It's Happening....Only A Matter of Time

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"It's about making connections to see how this pathology affects patients in multiple different ways, from several different angles."

That sounds a lot like what doctors do every day.

Maybe you should just go be a doctor.
 
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Let's take a look at all of the corners being cut here:

(1) Bachelor's in nursing vs taking all the pre-med required courses
(2) Skip med school (too much time, effort, and money; not to mention that you actually have to have the minerals to get in)
(3) Skip residency altogether (see above) and go straight to "fellowship"

I wonder what the requirements of this program are. Why are we making the same mistakes all over again in CCM?
 
Seems irresponsible to me. Maybe Idiopathic can comment as I believe he is a Vanderbilt CCM fellow.
 
This is why when I was discussing CCM fellowships with a recent grad from Vandy CT anesthesia he said "Dont go to Vandy for CCM!"
 
This is why when I was discussing CCM fellowships with a recent grad from Vandy CT anesthesia he said "Dont go to Vandy for CCM!"

That's stupid logic. PM me who said that to you so I can call him up and verbally punch him in the balls.

In regards to that article and the "fellowship" - some of the quotes and the terms used to describe their extra training are aggravating and infuriating to say the least. Do I think part of it is gamesmanship by the nurses to blur the lines between residents and NPs? Absolutely. I get as fired up as the next guy by the proliferation of midlevel providers and claims of "equivalency."

However, this program and the NPs at Vandy don't negatively affect my experience as a fellow at all. Our clinical acuity and demand necessitate their presence - we just don't have enough physician bodies to get all the work done. They have defined roles and, for the most part, are cognizant of their limitations.

My educational/clinical experience, and that of our residents, takes precedence and has not been compromised by the NP training program or the NPs themselves.

The current reality is that physician extenders are going to be part of the healthcare team; we are going to have to work with them in some capacity or another. To that end, we are learning how to manage them in this fellowship which only makes us better prepared for practice in the private or academic sector.

The Vandy CCM fellowship is top notch and our clinical exposure and breadth of experience are honestly some of the best in the country. I think that the added exposure to NPs and NP students (along with pharmacists, pharm students, nutritionists etc.) as part of the CCM team has given me valuable experience with managing multiple providers with differing skills, personalities and roles.

The fellow/attending are the leaders of this team and that is not going to change.
 
Seems irresponsible to me. Maybe Idiopathic can comment as I believe he is a Vanderbilt CCM fellow.

I dont understand where the problem is. We have over 200 critical care beds. We do not have enough interns, residents and fellows to take care of all the patients while still learning about actual ICU management. The NPs provide continuity in their respective units and they are there 24/7, so residents dont have to be (and since interns cant be). I imagine that I will have nurse practitioners working for me in the ICU for the entirety of my career.

Would you rather train the people who work for you or have someone else train them? Or do you think an large ICU conglomerate can function without midlevel providers?
 
My CCM program was trialing it's first two NPs during my fellow year. Both had been around the ICUs in various capacities. They were quite helpful. Very good at keeping the interns organized, following up on scut, writing transfer orders, etc. The residents and interns still did the admits and handled the bulk of the service. It added good continuity and smoothed transitions. I doubt the residents had complaints about their presence.


On the iPhone
 
Gah! When will it end?

I have two anecdotes I thought you guys might get a kick out of. I'm an UG finishing up and alot of my friends/class mates are premeds and have taken the prereqs with me. As you might imagine as we are drawing close to the end and application season is coming up many are having second thoughts about medicine as a career and have given up.

Two cases:

1.) One student took his MCAT twice: 20 the first time then a 22 the second. Gave up on medicine.

2.) The other has taken Organic chemistry 1 two times receiving a D then a C. They have taken Organic chemistry 2 twice getting an F and a D (D is good enough to graduate). The rest of their academic record is spotty too.

What do both have in common other than giving up med school? They're planning to go to an accelerated-combined RN/NP program next fall:eek:
 
That's stupid logic. PM me who said that to you so I can call him up and verbally punch him in the balls.

In regards to that article and the "fellowship" - some of the quotes and the terms used to describe their extra training are aggravating and infuriating to say the least. Do I think part of it is gamesmanship by the nurses to blur the lines between residents and NPs? Absolutely. I get as fired up as the next guy by the proliferation of midlevel providers and claims of "equivalency."

However, this program and the NPs at Vandy don't negatively affect my experience as a fellow at all. Our clinical acuity and demand necessitate their presence - we just don't have enough physician bodies to get all the work done. They have defined roles and, for the most part, are cognizant of their limitations.

