What constitues a "Mid-level Provider"

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VFlutter

VFlutter

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The intention of this thread was not to get opinions as to the motivations or usefulness of mid level providers.

This was more about outlining what should be required to work in the mid level role.
 

medicsb

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Here are some criteria that I think are required for a group to be considered mid-level providers:
  1. Graduate level education
  2. Prescriptive authority
  3. Ability to assess, diagnose, and treat
  4. Ability to bill for services
  5. Ability to perform advanced procedures? This is questionable
A decent general criteria, though I'd add physician supervision (direct or indirect), and then I'd add "limited" to the beginning of 2, 3, 4, and 5.

"mid level" sounds better than "band-aid."

Basically a provider requiring an advanced degree, like physical therapy, PA, NP, etc, that is not a physician but desperately wants to call themselves one.

I'd more likely apply this to NPs. I find that more PAs are fine with just being mid-levels and do not want to undermine physicians.

I think NPs and PAs can be helpful. THe NPs on the surgical service on which I am rotating seem to fill a role that I find to be appropriate. They do not do any procedures and their job is meant to assist the attendings and residents with data gathering, patient discharges, med recs, and post-op checks. They report to residents and attendings. They prescribe under the guidance of the team and there is little they will prescribe without consulting a physician. They are only on duty during the day.

There are PAs working in the ED under physician supervision and for sure most of the more silly consults tend to come from the PAs, but they do consult appropriately more often than not. Occasionally, the EM physician will get on the phone and cancel the consult and apologize.

The expansion of PAs and NPs has flourished since the 60s because of artificial limitations in the number of physicians trained, which started in the early half of the 1900s. Right now, there is something like 20 new medical schools slated to open in the US. Medicine is slowly but surely responding to the increased demand for physicians. I expect medical training to change in order to produce more primary care physicians (e.g having tracks for med students that is more primary care focused) As more physicians are trained and as more get pushed towards primary care, I expect NPs and PAs may have a more questionable future.
 

Veneficus

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2 of the NPs I know fill a very useful role without trying to undermine the doc.

They spend an extended period delving into pt history, medications, medication reactions, and eliciting side effect profiles.

They then either modify the treatment for better tolerance or present pertinant info to the MD prior to her exam and planning.
 

platon20

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The expansion of PAs and NPs has flourished since the 60s because of artificial limitations in the number of physicians trained, which started in the early half of the 1900s. Right now, there is something like 20 new medical schools slated to open in the US. Medicine is slowly but surely responding to the increased demand for physicians. I expect medical training to change in order to produce more primary care physicians (e.g having tracks for med students that is more primary care focused) As more physicians are trained and as more get pushed towards primary care, I expect NPs and PAs may have a more questionable future.

Actually its more like 50 new med schools. Plus the existing med schools are expanding like crazy. Its pretty easy to get accepted into med school these days -- I expect the quality of doctors to drop off quite a bit.

I agree with you about MDs being pushed by force into primary care. They will have no choice. Specialties like plastics, ENT, derm are going to be nearly impossible to get and you'll have to get super high USMLE scores adn near perfect grades.
 

platon20

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Not to side track this thread, but I have had the pleasure of interacting with some mid level providers that are more educated than the MD who's license they practice under.

More educated? No. More common sense and work better wtih people? Absolutely.

On the other hand, I have seen EMTs in training run circles around paramedics. That kind of stuff happens in all fields.

However, on average the physician will be superior to the midlevel, just as the AVERAGE paramedic will be superior to the new EMT trainee
 

platon20

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What about those that have no desire to be an MD? Around these parts we are seeing more PAs and students who openly state they have no desire to attend the full medical school. My girlfriend is in PA school and she feels it is a better deal then being an MD. The ER is run by PAs at night with a MD on call, and there are usually just 2 MDs during the day with 5-6 PAs. They do 99% of the work, they run the trauma team, and they get paid a very similar amount of money. Since they work under the doctor, he carries all the malpractice insurance and they carry very little. "Mid level" seems to be the endgame for more students then ever before

I disagree that PAs get paid a very similar amount of money. They get paid about half of what an MD in their field gets.

