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RAsPAsNPs taking over radiology
I am going to present a talk at a state radiologic society in a month. Topic is midlevel incursion.
This is a request for information
I know there are indications – something a little more than rumors, but still poorly documented – that some facilities are having PAs or NPs read radiology studies. Fortunately these cases are still hard to find. IF they were as prevalent as cases of midlevels staffing ICUs, etc, then the fight would be over. We have the opportunity to stop it now before it becomes a lost cause.
Is anyone aware of these situations. (right here, I will say that I know the difference between a PA reading the case him/her self and giving a preliminary that the Rad signs off on is a fine, blurred line.)
Any information you can give me about this will be welcome.If you have actual documentation of this – in the form of screen captures, etc. That would be golden.
Also – I am aware the Proscan suit died. I will be trying to contact the principles in that issue, but if anyone knows anything more than was on the prior thread, hey, send it along.
Beyond this – I am aware many IR’s are using PA’s and NPs. (I have one example of a new PA doing interventional neuro without backup). At the moment, I feel very negative about this. But, I want to listen. You IR’s can you tell me the pros and cons of using them?
Educate me.Obviously PM me if you like. I guarantee anonymity.
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61 Replies
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We use NP and PA to do H and P, see people in clinic, etc.
They assist in IR procedures by holding wires and they are credentialed to do paracentesis only.
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I have used RPAs for paras, thoras, LPs, fluoro, breast and thyroid biopsies. Nuts and bolts stuff. Would NEVER allow them to do angio unsupervised. They ALWAYS go over the cases and I usually dictate the case myself unless it is a fluoro case/LP which they dictate and I sign off on.
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Same at my practice. We have a large staff of PA’s doing thoras, paras, thyroid biopsies, barium, LP’s, PICCS, ports — they keep me in my chair and keep the techs out of my office! Frankly, they are too busy with scut to read plain films, and they have never expressed the desire to do so. Not only would that be bad medicine, but it wouldn’t make much business sense.
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slippery slope.
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Very slippery. Teach them procedures and watch it go down in flames in 15 yrs
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Midlevels have already encroached through the other specialties, and same with corporate takeovers. It’s the same game, you make a lot of money by having mid levels do the work md’s do. People go to ERs all over the usa and they may only be seen by a physician assistant…billing is the same as if they would have been seen by an ER dr. Would anyone knowingly rather be seen by a physician assistant over an MD physician? Of course not. Same would apply to having their imaging read. Business has no ethics, only dollars and cents.
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I know of a RP IR practice my friend is at where PAs do lines/ports, neph tube placement/exchange/ antegrade double J stents, bx including lung and kidney, fistula work and DVT lysis/thrombectomy. He has voiced his opinion on this being unsafe to no avail. Same group wanted to have them do prelims on CXR and bone films. Very slippery slope indeed pretty soon RP or hospital will say why do we need a doc.
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Radiology has become everyone for himself, short term gains, everythings going to hell. Why not cash out on mid levels if you can? No one else seems to care about the next generation of rads plus AI is close. Sucks to be early stage rad or in training.
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Quote from Drrad123
Radiology has become everyone for himself, short term gains, everythings going to hell. Why not cash out on mid levels if you can? No one else seems to care about the next generation of rads plus AI is close. Sucks to be early stage rad or in training.
^^ Very unfortunate but true.-
This is insane. Thank you to Phil starting this thread.
A complete dereliction of our duty of care to delegate this work.
Grassroots effort needed to arrest this.
Role of extenders should be to facilitate radiologists doing procedures more efficiently.
Not to throw the baby out with the bathwater by outsourcing the substantial part of the procedure to a less skilled less experienced less knowledgable individual and batch sign remotely….
IDEAS of how might be win-win
-hanging protocols a disaster in most pacs. Open cases and hang priors and match up key sequences measure nodules or tumors, do 3ds, and save
NOT: prelim for a signoff
– LP , para, thora: Prep skin. After doc does needlework collect sample, label tubes, bandaid and instructions
NOT: do the whole procedure
– dictate inpt or clinic consults, hold wires, hold groins, manage radial cuff
NOT: do the whole procedure
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I have worked in jobs where the rad does all procedures and in jobs where a PA does the basic procedures such as para, thora and lp.
