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Midlevels
#1
Browsing r/Residency, it seems like mid level encroachment is a real issue. However from a neurosurgical perspective I’ve never heard complaints. What do current residents think about midlevels? Competing for procedures like EVDs, bolts, etc, or helpful to take care of scut/run clinic basically? How involved are they in patient management on the floor/ICU and does this detract from your own learning? Any OR involvement? Thanks
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#2
Midlevels almost never interfere in your training on their own accord. Unlike you, they are working a job that they will be doing for the rest of their careers and don't have much to gain from stealing procedures or clinical learning from trainees. Some attendings are better than others about delegating appropriate duties to them (honestly, midlevels are probably more helpful than junior residents so this isn't surprising). I would say a red flag would be if individual attendings refuse to operate with residents and prefer a midlevel to participate, but I would say at most programs this is exceedingly rare. Privademic places are probably the notable exception.

Midlevels perform the tasks delegated to them (and many of them do this very well) but they don't bear ultimate responsibility. You will have to figure out what tasks to do AND take responsibility for them. Everyone usually understands this.
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#3
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#4
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#5
The reason midlevel encroachment is such an issue in other specialties like EM, anesthesia, IM/FM is because 90% of what those specialties do is formulaic. The majority of their work is essentially being commoditized. The reason you even need doctors is for the other 10% that breaks the mold and could have catastrophic consequences if not caught, but overall their jobs requires less doctors. A good example of that is why now we see CRNAs in almost every case, and an attending comes in for induction, if there's issues, or if the case is especially complicated. The problem with this for those specialties is that means there's overall less labor they are required for, leading to less demand for their services, which leads to a pay cut and less jobs.

In neurosurgery there's few parts within the OR that a midlevel can replace, and almost all of the care outside of the OR they can replace. The thing is we WANT them to take the care outside of the OR away, all that is is a time sink that keeps you from either the OR, research, whatever other endeavors you have, or your family. Within the OR midlevels can do simple exposures and closures but by the time you're a PGY-4 that part is just a pain in the ass anyways. The midlevels in our specialties can never actually replace the core of what we do. Within residency, neurosurg has always been extremely difficult because there's a small number of residents for a lot of patients and work, and the floor work/consults were always the least desirable and most annoying parts of residency. Midlevels take all of that off of your hands, leaving you to focus on operating.*

As far as demand for neurosurgeons go our national orgs do a good job of keeping the supply of neurosurgeons low, and as our specialty expands in areas like functional, spine, vascular demand increases. PA/NPs will never be able to replace what we do, only take away the annoying busy work. It's easy to entrust a NP/PA to the care of your allergies or managing your diabetes/HTN outpatient, no one would entrust their brain/spine to a midlevel. This is why the subject as a whole is less of an issue for us, and we actually welcome all of the midlevel help we can get.

TLDR: midlevels in other specialties can replace a majority of their job, whereas midlevels in neurosurgery only serve to take away the undesirable parts of neurosurgery that lead to us being overworked, but can never actually replace us.

*Disclaimer: i don't think midlevels should completely replace this part of residency. Dealing with consults and peri-operative management is an important part of PGY-1/2 education, but after that it serves only as busy work.
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#6
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#7
(08-31-2020, 01:39 PM)Guest Wrote: The reason midlevel encroachment is such an issue in other specialties like EM, anesthesia, IM/FM is because 90% of what those specialties do is formulaic. The majority of their work is essentially being commoditized. The reason you even need doctors is for the other 10% that breaks the mold and could have catastrophic consequences if not caught, but overall their jobs requires less doctors. A good example of that is why now we see CRNAs in almost every case, and an attending comes in for induction, if there's issues, or if the case is especially complicated. The problem with this for those specialties is that means there's overall less labor they are required for, leading to less demand for their services, which leads to a pay cut and less jobs.

In neurosurgery there's few parts within the OR that a midlevel can replace, and almost all of the care outside of the OR they can replace. The thing is we WANT them to take the care outside of the OR away, all that is is a time sink that keeps you from either the OR, research, whatever other endeavors you have, or your family. Within the OR midlevels can do simple exposures and closures but by the time you're a PGY-4 that part is just a pain in the ass anyways. The midlevels in our specialties can never actually replace the core of what we do. Within residency, neurosurg has always been extremely difficult because there's a small number of residents for a lot of patients and work, and the floor work/consults were always the least desirable and most annoying parts of residency. Midlevels take all of that off of your hands, leaving you to focus on operating.*

As far as demand for neurosurgeons go our national orgs do a good job of keeping the supply of neurosurgeons low, and as our specialty expands in areas like functional, spine, vascular demand increases. PA/NPs will never be able to replace what we do, only take away the annoying busy work. It's easy to entrust a NP/PA to the care of your allergies or managing your diabetes/HTN outpatient, no one would entrust their brain/spine to a midlevel. This is why the subject as a whole is less of an issue for us, and we actually welcome all of the midlevel help we can get.

TLDR: midlevels in other specialties can replace a majority of their job, whereas midlevels in neurosurgery only serve to take away the undesirable parts of neurosurgery that lead to us being overworked, but can never actually replace us.

*Disclaimer: i don't think midlevels should completely replace this part of residency. Dealing with consults and peri-operative management is an important part of PGY-1/2 education, but after that it serves only as busy work.