Example:

emergency physician = 300k
emergency room PA = 120k

primary care physician = 150k
primary care PA = 80k

This is why midlevels wont solve the access problem in medicine. They will run off to the high paying specialties just like the MDs do. Why would a PA choose to do primary care and take a 50% paycut when they can work in ER with ZERO extra training and make more money? Doesnt make any sense.
 
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VFlutter

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At my hospital we have House PA/NP who work with the hospitalists. They put in central lines, PICCs, and respond to all RRTs and codes. Some can intubate if necessary. We can also call them for simple orders if the attending can't be reached. For example if the attending never put in PRN orders we can call and get them from the PA/NP. During the night they provide house coverage, the only MDs in house are the CCPs and ER physicians.

Each MD group usually has their own PA/NP who will round for them and provide coverage while they are in surgery or the CCL. They are the ones who usually handle discharge paperwork.

We also have a few CRNA that round as pain management specialists.

Then each ICU has their own ACNPs who are very involved in patient care and will do various procedures like A lines and chest tubes.

There is a small group of surigcal NP/PA.

None of the providers are independent, outside of the CRNAs, and fully collaborate with MDs

Why would a PA choose to do primary care and take a 50% paycut when they can work in ER with ZERO extra training and make more money?

I could be wrong but I am pretty sure PAs have to go through extra schooling and a residency to work in the ER.
 
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medicsb

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Actually its more like 50 new med schools. Plus the existing med schools are expanding like crazy. Its pretty easy to get accepted into med school these days -- I expect the quality of doctors to drop off quite a bit.

I agree with you about MDs being pushed by force into primary care. They will have no choice. Specialties like plastics, ENT, derm are going to be nearly impossible to get and you'll have to get super high USMLE scores adn near perfect grades.

No, its actually closer to 20. Unless there are 30 schools in the very very early stages. (http://www.lcme.org/newschoolprocess.htm)

Also, it is still pretty hard to get in to medical school. Not to say that won't change once all schools are up and running. I doubt quality will be much different, instead of some students going to the Caribbean or over-seas, they'll be able to stay in the US.

Right now, something like 60% of family med residencies are made up of IMGs; that will likely shrink in the future.
 

platon20

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No, its actually closer to 20. Unless there are 30 schools in the very very early stages. (http://www.lcme.org/newschoolprocess.htm)

Also, it is still pretty hard to get in to medical school. Not to say that won't change once all schools are up and running. I doubt quality will be much different, instead of some students going to the Caribbean or over-seas, they'll be able to stay in the US.

Right now, something like 60% of family med residencies are made up of IMGs; that will likely shrink in the future.

You are ignoring all the DO programs. LCME only licenses MD schools. DO is a completely separate ballgame.

http://forums.studentdoctor.net/showthread.php?t=825147


1. MD - University of Hawaii-Kakaako - 2006

2. DO - Touro/Las Vegas - 2005

3. DO - PCOM/Atlanta - 2005

4. MD - University of Miami/FAU joint program - 2004

5. MD - Cleveland Clinic/Lerner - 2004

6. DO - LECOM/Bradenton - 2004

7. MD - Florida State University - 2002

8. DO - VCOM - 2002

9. DO - Rocky Vista University COM - 2008

10. MD - Florida International Univ - 2008

11. MD - Univ Central Florida - 2008

12. DO - Wisconsin College of Osteopathic Medicine, Wasau WI (http://wisccom.org/, http://www.wausaudailyherald.com/art...-school-Wausau)