Once a PA has gotten the hang of these procedures the benefits are numerous. The PA can save me from 20 phone calls and 5 instances of a tech stalking me in the reading room in one day. That has real consequences. That is 25 less times that I am interrupted while reading a case, which means I can do my job better.
So I am in support of mid levels for procedures. Basic stuff and only when they are well trained and you have gained trust in them.
This is the USA. A nation of exceptionalism…I mean of exceptional overuse and exceptional entitled ness. In my opinion if radiologists need to read 120-150 cases per day they need help where they can get it. And without a doubt that figure will increase every year.
I am against mid level interpretation to be sure. I am just advocating efficiency in a chaotic and over-utilized health system.
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Then teach RAs to protocol studies, and be the decision support for ER, to attack the overutilization, dont just concede the high ground and use RAs to aid and abet the over utilization
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Just say no! Give them an inch and they want a mile. Cant we learn from other specialties? First CRNAs were only going to do easy cases too. How can we let them do anything other than H&Ps, consults and protocols? Has the whole world gone crazy! This isnt Nam, there are rules!
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Twice now I have worked with PAs who, once trained and comfortable, tried to leverage their new found skills by cutting out the radiologists. By that I mean going to hospital administration behind our backs and asking for sweeter deal with more independence.
It is foolish to think you can train someone who gets much paid less than you and is not your partner/colleague to do your procedures, and it wont come back and bite you in the a**.
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The irony of the practice at the top of your training mantra is the challenging cases get dumped on the physicians and we have no good system to account for complexity, particularly in radiology. But, everything now is about $, so who cares?
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Some here are listing a wide range of procedures that PAs do. Breast biopsies? Thats somewhat surprising, even though the procedure is pretty straight forward. Chest ports have multiple risks, so I find that not safe without any supervision.
Its the IRs that should be very worried. Some PAs seem to be doing everything IR does in multiple community practices.
Theres not enough PAs to cover IR needs across the country. But, if some big hospitals sees an IR practice as a few IR trained rads with multiple PAs (like anesthesia), IR rad demand will dip. Word will spread on cost savings.
IR seems to be going down in flames. I feel sorry for the highly intelligent doctors seeking IR residency.
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For those that question the authenticity of the PA doing the a few high end cases I mentioned. The practice is RP Phoenix (formally EVDi). My friend has been fighting this since he was hired with little progress and has lost ground in some ways. But they are not the only person I know dealing with PA/NP stuff but that situation is definitely the most xtreme I personally have heard of.
As mentioned here many time radiology is viewed as a commodity and the last thing we need to do is given other physician and admin reason to see even more negatively then they already do. We should look at anesthesia or the ED and what has happened there and take steps to prevent it from happing in rads. But sigh I am sure the pursuit of the $ and padding those 401k accounts will ultimately win the day.
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As a managing partner in our practice that employs very talented PA’s and RPAs who have a limited but useful scope of practice, the only reason this has happened is downward pressure on reimbursements, and hospital demands for 24/7 IR coverage. The cheddar is reading diagnostic cases in the army of off-site rads who can’t be bothered to be in the hospital for $350K.
Thanks for coming to my TED talk. -
A managing partner ? Who are you kidding
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Our partnership has an executive board empowered to make decisions on behalf of the whole partnership. I didn’t realize this comment would yield incredulity.
[blockquote][b][i]A managing partner ? Who are you kidding[/i][/b]
[/blockquote] -
This b lingo tells me this is a PE backed practice or you are 130 rads large and as such have lost all reality with a normal pp.
I have yet to hear a group president refer to himself as the managing partner
Or the board as executive board .
Straight up tells me there are working rads and the non working fos rads.
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Not at all. We’re 20 rads, the 5 member board is elected every two years. It works well this way, rather than a tug of war with 20 type-A people trying to make business decisions.
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My IR buddy from U of Rochester told me they have a PA who essentially did all CT guided procedure with general supervision. There was evidently also a PA who did almost all LPs and those things got into the way of education. He didnt like his residency much though so take it with a grain of salt. I have no first hand experience with this place.
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I have a hard time buying the pa doing neuro ir shtick. Have proof?
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So if PAs and NPs are doing the “scut work” and other sub-specislties are poaching the high end money makers, what the hell will be left for the IR guy??