My educational/clinical experience, and that of our residents, takes precedence and has not been compromised by the NP training program or the NPs themselves.

The current reality is that physician extenders are going to be part of the healthcare team; we are going to have to work with them in some capacity or another. To that end, we are learning how to manage them in this fellowship which only makes us better prepared for practice in the private or academic sector.

The Vandy CCM fellowship is top notch and our clinical exposure and breadth of experience are honestly some of the best in the country. I think that the added exposure to NPs and NP students (along with pharmacists, pharm students, nutritionists etc.) as part of the CCM team has given me valuable experience with managing multiple providers with differing skills, personalities and roles.

The fellow/attending are the leaders of this team and that is not going to change.


You are correct that in the short term, this is a very reasonable thing. The problem is the people that finish the program and then start moving elsewhere. Maybe they start moving in to small hospital ICUs first and looking to claim equivalency. Throwing out the Vanderbilt ICU "fellowship" to try to compete with an IM doc that runs an ICU in the middle of nowhere.

Long term it's a pretty dumb idea. You can have NPs helping with scut on the floors and ICU, just don't try to give them trumped up ideas about extra training.
 
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Is it worth it to risk the careers of all critical care physicians in order to adequately staff one institution's ICU needs? That is the question. Vanderbilt is being very short-sided, selfish, and irresponsible.

If it's just a "staffing" issue, why not hire PA's and train them appropriately? I find PA's to be as good if not better than NP's, without the threat of independent practice.
 
Gah! When will it end?

I have two anecdotes I thought you guys might get a kick out of. I'm an UG finishing up and alot of my friends/class mates are premeds and have taken the prereqs with me. As you might imagine as we are drawing close to the end and application season is coming up many are having second thoughts about medicine as a career and have given up.

Two cases:

1.) One student took his MCAT twice: 20 the first time then a 22 the second. Gave up on medicine.

2.) The other has taken Organic chemistry 1 two times receiving a D then a C. They have taken Organic chemistry 2 twice getting an F and a D (D is good enough to graduate). The rest of their academic record is spotty too.

What do both have in common other than giving up med school? They're planning to go to an accelerated-combined RN/NP program next fall:eek:

oh good, anecdotes.
 
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"Second to none".

Where have I heard that before?

Sorry man. Any fellowship which has NP "fellows" isn't the best in the country.

Not even close.

Why does Vandy continue to produce some of the most militant NPs in the country?

Edit: With what appears to be help from the anesthesia dept? One of your staff is the co-director for this "fellowship". I mean, seriously?

That's stupid logic. PM me who said that to you so I can call him up and verbally punch him in the balls.

In regards to that article and the "fellowship" - some of the quotes and the terms used to describe their extra training are aggravating and infuriating to say the least. Do I think part of it is gamesmanship by the nurses to blur the lines between residents and NPs? Absolutely. I get as fired up as the next guy by the proliferation of midlevel providers and claims of "equivalency."

However, this program and the NPs at Vandy don't negatively affect my experience as a fellow at all. Our clinical acuity and demand necessitate their presence - we just don't have enough physician bodies to get all the work done. They have defined roles and, for the most part, are cognizant of their limitations.

My educational/clinical experience, and that of our residents, takes precedence and has not been compromised by the NP training program or the NPs themselves.

The current reality is that physician extenders are going to be part of the healthcare team; we are going to have to work with them in some capacity or another. To that end, we are learning how to manage them in this fellowship which only makes us better prepared for practice in the private or academic sector.

The Vandy CCM fellowship is top notch and our clinical exposure and breadth of experience are honestly some of the best in the country. I think that the added exposure to NPs and NP students (along with pharmacists, pharm students, nutritionists etc.) as part of the CCM team has given me valuable experience with managing multiple providers with differing skills, personalities and roles.

The fellow/attending are the leaders of this team and that is not going to change.
 
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"Second to none".

Where have I heard that before?

Sorry man. Any fellowship which has NP "fellows" isn't the best in the country.

Not even close.

Why does Vandy continue to produce some of the most militant NPs in the country?

What is your frame of reference here?
 
What is your frame of reference here?

Columbia, Hopkins, Vandy have done more through programs and various news articles to support and advance the mid-level revolution than nearly any other medical centers.

This NP fellowship is a joke and threat. Why doesn't your department see that?
 
That's stupid logic. PM me who said that to you so I can call him up and verbally punch him in the balls.

In regards to that article and the "fellowship" - some of the quotes and the terms used to describe their extra training are aggravating and infuriating to say the least. Do I think part of it is gamesmanship by the nurses to blur the lines between residents and NPs? Absolutely. I get as fired up as the next guy by the proliferation of midlevel providers and claims of "equivalency."

