[mpezeshkirad_710]

Honestly I’m looking for an exit strategy from rads as soon as possible. At this point I would not recommend it to any aspiring students, or recommend medicine at all probably. The trends in diagnostic rads appear grave. I am not sure about interventional.

[julie.young_645]

This is happening because we physicians have gotten fat and lazy, and sold ourselves to MBA’s. And MBA’s, thinking like MBA’s, have decided that we are nothing but a commodity. And commodities are bought and sold on the basis of price. 
 
WE LET THIS HAPPEN. ONLY Physicians can take back Medicine. But I’m not holding my breath. My observations about the younger generation of docs, from posts here and elsewhere, lead me to believe that as long as they get a paycheck, they don’t really care how it gets into their bank account. Until the paychecks stop. 
 
Go back and read what Phil has posted on this topic. Join PPP, and get involved. There ARE things we can do. Thanks to Phil for everything he has done to date. 

[tdetlie_105]

What is PPP?

[btomba_77]

[link=https://www.physiciansforpatientprotection.org/]
[/link] [link=https://www.physiciansforpatientprotection.org/]Physicians for Patient Protection:[/link]
 
Our mission is to ensure physician-led care for all patients and to advocate for truth and transparency regarding healthcare practitioners.

 

[Unknown Member]

Thank you, Phil. Excellent work.

[cieminsjohn]

is it too late to contact someone on this issue?  

[francomejiamurillo_751]

Politics matter.  Death by a thousand cuts is starting.  Want to keep your profession?  Lobbying makes a difference.    Obviously, the NPs know how the game is played.  

[tdetlie_105]

Quote from Theforce111

Politics matter.  Death by a thousand cuts is starting.  Want to keep your profession?  Lobbying makes a difference.    Obviously, the NPs know how the game is played.  

 
For various reasons, the NP/CRNA/nursing field has a much better public perception than physicians.  They are looked upon as noble, hard-working, compassionate individuals who have the patient’s best interest at heart.  Plus they are cheaper, “more cost efficient”.  We are looked upon as greedy/money hungry and uncaring (eg. we’d rather cut off the diabetics foot rather than provide preventative care).  No one seems to remember that we carry the highest liability for patients and have endured a much more challenging/expensive career pathway (and as a result are able to function at the level that we do).
 
I’d love to ask any of the individuals pushing this legislation if they would rather have their trauma/oncology scan read by a rad or a NP.

[khodadadi_babak89]

Quote from Nibbler

is it too late to contact someone on this issue?  

 
NO… It is in the Senate now for a vote. Contact all California senators. Does not matter if you are in california
 
Contact the Governor, ask to veto. 
 
MOREOVER _ beyond california – this fight continues in nearly every state, in one form or another. In some it is still about getting FPA, in some with FPA, it is about getting pay equity with physicians. California turning will not help us in the other states. 
 
YOU ALL NEED TO BE PRESSURING YOUR AMA REPS AND YOUR STATE RADIOLOGIC REPS TO DO SOMETHING. AMA IS DEFINITELY INVOLVED, BUT THE NEED TO SET PRIORITIES AND THIS HAS FALLEN BEHIND OTHERS.
 
THEN WORK WITH YOUR LEGISLATORS AS WELL. 
 

[tdetlie_105]

Quote from dergon

[link=https://www.physiciansforpatientprotection.org/]
[/link] [link=https://www.physiciansforpatientprotection.org/]Physicians for Patient Protection:[/link]

Our mission is to ensure physician-led care for all patients and to advocate for truth and transparency regarding healthcare practitioners.

 
thanks!

[khodadadi_babak89]

continued….

[khodadadi_babak89]

Quote from Takayasu

Honestly I’m looking for an exit strategy from rads as soon as possible. At this point I would not recommend it to any aspiring students, or recommend medicine at all probably. The trends in diagnostic rads appear grave. I am not sure about interventional.

 
You can run, but you can’t hide…… This is about WAY more than radiology. It is about WAY more than our careers. It is about your medical care and the fact you may not be allowed to see a physician.

You, your family, or someone you know will go to an ER with a life threatening situation. And there will be NO physicians to see you. Only nurses. You may get this faux doctor:

 

[khodadadi_babak89]

Or you may get this one who will actively take steps to kill you

 

[khodadadi_babak89]

Continued….

[Unknown Member]

Phil- Thanks for all your work on this!

[khodadadi_babak89]

Quote from boomer

Phil- Thanks for all your work on this!

 
Certainly – but we DO need everyone’s help.
 

[khodadadi_babak89]

FWIW – I got involved because I saw what was happening to my mother in law. How she was being mistreated. Over the past 2 years there have been about 5 serious errors 
 
To get the flavor – 
Her NP dc’d her Metformin. did not tell us. When I asked her later why, she said “Her sugars had been fine and I thought she didn’t need it”

She also did not write an order to check her blood sugars. And so she wound up in mild DKA.

I could not believe how stupid this was. But when I investigated, there are unlimited examples just like this happening to patients. ALL THE TIME.
 
And – the NPs are immune to malpractice.

The story of a college student killed by an NP. The supervising doc, who barely knew the NP, and never heard of the patient until after she was dead, was successfully sued. 6.2 million. The attorneys never bothered the NP:

[link=https://authenticmedicine.com/2020/06/the-anecdote-has-a-face-and-a-name/]https://authenticmedicine…has-a-face-and-a-name/[/link]
 

[ranweiss]

Honestly.
 
Radiology is NOT anesthesia. It’s not FP. it’s not ER. This is not a specialty for undertrained midlevel providers to start working on their own.
 
Mammo and NEURO IR? Are you KIDDING ME? Specialties that most rads MD’s are terrified to touch bc of the complications/misses? It’s just a matter of time before this implodes. 
 
I wouldn’t trust a NP or PA to interpret a chest x ray half the time, let alone mammo.
 
I also believe that the complexity of what we do will probably scare off a good amount of midlevels..Aside from the cardiology example, most of what these people go after is the low hanging fruit. Radiology is not that.
 
All that being said, we have be aggressive from a lobby perspective – because the midlevels want a cut of our paycheck. Let’s all learn a lesson from anesthesia and primary care, derm, etc. 

[khodadadi_babak89]

This directs you to the page of PPP white papers on various aspects of the crisis:

[link=https://www.physiciansforpatientprotection.org/topics-insights/]https://www.physiciansfor…n.org/topics-insights/[/link]

This is a brilliant piece regarding the inadequacy of their education:

[link=https://www.physiciansforpatientprotection.org/whats-going-on-with-nurse-practitioner-education/]https://www.physiciansfor…ractitioner-education/[/link]
 
(yes – written by me)

and here is a link to join….
[link=https://www.physiciansforpatientprotection.org/why-join/join-now/new-member-sign-up/]https://www.physiciansfor…ow/new-member-sign-up/[/link]
 
The cost is less than any other professional membership you have. 100.00% of this goes directly to efforts to promote the issue. There is no pay for officers, there are no office personnel, there is no travel allowance for officers. PURELY goes to the effort – such as a PR firm that gets pieces placed in the media.

And if you want to contribute more – that would be fantastic.  
 
When you join, you will get access to the private FB page. This is a very active group. Very. Please drop a note to introduce yourself, and let them know who you are and why you came. I did this and in 20 minutes had like 20 greetings. Very friendly, very motivated, very ethical group. Proud to be associated with these people. 
 

[jeevonbenning_648]

Exactly. Agree with you 100%.

I bought my first property in 2011 and my first rental in 2013. Fast forward 20+ deals (Active rentals and passive private placements), currently I am seeing $8K per month in my business checking account. This requires 1-2 hours per month roughly to manage.

This was the plan all along. I have a very small amount in a 401k that I am going to withdraw (penalty free under COVID-19) to put the nail in the coffin towards more real estate.

All time records of people wanting to be renters. Lack of housing supply. Work from home arrangements. Historically low mortgage interest rates. Inflation on the horizon. As if you didn’t need any more RED FLASHING LIGHTS to invest in real estate.

I have two rentals closing this month from a 1031 exchange, will allocate $50K to a 300+ unit in Austin in Sept, and committed $80K to a multifamily fund, with a sponsor I have done 4 previous deals with.

You need “F you money” first, THEN decide if you are passionate about radiology or is that the story you tell yourself so you can pay your bills.

[Unknown Member]

Real estate is good, no doubt. Dont you worry about diversification? Youve talked about leveraging in the past. All your eggs in one leveraged basket seems pretty risky. Anyone can seem like a genius in a bull market. What happens when things turn.

Im not being antagonistic, just asking legitimate questions as someone interested in real estate but perhaps more risk averse than you.

[jeevonbenning_648]

Real estate values went UP in 4 out of the last 5 recessions. Look it up.

Diversification is great, but unfortunately the only asset class I know that throws off a 10-15% dividend, and legally produces a $0 tax burden on income and capital gains, hedges and profits from inflation is – real estate. I’m all ears if I’m missing something.

[clickpenguin_460]

Sounds like a lot of upfront work for 8k/month

[jeevonbenning_648]

Yep, TONS of work. 1-2 hours a month last I checked would make even Tim Ferriss proud 😉

This real estate was SOO exhausting that I had enough time to travel to over 20 countries since 2010, tons of experiences and connections, built a dream body (fitter than when I was 20), learned two additional languages to a low fluency level, all while being a full time radiologist.

