NP's and pain

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How many of you have NP's in your office?

If you do, what do you allow them to do? Trigger points? Botox for headaches?

If your office has enough volume, I would suggest hiring a MD or DO pain physician rather than a NP. The NPs billings to insurers are frequently paid at 85% of the physician rates, you get many many phone calls from the NP wanting to know how to handle situations, they cannot take interventional pain call for you, and are expensive. In the back of our minds always exist the prospect that a NP that has been instructed "too well" by the physician will employ many techniques (including interventional) used by the physician.

on the other hand, NPs can be made responsible for follow up appointments, especially on med management patients, that can clear out much needed space and time for procedural appointments. NPs (and PAs also) cost a lot less, probably on the basis of 3 fold less than an MD.

I have 1 NP who sees the new evals with me (does the vast majority of the dictation, saving me lots of time) and sees followup patients. She does only trigger point injections that have been decided by me to be appropriate. The other pain clinics in the area all seem to employ a 1 NP/PA to 1 MD pattern.

When it is all said and done, given the hassle of NPs calling you or inappropriately not calling you, making bizarre decisions, getting paid less, requiring the doc to see some patients due to insurance or scripting limitations of their particular insurance company, vacation time for the NP, inability to cover call independently, making errors, knowledge deficits, either being too obsequious or pissing off patients, malpractice coverage for NPs/PAs, 8-4pm mentality, etc, it is really a wash. I had a good NP, but she is leaving for a practice much closer to her home and I will not replace her with another NP.

Do you guys view NPs and PAs as pretty much the same thing? Is there a practical difference between the two, such as training or rules pertaining to supervision, etc.?

There is a practical difference. PAs are usually males that think themselves to be a doctor and NPs are usually females that think themselves to be a doctor. Outside of that, PAs may have different prescribing privileges in some states (restricted) and must have their charts reviewed, and are supervised. The NPs in many states are completely independent, have a "collaborative agreement" in which 5% of their charts per month are reviewed by a non-supervising physician. Both can be problematic due to a lack of sense of any limitations on their scope of practice.....

I think the one class that doesn't get taught at PA or NP school is "critical thinking"...

from a financial point of view, a PA/NP is a better deal
from a sleep better at night/improved life-style point of view, an MD is a better deal.

Originally Posted by Tenesma

I think the one class that doesn't get taught at PA or NP school is "critical thinking"...

from a financial point of view, a PA/NP is a better deal
from a sleep better at night/improved life-style point of view, an MD is a better deal.

PA's: think they are a doc

NP's: "know" they are a doc

Originally Posted by ghost dog

PA's: think they are a doc

NP's: "know" they are a doc

completely disagree.

PAs = Physician "Associates" who go to Med school, and think they are mini-docs because they spend some time at "Med School"

NPs = Nurse Practitioners that are nurses first, think like nurses, and hopefully dont delude themselves into becoming self-aggrandizing and full of self-import and start thinking like they are docs

both need to be supervised closely, and more importantly vetted closely before accepting them in your office. Make doubly sure that you talk to their prior employers and references directly to make sure they didnt overreach their roles in the past, cause they may do it again.

both can be trained to work "collaboratively", but a careful pain doc should train that midlevel to be an extension of himself rather than as a separate practitioner. Counsel them/censure them if they start doing things unseemly...

Originally Posted by ghost dog

PA's: think they are a doc

NP's: "know" they are a doc

i agree with ghost doc.

NPs are far more annoying to deal with and have many more psych issue about not really being a physician.

Just remember that you are vicariously liable for everything your NP or PA does or does not do. When a lawsuit comes, they go after the deep pocket - the doctor. When you look at lawsuits against midlevels, they almost universally point the finger at the doctor and blame them.

Also look at your state laws for opioid prescribing. Many states restrict midlevels to Sched 3 or higher.

I had an NP for a couple years. I basically broke even with her, but it gave me a little more time with each patient. She picked up on several medical things I may not have noticed, as she still felt obligated to put a stethoscope to every chest, every visit.

Originally Posted by PMR 4 MSK

Just remember that you are vicariously liable for everything your NP or PA does or does not do. When a lawsuit comes, they go after the deep pocket - the doctor. When you look at lawsuits against midlevels, they almost universally point the finger at the doctor and blame them.

