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  • #61
    Originally posted by Panscan View Post

    Heck we had a post a couple weeks ago which was like "how can I best leverage mid-levels to make money"
    WCI had this guy (discussing a different subject) on the podcast not too long ago:
    https://www.kevinmd.com/blog/2020/01...s-and-nps.html

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    • #62
      Originally posted by G View Post

      Yeah, EM is an obvious target for criticism, but I find that more and more often I'm dealing with mid-levels everywhere--the surgical subspecialist, the medicine subspecialist, and of course primary and urgent care.

      As I've said elsewhere on the SDN type threads, Medicine opened pandora's box to make a little extra dough and/or improved efficiency, and now the younger physicians and surgeons (and our patients) are left with the consequences.
      Emergency Medicine is definitely not immune to this criticism. I was operating on call a few weeks ago and had an ER doc call into my room (which I hate—I’m busy focusing on an operation, I don’t need to be interrupted by anything non-emergent) about a hip fracture in the ER. I asked him to please call my PA to give him the info and so he could get started on the workup and the doc flat out refused.

      So you won’t talk to my PA in the middle of the day, but it’s ok for you to have your PA or NP working in the ER call me in the middle of the night and wake me up with some bullsh*t question on how to manage something simple that any PGY-1 would know? GTFO

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      • #63
        Originally posted by MaxPower View Post

        Emergency Medicine is definitely not immune to this criticism. I was operating on call a few weeks ago and had an ER doc call into my room (which I hate—I’m busy focusing on an operation, I don’t need to be interrupted by anything non-emergent) about a hip fracture in the ER. I asked him to please call my PA to give him the info and so he could get started on the workup and the doc flat out refused.

        So you won’t talk to my PA in the middle of the day, but it’s ok for you to have your PA or NP working in the ER call me in the middle of the night and wake me up with some bullsh*t question on how to manage something simple that any PGY-1 would know? GTFO
        1.) We don't know if someone is in the OR or not. We only know who is on call.
        2.) If it's during the day, most of the Orthos I know like to know if there is a hip fracture or something surgical as they may want to do it same day or it will at least help them with managing their schedule. At night I don't call and just put in a consult order so they can see them in the morning.
        3.) That's actually hilarious he wouldn't talk to your PA. I wouldn't make another phone call if I was talking with the doc on call already, either.

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        • #64
          Originally posted by G View Post

          You realize that you are literally describing the best case scenario in which a non-doctor practices medicine....
          And the worst case scenario - Years ago, I helped cover a physician who was employed by the hospital to start their hem/onc practice. He was experienced and had a couple of NP but was burning out.. Since he had helped me with coverage when I was out of the country in the past, I helped cover for him on weekends and when he went on conferences.

          He had one good NP and one bad one. The bad one had no clue about differential diag or treatment. Unfortunately she was the only one who was credentialed and doing the bone marrow exams ( the doc had given it up years ago since it was too low-paying) . Patients complained about the pain she caused while doing the procedure. One day she did a bone marrow on a patient and a report came back stating normal kidney tissue found. From that day onwards, all his bone marrows were done by radiology ( under greatly increased cost and extra unnecessary workload onto radiology).

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          • #65
            Originally posted by CordMcNally View Post

            1.) We don't know if someone is in the OR or not. We only know who is on call.
            2.) If it's during the day, most of the Orthos I know like to know if there is a hip fracture or something surgical as they may want to do it same day or it will at least help them with managing their schedule. At night I don't call and just put in a consult order so they can see them in the morning.
            3.) That's actually hilarious he wouldn't talk to your PA. I wouldn't make another phone call if I was talking with the doc on call already, either.
            1) So when the circulating nurse answers my phone and says I’m operating, or they call the OR desk to be transferred into the room they don’t know we are in the OR? Ok... I understand not knowing when they make the initial call, but c’mon.
            2) During the day, if I’m in the middle of an operation, I can’t see the patient, talk to anesthesia about doing the FI block, or get them posted, but my PA sure can do all of those things and help with that holy grail of ER throughput. But if you wait to talk to me until I’m done then the OR might be taken and patient care might be delayed. My PA knows my schedule and knows to put appropriate cases on for me during the day.
            3) He wasn’t talking to me. He was talking the circulating nurse. But I guess delaying patient care is hilarious.

            Last I checked we were on the same team, so if I ask an ER doc to please call my PA because I’m busy doing other things, not sure why that is an unreasonable demand. There aren’t too many ER docs (actually none) who will take my call when I call them back while they’re in the room with another patient, or doing a procedure, but whatever.
            Last edited by MaxPower; 04-22-2021, 08:14 AM.

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            • #66
              Originally posted by G View Post

              You realize that you are literally describing the best case scenario in which a non-doctor practices medicine....
              Unfortunately, yes. I've known nurses, as I am sure many of you have, who started as a floor nurse, or OR nurse, who think they can take two years of online courses, obtain a masters degree, and then practice equal to a fully trained MD/DO. It's scary

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              • #67
                Originally posted by MaxPower View Post

                1) So when the circulating nurse answers my phone and says I’m operating, or they call the OR desk to be transferred into the room they don’t know we are in the OR? Ok... I understand not knowing when they make the initial call, but c’mon.
                2) During the day, if I’m in the middle of an operation, I can’t see the patient, talk to anesthesia about doing the FI block, or get them posted, but my PA sure can do all of those things and help with that holy grail of ER throughput. But if you wait to talk to me until I’m done then the OR might be taken and patient care might be delayed. My PA knows my schedule and knows to put appropriate cases on for me during the day.
                3) He wasn’t talking to me. He was talking the circulating nurse. But I guess delaying patient care is hilarious.