I’ve learned, $8K a month that you don’t work for and legally pay $0 taxes on, is a big difference than $XXK a month you sit behind a computer for.

I’ll take that all day over earning that extra $1 while i giving $0.50 to the responsible and fair government.

[ester.mancuso_108]

Quote from Re3iRtH

Yep, TONS of work. 1-2 hours a month last I checked would make even Tim Ferriss proud 😉

This real estate was SOO exhausting that I had enough time to travel to over 20 countries since 2010, tons of experiences and connections, built a [b]dream body[/b] (fitter than when I was 20), learned two additional languages to a low fluency level, all while being a full time radiologist.

I’ve learned, $8K a month that you don’t work for and legally pay $0 taxes on, is a big difference than $XXK a month you sit behind a computer for.

I’ll take that all day over earning that extra $1 while i giving $0.50 to the responsible and fair government.

 
Wow you really love yourself. Thats great. 

[julie.young_645]

[i]@fteR31RtH[/i]’s cockiness about his investment prowess is a nice demonstration of why we are where we are. He is clearly totally interested in how much money he can make in the next 5 minutes, or perhaps in the next year to be generous. While I’m sure he’s a great radiologist, his eye is no longer on doing the best for his patients, but rather on doing what’s best for himself. I’ve seen many a brilliant partner declare their self-discovered expertise in the stock market. One guy just asked me the other day why Amazon (he says he owns thousands of shares) is considered a tech company, having no idea of their 900 pound gorilla presence in the cloud storage market. He understands buying low and selling high, but that’s the extent of his research. And as long as he makes money…
 
This is the attitude that allowed physicians to sell out to MBA’s. And all MBA’s see is that doctors are willing to sell themselves. All the messes with NP’s, and PE for that matter, follow from this. Thanks, boys. 

[Unknown Member]

A financially secure physician with passive income outside of medicine is exactly the opposite of what has allowed medicine to be taken over by MBAs (not MBAs) and PE. No need to look for a big cash grab in that situation. The radiologists who have and continue to sell out are the ones who have gotten greedy and shortsighted, and also feel the need to fund an overzealous lifestyle. Not at all the same as someone making long term investments.

How do you have any idea about wether or not rebirth is doing a good job taking care of patients? You have lashed out at others in the past for assuming things based on your posts, and here you do the same to someone else. To the extent of saying someones eye is no longer on doing what is best for his patients with no corroborating evidence whatsoever. More likely, being financially secure outside of medicine allows one to do a better job taking care of patients – no need to worship at the RVU altar.

[Unknown Member]

Quote from Upgrayedd

A financially secure physician with passive income outside of medicine is exactly the opposite of what has allowed medicine to be taken over by MBAs (not MBAs) and PE. No need to look for a big cash grab in that situation. The radiologists who have and continue to sell out are the ones who have gotten greedy and shortsighted, and also feel the need to fund an overzealous lifestyle. Not at all the same as someone making long term investments.

How do you have any idea about wether or not rebirth is doing a good job taking care of patients? You have lashed out at others in the past for assuming things based on your posts, and here you do the same to someone else. To the extent of saying someones eye is no longer on doing what is best for his patients with no corroborating evidence whatsoever. More likely, being financially secure outside of medicine allows one to do a better job taking care of patients – no need to worship at the RVU altar.

 
Not necessarily. You are making a false dichotomy fallacy. 

There are people who have north of 5 mil and still kill themselves to suck the last dollar out of a practice at any cost and there are people who are in 400K debt with negative net worth but still do the best for their patients and are happy with an average paying job that serves people well. 

Human greed is an interesting topic. Just because someone has 10 million in saving doesn’t make him more honest, less greedy or less money hungry. It is all about philosophy of life and perspectives. My 2 cents. 

 

[clickpenguin_460]

I would think that actually more money = more greed.  Once you start on the money treadmill, you can never have enough.

[ester.mancuso_108]

The hedonic treadmill that is.

[ipadfawazipad_778]

Anybody actually sending letters to CA legislators on this?  Is there a form letter we can send?

[ipadfawazipad_778]

Seems like our representative bodies should be all over this (ie ABR, ACR, ARRS).  Hope I am just missing something.

[jeevonbenning_648]

Net worth is largely meaningless. It’s only good for opening your brokerage account and looking happily at a number.

It’s all about how much durable income do you have coming in regardless of what you do, where you are, or if you work or not.

There are people who have a $10MM NW and still have to work (stuck in retirement and taxable accounts paying a 1.8% dividend)

There are those with cash flowing passive businesses / real estate which generates $120K a year with a net worth under $1MM.

[jtpollock]

Are you talking about first trust deeds?

[Unknown Member]

Christ almighty can you please stop polluting threads with your spiel? WE GET IT.

This thread is especially important and youve mucked it up.

[clickpenguin_460]

Yes, let’s get back on the topic of stopping the midlevels 🙂

[william.wang_997]

Thanks Dr. Shaffer for bringing this to attention. I am wondering where the extra need for radiology NP is coming from ? IR ? Diagnostic ? Both? I commend your efforts to bring this to wider attention. This is really serious, but I know some PP practices who hire NP IR folks.

[Unknown Member]

Is really like to know what these Neuro IR midlevels are doing? Cerebral angio!??

[ranweiss]

Quote from irfellowship2020

Is really like to know what these Neuro IR midlevels are doing? Cerebral angio!??

Insane to think about. You can probably teach a monkey to get femoral access and get up to the aortic arch…but it’s SO easy to cause a dissection on some of those smaller cerebral vessels..Crazy to think about midlevels doing that.

[khodadadi_babak89]

Quote from irfellowship2020

Is really like to know what these Neuro IR midlevels are doing? Cerebral angio!??

I only know of this one neuro IR midlevel. Most probably there are more. 
I am thinking of contacting her to see if she will talk to me.
 

[jeevonbenning_648]

Insightful and correct on all accounts.

Who is more likely to take their time to provide compassionate care to their patients.

Someone who’s salary is not at all based on RVUs, who’s outside investments are more than enough to fund their lifestyle, who is coming into work well rested everyday not dependent on their W-2 income – because they wanted to be at work, not had to be.

Who is more likely to sell out to MBAs.

The corporate guy who lives a lavish lifestyle, worried about his country club and boat, who may or may not be paying a tidy sum to wife #1. The guy who isn’t financially independent.

The exceptions only prove the rules. The whole point is you wouldn’t be worried about NPs and PAs if you had your Plan B and Plan C already taken care of.

[clickpenguin_460]

I would still be worried about them because I care about radiology and physicians as a whole as a valued profession.

[mpezeshkirad_710]

Quote from Upgrayedd

A financially secure physician with passive income outside of medicine is exactly the opposite of what has allowed medicine to be taken over by MBAs (not MBAs) and PE. No need to look for a big cash grab in that situation. The radiologists who have and continue to sell out are the ones who have gotten greedy and shortsighted, and also feel the need to fund an overzealous lifestyle. Not at all the same as someone making long term investments.

How do you have any idea about wether or not rebirth is doing a good job taking care of patients? You have lashed out at others in the past for assuming things based on your posts, and here you do the same to someone else. To the extent of saying someones eye is no longer on doing what is best for his patients with no corroborating evidence whatsoever. More likely, being financially secure outside of medicine allows one to do a better job taking care of patients – no need to worship at the RVU altar.

I agree with you here.

Quote from Re3iRtH

 
For the record this doesn’t worry me at all simply because it’s in one State (CA) that frankly doesn’t surprise me anymore any legislation they put out. The world is a big place. 

 
Yeah–if this is happening in CA do we need to worry it will happen imminently everywhere?
 
I don’t have faith in the radiology governing bodies.  They don’t care.  And rads don’t have political clout like cardiologists.

[Unknown Member]

NPs doing cerebral angio? Thats scary. I wouldnt let an NP do an angio on my dog. The problem is, I guarantee they think theyre adequately trained. I doubt they have any idea how easy it is and how many different ways they could wreck people.

Thats the difference between doctors and mid levels that Ive seen. Doctors have a healthy understanding for what they dont know. NPs have a smaller knowledge base, but an overinflated sense of confidence and they simply dont know how much they dont know. I guess their online education doesnt cover the Dunning Kruger Effect.

[rhiannonsmith84]

None of this would be an issue if the NP’s were subjected to the same liability standards to which radiologists are held.  A few large settlements against NP’s practicing radiology, and they would be uninsurable.  

[khodadadi_babak89]

Quote from Dumb Luck

None of this would be an issue if the NP’s were subjected to the same liability standards to which radiologists are held.  A few large settlements against NP’s practicing radiology, and they would be uninsurable.  

 
YEs – this required legislation to change
And the same people who are pushing for rights to do things they have no training for – and are successful – also oppose any attempt at making them responsible for what they do
 

[khodadadi_babak89]

OK  – so I searched my files a little more and came on this [strike]gem[/strike] P.O.S.
 
An abstract from the Journal of Neurointerrventional Surgery. Dated 2017

Authors : c. Schwegel, J. Fifi, T. Oxley, J Mocco — all Neurosurgery Mt. Sinai Hospital NY
N Rothman, S Loria, K Raunig – all Columbia university school of nursing.
K.  Muller – “neurosurgery” Columbia university school of Nursing.
 