CT and vascular surgeons had this kind of hubris before cardiologists came and swept away their most lucrative procedures over the course of 10-15 years.

Midlevels and their organizations are working harder than you know to expand their scope of practice, reduce licensing requirements, and increase demand for their services. Plus, they don't accrue the debt that MDs do and the marginal salary increase from just a couple extra years' schooling (many of which are now done online) is extraordinary. So the increased demand is going to be matched by ever-increasing supply. Why do you think most of your ICU nurses end up in NP or CRNA school? Restrictions on midlevel practice are being lifted across the country.


Midlevel are an essential part of modern patient care, but nobody is expendable and hospital administrators certainly don't think you are. Like anyone else, you have to keep proving your worth.
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#8
(08-31-2020, 07:14 PM)Guest Wrote:
(08-31-2020, 01:39 PM)Guest Wrote: The reason midlevel encroachment is such an issue in other specialties like EM, anesthesia, IM/FM is because 90% of what those specialties do is formulaic. The majority of their work is essentially being commoditized. The reason you even need doctors is for the other 10% that breaks the mold and could have catastrophic consequences if not caught, but overall their jobs requires less doctors. A good example of that is why now we see CRNAs in almost every case, and an attending comes in for induction, if there's issues, or if the case is especially complicated. The problem with this for those specialties is that means there's overall less labor they are required for, leading to less demand for their services, which leads to a pay cut and less jobs.

In neurosurgery there's few parts within the OR that a midlevel can replace, and almost all of the care outside of the OR they can replace. The thing is we WANT them to take the care outside of the OR away, all that is is a time sink that keeps you from either the OR, research, whatever other endeavors you have, or your family. Within the OR midlevels can do simple exposures and closures but by the time you're a PGY-4 that part is just a pain in the ass anyways. The midlevels in our specialties can never actually replace the core of what we do. Within residency, neurosurg has always been extremely difficult because there's a small number of residents for a lot of patients and work, and the floor work/consults were always the least desirable and most annoying parts of residency. Midlevels take all of that off of your hands, leaving you to focus on operating.*

As far as demand for neurosurgeons go our national orgs do a good job of keeping the supply of neurosurgeons low, and as our specialty expands in areas like functional, spine, vascular demand increases. PA/NPs will never be able to replace what we do, only take away the annoying busy work. It's easy to entrust a NP/PA to the care of your allergies or managing your diabetes/HTN outpatient, no one would entrust their brain/spine to a midlevel. This is why the subject as a whole is less of an issue for us, and we actually welcome all of the midlevel help we can get.

TLDR: midlevels in other specialties can replace a majority of their job, whereas midlevels in neurosurgery only serve to take away the undesirable parts of neurosurgery that lead to us being overworked, but can never actually replace us.

*Disclaimer: i don't think midlevels should completely replace this part of residency. Dealing with consults and peri-operative management is an important part of PGY-1/2 education, but after that it serves only as busy work.

CT and vascular surgeons had this kind of hubris before cardiologists came and swept away their most lucrative procedures over the course of 10-15 years.

Midlevels and their organizations are working harder than you know to expand their scope of practice, reduce licensing requirements, and increase demand for their services. Plus, they don't accrue the debt that MDs do and the marginal salary increase from just a couple extra years' schooling (many of which are now done online) is extraordinary. So the increased demand is going to be matched by ever-increasing supply. Why do you think most of your ICU nurses end up in NP or CRNA school? Restrictions on midlevel practice are being lifted across the country.


Midlevel are an essential part of modern patient care, but nobody is expendable and hospital administrators certainly don't think you are. Like anyone else, you have to keep proving your worth.

That analogy is pretty irrelevant. CT surgeons got their procedures stolen by cardiologists, other doctors, not midlevels. 

And yes midlevels and their organizations are working overtime for the government to expand their scope...... to allow them to manage diabetes, not do hemicranis and microdiscs. And even that is taking decades of lobbying. If we're all being honest with each other midlevels' scope should be expanded, most of the things FM/IM/EM docs do is mindless work. It sucks for them, but that still doesn't really address why neurosurgeons specifically should be worried.

If you were going to make that argument you could say that maybe there is the a day where the globus, Mazor, Rosa robots are so good at their job they can just be ran by a NP. Or companies like neuralink attempting to automate their surface electrode placements could be used for DBS and take all of those procedures away, and eventually a PA could just press a button and supervise. If you've used even the newest versions of these robots (or seen the last neuralink presentation) you know that we're not really close to that point yet. I'd say optimistically it's probably 15-20 years before the bots are that good, and then you add on another 5-10 years of lobbying and policy making, then sure in 30 years we might be in trouble. When that time comes i'll watch from my home in Nantucket.
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#9
I think you guys are grossly underestimating the abilities of PAs especially in community practice. Sure they might not be clipping aneurysms but putting in screws in straightforward anatomy does not require a lot of skill and helps improve patient turnover in the ORs. The private practice guys are not being called in to drop EVDs overnight. I think the difference between PAs in medicine is that PAs in neurosurgery definitely don't want the accountability that comes with having an MD after your name, so they aren't afraid to keep their scope limited where possible
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