Why don’t more physicians and med students question what’s happening with mid level encroachment and political change?

[sargon2123]

I could be wrong but it seems like even though we talk a lot about this stuff here, irl at my school no one is convinced that these things are a significant issue. Is it that med students are mostly sheep (no hate)?

I can see why physicians don’t want to talk about mid levels at least. The reason being they’ve chosen to hire a lot of them and want to keep that on the DL

---

Members don't see this ad.

 

[Dantrolene FC]

Talking about mid level encroachment is viewed as being a political topic and people don’t want to talk about it at work.

 

[InternistDO]

The AMA's political action committee (AMPAC) lobbies against midlevel encroachment all the time, though they have a bad rap on the internet for a variety of reasons. There are other organizations who do this but AMPAC is the largest, if you're looking for someone to donate to or work with.

Also don't forget that SDN (and Reddit) tend to catastrophize a lot, the sky has been falling here for at least a decade or more in regards to midlevels, CNRAs, reimbursement, Obamacare, etc. This is mostly because we're students and trainees who have yet to the see the fruits of our labour and are therefore extremely sensitive to issues that might mess with the status quo (since it takes us so long to graduate, finish residency, pay off loans). Not that all these issues aren't potentially serious, just consider that they might not be as bad as they seem on the internet.

 

[efle]

I think a lot of it comes from our relatively sheltered environment in medicine. At major tertiary/quarternary centers, midlevels tend to serve an appropriate role as a midlevel.

To see the scary **** like NPs practicing unsupervised as if they were an MD/DO, you have to go see primary care clinics in flyover states, or look into the sketchy cash cow niches like midlevel-run cosmetics clinics.

We simply don't get a lot of exposure to that stuff while training in ivory tower academic centers. It's out there, we just aren't seeing it on rotations.

 

[JustOnePing]

I could be wrong but it seems like even though we talk a lot about this stuff here, irl at my school no one is convinced that these things are a significant issue. Is it that med students are mostly sheep (no hate)?

I can see why physicians don’t want to talk about mid levels at least. The reason being they’ve chosen to hire a lot of them and want to keep that on the DL

an
My take: because physicians, by and large, are fractured by tribalism based on their specialties. They hardly agree nor work together in consensus as a unified voice in this country. Also, it doesn't help that the public generally perceives us as rich fat cats - look how physicians are unable to fight back against the all powerful ACGME/NRMP Match dual-combo (which the Supreme Court ruled was exempt from monopoly laws). This learned helplessness and compliance conditioning all starts at the pre-med level.

 

[Splenda88]

Oh no.... Not another thread about midlevels again...

 

[Dantrolene FC]

My take: because physicians, by and large, are fractured by tribalism based on their specialties. They hardly agree and work together in consensus as a unified force in this country. Also, the public perceives us as rich fat cats - look how physicians are unable to fight back against the all powerful NRMP Match (which the Supreme Court ruled was exempt from monopoly laws). This learned helplessness and compliance conditioning all starts at the pre-med level.

What’s wrong with the NRMP?

 

[JustOnePing]

What’s wrong with the NRMP?

Other than military GME slots which the military controls via their own match, the NRMP (in conjunction with the ACGME) are exempted from monopoly laws and solely control the Match and thus every PGY1 slot assignment by default via their algorithm. ACGME exclusively uses the NRMP for the match for training position assignment. The 2012 'All In' policy removed any leeway a program had to give training slots outside of the NRMP Match - 'pre-matching' used to be a thing. There's a big power imbalance due to the ACGME's monopoly exemption. Medical students have no choice but to play the game.

 

[VA Hopeful Dr]

I could be wrong but it seems like even though we talk a lot about this stuff here, irl at my school no one is convinced that these things are a significant issue. Is it that med students are mostly sheep (no hate)?

I can see why physicians don’t want to talk about mid levels at least. The reason being they’ve chosen to hire a lot of them and want to keep that on the DL

You are wrong, at least about the physician part of it (I can't speak to the med student part).

AAFP Advocacy Focus: Scope of Practice

The AAFP believes family physicians are uniquely qualified to lead coordinated care teams of allied health professionals in providing care for patients.

www.aafp.org

"The AAFP urges policymakers to delineate the roles of allied health professionals more clearly. These individuals play an important part in the delivery of health services, and provide essential assistance to family physicians in providing care as part of a physician-directed team. "

Physician-led team-based care

Download issue brief, survey and model PDFs to learn about the AMA's state legislative and regulatory campaign in support of the physician-led team model of care.

www.ama-assn.org

"The most effective way to maximize the complementary skill sets of all health care professionals is to work as part of a physician-led team. "

 

[Bill_Brasky.]