(I find it fascinating that Columbia university school of nursing has a department of Neurosurgery)

Title: Optimizing utilization of nurse practitioners and addressing practice barriers in neurointerventional surgery 
 

The recent success of mechanical thrombectomy in the treatment of large vessel occlusions, as well as the increased demand for minimally invasive endovascular procedures has created new workflow gaps in the field of neurointerventional surgery. Additionally, the recent recommendation to temporarily suspend neurointerventional fellowship programs has further stressed practice. Nurse Practitioners (NPs) have taken on specialized roles in the field in an effort to meet evolving demands. In doing so, they are being faced with several barriers for providing the highly specialized and procedure driven care that neurointerventional patients require. Despite the call for support of expanded NP practice by the Institute of Medicine and the Federal Trade Commission, training opportunities for NPs in interventional neuroradiology are severely limited, and fragmentations of privileging processes contribute to a practice environment where NPs must navigate hurdles without established interventional neuroradiology specific precedent. Increased procedural mentorship, standardization of fluoroscopy laws and regulations with regard to NPs, and development of role consistency across states is imperative for NPs to reach optimal utilization and practice at their fullest capacity. NP cerebral angiography performance has the capacity to reallocate interventionists time to more complex procedures, while incident to billing can generate revenue at a significant cost savings to departments. This makes NPs uniquely qualified to meet the evolving demands of practice. Efforts to overcome procedural, clinical, and legal barrier should be a priority to the field. Discussion surrounding manpower and NP utilization is an exciting opportunity for future neurointerventional practice development. 

when I get time, I will try to search out these authors to see what other mischief they are up to
 
[link=https://jnis.bmj.com/content/9/Suppl_1/A90.2?fbclid=IwAR29qCs23gfMTZ0sJy_v5IN3y1lVBlwzZVX4pWP35Rd4gBENI_0fyZnjNSg]https://jnis.bmj.com/cont…WP35Rd4gBENI_0fyZnjNSg[/link]

Does anyone know any of these Neurosurgeons?
 

[khodadadi_babak89]

Incidentally, the post from the PA who was doing neuro-interventional disappeared from FB some time ago. Don’t know the reasons.
 
I want to talk to her. Her name is Jennifer Wormeester and she lives in Grand Rapids, MI. Anyone here from the area, know the radiologists?
 

[loli.amaral_506]

are you guys saying that they have no liability because they are working under a MD or because the hospital assumes liability? 
 
Seems hard to imagine any radiologist would take that liability risk.  technically a family medicine doc could do neurosurgery but whether they could get malpractice insurance is a different question. 

[khodadadi_babak89]

Quote from catray

are you guys saying that they have no liability because they are working under a MD or because the hospital assumes liability? 

Seems hard to imagine any radiologist would take that liability risk.  technically a family medicine doc could do neurosurgery but whether they could get malpractice insurance is a different question. 

 
I am saying that they have virtually no malpractice risk. This is why I am saying this:
1) I am aware of some cases in which the NP killed the patient. No question. The doc got sued in one, and the doc and the hospital in another 
2) The cost of their insurance for $1m/$3m is about $1200/year – so clearly the carriers know they don’t get sued much at all. 
3) PAs and NPs in states without FPA, there is a legal requirement for the midlevels to have a supervising physician – one who signs for the responsibility. Incidentally, very frequently this supervision is absolute rubbish. In the one case in which a doc was sued, he was the medical director, required by his employer to assume responsibility, never saw the patient, never heard of the patient until the suit, and barely knew the NP. The NP was working in and ER by herself. No backup. 23 yo woman on BCPS came in with chest pain, SOB, tahcycardia, and low o2. whaddya think? NP gave her beta blockers because she wanted to slow her heart rate. NEVER once considered PE. Patient died. (This NP is still working ERs in an adjacent state, calls herself an emergency specialist).
 
4) In many cases of employed physicians, the hospital requires, as a condition of employment that you accept legal responsibility. No choice. Accept or don’t work. EVEN in FPA states, hospitals will require the physician to assume the legal responsibility. I think this may be what happened in this situation, someone, radiologist or not, was coerced into accepting her liability. 
 
I am trying to investigate this liability situation, and have talked to an insurance company, and I have some attorney contacts I want to talk to, but so far precisely how this works is eluding me.

 

[clickpenguin_460]

“In many cases of employed physicians, the [b]hospital requires, as a condition of employment that you accept legal responsibility. No choice. Accept or don’t work.[/b] EVEN in FPA states, hospitals will require the physician to assume the legal responsibility. I think this may be what happened in this situation, someone, radiologist or not, was coerced into accepting her liability.  ”
 
I’ve heard this from several friends.  Doesn’t seem right/legal.
 
The hospitals will also put in clauses that the physician has to teach and train the midlevel(s) too.  In some cases, they have done that and then been replaced by said midlevel.
  

[khodadadi_babak89]

Quote from Cubsfan10

“In many cases of employed physicians, the [b]hospital requires, as a condition of employment that you accept legal responsibility. No choice. Accept or don’t work.[/b] EVEN in FPA states, hospitals will require the physician to assume the legal responsibility. I think this may be what happened in this situation, someone, radiologist or not, was coerced into accepting her liability.  ”

I’ve heard this from several friends.  Doesn’t seem right/legal.
 

Yeah – it isn’t right – but it IS legal
 

The hospitals will also put in clauses that the physician has to teach and train the midlevel(s) too.  In some cases, they have done that and then been replaced by said midlevel.
 

 
No doubt.
 

[khodadadi_babak89]

I have a friend who is an ER doc in Louisiana. He had a bad patient who needed to be admitted to the ICU. He called to admit, and the person was an NP. He refused to admit the patient to her. 

He was labeled a “disruptive physician” and fired

This is not an isolated incident. 

[Unknown Member]

Quote from Re3iRtH

Real estate values went UP in 4 out of the last 5 recessions. Look it up.

Diversification is great, but unfortunately the only asset class I know that throws off a 10-15% dividend, and legally produces a $0 tax burden on income and capital gains, hedges and profits from inflation is – real estate. I’m all ears if I’m missing something.

 
Here’s an interesting fact.  Right now the median price of homes sold is spiking.
 
Why?  During hard economic times, poorer/lower income folks have to spend the same amount of money per month despite having no income or being unemployed.  This is because their expenses are stripped to the bone: food, utilities, etc.  Therefore, poorer people have no money to buy the less expensive homes.
 
On the other hand, the rich still have money and are the only ones buying, hence higher median prices of homes sold.
 
Finally, repeat this mantra to yourself every night before bed:
 
They are going to inflate the money supply
They are going to inflate the money supply
They are going to inflate the money supply
They are going to inflate the money supply
 
Start with something in real estate.  Even if it’s a REIT.

[mpezeshkirad_710]

Quote from radgrinder

They are going to inflate the money supply

Start with something in real estate.  Even if it’s a REIT.

I like with real estate that I can take cheap debt, leverage it, tax deduct it and then inflate it away.  I do hope rents and property values will keep pace with inflation.  With the interest rates and inflation the govt is punishing savers and rewarding debtors.
 
Not sure how the thread headed in this direction

Quote from Re3iRtH

 
You need “F you money” first 

 
FU money is vital.  Solid realty things you have going on there.

Quote from Cubsfan10

 
Sounds like a lot of upfront work for 8k/month 

 
8k/month post-tax is enough or close to enough to survive unemployment indefinitely.  Not opulently, but more than many Americans.  Not having to rely on wage income to survive would be tremendously liberating.

[jeevonbenning_648]

Totally agree.

I don’t think most people here will understand since they are okay with perpetually being stuck on the right side of the cash flow quadrant (employees and self employed). The rich do not work for money, and the rich do not pay taxes because they are passive investors.

They will continue to work for somebody else, deal with all the politics that go on at work, bite their tongue, save for a rainy day, and then give 50% of what they make to the government.

Personally I went super slow, did tons of research, and enjoyed my time building my real estate portfolio. I know people that received my results in about three years (took me about 5-6), however they went more full-time and aggressively at it.

[clickpenguin_460]

Quote from Re3iRtH

Totally agree.

I don’t think most people here will understand since they are okay with perpetually being stuck on the right side of the cash flow quadrant (employees and self employed). The rich do not work for money, and the rich do not pay taxes because they are passive investors.

They will continue to work for somebody else, deal with all the politics that go on at work, bite their tongue, save for a rainy day, and then give 50% of what they make to the government.

Personally I went super slow, did tons of research, and enjoyed my time building my real estate portfolio. I know people that received my results in about three years (took me about 5-6), however they went more full-time and aggressively at it.

 
Notice I said tons of upfront work, not whatever your maintenance work is. You just described how much extra time it took you.  I’m not even saying it’s a bad deal.  I was more commenting that it was more work than I expected for 8k/month and the 8k/month was less than I was expecting with 20+ properties.
 
 

[Unknown Member]

Nurse practitioners reading imaging is a gold mine for anyone using them.  Im sure rad partners and corporates are already all over this, maybe the rads they got rid of because of coronavirus volume drops will now be replaced by hiring nurse practitioners.  

[Unknown Member]

I imagine corporate is involved in sponsoring these organizations.

[clickpenguin_460]

No doubt.

