To use mid-levels, or not?!

[Turf Doc]

I generally couldn't care less who wants to be called doctor. If somebody with any kind of doctorate degree wants to introduce themselves as "doctor" in a public social setting, more power to them, although that's my sign to stay away from that person as they're probably a real stick in the mud. But, in a hospital or healthcare setting, doctor should only be used for physicians in order to not confuse patients and to clearly delineate roles.

Totally agree. I mean people should be used to it from college when basically every professor has a doctorate, and i called them all Dr. and didn't think twice about it. Although generally the doctorate of nursing is just really weird to me. Last i checked, doctor is supposed to basically be the terminal degree, the expert. But with these doctorate of nursing degrees im really not seeing how its not just a fake medicine degree.

[HikingDO]

From a non-physician perspective, huge difference between a PA and a NP.
A PA is purely a productivity enhancement too. If you train, direct, supervise and have hire/fire authority, it comes down to productivity and how effectively your personal practice can use the PA.
NP is adequately discussed above.

I’d take a PA over an NP any day of the week.

[wideopenspaces]

I work with NP trainees and honestly it's shocking to me how poorly trained they are and what they miss on patient interviews. No way in ************************ would I supervise them. I do know a few NPs who worked as nurses for a decade or two and then got their NP and they are good. But as a rule these DNP programs are garbage. If you can work full time while completing a 2 year DNP program, you are not being adequately trained to be in a physician role. Sorry.

And if you want to be called doctor, put in the 7-10 years to go to medical school and residency and then we can talk.

[Huggy]

From my observation, the only physicians that are comfortable with midlevels are those that are profiting directly from their employment. Continue selling out the future generation of physicians and demeaning your training for an extra buck.

[gap55u]

I supervise two very experienced NP’s who were nurses for a long time before doing a brick and mortar program, and who have been practicing for years. I did random chart audits at first, and now I see notes when they see my patients in cross coverage. They know their stuff and know their limits / when to ask for help. I view this as entirely different than the baby NP’s graduated from diploma mills with 1 year of “experience” - management is hiring those people. I would never supervise one of them. I have thought about backing down on supervision, but that would be odd.

[Random1]

So what actually is the purpose of putting a seen and agree on the note ? When you obviously did not see them. I see this all the time. The patient was seen sat in the urgent care and the doctor signs off on monday on the note. Really, you expect me to believe that you went in on sat , saw the patient on sat for that encounter. This is all about billing and nothing more.

[zlandar]

Huge variation in PAs and NPs when it comes to their training/former career background/attitude. Group has a former nurse who became a NP and the IR docs trained her to do some basic procedures. She also does the H&P for the IR docs and calls patients for f/u. She does a great job and knows her limits.

When she is off for a week everyone notices. We employ her and not the hospital.

[cards67]

I work along NP's no problem, they see their own patients and bill separately. They help see some of low-level stuff but also really help with patient education and patients who need more TLC, which I'm happy to not see myself. I have no interest in supervising midlevels nor need their help in seeing patients (except those tlc patients). Seeing patients is the easy part. Fielding messages, calls, prior auths, etc. is annoying and waste of my time and I'd gladly take help for that, which our midlevels do help with sometimes too.

[Turf Doc]

I supervise two very experienced NP’s who were nurses for a long time before doing a brick and mortar program, and who have been practicing for years. I did random chart audits at first, and now I see notes when they see my patients in cross coverage. They know their stuff and know their limits / when to ask for help. I view this as entirely different than the baby NP’s graduated from diploma mills with 1 year of “experience” - management is hiring those people. I would never supervise one of them. I have thought about backing down on supervision, but that would be odd.

You gotta love that the bar is so low for NP education that going to a "brick and mortar" program is a bragging point

[StarTrekDoc]

That would bother me until I realized that I could brand my practice offering the "Brain of a physician" advertising "Real" care. The patients they syphon off will likely not be missed

That's our university push compared to local competition. Better care.

Not efficient not access. Not glorious fancy facilities or red carpet customer service.


Plain old. Better care. It's your health after all.

[legobikes]

They also suck up the easier visits. Minor injuries, UTIs, URIs, Etc. Making your day more complicated and frustrating. Sure you can bill higher but I would rather see 2 99213s in place of 1 99214. It also helps keep they variety in the day and personally I like the quick stuff that makes people feel better. More satisfying compared to tweaking DM meds.

Yep, good point. I get paltry compensation for NP oversight and think I will stop doing it soon. Our PA on the other hand is pretty good.

[Turf Doc]

Yep, good point. I get paltry compensation for NP oversight and think I will stop doing it soon. Our PA on the other hand is pretty good.

Sometimes people post the numbers they're quoted in return for supervising and they're so low I don't understand why anyone would even entertain them.... like really its worth the hassle for 5k/midlevel?

[pit.alumni]

From my observation, the only physicians that are comfortable with midlevels are those that are profiting directly from their employment. Continue selling out the future generation of physicians and demeaning your training for an extra buck.

I think that's a generalization that is not really true. It may be specialty and setting dependent. There is no doubt that Private Equity is using APPs in place of physicians and then putting the risk on their employed physicians and it's bad for everyone (pts, apps and physicians) except for those profiting. On the other hand Physicians that invest in their PAs and NPs, train them well, can utilize them for tasks that do not really require a Physician level of care. In those settings the APPs can be compensated well, patients can be seen efficiently and get more face to face time with providers to get their questions answered, and the Physician owners can get reasonable compensation for the oversight.

[K82]

From a non-physician perspective, huge difference between a PA and a NP.
A PA is purely a productivity enhancement too. If you train, direct, supervise and have hire/fire authority, it comes down to productivity and how effectively your personal practice can use the PA.
NP is adequately discussed above.

You said you weren't a physician, I was just curious what your background work experience has been.

[Huggy]

I think that's a generalization that is not really true. It may be specialty and setting dependent. There is no doubt that Private Equity is using APPs in place of physicians and then putting the risk on their employed physicians and it's bad for everyone (pts, apps and physicians) except for those profiting. On the other hand Physicians that invest in their PAs and NPs, train them well, can utilize them for tasks that do not really require a Physician level of care. In those settings the APPs can be compensated well, patients can be seen efficiently and get more face to face time with providers to get their questions answered, and the Physician owners can get reasonable compensation for the oversight.

hmm interesting take. So who is doing the triaging to determine whether a patient’s medical problem is worthy of being evaluated by a physician versus hopefully one of those decently trained midlevels? Example, I just admitted a patient last night with a hemoglobin of 3 and melanotic stool who visited an NP (or APP as you like to call them) one week prior for generalized weakness, fatigue and feeling like her legs are “giving out.” No labs obtained, patient prescribed ibuprofen twice daily for her leg discomfort. Her only medical history is gastric ulcers and iron deficiency anemia requiring frequent transfusions by the way.

Additionally, I don’t see “APPs can be compensated well” and “physician owners can get reasonable compensation” as compelling reasons to justify the use of midlevels but to each their own. Does that not just prove my original statement that financial interests are the primary driver for the utilization of inferiority trained medical providers? And i think it is safe to assume based on your position that you have a financial interest in the employment of midlevels in your practice, please correct me if I’m wrong.