Also look at your state laws for opioid prescribing. Many states restrict midlevels to Sched 3 or higher.

I had an NP for a couple years. I basically broke even with her, but it gave me a little more time with each patient. She picked up on several medical things I may not have noticed, as she still felt obligated to put a stethoscope to every chest, every visit.

My country doesn't use these midlevels to the same extent as the US ( thank god).

However, I hit the jackpot - hired a nurse who was a doctor / cardiologist from China. She is incredible. She has none of the attitude / slack work ethic you sometimes get from nurses ; I am extremely happy with her.

I have actually heard CRNAs state they they have less lawsuits for lower amounts of money than anesthesiologist because they are BETTER. They really think that. It is not because if the nurse is sued for $10,000 the doctor will be sued for 10 million. No it is because they are better.PAs, NPs CRNAs and teenagers think they know everything because they just don't know what they don't know. Teenagers get it when they are about 40, mid-levels never do.

[QUOTE=PMR 4 MSK;12737348]Just remember that you are vicariously liable for everything your NP or PA does or does not do. When a lawsuit comes, they go after the deep pocket - the doctor. When you look at lawsuits against midlevels, they almost universally point the finger at the doctor and blame them.
QUOTE]

The general tone here is adversarial toward NPs and PAs. Don't these folks work in collaboration with you and with your supervision/permission? How is it that they are running around out of control?

Originally Posted by facetguy

The general tone here is adversarial toward NPs and PAs. Don't these folks work in collaboration with you and with your supervision/permission? How is it that they are running around out of control?

I think it's leftover animosity from the previous anesthesia docs

News flash. Nurses in general HATE YOUR GUTS. They smile and behave civil when you are present but when they are together and think you are not listining OMG! Some doctor called them a stupid nurse 13 years ago and they never got over it, another rolled their eyes at something. These woman can hold serios grudges and when they get together it is like lynch mob

Originally Posted by facetguy

The general tone here is adversarial toward NPs and PAs. Don't these folks work in collaboration with you and with your supervision/permission? How is it that they are running around out of control?

Depends on the NP... but many are not supervised well, and run amuck, shame on the supervising MD

Originally Posted by bedrock

I think it's leftover animosity from the previous anesthesia docs

do you mean the CRNA thing? i didnt understand your post...

Yes

Don't think that NP and PA don't resent the he%l out of you. They just don't say that to your face. Look at their actions, NP's have a separate nursing board governing them with independent practice rights, PAs want independant practice. They want to be called physician associates rather than assistants. They would like to think that they can be as good or better than us with less than half the training. If you think this is not the case, you are naive. Wake up. Judge by their actions not their words. Do any of them stand and say publically, "hey we really don't know what the heck we are doing, thank God for medical supervision." Never, they run around in their white coats as wanna be doctors. Some of you guys are major schmucks, I can't believe the level of naivetee. You will see later in life what is very clear to those experienced now

ahem...

i believe, and dont quote me on this, but i have a bit more experience working with NPs and PAs than you do. and i can tell you that the average clinical NP and PA want to take care of patients, and do not want the burden of being an MD.

the average NP and PA actually revel in the fact that there is someone else who is more responsible than them. Yes, there are outliers who think that they are better than doctors, and ive met a few of them. but the average working one does not think like that, and they do not have doctor envy.

its their governing boards, and those in academia, that are full of themselves and keep pushing for greater roles.

aren't you married to one duct?
Sleeping with an NP does not make you an expert on their maneuvers

The CRNA,NP, and PA organizational leadership is elected by the CRNAs,PAs, and NPs. They know exactly what they are doing by feigning obeisance to physicians while electing caustic and hostile leaders to carry their hidden banner of independent practice and parity in income while expanding their scope of practice to the point of the absurd. There is absolutely no question.

Listen to the voice of experience

I agree w/ Duct... in my experience it is the academic leadership of PAs/NPs that are pushing for full autonomy... and primarily NPs/PAs during their training buy that diatribe hook/line and sinker...

however, once they are out in the real world, most NPs/PAs are perfectly happy clocking in and out, and not having to take the ultimate responsibility... the older they get, the more they realize how little they really do know, and become even less interested in acting like "docs"...

but the trend is there - just look at the recent letter from Sebelius to AANA (February of this year) stating that she will look into allowing CRNAs to practice interventional pain...