13. DO - Touro (Harlem NY) - 2008

14. DO - Pacific Northwest (Yakima WA) - 2007

15. MD - Michigan State University (Grand Rapids MI) - 2008

16. MD - University of Arizona (Phoenix AZ) - 2007

17. DO - AT Still University (Mesa AZ) - 2007

18. DO - Lincoln Memorial/Debusk (Harrogate TN) - 2007

19. DO - William Carey Univ (Hattiesburg, MS, http://www.wmcarey.edu/asp/viewpr.asp?item=430) - 2009

20. MD - Commonwealth/Scranton (Scranton, PA, http://physiciansnews.com/spotlight/1006.html)

21. MD - MCG-UGA/Athens (http://www.uga.edu/news/artman/publi...Building.shtml)

22. MD - University of Cal Merced (Merced CA)

23. MD - University of Cal Riverside (Riverside CA)

24. MD - Texas Tech - El Paso (El Paso TX)

26. DO - MSUCOM (Detroit MI)

27. DO - Barry University (Miami FL)

28. DO - Center for Allied Health Nursing (FL), http://www.osteopathic.org/inside-ao...d-campuses.pdf

29. MD - Virginia Tech/Carilion (private, Roanoke VA)
http://www.carilion.com/ContentStore... Release.pdf

30. MD - Central Michigan University (http://www.mlive.com/news/sanews/ind...660.xml&coll=9)

31. MD - Oakland University (Michigan) http://www4.oakland.edu/view_news.aspx?sid=34&id=3803

32. MD/DO - St Thomas (St Paul MN) http://www.stthomas.edu/bulletin/new...ool5_11_07.cfm

33. MD - Temple/West Penn Allegheny, Pittsburgh PA (http://www.wpahs.org/medical-school)

34. MD - Hofstra Univ (http://www.hofstra.edu/home/News/Pre...medschool.html)

35. MD - Mercer/Savannah (http://www2.mercer.edu/News/Articles...hMedSchool.htm)

36. DO - WesternU COM/Lebanon OR (http://www.gazettetimes.com/articles...1_hospital.txt)

37. MD - Univ Washington/Spokane (http://depts.washington.edu/mediarel/spokane1.html)

38. DO - LECOM, Greenburg PA, Seton Hill Univ (http://www.osteopathic.org/index.cfm?PageID=acc_predoc)

39. DO - MSUCOM, Clinton Township MI, Macomb College (http://www.osteopathic.org/index.cfm?PageID=acc_predoc)

40. DO - Indiana Wesleyan University (http://www.osteopathic.org/inside-ao...d-campuses.pdf)

41. DO - Campbell University (NC) (http://www.osteopathic.org/inside-ao...d-campuses.pdf)

42. DO - Homer G Phillips (St Louis) (http://www.osteopathic.org/inside-ao...d-campuses.pdf)

43. DO - Marian University (Indiana) (http://www.osteopathic.org/inside-ao...d-campuses.pdf)

44. DO - Missouri Southern State Univ (Joplin MO) (http://www.osteopathic.org/inside-ao...d-campuses.pdf)

45. DO - Southwestern Penn (Beaver PA) (http://www.osteopathic.org/inside-ao...d-campuses.pdf)

46. DO - Univ Southern Nevada (http://www.osteopathic.org/inside-ao...d-campuses.pdf)

47. DO - Univ St Augustine (St Augustine FL) (http://www.osteopathic.org/inside-ao...d-campuses.pdf)

48. MD - Scripps Research Institute (La Jolla CA) (http://legacy.signonsandiego.com/new...n25school.html)

49. MD - California NorthState Univ COM (Elk Grove CA) (http://www.egcitizen.com/articles/20...4445565512.txt)

50. MD - Quinnipiac University (North Haven CT) (http://www.quinnipiac.edu/x4877.xml)

51. MD - Florida Atlantic Univ (Boca Raton FL) (http://articles.sun-sentinel.com/201...final-approval)

52. MD - Palm Beach Medical College (http://en.wikipedia.org/wiki/List_of...s#cite_note-48)

53. MD - Western Michigan Univ (Kalamazoo MI) (http://www.wmich.edu/wmu/news/2011/03/066.shtml)

54. MD - Cooper/Rowan (Camden NJ) (http://www.cooperhealth.org/content/...university.htm)

55. MD - Bataan/Univ New Mexico (Las Cruces NM) (http://en.wikipedia.org/wiki /List_of_medical _schools_in_the_United_States #cite_note-53)

