yo. When you have to go to school for 4 years, then 3-7 years of residency (which is no longer enough), +3-5 more years of some fellowship . . . you'll be 40-yo before you can work in any meaningful way?

No thank you.

I am reading this while seeing my NP teach her student NP who is wearing a long attending white coat.
Feeling very betrayed. I have no faith in this profession anymore. I hope I don't end up losing my job to a NP or PA.
We are seriously fools to train our replacements.

 

[sloh]

I am reading this while seeing my NP teach her student NP who is wearing a long attending white coat.
Feeling very betrayed. I have no faith in this profession anymore. I hope I don't end up losing my job to a NP or PA.
We are seriously fools to train our replacements.

Yet we'll lose our jobs if we don't cooperate and be "team players!"

 

[blue.jay]

Yet we'll lose our jobs if we don't cooperate and be "team players!"

I always used to hear that the misery and sacrifice in medical school and training is rewarded with job security and stability. I'm not sure about that anymore. Just feel like a fool losing out the best and productive years of my life learning something which isn't valued anymore.

 

[Taurus]

I am reading this while seeing my NP teach her student NP who is wearing a long attending white coat.
Feeling very betrayed. I have no faith in this profession anymore. I hope I don't end up losing my job to a NP or PA.
We are seriously fools to train our replacements.

Don't train your replacement. If you have to train them, teach them the bare minimum required.

 

[DrMetal]

I am reading this while seeing my NP teach her student NP who is wearing a long attending white coat.
Feeling very betrayed. I have no faith in this profession anymore. I hope I don't end up losing my job to a NP or PA.
We are seriously fools to train our replacements.

Not only do they have their own long attending white coats, hospitals are now allowing them to wear their own NP 'board certification' label on it as well. So the physician is no longer the sole 'board certified' entity . . . so too is the NP, the PA, the MA, hell even the janitor belongs to a board.

Don't worry about training them. There's plenty of them now, they can train each other. And quite frankly, most of what we do isn't that hard, you can train a monkey to do most of medicine.

[edit: I'm trying to see the sunshine.]

 

[DrMetal]

Don't train your replacement. If you have to train them, teach them the bare minimum required.

Nice signature. You have me convinced. Now try to convince the rest of the healthcare industry.

 

[blue.jay]

Don't train your replacement. If you have to train them, teach them the bare minimum required.

I don't teach or train or even talk to them. The NPs are teaching their own NP students. If there is a complicated patient these midlevels discuss among themselves instead of discussing with the supervising physician.
I'm just a bench clerk employed to cosign these midlevel notes.

 

[Taurus]

I don't teach or train or even talk to them. The NPs are teaching their own NP students. If there is a complicated patient these midlevels discuss among themselves instead of discussing with the supervising physician.
I'm just a bench clerk employed to cosign these midlevel notes.

Kill the snake by cutting off the head. Some physician had to teach the very first NP's who passed it on to future NP's. If you stop training NP's, eventually the knowledge base and skillset of NP's atrophy or never develop. And then they can't teach future generations of NP's... So everyone make a vow and refuse to teach NP's. This will go a long way to take back medicine from corporate healthcare and NP's.

 

[grt398]

Financial independence ASAP is pretty much what I advocate to people in person at this point. Even if that means continuing to live mostly like a resident for 5-6 years post training. Obviously if you have lots of kids or other family financial obligations that may change things, but I would imagine life is a lot less stressful if you can cover your living expenses with 5-7 shifts/month and just let the magic of compound interest grow your retirement portfolio.

 

[blue.jay]

Kill the snake by cutting off the head. Some physician had to teach the very first NP's who passed it on to future NP's. If you stop training NP's, eventually the knowledge base and skillset of NP's atrophy or never develop. And then they can't teach future generations of NP's... So everyone make a vow and refuse to teach NP's. This will go a long way to take back medicine from corporate healthcare and NP's.

With current state of affairs NP/PAs don't need physicians to be trained in cognitive specialities. I've worked with many midlevels and over the last 3 years they have NOT asked me even 1 question or seeked clarification. They either ask their own midlevels, Google, look up uptodate or consult specialist. The smart hardworking ones follow patient charts from home and end up learning from that experience. We are just legal liability stickers for these low paid workers to roam around freely and learn from their mistakes. I doubt any young millennial physician is teaching or eager to teach midlevels.
Medical training in this country is a joke. What we should be doing is that we protect the job duties to only MD/DO, but then we are framed as being greedy and elitist. NPs will be praised for having heart of a nurse, brain of a doctor, working hard for less pay to fill doctor shortage.
This profession is a joke. I don't know if I should feel sorry for kids planning to go to medschool or assume they are fools. Because majority of you won't be a surgeon or a radiologist.

 

[sunshinefl]

With current state of affairs NP/PAs don't need physicians to be trained in cognitive specialities. I've worked with many midlevels and over the last 3 years they have NOT asked me even 1 question or seeked clarification. They either ask their own midlevels, Google, look up uptodate or consult specialist. The smart hardworking ones follow patient charts from home and end up learning from that experience. We are just legal liability stickers for these low paid workers to roam around freely and learn from their mistakes. I doubt any young millennial physician is teaching or eager to teach midlevels.
Medical training in this country is a joke. What we should be doing is that we protect the job duties to only MD/DO, but then we are framed as being greedy and elitist. NPs will be praised for having heart of a nurse, brain of a doctor, working hard for less pay to fill doctor shortage.
This profession is a joke. I don't know if I should feel sorry for kids planning to go to medschool or assume they are fools. Because majority of you won't be a surgeon or a radiologist.