However, this program and the NPs at Vandy don't negatively affect my experience as a fellow at all. Our clinical acuity and demand necessitate their presence - we just don't have enough physician bodies to get all the work done. They have defined roles and, for the most part, are cognizant of their limitations.

My educational/clinical experience, and that of our residents, takes precedence and has not been compromised by the NP training program or the NPs themselves.

The current reality is that physician extenders are going to be part of the healthcare team; we are going to have to work with them in some capacity or another. To that end, we are learning how to manage them in this fellowship which only makes us better prepared for practice in the private or academic sector.

The Vandy CCM fellowship is top notch and our clinical exposure and breadth of experience are honestly some of the best in the country. I think that the added exposure to NPs and NP students (along with pharmacists, pharm students, nutritionists etc.) as part of the CCM team has given me valuable experience with managing multiple providers with differing skills, personalities and roles.

The fellow/attending are the leaders of this team and that is not going to change.

Surely you don't honestly believe everything you just wrote. Has your anesthesia department learned absolutely nothing with all the struggles with CRNA's? You're training your own replacements - they're not looking to be part of your team. That you and your department don't get this is absolutely astounding. Thankfully there are anesthesiologists and anesthesia groups and departments around the country waking up to this. It's unfortunate that Vandy seems to be leading the way in the totally wrong direction. Very sad. Please - join the ASA, contribute to ASAPAC and wake up!
 
It will start with "critical access" hospitals with medium acuity and less than 10 ICU beds... then it will balloon into a much bigger problem. Have we not learned from the past?

I know many NP's that do a phenomenal job in the ICU. None of them have "fellowships" in CCM. This "fellowship" most def. has the potential to end up blurring the lines between MD and NP's (especially with doctorates). Of course... academics won't ever be affected.... <sigh>

http://thehealthcareblog.com/blog/2010/05/12/nurse-practitioners-doctors/

No offense to the 2 posters here from Vandy.
 
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On one hand, I agree with Vandy folks that there are not enough residents/interns to cover ICUs and NP/PACs are needed to do the scutwork. However, why go overboard and establish a fellowship program for NPs? It must be from some genius in the deparment of anesthesia. It seems Anesthesia is the ONLY specialty that physicians are actively training and teaching nurses to replace themselves.

Can you image that Donna McArthur, Ph.D, R.N. goes to department of surgery and tried to establish the similar program with surgeons. She would be kicked out as soon as she utters "fellowship."
 
On one hand, I agree with Vandy folks that there are not enough residents/interns to cover ICUs and NP/PACs are needed to do the scutwork. However, why go overboard and establish a fellowship program for NPs? It must be from some genius in the deparment of anesthesia. It seems Anesthesia is the ONLY specialty that physicians are actively training and teaching nurses to replace themselves.

Can you image that Donna McArthur, Ph.D, R.N. goes to department of surgery and tried to establish the similar program with surgeons. She would be kicked out as soon as she utters "fellowship.”

I wonder if its because tuition is billable.
 
As someone who just signed up for a real CCM fellowship, I must say to Vanderbilt:
thanks-a-****ing-lot-greeting-card.jpg
 
Surely you don't honestly believe everything you just wrote. Has your anesthesia department learned absolutely nothing with all the struggles with CRNA's? You're training your own replacements - they're not looking to be part of your team. That you and your department don't get this is absolutely astounding. Thankfully there are anesthesiologists and anesthesia groups and departments around the country waking up to this. It's unfortunate that Vandy seems to be leading the way in the totally wrong direction. Very sad. Please - join the ASA, contribute to ASAPAC and wake up!

Guys/gals - I get it. I agree with a lot of what you are saying. I'm both an ASA and ASA-PAC member. I've been to the ASA legislative conference multiple times and am an outspoken critic of the midlevel creep we are seeing in medicine.

Send some emails to the powers that be at Vandy and see what the response is. I'll even forward this thread along. You don't have to agree with what's going on but please don't disparage my fellowship program because of the presence of NPs in the workplace.

We get excellent training and some of it is enhanced because of the presence of midlevel providers working in a defined role. I have gained valuable experience in managing a multidisciplinary team. I'm not staying here after fellowship, I really don't have anything to gain by lying to you - this is a tremendous program and this stupid NP "fellowship" and the presence of midlevels in the ICU did not negatively effect my education or experience this past year.
 
Guys/gals - I get it. I agree with a lot of what you are saying. I'm both an ASA and ASA-PAC member. I've been to the ASA legislative conference multiple times and am an outspoken critic of the midlevel creep we are seeing in medicine.

