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  • Doc gone. NP in.

    http://dfw.cbslocal.com/video/3868944-dozens-of-pediatricians-losing-jobs-as-childrens-health-clinics-close/

    Word on the street is these peds are getting replaced by NPs and telemedicine.

    Before AI, comes the NP.

     

  • #2
    The face of pediatric illness is changing and pediatric residencies are doing a very poor job of adapting to it.

    Thanks to immunizations, the number of children ill with potentially life-threatening infections has significantly decreased.  Yet training still focuses these illnesses which have nearly become esoteric.  Infectious epiglottitis almost does not exist anymore.  But continues to be stressed in training.  Meanwhile behavioral health problems are increasing.  And most pediatricians are relatively poorly equipped to deal with them.  I would argue that the most potentially life-threatening condition we (pediatricians) see on any given day might be  the adolescent with SI.  Not the febrile infant.

    Most children are healthy enough that you just need to stay out of their way and they'll be fine.  So you can have a not-very-good NP and the outcome is no different than a pediatrician.

    I am working on becoming a go-to guy for pediatric behavioral health.  It is not what I thought I would be doing but the need is there.  Hopefully it works out.  I've also considered going back to fellowship just to have a job that I think is safe from NP encroachment.  I think the handwriting is on the walls.

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    • #3




      The face of pediatric illness is changing and pediatric residencies are doing a very poor job of adapting to it.

      Thanks to immunizations, the number of children ill with potentially life-threatening infections has significantly decreased.  Yet training still focuses these illnesses which have nearly become esoteric.  Infectious epiglottitis almost does not exist anymore.  But continues to be stressed in training.  Meanwhile behavioral health problems are increasing.  And most pediatricians are relatively poorly equipped to deal with them.  I would argue that the most potentially life-threatening condition we (pediatricians) see on any given day might be  the adolescent with SI.  Not the febrile infant.

      Most children are healthy enough that you just need to stay out of their way and they’ll be fine.  So you can have a not-very-good NP and the outcome is no different than a pediatrician.

      I am working on becoming a go-to guy for pediatric behavioral health.  It is not what I thought I would be doing but the need is there.  Hopefully it works out.  I’ve also considered going back to fellowship just to have a job that I think is safe from NP encroachment.  I think the handwriting is on the walls.
      Click to expand...


      This is true in all fields. They hammer things at a rate grossly disporportional to what you'll see in practice, maybe never, and ignore stuff you'll see all day long. Lots of reasons but one is those rare genetic or immunologic issues are well known and studied. They can ask what genes, proteins, receptors, vaccines, etc...and so forth. Makes for easy question writing even if clinically useless.

      I answered more questions on my written boards about a genetic disease than there are pts with it in the US. Thats just absurd. But the everyday stuff doesnt always make for such great questions that make writers and takers feel smart and good about themselves.

      This is the paradigm shift that has to occur really, focusing proportional research/teaching to what we need to figure out but is small, and what we really really need to address that is absolutely massive. Always need those zebras and work towards it, but its too far in that direction right now.

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      • #4
        It's a disturbing story to hear.  MD's fired, NP's hired.  Really makes me want to increase savings even more and work hard now while the sun is still shining.

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        • #5
          Like it or not, mid level providers are here to stay. To fight it is like fighting the tide. I think as physicians (particularly those in private practice) we need to focus our efforts on how to use mid levels to our financial benefit while protecting certain aspects of our practice from being usurped.

          I know a pediatrician who employs a fleet of NPs who makes hundreds of thousands of dollars a year. I also know a pediatrician who takes extra call because her base salary is < 100,000. It’s all about how you use them to your advantage.

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          • #6
            For those that say we can't fight the mid-level battle please be aware that they may have NO clinical experience as a RN and do a two year program online. Their rotations are 500 hours of shadowing. The NPs of the past are gone and the new ones are in and it is frightening.

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            • #7
              In regards to hightower saying, “Really makes me want to increase savings even more and work hard now while the sun is still shining.”

              I think this goes for many aspects of medicine in their own way. I don’t feel so much threatened by NP’s, but oral chemotherapy is the crisis in my world. I openly tell everyone that I don’t see Oncologists having a lucrative field anymore in 10 years because oral chemo doesn’t bring in any income. Immunotherapy has saved our tails for the next 5 years, but that will be short lived. I’m saving like crazy now so I can be prepared to abandon ship in about 12 years when Oncologists basically become primary care providers writing prescriptions for chemo pills. You will slowly see the death of Oncology over the next decade unless oral chemo becomes covered under Part B.

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              • #8
                Midlevels are doing surgery. They're also in the EDs, the ICUs (pediatric, adult, neuro, surgical, neonatal, all of them), BMT units (where midlevels seem to be preferred over housestaff), not to mention all the clinics and many of the wards. It's an alarming trend but I don't think it's only pediatric outpatient medicine that is susceptible and more subspecialization won't necessarily guarantee job safety. It may require diversification into more esoteric branches of medicine that require more expertise and are not as protocolized or "practice-based." Things like clinical trials, translational medicine, the newest cellular therapies, new cardiac devices, the newest imaging modalities, consulting in academics, etc.

                 

                I will say that I think peds needs fewer residency spots and that a lot of outpatient pediatrics could be handled by midlevels. I would prefer if ALL well child care was done by midlevels and physicians only addressed acute illness in the outpatient world. However, sometimes these things are hard to disentangle.

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                • #9
                  The drug companies want antibody based immunotherapy because it is extremely lucrative but the next wave will be small molecule inhibitors that modulate receptor-cytokine or signaling molecule 1-signaling molecule 2 interactions. On the other hand, I'm not sure why chemotherapy is still billed in a way that's lucrative. I suppose someone could make writing an order for rituximab just as easy and just as remunerative (i.e. NOT) as ordering meropenem with ID approval.

