Fair warning this will be quite long and it's partly a seething rant about how in the past five years it's become clear the future of Medicine is a two tiered system where the rich see physicians and the poor see "providers" of varied expertise, and how this is being mediated and driven by Private Equity groups and exploited by an idpol discourse.
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This is an issue that has been brewing quietly in the background for the past decade, but has gone into overdrive the past five years. As someone who grew up with several physicians in the family, and who eventually went on to Medical school (even if only to abandon it afterwards ), this is an issue I hold close to my heart and one that I've researched as thoroughly as I can as it affects not only my former colleagues and friends, but all of us in this country, especially the most vulnerable, the poor and the uninsured.
It is no secret that most Americans aren't exactly well versed in Biology, Medicine or in the Medical system itself, and that is likely by design - it is easier to manipulate your population into denying itself their rights to socialized Healthcare if they have no idea what Healthcare even is, what a physician actually does, what Medical education entails, what other members of the medical team do, and why and when they should go to the hospital. People in America are afraid to call ambulances because they can't pay, they leave their friends to overdose and die on the streets because they're scared to be arrested, they have their children drink bleach because they read on Facebook that it cures autism, they spread black salve on their tumor because they can't afford chemo and their $20 a session by correspondence "dr" chiropractor told them it works, etc.
This country has no scruples whatsoever when it comes to Healthcare because it sees Medicine as a Business, not as Science or Art. This is important because it's this ignorance that allows for the issue I'll discuss to even happen - if everyone was better informed, this shit would never happen.
This country sees physicians as slaves and/or providers of services, not as physicians and healers who spend their entire lives consistently studying and improving themselves and dedicating themselves to helping others. Patients are customers. The system treats residents and students like nothing more than warm bodies they can use to squeeze more money for more profit for the hospital's shareholders and an extra % more for the CEO's yearly bonus or the University's budget. It's a clownworld system that has been in place for decades that no one has dared to do shit about because it's "worked" and because after 15yrs you could "at least" earn a good salary to live a good life and have a family (after paying back you 250-400k debt once your 3-7yrs on 30k salary as a resident are over).
Well, those days are about to end, too. And now patients are going to die for it. Let me explain. If I don't make sense or this is all over the place, I apologize, ESL is hard and there's many ideas in this post.
I will start by outlining what it takes for your average kid to become a doctor and what the politics is like - this is kinda important, so bear w me.
So, your regular kid will need a perfect to almost perfect GPA (especially nowadays), a very competitive MCAT score, thousands of hours of community/volunteer service that is relevant to their degree, hours of research experience and to charm some asshole during interviews. This shit by the time they are 21 years old. Once they are in Medical school, you can count on these kids having about 30 classes not by semester, by module. It is not just excessive, that shit is inhumane. My first year was bad, but by year 3 (when you're about to touch people), half your friends have had a nervous breakdown - or 5. Then you have Step 1, and that score pretty much determines what residences you can hope to match into once you finish school. It's insane pressure. Then you finish. Some people never fucking match, then it's just over.
Suicide is actually common, but talking about your mental health and admitting you are suicidal might be shooting yourself in the foot. Many cases of kids just not getting ahead once that happens - regardless of the "legality" of that. Many such cases.
Once you match, shit starts. Intern year is the worst. Everyone treats you like shit. Older residents treat you like shit, attendings will be a crapshoot, but you can count on nurses treating you like a fucking moron, every time. It's just a thing, everyone knows it happens. The medstudent and the intern are fucking idiots, right
Then you progress - until you're chief resident then an attending, when you FINALLY start making money and paying off debt.
Residents work 80-100hrs, for 30k.
Residency can last 3 yrs (IM, psych, OB) to 7yrs (some surgical specialties). Some docs will then go on for Fellowships (2years) afterwards. Throughout this entire process, there's Step 2 and 3, plus various Boards of the different specialties. Adding up the years, that's 15+ years of education, 250k dollars of investment, a LOT of mistreatment.
And, of course, being the cash cows of the hospital or hospital group or hospital owned practice or related leech staffed entirely by cons *ltants, MBAs and bus *ness school failsons.Those groups are themselves entirely owned by our friends from Priv *te Equ *ty groups
The people making the rules and running the hospital, the administr *tion heads, CFOs and CEOs aren't physicians as you'd think would be the most logical; they're generally nurses with administration MBAs
, so Karens with 2yr courses and PTA mom personalities. No fucking joke, that's literally the stereotype for a fucking reason. These people have 0 loyalty to the physicians and 0 knowledge of medicine; their loyalty is to the shareholders - and they fuck the students in the ass without lube consistently, as they can't complain or they risk losing their spot. The CEOs are generally financebro aholes who failed upwards or random soulless cons *ltants from an unrelated field, they run the entire thing with 0 regards to patient or staff safety.