Send some emails to the powers that be at Vandy and see what the response is. I'll even forward this thread along. You don't have to agree with what's going on but please don't disparage my fellowship program because of the presence of NPs in the workplace.

We get excellent training and some of it is enhanced because of the presence of midlevel providers working in a defined role. I have gained valuable experience in managing a multidisciplinary team. I'm not staying here after fellowship, I really don't have anything to gain by lying to you - this is a tremendous program and this stupid NP "fellowship" and the presence of midlevels in the ICU did not negatively effect my education or experience this past year.

Sorry dude - using mid-level providers in a defined role is one thing. Training your replacements is something else altogether. That was my point. A lot of anesthesia departments are finally getting the message - Vandy apparently has not. More and more departments are just saying NO when it comes to training CRNA's. If they're everything they claim they are, then why do they beg physicians to teach them? The same thing applies to this CCN fellowship for nurses. (it's not a CCM fellowship if nurses are doing it) Let the other nurses teach them. If they can't, too damn bad.
 
Thank God my future CCM fellowship does not train these nurses. They do use midlevels in the units but what Vanderbilt is doing seems to be shooting ourselves in the foot in the long run.
 
i would like to echo a question brought up earlier

Why train NP's instead of PAs?
 
SP and Idio, I'm sure your fellowship was great. I understand you saying NPs are necessary to 'get the work done' in your ICUs. That doesn't mean you start a 'fellowship' for them, to empower the movement, to bring them one step closer to claiming equivalence to YOU. Big difference between hiring NPs for daily function, and creating a fellowship.
 
SP and Idio, I'm sure your fellowship was great. I understand you saying NPs are necessary to 'get the work done' in your ICUs. That doesn't mean you start a 'fellowship' for them, to empower the movement, to bring them one step closer to claiming equivalence to YOU. Big difference between hiring NPs for daily function, and creating a fellowship.

Fair enough, we can all agree that this is not a great thing for ICU physicians in general. I dont think any of the fellows at Vanderbilt are excited about this progression. With that said, the development of DNP programs is going to stimulate this kind of subspecialized training (and there will be other fellowships).

Vanderbilt is a medical center that trains medical students, residents, fellows, post-docs, nurses, nurse practitioners, SRNAs, LPNs, care partners, janitorial staff, administrators - basically anything that is needed to run a hospital in the 21st century. Your opinion of the value of such training is really immaterial, as is mine, but I also dont think its an indictment of the anesthesia CCM fellowship that there happens to be someone doing clinical rotations with you and presenting patients to you on rounds (at least for three shifts a week on a few rotations a year).

In my opinion, this fellowship is something that was going to happen here, as an extension of the various nursing training programs, and as a member of the CCM department, Id rather be involved in the development and implementation of it than have it happen anyway without any input from our department. Ill admit to not knowing a ton about the 'fellowship' aspect of the program, as most of my experience with it comes from the same article posted above. Im sure over time we will see a more concrete presentation.

For those of you rigidly opposed to these developments, I salute you. There are numerous programs around the country that do not employ physician extenders, I am sure, and I encourage you to seek out those places to hone your skills. I happen to think the ICU of the future is very similar to the OR of the future, which will have physicians directing care and multiple tiered providers delivering the care, based on the acuity of the situation. Even with the inevitable repeal/dilution of the affordable care act, midlevel practitioners are going to remain part of the workforce.
 
Yeah, you'll be fine with all of the NP fellows rather than physicians like fakin'. Just fine and dandy.

oh thats our alternative? more residents/fellows that the hospital has to pay for or more faculty? great, i didnt see where that checkbox was. if you send me your plan for staffing 200 ICU beds without midlevel providers (and trying to break even) Ill pass that along to the administration.

remember, interns can only work 60 hours a week, residents and fellows < 80, and we already have 18anesthesia CCM faculty who also have OR/research responsibilities (how many do you have?), 45 residents, 15 anesthesia interns and 35 surgical interns. we have 7 ICU locations to provide 24/7 services to.

Thanks!
 
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and as a member of the CCM department, Id rather be involved in the development and implementation of it than have it happen anyway without any input from our department.

:wtf: But you guys are the only ones doing it! This is crazy, kill it the egg before it turns into a bigger problem.
 
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oh thats our alternative?

This is nonsense you staff it the way you staff any other unit big or small: if you have X amount of beds then you have Y amount of attendings where does the "we are bigger so we need midlevels" come in to play?
My guess is that it's just we are big enough to fund midlevels and spare a few $ on MD's salary :thumbdown:
 
Guys/gals - I get it. I agree with a lot of what you are saying. I'm both an ASA and ASA-PAC member. I've been to the ASA legislative conference multiple times and am an outspoken critic of the midlevel creep we are seeing in medicine.

