Doc gone. NP in.

[Complete_newbie]

MPMD wrote:

westcoastdoc wrote:

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...

Good point re: Derm. Those appt times are atrocious, no wonder there is APP creep.

I have no opinion on the matter either way, but I see more stories like this, going something like this:

PP physicians ---> Partners sell to PE (young physicians working towards partnership? yea take a hike) ---> PE firm "reorganizes" (read fire a few, more call, more work) physicians ---> Roll in them NPs/Telemedicine etc.

 

[hightower]

ENT Doc wrote:

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.

Click to expand...

Agreed.  Surgical sub-specialties seem to be a place of refuge.  I don't see how NP's/PA's can encroach much into the highly skilled and specialized surgical fields like ENT, Neuro, Ortho, Cardiothoracic, etc.  However, these are already insanely competitive fields, so students need to be aware of how difficult it will be to be to establish a career in those specialties now and in the future.  I just keep thinking of all the new DO schools popping up everywhere with questionable training and the number of students getting strapped with heavy student loan burdens and not much chance of being competitive for anything but the primary care fields.  It's a much different world for the medical profession these days.  I honestly plan on steering my kid(s) away from a career in medicine unless they really seem to love it and demonstrate strong natural talents that would make them one of the more competitive students.  If they are luke-warm about it or not showing extremely strong academics, I think their talents would be better used elsewhere.

 

[Dr. Mom]

Interesting that this post has focused on the NP aspect of the original post and not telemedicine.  Texas is where Teladoc started and is its busiest state.  So far telemedicine is not wanting midlevels.  They only want board certified physicians.  I see telemedicine as more limiting to NP's job security than to physicians.  In my experience, patients have seemed to prefer telemedicine with a physician as opposed to urgent care with a NP for routine episodic care.  It will be interesting to see how this shakes out in time.  Pediatric practices have long utilized midlevels but have been slow to adopt telemedicine.

[Dont_know_mind]

Tuxedo wrote:

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...

Autism and ADHD are certainly growth areas. Or maybe they are picked up more. I still have difficulty grasping what they are but they definately seem to be out there.

Do you have to do any extra training if you are already a paediatrician to use the term 'developmental paediatrician' ?

[hightower]

Another thought I had this morning regarding this...Could it be that another part of the problem is that MDs have made it too hard for themselves to specialize and focus on proving their worth through all of the outside regulation we've let into our career?  There are SO MANY hoops to jump through to become a specialized physician, but virtually none for mid-levels.  For instance, we have a dedicated diabetes focused NP working at one of our hospitals who does nothing but diabetes consults in the hospital.  She sent out an invitation link to a diabetes specific conference she attends every year for endocrinologists.  It offers no CME and requires you pay for your own travel and lodging.  All I could think (and I'm sure my partners felt the same) was "yeah right, like I have time for that."  Yet, it probably would be quite educational and is something primary care docs could benefit from, but I would bet it's much better attended by NP's/PA's.  This NP I'm referring to didn't have to apply to and complete an Internal Medicine residency, didn't have to worry about passing IM boards, didn't have to then apply for an Endocrinology fellowship and then sit for those boards, yet here she is operating like a highly specialized endocrinologist right out of NP school and she gets to focus on just one problem at a time, while her supervising physicians (the hospitalists) are forced to focus on a million problems at once with no time to become an expert on any of them.  I'm certain she's much better at managing diabetes at this point than most primary care docs.  It would be easy for her to prove her worth against ours.  Seems like we're kind of handicapping ourselves into being less competitive for our own jobs.

[Anne]

I agree with MPMD's sentiments.

Physicians should have been working all along to develop and enforce criteria for midlevel credentialing and quality assurance.  Instead we've sat back, been happy when the PA/NP does some of the work we don't want to do, and then complained when they start taking over some physician jobs.  I've worked with several PAs who worked harder than many physicians I know.   I agree that it is scarily easy to become an NP these days, and the training is insufficient.  Were physicians never in a position to prevent this from happening?  I think if the singular focus in these arguments against midlevels was quality of care, we would have been more successful.  In general, it is easy to read through the arguments and see that people are thinking about money and job security while talking about quality of care, and it's fairly easy to see through the veil.  The animosity towards midlevels rather than focusing our efforts on how we can all work together as a team for a win-win-win situation for us, them, and the patients, is just another nail in the coffin of our healthcare system.