                Last I checked we were on the same team, so if I ask an ER doc to please call my PA because I’m busy doing other things, not sure why that is an unreasonable demand. There aren’t too many ER docs (actually none) who will take my call when I call them back while they’re in the room with another patient, or doing a procedure, but whatever.
                1.) The clerk calls whoever is on call. I would suggest having your PA be the one who takes the initial calls if it's an issue.
                2.) In my experience Ortho doesn't ever admit primarily so talking with the orthopedist isn't the rate limiting step for ED throughput.
                3.) I'm assuming the circulating nurse has hands. He/she can write down the relevant information and then he/she can contact your PA. This is the most efficient process.

                We're definitely on the same team but I don't fault the ED doc not wanting to play phone tag since that happens much more than people who don't work in the ED realize. It sounds like a system issue where you work. If another physician needs to talk with me then they'll get me on the line. If they just need someone to take information down then they'll get someone that can do that if I'm unavailable.

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                • #68
                  Originally posted by Panscan View Post

                  ya the more common reality is the 22 yr old with 0 experience, attends online classes and goes to preceptorships that care 0 and teach them nothing and then they are minted to be equivalent to a doc in lots of states.

                  Just a ridiculous system. will be interesting to see how the EM organizations push back on the midlevels.
                  Don't forget that sometimes they crowd-source information/help from social media

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                  • #69
                    Originally posted by Nysoz View Post

                    Don't forget that sometimes they crowd-source information/help from social media
                    Unfortunately lots of doctors doing the same in various Facebook groups.

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                    • #70
                      90% of patients do not care if they get their 5 days of norco or zpak or whatever.

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                      • #71
                        Originally posted by Sundance View Post
                        I’ve also seen a dramatic change in my surrounding ERs (mostly rural) where now they are basically exclusively stacked with mid levels.

                        It’s been a huge problem as it significantly increases my calls at night as well as creating significant stress/concern of trying to figure out what they’re trying to say or what’s really going on at 3 in the am
                        Many factors, but as long as docs strongly prefer to work/live in big hospitals, large metro areas, and academic medical centers, we are surrendering territory to mid levels as they become predominant in smaller, rural, Indian health, and other underserved communities. For example in this whole conversation about EM: are there really no longer any EM jobs, or are the only jobs in ‘undesirable’ locations? If EM docs are not willing to work in small town rural Montana or Alaska despite job availability, it is inevitable those hospitals will seek out midlevels.

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                        • #72
                          Originally posted by FIREshrink View Post
                          Many factors, but as long as docs strongly prefer to work/live in big hospitals, large metro areas, and academic medical centers, we are surrendering territory to mid levels as they become predominant in smaller, rural, Indian health, and other underserved communities. For example in this whole conversation about EM: are there really no longer any EM jobs, or are the only jobs in ‘undesirable’ locations? If EM docs are not willing to work in small town rural Montana or Alaska despite job availability, it is inevitable those hospitals will seek out midlevels.
                          There are not really EM jobs in rural areas right now, either. That's part of the problem.
                          The market is nonexistent in my entire time zone!

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                          • #73
                            Originally posted by Eye3md View Post

                            Unfortunately, yes. I've known nurses, as I am sure many of you have, who started as a floor nurse, or OR nurse, who think they can take two years of online courses, obtain a masters degree, and then practice equal to a fully trained MD/DO. It's scary
                            Actually having any nursing experience at all is a step above of the current trend to go straight through without ever having worked as a RN.

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                            • #74
                              Originally posted by snowcanyon View Post

                              There are not really EM jobs in rural areas right now, either. That's part of the problem.
                              The market is nonexistent in my entire time zone!
                              ??? I have partners and acquaintances who live in a premier global tourist destination who commute out to the rurals, which are continuously looking for folks. I find it hard to imagine that a BC EM doc with experience couldn't get a permanent contract at any of them.

                              Interesting that your area is so saturated. Perhaps that is why your hospital bureaucrats treat you so poorly?

                              Comment


                              • #75
                                I am not a EM doc. But we have the same issue with contacting docs in other fields. We have hospital and STATE mandates that certain communications must be physician to physician. Being asked to call a PA would not satisfy our requirement to speak directly to a physician. Right now, 2021, they are just grappling with the cases in which the treating clinician is not a physician. So I feel for the ED doc who may not have had the choice to call a PA.

                                Not being in EM, maybe the answer is obvious, but here goes. I would have thought that anyone with EM training would be able to do primary care immediately. They would have to look up and study up on preventative medicine and some conditions that rarely present in the ED. I assume they could start work and do that as they go along. Or start off with a broad primary care refresher course. It is not the field they trained in and it may not be the field they want, but it would be a steady job.

                                I would think the same for working at an urgent care center. Or are they all staffed by midlevels?

                                Malpractice: I assume midlevels are held to the standards of midlevels, not physicians. If there is a bad outcome because the midlevel did not know what they were doing, it would only be malpractice if a qualified midlevel should have been able to handle the case correctly. If it would be expected for an EM doc to do it right, but not for a ED midlevel, then it is not malpractice. Just as an EM doc is not held to the standard of a cardiologist in managing an acute MI. "Why did you not immediately take them to the cath lab?" "Because that is not within the scope of practice for EM physicians."

                                Although it is frightening to think of places the have no physicians in the ED, appropriate use of midlevels depends on what someone with that level of training can reasonably handle. It does not depend on whether using them reduces the demand for EM physicians. Clearly there are some things that midlevels CAN do just fine. No sacrifice in quality of care by having them do those things. It will reduce demand for docs, which is probably appropriate. Just as a good independent EM group that cares about quality will hire midlevels to do the things they can do and free up the physicians to do doctor work. They may well hire midlevels instead of bringing on another physician.

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