Remember COVID and the PPE shortage? Entirely, squarely on the shoulders of hospital admins, who, ofc, weren't there lmao, they were happily working from home and shit, and the shortage never extended to THEM, no. They're inportant.The Katrina hospital disaster response shit, for those who remember? The admin said good fucking bye and the docs almost went to prison for murder because they had to compassionately ease the pain of some of the patients. No one heard shit from the admins, because they obviously got the fuck out the second it started raining, lmao. This isn't new, Hospital admins are soulless. The only physicians that EVER get anything out of those ghouls are surgeons, because surgeries are the sacred golden cash cows of the hospital, and you can't survive without surgeons.
Other physicians can be discarded.
This isn't widely known, but several attempts at unionizing, especially by resident docs, have been squashed. Obviously, it's hard for them to even try, for several reasons: the class position of most residents is on average middle to upper class; most poor kids can't afford medschool and a full time job, or the education it takes to even make it to school, that makes it so they have 0 knowledge of how to organize a union and the residents can't afford to shake the boat, they're thousands in debt, if they get kicked out of residency, it's over - the skills aren't translated into other jobs easily, and the hospital admin is VERY oppressive of them. The older docs simply don't want to put their careers and families at risk.
This is slowly changing though, as a bunch of docs are seeing their spots being filled by other "providers". A lot of new docs are scared of wtf they'll do in a decade when their specialties go to shit and their spots are filled by midlevels. All that money and education and shit taking for absolutely nothing.
Now wtf is a mid-level?
Often a nurse, with a Masters or a """doctorate""" (Jill Biden level), or not a nurse at all, but with a new ass Masters they made up less than 10yrs ago that somehow allows them to practice something that isn't Nursing OR Medicine, but convoluted enough to make the hospital money.
A nurse administers meds, does bedside care, coordinates care with the physicians, wound care, take bloods, etc. They don't practice medicine, they practice nursing. To graduate you need an associate degree or a bachelors- depending on the hospital you can work on the same capacity, and generally specialize in an area. They're invaluable to the Healthcare team.
What's happening is, in the US they've created mid-level categories; Nurse Practitioners (NPs), Physician Assistants (PAs) and Certified Nurse Anesthecists (CRNAs), and I'm sure there's some new ones cooking. The justification, of course, was Idpol
It was all about creating a role to fill a need in poor rural communities ravaged by the opioid epidemic where no doctor wanted to live, to fill the gap in the inner city where minorities experience RaCiAl BiAsEs in Healthcare and no access to primary care because no young student wants to do Primary care, to provide care to mentally ill patients in mostly mInOrItY communities
to improve the dIsPaRiTiEs, etc. Obviously, that never happened.
They became a "separate but equal" role to PCPs (
), then they became a cheap alternative to physicians to run ICU floors (
2), then they started opening fucking pain clinics and overprescribing opiates, but "it's okay because they're physician supervised", and now it's transformed into a monster where they have a fucking entire lobby dedicated to them practicing independently from ANY supervision AT ALL - and get this, they've gotten it in some states.
Now, take a seat, this is great:
To become an NP? The requirements:
- YOU DON'T EVEN NEED TO BE A NURSE. There are DIRECT ENTRY Masters of Nursing NP programs They're also 100% ONLINE
- 8 semesters
- 500 hours of "clinical experience", which amounts to "shadowing" another NP, which can be done "remotely" via Zoom.
- You can also be a DNP, a "doctorate", without thesis, ofc.
- pass the National exam, that isn't, of course, even close to the MCAT or Steps of Boards.
- you can then choose your specialty like Pokémon, and change if it doesn't suit you, on the job. That is a "perk".
The new "fad" now is pain and ketamine clinics. 5k a session per patient in packets of 10 sessions each.
bo$$ babe!☆°
I'm not fucking joking. Now, if you go to a hospital, or if you call your insurance group to find a specialist, say, a new psychiatrist for an appointment, they will tell you something like "you will be seen on day x with PROVIDER y", and that's because now everyone is a "provider". It's not doctor anymore, because °☆♡everyone is equal♡☆°. Then when you arrive, you get to see Ms Karen, Psych DNP, who will give you Lithium for your sads, Xanax for your anxiety, Ambien for your lack of sleep sometimes, Adderall for your sleepy, and some other shit that interacts with some other shit, but it's not her fault - she never took pharmacology or biochemistry, how the fuck could she even know??
A hospital will hire 5 NPs for the price of 1 doctor. And they are. And the idiot who pays for it is you and your loved ones. Literally, you pay the SAME amount for "Dr" Karen, DNP as you would for Dr Chad, MD/MBBS/DO, and the fucking hospital/clinic pays her less and pockets the difference
Don't you feel better for like, having helped eliminate those awful, awful Healthcare DIsPaRiTiEs?