[khodadadi_babak89]

Quote from striker79

Nurse practitioners reading imaging is a gold mine for anyone using them.  Im sure rad partners and corporates are already all over this, maybe the rads they got rid of because of coronavirus volume drops will now be replaced by hiring nurse practitioners.  

 
I have a couple of examples of this- people who wanted appointments with their sub specialist physicians were told they were furloughed…. but, if they wanted an appointment with the NP, they had just hired two…..

Again – this is real… this is happening.. there is no safety in being a radiologist.  

[lisbef3_453]

Quote from Phil Shaffer

  have been pushed (i.e. financed) by organizations such as the state hospital associations, CVS, Aetna, AARP/United Health care.

Beyond the threat to Radiology, these NPs are dangerous to patients.

 
I hate to say it, and I’ll join the crusade and kick in to PPP, but this is pissing in the ocean given that list of well moneyed Goliaths.
 
To your second, spot on point, they don’t care.  Noctors are a revenue stream.   Local imaging volume is off the rails because of them, and will continue until something like capitation kills the incentive to do so.  I’ve yet to meet a rad to push back on it.

[nelson33.jn]

Woeful, but expected as another aspect of the corporatization of medicine. Medicine has a chronic debilitating illness with no cure (call it corporate mediated mediocrity and insidious midlevel encroachment), and it’s not going to get better, its only going to get worse. EVERYONE and I mean EVERYONE is opposing us. There are massive headwinds against physicians from corporate lobbying, government marxist central planners,  and these know nothing white coat plated types. They are simply the cheaper more compliant alternative- whats not to love? Doctors may win some battles, the illness may go into remission for a time,b but the general trend is toward midlevels doing more and more training with less education and experience. The public will continue to get screwed with high deductibles and hospital padded healthcare costs and the savings will simply be kicked up to the administration as added bonus money. 
If a young person was asking me about healthcare as a career I would recommend a PA or NP degree. You will be able to do most of what a doctor can do (not as well, but quality doesn’t matter) without incurring half the debt (make that a quarter) or time it takes to get an MD degree. As someone on this forum once stated: “everyone wants to practice medicine but no one wants to read the big books”-heres the kicker- you don’t have to read the big books anymore. Nobody cares, the public is bamboozled and patients are none the wiser. 

[khodadadi_babak89]

Quote from Takayasu

Honestly I’m looking for an exit strategy from rads as soon as possible. At this point I would not recommend it to any aspiring students, or recommend medicine at all probably. The trends in diagnostic rads appear grave. I am not sure about interventional.

 
There is NO safe haven.
PA – 4 months out doing neurointerventional… and she knows she knows nothing..And she is training other PAs.

[tdetlie_105]

Quote from Phil Shaffer

Quote from Takayasu

Honestly I’m looking for an exit strategy from rads as soon as possible. At this point I would not recommend it to any aspiring students, or recommend medicine at all probably. The trends in diagnostic rads appear grave. I am not sure about interventional.

There is NO safe haven.
PA – 4 months out doing neurointerventional… and she knows she knows nothing..And she is training other PAs.

 
I’m assuming that PA has their own malpractice?  What company would insure a PA doing high level procedures like that without proof of adequate training? Thats basically malpractice on the insurance companies behalf. 

[khodadadi_babak89]

Quote from jd4540

Quote from Phil Shaffer

Quote from Takayasu

Honestly I’m looking for an exit strategy from rads as soon as possible. At this point I would not recommend it to any aspiring students, or recommend medicine at all probably. The trends in diagnostic rads appear grave. I am not sure about interventional.

There is NO safe haven.
PA – 4 months out doing neurointerventional… and she knows she knows nothing..And she is training other PAs.

I’m assuming that PA has their own malpractice?  What company would insure a PA doing high level procedures like that without proof of adequate training? Thats basically malpractice on the insurance companies behalf. 

 
This is a reply not only to this post, but all suggesting malpractice litigation as a solution….

I think this is a potentially fruitful line of attack.
However –
 
Those waiting in line to testify – there is no line. You are a physician. You are an expert in MEDICINE. You are NOT an expert in NURSING. So – the courts will not allow you to testify against them. Someone has told me that in some states you can, but I cannot find those states.

This speaks volumes – their cost for a 1M/3M policy? $1200 per year.

If we are able to get what they do redefined as medicine, not nursing, we may get somewhere. But, guess what, they fight that tooth and nail.
 
(Incidentally – in the case of the PA doing Neurointerventional – I have read that over and over. The radiologists are hostile to her. I think what happened is what I was talking about above – the hospital hired her to do this, to get the BIG BUCKS for neurointerventional, and the hospital didn’t care that she was incompetent. The radiologists froze her out).
 

[sanad50_506]

But what about AI ..arent we going to be displaced in 3 years ago and 5-10 years now  … I guess they can go in for as long as the gravy train goes on then pivot and be a cardiologist after a fellowship

[stlmchenry_510]

I dont understand thishow can NPs interpret diagnostic procedures?!! What???

[stlmchenry_510]

This needs to be stopped now. This will do more harm than good. This is really not going to be good. How do we stop this? We are physicians who have gone to school for radiology for 5-6 years after medical schoolwe need to be smart enough to figure out how to end this now. This is bad bad bad bad

[satyanar]

Quote from ar123

I also believe that the complexity of what we do will probably scare off a good amount of midlevels.

 
One would think right? Unfortunately, I think giving a sense of undeserved competency is baked into their training. it’s the exact opposite of M.D. training.

[khodadadi_babak89]

Quote from Thread Enhancer

Quote from ar123

I also believe that the complexity of what we do will probably scare off a good amount of midlevels.

One would think right? Unfortunately, I think giving a sense of undeserved competency is baked into their training. it’s the exact opposite of M.D. training.

 
You cannot underestimate them. 
 
If you are an NP in Florida, you have 30k in  loan debt, and you haven’t been able to find a job in two years (Fla is a tough market for them), and a hospital (or – a PE group) puts out an ad that says – 
We need you to read x-rays. We will train you in a couple of weeks to do this. You will be supervised by our  radiologists, and therefor you will have no malpractice exposure. 
 
You would have a TON of people applying. Not a bad idea actually to float a fake ad.

I know you would get plenty of takers, because I have seen it:

 

[rhiannonsmith84]

I think the NP’s will not be too eager to practice radiology because they will have to own their mistakes.  It’s not a field for the faint of heart, and they will have nobody upon whom to blame their misses.

[clickpenguin_460]

If there’s no liability, then why would they care?
 
We are always saying “well yea, but wait until they do ______ and the patients will notice and they will make mistakes.”  Well, they have been doing _____ and adding more.  The mistakes don’t matter.  The patient’s are forced to use them/take them.
 
As previously mentioned, their training includes repeated “you’re just as good as doctors.  Doctors are bad. etc.” 
 
Unfortunately, this is a fast moving capitalist train and I’m not sure there’s much we can do to stop it. 

[afazio.uk_887]

Well there is PACS which will keep all mistakes on record forever and Im sure a very long line of Rads willing to testify against med-levels who read imaging.

As we all have likely experienced, with PACS there is no escaping ur screwups and they seem to keep coming back to haunt you.

[clickpenguin_460]

That’s actually a very good point.  There is very little oversight available in clinical fields.   There’s a much easier way to peer review and record missing in our field (and pathology). 
 
 

[afazio.uk_887]

To be honest, if I were an NP Id want no part of reading imaging. Much easier and less stressful areas to encroach on MDs like primary care etc.

[briankn58gmail.com]

You cant assume theyre aware of whats best for them from a medicolegal standpoint. Their level of education coupled with the sheer volume of them being trained, combined with job opportunities at the right $ values, means very little nuanced thoughts like oh what will the ramifications in a field with relatively transparent errors

[clickpenguin_460]

Also true and I think they know that.  I think the issue is what was mentioned above and that is that there are now:
– 290,000 NPs (861,000 active physicians)
– 30,000 NPs trained per year (~37,000 new physicians matched in 2020)
 
The NPs are growing rapidly and will be out of jobs soon since they are not distributed across nearly as many fields.  Their rhetoric aside, they all want to work in the same places physicians do.  I think they will take what they can get at some point.  And, we didn’t even mention PAs or RAs.
 
 
[link=https://www.aanp.org/about/all-about-nps/np-fact-sheet]https://www.aanp.org/abou…bout-nps/np-fact-sheet[/link]
 
[link=https://www.aamc.org/data-reports/workforce/interactive-data/active-physicians-us-doctor-medicine-us-md-degree-specialty-2015]https://www.aamc.org/data…-degree-specialty-2015[/link]
 
[link=https://mk0nrmp3oyqui6wqfm.kinstacdn.com/wp-content/uploads/2020/06/MM_Results_and-Data_2020-1.pdf]https://mk0nrmp3oyqui6wqf…ts_and-Data_2020-1.pdf[/link]

[hdamis]

Quote from Waduh Dong

 
To be honest, if I were an NP Id want no part of reading imaging. Much easier and less stressful areas to encroach on MDs like primary care etc. 

 
 
Agree with Wadah Dong. NPs will not likely want to take on imaging since you can prove what they missed. More likely in my view is that they will actually increase imaging volume for radiologists.
 
Why? Because they want to get an MD involved (to spread the liability). By ordering an imaging exam, a radiologist will get roped into the case and they will have the option to literally ask you, “What should I do?” Happens all the time in rural ED settings. The rad is the only adult in the room.
 