Layer on AI and wow, Radiology seems to have some issues.
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Major issues dude. Race to the bottom fueled by Corps, AI and mid levels !!
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To those who say, the PAs and RAs can do a great job and patients love them. Of course. Many of these procedures are easy. A med student can be trained to do them. Once you do 10 paracentesis, how much harder does it get?
So the point isnt that they couldnt do a great job. Of course they can. It is about the privilege to do so. Go to medical school if you want the right to do it.
So what happens in 10 years if RAs/PAs do all the minor procedures? The rad who hasnt done in for 10 years is now less qualified to do them, since the RAs and PAs are all doing them now. Get the point? If we keep this going THEY will be better than the radiologist. THEY will be able to handle the complications. It is already happening in some places. The diagnostic rads are terrible at procedures cause they dont do them.
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And to add some more.
These minor procedures are the only time a patient gets to see a radiologist if RAs/PAs do them all, the patient will definitely never see a radiologist. They will equate a radiologist with the RA/PAs. Just like they do sometimes confuse the rad tech with a radiololgist.
People, it is a pain in the a@@ but get off the chair and go do that para or biopsy. It will help your circulatory system as well as your future radiologist. -
+1
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Quote from rozakk
I have a hard time buying the pa doing neuro ir shtick. Have proof?
I get it.
sounds unbelievable.
Much of what is happening now IS unbelievable, but it is happening. -
Quote from rozakk
I have a hard time buying the pa doing neuro ir shtick. Have proof?
More from the same PA
NOTE: she has been out of school four months.
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@ roentgen ray ….,
20 rads. 5 board members.
And you call yourself managing partner ?Id like a brief poll about how many other PP rads here refer to their bi-annual elected board and president as executive board and managing partner
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“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. ”
To more complex procedures? Isn’t the angiogram, the complex stuff? Or are they saying dictating the procedure (done by the NP) by the neurorinterventionalist is the more complex part? They should be getting the patient prep, ready and to be stuck with the needle and afterwards, clean up and do the scut work.
If they want to actually do the procedure, go to medical school and apply to nueroIR program.
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Quote from peehdee
“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. ”
To more complex procedures? Isn’t the angiogram, the complex stuff? Or are they saying dictating the procedure (done by the NP) by the neurorinterventionalist is the more complex part? They should be getting the patient prep, ready and to be stuck with the needle and afterwards, clean up and do the scut work.If they want to actually do the procedure, go to medical school and apply to nueroIR program.
Song by Albert King“everyone wants to go to heaven, but nobody wants to die”
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They want Np’s to shoot angios? Let me guess. The MD is the one responsible if they cause a dissection.
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I have a family member that is an orthopedic surgeon. He recently called proscan to ask about a read, and he was told to talk to the PA who read it. He was pissed and stopped sending any patients there.
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This is exactly the problem with mid level provider incursion/creep in medicine. They want the pay, schedule, and prestige (if there is any of this left for physicians today) but none of the responsibilities like malpractice and call etc.
Most of my friends and the mid levels Ive work with have seemed to use this as a means to circumvent the traditional blocks to maintain quality
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Would you be okay with the intrusion if they took the ‘call’ and responsibilities in malpractice?
If that’s the case, skip medical school. Go to graduate school and get NP or PA degree. No residency.
As Jean-Luc Picard said, “the line must be drawn heya’. -
No I am not fine with any of it at all. I think they should be treated no different than a intern write notes and do scut work and they should be paid like interns in training IMO.
I was just pointing out that mid levels expect physician benefits without the responsibility and many hospital and corporate medicine outfit want it that way also
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From a tech’s perspective, the mid level encroachment has caused a massive boom in uncessary exams. When I started, the mid levels in our ER were not allowed to order advanced imaging or even see higher acuity patients without a physician involved. Funny how much the radiation hawks were all over us about exposures in the past but this is immume since it’s a “emergency”.
Sometimes is painfully obvious when you can tell they are ordering CTA’s to just rule out everything. With COVID-19, we are doing more CTA chest when a mid-level sees them than a MD/DO.
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The rads see that too, of course, but are helpless. The hospitals love the extra revenue for sure.
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There is one article in the literature that says they order more, but it is not as much as one would imagine. I am not sure I believe it. I think it was like 5%.