They are happy clocking in and out but enjoy playing doctors, acting as if they know as much, can do as much, should be paid as much, supposedly more than half of our training was completely unnecessary. However, when crap hits the fan, they are quick to point their fingers at "the doctor". Open your eyes, they are petitioning for independent practice, N.Ps, PA,s CRNAs. Forget what they say to your face, Oh I'm so glad you are here as "the doctor" you are paying them, look at the actions of their paid mouthpieces.
They CAN get wiser with age but not all do. Teenagers, N.P.s,P.A.s,CRNAs have a tendency to know a little and think they know everything. They don't know -what they don't know, they don't know enough to be scared. A person with limited knowledge and training who realizes that and seeks appropriate counsel is valuable. But too many think they know it all.

Originally Posted by Tenesma

I agree w/ Duct... in my experience it is the academic leadership of PAs/NPs that are pushing for full autonomy... and primarily NPs/PAs during their training buy that diatribe hook/line and sinker...

however, once they are out in the real world, most NPs/PAs are perfectly happy clocking in and out, and not having to take the ultimate responsibility... the older they get, the more they realize how little they really do know, and become even less interested in acting like "docs"...

but the trend is there - just look at the recent letter from Sebelius to AANA (February of this year) stating that she will look into allowing CRNAs to practice interventional pain...

they must be greasing her real good.

my wife agrees with me - that the admin people are out of control.

doctors should be doctors, NPs and PAs are midlevels that need to run things by doctors pretty much all the time.

i worked with NPs and PAs in a variety of circumstances, but the majority of my working with them was in the ED.

to reiterate a point - imo, even those experienced PAs and NPs, while they know a lot, still are at the clinical level of a, at best, 2nd year resident, and that does include not only the ED midlevels but all the other hospital based midlevel providers covering a sundry of services, from NS to ICU to burn...

I do not agree with the comments on here regarding NPs and PAs. These practitioners are physician extenders. They are there to help your practice. Yes individual people you have encountered can be characterized with some of the statements made on here but
you need to look at what these practitioners can do for you. They allow you to see more patients, do more procedures, do less paperwork, and spend more time with your family.

They are not going to be asking for partnership, they are not going to steal patients when they leave, and work for 1/3 as much as an MD. Why would you hire another MD unless you are extended beyond the means of physician extenders, especially in light of the healthcare environment out there.

The main issue is finding a smart PA/NP who you can work well with and training them well. They can do most everything that you need them to. Yes you are liable for their work, but it is your responsibility to.
PA's are typically cheaper than NP's, at least in my area by 20% or so depending on experience.

Our VA just gave NPs license to independently prescribe narcs. I actually think they might be an improvement from the current situation. Maybe they will listen to my recommendations. Maybe...

Originally Posted by hyperalgesia

Our VA just gave NPs license to independently prescribe narcs. I actually think they might be an improvement from the current situation. Maybe they will listen to my recommendations. Maybe...

just dont teach them how to play with needles

IMHO, as a patient, I've found NPs to be surprisingly more condescending and self-righteous than MDs (who are typically thought of in such terms).

I'm friends with two DNP ("doctor" of nursing practice), and I tell you the very basic stuff they don't know is horrifying. One of them who's been in practice for a couple years came to me the other day and told me proudly she just did her first I&D of an ingrown hair. Her first I&D *EVER*, mind you. Asking very very basic stuff like whether and which ABX to put the patient on, whether to place a wick, how to explore the wound, etc. I mean super, super basic stuff.

I did one the first hour I was in the ER as a medical student.

Originally Posted by ResCon

IMHO, as a patient, I've found NPs to be surprisingly more condescending and self-righteous than MDs (who are typically thought of in such terms).

My experience as a med student with obs / gyne RNs still haunts me to this day. What a bunch of mega biatches. I believe they were under the impression that they were "doctors", as they got to catch a baby once in awhile when the Obs didn't make it to the delivery in time.

If I didn't hate obs to begin with ( and I did), the interaction with these highly unpleasant and rotund group of individuals certainly would of done the job very nicely indeed.