We have an NP working with a surgical group. She makes no decisions without imaging and consulting radiology–even when the imaging is totally unnecessary and it’s clearly a clinical decision (e.g. orders a diagnostic MG/US for bilateral diffuse breast pain or bilateral milky discharge or the dumbest so far, 11 year-old girl with asymmetric breast “lump”). 
 
JAMA article showed increased imaging when midlevels are running the case. [link=https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/1939374]https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/1939374[/link]
 

[clickpenguin_460]

I agree but increased imaging also = decreased reimbursement so it will help radiologists in the short term but destroy us through a thousand cuts in the long term.

[hugolpneves_898]

Phil what is rationale for having physician supervision even with FPA? Do NP/PA even want it or is it their way of having it both ways and avoiding major liability?

[khodadadi_babak89]

Quote from Flip

Phil what is rationale for having physician supervision even with FPA? Do NP/PA even want it or is it their way of having it both ways and avoiding major liability?

 
PURELY to have the physician absorb liability. I doubt there is any real supervision and truth be told, in states without FPA (requirely supervision) the supervision often amounts to review 10 charts per quarter. Totally useless. 

THERE ARE ethical physicians who work with or employ NPs and review most everything they do, as if they were interns. We must not lose sight of those few. 
 

[khodadadi_babak89]

this is typical. NPS asking random people who also are clueless to diagnose their patient saying “She has abdominal pain, I tried antibiotics, what else could it be”

YOUR care in 10 years? 
 
One response was 

“PPIs?”
Now THAT is quality medical care. Thorough H&P, developed diff dx, determined tests to narrow the diff dx, and found the dx.

Or.. is it “hey did you try Pepto bismol? How about eye of newt?
 

[clickpenguin_460]

LOL “GI is my weak area”
 
Can’t forget to throw that qualifier in there.
 
Perhaps compiling and saving all of these nonsense Internet posts by NPs could be used in the future as evidence for their incompetence.

[clickpenguin_460]

So many gems on this site… Can’t believe I haven’t looked before.
 
[link=https://allnurses.com/good-sources-learning-interpret-ctas-t701009/?tab=comments#comment-7441617]https://allnurses.com/good-sources-learning-interpret-ctas-t701009/?tab=comments#comment-7441617[/link]

[amber.qasmi0846]

Frightening thread.  I joined PPP as well.  

[seb_arrosa_904]

time to emigrate from this hellhole called the United States

[jun52.park]

They love throwing a ton of initials after their name. Massive sign of insecurity.

[qi_si1988]

My favorite response to nurses who suddenly can’t handle the responsibility they demanded: “I can’t tell you what to do with your patient.”
 
Someday, I’ll get a chance to try: “Sounds like your patient should see a physician.”

[yao.bw39_792]

Quote from DocESP

My favorite response to nurses who suddenly can’t handle the responsibility they demanded: “I can’t tell you what to do with your patient.”

Someday, I’ll get a chance to try: “Sounds like your patient should see a physician.”

I started doing that with an NP who is practicing independently.  But I was nice and said refer the patient to a pulmonologist, etc.  She stopped asking after she got that several times.

[khodadadi_babak89]

Quote from Nice Guy

Quote from DocESP

My favorite response to nurses who suddenly can’t handle the responsibility they demanded: “I can’t tell you what to do with your patient.”

Someday, I’ll get a chance to try: “Sounds like your patient should see a physician.”

I started doing that with an NP who is practicing independently.  But I was nice and said refer the patient to a pulmonologist, etc.  She stopped asking after she got that several times.

 
 
 
“It’s important that you have recognized this situation is beyond your training, and I  appreciate your faith in me. Yes, I know a fair amount about pulmonology from my training, but your patient deserves the most expert care you can find for him, and there are others more expert that me. I recognize that, and I know I am not the best – so you need to be referring to an expert. I think you know that, so I am curious, why did you ask me rather than refer to a pulmonologist?”
 

[ruszja]

Quote from Nice Guy

I started doing that with an NP who is practicing independently.  But I was nice and said refer the patient to a pulmonologist, etc.  She stopped asking after she got that several times.

 
Our specialist colleagues hate that. Neurosurg referrals for back-pain, pulmonology for uncomplicated asthma. Drives up the cost of healthcare with no appreciable benefit.

[clickpenguin_460]

You mean like when the midlevels order imaging tests they don’t need?
 
Hmm.
 
Someone should to a longitudinal study in an ED of something like this:
 
Follow the ED doctors and calculate their total imaging-related costs vs their total compensation packages and do the same for the midlevels.  Could try to go even further by adding up the costs of additional consults by midlevels.  The only things hospitals will listen to is cost.  You would have to show that hiring a midlevel doesn’t actually save money (or not enough money).

[khodadadi_babak89]

mayo did a study where the expert consultants blindly reviewed the consults that had been recieved
 
60% of those from midlevels were unnecessary

Objective: To compare the quality of referrals of patients with complex medical problems from nurse
practitioners (NPs), physician assistants (PAs), and physicians to general internists.
Patients and Methods: We conducted a retrospective comparison study involving regional referrals to an
academic medical center from January 1, 2009, through December 31, 2010. All 160 patients referred by
NPs and PAs combined and a random sample of 160 patients referred by physicians were studied. Five
experienced physicians blinded to the source of referral used a 7-item instrument to assess the quality of
referrals. Internal consistency, interrater reliability, and dimensionality of item scores were determined.
Differences between item scores for patients referred by physicians and those for patients referred by NPs
and PAs combined were analyzed by using multivariate ordinal logistical regression adjusted for patient
age, sex, distance of the referral source from Mayo Clinic, and Charlson Index.
Results: Factor analysis revealed a 1-dimensional measure of the quality of patient referrals. Interrater
reliability (intraclass correlation coefficient for individual items: range, 0.77-0.93; overall, 0.92) and internal
consistency for items combined (Cronbach a.0.75) were excellent. Referrals from physicians were
scored higher (percentage of agree/strongly agree responses) than were referrals from NPs and PAs for each
of the following items: referral question clearly articulated (86.3% vs 76.0%; P..0007), clinical information
provided (72.6% vs 54.1%; P..003), documented understanding of the patients pathophysiology
(51.0% vs 30.3%; P<.0001), appropriate evaluation performed locally (60.3% vs 39.0%; P<.0001),
appropriate management performed locally (53.5% vs 24.1%; P<.0001), and confidence returning patient
to referring health care professional (67.8% vs 41.4%; P<.0001). Referrals from physicians were also less
likely to be evaluated as having been unnecessary (30.1% vs 56.2%; P<.0001).
Conclusion: The quality of referrals to an academic medical center was higher for physicians than for NPs
and PAs regarding the clarity of the referral question, understanding of pathophysiology, and adequate
prereferral evaluation and documentation.
 

NOte also: 60% of the NPs had inappropriately managed the patient prior to referral.

 

[clickpenguin_460]

They should put a $ amount on that.  Also a newer and larger study.

[lisbef3_453]

Quote from Cubsfan10

You mean like when the midlevels order imaging tests they don’t need?

Hmm.

Someone should to a longitudinal study in an ED of something like this:

Follow the ED doctors and calculate their total imaging-related costs vs their total compensation packages and do the same for the midlevels.  Could try to go even further by adding up the costs of additional consults by midlevels.  The only things hospitals will listen to is cost.  You would have to show that hiring a midlevel doesn’t actually save money (or not enough money).

You have it backwards.  They are revenue generators for their employers in the right setting, meaning when not DRG bound.  That’s why this will end up on the radar of CMS and 3rd party payors (who frankly don’t care about either patients or doctors).   My concern is that they will, as with the DRA, respond with a scythe rather than a scalpel.

[clickpenguin_460]

Quote from Adahn

Quote from Cubsfan10

You mean like when the midlevels order imaging tests they don’t need?

Hmm.

Someone should to a longitudinal study in an ED of something like this:

Follow the ED doctors and calculate their total imaging-related costs vs their total compensation packages and do the same for the midlevels.  Could try to go even further by adding up the costs of additional consults by midlevels.  The only things hospitals will listen to is cost.  You would have to show that hiring a midlevel doesn’t actually save money (or not enough money).

You have it backwards.  They are revenue generators for their employers in the right setting, meaning when not DRG bound.  That’s why this will end up on the radar of CMS and 3rd party payors (who frankly don’t care about either patients or doctors).   My concern is that they will, as with the DRA, respond with a scythe rather than a scalpel.

 
Why not just put everyone through the CT scanner on the way into the hospital for “revenue generation” then?  Then have an NP look at the lab and image results and consult all of the services to which body parts are abnormal.  That would be some serious “revenue generation.”

[lisbef3_453]

Quote from Cubsfan10

Why not just put everyone through the CT scanner on the way into the hospital for “revenue generation” then?  Then have an NP look at the lab and image results and consult all of the services to which body parts are abnormal.  That would be some serious “revenue generation.”

Sounds like a typical day here.  Feature, not bug.

[Mohamed]

You mean the nps/PAs in your ed don’t orderset cta c/a/p with an indication of “pain, r/o dissection, aaa, central pe, other pathology” on any not clearly localizing pain patient regardless of age or risk factors?