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[link=https://twitter.com/patel_doctor/status/1317822149017669634?s=21]https://twitter.com/patel_doctor/status/1317822149017669634?s=21[/link]
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Interesting article in Radiology Business.
[link=https://www.radiologybusiness.com/topics/artificial-intelligence/radiologists-ceding-authority-nonphysician-practitioners?utm_source=newsletter&utm_medium=rb_artificial_intelligence]https://www.radiologybusi…rtificial_intelligence[/link]
[b]Radiologists urge peers to avoid ceding authority to nonphysician practitioners, opt for AI instead[/b] -
Quote from rozakk
I have a hard time buying the pa doing neuro ir shtick. Have proof?
Here is an interesting abstract from 2017. From Columbia in NY – which is a bastion of NP empowerment.
[link=https://jnis.bmj.com/content/9/Suppl_1/A90.2?fbclid=IwAR29qCs23gfMTZ0sJy_v5IN3y1lVBlwzZVX4pWP35Rd4gBENI_0fyZnjNSg]https://jnis.bmj.com/cont…WP35Rd4gBENI_0fyZnjNSg[/link]
some points to make:
They say
“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.”
Important note: Proponents of NP practice are very fond of the IOM report. And they should be. It was funded by a gift from the Robert Wood Johnson foundation – the most prominent and richest of the NP proponents to the IOM. $2.7 million. The committee was stuffed with proponents of NPs – such as CVS execs, Aetna Execs, Academic NPs. One doc who got all his research funding from RWJF. It was a purchased opinion. It was in no way a balanced policy or scientific opinion, it was a paid political announcement. The IOM sold their name.more…
” 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. ”
Fullest capapity – i.e. “top of their license” a catchphrase to allow any sort of nonsense expansion of scope of practice they desire.
“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. ”
comment – $ $ $ $ $ $ $ $. Where is the patient in this?“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.”
Comment – yeah. .”Exciting”
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Quote from vanilla corn
For those that question the authenticity of the PA doing the a few high end cases I mentioned. The practice is RP Phoenix (formally EVDi). My friend has been fighting this since he was hired with little progress and has lost ground in some ways. But they are not the only person I know dealing with PA/NP stuff but that situation is definitely the most xtreme I personally have heard of.
As mentioned here many time radiology is viewed as a commodity and the last thing we need to do is given other physician and admin reason to see even more negatively then they already do. We should look at anesthesia or the ED and what has happened there and take steps to prevent it from happing in rads. But sigh I am sure the pursuit of the $ and padding those 401k accounts will ultimately win the day.
Be careful pointing fingers. The hills have eyes.
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Quote from Drrad123
Radiology has become everyone for himself, short term gains, everythings going to hell. Why not cash out on mid levels if you can? No one else seems to care about the next generation of rads plus AI is close. Sucks to be early stage rad or in training.
Unfortunately, we have evolved into a toxic individualistic culture.-
On top of rads enabling these mid-levels… these mid levels also have a massive lobby pushing their interests to make them at the same level as physicians.
I often wonder what the heck the ACR is doing for all the money I’ve been paying them each year… are they proactively dealing with this?
Where is our lobby?-
ACR is too busy squeezing money out of rads with all their pay for play schemes like accreditation, MOC, and P4P. Meanwhile, AI and midlevels keep creeping with inadequate pushback.
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Quote from docholliday126
ACR is too busy squeezing money out of rads with all their pay for play schemes like accreditation, MOC, and P4P. Meanwhile, AI and midlevels keep creeping with inadequate pushback.
Hang on here.
The ACR ABR. The ACR has little or no input to the ABR. I think the ACR is doing a decent job and in fact is our only representative to the legislatures. The ABR – yeah – there are issues. -
Don’t let them practice under your license… Problem solved?
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I think the issue is that physicians are forced to allow them by their employers. If they don’t, they will be fired essentially.