I could be wrong but it seems like even though we talk a lot about this stuff here, irl at my school no one is convinced that these things are a significant issue. Is it that med students are mostly sheep (no hate)?

I can see why physicians don’t want to talk about mid levels at least. The reason being they’ve chosen to hire a lot of them and want to keep that on the DL

Medical schools mostly do not ventilate these things as doing so risks scaring premed applicants who might put two and two together to see the midlevel problem.

Not all physicians devalue their degrees by hiring midlevels.

Common midlevel problem lies:
1) There is a physician shortage
2) Some midlevels are as good or better than a physician
3) There is enough work for everyone
4) There is a role for midlevels
5) Midlevel independent practice will not affect patient safety
6) Midlevel independent practice will not affect a physician's livelihood
7) Midlevels will end up working in areas of physician scarcity
8) Midlevels encroachment will be limited to primary care medicine
9) Primary care medicine is easy enough for a midlevel to handle
10) Midlevel practice studies are not politically motivated
11) Competition from midlevels does not compromise patient safety
12) Physician education and training is excessive or unnecessary

 

[Chelsea FC]

I mentioned this during one of the few business/policy classes we had in M1 and got shut down hard by certain people in the class. Had a few classmates reach out to me to afterwards saying they agree but didnt want to speak up. The culture of med school is that you shouldn't talk about this stuff.

 

[Ho0v-man]

It’s unprofessional to think that your education is more valuable than a significantly less rigorous one.

I almost applauded when one of my clinical faculty said in a lecture “ You think about it like this because you’re supposed to be a doctor. If you just want to treat to the number because that’s what the numbers supposed to be then you should be in ****ing nurse practitioner school.”

‘Twas glorious.

 

[Bill_Brasky.]

I mentioned this during one of the few business/policy classes we had in M1 and got shut down hard by certain people in the class. Had a few classmates reach out to me to afterwards saying they agree but didnt want to speak up. The culture of med school is that you shouldn't talk about this stuff.

Don't give up. Speak louder. Join: https://www.physiciansforpatientprotection.org/

 

[datboi_58]

Just an anecdotal story : I’m a scribe for a specialty doctor and am not even in medical school yet. I am assigned to one team and we have a NP. She has more experience than me and is clinically more useful but diagnostically speaking, I sometimes catch her making simple mistakes that are just so clearly obvious. Just this past week, it was obvious the patient had one condition and she just misdiagnosed it. The patient even tried to point out her pain didn’t seem relevant to the diagnosis but she didn’t listen. I almost got scared for a second but thank God the doctor came in and he listened to NP and almost proceeded with her plan but the patient spoke up once again and he noticed the misdiagnosis. Now to be devil’s advocate, she is generally very useful and saves much time and energy for the doctor by taking care of many of the typical cases. Also, this is just one NP and is not representative of the entire population. But it is sometimes weird to think that she could now or at some point in the future independently function without physician supervision.

 

[deleted393595]

I think a lot of it comes from our relatively sheltered environment in medicine. At major tertiary/quarternary centers, midlevels tend to serve an appropriate role as a midlevel.

We have midlevels as primaries in our ICU (quarternary center)

 

[deleted393595]

Just an anecdotal story : I’m a scribe for a specialty doctor and am not even in medical school yet. I am assigned to one team and we have a NP. She has more experience than me and is clinically more useful but diagnostically speaking, I sometimes catch her making simple mistakes that are just so clearly obvious. Just this past week, it was obvious the patient had one condition and she just misdiagnosed it. The patient even tried to point out her pain didn’t seem relevant to the diagnosis but she didn’t listen. I almost got scared for a second but thank God the doctor came in and he listened to NP and almost proceeded with her plan but the patient spoke up once again and he noticed the misdiagnosis. Now to be devil’s advocate, she is generally very useful and saves much time and energy for the doctor by taking care of many of the typical cases. Also, this is just one NP and is not representative of the entire population. But it is sometimes weird to think that she could now or at some point in the future independently function without physician supervision.

Ever seen notes written by NPs or PAs? Even after multiple years of practice, it's still at the level of a 2nd year med student. Zero thought about future considerations for care. For instance, a particular patient we were operating on had no mention about current antibiotics or when cultures were drawn. It required a significant amount of waiting and calling around to figure out what the antibiotic plan would be.

They also incessantly order imaging and consults since they have no clinical judgement.

Whatever up-front savings come from using mid-levels are eaten up in the end by these ancillary costs.