Bonus points if they order it as life threatening so they don’t even have to wait for the creatinine to result

[ruszja]

Quote from Cubsfan10

Why not just put everyone through the CT scanner on the way into the hospital for “revenue generation” then?  Then have an NP look at the lab and image results and consult all of the services to which body parts are abnormal.  That would be some serious “revenue generation.”

 
I had a good one just now. US tech from an outlying hospital calls me in desperation. The ER noctor is pressuring her to put down that the common bile duct is abnormally dilated because if she doesn’t, the surgeon at the University hospital wont take the patient. Tech tells me ‘I can’t make it bigger than it is, please read out the study so I get her off my back’. I look at the US, and the CBD is the same 7mm it was 2hrs earlier when my partner read out the CT. I fully anticipate a page later tonight from the MR tech when the ER noctor orders a MRCP.

[ruszja]

This is gonna be a long night. Now a Knee CT for ‘swelling or osteomyelitis’…. (no plain film).

[yao.bw39_792]

Quote from fw

Quote from Nice Guy

I started doing that with an NP who is practicing independently.  But I was nice and said refer the patient to a pulmonologist, etc.  She stopped asking after she got that several times.

Our specialist colleagues hate that. Neurosurg referrals for back-pain, pulmonology for uncomplicated asthma. Drives up the cost of healthcare with no appreciable benefit.

A case I can remember doing that on was a follow up on what I had told her on the first Chest CT looked like a fungal infection and it was worse on the second exam months later.  So I think the referral was appropriate.

[lisa.kipp_631]

History has proven there will always be an NP who through pride or ignorance will take a job they don’t understand ie neurointerventional.  What I think is more likely will be reports that put the most hedged radiologist to shame and many normals with CT and MR follow-up recommended.  Also, a massive increase in the number of outside study overreads. Its gonna mean much more work for us, a lot of it unpaid.
 

Quote from goodkid21

Quote from Waduh Dong

 
To be honest, if I were an NP Id want no part of reading imaging. Much easier and less stressful areas to encroach on MDs like primary care etc. 

 

Agree with Wadah Dong. NPs will not likely want to take on imaging since you can prove what they missed. More likely in my view is that they will actually increase imaging volume for radiologists.

Why? Because they want to get an MD involved (to spread the liability). By ordering an imaging exam, a radiologist will get roped into the case and they will have the option to literally ask you, “What should I do?” Happens all the time in rural ED settings. The rad is the only adult in the room.

We have an NP working with a surgical group. She makes no decisions without imaging and consulting radiology–even when the imaging is totally unnecessary and it’s clearly a clinical decision (e.g. orders a diagnostic MG/US for bilateral diffuse breast pain or bilateral milky discharge or the dumbest so far, 11 year-old girl with asymmetric breast “lump”). 

JAMA article showed increased imaging when midlevels are running the case. [link=https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/1939374]https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/1939374[/link]

[clickpenguin_460]

Some academic centers (and maybe other places too but I don’t know) already have a ton of over-reads.  ED physician “I know it was just read by a board certified radiologist 3 hours ago but now they are transferred here and I want our guys to re-read it.”  It’s like a compliment that annoys you…it’s great.

[julie.young_645]

I’ve followed Phil’s work on revealing this situation with great interest, particularly as I transition from physician to patient. Sadly, you can see just how well we physicians can unite on an issue that affects us all on this very thread; i.e. we CAN’T.
 
But there is a greater problem here. This is all about money. A LOT of money. A really big sh1tload of money. Money that should be directed towards well-trained, competent, caring physicians. But as we see time and time and time again (to quote Dr. Smirniotopoulos of AFIP) if there is a way for a middle-man to jump in between the producers and the consumers of a product or service, and to skim money out of the revenue stream, they will do it until they are stopped. Think Enron, which didn’t actually DO [i]anything[/i], but made millions until the scam became blatantly obvious. 
 
Physician charges represent a LOT of money. Doing a bait-and-switch with an NP or some other cheaper provider siphons money to the MBA or whatever miscreant figures it out. But with this kind of money going into the pockets of the less-than-scrupulous, you can rest assured that they won’t give up without a fight. And any physician who dares to upset their applecart will be targeted. In this day and age, we will be labeled as greedy troublemakers on the decline, who are stuck in the past and unable to adapt to the new world with “providers” on the ascendancy. We can (and should) fight the battle in the various state legislatures, but rest assured that the MBA’s and other corporate types will be quite generous in their donations and payment to lobbyists who will be, shall we say, quite persuasive.
 
Frankly, the only venue where this can be properly vetted is that of public opinion. I’m thinking the media needs to be informed of what’s happening, so there can be more widespread education of the public itself. And yes, we’ll face some of the “greedy doctor just trying to stay rich” garbage, but I’m thinking the public might just come down on our side. Hope springs eternal…

[Unknown Member]

We all seem to be united in our opinion of NPs. I dont think there have been any dissenters on that.

[rhiannonsmith84]

As sure as the sun rises in the East, there will be cases of incontrovertible gross negligence committed by NP’s independently interpreting imaging.  They will need to be mercilessly prosecuted, maxing out their insurance policies, and going after personal assets to award the harmed patient.  These cases will need to be publicized, and the awards will need to be large to discourage NP’s from trying their hand at our field.  
 
Moreover, as radiologists we are physicians for other physicians.  The referring docs will not trust a read from an NP.  The doc may as well read the study and bill it herself, since at least she as the physician will know how to look at the organ system in which she is expert.  

[lisbef3_453]

Noctors will be essentially immune from malpractice as long as the docs and hospitals are the deep pockets.   Docs ‘going bare’ in a state that allows it like FL could alter this dynamic a bit.  The hospital suits have run the numbers and probably feel the risk is worth it.
One likely outcome is an across the board fee slashing response like the DRA.
Hospital systems got too big and too powerful.   This is how they deal with us.   ‘Supervising’ noctors will be a condition of employment/credentialing, as it already is for many ED docs.
 

[khodadadi_babak89]

Quote from Adahn

Noctors will be essentially immune from malpractice as long as the docs and hospitals are the deep pockets.   Docs ‘going bare’ in a state that allows it like FL could alter this dynamic a bit.  The hospital suits have run the numbers and probably feel the risk is worth it.
One likely outcome is an across the board fee slashing response like the DRA.
Hospital systems got too big and too powerful.   This is how they deal with us.   ‘Supervising’ noctors will be a condition of employment/credentialing, as it already is for many ED docs.

But NPs most often carry the same coverage most of us do -$1m/$3m, it cost them 20x less, though
 

[ggascat95_565]

The second NPs start issuing reports is the second Radiology value plummets to the clinician. What surgeon gives a rats ass about what some undereducated NP has to say? Or a hospitalist who just makes sure there isnt anything major after getting burned by a bad NP report?

More likely this would result in supervisory roles for Rads who have to sign off NP reports as a contract requirement, which would shift time from reading paid studies to CYA unpaid supervision. Happened to Anesthesia and to an extent EM.

Us residents might be screwed. Certainly med students with $400k+ student debt arent guaranteed a decent financial life.

[lisa.kipp_631]

Well, I put my money where my mouth is and joined Physicians for Patient Protection. 

[leann2001nl]

Can you imagine a subspecialty surgeon talking to a mid level reading imaging? Im sure that would be very interesting.

[clickpenguin_460]

Ha, I would pay good money to see an NP run a tumor board in front of the neurosurgeons.

[qi_si1988]

When I’m reading a study and I disagree with something another rad said in a prior report, I bend over backwards to avoid calling attention to the error.
I would not make such efforts if the prior reader was a noctor. Might even take pleasure in doing the opposite.

[yao.bw39_792]

Quote from Cubsfan10

Ha, I would pay good money to see an NP run a tumor board in front of the neurosurgeons.

The day before yesterday an NP who has been practicing for 15 to 20 years called me up and asked how come the neurosurgeon says there is a brain tumor and the radiologist doesn’t.  So I pulled up the study and looked at the report.  She didn’t know that the radiologist saying probable astrocytoma meant there was a tumor.

[clickpenguin_460]

Reminds me of the time when an ED NP rushed into the room to tell me that she reviewed the CT and that I “missed a giant mass in the pelvis.”
 
After looking again quickly to humor her and still seeing no mass, I asked her to point to it as she stood behind me with folded arms and attitude.
 
To what giant mass did she point? The normal uterus, of course.

[suman]

They aren’t going to read complicated MRIs that require subspecialty neurosurgeon involvement. Some kid will break his finger, get an xray in an urgent care clinic and have nurse look at it, put a splint on and send him home with an ortho follow up. Nurse will go thru a 2 week long training for reading broken fingers. Maybe some cxrs too.

It’s about taking the bulk of trivial readings away from radiologist, not the complicated rare cases. Those will be still escalated as needed.

Right now many people just don’t have timely access to imaging at all, which leads to disability. Which is despicable given that x-ray machines have trivial manufacturing cost and bulk of imaging is trivial to interpret. Any radiologist who’s pushing against this change is a selfish apothetic psychopath who would choose suffering for millions over losing a few bucks from his bottom line.

[khodadadi_babak89]

Quote from avocado

 Any radiologist who’s pushing against this change is a selfish apothetic psychopath who would choose suffering for millions over losing a few bucks from his bottom line.

 
This “selfish, apothetic, psychopath” has seen people killed with stupidity. My own mother in law had her diabetes medicine dc’d by a stupid NP.
Your opinions are manufactured not to argue a point, but to anger people. Definition of troll. No relation to reality. 