[VagabondMD]

hightower wrote:

Another thought I had this morning regarding this…Could it be that another part of the problem is that MDs have made it too hard for themselves to specialize and focus on proving their worth through all of the outside regulation we’ve let into our career?  There are SO MANY hoops to jump through to become a specialized physician, but virtually none for mid-levels.  For instance, we have a dedicated diabetes focused NP working at one of our hospitals who does nothing but diabetes consults in the hospital.  She sent out an invitation link to a diabetes specific conference she attends every year for endocrinologists.  It offers no CME and requires you pay for your own travel and lodging.  All I could think (and I’m sure my partners felt the same) was “yeah right, like I have time for that.”  Yet, it probably would be quite educational and is something primary care docs could benefit from, but I would bet it’s much better attended by NP’s/PA’s.  This NP I’m referring to didn’t have to apply to and complete an Internal Medicine residency, didn’t have to worry about passing IM boards, didn’t have to then apply for an Endocrinology fellowship and then sit for those boards, yet here she is operating like a highly specialized endocrinologist right out of NP school and she gets to focus on just one problem at a time, while her supervising physicians (the hospitalists) are forced to focus on a million problems at once with no time to become an expert on any of them.  I’m certain she’s much better at managing diabetes at this point than most primary care docs.  It would be easy for her to prove her worth against ours.  Seems like we’re kind of handicapping ourselves into being less competitive for our own jobs.

Click to expand...

Totally agree. As I have said before, a PA can train for six months to become a Derm PA. Why can’t I train for six months and do the same? (Become a low level, supervised Derm provider, that is.)

[Side Hustle Scrubs]

The best way to prevent being replaced is to be the boss (private practice) or be the gatekeeper (sit on credentials committee or other hospital politics).

Unfortunately, since 2016 fewer than half of all physicians are in private practice:  For the first time ever, less than half of physicians are independent.  Modern Healthcare, May 2017.

The shift away from private practice is a much larger discussion for another day, but as physicians surrender control and become employees they are giving up their main weapon to prevent being replaced.  She who signs the checks makes the rules.

[childay]

Vagabond MD wrote:

Totally agree. As I have said before, a PA can train for six months to become a Derm PA. Why can’t I train for six months and do the same? (Become a low level, supervised Derm provider, that is.)

Click to expand...

"supervised" and "low level" are questionable depending on the state and situation..

[Complete_newbie]

Does anyone have any resources of data (csv etc) re: NP training and pay anywhere? Please let me know. I'm curious to do an analysis. Thanks!

[Zaphod]

I think its very specialty, region, and situation specific (hospital, outpt, etc...). Maybe theyre running around, but they dont typically take stuff home as much, havent in the past been always on call (likely to change with responsibility) and werent thought of as first line in malpractice (also likely changing).

Driven midlevels can absolutely make great pay. When combined with how much easier it is, and faster, that adds up. Theres an RN first assist in town that is supposedly making 300+ here. Best job in surgery. Just operate with no clinical/call responsibility. I would totally do that job.

[VagabondMD]

childay wrote:

Vagabond MD wrote:

Totally agree. As I have said before, a PA can train for six months to become a Derm PA. Why can’t I train for six months and do the same? (Become a low level, supervised Derm provider, that is.) 

Click to expand…

“supervised” and “low level” are questionable depending on the state and situation..

Click to expand...

We can parse definitions and such, but there is no pathway for me to become a Derm physician extender while there is a pathway for someone with less education to do so.

[Zaphod]

Vagabond MD wrote:

childay wrote:

Vagabond MD wrote:

Totally agree. As I have said before, a PA can train for six months to become a Derm PA. Why can’t I train for six months and do the same? (Become a low level, supervised Derm provider, that is.) 

Click to expand…

“supervised” and “low level” are questionable depending on the state and situation..

Click to expand…

We can parse definitions and such, but there is no pathway for me to become a Derm physician extender while there is a pathway for someone with less education to do so.

Click to expand...

Absolutely agree. There should be a way for physicians in other specialties to somewhat rapidly be able to do a structured proctoring or something that lets them move across specialties.

There are zero valid arguments if we allow NP/PA to do it with so much less basic/practical knowledge.

[ACN]

When I go for my eye check, I always try to request to see the MD, however, 100% of the time I'm told no as I have medical problems with my eyes. My optometrists have been good at these practices, but still frustrating not being able to see the MD even when requested.

A little off topic, but it's annoying. Maybe one of our ophtho docs here can justify it for me. I'm guessing it's all financially related.

I figure in my future practice, I'll personally see all the physicians for injections and follow up.

[jpa]

Newly minted grad here....my generation NEEDS to be "taught the ropes" by current private practice physicians.  I went to a DO school, so I had several rotations in PP clinics and with PP hospitalist groups and even PP consult rotations, and nearly all of them taught me some business of medicine.  However, when I would discuss this business of medicine stuff with my fellow students on the residency interview trails or during my rotations at academic centers, most of them were pretty scared of the responsibility of private practice (academic medicine often looks down on them too it seems?).

If we owned our own jobs, it seems this would be less likely to be an issue?  All my PP preceptors reported salaries that were way above Medscape means, and they practiced good medicine, with good work-life balance