 

[throwaway1000000]

Well, I think lot of PAs/NPs are definitely not upto par when they just finish their education.
But we have physicians training them like they train residents. Sure, some of the mid-levels might never get upto speed but most human beings can learn medicine if they try hard enough. A medical school trained resident might pick up something in 3 yrs while a mid-level might take 6 yrs.
When we train them like we train residents, I think it's natural for them to ask for independence.
Solution is probably to utilize mid-levels only to do scut-work, admin work, triage work, etc but not really happening that way. Mid-levels are being used by proceduralists to staff the clinics while they go do procedures and make money for the hospitals and themselves. I wonder how long before mid-levels start to operate independently. That is the next natural step...
Mid-levels are staffing general floors, emergency rooms and like someone said above even ICUs!
I either see this going as two tier care where people with less money will be seen independently by mid-levels and patients with money seeing physicians
Or... mid-levels starting to increase their scope more and more until they are considered equals in lot of fields especially if insurance companies start to reimburse physicians and mid-levels the same way
Other solution is stop training them like we train residents but that probably won't happen.

 

[keolu hills]

Well, I think lot of PAs/NPs are definitely not upto par when they just finish their education.
But we have physicians training them like they train residents. Sure, some of the mid-levels might never get upto speed but most human beings can learn medicine if they try hard enough. A medical school trained resident might pick up something in 3 yrs while a mid-level might take 6 yrs.
When we train them like we train residents, I think it's natural for them to ask for independence.
Solution is probably to utilize mid-levels only to do scut-work, admin work, triage work, etc but not really happening that way. Mid-levels are being used by proceduralists to staff the clinics while they go do procedures and make money for the hospitals and themselves. I wonder how long before mid-levels start to operate independently. That is the next natural step...
Mid-levels are staffing general floors, emergency rooms and like someone said above even ICUs!
I either see this going as two tier care where people with less money will be seen independently by mid-levels and patients with money seeing physicians
Or... mid-levels starting to increase their scope more and more until they are considered equals in lot of fields especially if insurance companies start to reimburse physicians and mid-levels the same way
Other solution is stop training them like we train residents but that probably won't happen.

I am not for midlevels at all. But, unfortunately physicians are hiring them to see patients. However, to say that they should be doing administrative work/scut work, it sounds like you are confusing them with a medical assistant. Many of them do procedures in the operating room as well as see them in clinic.

 

[keolu hills]

Primadonna was a PA-C who became a physician (DO). When she was an intern, she was already functioning as a 2nd year resident. She was way ahead of her class in residency.

 

[throwaway1000000]

I am not for midlevels at all. But, unfortunately physicians are hiring them to see patients. However, to say that they should be doing administrative work/scut work, it sounds like you are confusing them with a medical assistant. Many of them do procedures in the operating room as well as see them in clinic.

I mean...you have to draw the lines somewhere. There is a lot of day to day stuff that interns and residents do that NPs and PAs can do if you want to delineate the training between MDs and NPs/PAs.
I have seen NPs on surgical wards do dressing changes, do everything related to social work, disposition, consulting other teams, hold family meetings, round with us, pre-round on established patients and take care of day to day work. They never stepped in the OR, saw new consults, staff clinics etc but were able to still have a good role in the team. This is how I think they their role should be.
I think the surgical fields have better grasp on how to utilize them than the non-surgical fields.
PA/NPs might not have the same amount of knowledge but they are doing the exact work as counterpart MDs in non-surgical especially in primary care! I see more and more staffing ERs, hospital wards, and like someone said ICUs. If we are letting them practice independently in these settings, they will eventually learn and would want to be seen as equivalent to MDs. Maybe not right out of their school but after a few years of practice they will get pretty good.

 

[keolu hills]

I mean...you have to draw the lines somewhere. There is a lot of day to day stuff that interns and residents do that NPs and PAs can do if you want to delineate the training between MDs and NPs and PAs.
I have seen NPs on surgical wards do dressing changes, do everything related to social work, disposition, consulting other teams, etc. They never stepped in the OR, saw new consults, staff clinics etc but were able to still have a good role in the team.
You can't be training them like a resident and expect them to stay as a resident forever.

PA-Cs do vein harvesting during an open heart surgery. I know a neurosurgical PA that participates in surgery with his neurosurgery attending.

 

[throwaway1000000]

PA-Cs do vein harvesting during an open heart surgery. I know a neurosurgical PA that participates in surgery with his neurosurgery attending.

Who is saying they are not? I am saying if you let them do everything you let a medical resident do eventually they will naturally ask for independence. It does not make sense for them to function as a resident for rest of their life although we expect them to.