I wrote this the moderator:

This person has a history of insulting people to elicit an angry response. I assume you are aware of this. His posts need to be removed, he needs to be banned, if you want to have AM as a forum for reasonable people to interact. If you allow him to continue to do this, reasonable people will leave.

If any others of you feel the same way, please report his post – or others – there are many, take your choice. 

 

[scandoc]

Found the PP partner clamoring to employ NPs.

[julie.young_645]

Quote from irfellow2019

Found the PP partner clamoring to employ NPs.

 
You mean avacatroll? He’s an NP himself. But listen to his justifications and you’ll have some idea of what the MBA’s are told. 

[Unknown Member]

Avocado is drooling to get his grimy little hands into interpreting imaging. His superficial level of knowledge and assessment of the situation is the VERY reason these people should not be anywhere near a dictaphone.

Abuse reported.

[Unknown Member]

Phil,

Ill try and help. I think youre actually close.

The issue I see is one of persuasion. Its hard to rip on NPs without the perception of doctors punching down on the nice mid levels in order to protect their fat paychecks.

The other interested parties…admin (admins gonna admin; theyre not our friend but not necessarily an enemy, theyll do whats best for them)…mid levels (kind of the same but also want help from docs)….patients (want to be treated well, but also tend to like mid levels personally and can usually see them faster)

Id suggest something along the lines of NPs do try hard. Then move on with the physician opinion.

You are acknowledging the effort but the obvious left unsaid is that no one wants critical medical decisions made by someone who is trying hard. And youre not punching down/attacking.

Thats also why NPs dont get chased hard during medmal. Theyre perceived as trying hard, but theyre not really thought of as experts. Thats the underlying theme. Try bringing out what everyone is thinking in a short way that is not too aggressive in a way that would be unseemly for a doctor.

[ruszja]

Quote from IR27

Can you imagine a subspecialty surgeon talking to a mid level reading imaging? Im sure that would be very interesting.

 
For some, it wouldn’t make a difference because they dont read the report anyway.

[francomejiamurillo_751]

Quote from brickydragon

Well, I put my money where my mouth is and joined Physicians for Patient Protection. 

 
Kudos.. In the end that is all that matters.  We can post and complain to each other all we want here but only money talks in politics. 

[cindyanne_522]

All those newly minted nDoctors with all the initial after their names are really, well , nurses. Nurses who are used to taking orders. And, they are fairly good at parroting back jargon. But their critical thinking as far as assessing a patient through medical imaging?  Being extremely charitable, untested at best.  Can an nDoctor studying for at nights, online for 2 or 3 years really compensate for the 6 years after medical schools rads now train for?!  ( not even considering the call hours which really adds on a year). BTW, whos training these nDoctor rads and at what institutions? Whats her/his name and credentials?
 
Look, there are a lot of young people who went into nursing as a quick way to ascend to a low-to-mid level earner in the medical-industrial complex. Good for those individuals. Now a fair number of them want the power in patient treatment, prestige and also some of the wealth that comes along with being a physician. BUT these same individuals want to avoid the strenuous years of going through medical school, passing boards, and getting trained through many years of residency.  A lot of nDoctors if asked will freely admit this-that they dont want to waste time ie invest in themselves to train to the highest levels of excellence in a field.  Becoming a doctor often means sacrificing ones youth, which a lot of nDoctors have no intention of doing.
 
So what is the end-product. A nDoctor is often an ancillary care provider that functions like a junior to mid level intern/resident.
 
This gap between a real boarded doctor and a nDoctor would be only accentuated if some commit to rads.  One could only imagine how long they would take to go through just xrays from the ER and ICUs on their own. They wouldnt be able to read their own cts or mris because it would take them 10x as long to put all the findings, even if they are using a programmed script. No imaging doctor could be supported by the owners of imaging to take that long. Nearly all rads would decline to help them through various stages of imaging dilemmas. If they make mistakes that non-rad doctors pick up, the ordering doctors will quickly go on the warpath, just like they do to real rads when our infrequent mistakes are made.  Only the slow service and many mistakes nDoc rads would make should drive clinicians to angrily storm the C-suite offices.  
 
Rad groups should not think about helping them. No cherry picking or turfing out the tough stuff-swallow it whole or leave it alone.  By the way, the reason why nDocs arent going to evolve as a threat to imaging interpretation ? Other boarded doctors overwhelming dont know what is what after looking at their own patients scans, even when rads have repeatedly conferred with many times about the same diagnosis (PE, appys, colitis, masses etc).
 

[reuven]

Quote from Waduh Dong

Well there is PACS which will keep all mistakes on record forever and Im sure a very long line of Rads willing to testify against med-levels who read imaging.

As we all have likely experienced, with PACS there is no escaping ur screwups and they seem to keep coming back to haunt you.

This is a goldmine for a plaintiff attorney

[khodadadi_babak89]

Quote from Waduh Dong

Well there is PACS which will keep all mistakes on record forever and Im sure a very long line of Rads willing to testify against med-levels who read imaging.

As we all have likely experienced, with PACS there is no escaping ur screwups and they seem to keep coming back to haunt you.

 
I agree with you – to a point. 

But I have learned over the past year that I totally underestimated their capacity to bumble through without knowing what they are doing, and not worry at all about it. 

Even after they totally screw something up, they do not know that they were wrong, and their colleagues tell them what a wonderful job they did because they were compassionate.
If anyone tells them they fkd up, they whine that it is “Mean” and that “Nurses eat their own”. They have massively developed defense mechanisms to excuse any screw up. ANY SCREW UP.

Just like the case above of the NP who gave an inferior MI Nitro, and killed him. She just said “no one told me that” and was done.  
 
 

[bunnie_face_936]

I wonder how much the 2 years of “nursing theory” mixed in with soft medicine lectures, a remedial board exam, and 200 trained clinical hours (I’ve seen 120 during the pandemic, is there really not a floor on this thing?) is going to help them read a CXR

[radiologistkahraman_799]

I can’t wait to sign up as an expert witness against them all

[bunnie_face_936]

Quote from TurboEcho

I can’t wait to sign up as an expert witness against them all

 
With California’s litigious nature and lack of tort reform, this is going to make for a perfect storm for some insane payouts. I expect a level of malpractice that would warrant a specialty shift for these non-physician “providers.”

[tdetlie_105]

Quote from ArticMan

Quote from TurboEcho

I can’t wait to sign up as an expert witness against them all

With California’s litigious nature and lack of tort reform, this is going to make for a perfect storm for some insane payouts. I expect a level of malpractice that would warrant a specialty shift for these non-physician “providers.”

 
For IR procedures, the standard of care does not change whether or not a radiologist was fellowship-trained in IR nor does it change with location (large university center versus small town community hospital).  I can’t imagine how a NP is therefore covered if/when there is a complication in a neuro IR case.  Who holds the liability in this scenario?  The hospital?  What physician would risk their license/livelihood by signing off on this?
 
 

[clickpenguin_460]

I’m pretty sure the physician is liable but if they work for a big hospital then the hospital would likely get hit with it.

NPs get away with a lot people there are always others checking their work/fixing their mistakes. They wont get “outed” until they are fully independent, hold the liability, and go in front of the med mal boards, mortality conferences, etc like physicians.

[clickpenguin_460]

In fact, physicians instituting better peer review systems to include mid levels would likely alleviate a lot of the problems and also expose the incompetence.

[ranweiss]

Let them practice independently and have their own liability.
 
They will only be protected if greedy radiologists hire them for cheap labor and make money on them. That’s the mistake the anesthesiologists made. We have to avoid that. 

[khodadadi_babak89]

Quote from ar123

Let them practice independently and have their own liability.

They will only be protected if greedy radiologists hire them for cheap labor and make money on them. That’s the mistake the anesthesiologists made. We have to avoid that. 

 
Or 
PE owned radiology businesses
Or
large health care organizations

We know for a fact these two types of organizations are founded on the principle of making as much money as they can, and replacing radiologists with cheap NPs would be a very tempting move for them.
Regardless of what any radiologists do, these two types of organizations will control the market, and will, I think , ensure radiologists are displaced in favor of NPs, just as  other specialists have been.
 
 

[suman]

Yeah there was opposition from some old rent seeking farts, but the language is in. Took some time to get regulators with half a brain cell to understand the true source of miseries in the US healthcare.

Remaining states and specialties will follow.

Great news for the patients (better, affordable care) and the Republic (fiscal health).

Now the next target is SB50 revival to rid California of the second biggest kind of rent seekers.

[khodadadi_babak89]

Quote from Re3iRtH

Totally agree.

I don’t think most people here will understand since they are okay with perpetually being stuck on the right side of the cash flow quadrant (employees and self employed). The rich do not work for money, and the rich do not pay taxes because they are passive investors.

They will continue to work for somebody else, deal with all the politics that go on at work, bite their tongue, save for a rainy day, and then give 50% of what they make to the government.

Personally I went super slow, did tons of research, and enjoyed my time building my real estate portfolio. I know people that received my results in about three years (took me about 5-6), however they went more full-time and aggressively at it.

 
May I suggest you start your own thread regarding your investments?

[julie.young_645]

There is a difference between “financially secure” and greedy.
 
No doubt you fall into the latter category, junior. 

