Serious discussion about residents vs midlevels

I feel slightly incompetent compared to more seasoned midlevels who have been working for years and years in different areas of medicine

You answered your own question, obviously you won't look as smart as someone with years of experience working in a similar role as a resident. If they still know more than you as an attending then you should prob start to worry.

I think it's natural to have to these feeling of inadequacy, and it's hard for older doctors to empathize because the midlevel surge we have right now simply did not exist 20 years ago. eg the ED at my transitional year program was basically run by 6 PA's and three MD's. When we did our one month ED rotation the PA's made me feel so dumb with their speed, their efficiency, and their knowledge of common ED presentations. Did my best not to let it get me down.

So here's the thing right. NP's/PA's are good at their highly specialized lane. They learn the algorithm/workflows they need to for their position and bang through them very efficiently. I work with NP's when I rotate in our neurocritical care unit, and during my first few weeks there they were so helpful, and they are still faster than me at getting things done, but I also began to see that they are really, just working very efficiently through their algorithm.

It's comparatively harder for them to think outside that algorithm when you need to make higher order decision making based on the clinical scenario in grey areas, and I had an easier time with that, because I understood more about the underlying processes.

Example: Patient comes in post cardiac arrest for targeted temp management in the setting of anoxic brain injury. NP has the timeline for the protocol for cooling, rewarming and neuroprognostic studies and their timeline down. But, what happens when you need to think about drug clearances, intracranial pressure crises during rewarming, contraindications to the medications/modalities we most commonly use to control shivering? I know how to navigate those questions better than they do, and how to adjust the algorithm for cooling, rewarming and neuroprognostic study acquisition in my experience.

As an attending who precepts both IM residents and mid levels:

The mid levels are usually really good about managing a chest pain obs, syncope obs, ambulatory dysfunction. My residents aren’t allowed to admit obs patients but they’re really good at managing train wreck transfers who may or may not have alcoholic hepatitis and intrinsic renal failure. There are a few mid levels who could handle it, but would take them hours to work it up and write on it. What I believe you do better as a resident is not anchor on a diagnosis if the chief complaint is chest pain but they’re really there for something else or seeing the patient on multiple psychiatric medications and attributing everything to psych.

Obviously results vary by resident but your differential diagnoses are more thought out and management is more detailed than an “if A then B”

So maybe they’re really good at simple bread and butter but they’re not really more competent than you

I saw this on my ER rotation and I think it pretty much sums up NPs/PAs. (Ignoring the ongoing push for “independent practice” that’s currently going on). Midlevels will always be at the level of a resident, throughout all of their career. They’ll have some freedom to pick and choose treatment, but will always have to present to someone above them. And I’m not saying they’re bad at all, simply their scope is very limited and will never truly function at the level of an MD/DO.

I feel like the fact that you feel incompetent means you are already above many mid-levels. Better to be aware of your limitations than confidently make decisions without strong knowledge base or have dated standards of care.

At least that’s what I tell myself to feel better.

They will be more competent than in you in one area that they've worked for awhile. But they don't go through rotations anymore like you do. Your ability to switch from GMF to cards consults to MICU to onc wards already means your knowledge base is beyond them.

Feel incompetent at what? A subspecialty? That's because the scope is so narrow and they've done the same thing repeatedly for years.

Now if it's like general hospital medicine or family med clinic or any generalist field - you should be far more competent than a typical midlevel and definitely better as a whole. If you're a PGY1, you may be caught up in learning logistics still which suppresses your clinical acumen briefly. But they should not even be near you in terms of knowledge or clinical acumen.

Again, this is extremely true for generalist fields. General medicine floors, the ED, ICU, clinic etc is where I see all the dumb stuff from midlevels. Something like cardiothoracic surgery? Not as much... but I've still had convos with very experienced midlevels in narrow fields and walked away rolling my eyes.