You are literally making me depressed

 

[wamcp]

Is this really the case? I'm sure it's getting more expensive but more competitive? I'm not disagreeing, but there's a number of allopathic and osteopathic schools opening up and that have opened up in the last few years. It almost feels like the competition to get into any medical school is becoming diluted similar to law school. Of course, the competition to get into the traditional top 20-40 will continue and/or increase.

Honestly I would rather have explosive proliferation of med schools than the current exponential growth of midlevel positions. Rather have MD DO everywhere than noctors taking care of my family.

 

[wamcp]

You are literally making me depressed

Just the truth and reality bro. I will be actively discouraging my kids from medicine. And am now close to financial independence in my early 30s for this specific reason. Saw the writing on the wall years ago

 

[aafisahar]

Honestly I would rather have explosive proliferation of med schools than the current exponential growth of midlevel positions. Rather have MD DO everywhere than noctors taking care of my family.

There's already a scary number of doctors practicing **** medicine. We don't need to lower the bar more.

 

[DrMetal]

There's already a scary number of doctors practicing **** medicine. We don't need to lower the bar more.

The # of medical schools, the # of doctors, where we set our imaginary bar . . . none of that matters.

Here's the bottom line: take any 'cognitive' non-procedural specialty . . .doctor walks in the room and states I want $200/hour or ($250K/year) to do it. The system will say, "screw you, we're hiring your NP equivalent for $100/hr or $150K/year to do the same job".

The doctor states: "But I harbor so much more knowledge."

The system retorts: "We don't care that you know the mechanisms of sarcoidosis. Most of your excess knowledge is not relevant to clinical practice, and we're not paying for it. The NP can manage fine without it in most situations (can look up things as needed), and the minimal risk associated with her lack of some knowledge is well worth our cost savings."

That's it. Nothing else matters! (great Metallica song . . . 30th year anniversary of the Black Album).

 

[hotsaws]

watch me shamelessly go into private practice and monetize midlevels for my own gain. Keeping it real. sorry I'm not sorry

 

[chessknt]

The # of medical schools, the # of doctors, where we set our imaginary bar . . . none of that matters.

Here's the bottom line: take any 'cognitive' non-procedural specialty . . .doctor walks in the room and states I want $200/hour or ($250K/year) to do it. The system will say, "screw you, we're hiring your NP equivalent for $100/hr or $150K/year to do the same job".

The doctor states: "But I harbor so much more knowledge."

The system retorts: "We don't care that you know the mechanisms of sarcoidosis. Most of your excess knowledge is not relevant to clinical practice, and we're not paying for it. The NP can manage fine without it in most situations (can look up things as needed), and the minimal risk associated with her lack of some knowledge is well worth our cost savings."

That's it. Nothing else matters! (great Metallica song . . . 30th year anniversary of the Black Album).

Cool where is that happening? I cant seem to find a hospital owned specialty practice that only has midlevels in it in my area which doesnt make any sense because I live by an enormous system that is all about massive profit, has cannibalized nearly every hospital for hundreds of miles to create a monopoly, generated 10+ figure revenue last year and for some reason they dont do that.

 

[DrMetal]

Cool where is that happening?

The 30th anniversary of the Metallica Black album? Later in September I think.

Or are you talking about the gutting of physicians? Well, it may not be happening quite as literally as my previous post, but here's probably how it's going down: Census is picking up post COVID, hospital decides it needs to add more ER providers and rounding hospitalists (say 20 new providers). CEO/CFO/CMO (who may not be a doctor) get together and decide, let's hire 12NPs and 8 MDs (instead of say 15 MDs and 5 NPs, that's what the ratio used to be 10 years ago).

So that's 12 MDs that don't even get to apply for the job (they don't even get the imaginary negotiation I posted above). Multiply that by dozens of hospitals in a given large city, by hundreds of cities/municipalities across the United States, and you're talking about thousands of lost physician jobs.

Again, I think we're all relatively safe. What we don't see (yet) is physicians getting laid off solely to be replaced by a mid level (if they retire, they may not be replaced by another physician, but that's different). But I wouldn't be surprised if that started to happen (contracts not getting renewed, etc). That's the next logical step in capitalism.

 

[sallyhasanidea]

The 30th anniversary of the Metallica Black album? Later in September I think.

Or are you talking about the gutting of physicians? Well, it may not be happening quite as literally as my previous post, but here's probably how it's going down: Census is picking up post COVID, hospital decides it needs to add more ER providers and rounding hospitalists (say 20 new providers). CEO/CFO/CMO (who may not be a doctor) get together and decide, let's hire 12NPs and 8 MDs (instead of say 15 MDs and 5 NPs, that's what the ratio used to be 10 years ago).

So that's 12 MDs that don't even get to apply for the job (they don't even get the imaginary negotiation I posted above). Multiply that by dozens of hospitals in a given large city, by hundreds of cities/municipalities across the United States, and you're talking about thousands of lost physician jobs.

Again, I think we're all relatively safe. What we don't see (yet) is physicians getting laid off solely to be replaced by a mid level (if they retire, they may not be replaced by another physician, but that's different). But I wouldn't be surprised if that started to happen (contracts not getting renewed, etc). That's the next logical step in capitalism.

SO do you recommend GI or cardiology as an escape for IM residents?