[jeevonbenning_648]

I’m with you there. I care deeply about the radiology profession.

But sometimes in life you realize that things have gone too far a certain way and like most things in life, we can’t control it. Just have to accept it.

At the end of the day, greedy or not, people will worry about themselves and their family over anything else.

For the record this doesn’t worry me at all simply because it’s in one State (CA) that frankly doesn’t surprise me anymore any legislation they put out. The world is a big place.

[khodadadi_babak89]

Quote from RADD2010

Thanks Dr. Shaffer for bringing this to attention. I am wondering where the extra need for radiology NP is coming from ? IR ? Diagnostic ? Both? I commend your efforts to bring this to wider attention. This is really serious, but I know some PP practices who hire NP IR folks.

 
I don’t know that there is a “need”, except a need for corporations to find the cheapest labor they can. 

OF course I know that many IR’s are using NPs for things like H&Ps (which, by the way, they are NEVER trained to do— “[b][i]What is this “H&P” of which you speak?”[/i][/b]. And PA’s for things like – supposedly easy cases. (and of course, they get bored and immediately try to expand their scope.)

 

[cieminsjohn]

Sent letter to senators.  Thank you

[khodadadi_babak89]

Quote from Dumb Luck

As sure as the sun rises in the East, there will be cases of incontrovertible gross negligence committed by NP’s independently interpreting imaging.  They will need to be mercilessly prosecuted, maxing out their insurance policies, and going after personal assets to award the harmed patient.  These cases will need to be publicized, and the awards will need to be large to discourage NP’s from trying their hand at our field.  

Moreover, as radiologists we are physicians for other physicians.  The referring docs will not trust a read from an NP.  The doc may as well read the study and bill it herself, since at least she as the physician will know how to look at the organ system in which she is expert.  

 
again, They get  a pass on malpractice. I don’t agree, I don’t like it, I don’t see how this could be, but I can observe what is happening as say it is indeed happening, even though I can’t put my finger on why…..yet.

[link=https://authenticmedicine.com/2020/06/the-anecdote-has-a-face-and-a-name/]https://authenticmedicine…has-a-face-and-a-name/[/link]
 
Some communication with the attorney indicated he felt a jury would be much more likely to return a verdict against a doc and a corporation than the poor little NP.

[ruszja]

Quote from Phil Shaffer

again, They get  a pass on malpractice. I don’t agree, I don’t like it, I don’t see how this could be, but I can observe what is happening as say it is indeed happening, even though I can’t put my finger on why…..yet.

[link=https://authenticmedicine.com/2020/06/the-anecdote-has-a-face-and-a-name/]https://authenticmedicine…has-a-face-and-a-name/[/link]

Some communication with the attorney indicated he felt a jury would be much more likely to return a verdict against a doc and a corporation than the poor little NP.

 
You are misrepresenting what the attorney stated about the trial strategy.

[clickpenguin_460]

I get what you’re trying to say and it’s the thing that is said for primary care…that you don’t need a doctor for 90% of the “normal stuff.”
 
The issue is that nothing is trivial.  Almost everything has the potential to be non-trivial.  The reason a radiologist is paid is for the subtle, non-trivial things. 
 
For example, a lot of partially trained people can see a fracture on XR.  Not just anyone can see the underlying subtle lytic lesion associated with it. 
 
Midlevels will be greatly exposed in radiology and their mistakes won’t be able to be hidden like they are in some clinical areas.

[suman]

That’s why process should involve proper escalation & follow up in the coming days, weeks or months (depending on issue and specialist availability).

But blocking nurses doing front line work is only hurting most patients because for bulk of the cases the care is needed ASAP for best outcomes and also happens to be trivial to deliver.

It’s not economically feasible (nor medically sound) to have every image interpretation gatekept by a radiologist with 14 years of post K12 education.

[sarah.r.huntington]

Quote from avocado

That’s why process should involve proper escalation & follow up in the coming days, weeks or months (depending on issue and specialist availability).

But blocking nurses doing front line work is only hurting most patients because for bulk of the cases the care is needed ASAP for best outcomes and also happens to be trivial to deliver.

It’s not economically feasible (nor medically sound) to have every image interpretation gatekept by a radiologist with 14 years of post K12 education.

I doubt you’re a doctor of any sort the way you write. If someone needs to act on a plain film finding, they will act on it and wait for the report later. This happens all the time in the ED for emergent findings, or on the wards for tube/line placement.
 
There is absolutely no delay with the current system, not the way you’re describing it.

[suman]

Quote from Xtatero

Quote from avocado

That’s why process should involve proper escalation & follow up in the coming days, weeks or months (depending on issue and specialist availability).

But blocking nurses doing front line work is only hurting most patients because for bulk of the cases the care is needed ASAP for best outcomes and also happens to be trivial to deliver.

It’s not economically feasible (nor medically sound) to have every image interpretation gatekept by a radiologist with 14 years of post K12 education.

I doubt you’re a doctor of any sort the way you write. If someone needs to act on a plain film finding, they will act on it and wait for the report later. This happens all the time in the ED for emergent findings, or on the wards for tube/line placement.

There is absolutely no delay with the current system, not the way you’re describing it.

If you think 95%+ of people who need care are getting it in a timely manner in the US you don’t know how medicine works in the US. Many simply avoid going into the clinic due to fear of financial penalty, and develop a disability as a result. Of those who do, many receive substandard care. There are many reasons for that but a core issue is selfish physician gatekeeping like the one we see in this thread. We have enough money in the country to deliver basic care in a timely manner to the population, yet we don’t (most of the other countries do, including impoverished sh*tholes like Vietnam).
 
None of that would be a problem if physicians were on a salary. Good news is everyone will be on salary some time after President Harris is elected this November. There will be 10x more nurses, many with basic radiology training doing front line readings. And physicians won’t be wasting time fighting for RVU scraps and instead focus on complicated cases properly escalated to them, albeit on a 200k / yr salary.
 
 
 

[clickpenguin_460]

The nursing propaganda is strong in this one.  Allnurses will welcome you if you want a better audience.

[marchirner]

Avo

I suppose if you had your way the NP could perform and interpret the MRI all while simultaneously performing the biopsy and interpreting the path results. If it looks suspicious just resect their entire liver right then and there on the spot. That would avoid delay in patient care.

[qi_si1988]

The whole “let under-qualified personnel handle the normal stuff” argument is childlish oversimplification at best, disingenuous at worst.
 
Firstly because they don’t know what they don’t know, and unexpected pathology (subtle lytic lesion of bone underlying a fracture, as mentioned above, lung mass on shoulder x-ray, etc.) will be missed because they don’t know/think to look for such things.
 
Secondly, because our goofball reimbursement system [i]depends[/i] on there being a bunch of normal/simple stuff mixed in with the abnormals. If you siphon out all of the “easy” stuff and leave rads with the complex/abnormal cases, they’ll suddenly be getting a fraction of the work done, and I guarantee you proponents of the noctors aren’t calling for boosting RVUs to compensate for this.
 
Not to mention the burnout factor: Give somebody nothing but messed-up cases to read, and I bet they’ll be looking to retire a helluva lot sooner.

[suman]

All I want is elimination of state-level Medical Boards. Nothing less, nothing more. If it’s going to bring the MD salaries back to their natural levels (100-200k) so be it, as long as consumers benefit. 
 
Have FTC regulate the medical cartel (instead of HHS / CMS / State Boards), including all of the medical licensing and scope of practice country-wide.
 
Either we do this ASAP or this will be the end of liberal democracies. 

“Everyone I disagree with is a nurse, including CA Assembly, competing healthcare models in Europe and elsewhere, operational efficiencies of RP, Orthopedic Surgeons and Cardiologists, Google’s Medical AI, PACS, and idea of legalizing healthcare for poor people” – signed AuntMinnie Radiologist

[leann2001nl]

Dont engage troll

[clickpenguin_460]

Here’s some good insight.
 
[link=https://allnurses.com/new-np-x-ray-reports-t701006/]https://allnurses.com/new-np-x-ray-reports-t701006/[/link]

[julie.young_645]

Quote from avocado

Either we do this ASAP or this will be the end of liberal democracies. 

 
Translation:  “I love communist party”
 
I’m sure you do, avacatroll. 
 

[clickpenguin_460]

It’s not their fault they don’t know anything.  Their training is woefully inadequate.  It’s like asking a medical student on his/her first day of school how to read temporal bone CT.  That student isn’t dumb…just not trained.  The issue is that the med student will get proper training and the NP never will.

[julie.young_645]

Quote from Cubsfan10

It’s not their fault they don’t know anything.  Their training is woefully inadequate.  It’s like asking a medical student on his/her first day of school how to read temporal bone CT.  That student isn’t dumb…just not trained.  The issue is that the med student will get proper training and the NP never will.

 
The difference is, in most cases, that the med student won’t attempt to read the T-bone CT. The NP [i]would[/i], with aid of a You-Tube video. 

[satyanar]

Quote from Cubsfan10

It’s not their fault they don’t know anything.  Their training is woefully inadequate.  It’s like asking a medical student on his/her first day of school how to read temporal bone CT.  That student isn’t dumb…just not trained.  The issue is that the med student will get proper training and the NP never will.

 
So true and it gets worse. I think many would better understand their limitations if their training did not include convincing them why they are worthy of doing more. It’s a political agenda that overlooks competency.