56. MD - Univ of Oklahoma/Tulsa Univ (Tulsa OK) (http://www.tulsaworld.com/news/artic...1_Univer322000)

57. DO - VCOM Carolinas Campus (Spartanburg SC) (http://www.vcom.vt.edu/news/groundbreaking.html)

58. MD - Univ of Houston (Houston TX) (http://en.wikipedia.org/wiki/List_of...s#cite_note-58)

59. DO - Marian University (http://www.marian.edu/medicalschool/Pages/FAQ.aspx)

60. DO - Southeast Alabama Medical Center (http://www2.dothaneagle.com/news/201...ool-ar-348324/)

61. MD - King School of Medicine, Abingdon VA (http://www.lcme.org/newschoolprocess.htm)

62. MD - Mayo/Arizona State, Scottsdale AZ (http://www.azcentral.com/business/ar...cottsdale.html)

63. DO - Monmouth College, NJ (http://www.osteopathic.org/inside-ao...d-campuses.pdf)

64. DO - Southern California COM, Los Angeles (http://www.osteopathic.org/inside-ao...d-campuses.pdf)

65. DO - Southern Univ of Utah COM, Cedar City UT (http://www.osteopathic.org/inside-ao...d-campuses.pdf)

66. DO - Liberty University, Roanoke VA (http://www.roanoke.com/business/wb/298456)
 

Bullets

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Mid level providers should be able to manage things like PromptCare so basic treatments like suturing, splinting and casting, prescribing things like analgesics for bone breaks, arthritics, and antibiotics for influenzas and other colds, basic diabetic emergencies, simple allergic reactions

The main ER, supervised by multiple MDs, should treat cardiac, neuro, multi system traumas, major allergic reactions, major pulmonary illnesses

I do not think a hospital visit requires a patient to be seen by a doctor simply because you walked into the door.

Mid level providers should be at least a Masters Degree education and have the ability to make independent treatments and prescriptions.
 

JPINFV

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Its pretty easy to get accepted into med school these days -- I expect the quality of doctors to drop off quite a bit.


Under which metric? Percent accepted continues to either be stable or decrease while MCAT and GPA continues to trend upwards. When a field has a 50%+ rejection rate, it's hard to call it "easy" to get accepted (not counting FMG schools like Ross or St. George).
 

JPINFV

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You are ignoring all the DO programs. LCME only licenses MD schools. DO is a completely separate ballgame.

http://forums.studentdoctor.net/showthread.php?t=825147

Well, I stand corrected. I had read elsewhere that even including DO schools in the works, the number was 22ish.

To be fair, the list is partially out of date (the independent University of California Riverside plan has been scrapped) and a lot of those are just announcements. It takes more than an announcement in a newspaper to open up a new medical school.
 

WTEngel

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Here are some criteria that I think are required for a group to be considered mid-level providers:

  1. Graduate level education
  2. Prescriptive authority
  3. Ability to assess, diagnose, and treat
  4. Ability to bill for services
  5. Ability to perform advanced procedures? This is questionable

I would agree with this list, and add to it:

Working under the supervision of a licensed physician (direct or indirect depending on the circumstances)

Ability to prescribe medications and obtain a DEA #

Also, in response to the previous poster who was stating how easy it was to get into medical school...please, in your spare time, go through the app process for kicks, and report back to us just how easy it is to get into medical school.

As someone who is currently in the process of trying to get into medical school, I find it pretty insulting that, with your apparent lack of knowledge on the matter, you decide to come around and profess to everyone how simple it is. As soon as you are accepted, you have every right to tell us how easy it is. Until then, your opinion carries the weight of Weekly World News and their latest Batboy story.
 

Carlos Danger

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The term mid-level provider or practitioner has been frequently used, somewhat loosely, on the forum over the past few days and I think it would be good to have a discussion as to what makes a mid level provider.

Currently the DEA only recognizes two groups as mid level providers, NP and PA.

Is the title something granted based on the position you are in or does it suggest a higher status and authority?

For example, is anyone who functions in a position in-between that of a Physician and lower professional a mid-level provider or are there some criteria that must be met?


Here are some criteria that I think are required for a group to be considered mid-level providers:

  1. Graduate level education
  2. Prescriptive authority
  3. Ability to assess, diagnose, and treat
  4. Ability to bill for services
  5. Ability to perform advanced procedures? This is questionable


So where do we set the bar or what are the minimum requirements?


Lets not turn this into a debate comparing professions.
I think your list there makes for a pretty good definition. CRNA's and (I think) CNM's have prescriptive authority in some states, as well.

"mid level" sounds better than "band-aid."
Basically a provider requiring an advanced degree, like physical therapy, PA, NP, etc, that is not a physician but desperately wants to call themselves one.