Oh, and get this: because they aren't doctors, they are lawsuit proof, kinda. It's an iffy area, still. Malpractice attnys are salivating, tho. However, new laws need to be written and regulations made.
As it stands, if one of them kills you, too fucking bad. The doctor "supervising" them gets fucked, and the Healthcare group/hospital owned practice/leeches/ghouls get sued, their insurance is who pays, Ms Karen provider is shielded. Amazing. Ms Karen is governed by the Board of Nursing, that knows 0 about Medicine. When this shit has happened in the past, they haven't done shit, they've said they DON'T KNOW how to discipline because Medicine is BEYOND THEIR SCOPE (no. fucking. shit.) and Karen, DNP was practicing beyond hers. No, this isn't comedy, this shit is real, UNREGULATED, and guaranteed to be happening in your neighborhood hospital and at your PCPs clinic.
Also, their organization (of course they have a fucking organization, the grifting never ends - the AANP) hardcore lobbies them to practice Medicine, while insisting they practice Nursing and yelling at doctors demanding they be recognized as equals and also demanding they be allowed to be unsupervised and be able to open clinics. Guess who fuels some cash monies to their coffers on the DL, something physicians don't have, (since the AMA is CUCKED beyond belief and FUCKING NEVER stands behind docs, it's fucking sad): PE firms
Oh, you want to weep? Read this:
https://www.nbcnews.com/health/heal...rol-many-hospitals-ers-nursing-homes-n1203161
Now, why would pr *vate equ *ty firms be so invested in funding for lobbying for NPs?
I'll let you r *tards figure that out by yourselves - what I CAN say, is that when I slaved for PE, other than fucking prisons, our targets were lots and lots and lots of suburban hospitals, urgent cares, trauma centers and ERs. The more debt, the better, the easier to negotiate the terms with the ret *r- I mean, with their current obviously very, very smart MBA filled group of genius overhead
Tbf it was quite satisfying to see their Karen PTA adm *ns and fat BBQ Kevin cons *ltants getting the boot or their overinflated salaries cut in half or being replaced by mid 20s NYC kids in suits.
It is, however, very fucking sad to know they'd simply fucking cut off old attendings bcs "cost" or ROI, or straight up just let go of physicians or nurses because of some stupid new algorithm or whatever. That's what PE does after takeover with any new acquisition, they neuter you. And every single place Bl *ckstone acquired, they got one of their groups to run, and their groups hired a shit ton of midlevels to staff them.
They made SO much fucking money with Covid, it's obscene.
STONKS.
Meanwhile, your regular primary care/internal medicine resident can't fucking get a fucking break. Imagine being 250k+ in debt earning 35k in a big city. Imagine being offered even less to go to rural buttfuck Alabama with 0 guarantee of a job afterwards because the hospitals are fucking closing. Clownworld. You want to do internal med or be a primary care doc in your community, but your fucking community is being taken over by midlevels and your hospital treats you like shit. You're thinking, maybe I should do psych?
Oh, fuck, but there's only so many spots and you don't match, wtf. Here's to another year of...ABSOLUTE FUCKING PANIC.
Yet, the government won't open more spots for some fucking reason and hasn't in DECADES and won't increase your hunger wage slavery salary while even state schools increase tuition, because they CAN and because they bow to research hospitals that plunge the knife into their poor students and twist for good measure.
Meanwhile, that PA that misdiagnosed that patients pneumonia now makes 180k a year and only went to school for like, 3 years with 0 debt.
I know I am not just beating a dead horse here, I am being a horse necrophiliac at this point, but I really just want to drive this home, just how insane the entire thing really is; there are actual Facebook groups (yes, Facebook) where PAs and NPs go to post asking about what others think the diagnosis of their patients is, while on the consult. They post the poor SOB's test results (because fuck HIPAA lmao) with screenshots so the other powerful bo$$b43bs can offer their opinions on diagnosis. During the fucking consult. While the fucking patient probably waits inside the consult room. Like can you fucking imagine this shit?!!
You have endless drivel about criticism of midlevels being muhsohjeeknee due to Nursing being a feeeeeeeemale profession, somehow. About "you must hate the poor and minorities" over the access to Healthcare propaganda crap, the "doctors are elitist asshole rich creeps", I mean, choose your poison.
And then, IMHO, the worst because it's the most dangerous, you have the nurse anesthetist, which are like NPs but they run anesthesia in the OR "under the supervision" of an anesthesiologist. The anesthesiologist is still supposed to induce and to take you out, and in theory, this is only supposed to occur in simple procedures.
Obviously, that's not happening, because of course it isn't.