I’m surprised that some clinicians haven’t filed a lawsuit over this before honestly. You shouldn’t be forced to expand your license to cover others if you don’t want to. Or maybe they have? Seems like a winnable case for a physician or anyone with a license for anything to me. -
Got a message from the California board – theyre looking for docs to serve on their advisory board to weigh in on NP regulations. I dont have a California license anymore but if someone does and is interested might be worth checking out to get your voice heard about nurse encroachment in medicine there (I think links for applications are on the NPAC and NMAC websites)
Board of Registered Nursing Seeks Physicians to Serve on Committees
The California Board of Registered Nursing (BRN) is currently looking for two qualified physicians to serve on its Nurse-Midwifery Advisory Committee (NMAC) and two physicians to serve on its Nurse Practitioner Advisory Committee (NPAC).
The NMAC and NPAC will advise and make recommendations to BRN on various matters pertaining to the practice of nurse-midwives and nurse practitioners, respectively.
If you are interested in applying to serve on the NMAC or NPAC, please submit your completed NMAC Application or NPAC Application, resume, and supplemental questionnaire to the BRN by December 4, 2020. All physician and surgeon applicants must possess an active and current license issued by the Medical Board of California. If you have any questions or require additional information, please send an email to [email protected]
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In reply to RoleCall
I think the issue is that physicians are forced to allow them by their employers. If they don’t, they will be fired essentially.^This is an issue. Trapped.
Also, some make more if signing off on extenders.
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Surprised malpractice attorneys have not picked up on this thin ice scenario and go after the supervising radiologists because sooner of later shortcuts and radiology extender standard of care will come back and bite you in the you know what.
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Quote from vanilla corn
I know of a RP IR practice my friend is at where PAs do lines/ports, neph tube placement/exchange/ antegrade double J stents, bx including lung and kidney, fistula work and DVT lysis/thrombectomy. He has voiced his opinion on this being unsafe to no avail. Same group wanted to have them do prelims on CXR and bone films. Very slippery slope indeed pretty soon RP or hospital will say why do we need a doc.
This is basically the whole gamut of IR in many places. Sounds apocryphal.
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If you cant beat the suits, join em. Make money off of pa, np, etc. while docs are being ethical and providing superior care, everyone else is steam rolling them.
This radiology gig wont last too much longer according to some with AI, may as well make some hay while the sun still shines. Plenty of groups around the country agree and are cashing the chips out.
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what is “too much longer”
– PGY2-
PAs and NPs have a significant role to play in IR for many procedures but I believe the line needs to be clear. I recall atleast one practice where an IR was supervising 6-8 PA/NPs with them performing IVC filters, drains, etc. this is driven by economics, not quality care
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Although i agree it is a slippery slope, we had a RPA in my prior practice that was fantastic at basic procedures (paras, thoras, LPs, fluoro). Patients loved him. He did not perform biopsies of any kind nor did he perform angio procedures. His docket was completely full every day. If he had a week off the rad covering for him many times couldn’t keep up with the fluoro. His salary was covered by the amount billed for his work. So, fiscally speaking, it was a much much better allocation of time and expertise to use a RPA for these procedures so the rads could continue to read studies. I’m sure there are more opportunistic PAs out there who would try to branch out and take over services, but if you treat your RPA well, it *shouldn’t* be a problem.
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Quote from dysdiadochokinesia
Although i agree it is a slippery slope, we had a RPA in my prior practice that was fantastic at basic procedures (paras, thoras, LPs, fluoro). Patients loved him. He did not perform biopsies of any kind nor did he perform angio procedures. His docket was completely full every day. If he had a week off the rad covering for him many times couldn’t keep up with the fluoro. His salary was covered by the amount billed for his work. So, fiscally speaking, it was a much much better allocation of time and expertise to use a RPA for these procedures so the rads could continue to read studies. I’m sure there are more opportunistic PAs out there who would try to branch out and take over services, but if you treat your RPA well, it *shouldn’t* be a problem.
why wouldn’t it be a problem. They see their income, and your income, and they think “I am working as hard, doing similar stuff, I want the same money” that is human nature. AANP has as a declared goal payment equality with physicians, and they got it in Oregon (forget that the NPs won’t see it, the companies who hired them, and are in collusion with AANP will get the $, the NPs will get as little as CVS or whoever can manage to pay them.)Worse -the admin sees this and decides they want to cash in, so they fire 3 rads, and put in PAs to now do biopsies, drainages, etc. OR … OR – as I have discovered – one put in a PA to do neurointervention. Now there is some damn good billing.
What is to stop them???
Absolutely nothing.
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