"Desperately want to call themselves one"? Keep stroking your own ego, dude.

I've known or worked with many PT's, OT's, SLP's, RD's, PharmD's, NP's, CRNA's, and engineers with doctoral degrees and I don't think I've ever once heard one refer to themselves as "doctor". It's always "Hi, I'm Julie - I'm a physical therapist" or "Hi, I'm John from anesthesia".

You might not like it, but mid-levels are being utilized more and more, precisely because they are more cost-effective than physicians.

Yeah, the ability to function as a physician without all that pesky medical school and buck-stops-here liability is nice.

You really don't know what you are talking about, on either count.

Medicine is a crappy field to be in these days. There was a large survey of physicians (5,000 I think) done last year where 90% of respondents said they would not recommend medicine as a profession. For all sorts of good reasons.

I've had several docs tell me things like "if I had it to do over again, I'd be a career firefighter", or "I should have been a PA/CRNA/NP".

And as for liability, there are many states where NP's and CRNA's practice with 100% autonomy, and are solely liable for their actions. Even in states where MD supervision is required, courts typically hold responsible the person that made the mistake, not the supervising physician, who may be 20 miles away at the time of the incident. Claims and MP premiums tend to be only slightly higher for doctors in primary care than they are for NP's and it's because the doctors make more money and are thus more often the target of lawsuits, not because they are "more liable" for their actions.

That doctors are "ultimately liable" for the actions of clinicians working "under them" is an absolute myth.

Even an EMS medical director faces little risk for being found responsible for faulty actions by paramedics, unless the paramedic's action can be shown to be a result of the MD's direct orders or failure to ensure proper training.

I don't think there is a lack of desire to be an MD. Everyone in healthcare wants to be a physician whether they admit it or not. The lack of ambition/desire/perserverence to attend medical school is what they are not willing to commit to. But that lack of ambition/desire does not mean they don't want to be an MD. It simply means they want to take a short-cut.

So you are personally aware of the motivations of millions of people you've never met? Fascinating.

Over the years I've known or talked to many ANP's and PA's who considered medical school and certainly had the intelligence, the grades, and the drive to succeed there.

Some of them chose another route because it was "easier", but many simply felt it made more sense to become and NP or PA. See above.
 

platon20

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I've had several docs tell me things like "if I had it to do over again, I'd be a career firefighter",


LOL, just LOL

You seriously believe this BS? Yeah I'm gonna give up my job as a PCP (average salary is 190k by the way) to work as a fireman and make 50k at best :rolleyes:

LMAO
 

NomadicMedic

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Folks. Lets keep this on topic and avoid any personal attacks or conjecture.

I'm watching this.
 

platon20

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what oldschool and some others dont realize about midlevels is that doctors make a TON of $$$ off of them.

Even in areas with independent scope of practice for midlevels, almost zero choose to actually do it.

New Mexico gave full independence to NPs in 1994. The claim at the time was that NPs would flood rural new mexico with their own clinics and treat the underserved.

15 years later, guess how many independent NP-run clinics are in New Mexico? ONE. They all went to work for doctors offices instead of starting thier own clinics. The doctors are making a ton of $$$ billing for their services.

NPs are NOT entrepreneurs -- they are "my job is 9 to 5" nurse nonsense which is why it is EXTREMELY RARE for them to attempt to open their own clinic, even in a state that allows them to do so.
 

Summit

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At my hospital we have House PA/NP who work with the hospitalists. They put in central lines, PICCs, and respond to all RRTs and codes. Some can intubate if necessary. We can also call them for simple orders if the attending can't be reached. For example if the attending never put in PRN orders we can call and get them from the PA/NP. During the night they provide house coverage, the only MDs in house are the CCPs and ER physicians.

Each MD group usually has their own PA/NP who will round for them and provide coverage while they are in surgery or the CCL. They are the ones who usually handle discharge paperwork.

We also have a few CRNA that round as pain management specialists.

Then each ICU has their own ACNPs who are very involved in patient care and will do various procedures like A lines and chest tubes.

There is a small group of surigcal NP/PA.

None of the providers are independent, outside of the CRNAs, and fully collaborate with MDs

I'd find that very fulfilling.
 
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