CRNAs are also nurses with an extra course. They haven't gone through medschool, they haven't gone through residency for anesthesia, they don't know pharmacology or anatomy or biochem or biophys or neurochem or anything remotely relevant whatsoever to what to do if a patient fucking crashes under anesthesia. So, naturally, people have started to, you know, DIE. You'll see their lobbying organization (something something grift must go on) cite studies about how the outcomes are "similar to their anesthesiologist counterparts"
, but it doesn't take an advanced aut *st to find gaping flaws in those ~studies~ prolly paid for by Bl *ckstone and Pal *din Capital
However, they're cheaper to the cons *ltants and the ROI is higher than those overpriced, fancy ass anesthesiologists. The soulless ghouls in hospital admin have done the calculations and decided that, even if they sue the "supervising anesthesiologist" who isn't even there, the payout is worth it, because they can only have that 1 anesthesiologist for like 5 CRNAs and save a shitton and the stoopid patients don't even know. The CRNA says "I'm rly sry, lmao" and moves somewhere else or opens a pain clinic, Pal *din Capital
negotiates a payout, everyone (except the patient, I guess, but who cares) is happy. Stonks
Literally they don't give a fuck if you die. They have factored in that patients WILL die sometimes due to mid-level's lack of medical experience and knowledge but it doesn't fucking matter because that way yields more $$$$$$ to the hospital and the pockets of the shareholders.
I read yesterday about a hospital somewhere where they have fired ALL anesthesiologists and have hired ALL CRNAs. Nothing can possibly go wrong. (It's on the noctor subreddit, and I'm too into this to look for it, but apparently it isn't a rare thing).
Now I've gotten exactly where I wanted to get with this rambling, convoluted essay. I have nothing against nurses in particular, tbf I respect them a ton and most of them aren't happy themselves with scope creep - it's not the best of them that take the NP route, after all. I am LIVID with a system that allows, that cheers for the downgrading and the straight up erosion of patient safety for an increase in profit. A system that throws their physicians and students in the trash. It's disgusting.
We're rapidly marching into a future where if you're wealthy, it's cool, you'll see a Dr for your issues, you'll be put under by an anesthesiologist, you'll be prescribed an evidence based treatment for your intractable depression, you'll be operated on by a board certified surgeon.
If you're poor, though? You can expect to be put under by a CRNA who may or may not have paralyzed or maimed someone, you might be prescribed evidence based treatment for depression or not, since Psych DNP doc Karen never took psychopharmacology or did psych residency, and in 10 years if you have appendicitis you might be getting cut by Provider Certified Surgical Specialist (it's now a thing in the UK, coming soon to a hospital near you)
Now, you have a RIGHT to advocate for yourself, to ASK for a physician when you make an appointment. When someone puts you in with a provider, speak up. This shit is straight up distopyan and will kill people. Problem is, and this finally ties with my first point, nobody knows any of this; Americans have no fucking clue there even IS a difference between provider and physician. The propaganda that NP and MD is "the same" works pretty fucking well. Installing this 2 tier distopyan system is being ridiculously easy.
I used to laugh when rightoids would go on about population replacement or population culling conspiracies, but it really DOES seem they just want to eliminate the poor.
Socialized medicine has never been farther away than now - this administration will be the WORST thing that has happened to this country in a LONG time.
This is the new reality for the poor and the new middle class - there will be no escaping it, no negotiating anything. Unless you have money to access the 1st tier of Medicine, you're done.
As it's becoming true of education now, with the removal of elite meritocracy-based entry schools in favor of "racially based" entry, any and all chances of upward mobility are being slowly eroded. We're now being more and more entrenched into poverty and there will be no way out for our children. It's getting bleak out there.
The recent idpol about racial disparities in Healthcare is being used to fuel this shit, too, with the bald faced lies about the lack of PCPs in rural communities, the lack of willing residents in Primary and IM, this absolute bullshit about mid-levels having the same education/experience/capacity as doctors and having been created ESPECIALLY so they could CURE this "disparities".
It's a fucking trap. They're NOT working in these needy areas, they're not going to buttfuck, Alabama or the south side in Chicago or in primary fucking care or psychiatry in Oakland; they're in fancy areas doing Botox and fillers, in LA doing ketamine clinics, in good suburban hospitals running ICU floors, and filling anesthesiologist spots in hospitals looking for more $.
If something isn't done to awake some sort of consciousness in students and in the population that's being served by this new generation of doctors, everyone loses. Neoliberalism is going to kill everything and everyone and this really is the end stage - this would never have happened even 15 years ago.
RaCiAl DiSpArItIeS my ass. Idpol will destroy this country.
Thanks for reading my unironic seethe treatise.
Sources and further reading:
r/noctor r/residency www.midlevel.wtf
www.reddit.com