Send some emails to the powers that be at Vandy and see what the response is. I'll even forward this thread along. You don't have to agree with what's going on but please don't disparage my fellowship program because of the presence of NPs in the workplace.

We get excellent training and some of it is enhanced because of the presence of midlevel providers working in a defined role. I have gained valuable experience in managing a multidisciplinary team. I'm not staying here after fellowship, I really don't have anything to gain by lying to you - this is a tremendous program and this stupid NP "fellowship" and the presence of midlevels in the ICU did not negatively effect my education or experience this past year.

Just out of curiousity, What behavior would you consider it reasonable for a department or a fellowship program to be disparaged?

It is OK to discriminate on the basis of behavior.
 
Training your replacements is something else altogether. That was my point. Let the other nurses teach them. If they can't, too damn bad.

That doesn't mean you start a 'fellowship' for them, to empower the movement, to bring them one step closer to claiming equivalence to YOU. Big difference between hiring NPs for daily function, and creating a fellowship.

I don't disagree with you at all. This "fellowship" is definitely a thinly veiled attempt, along with the DNP as a whole, to bolster claims of equivalency. I agree with what Idio wrote regarding being involved in, and controlling the development of, this type of program as it is the reality at our institution for whatever reason. This thing was likely happening as a mandate coming down from above and our department had a chance to dictate how it was run or have it dictated to us.

I don't feel as if Vandy is training replacements for intensivists. I see the enormous difference in physician vs. NP knowledge base and skills on a daily basis.

If healthcare in America degenerates to the point that an NP is hired over a physician in the unit based on salary or whatever then I really wouldn't want to be a part of it anyway.

I've inquired about why not AAs instead of SRNAs and why not PAs instead of NPs. I'll get back to you with answers.
 
Just out of curiousity, What behavior would you consider it reasonable for a department or a fellowship program to be disparaged?

It is OK to discriminate on the basis of behavior.

Doze, I'm cool with criticism of the department and instutution as a whole based on decisions they've made.

I'm just saying that the CCM fellowship is a separate, educational entity that doesn't have anything to do with the NPs or NP training. To imply that we (the fellows) receive substandard training or have a worsened experience because of their presence is misleading and untrue.
 
This is nonsense you staff it the way you staff any other unit big or small: if you have X amount of beds then you have Y amount of attendings where does the "we are bigger so we need midlevels" come in to play?
My guess is that it's just we are big enough to fund midlevels and spare a few $ on MD's salary :thumbdown:

read as, reduce anesthesiology staff "burden" and replace with cheaper alternative while those left standing (the administrative anesthesiologists that cut the deal) manage from above. It's not the OR of the Future as some would have others believe. Plenty of private docs have been leveraging off this game for a long while.
 
Residents. Neuro has a few ICU beds and they have a couple of PAs but many residents who are always around the unit so I don't really know their division of labor. PP hospital where I did Intern year had around 70-80 beds in the ICU total. Some of the pulm attendings had regular RNs who helped them skeletonize notes and do paperwork. The attendings did pretty much everything unless a resident was on service which would be only a few times a year unless in the transplant ICU which had year long resident coverage.
 
I for one welcome our new nursing overlords. I mean, come on. They care for the whole patient! Not just the annoying chemical and physiologic parts.
 
This thing was likely happening as a mandate coming down from above and our department had a chance to dictate how it was run or have it dictated to us.

F**k us up the a** and we'll provide the lube :eek:. Dude i get where you're coming from but to hear this from a young guy (not a baby boomer prick) is discouraging.

I don't feel as if Vandy is training replacements for intensivists. I see the enormous difference in physician vs. NP knowledge base and skills on a daily basis.

Doesn't everybody here see the vast difference between CRNAs and MDs on a daily basis??

I don't care one way or another since i'll be out of this business before the brown stuff hits the fan but if people don't find this disgusting they have a serious problem.
 
Found this interesting description of the Vandy APN intensivist service:

http://www.vanderbilt.edu/vanderbiltnurse/2012/04/on-a-patients-worst-day/

I love this line:

Two-thirds of Vanderbilt's MICU patients are managed by resident physicians, but the rest, including this patient, are managed by intensivist ACNPs.

I can see this line being used in the future at a critical access hospital somewhere in BFE:

"Our Critical care NP's managed 1/3rd of the patients at Vandy.... This critical care hospital with 10 ICU beds will be easily managed by our critical care nursing staff".

Give 'em some fuel and it will balloon into something that is not safe.
 
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