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                  • #10
                    With these disturbing trends -- would any of you recommend your kids to go to NP or PA school instead of med school (if your kids are interested in non surgical fields)?  We have PAs easily making 6 figures with minimal work and hardly any stress/responsibility.

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                    • #11




                      With these disturbing trends — would any of you recommend your kids to go to NP or PA school instead of med school (if your kids are interested in non surgical fields)?  We have PAs easily making 6 figures with minimal work and hardly any stress/responsibility.
                      Click to expand...


                      Would you be happy as a PA/NP? I wouldn't. Sure, it might be more responsibility and longer schooling, but I also got to learn more, get to be captain of the ship, get to own the business, and I get paid quite a bit better too. In many places, they're working harder for that lower salary too.
                      Helping those who wear the white coat get a fair shake on Wall Street since 2011

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                      • #12


                        Would you be happy as a PA/NP? I wouldn’t. Sure, it might be more responsibility and longer schooling, but I also got to learn more, get to be captain of the ship, get to own the business, and I get paid quite a bit better too. In many places, they’re working harder for that lower salary too.
                        Click to expand...


                        Bolded is not entirely out of reach for NP/PA.  In many places NPs can practice independently and start their own practices.  Also, I've come across a couple of PA owned practices where they hire locums and part-time docs to be their supervising physician.  In these cases the physician is actually the employee and the PA is the one signing the paychecks.

                        Mostly agree with everything else, though.  I'm way happier as a doc.

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                        • #13
                          If my kid was a 21 old college grad and wanted to practice medicine I would totally encourage med school.

                          If he was a 35 year old with 3 kids and a mortgage I would suggest PA school - less school, no residency and more flexibility. A PA could work for a neurosurgeon one week and a family doc the next. It would be easier for me to become a plumber than to change specialities.

                          I think NPs are undertrained and it is dangerous to equate them with the training of a physician or PA. I don’t blame my nursing friends for advancing their career but there’s a reason our group won’t hire NPs.

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                          • #14




                            With these disturbing trends — would any of you recommend your kids to go to NP or PA school instead of med school (if your kids are interested in non surgical fields)?  We have PAs easily making 6 figures with minimal work and hardly any stress/responsibility.
                            Click to expand...


                            That's not a fair characterization. The APPs I work with work much harder than the attendings for the most part. We have a fair amount of downtime between when cases are presented to us and they are basically running for their entire shifts.

                            There are plenty of reasons to worry about APP creep, but the idea that it's easy money just isn't one of them.

                            I have to say that for a forum that skews fairly free-market on other issues the relatively hostility to mid-levels is interesting to me. We can all have our opinions on quality but it appears to me that the market is sorting this out increasingly not in our favor. I don't have a great solution b/c I'm not sure we need a solution. There are certain models of physician practice that I see and think "that's going to be fun while it lasts." Something that has come up on another APP topic is derm. You can't get in to see a dermatologist; there is data on this. We're talking weeks even for an established pt. So you have this huge need and a relatively small guild of highly paid practitioners who do not seem very focused on increasing patient access. Something is going to give in that system in a free market. It's easy to say "well this PA did X hours while I did Y hours of training" and that's perfectly valid and important, but on the patient side you have a 5 week wait to see this highly trained person.

                            Comment


                            • #15







                              With these disturbing trends — would any of you recommend your kids to go to NP or PA school instead of med school (if your kids are interested in non surgical fields)?  We have PAs easily making 6 figures with minimal work and hardly any stress/responsibility.
                              Click to expand…


                              That’s not a fair characterization. The APPs I work with work much harder than the attendings for the most part. We have a fair amount of downtime between when cases are presented to us and they are basically running for their entire shifts.

                              There are plenty of reasons to worry about APP creep, but the idea that it’s easy money just isn’t one of them.

                              I have to say that for a forum that skews fairly free-market on other issues the relatively hostility to mid-levels is interesting to me. We can all have our opinions on quality but it appears to me that the market is sorting this out increasingly not in our favor. I don’t have a great solution b/c I’m not sure we need a solution. There are certain models of physician practice that I see and think “that’s going to be fun while it lasts.” Something that has come up on another APP topic is derm. You can’t get in to see a dermatologist; there is data on this. We’re talking weeks even for an established pt. So you have this huge need and a relatively small guild of highly paid practitioners who do not seem very focused on increasing patient access. Something is going to give in that system in a free market. It’s easy to say “well this PA did X hours while I did Y hours of training” and that’s perfectly valid and important, but on the patient side you have a 5 week wait to see this highly trained person.
                              Click to expand...


                              I agree with the free market aspect of this.  (Regarding how hard APPs work, this will vary depending on how they are utilized and in what practice, so it can vary widely.)  Like it or not, we haven't proven our value at the primary care level.  Google NP vs MD quality or anything remotely similar and you'll find a plethora of research coming from NPs showing how they are equivalent or BETTER at providing care.  MDs have been too passive about this, unwilling to do the hard research, or simply can't prove their value.  The NPs and PAs flooding the market are a market response to demand, especially where value is perceived to be the same if not better because of the lower cost to provide care.  There is a relative ceiling to what they can do given credentialing and licensure, so in the not-so-distant future the primary care field (ER included) will be awash with low-cost providers and salaries for all parties will drop, and jobs will be harder to find.  This market signal will create a lowering supply, etc.

                              For those of you reading this in med school who want a more secure job and steady income in the future, differentiate yourself by selecting a field that has a relatively high barrier for entry from midlevel encroachment, or have a skill set that differentiates yourself by adding clear value.  Medical schools and residencies need to be introspective as well and see if everything they are doing an teaching and time spent in all that training is really efficient.

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